Every finding on record at Dove Healthcare - Osseo

Based on observations and record review, the facility did not ensure drugs and biologicals were stored in accordance with currently accepted professional practice. This had the potential to affect stock medication that could be used for all residents. Currently there are 15 out of 31 residents (R) needing medication requiring temperature control for proper storage. (R3, R4, R5, R11, R12, R13, R19, R20, R21, R24, R27, R28, R33, R40, R41)Routine monitoring of temperature levels of medication refrigerators in both medication rooms is not consistently being done. There were 3 narcotics, 39 insulin pens, 5 other injectable types, 161 vaccines, 10 suppositories, and 3 ophthalmic suspensions that are temperature sensitive found in medication storage. Narcotic medication was not destroyed promptly and per WI Administrative Code 132.65 (6)(c).A scheduled medication was being stored in the unlocked refrigerator. Example 1The facility policy, titled Medication Storage, dated 2/2026 states:Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. 6. Refrigerated Products:a. All medications requiring refrigeration are stored in refrigerators located in the pharmacy and at each medication room.b. Temperatures are maintained withing 36-46 degrees F. Charts are kept on each refrigerator and temperature levels are recorded daily by the charge nurse or other designee. The Wisconsin Childhood Immunization Guidelines state: 1. Vaccines must be stored within these ranges: Refrigerator: Store between 2.0 C to 8.0 C or 36.0 F to 46.0 F.2. Temperature review and documentationDaily temperature review of each storage unit is required.To ensure medication is at the right temperature it requires monitoring of the refrigerator. Dates where refrigerated temperature were not documented and monitored at least once for the long-term care medication refrigerator were the following:During February 2026, 7 dates were missed: [DATE], 2/726, [DATE], [DATE], [DATE], [DATE] and [DATE].During [DATE] dates were missed: [DATE],[DATE]/26, [DATE], [DATE], [DATE], [DATE], [DATE], [DATE].During [DATE] dates were missed: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE],[DATE], [DATE], [DATE], [DATE], [DATE].During [DATE] dates were missed: [DATE], [DATE], [DATE]. Dates where refrigerated temperature were not documented and monitored at least once for the short-term rehab medication refrigerator were the following: During February 2026, 1 date was missed: yesterday [DATE].During [DATE] dates were missed: [DATE], [DATE], [DATE].During [DATE] dates were missed: [DATE], [DATE], [DATE].During [DATE] dates were missed: [DATE], [DATE], [DATE], [DATE], [DATE].During [DATE] dates were missed: [DATE], [DATE]. Temperature sensitive medication in the long-term care medication refrigerator included: Lorazepam solution 2mg/ml, 2 unopened for R13 (not in a lock box)Lantus Insulin pen 100units/ml, 5 unopened pens for R3Mounjaro pen 12.5mg/0.5ml, 1 unopened box- 4 pens for R4Lispro insulin pen 100units/ml, 3 unopened pens for R4Lantus Insulin pen 100units/ml, 5 unopened pens for R4Latanoprost Ophthalmic 0.005% solution, 1unopened bottle for R24.Latanoprost Ophthalmic 0.005% solution, 1unopened bottle for R5.Latanoprost Ophthalmic 0.005% solution, 1unopened bottle for R28.Novolog Flex Pen Insulin Aspart 100 units/ml, 3 unopened pens for R33Novolog Flex Pen Insulin Aspart 100 units/ml, 3 unopened pens for R27Novolog Flex Pen Insulin Aspart 100 units/ml, 1 unopened pen for R28Tresiba FlexTouch insulin pen 100 units/ ml, 2 unopened pens for R27Lantus Insulin pen 100units/ml, 1unopened pens for R11Influenza vaccine 0.5ml single dose syringe, 50 unopened stock vaccineInfluenza vaccine High Dose single dose syringe, 30 unopened stock vaccineArevyx RSV vaccine 100 mcg/0.5ml vials, 4 unopened stock vaccinesmNEXSPIKE COVID19 vaccine. 25 unopened stock vaccinesPneumovax vaccine, 25 unopened stock vaccinesPrevnar 20 vaccine, 6 unopened stock vaccines.Tylenol 650mg suppositories, 10 unopened stock suppositoriesTemperature sensitive medication in the short-term rehab medication refrigerator included: Prevnar 20 vaccine, 1 unopened stock vaccines.mNEXSPIKE COVID19 vaccine, 20 unopened stock vaccinesTuberculin TB solution, 1 stock vialLorazepam solution 2mg/ml, 1 unopened stock medicationNovolog Flex Pen Insulin Aspart 100 units/ml, 2 unopened pens for R21Lantus Insulin pen 100units/ml, 1unopened pens for R21Novolog Flex Pen Insulin Aspart 100 units/ml, 4 unopened pens for R20Lantus Insulin pen 100units/ml, 1 unopened pen for R20Novolog Flex Pen Insulin Aspart 100 units/ml, 2 unopened pens for R40Novolog Flex Pen Insulin Aspart 100 units/ml, 4unopened pens for R41Novolin Insulin 70/30- 2 unopened pens for R41On [DATE] at 10:42 AM, Surveyor observed rehab unit medication room as part of the Medication and Storage task with Registered Nurse (RN) G. The review of temperature logs showed they have a column to record temperatures titled AM Temp and initials, PM Temp and Initials, HS Temp and initials and a recheck column. Never was the temperature checked on all three shifts and [DATE], 2/726, [DATE], [DATE], [DATE], [DATE] and [DATE] there were no temperatures documented at all.On [DATE] at 10:48 AM, Surveyor interviewed RN G who stated we should be checking temperatures every shift. Surveyor and RN G reviewed the temperature logs together. After reviewing the log, RN G stated it is not completed. They should be taken each shift. RN G opened the refrigerator to take medication out of the refrigerator. Surveyor took temperature logs with to take to management to copy incomplete logs. On [DATE] at 1:12 PM, Surveyor observed long-term care unit medication room with RN L. Refrigerator was unlocked and logbook was incomplete. RN L stated we check temperatures every shift if we go into the refrigerator. RN L was busy, and Surveyor left medication room with temperature log to find ADON C or DON B to go through both refrigerators with SurveyorOn [DATE] at 1:36 PM, Surveyor observed the long-term care medication refrigerator temperature logs with Assistant Director of Nursing (ADON) C. ADON C obtained the key from the unit nurse and together entered the medication room. Surveyor showed temperature log to ADON C and explained she needed the help of ADON C to create the inventory of what is in the refrigerator. ADON C opened refrigerator up, it was unlocked, to start to pull medication from refrigerator. Surveyor and ADON C collectively created the refrigerator inventory. On [DATE] at 1:38 PM, Surveyor interviewed ADON C who stated temperatures should be taken at least daily. On [DATE] at 2:01 PM, Surveyor observed the short-term rehabilitation unit refrigerator temperature logs with ADON C. ADON C obtained the key from the unit nurse and together entered the medication room. Surveyor and ADON C reviewed the temperature logs for the short-term rehabilitation unit refrigerator. ADON C opened refrigerator up, it was unlocked, to start to pull medication from refrigerator. Surveyor and ADON C collectively created the refrigerator inventory. On [DATE] at 1:42 PM, ADON C stated she sees the incomplete temperature logs. Surveyor obtained the copies of temperature logs for both units from ADON C Example 2The facility policy, titled Accountability for Medications, dated [DATE] states: Disposition of Medications:8. Medication requiring destruction will be promptly destroyed according to the following Medication Destruction guidelines below. Medication Destruction:d. All medication destruction will be witnessed and completed by 2 licensed nurses.Oral Solid/Liquid Medication DestructionEmpty all solid/liquid Record destruction of medication the Drug Destruction log There is no definition of prompt in the destruction guidelines or the whole policy. Wis. Administrative Code DHS 132.65(g)(c)1, located under title (C) Destruction of Medications, states: 'Time limit.' Unless otherwise ordered by a physician, a resident's medication not returned to the pharmacy for credit shall be destroyed within 72 hours of a physician's order discontinuing its use, the resident's discharge, the resident's death or passage of its expiration date. On [DATE] at1:36PM, Surveyor observed the long-term care medication with ADON C. In the lock box was a zip lock bag with Lorazepam 2mg/ml opened vial with the words, expired 1-31-26. On [DATE] at 1:44 PM, Surveyor interviewed ADON C who stated yes, the medication is expired. Two nurses need to get rid of it, that should be gone. It's a group effort to keep track. We have a nurse who comes from the pharmacy to do audits and manage inventory. Example 3The facility policy, titled Medication Storage, dated 2/2026 states:Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. 2. Narcotics and Controlled Substances:a. Schedule II drugs and back up stock of Schedule III, IV, and V medications are stored under double-lock and key.The following medication were in an unlocked refrigerator and not in a lock box. Lorazepam solution 2mg/ml, 2 unopened for R 13 (not in a lock box). Lorazepam is a Scheduled IV narcotic medication.On [DATE] at 10:42 AM, Surveyor observed rehab unit medication room as part of the Medication and Storage task with RN G. RN G opened the refrigerator and pulled medication from the fridge. Refrigerator was not locked. On [DATE] at 10:48 AM, Surveyor interviewed RN G who stated yes, the rehab med room refrigerator should be locked. RN G and Surveyor completed the medication storage task. At the end, RN G attempted to lock the refrigerator. RN G stated I am not sure how this works, I need a key. RN G has been working for the facility since [DATE] per staff roster supplied by Nursing Home Administrator (NHA) A. On [DATE] at 1:12 PM, Surveyor observed long-term care unit medication room with RN K. Refrigerator was unlocked. RN K was busy, and Surveyor left medication room with plans to come back with management. RN K did not lock the medication refrigerator prior to exiting the room.On [DATE] at 1:36 PM, Surveyor observed the long-term care medication room refrigerator with ADON C. ADON C obtained the key to the medication room from the unit nurse and Surveyor and ADON C entered the medication room. ADON C opened refrigerator up, it was unlocked, to start to pull medication from refrigerator. Surveyor and ADON C collectively created the refrigerator inventory. On [DATE] at 1:38 PM, Surveyor interviewed ADON C who stated yes, the refrigerator is unlocked. It should be locked. On [DATE] at 2:01 PM, Surveyor observed the short-term rehab unit refrigerator with ADON C. ADON C obtained the key from the unit nurse and together Surveyor and ADON C entered the medication room. The medication refrigerator was unlocked and ADON C just opened the refrigerator and started an inventory list with Surveyor. On [DATE] at 2:01 PM, Surveyor interviewed ADON C who stated the refrigerator should also be locked, I don't know why it isn't. Prior to leaving the room, ADON C tried to see if she could lock the refrigerator without the key. ADON C stated I will have to get the key.

Based on observation, interview and record review, the facility has not established 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 Laundry Aide failed to follow infection prevention procedures while handling clean linen. This has the potential to affect all 31 residents (R) in the facility.Registered Nurse (RN) failed to clean tip of insulin pen prior to attaching a needle and administering insulin to 1 out of 3 residents observed for insulin administration. (R4)RN failed to clean the glucometer after use, prior to putting away, during 2 out of 3 resident observations of diabetic care. (R4, R20)CNA did not clean the non-mechanical lift between patient use. This affected 2 of 4 residents observed during a non-mechanical lift.This is evidenced by: Example 1 Per the facility procedure titled, Procedure for Laundry, dated 10/2025, states: Drying/Folding and Delivering Fold all linen on the counter or in the air being mindful to not let clean laundry hit the floor or yourself. On 2/24/26 at 8:05 AM, Surveyor observed Laundry Aide (LA) J staff folding laundry. LA J was observed folding a bath blanket, holding the bath blanket's center with LA J's chin and resting against LA J's chest, touching LA J's clothes. On 2/24/26 at 8:09 AM, Surveyor interviewed LA J regarding folding laundry. LA J stated when folding bath blankets, any linen or personal item you need to make sure they don't hit the ground. Surveyor asked LA J if there was concern if the item touched your clothes. LA J stated it is hard to not touch your clothes, back there (gestured towards doors that go to dirty laundry area), we put a gown on, in here we don't have to. LA J stated I should not have used my chin. On 2/24/26 at 814 AM, following interview with LA J, Surveyor walked across the hall and interviewed Environmental Services Director (ED) I. ED I stated the biggest thing is you have a dirty side and clean side. When on the dirty side you should have a gown and gloves on. When you leave the dirty area to go to the clear side make sure hands are clean. ED I stated when folding laundry, you need to make sure it is not wrinkled and keep everything clean. ED I stated when clothes are delivered, they need to be covered, everything is covered, dirty or clean. ED I stated when folding linen, you should keep it from touching the ground, keep it on the counter, and make sure it is not touching the floor. Surveyor asked if it matters if a person used their chin or chest to help fold linen. ED I stated LA J should not have used LA J's chin or chest when folding laundry. It should not touch LA J's clothing. Example 2 Per facility policy titled, Safe Use of Insulin Pens, last revised 2/2026, states: Procedure: 7. Attach pen needle: a. Remove the pen cap from the insulin pen. b. Wipe the rubber seal with an alcohol pad. c. Screw the pen needle onto the insulin pen. d. Twist open and remove outer cover from the pen needle. Per Center of Disease Control Guidelines titled, Considerations for Blood Glucose Monitoring and Insulin Administration, dated 9/7/2024, states: Never use fingerstick devices for more than one person. Do not share blood glucose meters. If you must share them in a healthcare or congregate setting, select a device designed for use in professional settings, not an over-the-counter device. Clean and disinfect blood glucose meters after every use, per the manufacturer's instructions. Insulin pens and other medication cartridges and syringes are for single patient use only. Never use them for more than one person. On 4/23/25 at 4:34 PM, Surveyor observed Registered Nurse (RN) H obtain a glucose reading and administer insulin to R4. RN H started the preparation of medication with hand hygiene at medication cart, parked down by the nurse's station. RN H pulled insulin from medication cart and applied needle. RN H did not wipe off the insulin pen end prior to applying the needle. RN H pulled the glucometer out of the medication cart drawer. RN H completed hand hygiene and entered the room with all supplies. No concerns with RN H's technique for obtaining blood glucose reading and administering insulin. When RN H was done with task, RN H picked up trash, insulin pen, and the glucometer and left room. RN H discarded the insulin needle in red box, put insulin back in bag and bag in med cart and put glucometer away in a case and into the medication cart. RN H did not wipe off the glucometer after use or prior to putting away. On 2/23/25 at 4:44 PM, Surveyor interviewed RN H about infection control and insulin pens and glucometers. Surveyor asked if the nurses should wipe off the end of the insulin pen prior to applying the needle. RN H stated that's a good question; I don't think that is generally practiced. There is a cap that stays on the pen all the time, so typically no. I guess when I teach about insulin pens, we teach to swab off the end of it. RN H stated you should wipe down a glucometer if it is shared. If it is theirs, you can put it back in its case. At 4:58 PM, RN H made a comment to Surveyor when Surveyor was walking by. RN H stated I guess they do wipe the end (of the insulin pen) off here. Surveyor asked what about the glucometer. RN H stated yes, they are supposed to be wiped off. RN H stated I'm not the best because I am a travel nurse. Findings include: Example 3 The facility policy titled Cleaning and Disinfection of Resident-Care Equipment, last revised 12/2024, states in part: Staff shall follow established infection control principles for cleaning and disinfecting reusable, non-critical equipment.each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident.multiple-resident use equipment shall be cleaned and disinfected after each use. On 02/24/2026 at 7:23 AM, Surveyor observed certified nursing assistant (CNA) D bring a Sara Steady (non-mechanical device used for transferring residents) into R8's room to assist transferring R8 onto a toilet. CNA D did not disinfect Sara Steady prior to using it with R8. Disinfection wipes were observed to be in a basket hanging on Sara Steady for staff use. Upon completion of R8's toileting in which R8 had a bowel movement and CNA D was observed touching Sara Steady with contaminated gloves, CNA D did not clean Sara Steady with disinfectant. CNA D left Sara Steady in R8's room and proceeded to another resident room. On 02/25/2026 at 7:00 AM, Surveyor observed CNA E bring a Sara Steady into R8's room to assist R8 to toilet. CNA E did not disinfect Sara Steady prior to using it with R8. Disinfection wipes were observed to be in a basket hanging on Sara Steady for staff use. CNA E did not disinfect Sara Steady after R8 completed toileting and removed Sara Steady from R8's room to store in hallway. At 7:15 AM, Surveyor observed CNA D retrieve Sara Steady from hallway where CNA E left it and brought it to R31's room, left it in doorway of room and left without cleaning device. At 7:40 AM, CNA D and CNA F returned to assist in R31's room and assist R31 to toilet using Sara Steady. CNA D and CNA F did not disinfect Sara Steady prior to using it with R31. Upon completion of R31's toileting, CNA F left room to transport R31 to a meal. CNA F informed Surveyor she would return to clean Sara Steady, which was observed by Surveyor to be done. Surveyor interviewed director of nursing (DON) B about what staff expectations were for disinfecting multi-resident use equipment. DON B stated all equipment is to be disinfected both prior to and after resident use. DON B stated it cannot be assumed cleaning of equipment was done prior to using it.

Based on interviews and record review, the facility did not ensure residents with limited range of motion (ROM) received services to maintain or prevent further reduction in ROM for 6 out of 6 residents (R) receiving restorative services. R3, R4, R5, R8, R15, and R23Facility has only one trained restorative aide and no back up aide if the restorative aide does not work. Residents do not receive consistent restorative services.This is evidenced by:The facility policy, titled Restorative Nursing Program, dated 2/2026 states:Policy: It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level.3. Nursing personnel are trained in basic, or maintenance nursing care that does not require the use of a qualified therapist or licensed nurse oversight. This training may include, but is not limited to: .f. Assisting residents with range of motion exercises, performing passive range of motion for residents who lack active range of motion ability. 12. Restorative aides will implement the plan for a designated length of time, performing the activities and documenting on the Restorative Aid Documentation Form or other facility designated form.Per the Center for Medicaid/Medicare Services (CMS) State Operations Manual (SOM) states in part: Based on the comprehensive assessment, the resident's care plan must include specific interventions. to maintain or improve the ROM.Residents have the right to choose their schedules, consistent with their interests, assessment and care plans.Per the restorative documentation code key, the following codes are available to document restorative services. RR means resident refused, RU means resident is unavailable and NA means not applicable. It is not defined when restorative services care planned is not applicable. Example 1R3 was admitted to the facility on [DATE], and has diagnoses that include Alzheimer's disease, diabetes, abnormalities of the gait, chondrocalcinosis (arthritis) of left and right knee, muscle weakness, pain, heart disease, major depression, and anxiety.R3's Minimum Data Set (MDS) assessment, dated 12/22/25, indicated that R3's cognition is moderately impaired. R3 does have clear speech and usually understands simple direction. R3 is independent for rolling left to right and can self-propel R3's wheelchair. R3 needs supervision to change positions and moderate assistance to transfer to the toilet. R3's care plan identifies 3 restorative interventions. The resident requires restorative intervention r/t Alzheimer's with goal to maintain tolerance for daily cares. Resident is known to decline restorative therapies despite encouragement and Education Date Initiated: 05/02/2025 Revision on: 01/08/2026The resident will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury through the next review date.Date Initiated: 05/02/2025 Revision on: 08/01/2025 Target Date: 03/22/2026#1- RESTORATIVE: NUSTEP: Level 5 time: 15min #2 - RESTORATIVE: Dressing/Grooming Program: upper body dressing with set up on edge of bed or in wheelchair.#3 - RESTORATIVE: Walking Program: please offer to walk me one time a day (preferred at breakfast) to meal, walk to fatigues.On 2/25/26 at 11:00 AM, Surveyor reviewed R3's restorative documentation.11/30/25-12/6/25: NUSTEP - Missed 3 days12/7/25-12/13/25: NUSTEP - Missed 1 day12/14/25- 12/20/25: NUSTEP - Missed 2 days, Dress/groom self - Missed 2 days, Walk to meal - Missed 1 day12/21/25-12/27/2512/28/25-1/3/26: NUSTEP - Missed every day1/4/26- 1/10/26: NUSTEP - Missed every day1/11/26- 1/17/26: NUSTEP - Missed every day, Dress/groom self - Missed 1 day1/18/26-1/24/26: NUSTEP - Missed 2 days1/25/26-1/31/26: NUSTEP - Missed 1 day2/1/26-2/7/26: NUSTEP - Missed 4 days, Dress/groom self - Missed 1 day, Walk to meal - Missed 1 day2/8/26-2/14/26: NUSTEP - Missed 2 days, Dress/groom self - Missed 1 day2/15/26- 2/21/26: NUSTEP - Missed every day, Dress/groom self - Missed 1 day2/22/26- 2/28/26: NUSTEP - Missed 4 days, Dress/groom self - Missed 5 days, Walk to meal - Missed 4 daysOver the last 13 weeks, R3's NUSTEP intervention was documented 3 times not applicable and refused 1-2 times a week during 4 of the 13 weeks. (Note documented dates resident refused to participate are considered dates restorative was attempted and counts as completed during this audit.)Over the last 13 weeks, R3's dress/grooming intervention was documented 20 times as not applicable and refused once in December and once in January to participate in his dressing and grooming restorative. Over the last 13 weeks, R3's walk to a meal intervention was documented as 21 times not applicable and refused 20 times.If NA/not applicable is being used as not available, no evidence or documentation that timing or restorative offerings have been evaluated to accommodate resident choices. On 3/23/25 at 1:57 PM, R3 stated I don't work with therapy anymore because I am what I am. But sometimes I walk to meals and do the NUSTEP thing, it's like a bike. Most days I don't get to exercise. They don't have anyone to take me. It's frustrating but what can I do. Example 2R4 was admitted to the facility on [DATE], and has diagnoses that include Alzheimer's disease, contracture, right knee, chronic pain, reduce mobility, cervicalgia (neck pain), osteoarthritis, right knee, artificial left knee joint, myalgia (muscle pain), arthrodesis permanently connects two or more bones in a joint to eliminate movement, type 2 diabetes with chronic kidney disease, depression, dementia, and anxiety.R4's MDS assessment, dated 12/26/25, indicated that R4's cognition is intact. R4 has clear speech and understands. R4 is dependent for R4's mobility, lying to sitting, and rolling left to right. R4 is unable to bear weight and requires a full mechanical lift for transferring from bed to wheelchair or transferring to the toilet. R4's care plan identifies 4 restorative interventions. The resident requires restorative intervention r/t history of falls, weaknessDate Initiated: 05/13/2025 Revision on: 05/13/2025The resident will maintain current level of mobility through review date.Date Initiated: 05/13/2025 Revision on: 08/01/2025 Target Date: 05/24/2026#1 - RESTORATIVE: ACTIVE ROM Program #1 BUE (bilateral upper extremities) Towel Exercises/Trunk Exercises 3x5x/233k MTWTHF#2- RESTORATIVE ACTIVE ROM Program #2 Hand Bike Level 4 x 10 minutes 3x-5x/week MTWTHF#3 - RESTORATIVE: Dressing/Grooming Program # 1 Face/Teeth 7x/week SMTWTHFS#4 - NURSING RESTORATIVE: GROUP EXERCISES: Bilateral upper and lower extremity strengthening exercises for 15 mins or as tolerated desired 5x/week On 2/25/26 at 11:00 AM, Surveyor reviewed R4's restorative documentation.11/30/25- 12/6/25: Upper extremities (weekdays) - Missed 4 days, Hand bike (weekdays) - Missed 4 days, Dress/groom (7 days a week) - Missed 1 day 12/7/25-12/13/25: Upper extremities (weekdays) - Missed 1 day, Hand bike (weekdays) - Missed 1 day, Dress/groom (7 days a week) - Missed 1 day 12/14/25- 12/20/25: Upper extremities (weekdays) - Missed 2 days, Hand bike (weekdays) - Missed 2 days, Dress/groom (7 days a week) - Missed 2 days, Group exercises (weekdays) - Missed 1 day12/21/25-12/27/25: Dress/groom (7 days a week) - Missed 2 days, Group exercises (weekdays) - Missed 1 day12/28/25-1/3/26: Upper extremities (weekdays) - Missed every day, Hand bike (weekdays) - Missed every day, Dress/groom (7 days a week) - Missed 1 day, Group exercises (weekdays) - Missed 2 days1/4/26- 1/10/26: Upper extremities (weekdays) - Missed every day, Hand bike (weekdays) - Missed every day, Dress/groom (7 days a week) - Missed 2 days, Group exercises (weekdays) - Missed 2 days1/11/26- 1/17/26: Upper extremities (weekdays) - Missed every day, Hand bike (weekdays) - Missed every day, Dress/groom (7 days a week) - Missed 1 day 1/18/26-1/24/26: Upper extremities (weekdays) - Missed 2 days, Hand bike (weekdays) - Missed 2 days, Dress/groom (7 days a week) - Missed 1 day 1/25/26-1/31/26: Upper extremities (weekdays) - Missed 1 day, Hand bike (weekdays) - Missed 1 day2/1/26-2/7/26: Upper extremities (weekdays) - Missed 3 days, Hand bike (weekdays) - Missed 3 days, Dress/groom (7 days a week) - Missed 1 day 2/8/26-2/14/26: Upper extremities (weekdays) - Missed 2 days, Hand bike (weekdays) - Missed 2 days, Dress/groom (7 days a week) - Missed 1 day 2/15/26- 2/21/26: Upper extremities (weekdays) - Missed every day, Hand bike (weekdays) - Missed every day, Dress/groom (7 days a week) - Missed 2 days, Group exercises (weekdays) - Missed 1 day2/22/26- 2/28/26: Upper extremities (weekdays) - Missed 4 days, Hand bike (weekdays) - Missed 4 days, Dress/groom (7 days a week) - Missed 6 days, Group exercises (weekdays) - Missed 4 daysOver the last 13 weeks, R4's upper extremity exercise intervention was documented 9 times not applicable.Over the last 13 weeks, R4's hand bike exercise intervention was documented 3 times not applicable, 2 times as resident unavailable, and never documented as refused to participate.Over the last 13 weeks, R4's dress/grooming intervention was documented 17 times as not applicable for dressing and grooming and never documented as refused to participate in dressing and grooming.Over the last 13 weeks, R4's group exercise intervention was documented 18 times not applicable and 1 time unavailable.If NA/not applicable is being used as not available, no evidence or documentation that timing or restorative offerings have been evaluated to accommodate resident choices.On 2/23/26 at 8:01 AM, Surveyor interviewed R4 who stated R4 has exercises R4 does with R4's upper body. R4 stated I can't do anything with my legs, they don't work. R4 stated the exercises are to help R4 keep her upper body strength. R4 stated R4 goes down to do the exercises but only when there is enough staff, which isn't often. R4 stated that R4 has the exercise plan but the restorative CNA has been on vacation and has been unable to go this past week. R4 thinks she should be back tomorrow. R4 states there is no one else that assists with restorative plans when the restorative CNA is gone. R4 stated DON B watched R4 while I did my hand bike last week. Otherwise, I was doing nothing. Example 3R5 was admitted to the facility on [DATE], and has diagnoses that include effusion, left knee, fatigue, impaired balance, limited mobility, limited range of motion, musculoskeletal impairment, high blood pressure, cardiac pacemaker, atrial fibrillation, congestive heart failure, and type 2 diabetes.R5's MDS assessment, dated 12/17/25, indicated that R5's cognition is intact. R4 has clear speech and understands. R5 is non ambulatory and requires assist 1-2 for activities of daily living and personal care and assist of 2 with the sit-to-stand mechanical lift for transfers from bed to wheelchair, and wheelchair to toilet. R5's care plan identifies 3 restorative interventions. The resident requires restorative intervention r/t weakness, hx. of Stroke. Date Initiated: 04/30/2025 Revision on: 04/30/2025The resident will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury through the next review date. Date Initiated: 04/30/2025 Target Date: 03/17/2026#1- NURSING REHAB/RESTORATIVE: ACTIVE ROM: Program 1 Arm Bike as tolerate- update NCN w concerns)- #2 - NURSING RESTORATIVE: GROUP EXERCISES: Bilateral upper and lower extremity strengthening exercises for 15 mins or as tolerated #3 - RESTORATIVE NUSTEP: Level 1 Time 10 minutes GOAL: 3-5 x/week to maintain strength and ROM for daily activities. Started 1/18/26 On 2/25/26 at 11:00 AM, Surveyor reviewed R5's restorative documentation. 11/30/25- 12/6/25: Arm bike (weekdays) - Missed 3 days, NU-STEP (3-5x/wk, wknds not x out) - Not started12/7/25-12/13/25: Arm bike (weekdays) - Missed 2 days, NU-STEP (3-5x/wk, wknds not x out) - Not started12/14/25- 12/20/25: Arm bike (weekdays) - Missed 3 days, NU-STEP (3-5x/wk, wknds not x out) - Not started12/21/25-12/27/25: NU-STEP (3-5x/wk, wknds not x out) - Not started12/28/25-1/3/26: Arm bike (weekdays) - Missed every day, NU-STEP (3-5x/wk, wknds not x out) - Not started1/4/26- 1/10/26: Arm bike (weekdays) - Missed every day, NU-STEP (3-5x/wk, wknds not x out) - Not started1/11/26- 1/17/26: Arm bike (weekdays) - Missed every day, Group exercises (weekdays) - Missed 1 day, NU-STEP (3-5x/wk, wknds not x out) - Not started1/18/26-1/24/26: Arm bike (weekdays) - Missed 2 days, NU-STEP (3-5x/wk, wknds not x out) - Not started1/25/26-1/31/26: Arm bike (weekdays) - Missed 1 day, NU-STEP (3-5x/wk, wknds not x out) - Started middle this week2/1/26-2/7/26: NU-STEP (3-5x/wk, wknds not x out) - Missed 1 day2/8/26-2/14/26: NU-STEP (3-5x/wk, wknds not x out) - Missed 1 day2/15/26- 2/21/26: NU-STEP (3-5x/wk, wknds not x out) - Missed 2 daysOver the last 13 weeks, R5's arm bike intervention was documented 5 times not applicable, 1 time unavailable, and twice R5 refused to participate in her arm bike restorative.Over the last 13 weeks, R5's group exercise intervention was documented 21 times not applicable.Over the last 3 weeks, R5's NUSTEP intervention was documented 14 times as not applicable.If NA/not applicable is being used as not available, no evidence or documentation that timing or restorative offerings have been evaluated to accommodate resident choices. Example 4 R8 was admitted to the facility on [DATE], and has diagnoses that include pain in left shoulder, chronic pain, age related osteoporosis, wed compression fracture of fifth lumbar vertebra, low back pain, and osteoarthritis, left shoulder. R8's MDS assessment, dated 12/4/25, indicated that R8's cognition is moderately intact. R8 has clear speech and usually understands. R8 is non-ambulatory and needs assist of 2 with non-mechanical sit to stand with gait belt for mobility and to transfer from bed to chair and back. R8 needs assist 1 for personal care and hygiene. R8's care plan identifies 2 restorative interventions. The resident requires restorative intervention r/t history of falls, weaknessDate Initiated: 05/13/2025 Revision on: 05/13/2025The resident will maintain current level of mobility through review date.Date Initiated: 05/13/2025 Revision on: 08/01/2025 Target Date: 05/24/2026#1 - NURSING REHAB/RESTORATIVE: ACTIVE ROM: Program #1 Arm Bike at level 2 x 12 minutes 5x/week MTWTHF.#2 - NURSING RESTORATIVE: GROUP EXERCISES: Bilateral upper and lower extremity strengthening exercises for 15 mins or as tolerated/desired 3x-5x/week. On 2/25/26 at 11:00 AM, Surveyor reviewed R8's restorative documentation.11/30/25- 12/6/25: Arm Bike - Missed 3 12/7/25-12/13/25: Arm Bike - Missed 1 12/14/25- 12/20/25: Arm Bike - Missed 2, Group Exercise - Missed 112/21/25-12/27/25 12/28/25-1/3/26: Arm Bike - Missed every day 1/4/26- 1/10/26: Arm Bike - Missed every day 1/11/26- 1/17/26: Arm Bike - Missed every day, Group Exercise - Missed 11/18/26-1/24/26: Arm Bike - Missed 2 1/25/26-1/31/26: Arm Bike - Missed 1 2/1/26-2/7/26: Arm Bike - Missed 3 2/8/26-2/14/26: Arm Bike - Missed 2 2/15/26- 2/21/26: Arm Bike - Missed every day, Group Exercise - Missed 1Over the last 13 weeks, R8's arm bike intervention was documented 3 times not applicable.Over the last 13 weeks, R8's group exercise intervention was documented 17 times not applicable.If NA/not applicable is being used as not available, no evidence or documentation that timing or restorative offerings have been evaluated to accommodate resident choices.Example 5R15 was admitted to the facility on [DATE], and has diagnoses that include osteoarthritis, muscle weakness, right artificial hip, and history of fallings. R15's MDS assessment, dated 2/5/25, indicated that R15 is cognitively impaired. R15 has intelligible words but can make herself understood and has clear comprehension. R15 has no upper and lower impairment and can independently roll left to right. R15 needs supervision to change positions and pivot stand. R15 requires substantial assistance with hygiene and activities of daily living.R15's care plan identifies 2 restorative interventions. The resident requires restorative intervention r/t impaired balance/mobility, dementiaDate Initiated: 05/13/2025 Revision on: 05/13/2025The resident will maintain current level of mobility through review date.Date Initiated: 05/13/2025 Revision on: 05/13/2025 Target Date: 04/23/2026#1 NURSING REHAB/RESTORATIVE: ACTIVE ROM Program #1 Hand Bike Level 4 x 10-15 min 3x-5x per week Monday Tuesday Wednesday Thursday Friday Date Initiated: 05/13/2025 Revision on: 1/13/2026#2 NURSING RESTORATIVE: GROUP EXCERCISES: Bilateral upper and lower extremity strengthening exercises for 15 minutes or as tolerated/desired. 5x/wk MTWTHF Date Initiated: 05/13/2025 Revision on: 11/13/2025 On 2/25/26 at 11:00 AM, Surveyor reviewed R15's restorative documentation.11/30/25- 12/6/25: Hand Bike - Missed 4 12/7/25-12/13/25: Hand Bike - Missed 1 12/14/25- 12/20/25: Hand Bike - Missed 3, Group Exercise - Missed 212/21/25-12/27/25: Group Exercise - Missed 112/28/25-1/3/26: Hand Bike - Missed every day 1/4/26- 1/10/26: Hand Bike - Missed every day, Group Exercise - Missed 11/11/26- 1/17/26: Hand Bike - Missed every day 1/18/26-1/24/26: Hand Bike - Missed 2 1/25/26-1/31/26: Hand Bike - Missed 1 2/1/26-2/7/26: Hand Bike - Missed 3, Group Exercise - Missed 12/8/26-2/14/26: Hand Bike - Missed 3, Group Exercise - Missed 12/15/26- 2/21/26: Hand Bike - Missed every day, Group Exercise - Missed 2Over the last 13 weeks, R15's hand bike intervention was documented 3 times not applicable.Over the last 13 weeks, R15's group exercise intervention was documented 17 times not applicable.If not applicable is being used as not available, no evidence or documentation that timing or restorative offerings have been evaluated to accommodate resident choices.Example 6R23 was admitted to the facility on [DATE] and has diagnoses that include age related osteoporosis, low back pain, thoracic spine pain, weakness, heart failure and congestive heart failure. R23's MDS assessment, dated 12/4/25, indicated that R23 is cognitively impaired. R23 has clear speech but distinct intelligible words resulting in her usually being understood and is sometimes able to understand. R23 has no upper and lower impairment and ambulates with a walker. R23 requires substantial assistance to roll left to right and go from a sitting to lying position and vice versa. R23 requires set up and partial assistance with hygiene and activities of daily living, like toilet hygiene and personal hygiene.R23's care plan identifies 2 restorative interventions. The resident requires restorative intervention r/t Impaired Balance, Dementia Date Initiated: 05/13/2025 Revision on: 05/13/2025The resident will maintain current level of mobility through review date.Date Initiated: 05/13/2025 Revision on: 05/13/2025 Target Date: 03/03/2026#1 RESTORATIVE: ACTIVE ROM Program #1 Hand Bike Level 4 x 10 minutes 3x-5x per week MTWTHF Date Initiated: 05/13/2025On 2/25/26 at 11:00 AM, Surveyor reviewed R23's restorative documentation.11/30/25- 12/6/25: Hand Bike - Missed 4 days 12/7/25-12/13/25: Hand Bike - Missed 1 day 12/14/25- 12/20/25: Hand Bike - Missed 3 days, Group exercises - Missed 2 days12/21/25-12/27/25: Group exercises - Missed 1 day12/28/25-1/3/26: Hand Bike - Missed every day 1/4/26- 1/10/26: Hand Bike - Missed every day, Group exercises - Missed 1 day1/11/26- 1/17/26: Hand Bike - Missed every day 1/18/26-1/24/26: Hand Bike - Missed 2 days 1/25/26-1/31/26: Hand Bike - Missed 1 day 2/1/26-2/7/26: Hand Bike - Missed 3 days, Group exercises - Missed 1 day2/8/26-2/14/26: Hand Bike - Missed 2 days, Group exercises - Missed 1 day2/15/26- 2/21/26: Hand Bike - Missed every day, Group exercises - Missed 2 daysOver the last 13 weeks, R23's arm bike intervention was documented 5 times not applicable and 1 time resident not available.Over the last 13 weeks, R23's group exercise intervention was documented 17 times not applicable.If not applicable is being used as not available, no evidence or documentation that timing or restorative offerings have been evaluated to accommodate resident choices.On 2/24/25 at 11:50 AM, Surveyor interviewed Certified Nursing Assistant (CNA) K who stated CNA K's primary role is to do restorative care. CNA K stated today she worked with both R3 and R4 on a dressing program. CNA K stated as long as they stretch while dressing, they are doing their restorative. CNA K stated those are the two CNA K gets up every time CNA K works. CNA K stated that R3 has a walking program and R3 does the NUSTEP. CNA K stated R3 did that already today for 15 minutes. CNA K stated R4 did 50 minutes on the arm bike today in 2 sections. CNA K stated R4 chooses to do that the 5 days a week when CNA K is here. Surveyor asked if it is R4's choice to only do her restorative when CNA K is here. CNA K stated no I am the only one technically trained to do restorative. No one else can. Surveyor asked CNA K what if you go on vacation or something. CNA K stated we just had that last week. They had someone lined up but that fell through, and R3 only went down to the bike 2 days when Director of Nursing (DON) B took her.On 2/24/26 at 4:10 PM, Surveyor interviewed DON B who stated that according to MDS, restorative should be 5 days a week. DON B stated that CNA K was gone but DON B took R3 down twice. DON B stated she does not think R4 received any therapy. Surveyor clarified that residents did not get 5 days of restorative. DON B stated, yes, no one got restorative.On 2/24/26 at 4:18 PM, Surveyor interviewed Nursing Home Administrator (NHA) A who stated CNA K took over the restorative program about one month ago when existing restorative CNA had some health issues. NHA A stated as CNA K stepped into the role, we had a working plan of someone backing her up. We planned for CNA M to back her up when CNA K went on vacation. NHA A stated NHA A was in the process of coordinating the training of CNA M before CNA K went on vacation, but therapy wasn't available initially when NHA A tried to coordinate the training and then NHA A got sick. NHA A stated CNA M was not trained before CNA K went on vacation; we did not have a backup when CNA K went on vacation. On 02/25/26 at 9:02 AM, Surveyor interviewed NHA A to clarify how some residents have it documented they received their restorative 7 days a week if there is only one restorative CNA. NHA A and DON B stated it is because of how charting is set up. All staff have access to do the residents' ROM, as staff are getting them dressed and it can be charted by any CNA. DON B stated that restorative of passive ROM and active ROM can be done by all CNAs and does not have to be restorative CNA.

Based on observation, interview and record review, the facility did not ensure that each resident received adequate assistance devices to prevent accidents or injury and promote safe transfers for 1 resident of 4 residents (R8) reviewed for accident prevention in a sample of 31.The facility did not utilize gait belt during a toileting transfer to enhance R8's function or safety and placed R8 at risk of injury.Findings include:The facility policy, titled Safe Resident Handling/Transfers, last revised 01/2025, states in part: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risk for injury and provide and promote a safe, secure and comfortable experience for the resident.R8 was admitted to the facility on [DATE] and has diagnoses of wedge compression fracture of fifth lumbar vertebra (fracture of spine lower back), age related osteoporosis (weak and fragile bones), cerebral infarction (stroke), macular degeneration (vision loss).R8's Minimum Data Set (MDS) assessment, dated 02/10/2026, indicated that R8 has a Brief Interview for Mental Status (BIMS) score of 8/15 which means moderate cognitive impairment. R8's care plan, last revised 08/01/2025, with a target date of 05/24/2026, states: I have chronic comorbidities which may affect my ability to perform activities of daily living (ADLs). I require assistance with ADLs and transfers. Interventions include Transfer: one assist non-mechanical sit to stand with gait belt.encourage to stand tall, allow her time.On 02/24/2026 at 7:23 AM, Surveyor observed R8 being assisted with toileting by certified nursing assistant (CNA) D. CNA D placed gait belt around R8's waist while R8 was sitting in recliner chair. R8 was able to grasp the bars of the Sara Steady (non-mechanical mobile lift device to assist with safe standing and short transfers) and lift self without assist to standing position on the Sara Steady foot platform. R8 was transported to toilet with Sara Steady device and placed onto toilet by CNA D. To be noted: toilet was low level without a high-rise seat in place and R8 had to bend low to be seated onto toilet. When toileting was completed, R8 was unable to reach forward far enough because of low level toilet to grasp bar of Sara Steady to stand self again. CNA D assisted R8 to stand position by steadily lifting while pulling upward on R8's shoulder/arm until R8 was able to stand on Sara Steady foot platform to be transported to a wheelchair. CNA D did not use the gait belt already in place around R8's waist when assisting R8 to standing position. Gait belt was loose around R8's waist and not effectively tightened for R8's transfer. On 02/24/2026 at 7:23 AM, during observation of R8 being transferred from toilet to wheelchair by CNA D, Surveyor asked CNA D what the proper transferring technique would be for residents who required assistance for standing. CNA D stated in R8's situation, there should have been a high-rise toilet seat in place on toilet so R8 could have reached the Sara Steady grab bars and assist self when standing. CNA D did not indicate need for use of gait belt for transfers. On 02/25/2026 at 8:43 AM, Surveyor interviewed director of nursing (DON) B what staff expectations are for proper transferring and lifting techniques of residents. DON B stated a gait belt was to be always used for manual or non-mechanical transfers of residents. DON B stated that no body part of a resident should be pulled on when lifting or transferring a resident at any time. Record review of facility staff education indicated CNA D completed 100% online training on 12/22/2025 for performing safe transfers.

Based on observation and interview, the facility did not inspect for compatibility of bed frames, mattresses, and bed rails for 8 of 8 residents (R) R12, R13, R16, R27, R3, R4, R14, R22. The facility failed to conduct as part of their regular maintenance program, inspection of all bed frames, mattresses, and bed rails for potential risk of entrapment on 8 of 8 residents (R) R12, R13, R16, R27, R3, R4, R14, R22 observed with side rails/enabler bars up during the survey process. This is evidenced by: Based on the Food and Drug Administration (FDA) documents entitled Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated March 10, 2006, Practice Hospital Bed Safety dated February 2013, and Guide to Bed Safety Rails in Hospitals, Nursing Homes and Home Health Care: The Facts as to the proper dimensions and distances apart of various parts of the bed such as distance between bed frames and mattresses, bed rails and mattress etc. to prevent entrapment by users of the bed. Example 1 On 10/18/23 at 11:07 AM, Surveyor observed right grab bar on R12's bed. R12 was admitted to facility on 05/24/23 and has diagnoses that include Parkinson's and osteoporosis. On 10/18/23, Surveyor reviewed R12's quarterly grab bar assessments which did not include inspection of bed frame, mattress, and potential risk of entrapment. R12's most recent quarterly Minimum Data Set (MDS), dated [DATE], indicates R12 has modified independence - some difficulty in new situation making decisions regarding tasks of daily life and requires extensive assistance with two-person physical assist for bed mobility and transfers. This would put R12 at risk for entrapment with the use of grab bars. On 10/17/23, Surveyor reviewed R12's current care plan which indicates R12 is a fall risk due to impaired mobility and history of falls. Example 2 On 10/18/23 at 11:07 AM, Surveyor observed bilateral grab bar on R13's bed. On 10/18/23, Surveyor reviewed R13's quarterly grab bar assessments which did not include inspection of bed frame, mattress, and potential risk of entrapment. R13 was admitted on [DATE] and has diagnoses that include non-traumatic brain dysfunction and dementia. R13's most recent annual MDS, dated [DATE], indicates R13 has a BIMS score of 5 and requires extensive assist with one-person physical assist with bed mobility and transfers. This would put R13 at risk for entrapment with the use of grab bars. On 10/17/23, Surveyor reviewed R13's current care plan which indicates R13 is a fall risk due to impaired mobility, cognition, and history of falls. Example 3 On 10/18/23 at 11:07 AM, Surveyor observed bilateral grab bars on R16's bed. On 10/18/23, Surveyor reviewed R16's quarterly grab bar assessments which did not include inspection of bed frame, mattress, and potential risk of entrapment. R16 was admitted to facility on 01/19/19, and has diagnoses that include non-traumatic brain dysfunction, cerebrovascular accident, and Alzheimer's disease. R16's most recent quarterly MDS, dated [DATE], indicates R16 requires extensive assist with one-person physical assist with bed mobility and limited assistance with one-person physical assist with transfers. This would put R16 at risk for entrapment with the use of grab bars. On 10/17/23, Surveyor reviewed R16's current care plan which indicates R16 is a fall risk due to history of falls and history of self-transferring. Example 4 On 10/18/23 at 11:07 AM, Surveyor observed left grab bar on R27's bed. On 10/18/23, Surveyor reviewed R27's quarterly grab bar assessments which did not include assessment of bed frame, mattress, and potential risk of entrapment. R27 was admitted to facility on 10/28/22 and has diagnoses of a CVA and is enrolled in hospice. R27's most recent quarterly MDS, dated [DATE], indicates R27 has both short term and long-term memory problems, is severely impaired-never/rarely makes decisions and requires extensive assist with two-person physical assist with bed mobility and transfers. This would put R27 at risk for entrapment with the use of grab bars. On 10/17/23, Surveyor reviewed R27's current care plan which indicates R27 is a fall risk due to history of falls and history of self-transferring. 43352 Example 5 R3 was admitted to the facility on [DATE], and has diagnoses that include paranoid schizophrenia, anxiety disorder, major depressive disorder, dementia, hypertensive heart disease, and type 2 diabetes. R3's Minimum Data Set (MDS) assessment indicated that R3 had a Brief Interview for Mental Status (BIMS) of 05 which indicated R3 has severe impairment. Surveyor reviewed R3's quarterly grab bar assessments which did not include inspection of bed frame, mattress, and potential risk of entrapment. Example 6 R4 was admitted to the facility on [DATE], and has diagnoses that include atrial fibrillation, acute kidney failure, and congestive heart failure. Surveyor observed grab bars on R4's bed during the initial tour on 10/16/23 at approximately 9:00 a.m. Surveyor reviewed R4's quarterly grab bar assessments which did not include inspection of bed frame, mattress, and potential risk of entrapment. Example 7 R14 was admitted to the facility on [DATE] and has diagnoses that include type 2 diabetes with diabetic neuropathy, acute kidney failure, and early onset Alzheimer's. R14's MDS indicated that R14 has a BIMS of 12, which indicates that R14 is moderately impaired. Surveyor reviewed R14's quarterly grab bar assessments which did not include inspection of bed frame, mattress, and potential risk of entrapment. Example 8 R22 was admitted to the facility on [DATE] and has diagnoses that include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysphasia, hypertension, and major depressive disorder. R22's MDS indicated that R22 has a BIMS of 12, which indicates that R22 is moderately impaired. Surveyor reviewed R22's quarterly grab bar assessments which did not include inspection of bed frame and mattress for compatibility, which increases potential risk of entrapment. On 10/18/23 at 11:07 AM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding side rail inspections using the hospital bed system standard. NHA A stated that they do not consider grab bars as siderails but as an assistive device. NHA stated they do not conduct siderail inspections for individual safety for risk for entrapment.

Based on observation, interview and record review, the facility did not ensure prior to the installation or use of bed rails, attempted to use alternative devices, assess the resident for risk of entrapment from bed rails, obtain consent with the resident or resident representative for review of risks and benefits of bed rails for 8 of 8 residents (R) R12, R13, R16, R27, R3, R4, R14, R22) observed with side rails/enabler bars during the survey process. The facility failed to attempt alternatives prior to installation of grab bars and failed to obtain informed signed consent of risk and benefit for grab bars with the resident or resident representative for R12, R13, R16, R27, R3, R4, R14, and R22. This is evidenced by: On 10/18/23 at 10:06 AM, Surveyor received and reviewed side rail policy entitled: Restraint-free environment which includes .8. The resident may request assist and/or grab bars to allow for proper mobility, rise from the bed and/or maintain items within reach. An assessment of the grab bar must be performed to ensure resident safety and proper use. Assessment must also indicate that this is not a restraint. If assessment determines that the grab bar is a restraint, the restraint policy and procedure must be followed. Example 1 On 10/18/23 at 11:07 AM, Surveyor observed right grab bar on R12's bed. R12 was admitted to facility on 05/24/23 and has diagnoses that include Parkinson's and osteoporosis. R12's most recent quarterly Minimum Data Set (MDS), dated [DATE], indicates R12 has modified independence - some difficulty in new situation making decisions regarding tasks of daily life and requires extensive assistance with two-person physical assist for bed mobility and transfers. This would put R12 at risk for entrapment with the use of grab bars. On 10/17/23, Surveyor reviewed R12's current care plan which indicates R12 is a fall risk due to impaired mobility and history of falls. On 10/18/23, Surveyor received R12's quarterly grab bar assessments which indicated on 07/06/23 risk for injury/entrapment: Impaired cognition/confusion. The assessment had no documentation of attempting alternatives prior to installation of grab bars, or evidence of informed signed consent of risk and benefit for grab bars with the resident or resident representative. Example 2 On 10/18/23 at 11:07 AM, Surveyor observed bilateral grab bar on R13's bed. R13 was admitted on [DATE] and has diagnoses that include non-traumatic brain dysfunction and dementia. R13's most recent annual MDS, dated [DATE], indicates R13 has a BIMS score of 5 and requires extensive assist with one-person physical assist with bed mobility NS transfers. This would put R13 at risk for entrapment with the use of grab bars. On 10/17/23, Surveyor reviewed R13's current care plan which indicates R13 is a fall risk due to impaired mobility, cognition, and history of falls. On 10/18/23, Surveyor received R13's quarterly grab bar assessments which indicated on 08/04/23 risk for injury/entrapment: Impaired cognition/confusion. The assessment had no documentation of attempting alternatives prior to installation of grab bars, or evidence of informed signed consent of risk and benefit for grab bars with the resident or resident representative. Example 3 On 10/18/23 at 11:07 AM, Surveyor observed bilateral grab bars on R16's bed. R16 was admitted to facility on 01/19/19, and has diagnoses that include non-traumatic brain dysfunction, cerebrovascular accident (CVA), and Alzheimer's disease. R16's most recent quarterly MDS, dated [DATE], indicates R16 requires extensive assist with one-person physical assist with bed mobility and limited assistance with one-person physical assist with transfers. This would put R16 at risk for entrapment with the use of grab bars. On 10/17/23, Surveyor reviewed R16's current care plan which indicates R16 is a fall risk due to history of falls and history of self-transferring. On 10/18/23, Surveyor received R16's quarterly grab bar assessments. Last assessment dated [DATE], had no documentation of attempting alternatives prior to installation of grab bars, or evidence of informed signed consent of risk and benefit for grab bars with the resident or resident representative. Example 4 On 10/18/23 at 11:07 AM, Surveyor observed left grab bar on R27's bed. R27 was admitted to facility on 10/28/22 and has diagnoses of a CVA and is enrolled in hospice. R27's most recent quarterly MDS, dated [DATE], indicates R27 has both short term and long-term memory problems, is severely impaired-never/rarely makes decisions and requires extensive assist with two-person physical assist with bed mobility and transfers. This would put R27 at risk for entrapment with the use of grab bars. On 10/17/23, Surveyor reviewed R27's current care plan which indicates R27 is a fall risk due to history of falls and history of self-transferring. 43352 Example 5 R3 was admitted to the facility on [DATE], and has diagnoses that include paranoid schizophrenia, anxiety disorder, major depressive disorder, dementia, hypertensive heart disease, and type 2 diabetes. R3's Minimum Data Set (MDS) assessment indicated that R3 had a Brief Interview for Mental Status (BIMS) of 05 which indicated R3 has severe impairment. On 10/18/23, Surveyor received R3's quarterly grab bar assessment dated [DATE]. The assessment had no documentation of attempting alternatives prior to installation of grab bars, and the facility did not obtain informed signed consent of risk and benefit for grab bars with the resident or resident representative. Surveyor observed R3 has grab bars on both sides of their bed during initial tour on 10/16/23 at approximately 9:00 a.m. Example 6 R4 was admitted to the facility on [DATE], and has diagnoses that include atrial fibrillation, acute kidney failure, and congestive heart failure. On 10/18/23, Surveyor received R4's quarterly grab bar assessment dated [DATE]. The assessment had no documentation of attempting alternatives prior to installation of grab bars, and the facility did not obtain informed signed consent of risk and benefit for grab bars with the resident or resident representative. Surveyor observed R4 has a grab bar on the right side of their bed during initial tour on 10/16/23 at approximately 9:00 a.m. Example 7 R14 was admitted to the facility on [DATE] and has diagnoses that include type 2 diabetes with diabetic neuropathy, acute kidney failure, and early onset Alzheimer's. R14's MDS indicated that R14 has a BIMS of 12, which indicates that R14 is moderately impaired. On 10/18/23, Surveyor received R14's quarterly grab bar assessment dated [DATE]. The assessment had no documentation of attempting alternatives prior to installation of grab bars, and the facility did not obtain informed signed consent of risk and benefit for grab bars with the resident or resident representative. Surveyor observed R14 has a grab rail on the right side of their bed, during initial tour throughout the day on 10/16/23. Example 8 R22 was admitted to the facility on [DATE] and has diagnoses that include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysphasia, hypertension, and major depressive disorder. R22's MDS indicated that R22 has a BIMS of 12, which indicates that R22 is moderately impaired. On 10/18/23, Surveyor received R22's quarterly grab bar assessment dated [DATE]. The assessment had no documentation of attempting alternatives prior to installation of grab bars, and the facility did not obtain informed signed consent of risk and benefit for grab bars with the resident or resident representative. Surveyor observed R22 has grab bars on both sides of their bed during initial tour throughout the day on 10/16/23. On 10/18/23 at 11:07 AM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding side rail assessments. NHA A stated that they do not consider grab bars as siderails but as an assistive device. They conduct a quarterly assessment which does not require assessment that grab bar is not a restraint. NHA stated they do not conduct siderail assessments for individual safety for risk for entrapment and have not done risk vs benefit education or obtain signed consents from resident or resident representative.

Based on observations, interviews and record reviews, the facility did not ensure residents received appropriate treatment and services to maintain or prevent further reduction in range of motion (ROM) and mobility for 5 of 5 residents (R) (R11, R13, R16, R3, R17). The facility did not consistently provide services or treatment for residents (R11, R13, R16, R3, R17) identified with having a restorative program. This is evidenced by: Example 1 R11 was admitted on [DATE] and has diagnoses that includes a stroke, Alzheimer's disease, and hemiplegia. R11's most recent annual Minimum Data Set (MDS), dated [DATE], indicates is severely impaired - never/rarely makes decision and has an activated Power of Attorney (POA) 5/16/23. R11 is totally dependent on staff for all Activities of Daily Living (ADL). On 10/17/23, Surveyor reviewed R11's care plan and restorative documentation from 9/28/23 through 10/17/23, which identifies the following individualized restorative program and missing documentation indicating the program was not completed. ROM: Lower body exercise: Bilateral lower extremity with moderate assist of passive ROM 10 repetitions of 3 sets supine in bed 7x week on AM and PM shifts: Noted 16 missed opportunities out of 40. Example 2 R13 was admitted on [DATE] and has diagnoses that include arthritis, non-traumatic brain dysfunction, and dementia. R13's most recent annual MDS, dated [DATE], indicates a BIMS score of 5 and has an activated POA. R13's MDS also indicates a decline in ADLs from previous MDS dated [DATE]. Bed mobility went from requiring limited assist to requiring extensive assist. Transfer ability went from limited assist to requiring extensive assist. Walk in room went from supervision to requiring limited assist. On 10/17/23, Surveyor reviewed R13's care plan and restorative documentation from 9/28/23 through 10/17/23, which identifies the following individualized restorative program and missing documentation indicating the program was not completed. Ambulation: 1 assist with walker and wheelchair (WC) in hallway. Complete 2 trials with distance to fatigue 7 x a week on AM shift. Noted 36 missed opportunities out of 40. Ambulation: 1 assist with walker and wheelchair (WC) in hallway with distance to fatigue 7 x a week on PM shift. Noted 12 missed opportunities out of 20. Dressing/grooming: set up at sink in WC with upper body and lower body clothing, allow patient to compete with cues and supervision 6x week. Noted 11 missed opportunities out of 18. ROM: Hand bike level 3 5x week to maintain tolerance for daily cares on AM shift. Noted 8 missed opportunities out of 14. Example 3 R16 was admitted to facility on 01/19/19, and has diagnoses that include non-traumatic brain dysfunction, cerebrovascular accident (CVA), and Alzheimer's disease. R16's most recent quarterly MDS, dated [DATE], indicates R16 requires limited assist with one-person physical assist with transfers and walk in corridor. Requires extensive assist with one person assist for dressing. On 10/17/23, Surveyor reviewed R16's care plan and restorative documentation from 9/28/23 through 10/17/23, which identifies the following individualized restorative program and missing documentation indicating the program was not completed. Ambulation: 50-100' with 1 assist and walker and WC to follow 5x week 2x on AM shift. Noted 21 missed opportunities out of 28. Ambulation in hallway to fatigue, walker, and WC to follow a7x week on PM shifts. Noted 11 missed opportunities out of 20. Transfer: static standing in parallel bar 3x to fatigue 2x a week. Noted 6 opportunities out of 9. Dressing/grooming: upper body dressing with set up while edge of bed or in chair - restorative to complete AM cares 7x week on AM and PM shifts. Noted 21 missed opportunities out of 40. ROM: NU Step Level 5 x 15 minutes 3x week on Am Shift. Noted 4 missed opportunities out of 8. ROM: Upper body exercise: Bilateral Upper Extremity Hand Bike Level 3 x 15 minutes 2x week on AM Shift. Noted 4 missed opportunities out of 6. 43352 Example 4 R3 was admitted to the facility on [DATE], and had diagnoses that include paranoid schizophrenia, anxiety disorder, major depressive disorder, dementia, hypertensive heart disease, and type 2 diabetes. R3's Minimum Data Set (MDS) assessment indicated that R3 had a Brief Interview for Mental Status (BIMS) of 05 which indicated R3 has severe impairment. On 10/17/23, Surveyor reviewed R3's care plan and restorative documentation, which identifies the following individualized restorative program. ROM Group exercises 5 times a week with a goal is strength for cares done Monday, Tuesday, Wednesday, Thursday, and Friday. On 10/17/23, Surveyor reviewed R3's care plan and restorative documentation from 9/28/23 through 10/17/23, which identifies the restorative program missing documentation indicating the program was not completed. Noted 9 missed opportunities out of 14. ROM Upper body exercise hand bike 5 times a week Monday, Tuesday, Wednesday, Thursday, and Friday to maintain tolerance for cares. Surveyor reviewed R3's care plan and restorative documentation from 9/28/23 through 10/17/23, which identifies the restorative program missing documentation indicating the program was not completed. Surveyor noted 11 missed opportunities out of 14. 47807 Example 5 R17 was admitted to the facility on [DATE], and had diagnoses that include Cerebrovascular accident (CVA) and hemiparesis. R17's Minimum Data Set (MDS) assessment indicated that R17 did not have a Brief Interview for Mental Status (BIMS) which indicated resident is rarely/never understood. On 10/18/23, Surveyor reviewed R17's care plan and restorative documentation, identifying the following individualized restorative program. 10/16/2023 Transfer: Standing to tolerance in paralell bars or grab bar in room, x 3 attempts as able 7x / wk. Sunday Monday Tuesday Wednesday Thursday Friday Saturday cAM [NAME] cOM cPMin T First date: 3/31/23 Goals: maintain strength for transfers On 10/18/23, Surveyor reviewed R3's care plan and restorative documentation from 9/28/23 through 10/17/23, which identified the restorative program indicating the program was not completed. Surveyor noted 48 missed opportunities. On 10/17/23 at 2:05 PM, Surveyor interviewed Certified Nursing Assistant (CNA) D and CNA E, who stated they are responsible for completing some of the individual programs and some are completed by the restorative aide. Both CNA D and CNA E stated that the restorative aide and CNA staff are expected to complete the program and required documentation and if they are unable to complete the program or if resident refuses, they should not leave blank and place a 0. On 10/17/23 at 4:21 PM, Surveyor interviewed Director of Nursing (DON) B regarding the blank documentation on the therapy logs. DON B stated that while reviewing restorative documentation last month blanks were noted. DON B brought information forward at the 9/26/23 QAPI meeting and are going to be starting a performance improvement plan (PIP) and started educating staff on 09/27/23 regarding expectation of charting restorative pans. DON B stated auditing is planned over the next month to ensure it is being done. On 10/18/23 at 11:18 AM, Surveyor interviewed DON B after reviewing documentation of education of staff during a meeting on 9/27/23, with expectations of completing restorative programs Surveyor informed DON B that since the staff meeting there continues to be blanks in the documentation indicating program was not completed. DON B stated that her expectations after receiving the education were there should be documentation supporting the program was completed or documentation to support why it was not completed. DON B stated that a formal PIP had not been developed but planned to start it today.

Based on staff interview and record review, the facility did not ensure their abuse policy was implemented for 1 of 8 employees reviewed for background checks. The facility allowed a Certified Nursing Assistant (CNA) G to work with residents on 01/14/23 and 01/15/23 before background check was received. Background check was received on 01/20/23. This is evidenced by: The facility policy, entitled Abuse, Neglect, Mistreatment, Exploitation and Misappropriation of Resident Property, dated November 2022, states: 1. Screening components . Abuse Policy Requirements: it is the policy of Dove Healthcare to screen employees and volunteers prior to working with residents. Screening components include verification of references, certification and verification of license and criminal background checks. Surveyor was completing the caregiver compliance check when Surveyor noticed that CNA G's start date was dated 01/14/23, and their reports from the Department of Justice (DOJ) and Integrated Background Information System (IBIS) were dated 01/20/23. The background check date was six days after the date of hire. Record review of the CNA Schedule from 01/14/23 to 01/20/23 shows that CNA G worked on 01/14/23 for eight hours and 01/15/23 for eight hours. The CNA Schedule shows that CNA G was shadowing with CNA H on 01/14/23 and CNA I on 01/15/23. CNA G did not work another day until after 01/20/23. On 10/18/23 at 9:20 AM, Surveyor interviewed Nursing Support (NS) F, who sets up the schedule for new hires. NS F was asked what the first week looks like for a CNA. NS F said that first, they have a few hours of general training, but after that general training on the computer is completed, they are sent to the floor to shadow another CNA. On 10/18/23 at 11:20 AM, Surveyor interviewed Director of Nursing (DON) B regarding staff background checks. When asked what their expectations would be regarding receiving a background check, DON B said they would expect staff to have a verified background check before being allowed to work on the floor.

Based on record review and interviews, the facility did not ensure the resident received care consistent with professional standards of practice for pressure injury care for 1 of 1 residents (R) 14. R14 had a deep tissue injury; weekly wound assessments with description of wound and measurements were not completed. Findings include: The facility policy, entitled Skin Assessment and Pressure Ulcer Prevention, with an effective date of August 2010, states in part With each dressing change or at least weekly, an evaluation of the pressure injury should be documented including location and measurements. R14 was admitted to the facility on [DATE] and has diagnosis that include type 2 diabetes with diabetic neuropathy, acute kidney failure, and early onset Alzheimer's. On 10/18/23 at 7:55 AM, Surveyor requested weekly wound measurements for the past 3 months from Director of Nursing (DON) B for R14's left heel. Surveyor received the documentation at 9:50 AM. Documentation indicates that measurements were completed on 7/29/23, 8/12/23, 8/22/23, 8/26/23, 9/13/23, 9/29/23 and 10/03/23. The pressure injury assessments were not completed weekly. Surveyor interviewed RN C on 10/18/23 at 12:32 PM. Surveyor asked her if she was the one who usually does the wound measurements. RN C indicated that RN C was responsible. Surveyor asked how often measurements and assessments should be done. RN C indicated usually weekly. Surveyor showed RN C the documentation of wound measurements starting at 7/29/23 and showed RN C the next measurement was 8/12/23 and asked if that looked right. RN C indicated yes and could not explain why there was a gap in weekly assessments. On 10/18/23 at 12:40 PM, Surveyor interviewed DON B and asked how often wound measurements should be done. DON B indicated they should be done every 7 days.

Based on observation and interview, the facility did not ensure pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 1 of 1 Residents (R19) observed receiving insulin. Staff did not follow current standard of practice of priming the insulin pen prior to setting the dose to be administered to ensure the insulin pen and needle are working and the air was removed to ensure the correct amount of insulin would be administered. This is evidenced by: Review of the [MEDICATION(S)] manufacturer's instructions with the revised date of 11/2020 read in part: Instructions for Use, [MEDICATION(S)]® 70/30 KwikPen®(human insulin [MEDICATION(S)] suspension and human insulin injection) 100 units/mL, 3 mL single-patient-use pen . Priming your Pen Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 8: To prime your Pen, turn the Dose Knob to select 2 units. Step 9: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 10: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. If you do not see insulin, repeat priming steps 8 to 10, no more than 4 times. If you still do not see insulin, change the Needle and repeat priming steps 8 to 10. Small air bubbles are normal and will not affect your dose On 06/29/21 at 7:48 am, Surveyor observed Registered Nurse (RN) C take R19's insulin pen out of the medication cart and push the insulin pen's button and not dial two units. RN C placed the needle on the pen and then dialed the 13 units. RN C did not observe to see if the air pockets were removed and insulin was at the tip of the needle. Surveyor interviewed RN C asking if priming the insulin pen is needed. RN C indicated she did by pushing the button. Surveyor asked if RN C would dial 2 units and observe insulin come out of the needle. RN C indicated no she did not dial two units to prime the pen, she pushes the button and don't need to put units in to prime the pen. On 06/30/21 at 2:40 p.m., Surveyor interviewed Director of Nursing (DON) B asking if education is provided to nursing staff for priming of insulin pens. DON B indicated the facility has a nursing educator that does frequent education to the nursing staff about priming the insulin pens with two units. DON B indicated the facility is in the process of having the pharmacist come into the facility and do frequent medication pass audits.

Based on observation and interview, the facility did not post the nurse staffing information for 3 of 3 days of survey with the potential to affect all 30 residents and visitors. The facility did not post the nurse staffing information in a prominent place readily accessible to residents and visitors. This is evidenced by: Surveyor observed during three days of survey the nurse staffing information was not posted. On 06/30/21 at 2:33 p.m., Surveyor interviewed Director of Nursing (DON) B asking where the nurse staffing posting was located and the retention of the postings. DON B indicated when the nurse schedule is printed each day it should be printed but did not believe it was being posted since there have not been visitors in the building. Surveyor was provided a copy of the daily posting, and it did not include the facility's name and did not have the total number of nursing staff directly responsible for resident care per shift. The posting is in a small print that would be difficult to identify and read. Surveyor was not provided the facility's retained daily postings for the last 18 months.

Based on interviews and facility record review the facility did not conduct testing of staff based on the county level positivity rate according to the recommended frequency. The facility did not have procedures for addressing resident and staff, including individuals providing services under arrangement and volunteers who refuse testing or are unable to be tested . This has the potential to affect all 28 residents that reside in the facility. The facility did not review the county level positivity rate to conduct COVID-19 testing of staff at the recommended frequency. The facility did not have a policy and procedure for addressing residents and staff that refuse testing or are unable to be tested . During outbreak testing 29 facility staff members that refused testing were not restricted from the building until the procedures for outbreak testing have been completed. This is evidenced by: On 09/28/20 at 10:35 a.m., Surveyor entered the facility and met and interviewed the Director of Nursing (DON) B. The DON B indicated two staff were confirmed positive for COVID-19 and two residents were confirmed positive for COVID-19. Resident (R) 4 lives on the 200 hall and R5 lives on the 100 hall. Surveyor asked what day the staff and residents tested positive. DON B indicated staff had called into the facility on [DATE] stating they were positive. DON B indicted on Monday 09/21/20 the facility called public health and confirmed the two staff had tested positive. On Tuesday 09/22/20 staff and residents were tested for COVID-19 and results were returned on Friday 09/25/20 and identified R4 and R5 were positive. R5 was transferred on 09/25/20 to the hospital with respiratory symptoms before the results were known. R4 did not have any respiratory or COVID-19 symptoms. Noted will be testing all residents and staff again on Tuesday The facility uses laboratory and has enough supplies. At 1:12 p.m., Surveyor interviewed DON B and Registered Nurse (RN) L about the outbreak and testing. DON B indicated public health was then called on Monday. The public health nurse directed the facility to test all residents and staff within 7 days and to wear masks. Surveyor asked who the two staff were that tested positive and which hall did they work and the date they last worked. DON B indicated CNA M and CNA N both work the long term hall which is the 200 hall. CNA M last worked 09/12/20 and CNA N last worked 09/17/20. Surveyor asked when is the facility doing COVID-19 testing. DON B indicated they are doing weekly testing. Surveyor asked if DON B and RN L monitor the county's positivity percentage rate. DON B and RN L indicated they do monitor the rate but can't recall and the NHA would look that up. On 09/29/20 at 8:00 a.m., Surveyor interviewed DON B and NHA M about required PPE while the facility is in an outbreak. Surveyor gave DON a copy of the Centers for Medicare and Medicaid Services (CMS) Ref: QSO-20-38-NH Memorandum and reviewed the need for staff to wear all PPE for all residents during the outbreak and reviewed the routine testing of staff based on their county- level positivity rates. Surveyor asked DON B if they know what their county positivity rate is at currently. DON B did not know. Surveyor reviewed since 09/10/20 - 09/23/20 the county is listed in the Red with a percentage of 10.8%. Surveyor asked how often staff should be tested . DON B indicated staff are being tested on ce a week. Surveyor reviewed the QSO-20-38-NH memo stating a county positivity rate in the past week of greater than 10% the minimum testing frequency is twice a week*. *This frequency presumes availability of Point of Care testing on-site at the nursing home or where off-site testing turnaround time is <48 hours. NHA M and DON B indicated they would not have enough supplies to complete twice a week testing. Surveyor asked if there is documentation of when and who was contacted to obtain testing supplies. The QSO-20-38-NH documents If the 48-hour turn-around time cannot be met due to community testing supply shortages, limited access or inability of laboratories to process test within 48 hours, the facility should have documentation of its efforts to obtain quick turnaround test results with the identified laboratory or laboratories and contact with the local and state health departments. Surveyor asked DON B if the facility has a policy for when staff and residents refuse to have a COVID-19 test completed. DON B indicated would have to look. At 3:08 p.m., Surveyor interviewed DON B asking when testing was going to start. DON B indicated on 09/15/20 was going to start weekly testing. We got notification the current testing lab was going to do the testing until the facility got paired with a lab. Surveyor asked DON B if known when NHA A would have looked at the county positivity percentages. DON B indicated can't tell what days he looked for the percentages. Surveyor asked DON B if she could recall talking about what approximately the percentages was when they talked about and what they would do. DON B indicated could not recall what the percentages were and that the county was in the green and they just planned to keep monitoring staff and residents and get matched up with the lab for testing. DON B indicated the facility's Point of Care testing machine was received on 09/08/20 and not used. DON B indicated DON B and RN L are the staff with knowledge to use the Point of Care testing machine. DON B indicated they had tested the residents last night and the ones tested were negative. DON B indicated they contacted the laboratory and they are able to send supplies to test again on Friday. Surveyor reviewed with DON B the weekly county positivity percentage rates listed on the website, document: Activity level Low is green with <5% county positivity rate in the past week requires minimum testing frequency of once a month. Activity level Medium is yellow with 5%-10% county positivity rate in the past week requires minimum testing frequency of once a week. Activity level High is red with >10% county positivity rate in the past week requires minimum testing frequency of twice a week. Week ending 08/19/20 the rate of 7.6% is in the yellow. Week ending 08/26/20 the rate of 6.1% is in the yellow. Week ending 09/02/20 the rate of 8.0% is in the yellow. Week ending 09/09/20 the rate is 5.9% is in the yellow. Week ending 09/16/20 the rate is 7.0% is in the yellow. Week ending 09/23/20 the rate is 10.8% is in the red. Surveyor asked the DON B when the facility conducted testing. DON B indicated testing was completed on 05/26/20, 09/15/20 and 09/22/20. The facility was doing weekly testing. Testing was not completed as required per the county positivity rate. Surveyor asked DON B if the facility has a policy for when staff and resident refuse to be tested for COVID-19. DON B indicated there is no policy. Surveyor asked for a list of staff who refused testing. Surveyor was provided with a list of 29 staff that refused to be tested for COVID-19 on 09/22/20. Surveyor asked DON B if the staff continued to work in the facility. DON B indicated yes otherwise there would be no staff to take care of the residents and asked what should they do. Surveyor asked if they would utilize the facility's emergency preparedness policy for short staff. Surveyor reviewed with DON B the QSO-20-38-NH memo documenting If outbreak testing has been triggered and a staff member refuses testing, the staff member should be restricted from the building until the procedures for outbreak testing have been completed.

Based on interview and observation, the facility did not establish an Infection Control Program under which it controls and prevents infections in the facility, or update policy, or implement all Personal Protective Equipment (PPE) to be worn during an outbreak to prevent the spread of infections such as COVID-19. This has the potential to affect all 28 residents that reside in the facility The facility identified a COVID-19 outbreak with a resident on both sides of the facility that tested positive for COVID-19. The facility did not have staff wear all recommended PPE of gloves, gown, eye protection and respirator/facemask for the care of all residents in the facility. This is evidenced by: Centers for Disease Control (CDC) guidance dated July 15, 2020, read in part: Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic If COVID-19 is suspected, based on evaluation of the resident or prevalence of COVID-19 in the community, follow the Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. This guidance should be implemented immediately once COVID-19 is suspected . Because of the higher risk of unrecognized infection among residents, universal use of all recommended PPE for the care of all residents on the affected unit (or facility-wide depending on the situation) is recommended when even a single case among residents or HCP is newly identified in the facility; this could also be considered when there is sustained transmission in the community. The health department can assist with decisions about testing of asymptomatic residents . HCP who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator (or facemask if a respirator is not available), gown, gloves, and eye protection. On 09/28/20 at 10:35 a.m., Surveyor entered the facility and met and interviewed the Director of Nursing (DON) B. The DON B indicated two staff were confirmed positive for COVID-19 and two residents were confirmed positive for COVID-19. Resident (R) 4 lives on the 200 hall and R5 lives on the 100 hall. Surveyor asked what day the staff and residents tested positive. DON B indicated staff had called into the facility on [DATE] stating they were positive. DON B indicated on Monday 09/21/20 the facility called public health and confirmed the two staff had tested positive and residents and resident's representatives were notified of the positive COVID-19. On Tuesday 09/22/20 staff and residents were tested for COVID-19 and results were returned on Friday 09/25/20 and identified R4 and R5 were positive. R5 was transferred on 09/25/20 to the hospital with respiratory symptoms before the results were known. R4 did not have any respiratory or COVID-19 symptoms. Noted will be testing all residents and staff again on Tuesday. The facility uses laboratory and has enough supplies. At 11:11 a.m. Surveyor conducted the initial tour of the facility and observed housekeeping staff in room [ROOM NUMBER] (non-COVID) and the only PPE worn was a face mask and gloves. Housekeeping staff was not wearing all recommenced PPE while cleaning the room. There was no sign or storage bin with PPE outside of the resident's room. Surveyor observed a nurse in room [ROOM NUMBER] (non-COVID) and the only PPE worn was a face mask. The nurse was not wearing all recommended PPE. There was no sign or storage bin with PPE outside of the resident's room. Surveyor observed Certified Nursing Assistant (CNA) J in room [ROOM NUMBER] obtaining vitals from the resident. CNA J was wearing a face mask and was not wearing all recommended PPE. At 11:19 a.m., Surveyor observed CNA H and CNA I transfer R7 from bed to wheelchair. Outside of R7's room there was no sign indicating R7 was on precautions and there was a storage bin outside of the room for the resident next door that had a sign on door. CNA H and CNA I wore a face mask and did not apply all recommended PPE before entering in R7's room. CNA H and CNA I washed their hands and applied gloves and CNA I applied the lift sling under R7 while in bed. CNA H left the room with the full mechanical lift after sanitizing the lift with a Clorox wipe. CNA H returned with another full mechanical lift and washed hands and applied gloves. CNA H and CNA I completed the transfer of R7 from bed to wheelchair. CNA H sanitized lift with a Clorox wipe and removed it from R7's room. CNA H and CNA I removed gloves and washed their hands. At 11:39 a.m., Surveyor observed CNA J enter R7's room. The only PPE worn was a face mask.CNA J did not wear all recommenced PPE to obtain R7's vitals. At 12:56 p.m., Surveyor interviewed CNA I asking if a resident is not on precautions/isolation what PPE would they wear today. CNA I indicated would only wear the face mask. Surveyor interviewed CNA F asking when staff start wearing the KN95 masks. CNA F indicated about a week ago. Surveyor asked what PPE are staff to wear going into a resident's room. CNA F indicated if not on precautions would just wear the face mask and not wear gowns or face shield/goggles during personal cares. At 1:02 p.m., Surveyor interviewed Housekeeping Lead (HL) K asking if going into a non-COVID resident room to clean what HL K would wear. HL K indicated they would wear a face mask and gloves. Surveyor asked what HL K would wear going into a resident's room that is on precautions. HL K indicated would wear mask, face shield, gown and gloves. At 1:12 p.m., Surveyor interviewed DON B and Registered Nurse (RN) L about the outbreak and reporting. RN L indicated the outbreak was reported to NHSN late on Friday 09/25/20 about 7:15 p.m. Normally would report to NHSN on Mondays around 10 a.m. DON indicated the Nursing Home Administrator (NHA) A tried to call the public health on the weekend about the two staff reporting positive for COVID-19 and the NHA was only able to leave a message. DON B indicated public health was then called on Monday. The public health nurse directed the facility to test all residents and staff within 7 days and to wear masks. Surveyor asked who the two staff were that tested positive and which hall did they work and the date they last worked. DON B indicated CNA M and CNA N both work the long term hall which is the 200 hall. CNA M last worked 09/12/20 and CNA N last worked 09/17/20. Surveyor asked to review the facility's policy for outbreak of COVID-19 in the facility. Surveyor reviewed the policy titled Novel Coronavirus Disease 2019 (COVID-19): Plan of action for suspected cases of novel coronavirus (COVID-19) related to symptoms and/or suspect history of exposure dated March 2020, read in part: .COVID-19 in Facility .9. The CDC suggest all health care workers where a mask at all times when in the facility and consider wearing full PPE. This determination will be made in consultation with the medical director, administrator, director of nursing, and local department of public health (DPH) based on the situation in the facility and the availability of PPE supplies . Surveyor asked DON B and RN L why staff are not wearing full PPE in every resident room since the first facility staff positive case of COVID-19 in the building and now having COVID-19 throughout the building. DON B indicated the policy states the CDC suggests and staff only wear PPE in resident rooms that are on precautions and positive rooms. On 09/29/20 at 8:00 a.m., Surveyor interviewed DON B and NHA M about required PPE while the facility is in an outbreak. Surveyor gave DON B a copy of the Centers for Medicare and Medicaid Services (CMS) Ref: QSO-20-38-NH Memorandum and reviewed: When COVID-19 is identified in the facility, staff wear all recommend PPE (i.e., gloves, gown, eye protection and respirator or facemask) for the care of all residents on the unit (or facility-wide based on the location of affected residents), regardless of symptoms (based on availability). DON B indicated yesterday evening PPE was placed out for staff to use when entering into any resident's room. At 8:26 a.m., Surveyor toured the facility and identified R8 was being assisted with breakfast by a staff member wearing PPE of face shield, mask, gown and gloves. Surveyor observed all resident rooms now had signs on the doors and storage bins with PPE outside of residents' doors. Staff is noted to be wearing washable gowns.

Based on interview and record review, the facility did not ensure the high-temperature dishwasher reached proper temperatures to clean and sanitize dishes and tableware for resident use and food preparation. This has the potential to affect all 32 residents who reside at the facility. Documented rinse cycle temperatures of the dishwasher did not always reach the required 180 degrees Fahrenheit. This is evidenced by: On 06/03/19 at 8:11 a.m., Surveyor conducted an initial tour of the kitchen. The Dietary Manager (DM) A informed Surveyor the dishwashing machine is a high-temperature machine, which uses hot water during the rinse cycle to clean and sanitize dishes and tableware. On 06/03/19, Surveyor received and reviewed the Dishwasher Temperature Log sheets from (MONTH) 2019 to 06/03/19. The log sheets state the following, in part, Please record the temperature of the 'wash cycle' and 'rinse cycle' on the dishwasher .Rinse Cycle-minimum 180 degrees F (Fahrenheit) .If temperature is below the required minimum, stop using the dishwasher until the minimum temperature reaches the required range. If temperatures do not reach the required range, contact maintenance or your department head. Note action taken in far right-hand column. If dishwasher needs service, wash dishes using the three-sink method . This form is located on a rack, near the dishwasher. The Dishwasher Temperature Logs identify the following rinse cycle temperatures of the dishwasher, in part: June 2019: -06/01/19: 164 degrees Fahrenheit, internal test strip documented as FAIL. Action Notes documented as Notified Supervisor. -06/02/19: 149.5 degrees, internal test strip documented as FAIL. No corrective action documented. -06/03/19: 171 degrees. No corrective action documented. May 2019: -05/06/19: 178 degrees Fahrenheit. No corrective action documented. -05/08/19: 176 degrees. No corrective action documented. -05/09/19: 177 degrees. No corrective action documented. -05/12/19: 178 degrees. No corrective action documented. -05/14/19: 178 degrees. No corrective action documented. -05/25/19: No rinse temperature documented. No corrective action documented. -05/26/19: No rinse temperature documented. No corrective action documented. -05/29/19: 160 degrees. No corrective action documented. March 2019: -03/05/19: 170.2 degrees Fahrenheit. No corrective action documented. -03/11/19: 170 degrees. No corrective action documented. -03/12/19: 172 degrees. No corrective action documented. -03/13/19: 175 degrees. No corrective action documented. There are no staff identifiers to determine which staff documented the temperatures on specific days. On 06/04/19 at 11:21 a.m., Surveyor interviewed Dietary Aide (DA) C. DA C stated an internal test strip (which tests the hot water inside the dishwasher) is run through the dishwasher one time each day. DA C stated the daily dishwasher temperature logs are observed by staff from a digital panel which displays the wash and rinse temperatures of the dishwasher. DA C stated the temperature logs are not documented from the internal temperature test strips. During the continued interview, DA C stated if the dishwasher does not reach the proper rinse temperature, staff then calls the dishwasher manufacturer. DA C further stated the manufacturer will adjust whatever is wrong with the dishwasher. DA C stated last week, staff had difficulty with the dishwasher not reaching the correct temperature, so there was someone in the facility to fix the dishwasher. Surveyor reviewed an EcoLab Service Call report, dated 05/28/19. The report states the following, in part, .Final Rinse Temperature (degrees Fahrenheit) .Today (Observed) 172 (degrees) .Adjusted (to) 187 (degrees) . On 06/04/19 at 12:57 p.m., Surveyor interviewed Cook B and DA D. Both Cook B and DA D stated if the dishwasher is not reaching the proper temperature, they would continue to run the dishwasher until the machine reached the proper rinse temperature. Cook B and DA D stated if the dishwasher did not reach the proper temperature, they would then wash the dishes in the kitchen three-compartment sink and let DM A know about the dishwasher. At 1:58 p.m., Surveyor received and reviewed a facility policy and the dishwasher manufacturer's guidelines. The facility policy entitled, Equipment Sanitation and Safety, which was last reviewed in (MONTH) (YEAR), states the following, in part: .1. All cleaning and sanitizing compounds are used following manufacturer's instructions for concentration and precautions .4. Dishwashing Machines: In order to properly clean and sanitize dishes and other utensils .Rinse water temperature must be 180 (degree) F. Supervisors must constantly be alert to insure these temperatures are maintained. All dishroom personnel MUST stop machines and call the supervisor should a drop in temperature occur . The undated dishwasher manufacturer's guidelines owner's manual states the following, in part, 1. Specifications .CYCLE TEMPERATURES .RINSE .180 (degrees)-195 (degrees) . On 06/05/19 at 10:40 a.m., Surveyor interviewed DM A regarding the dishwasher rinse temperatures. DM A stated she spoke with DA E, and DA [NAME] indicated he was averaging the higher rinse cycle temperature and documenting this number on the logs. DM A stated she thinks dietary staff were not educated about the proper dishwashing temperatures and how to record the temperatures on the logs. During the continued interview, DM A stated per the facility policy, dietary staff are supposed to stop using the dishwasher and wash dishes in the three-compartment sink. DM A confirmed no corrective action is documented on the days in which the rinse temperatures were below 180 degrees.

Based on observation, interview and record review, the facility did not ensure a resident maintains acceptable parameters of nutritional status; and is offered sufficient fluid intake to maintain proper hydration and health. This affected one of four residents (Resident (R) 22) who were reviewed for nutrition and hydration. R22's nutritional supplement was not consistently documented as provided or consumed. The resident is at risk of dehydration and has chronic urinary tract infections. The facility did not assess the resident's daily fluid needs, and the care plan does not identify the resident is at risk for dehydration. The resident's fluid preferences were not provided to R22 during breakfast and staff did not encourage the resident to drink fluids during meals. This is evidenced by: On 06/03/19, Surveyor reviewed R22's medical record. The resident has [DIAGNOSES REDACTED]. The medical record identifies the resident has a history of dehydration. The resident's medical record identifies the resident requires assistance with ambulation, dressing, personal hygiene, and transfers. The resident has an indwelling catheter. The resident's Brief Interview for Mental Status (BIMS) score, dated 05/22/19, was a 13 out of 15 points. According to the BIMS assessment, a score of 13 indicates the resident has intact cognitive function. According to the resident's Minimum Data Set (MDS), dated [DATE], the resident is 70 inches tall (approximately 5.8 feet), and weighs 186 pounds. Surveyor reviewed R22's nurses' and dietary notes, from 05/15/19 to 06/04/19. The notes state the following, in part: -05/16/19, nurses' notes: .resident arrives to (name of facility) with dark amber and foul-smelling urine; admitted ly doesn't hydrate well . -05/16/19, nurses' notes: .Oriented at all times-does get increased confusion with dehydration . -05/18/19, nurses' notes: .Fluids encouraged, (R22's name) does not like to drink very much . -05/19/19, nurses' notes: .catheter .draining dark amber urine. He declines drinking fluids much of the time, P[NAME] (Plan of Care) to encourage as much as possible .is hard of accepting fluids . -05/22/19, nurses' notes: .Fluids offered and encouraged. Urine dark amber . -05/24/19, dietary notes: Dehydration Risk Factor: ADMIT Draining wounds or pressure ulcers History of dehydration Chronic comorbidities .Isolation .Physical S/S (Signs and Symptoms of dehydration): None at this time, Hx (history) of chronic UTIs .Interventions: routine observation of fluid intake. Encourage fluid intake. -05/24/19, nurses' notes: .no problems with swallowing . -05/29/19, nurses' notes: .Assist resident with drinking fluids. Find out favorites-ice water and diet coke-and offer with every encounter/check on well-being . Surveyor reviewed the resident's initial nutritional assessment, dated 05/22/19. The assessment states the following, in part, Assessment Type: Initial .Feeding ability: Limited Assistance, straws with beverages .No chewing/swallowing problems noted .Fluid Intake: Less than 1500 cc/daily (cubic centimeters), encourage fluids throughout the day . There is no assessment of R22's daily fluid needs in the assessment or in the medical record. According to Surveyor's calculations, based on the resident's height and weight from the MDS, R22's daily fluid needs are approximately 2,632 cc's per day. R22's care plan states the following, in part, .05/29/2019 Note: Assist resident with drinking fluids. Find out favorites-ice water and diet coke-and offer with every encounter/check on well being .05/29/2019 Nutrition .Strength: regular diet, accepts supplements. Problem fair intake at meals, [MEDICAL CONDITION] open skin areas .Approaches .Encourage fluids throughout the day, I like diet shasta, orange juice, water, and strawberry water .Ensure plus (nutritional drink supplement) 3x (three times) per day .05/30/2019 Breakfast Drink: JCE (Juice) ORANGE. Lunch Drink: Diet Shasta, water .STRAWS with drinks .Please encourage me to drink enough fluids as this has been a struggle of mine .Offer me fluids frequently while awake. Encourage me and help me to take drinks when I need to . The care plan does not identify the resident is at risk for dehydration. Surveyor reviewed R22's Ensure supplement intakes, from 05/24/19 to 06/06/19. The intakes are documented as the following, in part: -05/24/19, lunch: 240 cc's -05/26/19, breakfast: 240 cc's; lunch: 240 cc's -05/27/19, supper: Refused -05/29/19, lunch: Out of the building; supper: 240 cc's -05/30/19, breakfast: 240 cc's; lunch: 240 cc's -05/31/19, supper: Refused -06/03/19, supper: 0 cc's The Ensure supplement was changed from three times a day, to once a day at supper, as of 05/31/19. There is no consistent documentation if the resident was provided, or consumed the nutritional supplement, three times a day, until 05/31/19. There is no consistent documentation if the resident was provided, or consumed the supplement at supper after 06/01/19. Surveyor reviewed the resident's daily fluid intakes, from 05/16/19 to 06/03/19. The daily fluid intakes are documented as the following, in part: -05/16/19: 1,050 total cc's -05/17/19: 1,010 total cc's -05/18/19: 1,230 total cc's -05/19/19: 1,110 total cc's -05/20/19: 850 total cc's -05/21/19: 1,670 total cc's -05/22/19:1,630 total cc's -05/23/19: 1,610 total cc's -05/24/19: 1,100 total cc's -05/25/19: 1,330 total cc's -05/26/19: 1,860 total cc's -05/27/19: 960 total cc's -05/28/19: 1,040 total cc's -05/29/19: 1,370 total cc's -05/30/19: 1,410 total cc's -05/31/19: 1,280 total cc's -06/01/19: 1,710 total cc's -06/02/19: 1,300 total cc's -06/03/19: 705 total cc's On 06/03/19 at 11:31 a.m., Surveyor observed the noon meal in the main dining room. R22 was sitting in a wheelchair at a dining room table. The resident had a covered cup of soda with a straw, and a covered cup of a purple liquid with a straw. A cup of covered water with a straw was also on the table. A paper covering was still located on the top portion of the straw in the water cup. At 11:51 a.m., R22 had eaten his meal and had not yet drank any fluids. Surveyor did not observe staff members encourage or assist the resident with drinking fluids. At 11:53 a.m., and 11:56 a.m., Surveyor observed R22 independently reach for the cup of soda and take a few sips each time. At 11:59 a.m., the resident was eating dessert. R22 was not observed to drink any water, and was not observed to drink any more fluids. Staff did not encourage or assist the resident with drinking any fluids, or removing the paper covering on the straw in the water cup. The observation ended at this time. On 06/04/19 at 7:37 a.m., Surveyor observed R22 lying in bed, and the resident was awake. There were no fluids located in the resident's room or bedside at this time. At 8:28 a.m., Surveyor observed the breakfast meal in the main dining room. R22 was sitting in a wheelchair at a dining room table. The resident had a covered cup of water with a straw. The resident was not provided or offered orange juice, per the resident's care plan. At 8:40 a.m., R22 had eaten the breakfast meal and had not yet drank any fluids. Surveyor did not observe any staff members encourage or assist the resident with drinking any fluids. At 8:42 a.m., the resident independently drank approximately one-third of water from the cup. At 8:47 a.m., Surveyor observed R22 self-propelling away from the dining room table. No staff members were observed to encourage the resident to drink fluids, and no additional fluids were offered to the resident during the meal. On 06/05/19 at 8:31 a.m., Surveyor observed R22 in the main dining room. The resident had a cup of water and a cup of white milk. Both cups were uncovered and did not contain straws. No orange juice was provided to the resident, per the resident's care plan. At 7:19 a.m., Surveyor interviewed R22. The resident was lying in bed, on his back at this time. A bedside table was to the left side of the resident's bed. A small can of Diet Shasta with a straw, and a covered mug of water, with a straw, was located on the bedside table. The resident stated he drinks a lot of water, per his doctor's orders. The resident stated he likes drinking orange juice, Diet Coke, and strawberry-flavored water. During the continued interview, Surveyor asked R22 if the resident is able to drink fluids independently, while lying in bed. The resident stated he is left handed and it is hard to drink while in bed, especially drinking out of a straw. The resident indicated he can only bend the straw down so far before he is sucking dry air. R22 indicated his mouth was currently feeling dry, because he hasn't had any water. Surveyor asked if staff encourage the resident to drink fluids throughout the day. R22 replied staff do not really encourage the resident to drink. On 06/05/19 at 8:34 a.m., Surveyor interviewed Registered Nurse (RN) F. The RN stated R22 drinks pretty well, and indicated staff encourage the resident to drink fluids at meal times. At 9:27 a.m., Surveyor interviewed Certified Nursing Assistant (CNA) J. The CNA stated she does not know what the resident likes to drink, and indicated the resident drinks water pretty well. CNA J stated she will encourage the resident to drink fluids whenever she is in the resident's room with R22. At 9:37 a.m., Surveyor interviewed CNA G. The CNA stated R22 enjoys drinking Coke and water. CNA G stated the resident does not need encouragement from staff to drink fluids, and the CNA does not believe R22 is at risk for dehydration. At 10:40 a.m., Surveyor interviewed Dietary Manager (DM) A. DM A did not know why the resident did not receive orange juice at breakfast, the mornings of 06/04/19 and 06/05/19, and indicated the resident's preference of orange juice is listed on the resident's dietary card. DM A did not know why R22 did not receive covers or straws on the resident's cups, during breakfast on 06/05/19. During the continued interview, Surveyor asked if the dietician assessed R22's daily fluid needs. DM A stated she and the facility dietician completed the resident's initial nutritional assessment together. DM A indicated R22's daily fluid needs are not assessed and documented, but DM A stated she and the dietician did talk about the resident's daily fluid needs. At 2:29 p.m., Surveyor interviewed CNA I. The CNA stated R22 likes to drink chocolate milk, Diet Coke and ice water. CNA I stated the resident's urine is dark in color so she pushes the resident to drink fluids. At 2:30 p.m., Surveyor interviewed CNA H. The CNA stated the resident likes to drink chocolate milk, Diet Coke and ice water. CNA H stated R22 does not drink very well, so the CNA offers fluids to the resident about every hour. At 1:14 p.m., Surveyor interviewed the Director of Nursing (DON) and the Nursing Home Administrator. The DON stated R22's fluid intakes are hit and miss, and the resident's intakes have been over 1,000 cc's per day. The DON stated the resident is at risk of dehydration.

Based on observation, interview and record review, the facility did not ensure a resident with limited mobility receives appropriate services, and assistance to maintain or improve mobility with the maximum practicable independence. This occurred for one of two residents (Resident (R) 22) who was reviewed for range of motion. R22's ambulation program was not documented as completed. The resident was not observed to walk to and from meals during three of three days of survey. This is evidenced by: On 06/03/19, Surveyor reviewed R22's medical record. The resident has [DIAGNOSES REDACTED]. The resident's medical record identifies the resident is at risk for falls, and requires assistance with ambulation and transfers. Surveyor reviewed R22's care plan. The care plan states the following, in part, .05/23/19 AMBULATION: To and from meals 1 (staff) assist with w/c (wheelchair) to follow 7 x/wk (times per week) .Goals: Maintain mobility .06/04/19 1 assist Front wheeled walker with W/C (wheelchair) to follow . R22's ambulation documentation was reviewed, from 05/23/19 to 06/03/19. The documentation states the following, in part: -05/24/19: No documentation if the resident was ambulated to and from supper, or if the resident refused ambulation. -05/25/19: No documentation if the resident was ambulated to and from breakfast, lunch and supper, or if the resident refused ambulation. -05/26/19: No documentation if the resident was ambulated to and from breakfast, lunch and supper, or if the resident refused ambulation. -05/28/19: No documentation if the resident was ambulated to and from breakfast, and lunch, or if the resident refused ambulation. -05/29/19: No documentation if the resident was ambulated to and from lunch, or if the resident refused ambulation. -05/30/19: No documentation if the resident was ambulated to and from supper, or if the resident refused ambulation. -06/03/19: No documentation if the resident was ambulated to and from breakfast, and lunch, or if the resident refused ambulation. Surveyor reviewed R22's nurses' notes, from 05/15/19 to 06/04/19. There is no documentation in the notes to identify if the resident has been refusing, or has been too weak to ambulate to and from meals. On 06/03/19 at 11:31 a.m., Surveyor observed staff wheel R22 in the main dining room in a wheelchair for lunch. On 06/04/19 at 8:28 a.m., Surveyor observed staff wheel R22 in the main dining room in a wheelchair. At 8:47 a.m., Surveyor observed the resident self-propel, via the wheelchair, out of the main dining room after breakfast. Staff did not offer to walk the resident out. On 06/05/19 at 8:31 a.m., Surveyor observed R22 self-propel out of the main dining room, after breakfast. Staff did not offer to walk the resident out. At 8:34 a.m., Surveyor interviewed Registered Nurse (RN) F. The RN stated R22 walks to every meal, and goes to the therapy room for exercises after breakfast. At 9:27 a.m., Surveyor interviewed Certified Nursing Assistant (CNA) J. The CNA indicated if she does not have time in the morning to walk R22 to breakfast, CNA J will try to walk the resident after breakfast. CNA J stated she normally charts when the resident ambulates. At 9:37 a.m., Surveyor interviewed CNA G. The CNA G stated she will document in the resident's medical record if R22 declines to ambulate to and from meals. At 2:29 p.m., Surveyor interviewed CNA I. The CNA stated she knows R22 is supposed to walk in the afternoons, but indicated the resident is usually too weak at that time. Because the resident is too weak, CNA I stated R22 does not ambulate in the afternoons. CNA I stated she will document 0's in the restorative documentation if the resident does not walk. The CNA stated she informs the nurses when the resident is too weak to ambulate. At 1:14 p.m., Surveyor interviewed the Director of Nursing (DON). The DON stated when the facility first initiated R22's ambulation program, staff was not walking the resident, due to the resident's care plan indicating the resident was non-ambulatory. The DON stated she fixed R22's ambulation status in the resident's care plan a couple of days ago. The DON indicated staff are supposed to document in the resident's record when R22 declines to ambulate.

Based on observation, interview and record review, the facility did not ensure each resident's care plan is reviewed and revised, based on the resident's needs and comprehensive assessment. This occurred for two of 18 residents (Residents (R) 22 and 24) whose care plans were reviewed. 1. R22's care plan was not updated to identify the resident receives a nutritional supplement once a day instead of three times a day. The care plan was not updated to identify the resident no longer uses a catheter leg bag. 2. R24's care plan was not updated to identify non-pharmacological interventions to promote sleep. This is evidenced by: 1. On 06/03/19, Surveyor reviewed R22's medical record. The resident has [DIAGNOSES REDACTED]. The resident's medical record identifies the resident has an indwelling urinary catheter, and requires assistance with ambulation, dressing, personal hygiene, and transfers. The resident's Brief Interview for Mental Status (BIMS) score, dated 05/22/19, was a 13 out of 15 points. According to the BIMS assessment, a score of 13 indicates the resident has intact cognitive function. Surveyor reviewed R22's nurses' notes, from 05/15/19 to 06/03/19. The notes state the following, in part: -05/24/19, fax to R22's primary physician: .We encourage high protein foods for him and offer snacks per his preference to encourage intake .may we initiate a supplement on the recommendations of the RD (Registered Dietician)? . -05/30/19: .Nutritional At Risk Comments .is eating well at breakfast and lunch .Supplement will be added at supper . According to R22's fluid intake records, the nutritional supplement was first documented as given to the resident, on 05/24/19. The resident's care plan was reviewed. The care plan states the following, in part, 05/29/19 Nutrition Approaches .Ensure plus (nutritional drink supplement) 3x (three times) per day . 05/16/19 .Urinary Approaches .I would like to use a (catheter) leg bag during the day . On 06/03/19 at 11:31 a.m., Surveyor observed R22 sitting in a wheelchair, seated at a table in the main dining room. The resident had a cup of Diet Coke and a cup which contained a purple-colored drink. No Ensure supplement was provided to the resident at this time. The resident had a covered catheter bag located below the wheelchair. The resident was not wearing a catheter leg bag. At 11:59 a.m., the resident was eating dessert and finished eating the noon meal. No Ensure supplement was offered or provided to the resident during the meal. On 06/04/19 at 8:28 a.m., Surveyor observed R22 sitting in a wheelchair, seated at a table in the main dining room. The resident had a cup of water. No Ensure supplement was provided to the resident at this time. The resident had a covered catheter bag located below the wheelchair. The resident was not wearing a catheter leg bag. At 8:47 a.m., the resident was observed to be self-propelling away from the table. No Ensure supplement was offered or provided to the resident during the breakfast meal. On 06/05/19 at 8:31 a.m., Surveyor observed R22 self-propelling away from the dining room table. No Ensure supplement was at the table where the resident was seated. The resident had a covered catheter bag located below the wheelchair. The resident was not wearing a catheter leg bag. At 8:34 a.m., Surveyor interviewed Registered Nurse (RN) F. RN F stated R22 receives the Ensure supplement for the breakfast and noon meals. The RN is not sure if the resident receives the supplement at supper. RN F stated the resident does not war a leg bag, as R22 prefers to have the catheter bag located below the wheelchair. At 9:37 a.m., Surveyor interviewed Certified Nursing Assistant (CNA) G. The CNA indicated the resident receives the Ensure supplement in the morning for breakfast. CNA G stated she does not believe R22 uses a catheter leg bag, as there are no leg bags located in the resident's room. At approximately 8:45 a.m., Surveyor interviewed R22. The resident stated he usually receives a chocolate supplement for meals. R22 indicated he did not receive the supplement this morning during the breakfast meal. At 10:40 a.m., Surveyor interviewed Dietary Manager (DM) A. DM A stated the resident's Ensure supplement was changed from three times a day, with meals, to just being offered at supper. DM A stated this change occurred on 05/31/19. The Dietary Manager stated she updated R22's care plan on 06/05/19. At 1:14 p.m., Surveyor interviewed the Director of Nursing (DON) and the Nursing Home Administrator (NHA). Surveyor discussed the observations of the resident not wearing the catheter leg bag, and the DON stated she would have to look into this. No additional information was provided to Surveyor. During the interview, the DON and NHA did not know why R22's Ensure supplement was changed to the supper meal instead of three times a day. The DON and NHA indicated the care plan should be updated with the correct changes regarding the supplement frequency. 2. On 06/03/19, Surveyor reviewed R24's medical record. The resident has [DIAGNOSES REDACTED]. The resident receives [MEDICATION NAME] (an antianxiety medication) 0.25 milligrams at bedtime, for [MEDICAL CONDITION]. The resident has been taking this dose, since 05/07/19. Surveyor reviewed the resident's sleep assessments, dated 01/24/19 and 04/24/19. The sleep assessments state the following, in part: -01/24/19: .The following sleep assist alternatives were discussed with the resident or family to assist the resident with restful sleep: covers darkened room door shut evening bath pillows for positioning pulling blinds at night white noise . -04/24/19: .The following sleep assist alternatives were discussed with the resident or family to assist the resident with restful sleep .assisting the resident with evening prayer covers darkened room door shut Discussed maintaining a consistent routine to enhance sleep. pillows for positioning pulling blinds at night Discussed the type of room environment that is provided . Surveyor reviewed R24's care plan. The care plan identifies the resident has anxiety, depression and difficulty with sleep. The staff approaches identified in the sleep care plan advise staff to provide a quiet environment and to offer the resident non-pharmacological interventions to help R24 sleep. The care plan does not specifically identify the non-pharmacological interventions, including those identified on the resident's sleep assessments. On 06/05/19 at 9:27 a.m., Surveyor interviewed CNA J, and asked what non-pharmacological interventions staff could use to promote R24's sleep. The CNA stated she does not know any interventions to help promote the resident's sleep. CNA J reviewed R24's care plan, and stated there are no interventions identified on the care plan. At 9:37 a.m., Surveyor interviewed CNA G. The CNA stated she has only worked twice on a PM shift, and she is not aware of any non-pharmacological interventions to help promote R24's sleep. At 2:29 p.m., Surveyor interviewed CNA I, and asked what non-pharmacological interventions staff could use to promote R24's sleep. The CNA stated R24 likes to read at night, and to offer the resident warm tea. CNA I further indicated they can lotion the resident's back and massage the resident's feet. At 2:30 p.m., Surveyor interviewed CNA H, and asked what non-pharmacological interventions staff could use to promote R24's sleep. The CNA stated she can get R24 involved in activities, ask the resident if the resident would like to walk around, and provide one-to-one visits. CNA H was unsure if non-pharmacological sleep interventions were located on the resident's care plan. At 1:14 p.m., Surveyor interviewed the DON and NHA. Surveyor asked what non-pharmacological interventions staff should use to promote sleep for R24. The DON stated R24 likes the room door closed, having a darkened room, bed time medications and has a bedtime routine. The DON stated the non-pharmacological interventions to promote sleep should be identified on the resident's care plan.

Based on observation, interview and record review, the facility did not develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and goals in order to meet a resident's medical, nursing, and psychosocial needs, which are identified in the comprehensive assessment. This occurred for two of 18 residents (Residents (R) 22 and 25) whose care plans were reviewed. 1. The facility did not develop a care plan for R22's use of an anticoagulant (blood thinner) and the chronic skin discoloration on the resident's leg. 2. The facility did not develop a plan of care related to [MEDICAL CONDITION] medications for R25. This is evidenced by: 1. On 06/03/19, Surveyor reviewed R22's medical record. The resident has [DIAGNOSES REDACTED]. The resident has been taking Xarelto 20 milligrams, since 05/15/19. Xarelto is an anticoagulant medication which is used to prevent and treat blood clots. Some of the potential risks involved when taking this medication are severe bleeding, being more prone to bruising, having pink, red or brown-colored urine, having bright red or black bowel movements, headaches, and feeling dizzy or weak. The resident's medical record identifies the resident is at risk for falls, and requires assistance with ambulation and transfers. The resident's Brief Interview for Mental Status (BIMS) score, dated 05/22/19, was a 13 out of 15 points. According to the BIMS assessment, a score of 13 indicates the resident has intact cognitive function. Surveyor reviewed R22's care plan. The resident does not have a care plan for the potential risks involved for taking the anticoagulant medication, and the care plan does not identify the resident is taking the anticoagulant. On 06/03/19 at 10:43 a.m., R22 was sitting in a wheelchair in front of a nurses' station. On the resident's left leg, approximately the mid-shin area of the front of the shin, there appears to be a dark-colored area with scabs present. Surveyor reviewed R22's nurses' notes, from 05/15/19 to 06/03/19. The notes state the following, in part: -05/15/19: .Has a large purple/blue area on lower left shin measures 10 cm (centimeters) and goes around his leg. He states he has had this a long time and it is not painful. According to Surveyor's calculations, 10 cm is approximately 3.93 inches. There is no other documentation or skin assessments regarding this darkened area on the resident's left leg. -05/29/19: .Post Tibial Pulse: Right (leg) Left (leg) Other: difficult to palpate (able to be felt) . A posterior tibial pulse is a pulse which is felt over the posterior (back) tibial artery. This artery is located behind the ankle bone on the inner aspect of the ankle. By locating a resident's pulse in a lower extremity, an assessment can be made to determine if the resident has circulatory issues, including the resident's risk of having [MEDICAL CONDITION]. On 06/05/19 at 7:28 a.m., Surveyor interviewed R22. The resident stated the darkened area on the left leg was due to a motorcycle accident when the resident was younger. The resident stated his leg almost had to be amputated, and his leg was infected. R22 stated his left leg has had a dark complexion ever since this injury occurred. The resident further stated a physician indicated the blood circulation in the resident's left leg is not good. R22 stated he has nerve damage in the calf muscle of the left leg and has lost some feeling in this area. Surveyor reviewed R22's care plan. The resident does not have a care plan for the chronic darkened area on the resident's left leg, including the potential for circulatory issues and the need to monitor for potential injury to the left leg. On 06/05/19 at 1:14 p.m., Surveyor interviewed the Director of Nursing (DON) and the Nursing Home Administrator. The DON stated the facility normally would have a care plan for the resident regarding the resident's anticoagulant. The DON stated the darkened area on R22's left leg is chronic, and the facility should have this identified on the resident's care plan. 2. R25's [DIAGNOSES REDACTED]. On 06/03/19 at 2:16 p.m., Surveyor reviewed R25's clinical record. The Minimum Data Set ((MDS) dated [DATE] indicated that R25 showed a PHQ-9 (a tool used to determine depression/depression severity) score of 3, showing minimal symptoms of depression at the time of the interview. Surveyor reviewed R25's Physician order [REDACTED]. (Milligrams) orally at bedtime for anxiety. R25 was also receiving [MEDICATION NAME] Oxalate (an antidepressant) 10 mg. orally every morning for depression. Surveyor reviewed R25's plan of care. The plan of care did not list depression or anxiety as diagnoses. The plan of care did not include behavior monitoring to assess/monitor R25's level of anxiety or assessment and monitoring for worsening symptoms of depression. The plan of care did not include non-pharmacological interventions for the treatment of [REDACTED]. On 06/05/19, Surveyor interviewed the DON. The DON agreed that R25's plan of care should have included a [DIAGNOSES REDACTED].

Based on record review and interview, the facility did not promptly consult a physician when 1 out of 6 sampled residents (R1) had a significant change in status. R1 developed symptoms that were not clearly defined to the physician in a fax that was sent on 05/25/18. R1 developed a change in status to include abnormal lung sounds, right side chest pain, congestion, and a decline in mental status on 05/26/18 at 1:46 p.m., and the facility did not consult a physician. R1 was transferred to the hospital on [DATE] at approximately 7:00 a.m. and admitted with pneumonia and [MEDICAL CONDITION]. This is evidenced by: R1 was admitted to the facility for rehabilitation following a fall and [MEDICAL CONDITION] on 05/15/18. Post-operative complications included [MEDICAL CONDITION] (irregular heart rate) and [MEDICAL CONDITION] (low blood count). The facility completed a brief interview for mental status and noted R1 scored 15 out of 15, which indicated R1 was cognitively intact. Review of the nurses notes on 05/25/18 at 11:27 a.m., Registered Nurse (RN)-A documented R1 had cold symptoms, right side chest pain, and crackles in both lung bases. On 05/25/18 at 1:07 p.m. and 1:09 p.m., RN-A noted R1 had stable blood pressure, but heart rate was in the 90's and had been creeping up. RN-A also noted R1 needed more help with activities of daily living and has been a bit listless and not processing tasks real clearly. The note indicated physician was updated. Surveyor was unable to locate this evidence or physician response. Surveyor asked for evidence of the physician update by RN-A noted above. The Director of Nurses (DON) printed off a document signed by RN-B stating R1 reported right side pain and cold symptoms. The cold symptoms were not defined for the physician. RN-B also stated in the fax document the nurse noted no cold symptoms for R1. There was no physical lung assessment completed or reported to the physician. The abnormal lung sounds noted on 05/25/18 was never included on the physician updates. The physician did not respond to this fax sent on 05/25/18 by RN-B. On 08/28/18 at 11:38 a.m., Surveyor interviewed the DON regarding the physician update dated 05/25/18 by RN-B. The DON stated the fax did not include any lung assessment. The DON confirmed the physician fax update did not include the crackles in R1's lungs. The DON confirmed the physician never responded to the fax sent on 05/25/18. On 05/26/18 at 1:46 p.m., RN-A again assessed R1 and noted fine scattered rales at bases. On 05/26/18 at 1:49 p.m., R1's daughter reported increased congestion, confusion, and shortness of breath. RN-A did not complete another lung assessment and did not assess R1 for congestion or signs of infection. RN-A did not contact the physician with the significant change in status reported by R1's daughter and assessed by self. On 05/26/18 at 5:50 p.m., Licensed Practical Nurse (LPN)-C noted R1 was unable to rate pain using the numerical pain scale. R1 had rated pain 12 times prior to this assessment using the numerical scale without difficulty. R1 showed a decline in cognition. On 05/26/18 at 5:52 p.m., LPN-C documented R1 had congestion in upper lung fields that cleared with coughing. LPN-C documented R1 had clear lower lung fields. This lung assessment was not confirmed by a registered nurse. LPN staff are not licensed to conduct assessments. On 05/26/18 at 8:44 p.m., LPN-C noted telephone call from R1's daughter reporting concerns with R1's declining condition. There was no registered nurse assessment of R1 following the daughter's report of R1's declining condition. On 08/28/18 at 12:00 p.m., Surveyor interviewed R1's daughter. The daughter stated family had reported R1's failing health several times the day before R1 was transferred. The daughter stated R1 was more confused, needed more help, was congested, and had right side chest pain. On 08/28/18 at 8:30 a.m., Surveyor interviewed the DON regarding change in resident status. The DON stated when a resident had a change in status, the registered nurse should complete a thorough head to toe assessment, unless the change is more specific. The registered nurse should then update the physician with findings. On 08/28/18 at 12:55 p.m., Surveyor interviewed RN-D regarding the staff nurse role with resident change in status. RN-D stated when a resident had a change in status, her role was to assess the problem and report to the case manager for further direction. RN-D stated when the case manager was not available, the physician must be updated with a change in status. Surveyor asked if the new onset of abnormal lung sounds would be considered a change in status and RN-D stated yes and the physician would be consulted for further instructions. On 08/28/18 at 1:10 p.m., Surveyor interviewed RN-E regarding change in status. RN-E stated she had been the case manager for several months. RN-E stated a resident with a history of [MEDICAL CONDITION] would require a heart and lung physical assessment. RN-E stated the progression of abnormal lung sounds goes from crackles, to rales, to rhonchi. RN-E stated if abnormal lung sounds were noted, the physician should be consulted for further directions. On 08/28/18 at 1:15 p.m., the Nursing Home Administrator (NHA) informed Surveyor that the facility followed the American Medical Director Association Acute Change in Condition Clinical Practice Guidelines. Surveyor reviewed the guidelines and noted, This guideline is not to replace the nurse's clinical judgment and notification can always be conducted if the nursing assessment leads to the conclusion that immediate intervention is required.

Based on record review and interview, the facility did not ensure nutritional care and services to residents who were identified with weight loss for 1 of 6 residents (R5) reviewed for nutrition and weight loss. R5 had significant weight loss; the facility did not implement new interventions to meet the resident's nutritional needs and did not inform the physician of the weight loss to identify if there are physiological changes. The facility did not have a system to verify weights to ensure accuracy. This is evidenced by: R5 was admitted [DATE] and has current [DIAGNOSES REDACTED]. Review of R5's nursing care plan read in part: 04/17/17 NUTRITION: --Strengths: good intake of foods/fluids, --Problems Type 2 diabetes, depression, NUTRITION GOALS X 12 WEEKS: --I will have no significant weight gain. NUTRITION APPROACHES: --Provide ordered diet ALL DIET, --Prefers large portions. Nutritional Service. Review of R5's weights: 12/10/19 - 192.0 pounds (#) 12/11/16 - 192.0 # 12/12/17 - 192.0 # 12/28/16 - 194.7 # No further weights obtained until: 02/15/17 - 198.1# 03/01/17 - 188 # (This is a 5.09% weight loss in 14 days) 03/08/17 - 186.8 # 03/15/17 - 184.2 # (This is a 7.02% weight loss in one month) 03/22/17 - 184.6 03/29/17 - 184.6 # 04/05/17 - 180.0 # 04/12/17 - 184 # 04/19/17 - 184 # 04/20/17 - 182.4 # 04/26/17 - 183 # 05/03/17 - 185.6 # 05/10/17 - 180.8 # (This is a 5.83% weight loss in 5 months) 05/12/17 - 181.4 # (This is an 8.43% weight loss in 3 months) Review of R5's medical record did not identify physician notification of weight loss. Review of the dietician notes documented on 12/16/16 an admission weight of 192 # with a food intake as being good with more than 75%. On 03/03/17, the dietician notes documented current weight of 188 # and documenting a weight loss/gain as having no significant change is on a regular diet with thin liquids and R5 having no chewing/swallowing problems, no significant change and having great intake at meals and over 1500 cc daily. Observations on 05/16/17 of lunch and on 05/17/17 of breakfast, R5 ate 75-100% of the food and fluids. On 05/17/17 at 10:35 a.m., R5 attended the group meeting and indicated at breakfast he receives too much food. On 05/17/17 at 11:11 a.m., Surveyor interviewed the Director of Nursing (DON) about R5's weight loss. The DON indicated weekly weights are to be completed if there is not a physician order [REDACTED]. The dietician reviews the weights. The nurses enter in the weights into the computer and should identify if there is a difference and should ask for a reweigh that day. The DON indicated she did not know why there was a lapse in weekly weights. The DON and the Nutritional Services Director (NSD) D indicated they believe the scale was not working correctly 03/01/17. NSD D indicated R5 receives large portions and R5 will ask for additional foods and the dietary staff will provide the food for R5. The DON indicated R5 is receiving supplements. Review of the supplement sheet document R5 should be receiving a 4 oz. magic cup at supper and 4 oz. of juice at breakfast and white whole milk at dinner and supper. The DON indicated this was initiated on 12/10/16 and no new interventions were started after that date. Surveyor requested any documentation of the scale not working correctly. No further information was provided. Surveyor reviewed with the DON there was a system failure of monitoring weights and to verify weights to ensure accuracy. The facility did not identify R5 has had a continued weight loss. The physician was not updated to explore the possibility of a medical condition contributing to weight loss. The facility did not evaluate and modify nutritional interventions.