Every finding on record at Cedar Crest Health Center

Based on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 58 residents who reside in the facility. Surveyor observed multiple staff wearing hairnets incorrectly. Surveyor observed staff not wearing a beard restraint. Surveyor observed staff enter the kitchenette area while the cook was serving food, not wearing hairnets. The facility policy, Meal Service Delivery from Unit Kitchens, dated February 2025, states, in part; .Hair Restraints .Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens. Hair nets are required by any employee in the kitchen while food is being prepared or served. All other employees assisting with meal service must have hair pulled back . On 2/10/25 at 11:59 AM, Surveyor observed dietary staff serving food. The dietary staff's hairnet was only covering her hair that was in a bun and the rest of hair was not covered. Surveyor observed 3 different staff go in the kitchenette area while dietary was serving lunch. Surveyor observed staff get items from fridge and wash their hands at the sink while not wearing a hairnet. On 2/10/25 at 12:45PM, Certified Nursing Assistant D (CNA) indicated they do not need to wear hairnets when going in the kitchenette. CNA D indicated the cook who is serving the food needs to wear a hairnet, but not the other staff that are in the kitchenette. On 2/11/25 at 9:06AM, Surveyor observed Dietary Aide I not wearing a beard restraint while working in the kitchen. On 2/12/25 at 8:47AM, Surveyor observed dietary staff serving food. Dietary staff was wearing a hairnet but had her bangs out of the hair net. On 2/11/25 at 9:15AM, Dietary Manager C (DM) indicated staff should wear beard restraints when in the kitchen and provided Dietary Aide I a beard restraint. DM C indicated staff should wear hair restraints properly and it should cover all of hair. DM C indicated if serving and/or cooking is occurring in the kitchenettes, staff should wear hair restraints when in the kitchenettes. If a staff needs something from the kitchenette area when serving is going on the staff should ask the dietary staff for assistance and not go in the kitchenette area. The facility failed to maintain a safe and sanitary environment in which food is prepared, stored, and distributed.

Based on staff interview and record review, the facility did not ensure coordination of care and the hospice communication process was followed for 1 of 2 sampled residents (R61) and 2 of 2 supplemental residents (R55 and R320) for hospice services. R61, R55, and R320 were admitted to hospice services and the facility failed to obtain hospice documentation. Evidenced by: The facility policy titled Hospice Program dated 7/2017 states in part .12. Our facility has designated Social Services to coordinate care provided to the resident by our facility staff and the hospice staff .He or she is responsible for the following: d. Obtaining the following information from the hospice: (1) The most recent hospice plan of care specific to each resident .(4) Name and contact information for hospice personnel involved in hospice care of each resident .(6) Hospice medication information specific to each resident .13. Coordinated care plans for resident receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) in order to maintain the resident's highest practicable physical, mental, and psychosocial well- being . Example 1 R320 was admitted to the facility on [DATE]. R320 was receiving hospice services at home prior to admission to the facility, and those services continued in the facility. R320's terminal diagnosis is severe protein malnutrition. Surveyor reviewed R320's EHR (Electronic Health Record) and was not able to find any documentation of R320's hospice enrollment, admission assessment, care plan, orders, or visit notes since admission to the facility. Example 2 R55 was admitted to the facility on [DATE]. R55 was receiving hospice services at home and those services continued in the facility. R55's terminal diagnosis is dementia d/t (due to) Parkinson's. Surveyor reviewed R55's EHR (Electronic Health Record) and was not able to find any documentation of R55's hospice enrollment, admission assessment, care plan, orders, or visit notes since admission to the facility. Example 3 R61 was admitted to the facility on [DATE] and signed on to receive hospice services the same day. R61's terminal diagnosis is sepsis. Surveyor reviewed R61's EHR (Electronic Health Record) and was not able to find any documentation of R61's hospice enrollment, admission assessment, care plan, orders, or visit notes. On 2/11/25 at 3:34 PM, Surveyor interviewed RN F (Registered Nurse). Surveyor asked RN F how the facility receives documentation from the hospice provider, RN F reported that the hospice typically faxes their notes and medical records puts them in the resident's EHR. Surveyor asked RN F to review R61's EHR to locate any hospice notes or documentation. RN F reported that there were no notes scanned in. Surveyor asked RN F if the expectation is that the hospice provider would fax notes to the facility, RN F stated yes. Surveyor asked RN F whose responsibility is it to follow up on the hospice notes, RN F stated that it would be the responsibility of the nurse working the shift. On 2/11/25 at 3:54 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what the expectation is for documentation of hospice visits, DON B reported that the expectation is that hospice would complete their assessment and either fax the notes or document in the resident's EHR. Surveyor asked DON B how staff know what the resident's hospice plan of care, visit frequency, and orders are if there is no documentation in the resident's EHR from the hospice provider, DON B states that the hospice nurse communicates each of their visits with the floor nurse or charge nurse. On 2/11/25 at 4:07 PM, Surveyor interviewed RN G (hospice RN). Surveyor asked RN G what the process is when they visit a resident at the facility, RN G states they meet with the resident, and if there are any concerns they will talk to the facility's nurse. Surveyor asked RN G if they fax their notes to the facility or document in the resident's EHR, RN G reported that they do a face to face with the nurse but do not fax their documentation. Surveyor asked RN G how they communicate the care plan with the facility, RN G stated that they only fax it if the facility asks for it. Surveyor asked RN G how the facility knows the frequency of visits, RN G reported that they should know that R61 is seen twice a week for nursing, once a month for Social Worker, and once a week for the Chaplain. Surveyor asked RN G how the facility staff would know that, RN G reported that is should be on the admitting orders. It is important to note that Surveyor reviewed R61, R55, and R320's medical records and there was no documentation of admission orders, admission assessments, nursing visit notes, Social Worker visit notes, Chaplain visit notes or the hospice plan of care. Of note: the facility obtained the appropriate documentation from the hospice provider for R61, R55 and R320 after Surveyor requested it. On 2/12/25 at 10:00 AM, Surveyor interviewed SW H (Social Worker). Surveyor asked SW H what their role is with a resident receiving hospice services, SW H reported that they make the referral, coordinate the initial visit, and update the team regarding the enrollment. Surveyor asked SW H who is responsible for ensuring that the facility receives the hospice visit notes, care plan, enrollment forms, and medication list, SW H reported that the hospice provider faxes the information over, and the documents get scanned into the EHR. SW H reported that they took for granted that they were getting the information and that no one checked.

Based on observation, interview, and record review, the facility did not ensure that self-administration of medications was determined to be clinically appropriate for 1 of 1 residents (R32). R32 was observed with an inhaler sitting on his bedside table. R32 did not have an order to self-administer medications, nor did he have an assessment completed to determine his competency for self-administering medications. This is evidenced by: The facility policy titled, Administering Medications, dated 2001, revision date April 2019, states, in part: Medications are administered in a safe and timely manner, and as prescribed . 27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely . R32 was admitted to the facility on [DATE] and has diagnoses that include Chronic Obstructive Pulmonary Disease (COPD), Generalized Anxiety Disorder, Depression Unspecified, Anxiety Disorder Unspecified, Acute Respiratory Failure with Hypoxia (a condition where the body's tissues do not receive enough oxygen), and Shortness of Breath. R32's Minimum Data Set (MDS), dated [DATE], indicated that R32 had a Brief Interview for Mental Status (BIMS) score of 14, indicating R32 is cognitively intact. Section GG of the MDS indicated that R32 requires partial to moderate assistance for all Activities of Daily Living (ADLs). R32's Care Plan, dated 1/10/25, states in part: Focus: The resident has altered respiratory status/difficulty breathing . Intervention: Administer medications/puffers as ordered. Monitor for effectiveness and side effects . R32's Physician Orders include, in part: Albuterol Sulfate Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) 2 puff inhale orally every 4 hours as needed for shortness of breath, wheezing or cough. Start date: 1/10/25. No end date. A review of R32's Medication Administration Record (MAR) in the electronic medical record for January and February indicated the medication was administered every day without any missed medications. The medication was signed out as being given by the nurses each day. Of note: R32 does not have a physician's order to self-administer medications, nor was there a competency assessment anywhere in R32's medical record for self-administering of medications. On 2/10/25 at 10:22 AM, Surveyor interviewed R32 in his room and observed an inhaler sitting on the table next to him. Surveyor asked R32 if he always had his inhaler in his room with him. R32 replied yes, he kept the inhaler at his bedside in case he felt short of breath. R32 indicated he used the same inhaler at home. On 2/11/25 at 4:12 PM, Surveyor interviewed LPN E (Licensed Practical Nurse) about R32's medications. Surveyor asked LPN E what the criteria is for a resident to have medications in their rooms. LPN E stated residents can have medications in their rooms if they are alert and oriented and able to sit up independently. Surveyor asked LPN E if R32 was allowed to have medications at bedside. LPN E replied yes, he was. Surveyor asked LPN E if any assessments had been done to ensure R32's competency for self-administering his own medications. LPN E stated they didn't do any assessments. Surveyor asked LPN E if R32 had a physician's order to self-administer medications. LPN E replied she wasn't sure. LPN E searched her medication cart in Surveyor's presence and could not find an inhaler for R32. LPN E stated, it must be in his room. On 2/12/25 at 11:07 AM, Surveyor interviewed DON B (Director of Nursing) and asked her what her expectation was for a resident to keep medications at their bedside. DON B indicated that if a resident shows interest in wanting to self-administer their own medications, they complete a self-administer assessment that is then reviewed at their weekly risk management meeting. DON B elaborated that if the resident is deemed competent, they would have a lock box given to them to store the medication in their room safely. Surveyor asked DON B who was responsible for completing the self-administer assessments with the resident. DON B replied that it is delegated to the nurses on the unit but that herself and the ADON (Assistant Director of Nursing) are also involved in the process. Surveyor asked DON B if R32 had a self-administer assessment. DON B reviewed R32's electronic medical record and stated that she did not see one. Surveyor asked DON B if R32 had a physician's order to self-administer medications. DON B reviewed his medical record and indicated she did not see one. Surveyor shared her observation of R32 having an inhaler in his room on his bedside table. Surveyor asked DON B if R32 should have a self-administer assessment for competency and a signed physician's order to have medications at bedside. DON B stated yes, he should have those in order to administer his medications independently and safely. The facility's failure to adequately assess and supervise medication administration enabled the resident to keep medications at the bedside and self-administer without demonstrating competency to do so.

Based on interview and record review, the facility did not ensure all alleged violations involving misappropriation are reported immediately to other officials including the State Agency in accordance with State law through established procedures for 1 of 3 residents (R1) reviewed for misappropriation. The facility became aware of an allegation of misappropriation for R1 on 7/14/23. The allegation was not reported to the State Agency within 24 hours. This is evidenced by: The facility policy titled, Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property, with an effective date of 2/15/17, states, in part: .d. Misappropriation. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent .Reporting and Response: Abuse Policy Requirements - It is the policy of this facility that abuse allegations (abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported immediately, but no later than 24 hours, to the Administrator or designee of the facility and to other officials including to the State Survey Agency in accordance with State law through established procedures. In addition, local law enforcement will be notified of any reasonable suspicion of a crime against a resident in the facility .External Reporting .a. Initial reporting of Allegations - If an incident or allegation is considered reportable, the Administrator or designee will make an initial (immediate or within 24 hours) report to the State Agency (F-62617). A follow-up investigation will be submitted to the State Agency within five (5) working days (F-62447) . R1 was admitted to the facility 5/24/23 with diagnoses including: atrial fibrillation, sick sinus syndrome, diabetes, osteoporosis, acute kidney failure, and pathological fracture, right femur. R1's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 5/30/23, indicates R1 has a Brief Interview for Mental Status (BIMS) score of 15 indicating R1 is cognitively intact. R1 is her own person. On 8/7/23 at 9:20 AM, Surveyor talked to Family Member E. Family Member E indicated the family discovered $548.46 worth of charges on R1's credit card that R1 did not make. Family Member E indicated R1's daughter emailed the facility to notify them of these charges on 7/14/23 at 8:54 AM. Family Member E indicated there were local and online charges that were made. Family Member E indicated there were several purchases from Pizza [NAME]. Family Member E went to Pizza [NAME] and explained that R1 was a victim of fraudulent charges and Pizza [NAME] provided receipts. Family Member E indicated on one of the receipts it had a person's name and a phone number. Family Member E indicated this name and phone number was from a housekeeping staff at the facility. Family Member E indicated the first charge that was made was while R1 resided at the rehab unit at the facility. Family Member E indicated that on 7/17/23 the housekeeping staff was still working at the facility and the police arrested the staff. Family Member E indicated she had a meeting with the Administrator, HR (Human Resources,) and DON (Director of Nursing) sometime last week and they finally apologized and stated they were not going to be reporting it to the state agency because it was too late to report. Family Member E provided Surveyor copies of the email that was sent to facility on 7/14/23, Pizza [NAME] receipts, and credit card statement. Surveyor reviewed documents. Family Member F emailed Executive Assistant D on 7/14/23 at 8:53 AM. The email stated, in part; Good Morning, my mother, ., was recently the victim of credit card theft/fraud. I am afraid it is probably related to (Facility Name.) On Wednesday, July 12th, I wanted to reconcile my mother's credit card bill and discovered $548.46 worth of charges that clearly were not hers. The fraudulent charges began June 26th while she was in the rehab portion of (Facility Name.) The card itself was not stolen, but someone must have written down her card number and identifying information. The card was used to purchase food locally and order deliveries from websites. The credit card company stopped the payments and is issuing her a new card. I wanted you to know what has happened. There may be other residents at risk as well. On 8/7/23 at 11:30 AM, Executive Assistant D indicated receiving the email from R1's family member on 7/14/23. Executive Assistant D indicated she forwarded the email to DON B (Director of Nursing.) On 8/7/23 at 2:23PM, Surveyor interviewed HR Director C (Human Resource Director.) HRD C indicated that 7/17/23 was the first time he was made aware of the accusation of misappropriation. HRD C indicated DON B provided him R1's credit card statement and the local Pizza [NAME] receipts. HRD C indicated after he reviewed the documents HRD C called the NHA A (Nursing Home Administrator) and then contacted the local law enforcement. HRD C indicated Housekeeper G's name and phone number was on one of the Pizza [NAME] receipts. HRD C indicated that Housekeeper G was working on 7/17/23. HRD C provided Surveyor Housekeeper G's time punches for 7/17/23 which showed 7:30AM-12:00PM for time worked. Of note, Housekeeper G was removed from duty on 7/17/23 once the facility confirmed a receipt contained a staff member, Housekeeper G's name. On 8/7/23 at 3:08 PM, DON B indicated abuse should be initially reported within 24 hours for the Skilled Nursing Facility (SNF,) investigated, and the final report should be submitted within five business days. DON B indicated for Assisted Living (AL,) abuse should be reported in five business days. DON B indicated they consulted with their legal team and the legal team directed the facility to report the misappropriation through AL since that is where R1 was residing at the time the facility became aware of the allegation. DON B indicated Executive Assistant D forwarded the email from Family Member F on 7/14/23 to DON B. DON B indicated the email would have come to her sometime in the afternoon, because it was at end of day discussion. DON B indicated she tried to call the family to get more information on 7/14/23. On 7/14/23 late afternoon, DON B emailed Family Member F and Family Member F emailed back saying she would call DON B on Monday, 7/17/23. On 7/17/23 around 8:30AM-8:45AM, Family Member F called DON B. DON B asked Family Member F if the family was going to involve law enforcement. Family Member F indicated they were gathering receipts. Family Member F emailed DON B Pizza [NAME] receipts and the credit card statement around 9:00 AM. DON B indicated HR Director C reviewed receipts and that HR Director C felt like a staff member may have been involved. DON B indicated they notified NHA A (Nursing Home Administrator) and then contacted law enforcement. Surveyor and DON B reviewed email from Family Member F to facility on 7/14/23. Surveyor asked if this was the email that was forwarded on to DON B. DON B indicated yes. Surveyor asked DON B in the email does the family believe the charges occurred from someone at the facility? DON B indicated yes. Surveyor asked if the family believes that it is someone at the facility would it be considered an accusation of misappropriation? DON B indicated yes. Surveyor asked DON B if this accusation should have been reported within 24 hours after the facility learned about the accusation? DON B indicated it is DON B's understanding that for AL guidelines the accusation should be thoroughly investigated and then sent in within five days. DON B indicated SNF guidelines were not followed because their legal department directed facility to follow AL guidelines. On 8/7/23 at 4:05 PM, DON B indicated the final self-report was sent on 8/4/23. DON B indicated there were no other notifications made to State agency regarding the investigation of misappropriation. It is important to note, the facility was made aware of an accusation of misappropriation on 7/14/23 and did not report to state agency for 16 business days, on 8/4/23. Housekeeper G, the alleged perpetrator, only worked in the nursing home. The facility failed to take immediate action upon discovery of the misappropriation and failed to protect other residents upon discovery.

Based on interview and record review the facility failed to ensure an alleged misappropriation was thoroughly investigated and the results of the investigation were reported to the State Agency within five working days of the incident for 1 of 3 residents reviewed for misappropriation (R1). The facility was made aware of an allegation of misappropriation for R1. The facility failed to complete a thorough investigation into this allegation. This is evidenced by: The facility policy titled, Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property, with an effective date of 2/15/17, states, in part: .d. Misappropriation. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent .Investigation: Abuse Policy Requirements - It is the policy of this facility that reports of abuse (mistreatment, neglect, or abuse including injuries of unknown source, exploitation, and misappropriation of property) are promptly and thoroughly investigated. Procedure - The investigation is the process used to try to determine what happened. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed. The information gathered is given to administration .c. Investigation Regarding Misappropriation - a complete an active search for missing item(s) including documentation of investigation is conducted. The investigation will consist of at least the following: A review of the completed grievance report An interview with the person or persons reporting the incident Interviews with any witnesses to the incident A review of the resident medical record if indicated A search of the resident room (with resident permission) An interview with staff members having contact with the resident during the relevant periods or shifts of the alleged incident Interviews with resident's roommate, family members, and visitors A root-cause analysis of all circumstances surrounding the incident R1 was admitted to the facility 5/24/23 with diagnoses including atrial fibrillation, sick sinus syndrome, diabetes, osteoporosis, acute kidney failure, and pathological fracture, right femur. R1's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 5/30/23, indicates R1 has a Brief Interview for Mental Status (BIMS) score of 15 indicating R1 is cognitively intact. R1 is own person. On 8/7/23 at 9:20 AM, Surveyor talked to Family Member E. Family Member E indicated the family discovered $548.46 worth of charges on R1's credit card that R1 did not make. Family Member E indicated R1's daughter emailed the facility to notify them of these charges on 7/14/23 at 8:54 AM. Family Member E indicated there were local and online charges that were made. Family Member E indicated there were several purchases from Pizza [NAME]. Family Member E went to Pizza [NAME] and explained that R1 was a victim of fraudulent charges and Pizza [NAME] provided receipts. Family Member E indicated on one of the receipts it had a person's name and a phone number. Family Member E indicated this name and phone number was from a housekeeping staff at the facility. Family Member E indicated the first charge that was made was while R1 resided at the rehab unit at the facility. Family Member E indicated that on 7/17/23 the housekeeping staff was still working at the facility and the police arrested the staff. Family Member E indicated she had a meeting with the Administrator, HR (Human Resources) and DON (Director of Nursing) sometime last week and they finally apologized and stated they were not going to be reporting it to the state agency because it was too late to report. Family Member E provided Surveyor copies of the email that was sent to facility on 7/14/23, Pizza [NAME] receipts, and credit card statement. Surveyor reviewed documents. Family Member F emailed Executive Assistant D on 7/14/23 at 8:53 AM. The email stated, in part; Good Morning, my mother, ., was recently the victim of credit card theft/fraud. I am afraid it is probably related to (Facility Name). On Wednesday, July 12th, I wanted to reconcile my mother's credit card bill and discovered $548.46 worth of charges that clearly were not hers. The fraudulent charges began June 26th while she was in the rehab portion of (Facility Name). The card itself was not stolen, but someone must have written down her card number and identifying information. The card was used to purchase food locally and order deliveries from websites. The credit card company stopped the payments and is issuing her a new card. I wanted you to know what has happened. There may be other residents at risk as well. On 8/7/23 at 10:00 AM, Surveyor met with R1 who is now residing at the Assisted Living section of the facility. R1 indicated she heard someone got into her purse while she was staying at the nursing home. R1 indicated her daughter and daughter-in-law have been looking into the incident. R1 indicated it was a previous staff person who made purchases on her credit card. R1 indicated she never talked to this staff person and doesn't know what she looks like. R1 stated, I couldn't imagine someone doing something like this. R1 indicated she feels safe at the Assisted Living but doesn't think she would feel safe staying at the nursing home. Surveyor asked if she was at the rehab section of the SNF (Skilled Nursing Facility). R1 indicated yes. On 8/7/23 at 11:30 AM, Executive Assistant D indicated receiving the email from R1's family member on 7/14/23. Executive Assistant D indicated she forwarded on the email to DON B (Director of Nursing). On 8/7/23 at 2:23PM, HRD C (Human Resource Director) indicated 7/17/23 was the first time he was made aware of the accusation of misappropriation. HRD C indicated DON B provided him R1's credit card statement and the local Pizza [NAME] receipts. HRD C indicated after he reviewed the documents HRD C called the NHA A (Nursing Home Administrator) and then contacted the local law enforcement. HRD C indicated Housekeeper G's name and phone number was on one of the Pizza [NAME] receipts. HRD C indicated that Housekeeper G was working on 7/17/23. HRD C indicated it all happened fast, however he was not able to verify the time the police officer arrived or how long Housekeeper G continued working. HRD C provided Surveyor Housekeeper G's time punches for 7/17/23 which showed 7:30 AM-12:00 PM for time worked. HRD C indicated the clock out time was manually entered. On 8/7/23 at 3:08 PM, DON B indicated misappropriation should be initially reported within 24 hours for the Skilled Nursing Facility (SNF), investigated and the final report should be submitted within five business days. DON B indicated for Assisted Living (AL) abuse should be reported in five business days. DON B indicated Executive Assistant D forwarded the email from Family Member F on 7/14/23 to DON B. DON B indicated the email would have come to her sometime in the afternoon, because it was at end of day discussion. DON B indicated she tried to call the family to get more information on 7/14/23. On 7/14/23 late afternoon DON B emailed Family Member F and Family Member F emailed back saying she would call DON B on Monday, 7/17/23. On 7/17/23 around 8:30 AM-8:45 AM, Family Member F called DON B. DON B asked Family Member F if the family was going to involve law enforcement. Family Member F indicated they were gathering receipts. Family Member F emailed DON B Pizza [NAME] receipts and the credit card statement around 9:00 AM. DON B indicated HRD C reviewed receipts and that HRD C felt like a staff member may have been involved. DON B indicated they notified NHA A and then contacted law enforcement. DON B indicated when the police arrived at the facility, they wanted to talk with R1 first. DON B indicated that interview took about 30 minutes and DON B stayed for the entire interview. After the interview, DON B went down to the rehab unit and Housekeeper G was not on the unit. Surveyor asked when was Housekeeper G pulled from unit? DON B indicated she would have to go by what HRD C said. Surveyor asked if DON B would expect Housekeeper G to be pulled from the unit as soon as it was realized she was potentially involved. DON B indicated yes. DON B indicated as far as she knows there is no documentation of when Housekeeper G was removed from the unit. DON B indicated again that she would go by what HRD C stated for the time frame. Surveyor asked DON B what constitutes for a thorough investigation? DON B indicated interviewing resident and family, establishing a timeline, and if there are other people that can be affected. DON B indicated with law enforcement involved this was a unique situation. DON B indicated they would have interviewed the accused employee as well, but in this situation the police arrested the employee. DON B indicated she had met with Housekeeper G's supervisor and the supervisor indicated Housekeeper G only worked in C-pod unit (rehab). DON B indicated R1 was in C-pod when she was in rehab. Surveyor asked if the dates of the fraudulent purchases coincide with when R1 was in rehab. DON B indicated yes. DON B indicated there were only two residents on the rehab unit that still resided there because there is heavy turnover with residents. DON B indicated the two residents on that unit voiced no concerns. Surveyor asked if any other residents were interviewed in the building and if Housekeeper G could potentially go into other rooms. DON B indicated, I have not seen that, I have seen her on C-pod and at the cafe, and I am generally out on my units and have not seen her loitering anywhere. DON B indicated residents in other areas of the building were not interviewed. DON B indicated at the July Resident Council meeting misappropriation was discussed and that Social Worker H led the meeting. Surveyor asked DON B if other direct care staff were interviewed regarding misappropriation. DON B indicated, I cannot say specifically that I did in all areas. Surveyor asked if the staff on C-pod (rehab) were interviewed. DON B indicated, No, the resident wasn't in that area, so I was down in Assisted Living. The only reason I can think of is that the investigation was actively being reviewed by law enforcement and so I had a concern with tampering with an active investigation . Surveyor reviewed Resident Council Meeting minutes 7/24/23, Social Services: No concerns. Resident rights reviewed: Self-determination On 8/7/23 at 4:01 PM, SW H (Social Worker) indicated she led the Resident Council Meeting on 7/24/23. Surveyor asked if SW H could remember if there were other things discussed besides self-determination. SW H indicated, That was all that was discussed. They were very quiet. Surveyor asked if misappropriation of funds was discussed. SW H stated, No. The facility failed to interview all residents and staff to ensure there was not additional concerns regarding misappropriation of resident funds.

Based on interview and record review, the facility did not ensure 1 of 1 sampled resident (R13) received the necessary care and services to maintain normal bowel habits and prevent constipation. The facility did not implement additional constipation interventions when R13 did not have a bowel movement for three or more days. Additionally, there was no care plan developed to direct staff on how to manage R13's constipation. This is evidenced by: The facility policy, Highlights, dated (MONTH) 2011, with a revision date (MONTH) 2019, states, in part: 1. Each resident upon admission to the facility will be assessed for risk of constipation. Some risk factors for constipation include: .limited physical activity, [MEDICAL CONDITION], stroke, .depression, dementia, and medications. 3. the unit nurse will assess and institute strategies that result in a consistency change in the stools and assist the resident with evacuation. This approach may require additional orders from the physician without waiting for further days of assessment. 4.residents that did not have a bowel movement the prior day will be considered Day 2 of no BM (bowel movement) .have not had a BM in 2 days will be considered Day 3, and so forth.6. For Day 3 residents strategies may include [MEDICATION NAME] (per standing order with instructions to update MD (Medical Doctor) if needed), Senna, [MEDICATION NAME], and similar . 7. Each resident with a history of constipation or at risk for constipation will have an individual care plan developed . R13 was admitted to the facility, on 12/12/1994, and has [DIAGNOSES REDACTED]. R13's Quarterly MDS (Minimum Data Set) assessment, dated 4/9/19, showed a BIMS (Brief Interview of Mental Status) score of 13 out of 15, indicating R13's cognitive status to be intact. Section G - Toilet Use - Score of 3 - Extensive assistance - resident involved in activity, staff provide weight-bearing support. Requires two plus persons physical assist. Section H 0400 - Bowel Continence - always incontinent (no episodes of continent bowel movements. Section H 0500 - Bowel Toileting Program - marked Yes. Section H 0600 - Bowel Patterns - Constipation present? Marked No. R13's care plan, initiated on 1/8/19 and a revision date of 7/9/19, under Nutrition Interventions/Tasks states, in part: Receives power pudding, coconut oil as well as raisins daily to promote easier passage of stool. R13's Nutritional Care plan, dated 4/9/19, states, in part, under Medications/Labs: PRN (as needed) bowel meds [MEDICATION NAME], MOM (Milk of Magnesia); on [MEDICATION NAME], KCl (Potassium Chloride), [MEDICATION NAME], Senna, Insulin, [MEDICATION NAME], MVI (Multivitamin), [MEDICATION NAME], Vitamin B12, [MEDICATION NAME], Cranberry, [MEDICATION NAME]. R13 has Physician order [REDACTED].>[MEDICATION NAME] - 150 MG by mouth three times a day for chronic pain [MEDICATION NAME] - 325 MG - 2 tablets by mouth every 4 hours PRN for pain. NTE (not to exceed) 4000 MG/24 hours. MAR (Medication Administration Record) indicates medication given 6/1, 6/4, 6/6, 6/9, 6/11, 6/12 (twice), 6/14, 6/21, 6/26 and 6/30 [MEDICATION NAME]-[MEDICATION NAME] 5 - 325 MG - give one tablet every 24 hours PRN for pain. MAR indicated [REDACTED]. Bowel Notes section states: 6 BMs past two weeks; resident has increased constipation problems due to decreased activity; takes multiple bowel meds daily plus power pudding BID (twice a day); resident also will request prunes/ PJ (prune juice) as needed. R13's Nutritional Care plan, dated 7/9/19, states, in part, under Medications/Labs: MVI, [MEDICATION NAME], Cranberry Powder, [MEDICATION NAME], Vitamin B12, KCI, Stool Softener. Bowel Notes section states: 10 BMs past two weeks no hard stools noted did have suppository on 7/5, 7/8; also receives Senna S BID, Power Pudding at least BID but at times more as resident will request as she needs; eats raisins often for breakfast; drinks water, diet soda with meals. R13's (MONTH) MAR (Medication Administration Record) shows resident started taking Coconut Oil three times a day on (MONTH) 13. R13 has a physician ordered [MEDICATION NAME] Suppository 10 MG (milligram), insert one suppository rectally every 24 hours as need for constipation, effective 10/24/18. R13's BM Report, from 5/27/19 through 7/11/19, noted the following. 6/4/19 - No BM 6/5/19 - No BM 6/6/19 - No BM 6/7/19 - No BM - MOM given 6/8/19 - No BM - Suppository was given 6/9/19 - 1 large BM 5:29 AM, 1 medium BM 1:27 PM 6/10/19 - 1 large BM 9:36 PM 6/11/19 - 1 small BM 2:13 PM - MOM given 6/12/19 - No BM 6/13/19 - No BM 6/14/19 - No BM 6/15/19 - No BM - Suppository was given 6/16/19 - 1 Large BM 9:32 AM and 1 Large BM 9:32 PM On 7/11/19 at 2:36 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor reviewed R13's BM Report with DON B. Surveyor asked if extra steps should have been taken when a resident is showing signs of constipation. DON B stated she would expect extra steps to be taken when a resident hasn't had a BM after 48 hours. DON B stated by Day 3 staff need to be moving to medication like [MEDICATION NAME], an extra dose of [MEDICATION NAME] or MOM (Please note: Resident receives 8 grams of [MEDICATION NAME] powder daily. Resident received MOM on 6/7, on day four of being constipated, and 6/11, after resident had shown to be having BMs, but then had no BMs from 6/12 to 6/16.) DON B stated if a resident is capable of pushing then perhaps a suppository. (Please note: R13 received a suppository on 6/8, five days after no BM, and 6/15, four days after no BM.) Surveyor asked when a physician should be consulted. DON B stated if the interventions aren't working, then probably by day 4; especially if the suppository is not working, but would not call MD before the suppository. (Please note: R13 received a suppository on 6/8, five days after no BM, and 6/15, four days after no BM; no contact was made to the physician.) Surveyor stated there was no additional documentation showing that extra interventions were being utilized with R13's constipation until 6/7 when MOM was given and 6/8 when a suppository was given; these are Day 4 and Day 5. Surveyor stated this happened also on 6/15 when resident was given a suppository, Day 4, and no documentation showing additional interventions. DON B stated the physician should have been contacted and documentation should have shown what additional interventions were in place.

Based on observation, interview, and record review, the facility did not ensure 1 out of 1 resident reviewed for restraints out of a total sample of 17 was properly assessed and care planned for the use of physical restraints (R13). Staff placed R13 outside in wheelchair and engaged both locks on the wheelchair. R13 was unable to release the left brake and had no way of accessing staff for assistance. Findings include: The facility policy entitled Use of Restraints, dated (MONTH) 5, 2009 and approved 8/26/09, states, in part: Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls 1. Physical Restraints are defined as any method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. 2. The definition of restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition, and this restricts his/her typical ability to change position or place, that device is considered a restraint. R13 was admitted to the facility, on 12/12/1994, and has [DIAGNOSES REDACTED]. R13's Quarterly MDS (Minimum Data Set) assessment, dated 4/9/19, showed a BIMS (Brief Interview of Mental Status) score of 13 out of 15, indicating R13's cognitive status to be intact. R13's care plan did not indicate an intervention for locking R13's brakes. There is no safety assessment for R13 to be outside unattended. Occupational Therapy Plan of Care, dated 11/7/18, indicates a half lap tray was provided to resident. Surveyor observed R13 using this tray to support left arm. On the morning of 7/9/19, Surveyor observed R13 sitting outside, in front of main entrance, in her wheelchair. R13 asked Surveyor for assistance stating, I'm stuck. R13 explained that she was unable to release the brake on the left side. R13 demonstrated how she was able to unlock the right side, but due to being unable to move her left arm, was unable to unlock the brake on the left side of the wheelchair. Surveyor asked who brought R13 outside; R13 stated AS [NAME] (Activity Staff). On 7/9/19 at 9:44 AM, Surveyor interviewed AS [NAME] regarding taking R13 outside. AS [NAME] stated she had taken R13 outside and told resident she was locking both brakes So she wouldn't roll away. Surveyor asked AS [NAME] if R13 is capable of unlocking the left brake; AS replied yes. Surveyor asked AS [NAME] how she monitored R13 when she was outside, in case resident needed assistance. AS [NAME] stated she informed A&D (hall) CNA (Certified Nursing Assistant) float who she believes checks on R13 approximately every 15 minutes when she is outside. On 7/9/19, Surveyor interviewed CNA F regarding R13 being placed outside in wheelchair. CNA F indicated AS informed her that R13 was sitting outside. Surveyor asked how often does one check on resident when they are outside. CNA F indicated she tries to check every twenty minutes or look out the windows to see how they are doing. Surveyor asked if R13's wheelchair brakes should be locked. CNA F stated only the right side as R13 can only reach her tray table with her left hand. On 7/9/19 at 1:47 PM, Surveyor spoke with ADON D (Assistant Director of Nursing) about engaging brakes on R13's wheelchair. ADON D stated resident will tell you not to lock the left side, but it would be common sense to put the brakes on since she is out front where there is car traffic. Surveyor asked if there is an assessment in place to determine R13's abilities to unlock the brakes. ADON D stated it is not care planned to only lock the one side, but they could. The resident cannot unlock the left side. Surveyor asked how does one know if resident wants to come inside. ADON D stated R13 will tell you how long she wants to be outside. On 7/10/19 at 9:14 AM, Surveyor asked AS [NAME] how she knows which residents are independent enough to be outside by themselves. AS [NAME] stated if she is not familiar with resident, she would ask a Charge Nurse. AS [NAME] indicated she is familiar with R13 as she has been here many years. On 7/10/19 at 4:23 PM, Surveyor asked ADON D if there was a specific safety assessment to determine if a resident can be outside, unattended. ADON D stated the only safety assessments we complete are FRAT (Fall Risk Assessment Tool), Device and Elopement. On 7/11/19 at 9:58 AM, Surveyor asked R13 how long she is normally outside, unattended. R13 stated a half hour to an hour. Surveyor asked R13 how she notifies staff that she is in need of assistance. R13 states she asks people in the area to get her assistance or she just starts yelling. Surveyor asked R13 how she felt when she felt stuck, because she couldn't release the left side brake. R13 stated she was very frustrated and when she becomes scared she just starts yelling. Surveyor asked if this has ever happened before; R13 stated yes. On 7/11/19 at 2:49 PM, Surveyor asked DON B (Director of Nursing) if a resident has a wheelchair with the locks on and they are unable to release those brakes, would that be considered a restraint. DON B stated yes, that would be considered a restraint. Surveyor asked how does staff know which residents are capable of being outside, unattended. DON B stated they should probably be asking a nurse each time as a resident can have a change of condition.

Based on interview and record review, the facility did not, at the time of transfer for hospitalization , provide to resident, family member, or legal representative written notice which specifies the duration of the bed hold policy for 2 of 2 residents (R50 and R51) and with further interview, the facility did not have a process in place to provide written notice upon transfer in place for any residents. This has the potential to affect all residents at the facility. Census at the time of survey was 67. The facility did not ensure that a system was in place for all residents to receive in writing a bed hold and return policy upon transfers or therapeutic leaves. Upon changing their electronic health records in (MONTH) of (YEAR), they did not have a system in place for the bed hold policy to be included when a resident was transferred out of the facility. Evidenced by: The facility policy titled Bed-Holds and Returns, revised 3/2017, states, in part: Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed hold and return policy. On 7/11/19 at 9:16 AM, Surveyor interviewed CSW C (Certified Social Worker). Surveyor asked her what was sent with the resident or their representative when they were sent to the hospital. She explained that the nurses print a packet to send with the resident. Surveyor asked if a written bed hold agreement was sent in the packet. CSW C stated that they just initiated the written bed hold agreement to be printed with the packet upon discharge to the hospital. Surveyor clarified that previous to the specific request for bed hold agreements sent with R50 and R51, bed hold agreements were not sent with residents after a switch to a new electronic health record provider. CSW C confirmed that residents did not receive the bed hold agreement upon discharge to her knowledge. She stated that they did call the residents or their representatives once they were at the hospital to confirm if they wanted a bed hold. On 7/11/19 at 1:23 PM, Surveyor interviewed DON B (Director of Nursing) and asked if each resident leaving for the hospital should receive a written bed hold agreement. She agreed that she would expect that they receive a written bed hold agreement. Example 1 R50 was a resident at the facility and, on 6/29/19, was sent to the ER (emergency room ) for a PEG (Percutaneous endoscopic gastrostomy (feeding tube)) tube replacement. She is her own person. Upon review of her documentation, she did not receive written notice which specifies the duration of the bed hold policy. Example 2 On 7/8/19 at 1:20 PM, Surveyor interviewed R51 who stated the facility sent her to the hospital because they couldn't find a blood vessel to start the IV (intravenous) that her doctor ordered at the facility. They sent her to the hospital and she came back to the facility the next day. Her records state she was sent to the hospital on [DATE]. Surveyor requested from the facility her packet that was sent to the hospital with her. A written bed hold policy was not sent with her.

Based on observation, interview and record review, the facility failed to ensure the dishwasher in the main kitchen and the dishwashers in the unit kitchens were monitored for safe water temperatures. This practice affected all the residents in the facility. The dietary staff did not test the internal dishwasher temperature per accepted standard of practice. This is evidenced by: The US Food Code 2013 includes the following: 4-302.13 Temperature Measuring Devices, Manual and Mechanical Warewashing. (B) In hot water mechanical WAREWASHING operations, an irreversible registering temperature indicator shall be provided and readily accessible for measuring the UTENSIL surface temperature. In the July 2013 Division of Quality Assurance, a article from the Dietician Consultant with the State of Wisconsin reads, For the high temperature machine, every foodservice operation must have an irreversible temperature measuring device to check the internal temperature of the machine to make sure surfaces that food comes in contact with reach a temperature of 160 degrees Fahrenheit or above. The external temperature gauges on the machine must be checked, but there also needs to be a secondary check using a heat sensitive tape or maximum registering thermometer to ensure that appropriate temperatures for sanitizing are reached. Foodservice operations need to have a system in place that determines in a timely manner when the machine is not effectively sanitizing and that corrective action is taken immediately. Foodservice operation's policy and procedure should reflect the frequency of the checks. It is important to note that checking once a month is not sufficient. Industry best practice suggests verification should, at a minimum, be once a day. The facility has a main kitchen dishwasher and 3 unit kitchenette dishwashers. One unit dishwasher serves the 100 and 400 units, another serves the 200 unit and the third the 300 unit. On 3/16/17 at 1:00 P.M., Surveyor observed in all three unit kitchens the Daily Quality Assurance Forms for February and March 2017 had evidence the facility completed internal dishwasher temperatures for two days, (2/28/17 and 3/4/17) the facility had no additional evidence that periodic internal dishwashing temperatures were monitored. The instructions on the Daily Quality Assurance Form that was found in the three unit kitchens read Temp Strip to be completed on Tuesday evening meal and Friday breakfast. Attach strips to this form. The Daily Quality Assurance Form for Tuesday 3/14/17, did not have a test strip pasted on it. On 3/15/17 at 8:00 A.M., Surveyor spoke with Dietary Manager (DM) C. DM C said the main kitchen dishwasher and the unit dishwashers were high heat machines. DM C said he runs the test strips on the main kitchen dishwasher to monitor the water temperature randomly. He said he does not keep a log of the test strips. DM C said the dietary aides run test strips in the unit dishwashers twice a week. Dietary aides paste the test strip on the Daily Quality Assurance Form. On 3/16/17 at 12:30 P.M., Surveyor spoke to Dietary Aide (DA) D. DA D said you are supposed to monitor the water temperature of the dishwasher by the temperature display on the dishwasher. DA D said you do a test strip, but she does not consistently do this. On 3/16/17 at 9:30 AM Surveyor interviewed DS (Dietary Steward) E working on the 300 unit (C Pod) about how the facility monitors dishwasher temperatures on the units. DS E stated that dishwasher temps are measured on the unit at each meal by looking at the digital read out on the outside of the dishwasher and recorded on the facility's Daily Quality Assurance form. Surveyor asked if the facility ever checked the internal temperature of the dishwasher. DS E stated that temperature stickers should be used and attached to a plate, then removed and attached to the Daily Quality Assurance form on Tuesday evenings and Friday at breakfast or whenever there is a question about the dishwasher temperatures. Surveyor and DS E reviewed the Daily Quality Assurance forms on the 300 unit, noting that on Tuesday 3/14/17 there was no indication that the temperature sticker was used to monitor the internal dishwasher temperature. DS E stated it should have been done and placed on the form and was not. Surveyor asked DS E who reviews the Daily Quality Assurance forms, DS E stated that each week the forms go to the main kitchen for DM C to review. At 9:40 AM Surveyor interviewed DA D on the 200 unit kitchenette and reviewed the dishwashing monitoring forms on the unit. DA D stated that the internal dishwashing temperatures should be monitored on Tuesday evenings and Friday mornings. DA D and Surveyor noted that on Tuesday 3/14/17 form, there was no indication that the temperature sticker was used to monitor the internal dishwasher temperature for 3/14/17. DA D stated the test strip was not done on 3/14/17 and should have been. At 9:50 AM Surveyor interviewed DS F on the 100/400 unit kitchenette and reviewed the dishwashing temperatures monitoring forms. DS F and Surveyor noted that on Tuesday 3/14/17 there was no indication that the temperature sticker was used to monitor the internal dishwasher temperature for 3/14/17. DS F stated the test strip should have been completed on 3/14/17 on the evening shift, and put on the form but was not. The facility had determined that internal dishwasher temperatures should be monitored twice a week (on Tuesday and Fridays) on the 3 kitchenette units, which the facility failed to do. The facility had no evidence of internal monitoring of dishwashing temps for these units on 2/3/17, 2/7/17, 2/10/17, 2/14/17, 2/17/17, 2/21/17, 2/24/17, 3/7/17, 3/10/17, and 3/14/17.

Based on observation, record review and interview the facility did not establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. The facility did not ensure: *They have a definitive standard of practice which they used for their definition of an outbreak. *Line listings for staff and residents are complete for outbreak / potential outbreak surveillance. *Nonessential staff is kept from the quarantined area. *Doors to the quarantined area are kept closed. *Equipment shared between residents is appropriately cleaned between uses. *Beds are thoroughly cleaned between residents. This had the potential to affect all 75 of the current residents residing at the facility. This evidenced by the following: On 2/22/15 at 7:45 am the State Survey team entered the facility for their recertification survey. Surveyor noted the doors leading to the C wing / C pod were closed. During the initial tour, during the breakfast meal time; with the exception of 2 residents (Residents 4 and 21), residents on the C wing / C pod were eating breakfast in their rooms. There was no group dining occurring. The facility stated they were under quarantine for a possible GI (Gastrointestinal) outbreak. Surveyor requested all outbreak information pertaining to this current outbreak. Definition On 2/23/16 at 8:11 am Surveyor spoke with RN (Registered Nurse) C regarding the facility Infection Control Program and asked RN C what specific standard of practice the facility uses to define an outbreak. RN C stated Three is the number but we review each time and it depends on the symptoms. We do it on an individual or per incident. RN C stated she would provide Surveyor with their standard of practice. On 2/23/16 at 11:10 am RN (Registered Nurse) C provided Surveyor with information the facility uses regarding their definition of an outbreak. The facility provided 3 resources: 1) CDC (Centers for Disease Control and Prevention) Reporting and Surveillance for Norovirus: . Definition of a Norovirus Outbreak. An outbreak of Norovirus is defined as an occurrence of two or more similar illnesses resulting from a common exposure that is either suspected or laboratory - confirmed to be caused by Norovirus. 2) Investigation and Management of Norovirus Outbreak in Long Term Care Facilities: .In general an outbreak of gastroenteritis in a LTCF (Long Term Care Facility) is defined as the presence of more diarrhea or vomiting than would usually be expected in the facility, or in a particular unit, for that time of year. An outbreak of Norovirus infection may be classified as suspected or confirmed . In general, outbreaks fall into one of two categories: Common (or point) source outbreaks or person - to - person (or propagated) outbreaks . Note: Norovirus outbreaks in LTCF that begin as common source outbreaks may continue as person - person outbreaks due to the contagious nature of the virus. Staff members can become infected and further spread the virus within the affected facility or to other facilities where staff members work. 3) Outbreak of Communicable Diseases Revised 8/26/2009. .An outbreak of diarrhea is defines as 3 % or more of the resident population within a seventy - two (72) hour period. RN C stated the facility takes all the resources into consideration. RN C could not at this time give Surveyor one specific standard of practice the facility uses as their standard. On 2/23/16 RN C also informed Surveyor that the facility also uses the Wisconsin Division of Public Health Recommendations For The Prevention And Control of Viral Gastroenteritis Outbreaks in Wisconsin Long - Term Care Facilities (Revision 10/20/09) for their definition. This definition states An outbreak of viral gastroenteritis should be suspected when two or more residents and / or staff develop new onset of vomiting and / or diarrhea within one to two days. On 2/24/15 at 2:35 pm Surveyor again spoke with RN C about the Infection Control Program and what definition they use for an outbreak. RN C stated We do not have a definition. We look at it all our resources and speak with the DON, Medical Director and Public Health to give the final determination if it is an outbreak. Surveyor asked RN C how staff could identify an outbreak without a definition if it were a Sunday afternoon and she, nor the DON, nor Medical Director were available. RN C stated They (Staff) would not make that decision. That would be the DON (who would make the decision). On 2/25/16 at 10:20 am RN C told Surveyor that the facility uses the CDC standard for defining an outbreak: Two or more similar illness resulting from a common exposure that is either suspected or laboratory - confirmed to be caused by Norovirus. It is important to note, CDC at http://www.cdc.gov/Norovirus/preventing-infection.html states: You should not prepare food for others or provide healthcare while you are sick and for at least 2 days after symptoms stop. Line Listing Outbreak 1/18/16 A review of staff line listing for the GI illness beginning 1/16/16 shows that between 1/16/16 and 1/21/16 6 staff, all having worked on the B unit, became ill with N (nausea), and / or V (vomiting), and / or D (diarrhea). No residents were affected. The County Public Health and Medical Director were notified on 1/19/16. The staff line list documents the following: CNA (Certified Nursing Assistant) U became ill with N, V, and D on 1/16/16. This line list does not indicate a well date, nor a return to work date. CNA V became ill with N, D, and Fa (Fatigue) on 1/18/16. This line list does not indicate a return to work date. RN (Registered Nurse) W became ill with N, V, and D on 1/18/16. This line list does not indicate a well date nor a return to work date. CNA X became ill with N and V on 1/18/16. This line list does not indicate a well date, nor a return to work date. CNA Y became ill with N, V, and D on 1/21/16. This line list does not indicate a well date, nor a return to work date. RN Z became ill with V on 1/21/16. This line list does not indicate a well date, nor a return to work date. Outbreak 2/13/16 A review of staff line listing for the GI illness beginning 2/13/16 shows that between 2/13/16 and 2/20/16 4 residents and 4 staff, all residing or having worked on the C unit became ill with N (nausea), and / or V (vomiting), and / or D (diarrhea) and / or Fe (fever), and / or Ma (Malaise) and / or Fa (fatigue). The staff line list documents the following: RN DD became ill with N and V on 2/11/16. This line list does not indicate when RN DD became well, and when she returned to work. Resident 19 became ill with N, V and D on 2/13/16, and with Fe on 2/16/16. This line list does not indicate when Resident 19 was placed in precautions, when she became well, and when she was removed from precautions. Resident 20 became ill with N, Fe, Ma, and Fa on 2/15/16. This line list does not indicate when Resident 20 was placed in precautions, when she became well, and when she was removed from precautions. Resident 12 became ill on 2/16/16 with D, Fe, and Fa on 2/16/16. This line list does not indicate when Resident 12 was placed in precautions, when she became well, and when she was removed from precautions. SW (Social Worker) AA became ill with N, V, and D. Although the date SW AA was placed on the line list is 2/17/16, this line listing does not indicate when SW AA became ill, when she became well, and when she returned to work. Staff BB became ill with N, V, and Fe on 2/16/16. This line list does not indicate when Staff BB became well, and when she returned to work. DA (Dietary Aide) Q became ill with V (vomiting) and Fe on 2/18/16. This line list does not indicate when DA Q became well, and when she returned to work. It is important to note DA Q was noted to be working on the C unit on 2/23/16. CNA CC became ill with Fe on 2/21/16. This line list does not indicate when CNA CC became well, and when or if she has returned to work. Resident 6 became ill with N, and Fe on 2/20/16. This line list does not indicate when Resident 6 was placed in precautions, when he became well and when or if he has been removed from precautions. CNA O became ill on 2/23/16 with N, and c/o (complaints of) being tired. This line list does not indicate when CNA O became well, and when she has returned to work. It is important to note CNA O was noted to be working on the C unit on 2/24/16. There is no documented explanation or justification as to why CNA O was permitted to return to work less than 48 hours of her documented date of illness onset. Non - essential Staff On 2/23/16 at 8:04 am Surveyor observed 3 Food Service Staff in the food service area of the C Pod. These staff included RD (Registered Dietitian) L, who was passing trays to residents eating in their rooms, and DM (Dietary Manager) N, who was talking with the DA (Dietary Aide) Q who was serving up breakfast from the stream table. On 2/23/16 at 8:32 am Surveyor observed DA (Dietary Aide) M pushing a dietary cart through the C pod, down the C Wing hall, and out the C wing doors heading toward the kitchen. RD L happened to be next to Surveyor . Surveyor asked RD L who that dietary staff was and what she was doing on the C Wing / C Pod. RD L identified the staff member as DA M and stated DA M was bringing the dirty breakfast trays from the Assisted Living Unit back to the kitchen. Surveyor asked RD L where the Assisted Living Unit was RD L stated the Assisted Living unit is right below us. RD L then pointed to the elevator (which was on the C Pod) stating that is where DA M had brought up the trays. Surveyor asked RD L if that was the only way for the AL trays to get back to the kitchen. RD L stated: No, she (DA M) should have gone another way. I will talk with her. On 2/23/16 at 8:11 am Surveyor spoke with RN (Registered Nurse) C who oversees the infection control program at the facility. Surveyor asked RN C about the non - essential dietary staff that was noted on the C pod. RN C stated the RD was essential to assist with the passing of the trays in an effort to meet the residents' dietary needs with timely, hot food. RN C did confirm that if other tasks needed to be done by the Dietary Manager, RD L could have performed these tasks and DM N could have avoided going on the unit. On 2/24/16 at 9:13 am Surveyor spoke with DA M via phone. Surveyor asked DA M why she had walked through the quarantine unit on the morning of 2/23/16. DA M stated: Honestly I didn't even think about it. I know better . Surveyor asked DA M if she had been given any instruction or education regarding the need to avoid going on the C Wing / C Pod unnecessarily. DA M stated she had been given no information or instruction about not moving through the C units. On 2/25/16 at 2:43pm Surveyor spoke with DM N regarding the necessity of his being on the C pod on 2/23/16 during the quarantine. DM N stated he had not seen DA Q in about a weeks' time and felt it important to check in with her. C Wing / C Pod Doors The C hallway and the C pods make up a T shape with the hallway making up the straight line of the T and the pods breaking off in either direction at the end of the hall. At the entrance to the C Wing hall there are 2 side by side doors that open onto C hallway. Due to the GI illness, these doors have signage indicating the doors are to remain closed On 2/23/16 at 7:56 am Surveyor observed one of the doors to the C Wing / C Pod to be open. No staff was about the door area. On 2/23/16 at 7:57 am Beautician R was observed entering the C wing through the open door. Beautician R did not close the door. After approximately 30 seconds Therapy Staff entered the C wing hallway through the open door, and closed the door after she entered the C Wing. On 2/24/16 at approximately 3:00 pm Surveyor observed both doors to the C hallway to be open. Glucometer On 2/23/16 at 11:59 am Surveyor observed RN (Registered Nurse) P check Resident 18's blood glucose with the use of a Glucometer. This device is kept in the med cart and is used to check the blood glucose of multiple residents. After checking Resident 18's blood glucose with the device RN P wiped the device down with a small alcohol wipe and was ready to return the device to the med cart. At this time Surveyor asked RN P about cleaning the device. RN P stated she had wiped the device with an alcohol wipe to clean it. Surveyor asked her if that is how the device is usually cleansed between residents. RN P stated: Well ., paused, and then stated that staff will also use a bleach wipe to wipe the device down and let it sit (to dry). Surveyor asked RN P how she usually cleanses the device. RN P remained silent, but took a bleach wipe from the side of the cart and cleansed the device. On 2/24/16 Surveyor was provided with the facility Policy Statement for Cleaning and disinfecting of Resident - Care Items and Equipment with a revised date of 7/2014. This statement states, in part: . 3. Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident. In addition, Surveyor was provided with teaching documentation (undated) used for training staff. This documentation states Possible Survey Citations - Failure to clean glucometers between use each med cart should have 2 glucometers, and after use of one it should be wrapped in a bleach wipe, then alternate. Halo Bars On 2/22/16 at 10:21 am Surveyor spoke with Resident 5. Resident 5 was in her room and seated in her chair. Surveyor noted Resident 5 had rounded assist bars on Resident 5's bed. These bars were covered in black foam which was secured with black tape. Surveyor observed these assistive bars (Halo bars) covered in foam and secured with black tape, on Resident 5's bed each day of this 4 day survey. On 2/23/16 at 10:15 am Surveyor again spoke with Resident 5. Again Resident 5 was seated in her chair in her room. Pointing to the foam covered assistive bars, Surveyor asked Resident 5 about the bars. Resident 5 stated they are used to help her move about in bed. Surveyor asked Resident 5 why they were covered with foam and tape. Resident 5 stated they were there when she was admitted to the room and assumed that maybe someone had gotten hurt so they padded them. It is important to note that Resident 5 was deemed as interviewable by facility staff during the initial tour of the facility on 2/22/16. Resident 5's MDS (Minimum Data Set) with an observation end date of 1/6/16 documents Resident 5 had a BIMS (Brief Interview for Mental Status) of 14/15. On 2/25/16 at 12:33 pm Surveyor spoke with Housekeeper S regarding the foam covered assistive devices on the beds. Surveyor asked Housekeeper S how the bars are cleaned if they have the foam and tape about them. Housekeeper S stated she was a newer employee and did not know how the bars are to be cleaned if they are covered in the foam. Housekeeper S stated no one had ever discussed this with her and that she would have to ask. On 2/25/16 at 12:58 pm Surveyor asked Housekeeper T how the halo assistive bars get cleaned when / if they have the black foam and tape about them. Housekeeper T stated they try to get in between the cracks of the foam to reach the metal bar with the cleaning cloth. Housekeeper T stated she was unsure if the foam is removed when a resident is discharged .

Based on observation, interview, and record review, the facility did not ensure that the comprehensive care plan was revised as needed for 4 residents out of 15 sampled residents (Residents 7, 14, 15, and 4). Resident 7's comprehensive plan of care states To wear slippers until left heel resolved. This order was discontinued but Resident 7's plan of care was not updated. Resident 14's physician's orders [REDACTED]. However these interventions were not provided. Resident 15's physician orders [REDACTED]. Resident 4's comprehensive care plan states Resident 4 is to be ambulated to and from the bathroom and dining room, and up to 50 feet about the unit. Resident 4's Plan of Care posted in his room states this restorative ambulation intervention had been discontinued on 2/20/16. This is evidenced by: Example 1 Resident 7's nursing intervention on her Comprehensive plan of care includes the following intervention: To wear slippers until left heel resolved. Resident 7's Certified Nursing Assistant Plan of Care dated 1/19/16 states No shoes. Wear gripper socks until feet healed. Of note, Resident 7's comprehensive care plan was not updated to reflect the new nursing intervention. On 2/25/16 at 12:25 PM and 1:05 PM, Surveyor spoke with Registered Nurse (RN) C. Surveyor asked RN C if Resident 7 should be wearing gripper socks or slippers. RN C stated that Resident 7 should be wearing gripper socks. Surveyor asked RN C if the intervention To wear slippers until left heel resolved should have been removed from her comprehensive care plan. RN C stated, Yes. Example 2 Resident 14's current physician's orders [REDACTED]. From 2/24 - 2/25/16 Surveyor noted there was no fall mat in place on the floor next to Resident 14's bed and there are is no bed alarm. On 2/24/16 at 2:24 PM, Surveyor spoke with Certified Nursing Assistant (CNA) D. Surveyor asked CNA D if the fall mat against Resident 14's wall should be on the floor. CNA D stated, We don't put the fall mat on the floor. We leave the fall mat against the wall to prevent Resident 14 from bumping the wall when we turn her. On 2/24/16 at 2:36 PM, Surveyor spoke with Certified Nursing Assistant (CNA) E. CNA E stated she was unsure about the use of the fall mat and was going to check and would get back to me. CNA E returned a few minutes later and stated that they fall mat is supposed to be against the wall as protection for her knees. On 2/24/16 at 3:00 PM, Surveyor spoke with RN C. Surveyor asked RN C if Resident 14 should have a fall mat and alarm in place. RN C checked and stated the alarm and fall mat were discontinued around 2 years ago. On 2/25/16 at 12:25 PM, Surveyor spoke with RN C. RN C stated that Resident 14's fall mat was discontinued on 9/5/14. RN C stated the alarm was discontinued around 2 years ago. Surveyor asked RN C if these changes should be updated on the Physician Orders. RN C stated, Yes. Example 3 Resident 15 has been a resident at the facility for over 3 years. Her [DIAGNOSES REDACTED]. Resident 15's Plan of Care in her closet states she is totally dependent on staff for transferring, and is non ambulatory. Resident 15's physician orders [REDACTED]. On 2/25/16 at approximately 1:30 PM Surveyor interviewed Director of Nursing B who stated that Resident 15 does not ambulate and it should have been discontinued from her physician's orders [REDACTED]. Example 4 Resident 4's [DIAGNOSES REDACTED]. Resident 4 has a history of falls. Resident 4's current comprehensive care plan documents the problem area of: Self Care Deficit (1/15/16). An intervention to this care planned problem includes Restorative - Ambulation - Ambulate with resident to / from bathroom, dining room, and on unit up to 50' (50 feet) with 2 wheeled walker and 1 assist. Wheel chair to follow (1/15/16). At no time during this 4 day survey did Surveyor observe Resident 4 to be ambulated. Resident 4's Plan of Care which is posted in Resident 4's room notes that his restorative ambulation intervention (ambulating with resident to / from bathroom, dining room, and on unit up to 50' with 2 wheeled walker and 1 assist with wheel chair to follow) had been discontinued on 2/20/16. On 2/25/16 at approximately 10:35 am Surveyor spoke with DON B regarding several topics including Resident 4's ambulation care plan. DON B confirmed Resident 4 is no longer ambulated on the unit.

Based on interview, and record review in 2 of 15 total residents reviewed (Residents 3 and 11) the facility did not conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. Resident 3 was observed to have a pummel cushion in place and the facility did not assure it was not a restraint or safe for as it was not assessed. Resident 11's [DIAGNOSES REDACTED]. The facility did not complete a comprehensive assessment regarding Resident 11's sleep hygiene to ensure the need for this supplement. This is evidenced by: The facility policy and procedure for Restraints approved 8/26/09 includes that prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. Example 1 Resident 3 was a resident at the facility for over 2 years. Her [DIAGNOSES REDACTED]. and Feb. 2016). On 2/22/16 at 10:11 AM Surveyor observed Resident 3 sleeping in her bed. Her wheelchair in her room had a pummel cushion in it. At 12:07 PM Surveyor observed Resident 3 eating lunch sitting in her wheelchair with the pummel cushion in place. Surveyor viewed her care plan hanging in her closet while she was eating lunch. The pummel cushion was not on this care plan. Later on 2/22/16 Surveyor viewed the care plan for Resident 3 in her medical record and did not find the pummel cushion on it. On 2/24/16 Surveyor requested of the facility the assessment for Resident 3's pummel cushion and later received a therapy assessment completed on 2/24/16. This assessment stated the cushion was for positioning but did not clearly state if it was a restraint for Resident 3. On 2/25/16 at approximately 1:30 PM Surveyor interviewed Director of Nursing B who stated that the pummel cushion was a trial for Resident 3 for positioning and stated it was not a restraint. She agreed that it should have been assessed prior to being put in place and stated she did not know what date it was started as it was not on the care plan. Example 2 Resident 11's [DIAGNOSES REDACTED]. Resident 11's Nurses Notes contain a note dated 11/10/15 at 9:36 am which states: Spoke with nurse practitioner regarding resident stating she has not been able to sleep the past couple of days and she is interested in a sleep aid. Results: new orders received and noted 11/10/15. Resident 11's physician's orders [REDACTED]. Give 1 hour prior to bedtime for sleep aide. Surveyor was unable to find a sleep assessment in Resident 11's record to determine Resident 11's usual sleep pattern, identify causative agents that may be contributing to her lack of sleep, and past history of her sleep hygiene, all which could then be used toward the development of an individualized plan of care. On 2/25/16 Surveyor requested to see a sleep assessment for Resident 11. DON (Director of Nursing) B stated no sleep assessment could be found for Resident 11.

Based on observation, interview, and record review, in 1 of 7 residents reviewed during the medication pass task, the facility did not provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. Resident 17's physician orders [REDACTED]. Resident 17 was not receiving this laxative daily as ordered, but on an as needed basis. This is evidenced by the following: On 2/23/16 at 7:47 am, during the medication pass task, Surveyor observed RN (Registered Nurse) H administer morning medications to Resident 17. These medications included Vitamin C 500 mg (milligrams), a Multivitamin, and Vitamin D3 1,000 units. Resident 17's current physician orders, signed and dated 2/1/16 documents that Resident 17 is also to receive Polyethylene Glycol 1 packet (17 gram) each day at 8:00 am. Surveyor did not observe RN H administer Polyethylene Glycol to Resident 17 on 2/23/16 when observing the 8:00 am medication administration to Resident 17. Resident 17's MARs (Medication Administration Records) for 1/2016 and 2/2016 both include the entry for Polyethylene Glycol 1 packet, however this is documented to be given not on a daily basis, but PRN (as needed). These MARs show that Resident 17 did not receive Polyethylene Glycol daily, but received Polyethylene Glycol once in 1/2016 (1/3/16), and twice thus far in 2/2016 (2/5/16 and 2/13/16). On 2/24/17 Surveyor requested clarification of Resident 17's Polyethylene Glycol order. On 2/25/16 at approximately 3:00 pm DON (Director of Nursing) B showed Surveyor a clarification order the facility had just received stating Resident 17's Polyethylene Glycol is to be given as needed. DON B confirmed the original order (prior to receiving this clarification order) indicated the laxative was to be given daily.

Based on observation, record review and interview, in 1 of 9 residents reviewed for fall concerns, (Residents 4) the facility did not ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. Resident 4 has a history of falls. Resident 4's fall interventions include a mat to be placed on the floor beside his bed and chair, Dycem to be placed above and below his chair cushion, and not to be left alone while in the bathroom. Observations were made when these care planned interventions were not being followed. This is evidenced by: The facility's policy, Fall Management Program dated 3/13/09, states: Policy: All residents experiencing a witnessed fall or found on floor will be assessed to determine what, if any, treatment is needed and action will be taken to ensure prompt and appropriate treatment is received as necessary. Purpose: To ensure that residents are appropriately assessed and treated post fall . 5. a. Documentation in medical record must include: .Action taken by staff . Environmental Factors: Assess presence of environmental factors that could cause or contribute to falls. Resident 4's [DIAGNOSES REDACTED]. Resident 4 has a history of falls. Resident 4's current comprehensive care plan documents the problem area of: Potential for Injury related to trauma - falls (1/15/16). Interventions to this care plan problem include: Mat next to chair / bed, and Dycem above and below cushion in recliner (1/15/16). In addition, Resident 4 has the care plan problem of Self care deficit (1/7/16) which includes the intervention of: Stay with resident in bathroom / shower (1/15/16). Resident 4's Plan of Care which is kept in Resident 4's rooms also states Resident 4 is not to be left unattended in the bathroom, is to have a mat next to his bed and chair, and a dycem is to be above and below the cushion of his chair. Unattended in Bathroom On 2/22/16 at 12:45 pm Surveyor observed CNA (Certified Nursing Assistant) J assist Resident 4 back to his room after lunch. Resident 4 was in a w/c (wheelchair). CNA J assisted Resident 4 from the w/c to the toilet with the use of a gait belt. Once Resident 4 was seated on the toilet, CNA J left the bathroom, closing the bathroom door, but not shutting it completely, and waited for Resident 4 to finish in the bathroom while she (CNA J) waited by Resident 4's bed. CNA J did not have Resident 4 in her line of vision. After a short time (approximately 70 seconds) CNA J asked Resident 4 if he was finished. CNA J then entered the bathroom and continued to assist Resident 4 with his cares. Floor Mat On 2/23/16 at 10:20 am Surveyor observed Resident 4 seated in his recliner chair in his room. The floor mat was not next to the chair, but folded up behind the resident door. Dycem On 2/23/16 at 11:32 am CNA K assisted Resident 4 from his chair to his w/c, and then to the toilet. CNA K remained with Resident 4 while he was on the toilet, and then transferred him back to the w/c so to bring him to the dining area. Surveyor noted the chair Resident 4 had been seated in had a blanket over the cushion. Surveyor could not see if there were dycem above and below the cushion as indicated in Resident 4's care plan. Once Resident 4 was safely seated in his w/c, Surveyor asked CNA K if she could lift the blanket so Surveyor could observe for dycem above and below the cushion. CNA K lifted the blanket to show the waffle cushion. There was no dycem atop the cushion. CNA K lifted up the cushion to show 2 dycem under the cushion. CNA K stated they are stuck together. CNA K separated the two dycem and placed one dycem under the waffle cushion, and one on top.

Based on observation, record review and interview, in 1 of 15 total residents reviewed (Resident 6) the facility must use the results of the assessment to develop, review and revise the resident's comprehensive plan of care. Resident 6 was observed to be in full contact and respiratory precautions 3 of the 4 days of this recertification survey. Resident 6's comprehensive care plan did not identify a problem and / or measurable goals associated with the need for PPE (Personal Protective Equipment), and did not identify what type of PPE was required when entering the room. This is evidenced by the following: Resident 6's [DIAGNOSES REDACTED]. On 2/22/16 at approximately 8:30 am during the initial tour of the facility Surveyor observed Resident 6's room door closed with a sign on the door instructing people to see the nurse before entering. There was a cart with PPE (Personal Protective Equipment) just outside Resident 6's room. Each page of the facility resident comprehensive care plans are divided into 4 columns: Problem, Approach, Goal, and Goal time. Resident 6's current care plan contains a page with a list of approaches dated 1/27/16 which included: *Use good handwashing technique before and after cares *Hand sanitizer is not effective against C - Diff. Use soap and water. *Administer medications as ordered, monitor side effects and effectiveness *Notify MD prn *Wear gloves with cares *Monitor vital signs during infection *Note characteristics of drainage *Monitor labs as ordered *Help resident to wash hands *Cough / deep breathing *Monitor diet status *Encourage hydration There is no Problem associated with these interventions, and no Goals associated with these interventions, however there is a Goal Time of Three months, 4 - 2016. Nowhere on Resident 6's care plan does it indicate Resident 6 is in isolation precautions which would necessitate the need for full PPE prior to entering the room. Nowhere on Resident 6's care plan does it indicate why or for what reason PPE is necessary. On 2/25/16 at 1:50 pm Surveyor spoke with DON (Director of Nursing) B regarding the facility's infection control program. Surveyor asked DON B to speak to Resident 6's infection control care plan. DON B stated the facility was unable to determine what the etiology of Resident 6's illness was so they did not know what to care plan. Surveyor asked DON B if she felt it should be care planned that Resident 6 was in isolation precautions. DON B stated: They would know if they saw the cart outside his room.

Based on observation, record review, and interview, in 2 of 13 active residents reviewed (Residents 12 and 14) the facility did not ensure services provided or arranged by the facility were provided by qualified persons in accordance with each resident's written plan of care. Resident 12's care plan instructs that Resident 12's heels should be floated off the mattress. Observations were made when this care planed intervention was not followed. Resident 14's Physician order [REDACTED]. This is evidenced by Example 1 Resident 12's comprehensive care plan has the problem area of: Potential for impairment of skin integrity. An intervention to this care plan problem includes: Float heels above mattress with pillows. On 2/24/16 at 1:42 pm Surveyor observed Resident 12 in bed. She was covered in a blanket from her shoulders down over her feet. Surveyor was unable to see her feet to tell if the heels were floated. Surveyor noted CNA O just outside Resident 12's room. Surveyor asked CNA O to lift Resident 12's blankets from her feet so to see if Resident 12's heels were floated. CNA O entered Resident 12's room and gently lifted the blankets off Resident 12's feet. Resident 12's heels were noted to be directly on the mattress. CNA O stated she would elevate Resident 12's heels. Example 2 Resident 14's Physician Orders, signed 2/2/16, state Apply boots when laying in bed and Float bilateral heels when in bed. Surveyor observed Resident 14 lying in bed without blue boots on and heels not floated. Resident 14's Care Plan states Float heels above mattress with pillows. Resident 14's care plan does not address blue boots. On 2/24/16 at 2:20 PM, Surveyor observed Resident 14 lying in bed without blue boots and both heels directly on the mattress (not floated). On 2/24/16 at 2:24 PM, Surveyor spoke with Certified Nursing Assistant (CNA) D. Surveyor asked CNA D to come into Resident 14's rooms, lift up the sheet, and tell me if Resident 14's heels are floated. As we stood in Resident 14's doorway, CNA D stated, I can look at them and see they're not (floated). We entered Resident 14's room and CNA D pulled back the covers. Resident 14 was not wearing blue boots and Resident 14's heels were directly on the mattress. CNA D stated that Resident 14 should be wearing blue boots and her heels should be up off of the mattress. CNA D stated she was not sure where Resident 14's blue boots were located. Surveyor asked CNA D if they might be in Resident 14's closet. CNA D check Resident 14's closet and found her blue boots and put them on her. On 2/25/16 at 12:25 PM and 1:05 PM, Surveyor spoke with Registered Nurse (RN) C. RN C stated that they are going to discontinue the blue boots for Resident 14, but it hasn't been done yet. RN C stated that Resident 14 should have had the blue boots on and her heels should have been floated so they were not touching the mattress.

Based on observation, interview, and record review, the facility did not ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 8 residents reviewed for falls (Resident 2). Resident 2 has a history of falls and has falling at the facility since re-admission on 11/23/15. Resident 2's fall plan of care has an intervention to have the call light in reach observations were made and interviews obtained that this intervention did not occur. This is evidenced by: Example 1 Resident 2 has the following Diagnoses: [REDACTED]. A Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/4/15 indicates a Brief Interview of Mental Status (BIMS) score of 11 indicating Resident 2 has moderate cognitive impairment. A Fall Risk Assessment was completed on 11/23/15 and Resident 2 scored a 7 indicating a low risk for falls. Resident 2 has a comprehensive plan of care dated 11/23/15 states in part; falling star program. Resident 2 has a Potential for Injury plan of care dated, 10/1/15, an intervention to this plan of care states in part; call light in reach. Nursing notes dated 11/23/15 at 9:57 AM state in part; had several falls recently. Nursing notes dated 11/26/15 at 09:22 AM state in part; fall without injury ambulating independently to the bathroom when he lost his balance and went backwards. Family able to reach him before he hit the floor however, Certified Nursing Assistant (CNA) passing by saw left arm hit the ground. New Intervention: encourage to seek help, however he is often seen ambulating on his own. Fall assessment dated [DATE] at 9:25 indicates a score of 16 indicating a high risk for falls. Physical and Occupational therapy ordered, will anticipate needs, and placed on falling star program. Nursing notes dated 12/7/15 at 11:31 AM state in part; Resident in bathroom and unsafely transferred from surface to surface. Found with back to bathroom wall, legs in front of him. New Interventions: stop sing to be placed across bathroom door as reminder to use call light for assistance and possible room change. On 12/7/15 at 2:30 PM Surveyor observed that Resident 2's room had been changed to across the hall and closer to the nursing station. Surveyor entered Resident 2's room and noted a Velcro stop sign across Resident 2's bathroom door (of note Resident 2's bathroom is not visible from Resident 2's bed or recliner. Resident 2 would have to stand and walk around a corner to see the stop sign across the bathroom door). Resident 2 has a sign on his cabinet which states Push call light to get help. On 12/7/15 at 2:50 PM Surveyor observed Physical Therapy Assistant (PTA) C walking Resident 2 and entered Resident 2's room. At approximately 2:51 PM Surveyor observed PTA C exit Resident 2's room. On 12/7/15 at approximately 2:51 PM Surveyor entered Resident 2's room. Resident 2 was sitting in his recliner. Surveyor observed a sign on Resident 2's walker which stated Push call light to get help. Surveyor observed Resident 2's call light hooked on the call light cord attached to the wall and not within Resident 2's reach. Of note, Resident 2 would have to stand and walk between the recliner and bed to reach the call light. On 12/7/15 at approximately 2:52 PM Surveyor stood in the doorway of Resident 2's room and summons help. Housekeeper (HSKP) D entered the room. Surveyor asked HSKP D if Resident 2 had his call light HSKP D stated No. HSKP D placed the call light on Resident 2's recliner. HSKP D stated the call light should always be put where a resident can reach it. On 12/7/15 at 3:03 PM Surveyor interviewed PTA C regarding the Resident 2's call light. PTA C stated she did not put the call light within Resident 2's reach that it was her error. PTA C stated the call light should always be within a residents reach. On 12/7/15 at 3:10 PM Surveyor interviewed Director of Nursing (DON) B regarding Resident 2's falls and fall interventions. Surveyor asked DON B why Resident 2 had a room change today. DON B stated to have him closer to the nursing station and within better view of nursing staff. Surveyor asked DON B if Resident 2 should have his call light within reach DON B stated yes residents should have their call lights within reach at all times. The facility failed to ensure that assistive devices in particular Resident 2's call light was within reach at all times.

Based on observation and interview the facility did not promote care for residents in a manner that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality for 1 of 8 Residents observed (Residents 2). Resident 2 has a history falls. The facility placed signs in Resident 2's room and on his walker to remind Resident 2 to use his call light for assistance. These signs are humiliating to Resident 2. The facility failed to ask Resident 2 how he felt about the use of the signage in his room and on his walker. This is evidenced by the following: Resident 2 has the following Diagnoses: [REDACTED]. Of note, per interview with Resident 2's family member, Resident 2's depression was so severe Resident 2 attempted suicide a couple of years ago while at the facility. A Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/4/15 indicates a Brief Interview of Mental Status (BIMS) score of 11 indicating Resident 2 has moderate cognitive impairment. Of note, Resident 2 is his own decision maker. A Fall Risk Assessment was completed on 11/23/15 and Resident 2 scored a 7 indicating a low risk for falls. Resident 2 has a comprehensive plan of care dated 11/23/15 states in part; falling star program. Resident 2 has a Potential for Injury plan of care dated, 10/1/15, an intervention to this plan of care states in part; call light in reach. Social Services notes dated 9/17/15 state in part; resident struggles with depression and history of [MEDICAL CONDITION]. He did have suicide attempt while here previously. Nursing notes dated 11/23/15 at 9:57 AM state in part; had several falls recently. Nursing notes dated 11/26/15 at 09:22 AM state in part; fall without injury ambulating independently to the bathroom when he lost his balance and went backwards. Family able to reach him before he hit the floor however, Certified Nursing Assistant (CNA) passing by saw left arm hit the ground. New Intervention: encourage to seek help, however he is often seen ambulating on his own. Fall assessment dated [DATE] at 9:25 indicates a score of 16 indicating a high risk for falls. Physical and Occupational therapy ordered, will anticipate needs, and placed on falling star program. Nursing notes dated 12/7/15 at 11:31 AM state in part; Resident in bathroom and unsafely transferred from surface to surface. Found with back to bathroom wall, legs in front of him. New Interventions: stop sign to be placed across bathroom door as reminder to use call light for assistance and possible room change. On 12/7/15 at 2:30 PM Surveyor observed that Resident 2's room had been changed to across the hall and closer to the nursing station. Surveyor entered Resident 2's room and noted a Velcro stop sign across Resident 2's bathroom door (of note Resident 2's bathroom is not visible from Resident 2's bed or recliner. Resident 2 would have to stand and walk around a corner to see the stop sign across the bathroom door). Resident 2 has a sign on his cabinet which states Push call light to get help. On 12/7/15 at approximately 2:51 PM Surveyor entered Resident 2's room. Resident 2 was sitting in his recliner. Surveyor observed a sign on Resident 2's walker which stated Push call light to get help. Surveyor interviewed Resident 2 about his room change. Surveyor asked Resident 2 if the facility asked him if he would like to change rooms. Resident 2 stated No and I was a little bit upset about the room change. Surveyor asked Resident 2 if he knew why he was moved. Resident 2 stated No, they just told me I was moving. Surveyor asked Resident 2 about the signage in his room including the sign on his cabinet and wheelchair that states Push call light to get help. Surveyor asked Resident 2 if he knew why the signage was in his room and on his walker. Resident 2 stated they put it there to remind me to push the button. Surveyor asked Resident 2 how he felt about the signage. Resident 2 stated I don't really care for it. It makes me feel helpless, hopeless and like a child. I do not care much for it at all. Surveyor asked Resident 2 if the facility asked his permission to hang the signs. Resident 2 stated they just put them up. Resident 2 then pointed to the sign on his walker that states Push call light to get help and stated it's a bit childlike isn't it. Surveyor asked Resident 2 if he consented to the stop sign on his bathroom door. Resident 2 stated No. Of note, this sign is not visible to Resident 2 from his bed or recliner. Resident 2 would have to stand and walk around a corner in order to see the stop sign. However, the stop sign is very visible to residents, visitors and staff from the hallway when passing by Resident 2's room. Resident 2 appeared very embarrassed and frustrated with the signage during the interview process. On 12/7/15 at 3:10 PM Surveyor interviewed Director of Nursing (DON) B regarding Resident 2's falls and fall interventions. Surveyor asked DON B why Resident 2 had a room change today. DON B stated to have him closer to the nursing station and within better view of nursing staff. Surveyor asked DON B about the stop sign and signage in Resident 2's room. DON B stated Surveyor should speak to Social Worker (SW) E as she is familiar with the signage and stop sign and was part of the team decision. On 12/7/15 at 3:15 PM Surveyor interviewed SW E regarding the room move and signage in Resident 2's room. Surveyor asked SW E if Resident 2 was in agreement with the room change. SW E stated Resident 2 was in agreement with the move according to Registered Nurse (RN) G. SW E stated RN G had spoken to him about the room change and reported he was in agreement with the move. Surveyor asked SW E about the stop sign and other signage in Resident 2's room. SW E stated she is aware that Resident 2 is frustrated with the signage but he has never refused them. Surveyor asked SW E if she has spoken to Resident 2 about how he feels about the signs that he states he feels hopeless, helpless and like a child. SW E stated I know he is frustrated with them his daughter has shared his frustrations with me I will go speak with him. Social Services notes dated 12/7/15 at 3:23 PM state in part; RN G called writer to say that she did talk to resident about room change and he was in agreement. RN G also called the daughter, Family Member, (FM) F to see if she thought that would be a good idea. All were fine with the move. State social worker here today and she was concerned that Resident 2 did not like the signs in his room reminding him to use his call light for help when he wanted to get up. Writer spoke with Resident 2 about the signs and he does not like them. Writer asked if he was Okay with them in his room or would he prefer that they be taken down. Resident 2 stated he wanted them to be taken down. Writer removed signs and explained to resident how important it is for him to ask for help when he wanted to get up. Resident 2 said he would. On 12/7/15 at 3:27 PM Surveyor interviewed Resident 2's daughter FM F regarding Resident 2's falls, signage and room change. Surveyor asked FM F about Resident 2's room change. FM F stated the facility had called on the morning of 12/7/15 and asked if it was okay to move her father. FM F stated she was in agreement as it may help the staff to reach Resident 2 more quickly. Surveyor asked FM F if she was aware Resident 2 was unhappy with the room change FM F stated she was told he was in agreement with the move. Surveyor asked FM F if Resident 2 had ever spoken to her regarding the signage in his room. FM F stated I know he is less than happy about the signage. I think it is a pride thing. He has some cognitive impairment and is at risk for falls. Surveyor asked FM F if he ever shared that the signage made him feel helpless, hopeless and that he felt the signs were childlike. FM F stated I am sympathetic that this is humiliating to have signage. I have to mention we do wait a long time for the call light to be answered at times. I understand he is humiliated and depressed. I just spoke with SW E today about the signage and she is aware that Resident 2 is frustrated with the signage. FM F stated I took him out of the facility today to the bank and the first thing he did prior to entering the bank is tear the sign off his walker and he tucked it away in his pocket. I know this has to be so difficult for him, my biggest concern is late call light response and then he tries to get up on his own. I know I need to be concerned with his humiliation and frustration with this signage especially if he is feeling helpless and hopeless. FM F stated to Surveyor I do not know if you are aware but he tried to commit suicide a couple of years ago while at the facility I know I need to be cognizant of that as well. I do not want these signs to lead to further depression. On 12/7/15 at 4:00 PM Surveyor interviewed RN G regarding the room change and signage for Resident 2. RN G stated she had spoken to Resident 2 during lunch and he was in agreement with the move. RN G stated she did not feel he was upset at all about the move. Surveyor asked RN G if she had received permission from Resident 2 to place the stop sign on Resident 2's bathroom door. RN G stated she did not get permission or speak to Resident 2 about the stop sign that was my error I should have spoken with him and received permission to hang the stop sign. Surveyor asked RN G if she was aware Resident 2 was frustrated by the signage RN G stated she was not aware Resident 2 was upset about the signage in his room or on his walker. Resident 2 verbalized his frustration with the signage in his room. The facility staff was aware of Resident 2's frustration yet the facility failed to speak with Resident 2 regarding his feelings about the signage. Resident 2 has a history of depression and verbalized feelings of frustration, humiliation, helplessness and hopelessness. The facility failed to act on Resident 2 verbalizations regarding the signage thus allowed Resident 2 to experience further feelings of humiliation and despair. Of note, the facility spoke with Resident 2 and removed all signage on 12/7/15.

Based on observation, interview, and record review, in 3 of 16 residents reviewed (Residents 4, 5 and 6) the facility did not ensure services provided or arranged by the facility were provided by qualified persons in accordance with each resident's written plan of care. CNA C did not place a dycem on top of Resident 4's cushion when she transferred him to his recliner per his care plan. Resident 5's heels were not floated in bed and Resident 5 did not receive a fruit smoothie at breakfast as per the plan of care. Resident 6's heels were not floated in bed as per the plan of care. Evidenced by: Example 1 Resident 4 has [DIAGNOSES REDACTED]. His most recent fall was on 11/30/14. Resident 4's Plan of Care that hangs in his closet updated 11/28/14 includes under safety "Dycem above/below cushion in recliner." On 1/15/15 at 11:49 AM Surveyor observed CNA C transfer Resident 4 from his wheelchair to his recliner. CNA C put a dycem below the waffle cushion and an incontinent pad on top. CNA C did not put a dycem on top of the cushion or the incontinent pad for Resident 4. On 1/20/15 at 10:45 AM Surveyor questioned Director of Nursing B who agreed resident's care plans should be followed and Resident 4 should have had a dycem on top of his cushion in his recliner. Example 2 Incident 1 Resident 5's physician orders, signed 1/6/15, include receiving a fruit smoothie with breakfast. Resident 5's dietary card for breakfast indicates Beverages: fruit smoothie daily and Likes: fruit smoothie daily-no seeds. On 1/15/15, at 8:27 AM, Surveyor observed Resident 5 eating breakfast. Resident 5 was served milk and water. Resident 5 was not given or offered a fruit smoothie. Resident 5 slept in on 1/20/15 and 1/21/15 and did not eat breakfast. On 1/21/15, at 9:18 AM, Surveyor interviewed Dietary Steward (DS) F regarding Resident 5's fruit smoothie. DS F frequently works on Resident 5's unit. DS F stated she was not sure if Resident 5 received a special beverage at breakfast. DS F stated if a resident was to receive a fruit smoothie she would mix it up on the unit or it might come from the kitchen. DS F stated she was not aware Resident 5 was to receive a fruit smoothie and had not made her one. On 1/21/15, at 9:42 AM, Surveyor interviewed Certified Nursing Assistant (CNA) J who stated she frequently works with Resident 5. CNA J stated for breakfast Resident 5 usually tells her what she wants. CNA J stated she has never given Resident 5 a fruit smoothie. On 1/21/15, at 10:25 AM, Surveyor interviewed Dietician G. Dietician G stated Resident 5 is to receive a fruit smoothie every morning which is made on the unit. Dietician G stated the fruit smoothies are per Resident 5's family request for hydration as Resident 5 drinks them well. Dietician G confirmed Resident 5 should be receiving the fruit smoothie every morning. Incident 2 Resident 5's care plan includes the intervention to float heels above mattress with pillows. On 1/20/15, at 8:18 AM, Surveyor and Registered Nurse (RN) E observed Resident 5 in bed. Resident 5's air mattress was not functioning fully and Resident 5's feet were not floated off the mattress. RN E repositioned Resident 5's feet and floated them on a pillow. Example 3 Resident 6's care plan, dated 6/23/14, includes the approach of float heels above mattress with pillows to address the problem of potential for impairment of skin integrity. On 1/14/15, at 2:27 PM, Surveyor observed Resident 6 in bed. Resident 6's feet were not float and were resting directly on the mattress. On 1/15/15, at 9:25 AM, Surveyor observed Certified Nursing Assistants (CNA) H and I assist Resident 6 into bed. CNA H places a small pillow between Resident 6's knees but did not float her heels and her feet were directly on the mattress. On 1/15/15, at 2:15 PM, Surveyor observed Resident 6 in bed and her heels were not floated. On 1/21/15, at 9:22 AM, Surveyor interviewed Registered Nurse (RN) E. RN E stated per Resident 6's care plan her heels should be floated when in bed with a pillow. Then Surveyor and RN E observed Resident 6 in bed. Resident 6's heels were directly on the mattress. There was a small pillow between Resident 6's knees but this was not floating the heels off the bed.

Based on observation, interview and record review, the facility did not follow accepted standards of practice when they did not properly verify [DEVICE] placement prior to medication administration in 1 of 1 observation (Resident 2) for residents receiving medications via their [DEVICE]. Surveyor observed Registered Nurse (RN) D administer [DEVICE] medications to Resident 2. RN D was ready to administer the first flush of water and medication prior to checking placement and residual for Resident 2. This is evidenced by: The facility policy, "Administering medications via gastrostomy tube", which is undated, states as follows: 3. Check tube for placement by infusing 30 cc of air and listening over umbilicus. For a PEG/PEJ, check that the black line is flush with the skin surface. 4. Aspirate gastric/[DIAGNOSES REDACTED] feeding tube prior to administering medications. On 1/15/15 at 11:58 AM, during the medication observation task, Surveyor observed RN D administer the following medications to Resident 2 via G tube: [MEDICATION NAME] 25 micrograms (mcg) tablet, [MEDICATION NAME] 5 milligrams (mg) tablet, [MEDICATION NAME] 10 milligrams (mg) tablet, and Liquid [MEDICATION NAME] 20 milliliters (ml). RN F crushed the [MEDICATION NAME] tablet, [MEDICATION NAME] tablet, and [MEDICATION NAME] tablet into fine powder in a plastic bag. RN D then poured the three crushed medications into one 30 ml medication cup. RN D measured liquid [MEDICATION NAME] in a 30 ml medication cup. RN D entered Resident 2's room. RN F filled the gradated cylinder with approximately 200 ml of tap water. RN D added 30 ml of water to the medication cup containing the slurry of a crushed [MEDICATION NAME] tablet, crushed [MEDICATION NAME] tablet, and crushed [MEDICATION NAME] tablet. RN D opened Resident 2's G tube and placed the syringe with a 30 ml flush of top water on the G tube port. Just as RN D was ready to instill the tap water flush, Surveyor stopped RN D. Surveyor asked RN D what she should have done before flushing the G tube. RN D stated she should have checked for placement as well as residual and did not do so. RN D removed the syringe containing 30 ml tap water flush from the G tube and exited the room to obtain a stethoscope. RN D returned with a stethoscope. RN D checked placement with air and checked residual. After confirming placement, RN D stated Resident 2's residual is approximately 5 ml. RN D stated Resident 2's residual is normally 5-10 ml. RN D flushed the G tube with 30 ml of tap water. RN D administered the slurry of [MEDICATION NAME] , [MEDICATION NAME], and [MEDICATION NAME] mixed with 30 ml of tap water. RN D flushed the G tube with 30 ml of tap water. RN D administered liquid [MEDICATION NAME] via G tube followed by a 60 ml flush with tap water. RN D stated she administered 60 ml as liquid [MEDICATION NAME] is "Gooey." On 1/15/15 at 12:10 PM, Surveyor spoke with RN D. Surveyor asked RN D if she should have checked for placement and residual prior to administering medication and flushes. RN D replied, "Yes, I definitely should have." Surveyor asked RN D why is it important to check placement before administering G tube medications. RN D replied, "So we know where those fluids are going." On 1/21/15 Surveyor spoke with Director of Nursing (DON) B. Surveyor asked DON to describe the process the nurses should be following when administering medications via G tube. DON B stated the nurse should tell the resident what they're going to be doing, check placement with air, check residual, flush the G tube, and after administering each medication, flush with tap water. If compatible, and reviewed by pharmacy the medications can be combined.