Every finding on record at Dove Healthcare - Rice Lake

Based on observation, interview, and record review, the facility did not ensure the resident environment remains as free of accident hazards as possible and each resident receives adequate supervision and assistive devices to prevent accidents for 1 of 1 resident (R) reviewed (R36).R36 was a 1 person assist with a 2 wheeled walker (WW) for transfers. Certified Nursing Assistant (CNA) transferred R36 without use of a gait belt and two wheeled walker, and R36 fell resulting in a displaced intertrochanteric fracture of right femur. R36 was transferred to another hospital requiring surgical repair of the fracture. This is evidenced by:Facility's policy titled Fall Prevention Program with a revised date of 01/2026 documented: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.5. Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. B. The plan of care will be revised as needed.R36 was admitted to the facility on [DATE]. R36's current diagnoses include intertrochanteric fracture of right femur, dementia, osteoarthritis of knee, difficulty in walking, and history of falling. R36's Minimum Data Set (MDS) assessment, dated 03/18/26, documented a Brief Interview for Mental Status (BIMS) score of 9/15, indicating moderate cognitive impairment. MDS documented R36 requires staff assistance with transfers. R36's care plan states the resident has an Activities of Daily Living (ADL) self-care performance deficit r/t (related to) recurrent falls and UTI (Urinary Tract Infection). Interventions initiated on 12/10/25 included Ambulation/Locomotion: Assist of 1 with 2WW (Wheeled Walker).R36's fall risk evaluation was completed on 05/03/26 with a score of 13 meaning to be at medium risk for falling. On 06/23/26, fall risk evaluation was completed with a score of 17 meaning high risk for falls.On 05/26/26 at 6:45 AM, facility's incident report documented Certified Nursing Assistant (CNA) K transferred R36 from the shower chair without a gait belt while in the tub room. Registered Nurse (RN) J was called to the shower room and found R36 lying flat on her back. CNA K reported R36 was transferring from the shower chair to the wheelchair and sat down on floor. CNA K reported R36 was lowered to the floor. CNA K reported they considered this a near fall, and CNA K felt like they stopped R36 from sustaining any injury. R36 did not hit their head. R36 landed on their buttocks. Skin intact. R36 had been dressed except to have their pants pulled up. R36 was wearing gripper socks. R36 requested to sit up. R36 denied neck pain. R36 was unable to describe any painful areas. R36 was transferred with a Hoyer lift with 2 CNAs and transferred to the wheelchair. R36 did not complain of pain while in the wheelchair. Gait belt was applied to R36, and walker was given to R36 to attempt to stand and pull up pants. When R36 applied weight on her legs, R36 said they were not able to stand due to pain in their right hip. RN J further examined R36 and R36 complained of severe pain with any movement of the right leg. R36's right leg was noted to be shortened and externally rotated. The facility called 911 and R36's Power of Attorney who was notified of the transfer. Emergency Medical Services (EMS) transferred R36 to local hospital. Review of Emergency Department note dated 05/26/26 documented at 7:49 AM, Chief Complaint: c/o (complained of) R (right) hip pain after R36 was assisted in shower this morning at [Name] due to a fall. Pt (Patient) has a history of dementia. No loc (loss of consciousness) reported. Pt landed on bottom. R leg is shortened and externally rotated compared to L (Left) leg. Doppler pulses present. X-ray of the right hip with pelvis shows: Impression 1. Comminuted moderately displaced versus impacted right proximal femur intertrochanteric fracture.4. Subjectively decreased bone density.we recommended orthopedics evaluation and patient will be transferred to [Name of hospital] for further evaluation and care and probable ORIF (Open Reduction Internal Fixation) of the hip. On 07/01/26 at 11:11 AM, Surveyor observed CNA L check the care plan before entering R36's room to assist with transfer to bed. CNA L used the walkie talkie to call for another CNA to assist with transfer. CNA L brought Hoyer lift into room. CNA M entered room, sanitized hands, and assisted CNA L with attaching R36 in sling, and they transferred R36 to bed according to the plan of care.On 07/02/26 at 9:43 AM, Surveyor interviewed RN J about R36's fall causing injury. RN J stated they were the charge nurse and were called in to the tub room. CNA K said they caught R36, and it was not a fall. R36 denied pain and was assessed briefly. R36 was mostly dressed and had gripper socks on. R36 was transferred from the floor with a Hoyer lift to the wheelchair. CNA K and CNA E tried to stand R36 up to pull up their pants and when R36 applied pressure to their R leg R36 said, Ow, can't. The CNAs transferred R36 to bed and noticed R36's leg was shorter. RN J called EMS and transferred to R36 to the emergency room (ER). RN J emailed the entire leadership team of the fall and transfer to ER. It all happened really fast, and RN J did not realize CNA K did not follow the care plan until filling out the fall report. RN N called asking about the fall and RN N came to the facility. Surveyor asked if RN J talked with CNA K about not using a gait belt. RN J stated CNA K is an experienced CNA and there was no reason to doubt CNA K. Surveyor asked if RN J received any training after this incident. RN J stated Director of Nursing (DON) B spoke with RN J about assessing and reporting, and there were quizzes to take. On 07/02/26 at 10:20 AM, Surveyor interviewed CNA E about R36's fall on 05/26/26. CNA E stated it was called over the walkie talkie that a Hoyer and sling were needed on the short-term wing. CNA E stated they were the second person to help get R36 off the floor and put R36 in the wheelchair. RN J had instructed to get R36 off the floor. R36 was dressed in pants which were not pulled all the way up and wearing grippy socks. Surveyor asked if R36's right leg was shorter than the left. CNA E stated they could not see this at that time. When R36 was in the wheelchair they were going to have R36 stand, and this is when it was noticed there was no gait belt in the room. Usually there is a bag attached to the walker or wheelchair that would have the gait belt. R36's gait belt was in the bag on R36's walker in R36's room. A gait belt is required when a resident is an assist of 1 staff. When they tried to have R36's stand R36 said, No. ow ow, and when Hoyer lifted to bed R36 complained of pain. When R36 was in bed, the nurse saw R36's right leg was shorter. CNA E stated they believed this all happened before breakfast between 6:30 AM and 7:30 AM. On 07/02/26 at 11:14 AM, Surveyor interviewed DON B about the timeline of R36's fall with injury. RN J had emailed DON B and RN O about R36's fall. CNA K got R36 ready in the morning in R36's room. R36 started to self-transfer and CNA K didn't use a gait belt or walker and transferred R36 to the shower chair and brought them to shower room for a shower. CNA K did not use a gait belt and walker after R36's shower. CNA K said they lowered R36 to the floor and felt by lowering to the floor there would be no injury. They got R36 off the ground with a Hoyer and placed R36 in the wheelchair. When R36 went to stand from the wheelchair R36 complained of pain when bearing weight to the leg. RN K was in the mind set of R36 was an easy lower to the floor that there were no injuries. CNA K did not use a gait belt, walker and R36 was standing on a towel. CNA K was removed from work that day and during the investigation. CNA K is no longer employed by the facility. DON B stated all nursing staff were educated, and nurses and CNAs completed the education. Nursing Home Administrator (NHA) A sent out a text message to all staff of the education needed to be completed. RN J was educated on process of reporting, interviewing the CNA, and gathering what happened. RN J did not find out about the gait belt not being used. Education of reporting right away and to pull staff from the floor. DON B stated RN K should have called DON B when the fall with injury occurred. Surveyor reviewed facility's investigation of incident. The facility's interventions started on 05/26/26 with suspending CNA K, local police notified, physician notified, POA notified, staff interviews completed, staff education regarding safe transfers and care plan adherence was initiated and ongoing with casual staff, and transfer audits were conducted. The facility completed audits on 05/31/26, staff education on 06/01/26, and the investigation on 06/01/26. Based on Surveyor's investigation, the facility was not in compliance related to preventing accidents when staff did not follow R36's care plan for transfers resulting in a fall with actual harm. The facility recognized the deficient practice, conducted an investigation, put interventions in place, and provided staff education. The facility has no current noncompliance. This is cited at past noncompliance actual harm/isolated.

Based on interview and record review, the facility did not ensure a resident received treatment and care in accordance with professional standards of practice for 1 out of 4 sampled residents (R10). -The facility did not comprehensively assess R10's non-pressure wounds weekly. -An intervention to prevent R10 from scratching their skin was discontinued, the facility did not implement a new intervention, and R10 continued to scratch at their skin. -Staff did not place elbow and heel protectors on R10 when R10 was up in their broda chair. -Staff did not place device in R10's hand to provide palm protection and prevent further contracture. -R10's treatment was discontinued and staff continued to provide treatment for 27 days after order was discontinued. -The facility did not implement a plan to ensure clear communication with hospice services. Findings include: R10 was admitted to the facility on [DATE]. Diagnoses included Parkinson's disease, contractures causing skin breakdown, anxiety, and history of pressure ulcers. R10 received hospice services to provide comfort for end-of-life care. R10's Minimum Data Set (MDS) assessment completed on 06/30/26, confirmed R10 scored 06/15 during Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. R10 makes their own healthcare decisions. WOUNDSThe facility policy titled Documentation of Wound Treatments, read, Wound evaluations are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates. The following elements are documented as part of a complete wound evaluation: Type of wound (pressure injury, surgical site, etc.) and anatomical location.Stage of wound, if pressure injury or the degree of skin loss if non-pressure.Measurements: height, width, depth, undermining, tunneling.Description of wound characteristics. R10's care plan included:Activities of Daily Living (ADL) self-care deficit and risk for skin breakdown related to fragile skin. History of scratching posterior right thigh and causing injury and bleeding. R10 refuses to have nails trimmed. Interventions: Elbow protectors to both arms, on in the AM, off HS. Date initiated 11/13/24.Encourage to report itchy skin to staff. Date Initiated: 01/09/25.Encourage to not scratch skin. Alert nursing to itching. Date Initiated: 01/17/25.Inner dry over personal foam dog. Thumb and index finger around head of dog. Picture of correct placement in closet. Date initiated: 01/28/26.White heel protectors on AM, off HS. Date initiated: 01/28/26. R10's weekly wound documentation included:-09/02/25, WEEKLY WOUND TRACKER, right thigh. L=0, W=0, D=0. Overall wound is improving, there are no signs of infection, no exudate, no odor. Wound edges are well defined. (Note, there are no measurements). -09/16/25, WEEKLY WOUND TRACKER, right thigh. L=0, W=0, D=0. Wound seems to be worsening. No signs of infection, no exudate, no odor. Wound edges are irregular. (Note, previous assessment completed on 09/02/25). -09/30/25, WEEKLY WOUND TRACKER, back of right thigh. L=0, W=0, D=0. There have been no changes in wound from previous week. No signs of infection, no exudate, no odor. Wound edges are irregular. (Note, previous assessment completed on 09/16/25). -10/16/25, WEEKLY WOUND TRACKER, back of right thigh. L=0, W=0, D=0. There have been no changes in wound from previous week. Wound edges are attached at base. (Note, previous assessment completed on 09/30/25). Note no further weekly wound tracker assessments related to thigh wound, documentation was in progress notes, which was not comprehensive and not weekly. -11/18/25, PROGRESS NOTE: Posterior (R) thigh no drainage, wound beds are red in color, 30 x 15 x 0. (Note, missing assessments from 10/16/25-11/18/25). -11/25/25, PROGRESS NOTE: Resident continues to have areas where she scratches, new Tx orders received today. Skin Tx: 1. Wash right thigh wounds with normal saline and pat dry 2. Apply non-stick to affected areas 3. Cover with 8x12 Tegaderm. (Note, no wound documentation from 11/25/25-04/07/26. Treatment order was current is R10's orders as of 07/02/26). -04/07/26, PROGRESS NOTE: (R)posterior thigh measures 26 x 12 x <0.1. There are 2 areas that are open, wound bed is red in color, no drainage. (Note, previous assessment completed on 11/18/25). -05/03/26, WEEKLY WOUND TRACKER, left hand/base of thumb. L=0.5 x W=0.5, D=0.1. Wound is improving. No signs of infection, no exudate, no odor. Wound edges are attached at base. (No weekly assessment in previous week, wound is documented as improving). -05/05/26, PROGRESS NOTE: (R) posterior thigh wound measures 27 x 13 x <0.1. No drainage present. (Note, last assessment on 04/07/26). 05/11/26, PROGRESS NOTE: Resident has scratched the dressing off right thigh, and it is bleeding. I spoke to resident's [husband] about the mitt. They had brought the mitt in for resident to wear to protect from scratching thigh. 05/12/26, PROGRESS NOTE: Mitts cannot be used as resident cannot remove them. DON ordering alternative fingertip protectors. On 07/01/26 at 10:10 AM, Surveyor observed R10 had long painted fingernails and did not have on fingertip protectors. R10's record did not include an order or task to place fingertip protectors. R10's care plan did not include an intervention of fingertip protectors. On 07/01/26 at 1:42 PM, Surveyor interviewed Director of Nursing (DON) B. DON B reported R10's fingertip protectors had been ordered in May and were in the medication room. DON B and Surveyor counted R10 had 40 fingertip protectors. Surveyor asked for evidence of the items ordered and documentation of administration and effectiveness of fingertip protectors. DON B reported 40 fingertip protectors were ordered, and it should be an order in R10's treatment record. DON B stated this would be her responsibility and she did not enter it. Surveyor repeated to DON B, 40 fingertip protectors were ordered, and 40 fingertip protectors were counted, indicating the fingertip protectors had not been used, and DON B stated yes. -05/17/26, WEEKLY WOUND TRACKER, left hand/base of thumb. Wound is now healed. (No weekly assessment since 05/05/26). -05/21/26, Treatment order, Apply split gauze over left hand base of thumb and forefinger palm guard open area daily and PRN until healed. -05/27/26, WEEKLY WOUND TRACKER, left hand, first web space. L=0.5, W=0.5, D=<0.1. Wound is improving, no signs of infection, scant amount of serous exudate, no odor. Wound edges epithelializing. -06/04/26, WEEKLY WOUND TRACKER, left hand, first web space. Wound is healed. Discontinue skin treatment of split gauze over left hand base of thumb and forefinger palm guard open area daily, continue treatment of inner dry placed over foam dog that is placed in palm of hand for protection related to contracted left hand is always moist. (Note, order was not discontinued in R10's record.) On 07/01/26, Surveyor reviewed R10's Treatment Administration Record (TAR) and noted licensed nursing staff were completing daily treatments of split gauze over left hand base of thumb and forefinger guard. On 07/01/26 at 2:09 PM, Surveyor interviewed DON B. DON B reported R10's order to discontinue the treatment was not discontinued in the system by Licensed Practical Nurse (LPN) H, and DON B was not sure why, but stated she would discontinue the order on this date. On 07/02/26 at 7:42 AM, Surveyor interviewed LPN H. LPN H could not remember why she did not discontinue R10's treatment order and confirmed R10's wound to left hand first web was healed. -06/16/26, PROGRESS NOTE: Right thigh (rear), self-scratched: Length = 40, Width = 12, Depth = <0.1, - Stage Unstageable. This is not a new skin alteration for resident. Upon examination found (R) posterior thigh-self scratched area has a couple open areas noted. This entire area measures 40 x 12 x <0.1. No drainage noted. Area cleaned, tx per TAR. (Note, last assessment 05/05/26). -06/23/26, WEEKLY WOUND TRACKER, 1st web of left hand, 0.5 x 0.5 x 0.1. Wound is improving. First identified on 04/25/26, facility acquired, healed. (Note, assessments show wound started on 05/27/26). On 07/02/26 at 7:42 AM, Surveyor interviewed LPN H. LPN H stated they do weekly assessments for pressure wounds Stage 1 and up and then continue to follow weekly. LPN H reported they do not do weekly assessments on skin tears, moisture associated skin damage, and non-pressure wounds. LPN H stated on bath days nursing staff should be doing a weekly skin check and documenting, including measurements, for any non-pressure related wounds. LPN H stated that sometimes R10 will scratch the skin open, and sometimes it is just scabbed and healing, and a lot of the time it is just redness. LPN H stated R10's posterior thigh wound is scattered, and when LPN H measures the area, the largest area and the smallest area are measured. LPN H reported other licensed nurses measure the entire area which is why the measurements for the wound are inconsistent. Surveyor asked LPN H if the weekly measurements would be accurate since staff are measuring differently, and LPN H stated the measurements would not be accurate. LPN H again stated, if a resident has a new skin opening, nursing staff should be documenting and measuring every time it is identified and weekly follow up should continue until it is healed. Surveyor asked what healed means and LPN H stated when scabbing is gone. On 07/02/2026 at 9:05 AM, Surveyor interviewed DON B. DOB stated weekly wound tracking should be completed for any wounds that are open, even redness, until healed. DON B stated, We recognized wound tracking is something we need to improve on, we are trying to revamp our weekly wound tracking system. DON B reported the facility had not implemented a performance improvement plan at the time of the Survey. On 07/02/26 at 10:27 AM, Surveyor observed LPN H complete wound care on R10's thigh. Surveyor asked LPN H to state the measurements and description of the wound. LPN H reported R10's wound to measure 20 x 4 and reported the area to be red with a small superficial area that was open, with no signs of infection. Surveyor observed the measurements to be correct; the area was red with a small open area measuring approximately 0.1 x 0.1. MEDICAL DEVICES On 07/01/26 at 10:10 AM, Surveyor observed R10 in her room. R10 was seated in a Broda chair, facing the television. R10 was neat and clean, wearing white socks on their feet, and feet resting on the footrest of the wheelchair. R10 answered most questions with yes/no answers. R10 answered yes when asked if staff are kind, treat her well, and provide adequate care. R10 answered no when asked if there were any concerns about the care provided. Surveyor observed that R10 was not wearing elbow and heel protectors. Surveyor observed R10 did not have inner dry over personal foam dog in left hand, as indicated in the care plan. Surveyor observed a picture in R10's closet, showing a stuffed [NAME] dog, approximately 4-6 inches long, the dog appeared to be stuffed with soft material, like a squishy stress toy. The dog was wrapped in a light layer of gauze and placed in R10's left hand. On 07/01/26 at 11:12 AM, Surveyor observed certified nursing assistants (CNAs) C and D assist R10 with cares before lunch. Surveyor observed CNA C place heel protectors on R10. On 07/01/2026 at 12:47 PM, Surveyor interviewed CNA E. CNA E reported R10 has protective gear in place, elbow pads, heel pads and dog for contracture of left hand. CNA E reported that R10 gets up for the day approximately 6:30 AM-7:30 AM. CNA E stated she did not get R10 up this morning and was not sure why R10 did not have elbow and heel protectors on and foam dog for left hand contracture. On 07/01/2026 at 12:53 PM, Surveyor interviewed CNA C. CNA C reported R10 gets up in the morning between 6:00 and 7:30 AM. CNA C reported R10 has elbow pads, heel pads, and dog for left hand. CNA C reported she did not get R10 up this morning and that CNA D and CNA E assisted R10 with getting up. CNA C did not know why R10 did not have elbow and heel protectors on, or foam dog in left hand. On 07/01/2026 at12:56 PM, Surveyor interviewed CNA D. CNA D stated she and CNA C got R10 up this morning between 6:30AM-7:30 AM. CNA C stated R10's elbow protectors were in the laundry, and R10 did not want shoes on and did not want anything on their feet. CNA C stated she reported this to Licensed Practical Nurse (LPN) F, the charge nurse before lunch. CNA C then stated R10's heel protectors were in the laundry, not the elbow protectors, because R10 has elbow protectors on right now. CNA C stated she could only find one heel protector and that is why R10 did not have heel protectors on. CNA C stated Surveyor asked CNA C to clarify what was in the laundry, the heel protectors or elbow protectors. CNA C said, heel protectors. Surveyor asked CNA C, you could only find one elbow protector this morning then. CNA C said yes, but she found another one when getting R10 ready for lunch. Surveyor asked CNA C if R10 only has one set of each elbow and heel protectors and CNA C said yes. CNA C stated R10 does not allow staff to place dog in their left hand. CNA C stated she put a pillow under R10's legs this morning, but Surveyor did not observe a pillow under R10's feet or legs and did not observe a pillow on R10's floor. On 07/01/2026 at 1:34 PM, Surveyor interviewed LPN F. LPN F reported CNA C reported to her around 9:00 or 10:00 AM, that R10 did not have heel protectors. LPN F said CNA C did not report anything about elbow protectors or the dog to be placed in R10's hand. LPN F stated CNA C should have reported this earlier when getting R10 up and not waited. LPN F stated R10 has only one set of heel protectors and usually residents have a backup set, and she was not sure why R10 did not have a backup pair of heel and elbow protectors. LPN F stated R10 has a history of skin issues, and pressure injuries to heels. On 07/01/26 at 2:09 PM, Surveyor interviewed DON B. DON B reported R10 should have more heel and elbow protectors, and she could order more. DON B stated if staff do not tell her she does not know if a resident needs more. DON B reported she would order more supplies for R10, as the expectation is staff will apply these to R10 every morning to prevent skin damage or pressure injuries. HOSPICEThe facility policy titled Coordination of Hospice Services, read, The plan of care will identify the care and services each entity will provide in order to meet the needs of the resident. The facility will communicate with hospice and identify, communicate, follow and document all interventions put into place by hospice and the facility. The facility will maintain communication with hospice as it relates to the resident's plan of care and services to ensure each entity is aware of their responsibilities. R10's care plan included:I am enrolled in Hospice. Date Initiated: 05/21/26.I will experience relief from physical, emotional and spiritual pain through next review date. Date Initiated: 05/21/26.I will have minimal symptoms of depression and anxiety through the next review date. Date Initiated: 05/21/26.My comfort will be maintained through the review date. Date Initiated: 05/21/26.Administer medications as ordered, monitor for side effects and/or adverse effects. Date Initiated: 05/21/26. On 07/01/26, Surveyor reviewed R10's hospice care plan. Surveyor noted the care plan did not identify what services hospice would be completing and how often. For example, hospice staff provide a shower one time weekly, every Wednesday. On 07/10/26, Surveyor reviewed R10's hospice communication in the electronic health record, miscellaneous tab. Surveyor noted hospice communication included hospice aide provided R10 a shower on 05/28/26 and 06/25/26. There was no other documentation in R10's record related to what services and dates hospice provided services. On 07/02/2026 at 6:43 AM, Surveyor interviewed Medication Technician (MT) G. MT G reported hospice calls the day before and informs licensed nursing staff when hospice staff will arrive the next day, what residents they will be seeing and what tasks they will be performing. MT G stated R10 does not have a hospice paper chart and documentation is in the electronic record, R10's hospice care and facility progress notes completed by licensed nursing staff, related to any hospice communication. MT G stated the facility CNAs would not know what hospice staff completed, as it is in the computer and CNAs do not have access to notes, and hospice staff does not document in the facility electronic record. On 07/02/2026 at 6:46 AM, Surveyor interviewed LPN I. LPN I reported all hospice documentation scanned into the resident's electronic record. LPN I stated when hospice staff leave the facility, they complete documentation on paper about what was completed, shower, dressing, etc. LPN I stated licensed nursing staff receive the paper documentation from hospice and scan into the resident's electronic record. LPN I was not sure if facility CNAs had access to the scanned items in a resident's record, but she did not think they did. On 07/02/2026 at 8:05 AM, Surveyor interviewed CNA C. CNA C reported hospice staff will call the night before and say what they will be doing the next day. Surveyor asked CNA C if they knew what the hospice care plan says. CNA C stated, There is a hospice care plan? No, I don't know what is says. Surveyor asked CNA C if the hospice staff documents in R10's electronic record. CNA C stated no. Surveyor asked CNA C, who documents R10's showers which hospice staff give resident. CNA C stated no one. Surveyor asked CNA C, how did they know if hospice trimmed nails, provided oral care, applied splints/braces, toileted, or assistance with meals. CNA C stated, we don't. CNA C stated the facility staff provide weekly shower for R10 on Tuesday evenings. CNA C stated facility staff do not know when hospice staff provide R10 with a shower or other care and it is not documented in R10's record. CNA C did not know what services hospice provided for R10, except for a shower. On 07/02/2026 at 8:08 AM, Surveyor interviewed CNA D. CNA D stated there is no communication between facility CNAs and hospice. CNA D stated hospice staff have been coming on Thursdays, but the CNAs don't know what tasks hospice completed. CNA D stated CNAs do not have access to nurses notes in the electronic record and there is no documentation when hospice provides cares. On 07/02/2026 at 10:00 AM, Surveyor interviewed hospice CNA O. Hospice CNA O stated per hospice provider hospice aides are to call the day prior and state who they are seeing and what they will be doing. Hospice CNA O thought communication with the facility was good. Hospice CNA O fills out a paper communication tool and gives it to the facility licensed nursing staff; she was not sure what happened to the paper communication tool after she gave it to the staff.

Based on interview and record review, the facility did not complete a thorough investigation of the alleged violation for 1 of 3 residents (R) reviewed. (R1)The facility failed to interview staff and other residents as part of the investigation.According to statute S483.12(c)(2) and S483.12(c)(3), the facility must have evidence that all alleged violations are thoroughly investigated to prevent further potential misappropriation while the investigation was in progress. R1 was admitted to the facility on [DATE] with a diagnosis of mild cognitive impairment. Surveyor reviewed the facility's investigative file that revealed on 11/24/25, R1 reported missing identification documents and an unauthorized $10,000 transfer and $5,000 withdrawal from his bank account that was later returned. Surveyor was unable to locate evidence that other residents were interviewed to ensure no other residents experienced misappropriation. No evidence was found that staff interviews were conducted in an attempt to determine further knowledge of the incident and/or if other residents reported similar concerns.On 01/05/26 at 11:45 AM, Surveyor interviewed R1 who reported that 5 cards were missing and R1 has a company that helps with finances. (This was inconsistent with what was reported by R1 to facility staff and what was noted in the report from Adult Protective Services.) On 01/05/26, Surveyor interviewed Nursing Home Administrator (NHA) A and asked if other residents or staff were interviewed regarding the incident. NHA A confirmed they did not feel they needed to because R1 reported their wallet being at R1's previous residence and R1 has intact cognition. Surveyor asked if they knew when R1's wallet came into the facility. NHA A reported they did not know and was going off what R1 reported. Surveyor informed NHA A of R1's inconsistent answers and the diagnosis of cognitive impairment. NHA A verbalized better understanding and will ensure interviews will be conducted moving forward.

Based on interview and record review, the facility did not ensure proper documentation and communication for discharge for 1 of 2 residents reviewed (R42).-Facility did not provide documented reasoning in the medical record for what needs could not be met for R42.-The facility did not provide and document sufficient preparation and orientation to R42 to ensure safe and orderly transfer or discharge from the facility. -Facility did not communicate with hospital staff after transfer to ensure R42 no longer needed skilled services.Findings include:Facility policy titled, Transfer and Discharge Requirements, last reviewed January 2020, reads in part: Medical record documentation will include the following.the basis for the transfer.as applicable, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs and the service available at the receiving facility to meet the need(s).If the transfer is due to a significant change in the resident's condition, but not an emergency requiring immediate transfer, then prior to any action, [Facility Name] must conduct the appropriate assessment to determine if a new care plan would allow the facility to meet the resident's needs.R42 was admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy (brain disorder secondary to sepsis), Parkinsons's disease, depression, and acute kidney failure.R42's pertinent medications include Pramipexole and Duloxetine.R42's most recent Minimum Data Set (MDS), dated [DATE], did not have a Brief interview for Mental Status (BIMS) score available. MDS did indicate R42 to be cognitively independent with daily decision making.R42's care plan prior to any noted concerns/behaviors included alteration in mood and risk for adverse effects related to antidepressant medication use and history of hallucinations, and potential for alteration to mood pattern. Interventions included report to physician signs of adverse reaction such as decline in mental status, behavioral health consults as needed, monitor me for changes in my mood or behavior. Notify my Medical Doctor (MD), Registered Nurse (RN) and Social Worker (SW) if you see concerns, and monitor/record mood to determine if problems seem to be related to external causes such as medications.On 05/30/35 at 9:00 PM, progress note indicated R42 attempted inappropriate touching and verbalized sexual comments to a female staff member during cares. Care plan was revised to include R42 to have 2 staff members for peri care on 05/30/25.On 05/31/25 at 4:30 AM, progress note indicated R42 had made a call to 911 stating R42 was being held captive by the facility, wanting to leave, and was hallucinating. Redirection of R42 was ineffective but R42 calmed when Family Member (FM) D arrived. Nurse Manager (NM) C was contacted. NM C informed staff R42 needed to go to the emergency room (ER) related to new onset behaviors.On 05/31/25 at 8:30 AM, progress note indicates ambulance was called. NM C was in facility and discussed with FM D that discharge is needed to meet R42's needs and facility would not be able to continue care.On 05/31/25 at 9:21 AM, progress note reads in part: Discharging hospital stated R42 had some hallucinations the night before discharge and it was attributed to infection and new setting. NM C did speak with FM D in regard to behaviors and how facility is unable to meet R42's needs at this time and that memory care would be more appropriate if after ER evaluation R42 is determined not to need further medical intervention.Of note, there is no physician documentation as to why R42's needs are unable to be met and the reason for discharge.On 05/31/25 at 10:40 AM, progress note states R42 was sent to ER and will not be returning to the facility.On 05/31/25 at 3:31 PM, progress note states FM D returned to the facility and stated two doctors evaluated R42 and reported there is absolutely nothing wrong with him. R42 was cleared by ER staff to return home with FM D.R2's record review did not show any indication of communication between facility and hospital staff after transfer for evaluation to determine if R42 would need to return to the facility.Record review indicated general behavior monitoring was in place since admission with each shift prior to morning of discharge marked NB (no behaviors observed). The AM shift the day of discharge, general behavior monitoring indicated VP (verbalizing persistent beliefs that are not true) and NI (no interventions attempted.)Surveyor noted no new interventions to help R42 with his behaviors demonstrated on 5/30/25.On 08/13/25 at 11:35 AM, Surveyor interviewed FM D. FM D stated the facility admitted R42 knowing about the diagnoses of Parkinson's and sepsis, as well as the episodes of hallucinations R42 had the night prior to admission to the facility and they accepted him. FM D was called to facility in relation to behaviors. FM D stated facility was sending R42 to ER for increased aggression and behaviors as they (the facility) did not know how to handle it. FM D stated facility told FM D the orders came from upper management that R42 could not stay there and not to bring him back. FM D was unable to name staff member but stated it was the same person that completed R42's admission paperwork. FM D was asked if she wanted R42 to return. FM D indicated after the way they were treated, she did not want to bring R42 back but instead took him home to care for him where he is still residing and doing well.On 08/13/25 at 1:23 PM, Surveyor interviewed DON B. DON B stated the whole situation happened really fast from behavior onset to transfer. DON B stated the reason for transfer was due to behaviors/combativeness and to evaluate for infection or something else. DON B stated the facility would not be able to meet R42's needs if R42 continued to be combative/behavioral. DON B stated the facility does not have any additional documentation to support statement of behaviors and interventions prior to transfer. DON B stated there was no contact to provider prior to transfer or documentation for the reason for discharge because it happened too fast. The facility should have had more documentation to demonstrate observation of behaviors.Record review indicates 4 hours between R42's 911 call by and staff call for transport via ambulance to ER.On 08/13/25 at 1:26 PM, Surveyor interviewed NM C. NM C stated R42 had been admitted to facility for short-term rehab and over the weekend had a change of condition. NM C stated R42 had called 911 stating R42 was held against R42's will and was verbally abusive to staff. NM C stated R42 wanted to go home and was combative, not allowing staff to touch R42. NM C stated R42 had been sexually inappropriate the evening prior to discharge. NM C stated R42 had a cognition change around 4:00 AM on 05/31/25. NM C did confirm R42 did not hit anyone in the facility. NM stated NM C arrived at the facility on 05/31/25 around 8-8:30 AM. NM C stated R42, FM D, and ambulance staff were present in R42's room and R42 was beginning to clear. NM C stated after R42 had made sexual comments to staff, the care plan was changed to two-assist with cares. NM C stated no physician orders were obtained for transfer, R42 was agreeable to discharge, and charge nurse was in contact with ER. NM C stated, regarding care plan changes, that R42 was 1:1, but not technically. NM C stated NM C had a conversation with FM D that R42's behaviors are not typically something they care for at the facility. NM C stated, in relation to ER staff being contacted, that FM D called later that day and said there was nothing wrong with R42. NM C stated NM C was the nurse who had done the admission paperwork for R42.On 08/13/25 at 2:44 PM, Surveyor interviewed Director of Nursing (DON) B. DON B stated the charge nurse has the responsibility to determine appropriateness for transfer and no provider notification/order is needed. DON B stated they were unable to find any additional documentation related to R42's discharge. DON B stated no behaviors were documented as R42 was only there for 2 days.

Based on interview and record review, the facility did not notify the resident (R) or the resident's representative(s) of the transfer/discharge reason, the duration of the bed-hold policy, and the reserve bed payment in writing. This has the potential to affect all 37 residents. R34 was transferred to the hospital on [DATE] and did not receive written notice of transfer or bed hold reserve payment notice. R42 was transferred to the hospital on 5/13/25, and R42 nor Family Member (FM) D received any written notice of transfer or bed hold reserve payment notice. R8 was transferred to the hospital on 7/24/25 and did not receive written notice of transfer or bed hold reserve payment notice This is evidenced by: Facility policy titled, “Transfer and Discharge Requirement,” with a reviewed date of 01/2020, states in part: “Notice Before Transfer: Before a resident transfer or discharges, Dove Healthcare will – a) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. Contents of the Notice: It is the policy of Dove Healthcare that the written notice of transfer or discharge must include the following: a) The reason for the transfer/discharge: b) The effective date of transfer/discharge: c) The location to which the resident is transferred/discharged : d) A statement of the resident's appeal rights including the name, address (mailing and email) and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request: e) The name, address, and telephone number of the State Long-Term Care Ombudsman…” Example 1 R34 was admitted to the facility on [DATE] with pertinent diagnoses of atrial fibrillation and constipation. R34's quarterly Minimum Data Set (MDS) assessment, dated 07/01/25, noted a Brief Interview for Mental Status (BIMS) score of 14/15 indicating cognition intact. On 07/11/25, R34 was transferred to the hospital via ambulance with nausea/vomiting and irregular heart rate and admitted to the hospital for treatment. R34 returned to the facility on [DATE]. Ombudsman notified. No documentation of written transfer notice or bed hold. On 08/13/25 at 11:52 AM, Surveyor interviewed Director of Nursing (DON) B regarding bed hold notice and written transfer notice. DON B stated that no written transfer notices were being provided to residents and was unaware of this requirement. DON B stated that bed hold notices are included with the admission packet but not given to residents at time of transfer. Example 2 R42 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (brain disorder secondary to sepsis), Parkinsons's disease, depression, and acute kidney failure. Most recent Minimum Data Set (MDS), dated [DATE], did not have a Brief Interview for Mental Status (BIMS) score available. MDS did indicate R42 to be cognitively independent with daily decision making. On 05/31/25, R42 was transferred to the hospital via ambulance with change in condition and increased behaviors. On 08/13/25 at 11:35 AM, Surveyor interviewed Family Member (FM) D. FM D stated R42 nor FM D received any paperwork upon leaving facility for transfer to hospital. On 08/13/2025 at 1:23 PM, Surveyor interviewed Director of Nursing (DON) B. DON B stated the whole situation happened really fast from behavior onset to transfer. DON B stated there was no contact to provider prior to transfer as everything happened too fast. On 08/13/2025 at 1:26 PM, Surveyor interviewed Nurse Manager (NM) C. NM C stated NM C did not get any discharge or leaving AMA paperwork, and no paperwork was given to R42 or FM D at the time of leaving. NM C also stated NM C did not go over a bed hold. Example 3 R8 was admitted to the facility on [DATE]. R8's current diagnoses include acute kidney failure, type 2 diabetes mellitus, chronic peripheral venous insufficiency, and weakness. On 07/24/25, R8 was transferred to the hospital with no urine output and increased edema. R8 returned to the facility on [DATE]. Review of R8's chart identified no documented bed hold notice including the daily rate cost and the notice for reason of transfer. On 08/11/25 at 11:24 AM, Surveyor interviewed R8 about written notice of bed hold and reason for transfer. R8 stated did not receive written notices.

Based on observations, interviews and record review, the facility did not prepare, store and distribute food in a sanitary manner. This has the potential to affect all 46 residents. Example #1: Nutritional Services Aide (NSA) C and Cook D were observed to spray dirty dishes, contaminate their clothing with the dirty water spray, and proceeded to put away clean dishes. The clean dishes were contaminated by coming into contact with NSA C and Cook D's soiled clothing. Example#2: NSA C was observed wiping a thermometer used to take food temperatures with an alcohol pad. The alcohol was not allowed to air dry before placing the thermometer into cups of beverages intended for resident consumption. Example #3: Cook D did not wash his hands when warranted in the kitchen when preparing resident lunch. This is evidenced by: Example #1: On 04/06/21 at 9:36 a.m., Surveyor observed NSA C washing dishes. NSA C wore a uniform-type top with no apron. NSA C wiped food debris from the dishes, sprayed the dirty dishes and loaded the dishes to a dish rack. NSA C repeated this process until the dish rack was full of dirty dishes. NSA C placed the dish rack into the dishwasher and continued wiping, spraying and loading dirty dishes to a dish rack. NSA C's uniform top was visibly soiled with dirty water from spraying the dirty dishes. NSA C proceeded to the clean dishes from the dish machine. Surveyor observed NSA C's soiled top coming into contact with the clean dishes and clean counter as she unloaded the clean dishes from the dish rack. Surveyor spoke with NSA C who indicated it is part of her usual work to do breakfast dishes. She is responsible for washing and putting away the dishes. Surveyor asked NSA C about the observation. NSA C indicated she should probably wear an apron when washing the dishes and remove it before proceeding to putting away the clean dishes. NSA C further indicated bacteria was introduced to clean dishes from her soiled top. NSA C further indicated she does not know where disposable aprons are; there are no disposable aprons available in the kitchen for her use. On 04/06/21 at 9:36 a.m., Surveyor observed Cook D washing large pans in a 3 compartment sink. Cook D was wearing a cloth apron that was visibly soiled from washing dishes. Cook D washed his hands and proceeded to the dish machine to put away clean dishes. Cook D carried the clean dishes against his apron to put the dishes away. Surveyor asked Cook D about the observation. Cook D indicated he should remove the apron before putting away the clean dishes. Surveyor spoke with Dietary Manger (DM) E who was present during the observation. DM E expressed staff should be wearing an apron when washing dishes. The apron should be changed between dirty and clean dishes. Surveyor requested the facility policy regarding washing dishes. The policy was received and reviewed by the surveyor. The policy titled Cleaning Dishes and Dish Machine which is not dated does not note the expectation as discussed with DM E. Surveyor asked DM E about the policy. DM E indicated the policy will need to be updated to include expectations of staff wearing an apron when washing dishes, removing the apron and washing hands prior to handling clean dishes. Example #2: On 04/06/21 at 11:34 a.m. Surveyor observed NSA C taking temperatures of beverages intended for resident consumption. The beverages are in a bin on a cart. NSA C is wearing the same uniform top as observed during dish washing. NSA C is not wearing an apron. NSA C leans into the beverage cart as she prepares to take the beverage temperatures. Surveyor asked NSA C if her top was clean. NSA C responded, No. Surveyor asked NSA C if there is potential for her top to come into contact with the beverages on the cart. NSA C responded, Yes, I probably should have on a clean apron. NSA C put on an apron and proceeded taking the beverage temperatures. NSA C wiped the thermometer probe with an alcohol pad and immediately inserted the thermometer into a glass of milk. NSA C wiped the thermometer with an alcohol pad and immediately inserted the thermometer into a glass of orange juice. The surveyor asked NSA C about the observation. NSA C indicated she did not wait between wiping the thermometer with alcohol and inserting the thermometer into the beverages. NSA C further indicated it is part of her usual job to check beverage temperatures. NSA C expressed she is not sure of time she should wait to allow the alcohol to dry. Surveyor asked DM E, who was present during the observation, about the expectation of waiting for alcohol to dry from the thermometer probe before inserting the thermometer into the beverages. DM E indicated staff are expected to allow the alcohol to dry by waiting about 10 seconds before inserting the thermometer into the beverages to take temperatures. There was not sufficient time when wiped and inserted immediately into the beverages. Surveyor requested and received the policy titled Taking accurate temperatures. The policy is not dated. The policy states in part: ~To take temperatures use a clean, rinsed, sanitized and air dried thermometer. Example #3: On 04/06/21 at 11:40 a.m., Surveyor observed Cook D preparing food items for the lunch meal. Cook D removed his gloves and donned clean gloves, without performing hand hygiene as he left the steam table/counter to gather various food items. Cook D went in and out of the refrigerator. Cook D opened the refrigerator door handle with his bare hands. Cook D donned gloves without hand hygiene as he returned to steam table. Cook D retrieved a can of tomato soup, poured the soup into a bowl and placed the bowl in the microwave with the gloved hands. Cook D removed the gloves and donned gloves to retrieve brownies and place on individual plates. Again Cook D did not wash his hands when he removed his gloves. Surveyor asked Cook D about the observation. Cook D responded he should be washing his hands. DM E, who was present during the observation, indicated whenever staff are doing a different task and leaving steam table area they should remove their gloves, wash their hands and put on clean gloves. Surveyor requested and received the policy titled Handwashing dated 2013. The policy states in part: ~Staff will wash hands as frequently as needed throughout the day following proper hand washing procedures. ~When to wash hands: After handling soiled equipment or utensils, before donning gloves for working with food.

Based on observation, interview and policy review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections for one of one Resident (R) 140 with an IV. Staff did not perform appropriate hand hygiene practices when accessing a PICC line. This is evidenced by: On 04/18/19 at 8:23 a.m., Surveyor observed Registered Nurse (RN) C administer IV medication via PICC line. R140's medication orders are [MEDICATION NAME] 2 gram/50ml at 100ml/1hour with a 10ml normal saline flush before and after infusion with the purple lumen and a 10ml normal saline flush to the red lumen of the PICC line. RN C gathered supplies, placed a barrier on the over bed tray table and set supplies down. RN C washed hands for approximately 3 seconds then applied hand sanitizer. RN removed protective sleeve on R140's arm and checked the PICC line site. RN C then set up the IV medication and pump. RN C, without washing or sanitizing hands, applied gloves and cleansed the lumen with an alcohol wipe, flushed the purple lumen and attached the IV line. Removed gloves and the pump was beeping with an error of air in line. RN C, without gloves, removed the IV line from the PICC line and removed the air from the line and reattached the IV after wiping the PICC line with alcohol. At 9:01 a.m., At the end of infusion of medications, RN C sanitized hands and with no gloves, removed the IV line from the PICC line, cleansed the PICC lumen with alcohol and flushed the line with 10 ml of saline. Without gloves on, RN C wiped the red lumen with alcohol and attempted to get blood return before flushing with saline. RN C was unable to get a blood return and unable to flush the line. RN C cleansed the lumen and applied a cap. At 11:20 a.m., RN C sanitized hands and without gloves on, removed the cap from the red lumen and was able to get a blood return and flush the line with the 10 ml of normal saline. Surveyor interviewed RN C and asked if it is facility policy to wear gloves during flushing of the PICC line. RN C indicated you don't have to wear gloves during flushing. On 04/17/19 at 3:30 p.m., Surveyor interviewed the Director of Nursing (DON) and asked if it would be policy to flush the PICC line without wearing gloves during the procedure. DON indicated gloves should be worn when flushing the PICC line. Surveyor reviewed the observation with the DON and requested the policy. Review of policy 5.1 Central Vascular Access Device ([MEDICAL CONDITION]) Flushing and Locking with the recent revision date of 05/01/15, read in part: .Procedure: .6. Don gloves. 7. Vigorously cleanse needleless connector with alcohol. Allow to air dry .

Based on observation, record review and interview, the facility did not ensure residents with limited range of motion receive appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for two of two (Residents (R) 5 and R6) reviewed for Passive Range Of Motion (PROM) services. R6 and R5 did not receive PROM exercises as planned in their individualized restorative program. This is evidenced by: 1. On 04/16/19 at 12:10 p.m., Surveyor observed R6 in the main dining room in a wheelchair appearing to be flaccid on the left side. Review of R6's medical record documents current [DIAGNOSES REDACTED]. Review of PROM assessment dated [DATE] identified no changes to the current PROM program: ROM: Passive ROM of Left Upper Extremity including shoulder flexion/extension, elbow flexion/extension, wrist flexion/extension, and finger flexion/extension while supine or sitting upright for 15 reps each. 7 x / wk. Sunday Monday Tuesday Wednesday Thursday Friday Saturday cAM, rAM rAMin R First Date: 04/16/2019 GOALS: Will allow staff to complete PROM exercises at least 4 days per week or as tolerated. and Lower Body exercise: Passive: Left Lower extremity including hip flexion/extension, knee flexion/extension, and ankle flexion/extension while lying supine in bed for 15 reps each. 7 x / wk. Sunday Monday Tuesday Wednesday Thursday Friday Saturday rAM rAMin R first date: 04/16/2019 GOALS: Will allow staff to complete PROM exercises at least 5 days per week or as tolerated. Review of the documentation of completed PROM: PROM of left upper extremity: January 2019 - 7 times February - 2 times March - 6 times April 1st -16th = 5 times PROM of left lower extremity: January 2019 - 8 times February - 1 time March - 4 times April 1 - 16th = 4 times 5. On 04/16/19 at 11:10 a.m., Surveyor observed resident in wheelchair having the right hand contracted and in a wheelchair arm rest. Review of R5's medical record document current [DIAGNOSES REDACTED]. Review of PROM assessment dated [DATE] identified no changes to the current PROM program: UPPER BODY EXERCISE: Passive ROM to Right Upper Extremity and Right lower extremity. 7 x /wk. Sunday Monday Tuesday Wednesday Thursday Friday Saturday rAM rAMin R First Date: 04/09/2019 GOALS: Will tolerate PROM at least 3 days per week or as desired. Review of the documentation of completed PROM: PROM of right upper extremity: January 2019 - 4 times February - 4 times March - 4 times April 1st -16th = 3 times 4/17/19 at 3:30 p.m., Interview with Director of Nursing (DON) about the restorative program. DON indicated that not all the Certified Nursing Assistants (CNAs) will document when they completed the restorative program. The Restorative Certified Nursing Assistants (RCNAs) will get pulled to work the floor when short staff. The facility is trying to fill CNA positions. Facility goal to try to have the afternoon RCNA complete what the day shift was unable to complete and to train more staff to be able to complete the restorative programs. DON indicated this issue was not brought to the Quality Assurance and Performance Improvement plan. 04/18/19 11:23 a.m. Surveyor interviewed RCNA A about R6 and R5's restorative plan. RCNA A indicated there are two restorative aides on day shift and RCNA A works full time and the other RCNAs work part-time. RCNA A works four days one week and every other weekend. RCNA A indicated she often is pulled to work the floor as a CNA. Over half of the time will be pulled to work as a CNA and when pulled to the floor the PROM will not get done. The CNAs will do the eating and walking restorative program. The CNAs don't know how to chart the restorative and so RCNA A will have to chart the completed program for that day. RCNA A will mark a zero for the minutes for when a resident refused and will chart refused or chart ill. RCNA A will always mark refused if the resident refuses and the days that are blank the resident did not get restorative. RCNA A will do the residents that have the program of the nu-step and/or the arm cycle first. Can't get all the residents done on the program on a shift. RCNA A will then alternate days of residents to be completed. RCNA A indicated R6 sometimes will be sleeping or have too much pain. RCNA A then will re-approach later. Often R6 will be forgotten. R5 doesn't refuse too often and is usually pretty good about wanting to do the restorative program. RCNA A thinks there is one person on the afternoon shift to do what doesn't get done during the day. RCNA A will bring to the attention of the DON if a change in the resident's ability and the program needs to change. RCNA A indicated the CNAs should know how to do the restorative program but don't have the time. The RCNAs will start on the short term unit at 8:00 a.m. then go to the dining room to help to assist to eat. Then at 9:00 a.m. or 9:30 a.m. will start restorative for available residents until 11:00 a.m. then will take lunch. At 12:00 p.m., RCNA A will go to the dining room to assist and after will do the rest of the residents that are not in the activities. At 1:00 p.m., Surveyor interviewed the DON who indicated the RCNA on the afternoon shift has not been doing restorative and has been working the floor. Recently there is a shortage of CNAs for the afternoon shift and the RCNAs have been working as a CNA. The facility has been trying to hire more staff and train staff to also do restorative.

Based on observation and interview, the facility did not ensure drugs and biologicals used in the facility were labeled in accordance with current accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date for one of two medication carts. Observation of one medication cart as having two insulin pens without open dates and/or expired dates. Staff transferring [MEDICATION NAME] package to an expired box and transferring [MEDICATION NAME] to an expired package with expired [MEDICATION NAME]. The medication cart contained expired [MEDICATION NAME] medication of a discharged resident. This is evidenced by: On [DATE] at 2:00 p.m. Surveyor reviewed med cart on 200 hall with Licensed Practical Nurse (LPN) B. Resident (R) 10's Humalog pen was open and used with no open date or use by date on the pen. The pharmacy dispense date was [DATE]. R10's [MEDICATION NAME] pen was open and used with no open date or use by date on the pen. The pharmacy dispense date was [DATE]. Surveyor interviewed LPN B about the insulin pens. LPN B indicated the pens should be dated when opened and have the discard date written on. The pens should only be good for 28 days. LPN B indicated the insulin pen will be discarded since not knowing when they were open. R90 is no longer in the facility as of [DATE] and has a box of [MEDICATION NAME] sulfate inhalation solution 2.5mg/3ml that was expired on (MONTH) (YEAR). R12's box of [MEDICATION NAME] sulfate inhalation solution 2.5mg/3ml with the expiration date on the box of (MONTH) (YEAR) and within the box has a foil package with the expiration date of (MONTH) (YEAR) and within the foil package contained 17 vials with the expiration date of (MONTH) 18 and 24 vials with the expiration date of (MONTH) 2020. Surveyor interviewed LPN B and asked if the nurses are to add/or combine medications to pharmacy packaging. LPN B indicated this should not have been done. LPN B indicated all of the medications of the [MEDICATION NAME] sulfate inhalation solutions will be destroyed as having no correct label for the [MEDICATION NAME]. LPN B indicated the insulins for R10 will also be destroyed. LPN B destroyed all medications appropriately. At 3:30 p.m., Surveyor interviewed and reviewed the findings with the Director of Nursing (DON). DON indicated the pharmacy consultant does not review the medication carts and only reviews the medications that are in the med room or contingency. DON indicated it is expected the nursing staff will date the insulin pens when opened and should be checking the expiration dates on all medications before giving to the resident. DON indicated they will be putting a plan in place to schedule medication cart review.

Based on observation, record review and interview, the facility did not ensure interventions to prevent falls were utilized for 2 (Resident (R)7 and R8) of 10 sampled residents reviewed for falls. R7 is a high risk for falls and has a fall history. R7 was observed ambulating with staff. The staff member did not ensure the gait belt was used appropriately while R7 ambulated. R8 is a high risk for falls and has a fall history. R8 was observed sitting in a wheelchair without an alarm, per the resident's current plan of care. As evidenced by: 1. On 01/31/17 at 2:30 p.m., Surveyor reviewed R7's medical record and it included the following documentation: ~ Minimum Data Set (MDS) assessment dated [DATE]: requires extensive assistance from one nursing staff for all ambulations and is at risk for falls. ~ Comprehensive nursing care plan, received 01/31/17: is to be ambulated with one staff and a gait belt and front wheeled walker (FWW). ~ Certified Nursing Assistant (CNA) care plan, received 01/31/17, is to be ambulated with one staff and a gait belt and front wheeled walker (FWW). On 02/01/17 at 9:40 a.m., Surveyor observed CNA-B place a gait belt on R7 in the dining room. R7 stood up from the chair with the use of the FWW and started to walk out of the dining room into the hallway and to the resident's room. CNA-B walked beside R7 without having a hand on the gait belt or the resident. On 02/01/17 at 9:50 a.m., Surveyor interviewed Licensed Practical Nurse (LPN)-A regarding R7's ambulation status per the current plan of care. LPN-A stated nursing staff should have their hand on the gait belt while R7 ambulates with the FWW. LPN-A stated R7 is a high risk for falls and has a fall history. On 02/01/17 at 10:03 a.m., Surveyor interviewed Registered Nurse (RN)-E regarding R7's MDS assessment dated [DATE], and the resident's CNA care plan. RN-E stated one assist for ambulation is defined as the resident having a gait belt on and the staff member having their hand on the gait belt while R7 ambulates with the FWW. On 02/01/17 at 2:30 p.m., Surveyor interviewed the Director of Nursing (DON) regarding the observation of R7 ambulating with CNA-B. The DON stated CNA-B should have been walking alongside R7 when ambulating in the hallway with the FWW and should have had her hand on the gait belt due to R7's fall history. 2. On 02/02/17 at 9:08 a.m., Surveyor reviewed R8's medical record and it included the following documentation: ~ MDS assessment dated [DATE]: is at risk for falls. ~ CNA care plan, received 02/02/17: has a history of falls and a pressure sensor alarm is to be in place at all times. On 02/02/17 at 9:25 a.m., Surveyor observed R8 in the dining room sitting in the wheelchair. Surveyor interviewed CNA-C at that time regarding the pressure sensor alarm for R8. CNA-C stated there was no alarm on R8's wheelchair and would have to see where the alarm was. On 02/02/17 at 9:10 a.m., Surveyor interviewed Registered Nurse (RN)-D regarding the observation of R8 sitting in the wheelchair without a pressure sensor. RN-D stated she found the pressure sensor alarm in R8's room and CNA-C forgot to put the alarm on. RN-D stated the pressure sensor alarm should have been on R8's wheelchair and CNA-C did not follow R8's current plan of care. On 02/02/17 at 9:30 a.m., Surveyor interviewed the Nursing Home Administrator (NHA) and DON regarding the above noted observation. The DON and NHA agreed a pressure sensor alarm should have been applied to R8's wheelchair and the CNA did not follow R8's current plan of care.

Based on interview and medical record review, the facility did not maintain clinical records that were complete and accurately documented, for 2 of 8 residents whose medical records were reviewed. Resident #4 received [MEDICATION NAME] ([MEDICATION NAME]) prior to her weekly bath due to anxiety. The facility did not consistently document the effectiveness of the [MEDICATION NAME]. Resident #5 had her [MEDICATION NAME] ([MEDICATION NAME]) discontinued and [MEDICATION NAME] ([MEDICATION NAME]) started 10/09/14. Facility staff continued to document in the behavior charting Resident #5 was on the [MEDICATION NAME] through 01/15/15. Resident #5's care plan also continued to identify Resident #3 was on the [MEDICATION NAME]. This is evidenced by: 1. On 02/05/15, Surveyor began review of Resident #4's medical record and identified Resident #4 had a physician order [REDACTED]. Resident #4's behavior log identified the following targeted behaviors: Increased anxiety as evidenced by (AEB) increased RR (respiratory rate), shaking/tremors, agitation and restlessness. Review of Resident #4's Medication Administration Record [REDACTED]. On 02/09/15, beginning at 10:30 a.m., Surveyor reviewed Resident #4's medical record with Registered Nurse (RN) A to locate documentation of the effectiveness of the [MEDICATION NAME] that was given prior to Resident #4's bath. Surveyor and RN B identified there were no results as to the effectiveness of the [MEDICATION NAME] documented on 12/02/14, 12/09/14, 12/23/14 or 12/30/14. Resident #4's 01/2015 MAR indicated [REDACTED]. There was no documentation as to the effectiveness of the [MEDICATION NAME] on 01/06/15, 01/13/15 or 01/27/15. During Surveyor 's discussion with RN A regarding the documentation of the results of the [MEDICATION NAME] prior to Resident #4's bath, RN A stated, "We are not consistent with charting the follow up on it." 2. During review of Resident #5's medical record beginning on 02/05/15, Surveyor identified Resident #5 had a physician order [REDACTED]. During review of Resident #5's behavior charting for 11/06/14-01/15/15, Surveyor identified nursing staff continued to document Resident #5 was receiving [MEDICATION NAME] 25 mg daily on the following dates: 11/12/14, 11/19/14, 11/26/14, 12/05/14, 12/10/14, 12/22/14, 12/29/14, 01/03/15, 01/08/15 and 01/15/15. On 01/21/15, the weekly behavior summary charting identified Resident #5 was taking the [MEDICATION NAME] 15 mg daily. On 02/05/15, Surveyor reviewed Resident #5's care plan problem dated 06/04/14, for [MEDICAL CONDITION] medication use and identified Resident #5's care plan contained documentation that Resident #5 was still on the [MEDICATION NAME]. On 02/05/15, the above issues were shared with the Director of Nursing (DON). On 02/09/15 at 10:20 a.m., Surveyor reviewed Resident #5's MARs and verified Resident #5 had received the [MEDICATION NAME] since the order change of 10/09/14.

Based on observation, interview and medical record review, the facility did not provide services in accordance with each resident's written care plan for 1 of 8 sampled residents (Resident #3). Resident #3's interdisciplinary care plan directed Resident #3's bed to be in the lowest position possible when resident is in bed. During observations, Resident #3's bed was not in the lowest position possible when the resident was in the bed. This is evidenced by: Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. Surveyor reviewed the resident's chart on 02/04/15 at 10:00 a.m. The resident's current Certified Nursing Assistant (CNA) care plan and interdisciplinary care plan stated, "Have bed in lowest position possible while in it." On 02/04/15 at 11:50 a.m., Surveyor was observing Licensed Practical Nurse (LPN) B during medication administration. Upon entering Resident #3's room, Surveyor observed Resident #3 in her bed and the entire bed height was significantly elevated. There were no staff working with Resident #3 at the time. LPN B gave Resident #3 her medications. Immediately after exiting Resident #3's room, Surveyor asked LPN B if there was a reason Resident #3's bed was up so high. LPN B said, "That's usually how it is." LPN B then lowered Resident #3's bed to a more normal bed height. Surveyor asked LPN B if having Resident #3's bed up that high is safe for Resident #3. LPN B stated, "She is alert and oriented usually. She doesn't move even if you are trying to help her move." Surveyor also asked if Resident #3 has had any falls from her bed. LPN B said, "No." On 02/04/15 at 2:45 p.m., Surveyor observed Resident #3 lying in bed. The bed was raised up to the level of the surveyor's hip. Surveyor questioned Registered Nurse (RN) A if the bed was in a raised position. RN A lowered the bed and stated, "The bed should not be up that high." On 02/05/15 at 2:30 p.m., Surveyor informed the Director of Nursing (DON) and the Nursing Home Administrator (NHA) of the surveyors' observations of Resident #3 lying in bed with the bed raised high. Surveyor questioned the NHA if staff are to follow the CNA care plans. The NHA stated, "Yes."

Based on observation, interview and facility policy and procedure review, the facility did not establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection for 3 (Residents # 2, 1, 3) of 5 sampled residents in relation to handwashing and glove use. This is evidenced by: Facility Policy and Procedure titled, "Hand Hygiene/Fingernails" with a Release Date of 10/28/2013 read in part: "Policy Statements: 1. Indications for hand hygiene a. Alcohol-based hand rub (ABHR) will be used: ix. After removing gloves b. Plain soap and water will be used: i. As an alternative to the use of alcohol-based hand rub. ii. When hands or gloved hands are visibly soiled. Procedure - iv. Dry thoroughly with a papertowel. v. Use paper towel to turn off hand operated faucets and discard into waste container." 1. On 04/10/14 at 1:35 p.m., Surveyor observed Certified Nursing Assistants (CNA) A and B provide personal cares for Resident #2. Resident #2 requires an extensive assist of two staff for transfers and dressing. CNAs A and B transferred Resident #2 from wheelchair to bed using the Maxie move lift. CNA A checked Resident #2's incontinence brief and indicated it was soiled and needed to be changed. CNA A and B pulled pants down and CNA A picked up the bottle of peri wash up and sprayed it onto the wipe and cleansed the peri area. CNA A removed gloves and, without sanitizing hands, applied clean gloves, and obtained more wipes from the drawer. CNA A and B rolled Resident #2 to the right side and took incontinence brief off and CNA A wiped stool from the buttocks with a peri wash on the wipe. CNA A removed gloves and, without sanitizing, applied clean gloves and cleaned stool from the buttocks. CNA A then took gloves off and, without sanitizing, applied clean gloves and obtained more wipes from the drawer. CNA A cleansed the buttocks and, without changing gloves, picked up the peri wash bottle with the soiled gloves to apply the peri wash to a clean wipe, then set the peri wash bottle onto Resident #2's blanket and continued to cleanse the buttocks; this practice was repeated three more times. CNA B dried the buttocks, removed gloves and sanitized hands and applied clean gloves. CNA A removed gloves, put the peri wash into the drawer and, without sanitizing hands, applied clean gloves and applied a clean brief, pulled pants up and repositioned Resident #2. CNA A removed gloves, washed hands and gathered the garbage bag. CNA B took the garbage bag to the soiled utility room and washed hands. On 04/15/14 at 10:30 p.m., Surveyor reviewed the above findings with the Director of Nursing (DON). The DON indicated she would expect proper hand washing and glove use from staff. 2. On 04/10/14 at 12:35 p.m., Surveyor observed the DON and CNA A assist Resident #1 to use the restroom. The DON and CNA A sanitized their hands and donned gloved. CNA A removed Resident #1's soiled incontinent pad, removed her gloves, washed her hands, shut off the water with paper towels, then dried her hands with the same paper towels. After performing peri care, CNA A removed her gloves, washed her hands, shut off the water with paper towels, wiped water off the sink and countertop, then dried her hands with the same paper towels. On 04/10/14 at 1:06 p.m., Surveyor observed CNA A and CNA B assist Resident #1 to bed. CNAs A and B sanitized their hands and donned gloves. When CNA A removed her gloves, she washed her hands, shut off the water with paper towels, then dried her hands with the same paper towels. 3. On 04/10/14 at 1:14 p.m., Surveyor observed CNA A and CNA B assist Resident #3 to bed. CNAs A and B sanitized their hands and donned gloves. When CNA A removed her gloves, she washed her hands, shut off the water with paper towels, then dried her hands with the same paper towels.