Every finding on record at Care and Rehab - Cumberland

Based on observation, interview and record review, the facility did not ensure that 1 of 3 residents (R) reviewed for pressure injuries (PI) (R32) received care consistently with professional standards of practice to prevent further deterioration and promote healing of an existing PI. R32 was at risk for PI development. The facility failed to provide adequate and consistent wound care treatments, did not complete comprehensive weekly assessment, and did not notify provider of new PI.Findings include: R32 was admitted to the facility on [DATE] with diagnoses including in part, atrial fibrillation, nonrheumatic aortic insufficiency, hypertensive heart disease, peripheral vascular disease, unilateral osteoarthritis left ankle and foot, hypertension, weakness, and presence of right artificial hip joint.R32's Minimum Data Set (MDS) assessment, dated 12/13/25, identified R32 required substantial maximal assistance for bed mobility, taking on and off footwear, rolling left to right, sit to lying, chair to bed, toileting, and for transfers. MDS indicated R32 was at risk for PIs.Surveyor reviewed R32's impaired skin integrity related to history of Stage 2 pressure injuries to bilateral buttocks on admission. Date Initiated: 12/12/2024 Revision on: 12/24/2024: in part:-Apply moisturizer to skin with cares and as needed. Do not massage over bony prominences and use mild cleansers for peri-care/washing. Date Initiated: 12/12/2024.-Educate resident and family as to the potential causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Date Initiated: 12/12/2024.-Encourage resident to reposition at least every two hours and sooner if needed. Date Initiated: 12/12/2024.-Follow facility policies/protocols for the prevention/treatment of skin breakdown. Date Initiated: 12/12/2024.-Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care. Date Initiated: 12/12/2024.-Resident has a pressure relieving mattress and has a roho cushion in w/c and recliner. (Check inflation per TAR) Date Initiated: 12/12/2024.-Skin treatments per TAR Date Initiated: 12/12/2024.-The resident requires supplemental protein, and nutritional shakes as ordered to promote wound healing. Date Initiated: 12/12/2024.-Wound nurse to monitor chronic wounds and pressure injuries weekly Date Initiated: 12/12/2024.Surveyor reviewed R32's discontinued physician orders:-On 01/03/26, revised on 1/11/26, and discontinued 01/21/26. Monitor scabbed area to the side of left fifth toe and change padded dressing if necessary. -On 01/18/26: Change every day. Minor wound care as needed (PRN). Nursing able to use the following as appropriate: Bacitracin, Telfa and Gauze, until healed/resolved. every evening shift.R32's current physician orders:-On 02/14/26; Cleanse both areas of left foot, skin prep and apply bordered foam and change every 3 days. every evening shift every 3 day(s) for unstable pressure from when cast was on.Surveyor reviewed R32's Braden skin assessments:-On 12/12/25: At risk for skin breakdown, score of 17.Surveyor reviewed R32's progress notes, stated in part, .-On 12/29/25 at 11:00 AM, PT/OT [Physical Therapy/Occupational Therapy] approached nursing to report that resident states she had severe pain to her right lower leg during therapy session to transfer off the toilet in preparation for her home visit. Resident examined and noted to have swelling to BLE [bilateral lower extremities] 1-2+, right slightly more swollen than left and tight socks in place creating pressure just below shin where she states that she had the sharp pain during transfer. Removed socks and placed tubigrip to create light even compression. Residents have good ROM but still state some moderate pain at rest and states I felt my leg snap. There are no obvious deformities other than slightly more swelling to right shin area. Assisted resident to rest her leg, apply ice and elevation until rounding MD here to evaluate early this afternoon. Acetaminophen analgesia offered as well.-On 12/29/25 at 6:04 PM, Resident returned from ER [emergency room] with DX [diagnosis] of tib/fib [tibia/fibula] fractures to [NAME] [lower extremities]. She arrived back in facility with glassed cast to LLE [left lower extremity]and orders to remain NWB non weight bearing] to the affected [NAME]. Ortho consult has been sent. Resident evaluated by writer with transferring with EZ stand to ensure that she was able to maintain NWB to LLE and she is able to do this safely with assist of 1 and EZ stand, may use 2 PRN. CMST [circulatory, motor, sensory testing] to be checked q [every] shift and PRN. Education provided to resident on importance of keeping [NAME] elevated and updating nursing if she has increased pain, tingling or numbness to [NAME]. Resident in agreement to alert staff if changes occur. Resident provided with facility WC [wheelchair] as her personal WC does not have elevating footrests and will not accommodate her need to keep [NAME] elevated.-On 01/13/26 at 12:38 PM, Resident seen by Ortho today.Findings: Left tib/fib fx, left lower extremity pressure- lateral leg below knee, medial foot and lateral foot. Recommendations include:1. TTWB [toe touch weight bearing] LLE, PT for safety and UE [upper extremity] strengthen, gait, and balance.2. Keep cast CDI [clean, dry, intact]. May shower with cast covered.3. Ice and elevation (toes above nose if possible).4. F/u2 weeks. Next appointment 01/27/26.Facility did not implement any new interventions for the development of 2 new PIs.R32's progress notes, continued, stated in part, .-On 01/17/26 at 9:58 PM, Resident has an open area on the left lateral outer 5th toe. It has a small sanguineous drainage dried around the wound edges. Wound is approximately .75 in X1 inch. It had border foam dressing on it.Action: Removed the old dressing. Cleansed wound and covered with bacitracin, telfa and gauze to protect from the cast.Facility did not implement any new interventions for R32's PI of the lateral 5th toe. Surveyor did not find that the facility updated a provider on call or completed a comprehensive weekly assessment.R32's progress notes, continued, stated in part, .-On 01/25/26 at 10:24 AM, Sore/scabbed area to left fifth pinky toe observed to be larger in size under cast. Unable to accurately measure sore d/t [due to] cast being in the way. Denies' presence of pain or discomfort. Free of s/sx of infection. Denies' presence of numbness and tingling to left foot. Area cleansed with wound cleanser, bacitracin applied, and layer of gauze placed over sore to protect area from cast. Message left with infection control RN regarding changes in wound size.Facility did not update provider on call when R32's lateral 5th toe deteriorated. Facility did not implement any new interventions for R32's PI of the lateral 5th toe. The facility did not complete a comprehensive weekly assessment.R32's progress notes, continued, stated in part,Consultation report dated 02/10/26 at 9:30 AM,Exam: Cast removed, scab to lateral proximal lower leg, lateral and medial foot. Xeroderma present. Sensation intact to light touch, toes warm, and well perfused. Ankle ROM not tested secondary to acute injury.May remove temporary splint and transition to Cam walking boot. May remove boot for skin hygiene, showers, and ROM. Continue wound care.WBAT in boot for transfers. 25% WB for distance in boot, Ankle and knee ROM.Skin Care- wounds from first splint with inadequate padding.Follow up in 5 weeks.On 02/11/26 at 2:26 PM, 003: New skin Issue. Location: Left lateral foot. Laterality / Orientation: Left. Issue type: Pressure ulcer / injury. Progress: New: new wound. Pressure ulcer staging: Unstageable pressure ulcer / injury. Unstageable ulcer due to slough and / or eschar. Wound acquired in-house. Exact date: 02/10/2026 Signs and symptoms of infection: None. Painful: No. Staged by: In-house nursing. Length (cm): 3.25 Width (cm): 3.46 Depth (cm): 0 Area (cm2): 7.29 Undermining: No. Tunneling: No. Eschar: 100%.#004: New skin Issue. Location: Left medial foot. Issue type: Pressure ulcer / injury. Progress: New: new wound. Pressure ulcer staging: Unstageable pressure ulcer / injury. Unstageable ulcer due to slough and / or eschar. Wound acquired in-house. Exact date: 02/10/2026 Signs and symptoms of infection: None. Painful: No. Staged by: In-house nursing. Length (cm): 2.05 Width (cm): 1.8 Depth (cm): 0 Area (cm2): 2.96 Undermining: No. Tunneling: No. Eschar: 100%.Skin Issues Note: Will add to wound rounds for 2/18. Pressure area from cast. Cast removed 2/10/26. Wound provider notified.On 02/17/26 at 9:04 PM, Skin warm & dry, skin color WNL and turgor is normal.Resident does not have an external device.#003: Skin issue has not been evaluated. Location: Left medial foot. Issue type: Pressure ulcer / injury. Pressure ulcer staging: Unstageable pressure ulcer / injury. Wound acquired in-house. Exact date: 02/10/2026 Staged by: In-house nursing. Undermining: No. Tunneling: No.#004: Skin issue has not been evaluated. Location: Left lateral foot. Laterality / Orientation: Left. Issue type: Pressure ulcer / injury. Pressure ulcer staging: Unstageable pressure ulcer / injury. Wound acquired in-house. Exact date: 02/10/2026 Staged by: In-house nursing. Undermining: No. Tunneling: No.Skin Issues Note: No new skin issues noted. Pressure ulcers evaluated by wound nurse on rounds on Wednesday. See notes.On 02/16/26 at 3:21 PM, Surveyor observed R32 to have a post op shoe with posterior splint on left foot.On 02/16/2026 at 3:29 PM, Surveyor interviewed R32 and asked how R32 injured her foot. R32 reported to Surveyor that she had a transfer in bathroom with physical therapy on 12/29/25 where R32 felt and heard a pop with burning sensation. Later that day, the provider came to visit R32 who stated yes, it is in fact broken and R32 was sent to the ER. R32 reported that she came back with a cast on. R32 stated, I feel like facility has not been taking care of my leg as its growing crooked and never gets looked at. I am lucky to even have the ace wrap come off once a week. If I ask staff to wash leg then they will but not often.On 02/17/26 at 2:31 PM, Surveyor interviewed Director of Nursing (DON) B and asked DON B what resident's wounds look like on left foot. DON B reported that DON B is unsure at this time as DON B thinks it is being initially evaluated by wound provider and Infection Control (IC) Registered Nurse (RN) C tomorrow on 02/18/26. Surveyor asked DON B to go with Surveyor to peek at R32's left foot, brace, and skin.On 02/17/26 at 2:35 PM, Surveyor entered R32's room with DON B, and DON B began taking the Ace wrap and post op boot off. DON B confirmed that R32 still had post op boot and posterior splint instead of the Cam boot recommended back on 02/10/26. When DON B took ace wrap off, Surveyor observed 3 different wounds: 1 wound on lateral side of foot, medial side of foot, and a dressing on left heel with no dates or initials on dressings. Surveyor asked DON B what left heel dressing was on R32's foot. DON B reported that DON B is unsure as DON B did not know R32 had an issue on R32's left heel. Surveyor asked DON B when the dressings were last changed. DON B reported that DON B is unsure but some nurses document and some don't on dressings. Surveyor asked for expectation of nurses signing correct date on dressing of wound dressing change. DON B reported that staff should be labeling dressings. R32 reported to DON B that resident is about to take a shower so that DON B could leave brace off until after shower. DON B left post op shoe and ace wrap off.On 02/17/26 at 2:41 PM, Surveyor interviewed IC RN C and asked how R32's wounds look on left foot. Surveyor inquired about the foam border dressing on R32's left heel. IC RN C reported to Surveyor that IC RN C did not know about R32's left heel wound, and that Wound Provider K will be onsite to assess R32's new wound tomorrow on 02/18/26.On 02/18/26 at 8:45 AM, Surveyor called Orthopedic Surgeon I to inquire about the resident's new wounds under cast. Surveyor left message for return call.On 02/18/26 at 9:08 AM, Surveyor interviewed IC RN C who also completes wound assessments weekly. IC RN C reported that IC RN C and wound provider will not be assessing wounds until 1pm-2pm today.On 02/18/26 at 9:32 AM, Surveyor interviewed Orthopedic Surgeon I and asked if Orthopedic Surgeon I could walk Surveyor through consultation visits Orthopedic Surgeon I had with R32 over the last couple months. Orthopedic Surgeon I reported that R32's initial consultation visit was on 01/13/26 when R32 arrived with a cast placed by the ER weeks prior. R32 was noted to have substantial eschar from the initial cast placed from the ER for the initial fracture and splint. Surveyor asked Orthopedic Surgeon I if Orthopedic Surgeon I could see the toes when resident came into clinic consultation. Orthopedic Surgeon I reported that the resident's toes would have been dorsally and laterally visible. Orthopedic Surgeon I reported that since resident had unstageable pressure injuries to the left medial foot and left lateral foot, the team decided to apply an old-fashioned cast that covered the whole foot and lower leg to assist the wounds in healing. Surveyor asked Orthopedic Surgeon I if R32 had any concerns with R32's left heel. Orthopedic Surgeon I reported only 3 issues with left medial foot, left lateral foot, and left upper shin area where cast had hit with pressure. R32 was seen recently on 02/10/26 and fracture looked good, so recommendations were to put temporary posterior splint on with post op shoe but change to a Cam boot once facility receives Cam boot. Orthopedic Surgeon I reported that at the time of visit R32's wounds were infection free and had full thickness eschar so wasn't able to stage.On 02/18/26 at 2:49 PM, Surveyor observed wound care with IC RN C and Wound Provider K. IC RN C removed 3 dressings at the left medial foot, left lateral foot, and heel. Surveyor asked IC RN C what is going on with R32's left heel and IC RN C stated, Oh I did not know resident had a heel injury. Surveyor asked IC RN C if the heel was documented in R32's medical record since a staff member was applying a dressing to R32's left heel with border foam. IC RN C reported that IC RN C has not seen any information pertaining to skin issues on R32's left heel. Wound Provider K reported after assessment that resident now has a new stage 1 PI on dorsal of left foot, and a new stage 3 on left heel. Wound Provider K reported to Surveyor that Wound Provider K is calling it pressure from the post op shoe strap over top of R32's foot and Wound Provider K stated, I am assuming that the stage 3 on heel is from pressure of the temporary splint. Wound Provider K reported R32's PI on the left lateral foot after debridement is still unstageable necrosis, and the medial left foot could not debride but unstageable necrosis as well. Wound Provider K changed dressing change orders to Medi honey, alginate, prep, and border foam change three times a week. Wound Provider K reported to Surveyor that IC RN C will take measurements and report this to Surveyor.On 02/18/26 at 3:15 PM, IC RN C gave Surveyor PI documentation with measurements.Surveyor reviewed measurements:-Left medial foot: unstageable PI, 1.63cm x1.64cm. Eschar 100%. in house acquired.-Left lateral foot: unstageable PI, 1.94cm x 3.13 cm. Slough and/or eschar in house acquired.-Left heal Stage 3 Full thickness skin loss, 0.98cm x 0.79cm x0.1 cm. Slough 100% in house acquired.-Left medial midfoot: Stage 1 PI, 0.57 cm x 0.98cm. non blanchable erythema or intact skin. in house acquired.On 02/18/26 at 3:17 PM, Surveyor asked IC RN C's expectations for staff documenting a new wound and who notifies the provider. IC RN C reported to Surveyor that all new wounds or skin issues are documented in the medical record and then IC RN C comes in every morning and reviews charting to see any new skin issues residents may have. IC RN C reported that whoever applied dressing to R32's left heel did not document that there was an issue, so IC RN C was not made aware of the new left heel PI.Surveyor found no interventions put into place after the discovery of R32's left heel PI.

Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infection, for 2 out of 13 residents (R) (R2 and R4) reviewed. R2 and R4 have indwelling medical devices and were not on Enhanced Barrier Precautions (EBP). Licensed Practical Nurse (LPN) H did not perform hand hygiene during water flush for R4's peg tube. Findings include: The facility's policy titled, Infection Prevention and Control Manual Enhanced Barrier Precautions (EBP)reads in part, .The purpose of Enhanced Barrier Precautions is to prevent opportunities for transfer of Multidrug-Resistant Organisms (MDROs) to employee's hands and clothing during cares, beyond situations in which staff anticipate exposure to blood or body fluids. High-contact resident care activities include Dressing, bathing/showering, transferring, providing hygiene, changing linins, changing briefs or assisting with toileting .3. Enhanced Barrier Precautions are to be implemented in addition to Standard Precautions . when facility identifies any resident with .c. Any indwelling medical device, for example . iii. Feeding tubes . State Operations Manual, Implementation of Transmission-Based Precautions reads in part, .When a resident is placed on transmission-based precautions, facility staff should implement the following: Clearly identify the type of precautions and the appropriate PPE to be used. Place signage that includes instructions for use of specific PPE in a conspicuous location outside the resident's room (e.g., on the door or on the wall next to the doorway), wing, or facility wide. Additionally, either the CDC category of transmission-based precautions (e.g., contact, droplet, or airborne) or instructions to see the nurse before entering should be included in signage. Ensure that signage also complies with residents' rights to confidentiality and privacy. Example 1 R2 was admitted on [DATE] with diagnosis that include hemiplegic and hemiparesis following a cerebral infarction affecting right side, aphasia, dysphagia, and gastrostomy. Most recent Minimum Data Set (MDS) completed on 11/21/25 indicated R2 was not able to complete a Brief Interview for Mental Status (BIMS) assessment. R2 is dependent on cares and has a feeding tube. On 02/17/25 at 7:30 AM, Surveyor observed that R2 did not have EBP signage on or near her door, nor did she have personal protective equipment at or near her door. On 02/17/26 at 7:36 AM, Surveyor observed Certified Nurse Assistant (CNA) E providing personal cares for R2. CNA E provided R2 with incontinence cares, a partial bed bath, and dressed R2. CNA E and Director of Nursing (DON) B then transferred R2 using a Hoyer lift. Both CNA E and DON B used hand hygiene, gloves and wore a mask during R2's cares and transfer. Neither CNA E nor DON B wore a gown. On 2/17/26 at 10 AM, Surveyor interviewed CNA E, who reported R2 does have a Percutaneous Endoscopic Gastrostomy (PEG) tube placed. CNA E is unsure why R2 is not on EBP. On 2/17/26 at 10:01 AM, Surveyor interviewed LPN F, who reported she also is unsure why R2 is not on EBP. LPN F reported she attempted to do R2's catheter flush this morning, and R2 refused. LPN F stated she did not wear a gown because R2 is not on EBP. On 2/17/2026 at 10:46 AM, Surveyor interviewed DON B, who stated R2 does not require EBP because area around R2's PEG tube site is healed, even though PEG tube remains in place. On 2/17/2026 at 2:32 PM, DON B reported after further investigation R2 is now on EBP for her indwelling PEG tube. Example 2 R4 was admitted to facility on 08/11/25. Surveyor reviewed R4's physician orders -Clean PEG tube insertion site and change PEG tube dressing daily. -Enteral Feed two times a day 16oz Jevity 1.5 BID via gravity -Enteral Feed four times a day for hydration 50 mL Free water flush Observations: On 02/16/26 at 2:10 PM, Surveyor did not observe an EBP sign outside R4's room. Surveyor did not observe a PPE cart anywhere in R4's room or outside R4's door. On 02/17/26 at 11:03 AM, Surveyor observed LPN H enter R4's room without sanitizing hands. Surveyor did not observe LPN H don Personal Protective Equipment (PPE) before entering and gathering R4's PEG tube supplies. LPN H placed tube feeding supplies on contaminated bedside table. Surveyor did not observe LPN H clean bedside table or re-sanitize hands. On 02/17/26 at 11:06 AM, Surveyor observed Infection Control (IC) Registered Nurse (RN) C come to R4's door and called for LPN H. LPN H walked to door and IC RN C reported to LPN H that R4 should be on EBP. IC RN C placed EBP sign on wall outside R4's door and placed a PPE cart inside R4's door. LPN H reported to IC RN C that once LPN H was done with PEG tube supplies LPN H would don PPE. IC RN C walked away from R4's door and LPN H finished placing R4's supplies on bedside table. LPN H walked over to R4's door and donned gown. LPN H reached into LPN H's pocket and pulled a pair of contaminated gloves out of pocket. While LPN H grabbed pair of gloves out of LPN H's scrub pockets, Surveyor could hear keys making noises in LPN H's scrub pocket. LPN H donned contaminated gloves, then grabbed contaminated garbage can, moving to side of bed, and then began drawing up gastric residual from R4's PEG tube with contaminated gloves. LPN H grabbed R4's PEG tube and began flushing water into R4's PEG tube. Surveyor observed LPN H take old dressing off and then grabbed clean dressing with contaminated gloves. LPN H reported that LPN H realized the new dressing had some kind of grime on it from R4's PEG tube from old dressing and LPN H touching the clean dressing with contaminated gloves. So, LPN H quickly threw the clean dressing in the garbage and grabbed another new dressing for R4's PEG tube site with contaminated gloves. LPN H applied new dressing to R4's PEG site with contaminated gloves. Surveyor observed LPN H doff contaminated gloves, placed PEG tube supplies on sink in R4's bathroom and exited R4's room. Surveyor did not observe LPN H sanitize hands in between glove changes nor exiting R4's room. On 02/17/26 at 12:00 PM, Surveyor interviewed LPN H and asked about process for utilizing EBP and hand hygiene between glove changes. LPN H reported should have used sanitizer and did not. On 02/17/26 at 12:20 PM, Surveyor interviewed IC RN C for expectation of hand hygiene during tube feeding, sanitizing hands between glove changes, and wearing EBP. Surveyor also stated to IC RN C that LPN H had gloves stored in LPN H's scrub pocket. IC RN C reported to Surveyor that staff are not to store gloves in scrub pockets when delivering cares. IC RN C reported that LPN H should have used hand hygiene such as sanitizing hands in between glove changes. IC RN C reported that IC RN C will be educating LPN H. IC RN C reported to Surveyor that IC RN C knows that the EBP signage and use was unclear so residents receiving tube feeding will now always be on EBP measures.

Based on interview and record review, the facility did not develop and implement a person-centered care plan for a resident consistent with resident rights including services to attain or maintain the resident's highest or practicable physical, mental or psychosocial needs for 1 of 5 residents (R5). R5 did not have a comprehensive person-centered care plan for the use of a high-risk medications of Apixaban, which is an anticoagulant, Furosemide, which is a diuretic, and Lantus subcutaneous solution, which is an insulin. Findings include:Facility policy titled, Care Planning, revised 12/25, states in part, See AMDA guidelines. American Medical Directors Association (AMDA) guidelines states in part, Care Plan .Interventions: Specific, actionable steps for nursing staff, including monitoring, non-pharmacological interventions, and pharmacological management.R5 was admitted on [DATE]. R5's diagnosis included diabetes mellitus with chronic kidney disease, atrial fibrillation, congestive heart failure, obstructive and reflux uropathy, and weakness.Review of R5's quarterly Minimum Data Set (MDS) assessment, completed on 12/10/25, indicated R5 is on the following high-risk medications, an anti-coagulant, a diuretic, and a hypoglycemic medication. MDS also indicated R5 had a brief interview of mental status (BIMS) score BIMS of 14/15, indicating intact cognition.R5's medications include an anticoagulant, Apixaban 2.5 mg by mouth two times a day for atrial fibrillation, a diuretic, Furosemide 20 mg by mouth one time a day for chronic kidney disease and congestive heart failure and a hypoglycemic, Insulin- Lantus subcutaneous solution 100 unit/ml, inject 50 unit subcutaneously one time a day related to type 2 diabetes mellitus with diabetic chronic kidney diseaseReview of R5's care plans and medication administration record did not document a plan of care for bleeding risk, diuretics risks, or insulin/hypoglycemic risks.On 02/18/2026 at 11:10 AM, Surveyor interviewed Certified Nurse Assistant (CNA) D who reported the CNAs do not have specific guidelines to look for residents but instead would report anything out of the ordinary. On 02/18/2026 at 11:18 AM, Surveyor interviewed Director of Nursing (DON) B who stated any changes noted for any resident, such as bleeding or side effects of any high-risk medication, would be reported to the nurse from the CNA and followed up on, just as any change in condition would be reported. DON B stated they do not have specific side effects or risks identified in residents' care plans or on the medication administration record. DON B stated to Surveyor there are no specific care plan interventions or specific monitoring identified for nursing staff to watch for with R5's high-risk medications.

Based on interview and record review, the facility did not establish an Infection Prevention and Control Program (IPCP) which must include, at a minimum, an antibiotic stewardship program with a system to monitor antibiotic use. This had the potential to affect 1 of 5 residents (R7) reviewed for unnecessary medications.Hospice placed R7 on Cephalexin 500mg oral to be given two times a day for a UTI, which was not diagnosed with a urinalysis (U/A) and a culture and sensitivity (C & S). Facility did not ensure the antibiotic stewardship program was followed and that the criteria used to identify infection, McGeer's, was followed.Findings:Facility policy titled, Antibiotic Stewardship Policy, copy with permission dated 2023 stated in part: .Procedure: .2. The Nurse will utilize the (insert facility identified/approved standardized criteria tools: i.e. Loeb Minimum Criteria, McGeer Constitutional Criteria, AHRQ-UTI SBAR, etc.) infection criteria protocol to assess/evaluate resident to determine if it is necessary to treat with antibiotics or if adjustments in therapy need to be made.3. Notify physician/practitioner of resident change of condition and evaluation information. The nurse will communicate to physician/practitioner the facility infection criteria protocol to treat the respective infection .5. If indicated, based upon (identified) criteria, an antibiotic is ordered, the physician/practitioner must identify the diagnosis/indication for use, the appropriate antibiotic, proper dose, duration and route.a. in the event that the prescribing practitioner orders an antibiotic without identification of infection criteria, the practitioner will be requested to identify rational for ordered antibiotic. The Medical Director may be contacted for further directions .10. The infection Preventionist will track antibiotic use and monitor adherence to evidence-based criteria, and compile reports related to monitoring antibiotic usage and resistance date.R7 was admitted to the facility on [DATE] with diagnoses of Urinary Tract Infection (UTI). There was an order in R7's Electronic Health Record (EHR) for Cephalexin 500 milligrams (mg) to be given two times a day for a UTI starting on 02/13/26 and ending on 02/18/26.On 02/17/26 at 7:17 AM, Surveyor was screening R7 and asked R7 about the antibiotic. R7 replied, Well, I think hospice services put me on this antibiotic for 5 days to see if it helps, but I don't know why? Normally I would expect them to do some sort of lab work before just putting me on an antibiotic.On 02/17/26 at 7:46 AM, Surveyor asked Director of Nursing (DON) B for a copy of any lab work that would justify R7 being on the antibiotic.On 02/17/26 at 8:45 AM, DON B provided Surveyor with a 'Comment to the Provider' dated 02/13/26 that stated in part: Also was hesitant. Hospice treat with no Urinalysis (UA)/Urine Culture (UC). Spoke with hospice regarding this and on McGeer's criteria. He stated he would relay message to provider .On 02/17/26 at 8:55 AM, Surveyor interviewed Infection Control (IC) C about this antibiotic being ordered for R7. IC C replied, This resident had urgency and hesitancy. When I spoke to hospice, they indicated that the provider wanted the antibiotic started right away to treat for comfort without any lab work.On 02/17/26 at 10:00 AM, Surveyor interviewed IC C about whether or not this antibiotic would meet the facility's antibiotic stewardship policy and protocol. IC C replied, This antibiotic does not meet McGeer's criteria by the resident's symptoms alone, and this resident has a history of urgency prior to coming. [R7] just has to go to the bathroom all of the time.

Based on record review and interview, the facility must ensure each resident is free from unnecessary medications as evidenced by completing adequate behavioral monitoring for 2 of 5 residents (R7 and R16) reviewed for unnecessary medications.Findings:Facility policy titled, PSYCHOTOPIC MEDICATIONS, revised 1/26, stated in part: 6. The specific targeted behaviors for which the drug is being administered will be entered by the nurse on the behavior monitoring record. The effectiveness of the psychotropic drug will be documented on the behavior sheet each shift. Total occurrences may be based on the personal observation or the observation of other staff members 8. The effectiveness of the psychotropic drug on the targeted behavior will be addressed at least monthly in the interdisciplinary notes .10. The behavior monitoring record will be reviewed quarterly . Example 1R7 was admitted on [DATE] with a Brief Interview of Mental Status (BIMS) score of 14/15 which indicated R7 was cognitively intact. R7 had diagnoses of anxiety and depression. R7's physician orders included in part:. Trazadone give 50 milligrams (mg) by mouth at bedtime for sleep related to major depressive disorder.Fluoxetine give 60 mg by mouth in the morning for depression related to major depressive disorder . R7's care plan stated in part: . Resident has potential for adverse effects r/t psychotropic medications Administer psychotropic medications as ordered by physician. Observe for and report to nurse any side effects and effectiveness. If medication is not effective, notify the nurse.Care team to review, consult with pharmacy and MD to consider dosage reduction if clinically appropriate at least every six months.Educate the resident/family/caregivers about risks, benefits and potential side effects Observe for and report to the nurse any occurrence of behavior symptoms: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards care team members/others etc.Observe for and report to the nurse any of the following adverse reactions of psychotropic medications: unsteady gait, 'chewing motion' movement of jaw, shuffling gait, rigid muscles, shaking, difficulty swallowing, complaints of dry mouth, depression, complaints of blurred vision, fatigue, complaints of inability to fall asleep or remain asleep), complaints of loss of appetite, weight loss, vomiting, behavior symptoms that are 'not usual' for this resident. Resident has potential for altered mood Administer medications as ordered. Monitor/document for side effects and effectiveness.Consult with pharmacy, MD to consider dosage reduction when clinically appropriate at least quarterly.Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms medications and sign consent to give medications at least every 15 months or sooner.INTERVENTIONS TO LESSEN MY POTENTIAL FOR OR ACTUAL MOOD/BEHAVIOR SYMPTOMS: 1) Offer/provide 1:1 for me to express my feelings/thoughts/concerns. 2) Encourage involvement in daily decision making 3) Reinforce strengths 4) Report pain indicators 5) Report changes in ability 6) Invite and assist with activities 7) Encourage reminiscence Monitor/document/report to Nurse/MD signs and symptoms of depression, including: hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness. Observe for and report to nurse any behaviors such as: tearfulness, anxiousness, pacing, wandering, exit-seeking behavior, making negative statements about wanting to be here, decrease/lack of social interaction with others Refer to activity care plan for activities of interest . On 02/17/2026 at 11:12 AM, Surveyor asked Infection Control (IC) C nurse for behaviors for this resident as she is on psychotropics. IC C replied, Well I think this resident is just on an antidepressant, but I will check on that. On 02/17/2026 at 1:19 PM, Director of Nursing (DON) B informed this Surveyor, We just do behavior monitoring and charting by exception as needed. On 02/17/2026 at 2:29 PM, Surveyor asked DON B, When do the nursing staff monitor and document behaviors when a resident is on psychotropic medications? DON B replied, We only monitor resident's behavior with antidepressants if they start showing depressive behaviors and that would trigger the monitoring at that time. On 02/18/26 at 10:38 AM, Surveyor reviewed the facility's policy and R7's care plans regarding psychotropic medications. Surveyor then asked DON B for documentation for behavioral monitoring for R7. DON B replied, We do not have any further documentation for behavioral monitoring on this resident. Example 2 R16 was admitted to the facility on [DATE] with diagnoses including in part, type 2 diabetes mellitus with hyperglycemia, hypertensive kidney disease stage 1-4, Alzheimer's disease, benign neoplasm of cerebral meninges, nonrheumatic aortic stenosis, dementia, personal history of methicillin resistant staph aureus (MRSA), and muscle weakness. R16's Minimum Data Set (MDS) assessment, dated 11/06/25, identified R16 had Brief Interview for Mental Status (BIMS) of 10/15 that identified R16 with moderate cognitive impairment. R16's psychotropic medication care plan: Resident has potential for adverse effects r/t psychotropic medications initiated on 10/25/24: -Administer psychotropic medications as ordered by physician. -Observe for and report to nurse any side effects and effectiveness. If medication is not effective, notify the nurse. -Care team to review, consult with pharmacy and MD to consider dosage reduction if clinically appropriate at least every six months. - Educate the resident/family/caregivers about risks, benefits and potential side effects. -Observe for and report to the nurse any occurrence of behavior symptoms: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards care team members/others etc. -Observe for and report to the nurse any of the following adverse reactions of psychotropic medications: unsteady gait, 'chewing motion' movement of jaw, shuffling gait, rigid muscles, shaking, difficulty swallowing, complaints of dry mouth, depression, complaints of blurred vision, fatigue, complaints of inability to fall asleep or remain asleep), complaints of loss of appetite, weight loss, vomiting, behavior symptoms that are 'not usual' for this resident. R16's physician orders included in part:.Venlafaxine HCl Oral Tablet 75 MG (Venlafaxine HCl), Give 75 mg by mouth two times a day related to unspecified depression. Surveyor reviewed Gradual Dose Reduction (GDR) dated 10/17/25 included in part: .Recommendation to assess for trial GDR of Effexor or provide documentation below if a GDR contraindicated. Surveyor found that the provider only discontinued Aricept and did not address R16's Effexor or trial a GDR. On 02/17/2026 at 11:12 AM, Surveyor asked IC C for behaviors for this resident as he is on psychotropics. IC C replied, Well I think this resident is just on an antidepressant, but I will check on that. On 02/17/2026 at 1:19 PM, Director of Nursing (DON) B informed this Surveyor, We just do behavior monitoring and charting by exception as needed. On 02/17/2026 at 2:29 PM, Surveyor asked DON B, When do the nursing staff monitor and document behaviors when a resident is on psychotropic medications? DON B replied, We only monitor residents' behavior with antidepressants if they start showing depressive behaviors and that would trigger the monitoring at that time. On 02/18/26 at 10:38 AM, Surveyor reviewed the facility's policy and R16's care plans regarding psychotropic medications. Surveyor then asked DON B for documentation for behavioral monitoring for R16. DON B replied, We do not have any further documentation for behavioral monitoring on R16.

Based on record review and interview, the facility did not provide the proper discharge documentation for 2 of 2 residents (R44 and R4) reviewed for discharge.Facility did not have bed hold or notice of transfer documentation for R44.Facility did not have Ombudsman notification and notice of transfer documentation for R4.Findings:Example 1R44 was admitted to the facility on [DATE] with a Brief Interview of Mental Status (BIMS) of 13/15, which indicated R44 was cognitively intact. R44 had Minimum Data Set (MDS) stating 'Discharge Return Anticipated' dated on 01/14/26 and 12/21/25.On 02/18/26 at 9:13 AM, Surveyor was unable to find a bed hold for discharge date of 01/14/26 and a notice of transfer form. Surveyor asked Director of Nursing (DON) B for these documents.On 02/18/26 at 9:43 AM, DON B came into the conference room asking Surveyor what needs to be on the 'Notice of Transfer.' Surveyor informed DON B, The Notice of Transfer needs to have 1) in writing, 2) in language they understand, 3) the reason for the transfer.On 02/18/26 at 10:01 AM, Nursing Home Administrator (NHA) A informed Surveyor there is no bed hold for the transfer to the hospital dated 01/14/26 because the resident and the resident's representative did not want this resident to return to the facility. Surveyor replied, In the future there has to be a bed hold that says, 'No' to indicate this. NHA replied, Oh, I get it, so it specifies that they do not want the bed held.On 02/18/26 at 10:03 AM, NHA A informed Surveyor, We do not have the notice of transfer documentation. We tell the resident/representative why we are sending the resident out and document in the medical chart, but we don't give them a notice in writing in language they understand why they are being sent to the emergency room.Example 2R4 was admitted to the facility on [DATE] with a BIMS of 00 which indicated R4 had severe cognitive impairment. R4 had MDS dated [DATE] stating 'Discharge Return Anticipated.'On 02/18/26 at 9:13 AM, Surveyor was unable to find an Ombudsman notification and notice of transfer form for R4's discharge date [DATE]. Surveyor asked DON B for these documents.On 02/18/26 at 9:43 AM, DON B came into the conference room asking Surveyor what needs to be on the 'Notice of Transfer.' Surveyor informed DON B, The Notice of Transfer needs to have 1) in writing, 2) in language they understand, 3) the reason for the transfer.On 02/18/26 at 10:03 AM, NHA A informed Surveyor, We do not have the notice of transfer documentation. We tell the resident/representative why we are sending the resident out and document in the medical chart, but we don't give them a notice in writing in language they understand why they are being sent to the emergency room.On 02/18/2026 at 10:04 AM, NHA A informed Surveyor that because this resident was transferred out on 10/31/25 we do not remove the resident from our computer system in case they are only gone for a short stay. Our social services sends the ombudsman notification out on the 3rd day of the month. Unfortunately, there was an overlap from the transfer and the social worker's ombudsman notification. So, this resident's ombudsman notification never happened.

Based on record review and interview, the facility did not conduct a Preadmission Screening Resident Review (PASRR) Level II screen for R1, who has a serious mental disorder and is taking psychotropic medication to treat symptoms of major mental disorder to ensure he received care and services to meet his needs. The facility practice affected 1 of 1 resident (R) reviewed (R1).Findings include:Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASRR requires that Medicaid-certified nursing facilities:Evaluate all applicants for serious mental illness (SMI) and/or intellectual disability (ID)Offered all applicants the most appropriate setting for their needs (in the community, a nursing facility, or acute care settings)Provide all applicants the services they need in those settingsPASRR screenings determine whether applicants might have an intellectual/developmental disability (ID/DD) and/or mental illness. This is a Level I Screen. The purpose of a Level I Screen is to identify individuals whose total needs require they receive additional services for their ID/DD and/or mental illness. Individuals who test positive at Level I are then evaluated in depth to confirm the determination of an ID/DD and/or mental illness for PASRR purposes. This is a Level II Screen. This assessment produces a set of recommendations for necessary services that are meant to inform the individual's plan of care. Nursing facilities may seek county exemption (DHS form F-20822), for applicants with ID/DD and/or mental illness whose stay in the facility is expected to be recuperative care or short-term. R1 was admitted on [DATE] with diagnoses that include schizoaffective disorder. R1 was prescribed the following psychotropic medications: Buspirone HCL, Clozapine, and Lorazepam.On 03/24/25, a Level I PASRR screening noted R1 had a major mental disorder and has taken psychotropic medications to treat symptoms or behaviors of a major mental disorder, indicating a Level II PASRR should be completed. The Level I PASARR done nearly one year ago, indicated yes for hospital discharge 30 day exemption from a Level II screening. On 02/17/26, Surveyor asked Director of Nursing (DON) B for a copy of R1's abbreviated PASRR level II.On 02/18/26 at 7:40 AM, DON B stated the facility does not have a PASARR II for R1. DON B reported the facility Social Worker is on vacation. However, DON B did call her and is still not able to locate or confirm that a PASARR II was ever completed for R1.

Based on observation, interview and record review, the facility did not ensure residents were safe in their environment to prevent the risk of falling. This occurred for 1 of 1 resident (R) reviewed for falls, (R16). The facility staff did not ensure R16 had dycem pad while R16 was sitting in recliner as care planned.Findings include: R16 was admitted to the facility on [DATE] with diagnoses including in part, type 2 diabetes mellitus with hyperglycemia, hypertensive kidney disease stage 1-4, Alzheimer's disease, benign neoplasm of cerebral meninges, nonrheumatic aortic stenosis, dementia, personal history of MRSA, and muscle weakness. R16's Minimum Data Set (MDS) assessment, dated 11/06/25, identified R16 had Brief Interview for Mental Status (BIMS) of 10/15 that identified R16 with moderate cognitive impairment. R16's fall risk care plan stated, R16 is at risk for falls r/t disease process, dementia initiated on 09/26/2023: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, initiated on 09/27/2023. Dycem in recliner, initiated on11/22/2025. Encourage to participate in activities that promote exercise, physical activity for strengthening and improved mobility, initiated on 09/27/2023. Surveyor reviewed R16's progress notes, state in part, -On 11/22/25 fall note: Late Entry: CNA alerted writer to resident room, stating resident was on the floor. Writer approached resident room and observed resident lying on the floor in front of recliner with head up, recliner in full upright position. Res was immediately assessed for injury and vitals were obtained. Vitals WNL, no apparent injuries noted. Res LOC intact and responses were appropriate.Action: Res was lifted with 2-assist and hoyer-lift from floor into bed. Res stated to writer that he went to adjust his chair and the chair started lifting and didn't stop- and before he knew it he was on the floor. Res denies hitting head but stated that he was unsure.Response: DON notified. POA notified via telephone and thanked for the update, stated she would call him tomorrow. Theoria on-call NP notified. Intervention of dycem to recliner when resident up out of bed. Encourage resident to ask for assistance with adjusting chair if needed. Observations: On 02/17/26 at 10:12 AM, Surveyor observed Certified Nurse Assistant (CNA) D and CNA G transfer R16 to recliner from bed with Hoyer lift. R16 was placed in recliner with no dycem in place on recliner seat. CNA D and CNA G exited R16's room. Surveyor did not observe any staff place the dycem pad in R16's recliner as ordered to prevent potential falls. On 02/18/2026 at 12:15 PM, Surveyor interviewed CNA G and asked if CNA G had placed dycem pad on recliner before transferring R16 to recliner from bed yesterday to prevent potential falls from occurring. CNA G reported to Surveyor that CNA G was unsure if dycem was in R16's recliner and did not place it in recliner when transferred R16 to recliner yesterday on 02/17/26. On 02/18/26 at 12:38 PM, Surveyor interviewed Director of Nursing (DON) B and asked DON B's expectation for R16 to have dycem in recliner when out of bed in recliner. DON B reported that staff should be making sure dycem is in recliner whenever R16 is in the recliner. Surveyor reported to DON B that Surveyor observed R16 placed in recliner without dycem underneath. DON B reported that staff should have verified dycem was in recliner before R16 was placed in recliner.

Based on observation, interview, and record review, the facility did not ensure 1 (R32) of 1 resident reviewed receiving physical therapy received the care necessary to meet professional standards.Facility did not obtain a Cam boot for R32's transfers as ordered from Orthopedic Surgeon I.Findings include:R32 was admitted to the facility on [DATE] with diagnoses including in part, atrial fibrillation, nonrheumatic aortic insufficiency, hypertensive heart disease, peripheral vascular disease, unilateral osteoarthritis left ankle and foot, hypertension, weakness, and presence of right artificial hip joint.R32's Minimum Data Set (MDS) assessment, dated 12/13/25, identified R32 required substantial maximal assistance for bed mobility, taking on and off footwear, rolling left to right, sitting to lying, chair to bed, toileting, and for transfers.Surveyor reviewed R32's ortho notes, which stated in part, .-On 02/10/26, Left tibia/fibula fractureMay remove temp splint and transition to tall Cam walking boot. May remove boot for skin hygiene and showers and ankle ROM. Weight bearing as tolerated for transfers in boot, 25% weight bearing for distance in boot. Ankle and knee range of motion.Skin care-wounds from first splint with inadequate padding.Follow up in 5 weeks. Next appointment 03/17/26. On 02/16/2026 at 3:29 PM, Surveyor interviewed R32 and asked how R32 injured her foot. R32 reported to Surveyor that she had a transfer in bathroom with physical therapy (PT) on 12/29/25 where R32 felt and heard a pop with burning sensation. Later that day provider came to visit R32 who stated it is in fact broken and sent to emergency room (ER). R32 reported that she came back with a cast on from the ER due to a displaced fracture of left fibula. R32 stated to Surveyor, I feel like facility has not been taking care of my leg as it's growing crooked and never gets looked at. R32 reported that the post op shoe on R32's foot is hurting all the time during transfers, and even when sitting in wheelchair.On 02/17/2026 at 6:38 AM, Surveyor observed R32 in wheelchair self-propelling around in R32's room. Surveyor observed a post op shoe and posterior splint on left foot.On 02/17/26 at 2:31 PM, Surveyor interviewed Director of Nursing (DON) B and asked if DON B knew that R32 was still wearing post op shoe instead of the Cam boot that was recommended by Orthopedic Surgeon I on 02/10/26. DON B asked Surveyor where Surveyor sees the recommendations. Surveyor showed DON B the recommendation orders from Orthopedic Surgeon I from a scanned document in R32's medical record scanned on 02/11/26. DON B reported that somehow R32's ortho orders did not make it into the medical record and expectation would be that the nurse on duty transcribes orders into medical record once new orders are known. Surveyor asked if resident has the Cam boot on now, and DON B reported that DON B was unsure but didn't think so. Surveyor asked DON B to go with Surveyor to peek at R32's left foot. On 02/17/26 at 2:35 PM, Surveyor entered R32's room with DON B. DON B confirmed that R32 still had post op boot and posterior splint instead of the Cam boot recommended back on 02/10/26.On 02/18/26 at 8:45 AM, Surveyor called Orthopedic Surgeon I to interview about post op shoe and Cam boot orders. Surveyor left message for return call.On 02/18/26 at 9:32 AM, Surveyor interviewed Orthopedic Surgeon I and asked if Orthopedic Surgeon I could walk Surveyor through consultation visits Orthopedic Surgeon I had with R32 over the last couple months. Orthopedic Surgeon I reported that R32's initial consultation visit was on 01/13/26 where R32 arrived from a cast placed by the ER weeks prior. R32 was noted to have substantial eschar from the initial cast placed from the ER for the initial fracture and splint. Then R32 was seen recently on 02/10/26 and fracture looked good, so recommendations were to put temporary posterior splint on with post op shoe but change to a Cam boot once facility receives Cam boot. Orthopedic Surgeon I reported that when Orthopedic Surgeon I went to apply Cam boot in the clinic visit, insurance stated Cam boot won't be covered and that the facility had to order it through DME services to have it covered. Surveyor asked if Orthopedic Surgeon I is aware that R32 is still being transferred via EZ-Stand with post op shoe and temporary posterior splint. Orthopedic Surgeon I stated that the posterior splint and post op shoe was to be used temporarily, and R32 absolutely needs to be in a Cam boot as soon as possible to provide stability while transferring from standing to sitting position.On 02/18/26 at 1:21 PM, Surveyor interviewed Physical Therapy Assistant (PTA) J and asked if R32 has a Cam boot on. PTA J reported to Surveyor that R32 does not have a Cam boot on and that R32 is wearing her post op shoe. Surveyor asked if PTA J was aware that R32 should be transferring with a Cam boot versus the temporary splint with post op shoe. PTA J reported that PTA J did not know that but maybe Physical Therapy (PT) L did. Surveyor requested PTA J to have PT L call Surveyor once PT L was available to talk.On 02/19/26 at 8:07 AM, Surveyor interviewed PT L and asked about R32's Cam boot. PT L reported that PT L received the orthopedic's orders on Wednesday February 11th, 2026. Surveyor asked if Cam boot was ordered for R32. PT L stated, I received CAM boot orders last week on Wednesday February 11th, but Cam boot wasn't ordered until this week on Tuesday February 17th, 2026. Surveyor asked PT L why the Cam boot was ordered a week later after seeing the orders prior. PT L reported that ordering the Cam boot is a shared responsibility between nursing and PT as nursing does all the ordering from special companies, but usually a resident will come back from an orthopedic clinic visit with Cam boot on and R32 did not come back with it on.At 8:16 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked if the Cam boot was ordered for R32. NHA A reported that the Cam boot was ordered on Tuesday 02/17/26. Surveyor asked where did NHA A order Cam boot from. NHA A reported that sometimes we order stuff off Amazon. Surveyor asked for verification of invoice or receipt for ordering R32's Cam boot. NHA A reported she would email it to Surveyor soon. On 02/19/26 at 9:27 AM, Surveyor received an email confirmation that NHA A ordered R32's Cam boot. NHA A was on phone with Surveyor and explained that R32's Cam boot was ordered now but should have been ordered when the Orthopedic Surgeon I's recommendations came through back on 02/10/26.

Based on interview and record review, the facility did not ensure care plan was revised to reflect resident's current needs and direct staff in providing necessary care and services. The facility practice affected 1 of 15 residents' care plans reviewed (R5).R5 had changes in mood and increased depression. R5's care plan was not updated to reflect changes identified, interventions, and monitoring of R5. Findings include:According to the Resident Assessment Instrument, The comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving.R5 was admitted to the facility on [DATE] with diagnosis that included type 2 diabetes mellitus, chronic kidney diseases, prostate cancer, and weakness.R5's Minimum Data Set (MDS) of 9/9/25 indicated R5's Resident mood interview/ Patient Health Questionaire-9 (PHQ- 9) R5 scored 01, indicating no or minimal depression.R5's most recent quarterly Minimum Data Set (MDS) dated [DATE] documented R3 scored 14/15 on a Brief Interview for Mental Status (BIMS), indicating intact cognition.On 12/15/25, R5 had another PHQ-9 with a score of 10 indicating moderate depression. Social Service note on 12/15/25 documents, Quarterly plan of care (POC) completed. PHQ-9 completed, and resident scored a 10, indicating moderate depression. Resident does admit to finding little interest in doing things, feeling depressed, trouble sleeping, and feeling tired. He has also had thoughts that he would be better off dead but would not hurt himself. Resident admits to dealing with a lot of changes medically, which has been hard on him. Writer did offer him the option of doing talk therapy with Encounter tele-health. He stated that he would think about it and let writer know if he would like to try it. Resident remains a full code status and his goal still remains to go home in the Spring. Writer will continue to offer support and assist as needed.Documentation indicates there was communication with medical doctor (MD), resident, durable power of attorney (DPOA), guardian, and dietary on plan of care. However, behavior/mood was not addressed in R5's care plan or treatment record.R5's medical record stated on 12/21/2025 resident reminiscing with nurse this AM and expressed past episodes of depression and thoughts of suicide. He did assure that he was not presently having any thoughts or plans of suicide but expressed that this is a difficult time of year for him with holidays. Will place on q shift behavioral monitoring x 7 days throughout holidays.R5's treatment record charted on 12/21/25, 12/22/25, 12/23/25,12/24/25, and 12/27/25 indicating no comments or behaviors noted. On 12/22/25, R5's medical record stated, Resident expressed that he is depressed about his situation of being in the nursing home and not being able to be home. Encouraged resident to focus on things that bring him joy in life at this time and working towards achievable goals (such as getting to a living situation where he can enjoy his cats). He agreed and stating understanding and did express that he was enjoying movies playing today and reminiscing. Spoke with Director of Nursing (DON) about offering services such as talk therapy. Resident was out to see his primary provider today and no paperwork returned. A late entry was documented as follows, 2/14/2026 05:10 Behavior/Mood Note, Late Entry: Resident made statement I pay you enough to do just enough so I don't kill myself. Writer ensured that resident had no safety or self-harm concerns and resident confirmed that he made statement out of frustration.On 2/17/2026 at 8:05 AM, Surveyor interviewed R5 who in conversation reported he has contemplated suicide. R5 reported he had verbalized a plan to get narcotics and stated he has also spoke to facility staff including the Social Worker. On 2/17/2026 at 8:10 AM, Surveyor interviewed SW designee/CNA, who reported she was aware of R5's verbalization of suicide in the past and is not sure what has been done. Referred Surveyor to DON B.On 2/17/2026 at 8:13 AM, Surveyor interviewed DON B, who denied awareness of R5's contemplations of suicide. After reviewing documentation, DON B reported there was documentation of R5's suicidal thoughts and this was addressed and documented when R5 was monitored for 7 days starting 12/21/25. Surveyor asked DON B what the procedure was for when residents verbalize thoughts of suicide. DON B stated they would assess resident for a plan, do a search of the room, and offer counseling.On 2/17/2026 at 2:20 PM, Surveyor interviewed DON B. Surveyor asked DON B about R5's care plan not addressing R5's change in mental status/increased depression. DON B stated it was addressed in R5's treatment administration record when R5's behaviors were monitored for 7 days. DON B stated it was a one-time episode of what was believed situational thoughts of suicide. Surveyor pointed out the increased PHQ-9 score had also indicated R5's change in mental status. R5's care plan does not address his change in condition and does not provide interventions for staff to monitor his behaviors or awareness of R5's thoughts of suicide.

Based upon interview and policy review, the facility did not ensure a thorough investigation for 1 of 1 (R1) resident reviewed for safety concerns.R1 fell during an assist of 1 transfer with Certified Nursing Assistant (CNA) C without proper safety measures in place. Facility did not complete a thorough investigation when they did not interview or investigate for potential risk to other residents throughout the facility.This is evidenced by:The facility's policy and procedure for Abuse Prevention, last reviewed 05/2025, includes, in part: .The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. The purpose of the policy is to use a systematic approach to the creating of a climate which encourages the protection of the right to be free from abuse. This will be done by:* 6. A thorough investigation of the allegation will be initiated. 7. The investigation may include, but not limited to:c. Interviewing other residents to determine if they have been abused or mistreated .R1 was admitted to the facility on [DATE] with the following diagnoses: palliative care, atrial fibrillation, congestive heart failure, unspecified dementia, chronic kidney disease, and history of falling. The Minimum Data set (MDS) dated [DATE] indicates R1 has a Brief Interview for Mental Status (BIMS) of 8/15 which indicates R1 has moderate cognition impairment. R1 transfers with assist of one, gait belt, and with walker. Surveyor reviewed investigation notes pertaining to R1's fall incident that stated in part: R1 interviewed about fall on 08/24/25. Facility Reported Incident (FRI) indicates CNA C was transferring R1 from the bathroom to R1's wheelchair and R1 fell on [DATE] at 6:44 AM. R1 did not have a gait belt on or non-slip footwear per plan of care when the fall occurred. Staff verbally educated CNA C on 08/24/25 on safe handling of residents. Director of Nursing (DON) B interviewed CNA C on 08/28/25 about R1's fall and provided written education pertaining to Safe Handling of Residents policy and importance of using gait belt and non-slip footwear.Surveyor did not find any documentation that other residents were interviewed or assessed for any past falls or potential neglect concerns regarding CNA C and safe transfers. On 09/18/25 at 8:57 AM, Surveyor interviewed DON B and asked DON B if any other residents were interviewed after R1's fall to inquire about potential other falls during CNA C transferring other residents and cares. DON B reported to Surveyor that DON B did not interview any other residents after identifying CNA C did not follow the care plan during a transfer. Surveyor did not find a thorough investigation completed to assess for other caregiver neglect concerns with other residents and CNA C.

Based on interview and record review, the facility did not ensure controlled medications were administered under professional standards of clinical practices for residents (R1, R2, R3, R4, and R5). R1, R2, R3, and R4 had narcotic medications, in which the facility did not ensure accurate documentation on the narcotic sheets. R5 has Lorazepam, which is a controlled substance, needing a double lock. The medication was not double locked. Findings include: On 07/07/25 at 12:25 PM, Surveyor observed medication cart on 200-300 hall with Registered Nurse (RN) C. Surveyor observed R1, R2, R3 and R4's narcotic sheets to have discrepancies. Surveyor reviewed R1's narcotic sheet for Morphine Concentrate 20mg/ml 15 ml bottle, take 10mg (0.5ml) by mouth every 4 hours as needed for shortness of breath or pain. R1's narcotic sheet was signed with start volume of 15 ml. -On 04/05/25 at 5:09 PM, signed out on narcotic sheet 0.5ml used. No documentation in R1's Medication Administration Record (MAR) that R1 received the narcotic. -On 04/09/25 at 12:05 PM, signed out on narcotic sheet 0.5ml used. No documentation in R1's MAR that R1 received the narcotic. -On 05/15/25 at 7:28 PM, signed out on narcotic sheet 0.25ml used. Incorrect dose was documented that it was used and no documentation in R1's Medication Administration Record (MAR) that R1 received the narcotic. -On 05/16/25 at 5:35 PM, R1's MAR documented that R1 received narcotic medication but there was no documentation on the narcotic sign out sheet that it was taken out of the Morphine bottle and given to R1. -On 06/30/25 at 6:15 AM, R1's MAR documented that R1 received narcotic medication but there was no documentation on the narcotic sign out sheet that it was taken out of the Morphine bottle and given to R1. Surveyor reviewed R2's narcotic sheet for Morphine Concentrate 20mg/ml 15 ml bottle, take 10mg (0.5ml) sublingual every 4 hours as needed for pain. R2's narcotic sheet was signed with start volume of 15 ml. -On 06/07/25 at 11:30 AM, signed out 0.5ml used and remaining 14.5 ml. -On 06/08/25 at 10:30 PM, nurse signed to right that the bottle had a volume of 20ml. -On 06/09/25 at 4:30 AM, signed out 0.5ml used and remaining 14.0 ml. -On 06/11/25 at 9:54 AM, signed out 0.5ml used and remaining 13.5ml. -On 06/11/25, Director of Nursing (DON) B signed to the right that the volume of medication was reading above the 16mls but really only filled to 15ml but generally to start due to shape of bottle consistent with expected volume. -On 06/11/25 at 9:00 PM, another signed out 0.5ml and remaining 16ml. -On 06/12/25 at 3:15 AM, signed out 0.5ml used and remaining 15.5ml. On 07/07/25 at 12:27 PM, Surveyor interviewed RN C asking why the count was off like that and was not corrected. RN C reported to Surveyor that RN C is unsure how that happened and does not know why the volume was changed and went back up. Surveyor asked RN C what the correct process is for counting remaining amount used and what to do if extra in the bottle. RN C reported to Surveyor that all narcotic bottles end up having a little extra volume than the bottle says. RN C reported that whatever the volume of the bottle is written on the label from the pharmacist is what is documented as its original volume. In this situation the bottle confirmed 15ml even though there was a slight amount over the 15ml; staff still document the 15 ml to start then count down after using the medication. RN C reported that at the end if there is liquid left in the bottle then it is discarded with a second licensed nurse and a new bottle is opened. Surveyor reviewed R3's narcotic sheet for Morphine Concentrate 20mg/ml 15 ml bottle, take 0.25ml by mouth every 2 hours as needed for shortness of breath and pain. R3's narcotic sheet was not signed on the sheet to show amount started with and the date it was dispensed with the nurse's name and title who completed the intake of R3's narcotic in the medication cart. Surveyor interviewed RN C and asked RN C why the narcotic sheet was not filled out appropriately so that staff know what is in the medication cart. RN C reported to Surveyor that RN C does not know why this was not filled out as facility policy. Surveyor observed R4's narcotic sheet for Morphine Concentrate 20mg/ml 15 ml bottle, take 0.25ml (5mg) by mouth every 2 hours as needed for shortness of breath and pain. Surveyor reviewed R4's narcotic sheet was signed with start volume of 15 ml. -On 06/22/25, signed out 0.25ml used and remaining 14.75 ml. -On 06/29/25 at 9:28 PM, signed out 0.25ml used and remaining 14.50ml. Nurse signed, Some spillage withdrawn of plug-in bottle. Surveyor did not observe any other updated volume written on narcotic sheet nor did Surveyor find a second verification from a licensed nurse to verify how much was accidentally spilled. On 07/07/25 at 12:29 PM, Surveyor interviewed RN C and asked RN C what is the correct process if a nurse accidentally spills a narcotic solution such as in R4's example. RN C reported to Surveyor that any spilled narcotic medication needs a second verified licensed nurse to verify and sign on narcotic sheet that there was a spill with remaining volume in bottle and a second signature to decrease chances of mistakes. Surveyor shared with DON B the discrepancies that Surveyor found with R1, R2, R3, and R4's narcotic sheets. Surveyor asked DON B if DON B can explain expectations for the discrepancies. DON B reported to Surveyor that R1's narcotic sheet should have been reviewed during the investigation of the facility report and found the errors Surveyor found. DON B reported that DON B thought DON B's process for educating staff and completing audits afterwards would change the system. DON B reported to Surveyor that DON B understands there are still discrepancies happening and that DON B needs to review more thoroughly and reach out to the potential nurses who are still having errors in medication administration of narcotics. Surveyor asked DON B why the count was off with R2's narcotic sheet and was not corrected. DON B reported to Surveyor that DON B is unsure how that happened. Surveyor asked DON B what the correct process is for counting remaining amount used and what to do if extra in the bottle. DON B reported to Surveyor that all narcotic bottles end up having a little extra volume in the bottle but whatever the volume of the bottle is written on the label from the pharmacist is what is documented as its original volume. DON B reported that DON B was just trying to validate the nurse who indicated there was 20mls in the bottle. DON B corrected the volume to 16mls but should have explained the process better on narcotic sheet. DON B reported that at the end of the bottle if there is liquid left in the bottle then it is discarded with a second licensed nurse and a new bottle is opened. Surveyor asked DON B's expectation of narcotic sheets being filled out when pharmacy dispenses a narcotic to the facility for a resident or in this situation for R3. DON B reported to Surveyor that DON B's expectation is for all staff to fill out the narcotic sheet with date it was dispensed and how much was dispensed, then staff store the labeled narcotic in the medication cart down the set hall. Surveyor interviewed DON B and asked DON B what the correct process is if a nurse accidentally spills a narcotic solution such as in R4's example. DON B reported to Surveyor that any spilled narcotic medication needs a second verified licensed nurse to verify and sign on narcotic sheet that there was a spill with remaining volume in bottle and a second signature to decrease chances of mistakes. DON B reported to Surveyor that in R4's example DON B did not feel it was necessary to have a second nurse verify the spillage as it was just the fluid out of the plunger. Surveyor asked if DON B was there on that day to verify it was the liquid from the plunger. DON B reported to Surveyor that DON B was not in the presence of the nurse when this was signed on narcotic sheet as a spillage. Example 2 On 07/07/25 at 12:41 PM, Surveyor observed medication storage room on hall 100 with RN D. RN D opened refrigerator and Surveyor observed R5's Lorazepam 2mg/ml oral concentrate 30ml bottle located in the door of the refrigerator. Surveyor asked RN D if Lorazepam is supposed to be double locked in the medication storage room. RN D reported to Surveyor that RN D thought it should be double locked but was not sure. RN D reported to Surveyor that RN D would go find out with Director of Nursing (DON) B. On 07/07/25 at 12:45 PM, Surveyor interviewed DON B and asked if DON B knows that Lorazepam is supposed to be double locked. DON B reported to Surveyor that DON B did not know that; she would be fixing this issue right away.

Based on interview and record review, the facility did not ensure that based on the comprehensive assessment of a resident, that residents receive treatment and care in accordance with professional standards of practice. The facility did not ensure that a Registered Nurse (RN) assessed a resident after a fall occurred. This had the potential to effect 2 of 7 residents (R) (R29, R193) investigated for accidents. Findings include: Wisconsin state statue Chapter N 6 titled Standards Of Practice For Registered Nurses And Licensed Practical Nurses dated December 2018, states, In the performance of acts in basic patient situations, the L.P.N. shall, under the general supervision of an R.N. or the direction of a provider: (a) Accept only patient care assignments which the L.P.N. is competent to perform. (b) Provide basic nursing care. N 6.04(1)(c)(c) Record nursing care given and report to the appropriate person changes in the condition of a patient. (d) Consult with a provider in cases where an L.P.N. knows or should know a delegated act may harm a patient. (e) Perform the following other acts when applicable: 1. Assist with the collection of data. 2. Assist with the development and revision of a nursing care plan. 3. Reinforce the teaching provided by an R.N. provider and provide basic health care instruction. 4. Participate with other health team members in meeting basic patient needs . (1m)?Basic nursing care means care that can be performed following a defined nursing procedure with minimal modification in which the responses of the patient to the nursing care are predictable. The facility policy, entitled Fall/Incident Assessment updated on 05/28/24, states, Procedure: resident fall. 1. Do not move the resident until a nurse assess the resident for potential injury 2. Notify the nurse. Example 1 R193 was admitted to the facility on [DATE] at 12:20 PM. Diagnoses included Alzheimer's disease, unspecified intracapsular fracture of right femur related to a fall at home. R193 entered the facility with an activated power of attorney, and the facility did not have time to complete Minimum Data Set (MDS) assessment or baseline care plan. On 11/12/24 at 2:45 PM, Surveyor completed record review of R193's recent fall. Surveyor found that R193 fell and fractured their left hip on 11/07/24 at 3:50 PM, a few hours after entering the facility. Surveyor looked for assessment of the fall and found an interdisciplinary report of the fall and review of the fall by the Director of Nursing (DON), but no initial fall report or assessment from staff member on duty at the time of the fall. On 11/13/24 at 8:38 AM, Surveyor interviewed DON B regarding the fall and initial fall report. DON B said R193 was assessed by a Licensed Practical Nurse (LPN). Initially there were no issues and R193 was assisted into their recliner by the LPN. DON B assessed R193 when R193 began having complaints of pain in left leg. DON B indicated the LPN who assessed R193 has not charted on the incident yet. R193 was transferred to the hospital, having a fractured hip. DON B indicated she has asked staff to chart the assessment. Surveyor asked DON B if an LPN can assess a resident after a fall, and DON B stated an LPN can. Surveyor did request evidence of this. Surveyor did note LPN had assessed R193 and moved them to the recliner prior to an RN assessment. On 11/13/24 at 12:52 PM, LPN E was interviewed regarding scope of practice. LPN E said as it refers to a fall, I can inspect a fall and report my findings. I'm always working with a Registered Nurse. I cannot assess the resident. No evidence was received from facility regarding LPNs being able to assess or move residents after a fall. 44863 Example 2 According to the Nurse Practice Act, an LPN can provide basic nursing care under the supervision of an RN. Basic nursing care includes monitoring vital signs, administering medications, and changing bandages. R29 was admitted to the facility on [DATE]. Diagnoses included dementia with agitation, history of stroke, repeated falls, weakness, unsteadiness on feet, and difficulty walking. R29's MDS assessment dated [DATE] confirmed the following: -Scored 02/15 during Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. On 11/13/24, Surveyor reviewed R29's falls, and noted the following: On 07/29/24, R29's progress notes indicated a Certified Nursing Assistant (CNA) notified an LPN that R29 sustained a fall. Documentation indicated an assessment was completed by LPN C, with no RN assessment. On 09/04/24, R29 sustained a fall. Documentation indicated an assessment was completed by LPN D, with no RN assessment. Surveyor was unable to locate evidence an RN assessment was completed for R29's falls to ensure R29 did not have an injury or change in condition.

Based on interview and record review, the facility did not ensure new care planned fall interventions were implemented post falls to prevent accidents for 1 of 7 residents (R) R29, reviewed for falls. The facility did not implement fall interventions or identify root cause for ten fall incidents, of which R29 sustained minor injury. Findings: The facility's policy titled, Fall/Incident Assessment, read in part .PURPOSE: To assure appropriate follow-through on all accidents and incidents; and to give guidance on preventive/corrective action. 8. The nurse will assess/evaluate the need for any changes in safety precautions and update the plan of care. 9. Document .Corrective action taken to resolve or minimize fall risk. 11. The fall team and DON reviews incidents weekly and make a final interdisciplinary note. R29 was admitted to the facility on [DATE]. Diagnoses included dementia with agitation, history of stroke, repeated falls, weakness, unsteadiness on feet, and difficulty walking. R29's Minimum Data Set (MDS) assessment dated [DATE] confirmed the following: -Scored 02/15 during Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. -Demonstrated verbal, physical, and wandering behaviors. -Required staff assistance with transfers and was able to independently propel his wheelchair. -Incontinent of bowel and bladder, requiring staff assistance with personal hygiene. R29's physician orders included the following: -Furosemide (diuretic), 20 mg daily. -Lorazepam (anti-anxiety), 0.5 mg twice daily, and as needed. R29's care plan included, The Resident is at risk for falls related to history of falls, pain, impaired vision, poor safety awareness, and dementia. Dated 01/04/24, Revised 04/24/24. Interventions: -01/12/24, Encourage participation in activities that will increase strength and mobility. -01/12/24, revised 08/27/24, Sensor alarms in wheelchair, recliner, and bed. Pressure sensing floor alarm by bed. -04/03/24, Therapy to evaluate and treat due to falls. -05/15/24, Remind resident to lift his feet up when in wheelchair without foot pedals. -06/10/24, Walk with resident with walker and assist of one, wheelchair to follow. -07/03/24, Anti-rollback device to wheelchair. -08/15/24, Bathroom visits. -10/24/24, Trial prompted every two hours toileting schedule. R29's fall risk assessments confirmed R29 is at high risk for falls. On 11/13/24, Surveyor reviewed R29's falls investigations for the previous three months and noted the following falls: -07/20/24, un-witnessed fall in bathroom. R29 sustained skin tear to right upper arm. Interdisciplinary team (IDT) review of fall; Root cause of fall was dementia with poor safety awareness. Remains a high fall risk. Care plan reviewed and remained appropriate. Surveyor noted no new intervention implemented. -07/29/24, R29 was ambulating with staff from the bathroom, R29 became weak, and staff lowered him to the floor. No injury. IDT review of fall; Care plan reviewed and remains appropriate. Surveyor noted there was no root cause identified. -08/15/24, R29 found on floor in room. R29 stated he needed to use the bathroom. IDT review of fall; Root cause of fall remains poor safety awareness and overestimation of abilities. Remains high fall risk. Care plan reviewed and remains appropriate. Surveyor noted R29's care plan was updated on 08/15/24, with a new intervention, Bathroom Visits, Surveyor was not able to verify the details of this intervention. -08/24/24, un-witnessed fall in bathroom. R29 sustained laceration to his right ear. -08/25/24, un-witnessed fall in bathroom. Sustained laceration to his right hand. IDT review of both falls occurring on 08/24/24 and 08/25/24; Root cause of falls is responding to toilet need. Will address with MD if he thinks resident might have BPH that could be causing frequent need to toilet. Pressure sensing mat placed on floor in front of bed. Care plan reviewed and updated. Fall risk remains high. Surveyor noted R29 does not have a diagnosis of benign prostatic hyperplasia (BPH), or other urinary tract diagnoses. Surveyor noted R29 is not prescribed medications to treat bladder, prostate, or urinary tract. The care plan was not updated with interventions to address the toileting need for R29 that was identified as the root cause for the 8/24 or 8/25 fall. -09/04/24, fall in facility hallway, no injury. Surveyor noted no root cause or new interventions on the care plan after this fall. -09/09/24, un-witnessed fall in dining room, no injury. IDT review of both falls occurring on 09/04/24 and 09/09/24; Root cause remains dementia with impaired safety awareness. Resident continues to be encouraged to attend activities to keep self busy. Fall risk remains high. Care plan reviewed and remains appropriate. Surveyor noted the same intervention was implemented on 01/12/24. -10/09/24, R29 fell in bathroom, hitting right rib area on toilet. IDT review of fall; Root cause of fall is dementia with poor safety awareness, inability to make needs known, and toileting need. Fall risk remains high. Care plan reviewed. Surveyor noted no new intervention was implemented. -10/11/24, R29 fell in the lobby area and sustained a skin tear to his left hand. IDT review of fall: Root cause of fall remains dementia with poor safety awareness. Fall risk remains high. Care plan reviewed and remains appropriate. Surveyor noted no new intervention was implemented. -10/16/24, Request for physical therapy (PT) and occupation therapy (OT) evaluation and treatment. -10/20/24, un-witnessed fall in bathroom, with no injury. R29 stated toileting need. IDT review of fall; Root cause is dementia with impaired safety awareness. Remains fall risk. Care plan reviewed. Orders received for PT/OT. Surveyor noted this is not a new intervention as PT/OT was requested on 10/16/24. -On 10/24/24, four days after the fall, the facility added an intervention to trial R29 on a two-hour prompted toileting schedule. On 11/13/24 at 10:32 AM, Surveyor interviewed Director of Nursing (DON) B. Surveyor asked why new interventions were not implemented after each incident. DON B stated, There is not always an intervention that will reduce the risk. Surveyor asked DON B how she would know that and if she could provide an example. DON B did not respond. On 11/13/24 at 11:52 AM, Surveyor interviewed DON B. DON B stated R29's two-hour toileting schedule has been effective since being implemented on 10/24/24. DON B stated, We should have implemented it sooner. DON B acknowledged the facility could improve their falls policy and procedures, as they are not always identifying a root cause and adding interventions to prevent future falls in a timely manner.

Based on interview and record review, the facility did not have documentation included in resident's medical record that the residents and/or the resident's responsible party received education regarding the benefits and potential side effects of the influenza vaccine, and the resident (R), either received the influenza immunization or did not receive the influenza immunization for 3 out 5 (R3, R13, R15) residents sampled. R3, R13, and R15 did not have declinations on file, nor was there documentation stating these residents or their representatives refused the vaccine and were educated on the benefits of receiving the influenza vaccine. Findings include: The facility policy titled, Influenza and Pneumococcal Vaccines Applies To: Residents reviewed 3/2024, states in part, Purpose: ensure resident's vaccinations are given as current CDC guidelines recommend. The CDC Influenza Vaccine Timing for Adults reads, in part, One dose of influenza vaccine is recommended for adults each flu season . R3 was admitted on [DATE] with medically complex conditions and a diagnosis that includes Parkinson's. R13 was admitted on [DATE] with medically complex conditions and a diagnosis that includes diabetes mellitus. R15 was admitted on [DATE] with medically complex conditions and a diagnosis that includes diabetes mellitus. On 11/12/24, Surveyor reviewed resident records. There was no evidence of R3, R13, or R15 receiving education or the influenza immunization in 2023 or 2024. Surveyor was unable to locate declination of the influenza immunization forms or education provided. On 11/13/24 at 11:37 AM, Surveyor interviewed Infection Preventionist (IP) F regarding R3, R13, and R15's influenza immunization status. IP F reported the influenza vaccine was refused by these residents. IP F indicated R15 has a signed declination of influenza on 9/22/22; however, there are no declination forms or progress notes indicating that the residents had been educated on or offered the influenza vaccine in 2023 or 2024. On 11/13/24 at approximately 11:50 a.m., Surveyor interviewed Director of Nursing (DON) B, who stated the facility's influenza refusal form indicates in part, I do not give the facility permission to administer an influenza vaccination annually. DON B indicated she thought the facility would not have to get a declination annually. Surveyor stated the facility must provide documentation indicating influenza vaccination education was provided and the vaccine was offered and refused each flu season. Surveyor was provided one influenza declination form for R15 signed in 2022. There was no evidence provided from the facility to support R3, R13, and R15 were provided education on, offered, or refused the influenza vaccine.

Based on interviews and record review, the facility did not complete and implement baseline or comprehensive care plans for 1 of 12 residents (R245) within 48 hours of admission, which included instructions on how to provide effective and person-centered care for the resident. No baseline care plan was developed within 48 hours to address the minimum healthcare information necessary to properly care for R245, including, but not limited to, such areas of catheter care, weight loss, functional abilities, and the assistance R245 requires. This is evidenced by: The facility policy, entitled Comprehensive Nursing Assessment, dated April 2019, states: 1. A RN [Registered Nurse] initiates nursing assessment focus on newly admitted residents that occurred during the shift and completes a temporary care plan that serves as the interim care plan. R245 was admitted to the facility on [DATE]. On 08/08/23, R245 was discharged to the hospital and admitted back to the facility on [DATE]. On 09/06/23 at 11:20 AM, Surveyor could not find a current care plan related to R245 in the electronic medical records. On 09/06/23 at 11:23 AM, Surveyor interviewed Director of Nursing (DON) B regarding the absence of a care plan. DOB B said she could not find a care plan in the facility's electronic medical records. DON B was unsure what had happened and continued looking through their computer system to find a short-term care plan. When DON B brought up R245's current care plan, the care plan read, No data, where the care plan system should have been found. Surveyor asked DON B what had happened to the care plan. DON B replied they didn't know. On 09/06/23 at 4:27 PM, Surveyor interviewed Licensed Practical Nurse (LPN) G about the missing baseline care plan. Surveyor asked to see the baseline care plan for R245. LPN G could not find the baseline care plan in the electronic medical records. Surveyor asked what LPN G would do in the absence of the baseline care plan. LPN G stated that they would read past progress notes and look at the resident's medical orders on file. On 09/07/23 at 11:39 AM, Surveyor interviewed RN I regarding R245's missing baseline care plan. Surveyor asked where they would typically find a baseline care plan, to which RN I replied that it is usually scanned into Point Click Care (electronic medical records) and can be found under the misc tab. RN I showed Surveyor an example of a baseline care plan for a random resident. Surveyor asked to see the baseline care plan for R245, but RN I could not locate a baseline care plan in the electronic medical records. RN I feared that someone may have thrown out the care plan without uploading the file, but they could not be sure what happened to the missing baseline care plan. On 09/07/23 at 11:48 AM, Surveyor interviewed DON B regarding expectations of a baseline care plan. Surveyor asked what DON B would expect regarding the timeline of the baseline care plan for any resident. DON B replied they would expect to see a baseline care plan created as soon as possible.

Based upon interview, record review and policy review, the facility did not ensure allegations of misappropriation were thoroughly investigated for 2 of 2 residents (R) (R22, R32) reviewed. R22 alleged she had lost clothing and did not know what had happened to the clothing. The facility did not complete a thorough investigation of the incident. R32's Power of Attorney (POA) said that R32 had lost a stuffed animal and was mentioned to staff but never knew what came of the complaint. The facility did not complete a thorough investigation of the incident. This is evidenced by: On 09/05/23 at 10:27 AM, Surveyor interviewed R22 regarding lost or stolen items. R22 said they had lost some clothing and had mentioned it to staff, and they were unsure how long the clothing had been missing. R22 was unsure what had happened and did not know if she had ever seen the clothing again. R22's most recent Brief Interview for Mental Status (BIMS) on 06/27/23 is a score of 15, meaning R22 is alert, oriented, and able to answer questions correctly. On 09/07/23 at 11:48 AM, Surveyor reviewed progress notes for R22 regarding missing items and did not find a record of missing clothing. Example 2: On 09/05/23 at 1:54 PM, Surveyor interviewed R32's POA regarding lost possessions. R32's POA said when their mother was first in the facility, R32 had a stuffed dog that went missing. The POA did mention to staff members the stuffed dog was missing. R32's POA said they did not know what happened to the stuffed dog, and no one told them from the facility, so R32's POA purchased a new stuffed dog for R32. On 09/07/23 at 11:48 AM, Surveyor reviewed progress notes for R32 regarding missing items and did not find a record of missing stuffed dog. On 09/05/23 at 2:04 PM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding their last 30 grievances that were not reported to the state. NHA A replied that they did not have any grievances. Surveyor asked if there was any grievances of misappropriation or lost items that might have been reported to staff, and NHA A replied no, they did not have anything. On 09/06/23 at 7:57 AM, Surveyor interviewed Certified Nursing Assistant (CNA) F regarding the procedure for reporting missing or stolen items. CNA F said if they are told about a missing item, they inform a nurse or social worker. They might also ask the head of the laundry department. On 09/06/23 at 12:32 PM, Surveyor conducted a QAPI (Quality Assurance and Performance Improvement) interview with Director of Nursing (DON) C. DON C stated that if staff/residents/family have concerns, they have an open-door policy but do not have a formal grievance process. The facility does not log or track grievances, but they do an informal investigation and document them in resident records. The facility will look into a more formal grievance process and tracking/logging with the transition to the new DON.

Based on observation, record review and interview, the facility did not review and revise the comprehensive care plans for 1 of 12 sampled residents (R), R28. R28's care plan was not updated to identify the resident no longer has to be on contact precautions. This is evidenced by: On 09/05/23, Surveyor reviewed R28's care plan with a printed date of 09/07/23. It stated, Contact precautions due to MRSA + wound culture. May come out of room for meals and activities as long as wound is covered and drainage is contained. On 09/07/23 at 10:17 AM, Surveyor observed wound care being done on R28. Staff did not apply personal protective equipment (PPE) other than gloves. On 09/07/23, Surveyor interviewed Registered Nurse (RN) I and asked if R28 was on any precautions. RN I indicated R28 had history of Methicillin Resistant Staph Aureus (MRSA) but was no longer on precautions. Surveyor interviewed Director of Nursing (DON) B and asked if R28's care plan was still current. DON B indicated it was not. DON B indicated R28 was off of precautions on Aug. 24th and would look for the information. Surveyor interviewed DON B and asked if R28 was still on contact precautions. DON B indicated it was resolved and staff forgot to revise the care plan.

Based on observations and interviews, the facility did not ensure personal privacy for 2 of 4 residents (R2 and R28) during personal cares and medical treatment. R2 and R28's curtains were not shut during cares and medical treatment to ensure personal privacy. This is evidenced by: The facility policy, entitled Privacy/Dignity, dated 03/2023 states in part Resident's privacy and dignity is maintained at all times and by all staff during all cares and interactions. On 09/07/23 at 9:55 AM, Surveyor asked R2 if it was ok for Surveyor to watch staff transfer R2 into bed. R2 indicated privacy doesn't matter here. Surveyor observed Certified Nursing Assistants (CNA) M and N lower R2 into bed. CNAs removed R2 shoes, then pulled down R2's pants, and opened up incontinent product to change resident all while the curtain was open. The window in R2's room looked out towards a parking lot that anyone walking by could see in. Maintenance was mowing the lawn at the time outside the window and would be able to see in the window, if looking in the direction of the room. Surveyor asked R2 if it bothered her that the shade was not pulled. R2 indicated nothing would be done about it; every day is different here. On 09/07/23 at 11:02 AM, Surveyor interviewed CNA M and asked what they do to provide privacy for the residents. CNA M indicated pull curtain between residents. Surveyor asked if there was anything else. CNA M indicated shut the door. Surveyor asked CNA M if there was anything else. CNA M indicated no. On 09/07/23 at 11:15 AM, Surveyor went over the steps CNA M and N took while performing cares on R2 and asked Director of Nursing (DON) B what she would expect staff to do differently. DON C indicated they would expect staff to close the shade. Example 2 On 09/07/23 at 10:17 AM, Surveyor observed Registered Nurse (RN) I and RN L, who is also the Infection Control Nurse, provide wound care to R28 in their room. R28 was sitting in their recliner with their shirt up on their back while they did the wound care. During the procedure, R28's shades were open so anyone going by the window could see in. Maintenance was mowing lawn at that time right outside the window, and would be able to see in the window if looking in the direction of the room.

Based on observation, interview and record review, the facility did not ensure a comprehensive care plan was achieved for 2 of 12 residents (R) reviewed for care plans (R31, R245). R31 did not have a care plan to address incontinence care. R245 did not have a care plan to address falls, nutrition, pressure injuries, and catheter care. This is evidenced by: R31 was admitted to facility on 04/13/23. Quarterly Minimum Data Set (MDS), completed and dated 07/21/23, indicated R31 was occasionally incontinent. R31 was coded to require supervision for toileting and extensive assist personal hygiene. R31's Activities of Daily Living (ADL) care plan states . set up and wash own peri care. A care plan was not developed for urinary incontinence and assistance with personal hygiene. On 09/07/23 at 9:09 AM, Surveyor interviewed Certified Nursing Assistant (CNA) D, who stated R31 wears pull ups and is usually incontinent of urine when arises in the am and at least 1x shift. On 09/07/23 at 9:47 AM, Surveyor interviewed CNA E who stated R31 would have urinary incontinence when first was admitted , and daughter preferred incontinent products were not worn, but R31 would go through pants quickly so now wears incontinent products. On 09/07/23 at 11:08 AM, Surveyor interviewed Director of Nursing (DON) C, who confirmed that R31 had a change in bladder status and was unable to locate a care plan to address incontinence care. 47807 Example 2 R245 was admitted to the facility on [DATE]. On 08/08/23, R245 was discharged to the hospital and admitted back to the facility on [DATE]. On 09/06/23 at 11:20 AM, Surveyor could not find a current care plan related to R245 in the electronic medical records. On 09/06/23 at 11:23 AM, Surveyor interviewed DON B regarding the absence of a care plan. DON B said could not find a care plan in the facility's electronic medical records. DON B was unsure what had happened and continued looking through their computer system to find a care plan. When DON B brought up R245's current care plan, the care plan read, No data, where the care plan should have been found. Surveyor asked DON B what had happened to the care plan, to which DON B replied they did not know. On 09/06/23 at 4:27 PM, Surveyor interviewed Licensed Practical Nurse (LPN) G about the missing care plan. LPN G has had some experience looking at care plans and updating them. Surveyor asked to see R245's care plan. LPN G could not find a current care plan in the medical records.

Based on interview and record review, the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) out of 4 sampled residents reviewed for falls. Resident #1 did not have a pressure alarm in wheelchair, as stated per plan of care, at time of fall on 06/01/16, resulting in a fractured arm. Resident #1 did not have quarterly risk assessments for falls per the facility policy. This is evidenced by: The facility policy, entitled, ECU FALL PREVENTION, states in part: All residents admitted to the Cumberland Extended Care Unit will be assessed with [REDACTED]. The extent of the risk will be determined through the use of a scoring system. An appropriate plan will be initiated. Fall risk assessment will occur quarterly and with annual review. A fall investigation will occur after each fall occurrence on the fall documentation form. Resident #1's Care Plan, dated 09/04/15, revised on 06/09/16, states: Mobility deficit with fall risk and pain R/T (related to) admit after fall with hip fx (fracture). COPD/CHF (Chronic Obstructive Pulmonary Disease/Congestive Heart Failure) with limited endurance. AEB (as evidenced by): frequent falls at home. res (resident) forgets limits. Completed PT/OT (Physical Therapy/Occupational Therapy) rehab ambulates with assistance as not safe to be indep (independent) with ambulation. Short of breath with all ambulation. self transfers despite alarms. This care plan included an intervention which stated: Sensor pad alarm in wheelchair, dated initiated 12/28/15, resolved on 06/09/16. Resident #1's Fall Risk Assessment, last completed 10/06/15, identified Resident #1 scored 18, which represented a high risk for falls. On 06/16/16 at 1:30 p.m., the Nursing Home Administrator (NHA) told Surveyor that this was the last fall risk assessment completed prior to Resident #1's fall on 06/01/16. The fall risk assessment was not completed quarterly for Resident #1. On 06/16/16, Surveyor reviewed Resident #1's medical record and the facility's fall investigation report and discovered the following: Licensed Practical Nurse (LPN) A documented on 06/01/16 at 6:20 pm: Resident was heard yelling out for help. Writer entered the room and found the res. (resident) sitting upright on the floor, her back against her wheel chair. Her call light cord and oxygen tubing was also observed to be next to the w/c (wheelchair). There were no other obstacles noted. Resident was unable to explain what happened, which would be normal for her cognitive status. Resident is alert, denies hitting her head, states I think I just hurt my arm, that hurts not me head. LPN documents an assessment. After assessment, resident was lifted from the floor with the hoyer lift and assist x 3. 911 was notified for packaging and transport EMT's (Emergency Medical Technicians) arrived and transferred res. (resident) to ER (emergency room ) via wheel chair. LPN A documented on 06/01/16 at 10:00 p.m., that Resident #1 returned from the ER at 7:30 p.m. with a [DIAGNOSES REDACTED]. The NHA documented a Verification of Investigation on 06/09/16 which included in part: The fall investigation determined the root cause for the fall was (Resident #1's first name) need or desire to transfer which led her to transfer without asking staff for assistance causing her to suffer a fall and fractured radius (arm) Staff interviews revealed that (Resident #1) had last been seen by staff on June 1st between 6:00 pm and 6:15 pm eating supper in the dining room. (Resident #1) was able to take herself from the dining room into her room following her supper meal. The time of the fall was 6:20 pm. Surveyor reviewed the staff interviews for Resident #1's fall investigation report. None of the interviews document whether an alarm was present or functioning. On 06/16/16 at approximately 1:30 p.m., Surveyor discussed this fall with the NHA and Director of Nursing (DON). The NHA stated that she didn't think to ask if an alarm was present or functioning. Surveyor reviewed Resident #1's care plan with the NHA and DON. The NHA stated that yes, according to the care plan Resident #1 should have had an alarm in the wheelchair. The NHA agreed that Resident #1 took self from dining room to her room and transferred self from wheelchair to recliner and then fell while transferring self from recliner back to wheelchair and that an alarm would have sounded during first transfer from wheelchair to recliner. On 06/16/16 at approximately 2:35 p.m., the NHA provided Surveyor with a note documented by LPN A on 03/08/16 which stated in part: .Res. frequently self transfers when she needs to use the bathroom, will use call light, but at times does not. The alarm is very distressing to resident and I would like to give her the opportunity to be alarm free. Will remove the alarm for a trial period and make a final determination in one week. The NHA stated that the alarm was discontinued, but not taken off the care plan. Surveyor asked the NHA if any further follow up note was made to the note on 03/08/16. The NHA stated that she could not find a follow up to the trial period of removing the alarm for one week. The NHA stated that prior to the fall, Resident #1 was assist of one with a gait belt for transfers and ambulated with two staff assist, one staff with gait belt and walker and one staff followed with wheelchair. Resident #1 is currently non-ambulatory and transfers with assist of an EZ stand. On 06/16/16 at 3:00 p.m., Surveyor explained to the DON and NHA that Resident #1 still had the wheelchair pressure alarm in place on plan of care. The above trial period of no alarm was not followed up and the alarm remained current on care plan. The alarm was not in place at time of fall and Resident #1 suffered a broken left arm in result of the fall. Resident #1 was not assessed quarterly per policy.

Based on medical record record review, observation and interview, the facility did not ensure that supervision and assistance devices were provided to prevent accidents for 2 of 10 sampled residents. 1. Resident #4 was assessed to be at high risk for falls and had a history of [REDACTED]. On 03/08/13, Resident #4 fell out of the wheelchair resulting in a laceration to the head and the left hand. Staff placed the resident in another resident's wheelchair with a pressure alarm attached. Resident #4's care plan stated to attach a clip alarm to the wheelchair. Staff did not check the placement of a clip alarm to ensure the resident's safety and to ensure that the care plan was followed. 2. Resident #1's finger was broken when a Certified Nursing Assistant (CNA) quickly pushed her to a table without first looking to see that her fingers were in the spokes of the wheelchair. The facility did not then put interventions into place, did not update the care plan, and did not train all appropriate staff to prevent recurrence. 3. The facility did not ensure that the resident environment remains free of accident hazards for 2 of 3 days of survey. Unlocked chemicals were found in 2 areas of the facility during the survey. This is evidenced by: 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per record review by Surveyor on 04/09/13, the Minimum Data Set ((MDS) dated [DATE] and 02/26/13 stated the resident was unable to walk and required extensive assistance of two staff with physical transfers. Resident #4 had impairment in both extremities and used a wheelchair. The resident did bear weight but had poor strength, problems following directions and moving feet. The resident's legs were weak bilaterally and the resident was unable to lift legs off bed on command. Actual range of motion was adequate but the resident was at risk for falls. The resident had transfer limits due to leg weakness and instability of right knee. Prior to admission the resident had a history of [REDACTED]. The care plan "Mobility/ Restorative plan" dated 08/29/12 stated, "Clip alarm to w/c (wheelchair) and bed at all times. When attempting to get up unassisted assure basic needs are met: toileting, hunger, thirst and comfort." Resident # 4 experienced falls on 10/20/12 and 12/19/12. On both occasions the resident leaned forward in her chair and tipped out onto her head. Interventions of restorative program to decrease restlessness, a move closer to the nurses station and shortening the clip alarm to prevent leaning forward were instituted. The nurses note entitled "Safety" dated 12/30/12 at 10:30 p.m. stated, "Res.(Resident) last fall was on 12/19/12 out of w/c in dining room. Clip alarm string has been shortened to alert staff sooner of res leaning forward since last 2 falls have been out of w/c while leaning forward. Res has attempted to reach for item on floor/ transfer 30 times in December setting off alarm and alerting staff of safety risk. Res is very quick when she reaches for an item on the floor. Res not distressed by alarm when it is activated. Will cont. (continue) with clip in w/c and bed at this time." The nurses note entitled "Safety" dated 01/30/13 at 7:00 p.m. stated, "Res last fall was on 12/19/12 out of her w/c. Res cont to use clip alarm in w/c and in her bed. Res's behavior is uncooperative mult.(multiple) times per day and res is constantly leaning forward in w/c grabbing for things on the floor. Res tries to get OOB (out of bed) without assistance on most nights, but requires assist to transfer. Res attempted self transfers 30+ times in December and 66+ times in January. Res behavior is un-safe due to res poor judgment ability 2 (secondary) Dementia with delusions. Res is extremely difficult to re-direct at times and becomes resistive. Res does not show signs of distress from alarm sounding." The nurses note entitled "Safety" dated 03/06/13 at 11:00 p.m. stated, "Res last fall was 12/19/12 out of w/c. Res cont to need clip alarm at all times. Res has attempted self transfers 24 times in February and alarms have alerted staff to potential safety risk. Alarm has not been distressing to resident. Res also has grab bars in bed for repositioning." The nurses note dated 03/08/13 at 7:35 p.m. stated, "w/c alarm sounded. Found laying on floor in dining room half on L side...Bloody L hand and forehead. Ambulance crew here.. Leans forward to pick up things drops on floor." Per the emergency report dated 03/08/13, the resident had a 5 centimeter laceration to the forehead that required 6 sutures and two abrasions to her left hand. The fall investigation report completed and signed by the DON stated, "Spoke with (CNA O's name) aide on days who was responsible for resident, stated did not check to see if resident was safe in w/c with clip alarm present, because the RN (Registered Nurse) had helped the resident into the w/c. Reminded (CNA O'S name) that care plan needs to be followed and appropriate measures taken. Spoke with (RN K's name) working that day, started that she put the resident in the wrong chair but was unaware it was the wrong chair. Didn't realize the resident wasn't clipped. Put her in (Resident #3's initials) chair which had a different censor. This happened around lunch time. Spoke with (CNA J's name) the evening aide. Stated her and (CNA Q's name) were working the West Wing and they had tried to get the res to go to the bathroom but she was very agitated and wanted to be left by the door. Was unaware res was in the wrong w/c saw that there was a clip alarm hanging on the back of the chair but didn't check to see if it was attached. Reminded all involved of the need to follow the care plan that this res has now had 2 falls with injuries." The investigation report also stated the resident was assessed by Occupational Therapy for wheelchair positioning. The resident received a tilted, lower wheelchair with a wedge cushion. The nurses note entitled "Falls/Safety" dated 03/12/13 at 1:10 p.m. stated," Res had a fall on 03/08/13 out of her w/c and had stitches to head. Writer received an order for [REDACTED]. Education of staff on making sure resident care plans are followed were also done. Res is very quick when she wants to be and will lean forward often to reach for items on the floor. Res was falling 1-2 times per week prior to admit. Res has fallen at ECU about every 3 months which is an improvement from before. Res has only fallen out of her w/c while leaning forward for items on floor." The facility's policy, "Care Planning" dated 03/2012 states, "Policy: A nursing assessment, the first step in the nursing process, is completed on each new admission, quarterly, annually and when a change in condition occurs. Procedure: 11. All CNA and nursing staff are informed of care plan changes in the 24 hour book, dry erase board at nurses' station and shift report. All staff upon hire are instructed in their responsibility in following the care plan." The facility's policy, "CNA Job Procedure Day Shift" dated 06/19/12 states, "23. Ensure that personal alarms and bed alarms are functioning and attached to resident/bed." On 04/10/13 at 2:15 p.m., Surveyor reviewed Resident #4's falls with the DON. The DON stated the staff were unable to reach the resident before she fell on [DATE]. The DON had no further information related to other interventions that were placed after this fall. Surveyor discussed the fall on 12/19/12 with the DON. The DON had no further information related to other interventions placed after this fall. The surveyor reviewed the fall of 03/08/13 with the DON. The DON stated the resident had been placed in another resident's wheelchair with a pressure alarm attached. The resident's care plan stated clip alarm in wheelchair. The care plan was not followed. The DON stated she retrained the staff involved with the fall to follow the resident's care plan but did not retrain all staff. On 04/10/13 at 2:20 p.m., Surveyor interviewed RN K related to Resident #4's fall on 03/08/13. RN K stated she was working the day shift on 03/08/13. RN K stated Residents #3 and #4 were sharing the same room due to remodeling. RN K stated Resident #4 was crawling out of bed before lunch. RN K stated she put Resident #4 in a wheelchair. The wheelchair had an alarm on it. RN K stated there were two wheelchairs in the middle of the room and grabbed one of the wheelchairs not realizing that it wasn't Resident #4's wheelchair. RN K stated, "It was my fault. I put her in the wrong wheelchair. We now have her wheelchair labeled with her name." On 04/10/13 at 2:25 p.m., Surveyor interviewed CNA J who was responsible for caring for Resident #4 on the evening shift of 03/08/13. CNA J stated Resident #4 was on her list of assigned residents. CNA J stated she asked resident if she needed to be toileted before supper. The resident refused. CNA J stated she did not realize that Resident #4 was in the wrong wheelchair. CNA J stated Residents #3 and #4 both have alarms on their wheelchairs. The boxes for the alarms which are both attached to the back of the wheelchairs resemble each other but are two different alarms. Resident #3 has a pressure alarm on her wheelchair and Resident #4 has a clip alarm on her wheelchair. CNA J stated she did not check to ensure that the resident had a clip alarm attached to her in the wheelchair. On 04/11/13 at 12:50 p.m., Surveyor discussed Resident #4's falls, interventions put in place after each fall and the facility not following the care plan with the DON. The DON stated after speaking with me on 04/10/13 she had started retraining staff related to following the care plan. No further information was provided. 2. Resident #1's medical record states that she has [DIAGNOSES REDACTED]. Her most recent MDS (Minimum Data Set) dated 01/05/13 indicates that she is limited in range of motion in her upper and lower extremities, and that she needs assistance of staff for transfers. According to Resident #1's nurses' notes, on 03/01/13, Resident #1 was sent to the emergency department in the adjoining hospital to have her hand examined after "she caught it in her wheelchair." It was determined that Resident #1 had fractured a finger in the incident when she had a follow up appointment on 03/06/13. The x-ray report states that there was a large hematoma (pooling of blood under the skin) present on her right hand, 3-4 digit, and "Fracture deformity is present involving the distal third metatarsal diaphysis..." According to the facility's investigation and follow-up, it was determined that Certified Nursing Assistant (CNA) N "went to push the resident's chair up to the table as usual and did not observe her hand position. Felt that she 'just didn't look'." CNA N was working in activities, as she sometimes does, that evening. During the noon meal on 04/09/13, Surveyor observed Licensed Practical Nurse (LPN) D go behind Resident #1's wheelchair, and LPN D wheeled Resident #1 out of the dining room to the nurses' station. LPN D did not ensure that Resident #1's hands were in her lap, and did not give Resident #1 any instructions before wheeling the resident out of the dining room. Resident #1 was then observed with her hands on her wheelchair wheels, wheeling herself by the nursing station. Resident #1's hands are deformed from arthritis. Surveyor interviewed CNA N on 04/11/14 at 2:22 p.m., and asked her to explain what happened with Resident #1 on 03/01/13. CNA N stated, "We were serving supper, (Resident #1's name) was about 3 feet from the table. I really quickly pushed her to the table, trying to be efficient. Her hand was in the wheel (spokes of the wheelchair), as it sometimes is. I should have looked. I felt just terrible about it, and have apologized to her. I have learned that I need to look every time I move her." Surveyor asked if anyone asked CNA N to write a statement about the incident, and CNA N stated, "No." Surveyor asked CNA N what Resident #1's reaction was to the incident, and CNA N stated, "She said 'ow'." The above interview continued, and CNA N stated, "Right away (Registered Nurse - RN R's name) came over and she knew that she needed to have it looked at in the ER." Surveyor asked CNA N to describe what Resident #1's hand looked like. CNA N stated, "It got puffy. Her hands are arthritic and 'veiny' anyway (many big blue veins present)." CNA N stated that the hand was also bruised. "They bandaged it and told us to keep it elevated. We tried to feed her afterwards. We didn't know it was broken yet." Surveyor asked CNA N to show her where CNAs find information regarding changes in residents' care. CNA N showed Surveyor the book where the CNAs do their charting. The DON was present during the interview, and guided CNA N to the care plans which were kept in binders at the nurse's station, and witnessed that CNA N was unable to find Resident #1's care plan without guidance. The DON stated that the facility does not have the CNAs carry care plan set sheets with them, so they do not take them home in their pockets, for confidentiality. Surveyor reviewed Resident #1's care plan during the survey, including a simultaneous review of the care plan with the Director of Nursing (DON) at 2:30 p.m. on 04/11/13, who confirmed that the care plan did not address the fact that Resident #1 had broken her finger in the spokes of the wheelchair, and how to prevent recurrence. Surveyor asked CNA N in the above interview if she was interviewed or counseled after the incident. CNA N stated that the Nursing Home Administrator (NHA) met with her to discuss it. The documentation from this meeting states, in part, "We reviewed safety factors related to this event. She did identify the actions she should have done. (CNA N's name) identified that she will always in the future assure that she checks around a wheelchair prior to pushing anyone." During the daily exit on 04/10/13 which began at 3:15 p.m., Surveyor asked the NHA if re-training was completed for all appropriate staff after this incident. The NHA stated that no, all staff were not re-trained, just CNA N, and no documentation of any follow-up training for other staff besides CNA N was provided. ENVIRONMENTAL HAZARDS 3. During the initial tour of the facility on 04/09/13 at 9:25 a.m. with Health Unit Coordinator (HUC) L, Surveyor observed the Central Bathroom. In an unlocked cabinet, the surveyor found one 4.4 ounced container (96 wipes) 1/4 full of Clorox bleach hydrogen peroxide disposable wipes. The container was labeled "Keep out of the Reach of Children." HUC L stated the wipes are to be locked in the Medication Room. HUC L removed the wipes from the room. At 9:27 a.m., Surveyor found one 33 ounced bottle of Fresh Breeze air freshner 1/4 full stored on the sink counter in the Clean Utility Room. The bottle was labeled, "Keep out of Reach of Children". HUC L stated the Fresh Breeze should be locked up and removed the bottle from the room. On 04/11/13 at 9:40 a.m., RN S provided Surveyor with the list of residents who display wandering behavior. Residents #3 and #4 reside 7 feet and 14 feet from the Central Bathroom and the Clean Utility Room. Both residents have behaviors of wandering in their wheelchairs. On 04/11/13 at 12:50 p.m. Surveyor discussed the surveyor's observations of chemical hazards unlocked during the initial tour of the facility on 04/09/13 with the Nursing Home Administrator and the Director of Nursing. During the tour of the general environment conducted on 04/11/13 beginning at 8:30 a.m., Surveyor noted that the door was propped open in the tub room behind the nurse's station, and there was a gallon-sized container of Turbo Clean disinfectant on the floor by the tub. The label on the Turbo Clean bottle instructs users to "Keep out of reach of children...Wear gloves to protect sensitive skin...Before disposal rinse container with fresh water...For external use only...If ingested call a physician, drink plenty of water and induce vomiting if necessary...Avoid eye contact. If splashed into eyes flush with fresh water." This container was shown to HUC (Health Unit Coordinator) L who stated that the CNAs (Certified Nursing Assistants) used this product to clean the tub, "they leave it out during the day while they're giving baths" and then HUC L left the room. Surveyor finished the tour of the bathing room, and then asked HUC L to place the container in a locked cupboard.