Every finding on record at Bethany St Joseph Care Ctr

Example 3R50 was admitted to the facility on [DATE], and has diagnoses that include acute kidney failure, neuromuscular dysfunction of the bladder, type 2 diabetes mellitus, and cellulitis of buttock. R50 developed his pressure wound after admission.R50's MDS, dated [DATE], indicates that R50 is moderately cognitively impaired. R50's MDS shows that he requires substantial/maximal assist for hygiene and personal cares and is dependent for mobility.R50's physician orders dated 3/7/25 and 5/2/2025, state Encourage resident to lay down for at least 1 hr. on his SIDE between meals to offload pressure to buttocks twice a day AM PM. R50's Treatment Record (E-TAR) printed 6/17/25, shows the order was first implemented 5/23/25. No order for remainder 7 hours of the shift, resulting in R50 sitting on his buttocks for extended periods.R50's Kardex (CNA Resident Care Plan), dated 6/17/25, states: Skin Care . Offload side-side as much as possible during the day. Surveyor requested and was not supplied with documentation that this was being done.R50's care plan, with last revisions dated 3/27/25, states:12/18/2024 I have a skin injury I need my nurses to monitor and assess my skin with my scheduled skin check check my skin with cares check my skin weekly.My Goal is to: keep my skin healthy and intact have my skin heal3/12/25 Because I am a diabetic poor tissue perfusion 2/13/25 DTI to left heal-DTI healed 3/12/25, 2/25 25 Stage 2 to Rt posterior thigh-changed to unstageable on 3/7/25.12/18/24 I need my aides to help with hygiene and general skin care; .offer me fluids when I change positions 12/18/24 I need my restorative aide to offer me fluids before and after my program reduce pressure and friction between myself and my bed or chair.12/18/24 I need everyone to report any changes to my nurse .Make sure I change positions frequently. 3/13/25 Skin Care: .Offload side-side as much as possible during the day.On 06/17/25 at 7:31 AM, Surveyor interviewed R50, who stated that R50 came in with a blister and now R50 has a wound. R50 does not think R50 is getting better. They keep monkeying with it and I have to go to the clinic every few weeks now. R50 is sitting in his bed at about a 20-degree angle.On 6/17/25 at 8:00 AM, R50 fell back to sleep. Surveyor observed that R50 remained positioned on his back at about 20-degree angle, pillow by right shoulder but not providing offloading support to the pressure wound On 06/17/25 at 10:05 AM, Surveyor observed R50 rolled for cares. R50 was placed back on his back again about 20 degrees, no offloading support to buttocks.On 06/17/25 at 11:04 AM, Surveyor had been in hallway outside R50's room observing. Surveyor had not observed anyone going into R50's room.On 06/17/25 at 12:00 PM, Surveyor observed R50 sitting up in bed at about 45 degrees with lunch tray.R50 remained with pressure on same area of his buttocks from 8:00 AM until 12:00 PM, except for rolling for cares at 10:05 AM. At 12:00 PM, while pressure was adjusted, R50 remained on his buttocks, with no offloading.On 06/19/25 at 12:21 PM, Surveyor followed up with R50 to clarify his movement. R50 stated they do not make me move a lot; they do use pillows when I'm in bed. R50 stated that at night when R50 goes to bed pillows are placed on R50's left side, then when R50 gets up about 5 AM they put it on the right side. R50 stated the Certified Nursing Assistant (CNA) comes in about 8:00 AM and gets me ready for the day. R50 stated R50 stays in bed for breakfast. Any pillows are removed. R50 states R50 usually gets up around 10:30 AM into my wheelchair for lunch. R50 stated that sometimes R50 goes back to bed, but usually not until just before dinner at 6 PM. R50 stated R50 stays in R50's bed until the staff come in about 8:30 PM to get R50 ready for bed. Surveyor asked R50 if he is sitting on his butt most of the time, or on his side. R50 stated, I am sitting in bed or in my chair most of the day. R50 stated R50 lays on his sides at night.On 06/19/25 at 11:14 AM, Surveyor interviewed Registered Nurse (RN) N who stated the order means we (the facility) have to ensure R50 lays down if R50 gets up for meals. RN N looked and confirmed there is no order to reposition in bed or a frequency. RN N states the nurse ensures R50 lays down by asking the CNAs and trusts the CNAs are telling the truth. RN N does not believe there is anywhere CNAs can chart if CNAs reposition someone. RN N stated again there is no specific frequency it just says offload frequently. RN N stated, [R50] could be on his butt for hours at a time.On 06/19/25 at 11:23 AM, Surveyor interviewed CNA M. CNA M stated CNAs know what each residents' abilities and care needs are because it is on the Kardex. A copy of the Kardex can be found on the wall inside the door of patient's room, in the computer or chart. The computer and chart copies are more in-depth than what is on the walls. CNA M stated we reposition residents, encourage residents to get up, everyone can get up with a lift. CNA M stated if they don't want to get up, we reposition them. CNA M stated that she makes sure everyone is repositioned every 2 hours or what the orders say. CNA M stated it is policy if they have a bed sore repositioning is ordered. CNA M stated that would be listed on the Kardex. Surveyor asked CNA M to read the Kardex for R50 and explain what the frequency for repositioning is. CNA M stated R50 has a pressure wound; it should say somewhere reposition every 2 hours. CNA M stated some residents have a button in the system they can press to show someone was repositioned and in what position, but it doesn't get used often, we get too busy. CNA M stated she is not sure if that is available for R50. On 06/19/25 at 11:37 AM, Surveyor interviewed the charge nurse, Licensed Practical Nurse (LPN) O, regarding protocol for repositioning and pressure wounds. Surveyor started by asking LPN O to read R50's orders and the Kardex. LPN O stated there should be a frequency. LPN O stated it is standard to reposition dependent residents every 2 hours unless indicated by a provider. LPN O stated the CNA Kardex order to offload side to side as much as possible during the day could be interpreted many ways. Surveyor asked LPN if R50 could be in one spot for 4 hours in an 8 hour AM or PM shift. LPN O stated, yes. LPN O stated it is the responsibility of the CNAs to reposition residents and the nurses' tasks to make sure it is done. Surveyor asked LPN O if Surveyor was missing an order or a spot that has a frequency for repositioning R50. LPN O stated no.On 06/19/25 at 1:02 PM, Surveyor interviewed Director of Nursing (DON) B. Surveyor started by sharing the physician orders, care plan, and Kardex and reviewing the different statements regarding repositioning. DOB B stated a physician's order is not needed for repositioning a resident but if ordered then it is an order and followed. DON B believes R50's pressure wound was unavoidable. DON B believes they did everything the facility could do to prevent it. DON B listed all the things they have in place. DON B did not mention repositioning. Surveyor asked DON B how often a person with a pressure wound should be repositioned. DON B stated every 2 hours. Surveyor asked if R50 has a repositioning plan. DON B did not answer. Surveyor restated to DON B, that DON stated repositioning should be every 2 hours. DON B said, Yes. Surveyor asked DON B if R50 refuses care what should staff do. DON B stated it should be documented. The E-TAR would have red initials if refused. Surveyor did not observe any red initials during record review indicating patient refuses to reposition. Example 2According to the National Institute of Health (NIH), a wound clinic consult should be considered with stage 3 or 4 pressure injuries as they involve damage to deeper tissues, with non-healing wounds (wounds that do not heal within eight weeks), or wounds that are recurrent.R42 was admitted to the facility on [DATE] with pertinent diagnoses of intervertebral disc disorder with myelopathy, diabetes mellitus type 2, polyneuropathy, chronic kidney disease stage 2, and hypothyroidism.R42's quarterly Minimum Data Set (MDS) assessment dated [DATE] noted a Brief Interview of Mental Status (BIMS) score of 15 indicating cognition is intact, has impaired range of motion on both lower extremities, is frequently incontinent of bladder, and has 2 stage 3 pressure injuries not present on admission.R42's care plan, dated 02/03/25, with a target date of 08/29/25, states: .am a diabetic, with poor tissue perfusion, have trouble feeling certain sensation, can't move around well on my own, (07/11/24) have 2 stage 3s to bilateral buttocks (chronic/healed and re-open) with interventions to monitor and asses skin with scheduled skin check, monitor nutrition or hydration intake, check skin weekly, reduce pressure and friction between self and bed or chair, ensure alternating air mattress and wheel chair cushion are functioning properly, report changes to nurse, make sure to change position frequently.R42's physician orders:07/11/24 Check mattress (alternating air) & w/c cushion (alternating air) for bottoming out, replace or repair if needed. Notify maintenance of any mattress changes every shift.07/12/24 Ensure w/c cushion is plugged in whenever resident is in her room three times a day.10/15/24 Stage 3 PI to LEFT & RIGHT buttock: (Do NOT change on bath day if clean/dry/intact): 1. Use Unisolve to remove old dressing. 2. Cleanse wound with wound cleanser/pat dry. 3. Apply skin prep to peri-wound/allow to dry. 4. Cover w/hydrocolloidal dressing/secure w/transparent dressing. 1 time a week on Wednesday. 10/15/24 Stage 3 PI to RIGHT & LEFT buttock: 1. Use Unisolve to remove old dressing. 2. Cleanse wound with wound cleanser/pat dry. 3. Apply skin prep to peri-wound/allow to dry. 4. Place collagen powder in wound bed. 5. Cover w/hydrocolloidal dressing/secure w/transparent dressing as needed.10/24/24 Encourage to eat protein (example: yogurt, custard, toast with peanut butter, meat sandwich) daily. 11/26/24 Prophylactic skin protection: 1. Apply Desitin to right AND left buttock fold/cleft three times day.12/02/24 Encourage resident to lay down each shift for 1 hour to offload pressure to buttocks twice a day.Surveyor reviewed R42's nutrition assessment and noted the following:12/03/24 Nestle Mini Nutritional Assessment score of 11, indicating likely at risk for malnutrition.05/28/25 Nestle Mini Nutritional Assessment score of 13, indicating a normal nutritional status.Surveyor reviewed R42's wound/skin assessments and noted the following:-Right lower buttock: Stage 3 06/30/24 Small open area noted to right lower buttock near gluteal fold.*New intervention: Cleanse open area with soap and water, pat dry and apply a small amount of Triad ointment to area every shift until healed. Alert Wound RN to worsening condition. Provider notified. Of note: no new interventions to offload area noted. No documentation noted for root cause of skin breakdown noted. 07/11/24 Initial Assessment L 0.6 cm x W 0.8 cmAction: Physician and Charge Nurse notified. Cleansed areas w/wound cleansers, triad applied to wound bed, skin prep to peri-wound, covered w/hydrocolloidal dressing, secured w/transparent dressing.*New Interventions: -Provide offloading every shift in bed on side as tolerated three times a day.-Bilateral buttocks/gluteal fold/ischial region/sit bones/left/right: Stage 3-1. Use Unisolve to remove old dressings. 2. Cleanse bilateral wounds w/wound cleanser, pat dry. 3. Apply triad to bilateral wound beds. 4. Apply skin prep to peri-wound liberally, allow to dry. 5. Cover both wounds with hydrocolloidal dressing and secure w/transparent dressing every 3 days.08/12/24 HEALEDAction: Treatment is discontinued and provider notified. *New intervention: Triad ointment applied three times a day.Of note: no documented skin assessment of right lower buttock between 08/13/24 - 12/01/24.12/02/24 (RE-OPENED) L 1.9 cm x W 2.0 cm x D 0.1 cmSkin Treatment: Has pressure reducing device for chair/bed. Receives turning/repositioning program. Receives nutrition or hydration intervention.Action: Physician notified*New intervention: -1. Use Unisolve to remove old dressings. 2. Cleanse bilateral wounds w/wound cleanser, pat dry. 3. Apply triad to bilateral wound beds. 4. Apply skin prep to peri-wound liberally, allow to dry. 5. Cover both wounds with hydrocolloidal dressing and secure w/transparent dressing 1 time a week.-Resident encouraged to lay down for 1 hour each shift to offload pressure to area.Of note: No new interventions implemented for alternative measures to offload PI or wound clinic/specialist consult for PI re-opening.Weekly wound assessments continued to show improvement.02/03/25 L 0.4 cm x W 0.4 cm x D 0.1 cmAction: continue to observe*New intervention: Changed treatment - Apply collagen powder to wound bed. Covered w/hydrocolloidal dressing 1 time weekly and as needed. Provider notified. 02/10/25 L 0.6 cm x W 0.8 cm x D <0.1 cmAction: continue to observe*No new interventions implement. Provider not notified of worsening PI measurements.02/24/25 L 0.3 cm x W 0.5 cm x D <0.1 cmAction: continue to observe03/03/25 L 0.3 cm x W 0.5 cm x D <0.1 cmAction: continue to observe*No new interventions implemented after no improvement in PI measurements.03/31/24 L 1.2 cm x W 1.5 cm x D 0.2 cmAction: Dietician consulted. Educated resident regarding additional supplementation for wound healing. Education given to resident regarding offloading. Resident stated being unable to lay on hips. *New interventions: Prosource supplement two times daily. Start trial of Glucerna supplement. Of note: no documentation of provider notified of wound worsening. 04/14/25 L 0.4 cm x W 0.8 cm x D 0.1 cmAction: continue to observeWeekly wound assessments continued to show improvement.05/26/25 HEALEDAction: continue to observe06/02/25 Area remains closed.06/09/25 (RE-OPENED) L 0.5 cm x W 0.4 cm x D <0.1 cmAction: Discussed with resident the importance of offloading and drinking supplements. Resident states I drink my supplements and I do lay down, but not on my side. Charting reflects that resident does often times decline to lay down in bed.*No new interventions implemented for alternative measures to offload PI or wound clinic/specialist consult for PI re-opening.Of note: no documentation of provider notified of wound re-opening. 06/16/25 L 0.4 cm x W 1.0 cm x D <0.1 cm*No new interventions implement. Provider not notified of worsening wound measurements. Of note: documentation of provider assessing wound was not noted in R42's chart or provided to Surveyor.-Left Lower Buttock: Stage 307/11/24 Initial Assessment: L 0.6 cm x W 0.5 cm x D 0.2 cmAction: Physician and Charge Nurse notified. Cleansed areas w/wound cleansers, triad applied to wound bed, skin prep to peri-wound, covered w/hydrocolloidal dressing, secured w/transparent dressing.*New Interventions: -Provide offloading every shift in bed on side as tolerated three times a day.-Bilateral buttocks/gluteal fold/ischial region/sit bones/left/right: Stage 3-1. Use Unisolve to remove old dressings. 2. Cleanse bilateral wounds w/wound cleanser, pat dry. 3. Apply triad to bilateral wound beds. 4. Apply skin prep to peri-wound liberally, allow to dry. 5. Cover both wounds with hydrocolloidal dressing and secure w/transparent dressing every 3 days.Of note: no prior skin breakdown to this area was noted. No documentation noted for root cause of skin breakdown noted. 08/19/25 L 0.4 cm x W 0.3 cm x D 0.1 cmAction: Treatment plan updated and provider notified.*New intervention: Changed from Triad to collagen powder to wound bed.09/23/24 HEALEDAction: will re-assess area next Monday to ensure area remains healed/closed.*New intervention: Discontinued dressings and apply Triad ointment three times daily.Of note: no skin assessment of left lower buttock area documented between 09/24/24 - 10/14/24.10/15/24 (RE-OPENED) L 0.6 cm x W 0.4 cm x D 0.2 cmAction: New treatment added to TAR. Education provided to resident regarding offloading of pressure to buttocks when in bed and continuing ProSource supplement daily.*New intervention: 1. Use Unisolve to remove old dressing. 2. Cleanse wound with wound cleanser/pat dry. 3. Apply skin prep to peri-wound/allow to dry. 4. Place triad in wound bed. 5. Cover w/hydrocolloidal dressing/secure w/transparent dressing 1 time a week on Wednesday.11/11/24 L 0.2 cm x W 0.2 cm x D <0.5 cmAction: continue to observe11/25/24 L 0.2 cm x W 0.2 cm x D <0.5 cmAction: continue to observe*No new interventions implemented after 2 weeks without improvement in PI.12/02/24 L 0.2 cm x W 0.6 cm x D <0.5 cmAction: Resident encouraged to lay down 1 time per shift to offload. Dietician consulted. Provider notified.*No new interventions implemented when width of PI increased.12/23/24 L 0.2 cm x W 0.2 cm x D <0.1 cmWeekly wound assessments continued to show improvement.01/06/25 HEALEDAction: Treatment will remain in place prophylactically to prevent breakdown. (Area has healed and broken down x2). Will re-assess area next Monday to ensure area remains healed.01/13/25 Area remains healed. Will continue with hydrocolloidal to ensure area does not break down.01/27/25 Area remains healed.02/03/25 (RE-OPENED) L 0.4 cm x W 0.4 cm x D 0.1 cmAction: Treatment updated. Provider notified.*New intervention: Changed Triad ointment to collagen powder to wound bed.Weekly wound assessments continued to show improvement.02/24/25 HEALEDAction: will re-assess area next week to ensure area remains healed*New intervention: Discontinued collagen powder and changed treatment to cleansing with soap and water and continue with hydrocolloidal dressing.03/03/25 - 04/28/25 area remains healed.05/05/25 (RE-OPENED) L 0.3 cm x W 0.5 cm x D 0.2 cmAction: Discussed with resident importance of lying down each shift on her side and continued compliance with ProSource supplement two times daily.*New intervention: Changed wound care to wound cleanser and Triad ointment to wound bed. Continue hydrocolloidal dressing.Of note: no documentation of provider notified of wound re-opening. No root cause to identify why PI is reopening.05/26/25 HEALEDAction: continue to observe*New intervention: Discontinued Triad ointment. Area cleansed with soap and water. Continue hydrocolloidal dressing.06/02/25 (RE-OPENED) L 0.5 cm x W 0.3 cm x D 0.2 cmAction: Treatment updated.*New intervention: Changed wound treatment to collagen powder and Triad ointment to wound bed. Continue hydrocolloidal dressing. Of note: no documentation of provider notified of wound re-opening. No root cause to identify why PI has reopened, or additional offloading interventions added.06/16/25 L 0.2 cm x W 0.2 cm x D <0.1 cmAction: continue to observeOf note: documentation of provider assessing wound was not noted in R42's chart or provided to Surveyor.On 06/19/25 at 12:45 PM, Surveyor observed R42 sitting in wheelchair in room. Alternating air pressure reducing cushion observed in place and operating appropriately. Surveyor asked R42 about interventions to relieve pressure. R42 stated that since the wounds opened, no other pressure reducing devices have been used. R42 stated that it is difficult for her to lay on her side in bed due to chronic bone inflammation and it is too painful. R42 stated no other pressure reducing device has been used to offload while laying down in bed other than the alternating air mattress. R42 stated drinking the recommended protein supplements daily. R42 stated the facility had never offered a consult with a specialized wound clinic. Surveyor asked R42 if the provider at the facility had ever assessed the wounds on her buttocks. R42 stated that she could not recall the provider ever looking at her wounds personally.On 06/19/25 at 1:00 PM, Surveyor interviewed Physician Assistant (PA) I regarding R42's pressure injuries (PIs). PA I stated the wound nurse (WN) assesses all wounds and would notify one of the providers with new orders for wound treatment via hand-written order sheet in the resident's chart. PA I stated being updated regularly with wound changes regarding R42, but could not recall specific details. Surveyor asked PA I why R42 was not referred to a wound clinic. PA I stated that R42 was a complex patient that had many concerns being monitored and that R42 often refused interventions. PA I stated that her professional opinion was that R42 was being cared for appropriately, wound clinic treatment was not necessary, and both PIs were unavoidable as the facility could not have done anything different to prevent both PIs from occurring or re-opening, but also stated that additional consultation for wound healing was not utilized to know for sure if other interventions could have been utilized to improve outcomes.On 06/19/25 at 2:16 PM, Surveyor interviewed RN H, who is the facility wound nurse, regarding treatment of R42's PIs. Surveyor asked RN H when the provider should be notified about a wound. RN H stated with any significant change. Surveyor asked RN H what a significant change would mean. RN H stated a wound worsening from baseline, signs of infection, increasing in size, or a drastic change occurring quickly. Surveyor asked RN H why the provider was not always notified when R42's wounds worsened or re-opened. RN H stated that she did not feel changes were significant to warrant provider notification. Surveyor asked RN H why R42 was not referred to the wound clinic for assessment. RN H stated that R42 had superficial PIs and did not feel they were significant enough for the wound clinic. Surveyor asked RN H if any other provider or specialist was contacted to assess or offer additional interventions for R42's PIs. RN H stated no. Surveyor asked RN H if any other offloading interventions or support surfaces were tried. RN H stated no. RN H stated that R42 frequently refused to lay on her side to offload buttocks, additional protein supplements were provided, and weekly skin treatments were provided. RN H stated that due to R42's size, lack of mobility, and frequent refusal of interventions led to the development and reoccurrence of these PIs and there were no additional interventions that could have been implemented to prevent these PIs from occurring. Based on interview, observation and record review, facility did not implement professional standards of practice to ensure that a resident does not develop pressure injuries (PIs), receives necessary treatment and services to promote healing and prevent new PIs from developing for 3 of 5 residents (R) reviewed. (R10, R42, R50) R10 was determined to be at moderate risk for PI development. R10 developed a stage 3 PI and facility did not consult physician for appropriate treatment and interventions to promote healing when the area would re-open or worsen, causing actual harm to R10. Continual education was not provided to R10 and representative for the need of repositioning and offloading the pressure area. R42 acquired two stage 3 PIs. The areas have healed and then reopened with increase in size, causing actual harm to R42. The physician was not notified of changes, a root cause to identify why the PI was reopening, or new interventions to promote healing were not implemented.R50 developed a stage 2 PI on 2/26/25 and on 3/7/25 R50's PI worsened to an unstageable PI, causing actual harm to R50. R50 was not repositioned in a consistent manner with standards of practice. The care plan was last updated with approaches related to PI on 3/13/25. This is evidenced by:National Pressure Injury Advisory Panel (NPIAP) guidance recommends repositioning all individuals with or at risk of pressure injuries on an individualized schedule, unless contraindicated. Determine repositioning frequency with consideration to the individual's level of activity and ability to independently reposition. Reposition the individual in such a way that optimal offloading of all bony prominences and maximum redistribution of pressure is achieved.Facility's policy titled, Pressure Injury Prevention Guidelines with the revised date of 02/27/25, read in part, 3. Interventions will be implemented in accordance with physician orders, including the type of prevention devices to be used and, for tasks, the frequency for performing them. 4. In the absence of prevention orders, the licensed nurse will utilize nursing judgement in accordance with pressure injury prevention guidelines to provide care and will notify physician to obtain orders . 9. The effectiveness of interventions will be monitored through ongoing assessment of the resident and/or wound. Considerations for needed modifications include a. Development of a new pressure injury. B. Lack of progression towards healing or changes in wound characteristics Example 1R10 was admitted to the facility on [DATE]. Current diagnoses include hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, congestive heart failure, diabetes mellitus type 2, morbid obesity, anxiety disorder, visual hallucination, edema, vascular dementia with behavioral disturbance, Alzheimer's disease, and chronic kidney disease stage 3a.Minimum Data Set (MDS), dated [DATE], a quarterly assessment documented R10 having a Brief Interview for Mental Status (BIMS) score of 7, meaning severe cognitive impairment. R10 had impairment to one side of upper and lower extremities. R10 needs maximum assistance from staff for toilet hygiene, dressing, personal hygiene, transfers, and bed mobility. R10 is at risk for PI and has 1 stage 3 PI that was not present on admission. MDS dated [DATE] an annual assessment documented R10 having a Brief Interview for Mental Status (BIMS) score of 10, meaning moderate impaired cognition. R10 had impairment to one side of upper and lower extremities. R10 is dependent on staff for lower body dressing, toilet hygiene, sit to stand transfers, and toilet transfer. R10 needs maximum assistance from staff for upper body dressing, personal hygiene. R10 did not have bed mobility assessed. R10 is at risk for PI and has 1 stage 3 PI that was not present on admission. R10's physician orders include:06/27/24 - general diet w/ soft foods. fluid restriction 2000 ml w/ small portions not receiving supplements at this time.03/24/25 Encourage resident to lay down for 1hr between breakfast and after lunch (NOT Thursday d/t residents activities schedule this day) twice a day 03/26/25 30 ml prosource x3 daily to promote wound healing. 04/28/25 Stage 3 to left of coccyx: Use large hydrocolloidal to cover entire coccyx region - Do Not change if clean/dry intact 1. Use Unisolve to remove old dressing. 2. Cleanse wound w/ wound cleanser, pat dry. 3. Apply skin prep to peri wound, allow to dry 4. Apply Triad to wound bed. 5. Cover wound w/ hydrocolloidal dressing with secure w/ transparent dressing. Every three days. R10's care plan, dated 05/19/21, I have the potential to experience skin breakdown . 05/05/25 I show this by: .I decline to sleep in bed and request to sleep in the recliner; therefore, I need a large per pad in my recliner for staff to reposition me. I am aware that the large peripad can result in skin breakdown .08/26/24 - stage 3 to left side of coccyx---HEALED 2/3/25, reopened 2/17/25 healed 4/14/25 then re-opened 4/28/25 presenting as a stage 2 08/05/25 (date should be 05/05/25) presents as a Stage 3. Interventions: 03/05/25 .reposition at least every 1-2 hours while I'm in a bed help me reposition at least every 1 hour when I'm in a chair offer me fluids when I change positions elevate my heels in bed reduce pressure and friction between myself and my bed or chair use pressure redistribution devices promote plus mattress use a lift sheet when moving me in my bed help me stay clean and dry reposition routinely. Use roho cushion in recliner, sheep skin to back of legs in stand lift, has personalized w/c cushion Ensure the alternating air cushion to my recliner is working.Care plan history on 07/22/24 added .use roho cushion in recliner, sheep skin to back of legs in stand lift, has personalized w/c cushion.On 07/30/23 added pressure redistribution devices promat plus mattress. Surveyor reviewed manufacturer's guidelines; mattress is appropriate for up to uncomplicated Stage 3 or 4 pressure ulcers. Braden scoring assessments for risk of skin breakdown:06/18/24 score 14 risk breakdown moderate risk 13-1409/11/24 score 14 risk breakdown moderate risk 13-1411/25/24 score 14 risk breakdown moderate risk 13-1402/21/25 score 14 risk breakdown moderate risk 13-1405/27/25 score 14 risk breakdown moderate risk 13-14.Weekly wound assessments of Left of coccyx - Stage 3 PI08/26/24 initial assessment has full thickness of skin lost, exposing the subq tissues - presents as a deep crater (pressure stg 3) slough 80% granulation 20% (New area) 2.0 cm by 0.3 cm total sq cm 0.6 cm. Has pressure reducing device for chair. Alternating air cushion added to recliner Ulcer care new tx started for PI matrix cushion to w/c. Procedure area is cleansed w/wound cleanser/pat dry/triad to wound bed/covered w/hydrocolloidal dressing/secured w/transparent dressing. MD notified via incident report/Dr. [Name], placed on rounds for 8/26/24 family notified POA/[Name] called. 09/02/24 Noted after admission stage 3 slough 80% granulation 20% worsening becoming larger 1.5 x 0.6 sq cm 0.9 cm Skin treatment: has pressure reducing device for chair. ulcer care treatment remains appropriate/no changes made to wound dressing treatment. New: Additional alternating air cushion will be added to w/c upon delivery. Surveyor observed proactive alternating pressure seat cushion in use. Review of manufacturer's user manual documented for long term care home care of patients suffering from pressure ulcers. 09/09/24 Stage 3 slough 80% granulation 20% 1.5 x 0.5 sq cm 0.75 improving becoming smaller.09/16/24 stage 3 slough 70% granulation 30% 1.5 x 0.9 sq 1.35 improving appears more clean becoming more shallow - dietician consulted for additional supplements to enable/enhance healing process. 09/17/24 Scheduled a 30 ml prosource x 2 daily to help promote wound healing. 09/23/24 stage 3 slough 60% granulation 40% improving appears more clean becoming more shallow 1.3 x 0.7 by 0.1, sq cm 0.91.Weekly wound assessments continued to show improvement.10/08/24 wound note documented reviewed with R10 and son [Name] the risks associated with R10 choosing to sleep in her recliner and not in the bed. Both [Name and R10 are aware of risk of skin breakdown, despite the risk R10's wants to continue to sleep in her recliner and son is agreeable with this.11/18/24 stage 3 granulation 100% improving appears more clean 0.4 cm x 0.8 x < 0.1, sq cm .32 procedure done area is cleansed w/ wound cleanser / pat dry, collagen to wound bed/covered w/ hydrocolloidal dressing/secured w/ transparent dressing. Note this is a change to the type of treatment. Weekly wound assessments continued to show improvement.01/20/25 stage 3 closed 50% epithelial 50% improving appears more clean 0.2 cm x 0.3 x < 0.1, sq cm .06 Area is cleansed w/wound cleanser/pat dry, collagen to wound bed/covered w/ hydrocolloidal dressing/secured w/ transparent dressing/ Frequency of TX (treatment) is every 3 days AM and PRN (as needed).01/27/25 stage 3 closed 60% epithelial 40% improving appears more clean 0.3 cm x 0.3 x < 0.1, sq cm .09.02/03/25 Closed healed - will re-assess area 2/10/25 to ensure area remains healed. Tx is left in place prophylactically as resident is prone to breakdown in this area. 02/10/25 remains healed continue to follow to ensure area remains healed. 02/17/25 Stage 3 Granulation 100% scant drainage, worsening area chronically heals and reopens. TX was left in place prophylactically, updated TX to include collagen powder becoming deeper becoming larger 0.8 x 0.4 x0.2, sq cm 0.32 granulation tissue. area is cleansed w/wound cleanser/pat dry/collagen powder to wound bed/covered w/ hydrocolloidal dressing/secured w/ transparent dressing **Tx Frequency is every 3 days and PRN**Note, Surveyor unable to locate the physician was notified the area has re-opened with drainage and the treatment that was implemented. 02/25/25 stage 3 Granulation 100% scant drainage improving 0.6 x0.4x0.2, sq cm 0.2403/03/25 stage 3 Granul

Based on observation, policy review, and interview, the facility failed to store, prepare, distribute and serve food in a manner that prevents foodborne illness to the residents. Male staff with facial hair did not wear beard restraints when over hot foods. This has the potential to affect all 68 residents in the facility. Findings: Facility policy titled, Dress Code revised 10/9/2010 and implemented July 2025 stated in part: .Hair .Mustaches and beards must be neat, clean and trimmed. If length is longer than 1/2-inch employee must wear a beard guard (per State regulations) . On 06/17/25 at 11:05 AM, Surveyor observed Nutrition Services (NS) E and NS F monitoring the temperature of hot foods with no beard restraints. NS E had facial hair just on the end of the chin measuring about 1 and 1/2 inches long by 2 inches wide and NS F had facial hair that started anterior to both ears and ran all the way down to the chin. Both NS E and NS F's facial hair was long enough to see across the kitchen as both had dark colored beards. On 06/17/25 at 1:49 PM, Surveyor interviewed Dietary of Nutritional Services (DNS) D about the observation made of facial hair not covered in the kitchen. DNS D informed Surveyor that the regulation states beards longer than ½ inch must have a hair restraint. Surveyor informed DNS D that both the State Operations Manual (SOM) and the WI Food Code both indicate facial hair must be covered with a beard restraint. There is no length given in the regulation; all facial hair is to be covered. DNS D replied, Well, that is a learning moment. I am going to change our policy and make sure effective immediately that all facial hair is covered in the kitchen.

Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infections that has the potential to affect 10 residents living in that resident hall (R) (R3, R7, R20, R30, R37, R50, R60, R314, R315, R316).Facility staff failed to transport linens in a manner to prevent the spread of infection, potentially effecting all residents living in affected hallway. (R3, R7, R20, R30, R37, R50, R60, R314, R315, R316).Facility staff did not properly take on and take off personal protective equipment (PPE) during cares for R50, who is on enhanced barrier precautions (EBP).Facility staff failed to clean mechanical lift in between resident use. (R37, R30)Staff failed to implement appropriate infection prevention and control practices during medication administration for R22, including hand hygiene and glove use with eye medication.This is evidenced by: The facility policy titled, Handling Soiled Linen, dated 4/19/2011, reviewed/revised 6/18/25 states: It is the policy of this facility to handle, store, process, and transport linen in a safe and sanitary method to prevent the spread of infection. The policy pertains to soiled linen .Contaminated linen is linen that has been soiled with blood or other potentially infectious material. 1. Linen can become contaminated with pathogens from contact with intact skin, body substances, or from environmental contaminates. Transmission of pathogen can occur through direct contact with linens or aerosols generated from sorting and handling contaminated linen.2. A used linen should be handled using standard precautions (i.e. gloves) and treated as potentially contaminated .3. Linen should not be allowed to touch the uniform or floor and should be handled as little as possible, with minimum agitation to avoid contamination of air, surfaces and persons.4. Used or soiled linen shall be collected at the bedside . and placed in a linen bag or designated lined receptacle. When task is complete, the bag shall be closed securely and placed in the soiled utility room .On 06/17/25 at 9:12 AM, Surveyor observed Certified Nursing Assistant (CNA) J roll all contaminated linen together after cares on R37 and walked down the hall with it unbagged to a contained receptacle/basket in the soiled utility room. The dirty linen was touching CNA J's clothing, CNA J was not wearing gloves. On 06/17/25 at 10:04 AM, Surveyor observed wound care for R50. During care, bedding fell on the floor. After care was completed, CNA J bundled the contaminated linen that had fallen on the floor, with the wet soaker pad and took it over to the bin located in the room. Nurse Technician (NT) L collected all the garbage and sealed in a bag and came over to same bin. The bin was full of the linen; NT L took the contaminated linen out and dropped it on the floor next to the bin. The bin was a waste receptacle for the disposable gowns and gloves. CNA J disposed of CNA J's gloves and gown in the bin, picked up the pile of contaminated linen from floor and rolled into a large ball. CNA J carried the large ball of contaminated linen down hall to soiled utility room. Dirty linen was placed on floor, not contained when transported down the hall, touched CNA J's clothing and CNA J had no gloves on.On 06/17/25 at 11:18 AM, Surveyor observed CNA J walking down the resident's hall towards soiled utility room with rolled up pile of contaminated linen and no gloves. On 06/17/25 at 11:26 AM, Surveyor observed CNA J roll up contaminated linen into a ball after providing cares for R7. CNA J did not wear gloves and held the unbagged contaminated linen against CNA's clothing while carrying the linen down the residents' hallway to the soiled utility room. On 06/17/25 at 12:29 PM, Surveyor observed CNA J come out of R30's room carrying unbagged contaminated linen close to CNA J's body, and not wearing gloves. CNA J carried the contaminated linen down the resident's hall to the soiled utility room. This had the potential to affect R3, R7, R20, R30, R37, R50, R60, R314, R315, R316 who live on this hallway.On 06/18/25 at 9:09AM, Surveyor interviewed CNA J, who stated usually CNA J puts everything into the sheet or bedspread and puts it around it and takes it down. A regular person (meaning one not on precautions) I don't worry so much about, but [R50] has blue bags for linen. CNA J stated, I try hold it away from body, (pause) mostly. If too much stuff CNA J states CNA J will put in a blue bag and take it down. On 06/18/25 at 10:15 AM, Surveyor interviewed Director of Nursing (DON) B, who stated DON B expected dirty linen coming out of room should not be on staff clothing, it should be brought right to the dirty utility, placed in the hamper and hand hygiene after that. When asked how it is to be carried out of the room, DON B stated, Infection control wise I would expect to have gloves on and carrying out the dirty linen in a bag or a hamper. Example 2 The facility policy titled, Personal Protective Equipment (PPE), revised 2006, states: PURPOSE: To assist nursing staff in protecting themselves, residents and visitors from potentially infection materials.PROCEDURE: Personal protective equipment will be removed before leaving the isolated area, and placed in an appropriately designated area or container for storage, washing, decontamination or disposal .Gloves will be worn anytime there is reasonable anticipated occupational exposure .Gowns will be worn in any occupational exposure situation .CDC poster titled Enhanced Barrier Precautions, states EVERYONE MUST: . Wear gloves and a gown for the following High-Contact Resident Care Activities .Devices care or use . urinary catheter .On 06/17/25 at 10:04 AM, Surveyor observed Registered Nurse (RN) G during cares of R50, who is on Enhanced Barrier Precautions (EBP), take off RN G's gloves, complete hand hygiene, and leave the room still wearing RN G's soiled gown. Surveyor watched RN G walk down the resident's hallway to get supplies. RN G proceeded to come back to the room, complete hand hygiene, put on new gloves, and continued to assist with cares wearing the soiled gown. On 06/18/25 at 1:57 PM, Surveyor observed CNA J provide catheter care to R50, who is on EBP. CNA J had no gown on during this procedure.On 06/18/25 at 1:57 PM, immediately following catheter care Surveyor interviewed CNA J regarding EBP. CNA J stated, We should be using PPE all the time when they (residents) are on EBP. Surveyor asked if there was a time CNA J should have worn a gown. CNA J stated, I should have had gown on during catheter care. On 06/18/25 at 2:08 PM, Surveyor interviewed RN G, who stated EBP should be used, when dealing with catheters, cares, cleaning up, incontinences, and stools. RN G stated RN G knew RN G wore her gown out of the room and came back without changing it. RN G stated RN G already told DON B what RN G had done.On 06/18/25 at 2:15 PM, Surveyor interviewed DON B, who stated EBP is needed and should be used, if any posted-on door, high contact activity listed on the sign such as dressing, bathing, toileting, transferring, wound care, and catheter emptying. DON B would expect staff to use EBP.Example 3 The facility policy titled, Lift cleaning, dated 6/18/25, states:1. Lifts will be cleaned after each resident use with Hydrogen peroxide wipes. Wipes will be stored in a bag attached to the lifts.On 06/17/25 at 11:04 AM, Surveyor observed CNA J prepare R37 to be transferred with a mechanical lift. When R37 was released from the mechanical lift, RN G pushed the mechanical lift into the hallway, completing hand hygiene as RN G walked back to the nurse's station. RN G did not wipe down the mechanical lift. Surveyor stayed in hall and monitored mechanical lift. CNA J came out of resident's room and did not wipe down the mechanical lift. After taking soiled linen to the dirty utility room, CNA J completed hand hygiene and entered R30's room.Surveyors continuously observed the mechanical lift not being used until 12:19 PM when taken into R30's room. On 06/17/2025 at 12:19 PM, Surveyor observed RN G and CNA J take R30 into her room to lay R30 down. CNA J grabbed the mechanical lift from outside R37's room and brought into R30's room. Mechanical lift was not cleansed before entering the room or using it with R30. After use, RN G placed mechanical lift outside of R30's room. RN G and CNA J completed hand hygiene and left R30's room. RN G went back to nurses' station and CNA went into R7's room. Neither RN G or CNA J wiped down the mechanical lift. Facility policy titled, Administration of EYE Drops or Ointments implemented on 1/7/25 and revised 6/17/25 stated in part: 2. Gather supplies: Medication, gloves, and tissues/gauze/cotton balls. Prepare a clean, dry surface for placing medication caps.3. Wash hands or utilize alcohol-based hand rub and apply gloves .On 06/16/25 at 2:36 PM, Surveyor observed Nurse Technician (NT) C touch multiple surfaces on the medication cart and touched the computer keyboard and put the computer to sleep. NT C then gathered medications for R22. NT C did not perform hand hygiene upon entering R22's room. NT C placed one eye drop in each of R22's eyes bare handed. NT C performed hand hygiene after the procedure when exiting the room.On 06/16/25 at 2:48 PM, Surveyor informed NT C of the observation made of no hand hygiene or glove use before administration of eye drops. NT C replied, I should've performed hand hygiene and put on gloves when I went into the room.On 06/17/25 at 9:46 AM, Surveyor explained the observation of NT C with DON B. DON B replied, She really should have performed hand hygiene then put on gloves before administering the eye drops.

Based on observations, interviews and record reviews, the facility did not ensure that residents with limited range of motion (ROM), received the appropriate treatment and services to maintain or prevent further reduction in ROM for 1 of 3 residents (R). (R22) R22's restorative plan was not implemented. R22 did not receive R22's maintenance program. This is evidenced by: The facility policy, titled Restorative Nursing Program, dated 8/15/06, states: To provide each resident with the opportunity to remain independent for as much and as long as possible despite impairment, disability, or handicap if he or she chooses . B. Nursing Responsibilities: 1. Document on resident cardex (sic) that resident is participating in a restorative nursing program. 2. Evaluate restorative nursing plan monthly with monthly nursing summary. 3. Monitor the effectiveness of program . C. CNA Responsibilities: 1. Note those residents' that are on a restorative program . 2. Carry out restorative program . 3. Document on Restorative Nursing Program documentation sheets, the amount of time [NAME] (in minutes) assisting resident in completing their program. R22 was admitted to the facility on [DATE], and has diagnoses that include chronic pulmonary embolism, mild cognitive impairment, depression, history intra cranial hemorrhage, osteoporosis, acute respiratory failure, and type 2 diabetes mellitus with chronic kidney disease. R22's Minimum Data Set (MDS) assessment, dated 4/1/25, indicates R22 is cognitively intact, with an impairment on one of R22's upper extremities and both of R22's lower extremities, requiring maximum assist with dressing, hygiene, and all movement. On 06/16/25 at 3:37 PM, Surveyor interviewed R22 who stated R22 had therapy, but it just stopped. R22 stated R22 is not sure why, thinks it was insurance. R22 stated, I didn't plateau. R22 is wheelchair dependent. On 06/18/25 at 9:32 AM, Surveyor interviewed Rehab Director (RD) K who stated R22 is not on case load at this time. R22 was last on the case load from 1/14/25 to 3/19/25. R22 was being seen under R22's part B benefits and only had 30 visits per calendar year. RD K stated because R22 had plateaued and was not improving the facility did not ask for an extension from insurance. RD K stated that a restorative plan was made so R22 could come down and ride the nu-step with nursing staff 3 times per week. RD K stated R22 likes the machine, and it will help R22 maintain her abilities. On 06/18/25 at 11:34 AM, Surveyor interviewed Certified Nursing Assistant (CNA) P who stated CNA P knows what residents need by reviewing the Kardex (CNA plan). CNA P took R22's Kardex off the wall in R22's room and showed it to Surveyor. CNA P stated R22 does not walk, she is maximal assist and in a wheelchair. CNA P turned Kardex so Surveyor could see the area titled RESTORATIVES was blank. On 06/18/25 at 11:56 AM, Surveyor interviewed Registered Nurse (RN) G who stated how restorative orders are processed. RN G stated therapy sends the order out and nursing supervisors implement the order. The order is printed on Kardex. RN G pulled the Kardex for R22 and showed under the section Therapy/Equip it states: Bring to therapy 3-5 times a week M-F to use the Nu-step. Surveyor asked RN G how RN G knows the order is being followed. RN G stated there would be charting. RN G could not find a spot in CNA charting where they would document this is done. On 06/18/25 at 11:07 AM, Surveyor interviewed Director of Nursing (DON) B who stated DON B expects the CNAs to follow the Kardex and implement the restorative order if it exists. Surveyor asked for evidence of implementation and compliance with order. On 06/18/25 at 2:15 PM, DON B provided Surveyor with additional paperwork. DON B stated the restorative order for R22 was in the wrong section of the Kardex and was not being implemented. A copy of the Kardex was provided showing it was removed from the wrong section but still not under RESTORATIVES section. DON B provided Surveyor with a copy of the new order for same restorative plan dated 6/18/25. DON B stated the charge nurse will implement this order and put it on the Kardex for the CNAs.

Based on interview and record review, the facility did not ensure residents (R) with indwelling Foley catheters received care and treatment consistent with professional standards of practice to prevent complications or urinary tract infections (UTI) from the catheter for 1 of 3 residents (R) reviewed, R33. R33's Foley catheter was changed on a routine basis without clinical indications. This is evidenced by: Facility's policy titled, Indwelling Catheter Use and Removal, with a reviewed date of 01/25/25, states in part: Policy: It is the policy of this facility to ensure that indwelling urinary catheters that are inserted or remain in place are justified or removed according to regulations and current standards of practice .Catheters and drainage bags should be changed based on clinical indication such as infection, obstruction, or when the closed system is compromised. Routine, fixed intervals is not recommended. R33 was admitted to the facility on [DATE] with pertinent diagnoses of neuromuscular dysfunction of bladder and retention of urine. R33's care plan, dated 07/14/22, with a goal date of 08/13/25, states: Bladder management with interventions of enhanced barrier protection (EBP), monitor intake/output, urinary retention, history of UTIs . R33's physician orders: 10/5/23 change indwelling foley catheter as needed for leaking or not draining. Reason for indwelling cath: neurogenic bladder 12/6/23 change foley catheter bag as needed to prevent build-up/odor. Ensure blue privacy covers are utilized to cover foley bags (located in CS) as needed 2x monthly maximum. 12/17/23 indwelling foley catheter 16Fr30cc 11/8/24 change indwelling foley catheter every 90 days Surveyor reviewed R33's treatment administration record (TAR) and noted R33's Foley was last changed on 05/08/25 per order and has been changed every 90 days per order. Surveyor reviewed R33's medical record for provider rationale to support recommendation for scheduled catheter changes. Surveyor was unable to find this documentation. On 06/18/25 at 10:42 AM, Surveyor interviewed Registered Nurse (RN) G regarding R33's Foley catheter orders. RN G stated that R33's Foley catheter is scheduled to be changed every 90 days according to current standards of practice. On 06/19/25 at 1:43 PM, Surveyor interviewed Director of Nursing (DON) B regarding R33's Foley catheter. DON B stated the facility's policy is that indwelling Foley catheters not be changed on a fixed schedule unless indicated by a provider. Surveyor asked DON B if R33 had a documented indication for a scheduled Foley catheter change. DON B stated no, that she could not find one. DON B stated recognition that this was missed and would reach out to the provider as this was not an acceptable practice.

Based on interview and record review, the facility did not ensure that a resident (R) who requires dialysis receives such service, consistent with professional standards of practice form 1 of 2 residents (R8) reviewed for dialysis. The facility failed to provide ongoing assessment of R8's condition and monitoring for complications before and after dialysis treatments. This is evidenced by: Facility policy titled, Dialysis Communication and Care, with an effective date of 01/26/18, states in part: Purpose: To ensure residents who require dialysis receive such services, consistent with professional standards of practice, their care plan and resident's goals and preferences. Procedure:1. Nursing will provide ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatment .3. There will be ongoing communication and collaboration with the dialysis unit, resident and/or representative regarding care and services . R8 was admitted to the facility on [DATE] with pertinent diagnoses of end stage renal disease and dependence on renal dialysis. R8's quarterly Minimum Data Set (MDS) assessment dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 15 indicating cognition is intact. R8's care plan, dated 01/28/25, and a goal date of 08/25/25, states: Fluid management with interventions to follow standards of care for dialysis, monitor fluid intakes, and weigh weekly . R8's physician orders: 01/28/25 Dialysis on Tuesday, Thursday, Saturday offsite 01/30/25 FLUIDS: Fluid restriction 1200ml/24 hours all liquids 05/12/25 Evaluate & Assess tunneled central line for hemodialysis - Monitor for signs of infection or complications like pain, swelling, drainage, or erythema at the insertion site. AM Monday Wednesday Friday 05/20/25 DIET Renal, CHO, minced & moist Of note: no order entered for vital signs to be completed. Surveyor reviewed R8's treatment administration record (TAR): -Dialysis port assessments not completed prior to dialysis treatments. -Vital signs not completed prior to or after dialysis treatments. Surveyor reviewed R8's nursing notes and did not note any dialysis port assessments completed prior to dialysis treatments. On 06/17/25 at 2:14 PM, Surveyor interviewed Nurse Tech (NT) C regarding dialysis standard of care. NT C stated that all residents receiving dialysis should have a pre/post dialysis assessment that includes weight, vital signs, and inspection of port/fistula site. NT C stated dialysis residents also have a communication book that is taken to their treatment for the dialysis unit to note changes/concerns to the facility, which the PM dialysis nurse assigned to the resident reviews. Surveyor asked NT C if R8 had a communication book. NT C stated no and was unsure why. Surveyor asked NT C how communication from the dialysis unit was completed for R8 if a book is not used. NT C stated not being sure, but that the dialysis unit would likely contact the charge nurse directly with concerns. On 06/17/25 at 3:05 PM, Surveyor interviewed Registered Nurse (RN) G regarding R8's dialysis assessments. RN G stated that R8's port is assessed daily per order, but not necessarily prior to dialysis treatment. Surveyor asked RN G why it was not assessed prior to dialysis treatment. RN G stated that as long as it was assessed daily, it did not matter. Surveyor asked RN G if R8 had a communication binder to send to dialysis. RN G stated no. Surveyor asked how changes/concerns are communicated. RN G stated either by phone or sending a paper with the resident back to the facility. Surveyor asked RN G if this would be standard of practice for communicating with the dialysis unit. RN G stated that it could be, because each resident is different. Surveyor asked how often R8's vital signs were obtained as there is no order entered for frequency. RN G stated that if an order is not entered than standard of practice is to complete vital signs weekly on bath day. Surveyor asked RN G if this would be considered appropriate monitoring for a resident on dialysis. RN G stated yes because they get vital signs done at every dialysis appointment. Surveyor asked how R8's vitals are monitored if this is not communicated with a binder at each appointment. RN G stated that if there was a concern, the dialysis unit would contact the facility directly so there is no need to do it that often at the facility. On 06/18/25 at 12:06 PM, Surveyor interviewed R8 regarding dialysis. R8 stated that a communication binder hasn't been used in a long time and that a piece of paper will be sent with her once in a while if there is a concern or change. R8 stated the facility does not assess the port site prior to dialysis treatment and sometimes assesses it after treatment. R8 stated that the facility does not complete vital signs pre/post dialysis treatment at any time. On 06/19/25 at 1:43 PM, Surveyor interviewed Director of Nursing (DON) B regarding dialysis communication and standard of care. DON B stated that every resident receiving dialysis should have a communication binder sent with to dialysis and an assessment of the port/fistula site and vital signs be completed pre/post dialysis treatment. Surveyor asked DON B if she was aware that R8 was not receiving pre/post treatment assessments, and no communication binder was being used. DON B stated not being aware of this. Surveyor asked DON B if this was an acceptable practice. DON B stated that it could be as long as any concerns/changes were still being communicated, but that the port and vitals should be assessed before and after treatment. Surveyor asked DON B if this aligned with the facility's policy for dialysis care. DON B stated it did not.

Based on interview and record review, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 1 resident (R59) reviewed for following physician orders. Findings: R59 was admitted to facility on 03/07/24 with diagnoses of hypertension, renal failure, and diabetes with neuropathy. On 03/20/24, occupational therapy placed a note in R59's chart indicating increased edema in bilateral lower extremities On 03/25/24, the physician conducted rounds for R59 and placed an order for Furosemide (a diuretic) 20mg daily to regimen, due to edema in bilateral lower extremities. On 03/28/24, R59 received a physician order for daily weights x 2 weeks then weekly due to bilateral lower extremity edema. The order was entered into R59's chart to obtain daily weights starting 3/29/24 through 04/11/24. On 04/24/24, Surveyor reviewed R59's recorded weights and noted facility failed to follow the physician order for daily weights for 11 days out of the 14-day period, obtaining only 3 weights on 04/02/24, 04/04/24, and 04/10/24. On 04/24/24 at 4:17 PM, Surveyor interviewed Director of Nursing (DON) B regarding the order for weekly weights and noted this had not been completed as ordered by physician. DON B stated a Performance Improvement Plan was just initiated as the order was placed for the certified nursing assistants to complete but was not followed through.

Based on observation, interview and record review, the facility did not ensure hand hygiene was conducted appropriately for 2 of 4 wound care observations (R32 and R65). This is evidenced by: The CDC had outlined the following indications for hand washing and the wearing of gloves: A. When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a nonantimicrobial soap and water or an antimicrobial soap and water. B. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations described in items. Alternatively, wash hands with an antimicrobial soap and water in all clinical situations described in items. C. Decontaminate hands before having direct contact with patients . F. Decontaminate hands after contact with a patient's intact skin. G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled. H. Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care. I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. J. Decontaminate hands after removing gloves . The CDC continues to direct healthcare workers with the technique of hand hygiene: . E. Change gloves during patient care if moving from a contaminated body site to a clean body site . The facility policy, entitled Hand Hygiene, dated 03/12/24, states: Purpose: To prevent and control transmission of infections and illnesses to residents and among staff and visitors and Handwashing required: always wash hands before doing cares on residents, after cleaning feces or urine, after resident cares, between residents, after using the bathroom, before and after meals, before returning to work after break, after removing gloves, before leaving a resident room (isolation and standard), when hands are visibly soiled, after repeated sanitizations (more than 10), and when suspected Norovirus or GI illness is present. The facility policy, entitled Dressing Changes, dated 07/20/05, states: Purpose: This procedure will be used for all dressing changes unless otherwise indicated by the M.D. Procedure: 1. Gather equipment. 2. Wash hands - don gloves 3. Place two barriers down - one for clean and one for dirty. 4. Open dressing supplies and place on clean barrier 5. Remove old dressings-place in plastic bag or on dirty barrier. 6. If extremity needs to be soaked place basin on barrier and extremity in water. 7. Remove gloves and wash hands. 8. If necessary open sterile dressings, cleaning solutions, and dressings at this time onto the clean barrier. 9. Put on clean gloves. 10. If dressings need to be cut-use scissors found in the individual residents' dressing kit. 11. Cleanse area with no touch technique, cleaning from center of wound to a few inches outside the affected area in a circular motion, dropping used materials in a plastic bag or onto dirty barrier. 12. Remove gloves, wash hands, don clean gloves. 13. Apply ointments as ordered using appropriate applicator. 14. Apply dressing taking care not to touch the open area with gloves. If at any time your glove comes in contact with wound or drainage, you must remove the gloves, wash hands, and re-glove before handling any of the items on the clean barrier. 15. Apply tape or other materials. 16. Write date, time, and initials on tape. 17. Remove gloves and wash hands. 18. Close plastic bag and take to disposal area. 19. Wash hands. If you have more than one wound on the same resident-use the same procedure for each wound. R32 was admitted to the facility on [DATE] and has diagnoses that include diabetes mellitus type 2, peripheral vascular disease, history of cerebral vascular accident affecting left side, cognitive impairment, and morbid obesity. R32's Minimum Data Set (MDS) assessment, dated 03/11/24, indicates that R32 has a Brief Interview for Mental Status (BIMS) score of 04 (severe cognitive impairment). R32 has an Activated Power of Attorney (APOA). R32's wound assessments, dated 04/22/24, shows that R32 has a stage 4 pressure injury to the left outer thigh. This pressure injury has two openings that are connected by a 9.5-centimeter tunnel making them one wound. The lower wound area was created by a surgeon to allow for drainage after an abscess had formed. A Penrose drain was placed in the hospital on 11/29/23 and removed on 03/07/24. R32 also has a reddened area under the left breast with prescribed treatment. Hospital Discharge Summary, dated 12/05/23, states that necrotizing fasciitis was discovered to the lower leg compartment after surgical incision and draining was performed by a surgeon. Hospital discharge summary states that without further debridement of the necrotizing fasciitis, this wound will never heal. R32's APOA opted to not put R32 through the surgeries that would debride the necrotizing fasciitis and allow possible healing. R32 has physician orders as follows: Left thigh wounds: AM/PM 1. Use Q-tip to remove old alginate. Cleanse wounds with normal saline and gauze. 2. Gently/loosely pack both wounds to left thigh w/ calcium alginate silver strips (OK to use calcium alginate squares) Do NOT moisten calcium alginate. Pack calcium alginate into wound dry with Q-tip. 3. Triad to denuded/eroded areas of wound edges. 4. Triad to red irritated area and moisture associated skin damage (MASD) around wound and in between wounds. 5. Cover with ABD pad (blue line to the outside) and hold in place with brown tape. Change twice a day AM/PM if tolerating well. Left breast: cleanse area with normal saline. Frost with Triad. Place Viva for protection. Twice a day AM/PM if tolerating well. On 04/23/24 at 3:00 PM, Surveyor conducted a wound care observation of R32's left thigh and left breast wounds performed by LPN I. Registered Nurse (RN) J, who is currently training, was in the room assisting with holding and repositioning R32. LPN I and RN J donned personal protective equipment (PPE) appropriately (R32 is in enhanced barrier precautions). LPN I sanitized her hands and set up a barrier with dressing supplies on a bedside table that included gauze, normal saline, Triad cream, Q-tips, tape, ABD bandage and box of gloves. LPN I placed the bedside table on the left side of R32's bed. RN J raised the bed, lowered the head of bed and positioned resident on her right-side facing doorway. Surveyor observed an ABD pad taped to the outer left thigh. LPN I donned gloves and placed a barrier pad under resident's left thigh/buttock area. LPN I removed old ABD bandage. Two areas were observed to the left thigh; one was close to the upper thigh buttock area (anterior) and the other was lower/mid-thigh (posterior). Both areas were packed with calcium alginate. The wounds appeared clean without signs of infection. LPN I used the long wooden stick end on Q-tip to remove the packing from the anterior wound and placed the packing on the old ABD pad. LPN I then used the same wooden end on Q-tip to remove the packing from the posterior wound. The waste was discarded in the garbage next to the bed. LPN I doffed her gloves and donned new gloves without washing or sanitizing hands. LPN I cleansed the wound areas with gauze soaked in normal saline. The skin area surrounding the wounds appeared scaly with dry patches. LPN I doffed gloves, discarded them, and donned new gloves without washing or sanitizing hands. LPN I opened a package of calcium alginate and used a clean pair of scissors to cut the alginate into strips. The strips were left on the inside of the calcium alginate package. LPN I then used a new Q-tip and with soft end packed the posterior wound and then packed the anterior wound. LPN I discarded Q-tip and alginate package, doffed gloves and discarded them. LPN I donned new gloves without washing or sanitizing hands. LPN I then applied Triad cream to the outer skin and peri-wound area excoriated skin. LPN I doffed gloves, discarded, and donned new gloves without washing or sanitizing hands. LPN I placed a new ABD pad over the area and secured with brown tape. LPN I dated and initialed the tape. LPN I gathered the barrier pad with waste and discarded, doffed gloves. LPN I did not wash or sanitize hands. RN J doffed gloves, discarded, used hand sanitizer, donned new gloves, and prepared R32 for the left breast dressing change. RN assisted R32 in holding up her left arm. LPN I donned new gloves without washing or sanitizing hands. LPN I exposed the area under left breast. This area was observed as pinkish red in color with no open areas. LPN I cleansed the area with gauze and normal saline then discarded waste. LPN I doffed gloves and donned new gloves without washing or sanitizing hands. LPN I applied Triad cream and a Viva cloth. LPN I doffed gloves and discarded in garbage. LPN I and RN J assisted R32 with repositioning and a boost up in the bed. Bedside table was next to resident's bed and call light attached to blanket within reach. R32's bed was then lowered. LPN I and RN J removed garbage and replaced bags. Waste was discarded in the garbage bin in room. LPN I and RN J doffed PPE, discarded and hand sanitized before leaving the room. On 04/24/24 at 4:01 PM, Surveyor interviewed LPN I regarding hand hygiene during R32's wound care. LPN I stated that LPN I should perform hand hygiene prior to performing the dressing change and then when completely finished, prior to putting gloves on and after taking them off, after taking off PPE and before leaving the room. 47284 Example 2 R65 was admitted to the facility on [DATE] and had diagnoses that included in part acute infective endocarditis, congestive heart failure (CHF), nonrheumatic aortic valve disorder, rheumatic mitral stenosis, pressure ulcer, anemia, severe protein calorie malnutrition, diabetes, malignant neoplasm of breast, and chronic kidney disease (CKD). R65's orders: Ensure that you use Unisolve to remove old dressing to promote skin integrity. Cleanse 4 stage 3 pressure injury (PI) to bilateral buttocks and 2 stage 2 PI with wound cleanser, pat dry. Apply small dab of Triad to wound beds. Spray peri-wound liberally with Cavilon. Allow to dry. Place a large Hydrocolloidal dressing cut in half to both side of gluteal cleft and coccyx ensuring that the wounds are covered. Do not secure with transparent dressing. Every three days and as needed (PRN). On 4/24/24 at 1:30 PM, Surveyor observed RN G perform wound care to R65's PIs. RN G performed hand hygiene and donned gown and gloves. RN G then cleansed the area with wound cleanser and gauze. RN G removed gloves; no hand hygiene was performed. RN G then put on new gloves, applied Triad to the wounds and then removed gloves; no hand hygiene was performed. RN G then put on new gloves and sprayed Cavilon spray to the wound and allowed to dry, applied hydrocolloidal to cover area and applied Triad around the hydrocolloidal dressing. RN G then removed gloves and used hand sanitizer. Hand hygiene should have been performed after each glove change. On 4/24/24 at 1:39 PM, Surveyor interviewed RN G and asked what the policy was for hand hygiene during wound care. RN G said hand hygiene before and after the start and stop of wound care. Surveyor asked RN G if when he changed gloves during the wound care, should he have performed hand hygiene. RN G said he was not sure and would have to ask the charge nurse what the standard of practice was. RN G said thinking about it, he should have used hand sanitizer after each glove change. On 4/25/24 at 8:29 AM, Surveyor interviewed the wound care nurse, RN H, and asked what the expectation for hand hygiene with glove change during wound care was. RN H said hand hygiene should be performed after each glove change. On 4/25/24 at 9:00 AM, Surveyor interviewed Director of Nursing (DON) B and asked what the expectation for hand hygiene with glove change during wound care was. DON B said hand hygiene should be performed after each glove change.

Based on observation, interviews and record reviews, the facility did not maintain an infection prevention and control program according to professional standards of practice when Enhanced Barrier Precautions (EBP) with appropriate Personal Protective Equipment (PPE) was not followed for 1 of 8 resident (R45) and lack of hand hygiene between glove changes during personal cares for 1 of 8 resident (R16). This was evidenced by: Example 1 The facility utilizes the Centers for Disease Control and Prevention (CDC) sign for EBP that states: Everyone must: .wear gloves and a gown for the following high contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: urinary catheter . The facility policy, entitled Enhanced Barrier Precautions, revised 4/05/24, states: .The use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of Multi Drug Resistant Organisms (MDRO)s to staff hands and clothing .Examples of high contact resident care activities requiring gown and glove use for EBP include [in part]: changing briefs or assisting with toileting, device care or use: urinary catheter . R45 was admitted to the facility on [DATE] and had diagnoses that included in part retention of urine, neuromuscular dysfunction of bladder, dementia, and adrenal cortical insufficiency. R45 had a urinary catheter. Outside R45's door was a PPE cart that included gloves and gowns, along with the CDC sign for EBP that stated, .wear gown and gloves when providing high contact resident care such as device care or use - urinary catheter or changing briefs or assisting with toileting . On 4/23/24 at 10:00 AM, Surveyor observed Certified Nursing Assistant (CNA) D and CNA F perform personal care of changing brief and catheter care to R45. Both CNAs did not wear a gown during the brief change. CNA D cleaned R45's perineal area and then cleaned stool while CNA F was in direct contact with R45, holding R45 in place. When finished holding R45, CNA F applied gown and gloves to empty R45 catheter. On 4/24/24 at 1:39 PM, Surveyor interviewed Registered Nurse (RN) G and CNA E and asked when to wear PPE of gown and gloves when a resident was on EBP. RN G and CNA E said to wear gown and gloves when doing high contact resident care such as wound care, catheter care, any personal care for residents who were on EBP. On 4/25/24 at 8:29 AM, Surveyor interviewed RN H and asked what the expectation of EBP when to wear gown and gloves. RN H said anytime direct care is provided, the gown and gloves need to be worn. On 4/25/24 at 9:00 AM, Surveyor interviewed Director of Nursing (DON) B and asked what the expectation of EBP when to wear gown and gloves. DON B said anytime direct care is provided, the gown and gloves need to be worn. 47657 Example 2 Facility policy entitled Hand Hygiene revised on 03/12/24 states in part .Purpose: To prevent and control transmission of infections and illnesses to residents and among staff and visitors: Handwashing required: always wash hands before doing cares on residents, after cleaning feces or urine, after removing gloves. On 04/24/24 at 8:49 AM, Surveyor observed CNA C conduct cares on R16. CNA C donned clean pair of gloves and with assistance of the sit to stand lift, transferred R16 out of recliner which had a urine-soaked pad on the recliner. CNA C proceeded to pulled down R16's urine-soaked incontinence pad and pants. CNA C proceeded to do the following: Applied lotion to R16's legs/feet, removed gloves and donned clean pair of gloves, applied compression stockings, took clean incontinent pad and secured in place, dressed in clean pants to knees, cleansed abdominal folds, applied powder and dry paper towel in abdominal folds, brought lift and secured resident from toilet to lift to standing position, cleansed buttocks and pulled up clean pants and transferred R16 to w/c, and removed mechanical lift sling. CNA C continued to complete upper body cares and dressing on R16 and applied lipstick, touching R16's chin with unclean hands to apply the lipstick. CNA C then brushed R16's hair, placed oxygen tubing into nares and unwrapped a sucker per R16's request. CNA C donned clean pair of gloves and removed soiled clothing and garbage from room, after all of the other cares were done. On 04/24/24 at 9:34 AM, Surveyor interviewed CNA C, regarding education received regarding hand hygiene during cares. CNA C stated CNA C received education to use either hand sanitizer or wash hands after removing gloves, before and after cares. CNA C confirmed hand hygiene was not conducted during cares. On 04/24/24 at 11:28 AM, Surveyor interviewed DON B regarding observation of lack of hygiene during morning cares which included incontinence care. DON B stated the expectation would be after completing incontinence care to remove gloves and conduct hand hygiene.

Based on observation and interview, the facility did not ensure the resident's right to personal privacy during a medical provider interview for 1 of 15 residents (R21). This is evidenced by: The facility policy entitled, Our Resident's Health Information is Confidential and on a Need to Know Basis reads in part, .protect resident's medical information from those who do not need to know the information . R21 was admitted to the facility on [DATE]. On 03/14/23 at 1:45 p.m., R21 along with eight other residents were attending the activity of hangman using a portable whiteboard led by Recreational Therapy Assistant (RTA) J. The activity was conducted in the Westview Lounge. Nurse Practitioner (NP) K came to get R21 from the activity and told the resident she needed to talk concerning medical information for a routine check in. NP K rolled R21 in the wheelchair to the other end of the Westview Lounge just behind the portable whiteboard. NP K talked with R21 concerning R21's medical information. The space where NP K and R21 were talking was open to the hall and the rest of the lounge, allowing anyone walking by or in the Westview Lounge to hear the conversation about confidential medical information related to R21. Two Surveyors were sitting on the other end of the Westview Lounge, behind the residents doing the activity, and both Surveyors could hear the conversation between NP K and R21. The conversation included confidential medical information. On 03/14/23 at 2:40 p.m., Surveyor spoke with RTA J after the activity was finished and asked RTA J if she could hear NP K and R21 talking during the activity. RTA J said yes, she could hear them talking. On 03/14/23 at 3:10 p.m., Surveyor spoke with Director of Nursing (DON) B to ask what the policy is concerning a provider speaking with a resident and how to keep the resident's information private. DON B stated they should be speaking to the resident in a private area or room where only the people who are in the need to know are there to hear the information. On 03/15/23 at 10:29 a.m., Surveyor spoke with R21 who stated NP K came and got her during the activity to talk about her medical information. NP K rolled her around the other side of the whiteboard in the Westview Lounge and talked about her medical information. R21 was unsure if the area was private or not.

Based on observations and interviews, the facility did not serve food in accordance with professional standards for food service safety. This has the potential to affect all 54 residents in the facility. Kitchen staff were observed changing gloves and not handwashing and touching ready to eat foods. Staff were observed opening straws for residents and touching the straw with their hands. Findings include: The facility policy, entitled Hand Washing Guide reads in part Hand hygiene must be performed after removing gloves. On 03/13/23 at 11:42 AM, Surveyor observed dining assistant (DA) H passing out waters to residents(R). DA H opened 2 straws by removing all the paper for R5 with bare hands, touched the straw and put in their milk and juice. On 03/13/23 at 11:44 AM, Surveyor observed DA F changed gloves, no hand washing, dishing up plates with gloved hands then dished up another tray put on tray slip, left dining room with same gloves on at 11:50 AM. DA F returned to the dining room with gloved hands, no hand washing when they returned, dished up a tray, with same gloved hands grabbed a dinner roll out of bag, continued dishing up another meal, grabbed dinner roll with same gloved hands, another tray, same gloved hands grabbed a dinner roll, covered tray, put slip on tray, got a new plate, grabbed dinner roll with same gloved hands, wiped down a tray with a towel, removed gloves and washed hands with soap and water, put on new gloves, grabbed meal slip, dished up another plate, grabbed dinner roll with same gloved hands, covered plate, grabbed towel with same gloved hands, filled up a coffee cup with same gloved hands, dished up a new plate, grabbed a diner roll out of bag with same gloved hands. On 03/13/23 at 11:49 AM, Surveyor observed Dining Supervisor (DS) E open 2 straws by removing all of the paper for a resident with bare hands then touched the top of straw and put it in cups of juice. On 03/13/23 at 11:59 AM, Surveyor observed certified nursing assistant (CNA) I open straws by removing all the paper and with bare hands and put in resident's milk and coffee. On 03/14/23 at about 11:25 AM, Surveyor observed DA G open 2 straws by removing all the paper and with bare hands and put in resident's milk and coffee. On 03/14/23 at 11:15 AM, Surveyor interviewed DS D and asked what they expected staff to do when they remove their gloves and put on a new pair. DS D indicated to always wash hands before putting on a new pair. On 03/15/23 at 9:25 AM, Surveyor interviewed Nutrition Director (ND) C and asked how do you expect food service workers to open straws for the residents. ND C indicated by not touching the top of the straw, take off the bottom half of the straw wrapper, holding the top of the straw with the paper on and put in the drink. 03/15/23 09:22 AM, Surveyor interviewed ND C and asked when they expect staff to wash hands. ND C indicated that they tell staff when in doubt wash your hands. Surveyor reviewed the observations of DA F with ND C and asked what DA F should have done in between glove changes. ND C indicated DA F should have washed their hands. Surveyor asked about grabbing the dinner rolls. ND C indicated they should have used a tongs.

Based on observation, interview and record review, the facility did not ensure 2 of 14 (R33 and R49) residents reviewed for comprehensive care plans had a developed care plan specific to the resident. R33 had a diagnosis of dementia and did not have a comprehensive care plan to include dementia. R49's care plan included outdated information for bladder management and had not been updated to include R49's current plan of care. This is evidenced by: Example #1 On 3/14/23, Surveyor reviewed R33's medical record. R33 was admitted to the facility on [DATE] with a primary diagnosis of major depressive disorder. Other diagnoses included, but not limited to cognitive communication deficit and vascular dementia. Review of R33's Minimum Data Set (MDS) assessment, dated 01/05/23, included the diagnosis of non-Alzheimer's dementia. Review of R33's care plan showed there is nothing written concerning dementia/memory care. On 3/14/23, Surveyor asked the Director of Nursing (DON) B for the dementia/memory care plan for R33. DON B provided R33's care plan for memory and communication that was created on 03/14/23. On 3/15/23, Surveyor received provider note dated 2/18/22 that stated R33 had underlying dementia based on history, patient evaluation and review of imaging. R33 clearly had underlying dementia, likely vascular, based on MRI. Example #2 On 3/15/23, Surveyor reviewed R49's medical record. R49 was admitted to the facility on [DATE] with a primary diagnosis of dementia. Other diagnoses included, but not limited to benign prostatic hyperplasia with lower urinary tract symptoms and retention of urine. Review of R49's MDS assessment, dated 01/11/23, stated use of indwelling catheter for urination. Review of R49's care plan showed bladder management created on 10/14/21 to include the need for self-catheterization when post void residual is greater than 150ml (milliliters). Review of R49's orders included indwelling foley catheter that is changed routinely in Urology per Urologist's orders. Change catheter as needed for leakage, obstruction or nurse discretion. On 3/13/23, Surveyor observed R49 sitting up in a Broda chair with an indwelling foley catheter present. The foley bag was covered for privacy. On 3/15/23, Surveyor spoke with Licensed Practical Nurse (LPN) N who stated R49's foley catheter is changed at the clinic and can be done here if needed. The foley catheter was a continuous indwelling foley, not intermittent. On 3/15/23, Surveyor spoke with DON B to see when care plans should be updated. DON B stated care plans should be updated quarterly and if there are any changes. Surveyor asked DON B if R49's care plan for bladder management had been updated. DON B stated no, the care plan was started on 10/14/21 with no updates. Currently, R49 was not self-catheterization as the foley catheter was now continuous. Surveyor asked if the care plan should be updated.

Based on interview and record review, the facility did not ensure all staff who provide care to the residents were fully vaccinated for COVID-19. This had the potential to affect all 54 residents. Certified Nursing Assistant (CNA) M was not fully vaccinated for COVID-19 while working in the facility. CNA M did not have a temporary delay or exemption from receiving the COVID-19 vaccination. Findings include: Facility policy entitled COVID-19 Vaccine Policy, last revised 01/25/22, stated in part, .It is the policy of this corporation that all eligible staff must receive the first dose of a two-dose COVID-19 vaccine .prior to providing any care or treatment .By February 28, 2022, all eligible staff have received the necessary doses to complete the vaccine series (i.e., one dose of a single-dose vaccine or all doses of a multiple vaccine series) or have been granted a qualifying exemption or are identified as having a temporary delay as recommended by the CDC [Centers for Disease Control] .The Infection Preventionist or designee, will contact each employee who does not meet the definition of fully vaccinated to determine: If eligible staff has received one-dose of the two-dose series and has an appointment for the second dose . On 03/14/23, Surveyor reviewed the COVID-19 Staff Vaccination Matrix provided by the facility. The document identified one staff member, CNA M, as partially vaccinated. Surveyor asked staff for CNA M's vaccination documentation, or documentation of exemption. On 03/15/23, Surveyor received CNA M vaccination records, which were printed from the Wisconsin Immunization Registry. The document showed CNA M received the first dose of a two-dose series of Pfizer COVID-19 vaccine on 02/17/22. The document showed CNA M was eligible for the second dose of the COVID-19 vaccine on 03/10/22. The document showed CNA M was overdue for the second dose of the vaccine. There was no record showing CNA M received the second dose of the COVID-19 vaccine. The current employee list provided by the facility identified CNA M had a date of hire of 02/21/22. For the week ending 03/05/23, the facility reported 94.6% of their residents had completed a primary series of COVID-19 vaccine, and 91.9% of their staff had completed a primary series of COVID-19 vaccine. The facility surveillance records showed the facility had a recent COVID-19 outbreak from 01/24/23 through 02/11/23. The outbreak involved four residents and three staff members. On 03/15/23 at 8:34 AM, Surveyor interviewed Registered Nurse (RN) L, who was responsible for Infection Prevention in the facility. Surveyor asked RN L if CNA M had received the 2nd dose of COVID-19 vaccine, or if CNA M had an approved exemption from the vaccine. RN L was unsure if CNA M had received the second dose of COVID-19 vaccine, or if CNA M requested or received an exemption from the vaccine. RN L would check into that. Surveyor asked if CNA M was currently working at the facility. RN L stated CNA M did currently work at the facility. On 03/15/23 at 10:27 AM, Nursing Home Administrator (NHA) A reported CNA M had been working at the facility for the past year and had not received a second dose of COVID-19 vaccine or an approved exemption. NHA A stated they had taken CNA M off the schedule until either vaccinated or exemption requested. NHA A stated CNA M fell through the cracks somehow, and they had started a Performance Improvement Project for this situation.

Based on observation and interview, the facility did not provide a safe, sanitary, and comfortable environment for residents, staff, and the public due to multiple areas of ceiling damage throughout the hallways and common areas of the building. This has the potential to affect all 74 residents in the building. Findings include: Over the three-day survey from 11/29/21 through 12/01/21, all 5 surveyors observed multiple areas on the ceilings in hallways and common areas of the building that had the following concerns: There were areas of the ceiling where the popcorn textured coating was bubbled, cracked, loose, hanging down, and some areas appeared to be ready to fall off the ceiling. Many areas were noted to have the popcorn texture missing with bare sheet rock or wall board exposed. There were also areas of the ceiling noted to have brownish yellow stains in the appearance of previous water damage. One area of exposed sheet rock on the ceiling of the 500 hallway was sagging and had the appearance of previously being wet. The exposed drywall in that area had grayish black spots consistent with the appearance of mold. The area surrounding this exposed drywall had yellow to brown stains in the appearance of previous water damage. Surveyors also noted several areas around ceiling vents with gray to black marks on the ceiling surrounding the vents. These areas of damage were noted on the ceilings of the 100, 200, 300, 400, 500, 600, and 700 hallways. Residents reside in each of these hallways. Multiple areas of this damage were also noted in the large common areas of the building. During the three days of the survey, multiple residents were observed traveling through the affected hallways, and multiple residents were observed sitting in the affected common areas. On 12/01/21 at 10:25 AM, Surveyor interviewed Maintenance Supervisor (MS) C. MS C was aware of the problems on the ceilings in the common areas and hallways. MS C stated they determined part of the cause was due to improper installation of the popcorn texture when the building was built. MS C believed the drywall was not primed prior to the installation, so the texture was coming loose and falling off in some areas. Surveyor asked if they had any water damage, or roof leaks that could have caused some of the ceiling damage. MS C stated the building did have some roofing issues, with leaking about 2-3 years ago, and that had caused some of the textured areas to loosen sooner. Surveyor asked if there were any safety concerns for the residents due to the pieces of the ceiling falling off. MS C stated any loose areas of the popcorn texture were removed as soon as they were noted to be loose, or looked in danger of falling. Surveyor asked if there was any concerns about possible mold growing in areas that had gotten wet from the roof leak. MS C did not think there were any areas of concern due to mold. Surveyor showed MS C the area on the 500 hallway with the grayish black marks on the exposed dry wall. MS C stated that area would be cleaned with a bleach solution. Surveyor asked if there was a plan in place to repair the ceiling damage. MS C stated they had been trying to deal with small areas piece by piece, as they occurred, but no formal plan was in place for repair of the ceilings. On 12/01/21 at 10:45 AM, Surveyor interviewed Director of Nursing (DON) B about the damage observed with the ceilings in the hallways and common areas of the building. DON B was aware of the problems with the ceiling coating coming off in hallways and common areas of the building. DON B stated it was caused by the roof leaking a few years ago. DON B stated the roof was repaired, but damage to the ceilings had not been fixed yet. DON B was aware that MS C was trying to patch and fix spots, as the popcorn coating was coming off. Surveyor asked if DON B had any concerns about mold in the water damaged areas. DON B was not aware of any mold concerns. DON B stated that DON B and the infection preventionist tried to watch for mold concerns. Surveyor described the area noted to have the appearance of mold growth on the exposed dry wall on the 500 hallway ceiling. DON B stated MS C would need to examine that area above the ceiling, and possibly cut out any mold damaged areas and replace if mold was found. DON B stated they were hoping to get the ceiling repair into the maintenance budget for next year, but there was no formal plan in place for the repair at this time. On 12/01/21 at 2:37 PM, Surveyor interviewed Nursing Home Administrator (NHA) A about the observed ceiling damage noted throughout the building. NHA A stated they were aware of the damage to the ceilings. NHA A reported the building was old, and the plumbing pipes ran through the ceilings, and tended to leak. NHA A stated they planned to fix the plumbing first. NHA A stated once the plumbing was fixed, they would repair the damage to the ceilings.

Based on observation and interview, the facility did not store medications and biologicals for 16 of 16 residents in a locked medication cart when unattended. This is evidenced by: On 11/30/21 at 1:19 p.m., Surveyor observed Registered Nurse (RN) D left the medication cart unlocked while gathering residents' meal trays from resident rooms. RN D brought the tray cart to the kitchen. At 1:20 p.m., RN D returned to the hallway with tray cart and wiped the tray cart down with disinfecting wipes and put into the closet and sanitized hands. RN D did not go to medication cart and went into Resident (R) 32's room to get the meal tray and brought it to the kitchen. When RN D returned to the hall, RN D did not go to the medication cart and went into R32's room and closed the door to assist with personal cares. At 1:27 p.m., RN D returned to the medication cart and Surveyor interviewed asking about the unlocked cart. RN D indicated she had forgot to lock the cart. When the top drawer was opened a medication cup was observed with crushed medication. RN D indicated the resident had refused the medication and was going to dispose of them in the medication room. On 12/01/21 at 7:15 a.m., Surveyor reviewed with Director of Nursing (DON) B the unlocked and unattended medication cart observation. DON B indicated RN D came and told DON B about the observation and education was completed at that time and will continue to complete audits.

Based on observation, interview and record review the facility did not ensure it maintained an infection prevention and control program designed to provide safe, sanitary and comfortable environment to help prevent the development and transmission of communicable disease and infections such as COVID-19 this has the potential to affect all 82 residents. Facitlity Policy titled, Standard of Care: Infection Control Measure for Coronavirus, dated 3/9/20, states in part . Admission and readmissions are quarantined for 72 hours after admission. Facility Policy titled, Standard of Care #23, Isolation Guides, undated, states in part . residents are not required to wear a face covering unless they are leaving the building. This is evidenced by: Current CDC (Centers for Disease Control) Guidelines (Website: https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html) note in part: . Considerations for new admissions or readmissions to the facility . A patient hospitalized for [REDACTED]. However, to ensure they are not infected, nursing homes should place them in Transmission-based Precautions in a separate observation area or in a single-person room until 14 days have elapsed since admission Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19. All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. According to the Center for Disease Control (CDC) 5/18/20/20 Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings includes Website: (https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html) not in part . Recommendations: 1. Minimize Chance for Exposures -Universal Source Control: Healthcare Personnel: As part of source control efforts, HCP should wear a facemask at all times while they are in the healthcare facility. When available, facemasks are generally preferred over cloth face coverings for HCP as facemasks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others. If there are anticipated shortages of facemasks, facemasks should be prioritized for HCP and then for patients with symptoms of COVID-19 (as supply allows). Cloth face coverings should NOT be worn instead of a respirator or facemask if more than source control is required. Patient and Visitor: Patients and visitors should, ideally, be wearing their own cloth face covering upon arrival to the facility. If not, they should be offered a facemask or cloth face covering as supplies allow, which should be worn while they are in the facility (if tolerated). They should also be instructed that if they must touch or adjust their cloth face covering they should perform hand hygiene immediately before and after. Facemasks and cloth face coverings should not be placed on young children under age 2, anyone who has trouble breathing, or anyone who is unconscious, incapacitated or otherwise unable to remove the mask without assistance. Patients may remove their cloth face covering when in their rooms but should put them back on when leaving their room or when others (e.g., HCP, visitors) enter the room. Screening for symptoms and appropriate triage, evaluation, and isolation of individuals who report symptoms should still occur. Facility Policy titled, Standard of Care: Infection Control Measures for Coronavirus, dated 3/09/20, states in part . 2. Prevention procedures. 10. New residents will be quarantined in room until 72 hours after admission. After 72 hours will be allowed to leave room and go to other areas in the building maintaining social distance, as long as no new symptoms develop. The facility policy titled, Standard of Care #23, Isolation Guides, undated, states in part . Droplet Precautions: Resident Placement. 3. Maintain a spatial separation of at least 3 feet between the infected residents and other residents and visitors. Masks. Masks will be worn by personnel when working within 3 feet of the resident. Resident Transport. 2. If transport or movement is necessary, a surgical mask will be placed on the resident to minimize resident dispersal of droplet nuclei. (Note: The facility policies reviewed do not talk of the need for residents not on precautions to wear any face coverings or to maintain a 6 foot social distance when in the facility.) Example 1 On 6/16/20, Surveyor had multiple observations throughout the day of residents in activities, in common areas, and walking in the halls independently or with staff without the use of face masks and not social distancing. On 6/16/20 at 10:45 AM, Surveyor interviewed RN C (Registered Nurse). Surveyor asked RN C when residents are to wear face coverings in the facility. RN C stated, The residents don't wear masks in the building. The only residents that wear masks are those that are going out for an appointment or a new admission for 72 hours. Residents are encouraged to do social distancing, things are done in smaller groups and we try to keep spacing in mind. On 6/16/20 at 11:52 AM, Surveyor observed a sign posted on the Memory Care unit stating, Encourage social distancing of at least 3 feet. On 6/16/20 at 1:40 PM, Surveyor interviewed CNA D (Certified Nursing Assistant). Surveyor asked CNA D when residents are required to wear masks in the facility. CNA D stated, The only times residents wear masks is when they are on precautions. Staff wear them all the time. On 6/16/20 at 12:56 PM, Surveyor interviewed DON/ICP B (Director of Nursing / Infection Control Preventionist and Nurse Manager E. Surveyor asked DON/ICP B when residents are required to wear face masks. DON/ICP B stated, Residents are strongly encouraged to wear a mask when leaving the building. New admissions should wear a mask for 72 hours when coming out of their room and anyone on precautions for respiratory symptoms. Surveyor asked DON/ICP B to help me understand why residents are not required to wear face masks when out of their rooms. DON/ICP B stated, 'This is their home and they struggle with communication. If they would like one we would provide it. On the Dementia Wing they wouldn't understand. It is about quality of life. Example 2 Facitlity Policy titled, Standard of Care: Infection Control Measure for Coronavirus, dated 3/9/20, states in part . Admission and readmissions are quarantined for 72 hours after admission. This occurred during multiple admission and readmissions in April and May. From June 1, 2020 until June 16, 2020, this facility had the following admissions and readmissions. R4 was admitted on [DATE] and placed on 72 hour transmission based precautions. R5 was admitted on [DATE] and placed on 72 hour transmission based precautions. R6 was admitted on [DATE] and placed on 72 hour transmission based precautions. R7 was admitted on [DATE] and placed on 72 hour transmission based precautions. R8 was admitted on [DATE] and placed on 72 hour transmission based precautions. On 6/16/20 at 10:45 AM, Surveyor interviewed RN C. Surveyor asked RN C when residents are to wear face coverings in the facility. RN C stated, The residents don't wear masks in the building. The only residents that wear masks are those that are going out for an appointment or a new admission for 72 hours. On 6/16/20 at 12:56 PM, Surveyor interviewed DON/ICP B and Nurse Manager E. DON/ICP B stated, Residents are strongly encouraged to wear a mask when leaving the building. New admissions should wear a mask for 72 hours when coming out of their room and anyone on precautions for respiratory symptoms.

Based on record review and interview the facility did not ensure 1 of 4 residents reviewed for as needed [MEDICAL CONDITION] mediations (R57) had a documented rationale for administration longer than the 14 day limit. R57 has an order for [REDACTED]. This is evidenced by: R57 has [DIAGNOSES REDACTED]. He has been under hospice care since (MONTH) of 2019. R57's medication orders include [MEDICATION NAME] 2mg/ml (milligrams/milliliters) concentrate dose ordered: (0.13ml/0.26mg) sublingual every 2 hours as needed. Use Cautiously for Restlessness and anxiety. The MAR (Medication Administration Record) finds R57 was given the medication 15 times in (MONTH) and 9 times so far in November. Review of the monthly notation by the facility's RPh (Registered Pharmacist) found no recorded irregularity for the continuation of the order past the 14 day limit without a rationale to extend the prescription. On 10/10/19 R57's PA-F (Physician assistant) noted on the facility's Psychoactive Medication Review form for the [MEDICATION NAME] for restlessness, No GDR (Gradual Dose Reduction) - All psychoactive medications were assessed. Gradual Dose Reduction clinically contraindicated at this time because: Ordered for end of life/hospice care. There is no mention of the 14 day limit. On 11/12/19 R57's MD-D recorded No GDR - All psychoactive medications were assessed. Gradual Dose Reduction clinically contraindicated at this time because: Will avoid rush of withdrawal . on Hospice (with increased) confusion (with) Terminal [MEDICAL CONDITION] (with) Dementia. There is no recognition of the 14 day timeframe for the PRN dose. On 11/13/19 at 2:30 p.m., Surveyor spoke with MD-C, who is the physician for the hospice provider. MD-C stated his organization is aware of the 14 day limit and going forward the physicians will write orders for PRN [MEDICAL CONDITION] medications with a 14 day stop date so that this reevaluation after 14 days is not missed in the future.

Based on observation and interview, the facility failed to have sufficient staff to provide and assist residents with meals for 7 of 17 sampled residents. R12, R13, R14, R15, R16, R17, and R18 were not assisted with meals in a sufficient and timely manner. The facility policy titled, Nutrition Standard of Care #6, not dated, states, in part . Nursing will assist with meals as needed. Example 1 On 3/27/19 at 11:34 AM, Surveyor observed R15 sitting at dining room table with dining silverware wrapped. No food or fluids were on table in front of R1. MDS (Minimum Data Set) indicates that R15 is extensive assist of 1 with eating. R15 sat without food and fluids at table until 12:10 PM when meal was served. R15's meal sat in front of resident in bowls with plastic lids until 12:20 PM when CNA F (Certified Nursing Assistant) sat down to assist R15 with meal. Using the reasonable person concept, this is an extended period of time to sit at a table without food or fluids being offered or being assisted with a meal. Example 2 On 3/27/19 at 11:39 AM, Surveyor observed R16 sitting at dining room table with dining silverware wrapped. No food or fluids were on table in front of R16. MDS indicates that R16 is extensive assist of 1 with eating. R16 sat without food or fluids at table until 12:17 PM when meal was served. R16's meal sat in front of resident until 12:23 PM when CNA F sat down to assist with meal. Using the reasonable person concept, this is an extended period of time to sit at a table without food or fluids being offered or being assisted with a meal. Example 3 On 3/27/19 at 11:50 AM, R17's tray was observed by Surveyor with food and fluids covered on bedside table. Continuous observation was completed by Surveyor and at 12:32 PM CNA entered room and assisted R17 with eating. R17 required limited assist of one staff member with eating. Example 4 On 3/27/19 at 11:55 AM, Surveyor observed R14's meal tray on bedside table. Food and fluids had all lids and covers remaining. Continuous observation was completed by Surveyor. At 12:22 PM, R14's food remains on bedside table covered. No staff has made any attempts at prompting or setting up R14's meal. At 12:43PM, tray remains untouched on bedside table. CNA H brought in tray for R14's roommate and assisted roommate with eating. No attempts were made at prompting or assisting R14 with set-up while CNA H was in room. At 12:45 PM, CNA H completed assisting roommate with meal, approached R14 and asked if R14 was going to eat. R14 stated, No. CNA H picked up meal tray and left room. R14 was independent with meal after set up according to most recent MDS. Set up was not completed, as R14's food remained covered and plastic lids were not removed from drinks. Example 5 On 3/27/19 at 12:00 PM, R18 was observed to be in bed sleeping with meal on bedside table with food and fluids covered. At 12:25 PM, housekeeping entered room and emptied garbage. At 12:32 PM, R18 was observed to be awake and feeding self. Surveyor asked R18 if food was good. R18 stated, Yes, but my beans a little cold. R18's most recent MDS indicates independent with meal after set-up; staff never entered R18's room to set-up meal. Example 6 On 3/27/19 at 12:14 PM, R12 and R13's trays were brought into their room. Trays were left on the bedside table with covers left on food and drinks. R12 was offered a drink of fluids by dietary staff, leaving tray at bedside. At 12:25 PM, two CNA's entered R12 and R13's room with towels and a gown and closed door behind them. At 12:30 PM, one nurse entered the room and closed the door. At 12:33 PM, one nurse and one CNA left room and closed door again upon leaving. At 12:42 PM, Surveyor knocked on door and entered to find CNA J assisting R12 with eating. Surveyor observed R13's food and drinks on bedside table covered and untouched. CNA J states that R13 did not want to eat lunch. R12 required extensive assist with meals and R13 was dependent on staff for meals according to their most recent MDS. Example 7 On 3/27/19 at 12:39 PM, Surveyor interviewed CNA C about R17's meal. CNA C had been in room about 5 minutes assisting R17 to eat meal. CNA C had been assisting someone else before R17. Surveyor asked CNA C if this was normal for R17 to wait as long as one did to receive assist with meal. CNA C stated that it depends on how many trays are served and how long it takes to assist each of the residents. On 3/27/19 at 12:45PM, Surveyor interviewed CNA I. Surveyor asked CNA I to explain the evening dining process. CNA I states that trays begin being passed at 5:30 PM in the dining room to those that are independent, then to those residents eating in their rooms, last are those residents that require assistance in the dining room. Supper is generally finished being served by 6:30 PM. Surveyor asked when residents are assisted, CNA I stated, Brought tray and assist with eating right away. Surveyor asked if CNA I felt staffing was an issue. CNA I stated, No, feel there is enough staff to do that. On 3/27/19 at 2:23 PM, Surveyor interviewed DS D (Dietary Supervisor) with ND E (Nutrition Director) present. Surveyor asked if DS D normally assisted in dining room procedures at noon meal. DS D stated that she usually is out there assisting with pouring coffee, cutting up things, and helping wherever needed. ND E stated that the 3 supervisors are usually present at noon meal. Surveyor asked ND E what staff does when they take a meal into a resident's room. ND E stated that they can help set up a tray or they will leave it covered and let nursing staff know that it is in the room so that the resident can be assisted with their meal. Surveyor asked ND E how long the trays can sit before the food starts to drop in temperature. ND E stated that cooling would start to occur in around 15 minutes. On 3/27/19 at 2:35PM, Surveyor interviewed CNA H. Surveyor asked who assists with delivering meals to residents in the facility. CNA H stated dietary staff, two staff from 200 Wing, the float and sometimes the social worker or the DS will assist, but not every day. Surveyor asked how meal service is provided to the residents. CNA H stated that independent residents are fed first, then residents in their rooms are fed and the residents who require assistance in the dining room are fed last. Surveyor asked if today was a typical day for serving residents. CNA H stated, No, some people are on precautions and cannot come out, but normally would. Surveyor asked how long it generally takes to serve the lunch meal. CNA H states the meal starts around 11:30 AM and they are generally done serving around 1:00 PM. On 3/27/19 at 2:42 PM, Surveyor interviewed CNA F about today's dining experience. CNA F indicated that there are usually more CNA's in the dining room assisting residents. There were more room trays today. Surveyor asked CNA F if there is a standard for how long a tray should sit in a room before a CNA assists the resident with it. CNA F stated they should assist within 2 minutes normally. CNA F stated that usually there are more assisted residents eating in the dining room. On 3/27/19 at 2:47 PM, Surveyor interviewed CNA G about today's dining experience. CNA G indicated that there is usually more CNA's in dining room assisting residents. CNA G indicated that there were more residents receiving room trays today. CNA G stated that sometimes R14 won't eat and that staff usually approach every 15-20 minutes to see if R14 will eat. Surveyor informed CNA G that no staff approached R14 for 50 minutes. CNA G stated that normally they don't wait that long to approach R14. CNA G also stated that usually they don't have as many trays as they did today. The facility failed to assist residents with the noon meal in a sufficient and timely manner.

Based on observation, interview and record review, the facility did not provide an environment which is free of accident hazards, and provides supervision and assistive devices to each resident to prevent avoidable accidents. This occurred for four of ten residents (Residents (R) 7, 8, 4 and 14) who were reviewed for falls; 19 mobile residents with [DIAGNOSES REDACTED]. 1. R7 sustained 18 falls from 03/17/17 to 06/02/17. The facility did not consistently implement new fall interventions related to the root cause of the resident's falls. The facility did not increase the frequency of R7's safety checks or implement supervision in order to prevent future falls from occurring. Staff documented the resident's 30-minute safety checks occurred before the time itself. The facility did not have multiple fall interventions identified on the resident's care plan; and fall interventions were not implemented during two days of survey. 2. Fall intervention, as outlined in the care plan, of non-slip material in the wheelchair was not implemented for R8 during two days of survey. An anti-rollback device on R8's wheelchair was not updated on the resident's care plan. 3. R4 had multiple falls were the facility did not implement new interventions, supervision or anticipation of needs to assist in prevention of future falls. 4. R14 had multiple falls where the facility did not follow the interventions necessary to prevent further falls. 5. Based on observation and interview, the facility did not ensure that chemical products were safely secured to prevent accidental exposure for 8 ambulatory residents and 11 residents who self propel with a [DIAGNOSES REDACTED]. 6. Based on observation and interview, the facility did not ensure that resident equipment in common areas were in good repair. This had the potential to affect 8 ambulatory residents and 11 residents who self propel. This is evidenced by: 1. On 06/12/17 at 3:00 p.m., Surveyor reviewed R7's medical record. R7 has [DIAGNOSES REDACTED]. Symptoms may include double vision, headaches, and pain around the eye). The resident was admitted to the facility on [DATE]. The medical record and care plan indicates the resident has double vision in the left eye and wears glasses with a clouded left lens; but the resident can see well with the right eye. R7's Brief Interview for Mental Status (BIMS) score, dated 03/24/17, was a 10 out of 15 possible points. According to the BIMS assessment, a score of 10 indicates the resident has moderately impaired cognition. FALLS R7 has had 18 falls, from 03/17/17 to 6/02/17. The resident is able to ambulate with a four-wheeled walker and the assistance of one staff member. The resident was placed on 30-minute safety checks, from 03/17/17 until 03/25/17, for safety. On 03/17/17 at 1:50 p.m., the resident sustained [REDACTED]. The resident was complaining of foot pain at the time of the fall and was confused. R7 had an appointment with a podiatrist on 03/18/17, and the facility completed a room audit on 03/21/17. On 03/22/17 at 6:50 p.m., R7 attempted to self-transfer to the bathroom and did not use the call light, or use the walker. As a result, the resident fell and hit her head on the floor, and received a laceration to the inner lip. The facility implemented the resident is to be assisted to the bathroom after every meal. Staff educated the resident on the safe use of assistive devices and the use of the call light. The facility also requested a medication review. The resident's care plan was updated with this intervention. The nurses' notes, dated 03/27/17, state the following, in part, .Resident took self to the bathroom during the night. Did have on gripper socks. Did not have her wheeled walker and did not use call light. Resident educated on importance and safety of using her call light and walker. Resident responds 'I know'. Will continue to observe, intervene and educate .(Resident 7's first name) often c/o's (complains of) dizziness when she first stands,. She;s (sic) had this difficulty for a long time On 04/01/17 at 7:55 p.m., R7 was walking into the hallway without assistance and without the walker. As a result, the resident fell after losing her balance. The facility placed a sign in the resident's room stating, Call don't Fall. The facility implemented having the resident in a nightgown and in bed between 7:30 p.m. and 8:00 p.m., and pulling the privacy curtain in the room to promote a quiet environment. The care plan was updated with these interventions. On 04/05/17 at 1:00 p.m., the resident was wearing gripper socks and self-transferring in R7's room without a walker. As a result, the resident fell and hit her head on the heating vent. R7 declined having the room rearranged at this time. The facility added non-skid floor strips between the bathroom and the bed, and educated the resident on using the walker and calling staff for assistance. R7's nurses' notes, dated 04/06/17 at 8:33 p.m., state the following, in part, .Resident continues to have some complaints of 'tailbone' pain, leg and back pain, and (sic) well as dizziness and nausea (which is chronic for her). Resident walked from her apartment (facility room) to (room 710) and back without staff assist, leaving her walker in 710's room. Resident did almost loose (sic) her balance in her doorway when this nurse came upon her without staff assist or assistive device. Resident continues to be confused per baseline . As of 04/06/17, the facility implemented the 30-minute safety checks. On 04/07/17 at 5:15 p.m., R7 was self-transferring in her room without the walker, and moved the bedside table. As a result, the Styrofoam cup which was on the bedside table fell , spilling soda and ice onto the floor, which caused the resident to slip and fall. The facility removed the second bed from the room, and instructed the resident on the safe use of assistive devices, safe transfer techniques and the use of the call light. At 10:50 p.m., staff was assisting the resident into bed, and the resident decided to get into bed on the opposite side of where staff had suggested. At this time, R7 crawled into bed, knees first, and the resident's knees slipped off the bed causing the resident to fall. The resident was instructed on safe transfer techniques, the use of the call light and the use of assistive devices. The Director of Nursing (DON) later completed a Risk versus Benefit education to the resident on completing transfers. It is noted, this is the sixth fall and the fifth documented time staff have educated R7 on the safe use of using assistive devices and using the call light; which the resident continues to not use the call light or use the walker. The resident continues to be confused, has visual deficits and issues with dizziness. The facility has not increased the frequency of the safety checks, or implemented any supervision for the resident to prevent future falls from occurring. On 04/12/17 at 5:45 p.m., R7 was eating supper in her room, wearing gripper socks, and was seated in a wheelchair. The resident was currently on 30-minute checks. The resident indicated she stood up from the wheelchair, walked a few steps, turned around to walk back to the wheelchair and fell , hitting her head. The resident had a pain rating of a 10 out of 10 to her head after the fall. The facility's new intervention was to keep the locked walker within the resident's reach at all times, and a Call don't Fall sign on the seat of the walker. This was updated on the resident's care plan. The resident's Power of Attorney for Healthcare was activated on 04/14/17. R7's nurses' notes, dated 04/15/17 at 10:34 p.m., state the following, in part, .Continues to self-transfer, resident was walking into room across hall, was reminded she needed staff assist when up and walking for safety and states to this writer, 'Oh please .' R7's Minimum Data Set, with a completion date of 04/19/17, identifies the resident was not able to complete a BIMS assessment. The MDS indicates the resident has short term memory deficits, and has some difficulty making decisions. On 04/21/17 at 4:45 p.m., R7 self-transferred and fell while removing clothing from the room closet. The resident was currently on 30-minute checks. The facility removed the fall mat from the floor next to the bed, as it was questionable if this was a fall hazard for R7. The facility also placed the resident on a daily ambulation program with staff, in order to exert extra energy. On 04/21/17, Occupational Therapy (OT) wrote a progress note which states, in part, .D/t (Due to) pt (patient) cognition she continually doesn't remember to use 4ww (four-wheeled walker) or call light .Pt continues to have episodes of dizziness which limits her standing tolerance .Pt con't (continues) to be a high fall risk . A Physical Therapy (PT) progress note, dated 04/21/17, states the following, in part, .Pts safety awareness is poor even after reiterating importance of having assistance w/ (with) movements in room .Pt has remained at a high falls risk w/ little change throughout treatment . On 04/23/17 at 2:55 p.m., R7 self-transferred from the recliner, bumped into the bedside table, spilling water on the floor which caused the resident to slip and fall. The walker was next to the resident by the recliner, but R7 did not use the walker prior to the fall. The resident hit her head on the floor, thus causing a laceration and a lump on the back of the resident's head. The resident was currently on 30-minute checks. The facility added Dycem (a non-slip material) below the resident's drinks on the tray table to prevent spillage. On 04/24/17, the physician ordered the use of motion alarms in R7's room, and a tab alarm while up in the wheelchair. On 04/25/17, the facility determined the motion and tab alarms would not be used, as it would cause R7 to be more agitated. R7 continued to remain on 30-minute safety checks. On 04/25/17, the resident's nurses' notes state, in part, .Staff cont to find (R7) up walking independently in her room;. even tho (sic) checked frequently,. She has very little insight into her limitations,. (R7) tells DR (Doctor) she doesn't remember the falls,. Her continued confusion and forgetfulness is quite evident . Nurses' notes, on 05/07/17, state the following, in part, (R7) was found on her knees next to her easy chair,. after lunch,. She was packing up her belongings .Then she got herself.back up in her recliner .Staff continue to find her up walking independent in her room,. even with freq (frequent) checks,. (R7) does not remember to use the call lite., or ask for help . The facility did not consider this incident as a fall. On 05/13/17 at 7:45 p.m., R7 was self-transferring in her room without the use of the walker. The resident was found face-down on the floor, and sustained a broken tooth from the dentures, and laceration to the left upper lip. The resident was on 30-minute checks. The facility requested a physician consult with a medication assessment. The facility did not increase the safety checks or implement any supervision to prevent future falls from occurring. On 05/18/17 at 1:00 p.m., R7 slid to the floor from the recliner as she attempted to self-transfer, and did not use the walker. The resident hit her head, and had a pain rating of 05 out of 10 to her head after the fall. The walker was located next to the resident in the recliner, but R7 did not use this device. The resident was on 30-minute checks. The facility implemented the resident to be encouraged to sit in common areas and spend less time alone in the resident's room. This intervention is not updated on the resident's care plan. On 05/19/17 at 8:40 a.m., R7 slipped on the floor outside the resident's bathroom door, and was not using the walker. The resident was on 30-minute safety checks. The facility buffed the bathroom floor, in order to make the floor less slick. The facility also added a grad bar to the bathroom wall between the sink and the door. On 05/21/17 at 2:25 a.m., R7 was self-transferring to the bathroom, without the use of the walker. As a result, the resident fell and sustained a scrape to the right knee. The resident was on 30-minute safety checks. The facility placed a black seat on the toilet. At 7:15 p.m., the resident was walking, independently, on the other side of the building using a walker. According to the incident report, as a staff member pursued the resident down the hallway, R7 started to run. At this time, another resident began speaking to R7, and R7 stopped abruptly, which caused R7 to lose her balance and fall. The resident hit her head, and sustained bruising to the right side of the head, a laceration to the right eyebrow and scrapes to the forehead. The resident was on 30-minute safety checks. The facility reviewed the type of walker with PT and OT, and the facility was to implement a dining and nutritional program with R7, since the resident was a former restaurant owner. This intervention was not added to the resident's care plan. Surveyor reviewed R7's medical record to review the facility's dining and nutritional program which was implemented for the resident. A message sent to staff by the DON, on 05/24/17, states the following, .Her passion has always been the restaurant business. If dining could find a way to involve (R7) with our dining experience .Suggestions might be menu planning, weekly kitchen tour/inspection, a cooking demo by (R7) . An email, sent by Dietary Manager (DM) D, to the DON, ADON and Nursing Home Administrator, in part, states the following, in part, .I am going to have her tour the kitchen sometime next week, and have her get the feel of being in a kitchen again. I am also going to have her watch us put away groceries .Today, I tried to meet with her to have her give me some input on our new summer menus .She wasn't in a good mood and she wanted me to leave. I talked with (RN B) and I asked her if she can let me know when (R7) is in a good mood and I can meet with her . Surveyor reviewed R7's medical record and there is no further documentation regarding the dining/nutritional program the facility has attempted as a fall intervention with the resident. Surveyor reviewed an Interdepartmental Referral From, dated 05/21/17, to PT and OT. The form states the following, in part, .Message: (R7) fell [DATE] while Running with walker. Is there any way to slow down top speed her walker can move, would different type be better for her? Reply: I can bring down a Front wheeled walker which may help to slow her a little but it won't prevent her from running if she wants to .She chooses to keep her own walker because it has a seat (and) a holder for her purse . A progress note by the Physician's Assistant, dated 05/22/17, states the following, in part, .I am seeing (R7) today for an add-on visit at the nursing home's request. She had multiple falls over the weekend, a couple of them with significant closed head injury. This has been an ongoing pattern since her admission .Staff reports that overall cognitively she seems to be declining .Multiple falls at the nursing home in a patient with progressive neurodegenerative disorder with history of (stroke), weakness, and impulsive transfers .At this point we have discussed a motion sensor alarm or seat belt alarm, but the nursing home would like to hold off as there is no evidence that this would reduce the falls . Nurses' notes, for R7 state the following, in part: -05/22/17 at 11:22 p.m.: Resident continues to self transfer this shift, continues with limited insight into own abilities . -05/23/17 at 11:51 p.m.: .She has been observed starting to walk in room or hall alone several times and intercepted by staff .Continued to remind resident often to use call light and wait for assist so to not fall again . On 05/26/17, the medical record indicates the facility had a Risk versus Benefit conversation with R7, on self-transfers, and not using a walker. It is noted, the resident continues to decline cognitively and education regarding the use of the call light and using a walker has not been an effective intervention for reducing falls. On 05/29/17 at 8:15 a.m., the resident slid from the side of the bed to the floor, when trying to get up and walk independently to the bathroom. The resident was wearing gripper socks, and the wheelchair was located next to the bed. The resident was on 30-minute safety checks. The facility again instructed the resident on the safe use of assistive devices and using the call light. The DON indicated she would review the nutritional risk and the resident's weight loss with the Registered Dietician. The resident continues to be confused and has not remembered to use the call light appropriately or use the walker when ambulating, yet the facility continues to provide education on the above safety interventions to R7. The intervention for this fall, to review the nutritional risk and weight loss is did not address the root cause of the fall. The facility did not implement a new toileting schedule based on the resident's need at the time of the fall, did not increase the frequency of the safety checks, and did not implement supervision to prevent future falls from occurring. On 06/02/17 at 6:45 p.m., R7 slid from a stationary chair in the resident's room, as she was attempting to place her purse on a table. The resident did not attempt to use the walker. The resident was on 30-minute safety checks. The facility added more non-skid strips to the floor in front of the floor of the chair, and is attempting to consult with a geriatric psychiatrist. The resident was offered and declined constant supervision in the resident's room. On 06/14/17 at 12:28 p.m., Surveyor interviewed DM D. DM D stated he has attempted multiple times to meet with R7 to engage the resident in the facility's dining and nutritional program; but the resident refuses. DM D further indicated these attempts to engage the resident and the resident's refusals have not been documented. Surveyor indicated engaging the resident in the facility dining/nutritional program is not identified on R7's care plan, to which DM D replied the DON would have to add this to the care plan. At 2:57 p.m., Surveyor interviewed RN B. Surveyor discussed the education provided to R7 after multiple falls. RN B replied R7 forgets what staff tell the resident after five minutes, the resident has no reliability and is not able to remember the education provided. RN B indicated the root cause of the resident's falls is dementia. On 06/15/17 at 9:30 a.m., the above observations were discussed with the DON and Assistant Director of Nursing (ADON). Surveyor asked if the facility increased the frequency of the safety checks; to which the DON indicated increasing the checks from 30-minutes would not be possible by nursing staff. Since R7 has had declining cognitive function, the surveyor inquired if the facility has assessed the resident's ability to understand the Call don't Fall signs in the room, to see if the resident knows what to do, who to call and when. The DON replied the facility has not attempted to assess the resident's understanding of these signs, and has not attempted to place alternative signs, indicating the resident is to use the call light or to use the walker before ambulating. During the continued interview, Surveyor discussed the intervention to remove the second bed from the resident's room, as this intervention did not address the resident slipped on soda, on 04/07/17. The DON stated she agreed the fall intervention did not match the root cause of the fall. Surveyor also noted the intervention, from the 05/18/17 fall, to have R7 sit in common areas, is not identified on the resident's care plan. The DON indicated this should be updated on R7's care plan as a current fall intervention. Surveyor asked the DON and ADON if at any time the facility considered implementing a toileting schedule for R7, since the majority of the resident's falls appear to occur when the resident is attempting to walk to/from the bathroom. The DON indicated an individualized toileting schedule was not implemented, and the DON further stated she can talk with R7 to see if the resident would be accepting of a toileting schedule. During the continued interview, Surveyor discussed increasing the resident's supervision in order to prevent falls. The DON indicated she asked R7, after the 06/02/17 fall, if the resident would like constant supervision; which would consist of someone sitting in the resident's room at all times. The DON stated R7 declined this intervention and replied this would be like a jail. Surveyor asked if the facility considered line-of-sight supervision or less invasive supervision techniques for the resident. The DON replied line-of-sight supervision had not been considered or attempted. SAFETY CHECKS Surveyor reviewed R7's Kardex and comprehensive care plans. Each care plan indicates the resident requires 30-minute safety checks by staff. On 06/13/17, Surveyor reviewed the resident's documented 30-minute checks, on the AM, PM and night shifts. The following safety checks were documented at a time earlier than the safety checks itself, in part: -03/20/17: The 3:30 a.m., 4:00 a.m., and 4:30 a.m. safety checks were all documented as complete at 3:15 a.m. -03/24/17: The 11:30 a.m. safety check is documented as complete as of 10:56 a.m., the 2:30 p.m. safety check is documented as complete at 2:02 p.m., and the 10:00 p.m. safety check is documented as complete at 9:48 p.m. -04/07/17: The 2:00 a.m. safety check is documented as complete at 1:30 a.m., the 4:00 a.m. safety check is documented as complete at 3:39 a.m. -04/12/17: The 1:30 a.m., 2:00 a.m., and 2:30 a.m. safety checks are all documented as complete at 1:20 a.m -05/15/17: The 1:30 a.m. safety check is documented as complete at 12:59 a.m., the 5:00 a.m. safety check is documented as complete at 4:33 a.m. -05/20/17: The 10:00 p.m. and 10:30 p.m. safety checks are both documented as being complete at 9:35 p.m. -06/11/17: The 1:30 a.m. safety check is documented as complete at 1:16 a.m., the 6:30 a.m. safety check is documented as complete at 6:07 a.m. -06/14/17: The 5:00 a.m. safety check is documented as complete at 4:41 a.m. OBSERVATIONS Surveyor reviewed R7's Kardex and comprehensive care plans. The Kardex care plan states the following, in part, .leave door open for safety checks .keep locked walker within reach, call don't fall sign on seat . The resident's care plan does not identify R7 uses an anti-rollback device on the wheelchair. On 06/13/17 at 7:21 a.m., Surveyor observed R7 sleeping in bed. The four-wheeled walker was located on the opposite side of the room, to the right of a wheelchair, next to a closet. The wheelchair had an anti-rollback device on the back. There was no sign on the seat of the walker to remind the resident to call for assistance. The room door was open about six or eight inches at this time. At approximately 8:00 a.m., nursing staff entered the resident's room and provided a fresh Styrofoam cup of water, and removed the older cup of water. At this time, the resident remained sleeping in bed. Staff left the room and did not place the walker within reach of the resident, and did not place a sign on the seat of the walker, to remind R7 to call for help. At 1:30 p.m., R7 was lying in bed, awake. The four-wheeled walker was located on the opposite side of the room, to the right of a wheelchair, next to a closet. The wheelchair had an anti-rollback device on the back. There was no sign on the seat of the walker to remind the resident to call for assistance. The wheelchair and walker appeared to be in the same position as they were in the morning. On 06/14/17 at 7:31 a.m., Surveyor observed R7 sleeping in bed. The four-wheeled walker was located on the opposite side of the room, to the right of a wheelchair, next to a closet. The wheelchair had an anti-rollback device on the back. There was no sign on the seat of the walker to remind the resident to call for assistance. The room door was open approximately six or eight inches. At approximately 8:10 a.m., nursing staff entered the resident's room and provided a fresh Styrofoam cup of water, and removed the older cup of water. At this time, the resident remained sleeping in bed. Staff left the room and did not place the walker within reach of the resident, and did not place a sign on the seat of the walker, to remind R7 to call for help. At 2:30 p.m., Surveyor observed R7 sitting in a stationary chair in her room. The four-wheeled walker was located on the opposite side of the room, to the right of a wheelchair, next to a closet. The wheelchair had an anti-rollback device on the back. There was no sign on the seat of the walker to remind the resident to call for assistance. The wheelchair and walker appeared to be in the same position in the room as they were in the morning. At approximately 2:35 p.m., Surveyor observed Resident Care Technician (RCT) F enter the resident's room and provide a fresh Styrofoam cup of water, and removed the older cup of water. Staff left the room and did not place the walker within reach of the resident, and did not place a sign on the seat of the walker, to remind R7 to call for help. At 2:50 p.m., Surveyor interviewed RCT F. RCT F indicated R7 is currently on 30-minute safety checks, and the walker is supposed to be next to the resident at all times. RCT F further indicated a sign is supposed to be on the seat of the walker, which reminds R7 to call for help. Surveyor indicated these safety interventions were not implemented at the time RCT F provided fresh water to R7, to which RCT F stated she was not aware. RCT F returned to the resident's room, and placed the walker next to R7. On 06/15/17 at 11:28 a.m., Surveyor observed R7 sitting in a wheelchair in a lobby. An anti-rollback device was located on the back of the resident's wheelchair. On 06/14/17 at 2:57 p.m., the surveyor interviewed RN B, and the above observations were discussed. RN B stated it is a good idea to have the walker placed next to R7 at all times, and stated the anti-rollback device should be identified on the resident's care plan. On 06/15/17 at 9:30 a.m., the above observations were discussed with the DON and ADON. The DON indicated the walker should be located next to the resident at all times, and staff try to keep it next to R7. The DON indicated a Call don't Fall sign should be located on the seat of the walker, in order to remind the resident to call for help. The DON indicated the anti-rollback device has now been added to the resident's comprehensive care plan. 2. On 06/13/17 at 8:48 a.m., Surveyor reviewed R8's medical record and identified [DIAGNOSES REDACTED]. The resident's most recent BIMS score, dated 04/12/17, was a 05 out of 15 possible points. According to the BIMS assessment, a score of 05 indicates R8 has severe cognitive deficits. On 04/16/17, R8 fell out of the wheelchair and hit her head. The facility implemented a new intervention to place Dycem below the resident while sitting in the wheelchair. R8's care plan indicates Dycem should be below the resident while in the wheelchair. The resident's care plan does not identify R8 uses an anti-rollback device on the wheelchair. On 06/13/17 at 7:24 a.m., R8 was assisted into the wheelchair by staff and brought out to the facility dining room for the breakfast meal. An anti-rollback device was located on the back of the resident's wheelchair. At this time, there was no Dycem material below the resident. The Dycem was observed to be placed on a dresser in the resident's room. On 06/14/17 at 8:21 a.m., the resident was sitting in a wheelchair in the dining room. An anti-rollback device was located on the back of the resident's wheelchair. There was no Dycem material in the resident's wheelchair. At this time, the Dycem was observed in the resident's room. At 2:35 p.m., R8 was observed sitting in a wheelchair in a hallway. An anti-rollback device was located on the back of the resident's wheelchair. There was no Dycem material in the resident's wheelchair. At 2:39 p.m., Surveyor asked RCT E if R8 is supposed to have Dycem in the wheelchair. RCT E replied she would have to look into this. At 2:44 p.m., RCT E went into R8's room and noted the Dycem material was located on top of a resident's dresser. At this time, RCT E brought R8 into the resident's room and transferred the resident out of the wheelchair. RCT E placed the Dycem on R8's wheelchair seat and cushion, and transferred R8 back into the wheelchair. At 2:48 p.m., Surveyor interviewed RCT F. RCT F indicated R8 currently requires the Dycem material in the wheelchair, and stated the resident also requires the use of the anti-rollback device. At 2:57 p.m., Surveyor discussed the above observations with RN B. RN B indicated the anti-rollbacks will have to be added to R8's comprehensive care plan. RN B further indicated the resident currently requires the use of the Dycem in the wheelchair as a safety intervention. On 06/15/17 at 9:30 a.m., the above observations were discussed with the DON and ADON. The DON stated the anti-rollback device should be updated on R8's comprehensive care plan. The DON further indicated the Dycem material is a current safety intervention and should be used in the resident's wheelchair. 3. On 06/12/17, Surveyor reviewed R4's medical record. R4's current [DIAGNOSES REDACTED]. 04/26/17 Minimum Data Set (MDS) documents R4's Brief Interview for Mental Status score of cognition as being severely impaired. Review of nurse's notes document in part: 03/22/17 15:56 INCIDENT TYPE: fall observed on floor DATE OF INCIDENT: 03/22/2017 TIME OF INCIDENT: 15:20 (3:20 p.m.) .Resident has been up roaming around in broda .resident was on the floor of the bodega dining room .ROOT CAUSE INTRINSIC Cognitive/Dementia restlessness .NEW INTERVENTION: MD consult . The fall investigation report new intervention documented to have blood pressures reviewed by the Physician Assistant (PA). After the MD and PA review, no new interventions were implemented. 03/28/17 8:24 a.m., INCIDENT TYPE: observed on floor, bottom half on floor, top half on bed, DATE OF INCIDENT: 03/28/2017 TIME OF INCIDENT: 07:30 (7:30 a.m.) .DESCRIBE DETAILS OF INCIDENT: Dietary aid noted resident half off the window side of bed with top half on bed and ribs on 1/4 side rail with her legs off of bed partially on and under radiator and the other knee on the floor .ROOT CAUSE INTRINSIC Visual impairment Cognitive/Dementia Incontinence Balance Gait .NEW INTERVENTIONS: Reposition bed add floor mat to both sides of bed . No new intervention of a toileting schedule was added when incontinence was identified as one of the root cause. 04/05/17 9:39 a.m., INCIDENT TYPE: fall observed on floor DATE OF INCIDENT: 04/05/2017 TIME OF INCIDENT: 08:35 (8:35 a.m.) .DESCRIBE DETAILS OF INCIDENT: Resident was observed on floor in Ballroom .Incontinent of urine at time of fall .ROOT CAUSE ROOT CAUSE EXTRI

Based on observation, interview and record review, the facility did not ensure that each resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 of 11 (Resident 3) sampled residents reviewed. R3's dentures were reported missing on two occasions and the facility did not recognize, assess and implement interventions to prevent future loss of dentures or ensure the impact on the resident due to the loss of the dentures was addressed. This is evidenced by: The facility policy, titled Broken/Missing Items Report states, .2 Missing items a. When a resident has reported a missing item, please gather the following information (resident name, room number, date, item description, location lost, and the amount of time missing) and report the Broken/Missing item report. See attached sheet.d. Items that have not been found will be reviewed on an individual basis by the social worker (and the Administrator as needed) during the one week follow up R3 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. Kardex (RCT care plan) printed 06/12/17 at 12:39 p.m. titled Dental states Full Dentures (upper only) - Extensive assist. 05/15/17 Minimum Data Set (MDS) documents R3's Brief Interview for Mental Status score of cognition as being mildly impaired. On 06/13/17 at 9:40 a.m., Surveyor observed R3 in room eating breakfast without dentures. On 06/13/17 during initial tour at 9:41 a.m., Surveyor interviewed Family Member (FM) I. FM I stated that things at the facility were fine except that they have lost three denture plates. FM I indicated that each time this happens, there is a lot of paperwork involved and it is difficult to deal with. FM I states that R3 is currently on a soft diet and not able to enjoy certain foods such as breakfast meat. On 06/13/17 at 1:30 p.m., Surveyor asked R3 how it was to eat without dentures. R3 replied, Not very good, everything is mixed up more and I don't care for that. Rice and meat should be separate. My meat ends up looking like tobacco and it doesn't sit well in my stomach. I am sensitive and a lot of things I can't eat. This is driving me crazy; I have never been without my teeth. When asked if R3 has been to a dentist, R3 stated, No because approval is needed first due to the fact that two sets have already been replaced. On 06/13/17 at 2:45 p.m., RN G called the conference room telephone and stated to Surveyor that sometime after 06/04/17 RN G called dietary supervisor and requested soft foods for R3 because of missing dentures. On 06/13/17 at 4:00 p.m., FM J called into the conference room to speak with surveyor at facility request via telephone. FM J indicated that R3 can no longer have foods that R3 enjoys such as sausage and potato chips because of the missing dentures. FM J indicated R3 can no longer go out for wings because of the missing dentures. When asked if FM J was offered for facility to care for the dentures at night FM J states, I have never been offered for them to take at night before. I didn't even know they would do it. On 06/13/17 at 11:00 a.m., Surveyor asked Social Worker (SW) K if she had any information related to R3's missing dentures. The following information was provided to Surveyor: Facility form, titled Broken/Missing Item Report complete 01/08/17 identifies item missing as lower dentures belonging to R3. The part of the form entitled ONE WEEK FOLLOW UP AND RESOLUTION states Family decided not to replace because they bothered R3 and she kept taking them out. Signed by SW K and dated 06/13/17. Facility form, titled Broken/Missing Item Report complete 06/04/17 identifies item missing as upper dentures belonging to R3. The part of the form entitled ONE WEEK FOLLOW UP AND RESOLUTION states Charge nurse spoke with family and they will look into getting new upper dentures. SW will write a letter explaining what was done to find them and what will be done in the future. R3 has now agreed to allow staff to keep dentures on the med cart at night. Signed by SW K and dated 06/12/17.