Every finding on record at Cedar Lake Health and Rehab Center

Based on interview and record review, the facility did not ensure allegations of abuse/neglect were reported to the State Agency (SA) for 1 resident (R) (R1) of 1 resident in a sample of 4 residents.R1 and their family filed a grievance with the facility on 3/26/26 that involved allegations of abuse/neglect. The facility did not report the allegations of abuse/neglect to the SA.Findings include:The facility's Patient Abuse, Neglect, Mistreatment, Misappropriation of Property and Exploitation policy, dated 3/2026, indicates: Alleged Violation: is a situation or occurrence that is observed or reported by staff, resident, relative, visitor, or other but has not been investigated .Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Reporting/Response: 1. Report all alleged violations to the Administrator, Nursing Administrator on-call, State Agency (Division of Quality Assurance (DQA)/Office of Caregiver Quality (OCQ)) .no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. R1 was admitted to the facility on [DATE] for rehab following hospitalization for a fall. R1 had diagnoses including multiple fractures of the pelvis with stable disruption of the pelvic ring, unspecified fracture of the sacrum resulting in pubic rami, and right sacral ala fracture. R1 also had diagnoses including spinal stenosis, lumbar region, age-related osteoporosis with current pathological fracture, cognitive communication deficit, and unspecified dementia. R1's Minimum Data Set (MDS) assessment, dated 4/7/26, stated R1 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating moderate cognitive impairment. R1 and their family filed a grievance with the facility on 3/26/26. The grievance indicated sometime during the night, R1 called out in pain and someone closed the door without checking on them. R1 also said staff did not apply cream the last 3 days which made their pain worse. A family member stated they went to the nurses' station on (3/23/26), (3/24/26), and (3/25/26) at approximately 7:00 PM to tell them they were leaving and R1 wanted to get into bed. The family member was told by a Certified Nursing Assistant (CNA) that they would not put R1 to bed because R1 would keep the CNA up all night with their call light. The CNA had worked with R1 and knew they used their call light frequently. The CNA also said there was no way they could put R1 to bed at that time because they were taking care of 10 residents and were short staffed. The grievance also indicated staff told R1 when they were newly admitted that they should not use their call light so much because it would wear out. The comment upset R1, made them feel like a nuisance, and made them fearful to use their call light. On 6/24/26, Surveyor reviewed the facility's investigation and staff education and noted the facility did not report the allegation of abuse/neglect to the SA. On 6/24/26 at 2:59 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B. DON-B indicated the facility's initial investigation was completed within 24 hours. The facility determined there was no abuse/neglect so the allegation was not reported. Surveyor informed NHA-A and DON-B that all allegations should be reported to the SA and the facility's investigation should be submitted with their 5-day report. Surveyor also informed NHA-A and DON-B that some of the investigatory interviews were completed after the 24-hour window and the date of resolution was listed as 4/1/26.

Based on interview and record review, the facility did not ensure care was provided in accordance with physician orders for 1 resident (R) (R2) of 4 sampled residents. R2's hospital discharge summary contained follow-up instructions for a right upper quadrant (RUQ) and left internal/external biliary drain to be flushed with 10 milliliters (ml) of saline twice daily. R2's medical record contained orders for a biliary drain and did not accurately reflect the orders. In addition, orders from an after visit summary on 5/4/26 indicated R2's biliary tube was attached to a bag after a tube exchange and the physician would tell them when to remove the bag and cap the drain. The orders were not transcribed into R2's medical record, were not clarified, and were not implemented. Findings include: The facility's Transcribing Physician Orders policy indicates: To ensure complete and accurate follow through on practitioners' orders .All orders transcribed by the Health Unit Coordinator (HUC), Medication Assistant, or Nurse Extern/trained designee must be checked and co-signed by a licensed nurse .Key Steps: 1. Check order against current practitioner's order to avoid conflicting orders .5. Send copy/notify appropriate departments of new orders .6. Check off completed order with first initial, last name, and title. 7. Nurse transcribing or co-signing to document in progress note. R2 was admitted to the facility on [DATE] with diagnoses including biliary acute pancreatitis and intraoperative complications of digestive system resulting in two drains being placed in their abdomen. R2's Minimum Data Set (MDS) assessment, dated 5/28/26, stated R2's Brief Interview for Mental Status (BIMS) score was 15 out of 15, indicating intact cognition. R2 was discharged home on 6/1/26.A hospital Discharge summary, dated [DATE], included the following instructions:~ Drain Follow-up:~ Faculty Owner: Medical Doctor (MD)-G~ Location: Right Upper Quadrant (RUQ)~ Drain Type: 12 Fr (French, size) to gravity bag~ Drain Placed By: (unknown initials)~ Drain Maintenance: Flush drain with 10 ml normal saline (NS) twice daily (BID)~ Faculty Owner: MD-G~ Drain Location: Left internal/external biliary drain~ Drain Type: 10.2 Fr to gravity bag~ Drain Placed By: Interventional Radiology (IR)~ Drain Maintenance: Flush drain with 10 ml NS BID~ Discharge instructions: Drain care: Continue drain care as instructed. Monitor and record drain output and bring the information to clinic follow-up: 0.9% sodium chloride (NaCl) syringe administer 10 ml once daily. Flush biliary drain once daily with 10 ml saline. (Of note: This instruction indicated to flush once daily versus the instruction above to flush BID).R2's Treatment Administration Record (TAR) included the following orders:~ Flushing biliary drain: Flush drain with 10 mls of NS BID for biliary drain maintenance (started: 3/21/26; discontinued: 4/10/26) ~ Biliary drain: Document output every shift (started: 3/21/26; discontinued 4/21/26)~ Biliary drain dressing change: Gauze dressing to be changed every other day or as needed if it becomes soiled. Use split gauze and secure with tape. It is okay to clean insertion site with NS and mild soap and water. Once daily (started: 3/22/26; discontinued: 4/21/26)~ Flushing biliary drains: Flush drains with 10 mls of 0.9% NS BID (started: 4/10/26; discontinued: 4/21/26) ~ Flushing both biliary drains: Flush drains with 10 mls NS BID (started: 4/22/26; discontinued 4/28/26)~ Document drain output each shift three times daily (TID) (started 4/23/26; discontinued 5/8/26)~ Flushing both biliary drains: Flush drains with 10 mls of 0.9% NS BID (started: 4/28/26; discontinued 4/29/26)~ Flushing both biliary drains: Flush drains with 10 mls of 0.9% NS BID. Flush the drains slowly. This will avoid abdominal pressure and the inability to breathe. BID (started 4/29/26; discontinued 5/4/26)~ Flushing biliary drain: Flush drain with 10 mls of 0.9% NS daily. Flush the drains slowly. This will avoid abdominal pressure and the inability to breathe. Once daily (started 5/5/26, discontinued: 5/26/26)~ Change dressing to biliary drain site/removal site once daily every 3 days (started: 5/7/26; discontinued 5/26/26)~ Empty drain bag each shift, document amount removed. TID (started: 5/7/26; discontinued 5/26/26)~ Biliary drain: Record drainage amounts each shift every shift (started: 5/26/26; discontinued 6/1/26)~ Flush biliary drain with 10 mls of 0.9% NS daily. Flush drain slowly. This will avoid abdominal pressure and the inability to breath. Once daily (started 5/27/26; discontinued 6/1/26)After comparing the discharge summary with R2's TAR, the following inconsistencies were identified:~ Two drains were identified in the discharge summary: RUQ 12 Fr to gravity bag and a left internal/external biliary 10.2 Fr to gravity bag. ~ One drain was identified on the TAR as a biliary drain to flush from 3/21/26 through 4/10/26. On 4/10/26, the order changed to flush both drains. A progress note on 4/6/26 indicated the biliary drains were flushed. (This was the first indicator in R2's progress notes and TAR that two drains were flushed.) ~ On 4/9/26, Advanced Practice Nurse Practitioner (APNP)-H ordered to continue to flush BOTH (upper case and underlined) drains daily with 10 mls of 0.9% NS each and record drain output daily. ~ The discharge summary stated both drains were attached to drainage. According to R2's TAR, staff documented drainage for the biliary drain. There was no documentation to indicate the facility contacted the discharging provider to clarify the discharge instructions which stated both drains were attached to drainage. ~ A progress note on 4/12/26 indicated the capped drain and the left drain with bag attached were flushed. (This was the first indicator in R2's progress notes or TAR that one of the drains was capped.) ~ Orders were entered in R2's TAR to change the biliary drain dressing from 3/22/26 through 4/21/26. Between 4/22/26 and 5/7/26, the TAR did not contain orders to change dressings for the drain(s). A progress note on 4/26/26 indicated both dressings were changed during a time dressing changes were not on R2's TAR. The next note on 5/8/26 indicated dressings were changed to BL (possible bilateral) biliary drains. The left drain site was crusty with no active drainage, redness or warmth, and there was 50 cubic centimeters (ccs) of green bile drainage from the bag. The left site was healed, no opening noted, slight pinkness with no drainage. ~ Two progress notes indicated two dressings were changed: A progress note on 3/22/26 indicated dressings to biliary drain remain (clean, dry, intact). A progress note on 4/16/26 indicated dressings were changed. ~ A progress note on 5/5/26 at 8:31 AM by Registered Nurse (RN)-F indicated R2 had a drain procedure on 5/4/26 and the right drain was removed. The center drain was replaced and had a drainage bag. A handwritten physician progress note, dated 3/30/26 and written by MD-G, indicated: IR to pull the capped drain if appropriate then record RUQ (biliary) drain output. Make follow-up appointment for MD-G to remove biliary drain when output less than 30 ccs per day for 2 days.MD-G signed handwritten orders on 3/30/26 that stated: .record daily intake/output from biliary drain daily; after capped drain removed, call to make an appointment with MD-G for biliary drain removal. MUST have intake/outputs recorded prior to removal. Will only pull when less than 30 ccs per day for 2 days.From 3/21/26 through 3/31/26, the daily drain output was documented between 7 mls and 35 mls. From 4/1/26 through 4/21/26, the daily drain output was documented between 1 ml and 150 mls. R2 was hospitalized from [DATE] through 4/22/26 for pneumonia. From 4/23/26 through 5/8/26, the daily drain output was documented between 0 ml and 645 mls: ~ 4/23/26: 10 mls (NOC shift)~ 4/24/26: 17.5 mls~ 4/25/26: 2 mls~ 4/26/26: 3.5 mls~ 4/27/26: 3 mls (AM and NOC shifts)~ 4/28/26 and 4/29/26: 0 ml~ 4/30/26: 20 mls~ 5/1/26: 10 mls (NOC shift)~ 5/2/26: 20 mls~ 5/3/26: 2 mls~ 5/4/26: 350 mls~ 5/5/26: 500 mls (AM and NOC shifts)~ 5/6/26: 575 mls (AM and NOC shifts)~ 5/7/26: 645 mls~ 5/8/26: 250 mls (This day had duplicate documentation on another order in the TAR. The amount is for the AM and PM shifts.)From 5/7/26 through 5/26/26, the daily drain output was documented between 150 mls and 900 mls: ~ 5/7/26: 500 mls (PM and NOC shifts)~ 5/8/26: 600 mls (This day had duplicate documentation on another order in the TAR. The amount is for the AM, PM, and NOC shifts.) ~ 5/9/26: 900 mls ~ 5/10/26: 850 mls~ 5/11/26: 450 mls (PM and NOC shifts)~ 5/12/26: 625 mls ~ 5/13/26: 750 mls~ 5/14/26: 330 mls (PM and NOC shifts)~ 5/15/26: 250 mls (AM and NOC shifts)~ 5/16/26: 250 mls ~ 5/17/26: 500 mls ~ 5/18/26: 425 mls (PM and NOC shifts)~ 5/19/26: 405 mls (PM and NOC shifts)~ 5/20/26: 300 mls (AM and NOC shifts)~ 5/21/26: 150 mls (AM shift; Went to hospital at 8:15 PM)R2 was hospitalized from [DATE] at approximately 8:15 PM through 5/26/26 at approximately 4:30 PM for a urinary tract infection (UTI), sepsis, and acidosis.From 5/26/26 through 6/1/26, the daily drain output was documented between 0 ml and 357.5 mls:~ 5/26/26: 5 mls (Returned from hospital at approximately 4:30 PM)~ 5/27/26: 20 mls~ 5/28/26: 10 mls (AM shift not documented)~ 5/29/26: 357.5 mls~ 5/30/26: 155 mls ~ 5/31/26: 0 ml~ 6/1/26: No documented drain output. (R2 discharged home.)The following progress notes indicate a change in condition for R2 prior to hospitalization on 5/21/26:A nurses' note on 5/17/26 at 7:42 PM indicated R2 had increased confusion and weakness. Vital signs were stable. There were no other symptoms or changes in condition noted. R2 was independent in their room with cares but was encouraged to call for help due to weakness. The on-call MD was updated and orderd a urinalysis (UA) with culture and sensitivity (C&S) and other labs.A nurses' note on 5/18/26 at 6:37 AM indicated the Nurse Practitioner (NP) was updated on R2's lab results. The NP ordered to hold Lasix and potassium for 1 day, and hold gabapentin for 1 dose.A nurses' note for physician communication on 5/21/26 at 10:18 PM indicated R2 had increased weakness, decreased appetite, overall decline, and a chole tube (in left abdomen) for pancreatitis. R2 also had a UTI and complicated gastrointestinal (GI) issues. R2 complained of nausea and feeling like they were hit by a bus. R2 declined to get out of bed, looked pale, and complained of body aches. R2 had been receiving antibiotics for over 48 hours, however, they continued to decline with increased drainage from the chole tube, blood pressure trending down, and heart rate trending up. R2 was transferred to the hospital to rule out sepsis.On 6/24/26 at 11:25 AM, Surveyor interviewed R2 who stated there were communication issues with orders the hospital had given the facility after R2 had one of two drains removed during a pre-scheduled procedure. R2 indicated staff continued to empty the drainage bag from the remainin drain 4 to 5 times per day, however, the drain was supposed to be capped after the procedure on 5/4/26. After R2 discharged from the facility and had a follow-up appointment, the radiologist informed R2 it was supposed to have stopped two weeks after the procedure. R2 stated it was disappointing. On 6/24/26 at 1:38 PM, Surveyor interviewed RN-C who completed discharge instructions with R2 and a family member on 6/1/26. RN-C stated R2 had one drain at the time of discharge but had two drains prior to that. RN-C educated R2 and their family member on how to flush and sanitize the port. RN-C stated nurses knew what to flush by reviewing the TAR. RN-C indicated R2 had one tube with sutures holding it in place and a bag attached to the tube. When RN-C flushed the tube, they detached the bag, sanitized, flushed, and reconnected the bag. RN-C stated they changed the dressing around the drain site every few days. RN-C did not recall any communication issues with the discharging hospital.On 6/24/26 at 2:44 PM, Surveyor interviewed Director of Nursing (DON)-B who reviewed R2's orders that did not differentiate the two separate drains for flushing, drainage amount, and dressing changes. R2's orders and medical record did not clearly define each drain. DON-B stated they would have RN-F (the manager for R2's unit) speak with Surveyor.On 6/24/26 at approximately 4:00 PM, Surveyor interviewed DON-B and Unit Manager RN-F. RN-F indicated if a HUC or Med Tech enters an order, a nurse double checks and signs off on the order; however, if a nurse enters an order, the order does not need to be double-checked. DON-B and RN-F could not provide evidence that both of R2's drains were flushed as ordered upon admission.On 6/24/26 at approximately 3:00 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-D who stated R2 had two drains when they were admitted . LPN-D stated initially only one of the drains was flushed then both drains were flushed twice daily. LPN-D stated when the flushes were done once daily, the AM shift completed the flushes. LPN-D stated R2 had one drainage bag and the other drain was capped. The capped drain was not being flushed until after a follow-up appointment. LPN-D could not recall dates. LPN-D stated when there is a new order, it is flagged for order entry and entered into the resident's medical record. If a nurse enters the order, another nurse does not have to double check the entry. Paper orders are put in a resident's paper chart after the nurse enters the orders and signs them. LPN-D did not recall any issues with R2's orders.On 6/25/26 at 2:29 PM, Surveyor interviewed Interventional Radiology (IR) RN-E who stated R2 and their family called the clinic on 6/5/26 and asked if 200 to 300 mls of fluid was normal to lose per day in the drainage bag. According to the IR notes, the provider stated the drainage bag should have been capped and not draining into a bag. The provider instructed the family to buy caps and cap the drain. RN-E stated they want to keep fluid from the drain in the body. RN-E stated the type of drain R2 had is almost always capped so the fluid can be routed to the bowel. RN-E reviewed R2's IR clinic notes and indicated a provider note on 5/4/26 indicated to keep left biliary drain attached to drainage bag, cap in 24 hours, and return to the clinic in 3 weeks. An after visit summary, dated 5/4/26, included the directions: You will have your biliary tube attached to a bag after your exchange. Your doctor will tell you when to remove the bag and place a cap. Usually the next day. RN-E indicated R2 had a left internal/external biliary drain in place at the time of the interview. RN-E verified R2's notes indicated they should have only had a biliary drain at that time which should have been capped. RN-E stated it was rare to have a collection bag on that type of drain for the length of time that R2 did which was from 5/4/26 through 6/1/26 when they discharged from the facility.On 6/25/26 at 4:11 PM, Surveyor interviewed RN-F who provided additional pages of R2's 5/4/26 after visit summary that were not originally provided to Surveyor but were in R2's medical record. The additional pages contained a nursing note written by RN-F on 5/5/26 at 8:31 AM that indicated R2 was out of the facility on 5/4/26 for a drain procedure. The right (RUQ) drain was removed. The center drain (billiary drain) was replaced and had a drainage bag connected. RN-F verified they processed the after visit summary when R2 returned from the appointment on 5/4/26 and provided a copy of the first page to the HUC to schedule an appointment. RN-F put the after visit summary in R2's chart as flagged which meant the chart was standing up in the nurses' station with the after visit summary sticking out. RN-F did not know who processed or reviewed the after visit summary and verified R2's medical record did not contain orders or clarification related to contacting the provider or capping the drain. R2 continued to drain fluid into the drainage bag through discharge on [DATE].

Based on staff interview and record review, the facility did not review and revise the comprehensive plan of care for 5 residents (R) (R73, R61, R56, R21, and R68) of 8 sampled residents.R73 fell on 4/4/26. An intervention for a Posey grip on top of R73's wheelchair cushion was not added to R73's care plan.R61 fell on 4/13/26. A post-fall intervention was not added to R61's care plan.R56 had a specialty air mattress that was not reflected on R56's care plan or Kardex (an abbreviated care plan used by nursing staff) and staff did not check the functioning of the air mattress each shift. In addition, R21 and R68 had specialty air mattresses which were not reflected on their plans of care.Findings include: The facility's Fall Prevention Program - Comprehensive Falls Management policy, dated 2/2026, indicates: .9. When a resident experiences a fall, the facility will: .4. Initiate an immediate appropriate new intervention to prevent similar incidents. Immediate interventions should be documented and communicated to the team. The Nurse Manager will update the care plan and Kardex. The facility's Mattress/Specialty Protocol policy, dated March 2026, indicates: The purpose of ensuring optimum use and maintenance of specialty mattress. Performed by nursing staff. Key steps include: 1. Nurse Manager to identify residents with specific nursing concerns that would benefit from the use of a specialty mattress. Request should be called in to Central Supply .3. Central Supply will adjust air flow control knobs to facility settings. a. Easy Air Pressure Guard: Therapy settings - alternate mode .Air Flow indicator - on .Comfort setting - 4. 4. Any specialty air mattress should be indicated on the resident's care plan and documentation in the electronic health record (EHR/medical record) should occur every shift .6. Certified Nursing Assistants (CNAs) may not adjust settings on specialty mattresses. If a resident requires adjustment, this should occur under the advisement of the Nurse Manager/Supervisor. Any change in setting from the facility settings in #2 above must be indicated on the care plan . 1. Between 4/20/26 and 4/21/26, Surveyor reviewed R73's medical record. R73 was admitted to the facility on [DATE] following hospitalization for a fall prior to admission which resulted in a pubic rami (a pelvic injury that often occurs in elderly individuals due to low energy falls or in high-energy traumas) and a right sacral alar fracture (disruption in the wing-shaped upper lateral part of the sacrum). R73 had diagnoses including spinal stenosis, lumbar region, age-related osteoporosis with current pathological fracture, cognitive communication deficit, and unspecified dementia. R73's Minimum Data Set (MDS) assessment, dated 3/19/26, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R73 had moderate cognitive impairment. R73's plan of care indicated R73 was at high risk for falls related to decreased mobility following a recent fall with pubic rami and right sacral fractures. R73's medical record indicated staff heard R73 yell I just fell on 4/4/26 at 7:00 AM. Staff discovered R73 on the toilet in the bathroom. A wheelchair next to R73 was not locked. R73 stated R73 slid out of the wheelchair which went out from under R73. R73 fell on R73's butt but got up and sat on the toilet. Immediate interventions included a Posey grip on top of R73's wheelchair cushion, remind R73 to lock wheelchair breaks prior to standing up, and remind R73 to call for assistance with the call light.Surveyor noted R73's care plan did not contain an intervention for a Posey grip on top of R73's wheelchair cushion. On 4/21/26 at 3:57 PM, Surveyor interviewed Registered Nurse (RN)-F who confirmed the post-fall intervention for a Posey grip on top of R73's wheelchair cushion was not added to the care plan. RN-F stated managers usually add care plan interventions, however, all nurses can add interventions.2. Between 4/20/26 and 4/21/26, Surveyor reviewed R61's medical record. R61 was admitted to the facility on [DATE] and had diagnoses including rheumatoid arthritis, epilepsy, cognitive communication deficit, and muscle weakness. A falls care plan related to epilepsy was initiated on 10/13/23. Prior to 4/13/26, R61's medical record indicated R61 last fell in February of 2025. On 4/13/26 at 11:20 PM, R61 had an unwitnessed fall. The facility's Risk Management Report indicated R61 was found on the floor on R61's back a few feet away and in front of R61's recliner with the left knee bent upward and right foot turned outward. R61's recliner was in a slight upright position. R61 stated R61 was sleeping in the recliner and slid out onto the floor. R61 attempted to get up but R61's right leg was not strong enough. R61 fell backwards onto the floor and hit R61's head and back. The Immediate Action Taken section indicated R61 would not turn or allow staff to help R61 off the floor. R61 screamed in pain and stated R61's lower back hurt. Emergency Medical Services (EMS) assisted R61 off the floor. R61 was sent to the emergency room (ER) for evaluation and returned to the facility on 4/21/26 with no injury. The ER report indicated R61 had normal pain that was magnified after the fall. On 4/21/26 at 4:27 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed an intervention was not added to R61's care plan after the fall.3. On 4/20/26, Surveyor reviewed R56's medical record. R56 was admitted to the facility on [DATE]. R56 received Hospice services and had a diagnosis of chronic right foot wound. R56's Significant Change MDS assessment, dated 2/11/26, had a BIMS score of 13 out of 15 which indicated R56 had intact cognition. R56's medical record indicated a new stage 2 coccyx (tailbone) pressure injury was discovered on 3/28/26. On 4/21/26 at 11:40 AM, Surveyor observed Certified Nursing Assistant (CNA)-C and CNA-D reposition R56 in bed. R56 had an air mattress with alternate and comfort level 4 settings that were indicated with a light. Surveyor interviewed CNA-C who stated air mattresses are delivered by Central Supply who usually set the mattress at 3 or 4. CNA-C stated if a resident has an air mattress, the mattress is reflected on the resident's Kardex. On 4/21/26 at 11:54 AM, Surveyor reviewed R56's Kardex with CNA-C. CNA-C stated CNA-D was new and CNA-C was training CNA-D. CNA-C stated new staff are trained to check a resident's care plan and Kardex for resident-specific care. CNA-C reviewed R56's care plan, Kardex, and CNA task documentation which did not reflect the air mattress. CNA-C reviewed the required documentation for another resident with a specialty mattress. CNA-C stated documentation should be completed by CNAs every shift. Task charting included: Every shift specialty mattress easy air/alternating pressure mattress; Is the mattress functioning properly? The CNAs should select yes or no. On 4/21/26 at 12:12 PM, Surveyor interviewed RN-E regarding the appropriate settings for air mattresses. RN-E stated air mattresses are set on the medium setting and nurses adjust the setting according to a resident's preference. On 4/21/26, Surveyor reviewed additional medical records which indicated: ~ R21 was admitted to the facility on [DATE] and was provided a specialty mattress on 10/22/25. R21's medical record included a specialty mattress in CNA task charting but not in R21's care plan or Kardex. ~ R68 was admitted to the facility on [DATE] and was provided a specialty mattress on 12/28/23. R68's medical record included a specialty mattress in CNA task charting but not in R68's care plan or Kardex. On 4/21/26 at 3:20 PM, Surveyor interviewed DON-B who stated specialty air mattresses are provided to residents for many reasons, including pressure injury prevention and comfort. DON-B stated the facility's policy and procedure was created to include the most commonly selected setting by residents which was setting 4 of 5 (with 1 being the softest and 5 the firmest). DON-B stated residents let staff know their setting preferences. If the setting is other than 4, the resident's care plan should reflect the setting. If the resident selects setting 4, the care plan will not change since setting 4 is the facility's default setting. DON-B verified a specialty air mattress should be reflected in a resident's medical record.

Based on staff and resident interview and record review, the facility did not ensure allegations of abuse/neglect were thoroughly investigated for 4 residents (R) (R1, R2, R8, and R6) of 8 sampled residents. R1 reported an allegation of abuse involving Certified Nursing Assistant (CNA)-C. During the investigation, staff reported an allegation of abuse involving CNA-C and R2. The facility did not thorougly investigate the allegations of abuse.The facility's grievance file contained grievances from R8 and R6 that included allegations of abuse/neglect involving CNA-E. The facility did not provide staff education in an attempt to prevent further abuse or neglect.Findings include: The facility's Patient Abuse, Neglect, Mistreatment, and Misappropriation of Property and Exploitation Policy, revised 4/2025, indicates: .Reporting/Response: .5. Taking all necessary actions as a result of the investigation, which may include, but are not limited to, the following: .c. Training of staff on changes made and demonstration of staff competency after training is implemented . 1.On 9/29/25, Surveyor reviewed a facility-reported incident (FRI) regarding allegations of abuse by CNA-C. The initial report was submitted to the State Agency (SA) on 9/7/25. The five-day report was submitted on 9/12/25. The report indicated at approximately 8:30 PM on 9/6/25, R1 reported to staff that CNA-C assisted R1 with cares during the night and called R1 a bitch when R1 asked for a different shirt. R1 requested that CNA-C not care for R1 in the future. The investigation included an interview with CNA-D that indicated on 9/7/25 at 9:00 AM, CNA-C completed cares for R2 and stated to CNA-D in front of R2, That shirt was pretty fucking tight. CNA-C was suspended pending the results of the investigation. The investigation did not indicate the facility provided staff education to prevent further verbal abuse. On 9/29/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including malignant neoplasm of colon, malignant neoplasm of liver and intrahepatic bile duct, and diabetes. A Minimum Data Set (MDS) assessment completed 8/21/25 included a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R1 had moderately impaired cognition. R1 had an activated Power of Attorney for Healthcare (POAHC).On 9/29/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including dementia, multiple sclerosis, edema, and stage 3 pressure injury. An MDS assessment completed 9/6/25 included a BIMS score of 10 out of 15 which indicated R2 had moderately impaired cognition. R2 had an activated POAHC.(See interview under example 2).2. On 9/29/25, Surveyor reviewed the facility's grievance file and noted grievances submitted by R8 on 8/20/25 and R6 on 8/21/25. The grievances indicated CNA-E asked residents to complete cares independently that residents were unable to complete and left residents' rooms without providing assistance. R8 and R6 asked that CNA-E not provide care for them in the future. On 8/22/25, CNA-E was educated on communication and resident care and that residents' capabilities can fluctuate daily. The grievance resolutions indicated email education was sent to all CNAs on 7/21/25 (which was a month prior to the grievances) that stated if a resident's care plan indicates the resident is independent, staff should still check on the resident, ensure necessary items are within reach, and be aware the resident may require assistance on certain days. Staff should complete rounds for independent residents no differently than for residents who require total care. On 9/29/25, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] and had diagnoses including myasthenia gravis, osteoporosis, and dementia. An MDS assessment completed 7/30/25 included a BIMS score of 12 out of 15 which indicated R8 had moderately impaired cognition. R8 had an activated POAHC. On 9/29/25, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including history of stroke, urinary tract infection (UTI), and depression. An MDS assessment completed 7/26/25 included a BIMS score of 15 of 15 which indicated R6 was not cognitively impaired. R6 did not have an activated POAHC.On 9/29/25 at 11:48 AM, Surveyor interviewed R6 who indicated R6 heard staff used inappropriate language during cares, including motherfucker and that fuck, on more than one occasion. R6 indicated it did not feel good to hear inappropriate language but it did not cause R6 harm. R6 also indicated CNA-E threw a catheter bag across the room and left R6 on the toilet with R6's pants and call light on the floor. CNA-E told R6 to get dressed and left the room. R6 yelled for assistance for approximately 30 minutes. R6 indicated R6 felt helpless when CNA-E neglected R6's cares and left R6 on the toilet without a call light within reach. R6 indicated the facility was aware of the concerns.On 9/29/25 from 1:25 PM to 1:40 PM, Surveyor interviewed CNA-F, CNA-G, and CNA-H who verified they last received abuse/neglect education in June of 2025.On 9/29/25 at 2:12 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated the incident with CNA-C was isolated and all staff education was not required. DON-B verified the all staff CNA education provided as a resolution for R8 and R6's grievances was initiated on 7/21/25 which was a month prior to the grievances. On 9/29/25 at 2:37 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated all staff education should be completed for any verified form of abuse/neglect.

Based on staff and resident interview and record review, the facility did not ensure allegations of abuse/neglect were reported to the State Agency (SA) for 2 residents (R) (R6 and R8) of 8 sampled residents.R6 alleged that staff neglected R6 and left R6 in the bathroom without a call light for 30 minutes. R6 also alleged that staff used inappropriate language, threw a catheter bag across the room, and did not provide assistance when asked. The allegations of abuse/neglect were not reported to the SA.R8 alleged that staff neglected to provide care. The allegation of neglect was not reported to the SA.Findings include: The facility's Patient Abuse, Neglect, Mistreatment, and Misappropriation of Property and Exploitation Policy, revised 4/2025, indicates: .Neglect - An intentional omission or intentional course of conduct by a caregiver, or a nonclient patient, including but not limited to: Restraint, isolation or confinement that is contrary to Cedar Community policies and procedures, is not part of the patient's treatment plan and, through substantial carelessness or negligence, does any of the following: .b. Substantially disregards a patient's rights under either Chapter 50 or 51 Stats., or a caregiver's duties and obligations to a patient .Reporting/Response: A. The facility will have written procedures that include: .c. Upon learning of an injury or incident of misconduct, Cedar Community will immediately review the situation to determine if it fits the definition of misconduct definitions (federal, state). When the situation fits, the Alleged Nursing Home Resident Mistreatment Report (online fillable form) will be completed immediately and sent to the Division of Quality Assurance (DQA)/Office of Caregiver Quality (OCQ) via the online reporting system .1. On 9/29/25, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including history of stroke, urinary tract infection (UTI), congestive heart failure (CHF), and depression. A Minimum Data Set (MDS) assessment completed on 7/26/25 included a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R6 was not cognitively impaired. R6 was responsible for R6's medical decisions.On 9/29/25, Surveyor reviewed a grievance for R6 that was dated 8/21/25. The form indicated Certified Nursing Assistant (CNA)-E asked R6 to do things on the evening of 8/20/25 that R6 could not do for R6's self. CNA-E put R6's pajama bottoms on the floor and asked R6 to put them on and thread the catheter tubing through the leg opening. R6 indicated R6 was unable to do that. CNA-E later told R6 to take off R6's sweater and undershirt and left R6's room. R6 called CNA-E to come back because R6 could not take off the sweater and undershirt independently. CNA-E returned and assisted R6. R6 requested assistance earlier in the evening because R6 was wet and uncomfortable sitting in R6's recliner. CNE-E said CNA-E could not help yet and was busy with other residents. CNA-E eventually returned and assisted R6. R6 stated when R6 tells CNA-E what R6 needs help with, CNA-E will remember and help R6 with those things the next time. On 9/29/25 at 11:48 AM, Surveyor interviewed R6 about the grievance. R6 indicated R6 heard staff members use inappropriate language with cares, including motherfucker and that fuck, on more than one occasion. R6 indicated it did not feel good to overhear inappropriate language but did not cause R6 harm. R6 also indicated CNA-E threw a catheter bag across the room and left R6 on the toilet with R6's pants and call light on the floor. CNA-E told R6 to get dressed and left the room. R6 yelled for assistance for approximately 30 minutes. R6 stated when R6's cares were neglected and R6 was left on the toilet without a call light within reach, R6 felt helpless. R6 indicated the facility was aware of the concerns. (See interview under example 2.)2. On 9/29/25, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] and had diagnoses including myasthenia gravis, dementia, and chronic kidney disease. An MDS assessment completed on 7/30/25 included a BIMS score of 12 out of 15 which indicated R8 had moderately impaired cognition. R8 had an activated Power of Attorney for Healthcare (POAHC) for medical decisions. On 9/29/25, Surveyor reviewed a grievance for R8 that was dated 8/20/25. The grievance indicated every time CNA-E waits on R8, CNA-E doesn't do what R8 asks and says R8 can do it by R8's self. R8 asks CNA-E to move the garbage can every night when R8 is in bed and indicated CNA-E should know that R8 wants the garbage can next to the bed at night. When R8 asks CNA-E to take off R8's shirt or move the table closer to the bed, CNA-E says R8 can do it by R8's self. R8 indicated CNA-E has a long, sad look on CNA-E's face. R8 asked if CNA-E ever smiles. When asked if CNA-E is trying to promote R8's independence, R8 didn't think so because R8 can still do things independently, including go to the bathroom during the night. R8 stated when R8 asks staff to do something it's because R8 needs help.On 9/29/25, Surveyor reviewed an interview with Licensed Practical Nurse (LPN)-I, dated 8/26/25, that indicated R8 told LPN-I that CNA-E put R8 on the toilet and told R8 to take R8's brief off and put on a new one. R8 stated R8 tried to remove the brief and got a skin tear when R8's ring cut R8's leg.On 9/29/25, Surveyor reviewed a statement by R8 that indicated CNA-E's behavior made R8 feel like CNA-E didn't want or like to help R8.On 9/29/25, Surveyor reviewed CNA-E's corrective action plan for R6 and R8's concerns. The action plan indicated R6 and R8 asked that CNA-E not provide care for them. CNA-E was asked not to leave residents with tasks they cannot complete, to review residents' Kardexes (abbreviated care plans used by nursing staff) and plans of care, and not to tell residents that CNA-E is too busy to provide assistance.On 10/15/25 at 2:20 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A via phone who indicated the facility did not feel the grievances should be reported to the SA for abuse/neglect and found the evidence to be subjective.

Based on interview, record review, and policy review, the facility failed to investigate an allegation of resident-to-resident abuse for 2 residents (R) (R4 and R3) of 3 residents reviewed for abuse. Findings include: Review of R4's Face Sheet located in the electronic medical record (EMR) revealed R4 was re-admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD). Review of R4's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 5/1/25, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R4 was cognitively intact. Review of R3's Face Sheet located in the EMR revealed R3 was re-admitted to the facility on [DATE] with diagnoses which included major depressive disorder. Review of R3's Quarterly MDS assessment, with an ARD of 3/13/25, revealed a BIMS score of 12 out of 15 which indicated R3 was moderately cognitively impaired. Review of the facility's summary of incident, dated 5/13/25, revealed on 5/13/25 at approximately 4:30 PM, Medication Aide (MA) 1 went in R3's room to administer medication. R3 stated R3's roommate (R4) was often in an angry mood and when R4 entered the room a few minutes earlier, R4 stated, You better watch out because you are next. Review of the facility's investigation, dated 5/20/25, revealed the only resident interviewed was R3. There were no interviews with other cognitively intact residents, including R4. During an interview on 6/12/25 at 1:07 PM, Registered Nurse Manager (RN) 1 confirmed there were no other residents interviewed during the investigation. RN 1 indicated the Social Worker spoke with R4 but not about what R4 allegedly said to R3. RN 1 agreed the investigation was lacking and other residents, including R4, should have been interviewed.

Based on interview, record review, and policy review, the facility failed to ensure the medical record was complete, accurate, and readily accessible for 1 resident (R) (R1) of 10 sampled residents. This failure had the potential for staff not to have knowledge about the resident and/or other residents residing in the facility. Findings include: Review of the facility's Documentation-Guidelines policy, revised 1/2025, revealed: .2. Record the services or care given to the resident and his reaction to it as an assurance of quality care. 3. Record the resident's condition and progress shown. 4. Serves as a source of legal protection against libel, fraudulent charges, or claims. 5. Serves as a source of information for statistics, chart audit, and research. 6. Provides a basis for planning resident care. Enter time care was provided in note. 2. Chart only the services you have given, a) Each licensed nurse and nursing assistant are responsible for his/her own acts and documentation of the same. Follow through from shift to shift is extremely important, a) This provides for continuity in total resident care. Review of R1's undated admission Record located in the electronic medical record (EMR) indicated R1 was admitted to the facility on [DATE] with a diagnosis of need for assistance with personal care. Review of a facility incident report, dated 5/29/25, revealed R1 had an unwitnessed fall when attempting to get to the bathroom. R1 had a skin tear on the elbow and hit R1's head. Range of motion varied, but discomfort was noted. A Nurse Practitioner was notified of the fall. Because R1 hit R1's head and was on Eliquis, an order was given to send R1 to the Emergency Department (ED) for evaluation. Review of toileting documentation in R1's EMR revealed no documentation that R1 was toileted on 5/28/25 after 7:21 PM through 5/29/25 at 5:00 AM. During an interview on 6/11/25 at 4:14 PM, Registered Nurse (RN) 1 said staff must offer R1 the bed pan frequently because R1 will not call for assistance and will try to get up on R1's own. RN 1 said on the night of 5/28/25 through the morning of 5/29/25, RN 1 provided toileting twice for R1. RN 1 said R1 didn't want the bed pan the first time so RN 1 checked R1's brief and pad. RN 1 said when RN 1 saw R1 later, R1 used the bed pan and voided. RN 1 stated RN 1 forgot to document the toileting in the Certified Nurse Aide (CNA) task section of R1's medical record. During an interview on 6/12/25 at 12:55 PM, RN 2 stated staff do not have to chart every time they toilet a resident, but should chart/document at least once per shift and more if able. RN 2 stated RN 2 did not know if anyone spoke with RN1 about not documenting any toileting during RN 1's shift, however, all nursing staff should have been reeducated on the expectation to document. During an interview on 6/12/25 at 1:20 PM, Director of Nursing (DON) B stated staff should offer toileting or use of the bed pan every two to two and half hours. DON-B stated staff do not have to document every encounter, but should document at least once per shift unless something unusual or uncommon occurs.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 59 residents residing in the facility. The dry storage area, coolers, and freezer contained multiple open, undated, unlabeled, and/or expired items. Documentation logs for the parts per million (PPM) of the sanitizing solution in the sanitizing buckets and 3-compartment sink were not completed. Staff did not appropriately test and maintain dishwasher temperatures. Staff did not maintain a sanitary dishwashing practice. Findings include: On [DATE], Director of Culinary Operations (DCO)-I verified the facility follows the Food and Drug Administration (FDA) Food Code as their standard of practice. Food Labeling/Storage: The 2022 FDA Food Code documents at ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking: (A) Except when packaging food using a reduced oxygen packaging method as specified under S ,d+[DATE].12, and except as specified in (E) and (F) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 Celsius (C) (41 Fahrenheit (F)) or less for a maximum of 7 days. The day of preparation shall be counted as day 1. The 2022 FDA Food Code documents at ,d+[DATE].18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition: (A) A food specified in ,d+[DATE].17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in ,d+[DATE].17(A), except time that the product is frozen; (2) Is in a container or package that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in ,d+[DATE].17(A). The facility's Food Service Safety policy, dated ,d+[DATE], indicates: It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state, and local authorities. Food will also be stored, prepared, distributed, and served in accordance with professional standards for food service safety .3. Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely proper storage .iv. Label, date, and monitor refrigerated food, including but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable), or discarded. v. Keep foods covered or in tight containers . The facility's Cold and Dry Storage policy, dated ,d+[DATE], indicates: .8. All items are to be properly labeled and dated if removed from their original packaging. Perishable meats must contain a seven day use-by date . The facility's undated Labeling and Dating Cooler Items policy, dated [DATE], indicates: All items taken from the cooler need dates put on them unless they already have dates .Fresh fruit-five day expiration .Lettuce-five day expiration .Bread-open date .Juice concentrates-open date .If an item does not have a date and you plan to keep it, it must have an expiration date. During an initial kitchen tour that began at 9:45 AM on [DATE], Surveyor and DCO-I observed the following undated, open and/or expired items: Dry Storage: ~A plastic container of ground pretzels dated ,d+[DATE] (opened date per DCO-I) with no use-by date ~An unlabeled and undated container of bulk flour (per DCO-I) ~An unlabeled and undated container of bulk oatmeal (per DCO-I) Cooler: ~An unlabeled and undated pan of prepared potatoes (per DCO-I) ~Three containers of macaroni salad dated ,d+[DATE] (prepared date per DCO-I) with no use-by dates ~Three containers of creamy cucumber salad dated ,d+[DATE] (prepared date per DCO-I) with no use-by dates ~Two containers of pureed creamy cucumber salad dated ,d+[DATE] (prepared date per DCO-I) with no use-by dates ~An open bag of cheddar cheese squares dated ,d+[DATE] with no use-by date ~An open bag of Monterey [NAME] cheese squares dated ,d+[DATE] with no use-by date ~A container of chopped onions dated ,d+[DATE] (prepared date per DCO-I) with no use-by date ~A container of pureed sugar cookies dated ,d+[DATE] (prepared date per DCO-I) with no use-by date ~A container of pureed oatmeal raisin dated ,d+[DATE] (prepared date per DCO-I) with no use-by date ~A bowl of pureed bread dated [DATE] (prepared date per DCO-I) with no use-by date. (The container was covered with plastic wrap, however, part of the wrap was peeled back which left the pureed bread open to air.) ~A container of stroganoff dated ,d+[DATE] (prepared date per DCO-I) with no use-by date ~Two containers of chocolate frosting dated ,d+[DATE] (prepared date per DCO-I) with no use-by dates ~A container of tomato paste dated ,d+[DATE] (opened date per DCO-I) with no use-by date ~A container of blueberry filling dated ,d+[DATE] (opened date per DCO-I) with no use-by date ~A container of cherries dated ,d+[DATE] (opened date per DCO-I) with no use-by date ~Five bags of shredded cheese: mozzarella dated ,d+[DATE], cheddar dated ,d+[DATE], Parmesan dated ,d+[DATE], two cheese blends dated ,d+[DATE] (all dates were opened dates per DCO-I) with no use-by dates Freezer: ~Eleven unlabeled bags (hamburger patties per DCO-I) dated ,d+[DATE] (opened date per DCO-I) with no use-by dates ~Numerous unlabeled and undated portioned cups (ice cream per DCO-I) ~A pan of frozen sliders dated [DATE] with no use-by date ~An unlabeled bag (breakfast sausage per DCO-I) dated ,d+[DATE] (opened date per DCO-I) with no use-by date ~An unlabeled bag (Italian sausage per DCO-I) dated ,d+[DATE] (opened date per DCO-I) with no use-by date ~Eight unlabeled bags (chicken breasts per DCO-I) dated ,d+[DATE] (opened date per DCO-I) with no use-by dates ~A pan of frozen pizza dated ,d+[DATE] with no use-by date ~An open, unlabeled, and undated package of food items (french fries per DCO-I) ~A bag of crumbled cooked sausage dated ,d+[DATE] (opened date per DCO-I) with no use-by date ~An open bag of pepperoni dated ,d+[DATE] (opened date per DCO-I) with no use-by date ~Three loaves of lemon blueberry bread dated ,d+[DATE] (prepared date per DCO-I) with no use-by dates ~A package of unidentified food (most likely diced ham per DCO-I) dated ,d+[DATE] (opened date per DCO-I) with no use-by date Unit Kitchen Storage: ~Eight unlabeled portioned cups (Jell-O per Dietary Aide (DA)-J) dated ,d+[DATE] with no use-by dates ~Twelve unlabeled portioned cups (Jell-O per DA-J) dated ,d+[DATE] (most likely the use-by date per DA-J) ~Four unlabeled bags of food (hamburger patties per DA-J) dated ,d+[DATE] (opened date per DA-J) with no use- by dates ~One unlabeled bag of food (breakfast sausage links per DJ-A) dated ,d+[DATE] (opened date per DJ-A) with no use-by date ~One metal container of portioned items labeled sausage ,d+[DATE]. The items in the container included: eight containers of pureed bacon, two containers of ground bacon, six containers of pureed sausage, one container of chicken, and 3 unlabeled and unidentified items (each was a different color) with no expiration dates ~Five unlabeled and undated containers of portioned items (ice cream per DA-J) On [DATE] at 9:45 AM, Surveyor toured the kitchen and coolers with DCO-I who indicated opened and pre-made food should contain open or made dates and use-by dates. DCO-I indicated staff should be aware of and date food items appropriately. DCO-I was unsure when the bulk flour and oatmeal were opened. DCO-I thought the items were good for 30 days but there was no way to tell when they were opened. DCO-I was unsure of the facility's policy regarding bulk flour and oatmeal. When asked how would staff know if items are still good if they are not dated, DCO-I was unsure. On [DATE] at 12:20 PM, Surveyor interviewed DA-J in the unit kitchen. DA-J did not know what the unlabeled and undated food items were and did not know when they were made or should be used by. DA-J was not familiar with the facility's food storage policies but indicated food should be labeled and dated. Sanitizing Solution: The 2022 FDA Food Code documents at ,d+[DATE].114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization-Temperature, pH, Concentration, and Hardness: A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times specified under ,d+[DATE].11(C) shall meet the criteria specified under ,d+[DATE].11 Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use instructions. The 2022 FDA Food Code documents at ,d+[DATE].116 Warewashing Equipment, Determining Chemical Sanitizer Concentration: Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. Ecolab Oasis 146 Multi-Quat Sanitizer data sheet indicate the sanitizing solution should be tested for effectiveness by measuring the PPM dilution range. The Hydrion Quat test strips are the appropriate testing strips. The sanitizer solution temperature needs to be tested and within ,d+[DATE] degrees Fahrenheit . The effective PPM range is ,d+[DATE] PPM. Surveyor requested the facility's policy for testing the sanitizing solution. A policy was not provided. During an initial kitchen tour on that began at 9:45 AM on [DATE], Surveyor observed sanitizer buckets, a sink filled with sanitizing solution, and a large container of Oasis 146 Multi-Quat Sanitizer. Surveyor requested to see sanitization logs for the 3-compartment sink and sanitizing buckets. DCO-I stated the facility did not have sanitization testing logs. DCO-I indicated kitchen staff test the sanitizer, but do not log or record the PPM. On [DATE] at 12:31 PM, Surveyor interviewed [NAME] (CK)-K who indicated CK-K knew how to test the sanitizing solution and used an Ecolab chlorine test strip. CK-K was not aware that the chlorine test strip was not the appropriate test strip for the sanitizing solution. In addition, CK-K did not test the temperature of the solution and was not aware CK-K needed to do so. On [DATE] at 12:35 PM, Surveyor interviewed Assistant [NAME] (AC)-L who had just prepared a bucket of sanitizing solution. When Surveyor asked AC-L to test the sanitizing solution, AC-L used an Ecolab sink and surface cleaner test strip. AC-L was not aware the sink and surface cleaner test strip was not the appropriate test strip for the sanitizing solution. In addition, AC-L did not test the temperature of the solution and was not aware AC-L needed to do so. On [DATE] at 3:03 PM, Surveyor interviewed DCO-I and Assistant Director of Dining (ADD)-M who confirmed the facility did not have a policy for testing the sanitizing solution and did not keep a log for testing. ADD-M was aware the appropriate sanitizing test strips were the Hydrion Quat test strips and indicated the facility had the appropriate test strips. ADD-M indicated ADD-M needed to review the process with kitchen staff. Dishwasher Temperatures: The 2022 FDA Food Code documents at ,d+[DATE].13 Temperature Measuring Devices, Manual Warewashing: Water temperature is critical to sanitization in warewashing operations. This is particularly true if the sanitizer being used is hot water. The effectiveness of cleaners and chemical sanitizers is also determined by the temperature of the water used. A temperature measuring device is essential to monitor manual warewashing and ensure sanitization. Effective mechanical hot water sanitization occurs when the surface temperatures of utensils passing through the warewashing machine meet or exceed the required 71 C (160 F). Parameters such as water temperature, rinse pressure, and time determine whether the appropriate surface temperature is achieved. Although the Food Code requires integral temperature measuring devices and a pressure gauge for hot water mechanical warewashers, the measurements displayed by these devices may not always be sufficient to determine that the surface temperatures of utensils are reaching 71 C (160 F). The regular use of irreversible registering temperature indicators provides a simple method to verify that the hot water mechanical sanitizing operation is effective in achieving a utensil surface temperature of 71 C (160 F). The 2022 FDA Food Code documents at ,d+[DATE].112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures: The temperature of hot water delivered from a warewasher sanitizing rinse manifold must be maintained according to the equipment manufacturer's specifications and temperature limits specified in this section to ensure surfaces of multi-use utensils such as kitchenware and tableware accumulate enough heat to destroy pathogens that may remain on such surfaces after cleaning. The surface temperature must reach at least 160 degrees F as measured by an irreversible registering temperature measuring device to affect sanitization. When the sanitizing rinse temperature exceeds 194 degrees F at the manifold, the water becomes volatile and begins to vaporize reducing its ability to convey sufficient heat to utensil surfaces. The lower temperature limits of 165 degrees F for a stationary rack single temperature machine, and 180 degrees F for other machines are based on the sanitizing rinse contact time required to achieve the 160 degree F utensil surface temperature. The 2022 FDA Food Code documents at ,d+[DATE].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. The facility's Primary Dish Machine Operation Instructions policy, dated ,d+[DATE], indicates: Sensor tags are sent through the machine three times per week to ensure the machine is functioning properly. Monday/Wednesday/Friday send a temperature sensor tab strip through the machine and record on the monthly temperature log sheet. During an initial kitchen tour that began at 9:45 AM on [DATE], Surveyor and DCO-I noted the dishwasher temperature did not reach the appropriate wash temperature. The three wash temperatures observed were 148 degrees F, 142 degrees F, and 144 degrees F. On [DATE] at 12:43 PM, Surveyor and DCO-I noted the dishwashing rinse temperature was 170 degrees F. On [DATE], Surveyor and DCO-I observed the dishwashing surface temperature log which did not contain sensor tags. DCO-I indicated staff are instructed to obtain dishwasher surface temperatures three times per week, however, staff throw away the sensors after use. DCO-I verified the log did not indicate whether or not the surface temperatures obtained were appropriate. On [DATE] at 2:53 PM, Surveyor interviewed AC-L and ADD-M who confirmed staff do not keep sensor tags. AC-L and ADD-M indicated there was no way to verify if the sensor tags reached the required temperature for safe dishwashing. On [DATE] at 3:03 PM, Surveyor interviewed DCO-I and ADD-M who confirmed temperature gauges on the outside of the dishwasher are not always reliable for temperature control and verified surface temperatures should be obtained and documented to ensure proper sanitization of dishes and silverware. Unsanitary Dishwashing: The 2022 FDA Food Code documents at ,d+[DATE].14 When to Wash: Food employees shall clean their hands and exposed portions of their arms as specified under S ,d+[DATE].12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles, and: .(E) After handling soiled equipment or utensils .(H) Before putting on gloves to initiate a task that involves working with food, and (I) After engaging in other activities that contaminate the hands. During an initial kitchen tour that began at 9:45 AM on [DATE], Surveyor and DCO-I observed the dishwashing area. DA-N was in the dirty dish area and another staff was in the clean dish area. Surveyor and DCO-I observed DA-N (who was processing dirty dishes) walk to the clean dish area and touch clean dishes and dish racks twice within 3 minutes without removing gloves, changing gloves, or performing hand hygiene. Immediately following the observation, Surveyor interviewed DA-N who confirmed DA-N did not complete hand hygiene and should not have touched clean dishes and dish racks. DA-N indicated DA-N forgot to complete hand hygiene but knows DA-N should do so. On [DATE] at 3:03 PM, Surveyor interviewed DCO-I and ADD-M who confirmed staff are trained on appropriate dishwashing techniques including proper hand hygiene and infection control practices. DCO-I indicated staff should not contaminate clean dishes or the clean dish area and should perform appropriate sanitary dish washing techniques and hand hygiene.

Based on staff interview and record review, the facility did not ensure the Ombudsman was notified of a hospital transfer for 1 resident (R) (R52) of 1 resident. R52 was transferred to the hospital on 12/31/24. The Ombudsman was not notified of R52's hospital transfer. Findings include: The facility's Transfer and Discharge policy, dated 7/2024, indicates: It is the policy of this facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident from the facility, except in limited circumstances .24. The Social Services Director will send a monthly report of all discharges to the Ombudsman .Emergency Transfer/Discharges: .8. The Social Services Director or designee will provide copies of notices for emergency transfers to the Ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis, as long as the list meets all requirements for content of such notices. From 2/17/25 to 2/19/25, Surveyor reviewed R52's medical record. R52 was admitted to the facility on [DATE] and had diagnoses including dementia, cognitive communication deficit, congestive heart failure (CHF), spinal stenosis, and abnormal gait. R52 had an activated Power of Attorney for Healthcare (POAHC). R52's medical record indicated R52 was transferred to the hospital on 12/31/24 due to a fall and elbow fracture. R52 was provided a written transfer notice, however, the facility did not notify the Ombudsman of R52's hospital transfer. Surveyor reviewed the December 2024 Ombudsman notifications and noted R52 was not on the monthly notification list. On 2/19/25 at 12:25 PM, Surveyor interviewed Social Worker (SW)-C who indicated if a resident transfers to the hospital and returns the same day, the facility does not notify the Ombudsman. SW-C indicated if a resident remains in the hospital overnight or is discharged , the facility notifies the Ombudsman.

Based on staff and resident interview and record review, the facility did not ensure 2 residents (R) (R3 and R12) of 21 sampled residents who required assistance for activities of daily living (ADLs) were provided care in a timely manner. On multiple occasions from 1/1/25 to 2/19/25, staff did not answer R3 or R12's call lights or provide care in a timely manner. Findings include: The facility's Call Pendant and Indicator Lights policy, dated January 2025, indicates: The purpose of this policy is to ensure the facility is adequately equipped with a call pendant to allow residents to call for assistance .3. Each resident will be evaluated for unique needs and preferences to determine any special accommodations that may be needed in order for the resident to utilize the call system. 4. Special accommodations will be identified on the resident's person-centered plan of care and provided accordingly . 1. On 2/18/25, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including cognitive communication deficit, urinary tract infection (UTI), viral intestinal infection, intervertebral disc degeneration, syncope and collapse, history of falls, and chronic nephritic syndrome. R3's Minimum Data Set (MDS) assessment, dated 2/15/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R3 had intact cognition. On 2/18/25 at 10:24 AM, Surveyor interviewed R3 who stated R3 often waits more than 30 minutes and up to an hour to go to the bathroom. R3 stated R3 cannot go to the bathroom independently and needs staff assistance. R3 indicated R3 is often incontinent due to the wait but does not want to wet R3's self. On 2/19/25, Surveyor reviewed a call light activity report for R3 from 1/1/25 to 2/19/25. The report indicated R3 had 117 call light response times that were over 20 minutes long. The 117 call lights response times included the following: ~20-29:59 minute response time = 59 instances ~30-39:59 minute response time = 29 instances ~40-49:59 minute response time = 8 instances ~50-59:59 minute response time = 9 instances ~60-89:59 minute response time = 10 instances ~90-120 minute response time = 2 instances 2. On 2/17/25, Surveyor reviewed R12's medical record. R12 was admitted to the facility on [DATE] and had diagnoses including cognitive communication deficit, retention of urine, need for assistance with personal care, difficulty in walking, irritable bowel syndrome, history of falling, and anxiety. R12's MDS assessment, dated 2/15/25, had a BIMS score of 12 out of 15 which indicated R12 had moderately impaired cognition. On 2/17/25 at 12:00 PM, Surveyor interviewed R12 who stated R12 often waits more than 20 or 30 minutes for assistance to use the bathroom. R12 indicated R12 had to wait over 40 minutes that morning and was not happy about it. On 2/19/25, Surveyor reviewed a call light activity report for R12 from 1/30/25 to 2/19/25. The report indicated R12 had 55 call light response times that were over 20 minutes long. The 55 call lights response times included the following: ~20-29:59 minute response time = 23 instances ~30-39:59 minute response time = 14 instances ~40-49:59 minute response time = 11 instances ~50-59:59 minute response time = 2 instances ~60-89:59 minute response time = 4 instances ~90-120 minute response time = 1 instance. On 2/19/25 at 9:40 AM, Surveyor interviewed Registered Nurse Supervisor (RNS)-F who indicated 20 minutes or less is the goal for call light response times. RNS-F indicated there are times when staff forget to shut off the call light after they respond to residents. RNS-F indicated staff should answer a resident's call light in a timely manner and turn off the light once they've met the resident's needs. RNS-F indicated staff should communicate with residents if there will be a longer call light response time, ensure residents' safety, and try to meet residents' needs as soon as possible. On 2/19/25 at 9:50 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-H who indicated call lights over 20 minutes are not acceptable. CNA-H indicated CNA-H tries to answer call lights within 15 to 20 minutes. CNA-H stated call light responses may have been longer the last few days due to staff having to don and doff personal protective equipment (PPE) for residents with COVID-19. On 2/19/25 at 10:02 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated call lights should be answered in 20 minutes or less. NHA-A indicated some staff forget to deactivate call lights after they answer them. On 2/19/25 at 11:17 AM, Surveyor completed a follow-up interview with R3 who stated the average call light response time is close to an hour. R3 indicated R3 does not feel staff address R3's needs but forget to turn off the call light. R3 stated R3 is adamant that staff turn off the call light before they exit the bathroom and leave R3 on the toilet. R3 stated R3 does that to ensure R3 can use the call light again to signal when R3 is finished or in case R3 needs more help or has an emergency. R3 stated long call light response times negatively impact R3's life because R3 does not want to sit in a wet brief or wet clothes.

Based on staff interview and record review, the facility did not ensure 2 residents (R) (R18 and R46) of 5 sampled residents were monitored for adverse reactions to high-risk medications. R18 was prescribed a fentanyl transdermal patch (an opioid medication) and oxycodone oral concentrate (an opioid medication) for pain. R18's plan of care did not contain monitoring interventions for adverse reactions to the high-risk medications. R46 was prescribed morphine (an opioid medication) and oxycodone (an opioid medication) for pain, spironolactone (a diuretic medication) for high blood pressure, and gabapentin (an anticonvulsant medication) for nerve pain. R46's plan of care did not contain monitoring interventions for adverse reactions to the high-risk medications. Findings include: Per the Federal Food and Drug Administration (FDA), opioid medications have a black box warning. A black box warning is the FDA's strongest safety warning given to medication. These medications have the potential for severe side effects. The facility's High Risk Medications policy, dated 7/2024, indicates: This facility recognizes that some medications are associated with greater risks of adverse consequences than other medications. These high-risk medications can include .opioids, diuretics .and any other medication that can bear a heightened risk. This policy addresses the facility's collaborative, systematic approach to managing high-risk medications for efficacy and safety .6) The resident's plan of care shall alert staff to monitor for adverse consequences of any high-risk medications given. 7) The resident's plan of care shall include interventions to minimize the risk of adverse consequences. 1. On 2/19/25, Surveyor reviewed R18's medical record. R18 was admitted to the facility on [DATE] and had diagnoses including vascular dementia, anxiety, and giant cell arteritis (GCA) with polymyalgia rheumatica (PMR) (GCA is blood vessel inflammation of the head/temporal region that causes head pain, scalp tenderness, and jaw pain. PMR is a condition that causes pain, stiffness, and inflammation in the muscles around the shoulders, neck, and hips). R18's Minimum Data Set (MDS) assessment, dated 1/16/25, had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R18 had severely impaired cognition. R18 received Hospice services and had an activated Power of Attorney (POA). R18's medical record indicated R18 was prescribed the following medications: ~Fentanyl transdermal (on skin) patch 72 hour 12 micrograms (mcg)/hour apply 12 mcg transdermally one time a day every 3 day(s) for pain ~Oxycodone oral concentrate 100 milligrams (mg)/5 milliliters (ml) give 0.5 ml every hour as needed (PRN) for severe pain/dyspnea (shortness of breath). R18's medical record and plan of care did not contain monitoring interventions for adverse reactions to opioid use including sedation, dizziness, nausea, vomiting, constipation, and respiratory depression. 2. On 2/19/25, Surveyor reviewed R46's medical record. R46 was admitted to the facility on [DATE] and had diagnoses including osteoarthritis, neuropathy, and hypertension. R46's MDS assessment, dated 1/13/25, had a BIMS score of 14 out of 15 which indicated R46 had intact cognition. R46 received Hospice services and had an activated POA. R46's medical record indicated R46 was prescribed the following medications: ~Morphine sulfate oral solution 20 mg/5 ml give 1 ml by mouth every hour PRN for severe pain or dyspnea, 0.5 ml for moderate pain or dyspnea, and 0.25 ml for mild pain or dyspnea ~Spironolactone oral tablet 25 mg give 1 tablet one time a day for diuretic ~Oxycodone oral tablet 5 mg give 2.5 mg by mouth every 4 hours PRN for severe pain ~Gabapentin oral capsule 100 mg give 1 capsule by mouth three times a day for neuropathy R46's plan of care indicated R46 had acute pain and contained interventions to encourage use of analgesics prior to physical therapy, evaluate for non-verbal indicators of pain, and evaluate vital signs. R46's plan of care also indicated R46 had hypertension and contained interventions to evaluate blood pressure. R46's medical record and plan of care did not contain monitoring for adverse reactions to opioid use including sedation, dizziness, nausea, vomiting, constipation, and respiratory depression; for adverse reactions to diuretic use including dehydration, headache, nausea, dizziness, and loss of appetite; and for anticonvulsant use including fatigue, tremors, rash, blurred vision, and weight gain. On 2/19/25 at 2:03 PM, Surveyor interviewed Nurse Manager (NM)-E who confirmed R18 and R46's care plans did not contain monitoring interventions for adverse reactions to the high-risk medications. On 2/19/25 at 2:07 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff should monitor for adverse reactions to high-risk medications, however, the facility has a new electronic health record system and staff are still learning how to use it. DON-B indicated nurses had pharmacology classes and know the side effects of high-risk medications. DON-B indicated Medication Technicians know even more since they administer medication daily. When asked what the facility's policy indicates regarding high-risk medication monitoring, DON-B indicated DON-B was unsure.

Based on staff interview and record review, the facility did not ensure a COVID-19 vaccine was administered for 2 residents (R) (R52 and R18) of 5 sampled residents. R52 and R18 were not administered a COVID-19 vaccine that R52 and R18's activated [NAME] of Attorney for Healthcare (POAHC) signed consent for. Findings include: The Centers for Disease Control and Prevention (CDC) guidelines at https://www.dcd.gov/mmwr/volumes/73/wr/mm7337e2.htm indicate: COVID-19 vaccination provides additional protection against severe COVID-19-associated illness and death. Since September 2023, 2023-2024 Formula monovalent XBB.1-strain COVID-19 vaccines have been recommended for use in the United States for all persons aged >6 months. However, SARS-CoV-2 continues to evolve, and since winter 2023-2024, Omicron JN.1 lineage strains of SARS-CoV-2, including the JN.1 strain and the KP.2 strain, have been widely circulating in the United States. Further, COVID-19 vaccine effectiveness is known to wane. On June 27, 2024, the Advisory Committee on Immunization Practices (ACIP) recommended 2024-2025 COVID-19 vaccination with a Food and Drug Administration (FDA)-approved or authorized vaccine for all persons aged >6 months. On August 22, 2024, the FDA approved the 2024-2025 COVID-19 vaccines by Moderna and Pfizer-BioNTech (based on the KP.2 strain) for use in persons aged >[AGE] years and authorized these vaccines for use in children aged 6 months-[AGE] years under Emergency Use Authorization (EUA). 1. On 2/18/25, Surveyor reviewed R52's medical record. R52 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, congestive heart failure (CHF), and cerebral vascular accident (CVA) (otherwise known as stroke). R52's Minimum Data Set (MDS) assessment, dated 1/7/25, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R52 had moderate cognitive impairment. R52 had an activated Power of Attorney for Healthcare (POACH). R52's medical record indicated R52 received a COVID-19 vaccine on 1/12/21. R52's medical record did not indicate R52 was offered or administered an updated COVID-19 vaccine. 2. On 2/18/25, Surveyor reviewed R18's medical record. R18 was admitted to the facility on [DATE] and had diagnoses including dementia, diabetes, and CVA. R18's MDS assessment, dated 1/6/25, had a BIMS score of 13 out of 15 which indicated R18 had intact cognition. R18 had an activated POAHC. R18's medical record indicated R18 received a COVID-19 vaccine on 3/12/21. R18's medical record did not indicate R18 was offered or administered an updated COVID-19 vaccine. On 2/19/25 at 9:29 AM, Surveyor interviewed Infection Preventionist (IP)-D who indicated the facility sent COVID-19 vaccination consent forms to R52 and R18's POAHC. The consent forms were reviewed and indicated R52 and R18's POAHC signed consent for R52 and R18 to receive a COVID-19 vaccine. R52's consent form was signed and dated 11/28/24. R18's consent form was signed and dated 10/10/24. IP-D verified R52 and R18 did not receive updated COVID-19 vaccines. IP-D indicated the facility is implementing a new tracking system for when residents' vaccines are due and/or have been administered.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 50 residents residing in the facility. The facility did not monitor and document food cooling temperatures. The facility did not monitor and document dishwasher surface temperatures. There were multiple open, undated, and/or expired food items in the dry storage area, and three coolers. Findings include: On [DATE] Dietary Manager (DM)-D verified the facility follows the Food and Drug Administration (FDA) Food Code 2022 as the facility's standard of practice. The facility's Food Service Safety policy, dated ,d+[DATE], indicated: It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state, and local authorities. Food will also be stored, prepared, distributed, and served in accordance with professional standards for food service safety .3. Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely proper storage .iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use by date, or frozen (where applicable)/discarded .4. When preparing food, staff shall take precautions in critical control points in the food preparation process to prevent, reduce, or eliminate potential hazards .c. Cooling-various strategies (e.g., placing foods in shallow pans, cutting roasts into smaller portions, utilizing ice water baths, and stirring periodically) shall be implemented to cool foods so that the total time for cooling does not exceed six hours . The facility's Food Storage-Use and Monitoring policy, with a review date of ,d+[DATE], indicated: To ensure all products for dietary department are properly received .3. Everything should be stamped with date of received . The facility's undated Label and Dating Cooler Items policy indicated: All items taken from cooler need dates put on them unless they already have dates .Fresh fruit-five day expiration .Lettuce-five day expiration .Bread-open date .Juice concentrates-open date. The facility's undated Label and Dating for Dry Items policy indicated: All items taken from storeroom need dates put on them unless they already have dates .All items taken out of a box need to be put in a bag with the date on it. The facility's Primary Dish Machine Operation Instructions policy, with a review date of ,d+[DATE], indicated: Monday/Wednesday/Friday send a temperature sensor tab strip through the machine and record on log sheet, date, and time. Food Cooling Temperatures: The FDA Food Code 2022 documents at ,d+[DATE].14 Cooling. (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 57 Celsius (C) (135 Fahrenheit) (F) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less. (B) Time/temperature control for safety food shall be cooled within 4 hours to 5 C (41 F) or less. The FDA Food Code 2022 section ,d+[DATE].15 documents Cooling Methods. (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S ,d+[DATE].14 by using one or more of the following methods based on the type of food being cooled: (1) Placing the food in shallow pans; (2) Separating the food into smaller or thinner portions; (3) Using rapid cooling equipment; (4) Stirring the food in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. During a continuous kitchen observation beginning at 7:35 AM on [DATE], Surveyor and DM-D observed the following foods in the reach-in freezer. DM-D confirmed the following foods were either leftovers from previous meals or pre-made and frozen for future use: -Chicken pot pie labeled with a date of ,d+[DATE] -Pizza casserole labeled with a date of ,d+[DATE] -Tater tot casserole labeled with a date of ,d+[DATE] -Tuna casserole labeled with a date of ,d+[DATE] -Minestrone soup in a stock pot labeled with a date of ,d+[DATE] -Lasagna labeled with a date of ,d+[DATE] -Breakfast sausage labeled with a date of ,d+[DATE] -Ground pork labeled with a date of ,d+[DATE] -Puree bacon labeled with a date of ,d+[DATE] -Broccoli wild rice soup in a stock pot labeled with a date of ,d+[DATE] Following the observation, Surveyor asked to review the facility's food cooling log. DM-D stated the facility does not have a food cooling log and indicated staff put food in uncovered shallow pans in the freezer, and do not cover the food until the temperature reaches 70 degrees. DM-D indicated DM-D was not aware food temperatures should be monitored and documented. When Surveyor asked DM-D if food is being cooled to the proper temperature within the food safety standard time frame, DM-D expressed understanding of why food temperatures should be monitored and documented and verified without monitoring, there is no way to ensure foods are safely and properly cooled. Dishwasher Surface Temperatures: The FDA Food Code 2022 documents at ,d+[DATE].13 Temperature Measuring Devices, Manual Warewashing. Water temperature is critical to sanitization in warewashing operations. This is particularly true if the sanitizer being used is hot water. The effectiveness of cleaners and chemical sanitizers is also determined by the temperature of the water used. A temperature measuring device is essential to monitor manual warewashing and ensure sanitization. Effective mechanical hot water sanitization occurs when the surface temperatures of utensils passing through the warewashing machine meet or exceed the required 71 C (160 F). Parameters such as water temperature, rinse pressure, and time determine whether the appropriate surface temperature is achieved. Although the Food Code requires integral temperature measuring devices and a pressure gauge for hot water mechanical warewashers, the measurements displayed by these devices may not always be sufficient to determine that the surface temperatures of utensils are reaching 71 C (160 F). The regular use of irreversible registering temperature indicators provides a simple method to verify that the hot water mechanical sanitizing operation is effective in achieving a utensil surface temperature of 71 C (160 F). During an initial kitchen tour beginning at 9:46 AM on [DATE], Surveyor and DM-D noted the dishwasher temperature log did not contain dishwasher surface temperatures. DM-D indicated staff are instructed to obtain dishwasher surface temperatures three times weekly, but stated staff throw away the test strip following the test. DM-D verified the log does not contain documentation to indicate surface temperatures are obtained and appropriate. DM-D indicated the facility used to keep the test strips to ensure the surface temperatures were appropriate, but stated the facility no longer follows that practice. On [DATE] at 2:40 PM, Surveyor interviewed DM-D who confirmed temperature gauges on the outside of the dishwasher are not always reliable for proper temperature control and verified surface temperatures need to be obtained and documented to ensure proper sanitization of dishes and silverware. Food Labeling/Storage: The FDA Food Code 2022 documents at ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when packaging food using a reduced oxygen packaging method as specified under S ,d+[DATE].12, and except as specified in (E) and (F) of this section, refrigerated, ready-to-eat, time/temperature control for food safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. The FDA Food Code 2022 documents at ,d+[DATE].18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A food specified in ,d+[DATE].17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in ,d+[DATE].17(A), except time that the product is frozen; (2) Is in a container or package that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in ,d+[DATE].17(A). During an initial kitchen tour beginning at 9:46 AM on [DATE], Surveyor and DM-D observed the following items in the dry storage area, walk-in cooler, dairy walk-in cooler, and produce walk-in cooler that were undated, opened and/or expired: Dry Storage Area Undated Food Items: -One container of dry beans -Four cans of diced tomatoes -Ten cans of cream of mushroom soup -Twelve cans of cream of celery soup -Two bags of seashell pasta plus one open, undated bag of seashell pasta -Four bags of rotini noodles plus one open, undated bag of rotini noodles -Six bags of egg noodles plus one open, undated bag of egg noodles -Two bags of penne noodles -Three bags of spaghetti noodles -IDDSI Level ,d+[DATE] puree bread mix with a best use by date of [DATE] -Twenty four bottles of ketchup -Five bags of chocolate pudding mix -One bag of chocolate mousse mix -Five yellow cake boxes -One open and undated cheesecake mix -Four boxes of basic muffin mix -One box of open and undated ,d+[DATE] biscuit mix Walk-In Cooler Undated Items: -Six pre-made boxed pies Walk-In Dairy Cooler Undated Items: -Ten packs of Swiss cheese -Seven packs of provolone cheese -Two 5 pound packs of American cheese -1 pound of butter -Two 32 ounce garlic herb spreads -Twelve unopened containers of concentrated juice and two open, undated containers of concentrated juice Walk-In Produce Cooler Undated Items: -One box of lemons -One box of oranges -One box of lettuce plus three heads of lettuce and one open, undated bag of lettuce -One box of 1 ,d+[DATE] bushel of green peppers -One box of 1 ,d+[DATE] bushel of cucumbers -10 pounds of mushrooms -One case of pineapple -One case of cantaloupe -One case of muskmelon Following the observation, Surveyor interviewed DM-D who indicated the facility's process is to ensure all items have a received or best buy date. DM-D stated when an item is opened, staff should label the item with an open date and ensure the item is discarded within the required time frame. DM-D verified the items noted above should have been dated with either a received date or use by date. DM-D was unsure why the food items were not dated.

Based on observation, staff and resident interview, and record review, the facility did not ensure a CPAP (continuous positive airway pressure) machine was ordered by a physician and routinely cleaned for 1 Resident (R) (R13) of 19 sampled residents. The facility did not ensure R13 had a physician order for CPAP use and that R13's CPAP equipment was routinely cleaned per the facility's policy and the manufacturer's recommendations. Findings include: The facility's undated Cleaning of Respiratory Equipment policy indicated: To maintain clean and sanitary equipment .wipe machine with a damp rag containing soap and water solution on a weekly basis . The Manufacturer's User Guide for R13's LinCare ResMed AirSense 10 machine indicated: It is important that you regularly clean your AirSense 10 device to make sure you receive optimal therapy .Regularly clean your tubing assembly, water tub and mask to receive optimal therapy and to prevent the growth of germs that can adversely affect your health . On 12/4/23, Surveyor reviewed R13's medical record. R13 was admitted to the facility on [DATE] with diagnoses including obstructive sleep apnea (when throat muscles intermittently relax and block the airway during sleep). R13's most recent Minimum Data Set (MDS) assessment contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R13 was not cognitively impaired. On 12/4/23 at 11:23 AM, Surveyor interviewed R13 who stated R13's CPAP equipment used to get cleaned, but had not been cleaned for several months. R13 stated AM shift staff used to clean the equipment so it had time to dry during the day. R13 verified R13 used the CPAP machine on a nightly basis. Surveyor observed R13's CPAP equipment and noted the mask was attached to the hose (inside R13's open bedside table drawer) which was attached to the machine. The water reservoir was empty and closed with visible condensation. Surveyor observed the mask and hose in the same position and location on multiple occasions during the survey from 12/4/23 through 12/6/23. On 12/4/23, Surveyor reviewed R13's medical record which did not contain physician orders for CPAP use or cleaning. R13's Treatment Administration Record (TAR) also did not indicate R13's CPAP equipment was routinely cleaned. R13's progress notes also did not indicate R13's CPAP equipment was routinely cleaned. On 12/5/23 at 12:16 PM, Surveyor interviewed Nurse Manager (NM)-C who verified R13 did not have a physician's order for use of the CPAP machine and R13's TAR did not contain an order to clean the CPAP equipment. NM-C stated when R13 returned to the facility from a previous hospitalization , physician's orders were not obtained for CPAP use or cleaning which is why the equipment was not being cleaned

Based on interview and record review the facility did not ensure its procedures for indicating a residents' code status was followed for 9 (R45, R71, R77, R82, R286, R69, R28, R52, R79), of 20 sampled residents. The Medical Intervention Goal (MIG) form was not signed by the physician and there was no signed physician orders [REDACTED]. -R45 was admitted on [DATE] with the Medical Intervention Goal (MIG) form declaring R45 to not receive Cardiac [MEDICAL CONDITION] Resuscitation (CPR). The MIG was not signed by the physician and R45 has no code status signed physician orders. -R71 was admitted on [DATE] with the Medical Intervention Goal (MIG) form declaring R71 to not receive Cardiac [MEDICAL CONDITION] Resuscitation(CPR). The MIG was not signed by the physician and R71 has no code status signed physician orders. -R77 was admitted on [DATE] with the Medical Intervention Goal (MIG) form declaring R77 to not receive Cardiac [MEDICAL CONDITION] Resuscitation (CPR). The MIG was not signed by the physician and R77 has no code status signed physician orders. -R82 was admitted on [DATE] with the Medical Intervention Goal (MIG) form declaring R82 to not receive Cardiac [MEDICAL CONDITION] Resuscitation (CPR). The MIG was not signed by the physician and R82 has no code status signed physician orders. -R286 was admitted on [DATE] with the Medical Intervention Goal (MIG) form declaring R286 to not receive Cardiac [MEDICAL CONDITION] Resuscitation (CPR). The MIG was not signed by the physician and R286 has no code status signed physician orders. -R69 was admitted on [DATE] with the Medical Intervention Goal (MIG) form declaring R69 to not receive Cardiac [MEDICAL CONDITION] Resuscitation (CPR). The MIG was not signed by the physician and R69 has no code status signed physician orders. -R28 was admitted on [DATE] with the Medical Intervention Goal (MIG) form declaring R28 to not receive Cardiac [MEDICAL CONDITION] Resuscitation (CPR). The MIG was not signed by the physician and R28 has no code status signed physician orders. -R52 was admitted on [DATE] with the Medical Intervention Goal (MIG) form declaring R52 to not receive Cardiac [MEDICAL CONDITION] Resuscitation (CPR). The MIG was not signed by the physician and R52 has no code status signed physician orders. -R79 was admitted on [DATE] with the Medical Intervention Goal (MIG) form declaring R79 to not receive Cardiac [MEDICAL CONDITION] Resuscitation (CPR). The MIG was not signed by the physician and R79 has no code status signed physician orders. Findings Include: Surveyor reviewed the Policy and Procedure Medical Intervention Guidelines, effective ,[DATE], revised ,[DATE] which states the following: Policy: To document each residents health care choices. Procedure: Key Steps: 1. Upon admission, admission coordinator, social services, or nursing staff will discuss medical intervention goals and document wishes of resident/resident representative. Resident/resident representative is made aware they can change their decision at any time. 2. A copy of the Medical Intervention Goals (MIG) form is placed in the front of the residents chart under the face sheet. * On new admissions, the original MIG form is completed by nursing, social services or admissions staff. Once completed, the original form is placed in the front of the chart. Admission staff will make a copy of the original form to place in the chart and forward the original to Medical Records who sends the form to the physician for signature. Once returned with physician signature, Medical Records will place signed copy in the Medical Record office chart. * When a change has been made by a resident or legal representative to an existing MIG form, a new form is completed. The old MIG is removed from the chart, a statement with the date is written on the back of the form stating it was discontinued and the old form is forwarded to Medical Records. A copy of the new form is placed in the front of the chart under the face sheet and the original is forwarded to Medical Records to send to the physician for signature. Once returned with physician signature, Medical Records will place signed copy in the Medical Record office chart. 3. If the resident/resident representative selects level 4 (Perform CPR) on the MIG, the admission coordinator, social worker, or nurse completing the form applies a RED CPR ID band to the resident's LEFT wrist. The nurse will add to the treatment sheet that verifies the placement of the red band on the left wrist daily on N[NAME] (night) shift. 4. The MIG is reviewed at each quarterly care conference and with any change of condition. 1. R45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R45 is R45's own person. R45's Admission Minimum Data Set ((MDS) dated [DATE] documents R45 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R45's cognitive skills for daily decision making are intact. On [DATE], Surveyor reviewed R45's code status per survey process. Surveyor notes the facility MIG form was signed by R45 on [DATE], but there is no physician signature. The MIG documents that R45 does not want CPR administered. Surveyor reviewed R45's current physician orders [REDACTED]. On [DATE] at 9:26 AM, Surveyor was provided a copy of R45's MIG form which was signed by the physician on [DATE]. 2. R71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R71 has an activated Health Care Power of Attorney (HCPOA). R71's Admission MDS dated [DATE] documents R71 has a BIMS score of 6, indicating R71's cognitive skills for daily decision making are severely impaired. On [DATE], Surveyor reviewed R71's code status per survey process. Surveyor notes the facility MIG form was signed by R71's HCPOA on [DATE], but there is no physician signature. The MIG documents that R71 does not want CPR administered. Surveyor reviewed R71's current physician orders [REDACTED]. On [DATE] at 9:31 AM, Surveyor was provided a copy of R71's MIG form which was signed by the physician on [DATE]. 3. R77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R77 is R77's own person. R77's Admission MDS dated [DATE] documents R77 has a BIMS score of 11, indicating R77's cognitive skills for daily decision making is moderately impaired. On [DATE], Surveyor reviewed R77's code status per survey process. Surveyor notes the facility MIG form was signed by R77's on [DATE], but there is no physician signature. The MIG documents that R71 does not want CPR administered. Surveyor reviewed R77's current physician orders [REDACTED]. On [DATE] at 9:28 AM, Surveyor was provided a copy of R77's MIG form which was signed by the physician on [DATE]. 4. R82 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R82 is R82's own person. R82's Admission MDS dated [DATE] documents R82 has a BIMS score of 11, indicating R82's cognitive skills for daily decision making is moderately impaired. On [DATE], Surveyor reviewed R82's code status per survey process. Surveyor notes the facility MIG form was signed by R82 on [DATE], but there is no physician signature. The MIG documents that R82 does not want CPR administered. Surveyor reviewed R82's current physician orders [REDACTED]. On [DATE] at 9:29 AM, Surveyor was provided a copy of R82's MIG form which was signed by the physician on [DATE]. 5. R286 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R286 has a HCPOA, and facilty states activation is in process. R286 does not have a completed MDS and no documented BIMS score. On [DATE], Surveyor reviewed R286's code status per survey process. Surveyor notes the facility MIG form was signed by the HCPOA of R286 on [DATE], but there is no physician signature. The MIG documents that R286 does not want CPR administered. Surveyor reviewed R286's current physician orders [REDACTED]. On [DATE] at 9:32 AM, Surveyor was provided a copy of R286's MIG form which was signed by the physician on [DATE]. On [DATE] at 11:06 AM, Surveyor interviewed Registered Nurse (RN-E) Unit Manager in regards to the code status procedure. RN-E stated that on the rehabilitation unit, the admitting nurse or the social worker gets the MIG form signed. RN-E then stated the MIG form goes in the front of the residents chart. RN-E stated the resident gets a red band if the resident wants CPR. This red band goes on the left wrist and is checked for placement in the Treatment Administration Record (TAR), one time a day. RN-E stated that if a resident is found pulseless, they first look at the left wrist and then a staff member would go to the paper chart and look at the MIG form to confirm the resident's code status. RN-E confirmed that staff do not access the electronic record to determine code status. RN-E stated that the MIG form is sent out for physician signature by Medical Records. RN-E stated once the MIG form is received back from the physician, the MIG form gets switched from a copy to the original in the resident's paper chart. Surveyor reviewed R45, R71, R77, R82, and R286 physicians' orders with RN-E and RN-E verified that R45, R71, R77, R82, and R286's code status was not on the physician's orders [REDACTED]. On [DATE] at 11:29 AM, Surveyor interviewed Medical Records (MR-D) in order to determine if there was a signed MIG form for R45, R71, R77, R82, and R286. MR-D stated a copy of the MIG form is placed on the chart when signed by the resident/resident representative. Medical Records receives the the original MIG form. MR-D stated to Surveyor that Medical Records only is responsible for the long term residents in regards to sending out the MIG form for physician signature. MR-D stated once Medical Records receives the returned physician signed MIG form, then the original gets filed in each residents' medical records file which is kept in Medical Records. The unsigned copy remains in each residents' paper chart which is kept on the nursing unit. MR-D verified that the physician signed MIG form does not go into the residents' paper medical chart on the nursing unit. MR-D informed Surveyor that Medical Records has not been sending the MIG forms for the residents on the rehabilitation unit to the physician for signature. MR-D stated, I don't know who is sending out the MIG form for the rehabilitation unit to get the physician signature .I just know it is not Medical Records. MR-D further stated that no matter what level is chosen, all MIG forms are supposed to be sent for physician signature. MR-D verified that R45, R71, R77, R82, and R286 do not currently have a physician signed MIG form in their medical record file. On [DATE] at 8:24 AM, Surveyor interviewed RN-E again in regards to the process of code status. RN-E stated that the first place a staff member would look to determine a residents' code status would the left wrist and then a staff member would go to the residents' paper chart to confirm the code status. On [DATE] at 8:37 AM, Surveyor interviewed the Social Worker (SW-C) who informed Surveyor that SW-C has nothing to do with the process of the MIG form on the chart. On [DATE] at 2:44 PM, Surveyor shared with Director of Nursing (DON-B) and Administrator(NHA-A) the concern of R45, R71, R77, R82, and R286 not having their MIG form signed by the physician and there are no signed physician orders [REDACTED]. 6. R69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] Surveyor reviewed Electronic Medical Record which documented R69 as a DNR (Do Not Resuscitate) under code status. On [DATE] Surveyor reviewed MD orders. There is no documentation of DNR order. On [DATE] Surveyor reviewed hard chart. Medical Intervention Goals was signed by R69 on [DATE] documented Level Three . Examples of care intended: [DIAGNOSES REDACTED]. hospitalization . Care not intended: Cardio [MEDICAL CONDITION] Resuscitation - CPR. The form in the hard chart was not signed by MD. On [DATE] Surveyor requested a signed DNR order from Director of Nursing (DON)-B. DON-B provided Surveyor a signed copy of Medical intervention Goals sheet signed by MD but dated [DATE]. There was no signed MD order from admission date of [DATE] through [DATE] directing code status for R69 as DNR. 7. On [DATE] Surveyor reviewed R28 medical record and discovered a Medical Intervention Goals form that indicate R28 designated level one care. Level one care is comfort measure and no CPR, hospitalization and intravenous fluids. The form is signed by R28 legal representative and a facility representative on [DATE] but not signed by the physician. On [DATE] at 3:00 p.m. during the daily exit meeting with Director of Nursing (DON) B and Nursing Home Administrator (NHA) A, Surveyor asked if there was a Medical Intervention Goals form that was signed by the physician. On [DATE] at 7:52 AM Surveyor received copy of medical intervention goals signed by physician dated [DATE]. On [DATE] at 09:00 AM Surveyor interviewed RN Manager I. RN Manager I stated when the medical intervention goal is filled out it is then given to medical records and they obtain the physician signature. RN Manager I stated she is not sure why the physician signature wasn't obtained prior to Surveyor mentioning the concern. RN Manager I confirmed the physician signature was obtained on [DATE]. 8. On [DATE] Surveyor reviewed R52 medical record and discovered a Medical Intervention Goals form that indicate R52 designated level three care. Level three care allows hospitalization and diagnostic measure but no CPR. The form is signed by R52 and a facility representative on [DATE] but not signed by the physician. On [DATE] at 3:00 p.m. during the daily exit meeting with DON B and NHA A, Surveyor asked if there was a Medical Intervention Goals form that was signed by the physician. On [DATE] at 7:52 AM Surveyor received copy of medical intervention goals signed by physician dated [DATE]. On [DATE] at 09:00 AM Surveyor interviewed RN Manager I. RN Manager I stated when the medical intervention goal is filled out it is then given to medical records and they obtain the physician signature. RN Manager I stated she not sure why the physician signature wasn't obtained prior to Surveyor mentioning the concern. RN Manager I confirmed the physician signature was obtained on [DATE]. 9. On [DATE] Surveyor reviewed R79 medical record and discovered a Medical Intervention Goals form that indicate R79 designated level two care. Level two care allows diagnostic measures but no CPR and hospitalization s. The form is signed by R79 legal representative and a facility representative on [DATE] but not signed by the physician. On [DATE] at 3:00 p.m. during the daily exit meeting with DON B and NHA A, Surveyor asked if there was a Medical Intervention Goals form that was signed by the physician. On [DATE] at 7:52 AM Surveyor received copy of medical intervention goals signed by physician dated [DATE]. On [DATE] at 09:00 AM Surveyor interviewed RN Manager I. RN Manager I stated when the medical intervention goal is filled out it is then given to medical records and they obtain the physician signature. RN Manager I stated she was not sure why the physician signature wasn't obtained prior to Surveyor mentioning the concern. RN Manager I confirmed the physician signature was obtained on [DATE].

Based on interview and record review, the facility did not follow facility policy and obtain MD orders for 2 of 4 residents (R343 and R82) reviewed for indwelling catheters. R343 and R82 were admitted to the facility with indwelling foley catheters without obtaining proper MD orders for placement, irrigating or changing as needed. Findings include: Surveyor reviewed the facility policy for Catheters with a review date of 6/2018 contains the following documentation; Skill 34.1 Insertion of a Straight or Indwelling Urinary Catheter . Assessment: 2. Review patient's medical record, including health care provider's order and nurses' notes. Note previous catheterization, including catheter size, response of patient, and time of catheterization. 1. R343 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Surveyor reviewed R343's Progress Notes. Documented on 4/28/19 at 7:53 AM was Resident had blood in her brief this morning when she was being changed. Writer with the assistance of nurse supervisor irrigated residents Foley; however did not receive output after. We were able to pull back a small blood clot from the Foley and afterwards resident did have output flowing . Res tolerated procedure well. Documented on 4/30/19 at 3:02 PM was dark red/brown, sludgy urine noted to catheter bag. (Nurse Practitioner) aware . Urinalysis with Culture and Sensitivity (UA w/ C&S) ordered (as soon as possible.) Foley catheter removed and new 16 (French) catheter placed. Bright red, urine with sedimentation noted. Patient tolerating procedure well. Surveyor reviewed R343's Cardex as part of the Comprehensive Plan of Care with a date of 4/26/19. Documented under Output was Foley Catheter: Insertion date: 4/14/19. There was no documentation under # French (size). Surveyor reviewed MD orders for R343. There is no MD order for placement, irrigation or changing catheter documented in electronic or paper chart. On 5/06/19 at 12:14 PM, Surveyor interviewed Registered Nurse (RN) Unit Manager-H. Surveyor asked what the facility's process is if someone comes in with an indwelling Foley catheter. RN-H stated an assessment is done by the admitting nurse. They find out why is it in, if they need a follow up with urology, [DIAGNOSES REDACTED]. Surveyor asked about R343's Foley catheter. RN-H stated the Foley was left in because the resident has a [MEDICAL CONDITION] bladder [DIAGNOSES REDACTED]. Surveyor asked if the facility would need an MD order if you are going to leave the Foley in place. RN-H stated yes, the order would read 'Foley per facility protocol.' Surveyor noted to RN-H there was no order for the Foley to stay in. Surveyor asked if you need an order to irrigate the catheter or change it. RN-H stated, yes. Surveyor noted Progress notes from 4/28/19 and 4/30/19 and there were no orders to irrigate or change the Foley catheter. RN-H stated, yes, I see it in the notes, I do not know why they would irrigate the Foley without an order. Surveyor asked why it was changed. RN-H stated there was an order to collect a urine sample and facility policy states when getting a urine sample to change the Foley. Surveyor asked how the nurse would know what size to change it to if there was no MD order. RN-H stated there should have been an order with size of catheter. 2. R82 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R82 is R82's own person. R82's Admission Minimum Data Set ((MDS) dated [DATE] documents R82 has a BIMS score of 11, indicating R82's cognitive skills for daily decision making is moderately impaired. The MDS also documents that R82 has an indwelling catheter and lists a [DIAGNOSES REDACTED]. Surveyor reviewed R82's Foley Catheter Assessment and Management dated 3/28/19. The assessment documents the following: -R82 has a valid medical justification for use of the indwelling catheter: retention and buttocks wounds. Summary: Discussed with Nurse Practioner (NP) and catheter to remain in place at this time due to retention and buttocks deep tissue injuries with slough present and R82 is incontinent of urine prior to Foley. The following practices are all checked yes: -Staff following the facility's protocol and/or written procedures for catherization. -All personnel are washing their hands before and after caring for the catheter/tubing/collecting bag. -Staff is securing catheter to minimize injury and positioning bag to decrease risk of infection. -Staff is cleaning the catheter and providing bowel care per protocol. -Fluid needs addressed and met. Surveyor reviewed the Urinary Incontinence and Indwelling Catheter Care Area Assessment(CAA) dated 4/3/19. The CAA states the following: R82 has an indwelling Foley present following a right femur surgery. R82 is currently transferring with 2 staff assist with the EX lift. R82 is active in therapy. Order to remove Foley 3/27/19 followed by a bladder scan and orders to cath if PVR is greater than 300ml. Food and fluid is encouraged as R82 tolerates. Surveyor noted that R82's indwelling catheter is not addressed in R82's care plan in R82's electronic medical record. The facility considers R82's Kardex as part of the care plan. Foley catheter is checked on R82's Kardex and documents that the indwelling catheter was placed in the hospital. The kardex lists retention and buttock wound for [DIAGNOSES REDACTED]. There is to be no monthly changes per protocol. Surveyor reviewed R82's urology consult which occurred on 3/27/19 and verified that there is an order for [REDACTED]. On 5/2/19, Surveyor reviewed R82's current physician orders [REDACTED]. Surveyor also reviewed R82's Treatment Orders Record(TARS) and notes there is no indwelling catheter care practices documented. On 5/6/19 at 11:48 AM, Surveyor reviewed R82's physician orders [REDACTED]. On 5/1/19 at 12:42 PM, Surveyor initiated a conversation with Registered Nurse (RN-E) Unit Manager in regards to R82's indwelling catheter. RN-E provided documentation to validate as to why the indwelling Foley catheter has not been removed. On 05/6/19 at 12:37 PM, Surveyor interviewed RN-E in regards to R82's indwelling catheter. RN-E in the interview validated there should have been indwelling Foley catheter orders for R82 on admission. Surveyor asked where is the Foley catheter order on the physician's orders [REDACTED]. RN-E confirmed there is no order for the Foley catheter, on the physician's orders [REDACTED]. RN-E validated that there should have been physician orders [REDACTED]. RN-E agreed the facility is missing key components of how to take care of the Foley catheter. RN-E stated that procedures like emptying, cleaning, strap or not , etc. should be listed on the TAR. Surveyor asked RN-E how would an agency staff member know to provide care for the indwelling catheter if it is not listed in the TAR or the physician orders. RN-E acknowledges they would not know and further validated it should be located in physician's orders [REDACTED]. Surveyor and RN-E reviewed together the Certified Nursing Assistants (CNA) Point of Care (P[NAME]) charting. R82's indwelling Foley catheter is listed in the P[NAME] and CNAs are recording output for R82. However, the category next to output titled Catheter Care per facility protocol is blank for R82. RN-E informed Surveyor this category was taken off the P[NAME] as of 4/1/19 because it is supposed to be recorded on the TAR. Surveyor noted that when RN-E and Surveyor reviewed R82's TAR, there was nothing documented in regards to the indwelling catheter. On 5/6/19 at 2:44 PM, Surveyor shared with Director of Nursing (DON-B) and Administrator(NHA-A) the concern that R82 did not have indwelling Foley catheter physician orders [REDACTED]. On 5/7/19 at 9:32 AM, Surveyor was provided by RN-E a copy of a physician's orders [REDACTED]. Surveyor was also given a copy of R82's TAR which documents as of 5/6/19 the following: Foley Catheter care per CLHRC policy.

Based on observation, interview and record review the facility did not ensure its medication error rate was below 5%. The facility error rate was 6.9% affecting 2 of 5 residents (R31 and R341) observed during the medication pass. * R31 did not have his [MEDICATION NAME] on for 24 hours as ordered. * R341 received Potassium Chloride Extended Release crushed, which is contraindicated. Findings include: On 5/6/19 at 7:04 AM, Surveyor observed Licensed Practical Nurse (LPN)-F prepare medications for R31. LPN-F opened a package labeled [MEDICATION NAME] 0.2 mg (milligrams)/hr (hour) 24 hour patch. Apply a new patch daily. LPN-F placed the [MEDICATION NAME] on R31's skin, but Surveyor did not observe LPN-F remove an old patch. Surveyor asked LPN-F if there was a patch from the previous day to be removed. LPN-F reported the patch is put on in the morning and is removed at HS (bedtime) the same day. Review of R31's MAR (Medication Administration Record) documented: [MEDICATION NAME] 0.2 mg/hr [MEDICATION NAME] 24 hr patch apply topically QD (Every Day) AM/ON, HS/OFF. Surveyor confirmed the MAR indicated [REDACTED] R31's signed physicians orders dated 3/4/19 documented: [MEDICATION NAME] 0.2 mg/hr [MEDICATION NAME] 24 hr patch (generic) apply topically QD. Surveyor noted the order did not indicate to remove the patch after 12 hours (at bedtime) the same day. Surveyor reviewed R31's physicians orders with Registered Nurse (RN) Unit Manager-I and asked why the MAR indicated [REDACTED]? RN Unit Manager-I stated, I'm not sure. Good question. Surveyor and RN Unit Manager-I approached the medication cart and spoke with LPN-F. Surveyor asked LPN-F why the [MEDICATION NAME] 24 hour patch is put on in the morning and removed at bedtime and not left on for 24 hours as ordered? LPN-F stated, I don't know why it's in the MAR indicated [REDACTED]. On 5/6/19 at 9:42 AM Surveyor spoke with Pharmacist-J about R31's [MEDICATION NAME] 24 hour patch. Surveyor asked Pharmacist-J if R31's [MEDICATION NAME] should remain on for 24 hours or be removed after 12 hours at bedtime as indicated on the MAR. Pharmacist-J stated, I have no idea why they would be removing the patch at bedtime. It is a 24 hour patch, so it should stay on for 24 hours. 2. On 5/6/19 at 7:40 AM, Surveyor observed LPN-G prepare medications for R341. LPN-G removed 1 tablet of Potassium Chloride 20 meq (milliequivalents) ER (Extended Release) and proceeded to crush the tablet. After crushing the tablet, LPN-G stated, She likes it in orange juice. LPN-G then walked to the dining room to obtain orange juice. While LPN-G was in the dining room, R341 stated to Surveyor, I can't swallow the potassium because it feels like sand in my throat, so I ask her to crush it and put it in orange juice. I have a different type of pill at home, it's round and like candy in the middle, it's much easier to swallow, but they told me I can't bring it in. LPN-G returned to the medication cart, mixed the crushed potassium into the cup of orange juice and handed the cup to the resident. R341 drank the mixture of orange juice and crushed potassium. R341's Discharge Summary dated 4/20/19 documented: Potassium chloride 10 meq ER tablet. Take 2 tablets by mouth daily. Surveyor noted the order did not indicate the medication could be crushed. On 5/06/19 at 9:42 AM, Surveyor spoke with Pharmacist-J about R341's Potassium Chloride Extended Release. Surveyor asked if R341's Extended Release Potassium Chloride should be crushed. Pharmacist-J stated, Potassium Extended Release should not be crushed. When it's crushed, it releases too much potassium. It can be dissolved easily in a little water or juice, but it should not be crushed. The Facility policy titled, Medication Administration with a review date of 4/2019 had no documentation in regards to crushing of medications. On 5/6/19 Surveyor advised Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the above observations. On 5/7/19 Surveyor was provided a nursing inservice record which was placed on all units in the facility dated 5/7/19 which documented, Topic: Medications that cannot be crushed. When dispensing medications during a medication pass make sure you are not crushing any medications that indicate CR-Controlled release, DR-Delayed release, SR-Sustained release, ER-Extended release or [MEDICATION NAME] coated medications. If a resident if having difficulties swallowing medications that cannot be crushed or prefer another form of the medication please contact pharmacy for an alternative form of the mediation.

Based on record review and interview, the facility did not keep 1 (R42) of 5 residents reviewed free from unnecessary drugs. * R42 received an antibiotic when she did not have appropriate signs and symptoms for use of the antibiotic. Findings include: The facility's policy with no date titled, McGeer's Criteria: Constitutional Criteria for Infection documents under the Table 2 section, UTI (Urinary Tract Infection) without indwelling catheter: Must fulfill both 1 AND 2: (1.) At least 1 of the following signs and symptoms subcriteria; (a.) Acute dysuria or acute pain, swelling, or tenderness of the testes, epididymis, or prostate; (b.) Fever or leukocytosis and at least 1 of the following: (i) Acute costovertebral angle pain or tenderness (ii) Suprapubic pain (iii) Gross hematuria (iv) New or marked increase in incontinence (v) New or marked increase in urgency (vi) New or marked increase in frequency. (c.) If no fever or leukocytosis, then 2 or more of the following: (i) Suprapubic pain (ii) Gross hematuria (iii) New or marked increase in incontinence (iv) New or marked increase in urgency (v) New or marked increase in frequency. (2.) One of the following microbiologic subcriteria (a) At least 10,000 cfu (colony forming units)/ ml (milliliter) of no more than 2 species of microorganisms in a voided urine sample. (b) At least 10,000 cfu/ml of any number of organisms in a specimen collected by in-out catheter. In the absence of a clear alternate source of infection, fever or rigors with a positive urine culture result in the non-catherized resident or acute confusion in the catherized residents will often be treated as a UTI. However, evidence suggests that most of these episodes are likely not due to infection of a urinary source. R42 was re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R42's Significant Change in Status MDS (Minimum Data Set) dated 3/19/19 documents a Brief Interview Mental Status score of 04, indicating that R42 is significantly cognitively impaired. Section G (Functional Status) documents that R42 has total dependence on staff and requires a two person physical assist for her transfer and toilet use needs. The MDS indicates R42 requires supervision with set up for eating. Section G0400 (Functional Limitation in Range of Motion) documents that R42 has no impairment to either side of her upper and lower extremities. Section H (Bladder and Bowel) documents that R42 is occasionally incontinent of bladder and has no appliances in place. R42's nursing note dated 4/6/19 documents, T (temperature) 97.8 (degrees Fahrenheit) BP (blood pressure) 120/76 .Resident more lethargic and not eating well this shift, resident denies feeling any different and states she feels fine. Denies dysuria or frequency. Resident is pale, lungs diminished at bases, and CNA's reporting they are noting concentrated urine. Spoke to .Optum ARNP (Advance Registered Nurse Practitioner) and received new order for UA (Urinalysis) with C & S (culture and sensitivity), may straight cath to obtain if needed. R42's nursing note dated 4/7/18 documents, UA with C & S pending; resident denies frequency or dysuria. Resident more alert this AM and is eating independently with cueing at times. Resident will be attending granddaughter's baby shower this afternoon. T (temperature) 97.8 (degrees Fahrenheit). R42's nursing note dated 4/7/19 documents, Resident left facility via Washing County Wheelchair taxi as arranged by her daughter to attend her granddaughters baby shower. Per daughter resident will return to facility around 1500 (3:00 PM). Resident ate lunch prior to leaving, however she needed to be fed as she was not eating independently despite being alert and orientated x 2 (person and place) at the time and also needed cueing to remember to swallow. Often noted resident was holding her pureed food in her mouth. R42's nursing note dated 4/7/18 documents, UA results received. NP (nurse practitioner) Optum updated with results .T (temperature) 98.7 (degrees Fahrenheit) .Explained to her needing assistance feeding and told to swallow with meals at breakfast and supper. N.O (new order) received for [MEDICATION NAME] 2 gram IM (intramuscular) x (for) 1 dose now and to mix with 1% [MEDICATION NAME]. Stated to call Optum with any change of condition and to let NP aware of culture and sensitivity when received. Daughter called with UA results and new order from Optum. Daughter stated that she was just fine at the baby shower today. Stated to call her anytime if needed. Surveyor reviewed R42's (MONTH) 2019 MAR (Medication Administration Record) which documents R42 received 2 grams of [MEDICATION NAME] ([MEDICATION NAME]), 1 dose on 4/7/19. Surveyor was unable to find any documentation in R42's medical record that R42 exhibited the following signs and symptoms: Acute dysuria or acute pain, swelling, or tenderness of the testes, epididymis, or prostate; Fever or leukocytosis and at least 1 of the following localizing UTI subcriteria: Acute costovertebral angle pain or tenderness, suprapubic pain, gross hematuria, new or marked increase in incontinence, new or marked increase in urgency, new or marked increase in frequency. Surveyor was also unable to find any physician documentation/[DIAGNOSES REDACTED]. R42's culture and sensitivity results dated as received on 4/7/19 documents R42's suspected UTI (Urinary Tract Infection) organism is resistant to [MEDICATION NAME] ([MEDICATION NAME]). On 05/06/19 at 2:49 p.m., during the daily exit, Surveyor informed Administrator-A and DON (Director of Nursing)-B of the above findings. Surveyor requested additional information from Administrator-A and DON-B that documented how R42 fit the facility's constitutional criteria for antibiotic use on 4/7/19. On 5/7/19 at 9:23 a.m., Surveyor was provided with documentation that R42 did not fit the facility's constitutional criteria for antibiotic use on 4/7/19. Surveyor noted that R42 did not fit the facility's criteria for antibiotic use when R42 received an antibiotic on 4/7/19. On 5/7/19 at 9:59 a.m., Surveyor informed IC (Infection Control) RN (Registered Nurse)-K of the above findings. Surveyor asked IC RN-K if R42 fit the facility's criteria for antibiotic use, as Surveyor was unable to find any documentation that R42 exhibited signs and symptoms or any physician documentation for the rationale for R42's antibiotic use on 4/7/19. IC RN-K informed Surveyor that R42 did not fit the facility's criteria for antibiotic use for on 4/7/19. Surveyor asked IC RN-K why R42 received the antibiotic [MEDICATION NAME] on 4/7/19 when R42's culture and sensitivity report documented that R42's suspected UTI organism is resistant to [MEDICATION NAME] ([MEDICATION NAME]). IC RN-K informed Surveyor that she did not know why R42 received the antibiotic [MEDICATION NAME] which per R42's culture and sensitivity report documented that R42's suspected UTI organism is resistant to [MEDICATION NAME] ([MEDICATION NAME]). On 5/7/19 at 10:11 a.m., Surveyor interviewed NP (Nurse Practitioner)-L regarding R42's antibiotic use on 4/7/19. Surveyor asked NP-L if R42 fit the facility's criteria for antibiotic use, as Surveyor was unable to find any documentation that R42 exhibited signs and symptoms or any physician documentation for the rationale for R42's antibiotic use on 4/7/19. NP-L informed Surveyor that R42 did not fit the facility's criteria for antibiotic use on 4/7/19. NP-L informed Surveyor that the nurse practitioner whom prescribed the antibiotic on 4/7/19 should have waited for R42's culture and sensitivity results to return to avoid prescribing R42 an antibiotic that R42's suspected UTI was resistant to.

Based on record review and staff interview, the facility did not ensure that residents that transferred to the hospital received the required information. This included the information regarding the State Ombudsman and information on how to appeal a transfer and/or discharge. This was observed with 3 (R61, R355 and R62) of 3 resident transfers to the hospital. R61 was transferred to the hospital on [DATE] and was not provided with the ombudsman information and how to appeal. R355 was transferred to the hospital on [DATE] and was not provided with the ombudsman information and how to appeal. R62 was transferred to the hospital on [DATE], and 2/27/18, and was not provided with the ombudsman information and how to appeal. Findings include: 1. Surveyor reviewed R61's medical record. R61 was transferred to the hospital for a right [MEDICAL CONDITION] on 1/9/18. The facility Transfer Form clinical information and Bed Hold information was provided, except information on how to appeal and Ombudsman contact information was not included. The medical record did not contain all the required information at the time of transfer. On 03/08/18 08:52 AM, Surveyor spoke with DON-B (Director of Nurses) regarding Ombudsman and State Appeal at the time of transfer. DON-B indicated they would look into it. On 03/08/18 11:11 AM SW-G (Social Worker) spoke with Surveyor. The facility was not sending the Ombudsman contact information, nor the State Appeal information, with a resident transfer. 2. R355's medical record was reviewed by Surveyor. R355 was hosptalized on [DATE] for [MEDICAL CONDITION]. R355 was provided Bed Hold information and a Transfer Form clinical information. The State Ombudsman and information on how to appeal was not included and provided with the transfer to the hospital. On 03/08/18 08:52 AM, Surveyor spoke with DON-B (Director of Nurses) about information provided at time of transfer regarding Ombudsman and State Appeal. DON-B indicated they will look in to it and 03/08/18 11:11 AM SW-G (Social Worker) spoke with Surveyor. The facility was not sending the State Ombudsman contact information, nor the State Appeal information, with a resident transfer. 3. R62's medical record was reviewed. R62 was transferred to the hospital on [DATE] for low hemoglobin and blood pressure and 2/27/2018 for rectal bleeding. R62 was provided the facility's Bedhold Notice and Readmission Rights information and a Transfer Form with clinical information. The State Ombudsman and information on how to appeal was not provided with the transfers to the hospital. On 3/8/2018 at 10:11 AM, Surveyor spoke with Social Worker (SW)-G about the information provided to R62 at the times of transfer. SW-G stated the facility was not sending the information regarding the State Ombudsman and State Agency at the times of transfer. On 3/8/2018 at 3:00 PM, Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the above information. NHA-A and DON-B provided no further information at that time.

Based on record review and interview, the facility did not ensure completion of the admission MDS (Minimum Data Set) within 14 days of admission for 1 (R311) of 25 residents reviewed. R311 was admitted on [DATE] and the facility is required to complete an admission MDS within 14 days of admission which would be due on 02/26/18. The facility chose to complete the admission MDS with a reference date of 02/19/18, on 2/19/18. The Admission MDS was signed by the Registered Nurse (RN) verifying completion on 02/19/18 (Section Z0500.) On 3/8/18, Social Worker D completed sections of the MD pertaining to Mood and Medications, and provided Surveyor with the completed MDS. The MDS should have been completed when the RN verified the completion of the MDS on 2/19/18. Findings include: Surveyor reviewed R311's medical record from 3/5/18 to 3/8/18. R311 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Surveyor was unable to locate in R311's medical record an admissions MDS that was completed and submitted within 14 days of admission. R311 was admitted on [DATE] and Surveyor was unable to locate an admission MDS in R311's medical record. On 3/8/18 at 12:25 p.m., Surveyor informed RN (Registered Nurse) Manager-C of the above findings. Surveyor asked RN Manager-C if R311 had a completed admissions MDS, as Surveyor was unable to locate it in R311's medical record. RN Manager-C informed Surveyor that she was not involved in the total completion and submission of R311's admission MDS and directed Surveyor to speak with MDS RN-E. On 3/8/18 at 12:41 p.m., Surveyor informed MDS RN-E of the above findings. Surveyor asked MDS RN-E if R311 had a completed admissions MDS that was submitted, as Surveyor was unable to locate it in R311's medical record. MDS RN-E informed Surveyor that R311 did not have a completed admissions MDS that was submitted and that she would complete one and submitted it today (3/8/18). On 3/8/18 at approximately 1:30 p.m., SW (Social Worker)-D provided Surveyor with a copy of R311's completed and submitted admissions MDS dated [DATE]. The admission MDS with a reference date of 02/19/18 was signed by the Registered Nurse (RN) as verifying completion on 02/19/18 (Section Z0500.) On 3/8/18, Social Worker-D indicated that on 3/8/18 she had completed the MDS sections regarding Mood and Medications. The MDS should have been completed when the RN verified the completion of the MDS on 2/19/18. SW-D informed Surveyor that MDS RN-E had submitted R311's admission MDS today as discussed (3/8/18). No further information was provided as to why the facility did not ensure completion of the admission MDS with 14 days of admission. (Cross Reference F656 & F758)

Based on record review and staff interviews, the facility did not ensure that 2 out of 17 residents (Resident's #29 and #6) who were assessed to be at high risk for falls, were provided with the adequate supervision and assistance devices to prevent accidents. ~ Resident #29 was admitted to the facility on [DATE] at risk for falls following a fall with a subarachnoid hemorrhage while at home. In the time period between 4/5/12 and 5/4/12 Resident #29 sustained falls on 4/21/12, 4/26/12 and 5/4/12 and had multiple documented episodes and anxiousness with attempts to self transfer. Following each fall and attempt to self transfer, the facility did not thoroughly assess Resident #29's fall risk factors. On 4/26/12, Resident #29 was very anxious and restless because he could not reach his girlfriend by phone. Staff did not implement 1:1 supervision when restless as directed in his care plan. During an attempt at self transfer, Resident #29 fell and sustained a traumatic brain injury with an intracerebral hemorrhage and cervical (C2) fracture. Resident #29 was hospitalized until 5/3/12 and returned with a cervical collar. Upon return to the facility the facility did not thoroughly assess Resident #29's risk factors for falls or establish a comprehensive care plan to prevent falls and Resident #29 fell again on 5/4/12. The facility's failure to ensure that Resident #29's falls were thoroughly assessed and that safety interventions were established and implemented to prevent further falls created a situation of immediate jeopardy that started on 4/26/12. On 5/8/12 at 10:30 a.m., Surveyor # notified Nursing Home Administrator (NHA)- A of the determination of immediate jeopardy at a scope and severity of J (immediate jeopardy/ isolated). The facility removed the immediate jeopardy on 5/8/12, however , the deficient practice continues at a scope and severity of a D (potential for harm that is not immediate jeopardy/isolated) as the facility continues to implement its correction plan related to accidents and supervision for fall prevention. Continued noncompliance is exemplified by: ~ Resident #6 was assessed to be at high risk for falls and had experienced 9 falls over a period of time. Upon review of Resident 6's medical record, it was noted that the facility did not comprehensively assess 7 of the falls in effort to reduce Resident #6's risk for future falls. Findings include: 1.) Resident #29 was admitted to the facility on [DATE] after experiencing a fall in his assisted living apartment. Resident #29 was discharged to the facility with [DIAGNOSES REDACTED]. Resident #29 was admitted to the facility to receive Physical and Occupational Therapy. The facility conducted a "Fall Risk Assessment" on 4/5/12. The assessment indicates that Resident #29 is cognitively impaired, has gait problems, has a history of falls, visual deficits and is on medication that may contribute to a fall. The score of the assessment was a total of 8- high risk. The assessment states that for those individuals who are at high risk; apply slipper socks/non- skid shoes at bedtime, provide nap/ rest periods throughout waking hours, pharmacy review of medications, complete pan assessment, therapy screen, review previous falls for any patterns, implement behavior management program, assess food and fluid intake, perform routine room checks, utilize bed/ chair alarms, assess for preventative devices, evaluate roommate appropriateness, room change- closer to nursing station. The assessment also states that "fall precautions are only guidelines and it is up to the licensed staff member to assign the resident to protocol based on individual needs and clinical judgement." Surveyor # conducted a review of the Individual Plan of Care for Resident #29, dated 4/5/12. The plan of care stated that Resident #29 has a potential for falls related to decreased safety awareness, Dementia manifested by attempts to transfer unassisted. Interventions listed included call light will be within reach and resident will alert staff when assistance is needed. The IDT Team Sheet/Cardex, dated 4/5/12 was also reviewed. This Cardex is considered by the facility to be apart of the plan of care and the direct care staff are to review and utilize the listed intervention on a daily basis. The Cardex stated that Resident #29 has a history of falls, confusion, high risk for falls- place bed against wall, chair alarm and bed alarm. According to the admission Minimum Data Set (MDS), with an assessment reference date of 4/12/12, Resident #29 scored a 9 on the brief interview for mental status which indicates that Resident #29 is moderately cognitively impaired. The MDS also indicates that Resident #29 needs limited, 1 person physical assistance to move about his room and to transfer. It was also noted on the MDS that Resident #29 has had falls both 1 month and 2- 6 months prior to admission to the facility. The Care Area Assessment (CAA) summary, dated 4/18/12 states that Resident #29 has a history of falls due to neuro disease process. No falls since admission, does self transfer at time and is reminded to wait for assist. Balance issues present. Surveyor # conducted a review of the nursing notes and the following was documented: Nursing note 4/21/12 at 11;07 a.m. states that writer was notified by housekeeper at 10:50 a.m. that Resident #29 was on floor in bedroom laying on left side/ stomach. Resident #29 stated, "I was getting out of my chair." Nursing Supervisor was notified. Resident #29 denies hitting head, complained of left shoulder and back pain. Writer updated physician, new order to obtain left shoulder/ thoracic spine x-ray. Cran checks negative, range of motion within normal limits. Floor alarm placed in resident's room at this time. (It was noted the X-ray of the left shoulder/ thoracic spine were negative). Surveyor # conducted a review of the "Interdisciplinary Assessment and Intervention Form", dated 4/21/12. The form indicates that Resident #29 had a fall on 4/21/12 at 10:45 a.m., in his room next to the bed. Resident #29 had shoved the box to the chair alarm and self transferred, falling next to the bed. The assessment and intervention form indicates that Resident #29 exhibits behaviors that may have contributed to this fall (transfers without assistance) and this fall was related to a pattern of poor judgement of safety, lack of physical stamina or strength. New interventions listed included to but a floor mat alarm placed in room and to place Resident #29 on 1 to 1 supervision when restless. The assessment and intervention form also included a recommendation from the "Falls Care Resource Team," which stated to consider not using floor mat alarm as Resident #29 might trip on it. A review of the Interdisciplinary Cardex showed that on 4/21/12, floor mats were added as well as provide 1 to 1 supervision when restless. It was noted that within the falls assessment and the plan of care, there was not further direction to staff as to what constitutes providing 1 to 1 supervision to Resident #29 and what may cause Resident #29 to become restless, and what behaviors he may exhibit when becoming restless. Nursing Note dated 4/26/12 at 8: 34 p.m., written by Registered Nurse (RN)- D states; at 7:10 p.m., nurse responding to chair alarm found Resident #29 in a pool of blood. Head most likely hit the corner of the nightstand. Nurse called for assistance, writer responded with vitals monitored. Resident #29 attempting to get up when writer entered room despite nurse encouraging not to move. Resident #29 assisted to his back as he would not stop attempting to get up. Pressure applied to blood to forehead. Pillow provided for Resident #29's comfort. Resident #29 complaining of headache, and short periods of drowsiness noted, however Resident #29 responds when staff tells him he needs to stay awake. Physician notified, new order to send to emergency room for evaluation and treatment. Resident #29 has a history of falls and is here post fall with brain bleed. Nursing Note dated 4/26/12 at 11:29 p.m. written by RN- E states; Writer was walking down hall and heard chair alarm sounding. Writer entered room to find Resident #29 face down in a puddle of blood. Writer called for help. Resident #29 able to answer questions, complaining of headache and head hurting. Writer is in agreement with Nurse Supervisor note. Writer was in room about half hour prior to fall, chair alarm sounding at time also. Resident #29 was having difficulty getting a hold of his girlfriend. Writer explained that his girlfriend was on vacation and she would call him. CNA told writer she was in room 10 minutes prior to fall due to chair alarm sounding. Resident #29 reminded multiple times prior to fall to call for help and wait for staff to assist him. Resident #29 agrees that he may fall and needs help, but still transfers all the time. Despite Resident #29's agitation and restlessness over not being able to reach his girlfriend - who was on vacation - staff did not implement 1:1 supervision as directed in the care plan when restless. Surveyor # continued to review Resident #29's medical record. It was noted that Resident #29 returned to the facility on [DATE] with a cervical collar. The "Nursing Admission Assessment," dated 5/3/12 states that Resident #29 was alert, orientated times 1, anxious and has a history of Dementia. It was noted that there was not an initial nurse's note about Resident #29's re-admission to the facility, a comprehensive assessment of his needs, or what overall condition Resident #29 is in. Surveyor # reviewed the Interdisciplinary Cardex, dated 5/3/12. The Cardex stated that Resident #29 had a history of [REDACTED]. It was noted that the actual Individual Plan of Care located within Resident #29's medical record had not been updated since 4/5/12, the initial admission, and did not contain any new interventions that were listed from the fall on 4/21/12 or 4/26/12. Surveyor # reviewed the facility's "Falls/ Care/ Assessment/ Reduction" policy, dated 4/2010. The policy states that the purpose is to reduce the number of falls and prevent injury by identifying causes of falls at the earliest opportunity. Also to provide prompt and appropriate assessment and intervention for the resident who has fallen. To identify possible causes of the falls and to increase the awareness of residents who are at risk for falls. This assessment is to be performed by Licensed Nurses and the procedure includes the following: * Falls Risk is completed for every resident on admission, quarterly, annually and with change of condition. * Residents are placed in the "high risk" category following one fall and if they are new admits. Appropriate interventions are initiated. Nurse Manager determines with the quarterly MDS, if resident continues to be at high risk. * All staff members are to monitor residents for situations potentially leading to falls and are to intervene appropriately within their scope of their expertise. Monitor residents for situations potentially leading to falls, example standing or walking unassisted, attempting to leave bed unassisted, ambulating without appropriate footwear, unsteady gait, changes in medication, medication side effects, wandering, pain, fatigue. It was noted that after the fall on 4/26/12 and upon Resident #29's readmission to the facility on [DATE], that the facility staff had not conducted a comprehensive assessment of Resident #29 and his potential for falls. The facility had not identified Resident #29's needs when readmitted after the fall on 4/26/12 leaving Resident #29 with a fractured cervical spine and intracerebral hemorrhage. The plan of care did not contain interventions addressing Resident #29's restlessness, what might be the cause and how to intervene, preventing the risk of further falls. Nursing Note dated 5/4/12 at 1:36 a.m. states that writer was at nursing station and heard chair alarm. Writer entered room to find CNA and Resident #29 who was sliding out of recliner at 9:15 p.m. on 5/3/12. Resident #29's buttocks had not made it to the floor. The chair alarm heard was resident's roommate's. Resident #29's chair alarm was still under his buttocks and had not gone off yet. Writer was in room several times to calm resident and other staff members made attempts as well to stop resident from attempting to self- transfer. Resident #29 had stated 1 hour prior to fall that he wants to die. Resident #29 refused his medication including Seroquel. Physician was notified of Resident #29's statement. CNA was in Resident #29's room 5 minutes prior to fall and he was in recliner resting without complaint. Resident #29 will be on 15 minute checks for entire shift. Resident #29 obtained 2 small skin tears to the left knee believed to be from knees sliding under the bedframe. Slipper socks were not on at time of fall and they were placed back on post fall. Resident #29 is currently sitting with staff at nursing station yelling his girlfriends name. Repeated attempts being made to calm Resident #29. Resident #29 has been with staff since incident due to repeated attempts to self- transfer. On 5/7/12 at 1:55 p.m., Surveyor # interviewed Unit Manager/ RN- F in regards to Resident #29. RN- F was able to verify that Resident #29's individual plan of care had not been updated in regards to his risk of falls since 4/5/12. RN- F stated that the Cardex is what is used by staff and is reviewed at the beginning of each shift. Surveyor # asked RN- F what interventions were in place for Resident #29 when he returned to the facility on [DATE]. RN- F sated that all new admissions are checked every 30 minutes and Resident #29 was placed in a room closer to the nursing station. He also had his bed against the wall and had a bed and chair alarm in place. RN- F stated that the night staff immediately put resident #29 on 15 minute checks after the incident on 5/3/12 and when the team met on 5/4/12, they decided to place Resident #29 on 1 to 1 supervision throughout all shifts until they can mange his restlessness and anxiety and that he is such a great fall risk. RN- F stated that Resident #29 will not be on 1 to 1 when his girlfriend is visiting with him, at meals or during therapy because there will be other people to be able to monitor him if he tries to self transfer. RN- F was able to verify that the new intervention of 1 to 1 was not addressed on the plan of care or on the staff Cardex. RN- F stated that although it was not written down, facility staff had been assigned since 5/4/12 to solely provide Resident #29 with 1 to 1 supervision. It was noted that there also was no indication on who would make sure after meals that the 1 to 1 supervision was put back into place and that Resident #29's girlfriend would alert staff when she was leaving, so staff could again begin the 1 to 1 supervision. RN- F was asked why the facility staff had not conducted a thought assessment of Resident #29's needs upon readmission on 5/4/12. RN-F stated that there was some confusion as to where his medical chart was located and the assessments had not been completed as of the time of interview on 5/7/12. As of the time of exit on 5/8/12, the facility was unable to provide additional information as to why they did not comprehensively assess Resident #29's risk for falls after he was readmitted to the facility on [DATE] after sustaining significant injuries from a fall on 4/26/12. Based on the review of the medical record including review of the plan of care for Resident t#29, the facility failed to comprehensively assess Resident #29's high risk of falls and develop a plan of care based on his individual needs. After the fall on 4/21/12, the facility staff had added the intervention that facility staff were to provided 1 to 1 supervision to Resident #29 when he was restless. The facility staff did not define how this intervention was to be carried out and what factors may lead to Resident #29 becoming restless, increasing his risk of falls. On 4/26/12, Resident #29 presented as being anxious about not being able to contact his girlfriend and facility staff did place him on 1 to 1 supervision before dinner time. This intervention was not communicated to all staff,and Resident #29 was able to return to his room independently. Resident #29 continued to set off his alarms, and was found to be standing in his room without proper footwear on. He was reminded several times to use the call lite, without success. Facility staff did not at this time, assess Resident #29 and his needs, providing further intervention to provide Resident #29 with supervision to reduce his risk of falling. Resident #29 did fall, sustaining a fracture to his Cervical Spine and Intracerebral hemorrhage. When Resident #29 was readmitted to the facility on [DATE], the facility again failed to comprehensively assess and develop a plan of care to reduce the risk of falls for resident #29, which led to an unwitnessed fall on the evening of 5/3/12. Although Resident #29 remains on 1 to 1 supervision as of 5/4/12, the facility did not put forth a plan on how the supervision was to be carried out by staff members and his girlfriend who visits daily. The facility's failure to ensure the safety of Resident #29 created a situation of immediate jeopardy that started on 4/26/12 and was removed on 5/8/12 when the facility implemented the following: ~ Resident #29 was comprehensively assessed for fall risk by the facility and updated interventions were added to Resident #29's care plan. ~ The facility defined 1:1 supervision for Resident #29 and when it should be implemented. ~The facility established a system to ensure that newly admitted Resident to the facility and residents at risk for falls are comprehensively assessed for risk and that individualized care plans will be established and revised as indicated. ~The facility established a quality assurance process to ensure ongoing implementation and revisions as needed. 2.) Resident #6 was admitted to the facility in 2009 with major [DIAGNOSES REDACTED]. From 11/19/11 to 4/24/12, Resident #6 sustained 9 falls. In reviewing the falls, while facility staff did put some interventions in place, they did not assess whether or not the interventions on Resident #6's care plan were implemented at the time of the fall, nor did they assess and document conditions surrounding the fall, such as when staff last saw Resident #6, when he was last assisted by staff, when he was last toileted, etc. This information is needed to help staff determine the root cause of the falls, and guide interventions to prevent future falls. If an intervention is on Resident #6's care plan, but staff do not note if the intervention was implemented at the time of the fall, they are unable to assess if the intervention is appropriate or not, or if the intervention should be continued, modified or discontinued. On 11/3/11, Resident #6 scored a "4" and was assessed as being at moderate risk for falls due to cognitive impairment, receiving 5-11 medications per day, and failing the ambulatory balance test. On 2/15/12, Resident #6 scored a "5" due to the conditions listed above plus bladder incontinence, and was again determined to be at moderate risk for falls. On 5/3/12, Resident #6 scored an "8", and is now considered to be a high risk for falls based on the above conditions plus gait problems, greater than 12 medications a day, and more than 3 falls in the past month. Page 2 of the Falls Risk Assessment form states: ~ 0 points: ...Evaluate footwear ...assess communication status ...review mobility/assistive device usage ... ~ 1-5 points = Moderate Risk: All of the above, plus: Apply slipper socks/non-skid slippers at bed time ...pharmacy review of medication orders and usage ...therapy screen/ evaluation ...review previous falls for patterns (time of day, location, etc.) ...monitor orthostatic blood pressure ...implement behavior management program ...implement urinary incontinence program ...assess food and fluid intake for adequacy ...utilize bed/chair alarms ... ~ 6-15 points =High Risk: All of the above, plus: Assess for preventative devices, implement Falling Leaf program ...room change closer to nurses' station ... Fall Precautions are only guidelines and it is up to the licensed staff member to assign the resident to protocol based on individual needs and clinical judgment. Implement appropriate Fall Precautions based on Risk category and on individual characteristics, add interventions to care plan and ID Team sheet ... Resident #6's Annual MDS (Minimum Data Set) dated 8/2/11 indicates Resident #6 had one fall with no injury since the previous assessment. Resident #6's Quarterly MDS dated [DATE] indicates he had two or more falls without injury since the previous assessment. Resident #6's falls include: - 11/19/11 at 5:35 a.m. Resident's alarm activated, found with upper body leaning across his bed and toes touching the floor in a semi-kneeling position ...no injury ...when asked what he was doing he stated "There was a lady laying on the other bed ..." The conversation changed out of context ... The Interdisciplinary Assessment and Intervention Form dated 11/19/11 noted Resident #6 had a history of [REDACTED]. Resident very anxious about bowels -offer the bathroom between 5:00 a.m. and 5:30 a.m. (The new intervention was) Put on ID (Interdisciplinary) Team sheet already. Surveyor # reviewed all the documentation provided regarding the fall and did not observe any information pertaining to when staff last saw Resident #6, when he was last toileted, if he needed to have a bowel movement at that time, or that he said anything regarding his bowels- just about a lady laying on the bed, etc. - 12/17/11 at 2:15 p.m. Staff responding to Resident #6's alarm found him with his upper body on the bed with his knees on the floor. The IDT (Interdisciplinary Team) recommended to get Resident #6 up at approximately 2:15 p.m. if awake in bed and added that intervention to the IDT sheet, commonly referred to as the CNA (Certified Nursing Assistant) care card. The Interdisciplinary Assessment and Intervention Form completed after the fall states: Correlation to Previous Falls- history of self-transferring. Was this fall related to a pattern of poor judgment of safety- yes. Fall precautions in place- Bed alarm, chair alarm, floor mat, frequent checks. Nurses' Notes state Resident #6 said he was late to meet his wife at 2:30 p.m. (Resident's wife does reside at facility, but they do not interact daily.) A Physical Therapy Screening dated 12/27/11 states Resident #6 has had two falls within a month (11/19/11 and 12/17/11), Resident self-transferring in both falls in bedroom. Their recommendations state: Staff to check on resident at end of a.m. shift. Resident very confused with both falls when staff questioned what he was doing. Try scoop mattress and trial landing strip mat by bed to decrease risk for injury. - 12/29/11 at 12:15 a.m. Resident #6's bed alarm was sounding. Resident #6 was found on his knees on his high impact bedside mat; states he was getting up for a drink, was too weak to stand up. The CNA lowered Resident #6 to the floor. The post fall assessment states his current care plan includes a bed and chair alarm, scoop mattress, and low impact mat. The new recommendation is to offer fluids each time staff is in the room. Surveyor # did not note any documentation indicating when staff last saw Resident #6, when they last assisted him, if he had been sleeping or up last time he was seen. The Physical Therapy Screening dated 12/30/11 states 1st fall 12/17/11, 2nd fall 12/30/11; Resident also had same type of fall on 11/19/11. Scoop mattress is in place with high impact mat. Recommend a.m. shift check resident to see if he wants to get up before end of shift. (Note: the fall 12/29-12/30 was at 12:15 a.m., just after midnight; the fall on 12/17 was at 2;15 p.m.; the fall on 11/19/11 was at 5:30 a.m., so that would only help with falls similar to 12/17-not 11/19 or 12/29.) - 1/18/12 at 1:30 a.m. Resident #6's alarm was sounding; CNA found resident on knees on high impact mat with upper body on bed. Interventions on Care Plan include: bed and chair alarm, alarmed floor mat, high impact mat, scoop mattress. Gripper socks on. Resident stated he may have been dreaming and rolled out of bed. Recommendation: High impact mat to be replaced with three mattresses. A Falls Team Referral dated 1/18/12 notes Resident #6 had two falls within 21 days between midnight and 2:00 a.m., found on his knees. The ID Team sheet instructs staff to check on him between those hours. They decided not to use the 3 mattresses at that time. In a subsequent interview with RN (Registered Nurse) Manager-C on 5/3/12, she stated the team decided the 3 mattresses may pose more of a tripping hazard for Resident #6, so they did not implement that. The Physical Therapy Screening dated 1/18/12 states they spoke with staff regarding Patient's frequent falls. Resident was being treated for [REDACTED]. At this time a bed buddy will not be initiated due to concerns of resident increasing attempts to get out of bed if an assistive device is placed. Staff is aware that therapy will be updated if falls continue and we will address at that time; falls team has addressed falls. Documentation reviewed by Surveyor # did not include information regarding Resident #6 prior to the fall, such as when staff last saw him, was he awake, restless, asleep, did staff offer fluids and toileting (for bowel) as per plan of care. Surveyor # interviewed RN Manager-C on 5/3/12 asking for this information. RN-C stated she did not have any additional information other than what was provided to Surveyor # . RN-C stated she would assume the care plan was followed unless there is documentation indicating otherwise. Surveyor # noted that the facility had not obtained all pertinent information needed to plan interventions to prevent future falls. - 2/27/12 at 1:30 a.m. Nurse's Notes state Resident #6's alarm was sounding; he tried to get out of bed, and fell on right side next to bed. Resident #6 stated he was getting out of bed because he had wet the bed and he forgot he couldn't stand. Interventions already on care plan: bed alarm, alarmed floor mat, high impact mat next to bed. The Physical Therapy Screening dated 2/27/12 states CNA's are currently checking resident more frequently between hours of midnight and 3:00 a.m. Will get him up if restless and offer food, fluids and change of position. Recommendations: Spoke with nurse manager and resident did have some medication changes and have been encouraging resident to go to bed between 2000 and 2100 (so he sleeps later through the night). Resident has high impact mat and bed and floor mat alarms. Bed should be in lowest position. Staff encouraged to check on resident more frequently throughout the night to prevent falls. The Falls Report Checklist dated 2/27/12 states Brief Analysis of Fall: fell while trying to get out of bed. Landed on right side next to bed. He said he wanted to get up because he wet the bed. New Intervention: Change towel under penis if it becomes saturated as resident often has leaking around Foley. (Note: Nurses' Notes dated 2/22/12 indicate Resident #6 had no urine output in his Foley catheter bag and his brief was wet. The nurse checked the catheter and noticed sediment in the Foley tubing that was blocking urine from flowing. Writer flushed Foley as ordered PRN (as needed) and Foley flushed without difficulty. Subsequent notes indicate no further leaking.) Surveyor # asked RN Mgr.-C if, in fact, Resident #6's bed was wet, and why they would simply replace the saturated towel rather than flush the catheter per orders if it was blocked. Also, if the catheter often leaked, as noted on the Fall Report Checklist, did they refer Resident #6 to his urologist or confer with his primary care physician regarding alternatives. RN Mgr.-C stated Resident #6 had no further leaking issues and she did not see any referrals related to his catheter. Surveyor # asked if any information was available regarding when Resident #6 was last seen or assisted by staff, if he was calm or sleeping, or restless or agitated, etc. RN-Mgr.-C stated she had no further information. Surveyor # noted without such information, how did they know if staff were checking on Resident #6 more frequently, as they are supposed to. - 3/20/12 at 2:25 p.m. Nurses' Notes state as the LPN (Licensed Practical Nurse) entered Resident #6's room, his alarm was sounding. The LPN observed Resident #6 slowly slide off the edge of the bed onto the mat. Resident #6 was confused and thought he was in the wrong bed and wrong room. The Interdisciplinary Assessment and Intervention Form dated 3/20/12 states Resident #6 was observed sliding off the edge of his bed at 2:25 p.m. Bed alarm sounding and mat alarm sounded when he sat on it; high impact mat in place. The form asks if this fall was related to footwear- staff answered "No". The new recommended intervention is "Gripper socks to be worn when taking afternoon nap." An Occupational Therapy Screening dated 3/22/12 reviewing falls on 2/27/12 and 3/20/12 states: Resident sat up on the side of the bed and managed to get over the scoop part of the mattress and slide onto his mat on the floor. Resident had TED stockings on at the time. The new intervention is for (Resident #6) to wear gripper socks to bed so if he would sit up that he wouldn't slide on the mat if he attempts to self-transfer. Surveyor # interviewed RN-C on 5/3/12, asking if footwear was not an issue, why is the new intervention related to footwear- to wear gripper socks for naps, noting falls in November and January note he was wearing gripper socks at that time. RN-C stated previously, Resident #6 wore gripper socks at night, not for naps, but during the day he wears TED hose which are slippery, so he actually needs the gripper socks more during the day with the slippery hose on (they come off at bedtime) than at night. Surveyor # noted Resident #6 has worn the hose for a long time, and the Fall Risk Assessment form directs staff to evaluate footwear for all residents- even those who score "0" on the assessment and are at low risk. Surveyor # asked if staff had attempted to get Resident #6 up if he was awake around 2:15 p.m., as directed by the care plan intervention dated 12/17/11 following a fall from bed that day at 2:15 p.m., and the recommendation on the Physical Therapy Screening dated 12/30/12- "Recommend a.m. shift check resident to see if he wants to get up before end of shift". RN-C stated she did not know if Resident #6 was awake at the end of day shift/2:15 p.m. or if staff attempted to get Resident #6 up from bed at that time. Surveyor # noted without knowing that information- they are not able to determine if that intervention works- if they don't know if it was even attempted. - 4/11/12 at 6:45 p.m. The Interdisciplinary Notes dated 4/11/12 at 9:55 p.m. state "at 6:45 p.m., Resident (#6) was found lying on his right side in front of the toilet; Resident was seen 10 minutes prior in the hall. (Resident #6) apparently toileted himself and attempted to transfer self into wheelchair; wheelchair with wheels unlocked in front of him. Resident alert, oriented ..." The Falls Report Ch