Every finding on record at Dove Healthcare - Bloomer

Based on observation, interview, and record review, the facility did not ensure that residents (R) received treatment and care in accordance with professional standards of practice for 1 of 1 resident (R) reviewed for wound care. (R5).The facility did not ensure weekly comprehensive wound assessments and did not assess wound treatment plan for effectiveness for R5's wound. This is evidenced by:Facility's policy titled Wound Treatment Protocols reviewed date of January 2026, read in part, With the Discovery of New Skin Issue.Document appropriately in the Skin Screen of Electronic Medical Record. Complete comprehensive skin assessment as necessary depending on classification of wound. Refer to dietary and therapies as appropriate.Documentation: Any new skin finding should have a Risk Assessment filled out in (Name of computer software). Weekly wound trackers will be completed weekly by the Certified Wound Nurse or by a designated RN (when filling in for Wound Nurse).R5 was admitted to the facility on [DATE]. R5's diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, ataxia, atrial fibrillation, congestive heart failure, chronic kidney disease stage 3A, pain in right and left hip, weakness, and history of falling. On 5/10/26, a Minimum Data Set (MDS) admission assessment documented a Brief Interview for Mental Status (BIMS) score of 13/15, meaning cognition is intact. Impairment on one side of upper and lower extremities. R5 depends on staff assistance for toileting hygiene, shower/bathe, upper and lower body dressing, footwear, and personal hygiene. Moderate staff assistance is needed for bed mobility and transfers. R5 was at risk for pressure injury and no unhealed pressure injury. The facility assessed R5 using the Braden scale for predicting pressure injury risk:05/04/26 score 17 - at risk for pressure injury. 05/11/26 score 18 - at risk for pressure injury. 05/16/26 score 15 - at risk for pressure injury.05/18/26 score 15 - at risk for pressure injury.05/25/26 score 16 - at risk for pressure injury.R5's physician orders documented:05/04/26 Regular diet, Regular - 7 texture, Regular/Thin Fluid consistency.05/17/26, I have new shearing to my right inner buttock. Please monitor healing progress. Update MD for worsening condition.06/08/26, WOUND CARE: Right Inner Buttock 1) Cleanse area with NS and Gauze 2) Apply bordered foam dressing to affected area 3) Encourage offloading as I allow every day shift every 3 day(s) for wound healing AND every 1 hours as needed for soiling.06/08/26, Behavior Note: Please document any attempts at offloading pressure from buttocks and document resident's acceptance or refusal. R5's care plan read in part:~ ACUTE SKIN CONDITION: - I was found to have shearing to my right buttock. - This area appears to be worsening - I prefer to sleep in my recliner at night, and often refuse to sleep in my bed - Staff attempt to offload pressure in my recliner, but I often refuse to allow them to place a pillow/blanket under one side - I have been switched to a ROHO cushion in my reclinerDate Initiated: 05/18/2026Revision on: 06/08/2026Interventions: Apply Calmoseptine as indicated Date Initiated: 05/18/2026 Monitor for pain treat as indicated. Date Initiated: 05/18/2026 ROHO cushion in recliner Date Initiated: 05/18/2026 Revision on: 06/08/2026 (Note: Previous intervention was EquaGel cushion in wheelchair and recliner - 5/18/26) .~ SKIN: - I am risk for skin breakdown r/t (related to) Decreased mobility; I have a history of actinic keratosis. I was admitted with scattered bruising to my body from my [NAME] home. - I prefer to sleep in my recliner and often refuse to sleep in bed. This puts me at risk for skin breakdown Date Initiated: 05/04/2026 Revision on: 06/08/2026Interventions: Assist with repositioning routinely with rounds Date Initiated: 05/04/2026 Check skin with care delivery. Report abnormalities to License Nurse Date Initiated: 05/04/2026. Use pillows/positioning devices as needed Date Initiated: 05/04/2026R5's medical record documented on 05/11/26, Skin Observation: no skin concern noted. skin is warm to touch.light fading bruise remains to left upper buttocks.buttocks is pink in color. On 05/16/26, an SBAR was faxed to Nurse Practitioner (NP) [R5] was found to have a new area of skin concern to the right buttock. Appears to have shearing to the right inner buttock about midway, measures 5.0cm x 1.0cm x 0cm. Very thin layer of tissue loss present, no visible open wounds. Writer applied calmoseptine and switched placed an equagel cushion in recliner since that is where he spends a majority of his day. Resident did complain of minor pain and tenderness to affected area. Any further orders? On 05/18/26 NP noted Ok as above. On 05/16/26, Skin observation tool: Right buttock shear 5.0 x 1.0 x 0 Resident was found to have a new area of skin concern to the right buttock. Area appears to have shearing to the right inner buttock about midway, measures 5.0cm x 1.0cm x 0cm. Very thin layer of tissue loss present, no visible open wounds. Writer applied calmoseptine and switched placed an equagel cushion in recliner since that is where he spends a majority of his day. Resident did complain of minor pain and tenderness to affected area.On 05/18/26, Skin observation tool: .Shearing remains on the right inner buttock, calmoseptine applied to buttocks, skin is pink. Tenderness noted to the area.On 05/25/26, Skin observation tool: .Shearing remains on the right inner buttock; however, this is improved. Calmoseptine continues to be applied with cares.On 06/01/26, Skin observation tool: Coccyx shearing. Right buttock shearing. Resident's skin appears to be grossly intact. Known skin concerns noted to right buttock and coccyx, shearing dressed in calmoseptine after shower. On 06/08/26, Skin observation tool: Right buttock Shearing 4 x 3 x 0.1 cm Skin is clean dry and intact. Resident does have shearing to his right inner buttock, total area measures 4.0cm x 3.0cm x 0.1cm with four linear open areas of skin. New bordered foam applied after shower .Surveyor noted the skin observation tool did not document a comprehensive assessment of the wound to identify if the shearing would be caused from pressure. Measurements of the wound were not completed weekly. No description of drainage present with amount, type, color, odor. No assessment of wound bed, surrounding skin, signs of infection or pain. R5's progress notes: 6/8/2026 10:50AM, Skin/Wound Progress NoteNote Text: Shearing to right buttock continues to worsen. Resident is noted to have multiple open sores to inner right buttock which measure approximately 0.25cm in depth. Resident is noted to also have a circular sore to inner left buttock that remains surface level but is open. Entirety of buttock is bright red in color and causes resident discomfort. I did notify CM, and she advised to put a 4x4 on sores to right buttock and encourage offloading. Nurse tried to offload resident with a pillow, but he stated, This is uncomfortable, I can't sit like this. So, pillow was removed and CM switched cushion in resident's chair to a roho cushion. Resident was educated about the changes in his sores and was accepting of the dressing being applied. I did also tell resident that wound nurse would most likely assess the area on Thursday to determine possibly switching course of treatment and resident was thankful for the information.On 06/09/26 at 7:46 AM, Surveyor observed R5 sleeping in recliner, covered with a blanket, lights were out and door closed. On 06/09/26 at 7:50 AM, Surveyor interviewed Licensed Practical Nurse (LPN) C about R5's dressing to buttocks. LPN C stated the order for the dressing was started and applied yesterday and it is to be changed every 3 days.On 06/09/26 at 8:15 AM, Surveyor interviewed R5 about sleeping in recliner and positioning. R5 stated that breakfast came around 7:05 AM and staff got resident up and washed up before breakfast and sat back in recliner. R5 stated they did sleep in recliner all night. Surveyor asked if staff came in and asked if R5 needs to use the toilet after breakfast. R5 stated they will put the call light on for staff to assist with going to the bathroom and they come right away. Surveyor asked if R5 is able to reposition self in recliner so not sitting in the same spot or on the open area. R5 stated they are able to move some, and this new cushion is much better and does not hurt. Surveyor observed R5 is sitting more on left buttock while in recliner.On 06/09/2026 9:42 AM, Surveyor interviewed Certified Nursing Assistant (CNA)D asking what time R5 got up this morning. CNA D stated R5 got up and dressed around 6AM. Surveyor asked how frequent does R5 use the bathroom. CNA D stated R5 uses the bathroom very frequently, and CNA D needs to assist R5 and apply ointment to buttocks.On 06/09/26 at 9:46 AM, Surveyor observed CNA E transfer R5 to the toilet. CNA E applied gait belt to R5. While CNA E went to the bathroom to get gloves, R5 scooted buttocks to the edge of recliner to use walker to assist to stand with CNA E holding gait belt. When CNA E pulled R5's pants and brief down Surveyor observed a boarder foam covering both buttocks and coccyx area. On 06/09/26 at 9:51 AM, R5 put call light on. CNA E assisted R5 with cleaning of peri area. CNA E assisted R5 to recliner. Surveyor interviewed CNA E asking if CNA E had any knowledge of what R5's buttock wound looks like. CNA E stated they had not seen the area and can't recall the last time working with R5 and seeing buttocks. CNA E stated she floats between the halls and does med pass most of the time. On 06/09/26 at 11:12 AM, Surveyor interviewed Director of Nursing (DON) B asking if weekly comprehensive wound assessments with measurements and wound description were completed for R5. DON B stated R5 was not seen by the wound nurse that comes to the facility. DON B stated R5's wounds would open and close. Surveyor asked where the comprehensive wound assessments were located when the area would open again. DON B stated it was noted in the progress notes. DON B stated there was a time were the computer system had assessments drop off causing the assessments not being scheduled to be completed. Surveyor asked DON B if there was a report that this occurred with R5's wound assessments. Surveyor reviewed with DON B there were skin observation tool assessments completed for 05/18/26, 05/25/26, and 06/01/26 with no measurements or description of wound characteristics. On 06/09/26 at 11:17 AM, DON B returned and stated the computer system error did not affect R5's assessments. DON B stated the wound assessments were not complete and would expect the staff to conduct a full wound assessment weekly.

Based on observation, interview, and record review, the facility did not ensure that 2 of 2 residents (R7 and R38) reviewed for accidents received adequate supervision and assistance to prevent accidents.The facility did not follow fall interventions identified in R7's care plan.The facility did not implement interventions or educate staff after R38 sustained an injury during a transfer with a mechanical lift.Findings include:The facility's policy titled, Incident and Accidents (Risk Management) read in part, The purpose of incident reporting can include: Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care.Example 1R7 was admitted to the facility on [DATE], with diagnoses included traumatic brain injury, epilepsy, cerebrospinal fluid drainage device, abnormalities of gait and mobility, paralysis of right side following a stroke, and history of falling.R7 scored 00/15 during Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. R7 has an activated Power of Attorney (POA) to assist with decision making.R7's care plan included:I am at risk of falling due to my decreased level of functioning following my stroke.I fall down sometimes because I am impulsive since my stroke, so I think I can do more than I am able.My right sided weakness does not allow me to stand on my own, but I do not remember this, so I will stand and fall.I am known to self-transfer after my visitors leave, so they now report to the nursing staff when they leave.I still have had multiple falls doing many things without a pattern that causes me to fall.Interventions included:Wheelchair should be left next to the bed and recliner with brakes locked when not in wheelchair, revised 06/03/26.Assist to bathroom before and after meals and encourage to rest in recliner following the bathroom, initiated 05/28/26.Ensure that I am up before 9:00 AM whenever possible, revised 03/31/26.Do not leave me unattended in my room unless I am in my recliner or bed, revised 06/05/25.Use wall bar in bathroom during transfers, initiated 02/13/26.Fall mat on floor next to me while I am unattended in my room un my recliner or bed, revised 02/13/25.Remind visitors to alert staff when they are leaving the room, initiated 02/13/25.On 06/08/26, Surveyor reviewed R7's falls and noted:-04/22/25, during a transfer.-05/07/25, fall out of bed.-05/30/25, assisted to the floor.-09/05/25, fall while ambulating to the bathroom.-05/07/26, assisted fall.-05/27/26, unwitnessed fall behind nurses' station.-06/01/26, unwitnessed fall in the dining room.Surveyor reviewed R7's record and noted R7 was hospitalized on [DATE] and 04/25/26 for stroke-like symptoms. Both hospitalizations concluded that R7 did not suffer from a stroke, but R7 continued to have intermittent stroke-like symptoms. The facility monitored R7 daily for stroke-like symptoms and R7 continued with follow-up neurology appointments.On 06/09/26 at 7:46 AM, Surveyor observed R7 in the dining room while eating breakfast. R7 was seated in her wheelchair at a table and eating independently with modified utensils.On 06/09/26 at 8:15 AM, Surveyor observed R7 in her room, seated in her wheelchair, an overbed table was next to her. Surveyor observed no staff present in the room and no fall mat placed on the floor. Surveyor continued to observe R7 for 19 minutes.On 06/09/26 at 8:34 AM, Surveyor observed Registered Nurse (RN) G enter R7's room. Surveyor interviewed RN G. Surveyor asked RN G if R7 was toileted after breakfast per her care plan. RN G reported R7 was not as R7 had been having stroke-like symptoms in the dining room during breakfast, and R7 had been brought to her room for monitoring. RN G stated she had been on the phone with R7's provider as R7 has a neurology appointment this morning. Surveyor asked RN G if R7 was to be supervised in her room if she was not in her bed or recliner. RN G stated R7 had her call light with her. Surveyor asked RN G if R7 was to be unsupervised in room if she was in her wheelchair. RN G stated no, she didn't think she was supposed to be unsupervised.On 06/09/26 at 9:32 AM, Surveyor interviewed Director of Nursing (DON) B. DON B reported R7 was brought to her room so nursing staff could assess R7 and update the provider. Surveyor asked DON B if R7 was safe in her room, while in her wheelchair and also reportedly having stoke-like symptoms. DON B stated sometimes R7 has absence seizures which resemble stroke-like symptoms.DON B stated she spoke with RN G about R7 being left in her room in her wheelchair unsupervised. DON B stated due to the situation RN G made a judgement call to leave R7 unsupervised in her room, while RN G called the provider. Example 2R38 was admitted to the facility on [DATE], with diagnoses including paralysis of left side of the body following a stroke.During Brief Interview for Mental Status (BIMS), R38 scored 12/15 indicating moderately impaired cognition. R38 makes his own health care decisions.R7's care plan included:I have 0.5cm x 0.5cm skin tear to my left lateral forearm. It was pinched during a transfer, staff reported immediately, initiated 05/26/26.Interventions: Apply treatment as ordered, monitor and document as ordered, update provider with worsening.I have an ADL self-care deficit related to hemiplegia, limited mobility, stroke, and obesity, revised, 02/04/26.Interventions: left sided hemiparesis and hemiplegia, initiated 02/04/26. Transfer, Hoyer lift assist of two, revised 05/05/26.R38's progress notes on 05/21/26 read, Situation: Resident sustained a new skin tear to the lateral left forearm, measures 0.5cm x 0.5xm x 0.1cm. Very minimal bleeding noted, skin flap intact and attached. Area was cleansed with NS and gauze, RN applied xeroform and bordered foam dressing. Root cause was residents' arm was pinched in the Hoyer sling when being sat down in his W/C. Resident has hemiplegia and is flaccid on the left, causing residents arm to lay different in the Hoyer sling. Resident was unaware of skin tear.On 06/09/26 at 8:42 AM, Surveyor interviewed R38. R38 reported his arm fell out of the Hoyer sling and onto the bar of the Hoyer lift, and that is how it got pinched. Surveyor noted the injury occurred on R38's left arm, which R38 cannot function due to a stroke. R38 reported he felt like it was a matter of educating him and staff to watch and make sure his arm is placed appropriately. R38 reported he was not sure if staff received any education.On 06/09/26 at 8:59 AM, Surveyor interviewed CNA H. CNA H stated he was not present when R38 was injured during a transfer. CNA H stated he learned about it in report, and that R38's arm fell out of the sling when staff were transferring him into a chair. Surveyor asked CNA H if staff received training on transferring R38 after his injury, CNA H stated staff did not receive training but are to make sure someone is on R38's left side when transferring. CNA H stated staff receive training on mechanical lift transfers upon hire, and he has been working at the facility approximately seven months.On 06/09/26, Surveyor interviewed DON B. DON B stated after R38 sustained a skin tear during the Hoyer lift transfer, CNA education was completed at a CNA meeting. DON B will provide that to Surveyor. DON B stated the education was related to proper Hoyer use, arm placement in sling, and cueing R38. Surveyor reviewed the training provided by DON B. CNA meeting agenda held on 05/27/25, note date is correct and not an error. Agenda included an area highlighted by DON B, Cares: remind to explain what you are doing to residents before you perform the task. Ensure arms and legs are in safe positioning. We want residents to know what to expect during specific care prior to moving them. We remind residents to voice their concerns at the time of the incident so that the employees can remember for next time. There was no signature sheet included with training material.Surveyor reviewed Resident Council minutes dated 05/27/26, and areas highlighted by DON B included the following: reminder State Survey is due any day. An NHA intern would be starting at facility. High school and college students would be working more since school is out. Review of the grievance process.This Surveyor's investigation determined there was no education provided to staff on transferring R38 with Hoyer lift and no individual interventions added to R38's care plan to reduce potential for future injuries.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the State Survey Agency, in accordance with State law through established procedures for 1 of 3 sampled residents reviewed. (R1)-The facility did not submit the misconduct incident report within five business days of discovery of the incident.The facility policy titled, Resident Abuse, Neglect, Misappropriation of Property, and Exploitation Prevention Program, with a revision date of October 2025, states, .Reporting allegations immediately: a. But not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . The investigative findings will be submitted to the Division of Quality Assurance, (DQA) Office of Caregiver Quality, (OCQ) department within five working days of the initial report and the initial date the entity knew or should have known about the misconduct.R1 was admitted to the facility on [DATE] with diagnoses that include dementia, history of falls, unilateral post traumatic left hip osteoarthritis and anxiety. On 09/18/25, the facility completed a Brief Interview of Mental Status (BIMS) assessment for R1 that resulted in a score of 5/15 meaning R1 has severe cognitive impairment. Minimum Data Set (MDS), dated [DATE], indicates R1 is dependent on staff for transfers, toileting, and bed mobility, and uses a wheelchair for mobility and a mechanical lift for transfers. R1's care plan notes that on 10/26/25, R1 sustained a fall due to lifting arms up in Hoyer sling causing R1 to slide in the sling and was lowered to the floor. On 10/29/25, cradle sling was added as a new intervention. R1's pain care plan notes the following:01/31/25 History of pain due to osteoarthritis to left hip10/27/25 History of pain due to osteoarthritis to left hip and fracture of right tibia10/29/25 History of pain due to osteoarthritis to left hip and fracture of right tibia and femoral neck fracture.In review of R1's electronic health records (EHR), was noted that the incident occurred on 10/26/25 at 2:00 PM. On 10/27/25 at 4:55 AM, R1 reported leg hurt. At 7:35 AM, R1 was yelling out in pain to right leg. At 8:19 AM, staff updated the provider who ordered portable x-ray that was performed. Physician progress note, dated 10/29/25, indicated R1's x-ray showed osteopenia and a tibial plateau fracture. The physician reached out to orthopedics for their recommendations which was to send R1 to the emergency room for repeat x-rays which was completed. The repeat x-ray results noted a possible right femur neck fracture and confirmed a right tibial fracture.On 01/27/26, Surveyor interviewed Nursing Home Administrator (NHA) A and Director of Nursing (DON) B and asked if they are aware of the incident. They immediately provided a file of the incident which included a complete investigation. Surveyor asked why this incident was not reported to DQA. NHA A stated it was not reported since there was no impact, the injury was not immediate, and R1 had no pain until around 2:00 AM. Surveyor asked if it was possible that symptoms can develop later. DOB B stated it is possible. Surveyor asked what prompted them to complete such a thorough investigation if they felt it was not reportable. NHA A stated they felt it was past noncompliance. NHA A stated understanding now and agreed that once it was identified there was great bodily harm/fracture, DQA should have been notified at that time and then completed the final report within 5 business days.

Based on observations, interviews and record review, the facility did not prepare and distribute food in a sanitary manner. This has the potential to affect all 49 residents. Surveyor observed [NAME] D wearing a beard cover that did not cover a full moustache. Surveyor observed [NAME] E not wearing a beard cover despite having facial hair. Findings include: It is the policy of the facility that all staff and entrants to the kitchen shall wear hair nets on exposed hair. Facility policy titled Hair Restraints, dated 1/7/2020 states the expectations that all dietary staff and staff entering the kitchen will wear a hair net in restricted area while in the kitchen. Policy also states that Hair needs to be restrained or covered. The policy further states, Hats may be wore [sic] with hair net. On 04/09/25 at 10:23 AM, Surveyor observed [NAME] D wearing a hair net and a beard cover, but the beard cover did not extend over a moustache. [NAME] D was working at the counter preparing apple crisp for dessert. Surveyor observed [NAME] E wearing a hair net, but no beard cover. [NAME] E was at the counter preparing individual side salads according to resident request tickets. On 04/09/25 at 10:25 AM, Surveyor interviewed [NAME] D and asked about proper hair net and beard covering procedure. [NAME] D reported surprise that moustaches must be covered. Surveyor interviewed [NAME] E and asked about proper hair net and beard covering procedure. [NAME] E stated belief that a beard under 2 centimeters long did not require a cover. In surveyor's presence, Nutritional Services Director (NSD) C informed [NAME] D that a beard cover must also cover a moustache and informed [NAME] E of requirement to wear a beard cover.

Based on interview and record review, the facility did not ensure staff postings were accurate which has the potential to affect 49 out of 49 residents. Review of staffing schedules and required staff postings revealed discrepancies between the documents. This resulted in inaccuracies with the total number and the actual hours worked for licensed and non-licensed staff directly responsible for resident care each shift. This is evidenced by: Surveyor reviewed the schedules and staff postings from 03/10/25-04/09/25 with the following inaccuracies: 03/10/25 AM SHIFT: STAFF POSTING-0 Medication Technician (MT). STAFF SCHEDULE:1 MT. PM SHIFT: STAFF POSTING-1 Registered Nurse (RN). STAFF SCHEDULE-0 RN. NOC SHIFT: STAFF POSTING-3 CNA for a total of 10 hours. STAFF SCHEDULE-3 CNA for 8 hour shift. 03/11/25 AM SHIFT: STAFF POSTING-1 Licensed Practical Nurse (LPN), 0 MT, 9 CNA. STAFF SCHEDULE-0 LPN, 2 MT, 8 CNA. PM SHIFT: STAFF POSTING-0 MT. STAFF SCHEDULE- 2 MT. NOC SHIFT: STAFF POSTING-1 CNA. STAFF SCHEDULE-4 CNA. 03/12/25 AM SHIFT: STAFF POSTING-0 MT, 9 CNA. STAFF SCHEDULE-1 MT, 7 CNA. NOC SHIFT: STAFF POSTING- 2 CNA. STAFF SCHEDULE-3 CNA. 03/13/25 AM SHIFT: STAFF POSTING-2 RN, 0 MT, 9 CNA. STAFF SCHEDULE-1 RN, 1 MT, 7 CNA. NOC SHIFT: STAFF POSTING: 0 CNA. STAFF SCHEDULE-4 CNA. 03/14/25 AM SHIFT: STAFF POSTING-1 LPN, 0 MT, 7 CNA. STAFF SCHEDULE-0 LPN, 1 MT, 8 CNA. 03/15/25 AM SHIFT: STAFF POSTING-1 RN. STAFF SCHEDULE-0 RN. PM SHIFT: STAFF POSTING-1 LPN, 0 MT, 14 CNA. STAFF SCHEDULE-0 LPN, 1 MT, 11 CNA. 03/16/25 AM SHIFT: STAFF POSTING-1 RN, 0 MT. STAFF SCHEDULE-0 RN, 1 MT. PM SHIFT: STAFF POSTING-2 LPN, 14 CNA. STAFF SCHEDULE-0 LPN, 12 CNA. NOC SHIFT: STAFF POSTING-1 CNA. STAFF SCHEDULE-3 CNA. 03/17/25 AM SHIFT: STAFF POSTING-0 MT. STAFF SCHEDULE-1 MT. NOC SHIFT: STAFF POSTING-1 CNA. STAFF SCHEDULE-3 CNA. 03/18/25 AM SHIFT: STAFF POSTING-1 LPN, 0 MT, 7 CNA. STAFF SCHEDULE-0 LPN, 1 MT, 8 CNA. PM SHIFT: STAFF POSTING-6 CNA. STAFF SCHEDULE-11 CNA. NOC SHIFT: STAFF POSTING-0 CNA. STAFF SCHEDULE-3 CNA. 03/19/25 AM SHIFT: STAFF POSTING-0 MT. STAFF SCHEDULE-1 MT. PM SHIFT: STAFF POSTING-1 RN, 1 LPN, 8 CNA. STAFF SCHEDULE-2 RN, 2 LPN, 10 CNA NOC SHIFT: STAFF POSTING 3 CNA. STAFF SCHEDULE-4 CNA. 03/20/25 NOC SHIFT: STAFF POSTING-1 CNA. STAFF SCHEDULE-3 CNA. 03/21/25 NOC SHIFT: STAFF POSTING-1 CNA. STAFF SCHEDULE-4 CNA. 03/22/25 AM SHIFT: STAFF POSTING-1 RN, 0 MT. STAFF SCHEDULE-0 RN, 1 MT. PM SHIFT: STAFF POSTING-0 MT, 13 CNA. STAFF SCHEDEULE-1 MT, 11 CNA. NOC SHIFT: STAFF POSTING-0 CNA. STAFF SCHEDULE-3 CNA. 03/23/25 AM SHIFT: STAFF POSTING-1 RN. STAFF SCHEDULE-0 RN. NOC SHIFT: STAFF POSTING-0 CNA. STAFF SCHEDULE-3 CNA. 03/24/25-NO RN 8 HOURS AM SHIFT: STAFF POSTING-0 MT, 6 CNA. STAFF SCHEDULE-1 MT, 8 CNA. PM SHIFT: STAFF POSTING-10 CNA. STAFF SCHEDULE-9 CNA 03/25/25 AM SHIFT: STAFF POSTING-0 MT. STAFF SCHEDULE-1 MT. NOC SHIFT: STAFF POSTING 1 CNA. STAFF SCHEDULE-3 CNA. 03/26/25 AM SHIFT: STAFF POSTING-0 MT. STAFF SCHEDULE-1 MT. NOC SHIFT: STAFF POSTING-1 CNA. STAFF SCHEDULE-3 CNA. 03/27/25 AM SHIFT: STAFF POSTING-1 LPN, 0 MT, 10 CNA. STAFF SCHEDULE-0 LPN, 1 MT, 7 CNA. NOC SHIFT: STAFF POSTING-0 CNA. STAFF SCHEDULE-4 CNA. 03/28/25 AM SHIFT: STAFF POSTING-0 MT, 6 CNA. STAFF SCHEDULE-1 MT, 8 CNA. PM SHIFT: STAFF POSTING-1 LPN, 0 MT. STAFF SCHEDULE-0 LPN, 2 MT. NOC SHIFT: STAFF POSTING-1 CNA. STAFF SCHEDULE-3 CNA. 03/29/25 AM SHIFT: STAFF POSTING-1 RN, 0 MT, 10 CNA. STAFF SCHEDULE-0 RN, 1 MT. 7 CNA. PM SHIFT: STAFF POSTING-1 LPN, 0 MT, 13 CNA. STAFF SCHEDULE-0 LPN, 1 MT, 11 CNA. NOC SHIFT: STAFF POSTING-1 CNA. STAFF SCHEDULE-4 CNA. 03/30/25 AM SHIFT: STAFF POSTING-1 RN. STAFF SCHEDULE-0 RN. PM SHIFT: STAFF POSTING-2 LPN, 0 MT, 10 CNA. STAFF SCHEDULE-0 LPN, 1 MT, 12 CNA. NOC SHIFT: STAFF POSTING-1 CNA. STAFF SCHEDULE-3 CNA. 03/31/25 AM SHIFT: STAFF POSTING-0 MT. STAFF SCHEDULE-1 MT. PM SHIFT: STAFF POSTING-1 RN. STAFF SCHEDEULE-0 RN. NOC SHIFT: STAFF POSTING-1 CNA. STAFF SCHEDULE-3 CNA. 04/01/25 AM SHIFT: STAFF POSTING-3 RN, 0 MT, 9 CNA. STAFF SCHEDULE-2 RN, 1 MT, 7 CNA. NOC SHIFT: STAFF POSTING-0 CNA. STAFF SCHEDULE-3 CNA. 04/02/25 AM SHIFT: STAFF POSTING-1 LPN, 0 MT. STAFF SCHEDULE-0 LPN, 1 MT. PM SHIFT: STAFF POSTING-0 LPN. STAFF SCHEDULE-1 LPN. NOC SHIFT: STAFF POSTING-1 CNA. STAFF SCHEDULE-3 CNA. 04/03/25 PM SHIFT: STAFF POSTING- 0 MT. STAFF SCHEDULE-2 MT. NOC SHIFT: STAFF POSTING-2 CNA. STAFF SCHEDULE-3 CNA. 04/04/25 AM SHIFT: STAFF POSTING: 0 MT. STAFF SCHEDULE-1 MT. NOC SHIFT: STAFF POSTING-1 CNA. STAFF SCHEDULE-3 CNA. 04/05/25 AM SHIFT: STAFF POSTING-0 MT, 10 CNA. STAFF SCHEDULE-1 MT, 8 CNA. PM SHIFT: STAFF POSTING-0 MT, 15 CNA. STAFF SCHEDULE-2 MT, 12 CNA. NOC SHIFT: STAFF POSTING-0 CNA. STAFF SCHDEULE-3 CNA. 04/06/25 AM SHIFT: STAFF POSTING- 1 RN. STAFF SCHEDULE-0 RN. NOC SHIFT: STAFF POSTING-0 CNA. STAFF SCHEDULE-3 CNA. 04/07/25 AM SHIFT: STAFF POSTING-0 MT, 8 CNA. STAFF SCHEDULE-2 MT, 9 CNA. 04/08/25 AM SHIFT: STAFF POSTING-0 MT, 10 CNA. STAFF SCHEDULE-1 MT, 8 CNA. PM SHIFT: STAFF POSTING-0 MT, 11 CNA. STAFF SCHEDULE-2 MT, 13 CNA. NOC SHIFT: STAFF POSTING-1 CNA. STAFF SHCEDULE-3 CNA. 04/09/25 NOC SHIFT: STAFF POSTING-1 CNA. STAFF SCHEDULE-3 CNA. The staffing total hours for all the dates indicated above are also inaccurate due to the discrepancies in the schedules and staff postings. On 04/10/25 at 7:58 AM, Surveyor interviewed Director of Nursing (DON) B. DON B reviewed and acknowledged the staff posting and the staff schedules were not matching. DON B stated the facility had noticed this about 3-4 months ago and thought it had been corrected. DON B stated the daily posting information is pulled from a computer software program and the staff schedules are pulled directly from timecard punches. DON B reported she would call Human Resources department to see if this could be corrected.

Example 1 Based on observations and interview, the facility did not ensure dietary staff prepared and distributed food in accordance with professional standards of practice. This has that potential to affect all 44 residents. The facility did not ensure that the hot water dishwashing machine was reaching adequate temperatures to prevent the spread of disease. Dietary staff observed not washing hands in between glove use. Dietary staff touching food with contaminated gloves. Findings include: On 03/13/24 at 11:43 AM, Surveyor reviewed the dishwashing temperature log and noted that for the month of March, there were four rinse cycle temperatures recorded below 180 degrees +/- 2 degrees. The dates of the low temperatures were 03/05/34, 03/06/34, 03/08/24, and 03/12/24. On 03/13/24, Surveyor reviewed the manual for dishwasher CMA-180VL which recommends that the rinse cycle for the hot water dishwasher be between 180 degrees Fahrenheit and 195 degrees Fahrenheit. On 03/13/24, Surveyor reviewed the dishwashing temperature log for the month of February. In February there were 46 instances out of 96 opportunities where temperatures recorded were lower than the recommended 180 degrees. On the February log, it documents the Dietary Manager (DM) H does a weekly check of the proper rinse cycle temperature. On 03/13/24 at 1:30 PM, Surveyor interviewed Dietary Aide (DA) L regarding dishwashing. DA L stated the rinse cycle is running at about 180 degrees and if it is lower they will tell DM H. DA L was not sure how low the temperature would need to be to alert DM H. On 03/13/24 at 1:33 PM, Surveyor interviewed DA M regarding dishwashing. DA M said staff do record the temperatures for the rinse and wash cycle and when. Surveyor asked what temperature staff would need to record to alert DM H of a concern. DM H stated, probably around 140 degrees Fahrenheit. On 03/13/24 at 1:39 PM, Surveyor interviewed DM H regarding the dishwasher temperatures. DM H said the rinse cycle should be above 180 degrees. Surveyor asked why they had many recorded temperatures that did not reach the 180-degree threshold. DM H said staff are not recording the proper temperatures. DM H said they do weekly checks to make sure the machine is working properly. DM H expects that any temperature below 180 degrees be reported, so they can make sure the dishwasher is working properly. 43352 Example 2 The facility policy, entitled Nutritional Services Procedure General Food Handling Guidelines, with an effective date of January 2017, reads in part 1. Single-use gloves, tongs, deli paper or another barrier will be utilized when handling food directly. 4. Hands are to be washed when entering the kitchen and before putting on single-use gloves. The facility policy, entitled Nutritional Services Procedure General Food Handling Guidelines, with an effective date of January 2017, reads in part 1. Single-use gloves, tongs, deli paper or another barrier will be utilized when handling food directly. 4. Hands are to be washed when entering the kitchen and before putting on single-use gloves. On 03/12/24 at 11:40 AM, Surveyor entered kitchen to observe lunch preparation. Surveyor observed Cook I put on gloves, open a drawer, grab a knife, open the butter dish then buttered 4 pieces of bread with the same contaminated gloved hands that had just touched other contaminated surfaces. At 11:50 AM, Surveyor observed Cook I with gloved hands grab a metal container off the shelf, with same gloved hands opened the sealed plastic on a rack of buns and picked up the buns with the same gloved hands that just touched other contaminated surfaces. Cook I picked up each bun and put them into the metal container. Cook I removed gloves, went and got a second container to put the remaining buns in the container. Cook I put on a new pair of gloves without washing her hands and picked up the rest of the buns in the package and moved them to a metal container. On 03/12/24 at 12:00 PM, Surveyor observed Cook J wash hands, put on gloves, open up the steam table lids to start serving lunch, then open a loaf of bread. Cook J grabbed 2 slices of bread from the package with her same gloved hands that had just touched other surfaces. Cook J continued dishing up the rest of the meal with the same contaminated gloves. Cook J took a meal ticket, then a bun with the contaminated gloved hands. Cook J then went to the warmer, opened the door grabbed a bowl out, then with the same contaminated gloved hands grabbed a bun from the container, tore up the bun into bite size pieces and continued serving lunch. Cook J did not change gloves, wash hands or put on new pair of gloves. 48793 Example 3 On 03/12/24 at 12:03 PM, Surveyor observed Cook K grab a plate with Cook K's left gloved hand, and then Cook K grabbed buns with Cook K's left gloved hand. Cook K separated buns with both gloved hands and used a spoon to place sloppy joe mix on the bottom side of the bun, then grabbed the top bun and placed it on the sandwich with both gloved hands. Cook K handed the tray to the staff who delivered the lunch tray to R2. On 03/12/24 at 12:05 PM, Surveyor observed Cook K grab a plate with Cook K's left gloved hand, and then Cook K grabbed buns with Cook K's left gloved hand. Cook K separated buns with both gloved hands and used a spoon to place sloppy joe mix on the bottom side of the bun, then grabbed the top bun and placed it on the sandwich with both gloved hands. Cook K handed the tray to the staff who delivered the lunch tray to R245. On 03/12/24 at 12:07 PM, Surveyor observed Cook K grab a plate with Cook K's left gloved hand, and then Cook K grabbed buns with Cook K's left gloved hand. Cook K separated buns with both gloved hands and used a spoon to place sloppy joe mix on the bottom side of the bun, then grabbed the top bun and placed it on the sandwich with both gloved hands. Cook K handed the tray to the staff who delivered the lunch tray to R18. On 03/12/24 at 12:09 PM, Surveyor observed Cook K grab a plate with Cook K's left gloved hand, and then Cook K grabbed buns with Cook K's left gloved hand. Cook K separated buns with both gloved hands and used a spoon to place sloppy joe mix on the bottom side of the bun, then grabbed the top bun and placed it on the sandwich with both gloved hands. Cook K handed the tray to the staff who delivered the lunch tray to R5. On 03/13/24 at 1:33 PM, Surveyor interviewed Dietary Manager (DM) H and asked about hand hygiene with serving food to residents such as touching buns with the same gloved hands that have touched utensils, plates, and other equipment. DM H indicated that staff are to change gloves in between touching utensils, plates, or any surfaces before touching buns or ready-to-eat foods.

Based on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility did not properly wipe down lifts after use (R35, R13), did not perform proper hand hygiene (R35, R95) when performing wound care, and did not ensure proper infection control techniques during medication pass (R6). This has the potential to affect 4 residents. Findings include: Example 1 The facility policy, entitled, Durable Medical Equipment Cleaning Procedure dated March 2021, states: 2. Device parts that come in contact with resident's intact skin should be cleaned after contact made/or prior to use with the next resident. a. This equipment may include but not limited to . lift equipment, slings and other items identified as common use equipment On 03/13/24 at 8:50 AM, Surveyor observed Certified Nursing Assistant (CNA) F complete morning cares for R35 who was on contact precautions for Clostridioides Difficile (C.Diff). After transferring R35 with a Hoyer lift, CNA F pushed the Hoyer lift down the hall to a designated resting spot. CNA F then left the Hoyer lift and did not wipe it down. CNA F moved on to help with the next resident who required help. Surveyor did stop CNA F and ask what they were planning to do after not wiping down the Hoyer lift. CNA F said they were going to help with the next resident. Surveyor asked CNA F when would they wipe down lifts. CNA F said after each use especially when leaving a room where someone is on contact precautions. CNA F said they had just forgotten to wipe down the lift in their rush to get to the next resident in need. On 03/13/24 at 9:27 AM, Surveyor observed CNA E transfer R13 into their wheelchair before heading to an appointment. During the transfer, R13 did place their hands on the sit-to-stand lift. CNA E had touched other items in the room and did have contaminated hands. After the transfer, CNA E pushed the lift down the hallway and placed it in the designed lift area. CNA E left the lift and walked down the hallway to help the next resident. Surveyor did stop CNA E and ask if they had sanitized the lift after use. CNA E said they did not because they did not do anything with R13 that was dirty like incontinence care, they were simply moving R13 into their wheelchair. On 03/13/24 at 12:02 PM, Surveyor interviewed Director of Nursing (DON) B regarding expectations of sanitizing lifts after use. DON B would expect that lifts be sanitized after each use. 40181 Example 2 Findings include: Facility policy entitled, Dressing Change Procedure, last reviewed 09/23, stated in part: .13. Remove gloves. 14. Sanitize hands and put on a new pair of gloves . On 03/13/24 at 8:03 AM, Surveyor observed wound care performed for R35 by Licensed Practical Nurse (LPN) C. Surveyor observed a sign outside R35's door stating contact precautions. LPN C stated R35 had wound cultures in the past showing Methicillin-Resistant Staphylococcus aureus (MRSA), so R35 was on contact precautions for cares. LPN C used alcohol-based hand rub (ABHR) and donned a gown and gloves prior to entering R35's room. Certified Nursing Assistant (CNA) F was already in the room with gown and gloves on when Surveyor entered the room. CNA F assisted R35 to turn on left side toward the wall. LPN C pulled down R35's pajama bottoms and unfastened brief. LPN C removed the old wound dressing and incontinent brief and threw in the trash. LPN C removed gloves, used ABHR and went to bathroom to obtain saline out of a bin in the bathroom. LPN C placed the saline container on the over bed table and put on clean gloves. LPN C did not use ABHR after touching multiple surfaces in the bathroom before putting on clean gloves. LPN C cleansed wounds and packed left wound with gauze per orders. LPN C removed gloves and put on clean gloves. LPN C did not sanitize hands before putting on clean gloves. LPN C cut a piece of calcium alginate with scissors and dabbed santyl ointment on right buttocks wound with the finger of one glove and then covered with the calcium alginate. LPN C removed gloves and applied clean gloves. LPN did not sanitize hands after removing old gloves and putting on clean gloves. LPN C completed the cares without further concern for infection control and washed hands with soap and water after the procedure. Surveyor interviewed LPN C immediately after the procedure. LPN C stated they should have washed hands or used ABHR between each glove change but did not do that with each glove change during this procedure. On 03/13/24 at 8:22 AM, Surveyor observed CNA E and LPN C enter R95's room to transfer R95 to the recliner to perform wound care. Surveyor observed a sign outside R95's room that stated contact precautions. Both CNA E and LPN C had put on proper PPE for contact precautions prior to entering R95's room. After LPN C had removed the gripper sock, ace wrap, tubigrip and old gauze dressing from R95's right leg, LPN C removed gloves, used ABHR and called on walkie talkie for pain medication. LPN C put on clean gloves after touching the walkie talkie without sanitizing hands. LPN C removed sock, ace wrap, tubigrip and old gauze dressing from R95's left leg. LPN C removed gloves, used ABHR, and called on walkie talkie again for pain medication and supplies. LPN C put clean gloves on without sanitizing hands after touching walkie talkie. LPN C continued wound care to legs with proper infection control procedures. LPN C was working on the back of R95's left leg, LPN C placed R95's bare left heel on LPN C's knee. R95's heel was directly on LPN C's uniform, as the isolation gown was hanging between LPN C's knees. LPN C continued wound care to legs with proper infection control procedures. LPN C removed gloves, used ABHR, cut tubigrip for left leg, and called on walkie talkie again. LPN C did not use ABHR after touching walkie talkie. LPN C got more roll gauze from a drawer in the bathroom, and put on clean gloves without sanitizing hands prior to putting on clean gloves. LPN C placed xeroform dressings on R95's left leg and removed gloves. LPN C did not use ABHR and opened more xeroform dressing packages. LPN C put on clean gloves without sanitizing hands and completed wound care procedure without further infection control concerns. On 03/13/24 at 2:14 PM, Surveyor interviewed DON B and Infection Preventionist (IP) D. Surveyor informed DON B and IP D of observations of no hand hygiene between glove changes during wound care observation for R35 and R95. They stated all staff should perform hand hygiene every time they change their gloves during wound care. 48793 Example 3 On 03/13/24 at 8:27 AM, Surveyor observed Medication Aide (MA) G prep R6's medications. MA G primed the Novolog pen and then drew a total of 8 units. MA G primed the Glargine pen and then drew a total of 10 units. MA G set insulin pens on top of medication cart. On 03/13/24 at 8:37 AM, Surveyor observed MA G grab R6's two insulin pens off the medication cart and place them in MA G's scrub pockets on MA G's shirt. On 03/13/24 at 8:58 AM, Surveyor observed MA G enter R6's room, grab R6's Novolog insulin pen out of MA G's scrub pocket, and administer 8 units in the upper left quadrant of R6's abdomen. MA G placed R6's Novolog insulin pen on R6's bedside table. MA G grabbed R6's Glargine insulin pen out of MA G's scrub pocket and administered 10 units in the lower left quadrant of R6's abdomen. MA G placed R6's Glargine insulin pen on R6's bedside table. MA G recapped both insulin pens and placed insulin pens in MA G's scrub pocket. On 03/13/24 at 9:01 AM, Surveyor interviewed MA G and asked if it was a normal process to place resident medications in personal pockets when walking into residents' rooms to administer medications. MA G indicated that MA G shouldn't have placed R6's insulin pens in pockets and this is not the best practice. On 03/13/24 at 11:55 AM, Surveyor interviewed IP D and asked about expectations for infection control practices during medication administration such as insulin pens and how staff carry insulin pens to and from resident rooms. IP D indicated the expectation is that all nursing staff use standards of practice for hand hygiene and glove use. IP D indicated that most staff utilize pushing medication carts close to where their medications are being dispersed. IP D indicated that MA G should not have placed R6's insulin pens in MA G's scrub pocket.

Based on observation, record review and interview, the facility did not ensure that residents are free of significant medication errors for 1 of 7 residents (R6) observed for medication pass. R6 was given 8 units of Insulin Aspart (Novolog) short-acting insulin an hour before breakfast. R6 was to have received 8 units of Insulin Aspart (Novolog) 15-30 minutes before breakfast, to prevent hypoglycemia (low blood sugar). This is evidenced by: Surveyor reviewed the policy Insulin administration dated 03/13/24 which states in part, Please ensure that all residents receive a meal within 30 minutes of receiving insulin . Surveyor reviewed the policy Protocol for Diabetes Management last reviewed 06/2023 which states in part, .Hypoglycemia signs and symptoms (remember that some residents may not experience symptoms or may only experience confusion or lethargy making their symptoms harder to recognize) #1-17: Confusion, lethargy poor concentration, hallucinations, generalized weakness, aggression, blurred vision, nausea, falling, hunger, seizures, shakiness, sweating, tachycardia, tingling in extremities, numbness around kips, and/or dizziness . R6 was admitted on [DATE] with a diagnosis in part, of pressure-induced deep tissue injury to the right heel, chronic kidney disease stage 3, and type 2 Diabetes Mellitus (DM) with foot ulcer, kidney complication, and diabetic neuropathy associated. R6's minimum data set (MDS) assessment completed on 01/23/24, confirmed R6 scored 15 during the Brief Interview for Mental Status (BIMS), indicating R6 is cognitively intact. Surveyor reviewed physician orders printed on 03/14/23 that included: -On 02/01/24 Blood sugar check as needed -On 02/09/24 Insulin Aspart (Novolog) 8 units of subcutaneous injection twice a day before meal for DM2. -On 02/23/24 Insulin Aspart (Novolog) units per sliding scale four times a day before meals. 200-249=1 unit 250-299=2 units 300-349=3 units 350-399=4 units greater than 400=5 units and notify MD Surveyor reviewed the physician progress notes stated in part, .On 07/31/23 glucose range from 07/21/23-07/28/23 BG's 68-330 mg/dl less than 100mg/dl 10 times over one week, reduce insulin glargine and aspart, update labs in November. On 09/13/23 reviewed glucose levels and no changes. On 10/04/23 reviewed glucose levels and noted [R6] has had some relative hypoglycemia with recent changes, and we need to reduce [R6's] dose of insulin glargine. Reduce insulin glargine to 24 units subcutaneously every night. On 11/07/23 reviewed glucose levels and no changes. On 02/29/24 reviewed glucose levels were low 100s before breakfast, 200 range at lunch, 300-500 at supper, and 192-493 at bedtime. If it is covered, [R6] might be a good candidate for Farxiga to manage BG's . Surveyor reviewed blood sugar results for morning (AM) and bedtime (HS) results in the past week stated in part, -03/07/24 AM result at 8:29 AM 89 -03/07/24 HS result at 8:27 PM 296 -03/08/24 AM result at 8:05 AM 85 -03/08/24 HS result at 9:03 PM 167 -03/09/24 HS result at 9:06 PM 67 -03/10/24 AM result at 9:34 AM 62 -03/10/24 HS result at 10:03 PM 66 -03/11/24 AM result at 9:48 AM 80 -03/11/24 HS result at 10:57 PM 266 -03/12/24 AM result at 9:39 AM 90 -03/12/24 HS result at 9:09 PM 250 Surveyor noted during review of recent blood sugars, R6 had low morning blood sugars. Observations: On 03/13/24 at 8:27 AM, Surveyor observed Medication Aide (MA) G enter R6's room and gather Blood Sugar (BG) monitoring supplies. R6's BG result was 108. R6 stated, I am not feeling well this morning, and am extra tired. MA G indicated to R6 that maybe R6 was just tired. On 03/13/24 at 8:58 AM, Surveyor observed MA G enter R6's room, grab the Novolog insulin pen and administer 8 units in the upper left quadrant of R6's abdomen. Surveyor asked R6 if R6 had breakfast yet. R6 indicated that R6 had not had breakfast yet but R6 was super sleepy. R6 stated, I am seeing things and not feeling well, what is today's date. MA G indicated to R6 that MA G would relay this information to the charge nurse as that did seem odd that R6 was seeing things that were not there. On 03/13/24 at 9:01 AM, Surveyor interviewed MA G and asked if it was a normal process to give insulin before breakfast was delivered. MA G indicated that R6 will get R6's breakfast tray shortly after giving insulin. MA G indicated that R6 usually receives meals right after giving insulin. On 03/13/24 at 9:05 AM, Surveyor observed MA G go to Licensed Practical Nurse (LPN) C and state that R6 was acting kind of weird and seeing things that were not there. LPN C indicated that LPN C would go in and check on R6 in a little while. On 03/13/24 between 8:58 AM to 9:52 AM, Surveyor observed R6 did not have breakfast nor had been offered breakfast. Surveyor did not observe anyone go into R6's room to re-check on R6 for the possible symptoms of hallucinations and tiredness. On 03/13/24 at 9:52 AM, Surveyor did not observe R6 eating or a breakfast tray in R6's room. Surveyor interviewed LPN C and asked if R6 had received breakfast yet as R6 received R6's 8 units of Novolog insulin at 8:58 AM. LPN C indicated that LPN C would ask R6. Surveyor observed LPN C enter R6's room and ask R6 if R6 had eaten breakfast and R6 stated, Not yet I am not very hungry, but I will take a banana as I don't feel good. LPN C exited R6's room to grab a banana. LPN C asked R6 about R6 seeing things that were not there. R6 indicated that she doesn't feel good and doesn't know why she is seeing things. LPN C stated to R6 that maybe anxiety medication needed to be adjusted. LPN C also indicated to Surveyor that R6 should not have had insulins before R6's breakfast meal if R6 was not eating breakfast. On 03/13/24 at 9:54 AM, LPN C exited R6's room to grab a banana for R6. On 03/13/24 at 9:57 AM, Surveyor observed LPN C enter R6's room and handed R6 a banana. LPN C exited R6's room and approached MA G explaining that insulin is to not be given unless food is given to R6 first. LPN C instructed MA G to recheck R6's BG in 15-20 minutes. Surveyor did not observe a BG check immediately performed once LPN C knew R6 did not have breakfast after administering short-acting insulin and was symptomatic. On 03/13/24 at 10:15 AM, Surveyor observed MA G enter R6's room and recheck BG. R6's BG result was 108, 18 minutes after R6 ate the banana. On 03/13/24 at 11:48 AM, Surveyor interviewed Director of Nursing (DON) B and asked what expectations are for nursing staff administering fast-acting insulins to residents before meals. DON B indicated that nursing staff is to follow physician orders for any special orders about insulin administration, but that the standard of practice is that fast-acting insulin be given no earlier than 15-30 minutes before meals. Surveyor informed DON B that R6 received R6's Novolog an hour before R6 was offered food. DON B indicated that R6 has special orders regarding R6's insulins as R6's BG's have been fluctuating. R6 has had low blood sugars at times. DON B indicated that R6 visits an endocrinologist and since R6 does sleep in a lot she receives long-acting insulin in a more scheduled controlled environment but R6 should not be receiving R6's short-acting any earlier than 30 minutes before R6's meals.

Based on interviews and record review, the facility did not offer pneumococcal immunization as required for 1 resident (R8) of 5 residents reviewed for immunizations. R8's medical record did not contain documentation indicating the facility offered or administered the pneumococcal immunization. Findings include: The facility's policy titled Resident Immunization Program .1. The facility's medical director provides a standing order for recommended vaccines according to the CDC guidelines .3. To avoid duplication of immunization information the admission investigation process may take 5-7 days .4. If the resident requires an immunization the resident will be informed, given the facts sheet for the planned immunization, and asked to give consent to administer the vaccination .8. The facility's vaccination program will include the recommended pneumococcal vaccinations with PSVC23 and PCV13 . R8 was admitted on [DATE] with a BIMS of 14. Diagnoses: Personal history of pneumonia on 6/16/22, Pleural effusion 5/9/22, Hypoxia 5/9/22, Chronic systolic and diastolic heart failure. On 1/25/23 at 9:00 AM, Surveyor reviewed R8's immunizations in medical record. Influenza declination on 9/28/22. Covid declination 9/23/22. Pneumococcal no declination form noted in medical record or evidence the vaccine had been offered or given. On 1/25/23 at 9:15 AM, Surveyor reviewed R8's Pharmacy monthly notes since admission on 1/27/22 and no notation noted to pneumococcal vaccine. On 1/25/23 at 2:00 PM, Surveyor interviewed Infection Preventionist (IP) E, asking what the process is to ensure all residents receive their vaccinations. IP E replied upon admission, we look up their immunizations and if any are missing, we educate and update them unless they decline. Then we have them sign a declination form. On 1/25/23 at 2:08 PM, Surveyor interviewed Case Manager (CM) D about the process to ensure all residents receive their vaccinations. CM D replied upon admission, we look up their vaccination history in the Wisconsin Immunization Record and if they are missing something I then forward that to IP E and they then get their updated immunizations unless they decline. On 1/25/23 at 2:45 AM, Surveyor interviewed R8 about whether she was offered a pneumococcal vaccine upon admission and R8 replied I do not remember back a year ago, but I don't usually take the immunization shots. I know that they did ask me today and I told them no.

Based on record review and interview, facility staff failed to ensure residents are as free of accident hazards as possible for 1 of 3 residents reviewed with falls. R16 was transferred with a Mechanical lift (sit to stand) with one staff instead of two staff as her care plan requires. During the transfer a loop that was not fully attached on the machine came unhooked and the resident was lowered to the floor. This is evidenced by R16 was admitted to the facility on [DATE] with diagnoses including, Parkinson's disease, Chronic obstructive pulmonary disease, hypertensive heart disease with heart failure, atrial fibrillation, chronic diastolic (congestive) heart failure, obstructive sleep apnea, type 2 diabetes, dementia, rheumatoid arthritis, essential tremor, presence of bilateral artificial knee joints, and weakness. Review of progress notes revealed that on 01/14/23 at 1747, R16 had a fall. Certified Nursing Assistant (CNA) G was attempting to assist R16 to the bathroom, and was transferring R16 in a mechanical lift, sit to stand. The notes state; Human error occurred during transfer. The lift's sling loop was not pushed all the way down. When lift was raised up the loop popped off and resident leaned to the right and was caught by staff and lowered to the ground. Resident did not hit her head. Minor injury occurred, 1.5 cm by 1 cm bruise on the left shin. Review of R16's care plan revealed that R16 required the assistance of 2 staff for safety when using the sit to stand. At the time of the fall, the plan of care was not followed as one staff was used and not two. Interview with Director of Nursing (DON) B on 01/25/23 at 12:39 PM revealed that following the incident, education was done immediately with CNA G who stated that she wasn't aware that R16 was to be assisted by two staff when using the sit to stand. CNA G was also educated on making sure that the loops on the sling go completely over the pegs so they will not become detached. DON B stated that she has plans to do education with all staff at the next CNA meeting in February, but all staff training has not been completed as of yet.

Based on observation, interview and record review, the facility did not ensure each resident is treated with dignity in a manner and in an environment that promotes enhancement of his or her quality of life. This occurred for 2 of 3 residents (R) observed being fed by staff. (R13 and R10) Staff stood next to the table while feeding R13 and R10. Findings include: On 01/24/23 at 10:00 AM, Surveyor observed Care Assistant (CA) C standing beside the table while feeding breakfast to R13 in the dining room. The breakfast meal appeared to be ground or mechanically altered. On 01/24/23 at 12:05 PM, Surveyor observed CA C standing beside a table in the dining room while feeding R13 and R10. CA C walked back and forth beside the table between R13 and R10 while offering each resident bites of food. R13 had a ground or mechanically altered meal. R10 had a pureed meal. On 01/24/23 at 12:34 PM, Surveyor interviewed CA C who stated she was not a Certified Nursing Assistant (CNA) and had not taken a CNA training class. CA C stated she had only worked in the facility for approximately two weeks and was shown how to feed residents as part of orientation. CA C did not remember if anyone told them they should not stand over a resident when feeding them. CA C did not know they should sit beside the residents when assisting them with eating. Review of R13's medical record identified R13 had a diagnosis of dementia with behavioral disturbances and dysphagia (difficulty swallowing). R13's Minimum Data Set (MDS) assessment, dated 11/23/22, identified R13 required extensive assistance of one for eating. R13's diet orders were Dysphagia II-fork mashable. Review of R10's medical record identified R10 had a diagnosis of Alzheimer's dementia and abnormal weight loss. R10's MDS assessment, dated 11/15/22, identified R10 required extensive assistance of one person for eating. R10's diet orders were Dysphagia I-pureed. On 01/24/23 at 3:20 PM, Surveyor informed Director of Nursing (DON) B of the two observations of CA C standing over two residents while feeding them in the dining room. DON B stated staff should not stand over residents when feeding them. DON B stated CA C should have been seated beside the residents to assist them with eating.

Based on observation, interview and record review, the facility did not ensure staff had successfully completed a State-approved training course that meets requirements before feeding residents. This occurred for 2 of 3 residents (R) observed being fed by staff. (R13 and R10) Care Assistant (CA) staff, who was not an approved feeding assistant, was observed feeding R13 breakfast and lunch in the dining room. CA staff were observed feeding R10 lunch in the dining room. Findings include: On 01/24/23 at 10:00 AM, Surveyor observed CA C standing beside the table while feeding breakfast to R13 in the dining room. The breakfast meal appeared to be ground or mechanically altered. On 01/24/23 at 12:05 PM, Surveyor observed CA C standing beside a table in the dining room while feeding R13 and R10. CA C walked back and forth beside the table between R13 and R10 while offering each resident bites of food. R13 had a ground or mechanically altered meal. R10 had a pureed meal. On 01/24/23 at 12:34 PM, Surveyor interviewed CA C who stated she was not a Certified Nursing Assistant (CNA) and had not taken a CNA training class. Surveyor asked if CA C was a paid feeding assistant. CA C stated she was a Care Assistant. Surveyor asked if CA C had received any training on how to feed residents. CA C stated she had only worked in the facility for approximately two weeks and was shown how to feed residents as part of orientation. Review of R13's medical record identified R13 had a diagnosis of dementia with behavioral disturbances and dysphagia (difficulty swallowing). R13's Minimum Data Set (MDS) assessment, dated 11/23/22, identified R13 required extensive assistance of one for eating. R13's diet orders were Dysphagia II-fork mashable. Review of R10's medical record identified R10 had a diagnosis of Alzheimer's dementia and abnormal weight loss. R10's MDS assessment, dated 11/15/22, identified R10 required extensive assistance of one person for eating. R10's diet orders were Dysphagia I-pureed. On 01/24/23 at 2:56 PM, Surveyor interviewed Director of Nursing (DON) B, who stated they did not employ paid feeding assistants, but did have Care Assistants on staff. DON B stated the CAs were basically just helper staff who were waiting to take the CNA training class. Surveyor asked DON B if the CAs had received training to feed residents. DON B stated they train them a little on how to feed residents during orientation and did allow CAs to feed residents in the dining room. Surveyor asked for a job description for the Care Assistants. On 01/24/23 at 3:20 PM, DON B provided the job description for the Care Assistants and clarified that they were mistaken and the CAs should not feed the residents. DON B stated CA C had not received proper training to feed residents safely.

Based on observation and interview, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections during 2 of 2 observations of water pass. Care Assistant (CA) C and Certified Nursing Assistant (CNA) F removed resident's used water mugs and did not perform hand hygiene before touching the next resident's clean water mug. Care Assistant (CA) C, without the required Personal Protective Equipment (PPE), entered a resident's room that is on droplet precautions to deliver a clean water mug. This is evidenced by: Review of the facility's policy Hand Hygiene with the last reviewed date of 03/21, read in part: 2. Indications for hand washing and hand antisepsis, Before: having contact with residents .handling food .Right After .Having contact with resident items, such as dressings, dirty laundry, dishes or trash. On 01/25/23 at 8:15 a.m., Surveyor observed CA C without a gown, gloves or face shield or goggles enter Resident (R) 17's room that is on droplet precautions to bring in a clean mug of water and returned with dirty mug. CA C sanitized hands and then touched R17's dirty mug again to check amount drank and did not sanitize hands. CA C picked up the pen and clipboard to write down the intake. CA C, without sanitizing hands, picked up a clean water mug and brought to R10's room and exited room with a dirty mug and did not sanitize hands. CA C entered R37's room and touched R37's TV remote control, then gave the remote to the housekeeper to assist with programing the TV. Housekeeper left room and sanitized hands. CA C left R37's room without sanitizing hands and brought into R37's room a glass of water touching the upper part of the glass. On 01/25/23 at 8:30 a.m., CA C walked out of R32's room with dirty mug of water, and without sanitizing hands, brought a clean mug of water to R6's room and brought out dirty mug then sanitized hands. CA C went to the second hallway to R13's room and brought out dirty water mug and did not sanitize hands and brought a clean mug of water to R27's when exited with dirty mug and placed on cart then sanitized hands. Entered R1's with a clean mug of water and returned with dirty and did not sanitize hands and brought clean mug into R193's and exited with dirty mug and did not sanitize hands. CA C continued the same process of exiting with dirty water mugs, and with no hand hygiene, delivered clean water mugs for R4, R18, R11, R7 and R36. On 01/25/23 at 2:17 p.m., Surveyor observed CNA F taking out dirty water mugs out of resident's rooms and without hand hygiene passing clean water mugs for the rooms on the first part of the 200 hall. On 01/26/23 at 12:00 p.m., Surveyor interviewed Director of Nursing (DON) B asking about training and infection control. DON B indicated staff have yearly infection control training on the computer and before new hires work the floor are to complete the training. Surveyor asked when passing water to R17 who is on droplet precautions, are staff to wear full PPE. DON B indicated 100% they are to wear all PPE of gown, gloves, mask, and goggles. Surveyor asked who does the water pass training for the Care Assistants. DON B indicated the care assistants are trained with the seasoned Certified Nursing Assistant. Surveyor reviewed observations with CA C and CNA F passing water and no hand hygiene after touching dirty water mugs and CA C passing water without wearing gown, gloves and goggles to R17 who is on droplet precautions. DON B indicated education will be provided.

Based on observation and interviews, the facility did not secure 2 out of 2 medication carts. The facility was divided into 100 wing and 200 wing. Each wing had a medication cart that stored narcotics. The medication carts were not stored behind a locked door or affixed to the facility in any way. This was a single story facility and the main entrance was 40 to 45 yards from each medication cart risking unauthorized access to the narcotics stored in each cart. The 100 wing had a census of 15. There were 25 narcotic medications for 13 total residents unsecurely stored in the 100 wing medication cart. The 200 wing had a census of 19. There were 31 narcotic medications for 15 total residents unsecurely stored in the 200 wing medication cart. This is evidenced by: The three day survey began at approximately 10:00 a.m. on 11/09/2021. During the three day survey, all Surveyors observed medication carts stored locked next to the nurses station on both 100 wing and 200 wing and not locked behind a door or secured to the facility in any way. Surveyor conducted the medication pass observation on 11/10/2021 and 11/11/2021. Surveyor observed medications carts parked next to the nurses station on both wings from 7:30 a.m. through 6:00 p.m. LPN (Licensed Practical Nurse)-D, LPN-E, and RN (Registered Nurse)-F would dispense medications from the medication cart parked next to the nurses station. All licensed nurses would walk medications down the hallway to each resident room leaving the cart unattended and unsecured for several minutes with each resident interaction. Surveyor also observed unattended nurses stations when all staff were in resident rooms providing care. Medication carts were locked but not affixed to the facility in any way and easily removable from the building. On 11/10/21 at 9:00 AM, Surveyor interviewed LPN-D regarding medication cart storage. LPN-D stated the medication rooms were too small to store the medication carts. LPN-D stated the carts were locked and parked next to the nurses station when not in use. LPN-D confirmed the medication cart could be wheeled out of the building by an unauthorized person with a desire to obtain narcotics. On 11/10/21 at 11:28 AM, Surveyor interviewed LPN-E regarding medication cart storage. LPN-E stated medication carts were stored in the hallway as the medication room was too small. LPN-E stated the medication carts were locked but if an unauthorized person wanted access to the narcotics, the medication cart could be wheeled down the hall and out of the building. On 11/10/21 at 3:05 PM, Surveyor interviewed DON (Director of Nurses)-B who stated the medication carts were always stored in the hallway next to the nurses station and not affixed to the facility in any way. DON-B stated the medication carts were to be locked when not in attendance by a licensed nurse. DON-B confirmed the medication rooms were too small to store the carts.

Based on observation, record review, policy review and interview, the facility did not provide care and services in accordance with current standards of practice for 1 (R8) out of 1 residents with a G-tube (gastric tube). LPN (Licensed Practical Nurse)-D did not check placement of the G-tube for R8 prior to medications, fluids, and nutritional administration. This is evidenced by: Surveyor requested and reviewed the facility policy titled Enteral Tube Care. The policy instructed nurses to check for placement prior to any medication or nutrition administration by checking for residual and gastric contents. R8 was admitted to the nursing facility on 10/21/2020 due to aspiration pneumonia. Additional medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R8 had a court appointed guardian who elected full cardiopulmonary resuscitation in the event R8's heart stopped or breathing failed. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility completed an annual MDS (Minimum Data Set) assessment on 10/28/21 for R8 with the following data noted: ~able to make self understood and understand others. ~required total staff assistance with eating. ~weight was 163# with no weight loss or gain. ~received 51 to 100% of nutrition and fluids via G-tube. Review of the MDS data noted R8 has had 10 hospitalization s for aspiration pneumonia since admitted [DATE]. On 11/10/21 beginning at 8:24 a.m., Surveyor observed LPN-D dispense 12 medications to be administered via the G-tube. LPN-D discretely exposed R8's G-tube, attached a large syringe, flushed the tube with 120 mls (milliliters) of tap water, but did not check placement of the G-tube. LPN-D began administering each medication that was crushed and dissolved in water. Following the administration of each medication into R8's G-tube, LPN-D flushed with 10 mls of water. In addition to the 12 medications and water flushes, LPN-D also instilled 8 ounces of [MEDICATION(S)] feeding product followed by another 120 mls of tap water. On 11/10/21 at 11:00 a.m., Surveyor interviewed LPN-D regarding enteral tube care. LPN-D stated she had been trained in nursing school as well as new employee orientation to check G-tube placement via a residual check. LPN-D stated she usually would check for residual before starting R8's nutrition or medication administration. LPN-D stated if G-tube placement was not checked, it could result in internal complications. On 11/11/2021 at 12:50 p.m., Surveyor interviewed RN (Registered Nurse)-C regarding R8's dysphagia. RN-C stated R8 was aware of the restrictions on eating or drinking, but R8 wanted to risk aspiration pneumonia and hospitalization s to satisfy the desire to eat. RN-C stated when R8 does eat or drink, the symptoms of aspiration pneumonia are almost immediate. RN-C stated R8 presents with shortness of breath, wheezing, and low oxygen saturations. RN-C stated with symptoms of respiratory distress and full code status, R8 would be transferred to the hospital. RN-C stated R8 does have physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/10/21 at 3:45 p.m., Surveyor interviewed DON (Director of Nurses)-B regarding facility practices for administering medications and nutrition via a G-tube. DON-B stated according to the facility policy, staff are to check placement using a residual check prior to administering any medications or nutrition via G-tube. DON-B stated upon hire, all nursing staff are trained on all nursing procedures. DON-B stated all nursing staff must complete a skills checklist annually as well and perform all nursing tasks in accordance with the facility policy. DON-B stated nursing staff have access to all facility polices via the computer and are expected to follow the procedures as the policies describe.

Based on observation, interview, and policy review, the facility did not require staff to wear face masks at all times when in the facility consistent with accepted standards of practice. This had the potential to affect all 43 residents in the facility. Facility staff were entering the facility without wearing face masks, then going to separate storage areas to apply a surgical face mask. Based on CDC guidance, staff should be wearing source control upon entry to the facility and can switch to facility Personal Protective Equipment (PPE) when they reach the PPE supply area. This is evidenced by: The CDC guidance Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic notes the following: Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19, or exposure to others with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection and that they are [MEDICATION NAME] source control. Implement Universal Source Control Measures o Source control refers to use of well-fitting cloth masks or facemasks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing. Because of the potential for asymptomatic and pre-symptomatic transmission, source control measures are recommended for everyone in a healthcare facility, even if they do not have symptoms of COVID-19. Health Care Personnel (HCP) should wear a facemask at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers. o When available, facemasks are preferred over cloth face masks for HCP as facemasks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others. Cloth masks should NOT be worn instead of a respirator or facemask if more than source control is needed. o To reduce the number of times HCP must touch their face and potential risk for self-contamination, HCP should consider continuing to wear the same respirator or facemask (extended use) throughout their entire work shift, instead of intermittently switching back to their cloth mask. o HCP should remove their respirator or facemask, perform hand hygiene, and put on their cloth mask when leaving the facility at the end of their shift. Surveyor conducted initial tour of facility. All staff members and visitors observed in resident-care areas, kitchen, recreation area, and administrative offices were wearing face masks. On 01/13/21, at 08:45 a.m., Surveyors observed Cook E as Cook E was entering the building through the main entrance into the lobby. No signage had been posted by the facility stating face masks were required upon entrance. Cook E entered the facility without wearing a face mask. Cook E stopped at a covid screening table, and filled out a screening form, then had temperature taken. Next, Cook E entered a hallway which contained the kitchen area. At 9:53 a.m., Surveyor observed Certified Nursing Assistant (CNA) G enter facility entryway with no face covering. Administrative Assistant (AA) I unlocked front entryway door and asked CNA G to don a surgical facemask prior to entering facility; CNA G complied with request. At 9:56 AM Surveyor observed CNA H enter facility entryway with no face covering. A passing staff member began to unlock the front entryway door to allow CNA H access, when AA I called out to wait a minute. AA I then brought a surgical mask to the door and asked CNA H to don the facemask prior to entering the facility. CNA H complied with request. At 10:03 AM Surveyor observed an unidentified staff member enter the staff breakroom wearing a surgical facemask. At 10:05 AM the staff member came out of the breakroom and exited the facility through the front door wearing no face covering. At 10:20 a.m., Surveyor interviewed Housekeeper (HK) C. HK C told Surveyor surgical face masks are stored in the housekeeping closet, where each Housekeeper uses a different mask on a different day. HK C stated she enters the building without wearing a face mask, performs Covid screening tasks, then walks to the housekeeping storage closet and dons a mask. Then HK C begins her housekeeping duties. At 10:45 AM Surveyor interviewed CNA G. CNA G stated when he arrives at facility, he must be let in because the entry doors are locked. CNA G then scans his temperature and signs in on log book. CNA G then proceeds to the employee breakroom, where his locker is located. In the employee breakroom, CNA G clocks in and dons a surgical mask. CNA G stated he does not usually wear any face covering when reporting to work until donning facemask in breakroom, and this is common practice for many other staff as well. CNA G stated all staff are required to have a facemask on before reporting to the resident care area to work. CNA explained each staff member is given three surgical masks which are color-coded and kept in a brown paper bag; the masks are rotated so each is worn every three days. If a mask becomes soiled or breaks, a new mask may be obtained from storage. At 11:10 AM Surveyor interviewed AA I, who is responsible for ordering and maintaining supply of Personal Protective Equipment (PPE). Surveyor asked if the facility had experienced difficulty in securing adequate supply of PPE. AA I stated gloves were currently on allocation, so those were being ordered on a week by week basis. AA I stated she used a variety of avenues to order and secure adequate supplies of all PPE, and the facility had not run out of anything. Surveyor asked specifically about the stock of face masks. AA I stated masks were not on allocation, and facility supply was pretty well stocked. At 11:15 a.m. Surveyor interviewed Nutritional Services Aide (NSA) D. NSA D stated when she arrives at the facility, she is let in by the staff. Then she fills out the covid screening form and scans her temperature. Next, NSA D clocks in and goes into the kitchen. Once in the kitchen, NSA D dons a hairnet. Then NSA D dons a surgical face mask. Surveyor asked NSA D to explain how and when she received staff education regarding the use of surgical face masks, and what was included in the education. NSA D stated Yes, we had teaching last April and also when we had a positive case. We were taught how to store the masks, we each have an area next to the dry storage .no, we were not taught to wear a mask until we get to the kitchen. At 11:25 a.m., Surveyor interviewed Cook F. Cook F stated I enter the facility and sign in, then go to the kitchen. I apply my face mask there, not when I enter the facility. Surveyor asked Cook F to describe the facility education she received regarding when to apply a surgical face mask. Cook F stated We were taught to store them in 3 bags. They were to be stored in the kitchen area .no they did not tell us anything about wearing a face mask when we walk in and go to the kitchen. At 11:30 a.m., Surveyor interviewed Director of Nurses (DON) B. DON B told Surveyor the facility has had no Covid positive cases in the facility since 10/26/20 (3 residents), and no Covid positive staff cases since 12/15/20 (1 staff member). The DON produced evidence of staff teaching and audits for donning PPE. DON B produced signage indicating when PPE is to be worn, and told Surveyor the signage is posted throughout the building, as observed. There was no information on the signage or staff education review that included staff were to don face masks when entering the building. DON B produced a policy entitled Healthcare Employee Masking At all Times. The policy outlined the facility's surge capacity with contingency capacity measures. DON B stated the facility practices PPE surge capacity using a contingency capacity strategy. This included staff reusing face masks. Surveyor asked DON B if there was a shortage of PPE in the facility. The DON stated No, we do have staff put on new face masks if their issued face masks become soiled or ripped .after staff enter the building, they go to assigned areas and put on their face masks. The DON provided Surveyor with evidence the facility complies with current standards of practice regarding covid reporting and monitoring for residents and staff. At 2:00 p.m., Surveyor reviewed a document entitled Concern Form. The concern form outlined a concern that stated, in part, .reported they witness staff members entering the building not wearing masks The NHA, who investigated the concern, informed R3's family member the way the building is set up we do not have an area before entering the facility to store employee masks and that is why they come in, get screened and go straight to their mask area before going to work.

Based on observation, record review and interviews, the facility did not follow professional standards for food service safety. This had the potential to affect all 45 residents in the facility. Facility staff did not have hair restrained during food preparation. This is evidenced by: On 01/06/20 at 10:40 a.m., Surveyor toured the facility kitchen. Surveyor observed Cook F was wearing a baseball cap. The baseball cap did not restrain loose hair in the back of the cap or the bang area. Surveyor observed Cook [NAME] Cook G was wearing a baseball cap. The baseball cap did not restrain loose hair in the back of the cap or the bang area. Surveyor interviewed Cook F. Cook F stated, Yes we can wear caps. I wore them at another facility can we wear caps? Surveyor interviewed Cook G, who stated, I didn't know we couldn't wear them (baseball caps). On 01/07/20 at 8:49 a.m., Surveyor interviewed Dietary Manager (DM) [NAME] DM J stated, Yes I agree with you. The hair was not restrained. Surveyor and DM J reviewed the facility policy, entitled Infection Control Standards/Nutritional Services Committee which stated in part, .hair restraints will be worn at all times by all staff in the kitchen/kitchenettes.

Based on record review and interview, the facility did not monitor and assess postoperative wound conditions according to current standards of practice. This occurred for 1 of 13 residents reviewed for quality of care, Resident (R) R22. R22 requires assistance with postoperative wound care. The facility did not monitor or assess the wound according to current standards of practice. This is evidenced by: R22's [DIAGNOSES REDACTED]. R22's Brief Interview for Mental Status (BIMS) shows severe cognitive impairment. On 01/07/20 at 3:13 p.m., Surveyor reviewed R22's clinical record. The record showed on 11/07/19, R22's left leg showed signs of cyanosis and swelling. The facility contacted the physician and R22 was transferred to the hospital. R22 was admitted to the hospital secondary to total blockage of the left femeroal popliteal artery. R22 underwent a femeroal/popliteal bypass graph and returned to the facility on [DATE]. R22 had an open surgical incision. Upon readmission on 11/14/19, there was no initial admission assessment of the wound. On 11/15/19, it was noted the left groin incision dressing was dry and intact with some dried blood around the edges. Right knee (donor) incision was intact. On 12/02/19, the progress notes stated: Wound is increasing in size and depth with more drainage noted. There is no description of the wound base, no description of the drainage characteristics, and no length, width or depth measurements. No description of the surrounding tissue was noted. No physician update was noted. There was no indication the surgical incisions were assessed for signs or symptoms of infection. R22 was not assessed for signs of a systemic or incision infection (increased temperature, pain, swelling, increased redness, increased wound drainage). On 12/06/19, the left groin incision was measured. The left groin incision measured 1.5 cm (centimeters) x 2 cm. A substantial amount of yellow drainage was noted. No assessment of the wound base or the surrounding tissue was recorded. No depth was measured. A small amount of serous drainage was noted on the left knee. R22 was not assessed for signs of a systemic or incision infection (increased temperature, pain, swelling, increased redness, increased wound drainage). On 12/07/19, the documentation read: Left groin wound continues to be open and draining yellow green drainage . R22 was not assessed for signs of a systemic or incision infection (increased temperature, pain, swelling, increased redness, increased wound drainage). On 12/08/19 a note entitled Weekly skin assessment read, in part: .surgical incision continues to heal; edges are intact with moderate amount of drainage noted incision in left groin area is draining small amount of yellow drainage. There was no assessment of the wound base or the surrounding tissue. Wound length, width and depth of the area(s) were not obtained. There was no indication that the surgical incisions were assessed for signs or symptoms of infection. R22 was not assessed for signs of a systemic or incision infection (increased temperature, pain, swelling, increased redness, increased wound drainage). On 12/09/19, Keflex (an antibiotic) 500 mg (milligrams) was ordered x 5 days for R22 due to increased drainage at affected site. The area was not recorded as the left groin incision or the right knee donor site. No wound characteristics, description of wound drainage, length, width or depth measurements were recorded. The condition of the wound base was not assessed. On 12/11/19, Keflex was discontinued and [MEDICATION NAME] (an antibiotic) 750 mg. x 2 weeks was ordered. The progress notes stated that the medication was for a left groin wound infection. The incision was not assessed to include wound base description, size, or amount of drainage. R22 was not assessed for signs of infection (increased temperature, pain, swelling, increased redness, increased wound drainage). On 12/11/19, a nutrition at risk meeting was held. No additional nutritional interventions were added. On 12/31/19, a progress note faxed to the physician stated redness and swelling were present in R22's left foot. Keflex 500 mg. was ordered x 5 days. There was no assessment of the surgical incision sites. On 01/08/20 at 10:55 a.m., Surveyor interviewed Director of Nursing (DON) B. DON B stated the facility follows the NPIAP (National Pressure Injury Advisory Panel) standards of practice for wound care. These include, but are not limited to: Daily wound assessments during wound care to include wound characteristics and drainage, weekly wound measurements, and regular physician updates. An interdisciplinary approach should include other measures to promote healing, such as a dietary consult for nutritional support. DON B stated that facility did not assess or measure the wound since the resident was being seen in the wound clinic. DON B stated a wound program would be put into place.

Based on observation, interview and record review, the facility did not provide care consistent with professional standards of practice to prevent the development of a pressure injury for 1 of 1 residents reviewed for pressure injuries (Resident (R) 21). R21 developed a stage 2 pressure injury to the left outer ankle in (MONTH) of 2019 which remains unhealed. The facility did not regularly assess the wound condition per their policy and professional standards. The facility did not update the physician about the wound or change in condition of the wound on a timely basis. This is evidenced by: On 01/06/20 at 11:48 AM, Surveyor interviewed R21 who stated R21 had a sore on the left ankle bone that had a bandage on it. R21 expressed concern about the sore not healing and stated R21 felt R21 should go to a wound clinic to have it looked at. R21 stated hospice recently gave R21 a boot to wear in bed to help the sore heal. Record review identified R21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R21's Brief Interview of Mental Status score on the quarterly Minimum Data Set (MDS) assessment dated [DATE] was 14, which indicated R21 was cognitively intact. The MDS also indicated R21 was at risk for skin breakdown. Nursing note dated 05/15/2019: OTHER SKIN CONDITION: erosion OTHER L[NAME]ATION: over left medial malleolus (ankle bone) SIZE: 1.2X (by) 1.3 CM (centimeters) DESCRIPTION: Color: bright pink Skin open Other: scant serous drainage PAIN: No pain at site. TREATMENT: Treatment Implemented: cleansed with normal saline, covered with bordered foam dressing . No documentation was found to show R21's physician was updated about this newly identified skin condition. Nursing note dated 05/21/19: .OTHER SKIN CONDITION: Ulcer. OTHER L[NAME]ATION: over left lateral malleolus. SIZE: 1.2X1.4 CM. DEPTH: 0.1 CM. WOUND BASE: pink pale 25 percent slough pale yellow, wet, soft 75 percent. DRAINAGE: moderate amount yellow, thin. EDGES: regular. PERI WOUND: clean and intact no maceration, [DIAGNOSES REDACTED], swelling or induration. PAIN: No pain at site. TREATMENT: cleansed with normal saline, pat dried with gauze, skin protectant applied to peri wound covered with bordered foam dressing. Nursing note dated 05/22/19: LOWER EXTREMITY WOUND: dressing to left malleolus and pressure dressing to right anticubital on throughout the shift; no complaints of pain to these areas; off buttocks in bed side to side and heels floated. No further documentation about wound care or the condition of the wound on R21's left lower extremity was found on the medical record until 06/07/19. No documentation of update about the wound to R21's physician was found on the medical record during that time frame. Nursing note dated 06/07/19: NEW SKIN ISSUE IDENTIFIED: 06/07/2019 DESCRIPTION: open area to outer boney prominence of the left ankle .SUMMARY OF TEAM DISCUSSION: Cause was noted to be related to: resident's position while in bed. IMMEDIATE INTERVENTIONS: to prevent further incidents: implement an air mattress, and podus boot to be worn at bedtime. A fax was sent to R21's physician on 06/07/19 informing of the wound on R21's left ankle and treatment recommended by hospice to change dressing every 3 days. It is noted this communication with the physician is 23 days after the wound was initially identified. Documentation between 06/07/19 and 06/13/19 indicated the dressing to the left ankle was clean, dry and intact and R21 had no complaints of pain to the area. The dressing was changed on 06/10/19 with no wound measurements documented. Nurses note dated 06/13/19: OTHER SKIN CONDITION: Color: periwound pale white, inner wound pink and [MEDICATION NAME] Skin open 2 cm X 1.5 cm. INTERVENTIONS: dressing changed, cleansed, new [MEDICATION NAME] and meilex applied. no signs or symptoms of infection. Nurses note dated 06/14/19: LOWER EXTREMITY WOUND: dressing is changed, [MEDICATION NAME] AG is applied to open area and it is covered with a bordered foam dressing, do (sic) drainage noted, no redness to periwound, appears to have new skin growth. Review of nursing documentation from 06/14/19 through 07/22/19 showed dressing changes to left ankle wound done on 06/14/19, 06/16/19, 06/19/19, 06/23/19 and 06/25/19. There was no documentation of measurement of the wound or the condition of the wound bed during that time frame. There was no documentation on R21's medical record of wound care completed, wound measurements, or condition of the left ankle wound from 06/25/19 through 07/22/19. The orders for wound care during that time frame were for wound care every three days. Nurses note dated 07/22/19: OTHER SKIN CONDITION: small amount of yellow green drainage left lateral malleolus on old dressing; area healing; less depth; filling in; wound edges granulation. No documentation of wound measurements were identified in the note. Nurses note dated 07/23/19: OTHER ULCER: L[NAME]ATION: Left lateral malleolus. SIZE: 0.9X0.8 CM. DEPTH: 0.1 CM. WOUND BASE: yellow pale, adherent slough-75 percent. pink pale, non-granular 25 percent. DRAINAGE: moderate amount yellow, thick. EDGES: even. PERI WOUND: pale pink extending 0.4 CM from wound margins. TREATMENT: Appropriate. PAIN: No pain at pressure injury site. Record review identified no documentation of R21's left ankle wound bed condition or measurements from 07/24/19 through 11/28/19. Nurses notes during that time frame stated Dressing to left ankle is changed, no drainage noted. Denied pain to wound site. Weekly skin assessments during that time frame stated: resident continues to have open area on the left ankle area continues to improve new dressing is applied after bath. On 09/09/19, new wound care orders from Hospice were received: Wound to Left Ankle. Apply Med honey to clean dry surface. Secure with 2 x 2 [MEDICATION NAME]. Facility staff: Change dressing three times a week. On 10/15/19, new wound care orders from Hospice were received: Change wound care to as follows: To left ankle/lateral malleolus: Clean with NS (normal saline), pat dry, apply [MEDICATION NAME] ag to base of wound, cover with adherent foam dressing. Facility staff to change 2 x/week and as needed to maintain integrity of bandage. A progress note from R21's primary physician dated 11/22/19 stated, in part: .Patient was sent over from nursing home with request to evaluate (R21's) left ankle. Concern is that (R21) has had an ulcer on that ankle for over six months that just does not healing (SIC). Has not been infected and has been treated with [MEDICATION NAME] Silver and [MEDICATION NAME] changing about every three days or so. Just does not close. Patient really doesn't complain of any discomfort in the area. Hospice has been working with the patient and they have offered to have (R21) use offloading boots but (R21) has refused to use those . No changes were made to wound care at that time. The physician recommended encouraging R21 to use the offloading boots. Nurses note dated 11/28/19: OTHER ULCER: SIZE: 1.0X1.0 CM. DEPTH: 0.6 CM. CLINICAL STAGE: Stage 3. WOUND BASE: reddened. DRAINAGE: tan small amount. EDGES: macerated. PERI WOUND: clean and intact. HEALING PROGRESS: no change, TREATMENT: Appropriate. PAIN: No pain at pressure injury site. Nurses note dated 12/02/19: LOWER EXTREMITY WOUND: on left ankle 1.0 cm x 1.0 cm depth 0.5 cm. There was no description of condition or appearance of wound in that note. Nurses note dated 12/10/19: OTHER SKIN CONDITION: Dressing to left ankle changed. area is getting deeper and possibly larger in circumfrance (SIC). There was no documentation of appearance or condition of the wound bed or measurements in that note. There was also no evidence of communication with R21's physician about deteriorating condition of the wound. Weekly skin assessment dated [DATE]: Dressing changed to non healing ulcer to left outer ankle, area appears to be larger and deeper. (R21) denied any pain to the area. Resident is declining to wear the off loading boot. No other skin concerns. There was no documentation of the condition or appearance of the wound bed, or measurements of the wound in that note. There was no evidence of communication with R21's physician about the deteriorating wound condition at that time. Appointment Communication Tool dated 12/31/19 from R21's primary physician: Wound slightly improved. Reinforced importance of off loading boots while in bed. Will recheck when next on rounds. No changes were made to wound care orders. There was no documentation of wound measurements between 12/02/19 through 01/07/20 identified on R21's medical record. Nurses note dated 01/07/20: OTHER ULCER: L[NAME]ATION: left outer ankle SIZE: 1.75X2.0 CM WOUND BASE: pink yellow DRAINAGE: slightly odorous small amount EDGES: reddened PERI WOUND: clean and intact HEALING PROGRESS: no change, TREATMENT: Appropriate PAIN: No pain at pressure injury site. On 01/07/20 at 10:13 AM, Surveyor observed Licensed Practical Nurse (LPN) D provide wound care to R21's left outer ankle wound. No concerns were identified with wound care procedure or infection control during the procedure. During the wound care procedure, R21 requested a mirror to observe the wound and expressed concern about the wound not healing. R21 expressed the desire to go to a wound clinic. LPN D reminded R21 that R21 had just been to see R21's primary physician on 12/31/19 and no changes to the wound care were made. The physician encouraged more regular use of the pressure relieving boot when in bed. On 01/07/20 at 10:27 AM, Surveyor interviewed LPN D who reported R21's wound had been evaluated by a physician multiple times, and most recently on 12/31/19. LPN D stated no changes were made in wound care at that time, but physician recommended R21 use the off loading boot more consistently when in bed. LPN D stated R21 did not always agree to wear the boot. LPN D stated hospice supplied the boot to improve pressure reduction approximately one month ago. LPN D stated the wound was pressure related and it had been open since last summer. LPN D stated the wound had not gotten worse, but had not shown any signs of healing. On 01/07/20 at 11:48 AM, Surveyor interviewed Certified Nursing Assistant (CNA) E, who stated most of the time R21 refused to let them put the boot on when they laid R21 down in bed, or R21 would put the call light on shortly after lying down and ask to have the boot removed. Review of R21's care plan identified the following, in part: General interventions: .Assist with repositioning every 2 hours and PRN (as needed). Pillow under feet when in bed .Resident has an off loading boot for (R21's) left foot, encourage (R21) to wear .07/19/19 SKIN D[NAME]UMENTATION: I have an open area to the boney prominence of my left outer ankle assess for signs or symptoms of infection every shift AM PM N[NAME] x 10 days. 11/18/19 SKIN D[NAME]UMENTATION: document on open are to left outer ankle on dressing change days every three days AM first date: 08/21/2019 Until resolved. 11/21/2019 SKIN D[NAME]UMENTATION: Assess and document on the size and appearance of the wound on my left ankle. Measure Wound Weekly 1 x wk. Monday PM first date: 11/21/2019 It is of note the documentation in R21's medical record did not show evidence of weekly assessment and documentation of size and appearance of the wound. Review of documentation showed measurements of R21's left ankle wound six times in the last 8 months. The skin section on R21's Significant Change MDS assessment dated [DATE] indicated no unhealed pressure injuries. The skin section on R21's MDS assessment dated [DATE] indicated no unhealed pressure injuries. It is of note R21's medical record showed documentation of an unhealed pressure injury to the left outer ankle beginning on 05/15/19. Surveyor interviewed Nurse Manager (NM) C at 1:10 PM on 01/07/20 about facility standards and wound care procedures. NM C stated facility policy was whoever did a dressing change should measure the wound and document the wound appearance and condition at least weekly. Surveyor reviewed the wound documentation on R21's medical record with NM C, and NM C agreed that weekly wound measurements and wound documentation were missing from R21's chart. NM C provided facility policies and procedures on Wound Treatment Protocols and stated the facility used the National Pressure Injury Advisory Panel standards for staging, care and treatment of [REDACTED]. The Wound Treatment Protocols stated in part: On Discovery of New Skin Issue *Notify the Physician and Interdisciplinary Team .*Document appropriately in the Skin Screen of Electronic Medical Record . On 01/07/20 at 3:45 PM, Surveyor interviewed Director of Nursing (DON) B about R21's left ankle wound. Surveyor reviewed the documentation provided from R21's medical record with DON B. DON B stated the physician should have been notified of the new open wound when it was identified on 05/15/19, and agreed the documentation did not show notification of the physician until 06/07/19. DON B stated the wound should have been measured weekly, but agreed the documentation on R21's medical record showed evidence of wound measurement only six times in the past 8 months. DON B stated it was the facility policy to measure and document wound condition weekly. When asked if the physician should be notified if a resident's wound shows a deteriorating condition, or is non-healing with current treatment, DON B agreed the physician should be notified in these circumstances. DON B confirmed R21's medical record did not show evidence of consultation with the physician when documentation indicated a deterioration in the wound. DON B also agreed that due to the minimal documentation and measurement of R21's wound over the past 8 months it was difficult to determine if the wound was getting worse or not responding to the current treatment.

Based on record review and interview, the facility did not review and revise the comprehensive care plan to include interventions for fall prevention for 1 of 6 residents reviewed for falls, Resident (R) R22. R22's care plan was not updated to include fall prevention monitoring for R22 after sustaining falls on two separate occasions. This is evidenced by: R22's [DIAGNOSES REDACTED]. R22's Brief Interview for Mental Status (BIMS) shows severe cognitive impairment. On 01/07/20 at 12:00 p.m., Surveyor reviewed R22's clinical record. The record showed that on 11/17/19 at 7:30 p.m. staff found R22 on the floor in her room, next to her recliner, calling out for help. R22 told staff she did not know why she got out of her chair and fell . R22 had spilled her mug of water. R22 was uninjured. The facility instituted a fall intervention which read Place resident on 15 minute safety checks. On 12/05/19 at 6:30 p.m., staff found R22 sitting on the floor in her room at the base of her recliner. R22 was uninjured. R22 was not able to say what she was doing at the time. The facility instituted a fall intervention which read Put 30 minute checks in place. Surveyor reviewed R22's plan of care. Under the category entitled Falls there were no interventions listed to include the fall interventions for 11/17/19 or 12/05/19. On 01/08/20 at 12:54 p.m., Surveyor interviewed Director of Nursing (DON) B. DON B agreed the safety check interventions should have been added to R22's plan of care.

Based on observation, interviews and record review, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 2 of 10 residents (#4, #7) reviewed for pain and for 1 of 10 residents (#2) reviewed with increased bowel incontinence. Resident #4 had a fall and injured the left arm that had caused increased pain. A complete pain assessment had not been completed, and new interventions for pain control were not put in place. Resident #7 had increased neck pain documented and had medication changes to address pain. A complete pain assessment was not completed. Resident #2 was hospitalized and returned to the facility on [DATE]. The resident had a decline in her bowel function at this time. The facility did not complete a bowel assessment. This is evidenced by: The facility policy titled, Pain Assessment, last revised 09/13/12, includes in part: Purpose: Each resident has the right to an appropriate assessment and pain management... Policy:...It is the intention of the interdisciplinary staff...to assist in maintaining comfort in all residents and to minimize pain so that it does not interfere with their ability to function. Procedure: 1. A formal Pain Assessment is performed upon admission...All residents will have pain assessed with [REDACTED]. 3. Staff is educated/updated on the importance of pain management and recognizing pain in individuals... Example 1 Resident #4's quarterly Minimum Data Set (MDS), dated [DATE], documents a brief interview for mental status as a score of 15. This means Resident #4 is alert and oriented and able to answer questions correctly. The pain was identified as occurring frequently, and rated at "8." The care problem Pain: Comfort, Alteration: dated 12/20/13 and printed on 02/24/14 at 8:45 a.m. includes in part; (Resident) has a history of pain...(Resident) prefers to request her pain medication as needed. Approaches in part: Update MD if pain medications are not effective after they are given. Update MD if (Resident) states (or it is observed that she has pain and has a decrease in her mood, appetite, sleep, or activity level), try alternative methods of pain control such as Ipod music or Ice... The current physician orders [REDACTED]. [MEDICATION NAME] HCL 50 mg tablet dose ordered: 1 tablet/50 mg by mouth daily 2000 (8:00 p.m.) for moderate to moderately severe pain, dated 12/26/13. 12/27/13 [MEDICATION NAME] 650 mg 1 tablet by mouth every 8 hours as needed for pain less than 7, fever. [MEDICATION NAME] HCL 50 mg tablet dose ordered 1 tablet by mouth every 4 hours as needed for pain rated 7 - 10 The nurses' notes include in part: 12/20/13 13:20 (1:20 p.m.), A complete pain assessment was completed, including, location, duration, onset, description, alleviating factors, exacerbating factors, effects of pain and response to medication. 02/20/14 22:14 (10:14 p.m.) "Incident type: fall Time of incident: 16:30 (4:30 p.m.)...Investigative findings: ..resident alert and oriented, stated she slipped from her socks, denies hitting her head, complains of pain to her left upper arm only, but able to move and bend arm without difficulty." An X-ray of the left shoulder was ordered on [DATE] and was negative for any fracture. 02/21/13 9:31 a.m., "Prn (as needed) med given: [MEDICATION NAME] HCL 50 mg tablet given for pan/discomfort Pain level before med: 9 Location: left arm/shoulder." 11:00 "Prn med given: [MEDICATION NAME] 650 mg tablet given for pain/discomfort pain level before med: 7 location: in left arm shoulders." There is no effectiveness of the pain medication documented. 02/21/14 1:33 p.m. "Res took [MEDICATION NAME] for pain in left arm 8/10 and had a warm blanket applied to left arm she stated, 'that feels wonderful'." There is no effectiveness of the pain medication documented. 13:59 (1:59 p.m.) "Prn med result: 13:56 (1:56 p.m.), Tylenol, [MEDICATION NAME], and topical cream provided, relief at the time, but needs continuous meds at this time for left shoulder pain, also has [MEDICATION NAME]." 02/21/14 22:30 (10:30 p.m.) "Prn med given: [MEDICATION NAME] 650 mg tablet given for pain. Pain level before med: 8 Location: in right shoulder." There is no effectiveness of the pain medication documented. 02/22/14 8:31 a.m., "Prn med given: [MEDICATION NAME] HCL 50 mg..Pain level before med: 9 Location: in left arm, shoulder." 14:03 (2:03 pm.) "Prn med result: 11:30 Med effective..." 14:36 (2:36 p.m.) "...11:30 prn charted in error. Prn med result: 10:30 pain reduced slightly following [MEDICATION NAME] pain level after med: 8 Actions: Ice applied and prn Tylenol given. Pain improved following ice and Tylenol to 3 at 11:30" 15:08 (3:08 p.m.) "Prn med given: [MEDICATION NAME] HCL 50 mg tablet given for pain. Pain level before med: 9 Location: in left shoulder" 02/24/14 04:06 a.m., "Prn med given: Ben Gay [MEDICATION NAME] for pain/discomfort in right shoulder/arm. Pain level before med: 9..." 05:04 a.m. Prn med result: 05:03 a.m. Improved but still present, resident wishes to rest in chair and continue to let pain medication and cream take action." 7:42 a.m. "Prn med given: [MEDICATION NAME] 650 mg Tablet given for pain/discomfort pain level before med: 8 Location: in left shoulder..." 9:47 a.m. "Prn med given: [MEDICATION NAME] HCL 50 mg given for pain, pain level before med 8.5, location in left shoulder." 14:25 (2:25 p.m.) "Prn pain med given: [MEDICATION NAME] HCL 50 mg tablet given for pain, pain level before med: 8" 15:18 (3:18 p.m.) "Prn pain med given: [MEDICATION NAME] 650 mg, tablet given for pain level before med: 9, location in upper left arm." 21:07 (9:07 p.m.) "Prn med result: 16:07 no further complaints" Observations On 02/24/14, Surveyor observed Resident #4 sitting in a recliner. Surveyor asked how she was doing today. Resident #4 stated, "My shoulder has so much pain." Resident #4 was holding her left arm in a bent position and was not using the left arm. On 02/24/14, Certified Nursing Assistant (CNA) D assisted Resident #4 to the toilet. Resident #4 stated as she walked to the toilet, "This hurts me so bad." CNA D asked the resident to rate her pain. Resident #4 rated the pain at a "9," and said, "My arm is killing me." On 02/24/14 at 8:50 a.m., Surveyor observed Resident #4 in her room sitting in a wheelchair and went in to speak with her. Resident #4 said she would like to be able to get in and out of her wheelchair by herself, but she just cannot do it because of her left arm. Resident #4 said she normally does everything for herself. On 02/24/14 at 2:55 p.m., Surveyor spoke with Resident #4 again. Resident #4 stated, "It hurts so bad. I tried to go to Bingo, but I could not do it. I cannot wait to feel good again." On 02/25/14 at 7:15 a.m., Surveyor stopped to see Resident #4; who was sitting in her wheelchair. Resident #4 talked about having her bath this morning, and stated, "My elbow to my shoulder hurt bad. I think I had pain medication before my bath." On 02/25/14 at 9:35 a.m., Surveyor went into Resident #4's room with CNA F. Resident #4 was crying and said, "It hurts from my elbow up into my shoulder." CNA F asked the resident about her pain. Resident #4 stated, "8.5 - 9. I cannot stand it; there is no fix for this. I need help getting into my chair. I cannot do it myself. I tried to go to devotions this morning, and I could not do it. I need to sit in my reclining chair." CNA F assisted Resident #4 into her recliner and offered her a warm blanket for her left arm. CNA F asked, "Have you had your pain medicine?" Resident #4 stated, "I am pretty sure I had it before my bath this morning." Surveyor continued to observe CNA F to see if she reported the pain to a nurse. Survey did not observe CNA F go to a nurse. On 02/25/14 at 10:15 a.m., Surveyor was observing medication pass with Licensed Practical Nurse (LPN) G. LPN G stated she would be changing the [MEDICATION NAME] on Resident #4. Surveyor asked if Resident #4 had any prn pain medications this morning for her arm pain. LPN G said, "Are you sure you are talking about the right resident?" Surveyor then asked if the CNA had reported any concerns about pain with Resident #4 this morning. LPN G stated, "No," and looked at the prn Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"She has not received any pain medication since her scheduled pain medication last night." LPN G and Registered Nurse (RN) J went into Resident #4's room at 10:20 a.m. LPN G asked the resident to rate her pain. Resident #4 stated, "9." LPN G asked if she wanted something for pain. Resident #4 stated, "Yes, if I can have something." LPN G stated she would get her prn pain medication. Interviews On 02/24/14 at 1:35 p.m., Surveyor interviewed RN C about Resident #4's independent transferring ability. RN C stated, "She has been independent going to the bathroom and with all transfers. She decides if she needs help." Surveyor asked if there have been any changes in pain medications since the fall. RN C said, "I know she is in a lot of pain, but has her scheduled [MEDICATION NAME] at bedtime, and a [MEDICATION NAME]." RN C reviewed her prn medication use and stated, "I see she has been taking the prns quite regularly since the 20th." Surveyor asked for the most recent pain assessment. RN C reviewed the medical record and stated the full assessment was completed on 12/20/13 at the time of her quarterly review. On 02/24/14 at 1:50 p.m., Surveyor interviewed CNA E about Resident #4's ability to care for herself since her fall on 02/20/14. CNA E said, "She was an independent transfer," as she showed Surveyor the ambulation status on the clipboard in Resident #4's room. CNA E said, "Since her fall she has asked for help with everything, all transfers into and out of her chair and toileting." Surveyor asked why she was needing the increased assistance. CNA E stated, "Because her arm hurts so bad." On 02/24/14 at 2:05 p.m., Surveyor interviewed CNA D about the cares for Resident #4. Surveyor asked if the range of motion exercises were performed on the left arm today. CNA D said, "No, I think we are waiting for a physical therapy evaluation. She is not transferring herself because of the pain and favoring of her left arm." On 02/25/14 at 10:50 a.m., Surveyor interviewed the Director of Nursing (DON) about the pain concerns. The DON stated they have contacted therapy to evaluate her today. The DON stated that Resident #4 has a history of liking to be in control and will ask for pain meds when she needs them. The DON stated that Resident #4 used to work at the facility and is very self conscious about being seen as dependent. Surveyor stated the resident's condition has changed since her fall and asked for the last complete pain assessment. The DON stated, "If you look at my documentation yesterday you will see that she wants to request her pain pills and refuses to have them scheduled." Surveyor shared the observation from this morning, when the CNA did not report the pain to the nurse and the resident had not gotten any pain medication since the night before. The DON said she would look into it and get back to the surveyor. The nurses' note reads: 02/24/14 14:39 (2:39 p.m.) "Resident at times will request staff help if needed following her recent fall. Writer called PT to ask to screen resident. Resident desires to request pain pills on her own and will and refuses to have them scheduled. Resident desires to remain independent as possible to her decisions." On 02/25/14 at 12:15 p.m., the DON spoke with Surveyor and explained the reason the CNA did not tell the nurse about the pain is because the resident told her she had been given something for pain. Surveyor stated if the CNA had reported it, the nurse would have been able to assess the pain and realize she had not received any pain medication yet today. The DON stated, "That is true, I did speak with the resident again today and told her the inspectors had concerns. The resident is agreeing to have scheduled pain medication and new orders are being processed." Surveyor reviewed the orders received on 02/25/14. 10:45 a.m. PT evaluate and treat 12:45 a.m. Please change scheduled [MEDICATION NAME] to 50 mg po tid (three times a day). The previous order was [MEDICATION NAME] 50 mg at HS (hours of sleep). On 02/25/14 at 3:35 p.m., Surveyor interviewed RN H about the facility practice for doing pain assessments. RN H stated, "We do a complete pain assessment on admission, and then whenever we change a pain med or see increased signs of pain in a resident." RN H pulled up the pain assessment that is to be used in the computer system. The assessment contains all aspects related to pain. Surveyor asked when the last pain assessment was completed for Resident #4. RN H said, "Not since 12/20/13." Example 2 Resident #7's quarterly MDS, dated [DATE], documents Resident #7 has pain, almost constantly, that makes it hard to sleep, limits activities, and is described as moderate pain. Resident #7's BIMS score is 8, meaning moderate cognitive impairment. The nurses' notes document in part: 01/08/14 A complete pain assessment was completed that includes in part, "Manner of expressing pain: verbal Location of pain: neck Description of pain: sharp Alleviating factors: none Exacerbating factors: none Plan: current medications Response to medications: [MEDICATION NAME] twice a day and prn, Tylenol as needed." Physician order [REDACTED]. 01/10/14 Prn med given: [MEDICATION NAME] 325 mg 2 tabs given for pain. Pain level before med: Severe Location: in neck...prn med result...informed will have increased meds for pain and topical also..." Physician order [REDACTED]. Administration instructions: give with [MEDICATION NAME] 2 x/day. 01/15/14 Prn med given: [MEDICATION NAME] HCL 50 mg given for pain/discomfort. Non verbal pain indicators before med: Vocal complaints of pain (that hurts, ouch, stop), hollering oh my neck, oh my neck." There is no effectiveness of the pain medication documented. The nurses' notes document continued use of prn use of [MEDICATION NAME] and [MEDICATION NAME] along with scheduled [MEDICATION NAME] and [MEDICATION NAME] for pain. The physician orders [REDACTED]. Surveyor could not locate a complete pain assessment since 01/08/14; there have been three pain medication changes since that date. On 02/25/14 at 3:35 p.m., Surveyor interviewed RN H about the facility practice for doing pain assessments. RN H stated, "We do a complete pain assessment on admission, and then whenever we change a pain med or see increased signs of pain in a resident." RN H pulled up the pain assessment that is to be used in the computer system. The assessment contains aspects related to pain. Surveyor asked when the last pain assessment was completed for Resident #7. RN H said, "Not since 01/08/14." On 02/25/14 at 4:20 p.m., Surveyor spoke with the DON about the pain assessment concerns. The DON stated she has already spoken with RN C about developing a better system for tracking pain assessments. Example 3 Bowel Assessment The facility policy titled Bowel Assessment/Management, last revised 09/06/13, includes in part: Procedure: Residents bowel function will be assessed using the Bowel Assessment Tool on admission, and with readmission. If a resident is a candidate for bowel management, it will be determined with these assessments. Resident #2 had developed swallowing difficulty in the nursing home along with abdominal pain and vomiting. A nasogastric tube was placed on 12/17/13. On 12/18/13, Resident #2 was admitted to the hospital for evaluation and returned to the facility on [DATE] on tube feedings. The quarterly MDS, dated [DATE], documents that Resident #2 was always continent of bowel. The significant change MDS completed on return from the hospital with assessment reference date of 12/27/13, documents Resident #2 is always incontinent of bowel. Surveyor reviewed the medial record and looked for a bowel assessment at the noted time of the bowel decline and could not locate one. On 02/25/14 at 10:00 a.m., Surveyor interviewed RN C, who completes the MDS. RN C stated she would look for a bowel assessment. RN C returned shortly and said, "I can not find an assessment. I know we looked at it and tried to figure it out. We thought it might be related to the tube feedings, or even thought of [MEDICAL CONDITION], but then she was not tested because she improved." Surveyor asked for her recent bowel patterns. The current bowel pattern documented two incontinent bowel movements in the past three weeks. RN C stated the resident had suppositories on those two dates, and that was the reason for some incontinence. Surveyor stated the facility policy indicates an assessment is to be done when a resident is readmitted , so that the facility can implement interventions to maintain and restore bowel continence. RN C stated she will monitor at the quarterly MDS reviews and complete bowel assessments for the residents.