Every finding on record at Eastview Health and Rehabilitation Center

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 51 residents residing in the facility. The cooler, counters, and areas underneath kitchen equipment were not in a clean condition.Drywall near the exterior kitchen doors contained holes.Findings include:The 2022 Federal Food Code documents at 6-501.12 Cleaning, Frequency and Restrictions: Cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. A regular cleaning schedule should be established and followed to maintain the facility in a clean and sanitary manner. Primary cleaning should be done at times when foods are in protected storage and when food is not being served or preparedThe 2022 Federal Food Code documents at 6-202.15 Outer Openings, Protected: Outer openings of a food establishment shall be protected against the entry of insects and rodents by: (1) Filling or closing holes and other gaps along floors, walls, and ceilings; (2) Closed, tight-fitting windows; and (3) Solid, self-closing, tight-fitting doors.The 2022 Federal Food Code documents at 6-501.17 Absorbent Materials on Floors, Use Limitation: Cleanliness of the food establishment is important to minimize attractants for insects and rodents, aid in preventing the contamination of food and equipment, and prevent nuisance conditions. A clean and orderly food establishment is also conducive to positive employee attitudes which can lead to increased attention to personal hygiene and improved food preparation practices. Use of specified cleaning procedures is important in precluding avoidable contamination of food and equipment and nuisance conditionsOn 5/21/26 at 9:00 AM, Surveyor completed a tour of the kitchen and noted the following: ~ Debris, crumbs, and rodent traps underneath the stoves and oven. On 5/21/26 at 9:20 AM, Surveyor interviewed [NAME] (CK)-E who indicated the areas do not get cleaned well.~ Two holes in the outer kitchen wall next to a counter. One hole was toward the back of the counter on the left and contained a pipe. The other hole was in the drywall between the kitchen and dish area.~ A hole large enough for a rodent to enter the building near the employee entrance door outside the main kitchen. ~ A pile of long grain and wild rice that Surveyor initially mistook for rodent droppings. On 5/21/26 at 10:30 AM, Surveyor and Maintenance Staff (MS)-C observed the holes in the walls and doorway. MS-C was not aware of the holes.On 5/21/26 at 10:45 AM, Surveyor interviewed Dietary Manager (DM)-D who confirmed staff had seen rats and a rat was caught in the kitchen one month ago. DM-D also indicated staff who arrived for work in the morning noted bread and cake had been gnawed. DM-D indicated kitchen staff have been using the microwave as a breadbox and there is a sign on the bread rack to ensure staff do not leave anything out overnight. DM-D verified the importance of ensuring areas underneath counters and equipment and behind boxes are clean when rodents have been observed so staff can tell if there are any remaining issues.

Based on observation, staff interview, and record review, the facility did not maintain an effective pest control management program. This practice had the potential to affect all 51 residents residing in the facility.The kitchen contained multiple traps for rodents, including rats. Staff statements were inconsistent regarding knowledge of rats, the number of rats caught, who set the traps, and who managed the traps. The facility did not provide documentation that a pest control company was called when rats were first observed in the kitchen.Findings include:The facility's undated Pest Control policy indicates: .3. Document problems found during inspections and the remedial actions taken .11. Cover exterior openings in the buildings foundation with screen wire or wire mesh. On 5/21/26 at 9:00 AM, Surveyor entered the kitchen and observed 2 metal traps in the dry storage area, 3 traps in the dishwashing room, and approximately 5 traps in the main kitchen area under counters and equipment. On 5/21/26 at 9:10 AM, Surveyor asked Dietary Aid (DA)-F about the traps underneath the sink where DA-F was working. DA-F indicated rats were seen in the kitchen. DA-F indicated staff arrived to work earlier in the week and found bread products that had been chewed. DA-F indicated Maintenance Staff (MS)-C was in the kitchen earlier in the week and closed up a hole underneath the dish area where the rats could be entering. DA-F indicated MS-C was taking care of the traps. DA-F indicated all food that had been gnawed or chewed was thrown away. DA-F confirmed none of the food was served to residents. On 5/21/26 at 9:40 AM, Surveyor interviewed and entered the dish area with MS-C. When Surveyor asked about a hole covered with mesh and steel wool where a pipe came out of the wall underneath the sink, MS-C indicated MS-C had covered the hole at the end of April due to rodent concerns. When Surveyor asked what kind of rodents, MS-C stated mice. When asked if there were concerns about rats, MS-C indicated MS-C had not heard any rat concerns prior to that week. When asked if MS-C had seen a video of a rat in the kitchen, MS-C indicated no. MS-C indicated MS-C first heard of a video last week when kitchen staff said they saw a rat. Regarding the traps in the kitchen, MS-C indicated MS-C only took care of 2 sticky traps in the dishroom and the facility's pest control company took care of 2 metal traps in the dry storage area. MS-C indicated MS-C did not take care of the other traps in the main kitchen. MS-C stated MS-C was not aware rats were caught in the kitchen and was only aware of small mice. During the interview, Surveyor requested the last 6 months of pest control company visits. MS-C indicated MS-C would contact the pest control company since MS-C did not have the documentation onsite.At 10:30 AM, Surveyor completed an outside tour with MS-C and showed MS-C [NAME] and areas alongside the building, including one that contained a bunnies nest. MS-C was not aware of the areas and stated MS-C needed to take care of some of the areas. Surveyor also pointed out areas in the kitchen where there were holes in the drywall, including an outer wall in a corner behind a counter outside the dishroom, in the same wall adjacent to the dishroom, and next to an outer door outside the main kitcehn door where staff entered near the timeclock.On 5/21/26 at 10:45 AM, Surveyor interviewed Dietary Manager (DM)-D who indicated maintenance staff set all the traps in the kitchen. DM-D indicated the rodent problem had been going on for a few months. DM-D indicated kitchen staff observed bread products that had been nibbled on. DM-D instructed staff not to leave anything out and to use the microwave as a breadbox. DM-D indicated Nursing Home Administrator (NHA)-A knew about the issue approximately a month ago after DM-D threw away a large rat that was caught in one of the traps. DM-D stated DM-D picked up the trap and threw it out. DM-D indicated DM-D told NHA-A who was going to talk to MS-C. DM-D confirmed MS-C put the mesh under the dishwasher on 5/19/26 (not the end of April as MS-C had indicated). On 5/21/26 at 3:41 PM, Surveyor asked Director of Nursing (DON)-B if DON-B had received a video from staff of a rat in the kitchen. DON-B indicated DON-B received a poor quality grainy video of a small animal in the kitchen but could not say if it was a rat. DON-B indicated DON-B received the video months ago and passed the video onto NHA-A. On 5/21/26 at 11:08 AM, Surveyor interviewed NHA-A who indicated NHA-A first heard of a recent rat concern this week. NHA-A indicated NHA-A talked to DM-D that morning and just found out DM-D caught a rat in a trap approximately 6 weeks ago. Surveyor asked about NHA-A's use of the words recent concern and asked when NHA-A was made aware of a previous concern. NHA-A indicated the facility educates staff in the spring and fall because the facility is in the country. NHA-A indicated as soon as NHA-A found out about the concern, NHA-A did a walk-through of the kitchen, began education about pest control, and stated if staff see something they should say something. Surveyor requested the past 6 months of pest control logs. NHA-A indicated the pest control company was contacted, however, the pest control staff was on the road and would send the logs to the facility as soon as possible. Surveyor requested the phone number for the pest control company and receipts for paid bills. In a subsequent interview at 4:05 PM, NHA-A indicated NHA-A had never seen a video of a rat in the kitchen. On 5/21/26 at 11:38 AM, Surveyor contacted the facility's pest control company via phone but did not receive a return call. The facility provided bills from the pest control company which indicated bills were sent twice monthly. The bills did not indicate how many traps the company kept, where the traps were located, concerns identified on each visit, or what was completed during each visit. On 5/21/26 at 12:41 PM, Surveyor reviewed the facility's education and staff signature pages. Surveyor interviewed DA-G who indicated DA-G had worked every day since Monday (5/18/26) and was not provided education about pest control. DA-G's signature was not on the staff signature page. On 5/21/26 at 4:05 PM, Surveyor informed NHA-A of the inconsistencies in the timeline of events, when issues were known and by who, who was managing which traps, when various areas of mitigation for rodents were implemented, and that not all staff who worked in the kitchen that week were educated. Due to the inconsistencies and the fact that staff education was incomplete, the facility did not meet the standard for an effective pest control program.

Based on staff and resident representative interview and record review, the facility did not ensure 1 resident (R) (R1) of 4 sampled residents received care and treatment to maintain their highest practicable physical well-being.R1 was at risk for constipation due to reduced mobility and the use of pain medication. R1's medical record contained incomplete bowel and bladder tracking upon admission, incomplete shift monitoring for bowel movements, and a delayed response for signs of constipation. In addition, staff did not consistently complete monitoring for incontinence, food and fluid intake, and repositioning. On 4/25/26, R1 was sent to the hospital and diagnosed with stercoral colitis (inflammation of the colon caused by fecal impaction, which can lead to perforation) as well as urinary retention and severe bilateral hydronephrosis (swelling of one or both kidneys that occurs when urine cannot drain properly into the bladder and backs up). Findings include:The facility's Bowel Management policy, revised 4/24/25, indicates: It is the practice of this facility to conduct a comprehensive evaluation to ensure each resident receives appropriate treatment and services to support their overall health and wellbeing. It is also the expectation to complete routine monitoring for potential bowel complications (constipation, ileus, impaction). Facility practices may include: 1. Identification of history of patterns of bowel bladder function. 2. Identification of mobility limitations which affect elimination. 3. Reviewing medications and diagnoses which affect bowel and bladder functions. 4. Routine monitoring and evaluation of bowel functioning. 5. Identification of appropriate treatment plans for the resident .Comprehensive bowel data collection and evaluation may include: a. Known history of relevant medical diagnosis .c. Medication regimen review related to bowel regimen or concerns for potential side effects regarding bowel health. Procedure: (This section was blank on the policy.)The facility's Hydration (Food/Fluid) Monitoring policy, revised 10/3/24, indicates: .The resident will be monitored for signs and symptoms of .Dehydration .including, but not limited to .decreased urinary output .fluid overload .electrolyte imbalance. Documentation: .Record beverage intake in the designated locations (meal intake records, Medication Administration Record (MAR) as indicated) .Record output in designated locations (MAR or output records).The facility's Offering/Serving Bedtime Snacks policy, revised 2/26/25, indicates: It is the practice of the facility to offer and serve residents with a nourishing snack in accordance with their needs, preferences, and requests at bedtime on a daily basis. Guidelines: 1. Nursing staff offer a bedtime snack to residents .on a daily basis .5. It may be necessary for nursing staff to assist a resident with intake of a snack .6. Intake of bedtime snack is documented in the medical record.On 5/21/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including fracture of the right acetabulum (a cup shaped structure in the pelvis/hip) and dislocated right shoulder with sling following a fall, osteoarthritis, and severe protein calorie malnutrition. R1's Minimum Data Set (MDS) assessment, dated 4/30/26, indicated R1 was rarely or never understood. The MDS assessment indicated R1 was always incontinent of bowel and bladder, required extensive assistance for toileting, substantial/maximal assistance for mobility, and supervision for eating/drinking. R1 received therapy for weakness and reduced mobility and required a full body lift for transfers. admission notes indicated R1 was non-weight bearing status. R1's pain care plan contained interventions to monitor/document for side effects of pain medication and observe for constipation.R1's bowel care plan indicated R1 would have a bowel movement (BM) at least every 3 days and contained interventions to monitor and record BMs and implement BM protocol as needed.R1's bladder care plan indicated R1 was incontinent of bladder and was not on a trial voiding program. The care plan contained interventions to monitor/document signs/symptoms of no ouput (4/16/26) and prompt toileting/toilet upon request (4/22/26). R1's nutrition care plan indicated R1 had a nutritional problem and contained an intervention to monitor and record meal/fluid intakes per facility protocol. R1's skin care plan indicated R1 had potential/actual impairment to skin integrity and contained an intervention to turn and/or reposition every 2-3 hours. R1's communication care plan indicated R1 had a communication problem and contained an intervention to anticipate and meet needs.R1 had the following physician orders:~ Hydrocodone-acetaminophen 5-325 milligrams (mg), 1 tablet by mouth every 4 hours as needed (PRN) for moderate to severe pain. (R1's Medication Administration Record (MAR) indicated R1 received the medication.)~ Milk of Magnesia, give every 24 hours PRN for constipation per bowel protocol~ Bisacodyl rectal suppository, give every 24 hours PRN for constipation per bowel protocol~ Fleet rectal enema, 1 applicator rectally every 24 hours PRN for constipation per bowel protocol~ Daily monitoring for signs/symptoms of malnutrition, such as .constipation/diarrhea .R1's medical record indicated R1 was transferred to the Emergency Department (ED) on 4/25/26 and admitted to the hospital. Hospital admission records, dated 4/25/26, indicated R1 presented with a chief complaint of concern over possible bowel obstruction and was admitted with severe constipation with stercoral colitis likely secondary to narcotic use in the setting of immobility, dehydration, and acute kidney injury. A computerized tomography (CT) scan of the abdomen/pelvis indicated no evidence of intestinal obstruction. R1 had a prominent rectal stool burden with rectal expansion that measured up to 7 centimeters (cm). R1 was also admitted with diagnoses of acute kidney injury, urinary retention, severe bilateral hydronephrosis (swelling of one or both kidneys that occurs when urine cannot drain properly into the bladder and backs up). There was evidence of urinary bladder outlet obstruction with severe distention of the bladder. Straight catheterization was completed with 1,475 milliliters (ml) of output. Following hospitalization, R1 enrolled in Hospice services and transferred to an assisted living (AL) facility. A Hospital admission History and Physical, dated 4/25/26, indicated R1 had a diagnosis of severe protein calorie malnutrition. R1 was previously diagnosed with severe protein calorie malnutrition and continued with poor oral intake per R1's son. Additional diagnoses included generalized weakness, physical deconditioning, failure to thrive, and dehydration for which R1 received 1 liter of normal saline in the ED.On 5/21/26 at 11:45 AM, Surveyor interviewed Family Member (FM)-H who indicated R1 was in the hospital for 3 days following a hip fracture prior to being admitted to the facility. R1 was in the facility for 8 days and was readmitted to the hospital for 7 days. FM-H indicated the facility did not monitor R1's liquids and solids. FM-H indicated R1 was weak and confused and staff provided a large, heavy mug of water at the bedside which R1 could not lift. FM-H indicated staff did not offer to assist R1 with drinking from the mug. FM-H indicated when another family member visited 3 or 4 days after admission, R1 stated R1 was thirsty and had dry, chapped lips. The family member noted R1 could not lift the water mug independently. FM-H was at the facility during the one and a half days prior to R1's transfer to the hospital. Staff indicated R1 was not eating or drinking and had not had a bowel movement. Upon arrival at the ED, FM-H indicated an ED physician stated R1 had a bed sore on the buttocks. FM-H indicated the facility's wound nurse indicated the area was urine irritation, not a pressure injury. FM-H indicated the area on R1's buttocks was referered to as a stage 2 (pressure injury) when R1 was enrolled in Hospice services and transferred to an assisted living facility. FM-H indicated FM-H was told in the ED that R1's bowels were backed up. R1 required intravenous (IV) fluids for hydration. FM-H also indicated the hospital removed nearly 1.5 liters of urine from R1's bladder. R1's bowel monitoring records and MAR indicated the following:~ 4/16/26: Bowel monitoring was not completed on the PM and night (NOC) shifts.~ 4/17/26: R1 did not have a BM on the AM or PM shifts. Bowel monitoring was not completed on the NOC shift.~ 4/18/26: R1 did not have a BM on the AM, PM, or NOC shifts.~ 4/19/26 (day 3): Bowel monitoring was not completed on the AM and NOC shifts. R1 did not have a BM on the PM shift.~ 4/20/26 (day 4): R1 did not have a BM on the AM shift. Bowel monitoring was not completed on the PM and NOC shifts. ~ 4/21/26: R1 had a small BM on the AM shift (documented at 1:59 PM). Bowel monitoring was not completed on the PM shift. R1 did not have a BM on the NOC shift. (Of note: This is the first documented BM for R1 from 4/16 to 4/21 (5 days).)~ 4/22/26: R1 did not have a BM on the AM, PM, or NOC shifts. A bisacodyl rectal suppository was administered at 7:43 PM. (The suppository was documented as effective on 4/23/26 at 9:16 AM.)~ 4/23/26: R1 had a small BM on the AM and PM shifts and no BM on the NOC shift. A suppository was administered at 10:55 PM. (The suppository was documented as ineffective on 4/24/26 at 8:27 AM.)~ 4/24/26: Director of Nursing (DON)-B completed a manual extraction of BM. R1 had a medium BM on the AM shift, a small BM on the PM shift, and no BM on the NOC shift.~ 4/25/26: A suppository was administered at 5:24 AM which was documented as ineffective at 7:25 AM. A fleet enema was administered at 7:26 AM which was documented as ineffective at 9:11 AM. R1 was sent to the ED for evaluation. (Of note: Milk of Magnesia was not administered from 4/16/26 to 4/25/26.)R1's bladder continence/incontinence documentation indicated the following:~ 4/16/26: Documentation was not completed on the PM and NOC shifts.~ 4/17/26: Documentation was not completed on the NOC shift.~ 4/19/26: Documentation was not completed on the AM shift. ~ 4/20/26: Documentation was not completed on the PM and NOC shifts.~ 4/21/26: Documentation was not completed on the PM shift.(Of note: Output in ml was not completed for any of the entries.) R1's meal/fluid intakes documentaton indicated the following:~ 4/16/26: Documentation was not completed for 2 of 2 opportunities.~ 4/17/26: Documentation was not completed for 1 of 3 opportunities.~ 4/19/26: Documentation was not completed for 2 of 3 opportunities.~ 4/20/26: Documentation was not completed for 2 of 3 opportunities. ~ 4/21/26: Documentation was not completed for 1 of 3 opportunities.~ A nutritional evaluation, dated 4/22/26, indicated: Meal intake 0-25%, occasional acceptance of bedtime (HS) snack. Fluid intake 0-1500 ml. Plan/Recommendations: Poor appetite .will continue to monitor intakes. R1's medical record included tracking records labeled activities of daily living (ADLs) which indicated 2 of 26 meals contained no documentation; 6 of 26 meals contained code 98 which was not one of the options in the identification key for eating; 8 of 26 meals indicated R1 had 0% intake of food. Documentation for 2 meals indicated R1 was independent and completed the activity with no assistance or helper. Of the two meals, R1 ate 0% of one and 25% of other. Surveyor noted 1 of 26 meals was coded to indicate R1 was dependent on staff. R1 ate 100% of the meal (the only entry during R1's stay in which R1 ate 100% of a meal). HS snack monitoring contained missing documentation for 3 of 9 days.R1's turning/repositioning documentation indicated the following:~ 4/17/26: Documentation was not completed on the NOC shift.~ An initial wound assessment, dated 4/18/26, indicated R1 had fragile skin and incontinence-associated dermatitis on the left buttock.~ 4/19/26: Documentation was not completed on the AM shift.~ 4/20/26: Documentation was not completed on the PM and NOC shifts.~ 4/21/26: Documentation was not completed on the PM shift. A progress note, dated 4/24/26 at 2:42 PM, indicated staff spoke with R1's son and daughter-in-law regarding R1's overall condition. R1's family stated they were aware R1 was not eating well and not progressing. Comfort cares and Hospice services were reviewed. R1 was alert and answering questions appropriately. Staff assisted R1 with eating. R1 took approximately 12 bites and drank approximately a half glass of milk.A progress note, dated 4/25/26 at 1:34 PM, indicated R1 was transferred to ED that morning for evaluation of no BM despite enema and bowel aids. R1's bladder was palpable. A CT scan showed probable pneumonia; bowels show constipation; a straight cath obtained 1400+ ml of urine.A progress note, dated 4/26/26 at 9:10 AM, indicated a hospital nurse stated R1 was admitted with stercoral colitis and continued to have small but frequent BMs. On 5/21/26 at 12:02 PM, Surveyor interviewed Certified Occupational Therapy Assistant (COTA)-J who indicated R1 was weak and in discomfort and had a hard time following commands. COTA-J believed R1 could feed R1's self but did not want to because R1 was not feeling well.On 5/21/26 at 12:04 PM, Surveyor interviewed Physical Therapy Assistant (PTA)-K who indicated R1 fatigued easily and either did not understand or did not want to when asked to take a drink. PTA-K indicated a family member who visited stated R1 was more confused than they had ever seen.On 5/21/26 at 2:15 PM, Surveyor interviewed DON-B who confirmed it was safe to assume if bowel monitoring was not documented, R1 did not have a BM. DON-B indicated the facility does not have a written bowel protocol and the policy is vague. DON-B indicated DON-B expects staff to administer Milk of Magnesia on day 3 of no BM, a suppository on day 4 of no BM, and a fleets enema on day 5 of no BM. DON-B confirmed R1's medical record did not contain consistent tracking of fluid intake and confirmed a snack should be offered each evening. DON-B confirmed R1's repositioning documentation was incomplete.On 5/21/26 at 2:32 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-I and DON-B. who indicated LPN-I tried to give R1 Milk of Magnesia on approximately 4/19/26 (LPN-I could not recall the exact date), however, R1 was not able to tolerate it and did not drink it. LPN-I indicated LPN-I did not document the attempt because R1 did not take the medication. LPN-I indicated LPN-I administered a suppository on 4/22/26 which was ineffective. When Surveyor indicated the documentation stated the suppository was effective, LPN-I indicated R1 only had a small BM, so LPN-I told the NOC shift nurse it was ineffective and to repeat the suppository on the NOC shift. LPN-I reviewed R1's MAR and confirmed the NOC shift nurse did not administer a suppository. LPN-I thought the NOC shift nurse noted R1's MAR indicated the 4/22/26 suppository was effective and did not readminister a suppository despite being told by LPN-I to do so. LPN-I indicated LPN-I administered a suppository again on the 4/23/26 PM shift because R1's abdomen was distended and R1 was uncomfortable. LPN-I confirmed the suppository was also ineffective. Surveyor reviewed bowel monitoring documentation for 4/22/26 with LPN-I who confirmed the documentation indicated R1 did not have a BM on the AM, PM, or NOC shifts. LPN-I indicated R1 could lift the water mug if there was a little bit of water in it and could drink from it with a straw. LPN-I indicated R1 could lift and drink from a 4-ounce cup. DON-B indicated DON-B completed manual extraction of BM for R1 on 4/24/26. DON-B confirmed a suppository and enema administered on 4/25/26 were ineffective. DON-B confirmed there were no documented attempts to treat R1's bowels until 4/22/26 and confirmed R1's bowel monitoring was incomplete. DON-B confirmed what was documented between 4/16/26 and the 4/21/26 AM shift (4.5 days) indicated R1 did not have a BM. Documention on 4/21/26 indicated R1 had a small BM on the AM shift and no BM again until small BMs on the 4/23/26 AM and PM shifts. Documentation on 4/24/26 (the date of manual extraction) indicated R1 had a medium BM on the AM shift and a small BM on the PM shift. On 5/21/26 at 2:00 PM and 3:50 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated R1 had multiple medical issues upon admission and was at high risk for constipation due to pain medication. NHA-A indicated if a resident does not eat supper, Certified Nursing Assistants (CNAs) should tell the nurse. All residents should get an HS snack if they would like one. NHA-A indicated R1 was not eating because R1 was not hungry and did not want to eat.

Based on observation, interview, and record review, the facility did not ensure the resident environment remains as free of accident hazards as possible and each resident receives adequate supervision and assistive devices to prevent accidents for 1 of 4 residents (R) reviewed (R1.)R1 was repositioned inappropriately by unqualified staff which resulted in right humerus fracture.This is evidenced by:Facility policy titled, Safe Resident Handling/Transfers, with a reviewed date of 05/23/23, states: Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident.Policy Explanation: All resident require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. While manual lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of mechanical lifts are a safer alternative and should be used. Compliance Guidelines: 11. Nursing staff will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices.12. Nursing staff must demonstrate competency in the use of mechanical lifts prior to use and annually with documentation of that competency placed in their education file. 14. Resident lifting and transferring will be performed according to the resident's individual plan of care.According to the Department of Health Services/Division of Quality Assurance publication Role of the Non-Certified staff in the Provision of Care dated 11/2021 Guidance: In 2000, the Department approved the following list of tasks that an individual can perform without being listed on the Wisconsin Nurse Aide Registry as a nurse aide to assist long-term care facilities with the implementation of helpers or hospitality aides and to ensure that the facility remains in compliance with nurse aide training requirements. An individual performing the following non-direct care tasks would not need to be a certified nursing aide. Resident rooms: Perform non-direct care tasks-no physical contact with the resident is allowed.R1 was admitted to the facility on [DATE] with diagnoses of spastic quadriplegic cerebral palsy, contracture of left wrist, contracture of left hand, and cervical disc degeneration.R1's annual Minimum Data Set (MDS) assessment, dated 03/23/26, noted a Brief Interview for Mental Status (BIMS) score of 15/15, indicating cognition is intact. R1 had impaired range of motion (ROM) on both sides of upper and lower extremities. R1 is dependent assist with all activities of daily living (ADL).R1's care plan, dated 12/23/24, with a target date of 04/19/26, states: The resident has an ADL self-care performance deficit with a goal resident will improve current level of function in ADLs. Interventions include Bed Mobility: extensive total assist. Transfer: Hoyer total assist.R1's Certified Nursing Assistant (CNA) Kardex, dated 10/01/25, states: Resident Care: Transfers/Ambulation: transfers with total assist and full sling lift.Of note: fireman method lifting technique was not documented as a safe method to boost R1.Surveyor reviewed R1's therapy evaluations and noted no documentation of evaluating a fireman method to use as a safe method to reposition R1.On 02/10/26, at approximately 3:00 PM, R1 was observed by Certified Nursing Assistant (CNA) U sliding downward in the wheelchair. CNA U asked Business Office Manager (BOM) N to assist in repositioning R1. CNA U and BOM N attempted to reposition R1 using the Hoyer sling positioned under R1, but the sling was too far down to safely move R1. CNA U and BOM N then repositioned R1 using a fireman boost to boost R1 by lifting R1 under each arm and pulling up on R1's pants/briefs to a more upright position. As CNA U and BOM N pulled R1 up, they heard a popping sound in R1's right arm. The provider was notified and on 02/11/26, an x-ray was completed showing a fracture of the surgical neck of right humerus. No surgical intervention. Treatment with sling to right arm. Facility completed investigation of incident, noting root cause to be staff being unaware of proper wheelchair device placement. Interventions implemented included therapy screening for wheelchair positioning, staff education, and pictures placed in resident room noting wheelchair positioning.Surveyor reviewed completed staff training after R1's incident, dated 02/10/26 - 02/18/26, and noted in-service training topic was to use Hoyer sling to boost resident and not to lift by the arms.Of note: Surveyor reviewed completed CNA training and competency topics and noted no education regarding use of fireman method for transferring/repositioning residents. BOM N is not a CNA and should not complete hands-on patient care/repositioning.On 04/15/26 at 10:13 AM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding R1's incident. NHA A stated that non-nursing staff are allowed to assist with repositioning as that is not considered a direct-patient care action. R1 was sliding down in the wheelchair and staff could not use the Hoyer lift to reposition, so they used the fireman method to pull R1 up with her arms. Surveyor asked NHA A if this would be an appropriate method to reposition a resident with contractures. NHA A stated that there was not another option if staff couldn't get the Hoyer sling in position.On 04/15/26 at 3:47 PM, Surveyor interviewed BOM N regarding incident. BOM N stated that CNA U had called out to her asking for help in repositioning R1. BOM N stated that she and the CNA had tried to position the Hoyer sling under R1 to use the mechanical lift, but weren't able, so they decided to use the fireman method. BOM N stated she was positioned on R1's left side and the CNA was on R1's right side. BOM N stated she was hesitant to reach under R1's left arm because of the contractures, so instead BOM N positioned her body close to R1's left arm and reached behind R1 grabbing hold of R1's pants and/or briefs. BOM N stated the CNA on R1's right side reached under R1's right arm and grabbed hold of R1's pants/briefs and together they lifted R1 upright and heard a popping sound. Surveyor asked if the fireman pull was a commonly used method to reposition residents. BOM N stated she did not know. Surveyor asked BOM N if she received any training in repositioning residents. BOM N stated not officially, but that the NHA had shown her in the past. Surveyor asked BOM N if she had any CNA training. BOM N stated no. Surveyor asked BOM N if it was common for unlicensed/untrained staff to assist with resident transfers/repositioning. BOM N stated that she doesn't typically help because she is afraid of something like this happening, but non-nursing staff are allowed to help with boosts.On 04/15/26 at 3:57 PM, Surveyor attempted to interview R1. Surveyor asked R1 if she remembered the incident with her arm being injured. After several seconds, R1 was able to move head up and down, indicating yes. Surveyor asked R1 if she could say what happened. R1 looked at Surveyor and was unable to voice words. Surveyor attempted to ask additional questions, but R1 was only able to respond with yes or no answers. No meaningful conversation was made.Surveyor was unable to interview CNA U identified in the incident.R1's plan of care was not followed, R1 was repositioned by a CNA and a non-certified staff. As a result, R1 suffered a fractured humerus.

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 which had the potential to affect all 53 residents.-Cook Q did not have a hair or beard restraint on while preparing food.-Cook P did not have a beard net on while preparing food.-Unlabeled and undated food items observed in the cooler.-Expired food items observed in the cooler and freezer.-Excessive frost/ice build-up observed in the freezer including directly above food items.Findings include:On 04/13/26 at 9:00 AM, Surveyor entered the facility's kitchen for the initial tour. Surveyor observed [NAME] Q, who had visible hair/stubble on both [NAME] Q's head and face, was not wearing hair restraints of any kind. Surveyor observed [NAME] P wearing a hair restraint on [NAME] P's head but did not have a beard restraint with facial hair present.On 04/13/26 at 9:05 AM, Surveyor observed glasses of liquid with lids on a tray in the cooler that were not labeled or dated. On another tray in the cooler, unlabeled/undated containers of cottage cheese, and a sandwich that was dated 04/11/26 were observed by Surveyor. Surveyor observed two small containers containing unknown food items on the shelf of the cooler, that were not labeled or dated.On 04/13/26 at 9:10 AM, Surveyor entered the freezer and observed a pack of soft tortillas that were past the use by date and the package wide open. Surveyor observed plastic trays on the top shelf directly under the fans in the freezer. Both trays contained white and brown ice that appeared to have dripped from the unit above. The mounds of ice were 3 and 4 inches tall in some areas. Surveyor observed that directly above a pumpkin pie on another shelf was excessive frost and ice build-up on a pipe.On 04/14/2026 at 8:09, AM Surveyor completed a follow up kitchen inspection. Surveyor observed [NAME] Q again with no hair restraints and [NAME] P with no beard restraint.On 04/14/26 at 11:55 AM, Surveyor interviewed Dietary Manager (DM) I. Surveyor informed DM I of the unlabeled and expired food observed in the refrigerator and freezer previous and current day. Surveyor also asked DM I about the frost/ice buildup in the freezer, to which DM I acknowledged that has been an ongoing issue. DM I acknowledged the other concerns.On 04/14/26 at 1:00 PM, Surveyor interviewed DM I about hair restraints. DM I stated the kitchen policy for hair restraints states anything under 1/4 inch in length does not require hair restraints. DM I provided Surveyor with a copy of the policy which was from the facility company and was not dated. DM I did not provide a nationally recognized standard of practice for which the policy is based on.On 04/15/26 at 8:27 AM, Surveyor interviewed DM I. DM I stated the expectations of staff would be to put an open date, label, and use by date on any items placed in the cooler or freezer. DM I stated the kitchen staff should be looking for expired items and disposing of them, but usually DM I does it. DM I stated it was appropriate to place a label just on the tray of drinks and/or cottage cheese as long as they were going to be used that same day. DM I would expect each individual item to be labeled for longer use or placed in a separate pan with a label on it. When asked about the freezer, DM I stated the frost build-up has been like that as long as DM I has been working at the facility, which is 8 years. When asked how often it gets addressed, DM I stated, When someone complains about it. DM I stated Maintenance looks at it all the time, but DM I thinks maybe it's time to get a professional to come look at it. DM I stated at times DM I will go and take the trays full of ice and knock the ice off out the back door. DM I updated on the federal regulations regarding hair restraints and DM I acknowledged all staff should be wearing hair restraints when working in the kitchen with the food.On 04/15/26 at 8:41 AM, Surveyor updated Director of Nursing (DON) B about kitchen concerns. DON B acknowledged.On 04/15/26 at 11:16 AM, Surveyor interviewed Maintenance Director (MD) J. MD J stated about every 28 days the defrosting mechanism in the freezer needs maintenance. MD J stated some of the insulation had come off with the frost and the copper supply needs to be replaced which MD J planned to do that after the defrosting the freezer. MD J stated MD J checks the freezer weekly and the ice builds up in that short time. When asked if it was appropriate to store food directly under the ice buildup, MD J stated, Well when I'm done defrosting it would be warranted. MD J stated the facility does have a local outside source that can perform maintenance and possibly come about twice yearly. MD J stated the outside source has never reported any concerns regarding the ice buildup. MD J stated MD J just takes care of it, and it takes about 45 minutes each time.

Based on observations, interviews and record reviews, the facility did not ensure residents were correctly positioned to eat meals in bed to promote the highest practical well-being for 2 of 6 residents (R) reviewed. (R7 and R40)R7 was in bed in a lying position the whole time the breakfast tray was provided. R7 was not checked on or repositioned to effectively see and eat the meal.R40 was in bed in a lying position not eating until a family member arrived and asked staff for assistance. R40's position did not allow him/her to adequately see or eat the meal.Example 1 R7 was admitted to the facility on [DATE] with heart disease and rheumatoid arthritis. R7's care plan with a target date of 04/26/26 indicates R7 requires extensive assist of 1-2 and assist as needed and can feed self meals after set-up and to assist as needed. R7's care plan initiated on 02/25/26 notes a nutritional concern related to inability to manage self-care, variable intake and advanced age. R40 was admitted to the facility on [DATE] with heart failure, COPD, and muscle weakness. R40's care plan with a target date of 06/07/26 states R40 is independent with bed mobility and meals. Care plan initiated 04/10/26, indicated that R40 has a terminal prognosis and is to receive comfort care. Care plan initiated 11/25/25 indicates R40 has a nutritional concern related to heart failure, COPD, need for therapeutic diet and variable intake. On 04/14/2026 at 8:14 AM, Surveyor observed Certified Nursing Assistant (CNA) F set up R7 breakfast in bed. CNA F elevated the head of the bed. Tray was placed in front of R7 slightly below eye level. R7's body was at a 40-degree angle and chin is at table height. CNA F told R7 s/he needs to get boosted up. During continuous observation, CNA F then left the room, and the boost did not happen. At 8:25 AM, R7 was still at a 40-degree angle. On 04/14/2026 at 9:24 AM, CNA F returned and removed R7's breakfast tray. R7 only ate most of the hot cereal. Surveyor interviewed R7 and asked if s/he was able to eat breakfast sitting so low in the bed. R7 said it was very difficult. Example 2 On 04/14/2026 at 8:24 AM, Surveyor observed R40 lying in bed sleeping with breakfast not touched but is set up in front of him/her. R40 woke up at 8:50 AM and was holding a coffee cup with straw. Surveyor observed R40's breakfast tray at eye level and the top of table was at R40's upper lip region. R40's body was at a 35-degree angle and diagonal in the bed with R40's feet hanging off the edge off the right side up against the wall. During Surveyors continuous observation, staff did not check on, assist, or correct R40's position. At 9:03 AM, Family member D entered R40's room and requested CNA to help sit him/her up so he can eat. Family member D stated, He can't eat like that. CNA F straightened R40 some and elevated the HOB more where R40 was then able to see the meal and feed self. Family Member D encouraged R40 to eat. R40 then began to eat food. On 04/14/2026 at 1:19 PM, Unit manager C and RN E stated they boosted and set up R40 between 8:15 and 8:30am. On 04/14/2026 at 10:46 AM, Surveyor interviewed DON B and asked what the expectation is regarding the CNA role if a resident eats in their room? DON B said they would expect the CNA to deliver the tray, offer clothing protector, set up the meal, elevate the head of bed at a position of comfort and at an appropriate height to eat. Both R7 and R40 triggered for weight loss and care plans identify nutritional problems. Neither were positioned, checked on, or assisted to ensure needs were acceptable, obtainable, and/or in a timely manner.

Based on observation, interviews, and record reviews, the facility did not ensure residents received services by qualified staff with the correct certification and skills for 2 of 15 residents (R) that require mechanical lifts. (R1, R54) Activity Aide H, a non-certified personnel, assisted R54 with a direct care mechanical transferBusiness office manager N, a non-certified personnel, assisted R1 with repositioning in a wheelchair.The facility policy titled, Safe Resident Handling/Transfers, states, .Two staff members must be utilized when transferring residents with a mechanical lift. According to Department of Health Services (DHS) form P-01559 dated 11/2021, titled, Role of non-certified staff in provision of care, states, In 2000, the Department approved the following list of tasks that an individual can perform without being listed on the Wisconsin Nurse Aide Registry as a nurse aide to assist long-term care facilities with the implementation of helpers or hospitality aides and to ensure that the facility remains in compliance with nurse aide training requirements. An individual performing the following non-direct care tasks would not need to be a certified nurse aide.Perform non-direct care tasks - no physical contact with the resident is allowed. According to Wisconsin Department of Health services, Wisconsin.gov website, only trained personnel are authorized to operate sit-to-stand lifts. This includes certified nursing assistants and other healthcare professionals who have received proper training and are qualified to use the equipment safely. The use of powered patient lift assist devices, such as sit-to-stand lifts, is regulated to ensure the safety of both patients and healthcare workers. Example 1 R54 was admitted to the facility on [DATE] with dementia, Parkinson's disease, and degenerative back and neck disorders. On 04/14/2026 at 8:17 AM, Surveyor observed Certified Nursing Assistant (CNA) G and Activity Aide (AA) H transfer R54 on and off the toilet using a sit-to-stand mechanical lift. AA H pushed the button on the lift which changed the position of R54, lifting him on and off the toilet. Surveyor asked AA H if s/he is a CNA or received training using a mechanical lift. AA H stated that s/he was not trained at the nursing home and is not a CNA. Surveyor asked what her role was, and AA H said s/he helps on the floor and does activities. Surveyor asked what the policy is for mechanical transfers. CNA G stated they use 2 staff assist for anything with a button and only one must be a CNA. On 04/14/2026 at 10:46 AM, Surveyor interviewed Director of Nursing (DON) B and asked what the policy is for staff using mechanical lifts. DON B stated they require 2 staff assist for sit-to-stand lifts and anything with a battery or a button. One needs to be qualified, and the other does not. On 04/14/2026 at 1:38 PM, Surveyor requested all yearly training, education, performance evaluations, and competencies for AA H. Surveyor reviewed the information that confirms AA H's job title was an Activity Aide with date of hire as 05/20/25. Surveyor reviewed competencies and none were found regarding training for transfer assistance. Surveyor looked up Wisconsin CNA registry, and no records were found matching AA H's name. On 04/14/2026 at 2:45 PM, Surveyor interviewed DON B who confirmed there are no current staff in a CNA course that are not certified. Surveyor asked what roles AA H performs. DON B stated AA H is an activity aide, helps pass meal trays and transports residents. Surveyor asked if AA H is trained to use the sit-to-stand lift. DON B said no, but s/he needs to be with a CNA and can only press the button. Surveyor asked if DON B would consider pressing the button as part of a transfer process and operating the lift. DON B said, Yes, but they only are pressing a button. Example 2 R1 was admitted to the facility on [DATE] with spastic quadriplegic cerebral palsy, contracture of left wrist, contracture of left hand, and cervical disc degeneration. R1's care plan, dated 12/23/24, with a target date of 04/19/26, states: .Transfer: Hoyer total assist. (Fireman method lifting technique was not documented as a safe method to boost R1.) Surveyor reviewed R1's therapy evaluations and noted no documentation of evaluating a fireman method to use as a safe method to reposition R1. Surveyor reviewed incident report regarding R1 that stated on 02/10/26, at approximately 3:00 PM, R1 was observed by CNA U sliding downward in the wheelchair. CNA U asked Business Office Manager (BOM) N to assist in repositioning R1. CNA U and BOM N attempted to reposition R1 using the Hoyer sling positioned under R1, but the sling was too far down to safely move R1. CNA U and BOM N then repositioned R1 using a fireman method to boost R1 by lifting R1 under each arm and pulling up on R1's pants/briefs to a more upright position. As CNA U and BOM N pulled R1 up, they heard a popping sound in R1's right arm. The provider was notified and on 02/11/26 an x-ray was completed showing a fracture of the surgical neck of right humerus. No surgical intervention. Treatment with sling to right arm. On 04/15/26 at 10:13 AM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding R1's incident. NHA A stated that non-nursing staff are allowed to assist with repositioning as that is not considered a direct-patient care action. R1 was sliding down in the wheelchair and staff could not use the Hoyer lift to reposition, so they used the fireman method to pull R1 up with her arms. Surveyor asked NHA A if this would be an appropriate method to reposition a resident with contractures. NHA A stated that there was not another option if staff couldn't get the Hoyer sling in position. On 04/15/26 at 3:47 PM, Surveyor interviewed BOM N regarding incident. BOM N stated that CNA had called out to her asking for help in repositioning R1. BOM N stated that she and the CNA had tried to position the Hoyer sling under R1 to use the mechanical lift, but weren't able, so they decided to use the fireman method. BOM N stated she was positioned on R1's left side and the CNA was on R1's right side. BOM N stated she was hesitant to reach under R1's left arm because of the contractures, so instead BOM N positioned her body close to R1's left arm and reached behind R1 grabbing hold of R1's pants and/or briefs. BOM N stated the CNA on R1's left reached under R1's left arm and grabbed hold of R1's pants/briefs and together they lifted R1 upright and heard a popping sound. Surveyor asked if the firemen method was a commonly used method to reposition residents. BOM N stated she did not know. Surveyor asked BOM N if she received any training in repositioning residents. BOM N stated not officially, but that the NHA had shown her in the past. Surveyor asked BOM N if she had any CNA training. BOM N stated no. Surveyor asked BOM N if it was common for unlicensed/untrained staff to assist with resident transfers/repositioning. BOM N stated that she doesn't typically help because she is afraid of something like this happening, but non-nursing staff are allowed to help with boosts.

Based on interview and record review, the facility did not ensure residents with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 5 of 5 residents reviewed (R20, R29, R32, R1, R34).-The facility staff did not routinely complete R20's ambulation, exercise, and Activities of Daily Living (ADL) programs.-The facility staff did not routinely complete R29's ambulation program.-The facility staff did not routinely complete R32's ambulation, exercise, and range of motion (ROM) programs.-The facility staff did not routinely complete R1's ROM programs.-The facility staff did not routinely complete R34's ROM programs.Findings include: Example 1 R20 was admitted to the facility on [DATE]. On 03/19/26, R20's Minimum Data Set (MDS) assessment showed a Brief Interview for Mental Status (BIMS) score of 11/15 indicating moderate cognitive impairment. R20's diagnoses include cerebral palsy, epilepsy, congenital hydrocephalus, and morbid obesity. On 04/13/26 at 11:45 AM, Surveyor completed an initial interview with R20. R20 along with Family Member (FM) V, voiced concerns that R20 is not getting ambulated as R20 should. There is concern that R20 will decline or lose the ability if R20 isn't doing it on a regular basis. FM V stated depending on which Certified Nursing Assistant (CNA) is working, R20 may get to walk one time here and there but it is not every day and not consistent and R20 confirmed this. R20's annual MDS assessment, dated 03/19/26, section O0500 Restorative Nursing Programs stated, Record the number of days each of the following restorative programs was performed (for at least 15 minutes a day) in the last 7 calendar days (enter 0 if none or less than 15 minutes daily). Range of motion was marked completed 1 day. Surveyor reviewed R20's CNA tasks which include: Ambulation Program: Twice a day ambulate in hallway. Allow time for foot clearance. Wheelchair to follow, distance as tolerates. R20 needs encouragement to ambulate, if refuses re-approach, if still refuses let FM V know and FM V will talk to R20. Surveyor reviewed CNA task documentation and noted the following for February: 12 shifts marked as not applicable (02/01/26, 02/03/26, 02/05/26, 02/06/26, 02/09/26, 02/11/26, 02/12/26, 02/15/26, 02/17/26, 02/18/26, 02/19/26, 02/24/26). 25 shifts no documentation (02/01/26, 02/02/26, 02/03/26, 02/05/26, 02/07/26, 02/08/26, 02/09/26, 02/10/26, 02/11/26, 02/13/26, 02/14/26, 02/15/26, 02/16/26, 02/17/26, 02/18/26, 02/21/26, 02/22/26, 02/25/26, 02/26/26, 02/27/26, 02/28/26). Surveyor reviewed CNA task documentation and noted the following for March: 2 shifts marked as not applicable (03/22/26, 03/28/26). 45 shifts no documentation (03/01/26, 03/02/26, 03/03/26, 03/04/26, 03/05/26, 03/06/26, 03/07/26, 03/08/26, 03/09/26, 03/10/26, 03/11/26, 03/13/26, 03/14/26, 03/15/26, 03/16/26, 03/17/26, 03/18/26, 03/19/26, 03/20/26, 03/21/26, 03/23/26, 03/24/26, 03/25/26, 03/26/26, 03/27/26, 03/28/26, 03/29/26, 03/30/26, 03/31/26). Surveyor reviewed CNA task documentation and noted the following for April prior to Survey entrance: 1 shift marked as not applicable (04/06/26). 17 of 24 possible shifts had no documentation (04/01/26, 04/02/26, 04/03/26, 04/04/26, 04/05/26, 04/07/26, 04/08/26, 04/09/26, 04/11/26, 04/12/26). DON (Put on) brace to right foot. Ambulate resident with front-wheeled walker. Assist of 1 with gait belt and wheelchair to follow. Surveyor reviewed CNA task documentation and noted the following for February: 13 shifts marked as not applicable (02/01/26, 02/03/26, 02/05/26, 02/06/26, 02/09/26, 02/11/26, 02/12/26, 02/15/26, 02/17/26, 02/18/26, 02/19/26, 02/24/26). Surveyor reviewed CNA task documentation and noted the following for March: 3 shifts marked as not applicable (03/01/26, 03/22/26, 03/28/26). 45 shifts not documentation (03/01/26, 03/02/26, 03/03/26, 03/04/26, 03/05/26, 03/06/26, 03/07/26, 03/08/26, 03/09/26, 03/10/26, 03/11/26, 03/13/26, 03/14/26, 03/15/26, 03/16/26, 03/17/26, 03/18/26, 03/19/26, 03/20/26, 03/21/26, 03/23/26, 03/24/26, 03/25/26, 03/26/26, 03/27/26, 03/28/26, 03/29/26, 03/30/26, 03/31/26). Surveyor reviewed CNA task documentation and noted the following for April prior to Survey entrance: 1 shift marked as not applicable (04/06/26). 17 of 24 possible shifts had no documentation (04/01/26, 04/02/26, 04/03/26, 04/04/26, 04/05/26, 04/07/26, 04/08/26, 04/09/26, 04/10/26, 04/11/26, 04/12/26). Restorative Nursing Program/ADLs: sit on the edge of bed and perform upper body bathing/dressing, donning up to knees for lower body. Provide limited assist for standing to wash peri area and adjust clothing over hips. Surveyor reviewed CNA task documentation and noted the following for February: 10 shifts no documentation (02/02/26, 02/07/26, 02/08/26, 02/14/26, 02/16/26, 02/21/26, 02/22/26, 02/23/26, 02/25/26, 02/27/26). Surveyor reviewed CNA task documentation and noted the following for March: Task only completed on 3 shifts (03/01/26, 03/03/26, 03/06/26). No documentation for the rest of the month. Surveyor reviewed CNA task documentation and noted no documentation for April prior to Survey entrance. Sitting bilateral lower extremity exercises 10 reps twice a day. 1. Hip flexion 2. Quadriceps Strengthening 3. Ankle Pumps 4. Hip Abduction/Adduction Surveyor reviewed CNA task documentation and noted the following for February: 9 AM shifts with no documentation (02/02/26, 02/07/26, 02/08/26, 02/14/26, 02/21/26, 02/22/26, 02/23/26, 02/25/26, 02/27/26). Only 1 PM shift with documentation noted (02/23/26). Surveyor reviewed CNA task documentation and noted the following for March: Only 2 AM shifts with documentation of completion (02/03/26, 02/06/26). No documentation noted for any PM shift. Surveyor reviewed CNA task documentation and noted no documentation for April prior to Survey entrance. Example 2 R29 was admitted to the facility on [DATE]. On 04/04/26, R29's Minimum Data Set (MDS) assessment showed a Brief Interview for Mental Status (BIMS) score of 11/15 indicating moderate cognitive impairment. R29's diagnoses include stage 3 chronic kidney disease, major depressive disorder, congestive heart failure, muscle weakness, and peripheral vascular disease. On 04/13/26 at 11:15 AM, Surveyor completed initial interview with R29. R29 is concerned that R29 is not getting walked like scheduled and is afraid of losing the ability. R29 reported that since R29 is no longer eligible for therapy, R29 would like to continue the walking program in hopes to eventually be able to go to an assisted living facility. R29's annual MDS assessment, dated 04/04/26, section O0500 Restorative Nursing Programs stated, Record the number of days each of the following restorative programs was performed (for at least 15 minutes a day) in the last 7 calendar days (enter 0 if none or less than 15 minutes daily). No restorative program listed in the assessment. Surveyor reviewed R20's CNA tasks which include: Ambulate in hallway with walker and 1 assist. Wheelchair to follow. Surveyor reviewed CNA task documentation and noted the following for February: 6 AM shifts were marked as not applicable (02/01/26, 02/09/26, 02/12/26, 02/15/26, 02/17/26, 02/19/26). Only 7 AM shifts documented (02/03/26, 02/04/36, 02/05/26, 02/06/26, 02/10/26, 02/23/26, 02/26/26). Only 2 PM shifts documented (02/21/26, 02/23/26). Surveyor reviewed CNA task documentation and noted the following for March: 3 shifts marked as not applicable (02/13/26 PM, 02/22/26 AM, 02/28/26 AM). 1 AM shift documented as complete (02/06/26) No other documentation noted. Surveyor reviewed CNA task documentation and noted the following for April prior to Survey entrance: 2 shifts documented for completion (04/02/26 PM, 04/10/26 AM). 22 of 24 possible shifts were noted to have no documentation. On 04/15/26 at 7:10 AM, Surveyor interviewed Certified Nursing Assistant (CNA) L regarding restorative programs. CNA L stated that any restorative or exercise programs would be found in point of care charting under Q-shift. When asked if the programs always get completed, CNA L replied, Not every time. If we are short staffed or someone just doesn't show up, they don't get done. CNA L stated CNA L believed R20 and R29 are both on walking programs. On 04/15/26 at 7:18 AM, Surveyor interviewed Registered Nurse (RN) M in relation to restorative programs. When asked about where to find if a resident is on a restorative program, RN M stated RN M would look in the care plan. RN M stated that any of the nursing staff can complete the restorative/exercise programs but primarily The CNAs do. When asked if all the restorative programs get done, RN M stated, When we are short staffed, probably not. When asked who follows up to make sure it's getting done, RN M responded with, I don't follow up and ask if they've done it. RN M stated RN M would have to look in R20 and R29's charts and was unsure about restorative programs for both residents. On 04/15/26 at 8:41 AM, Surveyor interviewed Director of Nursing (DON) B regarding restorative program expectations. DON B stated the restorative and exercise programs are located in the point of care charting and in the care plans. DON B stated from the care plan it also forwards to the Kardex. DON B stated the CNAs complete these tasks and document in point of care. When asked if the programs always get done, DON B stated, I know that we have some patients that refuse them. I see them doing ROM. DON B stated that yes, CNAs have the ability to mark refusals in their charting. When asked about who follows up to make sure they are being completed, DON B did not have an exact answer. DON B stated MDS coordinator will at times make changes as a decline occurs. DON B's expectation is that the CNAs complete the tasks and document completion. DON B reported to Surveyor the charting for point of care was entered wrong and it did not populate for the CNAs to complete on some programs. DON B acknowledged there were multiple holes in the charting indicating the task was not completed. Example 3 R32 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction (stroke) affecting right dominant side. R32's annual Minimum Data Set (MDS) assessment, dated 03/16/26, noted no Restorative Nursing Programs. Surveyor reviewed R32's Certified Nursing Assistant (CNA) tasks and noted: Restorative bilateral lower extremity (BLE) exercise program: 10-15 reps each exercise 1-2 sets: 1. Leg extensions. 2. Marching. 3. Toe raises. 4. Heel raises. 5. Foot press. 6. Knees out. 7. Knees in. Every shift; Restorative right upper extremity (RUE) self-exercise program: 20 reps each exercise 1 set: 1. Shoulder flexion/extension. 2. Shoulder abduction/adduction. 3. Pronation/supination. 4. Wrist flexion/extension. 5. Ulnar/radial deviation. 6. Flex and extend fingers. 7. Elbow flexion/extension. Every shift; Ambulate in hallway using hemi walker, gait belt assist of one with wheelchair to follow every shift; Passive Range of Motion (PROM) fingers right hand: flexion, extension, rotation. PROM wrist right hand: flexion, extension, supination. Complete prior to brace wear. Every shift. Right wrist/hand splint on in am and on all day, off at bedtime every shift. Surveyor reviewed R32's CNA task completion of restorative care and noted: -January 2026: no documentation on at least one shift: 01/03/26, 01/04/26, 01/06/26, 01/08/26, 01/15/26, 01/16/26, 01/19/26, 01/20/26, 01/22/26, 01/23/26, 01/24/26 – 01/31/26. Task documented as not completed on 01/17/26 and 01/18/26. -February 2026: no documentation on at least one shift: 02/01/26 – 02/05/26, 02/07/26 – 02/22/26, 02/24/26 – 02/28/26. -March 2026: no documentation on at least one shift: 03/01/26 – 03/05/26, 03/07/26 – 03/31/26. -April 2026: documentation on at least one shift: 04/01/26 – 04/15/26. On 04/15/26 at 10:26 AM, Surveyor interviewed Director of Nursing (DON) B regarding restorative nursing program. DON B stated that the expectation is for CNAs to complete all restorative cares every shift and to document when completed or if resident refused. Example 4 R1 was admitted to the facility on [DATE] with diagnoses of spastic quadriplegic cerebral palsy, contracture of left wrist, contracture of left hand, and cervical disc degeneration. R1's annual Minimum Data Set (MDS) assessment, dated 03/23/26, noted no Restorative Nursing Program. Surveyor reviewed R1's CNA tasks and noted: PROM BLE 15 reps x 1 set 1. HIP PROM-flexion/extension 2. HIP Abduction/adduction 3. Hamstring stretch every shift. PROM: 15 reps x 1 set BUE 1.gentle PROM to elbows, wrist and fingers every shift. Surveyor reviewed R1's CNA task completion of restorative care and noted: -February 2026: no documentation on at least one shift: 02/04/26, 02/05/26, 02/07/26 – 02/22/26, 02/24/26 – 02/28/26. -March 2026: no documentation on at least one shift: 03/19/26 – 03/31/26; marked as 'not applicable' on 03/18/26 and 03/22/26. -April 2026: no documentation on at least one shift: 04/01/26 – 04/15/26. Example 5 R34 was admitted to the facility on [DATE] with bilateral osteoarthritis of hip. R34's quarterly MDS assessment, dated 03/13/26, noted no Restorative Nursing Program. Surveyor reviewed R34's CNA tasks and noted: Active BLE ROM exercises: 15 reps 2 times daily: 1. Leg extensions. 2. Marching. 3. Toe raises. 4. Heel raises. 5. Foot press. 6. Knees out. 7. Knees in. Surveyor reviewed R32's CNA task completion of restorative care and noted: -January 2026: no documentation on at least one shift: 01/05/26, 01/19/26 and 01/23/26. -February 2026: no documentation on at least one shift: 02/10/26, 02/15/26, 02/24/26, 02/28/26. -March 2026: no documentation on at least one shift: 03/01/26, 03/05/26, 03/14/26, 03/15/26, 03/17/26 – 03/19/26, 03/22/26, 03/24/26 – 03/30/26. -April 2026: no documentation on at least one shift: 04/01/26 – 04/15/26.

Based on interview and record review, the facility did not ensure Minimum Data Set (MDS) assessments were coded correctly for 1 of 16 residents (R32) reviewed for MDS accuracy.The facility did not correctly code R32's dental status as edentulous.This is evidenced by:R32 was admitted to the facility on [DATE].R32's admission Minimum Data Set (MDS) assessment, dated 03/18/23, noted R32 had no natural teeth or tooth fragments. R32's most recent MDS, dated [DATE], noted no dental concerns.On 04/13/26 at 1:52 PM, Surveyor interviewed R32. R32 stated he had no teeth and no dentures since admission to the facility in 2023.On 04/15/26 at 9:41 AM, Surveyor interviewed MDS Coordinator S regarding R32's MDS assessments. MDS Coordinator S stated being aware that R32 had no teeth or dentures and had no idea why the MDS assessments completed after admission were marked incorrectly.

Based on interview and record review, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents choices for 1 of 16 residents reviewed (R20).-Facility staff did not perform post-seizure activity assessments and documentation per care plan.Findings include:Facility policy titled, Seizure Precautions, last revised on 11/26/25, reads, Assess the resident for any injuries, including the oral cavity.document in the medical record.date and time seizure began, duration of the seizure, any precipitating factors.resident's response to the seizure, any medications received, post-seizure vital signs, oxygen saturation, and mental status, any instructions on seizure management and injury prevention, and notification of practitioner and family.Facility policy titled, Comprehensive Care Plans, last revised on 02/05/25, reads, 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.qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions.R20 was admitted to the facility on [DATE].On 03/19/26, R20's Minimum Data Set (MDS) assessment showed a Brief Interview for Mental Status (BIMS) score of 11/15 indicating moderate cognitive impairment.R20's diagnoses include cerebral palsy, epilepsy, congenital hydrocephalus, and morbid obesity.R20's care plan includes states in part: R20 has a seizure disorder related to epilepsy and hydrocephalus with interventions including post seizure treatment.after seizure take vital signs, and neuro check.seizure documentation.location of seizure activity, type of seizure activity, duration, level of consciousness, any incontinence, sleeping or dazed post-ictal state, after seizure activity.Physician order from 03/29/25 includes monitor for the following complications related to cerebral palsy: decrease in strength and energy, decreased appetite, swallowing difficulties, increased salivation, changes in continence, seizure activity, difficulty breathing, increased confusion, increased pain, decline in functional mobility one time a day. Document N if monitored and none of the above observed. Document Y if monitored and any of the above observed. Add progress note.On 01/04/26, a progress note states Family Member (FM) V reported small seizure activity after supper in FM's room. R20 states R20 is fine now.On 01/04/26, a progress note states grand mal seizure activity reported by Physical Therapist while in the gym today. Will monitor.On 03/03/26, Nurse Practitioner (NP) W progress note states Seizure disorder: Patient continues having intermittent seizures despite medication adherence. Will obtain Keppra level. Continue Keppra and Lamictal as previously prescribed. Continue following with neurology as previously planned or sooner if seizure activity worsens.On 04/07/26, a progress note states FM V reported to writer that R20 had a seizure at 1910 (7:10 PM). Resident doing well post seizure.Surveyor reviewed R20's electronic health record (EHR) and found the order in the treatment record for seizure monitoring was marked administered and not marked indicating yes or no per instructions. There are no noted neurological checks post-seizure activity per the care plan for the dates reviewed and noted in the progress notes. Surveyor noted there were no assessments or progress notes present in R20's EHR post seizure activity.On 04/15/26 at 7:10 AM, Surveyor interviewed Certified Nursing Assistant (CNA) L in relation to seizures and seizure activity. CNA L stated R20 has not had a seizure that CNA L is aware of since CNA L has been here in December. CNA L stated if CNA L noticed a resident having a seizure, CNA L would roll them on their side and call for help. CNA L would then send that person to get a nurse. CNA L stated the nurse may have CNA L get a set of vitals.On 04/15/26 at 7:18 AM, Surveyor interviewed Registered Nurse (RN) M in relation to seizures and seizure activity. RN M stated if a resident had a seizure or seizure activity, RN M would assess the resident, obtain vitals, make sure they are stable, administer PRN medications (as needed) if appropriate and available, and report to POA (power of attorney)/Guardian. When asked about what to do if R20 had a seizure, RN M stated he has never had one for RN M so RN M would have to look into it further. RN M stated RN M would then update the provider when the resident is stable. On 04/15/26 at 08:17 AM, Surveyor interviewed Family Member (FM) V. FM V stated that occasionally the nurse or CNA will get a blood pressure when FM V has witnessed R20 having a seizure but has never seen an actual assessment or Neuro checks performed. FM V stated no one checks R20's eyes or has R20 squeeze their hands/fingers. On 04/15/26 at 8:41 AM, Surveyor interviewed Director of Nursing (DON) B in relation to R20's seizure monitoring. DON B stated if a resident had a seizure or seizure activity, DON B would expect CNAs to report it to a nurse. DON B would expect the nurses to complete an assessment, gather information, update NP W, and perform normal monitoring. DON B stated the nurses should also document any abnormal activity. DON B was asked about where to find the information regarding R20's seizure care. DON B stated it is in the care plan and that R20 has a seizure and anticonvulsant care plan. When asked if there is any documentation in the MAR/TAR (medication administration record/treatment administration record) DON B stated, No, it would be in a progress note. When asked if the nurses would obtain neuro checks per the care plan, DON B stated that would part of their gathering of data. Surveyor informed DON B per the care plan, the post seizure directions/assessments were not being followed/completed and DON B acknowledged understanding.

Based on observation, interview and record review, the facility did not ensure that 2 of 2 residents (R) reviewed for pressure injuries (PI) (R49 and R50) received care consistently with professional standards of practice to prevent further deterioration and promote healing of an existing PI.R49 admitted to the facility with multiple PIs. The facility failed to provide complete admission comprehensive PI assessments.Facility staff did not conduct hand hygiene after removal of gloves during R50's PI care treatment. This is evidenced byThe standard of practice for staging pressure injuries and skin and tissue assessment is based on the NPIAP (National Pressure Injury Advisory Panel) system, which categorizes injuries from Stage 1 to Stage 4, along with Unstageable and Deep Tissue Pressure Injury (DTPI). Staging is based on the anatomical depth of tissue destruction (epidermis, dermis, muscle, bone). Conduct a comprehensive skin and tissue assessment for all individual at risk of pressure injuries as soon as possible after admission/transfer to the healthcare service.Example 1R49 was admitted to the facility on [DATE]. R49's diagnoses include PI of sacral region stage 4, severe protein-calorie malnutrition, methicillin resistant staphylococcus aureus, pressure-induced deep tissue damage, PI of other site stage 3, infection of the skin and subcutaneous tissue, PI part of back, unstageable, PI of other site stage 2, PI of other site unstageable, PI of right heel stage 4, fracture of sacrum, and PI of right heel stage 3.A Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 7/15, meaning severe cognitive impairment. R49 is at risk for PI. Unhealed PIs present on admission were 1 stage 3, 2 stage 4, 5 unstageable, and 1 deep tissue injury (DTI). Initial wound assessments on 03/30/26 documented the following and were not completed.Coccyx, pressure, measurements of 5 cm x 4.5 cm x 0.2 cm, and unstageable.Right heel, pressure, measurements of 3 cm x 2.5 cm x .2 cm, unstageable and no exudate. Mid back, pressure, measurements of 2.5 cm x 1 cm, unstageable, 25% epithelization, and no exudate.The facility provided a QuickShot picture and documented site dated 03/30/26. No comprehensive assessment was completed to include measurement, stage, and complete description of the PIs. The areas documented were right LE (lower extremity) med (medial) pressure, left foot lateral distal pressure, right lower leg shin area scab and pressures, and right bottom foot lateral stage 3.On 04/03/26 wound assessment details report documented PIs were identified on 03/30/26. The facility was unable to provide 03/30/26 admission initial assessments for areas of lt (left) ft (foot) lat (lateral) med - stage 3, lt ft lat prox (proximal) - unstageable, mid upper back - unstageable, RLE (Right Lower Extremity) lat - unstageable, lt shin - unstageable, and rt great toe - stage 3.On 04/15/2026 at 4:04 PM, Surveyor interviewed Director of Nursing (DON) B asking about admission assessment with measurements and staging of PIs. DON B stated R49 came in with all 13 PIs. The nurse only did the three major PIs assessments and did not complete a full assessment of all PIs as instructed. Example 2Facility's policy titled Hand Hygiene dated 03/27/25, documented .The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.R50 was admitted to the facility on [DATE]. R50 had a PI to the left heel.On 04/14/26 at 11:19 AM, Surveyor observed Registered Nurse (RN) R washed hands and turned faucet off with clean hands. RN R applied gloves, placed barrier on side of bed, removed R50's left sock and wound dressing. RN R removed gloves, did not complete hand hygiene, put normal saline on gauze, applied gloves and cleansed left heel. RN R removed gloves, did not complete hand hygiene, opened the gauze wrap and applied gloves. With gloved hands RN R applied betadine pad to wound bed and wrapped foot with the gauze wrap. On 04/15/2026 at 3:51 PM, Surveyor interviewed DON B asking about hand hygiene after glove change during PI wound care. Surveyor reviewed observation with RN R completing R50's wound care and not performing hand hygiene during glove changes. DON B stated hand hygiene is expected with removal of gloves. The clinical manager had just reviewed hand hygiene with RN R prior to wound care. We will continue education.

Based on observation, interview and record review, the facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 of 16 residents (R37) reviewed.R37's olanzapine medication label did not match physician's orders.This is evidenced by:Facility policy titled, Labeling of Medications and Biologicals, with a reviewed date of 11/12/2024, states: Policy: All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. Policy Explanation and Compliance Guidelines: .4. Labels for individual drug containers must include: a. the resident's name; b. The prescribing physician's name; c. the medication name; d. the dose, strength, and quantity of the medication; .g. appropriate instructions and precautions.12. The pharmacy must be informed of any order changes or changes in directions for the use of the medication.R37 was admitted to the facility on [DATE].R37's physician orders:01/22/26 olanzapine 2.5 mg tablet Give 1 tablet by mouth one time a day for unprovoked behaviors in dementia with directions: Give a half tablet by mouth daily at noon and give 1 tablet by mouth every evening.Previous orders for olanzapine include:11/25/26 olanzapine 2.5 mg tablet Give 1.25 mg by mouth one time a day for unprovoked behaviors in dementia with directions: Give a half tablet by mouth daily at noon and give 1 tablet by mouth every evening.On 04/14/26 at 1:12 PM, Surveyor interviewed Licensed Practical Nurse (LPN) T for clarification of R37's olanzapine order. LPN T stated the nursing staff use the electronic medical record (EMR) to verify records and pulled up R37's EMR. LPN T showed Surveyor that R37's current olanzapine order was for 2.5 mg given daily at 3 PM. Surveyor asked LPN T what the included directions of giving a half tab at noon and 1 tab in evening meant. LPN T stated that it was part of an old order and the pharmacy must not have corrected it. Surveyor asked LPN T to show Surveyor R37's medication dispensing card provided by the pharmacy. LPN T opened medication cart and pulled out 4 pharmacy labeled medication cards for olanzapine. Two of the olanzapine medication cards contained full tablets and 2 olanzapine medications cards contained half tablets. All of the olanzapine medication cards had the same pharmacy label attached stating, Olanzapine 2.5 mg tab Give 1/2 tab PO daily at noon - Give 1 tab PO every evening. None of the 1/2 tabs were missing from the medication cards. The 1/2 tab medication cards had dispensed dates of 12/13/25 and 03/13/26. Surveyor asked LPN T if the pharmacy label matched the physician orders. LPN T stated yes because staff do not look at the pharmacy label's direction and only go by the order in the resident's EMR.On 04/14/26 at 2:05 PM, Surveyor interviewed Director of Nursing (DON) B regarding medication labeling. DON B stated it does not matter if the medication card does not match because staff are expected to follow orders in EMR. DON B stated that the facility does have labels that can be used to correct errors on the medications, but they frown on that because the label should not be changed.

Based on interview and record review, the facility did not ensure residents received routine dental services for 1 of 2 residents (R32) reviewed.R32 has not had routine dental services since admission in 2023.This is evidenced by:Facility policy titled, Dental Services, with a reviewed date of 11/12/24, states: Policy: It is the policy of this facility to assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care. Definitions: 'Routine dental services' means an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease.taking impressions for dentures and fitting dentures.8. For residents or resident representatives who do not wish to be referred for dental services: a. The physician shall be notified. b. The dietician shall be consulted to assess for any necessary change in diet. c. The resident's plan of care will be revised to reflect preferences. 9. All actions and information regarding dental services, including any delays related to obtaining dental services, will be documented in the resident's medical record.R32 was admitted to the facility on [DATE].R32's admission Minimum Data Set (MDS) assessment, dated 03/18/23, noted R32 had no natural teeth or tooth fragments. R32's most recent MDS, dated [DATE], noted no dental concerns. R32's Brief Interview for Mental Status (BIMS) score was 15/15, indicating cognition is intact.Surveyor reviewed R32's medical record and noted no documented routine dental visits since admission.Surveyor reviewed R32's care plan and noted no refusal of dentist services or documentation of notifying provider of refusal of dental services.On 04/13/26 at 1:52 PM, Surveyor interviewed R32. Surveyor asked R32 if the facility assists with arranging routine dental services. R32 stated he came to the facility in 2023 with no teeth or dentures so why would he need to see a dentist. Surveyor asked R32 why he did not have dentures. R32 stated he couldn't afford them. Surveyor asked if R32 would want dentures if he could afford them. R32 stated, sure.On 04/14/26 at 11:42 AM, Surveyor interviewed Unit Manager (UM) C regarding R32's dental appointments. UM C reviewed the upcoming appointment binder and stated R32 had no upcoming dental appointments scheduled. UM C reviewed R32's chart and stated she could not find any past dental appointments/visits since admission.On 04/14/26 at 2:05 PM, Surveyor interviewed Director of Nursing (DON) B regarding R32's dental appointments. DON B stated that R32 had no teeth and did not express any interest in getting dentures. Surveyor asked DON B if she had asked R32 if he would want to get dentures. DON B stated that this had never been explicitly asked, but that she would.

Based on observation, staff interview and record review, the facility did not ensure care and treatment provided were consistent with professional standards of practice and resident preference for 2 residents (R) (R1 and R2) of 7 sampled residents.R1 sustained a wound on the right knee during a fall on 2/26/26. Staff did not monitor the wound since it was identified.R2 had a U shaped scar on the left back. Staff and R1's family indicated the area was bruised and had drainage in the recent past. R2's medical record did not contain documentation regarding the area.Findings include: The facility's Wound Treatment Management policy, revised 12/3/24, indicates: To promote wound healing of various types of wounds .Treatment decisions will be based on a. etiology of the wound .b. characteristics of the wound .c. location of the wound. d. goals and preferences of the resident/representative .The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include a. Lack of progression towards healing. b. Changes in the characteristics of the wound. The facility's Pressure Injury Prevention and Management policy, revised 4/17/25, indicates: Licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. According to the National Institutes of Health (NIH) website (4/6/26), a wound is defined as a disruption of the normal anatomical structure and function of skin or tissue .it involves broken skin or damaged underlying tissue with intact skin . According to the NIH Nursing Fundamentals Open Resources for Nursing book, dated 2021, skin integrity is a medical term that refers to skin health. Impaired skin integrity is a nursing diagnosis the North American Nursing Diagnosis Association ([NAME]) International defines as, altered epidermis/or dermis (outer most layer of skin/tissue below the epidermis). 1. From 3/30/26 to 3/31/26, Surveyor reviewed R1's medical record. R1 had diagnoses including cerebral vascular accident and hemiplegia. R1's Minimum Data Set (MDS) assessment, dated 2/9/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1's cognition was intact. On 3/30/26 at 10:36 AM, Surveyor interviewed R1 who stated R1 had a fall which caused a rug burn on R1's right knee. R1 pulled up R1's skirt and showed Surveyor the wound. Surveyor observed a circular wound in the center of R1's knee with a reddened peri wound. The center of the wound was yellow in color with visible depth and contained red lines that crossed the front of the knee. R1 stated staff looked at the wound when R1 fell but didn't do anything afterward. R1 indicated R1 wanted staff to look at the wound and do something about the wound. Weekly skin assessments for R1 on 2/10/26, 2/15/26, and 2/22/26 identified 2 scabs on top of the scalp that were self-inflicted. Weekly skin assessments for R1 on 3/1/26, 3/8/26, 3/15/26, 3/22/26, and 3/29/26 indicated R1's skin was intact. There was no indication of a right knee abrasion. A fall report on 2/26/26 indicated a right front knee abrasion was observed at the time of the incident. On 3/30/26 at 1:42 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-E who indicated R1 did not have any wounds or abrasions. LPN-E indicated if a resident had a wound or abrasion, the area would be documented and monitored even if there was no treatment. LPN-E verified R1's medical record did not contain documentation or monitoring for a right knee wound. LPN-E stated LPN-E would observe R1's right knee for a wound. On 3/30/26 at 2:00 PM, Surveyor interviewed Director of Nursing (DON)-B who was not aware R1 had a wound. DON-B reviewed R1's progress notes and stated there was no indication R1 had any wounds. On 3/30/26 at 3:10 PM, Surveyor again interviewed LPN-E who stated R1's right knee wound was related to a fall on 2/26/26 and was previously documented. LPN-E indicated the wound looked newer and stated R1 informed LPN-E that R1 was picking at the wound. LPN-E indicated the plan was to keep the wound open to air and monitor. On 3/31/26 at 11:16 AM, Surveyor interviewed Registered Nurse (RN)-G who indicated if a wound or bruise is identified, nurses monitor the area. RN-G indicated R1 did not have any wounds. RN-G reviewed R1's Medication Administration Record (MAR) and Treatment Administration Record (TAR) and indicated if R1 had a wound, the wound would be on the MAR or TAR for the nurses to monitor until the wound was healed. When Surveyor asked about R1's right knee wound, RN-G indicated RN-G was told in morning report that R1 picked at a scab. RN-G indicated R1's right knee wound should be monitored. On 3/31/26 at 11:21 AM, Surveyor interviewed R1 who confirmed R1 picked at R1's right knee wound. On 3/31/26 at 1:25 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-F who stated if CNA-F observes a new wound or bruise on a resident or observes a change in an existing wound or bruise, CNA-F informs the nurse. CNA-F did not indicate CNA-F actively observes wounds for changes. On 3/31/26 at 2:21 PM, Surveyor interviewed DON-B who indicated nurses are not expected to monitor R1's right knee wound because CNAs observe wounds and update the nurses with changes. DON-B was unsure if R1's wound was larger or smaller than when it was first identified and was not sure if there were any changes to the wound bed. On 3/31/26 at 2:21 PM, Nursing Home Administrator (NHA)-A indicated CNAs are well trained and know to update the nurse if there are any changes in a resident's wound, including R1's right knee wound. NHA-A indicated CNAs observe residents' skin daily with dressing/undressing and bathing. 2. From 3/30/26 to 3/31/26, Surveyor reviewed R2's medical record. R2 was admitted to the facility 11/18/25 and had diagnoses including heart failure and muscle weakness. R2's MDS assessment, dated 11/24/25, had a BIMS score of 12 out of 15 which indicated R2's cognition was moderately impaired. R2's care plan indicated R2 had potential/actual impairment to skin integrity related to incontinence, anemia, coronary artery disease, and chronic obstructive pulmonary disease. On 3/30/26 at 1:30 PM, Surveyor interviewed CNA-F who indicated R2 had a scar on the left back that was previously a bruise. CNA-F stated the impaired skin was weeping previous to scar formation and CNA-F reported the impaired skin to the nurse which is CNA-F's usual practice. CNA-F could not recall the nurse's name. CNA-F stated after CNA-F informs the nurse of a skin change, it is the nurse's responsibility to document the change and determine treatment. An Unwitnessed Fall Document, dated 1/14/26 at 11:30 AM, included a summary of an unwitnessed fall that occurred in R2's room. R2 was found on the floor next to wheelchair. The document indicated there were no injuries at the time of the incident and no injuries observed post-incident. A progress note, dated 1/18/26 at 1:40 PM, indicated R2 had a faded bruised area on the left back rib cage with a scant amount of blood related to a recent fall. There was no further documentation of the area in R2's medical record. R2's Weekly Skin Check assessment forms indicated the following: ~11/19/25 at 9:00 AM: Skin Condition: intact, dry and fragile, no open areas ~11/25/25 at 10:00 PM: Right knee (front) scab present on admission; Back of head - bump; Skin Condition: intact, dry and fragile, abrasion/bruise; no open areas ~ 12/2/25 at 12:42 PM (effective date): Right knee (front) scab present on admission; Back of head - bump; Skin Condition: intact, dry and fragile, abrasion/bruise; no open areas ~ 12/9/25 at 12:42 PM (effective date): Skin Condition: intact, dry and fragile; no open areas ~ 12/16/25 at 12:41 PM (effective date): Skin Condition: intact, dry and fragile, abrasion/bruise; no open areas ~ 12/23/25 at 3:00 PM: Top of scalp purple bruise post fall injury; Skin Condition: intact, dry and fragile, abrasion/bruise; no open areas ~ 1/4/26 at 6:00 PM: Skin Condition: intact, dry and fragile; no open areas ~ 1/8/26 at 8:00 PM: Groin redness/rash; Skin Condition: intact, dry and fragile, rash; no open areas ~ 1/19/26 at 12:00 AM: Skin Condition: intact; Open Area not marked yes or no ~ 1/26/26 at 12:40 PM (effective date): Skin Condition: intact; no open areas ~ 2/3/26 at 4:00 PM: Skin Condition: intact; no open areas ~ 2/9/26 at 4:00 PM: Skin Condition: intact, dry and fragile; no open areas ~ 2/16/26 at 4:00 PM: Skin Condition: intact, dry and fragile; no open areas ~ 2/23/26 at 12:00 AM: Skin Condition: intact; Open Area not marked yes or no ~ 3/2/26 at 12:00 AM: Skin Condition: intact; Open Area not marked yes or no ~ 3/9/26 at 7:00 PM: Skin Condition: intact, dry and fragile; no open areas ~ 3/16/26 at 2:57 PM (effective date): Skin Condition: intact, dry and fragile; no open areas ~ 3/23/26 at 10:30 AM (effective date): Skin Condition: intact, dry and fragile; no open areas ~ 3/30/26 at 11:00 AM: Skin Condition: intact; no open areas On 3/30/26 at 11:26 AM, Surveyor interviewed Family Member (FM)-K who indicated FM-K observed R2's back on 2/5/26 and noted a U shaped mark on the left back rib cage. FM-K stated the mark appeared to be a bruise. On 3/31/26 at 2:50 PM, Surveyor interviewed DON-B and NHA-A. NHA-A stated staff would not document scar tissue on skin assessments. DON-B stated documentation depends on the area. DON-B showed Surveyor a photo of R2's left back that included a U shaped scar. There were no measurements of the scar. During an observation of cares by CNA-J on 3/31/26, Surveyor noted the U shaped scar was approximately one-inch wide and the U shaped line was approximately 1/8-inch thick. DON-B indicated the photo of R2's back was taken on 3/31/26 just prior to the interview. The facility did not have other photos to compare the current state of R2's scar and no measurements were obtained. When asked if DON-B should have identified the location and details on the Weekly Skin Check assessment forms DON-B completed, DON-B stated thoroughness would have been helpful. DON-B stated the information recorded on Weekly Skin Check assessment forms is obtained by using CNAs' observations of residents' skin during daily cares and on bath days and when nurses assess residents' skin. DON-B stated DON-B may not be able to assess all of a resident's skin during an assessment due to the resident's position. (Of note: There was no documentation that indicated the U shaped scar observed on R2's back was the impaired skin identified in the above mentioned progress note or in the Weekly Skin Check documentation; however, CNA-F regularly worked with R2 and stated the U shaped scar on R2's left back was the the same impaired skin that CNA-F noted was weeping in the past.)

Based on observation, staff interview, and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 2 residents (R) (R1 and R6) of 7 sampled residents.R1's care plan contained an intervention for the assistance of 2 staff and a manual stand assist lift for transfers. On 2/15/26, Registered Nurse (RN)-C transferred R1 without a second person which resulted in a fall.R6's care plan contained an intervention to use a pivot disc with transfers. On 3/31/26, Certified Nursing Assistant (CNA)-F transferred R6 with a Lumex (manual stand assist lift). R6 used a Lumex to transfer in the past but was not re-assessed for use of the lift. In addition, R6's care plan was not revised to reflect R6's current transfer status.Findings include:The facility's Fall Prevention Program policy, revised 10/1/25, indicates: Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care .The plan of care and Kardex will be revised as needed.The facility's Accidents and Supervision policy, last revised 10/8/24, indicates: Implementation of interventions using specific interventions to try to reduce a resident's risk from hazards in the environment .Documenting interventions (e.g., plans of action developed through the QAA Committee or care plans for the individual resident) .Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of Supervision: .b. Based on the individual resident's assessed needs and identified hazards in the resident environment.The facility's Comprehensive Care Plans policy, revised 5/1/25, indicates: It is the guideline of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs .The comprehensive care plan will be reviewed and revised by the Interdisciplinary Team after each Comprehensive and Quarterly Minimum Data Set (MDS) assessment.1. From 3/30/26 to 3/31/26, Surveyor reviewed R1's medical record. R1 had diagnoses including cerebral vascular accident and hemiplegia. R1's Minimum Data Set (MDS) assessment, dated 2/9/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition.A fall report, dated 2/15/26, indicated R1 was lowered to the ground during a transfer from chair to shower chair using a Lumex because R1 couldn't stand anymore.On 3/31/26 at 9:45 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated it appeared only one staff (RN-C) assisted R1 during the transfer on 2/15/26 when R1 fell. DON-B reviewed R1's Activities of Daily Living (ADL) self-care performance care plan (dated 2/11/26) that indicated R1 transferred with a Lumex and two staff. DON-B indicated there should have been two staff assisting with R1's transfer on 2/15/26.On 3/31/26 at 10:49 AM, Surveyor interviewed RN-C who verified RN-C transferred R1 without a second staff on 2/15/26 when R1 fell. RN-C stated RN-C thought R1 required the assistance of one staff for transfers and was in error if the care plan indicated otherwise.2. From 3/30/26 to 3/31/26, Surveyor reviewed R6's medical record. R6 had diagnoses including multiple sclerosis and cerebral vascular accident. R6's MDS assessment, dated 1/4/26, had a BIMS score of 7 out of 15 which indicated R6 had severely impaired cognition.R6's ADL self-care performance care plan, dated 2/11/26, indicated R6 transferred with a pivot disc and 1 staff.On 3/31/26 at 7:45 AM, Surveyor observed CNA-F transfer R6 from bed to wheelchair with a Lumex. R6 followed CNA-F's verbal cues to successfully transfer from bed to wheelchair.On 3/31/26 at 11:00 AM, Surveyor interviewed DON-B who indicated staff had used the Lumex with R6 for 4 years. DON-B reviewed R6's care plan and verified the care plan indicated R6 transferred with a pivot disc and the assistance of 1 staff. DON-B verified the care plan was incorrect. DON-B stated R6 received a new custom-fit wheelchair and had to use a pivot disc for transfers due to the size of the wheelchair. DON-B indicated R6 had since received a second wheelchair which allowed for use of the Lumex. DON-B could not find therapy notes that indicated R6 was re-assessed for use of the Lumex with transfers.On 3/31/26 at 12:15 PM, Surveyor interviewed Physical Therapy Assistant (PTA)-I who was not sure how R6 transferred and did not have access to therapy notes.On 3/31/26 at 12:18 PM, Nursing Home Administrator (NHA)-A provided physical therapy notes (dated 12/2/25) that indicated a pivot disc for transfers would be trialed on 12/2/25 related to a feature on R6's custom fit wheelchair that did not allow the Lumex to fit under the wheelchair for toilet transfers. Therapy notes (dated 12/2/25) indicated prior to trial of the pivot disc, R6 used a Lumex to transfer to the toilet. Discharge recommendations on 12/11/25 indicated to continue with the pivot disc for toilet transfers.

Based on observation, staff interview and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 1 resident (R) (R3) of 1 sampled resident.R3 was on enhanced barrier precautions (EBP) due to carbapenem-resistant Pseudomonas aeruginosa (CRPA) colonization. Certified Nursing Assistant (CNA)-D and Nursing Home Administrator (NHA)-A did not wear a gown or gloves while transferring R3 from bed to wheelchair with a mechanical lift.Findings include:The facility's Enhanced Barrier Precautions policy, revised 9/9/25, indicates: EBP refer to an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high-contact resident care activities .High-contact resident care activities include: a. dressing; b. bathing; c. transferring; d. providing hygiene; e. changing linens .EBP should be followed outside the resident's room when performing transfers .examples of MDROs targeted by the Centers for Disease Control and Prevention (CDC) include: .c. carbapenemase-producing carbapenem-resistant Pseudomonas aeruginosa .From 3/30/26 to 3/31/26, Surveyor reviewed R3's medical record. R3 had a diagnosis of stroke with hemiplegia. R3's Minimum Data Set (MDS) assessment, dated 2/20/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R3's cognition was intact.A care plan, dated 2/18/26, indicated R3 had CRPA colonization. The care plan contained an intervention to observe EBP for infection control.On 3/30/26 at 1:17 PM, Surveyor observed an EBP sign on R3's door and a personal protective equipment (PPE) next to R3's room. Surveyor observed CNA-D enter R3's room without donning a gown or gloves and attach a lift sling to a mechanical lift. NHA-A then entered the room without donning a gown or gloves. NHA-A operated the mechanical lift while CNA-D held onto R3 in the sling to maneuver R3 toward a wheelchair. NHA-A held R3's leg to prevent it from hitting the lift while CNA-D positioned the wheelchair underneath R3. CNA-D guided R3 into the wheelchair while NHA-A operated the lift. NHA-A sanitized the lift while CNA-D gave R3 a hat and made R3's bed. NHA-A wheeled the lift out of the room.On 3/30/26 at 1:27 PM, Surveyor interviewed NHA-A who indicated neither NHA-A or CNA-D needed to observe EBP during the transfer because NHA-A and CNA-D did not provide direct care to R3.On 3/30/26 at 1:30 PM, Surveyor interviewed CNA-D who indicated CNA-D did not need to wear a gown or gloves during the transfer because CNA-D did not provide direct care to R3.On 3/30/26 at 2:00 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated DON-B was told EBP was only required for direct care of residents which did not include transfers.

Based on staff and resident representative interview and record review, the facility did not notify a Power of Attorney for Healthcare (POAHC) of a change in condition for 1 resident (R) (R1) of 1 sampled resident. R1 had bruising on the legs and buttocks from multiple falls and behaviors. R1's POAHC (POAHC-E) was not notified of the injuries. Findings include: The facility's Notification of Changes policy, dated August 2024, indicates: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification .The facility must inform the resident, consult with the resident's physician, and or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: 1. Accidents: a. Resulting in injury . On 5/13/25, Surveyor reviewed R1's medical record. R1 had diagnoses including nontraumatic subarachnoid hemorrhage, Lewy body dementia, depression, and history of falls. R1's Minimum Data Set (MDS) assessment, dated 4/13/25, had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated R1 was severely cognitively impaired. R1 had an activated POAHC for healthcare decisions. R1's medical record contained the following progress notes: ~ A progress note, dated 3/31/25 at 8:38 AM, indicated R1 had a small bruise bruise on the right outer buttock by the hip possibly from a fall on 3/28/25. The note did not indicate POAHC-E was notified. ~ A progress note, dated 3/31/25 at 10:44 AM and written by Director of Nursing (DON)-B, indicated new orders were received. POAHC-E was updated on R1's behaviors and would come sit with R1 in a of couple hours. The note did not indicate POAHC-E was notified of the bruising. ~ A progress note, dated 4/1/25 at 4:45 AM, indicated R1 was found on the floor next to R1's bed. R1 hit, pinched, and kicked staff. R1 was assisted off the floor by two staff and refused the Hoyer lift. R1 had a large bruise on the right hip with minimal swelling. The physician was updated via fax. The note indicated staff would update POAHC-E in the morning because POAHC-E requested not to be called again that night. The note did not indicate POAHC-E was notified of the bruising. Surveyor reviewed R1's fall investigations and skin assessments. A skin assessment completed on 3/31/25 as well as a fall investigation and skin assessment completed on 4/1/25 indicated the bruising was consistent with multiple falls and behaviors. POAHC-E was not notified of the bruising. On 5/13/25 at 10:11 AM, Surveyor interviewed POAHC-E who was not aware of R1's bruises until R1 was sent to the emergency room (ER) on 4/13/25 where POAHC-E observed the bruising. POAHC-E was updated by the facility regarding R1's most recent falls on 3/29/25, 3/31/25, 4/1/25, and 4/13/25. POAHC-E was not notified of the bruising on R1's buttocks and legs which were in various stages of healing. POAHC-E indicated they were distressed that they were not notified of the injuries. POAHC-E was with R1 at the ER following the fall on 3/31/25 and stated bruising was not present at that time. On 5/13/25 at 2:21 PM, Surveyor interviewed DON-B who thought nursing staff were going to update POAHC-E. DON-B reviewed R1's medical record and found no documentation that indicated POAHC-E was notified of the bruising. DON-B confirmed DON-B did not notify POAHC-E of the bruising on 4/1/25. DON-B confirmed the facility did not have documentation that indicated POAHC-E was notified of the injuries R1 sustained from multiple falls.

Based on observation, staff interview, and record review, the facility did not ensure the accurate administration of medication for 1 resident (R) (R7) of 13 sampled residents. R7 had an admission order to hold clopidogrel (Plavix) prior to an appointment to have a urinary stent removed. The facility missed the appointment and the order to hold medication on R7's discharge instructions and After Visit Summary (AVS) from the hospital. Findings include: On 5/14/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including acute kidney injury, bladder cancer, complicated urinary tract infection (UTI), and atrial fibrillation. R7's Minimum Data Set (MDS) assessment, dated 3/31/25, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R7 was not cognitively impaired. R7 discharged from the facility on 3/31/25. Surveyor reviewed R7's Discharge Summary and After Visit Summary (AVS) from R7's hospital stay prior to admission. Surveyor noted the AVS, dated 3/26/25, was scanned into R7's medical record on 3/26/25. The AVS indicated R7 should follow-up with the urologist for stent removal on 4/1/25 and the oncologist and nephrologist. R1 should follow-up with Physician (PH)-C in 1 week. The Discharge Summary contained an order to stop Plavix on 3/29/25 pending stent removal. Surveyor reviewed R7's Medication Administration Record (MAR) and noted an order for clopidogrel bisulfate (Plavix) oral tablet 75 milligrams (mg) give 1 tablet by mouth one time a day for (atrial fibrillation). The MAR indicated R7 received the medication from 3/27/25 through R7's discharge on 3/31/25. The medication was not stopped on 3/29/25 per the order on R7's hospital Discharge Summary. Surveyor noted R7's medical record did not indicate R7 had a stent removal appointment on 4/1/25. On 5/14/25 at 1:45 PM, Surveyor interviewed Admissions Director (AD)-D who confirmed the stent removal appointment and hold medication order were missed. AD-D indicated AD-D usually gets paperwork from the hospital and can access the hospital's system. AD-D indicated AD-D did not see the appointment or medication hold and stated Director of Nursing (DON)-B (who confirms the orders) did not see a paper copy of the orders. AD-D indicated when the facility realized the error, they changed their process to ensure all nurses see a paper copy of scanned items so nothing is missed. AD-D indicated the education was a conversation between staff and there was no signed documentation of the education. On 5/14/25 at 1:41 PM, Surveyor interviewed DON-B who confirmed R7's appointment and Plavix hold order were missed on R7's admission orders. DON-B indicated DON-B did not know about the appointment until R7's family indicated to staff that R7 had an appointment. DON-B indicated some of R7's paperwork was scanned into R7's medical record without DON-B seeing a paper copy of it. DON-B indicated the facility changed their process as a result of the error to ensure AD-D makes paper copies of all scanned admission records so DON-B and the nurses see them. DON-B confirmed the education was a conversation between a few staff and indicated formal education was not completed.

Based on observation, staff and resident representative interview, and record review, the facility did not ensure fall interventions were implemented for 1 resident (R) (R1) of 3 sampled residents. R1 had a history of falls and sustained multiple falls in the facility. The facility did not implement fall interventions or safety measures to prevent future falls or injury. Findings include: The facility's Fall Reduction Policy, revised 7/1/19, indicates: Purpose: To provide an environment that remains as free of accident hazards as possible. To identify residents who are at risk for falling and to develop appropriate interventions to provide supervision and assistive devices to prevent or minimize fall related injuries .to promote a systematic approach and monitoring process for the care of residents who have fallen and/or those who are determined to be at risk .2. Each resident will be evaluated for risk of falls using a fall risk upon admission, readmission, upon a significant change of condition, quarterly, and following each fall. 3. Residents with a a fall risk assessment score greater than 10 should be considered at high risk for falling. 4. Identified risk factors should be discussed in documentation and addressed in the resident's care plan to assure individualized interventions to reduce the risks are implemented. 5. Residents identified to be at high risk for falling along with interventions to manage that risk will be communicated to caregivers via the care planning process .7. Document in the clinical record a summary of the fall including, but not limited to, assessment, intervention, and resident response .12. The care plan should be reviewed after every fall and updated with a new intervention, when applicable. On 5/13/25, Surveyor reviewed R1's medical record. R1 had diagnoses including nontraumatic subarachnoid hemorrhage, Lewy body dementia, depression, and history of falls. R1's Minimum Data Set (MDS) assessment, dated 4/13/25, had a Brief Interview for Mental Status (BIMS) score of 0 out of 10 which indicated R1 was severely cognitively impaired. R1 had an activated Power of Attorney for Healthcare (POAHC). R1's medical record indicated R1 was admitted to the facility for rehabilitation due to a fall from a standing position that resulted in a traumatic subdural hemorrhage. R1 was assessed for falls risk on 3/22/25 with a score of 15 which indicated R1 was at high risk for falls. R1's baseline care plan, initiated on 3/21/24, indicated R1 was confused, incontinent of bowel and bladder, independent with transferring and bed mobility, and required assistance with ambulation. Surveyor noted R1's baseline care plan did not contain any falls interventions. R1's comprehensive care plan did not contain any fall interventions until 3/28/25. R1's medical record indicated R1 fell at the facility on 3/22/25 (two falls), 3/23/25, 3/29/25, 3/31/25, 4/1/25, and 4/13/25. Surveyor reviewed R1's fall investigations and noted the following: ~ R1 had an unwitnessed fall on 3/22/25 at 9:30 PM. R1 was found sitting on the floor and got R1's self up from the floor. ~ R1 had an unwitnessed fall on 3/22/25 at 11:30 PM. R1 was found rolling on the floor and got R1's self up from the floor. ~ R1 had an unwitnessed fall on 3/23/25 at 12:15 AM. R1 was found crawling on the floor and got R1's self up from the floor. Surveyor noted there were no fall interventions or safety measures implemented to prevent injury or future falls after R1's falls on 3/22/25 and 3/23/25. A fall investigation indicated R1 was seen in the emergency room (ER) on 3/23/25 at 1:00 PM per POAHC-E's request. R1 was admitted to the hospital and diagnosed with gallstones. R1 returned to the facility on [DATE]. On 5/13/25 at 10:11 AM, Surveyor interviewed POAHC-E who indicated R1 had a history of falls and was diagnosed with a nontraumatic subarachnoid hemorrhage and admitted to facility for rehabilitation. POAHC-E expressed concern that fall interventions and safety measures were not added to R1's care plan upon admission despite R1's history of falls with injuries. POAHC-E indicated R1 had several falls at the facility but no new interventions were discussed or added to R1's care plan until after the fall on 3/28/25. POAHC-E indicated R1 had multiple falls shortly after admission to the facility but was not assessed by a physician until POAHC-E requested R1 be seen in theER on [DATE] due to R1's history of falls with hemorrhage. POAHC-E stated falls may have been prevented if fall interventions were implemented upon admission. On 5/13/25 at 2:21 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated R1 was placed on 15-minute checks following the first fall on 3/22/25 and indicated all new admissions are put on 15-minute checks for the first 72 hours. DON-B verified 15-minute checks were not an individualized fall intervention for R1 and confirmed fall interventions were not implemented for R1 upon admission. DON-B reviewed R1's medical record and confirmed there were no fall interventions implemented for R1 following multiple falls. DON-B also verified R1's baseline care plan did not contain fall interventions in accordance with the facility's policy.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 52 residents residing in the facility. Staff did not monitor or document cooked food temperatures. Staff did not test or document parts per million (PPM) of the quaternary sanitizing solution per manufacturer's instructions. Food items were not discarded when beyond their expiration or use-by dates and/or not stored in a manner to prevent cross-contamination. Staff did not complete appropriate hand hygiene during meal service. Cold food items were not maintained at a proper temperature during meal service. Findings include: On 1/26/25 at 11:40 AM, Surveyor interviewed Dietary Manager (DM)-N who stated the facility follows the State and Federal Food Codes. Food Temperatures: The 2022 Food and Drug Administration (FDA) Food Code documents at 3-401.11 Raw Animal Foods: Raw animal foods such as eggs, fish, meat, poultry, and foods containing these raw animal foods, shall be cooked to heat all parts of the food to a temperature and for a time that complies with one of the following methods based on the food that is being cooked. The 2022 FDA Food Code documents at 2-103.11 Person in Charge: The person in charge shall ensure that: (G) employees are properly cooking time/temperature control for safety food, being particularly careful in cooking those foods known to cause severe foodborne illness and death, such as eggs and comminuted meats, through daily oversight of employees' routine monitoring of the cooking temperatures using appropriate temperature measuring devices properly scaled and calibrated. The facility's Food Preparation and Storage policy, dated October 2021, indicates food and nutrition service employees shall prepare and serve food in a manner that complies with safe food handling practices .(7) The internal cooking temperatures/times for specific foods must be reached to kill or sufficiently inactivate pathogenic microorganisms. The facility's Meal Service-Temperatures policy, dated 2/23/17, indicates to ensure appropriate food temperatures during meal service .(1) The cook shall take temperatures of food (as appropriate) during meal preparation to ensure food is cooked or chilled to the appropriate temperature .(2) Temperatures shall be recorded on the Temperature Report Form or directly on a copy of the week-at-a-glance menu at each meal. On 1/26/25 at 11:40 AM, Surveyor completed an initial tour of the kitchen with DM-N. During the initial tour, DM-N confirmed kitchen staff complete one set of temperatures prior to meal service but do not consistently monitor or document cooking temperatures. DM-N stated DM-N became aware of the requirement last week while at a conference. DM-N stated DM-N was in the process of creating a procedure but had not done so yet. Sanitizing Bucket Logs: The 2022 FDA Food Code documents at 2-103.11 Person in Charge: The person in charge shall ensure that .(L) Employees are properly sanitizing cleaned multi-use equipment and utensils before they are reused, through routine monitoring of solution temperature and exposure time for hot water sanitizing, and chemical concentration, ph, temperature, and exposure time for chemical sanitizing. The 2022 FDA Food Code 2022 documents at 3-304.14 Wiping Cloths, Use Limitation: (B) Cloths in use for wiping counters and other equipment surfaces shall be: (1) Held between uses in a chemical sanitizer solution at a concentration specified. The 2022 FDA Food Code documents at 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration: Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. The facility did not provide a policy related to monitoring chemical sanitizing solutions. On 1/26/25 at 11:40 AM, Surveyor completed an initial tour of the kitchen with DM-N. During the initial tour, DM-N stated kitchen staff do not use test strips to test the sanitizing solution in the sanitizing buckets (per the manufacturer's instructions). DM-N stated DM-N became aware of the requirement last week while at a conference. DM-N stated DM-N was in the process of creating a procedure but had not done so yet. Food Labeling/Storage: The 2022 FDA Food Code documents at Manufacturer's Use-By Dates: The manufacturer's use-by date is its recommendation for using the product while its quality is at its best. Although it is a guide for quality, it could be based on food safety reasons. It is recommended that food establishments consider the manufacturer's information as good guidance to follow to maintain the quality (taste, smell, and appearance) and salability of the product. If the product becomes inferior quality-wise due to time in storage, it is possible that safety concerns are not far behind. The facility's Food Receiving and Storage policy, revised October 2022, indicates: Food shall be received and stored in a manner that complies with safe food handling practices .(7) Dry foods are stored in bins and removed from the original packaging, labeled, and dated (use by date) .(8) All foods in the refrigerator or freezer are covered, labeled, and dated (use-by date). On 1/26/25 at 11:40 AM, Surveyor completed an initial tour of the kitchen with DM-N. During the initial tour, Surveyor noted the following: Dry Storage: ~ An open, uncovered, and unsealed box of thickening powder that was exposed to air Refrigerator: ~ Two open containers of sour cream with open dates of 12/10/24 and manufacturer's use-by dates of 1/16/25 ~ Sixteen 1 quart containers of heavy cream with manufacturer's use-by dates of 1/11/25 During the observations, Surveyor interviewed DM-N who stated the facility does not use use-by dates unless they are manufacturer's use-by dates. DM-N indicated kitchen staff puts stickers on items when they come in and write the date on the item when it is opened. DM-N stated staff refer to the Food Storage and Retention Guide for use-by dates. DM-N indicated DM-N intended to throw out the heavy cream containers the previous day but forgot. DM-N removed the heavy cream and sour cream containers during the tour and instructed staff to discard them. On 1/26/25 at 11:40 AM, Surveyor reviewed the facility's undated Food Storage and Retention Guide that indicated sour cream should be stored in the refrigerator and discarded per the manufacture's use-by date. Surveyor noted heavy cream was not listed in the guide. Hand Hygiene: The 2022 FDA Food Code documents at 2-301.14 When to Wash: Employees shall clean their hands and exposed portions of their arms as specified under 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms .(D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue .(E) After handling soiled equipment or utensils; (F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; .(H) Before donning gloves to initiate a task that involves working with food; and (I) After engaging in other activities that contaminate the hands. The facility's Food Preparation and Service policy, revised October 2021, indicates food and nutrition service employees shall prepare and serve food in a manner that complies with safe food handling practices .(22) Bare hand contact with food is prohibited. Gloves must be worn when handling food directly, however, gloves can also become contaminated and/or soiled and must be changed between tasks. Disposable gloves are single-use items and shall be discarded after each use. On 1/27/25 at 11:33 AM, Surveyor observed [NAME] (CK)-O complete lunch tray line service in the main kitchen. While CK-O served food with gloved hands, Surveyor observed CK-O touch the handles of food utensils, the top of a tray cart, and a countertop. With the same gloved hands, Surveyor also observed CK-O touch ready-to-eat buns on 18 occasions. CK-O also pulled up the waistband of CK-O's pants and touched 4 buns with the same gloved hands. CK-O then asked DM-N for a towel to wipe a food substance off the thumb of CK-O's glove. DM-N provided CK-O with a paper towel. CK-O wipe food debris from CK-O's gloved thumb and continued to serve buns on 7 trays. Surveyor did not observe CK-O change gloves or complete hand hygiene during meal service. Also during lunch service, Surveyor observed Dietary Aide (DA)-P provide tray line assistance with gloved hands and noted DA-P touched the nose/brim of DA-P's glasses and mouth. DA-P then touched trays and residents' plates without completing hand hygiene. DA-P also put carrots from a resident's plate back in a steam table container with DA-P's gloved hand. Without completing hand hygiene, DA-P removed the glove and donned a clean glove. Surveyor also observed DA-P run DA-P's gloved hands along the wheels of the tray line conveyor and then touch buns, plates, and utensils on residents' trays without completing hand hygiene. On 1/28/25 at 2:01 PM, Surveyor reviewed the above concerns with DM-N who verified Surveyor's observations and concerns. Cold Food Temperatures: The 2022 FDA Food code documents at 3-501.16 Time/Temperature Control for Safety Food, for Hot and Cold Holding: Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature danger zone of 41 degrees Fahrenheit (F) to 135 degrees F too long. Up to a point, the rate of growth increases with an increase in temperature within this zone. Beyond the upper limit of the optimal temperature range for a particular organism, the rate of growth decreases. Operations requiring heating or cooling of food should be performed as rapidly as possible to avoid the possibility of bacterial growth (A) Except during preparation, cooking, or cooling, or when time is used as the public health control .(1) At 135 degrees F or above or (2) At 41 degrees F or less. The facility's Food Preparation and Service policy, revised October 2021, indicates food and nutrition service employees shall prepare and serve food in a manner that complies with safe food handling practices .Food Preparation, Cooking and Holding Temperatures and Times: (1) The danger zone for food temperatures is between 41 degrees F and 135 degrees F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. (2) Potentially hazardous foods include meats, poultry, seafood, cut melon, eggs, milk, yogurt and cheese. (3) The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. On 1/27/25 at 11:33 AM, Surveyor observed lunch service. Upon entering the kitchen, Surveyor observed butterscotch pudding with whipped topping stacked in a meal cart ready for service. Surveyor noted the holding temperature was 54.1 degrees F at the beginning of tray line service. Surveyor requested DM-N recheck the temperature at the end of service which was 60.8 degrees F at 12:43 PM. DM-N acknowledged the temperature should be at 41 degrees F or less. Following the observation, Surveyor observed the ingredients on a can of [NAME] Creek Butterscotch Pudding which included skim milk. Information on the can stated to refrigerate the contents in a separate container after opening. Surveyor also observed the ingredients on a container of Rich's On Top Whipped Topping which included cream and skim milk. The package indicated the product was perishable and to keep refrigerated.

Based on observations, staff and family interviews and record reviews the facility did not consistently incorporate aggressive measures to ensure 1 of 6 residents (R4) reviewed for weight loss, maintained acceptable parameters of nutrition. R4 experienced a 6.13% weight loss in one month. The facility did not identify R4's eating habits, provide snacks in between meals or complete a reassessment following the significant weight loss resulting in an additional 6% weight loss the following month. This is evidenced by: R4 was admitted to the facility on [DATE]. Medical diagnoses include, but are not limited to Alzheimer's Dementia, [MEDICAL CONDITION] Reflux Disorder (GERD), Sleep Disorder, and a recent hospitalization (6/14/17) for Urinary Tract Infection [MEDICAL CONDITION]. There is no [DIAGNOSES REDACTED]. RECORD REVIEW: 1. R4 was admitted to the facility with an initial weight of 172.8 pounds (lb) dated 5/3/17. Following is a list of the documented weights of R4 with interventions added in parenthesis: 5/3/17: 172.8 5/6/17: 168.6 (5/1/17 regular diet) 5/9/17: 175 5/16/17, 5/22/17 and 5/29/17: 173 6/5/17: 162.2 Note: This is a 6.13% weight loss in 1 month with no changes made to improve R4's intakes. 6/12/17: 162 6/16/17 (following R4's return from the hospital, the diet was Heart Healthy with fortified foods) 6/20/17: 160 6/22/17 portion size was changed to small 6/28/17 the diet was changed to regular/liberalized with fortified foods. Supplement 2.0, 4 ounces twice daily was added 6/30/17 [MEDICATION NAME] was added, 25 milligrams (mg) daily for 14 days then to increase to 50 mg daily. 7/3/17: 151.9 Note: Resident experienced a 6.3% weight loss in this 30-day period resulting in a 12% weight loss from admission. Beginning on 7/17/17, the facility added between meal snacks, three times daily and to assist R4 with her meals (7/20/17). 2. Physician Visits: The initial Physician Dictation for R4 was dated 5/30/17. This was an Introductory Visit note for the admission of R4 to the facility. Included in this dictation is the following information: ~ Feeds herself but snacks frequent small meals. Does not eat much of any one organized meal; ~ Has a day/night reversal. Likes to sleep during the day and up at night; Note: This was not incorporated into R4's plan of care. The next Physician visit was dated 6/29/17 and includes the following information: ~ Recent hospitalization [MEDICAL CONDITION] event with a rather fast bounce back ~ Suspicious of a portal in the Gastrointestinal tract and a possible hidden tumor. (This has never been verified.) 3. Nutritional: Nutritional History-admitted d 5/9/17: 1. Shakes with lunch and supper 2. Likes corn flakes, dislikes hot cereal 3. Meals in the dining room, requires assistance Nutritional assessment dated [DATE], following hospitalization [DATE] - 6/16/17: 1. Diet is Heart Healthy with fortified foods at breakfast and lunch (ordered from the hospitalization ) 2. Poor intakes 3. Significant weight changes of 13 pounds in one month, unplanned 4. Recommend diet be changed to Regular, continue fortified foods for breakfast and lunch. Meal portions will be changed to small, continue to provide encouragement and assistance. Start 4 oz of the 2.0 Med Pass Supplement twice daily. 4. Minimum Data Set Assessments (MDSA's): R4's admission Minimum Data Set Assessment (MDSA) dated 5/8/17 and the most recent quarterly assessment dated [DATE] indicated that R4 requires only supervision and set-up for meals. She has no behaviors coded on these assessments. Admission MDS indicates in Section F0400 (D) Interview for Daily Preferences that snacks between meals are very important to her. 5. Interdisciplinary Team Progress Notes: ~ 5/4/17- Says no to everything, verbal encouragement needed for tasks, staff to continue to encourage Note: Much of the charting from this time period until 5/26/17 is that of R4 refusing therapies, meals, getting out of bed or taking medications. ~ 5/26/17- Daughter tells staff to tell resident, It's part of the curriculum. ~ 6/14/17- hospitalized for [REDACTED]. ~ 6/27/17- the request for diet change and addition of supplement was approved by the Nurse Practitioner ~ 7/17/17- Nutritional note: significant 10.3 pound (lb) weight loss over past month. Current weight 151.7; weight one month ago was 162. Has had 21.3 lb loss over past 2 months. Diet revised in June with addition of supplement and fortified foods. Antidepressant added 6/29/17. Continues to dine in her room with assistance provided. Staff to continue to encourage meals and fluids encouraged throughout the day. ~ 7/18/17- Facsimile sent to Physician regarding weight loss ~ 7/20/17- Weight of 7/18 indicates 2.2 lb loss since 7/10. Rechecked today, was 149.7 lb, 2 lb loss. Additional supplements between meals initiated on 7/18, staff providing assistance with meals. Physician with no further recommendations. Note: Survey Team observed supplement being provided on 7/20/17 mid-morning snack pass. 5. Care Plans: Date of Initiation is 5/15/17: A. Potential for nutritional problem related to decreased appetite at meals, snacking and history of GERD. Approaches: a Provide regular diet with thin liquids, fortified foods each meal. Supplements have been offered and refused (Revised 7/18/17). b. Needs a calm, quiet setting at meal times with adequate eating time. Eats meals in room. Prefers to nibble and snacks provided by family (Revised 7/18/17). c. Weigh per facility policy (Revised 7/18/17). On 7/18/17, the Unit Manager hand wrote the following intervention: Attempt to assist at meals as resident will allow. Be aware that resident often refuses assistance with meals. B. Activities of Daily Living (ADL's) Self Care Performance Deficit related to dementia .poor motivation. (Initiated 5/15/17): Included in the interventions for ADL's is the following statement: Be aware, will often respond no to requests to complete ADL's, will usually cooperate if told This is what's on the curriculum. (Initiated 5/23/17). 6. Meal Intakes: The meal intakes for R4 were reviewed by Surveyor and the following was noted since R4's admission to the facility: May, 2017: There were a total of 92 meals offered (3 meals per day for 31 days with the exception of 5/1 breakfast, as this was admission day). R4's initial intakes for May 1-15 were fairly stable at 25-100% and a noted decline was evident 5/22 with intakes: 0% intakes were recorded for 36 meals 25% was recorded for 33 meals 50% for 12 meals 75% for 4 meals 100% for 4 meals 3 meals were not recorded June 2017: There were 82 meals total as R4 was in the hospital 6/14/17 through 6/16/17. 0% solid intakes documented for 62 meals 25% solid intakes documented for 16 meals 50% solid intakes for 3 meals 1 meal was not documented. July 2017: A total of 58 meals were calculated (7/1 - 7/20 breakfast): 0% solid intakes was documented for 46 meals 25% intake for 8 meals 50% intake for 1 meal 1 meal was documented as 6 bites, and two meals were documented as bites OBSERVATIONS/INTERVIEWS: 1. 7/17/17 at 9:15 a.m., during the initial tour of the facility, Surveyor observed R4 in her room, in bed with the head of the bed elevated to approximately 90 degrees. The over the bed table was in front of R4 with the meal tray containing scrambled eggs and a cinnamon roll. The meal appeared to be untouched and R4 was asleep with her head down leaning toward her left shoulder. There were no staff in the room encouraging R4 to eat. At 10:20 a.m., the meal tray was removed but R4 remained in bed as previously noted and the tray table was still in front of her. 2. On 7/17/17 R4 received her meal tray at 12:29 p.m. by the Clinical Manager of the Unit. The resident remained as noted above, on her back at 90 degrees. The meal consisted of roast pork, mashed potatoes with gravy, broccoli and a cherry cobbler dessert. She also was delivered 8 ounces (oz) of whole milk. At 1:35 p.m., CNA-E (Certified Nursing Assistant) and LPN-F (Licensed Practical Nurse) entered the room to reposition R4. Surveyor followed the two staff into the room. R4 had consumed all of her milk and one bite of broccoli. The tray was removed. No staff had entered the room during this meal to encourage or assist R4 with her meal. No alternatives were encouraged or offered. Between 1:35 p.m. and 2:50 p.m., no snacks or beverages were offered to R4. At 2:50 p.m., CNA-G and CNA-H entered R4's room. The two staff completed an incontinence check but did not offer water, juice or any substantial snack to R4. At 3:02 p.m., the snacks were delivered to the Unit. There were 9 snacks on the tray, each assigned to specific residents. There were no snacks assigned to R4. At 3:23 p.m., Surveyor approached CNA-G and asked her if she was informed of any resident on her unit that did not take lunch. CNA-G responded that she was not informed of any resident not eating today. At 4:02 p.m., Surveyor approached the evening shift nurse, LPN-J and asked her if she knows of any residents on her unit that did not eat lunch on this day. LPN-J stated she was not informed in report of any residents on her unit that did not eat today. The Surveyor then asked LPN-J what procedure she would follow had it been reported to her that a resident did not eat. LPN-J stated, I would first determine why the resident did not eat and then ensure a snack was provided. Often CNA staff will say that the resident refused, but I would tell them to continue to encourage a snack. But today, no. No reports today of anyone not eating. At 4:40 p.m. Surveyor approached CNA-H. The Surveyor asked her if anyone reported any resident not eating lunch today. CNA-H stated she knew there was someone that didn't eat but could not recall who it was and she thought it was someone other than R4, as she mentioned the name of R 14. At 5:02 p.m., LPN-J entered R4's room to administer medications. Along with the medications, LPN-J gave R4 4 oz of a health shake, which she accepted. Between 2:50 p.m. and 5:02 p.m., no staff entered R4's room to offer or encourage a substantial snack or beverage. 3. On 7/18/17 R4 received her meal at 8:06 a.m. by CNA-K. It consisted of scrambled eggs, 1 slice of toast with grape jelly and a bowl of corn flakes. The liquids consisted of an 8 oz carton of whole milk and coffee. CNA-K added about 4 oz of milk to the cereal as well as a packet of sugar and also spread the jelly over the toast. She then left the room. From 8:06 a.m. - 8:44 a.m., no staff had yet entered R4's room to encourage or assist her to eat or offer alternatives. At 8:44 a.m., CNA-M entered R4's room and asked her, Are you going to eat any more? The resident replied, No and CNA-M removed the meal tray. At 9:12 a.m., Family-U entered R4's room. A brief interview was conducted. Family-U stated they noticed a dramatic change in R4 upon her move from a previous facility, which had closed down. She stated R4 was much more mobile and independent and now requires total assistance with everything. She stated that R4 had lost 10 pounds during the June UTI [MEDICAL CONDITION] and that it's been downhill ever since. Family-U stated that she was very disappointed in the decreasing weights. She informed the Surveyor that R4 will say no to everything and people need to be a little more aggressive with mom . Family-U also stated the facility was informed of this when R4 was admitted . Family-U was informed of the observations made by the Surveyor and asked if R4 would get angry at attempts of assistance. Family-U stated that R4 does not like help with eating but that her expectation is that staff make an attempt. She stated, If you see that mom isn't eating you should at least encourage her to eat. I'm very disappointed. During continued observations no staff had entered to offer snacks to R4. At 10:00 a.m., snacks arrived on the unit. There were two snacks assigned to residents. R4 received a cup of coffee for her mid-morning snack. At 11:16 a.m., Surveyor approached LPN-P, R4's nurse for this dayshift. The Surveyor asked LPN-P if anyone reported any residents on her unit with no morning intake. LPN-P stated, No, not anything out of the normal. Not anyone today. At 11:06 a.m., the Nursing Home Administrator entered the room and placed two fun-size 3 Muskateer candy bars on R4's over the bed table, in front of her. She then left the room. No other snacks were provided to R4 At 11:29 a.m., Family-U returned to visit R4. R4 was served her meal at 12:04 p.m. by CNA-K. The meal consisted of Salisbury Steak with gravy, mashed potatoes with gravy, Brussels sprouts, one slice of bread and lemon pudding. The fluids on the tray were 8 oz whole milk and coffee. Family-U remained in the room during the mealtime and encouraged R4 to eat while reading to her. At 12:20 p.m. the meal tray was removed. Family-U stated, With encouragement, she has taken a few bites and drank nearly all her milk, about 3/4 of it. At 3:25 p.m., the snacks arrived on the unit from kitchen staff. There were none provided for R4. Surveyor approached the three staff at the desk (CNA-R, CNA-S and LPN-Q), each reviewing papers. The Surveyor asked the three staff if they received report from the day shift of any residents on the unit that did not eat well today. Each indicated that they received no reports of R4 not eating. At 3:45 p.m., Surveyor approached the Clinical Manager for R4's unit and asked her what the expectation is of staff when a resident does not eat. The Clinical Manager stated staff are to encourage and assist with meals, give extra fluids or offer snacks in between meals, and to notify the nurse. The nurse then informs the Registered Dietician, who then monitors weights, contacts the doctor and orders supplements. The Clinical Manager stated R4 has been poorly motivated with meals since admitted . Initially R4 was eating in the assisted dining room, would take two bites, then leave. Since then, her meals have been served in her room. At 4:05 p.m., Surveyor approached the Staff Development Coordinator (SDC) on what she teaches to staff in regards to resident low intakes with meals. The SDC stated she teaches staff to continually reproach the resident and try to get them to eat. She stated any intakes of 0-25% are to be reported to the nurse, so they in turn can offer a snack and investigate the cause of the low intake. On 7/19/17 at 9:14 a.m., Surveyor met with the NHA and Clinical Manager to discuss R4 and her intakes and interventions the facility has attempted. The NHA stated R4 was initially served meals in the assisted dining room, but would often refuse. The facility then changed the meal service to R4's room. They indicated R4 refuses meals and medications frequently. It was then placed on R4's care plan for staff to state, It's part of the curriculum as R4 has a Masters in Education and responds well to authority and higher education. They stated this approach is sometimes effective. The NHA stated R4's Physician was notified on 5/30/17 of the decreasing intakes and completed an oral exam, which found no issues, and the family desired nonaggressive care. The Physician again saw R4 on 6/29/17 and noted no chewing or swallowing issues. The NHA stated at that time, the Physician thought there might be a hidden tumor, but this was not verified. The NHA stated there was no Speech Therapy evaluation ordered or conducted. The resident was receiving Occupational Therapy for functional abilities for feeding herself, but R4 had refused that as well. [MEDICATION NAME] was then added to R4's medication regimen. At 9:40 a.m., Surveyor met with the Social Worker (SW) regarding R4. The SW stated she met with R4's Power of Attorney (POA) /daughter , Family-T several times to discuss Comfort Cares. She stated Family-T is not ready for Comfort Cares for R4. She stated R4 likes authority and occasionally will be responsive to authority. At 10:10 a.m., Surveyor observed CNA-K complete morning cares on R4. CNA K used It's part of the curriculum today on R4. At 12:15 p.m., Family-T visited R4. Surveyor interviewed Family-T regarding previous functional abilities and current abilities. Family-T stated prior to 5/1/17 (admission), R4 was rather independent, self transferring from bed to wheelchair and vice versa. She stated R4 resided on the Dementia Unit in the previous facility and would go into the dining room, eat a few bites, then propel herself back to her room, crawl in bed and rest. She would then get back up and propel herself back to the dining room, eat three bites and go back to her room. Family-T stated that R4 repeated this several times, and the previous facility staff were aware of R4's habits and kept her meal trays on the table until the majority of the meal was eaten and R4 indicated she was finished. Family-T stated since being in this facility, this practice was not observed. She stated, historically, if R4 ate a good breakfast, she would just pick at lunch and supper, but did eat snacks that the family brought in, throughout the day. Family-T stated that R4 always has needed strong encouragement to eat, that she respects authority, and that she has given this facility that information when R4 was admitted . Family-T also stated that R4 drinks 3-4 milks per meal, sometimes white and sometimes chocolate, and that she also likes ice cream and juices. Family-T stated that she has only seen white milk served and coffee. Family-T's expressed concern about R4's weight loss and stated, If they know that she is losing weight, why aren't they adding extra milks or nutritional juices to her trays? She still drinks good. Since R4 has been living in the facility, Family-T states she no longer transfers herself and cannot propel her own wheelchair. She has noticed numerous declines in R4's self-bathing abilities and feeding abilities Family-T stated, I am not asking them to force her to eat, just to be a little more encouraging or aggressive. Family-T stated that since the previous facility that R4 lived at had closed down, one of the staff nurses that used to work with R4, came to this facility to work. At 1:18 p.m., Surveyor approached LPN-C regarding her knowledge of R4. She had worked at the previous facility that R4 lived at prior to its closing down. LPN-T indicated that she knew R4 well and reiterated the practice of R4 coming and going during meals. LPN-T stated that R4 would repeatedly come to the dining room, eat a few bites, go back to her room and come back again, eat a few bites and then leave. She stated R4 did this 3-4 times throughout each meal, stating We just knew her routine and we would leave the tray on the table until she was finished. LPN-T stated that R4's preferences for supper was always soup and a sandwich. She stated that the last 4 months of the previous facility still being open that she had worked the night shift and R4 would get up 2-3 times each night, come to the desk and ask for something to eat. R4 would get a 1/2 sandwich and milk and would eat and drink it all. She stated R4 also enjoyed chocolate Mighty Shakes or chocolate milk. She also liked ice cream and snacked on any junk foods. LPN-T stated that no staff from this facility has talked to her about R4's routine and habits. At 1:40 p.m., Surveyor interviewed the Dietary Manager (DM). The Dietary Manager stated they tried several approaches in order to get R4 to improve her intakes, including a mechanical diet, which she refused, nutritional juices and health shakes. The DM indicated that these interventions were not retried after initial refusals. The DM stated initially R4 was assigned meals in the assisted dining room, but that it was too noisy for her, so they moved her meals to her room. The DM also stated R4 receives fortified mashed potatoes and whole milk. She further stated she has offered other interventions, including ice cream, flavored coffee creamers, all flavors of health shakes and nutritional juices, but R4 refused them all. The DM stated that she did not have evidence of these approaches, and these interventions were not repeated after the initial refusals. Sandwiches and soup were never attempted, and midnight snacking was not offered to R4. The DM stated that on 6/28/17 they added a 2.0 health shake twice daily with medication passes. The last Nutritional Assessment that Surveyor had was one dated for 6/22/17. DM stated that there were no others besides nutritional history reports. Surveyor requested evidence of all interventions attempted. On 7/20/17 at 12:35 p.m., Surveyor met again with the DM to discuss R4. The DM stated she did not maintain evidence of all interventions attempted for R4. The DM was asked what the procedure for reassessment was. The DM stated a reassessment would be conducted with any dramatic changes with the resident. When asked if a reassessment was completed, the DM stated that one was not yet completed but that R4 is coming due for an MDS and one would be completed at that time. The DM stated that yesterday (7/19/17) they added ice cream and chocolate milk to R4's approaches. Follow up inerview with CNA R at 11:30 a.m. indicated R4 had drank 2 8 oz glasses of milk and eaten 1/2 cheese omelet. CNA R stated R4 did really good with encouragement.

Based on observation, interview, and record review, the facility did not ensure that 2 of 4 sampled residents reviewed for pain received the necessary care and services to attain their highest practicable physical, mental, and psychosocial well-being. Resident #1 was admitted to the facility following surgical repair of a broken ankle. admission orders [REDACTED]. The [MEDICATION NAME] was not however obtained on the day of admission to the facility. Resident #1 was subsequently without pain control, with the exception of Tylenol, for more than 20 hours when the facility finally received the [MEDICATION NAME], the day after admission. During this time frame, Resident #1 indicated that she had had significant pain. Resident #6 was admitted to the facility following a Motor Vehicle Accident (MVA) in which she sustained multiple fractures of the lower extremities, rib fractures, and a left hand fracture. The fractures of the lower extremities required multiple surgical procedures. On 1/7/12, Resident #6 was readmitted to the facility following further surgical repair of the right lower extremity. admission orders [REDACTED]. The [MEDICATION NAME] was not however obtained timely on the day of readmission. Resident #6 indicated that because she hadn't received pain medication timely, she had significant pain. This is evidenced by: Example #1: Surveyor # completed a review of Resident #1's clinical record and noted the following. Resident #1 was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. The MDS assessment dated [DATE], indicated Resident #1: ~Has no memory or cognition problems; ~Requires extensive assistance of 1 or 2 staff persons for transfers, bathing, dressing, grooming and toileting; ~Does not walk; and, ~Has frequent pain with the worst pain rated at an 8 out of 10 on a numeric rating scale of 0 to 10 with 10 being the worst pain. Resident #1's Care Area Assessment (CAA) summary for pain indicated: "...frequent requests for pain Rx (medication) - expresses pain @ (at) ...8 @ Xs (times)...exceptable (sic) level of pain on scale 1-10 is 2..." Resident #1's care plan for pain dated 1/22/12, indicated Resident #1's acceptable pain level goal was 2 or less. The care plan directed staff to administer pain medication according to the physician's orders [REDACTED]. Resident #1's most current pain assessment was dated 1/22/12. The pain assessment indicated Resident #1 had intermittent acute pain which Resident #1 had rated as 7 on a pain scale of 0-10. Surveyor # completed a review of Resident #1's hospital records. The records dated 1/9/12 and 1/21/12, indicated Resident #1 had a fall on 1/6/12. Because of the amount of soft tissue swelling, the surgical repair was not done until 1/20/12. The hospital records indicated that on 1/20/12, Resident #1 had 10 screws, 2 K-wires, and 1 plate placed to repair the ankle fracture. Surveyor # completed a review of the Medication Administration Report from the hospital. From 1/20/12 until hospital discharge on 1/21/12, Resident #1 received Tylenol, [MEDICATION NAME] and [MEDICATION NAME]. All medications with the exception of Tylenol are narcotic pain medications. Surveyor # completed a review of Resident #1's admission orders [REDACTED]. Surveyor # completed a review of Resident #1's nursing notes and noted the following: ~1/21/12, "...admitted ...due to Rt (right) ankle fx (fracture)..." This admission note did not contain the time the entry was made. ~1/21/12, ..."1845 (6:45 p.m.)...transferred to facility...pain being monitored...clarification of orders received...MD (Medical Doctor) will be in am (morning), to write scripted (sic) for Narcotic, Resident aware..." Surveyor # completed a review of Resident #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] This is 20+ hours since Resident #1 was admitted to the facility. On 2/8/12 at 10:45 a.m., Surveyor # spoke with LPN-E (Licensed Practical Nurse). LPN-E indicated she was the nurse who admitted Resident #1. Surveyor # asked LPN-E about Resident #1 not receiving the pain medication [MEDICATION NAME] as ordered. LPN-E indicated Resident #1's admission paperwork did not contain a prescription for [MEDICATION NAME]. LPN-E indicated the pharmacy would not dispense a narcotic medication without a prescription. LPN-E indicated she called the physician who indicated they would come in the next day and write the prescription, and in the meantime they were to treat Resident #1's pain with Tylenol. Surveyor # asked LPN-E about Resident #1's pain level upon admission. LPN-E indicated she could not recall. On 2/8/12 at 1:10 p.m., Surveyor # spoke with Resident #1. Resident #1 indicated it was "rough" when she was first admitted . Resident #1 indicated she had had "a lot of pain" and that "there was a mix-up in her pills." Resident #1 stated the only pain medication she got was Tylenol. Resident #1 also stated the pain "was the worst pain I ever had." Resident #1 also indicated she did not sleep at all the first night because of the pain. Surveyor # asked Resident #1 how her pain was now. Resident #1 indicated it was well controlled. On 2/8/12 at 1:45 p.m., Surveyor # spoke with RN-J, RN-K, and RN-L. RN-K indicated she was the Clinical Manager on the unit in which Resident #1 resided. Surveyor # asked RN-K about the circumstances surrounding Resident #1 not receiving [MEDICATION NAME] timely. RN-K indicated they did not receive a prescription from the hospital for the [MEDICATION NAME]. RN-K stated the pharmacy would not dispense the medication without a prescription. RN-K stated the physician was contacted and indicated that he would be in the next day to write the prescription. RN-K indicated staff administered Tylenol and she felt Resident #1's pain had been controlled with the Tylenol. Example #2: Surveyor # completed a review of Resident #6's clinical record and noted the following. Resident #6 was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. On 1/4/12, Resident #6 was hospitalized for [REDACTED]. Resident #6 returned to the facility on [DATE]. Surveyor # completed a review of Resident #6's hospital records dated 1/6/12. The records indicated that on 1/4/12, Resident #6, "...was taken to the operating room for removal of [DEVICE], right lower extremity, and open reduction and internal fixation of right fibula fracture and open reduction and internal fixation of right comminuted intraarticular pilon fracture..." The hospital records also indicated that following the surgery, the physician changed Resident #6's pain medication from [MEDICATION NAME] to [MEDICATION NAME] to better control her pain. The MDS assessment dated [DATE], indicated Resident #6: ~Has no memory or cognitive impairments; ~Requires the assistance of 1 to 2 staff persons for bathing, dressing, grooming, and toileting; ~Does not walk; and, ~Has occasional pain that Resident #6 rated at a 10 on a numeric rating scale from 0-10 with 10 being the worst pain. Resident #6's Care Area Assessment (CAA) summary for pain was dated 1/19/12. It indicated Resident #6 had multiple fractures, was on several pain medications, and that Resident #6's pain was controlled. Resident #6's care plan for pain was dated 1/19/12. It indicated Resident #6's acceptable pain level was 2-3. The approaches include: administer pain medications the physician had ordered, monitor for the effectiveness of the pain medication, and report to the physician if the pain medications were not effective. Resident #6's current pain assessment was dated 1/7/12. It indicated Resident #6 had rated her pain severity at 8 on a numeric rating scale of 0-10. It also indicated that Resident #6 stated the pain was "...generalized....constant, throbbing..." Surveyor # completed a review of Resident #6's readmission orders [REDACTED]. Surveyor # completed a review of the hospital Medication Administration Report for Resident #6. It indicated Resident #6 had been given [MEDICATION NAME] on 1/7/12 at 2:00 p.m. Surveyor # completed a review of Resident #6's nursing notes and noted the following: ~1/7/12, "...18:30 (6:30 p.m.)...admitted ....Had ORIF (Open Reduction and Internal Fixation) to Rt (right) ankle...R (right) leg has splint....L (left) arm has plaster cast...pain adequately (sic) controlled..." On 2/8/12 at 11:00 a.m., Surveyor # spoke with Resident #6. Resident #6 indicated that when she returned to the facility from the last hospital stay, she was in a lot of pain. Resident #6 indicated on the day she was discharged from the hospital she had received [MEDICATION NAME] at 2:00 p.m. at the hospital. Resident #6 indicated she had requested pain medication upon arrival to the facility. Resident #6 indicated she did not receive the [MEDICATION NAME] as requested as the hospital had not sent a prescription for the medication, therefore the facility could not order it. Resident #6 stated she was in "unbearable, want to die pain," and she "hurt everywhere." Resident #6 indicated she finally did receive the [MEDICATION NAME] at about 8:30 p.m. Resident #6 stated that because of the amount of pain she was in, it took about 2 days for the pain to get back under good control. On 2/8/12 at 1:45 p.m., Surveyor # spoke with RN-J, RN-K, and RN-L. RN-J indicated she was the Clinical Manager on the unit in which Resident #6 resided. Surveyor # asked RN-J about the circumstances surrounding Resident #6 not receiving [MEDICATION NAME] timely. RN-J indicated they did not receive a prescription from the hospital for the [MEDICATION NAME]. RN-J stated they received the prescription that night and Resident #6 did receive [MEDICATION NAME] at 8:30 p.m.