Every finding on record at Dove Healthcare - West Eau Claire

Based on interview and record review, the facility did not notify the Ombudsman of resident transfer to the hospital for 4 of 5 residents (R76, R51, R30, and R1) reviewed.R76 was transferred to the hospital on [DATE]. The Ombudsman was not notified of this transfer.R51 was transferred to the hospital on [DATE]. The Ombudsman was not notified of this transfer.R30 was transferred to the hospital on [DATE], 04/11/26, 04/17/26, 5/15/26, 5/22/26, and 5/29/26. The Ombudsman was not notified of these transfers.R1 was transferred to the hospital on [DATE] and 05/30/26. The Ombudsman was not notified of these transfers. This is evidenced by: Facility policy titled, Transfer and Discharge, with a revised date of 11/2025, states: .10. Emergency Transfers to Acute Care. h. Transfer notices will be provided to the Ombudsman. They may be sent when practicable, such as in a list of residents on a monthly basis, as long as the list meets all requirements for content of such notices. Example 1 R76 was admitted to the facility on [DATE]. On 03/05/26, R76 was transferred to the hospital. No documentation of Ombudsman notification was noted. On 06/09/26, Surveyor reviewed facility's documentation of Ombudsman notification of transfers for March 2026. The fax submitted to the Ombudsman, dated 04/01/26, did not include R76. On 06/09/26 at 3:27 PM, Surveyor interviewed Social Worker (SW) E regarding Ombudsman notification. SW E stated the list provided to the Surveyor was accurate and included all residents transferred and discharged . Surveyor asked SW E to find R76 on the provided documentation. SW E was unable to find R76 on list. On 06/10/26 at 7:54 AM, Surveyor interviewed SW E about Ombudsman notification. SW E stated being unsure what had happened, but R76, R51, R30, and R1 were somehow not on the list, and the Ombudsman was not notified of their transfers. Example 2 R51 was admitted to the facility on [DATE]. On 03/20/26, R51 was transferred to the hospital. No documentation of Ombudsman notification was noted. On 06/09/26, Surveyor reviewed facility's documentation of Ombudsman notification of transfers for March 2026. The fax submitted to the Ombudsman, dated 04/01/26, did not include R51. Example 3 On 06/09/26, Surveyor reviewed R30's medical record regarding hospitalizations and noted: On 04/03/26, R30 was transferred to the hospital. No noted documentation of ombudsman notification. On 04/11/26, R30 was transferred to the hospital. No noted documentation of ombudsman notification. On 04/17/26, R30 was transferred to the hospital. No noted documentation of ombudsman notification. Surveyor reviewed ombudsman notifications for April 2026, and R30 was not included. On 05/15/26, R30 was transferred to the hospital. No noted documentation of ombudsman notification. On 05/22/26, R30 was transferred to the hospital. No noted documentation of ombudsman notification. On 05/29/26, R30 was transferred to the hospital. No noted documentation of ombudsman notification. Surveyor reviewed ombudsman notifications for May 2026, and R30 was not included. Example 4 R1 was admitted to the facility on [DATE]. On 02/10/26, R1 was transferred to the hospital. No documentation of Ombudsman notification was noted. On 06/09/26, Surveyor reviewed facility's documentation of Ombudsman notification of transfers for February 2026. The fax submitted to the Ombudsman, dated 03/04/26, did not include R1. On 06/09/26 at 3:27 PM, Surveyor interviewed SW E regarding Ombudsman notification. SW E stated that the list provided to the Surveyor was accurate and included all residents transferred and discharged . Surveyor asked SW E to find R1 on the provided documentation. SW E was unable to find R1 on list. On 05/30/26, R1 was transferred to the hospital. No documentation of Ombudsman notification was noted. On 06/09/26, Surveyor reviewed facility's documentation of Ombudsman notification of transfers for May 2026. The fax submitted to the Ombudsman, dated 06/03/26, did not include R1. On 06/09/26 at 3:27 PM, Surveyor interviewed SW E regarding Ombudsman notification. SW E stated that the list provided to the Surveyor was accurate and included all residents transferred and discharged . Surveyor asked SW E to find R1 on the provided documentation. SW E was unable to find R1 on list.

Based on observation, interview and record review, the facility did not ensure that 1 of 4 residents (R) reviewed for pressure injuries (PI) (R1) received care consistently with professional standards of practice to prevent further deterioration and promote healing of an existing PI. R1 was at risk for PI development and had 2 existing PIs. The facility failed to provide adequate wound care treatment to R1's PI on coccyx.Findings include: Facility policy titled, Pressure Injury Prevention and Management, dated last revised 01/26, states: .4. Interventions for prevention and to promote healing; c. ii. Minimize exposure to moisture and keep skin clean, especially of fecal contamination. R1 was re-admitted to the facility on [DATE], with diagnoses including unspecified dementia, asthma, chronic respiratory failure, severe sepsis with septic shock, infection reaction due to indwelling urethral catheter, type 2 diabetes mellitus, pressure ulcer of sacral region stage 3, and benign prostatic hyperplasia. A suprapubic foley catheter was in place prior to admission. R1's Minimum Data Set (MDS) assessment, dated 04/17/26, identified R1 was at risk for PIs with 1 stage 3 PI. R1's care plan, dated 02/13/26, with revision date of 05/16/26, states: [R1] have a history of pressure injuries to coccyx and left and right heel. History of MASD to buttocks, gluteal cleft, and upper thigh area. Interventions include administer treatments as ordered and monitor for effectiveness. R1's orders:On 05/21/26 Wound care: Sacrum 1. Cleanse areas with wound wash and gauze. 2. Apply skin prep to peri wound/buttock. 3. Apply calcium alginate with silver to wound bed and cover with foam dressing. 4. Change daily and as needed for soiling/dislodgement/saturation every day shift for wound healing. On 06/09/26 at 2:16 PM, Surveyor observed Registered Nurse (RN) P enter R1's room to provide wound dressing care to R1's PI on sacrum and assess R1's new open area on scrotum. Surveyor observed RN P don personal protective equipment (PPE) gown and walk into R1's room. RN P did not observe RN P sanitize hands upon entering R1's room. RN P placed all wound care supplies on R1's counter near the sink and reached into R1's cabinets looking for more supplies. RN P grabbed scissors with contaminated bare hands out of R1's wound care bucket in cabinet and walked over to R1's bed. RN P placed all wound care supplies including scissors directly on R1's end table on top of R1's personal belongings such as a shirt, napkin, and wedge at the foot of R1's bed. Surveyor did not observe RN P sanitize R1's end table before placing wound care supplies on end table. RN P donned gloves and then RN P and Certified Nurse Assistant (CNA) Q uncovered and rolled R1 to the right towards RN P. CNA Q removed R1's sacrum dressing and placed it in the trash. Surveyor observed RN P and CNA Q roll R1 towards CNA Q. RN P grabbed saline and gauze and gently cleansed R1's sacrum PI. RN P grabbed adhesive prep wipe and began wiping around R1's sacrum PI. RN P did not doff contaminated gloves prior to prepping R1's skin. RN P grabbed contaminated scissors with RN P's contaminated gloves and cut new piece of foam border from packaging. RN P grabbed foam border with contaminated gloves and placed contaminated foam border into R1's open PI on R1's sacrum. RN P picked up Mepilex dressing and placed it over the contaminated foam border. RN P labeled Mepilex. On 06/09/26 at 2:36 PM, Surveyor interviewed RN P and asked if they should have sanitized R1's end table and placed a protective border between R1's wound care supplies and R1's belongings on end table. RN P reported to Surveyor that they should have cleansed R1's end table prior to placing wound care supplies on end table. Surveyor asked RN P what the process is for performing hand hygiene and changing gloves often during a wound dressing change going from dirty to clean. RN P reported to Surveyor they missed several opportunities to change contaminated gloves and sanitize hands when performing glove changes and when entering and exiting R1's room. Surveyor asked RN P if it was important to doff contaminated gloves when cleansing the open PI then prepping skin for the clean dressing. RN P reported to Surveyor they should have doffed gloves, sanitized hands, and then donned new pair of clean gloves. On 06/09/2026 at 3:06 PM, Surveyor interviewed Director of Nursing (DON) B and asked what the expectation is for hand hygiene and keeping wound care supplies during a wound care dressing change. Surveyor informed DON B, RN P missed several opportunities to perform hand hygiene and to sanitize R1's end table prior to placing wound care supplies on end table. DON B reported to Surveyor, RN P was nervous, but DON B's expectation is RN P should have sanitized hands prior to entering R1's room. RN P should have sanitized or created a clean barrier between R1's end table and R1's wound care supplies. DON B reported to Surveyor RN P should have doffed contaminated gloves, sanitized hands, and donned clean gloves prior to prepping R1's skin for new wound dressing. DON B reported there will be further education for RN P.

Based on observation, interview, and record review, the facility did not ensure residents with an indwelling foley catheter received care and treatment consistent with professional standards of practice to prevent complications or urinary tract infections (UTI) for 2 of 4 residents (R) reviewed (R76 and R1) .R76 had an indwelling foley catheter which was not secured to prevent trauma or movement of catheter tubing.R1's foley catheter bag was leaking. Facility staff placed leaking catheter bag in bin placed on floor to collect the leaking urine. This is evidenced by: Facility policy titled, Catheter Care, with a revised date of 02/2026, states: Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use.10. Ensure the catheter tubing is secured by use of stat lock or leg secure device.11. Report abnormal findings to the nurse and document any care that needs to be in the resident record. Example 1 R76 was admitted to the facility on [DATE] with acute pyelonephritis and urinary retention. An indwelling foley catheter was in place prior to admission. R76's care plan, dated 02/16/26, with a target date of 08/11/26, states: [R76] has indwelling foley catheter with a goal to show no signs or symptoms of urinary infection. Interventions include ensure stat lock or cath secure in place. R76's orders: 03/16/26 cath secure: check placement every shift 05/28/26 cath secure: alternate location of cath secure device every 3 days and as needed. Use foley strap instead of adhesive. On 06/08/26 at 10:29 AM, Surveyor observed R76 lying supine in bed with foley catheter bag hanging under the bed. Foley tubing was not secured by leg strap to R76. A blue clip on the foley tubing was clipped to R76's bed sheet. Surveyor asked Certified Nursing Assistant (CNA) C if R76 was supposed to have a foley securement device. CNA C stated no because R76 has an issue with adhesives so they can't use a securement device. On 06/09/26 at 8:17 AM, Surveyor observed R76 lying in bed with no foley securement device in place and tubing clipped to R76's bed sheet. Surveyor asked CNA C if there was supposed to be a foley securement device. CNA C stated a Velcro strap is used if R76 is up in the wheelchair, but nothing used when R76 is in bed. Surveyor asked CNA C why a securement device wasn't used in bed. CNA C stated that is what another CNA had told them because of skin irritation related to adhesives. On 06/09/26 at 9:17 AM, Surveyor interviewed Nurse Tech (NT) F regarding R76's foley securement device. NT F that there should be a Velcro strap in place, but the floor nurse might have more information. On 06/09/26 at 9:31 AM, Surveyor interviewed Registered Nurse (RN) G regarding R76's foley securement device. RN G stated R76 should have a securement strap in place and did not know why there was not one being used. On 06/09/26 at 11:20 AM, Surveyor interviewed Director of Nursing (DON) B regarding R76's foley securement. Surveyor asked DON B the expectations related to residents with foley catheters and securement devices. DON B stated that a securement device should be in place. Example 2 R1 was re-admitted to the facility on [DATE] with diagnoses including unspecified dementia, asthma, chronic respiratory failure, severe sepsis with septic shock, infection reaction due to indwelling urethral catheter, type 2 Diabetes Mellitus, pressure ulcer of sacral region stage 3, and benign prostatic hyperplasia. A suprapubic foley catheter was in place prior to admission. R1's care plan, dated 11/26/25, with revision date of 02/16/26, states: [R1] has suprapubic catheter for obstructive uropathy with a goal to be/remain free from catheter-related trauma. Interventions include ensuring stat lock or catheter secure in place and report abnormal findings to the nurse during catheter care. Proper placement of leg strap/stat lock checked every shift. R1's orders: 02/16/26 Change catheter drainage graduate/container every night shift 06/03/26 Foley catheter: Suprapubic size: 16 Fr balloon: 5cc-ok to inflate 10cc Change foley catheter monthly or with occlusion and as needed. Chart in progress notes if foley is changed every hour as needed. On 06/08/26 at 10:21 AM, Surveyor observed R1 sitting in wheelchair in room with a pink basin under R1's wheelchair. Surveyor observed R1's catheter bag sitting inside the pink basin. On 06/09/26 at 7:33 AM, Surveyor observed R1 sitting in wheelchair sleeping in room. Surveyor observed R1's catheter bag lying on the floor with no privacy bag on. Surveyor observed R1's room in disarray with a pink basin under R1's bed. On 06/09/26 at 8:01 AM, Surveyor observed R1 sitting in wheelchair in room eating breakfast. Surveyor observed pink basin under R1's wheelchair with their catheter bag sitting inside the pink basin. On 06/09/26 at 9:07 AM, Surveyor overheard Nursing Support (NS) S say to R1, Oh my, I almost slipped. Not sure what that is in the corner of your room. It is very slippery. Surveyor entered R1's room and observed NS S picking up R1's floor mat. Surveyor observed some type of liquid dripping down R1's fall mat. Surveyor interviewed NS S and asked what the liquid was in the corner of R1's room. Surveyor smelled strong urine in R1's room. Surveyor asked NS S if they were aware staff were placing a pink basin under R1's catheter while they were in wheelchair. NS S reported to Surveyor they were unaware staff were doing that and did not know what was going on with the pink basin. Surveyor asked NS S what the liquid observed smelled like. NS S stated, Smells mixture of sweat and urine, but I don't know for sure. I will call for sanitation to thoroughly clean [R1's] floor. NS S reported to Surveyor they will have to get another floor mat as R1's floor mat is saturated with some kind of liquid substance. NS S walked out of R1's room with contaminated floor mat in a plastic bag. On 06/09/26 at 9:13 AM. Surveyor observed NS S enter R1's room and began talking with R1. NS S stated to R1, I am going to have sanitation come clean as I almost slipped in whatever is in the corner of your bedroom. Surveyor observed NS S exit R1's room again. On 06/09/26 at 9:14 AM, Surveyor observed NS S walk down hallway to let Environmental Services (EVS) know about R1's floor being slippery and needing it to be thoroughly cleaned in the corner near bed and under bed. On 06/09/26 at 9:26 AM, Surveyor observed Certified Nurse Assistant (CNA) N enter R1's room to take R1 to exercise activity. Surveyor interviewed CNA N and asked if they could double check that R1's catheter bag was clamped tight and not leaking. CNA N grabbed catheter bag and checked the clamp. Surveyor asked CNA N if they knew why the pink basin on the floor keeps being placed under R1's catheter bag. Surveyor observed catheter bag to be labeled 06/08/26 and CNA N reported to Surveyor, R1's catheter bag was clamped and did not have pink basin under catheter bag anymore. On 06/09/26 at 9:36 AM, Surveyor interviewed CNA U and asked them if they were aware of any catheter leaking concerns for R1's suprapubic catheter. CNA U reported to Surveyor they oversee showers but unsure about R1. Surveyor asked CNA U who was R1's CNA. CNA U reported to Surveyor at this time CNA U is R1's CNA but are unsure of any leak concerns at this time. Surveyor asked CNA U why someone keeps placing a pink basin under R1's catheter. CNA U reported to Surveyor some aides must be placing basin under instead of hanging from R1's wheelchair or bed. On 06/09/26 at 9:43 AM, Surveyor interviewed NS S and asked if they figured out what the liquid was on R1's floor mat and all over floor. NS S reported to Surveyor after cleaning R1's floor mat, it smelled and looked as if it was old urine sitting under the floor mat. Surveyor asked NS S if R1's catheter was leaking. NS S reported to Surveyor they are unsure but will report this to the nurse on duty. On 06/09/26 at 9:48 AM, Surveyor interviewed Registered Nurse (RN) P and asked if they had knowledge about R1's catheter bag leaking. RN P reported to Surveyor that they checked R1's medical record and could not find if catheter bag was changed or leaked. Surveyor reported to RN P, Surveyor observed R1's catheter bag labeled 06/08/26 and a puddle of urine in the corner of R1's room. RN P reported to Surveyor staff must have changed it due to potential leak. RN P stated, Staff use the pink basins sometimes to make sure catheter bags do not touch the floor. Surveyor asked RN P if the facility utilizes privacy catheter bags, so they don't touch floor as well. RN P reported to Surveyor the facility does use privacy bags for catheters and will get one for R1 right away. On 06/09/26 at 2:28 PM, Surveyor interviewed RN P and asked for details about R1's catheter change. RN P reported to Surveyor staff reported to RN P catheter bag and tubing was changed due to a leak yesterday on 06/08/26. Surveyor asked RN P where the catheter bag was leaking. RN P reported to Surveyor they were unsure as they did not get much detail, and the catheter bag change was not documented in R1's medical record. On 06/09/26 at 3:35 PM, Surveyor interviewed Director of Nursing (DON) B and asked if they knew why staff were putting a pink basin under R1's catheter when in bed or wheelchair. DON B reported to Surveyor DON B spoke with Regional Resource V who reported staff were using the pink basin as a barrier between the floor and R1's catheter bag. Surveyor asked DON B if they knew R1's catheter bag was leaking. DON B reported to Surveyor this is the first DON B has heard about R1's catheter. Surveyor reported to DON B Surveyor's observation of R1's catheter bag leaking. Surveyor asked DON B what the expectation is for staff documenting in R1's medical record with concerns of leaking catheter or catheter changes. DON B reported to Surveyor they are still reaching out to staff to determine what happened with R1's catheter. DON B reported the next steps would be to follow up with urology.

Based on observation, interview, and record review, the facility did not provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 of 18 residents (R) reviewed (R66, R76).-Certified Nursing Assistant (CNA) N performed restorative tasks for R66 without wearing Personal Protective Equipment (PPE). R66 is on enhanced barrier precautions.-Medication Aide (MA) H did not change gloves and perform appropriate hand hygiene prior to and during medication administration involving R76's feeding tube.Findings include:The facility policy titled, Enhanced Barrier Precautions, last revised January 2025, includes: Personal Protective Equipment (PPE) is necessary when performing high-contact care activities.Example 1On 06/08/26, Surveyor reviewed R66's medical record related to precautions. R66 was noted to be on Enhanced Barrier Precautions (EBP) related to indwelling Foley catheter.On 06/08/26 at 10:12 AM, Surveyor observed CNA N enter R66's room to perform restorative care. CNA N did not don any Personal Protective Equipment (PPE) prior to contact with R66.On 06/08/26 at 11:13 AM, Surveyor interviewed CNA N about restorative care and EBP. When asked if CNA N wears PPE when providing restorative care to residents on EBP, CNA N replied, No, was I supposed to? CNA N stated they thought PPE was only required for performing personal area cares. When asked if education for EBP was provided to CNA N, CNA N stated yes.Example 2The facility policy titled, Medication Administration via Enteral Tube, last revised 02/2026, includes: place needed supplies on the bedside stand or overbed table, arranging so they can be easily reached .perform hand hygiene and apply gloves.On 06/09/26 at 8:50 AM, Surveyor observed MA H administering medications to R76 via gastrostomy tube (G-tube). Prior to administration, Surveyor observed MA H don gloves, remove soiled linens from a bedside table and place it in a bag, remove other items from the table, grab the bathroom handle to enter and retrieve water, and unhook the tube supplying nutrition to the G-tube. Surveyor observed MA H then administer medications via G-tube, remove an old Scopolamine patch, place a new patch, and administer insulin to R76. MA H did not change gloves or perform hand hygiene throughout the entire process.On 06/09/26 at 9:43 AM, Surveyor interviewed MA H about hand hygiene and glove changing. MA H stated MA H should have changed gloves and performed hand hygiene prior to medication administration and between each type of task.On 06/10/26 at 11:44 AM, Surveyor interviewed Director of Nursing (DON) B about EBP, PPE, and hand hygiene. Surveyor made DON B aware of observations of CNA N not donning PPE to perform restorative care to R66 and the lack of hand hygiene provided by MA H when administering medications to R76. DON B acknowledge these events are not standards of practice. DON B stated precaution education is provided to all staff upon hire, annually, and more often when needed. DON B stated the most recent education was provided in January 2026 during the skills fair.

Based on observation, interview, and record review, the facility did not ensure medication error rates are not 5 percent or greater for 2 of 4 residents (R) observed (R76, R73).-Nursing staff did not measure Voltaren gel prior to administration for R73.-Nursing staff splashed and spilled medications prior to administration via gastrostomy tube for R76.-Nursing staff did not flush the correct amount of water between medications for R76.-Nursing staff administered sublingual medication via gastrostomy tube for R76.Findings include:The facility policy titled, Medication Administration, last revised 01/01/25 states: Ensure that the six rights of medication administration are followed including right dose and right route.Example 1On 06/09/26 at 7:26 AM, Surveyor observed Medication Aide (MA) H administer medications to R73. R73 has an order for Voltaren gel 1% apply to right shoulder topically one time a day for pain. Apply 4 grams. Surveyor observed MA H open the tube, place two dime-size amounts of gel onto MA H's gloved hand and then use the other gloved hand to rub the Voltaren gel onto R73's left hip. MA H placed another nickel-size amount on the left gloved hand and proceeded to rub the gel on the back of R73's neck and bilateral shoulders.On 06/09/26 at 7:30 AM, Surveyor interviewed MA H about the dosage for Voltaren gel. MA H stated there wasn't a set amount. Surveyor asked MA H to review the order in R73's medication administration record, which indicated the amount as 4 grams. Surveyor asked MA H how they knew 4 grams were administered. MA H replied, I guess I should have measured it.Example 2The facility policy titled, Medication Administration via Enteral Tube, last revised 02/2026, includes: Intent-To ensure medications administered [NAME] enteral tubes are given safely and correctly to prevent harm, maintain tube patency, and achieve intended therapeutic effects.sublingual medication will not be administered through enteral tube.flush enteral tube with at least 15ml of water to ensure drug delivery and clear the tube.On 06/09/26 at 8:50 AM, Surveyor observed MA H administering medications to R76 via gastrostomy tube. MA H crushed each of the following medications and placed them in their own medication cup:-Aspirin 81mg chewable tablet give one tablet via percutaneous endoscopic gastrostomy (PEG)-tube-Esomeprazole Magnesium Oral Capsule Delayed Release give 20mg via PEG-tube-Finasteride oral tablet 5mg give one tablet enterally-Losartan Potassium oral tablet give 50mg enterally-Multivitamin oral tablet give one tablet via PEG-tube-Rosuvastatin Calcium oral tablet 20mg give one tablet enterally-Hyoscyamine Sulfate oral tablet 0.125mg give 1 tablet sublinguallySurveyor observed MA H add unmeasured, uneven amounts of water to each cup to dissolve the medication. Surveyor asked how much water should be added, MA H stated enough to help dissolve it for administration. MA H then used a syringe to flush the tube prior to medication administration. MA H took the syringe to the first medication cup, drew most of it up into the syringe, and then squirted it back into the medication cup as a way to mix it. This was repeated a couple of times with each medication causing some to splash out onto the table. When drawing the medication up each final time before administering via gastrostomy tube, MA H held the syringe into a washcloth to remove the access air. This caused some of the medication to remain in the washcloth and in one instance, some was splashed onto R76's sheet. Surveyor observed MA H administer water flushes between each medication of different amounts. Surveyor asked MA H how MA H knows how much water to flush with in between medications, and MA H replied, About 10. Surveyor observed that 10ml was not administered each time.On 06/09/26 at 9:30 AM, Surveyor interviewed MA H about the order for Hyoscyamine stating to administer sublingually. MA H stated MA H would have to look into it as most medications for R76 were supposed to be administered via gastrostomy tube.On 06/10/26 at 11:44 AM, Surveyor interviewed Director of Nursing (DON) B about medication administration. Surveyor made DON B aware of Surveyor's observations of wrong Voltaren dose for R73 and medications spilling, wrong route, and the amount of water flushed in between medications when administering via PEG tube for R76. DON acknowledged this is not professional standard of practice. DON B acknowledged due to spilling of each medication, there was no way to know exactly how much of each medication was administered. DON B stated staff were provided education on medication administration in January 2026 and the education included using a minimum of 15ml of water between each medication.

Based on record review and interview, the facility did not ensure that 1 of 1 resident (R) reviewed received appropriate respiratory care during administration of respiratory therapy (R1). Registered Nurse (RN) P did not perform post respiratory assessments for R1 when administering nebulizer treatments.Findings include: The facility policy titled Specific Medication Administration Procedures for Oral Inhalation Administration, dated 05/18, in part: .L. Remain with the resident for the treatment unless the resident has been assessed and authorized to self-administer. M. Approximately five minutes after treatment begins (or sooner if clinical judgement indicates) obtain the resident's pulse. T. Obtain post-treatment pulse, respiratory rate, and lung sounds and document findings in the medical record if indicated by facilities policy and procedures. R1 was re-admitted to the facility on [DATE] diagnoses including unspecified dementia, asthma, chronic respiratory failure, severe sepsis with septic shock, infection reaction due to indwelling urethral catheter, type 2 Diabetes Mellitus, pressure ulcer of sacral region stage 3, and benign prostatic hyperplasia. R1's orders:06/03/26 Budesonide inhalation suspension 0.5MG/2ML, inhale 2ml orally via nebulizer two times a day for asthma. Ensure complete pre and post assessments. Rinse mouth with water after. Ok to mix with DuoNeb.06/03/26 Pre respiratory evaluation: Document lung sounds for left and right lungs. For lung sounds: D=Diminished, C=Crackles, R=Ronchi, CL=Clear, RA=Rales, W=Wheezes. Document respiratory, pulse, and O2 saturations percent. Add number of minutes for assessment, four times a day.06/03/26 Post respiratory evaluation: Document lung sounds for left and right lungs. For lung sounds: D=Diminished, C=Crackles, R=Ronchi, CL=Clear, RA=Rales, W=Wheezes. Document respiratory, pulse, and O2 saturations percent. Add number of minutes for assessment, four times a day. On 06/09/26 at 8:30 AM, Surveyor observed RN P enter R1's room with nebulizer treatment. Surveyor observed RN P place it on R1's face and turn machine on. RN P exited R1's room and told R1 they would be back soon. Surveyor did not observe R1's pre-nebulizer treatment performed. On 06/09/26 at 8:57 AM, Surveyor observed Nursing Support (NS) S enter R1's room. NS S announced themselves and began removing nebulizer mask from R1's face. NS S exited R1's room. Surveyor did not observe R1's post nebulizer treatment performed. On 06/09/26 at 9:48 AM, Surveyor reported to RN P, Surveyor did not observe a pre and post nebulizer treatment. RN P reported to Surveyor they completed pre nebulizer treatment assessment but did not perform post nebulizer assessment. Surveyor asked RN P if it is normal process for R1 to have a pre and post assessment completed during nebulizer treatment. RN P reported to Surveyor that R1 should have had pre and post completed as R1's order states to perform prior to neb treatment and post treatment. Surveyor asked RN P their time frame to recheck on R1's nebulizers after starting it. RN P reported to Surveyor they usually go back within 30 minutes after starting nebulizer, but RN P did not. On 06/09/26 at 11:14 AM, Surveyors interviewed Director of Nursing (DON) B and asked what the expectation is for staff, who is responsible for completing pre and post assessments. DON B reported to Surveyor DON B's expectation is RNs are the only ones who perform lung assessments with expectation to perform the lung assessment within 15 minutes pre and post nebulizer treatment.

Based on interview and record review, the facility did not ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications for 1 of 3 residents (R) reviewed (R76).Facility did not ensure R76's percutaneous gastrostomy (PEG) tube was properly placed prior to administering medications.This is evidenced by:Facility policy titled, Care and Treatment of Feeding Tubes (Enteral Tubes), with a revised date of 05/05/25, states: .6. In accordance with facility protocol, licensed nurses will monitor and check that the feeding tube is in the right location: a. Tube placement will be verified before beginning a feeding and before administering medications.R76 was admitted to the facility on [DATE] with dysphagia following cerebral infarction. A PEG tube was in place on admission to administer enteral feeding and medication administration.On 06/09/26 at 8:54 AM, Surveyor observed Medication Aide (MA) H disconnect R76's tube feeding to administer medications. Surveyor observed MA H attach syringe to R76's PEG tube and pull back on the plunger. Surveyor asked MA H to explain what assessment is being completed prior to administering medications. MA H stated that she is a MA and cannot do assessments, only administer the medications. Surveyor asked MA H if a nurse had assessed R76's PEG tube placement prior to MA H administering these medications. MA H stated yes sometime this morning before 7 AM by Registered Nurse (RN) G.R76's medical record did not note a PEG tube assessment documentation for 06/09/26.On 06/09/26 at 9:31 AM, Surveyor interviewed RN G regarding assessment of R76's PEG tube. Surveyor asked RN G if they had assessed R76's PEG tube placement today. RN G stated no, they had not had time yet. Surveyor asked RN G if a Medication Aide can administer medications via PEG tube without a nurse assessing for placement first. RN G stated no, and they are expected to get the nurse first to do the assessment.On 06/09/26 at 11:15 AM, Surveyor interviewed Director of Nursing (DON) B regarding R76's PEG tube assessment. Surveyor asked DON B if Medication Aides are expected to do an assessment prior to administering medications via PEG tube. DON B stated no, only the RN can do an assessment. Surveyor asked DON B if the expectation is for the nurse to complete an assessment prior to administering medications via PEG tube. DON B stated yes.

Based on observation, interview, and record review, the facility did not ensure a resident (R) had the right to refuse a medication for 1 of 4 residents (R76).-R76 gave non-verbal indications regarding placement of a Scopolamine patch, and Medication Aide (MA) H continued to place the patch on R76.Findings include:On 06/09/26 at 8:50 AM, Surveyor observed Medication Aide (MA) H administering medications to R76. MA H did not explain to R76 what MA H was going to do before attempting to apply a Scopolamine patch behind R76's left ear. While trying to apply the patch, Surveyor observed R76 grimacing and pulling R76's head away. R76 was jerking R76's head from side to side. MA H asked R76 if it was ok for MA H to try again, and R76 shook their head, indicating no. MA H gently held R76's face with the left hand and placed the patch behind R76's left ear with the right hand. R76 was observed to pull away from MA H. MA H placed the patch behind R76's left ear.On 06/09/26 at 9:43 AM, Surveyor interviewed MA H regarding placement of the patch. MA stated R76 does not usually refuse the patch and acknowledged MA H should have explained the procedure prior to attempting to place the patch or reapproached.On 06/10/26 at 8:41 AM, Surveyor interviewed Registered Nurse (RN) L regarding indications a non-verbal resident was refusing medications. RN L stated non-verbal indicators such as shaking their heads, shutting their mouth, swatting you away, and other motions/actions would give the indication of refusal. RN L stated they would try to educate and help a resident understand why the medication is important, reapproach if necessary, and document any refusal. The provider and case manager would then be updated.On 06/10/26 at 11:44 AM, Surveyor interviewed Director of Nursing (DON) B about residents' rights to refuse medications. Surveyor made DON B aware of Surveyor's observation regarding the Scopolamine patch for R76. DON B acknowledged MA H did not follow standards of care and should have approached the situation differently.

Based on observation, interview, and record review, the facility did not ensure the timeliness of revisions for each resident's person-centered, comprehensive care plan for 1 of 18 residents (R) reviewed (R66).-R66 had tracheostomy removed on 11/12/25 and care plan currently includes interventions related to trach care.-R66 now takes food orally and is on a mashable texture. Care plan states all nutrition is administered via gastrostomy tube and is full liquid.Findings include:The facility policy titled, Comprehensive Care Plan, last revised on 03/10/25, includes: The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS) assessment. The comprehensive care plan will describe.the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.On 06/08/26 at 10:07 AM, Surveyor interviewed R66 and Family Member (FM) W regarding care received by the facility. Surveyor observed R66 no longer had a tracheostomy. FM W stated R66 had the tracheostomy removed in November 2025. When asked about R66's nutrition, FM W stated R66 took all food by mouth, but it must be very soft.On 06/09/26, Surveyor reviewed R66's care plan regarding tracheostomy care. The care plan includes ensuring the trach ties are secured at all times.On 06/09/26, Surveyor reviewed R66's care plan regarding nutrition. The care plan states R66 requires tube feeding as R66 is unable to obtain adequate nutrition orally. The care plan states R66 receives a full liquid diet.On 06/09/26, Surveyor reviewed R66's physician orders, which indicate R66 has a regular diet with fork-mashable texture, and thin liquids.On 06/10/26 at 8:41 AM, Surveyor interviewed Registered Nurse (RN) L about care plan revisions. RN L stated care plans are updated with a combination of nursing staff, management, therapy, and other members of the care team as changes happen.On 06/10/26 at 11:44 AM, Surveyor interviewed Director of Nursing (DON) B about care plans. DON B stated care plans are updated by the members of the interdisciplinary team and departments including nurse managers, nurses, social services, therapy, dietary, activities, and infection control. Nursing staff are then made aware of changes. Surveyor made DON B aware of updates not made to R66's care plan regarding tracheostomy care and nutrition, as R66 has had 2 quarterly MDS assessments since the tracheostomy was removed and 1 since diet was changed. DON B acknowledged and stated the updates would be made.

Based on observation, record review, and interview the facility did not prepare foods in a sanitary manner. Nutritional Service Aide (NSA) P did not allow the thermometer probe to air dry of alcohol prior to inserting into each of the nine food items intended to be served to residents for lunch. This had the potential to affect all 66 residents in the facilty. NSA N did not perform hand hygiene in between passing water pitchers to residents (R). This affected 10 of 10 residents observed receiving water pitchers (R48, R21, R20, R27, R22, R32, R45, R34, R60, and R269). NSA P prepared and served food to residents without proper hand hygiene and touched ready to eat foods with contaminated gloved hands. This affected 7 of 7 residents observed (R26, R267, R48, R22, R11, R6, and R268). This is evidenced by: Example 1 The facility procedure titled, Nutritional Services Procedure Appearance and Temperatures reviewed on March 2023 stated in part, 7. Temperatures will be taken by cleaning the thermometer with approved cleaning wipe, allowing cleaner to dry for 10-15 seconds, and placing the thermometer in center of food item. On 3/19/25 at 11:03 AM, Surveyor observed NSA P check temperatures of the foods being served at the second-floor kitchenette. NSA P wiped the thermometer probe with an alcohol prep pad and immediately inserted the thermometer into country fried steak. NSA P then continued to wipe the thermometer after each food item and immediately insert the thermometer into the next food item without allowing for the probe to dry after wiping it with the alcohol pad. NSA P used the same thermometer wiping with approved wipe and sticking it in next food without waiting after wiping with cleaning wipe. NSA P did this for all 9 foods she checked the temperature on. NSA P reported she has had training on checking food temperatures but does not recall having to wait after wiping the probe with alcohol prep pad. On 3/19/25 at 2:06 PM, Surveyor interviewed Nutritional Service Director (NSD) S about the expectations of checking temperatures of foods prior to serving. NSD S reported the expectation is after wiping the thermometer with approved cleaning wipe, the cleaner should be allowed to air dry for 10-15 seconds before placing into food item. Surveyor explained this did not occur with recent observation. NSD S acknowledges this has the potential to contaminate the foods served. 48793 Example 2 Surveyor reviewed policy titled, Water Pass, dated June 2002, last reviewed in January 2023, which states in part: .#4. Sanitize hands and wear gloves for process. #5. Remove old cups from rooms and replace with [NAME] pass. a. Use one hand for clean mugs and one hand for dirty mugs or sanitize hands before leaving room. b. Place dirty mugs in bus tub away from clean mugs . On 03/18/25 at 12:59 PM, Surveyor observed NSA N deliver new water to residents on second floor. Surveyor observed NSA N grab a clean water jug and deliver water jug to R48. Surveyor observed NSA N take R48's used water jug and place used water jug on clean water cart. Surveyor did not observe NSA N sanitize hands upon exiting R48's room. NSA N then grabbed another new water jug and entered R21's room. Surveyor observed NSA N take R21's used water jug and place used water jug on clean water cart. Surveyor did not observe NSA N sanitize hands upon exiting R21's room. On 03/18/25 at 1:05 PM, Surveyor observed NSA N grab a clean water jug and deliver water jug to R20, R27, R22, and R32, and take out used contaminated water jugs and place on cart for R20, R27, R22, and R32. Surveyor did not observe NSA N sanitize hands upon exiting R20, R27, R22, and R32's rooms. On 03/18/25 at 1:08 PM, Surveyor observed NSA N grab a clean water jug and deliver water jug to R45, R34, R60, and R269, and take out used contaminated water jugs and place on cart for R45, R34, R60, and R269. Surveyor did not observe NSA N sanitize hands upon exiting R45, R34, R60, and R269's rooms. On 03/18/25 at 1:15 PM, Surveyor interviewed NSA N and asked about sanitizing hands in between passing waters to the units. NSA N indicated that NSA N was not trained that way, but NSA N stated, That makes sense and is probably more sanitary. I can start doing that if that's what I need to do. On 03/19/25 at 2:25 PM, Surveyor interviewed NSD O and asked expectation of NSA N for hand hygiene during water pass to residents. NSD O indicated that NSA N should be sanitizing hands in between passing clean water jugs and taking the contaminated old jug out of each resident's rooms. Example 3 Surveyor reviewed policy titled, Personnel Sanitation Standards, dated January 2017, last reviewed in March 2024, which states in part: . #3. Wear single use disposable gloves and use tongs when required to avoid bare hand contact with ready to eat foods. #5. Hands must be washed after removing gloves, using the restroom, after leaving storage rooms, taking out trash, etc., after touching your hair, mouth, or nose, and at any other time hands may become soiled . On 03/19/25 at 7:44 AM, Surveyor observed NSA P grab utensils and cook on the stove. Surveyor observed NSA P touch face and readjust mask with gloved hands. NSA P then grabbed bread out of bag with contaminated gloves and placed bread in toaster. Surveyor observed NSA P grab finished toast and add butter to the toast with contaminated gloves. NSA P then placed toast on tray and breakfast tray was delivered to R267. On 03/19/25 at 7:47 AM, Surveyor observed NSA P take glasses off and wipe down glasses with gloved hands. NSA P then doffed gloves and grabbed a clean pair of gloves. NSA P did not sanitize in between doffing contaminated gloves and donning new gloves. On 03/19/25 at 7:52 AM, Surveyor observed NSA P reach for a trash can with contaminated gloves. Surveyor observed NSA P doff contaminated gloves, throw gloves into the trash can, and then re-apply new gloves. Surveyor did not observe NSA P sanitize in between. NSA P grabbed toast once it was done cooking in toaster with contaminated gloved hands. NSA P placed butter and jelly on toast with contaminated gloved hands. NSA P then placed toast on tray and breakfast tray was delivered to R11. On 03/19/25 at 8:00 AM, Surveyor observed NSA P take contaminated gloves off, readjust face mask and then don clean gloves. Surveyor did not observe NSA P sanitize in between doffing contaminated gloves and donning new pair of gloves. Surveyor observed NSA P grab eating utensils and place on napkin on breakfast tray. Surveyor observed NSA P grab bread with contaminated gloves and place in toaster. NSA P grabbed a spatula and flipped hash browns on griddle. NSA P grabbed toast with contaminated gloves and placed on breakfast tray. NSA P then placed toast on tray and breakfast tray was delivered to R26. On 03/19/25 at 8:12 AM, Surveyor observed NSA P touch waist with gloved hands and rest right hand on waist. NSA P then grabbed cooked toast out of toaster with contaminated gloves. NSA P placed butter on toast and then laid toast on breakfast tray and tray was delivered to R6. On 03/19/25 at 8:14 AM, Surveyor observed NSA P pick up utensil for sausage patty. NSA P then used left contaminated glove hand to hold sausage patty down and used right hand to cut the sausage patty. NSA P then grabbed cooked toast out of toaster with right contaminated gloved hand and placed on breakfast tray. NSA P buttered the toast and then placed toast on tray and breakfast tray was delivered to R22. Surveyor did not observe any hand hygiene performed. On 03/19/25 at 8:18 AM, Surveyor observed NSA P grab cooked toast out of toaster with right contaminated gloved hand and place on breakfast tray. NSA P then placed toast on tray and breakfast tray was delivered to R268. Surveyor did not observe any hand hygiene being performed. On 03/19/25 at 8:25 AM, Surveyor observed NSA P grabbing silverware for R48's breakfast tray. Surveyor observed NSA P readjust glasses with gloved hands and then readjust face mask over nose. NSA P then started serving oatmeal and eggs in R48's bowl on breakfast tray. NSA P took lids and placed on top of bowls with contaminated gloved hands and breakfast tray was delivered to R48. On 03/19/25 at 8:37 AM, Surveyor interviewed NSA P. Surveyor asked NSA P what the expectation of hand hygiene is when prepping and serving residents their meals. NSA P indicated in between glove changes and any time gloves meet contaminated surfaces. Surveyor indicated to NSA P that Surveyor observed NSA P touching face and glasses and readjusting mask with contaminated gloves. Surveyor observed NSA P grab bread out of bag and place in toaster, then grab with contaminated gloves and butter the toast during all of prepping and serving. NSA P indicated that NSA P is supposed to use tongs to grab bread in and out of bag and toaster. On 03/19/25 at 2:25 PM, Surveyor interviewed NSD O and asked expectation of NSA P for hand hygiene during meal prep, in between glove changes, and serving of meals to residents. NSD O indicated that NSA P and all staff are to sanitize between glove changes. If gloves become contaminated with contaminated surfaces or personal contaminated surfaces to doff gloves, wash or sanitize in between then don new pair of clean gloves.

Based on interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who had completed the minimum qualification requirements for the position. This practice could potentially affect all 63 residents residing in the facility. Findings include: On 3/20/25 at 11:40 AM, Surveyor interviewed Nutritional Services Director (NSD) S, requesting verification of her qualifications. NSD S reported she completed an all day certification course. The certificate NSD S provided is from the National Registry Of Food Safety Professionals and it states NSD S has successfully satisfied the requirements for the International Food Safety Manager under both Conference for Food Protection Standards and ISO/IEC 17024 Standards. Certificate issued 11/16/21 and expiration date is 11/16/26. Surveyor asked NSD S if she had other schooling or training other than the conference certificate, NSD S reported she did not. NSD S did state the facility does have a Registered Dietician that comes to the facility a couple of times a week and is available to her daily Surveyor informed NSD S and NHA A the certificate provided does not meet requirements for a certified dietary manager.

Based on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This affected 3 of 33 (R) residents reviewed for infection control (R20, R23, R61). -Observation of LPN I not disinfecting bedside table and wound supplies during wound care dressing for R20. -Improper hand hygiene was observed during wound care and personal care for R20, R23, and R61. Findings include: Example 1 On 03/18/25 at 3:29 PM, Surveyor observed Licensed Practical Nurse (LPN) I enter R20's room and start prepping for completing R20's wound dressing change on coccyx. Surveyor observed LPN I don Personal Protective Equipment (PPE) and enter R20's room. Surveyor did not observe LPN I sanitize hands before entering R20's room. Surveyor observed LPN I grab supplies from R20's drawer and place on bedside table. Surveyor did not observe LPN I sanitize or wipe down bedside table before placing wound dressing supplies on bedside table. LPN I began moving a trash can over to the bedside table. Surveyor observed LPN I begin pulling R20's pants down, pull off the old wound dressing and throw the soiled dressing in the trash can. LPN I removed soiled gloves and sanitized hands. LPN I donned clean gloves and then placed left gloved hand into LPN I's left scrub pocket. LPN I pulled contaminated scissors out of LPN I's pocket. LPN I used contaminated scissors that were located in LPN I's left scrub pocket and cut the calcium alginate for R20's wound. LPN I then took the piece of calcium alginate, which was cut, and packed the contaminated calcium alginate into R20's wound bed on sacrum. LPN I changed gloves and applied the sacral dressing over R20's wound. Surveyor observed LPN I pick up scissors and place back in LPN I's left scrub pocket. LPN I put wound supplies away in drawer, sanitized hands, and walked out of R20's room. On 03/18/25 at 3:47 PM, Surveyor interviewed LPN I and asked LPN I what is LPN I's process when entering an Enhanced Barrier Precaution (EBP) room and prepping wound supplies for R20. LPN I indicated that LPN I would sanitize hands before donning PPE and LPN I usually wipes down the bedside or places a barrier down before placing wound care supplies on table. LPN I indicated to Surveyor that LPN I did not place a barrier or wipe down the bedside table. Surveyor asked LPN I to explain why LPN I pulled a pair of scissors out of LPN I's pocket and used the contaminated scissors to cut R20's calcium alginate that was applied to R20's wound bed. LPN I stated, I thought immediately when I started cutting the calcium alginate. I knew I shouldn't have done that. I am sorry. Surveyor asked LPN I what the normal process for utilizing scissors would be. LPN I indicated that LPN I should have sanitized with an alcohol pad before and after use and to not pull scissors out of LPN I's scrub pocket. On 03/19/25 at 2:52 PM, Surveyor interviewed Infection Control Preventionist (ICP) D and asked ICP D what expectation is for prepping for wound care dressing. ICP D indicated that ICP D expects nurses to wipe down surfaces or create a barrier before prepping for supplies. ICP D indicated that all residents with wounds should have designated supplies for their own or that any extra equipment needed is sanitized before and after use for multiple residents. 51095 Example 2 Surveyor requested and received the facility policy titled Hand Hygiene dated 12/2024. The policy in part read: Policy: All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents an visitors. Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated; using proper technique consistent with accepted standards of practice. 2. Hand Hygiene is indicated and will be performed under he conditions listed in, but not limited to, the attached table. ~Before applying and after removing personal protective equipment (PPE), including gloves. On 3/19/25 at 7:32 AM, Surveyor observed Registered Nurse (RN) Q provide wound care to R23. RN Q cleansed wound on R23's coccyx using a 4x4. Surveyor noted RN Q cleaned stool from rectal area. Certifiied Nursing Assistant (CNA) R held skin of R23's buttocks with gloved hands and assisted RN Q with incontinence and wound cares. Immediately after, and without changing gloves, CNA R proceeded to dress R23, put R23's shoes on and used the Hoyer lift to transfer R23 into his wheelchair. CNA R applied pads and leg straps with same gloves she wore for R23's cares. After R23 was up and in his wheelchair, CNA R removed the gloves, and without using any hand hygiene, CNA R put on new gloves and proceeded to R23's bathroom with his toothbrush. On 3/19/25 at 7:55 AM, Surveyor interviewed CNA R who reported she thought she changed gloves after assisting with R23's cares. Surveyor asked CNA R when should hand sanitizer or hand washing be performed. CNA R acknowledged she did not use hand sanitizer or wash her hands after removing her gloves and donning new gloves. CNA R then removed her gloves, used hand sanitizer and put on new gloves. On 3/19/25 at 2:48 PM, Surveyor interviewed ICP/RN D. ICP D acknowledged the expectations of CNAs would be to change gloves after personal cares and wound care and to perform hand hygiene after removing gloves and prior to putting on new gloves to prevent the spread of infectious diseases. 30570 Example 3 On 3/19/25 at 6:42 AM, Surveyor observed R61's room door with a posting that read Enhanced Barrier Precautions. Surveyor observed CNA C don gloves and a gown to enter R61's room to prepare R61 for a shower. CNA C explained R61 is on Enhanced Barrier Precautions due to having a feeding tube. CNA C did not perform hand hygiene prior to donning the gown and gloves to care for R61. CNA C rolled R61 side to side in bed to remove bedding from under R61. CNA C expressed the bedding was wet. CNA C bagged the wet linens, removed her gloves and donned gloves to proceed with R1's preparation for his shower. CNA C did not perform hand hygiene when removing her soiled gloves before donning clean gloves. On 3/19/25 at 10:20 AM, Surveyor spoke with CNA C about the observation. CNA C expressed she should have done hand hygiene before donning PPE and with change of gloves. CNA C further expressed it is important to keep everything clean and to prevent cross contamination from dirty to clean. On 3/19/25 at 2:40 PM, Surveyor spoke with Registered Nurse (ICP/RN) D, who is the facility's Infection Control Preventionist, about the observation. ICP/RN D indicated he would expect staff to perform hand hygiene prior to donning PPE and between glove changes to minimize the spread of organisms.

Based on observation, interview and policy review, the facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles, did not ensure only authorized personnel had access to medications for 3 of 3 random observations. -One observation was made of resident (R) medications left on top of the medication cart when the cart was unattended and out of view of staff. (R37) -Observation of prescribed Nystatin powder left unattended in R14's room during 2 observations Findings include: Surveyor reviewed policy titled, Preparation and General Guidelines, dated May 2018, states in part: . A. The following equipment and supplies are acquired and maintained by the facility for the proper storage, preparation, and administration of medications: 1. Lockable medication carts, cabinets, drawers, and/or rooms with well-lit medication preparation areas . Example 1 On 03/18/25 at 4:21 PM, Surveyor observed an unlocked medication cart down 2300 hall. Surveyor observed no staff members in sight. Surveyor observed the unsupervised and unlocked medication cart to have two pop packs labeled with R37's name and the medication Famotidine with pills still in the pop packs sitting on top of the medication cart. On 03/18/25 at 4:31 PM, Surveyor observed different staff walk by the medication cart down the hallway. On 03/18/25 at 4:34 PM, Surveyor walked down hallway and around the corner to approach Licensed Practical Nurse (LPN) J. Surveyor interviewed LPN J and asked why medication cart is unlocked and why there are medications on top of medication without being supervised. LPN J indicated that LPN J meant to take Famotidine medication to the medication storage room but did not yet. LPN stated, I will go do this now. Surveyor asked LPN J if LPN J could even see LPN J's medication cart down the hallway. LPN J indicated that LPN J could not see the medication cart from where LPN J was sitting in the lounge. Example 2 On 03/18/25 at 11:52 AM, Surveyor observed Nystatin powder left on bedside table in R14's room. R14 was sitting in room watching TV in wheelchair. Example 3 On 03/19/25 at 9:19 AM, Surveyor observed Certified Nurse Assistant (CNA) K bring Eucerin cream and prescribed Nystatin powder down the hallway into R14's room. Surveyor observed CNA K place medications in the left top drawer. Surveyor interviewed CNA K and asked what CNA K was doing with the medications. CNA K indicated that CNA K was bringing it back from the bath house where CNA K had applied to R14. CNA K showed Surveyor R14's drawer where medications are kept. Surveyor observed the left top drawer to be not lockable. Surveyor observed a right top drawer that has a lock. Surveyor observed CNA K had placed Eucerin and prescribed Nystatin powder in top left drawer. Surveyor asked CNA K why CNA K did not place prescribed medications in locked drawer in R14's room. CNA K indicated that only nurses have the key to the locked drawer. On 03/19/25 at 9:27 AM, Surveyor interviewed Nurse Tech (NT) M and had NT M follow Surveyor into R14's room. Surveyor requested NT M look in nonlockable drawer and explain what medications are in R14's drawer. NT M indicated there was prescribed Nystatin powder and over the counter Eucerin cream. NT M indicated the prescribed Nystatin powder should be locked in the locked drawer to the right of this left drawer. NT M unlocked right drawer and placed prescribed Nystatin powder in the lockable drawer and locked the drawer. On 03/19/25 at 9:37 AM, Surveyor interviewed Nurse Manager Registered Nurse (RN) F who manages 2300 and 2200 hall. Surveyor asked Nurse Manager RN F the expectation for locked medications in rooms. Nurse Manager RN F indicated that any prescription medications in residents' room should be always kept in locked drawer unless being used by a licensed individual.

Based on observation, record review and interview, the facility did not provide the needed supervision and care planned approaches to prevent a fall. The facility practice had the potential to affect 1 of 5 residents (R61) reviewed for falls. Certified Nursing Assistant (CNA) C did not remain at bedside after removing R61's bedside mat and body pillow placing R61 at risk for fall and injury. This is evidenced by: Surveyor requested and received the facility policy titled Fall Prevention Program dated 8/2024. The policy in part read: Policy: 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. ~Each resident's risk factors and environmental hazards will be evaluated when developing the residents comprehensive plan of care. Surveyor reviewed R61's most recent minimum data set (MDS) which was an admission MDS dated [DATE]. The MDS indicated R61 usually understands, usually is understood with a severely impaired cognition. R61 is dependent on staff for bed mobility and transfer. R61 has impairment in range of motion of one upper extremity. R61's diagnosis included encephalopathy and unspecified disorder of psychological development. R61 experienced 2 falls since his admission resulting in no injury. R61 experiences hallucinations and has verbal and physical behaviors that interfere with his care. Surveyor reviewed R61's Fall Risk assessment dated [DATE] which noted: ~Resident is confused and sometimes tries to get out of chair or bed without help ~Resident is confused and doesn't understand own limitations ~Resident is confused and does not follow simple directions ~Resident will rise without staff assist/supervision ~Resident does not/cannot recognize own limitations and does not act appropriately ~fell in the past 30 days ~Resident was injured in fall and injuries are: fracture Surveyor reviewed R61's falls since his admission and noted R61 experienced 4 falls. Surveyor noted 3 of R61's falls were from his bed. Surveyor reviewed R61's CNA Safety Precautions and noted the following: ~Bed should be kept as low to the floor as possible with floor mat on the floor on exit side ~Use pillows for positioning on exit side of bed Surveyor reviewed R61's comprehensive care plan and noted: Fall Safety: 3/18/2025: ~Bed should be kept as low to the floor as possible with floor mat on the floor on exit side ~Use pillows for positioning on exit side of bed On 3/19/25 at 6:42 AM, Surveyor observed CNA C assist R61 in bed in preparation for a shower. R61 was observed in bed with bed at CNA C's waist height. CNA C removed R61's floor mat that was in front of R61's bed and placed it against a chair across the room. CNA C removed R61's blankets, positioning pillow and brief. CNA C offered R61 a urinal and left bedside to gather a bag from R61's bathroom. CNA C returned to bedside and took R61's urinal to the bathroom to empty, again leaving R61's bedside. CNA C rolled R61 side to side in bed to remove wet linens from his bed. CNA C walked from R61's bed to his closet and offered R61 clothing options. Surveyor observed R61 roll toward the front of his bed, where there was no mat. Surveyor asked CNA C if R61 has fallen in the past. CNA C responded R61 has fallen from bed, and that is why the body pillow is in place with floor mat and low bed. Surveyor noted the body pillow had been removed, and the floor mat was against a chair across the room. CNA C cued R61 to stay on his back as she walked away from bedside to return to R61's closet for a clean brief. CNA C stated to R61, You're gonna fall right off the bed if you keep doing that, we don't want that to happen, as she walked to R61's room door and looked into the hallway. CNA C returned to bedside and expressed, One day his whole legs were hanging off the end of the bed. R61 again tried rolling toward CNA C who was at bedside. CNA C walked from bedside back to R61's room door, and R61 was observed moving around the bed. CNA C returned to bedside and R61 rolled to wall and back to his back. CNA C walked from R61's bedside to outside his room to obtain a hoyer lift. CNA C returned to R61's bed to hook up a hoyer sling. CNA C and another CNA transferred R61 to a shower chair and preceded to the shower room. On 3/19/25 at 10:16 AM, Surveyor spoke with CNA C about the observation. CNA C expressed she probably should not have walked away from R61's bed due to his fall risk or have R61's interventions in place if leaving bedside. On 3/19/25 at 9:59 AM, Surveyor spoke with Nursing Home Administrator (NHA) A and Director of Nursing (DON) B about the observation. DON B expressed she would expect fall interventions to be in place if staff are not at R61's bedside. DON B further expressed it is important as R61 has tried to self transfer from bed and is at risk for falling specifically from bed. DON indicated staff should gather supplies and remain at bedside to supervise R61 in bed.

Based on observation, interview and record review, the facility did not ensure that 1 of 3 residents (R) reviewed for pressure injuries (PI) received care consistent with professional standards of practice to prevent at risk of skin breakdown from occurring (R267). R267 was at risk for PI development. The facility failed to provide adequate and consistent repositioning as care planned. Findings include: Surveyor reviewed policy titled, Turning and repositioning, dated September 2024, last reviewed in October 2024, states in part: . #1. All residents at risk of, or with existing pressure injuries, will be turned and repositioned. #3. A routine schedule includes using both side-lying and back positions, alternating from the right, back, and left side. A resident's condition will determine whether a specialized turn schedule is warranted. #6. Repositioning techniques in bed: h. Ensure that heels are floated off the surface of the bed with pillows or devices designed to do so. If using heel protector, the heel must still be floated . R267 was admitted to the facility on [DATE] with diagnoses including, in part, acute and chronic respiratory failure with hypoxia, coronary artery disease, heart failure, diabetes mellitus, peripheral vascular disease, and end stage renal disease. R267's Minimum Data Set (MDS) assessment, dated 03/14/25, identified R267 required assistance for bed mobility, taking on and off footwear, rolling left to right, sit to lying, chair to bed, toileting, and for transfers. MDS also indicated that R267 was determined to be at risk for PIs. Surveyor reviewed R267's care plan: -2 assist with full mechanical lift. Non ambulatory. -Air mattress with safety edges bolster system, level 3 pump setting. -Float heels. -Reposition 1 assist. -Evaluate repositioning needs and individualized as needed. -Assist with repositioning as CNA care plan reflects. Surveyor reviewed R267's Braden scale: -On 03/13/25, Braden scale assessment completed with score of 14 indicating that R267 was at a moderate risk of skin breakdown. On 03/18/25 at 10:32 AM, Surveyor observed R267 lying in bed, supine with heels lying flat on the bed. Surveyor observed Podus boots lying on wheelchair. Surveyor did not observe Podus boots on R267 or R267's heels elevated to off load pressure. On 03/18/25 at 1:47 PM, Surveyor observed R267 lying in bed, supine with heels lying flat on the bed. Surveyor observed Podus boots lying on wheelchair. Surveyor did not observe Podus boots on R267 or R267's heels elevated to off load pressure. On 03/18/25 at 4:52 PM, Surveyor observed R267 lying in bed, supine with heels lying flat on the bed. Surveyor observed Podus boots lying on wheelchair. Surveyor did not observe Podus boots on R267 or R267's heels elevated to off load pressure. On 03/19/25 at 6:41 AM, Surveyor observed R267 lying in bed supine with heels directly flat on the bed. Surveyor observed Podus boots lying in wheelchair parked at the end of R267's bed. Surveyor did not observe Podus boots on R267 or R267's heels elevated to off load pressure. On 03/19/25 at 8:42 AM, Surveyor observed R267 lying in bed supine sleeping with heels directly flat on the bed. Surveyor observed head of bed up to 90-degree angle and a breakfast tray in front of R267. Surveyor observed Podus boots lying in wheelchair parked at the end of R267's bed. Surveyor did not observe Podus boots on R267 or R267's heels elevated to off load pressure. On 03/19/25 at 8:44 AM, Surveyor interviewed Registered Nurse (RN) H and asked RN H about R267's disposition in room. RN H indicated that R267 spends most of R267's time in bed, was feeling a little anxious last night, and staff notified hospice care. Surveyor asked RN H if R267 has any skin breakdown currently. RN H indicated that R267 does not have any open areas but is at risk of skin breakdown and has an air mattress in place. On 03/19/25 at 8:48 AM, Surveyor observed RN H enter R267's room and grab breakfast tray. RN did not readjust R267's bed. Surveyor observed R267 still in 90-degree angle lying in bed with eyes closed. Surveyor observed R267's heels directly on bed. On 03/19/25 at 9:13 AM, Surveyor observed R267 lying in bed supine sleeping with heels directly on bed. Surveyor observed head of bed up to 90-degree angle. Surveyor observed Podus boots lying in wheelchair parked at the end of R267's bed. Surveyor did not observe Podus boots on R267 or R267's heels elevated to off load pressure. On 03/19/25 at 9:59 AM, Surveyor observed R267 lying in bed supine sleeping. Surveyor observed head of bed up to 90-degree angle. Surveyor observed Podus boots lying in wheelchair parked at the end of R267's bed. Surveyor did not observe Podus boots on R267 or R267's heels elevated to off load pressure. On 03/19/25 at 11:15 AM, Surveyor observed RN H and RN G enter R267's room. Surveyor observed RN H give morphine oral to R267 and then RN H and RN G exited R267's room. Surveyor did not observe RN G or RN H reposition R267. On 03/19/25 at 11:18 AM, Surveyor interviewed RN H and RN G and asked if RN H or RN G had been in R267's room to reposition R267. RN H indicated Surveyor would need to speak with Certified Nurse Assistant (CNA) L as RN H and RN G have not repositioned R267. RN G indicated that repositioning should be every 2 hours. Surveyor asked RN H and RN G if RNs know about how often R267's Podus boots are supposed to be on. RN G indicated that RN G is unsure. RN H reviewed R267's Electronic Health Record (EHR) and RN H indicated there was no set order for Podus boots. RN H indicated that Podus boots should be on for off-loading R267's heels. On 03/19/25 at 11:25 AM, Surveyor interviewed CNA L and asked how often is R267 supposed to be repositioned. R267 indicated that CNA L usually completes repositioning every two hours. Surveyor indicated to CNA L that Surveyor has been observing for repositioning and did not see a reposition completed for R267. CNA L indicated that CNA L went into R267's room around 10:30 AM and changed her. Surveyor indicated to CNA L that Surveyor has seen R267 in the same position supine with pressure to R267's sacrum and R267's heel directly lying on the bed. CNA L indicated that CNA L needs to go in there shortly to reposition R267 off R267's bottom. Surveyor asked CNA L if Podus boots are supposed to be on. CNA L indicated that CNA L was unsure and started to review the CNA care plan. CNA L indicated to Surveyor that CNA L thinks Podus boots should be on only at night, but night shift did not place them on last night as CNA L came on this morning and did not see Podus boots on. CNA L indicated that Podus boots have been in R267's wheelchair since CNA L came on shift. Surveyor asked CNA L if R267 can reposition self. CNA L indicated that R267 cannot reposition self and requires total assistance for repositioning. On 03/19/25 at 11:35 AM, Surveyor observed CNA L and RN G enter R267's room. Surveyor observed CNA L and RN G exit R267's room shortly after entering. On 03/19/25 at 11:43 AM, Surveyor interviewed RN G and asked what side RN G repositioned R267. RN G indicated that R267 was repositioned to the right side and a pillow placed under the left side of R267 so that R267 is off R267's bottom. Surveyor requested RN G show Surveyor R267's reposition that RN G and CNA L completed at 11:35 AM. RN G pulled R267's covers off and Surveyor noted R267's heels still touching the bed and Podus boots in wheelchair. RN G indicated that RN G should probably get a thicker pillow to off load the pressure on heels or place the Podus boots on R267. Surveyor observed R267 still lying in a slight angled supine position with pillow slightly under R267's left side. Surveyor asked RN G if the reposition that RN G and CNA L completed at 11:35 was enough to off load pressure to R267's coccyx/sacrum area and if RN G could place hand underneath R267 and feel if R267's bottom is touching the mattress. RN G placed hand underneath R267's bottom and stated, Oh yea her bottom is still touching the mattress. I will need to gather [CNA L] again and try to reposition better or get another pillow underneath her. On 03/19/25 at 11:50 AM, Surveyor interviewed Nurse Manager RN E and asked expectations for R267's Podus boots and what is the expectation for off-loading R267's heels and sacrum area. Nurse Manager RN E indicated that expectation is that R267 is repositioned roughly every 2 hours. When a resident has a decline in status as R267 did last night and Hospice will be coming in today to assess R267, then Nurse Manager RN E's expectation would be that repositioning would need to be increased due to decrease in mobility. Surveyor asked what exactly does repositioning mean to Nurse Manager RN E. Nurse Manager RN E indicated that staff are to reposition and alternate from side to side lying for example left side to back then to right side then to back and so forth. Surveyor indicated to Nurse Manager RN E that Surveyor did not observe R267 repositioned fully off R267's bottom to reduce pressure to the coccyx and sacrum area and heels directly pressed against bed. Nurse Manager RN E indicated that most residents don't want to be solely on their whole side, but expectation is for staff to try and off-load the pressure as best as possible. On 03/19/25 at 3:41 PM, Surveyor interviewed Director of Nursing (DON) B and asked what the expectation is of staff repositioning residents who are dependent on cares from staff. DON B indicated that staff need to reposition at least every 2 hours and sometimes given the resident's status that some residents are repositioned hourly per individualized needs.

Based on observation, interview and record review, the facility did not ensure a resident received adequate supervision and assistance to prevent falls and injury. This occurred for 1 of 5 residents (R) reviewed for falls, (R30). The facility did not report to oncoming staff, nor change R30's care plan to reflect the change in transfer status for R30. Staff utilized a walker to transfer R30, resulting in actual harm when R30 had a fall that resulted in a fractured femur and hip requiring surgery, and fractured rib. Thin liquids were observed in R17's room, who had a dietary order for honey-thickened liquids and not to leave R17 unattended with liquids. Findings include: Example 1: The facility policy, entitled Fall Risk Recognition and Fall Prevention Program, states: .When a fall occurs, electronic medical record documentation is completed. The documentation includes specific information related to the fall so that the investigation of the fall along with the evaluation of current and additional preventative measures can be accomplished immediately . assure that immediate interventions are in place and assure that the care plan has been updated . R30 was admitted to the facility on [DATE] with diagnoses that include in part: staphylococcal arthritis right wrist, osteomyelitis right toe, rheumatoid arthritis, diabetes, atrial fibrillation with anticoagulant use, abnormalities of gait and mobility, total left hip arthroplasty (unknown when but greater than 2019). R30's Minimum Data Set (MDS) assessment, dated 11/20/23 (before the fall), indicated that R30 had impairment to both upper extremities (UE), no impairment to both lower extremities (LE). R30 was wheelchair dependent, dependent for dressing and toileting, max assist for personal hygiene and transfers. Brief Interview for Mental Status (BIMS) = 14 indicating cognitively intact. Pain = 0 (no pain). R30's MDS assessment, dated 01/14/24 (after the fall), indicated that R30 had impairment to both UE, impairment to one side LE. R30 was wheelchair dependent, dependent for toilet and dressing lower body, max assist for dress upper body, max assist for personal hygiene. R30's transfers: roll/sit to lying - not done due to condition. Lying to sitting on side of bed - max assist. Sit to stand - R30 refused. Chair/bed to chair transfer and toilet transfer - dependent. BIMS = 10 indicating moderately impaired. Pain = 4 out of 10 pain scale. Based on R30's MDS assessments, he declined after the fall requiring more dependance on staff. R30's mental status also decreased with an increase in pain. R30's fall risk assessments completed 11/14/23 and 12/13/23 both indicated R30 was at risk for falls. Assistive devices definitions: [NAME] Stedy - non mechanical: resident uses own strength/ability to stand. Less assistance. EZ sit to stand lift - mechanical: machine lifts the resident. More assistance. R30's Care Plan, dated 12/30/23: Falls Documentation: I had a fall on 12/30/23 out of my recliner. Watch for any bruising, swelling and pain to his back area. No mention of change in transfer status to the EZ sit to stand lift that was implemented on 12/30/23. R30's Care Plan dated 12/31/23: 12/30/23 resident fall recorded this date complete neuro checks and vitals as directed. Falls documentation: I had a fall on 12/30/23. Every shift observe for any injury related to fall, any other changes in condition. Eval if new intervention is working. Intervention: [nothing listed] Again, no mention of change in transfer status to the EZ sit to stand lift that was implemented on 12/30/23. R30's Certified Nursing Assistant (CNA) Care Plan dated 12/28/23: 1 assist front wheeled walker (right green dysem to be wrapped around right handle prior to transferring). No mention of change in transfer status to the EZ sit to stand lift that was implemented on 12/30/23. R30's CNA Care Plan dated 12/31/23 at 8:23 AM: 1 assist EZ sit to stand lift. This was updated after the second fall that occurred on 12/31/23 at 8:00 AM. Case Manager Registered Nurses (RN) or floor nurses are able to make the changes to the care plan at the time changes are needed. R30's care plan was not updated after the first fall. R30's nursing notes stated on 12/30/23 at 6:45 PM, R30 fell when CNA used a [NAME] stedy to transfer R30 out of the recliner. R30 tried to stand up but he did not push enough with his legs and was sitting at the edge of the recliner. R30 slipped out of his recliner and slipped out of the chair between the chair and the nightstand by his bed. RN assessed R30 with no injuries noted. Intervention: to use a EZ sit to stand lift. R30's nursing notes stated on 12/31/23 at 8:00 AM, R30 was transferring from bed to wheelchair with CNA, gait belt and walker were being used to transfer. R30 states he was in a hurry and rushed to sit down, he didn't sit far enough back in the chair and immediately slid out into a sort of squatted position before crumpling to the floor. There was a loud popping and snap heard by both the resident and CNA, resident reports that left lower extremity pain began following the sound. R30's care plan was not updated to the EZ sit to stand lift resulting in the current care plan indicating R30's transfer with a walker. The oncoming CNA did not get report that R30 had fell the night before requiring him to be transferred with a EZ sit to stand lift. The CNA used a walker to transfer R30 and he fell resulting in injury. R30's 12/30/23 fall investigation completed by the facility's interdisciplinary team (IDT), dated 01/03/24 stated: CNA states that during her shift she used the [NAME] stedy with resident despite him being care planned as a 1 assist with 2-wheel walker because first attempt to stand with walker he was not very stedy so she felt it more safe to use the [NAME] stedy as this is what he was transferring with prior to being upgraded to 1 assist 2-wheel walker on 12/28/23. She states she then transferred him a couple times during the shift with a [NAME] stedy and he did well with this and had no safety concerns. At the time of the fall, she was going to get him out of the recliner to get him ready for bed. She states that she had the [NAME] stedy in front of him, gait belt on, grippy socks on and then he stood up a bit but not all the way, so he lowered back down to the recliner and did not sit far enough back so he started sliding down to floor. CNA states she grabbed the gait belt and lowered him gently to the floor and his feet remained on the [NAME] stedy platform pushing it away slightly. Root cause: Bilateral lower extremity weakness and weakness to right hand are root cause of fall. Resident had been consistently participating in Physical Therapy/Occupational Therapy (PT/OT) but making limited progress. He was just recently upgraded from [NAME] stedy transfer to 1 assist with 2-wheel walker on 12/28/23. This may have been too soon of an upgrade for transfers with nursing staff as CNA felt on 12/30/23 that resident could not safely transfer with walker. Resident may have been weaker with transfer due to fatigue as it was later in the day. R30's 12/31/23 fall investigation completed by the facility's IDT, dated 1/01/24, stated: Writer talked with CNA who was present at time of fall and lowered resident to floor. Writer asked CNA why resident was transferring with a walker when he was recently changed to a EZ sit to stand lift. CNA states that he was surprised to find out after the fall that resident was a EZ sit to stand lift versus a walker. CNA states that he did not hear this in report from previous shift or his nurse. Both CNA and LPN on duty day of the fall were educated on importance to ensure communication of status changes and falls are passed on shift to shift and from nurse to CNA. Root Cause: Believe incident related to not using EZ sit to stand lift as directed in new CNA care plan. Deep dive noted that computer was not updated after 12/30/23 fall until following day which means report and communication failure related to resident falling. CNA did not mean or intend to not follow care plan, as the care plan on him did show that he was transferring according to his status of a walker. The injury is not suspicious. Care plan not followed. Potential care giver misconduct: does not meet definition of care giver misconduct. No intent, abuse or neglect was noted. IDT reviewed fall and noted that staff made human error of failure to communicate. R30 was sent to the emergency room and admitted to the hospital to have Open Reduction and Internal Fixation (ORIF) surgery for a femur fracture of left femur and fracture left hip. ORIF is surgery to fix a broken bone. Open reduction means that the bone is moved back into the right place with surgery. Internal fixation means that hardware (such as screws, rods, or pins) is used to hold the broken bones together. R30 also had a fracture of one rib and acute posthemorrhagic anemia requiring 1 unit blood transfusion. R30's Social Worker note in November 2023 before the fall on 12/31/23, stated R30 was admitted for strengthening status post bacteremia sepsis of right wrist. He was at an assisted living facility and would like to return. He is focused on therapy and going home when able. Interviews: On 02/06/24 at 2:12 PM, Surveyor asked CNA X how she knows what the transfer status was for a resident. CNA X said she would know based on the resident's care plan. Surveyor asked CNA X if the transfer status changed for a resident overnight, how would the next CNA know. CNA X said we would give this information during shift change report. On 02/06/24 at 2:39 PM, Surveyor asked CNA Y how she knows what the transfer status was for a resident. CNA Y said she would know based on the resident's care plan. Surveyor asked CNA Y if the transfer status changed for a resident overnight, how would the next CNA know. CNA Y said we would give this information during shift change report. On 02/06/24 at 2:45 PM, Surveyor asked Licensed Practical Nurse (LPN) EE how the nurses know what the transfer status was for a resident. LPN EE said she would know based on the resident's care plan and the report sheet. Surveyor asked LPN EE if the transfer status changed for a resident overnight, how would the next nurse know. LPN EE said we would give this information during shift change report. On 2/06/23 at 2:55 PM, Surveyor asked Physical Therapy Assistant (PTA) AA what R30's transfer status was in December. PTA AA said on 12/11/23 R30's transfer status was 1 person assist EZ sit to stand lift. On 12/28/23, R30's transfer status was 1 person assist for ambulation and pivot assist with a 2-wheel walker with dysym on right hand grip. There were no other PT adjustments to the transfer status of R30 for the month of December. Surveyor asked PTA AA if staff taking care of R30 can change transfer status. PTA said they can always downgrade not upgrade. PT needs to assess to be able to upgrade the transfer status. Downgrade transfer status means the resident requires more assistance with transfer. Upgrade transfer status means the resident requires less assistance with transfer. On 02/06/24 at 3:00 PM, Surveyor asked Case Manager RN (CM) U what interventions were put into place due to R30's fall on 12/30/23. CM U said they advanced R30's transfer status to an EZ sit to stand lift because a [NAME] stedy was used during the fall on 12/30/23. Surveyor asked CM U who would have changed R30's care plan to indicate this change. CM U said the care plan should have been changed by the case manager or floor nurse to reflect this change and a shift-to-shift report of this change needs to be given to the nurses and CNAs. Surveyor asked CM U if the proper transfer technique was used for R30 on 12/31/23 (a 2-wheel walker with gait belt was used). RN said the CNA should have been using an EZ sit to stand lift, not a walker. On 02/06/24 at 3:40 PM, Surveyor spoke with Director of Nursing (DON) C concerning R30's falls on 12/30/23 and 12/31/23. DON C said on 12/28/23 R30 was changed to 1 assist with walker. On 12/30/23, staff was using a [NAME] stedy as they can increase the level of assistive device if they feel necessary. Because R30 fell using a [NAME] stedy, it was determined to use a EZ sit to stand lift. On 12/31/23, the CNA was following the care plan to use a walker. R30 can wax and wane and can go between using a walker or a mechanical lift. The CNA was not aware the transfer status changed after the fall the night before. The care plan was not updated until 8:23AM on 12/31/23 to the mechanical EZ lift as an intervention from the fall on 12/30/23. The CNA the night before should have reported to the oncoming CNA at shift change this resident's change in transfer status. The facility did education to the CNAs concerning communication at shift change report to notify of any change in resident status such as transfer status. The facility investigated this situation to find the CNA did not do this intentionally; he was not aware the change in transfer status for R30. Surveyor asked DON C if R30 had any diagnosis of bone disease. DON C provided R30's list of diagnoses and said R30 does not have a history of bone disease. DON C provided the education that the facility gave to the CNAs on 1/09/23, nine days after R30's fall with injury. The education included Communication: shift to shift report is essential. You must do walking rounds with your co-worker each shift to communicate changes in: care plans (transfers, Activity of Daily Living (ADL), needs, etc), appointments or planned outings, toileting needs, recent falls or other changes in conditions. On 02/06/24 at 4:40 PM, Surveyor asked LPN V if nurses can change transfer status for the residents. LPN V said nurses can change transfer equipment to require more assistance, but not change the transfer equipment to require less assistance. PT needs to assess and change the status to less assistance. CNAs cannot make the decision about using less assistive devices. They would let the nurses know how the resident was transferring and the nurse would make the decision to use more assistance for transfer. On 02/07/24 at 8:09 AM, Surveyor asked DON C if nurse education was provided for need to update the resident's care plan after an incident needing interventions placed. DON C said they did not do any education to the nurses, but to all the case managers that they need to update the care plan after the change or notify the nurse to do so. On 02/07/24 at 8:15 AM, Surveyor asked CM U how the resident care plans are updated. CM U said the floor nurses can update the care plan when filling out the fall assessment. There was a button they would click that would add new interventions to the resident's care plan. Surveyor asked CM U why the transfer status for R30 was not updated. CM U said R30 did not have the care plan updated after the first fall on 12/30/23. We found that the care plan was not updated after auditing the record. R30's care plan was updated on 12/31/23 at 8:23AM after the second fall. On 02/07/24 at 8:20 AM, Surveyor asked CNA W how R30 was before the fall compared to now. CNA W said R30 seems about the same with mood/behavior. After the fall, R30 was a little down at first, but now almost back to baseline. R30 was improving on transfer as R30 was a hoyer lift (maximum transfer) at first when he returned after the fall. Now, he was EZ lift stand with 2 CNAs. R30 was not back to the walker transfer status. He still needs work to get to that point. On 02/07/24 at 9:30 AM, Surveyor spoke with R30's Power of Attorney (POA) BB who said R30 has had cognitive decline even a little before the fall. R30 was on heavy pain meds after the fall and was more out of it. Now, R30 was getting better with pain and pain medications have decreased. POA BB said R30 was coming back now a little but can see the decline in energy and mood since the fall. R30 was at an assisted living facility but sent here to do strengthening and medical care for an infected wrist. POA BB said they were unsure where R30 will go after recovering from the fall with a broken hip/leg. We have conference on 02/21/24 to discuss this. It was still up in the air where R30 will go to. On 02/07/24 at 10:00 AM, Surveyor asked R30's Medical Doctor (MD) Z what they would have expected to happen for the transfer status of R30 on 12/31/23. MD Z said she would have expected shift change report to include the change in transfer status of R30 and the CNA to have used the mechanical lift that was the intervention after the first fall. Surveyor asked MD Z how R30's level of activity/mood changed since the fall. MD Z said upon admit initially R30 was not able to walk on his own and cognitively he was not to the level of being able to make his own decisions. Prior to the fall his cognition was improving and could vary day to day. R30 was originally planning to go back to assisted living but he was not at discharge point before the fall. The fracture did not change the discharge plan if anything R30's cognition will change the plan. The change in cognition could have changed related to having surgery, unable to say for certain. R30's diagnosis with diabetes, foot wound, balance, neuropathy created a huge risk for falls. R30 had poor insight to what he needed to do, needing queuing. The fracture was healing well and R30 was not losing weight. MD Z said she cannot say the fall was the cause of the decline. R30 was probably back to the mid level of baseline. Surveyor asked MD Z about anticoagulant use with a femur fracture if that can cause the need for a blood transfusion. MD Z said it can be a typical response. R30 did not have any issues with low blood levels before the fall and no concerns with it now. 48793 Example 2 R17 was admitted to the facility on [DATE], with diagnoses including in part, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, dysphagia, gastrostomy, and acute respiratory failure. R17's most recent Minimum Data Set (MDS) assessment, dated 12/11/23, indicated R17's Brief Interview for Mental Status (BIMS) scored a 13. A score of 13 indicates that the resident is cognitively intact. The MDS assessment identified R17 required extensive assistance of one person for eating. Review of R17's medical record identified an initial speech evaluation assessment dated [DATE]. The assessment indicated that R17 is NPO-tube-feeding and presents with severe oral and pharyngeal phase dysphagia. On 02/02/24, Speech-Language Pathologist (SLP) note indicates that R17 was seen for discharge from ST services as the target goal was met for the least restrictive diet, improved quality of life, and implementation of the pleasure feeding program. SLP created pleasure feeding guidelines that included specific instructions on diet recommendations to staff, and directions for facility staff to implement which included: Total 1:1 assistance for all oral intakes, R17 must be seated upright in a chair or bed and must be alert/engaged. R17 is recommended to remain NPO tube-feeding for nutrition, hydration, and medications but is allowed to pleasure feed on pureed textures and honey-thick liquids to assist with improved quality of life. R17's care plan indicates on 02/02/24 that R17 is on a pleasure feeding program. Honey thick liquids and pureed foods, need to sit upright and have 1:1 assistance feeding with small bites on a spoon. Never leave food in front of R17 unsupervised, and never give food/liquid if sleepy at all. R17's care plan indicates on 02/05/24 that R17 requires total assistance with meals and drinks, see the Certified Nurse Assistant (CNA) plan. R17's care plan indicates on 02/07/24 do not leave any fluids within reach. 1:1 assistance with honey thick liquids is only allowed when R17 is alert and sitting upright. Physician orders dated on 02/06/24 indicate R17 is on Dysphagia I pureed pleasure feeding program and honey thicken liquids. On 02/07/24 at 7:19 AM, Surveyor observed R17's call light go on. Surveyor observed R17 coughing and calling out, I need something to drink. On 02/07/24 at 7:21 AM, Surveyor went into R17's room and observed a cup on the bedside table with a straw in it. The water inside the cup was regular thin liquids. This cup was within R17's arm reach to take and drink. On 02/07/24 at 7:42 AM, Surveyor observed CNA M and CNA N go into R17's room and turn the call light off. CNA M and CNA N exited R17's room. On 02/07/24 at 7:44 AM, Surveyor interviewed CNA J and asked if she knew if R17 was to have thin liquids in the room. CNA J stated no she does not believe R17 is supposed to have any liquids in R17's room. CNA J immediately went into R17's room removed the thin liquids and stated she would notify the Registered Nurse (RN) on duty. On 02/07/24 at 8:15 AM, Surveyor interviewed RN F and asked if she knew if R17 was to have thin liquids in the room and that Surveyor observed R17 coughing and asking for water again. RN F stated she is a 1:1 assist and supervise with food and liquids. RN F indicated she would go into R17's room right away and assess R17. On 02/07/24 at 8:20 AM, Surveyor observed RN F enter R17's room and begin vitals on R17. RN F removed the cup of thin liquids and threw the cup in the trash. On 02/07/24 at 9:22 AM, Surveyor interviewed Case Manager RN D and asked about R17's diet. Case Manager RN D indicated that recently SLP has been trying to integrate foods. R17's diet is honey-thick liquids, Dysphagia III diet. Surveyor asked Case Manager RN D if it is common practice to have thin liquids sitting on the table with a honey-thick liquid diet resident. Case Manager RN D indicated that she would have to investigate who gave R17 thin liquids because thin liquids cannot be given to R17 or be left in R17's room for any reason.

Based on observation, interview and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety by not wearing beard nets appropriately. This has the potential to affect 31 of the 64 residents residing in the facility (R34, R37, R8, R5, R1, R10, R20, R49, R29, R24, R25, R21, R23, R162, R38, R42, R40, R3, R48, R31, R28, R45, R43, R12, R19, R27, R16, R213, R35, R9, and R7). Findings include: The federal food code, entitled FDA Food Code 2022, dated as the January 18, 2023, Version, 2-402 Hair Restraints. (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. On 02/05/24 at 11:39 AM, Surveyor observed Dietary Aide (DA) CC plating food off the steam table for the residents on the facility's second floor kitchenette. DA CC's beard was not covered while DA CC was plating food for R34, R37, R8, R5, R1, R10, R20, R49, R29, R24, R25, R21, R23, R162, R38, R42, R40, R3, R48, R31, R28, R45, R43, R12, R19, R27, R16, R213, R35, R9, and R7. Surveyor observed that DA CC had a beard that could be seen from approximately 100 feet away from where the Surveyor was standing. On 02/06/24 at 10:49 AM, Surveyor interviewed Dietary Manager (DM) DD regarding beard net usage. DM DD said that they would require a beard net if the beard were visible; a beard net is preferred when an employee is serving food. DM DD was not worried about a beard covering when dietary employees were bringing food to employees in the dining room but would require one when dietary aides were dishing up food at the steam table.

Based on observation, interview and record review, the facility did not maintain an infection prevention and control program for proper linen handling, urine disposal, hand hygiene, and sanitizing mechanical lifts to help prevent the development and transmission of communicable diseases and infections for 10 of 64 Residents (R). (R13, R317, R313, R315, R17, R23, R39, R5, R42, and R30) Findings: The facility policy entitled, Linen Handling Guidelines last reviewed January 2023, stated in part: .4. Soiled linens are place in a garbage bag . 11. Bagged linens and garbage are kept away from body and floor when transporting to soiled linen room/container . Resident (R)13 has a diagnosis of Methicillin Resistant Staphylococcus Aureus (MRSA) via nasal swab and previously reported in the urine on 07/24/23. On 02/06/24 at 10:00 AM, Surveyor observed Certified Nursing Assistant (CNA) S pick up soiled towel and washcloth from R13's bed with bare hands, holding the linens against CNA S's body and carry the linen out of R13's room and across the hall to the dirty linen closet. CNA S then used alcohol-based hand rub to clean CNA S's hands. Surveyor informed CNA S of the observation made with the dirty linens. CNA S replied, I should not have done that. I should have had gloves on carrying the linen or had the linen in a bag when I took it out of the room. On 02/07/24 at 4:50 PM, Surveyor interviewed Director of Nursing (DON) B (Interim DON) and DON C (Regional Clinical Resource) about the observation made of CNA S carrying dirty linens against CNA S's body and asked what would the expectation be. Both DON B and DON C agreed that this was not the proper standards of care. DON C stated, This CNA should not have had dirty linens against the body and without gloves. 43352 Example 2 On 02/07/24 at 11:27 AM, Surveyor observed CNA R walking down the hall with a bundle of linens rolled up into a big ball held against CNA R's stomach, with CNA R's arms wrapped around the linen. On 02/07/24 at 11:29 AM, Surveyor interviewed CNA R and asked if the room CNA R put the linens in was the dirty laundry. CNA R indicated yes and garbage. Surveyor asked CNA R if they were bringing down dirty bedding and CNA R indicated yes, the resident was getting a shower and CNA R just stripped the bed. 48793 Example 3 On 02/05/24 at 2:15 PM, Surveyor observed CNA K enter R317's room to empty the catheter bag. CNA K used hand hygiene and then applied gloves. CNA K gathered supplies and placed the graduate on the floor on top of paper towels. CNA K opened a catheter bag and drained some urine into the graduate. CNA K entered R317's bathroom and assessed urine to be 825 ml in the graduate then dumped the urine into R317's bathroom sink. Surveyor observed urine splashing against the wall next to the sink. Surveyor observed R317's toothbrush to be lying on the side of the bathroom sink. CNA K went back to the catheter bag and drained the remaining urine. CNA K entered bathroom and assessed urine to be 225 ml then dumped urine into R317's bathroom sink. CNA K rinsed the graduate in the sink and then replaced the graduate back into the plastic bag and set it on the back of the toilet. CNA K went back to the catheter bag wiped the end off with an alcohol wipe and reconnected under the sheath. CNA K took gloves off, sanitized hands, and exited R317's room. On 02/05/24 at 2:27 PM, Surveyor interviewed CNA K and asked if the process Surveyor watched with dumping urine in the bathroom sink was appropriate for infection control measures. CNA K indicated that dumping the urine in the sink was the way CNA K was taught by the facility. CNA K stated she just does what she is told. On 02/07/24 at 5:20 PM, Surveyor interviewed DON B, DON C, and Nursing Home Administrator (NHA) A and asked about expectations for staff when emptying the graduate of urine from the Foley bag and where the urine is to be disposed. DON B indicated the urine should be dumped in the toilet after measuring, and DON C indicated that CNA K will need more education. DON C indicated that CNA K should have emptied urine in the toilet and not in the sink. Example 4 On 02/05/24 at 9:04 AM, Surveyor observed Phlebotomist O (direct employee of facility) enter R313's room. Phlebotomist O set the blood bag on R313's bedside table. Surveyor did not observe any hand hygiene performed by Phlebotomist O before entering and then applying gloves. Phlebotomist O drew blood and then removed gloves. R313 is on contact precautions for MRSA in the right foot wound. On 02/05/24 at 9:11 AM, Surveyor observed Phlebotomist O exit R313's room and did not perform hand hygiene. Phlebotomist O entered R315's room, laid a red lab bag on R315's bedside table and placed gloves on. Surveyor did not observe hand hygiene performed before or after Phlebotomist O started drawing R315's blood. Phlebotomist O took her gloves off. On 02/05/24 at 9:14 AM, Surveyor observed Phlebotomist O exit R315's room, enter R17's room and laid the red lab bag on the side table. Surveyor did not observe Phlebotomist O perform hand hygiene. Phlebotomist O placed gloves on and drew R17's blood. Phlebotomist O took gloves off, grabbed the red bag and exited R17's room. Surveyor did not observe any hand hygiene performed before or after drawing R17's blood. On 02/06/24 at 11:24 AM, Surveyor interviewed Director of Nursing (DON) C and Infection Preventionist (IP) GG about expectations of hand hygiene practices during blood draws. DON C indicated that the expectation would be using standard practices of infection control by washing hands or using hand sanitizer before and after applying gloves and before entering rooms and between residents. IP GG indicated that Phlebotomist O will need more education and should have been practicing hand hygiene between residents. 47284 Example 5 On 2/06/24 at 1:33 PM, Surveyor observed CNA K empty the urine from R23's catheter bag. CNA K emptied the urine into the toilet, removed her gloves, but did not do hand hygiene after this. CNA K then went into R39's room to get his lunch tray and brought the tray to the food tray cart. No hand hygiene performed. CNA K then went into R5's room, placed her hands on the bedside table, grabbed the door handle and came out of the room. CNA K did not do hand hygiene. CNA K grabbed the walkie to talk on it and walked to the dining room. Hand hygiene should have been completed after removing gloves, going into get the food tray, after placing the tray into the food tray cart, before going into resident room, and after leaving the resident room. Example 6 R42 was admitted on [DATE] with a diagnosis of Crohn's disease (a type of inflammatory bowel disease that is characterized by swelling of the tissues (inflammation) in your digestive tract, which can lead to abdominal pain, severe diarrhea, fatigue, weight loss and malnutrition) and Ileostomy (is a surgically made opening that connects your ileum to your abdominal wall). On 02/07/24 at 9:16 AM, Surveyor observed Registered Nurse (RN) T change the appliance on R42's colostomy. After removing the appliance, RN T cleaned the skin around the stoma with wound cleanser, dried the skin with 4x4 gauze and then removed the single use gloves. RN T put on new single use gloves without proper hand hygiene. RN T placed a skin barrier ring around the stoma and placed a new appliance with bag over the stoma and secured in place. RN T removed gloves and put on new gloves without performing any hand hygiene in between. RN T wrote the date and RN T's initials on the appliance and replaced the soiled belt secure device. On 02/07/24 at 9:29 AM, Surveyor interviewed RN T asking about the two observations made of glove changes without proper hand hygiene. Surveyor asked RN T what the process is for hand hygiene referring to glove changes. RN T replied, I should have performed hand hygiene in between taking my dirty gloves off and putting on new gloves. Surveyor asked RN T, What is expected before you put on gloves or after you remove gloves? RN T replied, I use sanitizer or alcohol. On 02/07/24 at 4:50 PM, Surveyor interviewed DON B and DON C about this observation. Surveyor asked, What is the expectation of hand hygiene in between glove use? DON C replied, This is not proper standards of care, this CNA should have performed hand hygiene between glove use. Surveyor asked DON C, Would you have a policy regarding hand hygiene between glove changes? DON C replied, I am not sure that we do. That is just simply a standard of practice that we are taught back in school. No further information given to Surveyor regarding this. Example 7 On 2/07/24 at 7:30 AM, Surveyor observed the transfer of R30 with the use of an EZ sit to stand lift. CNA M removed the EZ sit to stand lift from R30's room and placed the lift into the storage cubby at the beginning of the 1200 hall. CNA M did not sanitize the EZ sit to stand lift after use. The EZ sit to stand lift did have disinfectant wipes located in a holder on the lift. Reusable equipment such as the EZ sit to stand lift, needs to be cleaned after each use to prevent the spread of germs.

Based on observation, interviews and record review, 2 of the 8 dependent residents (R) reviewed did not receive required assistance with Activities of Daily Living (ADL) of incontinence cares and eating of a meal. (R17 and R30) Findings include: Example 1 R17 was admitted to the facility on [DATE], with diagnoses including in part, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, dysphagia, gastrostomy, and acute respiratory failure. R17's most recent Minimum Data Set (MDS) assessment, dated 12/11/23, indicated R17's Brief Interview for Mental Status (BIMS) scored a 13. A score of 13 indicates that the resident is cognitively intact. The MDS assessment identified that R17 required total extensive assistance for activities of daily living (ADL) and at risk for development of pressure injuries. R17's care plan indicates on 12/01/23 that R17 is non-ambulatory, assist of two staff with using a full mechanical lift (Hoyer) for transfers, and two staff assist for bed mobility on both sides. On 02/06/24 from 7:40 AM until 8:34 AM, Surveyor observed R17 lying in bed on back in bed. On 02/06/24 at 8:34 AM, Surveyor observed Certified Nurse Assistant (CNA) J and CNA L go into R17's room and look at R17. CNA J and CNA L walked out and stated they would come back later. Surveyor did not observe CNA J and CNA L reposition R17 and observed R17 to still be lying on her back, awake in bed. On 02/06/24 at 8:42 AM, Surveyor observed Nurse Tech (NT) H go into R17's room and complete medication administration through a g-tube. Surveyor observed medication administration and did not observe R17 repositioned. On 02/06/24 at 9:53 AM, Surveyor observed R17 still in bed, blanket on the floor and R17 lying in the same position on the back. On 02/06/24 at 9:54 AM, Surveyor interviewed CNA J and asked when was the last time R17 was repositioned and what is the usual time frame for repositioning. CNA J indicated that CNA J thinks she repositioned R17 around 7:30 AM, and usually, CNA J repositions every 2 hours and as needed. CNA J indicated that R17 is due to be repositioned. On 02/06/24 at 10:06 AM, Surveyor observed CNA J and CNA L go into R17's room. Surveyor observed a bed bath performed. Surveyor observed CNA J and CNA L roll R17 to the left side of the bed. Surveyor observed the bedding was soaked underneath R17's brief, through the fitted sheet, and onto the mattress. R17 had an incontinent bowel movement and urine in brief. Surveyor observed the skin to be red and moist. CNA J and CNA L cleaned R17's brief, applied calmoseptine cream to the coccyx area, and changed to a new brief. CNA J and CNA L then transferred R17 into the wheelchair with Hoyer lift. CNA J and CNA L exited R17's room at 10:17 AM. On 02/07/24 from 7:03 AM to 9:30 AM, Surveyor observed R17 lying on her back in bed awake in the dark. On 02/07/24 at 9:30 AM, Surveyor observed CNA J and CNA N enter R17's room. On 02/07/24 at 9:44 AM, Surveyor observed care performed on R17. Surveyor observed CNA J and CNA N roll, change, dress R17, and then transfer R17 into the wheelchair with the Hoyer lift. On 02/07/24 at 9:46 AM, Surveyor interviewed CNA J and asked why R17 was not repositioned or out of bed yet. CNA J indicated she is doing the best she can and that hall 1300 is kind of a heavier hall. CNA J indicated one CNA is scheduled per hall and sometimes the facility provides a float. On 02/07/24 at 3:45 PM, Surveyor interviewed Director of Nursing (DON) B, DON C and asked about expectations for staff assisting residents in repositioning. DON C indicated the expectation for repositioning is at least every two hours especially if they are at risk. Example 2 R30 was admitted to the facility on [DATE] with diagnoses that include in part: staphylococcal arthritis right wrist, diabetes, and atrial fibrillation. R30's Minimum Data Set (MDS) assessment, dated 01/14/24, indicated that R30 was wheelchair dependent, dependent for dressing and toileting, max assistance for personal hygiene and transfers, set-up, and assistance for eating. R30's Brief Interview for Mental Status (BIMS) is a score of 14 indicating cognitively intact. R30's physician orders indicate R30 is on a carb-controlled, dysphagia III mechanical soft. R30's care plan on 01/08/24 indicates offering R30 setup and assistance at meals and providing adaptive meal equipment as indicated. R30's care plan on 01/30/24 indicates that R30 requires assistance with mealtimes and built-up silverware. On 02/06/24 at 11:57 AM, Surveyor observed CNA I wheel R30 in a wheelchair into the dining room. On 02/06/24 at 11:58 AM, Surveyor observed R30 to have assistive devices in place on the lunch tray. On 02/06/24 at 12:01 PM, Surveyor observed R30 trying to use his assistive spoon device to pick up peaches. Surveyor observed R30 struggling to get peaches picked up on the spoon and into R30's mouth. Peaches kept falling on R30's lap and falling onto the floor. R30 stated out loud, F***, it dropped, and I can't get this. On 02/06/24 at 12:16 PM, Surveyor observed R30 still struggling with getting the cut-up peaches on R30's spoon. Peaches kept falling off the spoon and onto the table. R30 stated out loud, Damn it I can't get this. On 02/06/24 at 12:18 PM, Surveyor interviewed Cook Q and asked for assistance to help R30 receive help with food. Cook Q indicated that Cook Q could not help but would get a CNA. Cook Q found CNA I down the hall and asked for CNA I to help R30. CNA I came into the dining room and asked R30 if he was ready to go to his room. CNA I did not give R30 time to respond and started pushing R30 back to his room. R30 did not finish his meal. On 02/06/24 at 12:19 PM, Surveyor observed Assistant Director of Nutrition Services P pick up R30's lunch tray and clean the plate off into dirty dishes. On 02/06/24 at 12:30 PM. Surveyor interviewed CNA I and asked if he knew if R30 was done with his lunch meal before he took him away to his room. CNA I indicated that R30 did not say anything, so he took him to his room. On 02/07/24 at 4:57 PM, Surveyor interviewed Director of Nursing (DON) B and DON C and asked about expectations for supervision/assisting residents in the dining room when there is known help needed. DON B and DON C indicated they would want their staff to help any residents that need setup/supervision. DON C indicated the facility would expect CNAs to take the time to listen to residents and assist as needed. DON C indicated that R30 should have received help with his lunch meal.

Based on observation and interview, the facility did not ensure each resident is treated with dignity and receive assistance when requested in a manner and in an environment that promotes enhancement of his or her quality of life. This occurred for 1 of 16 residents (R) reviewed. (R17) Findings include: R17 was admitted to the facility on [DATE], with diagnoses including in part, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, dysphagia, gastrostomy, and acute respiratory failure. R17's most recent Minimum Data Set (MDS) assessment, dated 12/11/23, indicated R17's Brief Interview for Mental Status (BIMS) scored a 13. A score of 13 indicates that the resident is cognitively intact. The MDS assessment identified that R17 required total extensive assistance for activities of daily living (ADL). R17's care plan indicates on 12/01/23 that R17 is non-ambulatory, assist of two staff with use of full mechanical lifts (Hoyer), and two staff assist in bed on both sides. On 02/06/24 at 12:51 PM, Surveyor observed R17 yelling out while sitting in wheelchair in front of the window in the common lounge area near 1300 hall. Assistant Director of Nutritional Services P stopped and spoke with R17. R17 requested to be taken back to the room. Assistant Director of Nutritional Services P responded to R17 that he would let a Certified Nurse Assistant (CNA) know to take R17 to her room. Assistant Director of Nutritional Services P let Nurse Tech (NT) H know that R17 wanted to go to her room. Surveyor observed NT H walk the opposite way down the hallway. On 02/06/24 at 1:00 PM, Surveyor observed Registered Nurse (RN) F and RN G sitting at the table across the hall of the lounge area. R17 continued to yell, and RN F and RN G did not assist R17. On 02/06/24 at 1:05 PM, Surveyor observed CNA J and CNA L walk past R17 while R17 was stating, I want to go to my room. CNA J and CNA L did not assist R17. On 02/06/24 at 1:10 PM, Surveyor observed another employee walk by R17 while R17 was stating, I want to go to my room. The employee did not stop to assist R17. On 02/06/24 at 1:14 PM, Surveyor observed RN D take R17 back to the room with a snack to assist R17 in eating. On 02/07/24 at 4:57 PM, Surveyor interviewed Director of Nursing (DON) B, and DON C and asked about expectations for assisting residents in day-to-day activities and ADLs when there is known help needed such as meals in the dining room or activities in common areas. DON B and DON C indicated they would want their staff to help any residents who need assistance. DON C indicated the facility would expect all staff with direct care capabilities to take the time to listen to residents and assist as needed.

Based on observation, interview, and record review, the facility did not ensure that each resident (R8) receives the necessary care and services to attain or maintain the highest physical, mental and physiological well-being. R8 did not receive effective pain management, consistent with professional standards of practice, plan of care goals and the resident's preferences, for 1 of 17 residents reviewed for pain. R8 experiences reoccurring episodic pain during dressing changes. R8 was observed to experience pain during a dressing change on 08/22/17. R8 was observed to say stop but staff did not stop. R8 stated, I want my pain medication right now. Staff did not provide further pain medication at that time. This is evidenced by: The facility policy, entitled Pain Assessment and Management, dated April 2005, states in part, all residents will have appropriately and timely pain assessment and adequate pain management All residents/patients will be assessed for pain. All staff will validate and respect the residents' report of pain and respond promptly with treatment options. R8 was admitted to the facility with [DIAGNOSES REDACTED]. R8's Minimum Data Set (MDS) with an assessment reference date (ARD) 06/14/17, identifies a brief interview for mental status score of 14, meaning cognitively intact and identifies R8 has no limits in short term or long term memory. The assessment indicates R8 is on a scheduled and an as needed pain medication. It indicates the pain is almost constant and at a level of 8 on a 0-10 scale with 10 being the highest level. R8's care plan related to pain indicates; -end stage terminal diagnosis - choosing comfort care vs. curative measures at this time. - I am able to rate and describe my pain using numbers and verbal pain scale. - I am enrolled in hospice. As my overall condition declines I am at risk for no longer being able to accurately rate and describe my pain. - I have a wound to my left lower extremity which causes me great pain. Surgical consult indicated need for amputation but resident refuses this. Wound not expected to heal due to minimal circulation- I prefer to be premedicated with PRN [MEDICATION NAME] prior to dressing changes. I have [MEDICAL CONDITION]- and take medications to help control symptoms related to this to promote comfort. -my locations of pain vary in location .Due to declining health, cognitive/mood impairment and choice for bedfast status majority of the time this is to be expected and unavoidable. I am noted to repeat the same number of 7 or 9 no matter what when asked about my pain- nurse to determine which pain scale is appropriate due to varying state of health and cognitive impairment. I take the antidepressant duloxetine to manage pain. - Resident has history of falsely identifying situations that caused her lower extremity wound which is related to and documented to poor circulation states foot pedal hit her leg, pump for her air mattress .caused wound . belief that when dressing changes are removed i.e. contact layer dressing that staff is removing her skin from her leg, despite education on what the dressing looks like, the purpose of the dressing, and how it will make dressing changes more comfortable .offer me my pain medications to assist with keeping my pain under control. R8's current physician orders [REDACTED]. patch /72 hours, [MEDICATION NAME] sulfate 10 to 20 mg every 2 hours as needed for pain (this reflects a dose increase which occurred on 08/18/17). R8 also receives [MEDICATION NAME] 5 mg three times a day as needed for muscle spasms. R8's medical record identifies many changes in pain medication, the latest occurring on 08/18/17, in which R8's [MEDICATION NAME] was discontinued and her [MEDICATION NAME] was increased to every 2 hours as needed. R8 also receives [MEDICATION NAME] 0.5 mg every 2 hours as needed for anxiety, as she often has anxiety associated with pain. Nursing notes 08/20/17 reveal pre-medication with [MEDICATION NAME] and [MEDICATION NAME] was given prior to a dressing change. [MEDICATION NAME] was documented as given for resident verbalizing anxiety over upcoming dressing change, medication helps with restlessness during dressing change. The documentation states pain level increases to severe during dressing change. Interventions include position changes, rest, distraction 1:1 and reassurance. Documentation continues with Med effective, resident able to tolerate dressing change well. Observations on 08/22/17 at 10:10 a.m., of R8's dressing change on her lower left leg. Registered Nurse (RN) A and RN E performed the dressing change. RN E reported that an hour prior to the dressing change R8 had been pre-medicated with [MEDICATION NAME] sulfate 20mg and [MEDICATION NAME] 2 mg. RN A performed the dressing change, and RN E held the leg, and talked with R8 intermittently to try to distract her. During the course of the dressing change while RN A was removing drainage from around the wound bed with a clean Q tip, R8 stated, Don't do that. RN A continued stating she just needed to get the drainage cleaned up. The wound was actively bleeding. RN A used 4 by 4 sterile gauze to apply pressure to the wound and to soak up the blood. As RN A did this, R8 was wincing, thrusting her head backwards, and stated, Please stop. As RN A lifted the gauze from R8's leg the gauze was observed to cling to the open wound. RN A slowed her actions a little but kept moving, touching R8's leg. The wound care did not stop. Wound care was observed to continue, despite R8's request to stop. As it continued R8 stated, Don't do that and she thrusted her head backwards, grimacing and tears came to her eyes. RN A continued applying pressure to the wound and then lifting the gauze which clung to the wound each time, until the bleeding slowed. As RN A applied the wound gel, R8 inhaled sharply, and moaned out loud twice and then stated, I want my pain meds right now. RN E responded, and told R8 when she last had her pain medications. As RN A continued with the dressing change, R8 would continue to thrust her head back, grimace and moan out in pain. This continued until the dressing change was completed. When the dressing change was finished, RN E took a tissue and dried the tears pooled by R8's eyes. Review of R8's record of the 08/22/17 dressing change reveals that the wound length is 31.32 cm, width is 9.08 cm Depth .1 cm. Area to left lower anterior extremity continues to have open wound present. Majority of wound is red in color with granular tissue present. Wound edges are attached to the wound base. Slight maceration is present along the medial aspect of the wound along the wound edge. Moderate amounts of serosanguinous draining noted on the old dressing. Buildup of drainage/wound gel was noted along the wound edges that were partially removed with a Q-tip. Following cleansing of wound, small amount of bloody drainage present from a granular tissue bud. Scattered scabbed areas remain present towards the distal portion of the lower extremity with surrounding scar tissue present. Resident continues to complain of pain/discomfort with dressing change in which she was premedicated prior to dressing change and pain medications were recently adjusted by Hospice. Distraction also continues to be used during dressing change which is also helpful. Nursing staff have continued to use the Solosite Wound gel, contact layers, a non-adherent pad, and Kerilex which has been the most comforting dressing for resident. Nursing staff along with hospice will continue with current treatment plans interventions as comfort is the goal for resident. Interview with RN A and RN E on 08/22/17 at 10:29 a.m., immediately following the dressing change. RN E asked if there were any concerns. Surveyor relayed concern over pain. RN E stated that R8 was premedicated with both the [MEDICATION NAME] and [MEDICATION NAME]. RN E stated that the facility recently discontinued the [MEDICATION NAME] related to increased delusions, hallucinations about her bed standing on edge, etc. RN E stated R8 tolerates the dressing change better now than she had in the past. RN E stated that it is hard to determine which of R8's symptoms is fear based versus pain. RN A stated that such good blood return is new for R8. RN A confirmed that R8 was in pain during the dressing change, and that a recent change in pain medication had occurred last Friday, yet the pain continues. On 08/23/17 at 9:40 a.m., an interview with R8 revealed the following information. R8 stated her leg hurts so much. R8 stated that it feels like it is swelling into the bandage. When asked how she felt about her pain during the dressing change yesterday, R8 stated, I thought they gave me enough pain medication, but during the process I found out it wasn't. R8 stated that if they could just stop and give me a 5 minute breather it would be helpful. When asked about her asking staff to stop during the dressing change, R8 stated they say they will stop, but when they keep going, it shows no respect for the patient - the decision should be up to the patient. When asked about overall pain management, she stated, it is ok; there are good times and bad times. If they are pulling on the wrap dressing it increases the pain, especially during the dressing changes. It would be better if I could go to sleep during the dressing changes, it would be better for everyone if I could just sleep through those. When asked if she would want more pain medication even if she was more sleepy, R8 said yes, it's ok if I get sleepy. R8 stated that she would like more scheduled pain medication, and would like to see the schedule so that she knows when it is coming next. R8 stated it gets frustrating when you have to ask for the pain medication, and it keeps getting worse. They say they are coming but it is not soon enough. My goal is to be comfortable here. On 08/24/17 at 8:00 a.m., an interview with Certified Nursing Assistant (CNA) N revealed that R8 complains of pain often. R8's nonverbal signs of pain include wincing/grimacing when you turn her and she gets teary eyed/cries. CNA N states that R8's pain can change day by day, some days are good and some are bad. CNA N stated if she sings to her that seems to help. CNA N stated that she has helped with R8's dressing changes before. CNA N states that when she has helped with the dressing changes, R8 has been in pain during them. On 08/24/17 at 8:25 a.m., an interview with RN A revealed that she frequently completes R8's dressing change, but that the unit nurses do it also. Surveyor asked if the dressing change that was observed was typical for R8. RN A stated that R8 normally expresses pain with her dressing change, but as soon as they stop touching the area the pain is gone. When asked about R8's pain medication, RN A stated R8 had received her as needed pain medication about an hour before the dressing change, and [MEDICATION NAME] and [MEDICATION NAME] and that R8 is on a [MEDICATION NAME]. When asked if RN A felt this was effective for R8, she stated that it is hard question, yes and no. RN A stated R8 is still having pain, but I think some of it is the anxiousness of anticipated pain as well. RN A stated that R8's pain seems to have peaks and valleys, some parts of the dressing change are more painful than others. When asked about dressing change documentation, when it states pain/discomfort with dressing changes in which she was pre-medicated prior to dressing change, does this indicate that the resident was premedicated but still exhibited pain during the dressing change. RN A stated that yes it does indicate that R8 was having pain during the dressing change, despite the premedication. When asked to identify R8's nonverbal indicators of pain, RN A indicated she closes her eyes, thrusts her head back, wincing and her tone of voice changes. When asked what she should do during a dressing change if the resident says stop. RN A stated she should stop. When asked why she didn't stop during R8's dressing change when R8 said stop, RN A paused, then stated that she felt it was better to just try to get it over with quickly. When asked about R8 stating she wanted more pain medication now, RN A stated that RN E had just given her the pain medication, and told the resident when she last had it. RN A said that sometimes R8 forgets when she last had her pain medication, and RN A thought that is what was occurring then. RN A stated that a while ago we had pain medications at a higher level, using [MEDICATION NAME], but the pain was still there and the side effects were more upsetting to R8. RN A stated this was a hard case and they had tried doing the dressing changes every third day, but that increased the pain. RN A stated she has asked herself, when she (R8) is here for comfort, why are we doing this, but then the wound began to heal. When she was admitted they thought R8 would never heal, would eventually become septic from the wound and die. When asked if RN A spoke to anyone about R8's continued pain during the observed dressing change, RN A stated she had not, but that RN E would have taken care of that. RN A stated they need to work on getting her pain under better control during dressing changes. RN A stated one time they had R8's daughter on the phone during the dressing change, and that seemed to help with pain control. On 08/24/17 at 9:25 a.m., interview with RN E revealed the following information. R8's nonverbal indicators of pain include grimacing, wincing, sharp staggered intake of air, tensing, and when she tells us to be done. RN E said she tries to distract R8 by talking with her, and sometimes they sing Beatles songs, which seems to help. RN E stated she premedicated R8 with her [MEDICATION NAME], and [MEDICATION NAME] and that R8 is on scheduled [MEDICATION NAME]. When asked if the medications given appeared to be enough to control R8's pain during the dressing change. RN E reported that they changed the medication again last week but, for dressing changes it's not enough. RN E stated that R8 sleeps soundly after the dressing change is completed. When asked if she reported that the pain medication was still not enough during the dressing change to anyone, RN E reported she did not. RN E added that hospice usually assesses pain whenever they are here. When asked if a resident says to stop during a dressing change, what are you to do, RN E responded, Stop. When asked if R8 has asked them to stop during dressing changes before the one observed, RN E stated, Yes. When asked what is/was to be done if R8 says stop, RN E responded that we take it as more of a wait, pause, chat a bit don't do things with the leg .we then ask are you ready prior to proceeding. When asked why no one stopped the dressing change when R8 said stop during the dressing change that was observed, RN E didn't respond. When asked about R8 stating she wanted more pain medications right now, RN E stated that R8 seldom remembers when she had her last pain medications, so she just reminded her that she had already had them. RN E stated she didn't know how to achieve great pain control for R8, as they had tried multiple pain medications and it wasn't any better. RN E stated R8 tolerates it better now than she had in the past. When asked what she meant by this, RN E stated that R8's mental status has improved, that R8 still has fear about the dressing changes, but it is less now, and that the wound remains tender though. On 08/24/17 at 1:17 p.m., an interview with R8 revealed the following information. R8 stated she has pain every time the dressing change is done. R8 stated during the dressing change her pain is continuous but has variables to it. R8 stated her pain is more than discomfort. When asked to elaborate, R8 stated that some parts of the dressing change are more painful than others. R8 stated that sometimes when they take off the layer right next to her open area, it feels like they are ripping my skin. Surveyor asked if severe pain is an acceptable level of pain to her during the dressing changes, R8 responded saying, if it makes me cry, or twist around or squiggle around in bed, it is an unacceptable level of pain. R8's medical record documents many changes in medication. The last occurring on 08/18/17. Despite these changes, R8 continues to have uncontrolled episodic, and re-occurring pain during dressing changes, as indicated by her verbal and non-verbal indicators of pain. R8 also experiences anxiety in relation to pain with her dressing changes. During the observed dressing change on 08/22/17, staff did not stop, when the resident requested they stop, and staff did not provide additional pain medication, when the resident requested it. R8's medical record also indicates pain level increases to severe during dressing change, related to the dressing change on 08/20/17. R8 states, and R8's medical record indicate, the resident's goal is to be comfortable.