Every finding on record at Edenbrook of Oshkosh

Based on observation, staff and resident interview, and record review, the facility did not ensure 4 residents (R) (R1, R18, R53, and R41) of 4 sampled residents received the necessary care and services to prevent pressuries injuries from developing or worsening and/or promote healing.R1 was admitted to the facility with stage 3 and 4 pressure injuries. During wound care, Registered Nurse (RN)-H applied ointment to the wound bed of R1's stage 4 left buttock pressure injury with a soiled glove.R18's specialty air mattress was not turned on during an observation on 5/3/26. In addition, R18 did not have an order for the mattress and the setting wasn't indicated in R18's medical record. R53 and R41's specialty air mattresses were not set correctly.Finding include: The facility's Pressure Injury Prevention and Wound Care Management policy and procedure, revised 8/25/25, indicates: .A resident who has a pressure injury will receive care and services to promote healing and prevent additional ulcers .Air mattress settings will be set per manufacturer's guidelines and communicated to staff via the care plan and Kardex (an abbreviated care plan used by nursing staff) .The goals of wound treatment are to: .Protect the ulcer from contamination. 1. From 5/3/26 to 5/5/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including spina bifida, paraplegia, and neuromuscular dysfunction of bladder. R1's Minimum Data Set (MDS) assessment, dated 2/27/26, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R1's cognition was intact. R1's medical record indicated R1 had a stage 4 pressure injury on the left buttock and a stage 3 pressure injury on the right buttock for which R1 was evaluated by wound physicians monthly. R1's wounds were chronic. R1 routinely refused to offload pressure. R1's medical record contained a wound care order to apply wound ointment two times daily and as needed to buttocks (dated 4/21/26). On 5/4/26 at 11:27 AM, Surveyor observed Registered Nurse (RN)-H don a gown and enter R1's room with wound ointment in a cup and a tongue depressor. RN-H completed hand hygiene, applied gloves, and assisted R1 onto the right side. When RN-H pulled the privacy curtain, R1 stated R1 wanted the curtain open. RN-H opened the curtain. RN-H applied wound ointment to R1's right buttock pressure injury and around the left buttock pressure injury with the tongue depressor. RN-H dipped RN-H's gloved fingers in the cup of ointment and applied the ointment to the wound bed of R1's left buttock pressure injury. RN-H then removed the gown and gloves and completed hand hygiene. RN-H repositioned R1 onto R1's back and exited the room. On 5/4/26 at 11:36 AM, Surveyor interviewed the facility's wound care nurse (RN-I) who verified the treatment for R1's pressure injury was to apply ointment. RN-I indicated the wound should have been cleansed with soap and water prior to applying ointment. RN-I verified there was not an order to cleanse the wound prior to applying ointment; however, RN-I felt RN-H should have followed standard practice to cleanse the wound prior to applying ointment. RN-I indicated RN-H should have removed gloves, cleansed hands, and donned clean gloves after repositioning R1 and touching the privacy curtain. RN-I indicated RN-H should have used the tongue depressor to apply ointment to the inside of the pressure injuries, removed gloves, and cleansed hands and should have donned clean gloves and used another tongue depressor to apply ointment to the outside of the pressure injuries. On 5/4/26 at 12:06 PM, Surveyor interviewed RN-H who confirmed RN-H should have applied ointment to the wound bed with a tongue depressor prior to applying ointment to the outside of the wound. 2. Between 5/3/26 and 5/5/26, Surveyor reviewed R18's medical record. R18 was admitted to the facility on [DATE] and had diagnoses including unspecified protein calorie malnutrition and encounter for palliative care. R18 received Hospice services. R18's MDS assessment, dated 4/15/26, had a BIMS score of 6 out of 15 which indicated R18 had severely impaired cognition. A Braden Scale assessment, dated 4/9/26, indicated R18 was at risk for skin breakdown. A skin care plan, initiated 4/9/26, contained an intervention for a specialty mattress to relieve pressure (initiated 4/10/26). R18 had an ATLAS 5 Minds mobility air mattress. The manufacturer's instructions indicate: The ATLAS mattress is a self-adjusting air mattress and can be used without a pump, however, this manual describes its use with a pump. Step 1: Turn on the power. Weight/pressure set up: Users can adjust air flow to the mattress to a desired firmness according to the user's weight or the suggestion from a healthcare professional. On 5/3/26 at 10:02 AM, Surveyor interviewed R18 and noted R18's air mattress was not on. R18 wasn't sure why the mattress was not on and indicated staff do not do anything with the air mattress. On 5/4/26 at 2:10 PM, Surveyor observed R18 in bed and noted R18's air mattress was turned on. R18 stated Hospice Nurse (HN)-L was just in the room, noticed the mattress was not on, and turned the mattress on. The mattress was set at 180. R18 indicated the mattress felt fuller in R18's back area and stated R18 did not have any wounds. On 5/4/26 at 2:13 PM, Surveyor exited R18's room and observed Assistant Director of Nursing (ADON)-E talking to HN-L. HN-L verified HN-L noted R18's mattress was not on and turned it on. Surveyor informed ADON-E that R18's mattress was not on during an observation on 5/3/26. Surveyor also indicated R18's orders and care plan did not contain a mattress setting. ADON-E confirmed there should be orders. HN-L stated HN-L would provide orders. ADON-E confirmed staff should check a resident's air mattresses to ensure it is functioning as indicated by an order in the resident's Treatment Administration Record (TAR). HN-L indicated Hospice provided R18 with the mattress shortly after R18 was admitted to the facility. ADON-E stated R18's mattress does not need air to provide support and can be a regular mattress or an air mattress. On 5/4/26 at 10:46 AM, Surveyor interviewed Director of Nursing (DON)-B who stated sometimes Hospice staff provide air mattresses without telling the facility. DON-B stated if Hospice staff set the mattress at 180, that is the setting staff follow. DON-B indicated orders were just entered for R18 and R18's care plan was updated. 3. Between 5/3/26 and 5/526, Surveyor reviewed R53's medical record. R53 was admitted to the facility on [DATE] and had diagnoses including fractured tibia, risk for delayed healing related to anemia, at risk for pressure ulcer related to Foley catheter, and blister left shoulder. R53's MDS assessment, dated 3/20/26, had a BIMS score of 15 out of 15 which indicated R53 had intact cognition. R53 made R53's own healthcare decisions. A care plan, dated 12/19/24, indicated R53 was at risk for skin alteration. The care plan contained an intervention for a specialty air mattress. R53's medical record contained an order, dated 10/30/25, to check the air mattress is functioning properly and set to 110-180 every shift A Braden Scale assessment, dated 4/14/26, indicated R53 was at risk for skin breakdown. R53 had a Proactive Air Mattress Selectis Serenity 2000/3000. The manufacturer's recommendations indicate to set the pressure dial or digital input to the user's exact body weight. On 5/3/26 at 10:43 AM and 5/4/26 at 2:02 PM, Surveyor noted R53's air mattress was set at 320. On 5/4/26 at 2:48 PM, Surveyor and DON-B observed R53's air mattress which was set at 320. DON-B verified the setting was incorrect and set the air mattress to 150. 4. Between 5/3/26 and 5/526, Surveyor reviewed R41's medical record. R41 was admitted to the facility on [DATE] and had diagnoses including quadriplegia, diabetes, risk for delayed healing, below the knee amputee, and risk for pressure ulcer related to Foley catheter. A care plan, dated 10/16/25, indicated R41 was at risk for skin alteration. The care plan contained an intervention for a specialty air mattress. R41's medical record contained an order, dated 2/5/26, for a Drive air mattress set to weight 180-250. (Of note: The manufacturer's recommendations indicate to select the setting based on the patient's weight, comfort, and tolerance.) A Braden Scale assessment, dated 5/5/26, indicated R41 was at risk for skin breakdown. On 5/4/26 at 2:44 PM, Surveyor observed R41's air mattress and noted it was set at 620. On 5/4/26 at 2:58 PM, Surveyor and DON-B observed R41's air mattress which was set at 620. DON-B verified the setting was incorrect and set the air mattress to 218.

Based on staff interview and record review, the facility did not ensure a Pre-admission Screening and Resident Review (PASRR) Level I Screen was accurately completed and a Level II Screen was completed for 1 resident (R) (R8) of 7 sampled residents.R8 was admitted to the facility with diagnoses including schizoaffective disorder and anxiety disorder and was prescribed antianxiety medication. The facility did not correctly identify R8's mental illness diagnoses or medication on a PASRR Level I Screen and did not submit for a Level II Screen.Findings include:From 5/3/26 to 5/5/26, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] and had diagnoses including schizoaffective disorder and anxiety disorder. R8's Minimum Data Set (MDS) assessment, dated 4/16/26, had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated R8 had moderate cognitive impairment. R8 had an activated Power of Attorney for Healthcare (POAHC) to assist with healthcare decisions.R8's PASRR Level I Screen, dated 4/16/26, indicated R8 did not have a major mental disorder and was not prescribed major tranquillizer or antipsychotic medication. Based on the information provided on the Level I Screen, the facility did not submit for a Level II Screen. (Of note: The PASRR Level I Screen did not reflect R8's diagnoses of schizoaffective disorer or anxiety disorder.)R8 had a physician order, dated 4/17/26, for lorazepam (antianxiety medication) for use as needed for anxiousness. (Of note: R8's PASRR Level I Screen did not indicate R8 was prescribed lorazepam for anxiety.On 5/4/26 at 1:34 PM, Surveyor interviewed Social Services Aide (SSA)-D who stated an updated PASRR Level I Sreen and referral for a Level II Screen were submitted on 5/3/26 due to R8's order for lorazepam. SSA-D stated R8 admitted to Hospice services while at the facility on 4/16/26 and a PASRR Level II Screen would not have been done because R8 was not on medication for schizoaffective disorder.On 5/4/26 at 1:53 PM, Surveyor interviewed Certified Social Worker (CSW)-C who stated CSW-C would not have initiated a PASRR Level II Screen since R8 was not on medication for schizoaffective disorder at the time of admission. When Surveyor indicated R8's PASRR Level I Screen did not indicate R8 had a major mental disorder, CSW-C stated it was overlooked. CSW-C also stated since there was no medication prescribed, CSW-C would not have sumitted for a PASRR Level II Screen. CSW-C verified a PASRR Level II Screen should have been submitted when lorazepam was ordered on 4/17/26. CSW-C verified PASRR Level I and Level II Screens were submitted on 5/3/26 to accurately reflect R8's diagnoses and lorazepam order.

Based on staff and resident interview and record review, the facility did not ensure their bowel protocol was followed or daily weights were obtained for 2 residents (R) (R30 and R15) of 2 sampled residents.R30 went 4 days without a bowel movement. R30 was not offered medication to help promote a bowel movement on day 3 per facility protocol. R15 was not weighed daily in accordance with a physician's order.Findings include: The facility's standing orders include: ~ Milk of Magnesia (MOM) 30 milliliters (ml) by mouth as needed (PRN) on third day without bowel movement (BM) except in renal failure or with glomerula filtration rate (GFR) of less than 45 ~ Senna-docusate sodium tablet 8.6-50 milligrams (mg) 1 tablet by mouth every 12 hours as needed for constipation and/or if no bowel movement in 3 days ~ Fleet enema as needed for constipation if no results from the suppository ~ Maalox 15-30 ml every 2 hours as needed for gastrointestinal (GI) distress 1. Between 5/3/26 and 5/5/26, Surveyor reviewed R30's medical record. R30 was admitted to the facility on [DATE] and had diagnoses including displaced intertrochanteric fracture of the left femur, irritable bowel syndrome, and pain in left knee. R30's Minimum Data Set (MDS) assessment, dated 4/23/26, had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated R30 had moderate cognitive impairment. R30 was R30's own decision maker. On 5/4/26 at 9:00 AM, Surveyor interviewed R30 who indicated R30 experienced occasional constipation since admission to the facility. R30 stated R30 had been eating Nutrigrain bars to help with bowel movements. R30 stated staff had not offered stool softeners or any bowel medications for constipation. R30 stated R30 used stool softeners and digitally removed stool from R30's rectum at home due to constipation prior to admission. R30 had the following orders: ~ MiraLax oral powder 17 grams (gm)/scoop - Give 1 scoop by mouth as needed (PRN) daily for constipation ~ Milk of Magnesia oral suspension 2400 mg/30 ml - Give 30 ml by mouth as needed daily for constipation ~ Fleet enema rectal enema 19-7 gm/197 ml - Insert 1 application rectally as needed daily for constipation ~ Bisacodyl rectal suppository 10 mg - Insert 1 suppository rectally as needed daily for constipation R30's medical record indicated the following: ~ R30 did not have a bowel movement on 4/25/26, 4/26/26, 4/27/26, or 4/28/26 (4 days). ~ There were no documented PRN bowel medications administered for R30 since admission. ~ R30's Medication Administration Record (MAR) and progress notes contained no documented refusals of bowel medications. On 5/4/26 at 9:09 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-G who stated nurse managers give floor nurses a list of residents daily who need medication for constipation. If a resident refuses the medication, it is documented in their medical record. On 5/4/26 at 12:50 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-E regarding the facility's protocol for PRN bowel medications. ADON-E stated if a resident has not had a bowel movement in 72 hours, PRN bowel medication is administered. If the resident doesn't have a bowel movement in 5 days, a rectal suppository is administered. If a resident refuses, it is documented in their medical record. On 5/5/26 at 10:56 AM, Surveyor interviewed Director of Nursing (DON)-B who verified R30 should have been offered bowel medication on day 3 when R30 went 4 days without a documented bowel movement. 2. Between 5/3/26 and 5/5/26, Surveyor reviewed R15's medical record. R15 was admitted to the facility on [DATE] and had diagnoses including acute on chronic heart failure with preserved ejection fraction (CMD), acute hypoxic respiratory failure, and moderate pulmonary hypertension. R15's MDS assessment, dated 5/11/26, had a BIMS score of 15 out of 15 which indicated R15 had intact cognition. R15 was R15's own decision maker. R15 had an order upon admission for daily weights for 3 days (dated 4/28/26). On 4/29/26, staff obtained R15's weight in a wheelchair but did not obtain R15's weight out of the wheelchair. An accurate weight was not documented. R15's medical record indicated R15 was seen by the physician on 4/30/26 for follow-up after a recent hospitalization. R15 was hospitalized from [DATE] to 4/21/26 for a right total knee replacement. R15 was transferred to the Emergency Department (ED) on 4/23/26 with acute respiratory failure secondary to volume overload and suspected underlying interstitial lung disease (inflammation or scarring of lung tissue causing breathlessness and dry cough). R15 remained on Bumex (a diuretic medication used to treat edema (fluid retention)). The facility could not track/trend R15's weight because they had only obtained one weight since admission. On 4/30/26 and 5/1/26, R15's weight was not obtained. On 5/2/26, an order was entered in R15's medical record for daily weights. On 5/2/26, R15's weight was not obtained. On 5/4/26 at 1:33 PM, Surveyor interviewed DON-B who confirmed R15 should have been weighed on the above dates. DON-B stated if staff are unable to obtain a weight, there should be a note in the resident's medical record.

Based on observation, staff interview, and record review, the facility did not ensure 2 residents (R) (R7 and R1) of 3 sampled residents received appropriate care and services to prevent urinary tract infections (UTIs).The facility did not ensure R7 and R1 received catheter care in a manner that decreased the risk for infection. R7's catheter bag and tubing were on the floor on multiple occasions. R1's uncovered catheter bag was also on the floor. Findings include: The facility's Policy & Procedure Catheter Care, revised 1/28/25, indicates: Staff will maintain consistent and adequate hygiene standards for residents with an indwelling catheter in order to maintain comfort, function, and prevent infection and other complications. 1. On 5/3/26, Surveyor reviewed R7's medical record. R7 had diagnoses including type 2 diabetes with other circulatory complications, chronic kidney disease stage 3, and urinary tract infection (UTI) (dated 3/24/26). R7's Minimum Data Set (MDS) assessment, dated 3/2/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R7 had intact cogntion. R7's care plan, revised 3/6/26, indicated R7 had alteration in elimination related to an indwelling catheter due to obstructive uropathy. R7 saw urology and had several failed voiding trials. The care plan contained a goal that indicated R7 would have no complications related to the indwelling catheter. The care plan contained an intervention to ensure the catheter bag and tubing were off the floor (dated 7/1/25). On 5/3/26 at 10:13 AM and 5/4/26 at 4:47 AM, Surveyor observed R7 asleep in bed and noted R7's catheter bag and tubing were on the floor next to the bed. On 5/4/26 at 5:06 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-F who verified CNA-F completed catheter care for R7 at 3:30 AM. During the interview, Surveyor and CNA-F observed R7's catheter bag and tubing on the floor next to R7's bed. CNA-F indicated the catheter bag and tubing should not be on the floor and should be hung from R7's bed. On 5/5/26 at 7:33 AM, Surveyor noted R7's catheter bag was hung from side of the bed and was off the floor. The catheter bag contained a red substance. On 5/5/26 at 7:36 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-E who was not aware of the red substance in R7's catheter bag and observed the bag with Surveyor. ADON-E stated ADON-E would update the Nurse Practitioner (NP) who was doing rounds about possible blood in R7's catheter bag. ADON-E stated R7's bed is older and at times it is diffiult to hang the catheter bag on the side of the bed. ADON-E verified leaving a catheter bag and tubing on the floor is not conducive to the prevention of infection. ADON-E stated ADON-E was also the facility's Infection Preventionist and woud determine other ways to create a barrier so R7's catheter bag was not in contact with the floor. On 5/5/26 at 9:43 AM, ADON-E indicated to Surveyor the NP would order a urinalysis and culture for R7 due to blood in R7's catheter bag. 2. From 5/3/26 to 5/5/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including spina bifida, paraplegia, UTIs, and neuromuscular dysfunction of bladder. R1's MDS assessment, dated 2/27/26, had a BIMS score of 14 out of 15 which indicated R1 had intact cognition. R1's care plan for elimination, revised 2/24/26, contained an intervention to maintain catheter and tubing off the floor. R1's medical record indicated R1 had UTIs on 1/10/26 and 4/12/26 and was treated with antibiotics. On 5/3/26 at 12:55 PM, Surveyor observed R1's uncovered catheter bag on the floor next to R1's bed. On 5/3/26 at 1:04 PM, Surveyor interviewed CNA-J who indicated R1's catheter bag should not be on the floor. CNA-J entered R1's room, removed the bag from the floor, and hung the bag on the side of R1's bed.

Based on observation, staff and resident interview, and record review, the facility did not ensure the accurate administration of medication for 1 resident (R) (R15) of 6 sampled residents. R15 did not receive gabapentin (an anticonvulsant medication often used to treat pain) in a timely manner. In addition, R15 did not receive the correct dose on 5/1/26 after the physician changed the order on 4/30/26.Findings include: The facility's Liberalized Medication Administration Policy, revised 2/12/24, indicates: Medications should be administered at appropriate times per pharmacy regulation. Medications ordered at prescribed times will be given as ordered. Between 5/3/26 and 5/5/26, Surveyor reviewed R15's medical record. R15 was admitted to the facility on [DATE] and had diagnoses including neuropathy, chronic pain of both knees, and status post total right knee replacement. R15's Minimum Data Set (MDS) assessment, dated 5/11/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R15 had intact cognition. R15 was R15's own decision maker. On 5/3/26 at 10:33 AM, Surveyor interviewed R15 who stated R15 had not received R1's AM medications and was still waiting for a pain pill. In a subsequent interview on 5/4/26 at 9:10 AM, R15 stated R15 had neuropathy which affected R15's feet. R15 stated R15 took gabapentin 3 times daily at home but spaced it out so it worked consistently. On 5/3/26 at 10:55 AM, Surveyor observed Registered Nurse (RN)-K provide medication to R15. R15's medical record contained an order for 400 milligrams (mg) of gabapentin for osteoarthritis three times daily (dated 4/28/26). The medication was scheduled for 8:00 AM, 12:00 PM, and 4:00 PM. R15's Medication Administration Record (MAR) indicated the following: ~ On 4/29/26, R15's 8:00 AM dose of gabapentin was administered at 10:16 AM. ~ On 4/30/26, R15's 8:00 AM dose of gabapentin was administered at 10:02 AM. R15's medical record indicated R15 was seen by the physician on 4/30/26. R15's primary complaint was peripheral neuropathy in bilateral feet. Prior to hospitalization, R15 was on 900 mg of gabapentin three times daily which R15 stated worked well. R15's gabapentin was decreased to 400 mg three times daily in the hospital. The physician did not know why. R15 told the physician R15's neuropathy was bothersome and felt like pins and needles in both feet that caused R15 to feel restless. The physician changed R15's gabapentin order on 4/30/26. The physician discontinued the 400 mg of gabapentin and prescribed 600 mg of gabapentin three times daily for 3 days and then 800 mg three times daily. R15's MAR indicated R15 received 1000 mg of gabapentin three times on 5/1/26. R15 was administered 400 mg and 600 mg during the AM, noon, and PM medication passes. On 5/3/26, R15's 8:00 AM dose of gabapentin was administered at 10:57 AM. The 12:00 PM dose was administered at 1:22 PM which was 2 hours and 25 minutes after the first dose. On 5/4/26 at 1:33 PM, Surveyor interviewed Director of Nursing (DON)-B who was not previously aware of any medication errors for R15 and confirmed the wrong dose of gabapentin was provided on 5/1/26. DON-B stated staff must not have discontinued the previous dose as ordered by the physician and administered the 400 mg and 600 mg doses that day. When Surveyor informed DON-B about the late gabapentin doses, DON-B confirmed if a medication is prescribed at a certain time, the medication should be administered within one hour prior to or after the scheduled time. DON-B stated if a medication is administered late, staff should ensure the next dose is provided at an equal interval to the scheduled time.

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 72 residents residing in the facility. Food was not sealed, labeled, or dated appropriately.Food temperatures were not consistently documented prior to meal service.Kitchen cookware was not stored properly. In addition, kitchen equipment and the floor were not in clean condition. The rehab unit refrigerator was not in clean condition and contained undated and expired resident food.Staff touched ready-to-eat food with soiled gloves during lunch service.Findings include:On 11/25/25 at 8:39 AM, Surveyor completed a kitchen tour with Dietary Manager (DM)-C who indicated the facility follows the Wisconsin Food Code.Labeling/Dating/Storage:The Wisconsin Food Code documents at 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking: (A) Except when packaging food using a reduced oxygen packaging method as specified under paragraph 3-502.12, and except as specified in paragraphs (E), (F), and (H) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature and time combination of 41 degrees Fahrenheit (F) or less for a maximum of 7 days. The day of preparation shall be counted as day 1. Commercially processed food open and held cold (B) except as specified in paragraph (E)-(H) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked at the time the original container is opened in a food establishment and, if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in paragraph (A) of this section and; (1) The day the original container is opened in the food establishment shall be counted as day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety.During a kitchen tour that began at 8:39 AM on 11/25/25, Surveyor observed the following: Walk-In Cooler:~ An unlabeled and undated bag of sliced ham that contained an unidentifiable black spot~ An unlabeled and undated bag of sliced turkey~ A one-quarter full five pound container of [NAME] sour cream with no open date~ Three unlabeled and undated plastic bins of juice mixes (per DM-C)~ An unlabeled and undated bag of chopped ham~ Two unlabeled and undated disposable condiment cups with a red substance~ An undated and unsealed bag of shredded lettuce~ An unlabeled and undated covered metal serving pan of rice (per DM-C)Dry Storage:~ A snack tray that contained an unlabeled and undated bag with half of a peanut butter and jelly sandwich that was hard to the touch~ An unlabeled and undated bag of either cake or muffin mix (per DM-C) ~ Three unlabeled and undated containers of Cheerios, [NAME] Krispies, and Raisin Bran (per DM-C) in plastic bins~ Two open and unsealed bags of cereal ~ Two open and undated bags of pastaWalk-In Freezer:~ An unlabeled and undated bag with 2 pieces of French toast (per DM-C)~ An open, unlabeled, and undated bag of Snicker pieces~ An unlabeled and undated sealed container with 2 round white cakes On 11/25/25 at 9:15 AM, Surveyor interviewed DM-C who confirmed all food items should be sealed, labeled, and dated. DM-C indicated DM-C was going to take over full-time the following week and had been working part time between 2 facilities for the past 3 weeks. DM-C was aware there were issues with labeling, dating, and ensuring food items were sealed.Food Temperatures:The Wisconsin Food Code documents at 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S 3-501.19, and except as specified under paragraphs (B)-(C) of this section, time/temperature control for safety food shall be maintained: (1) 135 degrees F or above, except that roasts cooked to a temperature and for a time specified in paragraph 3-401.11 (B) or reheated as specified in paragraph 3-403.11 (E) may be held at a temperature of 130 degrees F or above; or (2) At 41 degrees F or less. On 11/25/25 at 8:55 AM, Surveyor reviewed the facility's holding temperature logs and noted [NAME] (CK)-D completed breakfast temperatures on 11/25/25, however, they were written on the back of a piece of paper. Surveyor noted holding temperatures were not completed prior to meal service on the following days:~ For the week of 11/9/25 through 11/15/25, the log contained missing temperatures for all meals on 11/9/25; missing temperatures for supper on 11/12/25; missing temperatures for lunch and supper on 11/13/25; missing temperatures for breakfast and lunch on 11/14/25 and 11/15/25; and missing temperatures for all meals on 11/24/25. On 11/25/25 at 8:55 AM, DM-C confirmed holding temperatures should be documented prior to meal service. Equipment Storage/Cleanliness:The Wisconsin Food Code documents at 4-602.12 Cooking and Baking Equipment: (B) The cavities and door seals of microwave ovens shall be cleaned at least every 24 hours by using the manufacturer's recommended cleaning procedure.The Wisconsin Food Code documents at 4 601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.During the initial kitchen tour that began at 8:39 AM on 11/25/25, Surveyor observed the following: ~ An open shelf next to the dishwashing area with metal pans and bowls. The bowls were not stored upside down.~ A portable heating [NAME] that contained an unsealed bag of plastic cups. The bag contained a sticky substance.~ A microwave that contained dried food debris.~ Dust and debris on the floor underneath the shelving. ~ A breakfast cart in the dining room with dispensable cereal containers. There was dried cereal and wrappers/paper on the cart and surrounding floor. Surveyor observed the cart again at 11:00 AM and noted the cart/floor had not been cleaned.During an observation of lunch service on 8/25/25 at 11:00 AM, Surveyor observed clean adapted plates on the bottom shelf next to the steam table that were not stored upside down. The shelf contained crumbs and debris.On 11/25/25 at 9:15 AM, Surveyor interviewed DM-C who indicated there was not a cleaning schedule for the kitchen. DM-C confirmed dishes were not stored properly and many areas were unclean.Unit Refrigerator:The facility's Food Safety Requirements policy, dated 11/26/17, indicates: Monitor: Employees will be appointed to check resident refrigerators for .food containment and quality and disposal of items per center-specific schedule. On 11/25/25 at 12:43 PM, Surveyor observed the rehab unit refrigerator used to store resident food and noted the following: ~ An unlabeled container of Better gravy~ A bottle of Dunkin' coffee with a best-by date of 10/2025~ An 8 ounce bottle of Mulu lactose free skim milk with an expiration date of 6/8/25~ A container with room number that was dated 11/6/25~ An undated container of Alaskan Krab~ An open, half-full, unlabeled, and undated 18.5 ounce bottle of Pure Leaf brewed tea~ An unlabeled and undated container with a room number~ A bag of what appeared to be fried chicken dated 10/12/25Surveyor also observed crumbs and spills on the refrigerator shelves and a sticky substance under the drawers. On 11/25/25 at 12:53 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-E who was not sure who was responsible for cleaning the refrigerator. LPN-E confirmed the refrigerator was dirty and contained undated and expired items.Hand Hygiene:The Wisconsin Food Code documents at 3-304.15 Gloves, Use Limitation: (A) If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation.The Wisconsin Food Code documents at Chapter 2 Personal Cleanliness 2-301.14 When to Wash: Food 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; (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 putting on gloves to initiate a task that involves working with food; and (I) After engaging in other activities that contaminate the hands. On 11/25/25 at 11:00 AM, Surveyor observed CK-D prepare and serve lunch. The menu included manicotti with sauce, garlic toast, and asparagus pieces. Alternative meals were a beef patty and chicken. Surveyor noted the following:~ CK-D changed gloves multiple times during meal service without washing hands.~ On 3 occasions, CK-D pulled CK-D's face mask down with a gloved hand and then continued serving food. CK-D touched ready-to-eat food by cutting and putting garlic toast on plates.On 11/25/25 at 11:25 AM, Surveyor observed CK-D pick up cooked chicken with a gloved hand that had touched multiple areas in the kitchen, including utensils, containers, and meal tickets. CK-D put the chicken in a blender to grind. CK-D then removed the top of the blender and touched the ground chicken with a gloved hand. CK-D tore a piece of chicken with gloved hands and placed the smaller pieces back in the blender. When the chicken was ground to the correct consistency, CK-D used the same gloved hand to guide the ground chicken into a serving dish. On 11/25/25 at 12:02 PM, Surveyor interviewed CK-D who confirmed the above observations. On 11/25/25 at 2:30 PM, Surveyor informed DM-C of Surveyor's observations during meal service. DM-C indicated DM-C observed some of the same things and would work on training staff.

Based on observation, staff and resident interview, and record review, the facility did not ensure meals were served timely. This practice had the potential to affect more than 4 of the 72 residents residing in the facility.On 11/25/25, the lunch meal was served late.Findings include:The posted meal times on the meal service line for lunch were: Hall 4: 11:30 AM - start by 11:10 AM; Hall 2: 11:40 AM - start by 11:30 AM; Hall 1: 11:50 AM - start by 11:35 AM; Dining Room: 12:05 PM - start by 11:55 AM.On 11/25/25 at 11:00, Surveyor entered the kitchen to watch lunch service and noted the Hall 4 meal service started at 11:45 AM. The Hall 4 lunch service cart was completed and sent to the unit at 12:00 PM. On 11/25/25 at 12:00 PM, Surveyor heard Dietary Manager (DM)-C tell staff to move along because meal service was late. On 11/25/25 at 12:07 PM, Surveyor noted the Hall 2 meal service started but should have started at 11:40 AM. Surveyor followed the Hall 2 cart to the unit which was completed and sent to the unit at 12:30 PM.On 11/25/25 at 12:43 PM, Surveyor observed Certified Nursing Assistants (CNAs) start delivering meal trays on Hall 2.On 11/25/25 at 1:16 PM, the last meal tray was delivered on Hall 2.On 11/25/25 at 12:40 PM, Surveyor interviewed R7 (whose Minimum Data Set (MDS) assessment, dated 11/20/25, indicated R7 had intact cognition). R7 indicated meal trays should have been served by then but were consistently late. On 11/25/25 at 1:03 PM, Surveyor interviewed CNA-F who confirmed meal trays are frequently served late. On 11/25/25 at 2:30 PM, Surveyor interviewed DM-C who was aware meals were frequently served late. DM-C indicated DM-C was recently asked to work full-time at the facility to help with issues in the kitchen. DM-C had worked between 2 facilities for the previous 3 weeks. DM-C indicated DM-C would address the timeliness of meals.

Based on observation, staff interview, and record review, the facility did not provide meals according to prescribed diets for 3 residents (R) (R9, R10, and R11) of 3 sampled residents. R9, R10, and R11 had orders for a consistent carbohydrate diet. On 11/25/25, residents on consistent carbohydrate diets were supposed to receive a half slice of garlic toast. R9, R10, and R11 received a full slice of garlic toast.Findings include:The facility's Diet and Diet Orders policy, revised 12/11/23, indicates: .11. Residents on therapeutic or mechanically-altered diets will not receive food or fluids outside the diet order unless approved by the attending physician in conjunction with the dietitian, nursing, and/or therapy. On 11/25/25, Surveyor reviewed R9's medical record. R9 had a diagnosis of type 2 diabetes and was prescribed a consistent carbohydrate (diabetic) diet.On 11/25/25, Surveyor reviewed R10's medical record. R10 had a diagnosis of type 2 diabetes and was prescribed a consistent carbohydrate with no added salt diet.On 11/25/25, Surveyor reviewed R11's medical record. R11 had a diagnosis of type 2 diabetes and was prescribed a consistent carbohydrate (diabetic) diet.On 11/25/25 at 11:00 AM, Surveyor observed food preparation and lunch service. The lunch menu indicated residents on consistent carbohydrate diets should receive 1 each manicotti with meat sauce; 4 ounces of asparagus cuts, a half slice of garlic toast, 4 ounces of canned fruit, and 8 ounces of milk. During meal service, Surveyor observed [NAME] (CK)-D put a full slice of garlic toast on R9, R10, and R11's meal trays. Surveyor observed R9, R10, and R11's tray cards that CK-D had reference to which indicated R9, R10, and R11 should receive a half slice of garlic toast. On 11/25/25 at 12:02 PM, Surveyor interviewed CK-D who did not notice the tray cards indicated the residents should receive a half slice of garlic toast. On 11/25/25 at 2:30 PM, Surveyor interviewed Dietary Manager (DM)-C who confirmed residents' diet orders should be followed.

Based on observation, staff and resident interview, and record review, the facility did not ensure 2 residents (R) (R2 and R9) of 3 sampled residents received the appropriate care and services to prevent urinary tract infections (UTIs). The facility did not initiate or transcribe an admission order to change R2's Foley catheter monthly and as needed.The facility did not initiate or transcribe a urology clinic order to change R9's Foley catheter monthly and as needed. In addition, R9 was not placed on enhanced barrier precautions (EBP) despite having an indwelling medical device.Findings include:The facility's Physician Orders policy, revised 11/13/24, indicates orders must be recorded in the medical record and transcribed to the Medication Administration Record (MAR) or Treatment Administration Record (TAR). The facility's Foley Catheter Management policy, revised 1/28/25, indicates there will be a medical necessity/justification for the use of a urinary catheter which will be identified by the physician order. The policy also indicates indwelling Foley catheters will not be changed at routine or fixed intervals. The facility's Enhanced Barrier Precautions (EBP) policy, dated 3/26/25, indicates the facility will implement EBP during high-contact resident care activities when caring for residents who have an increased risk for acquiring a multidrug-resistant organism (MDRO) such as a resident with an indwelling medical device. EBP refers to an infection control intervention that employs targeted gown and glove use during high-contact resident care activities. A posting with clear signage of EBP should be placed on the door/wall outside the resident's room and the facility will ensure personal protective equipment (PPE) and alcohol-based hand rub is readily accessible to staff. 1. On 7/29/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including dementia, traumatic ischemia/rhabdomyolysis, and history of falls. R2 had an Activated Power of Attorney for Healthcare (POAHC) who assisted with medical decisions. R2's Minimum Data Set (MDS) assessment, completed on 6/19/25, indicated R2's cognition was severely impaired. Hospital discharge instructions, dated [DATE], indicated R2 had a UTI upon admission and a chronic Foley catheter. Physician orders upon discharge from the hospital were to change the Foley catheter monthly and irrigate with 60 milliliters (ml) of normal saline as needed. Surveyor noted the order was not transcribed in R2's medical record and was not on R2's MAR or TAR.On 7/29/25 at 1:01 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated the hospital discharge order should have been transcribed in R2's TAR; however, the facility's policy indicates not to complete Foley catheter changes routinely or at fixed intervals to prevent the possibility of causing infection. DON-B indicated R2's physician should have been notified of the order and should have provided an order to change the Foley catheter as needed with indications, including but not limited to if the catheter is plugged and if R2 has decreased urine output or urinary changes. DON-B indicated R2's physician did not provide alternative orders and verified the hospital discharge order should have been transcribed and implemented. 2. On 7/29/25, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] and had diagnoses including cerebral infarction, hemiplegia, hemiparesis, UTI, and diabetes. R9 made R9's own medical decisions. R9's MDS assessment, completed on 7/3/25, indicated R9's cognition was moderately impaired. R9's medical record contained an order from the urology clinic, dated 7/22/25, for monthly and as needed Foley catheter changes. The order was not transcribed on R9's MAR or TAR.On 7/29/25 at approximately 12:30 PM, Surveyor interviewed R9 who indicated R9 had an order from the urology clinic on 7/22/25 to change R9's Foley catheter but it had not been changed. Surveyor did not observe an EBP sign outside R9's room and did not observe PPE near R9's room. On 7/29/25 at 12:36 PM, Surveyor interviewed Registered Nurse (RN)-D who verified R9 had a Foley catheter but indicated R9 did not need to be on EBP. On 7/29/25 at 12:38 PM, Surveyor observed the outside of R9's room with DON-B who indicated R9 should be on EBP due to the Foley catheter. Surveyor observed DON-B post an EBP sign outside R9's door.On 7/29/25 at 1:01 PM, Surveyor interviewed DON-B who verified R9 had an order from the urology clinic on 7/22/25 for monthly and as needed Foley catheter changes. DON-B indicated the order should have been transcribed on R9's TAR which DON-B completed during the interview. DON-B indicated nursing staff would implement the urology clinic order on the 7/29/25 PM shift and confirmed the order should have been transcribed when received on 7/22/25.

Based on staff interview and record review, the facility did not ensure 1 resident (R) (R2) of 1 sampled resident received timely laboratory services. The facility did not complete physician orders for R2 to prevent potential cancellation or delay of a medical procedure. Findings include: The facility's Physician Orders policy, revised 11/13/24, indicates the purpose of the policy is to ensure physician orders are transcribed and implemented in accordance with professional standards. The policy also indicates orders must be recorded in the medical record and transcribed to the Medication Administration Record (MAR) or Treatment Administration Record (TAR). On 7/29/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including dementia, traumatic ischemia/rhabdomyolysis, history of falls, and sick sinus syndrome. R2 had an activated Power of Attorney for Healthcare (POAHC) who assisted with medical decisions. R2's Minimum Data Set (MDS) assessment, completed on 6/19/25, indicated R2's cognition was severely impaired. R2's medical record contained orders from the urology clinic on 7/7/25 with surgical instructions and indicated the failure to comply may result in cancellation of R2's procedure. The orders included a pre-op history and physical (H&P) to be completed no more than 30 days prior to the procedure scheduled for 7/25/25 and a urine culture on 7/11/25. On 7/29/25 at 9:09 AM, Surveyor interviewed Assisted Living Nurse (ALN)-C who indicated R2's medical procedure was delayed because the physician's orders were not completed timely. On 7/29/25 at 1:01 PM, Surveyor interviewed Director of Nursing (DON)-B who verified the facility received orders from the urology clinic on 7/7/25 to provide a pre-op H&P and complete a urine culture on 7/11/25. DON-B indicated the pre-op H&P was completed by the facility's provider on 7/8/25, however, the facility did not send the H&P to the urology clinic. DON-B also indicated nursing staff could not obtain a urine sample as ordered on 7/11/25 because R2 left the facility at 9:45 AM. DON-B indicated the facility should have notified R2's receiving facility that the order was not completed and needed to be completed to ensure continuity of care and prevent the delay of R2's surgical procedure.

Based on staff and resident interview and record review, the facility did not ensure an allegation of neglect was thoroughly investigated for 1 resident (R) (R2) of 15 sampled residents. R2 alleged that Certified Nursing Assistant (CNA)-H left R2 naked and without a gown on the 6/18/25 night shift. The facility did not thoroughly investigate the allegation of neglect.Findings include: The facility's Policy & Procedure Vulnerable Adult Abuse and Neglect Prevention, revised 3/25/25, indicates: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, neglect, mistreatment, or exploitation. The facility will follow the federal guidelines dedicated to the prevention of abuse and timely and thoroughly investigate allegations .residents and staff will be protected from abuse, neglect, and harm while they are residing at the facility. There is zero tolerance for abuse or harm of any type .The facility will strive to educate all participants in techniques to protect all parties .Willful .means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .11. Neglect: (a) The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. (b) The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to, food, clothing, shelter, healthcare, or supervision which is: i. Reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety .and ii. Which is not the result of an accident or therapeutic conduct. (c) The absence or likelihood of absence of care services, including but not limited to food, clothing, shelter, healthcare, or supervision necessary to maintain the physical and mental health which a reasonable person would deem essential to obtain or maintain the vulnerable adult's health, safety or comfort .Resident Protection Program Policy & Procedure: .4. Investigation: a. Upon receiving a complaint of alleged maltreatment, the Administrator must be notified immediately and they, the Director of Nursing (DON), or assigned designee will coordinate an investigation which will include completion of witness statements. b. All parties involved including two of the following - staff, residents, or visitors who were potentially involved or observed the alleged incident are to be interviewed by the DON, Director of Social Services, or their designee .j. The investigation and written findings are completed and reviewed with the Administrator, DON, and Director of Social Services .h. Education will be provided as needed to all parties involved .Each alleged report will be individually investigated .The appropriate person .or designee will conduct interviews with the appropriate staff, volunteers, visitors, etc. Within 5 business days, an investigation report will be completed and turned into the Department of Health which includes .iii. Details of the facility's investigation including a summary of information obtained from interviews of residents, staff, and witnesses .vii. Any action that has been taken to prevent recurrence of the incident . On 7/1/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including aftercare following joint replacement surgery, diabetes, asthma, and obesity. R2's Minimum Data Set (MDS) assessment, dated 6/23/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R2 was not cognitively impaired. R2 made R2's own healthcare decisions. A care plan, dated 6/18/25, indicated R2 required the assistance of one staff for dressing. On 7/1/25, Surveyor reviewed a facility-reported incident (FRI) that contained a grievance from R2, dated 6/19/25, that indicated on the 6/18/25-6/19/25 night (NOC) shift, staff did not answer R2's call light and R2 used a phone to call for assistance. The investigation indicated CNA-H removed a bed pan from underneath R2 at 1:00 AM and the bed pan spilled. R2's gown was wet and CNA-H did not assist with R2's wet gown until R2 asked. R2 indicated CNA-H removed R2's wet gown, left R2 naked, left the room, and did not return. R2 called at 4:00 AM and a Registered Nurse (RN) assisted R2 with donning a clean gown. R2 indicated CNA-H was rude when R2 requested an RN and told R2 the RN was busy. R2 indicated CNA-H always stood at the door which made R2 feel as if CNA-H did not want to take care of R2 and always rushed to get out which hurt R2's feelings. Surveyor noted the FRI did not contain an interview or statement from the RN who assisted R2 with the gown. In addition, the education the facility provided to staff did not include customer service or dignity which was part of R2's grievance and did not include all staff who worked the 6/18/25-6/19/25 night shift. The facility provided a nursing staff list which contained 38 CNAs. Surveyor noted the facility's education sheets were completed with only 34% of the CNAs who worked on the shift when the incident occurred. The FRI also did not include an investigation for why R2 used a phone to call for assistance instead of the call light. The investigation did not indicate how long R2 was left naked or if R2 was still naked when the RN assisted R2 with a clean gown. On 7/1/25 at 8:49 AM, Surveyor interviewed R2 who indicated R2 was left in urine for hours. R2 stated R2 did not want to use the call light because staff do not answer call lights timely and instead used R2's phone to call for assistance. R2 indicated CNA-H was terminated because CNA-H was rude and left R2 naked without a gown for a long time. R2 indicated the gown was soiled after R2 used the bedpan. R2 indicated an unknown nurse assisted R2 with a clean gown. R2 indicated other unknown staff were also rude. On 7/1/25 at 9:17 AM, Surveyor interviewed R13 who indicated some staff have loud and rude voices which R13 does not like. R13 indicated an unknown nurse administered medications in one spoonful and R13 felt the nurse rushed to administer the medication. R13 also indicated a male staff entered R13's room during the night in the past two weeks and turned off the light above R13's bed. R13 indicated R13 used the light as a night light and was afraid of the dark. R13 indicated Director of Nursing (DON)-B informed R13 that the staff was let go. When Surveyor asked if the staff was aware that R13 liked the light on at night, R13 stated yes. On 7/1/25 at 9:43 AM and 1:35 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated the concerns regarding CNA-H were a form of neglect and CNA-H no longer worked at the facility. NHA-A indicated the primary issue was that CNA-H was rude and made residents feel rushed, however, CNA-H denied the allegations. NHA-A indicated R2 being left without a gown was a he said/she said situation and NHA-A did not know which nurse was on duty that night. NHA-A also indicated other residents complained of customer service issues with CNA-H.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe manner. This practice had the potential to affect more than 4 of the 71 residents residing in the facility. Holding temperatures were not completed for all items served. Findings include: During an initial kitchen tour on 3/24/25 at 9:08 AM, Dietary Manager (DM)-I indicated the facility follows the State of Wisconsin Food Code. The facility's Hospitality and Dining Services (Accuracy and Quality of Food Service 1-8) policy, dated 1/1/20, indicates: .Hot foods will be kept hot (>135 degrees Fahrenheit (F)) and cold foods will be kept cold (<41 degrees F) prior to and during service. Cooking of hot foods should be completed no more than 30 minutes prior to meal service. The Wisconsin State Food Code documents at 3-501.16, Time/Temperature Control for Safety Food, Hot and Cold Holding: (A) .Time/temperature control for safety food shall be maintained: (1) 135 degrees F or above, except that roasts cooked to a temperature and for a time specified in paragraph 3-401.11 (B) or reheated as specified in paragraph 3-403.11 (E) may be held at a temperature of 130 degrees F or above; or (2) At 41 degrees F or less. On 3/25/25 at 11:26 AM, Surveyor observed lunch service in the kitchen. Surveyor reviewed the holding temperature logs and noted spaces for 3 temperatures (entree, side, and dessert). The lunch meal was Swiss steak with tomatoes and onions, green beans, and mashed potatoes. The dessert was mandarin orange cake. Surveyor observed DM-I temp the Swiss steak, beans, and dessert. DM-I put the thermometer away and documented the temperatures. When Surveyor asked if any other temperatures were taken, DM-I confirmed only 3 temperatures were taken. Surveyor then asked DM-I to temp the mashed potatoes which were above 135 degrees. When Surveyor asked if there were residents on pureed or ground diets, DM-I indicated yes. Surveyor then asked DM-I to temp the pureed beans which were 127.5 degrees F. DM-I indicated DM-I would reheat the pureed items. When Surveyor asked if beverages were temped, including milk and juice which were pre-set on carts in ice, DM-I indicated beverages were not temped. Surveyor observed lunch service on a resident wing and tested a meal tray at the end of meal service. Surveyor noted the trays arrived at 11:47 AM. Surveyor observed 1 Certified Nursing Assistant (CNA) serve drinks and meal trays. The last resident received their tray at 12:24 PM. Surveyor temped the milk on the beverage cart at the end of meal service which was 43.4 degrees F. On 3/26/25, Surveyor interviewed DM-I who indicated the milk was not temped. DM-I indicated when items leave the kitchen, it's the responsibility of nursing staff to serve food and beverages timely and keep the milk on ice so the temperature stays within the required range.

Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 5 residents (R) (R121, R124, R127, R58, and R19) of 6 sampled residents observed during medication administration and the provision of care. During observations of medication administration and/or care for R121, R124, R127, and R58, Licensed Practical Nurse (LPN)-D did not complete appropriate hand hygiene. Staff did not abide by enhanced barrier precautions (EBP) when providing catheter care for R19. Findings include: The facility's Infection Control Program, revised 5/8/24, indicates: The infection control program exists to ensure a safe and comfortable environment for residents and personnel. It is designed to help prevent the development and transmission of disease and infection .Preventing Spread of Infections: The facility must require staff to clean their hands after each direct resident contact using the most appropriate hand hygiene professional practices .Implement hand hygiene practices consistent with accepted standards of practice. The facility's Enhanced Barrier Precautions policy, dated 3/26/24, indicates: It is the policy of this facility that enhanced barrier precautions (EBP) .will be implemented during high-contact resident care activities when caring for residents that have an increased risk of acquiring a multidrug-resistant organism (MDRO) such as a resident with .indwelling medical devices .EPB refer to an infection control intervention designed to reduce transmission of MDROs that employs targeted gown and glove use during high contact resident care activities .EBP are used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staffs' hands and clothing .EBP are indicated for residents with .indwelling medical devices .examples include .urinary catheters .For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: dressing, bathing/showering, providing hygiene .device care . 1. On 3/25/25 at 8:58 AM, Surveyor observed medication administration for R121 and noted LPN-D did not complete hand hygiene prior to: preparing medication for R121, entering R121's room, obtaining R121's temperature and blood pressure, administering R121's medication, and providing water. LPN-D also did not complete hand hygiene after exiting R121's room. 2. On 3/25/25 at 9:10 AM, Surveyor observed medication administration for R124 and noted LPN-D did not complete hand hygiene prior to: preparing medication for R124, entering R124's room, administering R124's medication, and providing a supplement drink. LPN-D also did not complete hand hygiene after exiting R124's room. 3. On 3/25/25 at 9:14 AM, Surveyor observed wound care for R127. Surveyor noted LPN-D entered R127's room and did not complete hand hygiene. LPN-D donned gloves and observed R127's left heel wound. LPN-D removed gloves and exited R127's room without completing hand hygiene. LPN-D then entered a medication storage room, obtained a bandage, and exited the storage room without completing hand hygiene. LPN-D then entered R127's room and applied a bandage without completing hand hygiene and donning gloves. LPN-D then exited R127's room without completing hand hygiene. 4. On 3/25/25 at 9:27 AM, Surveyor observed medication administration for R58 who was on EBP. Surveyor noted LPN-D did not complete hand hygiene prior to: preparing medication for R58, entering R58's room, obtaining R58's temperature and blood pressure, administering R58's medication, and providing water. LPN-D also did not complete hand hygiene after exiting R58's room. On 3/25/25 at 9:37 AM, Surveyor interviewed LPN-D regarding hand hygiene during medication administration and cares for R121, R124, R127, and R58. LPN-D verified LPN-D did not complete hand hygiene while entering and existing residents' rooms, prior to wound care, and during medication administration. On 3/25/25 at 1:22 PM, Surveyor interviewed Registered Nurse (RN)-H regarding hand hygiene during medication administration and cares. RN-H indicated hand hygiene should be complete prior to preparing medication and entering residents' rooms, before and after wound care, and after exiting residents' rooms. 5. From 3/24/25 to 3/26/25, Surveyor reviewed R19's medical record. R19 was admitted to the facility on [DATE] and had diagnoses including urine retention and neuropathic bladder with chronic suprapubic urinary catheter. R19's Minimum Data Set (MDS) assessment, dated 12/25/24, indicated R19 had intact cognition. R19's care plan, dated 12/20/24, indicated R19 was on EBP related to a urinary catheter. On 3/24/25 at 10:54 AM, Surveyor interviewed R19 who indicated nursing staff are inconsistent with wearing gowns when providing catheter care. On 3/26/25 at 10:25 AM, Surveyor observed CNA-K provide catheter care for R19. CNA-K did not wear a gown while providing catheter care. On 3/26/25 at 10:40 AM, Surveyor interviewed CNA-K who indicated nursing staff typically wear gloves but not a gown during catheter care. CNA-K indicated CNA-K did not receive education regarding EBP. On 3/26/25 at 10:48 AM, Surveyor interviewed CNA-L who indicated CNA-L did not receive education regarding EBP.

Based on staff and resident representative interview and record review, the facility did not ensure 2 residents and their representatives (R) (R1 and R6) of 20 sampled residents were informed of care conferences. R1 and R6's representatives were not informed of R1 and R6's care conferences. Findings include: The facility's Care Conference Policy, revised 6/20/23, indicates: .To provide interdisciplinary communication with the resident and/or their legal representative for purposes of the development of an individualized comprehensive plan of care .2. A calendar of resident conferences shall be distributed to the interdisciplinary team. 3. The resident and/or their responsible party will receive communication in advance of the scheduled care conference .7. The Care Conference UDA .should be completed for attendance for tracing and record of discussion. 1. From 3/24/25 to 3/26/25, Surveyor reviewed R1's medical record. R1 received Hospice services and was admitted to the facility on [DATE]. R1 had diagnoses including diabetes and congestive heart failure. R1's Minimum Data Set (MDS) assessment, dated 2/7/25, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R1 had intact cognition. R1 had a Statement of Incapacity (SOI), dated 7/10/24, and had an activated Power of Attorney for Healthcare ((POAHC)-M). On 3/24/25 at 11:34 AM, Surveyor interviewed POAHC-M who indicated POAHC-M was not informed of any care conferences and had not attended any care conferences since R1 was admitted to the facility. On 3/25/25 at 11:29 AM, Surveyor interviewed Social Worker (SW)-G who confirmed care conferences were completed quarterly. SW-G indicated R1 attended a care conference on 2/26/25. SW-G indicated POAHC-M does not attend R1's care conferences due to work. SW-G indicated the facility informs POAHC-M of the care conferences, however, POAHC-M does not want to attend. SW-G indicated R1 has only had one care conference since admission on 7/31/24. SW-G indicated SW-G does verbal notification and does not document when SW-G informs residents or their representatives of care conferences. SW-G confirmed there was no documentation that POAHC-M was notified of R1's care conferences and verified only R1 attended the care conference. Surveyor reviewed R1's care conference summaries dated 7/31/24, 11/6/24, and 2/26/25. Documentation indicated only R1 was present. There was no documentation that POAHC-M was notified or attended. 2. From 3/24/25 to 3/26/25, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including respiratory failure, dementia, and anxiety. R6's MDS assessment, dated 1/2/25, had a BIMS score of 11 out of 15 which indicated R6 had moderate cognitive impairment. R6 had an SOI, dated 10/31/23, and an activated POAHC (POAHC-N). On 3/24/25 at 12:08 PM, Surveyor interviewed POAHC-N who indicated POAHC-N was not informed of care conferences and had not attended a care conference since R6 was admitted to the facility. On 3/25/25 at 11:32 AM, Surveyor interviewed SW-G regarding R6's care conferences. SW-G indicated SW-G does a verbal invite to care conferences but does not document the invite. SW-G indicated R6's last care conference was in January 2025 and included R6, nursing staff, and activity staff. SW-G was unsure if POAHC-N was present. SW-G indicated POAHC-N does not come to the facility on the same day as R6's care conferences, however, the facility can be flexible with care conferences. When Surveyor asked if there were any attempts to coordinate dates and times with resident representatives, SW-G indicated SW-G usually has written times and calls representatives, however, if there is not a written time for the resident then SW-G completed a verbal notification. SW-G indicated POAHC-N probably could not come or was not notified of the care conference. SW-G indicated if POAHC-M and POAHC-N indicated they were not notified that could be because the facility did not notify them. Surveyor reviewed R6's care conference summaries dated 8/6/24, 11/5/24, and 1/14/25. Documentation indicated only R6 was present. There was no documentation that POAHC-N attended, was invited, or was notified. On 3/26/25 at 10:09 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated resident representatives should be invited to care conferences quarterly. NHA-A indicated notification of care conferences and participants should be documented.

Based on staff and resident representative interview and record review, the facility did not ensure written notification for a roommate was provided for 1 resident (R) (R6) of 2 sampled residents. R6 received a roommate on 3/20/25. R6's representative was not notified prior to the move. Findings include: The facility's Room Change policy, revised 3/17/23, indicates: The facility will move the resident and their belongings safely and with the least possible confusion for the resident. The resident's preferences should be considered when making a room or roommate change. Whenever a resident is transferred from one room to another within the facility, a written notice of transfer must be given to the resident and/or family prior to the move according to state law .1. If a resident is moving at the request of staff, a written explanation of why the move is necessary needs to be provided to both residents/families/representatives as one is getting a room change and the other is getting a new roommate. 2. Obtain the resident/durable power of attorney's agreement to the transfer. The agreement may be verbal with documentation on the room change form of discussion. 3. The resident should be provided with a tour of the new location, have a chance to meet his/her new roommate, and express any concerns about the move. 4. The notice is given in advance, except in situations outside the facility's control such as: change in level of care as determined by utilization review, change in a medical or treatment program, or your or another resident's welfare documented in the medical record . From 3/24/25 to 3/26/25, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including respiratory failure, dementia, and anxiety. R6's Minimum Data Set (MDS) assessment, dated 1/2/25, had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R6 had moderate cognitive impairment. R6 had a Statement of Incapacity (SOI), dated 10/31/23, and an activated Power of Attorney for Healthcare ((POAHC)-N). On 3/24/25 at 12:08 PM, Surveyor interviewed POAHC-N who indicated POAHC-N was not informed in advance of a roommate moving into R6's room. POAHC-N indicated POAHC-N went to the facility on [DATE] to discuss with Social Worker (SW)-G why POAHC-N was not notified in advance of the move. On 3/25/25 at 11:21 AM, Surveyor interviewed SW-G regarding notification of residents/representatives of room changes/roommates. SW-G indicated notification depends on if the move is an emergency or not and indicated notification is usually given 24 hours before the move. When Surveyor asked if POAHC-N was notified of R6's roommate, SW-G was unsure. SW-G stated SW-G notified R6 on 3/20/25 but indicated R6 was forgetful. SW-G documented the notification on 3/21/25. SW-G confirmed R6's roommate moved in on 3/20/25. SW-G confirmed POAHC-N came to the facility to discuss the situation on 3/23/25 and made SW-G aware that POAHC-N did not receive advance notice. SW-G indicated POAHC-N should have been notified at least 24 hours before R6 received a roommate. On 3/26/25 at 10:09 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated resident representatives should be notified in writing of room changes/roommates prior to the room change or addition of a roommate.

Based on observation, staff interview, and record review, the facility did not ensure a clean or home-like environment for 1 resident (R) (R41) of 20 sampled residents. R41's bedside tray table was not in a clean condition. Findings include: The facility did not have a policy regarding a clean, comfortable, and home-like environment. The facility provided an untitled and undated cleaning list that indicated: Resident Room Over-Bed Tables, scrub all areas of table (legs, base, stand, table top and table bottom). Polish if necessary. From 3/24/25 to 3/26/25, Surveyor reviewed R41's medical record. R41 was admitted to the facility on [DATE] and had diagnoses including schizoaffective disorder, bipolar type, bipolar disorder, anxiety disorder, dementia, muscle weakness, lymphedema, and pain in right and left knee. R41's Minimum Data Set (MDS) assessment, dated 3/15/25, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R41 had moderately impaired cognition. R41 had a corporate Guardian for decision making. R41's care plan, dated 12/19/24, indicated R41 had limited physical mobility related to schizophrenia, obesity, and dementia. A nutrition care plan, revised 3/17/25, indicated R41 preferred to eat in R41's room and could eat independently with set up assistance. R41 liked cranberry juice and/or milk with meals. On 3/24/25 at 12:24 PM, Surveyor observed staff place a lunch tray on R41's bedside table. Staff set up the tray and R41 slowly ate with a fork. R41 picked up a cup throughout the meal and drank cranberry juice. R41's movements were slow and R41 closed R41's eyes frequently. On 3/25/25 at 12:24 PM, Surveyor again observed staff serve R41's lunch tray. Staff placed the tray on R41's bedside table and completed set up assistance. R41 again used a fork and ate with slow movements. R41 also drank juice throughout the meal with slow movements. On 3/25/25 at 3:21 PM, Surveyor entered R41's room with Licensed Practical Nurse (LPN)-C who interacted with R41 and noted a piece of food in R41's bed. LPN-C removed the piece of food. Surveyor noted R41's bedside table contained 2 dried liquid stains. On 3/25/25 at 4:27 PM, Surveyor observed R41's bedside table again and noted the 2 liquid stains were still there. On 3/26/25 at 9:19 AM, Surveyor entered R41's room with LPN-C and observed 2 pieces of dried and shriveled food on R41's bedside table. When Surveyor asked if R41 had eaten breakfast, LPN-C indicated R41 refused breakfast that morning. When Surveyor asked how often bedside tables were cleaned, LPN-C was not sure and indicated the dried food was probably from the day before. LPN-C confirmed staff should wipe R41's bedside table after meals because R41 used the bedside table for all meals. On 3/26/25 at 1:04 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated R41's bedside table should be cleaned if it is visibly dirty.

Based on staff and resident interview and record review, the facility did not ensure care plans were updated for 3 residents (R) (R41, R10, and R37). R41 had an order to float heels. R41's care plan was not updated with the order and R41's heels were not floated. R10 and R37 had a known conflict with each other. R10's and R37's care plans did not reflect the conflict and did not contain interventions for redirection or how to avoid altercations. Findings include: The facility's Care Plan-Baseline and Comprehensive policy, dated 6/20/23, indicates: .12. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 1. From 3/24/25 to 3/26/25, Surveyor reviewed R41's medical record. R41 was admitted to the facility on [DATE] and had diagnoses including schizoaffective disorder, bipolar type, dementia, patients non-compliance with medical treatment and regimen, muscle weakness, bilateral primary osteoarthritis of knee, peripheral vascular disease, and pain in right and left knee. R41's Minimum Data Set (MDS) assessment, dated 3/15/25, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R41 had moderate cognitive impairment. R41 had a corporate Guardian for decision making. R41's care plan (dated 3/19/23) indicated R41 had pain related to the right knee and peripheral vascular disease. R41 also had a care plan (revised 2/9/25) related to potential for impairment to skin integrity related to decreased mobility and incontinence. R41 had no history of pressure injuries or skin impairment. R41's medical record indicated a Nurse Practitioner (NP) saw R41 on 3/18/25 and noted R41 had weakness in both lower extremities and staff should continue to assist R41 with cares and mobility. R41's heels were floated on a pillow during the visit which relieved R41's heel pain. The NP wrote an order for R41's heels to be floated on a pillow when in bed. Surveyor noted an order in R41's medical record, dated 3/18/25, to float heels while in bed. On 3/25/25, Surveyor reviewed R41's care plan and Kardex (an abbreviated care plan used by nursing staff) which did not contain the intervention. On 3/25/25 at 1:49 PM, Surveyor entered R41's room with Licensed Practical Nurse (LPN)-C who lifted R41's sheets and confirmed there was not a pillow under R41's heels. LPN-C indicated the order to float heels was a new order. When Surveyor informed LPN-C the order was not on R41's care plan or Kardex, LPN-C indicated if the order was not there, the Certified Nursing Assistants (CNAs) would not know to do it. LPN-C then floated R41's heels on a pillow which R41 was agreeable to. On 3/26/25 at 9:19 AM, Surveyor entered R41's room with LPN-C and checked R41's heels. LPN-C indicated staff did not put the pillow in the correct position. The pillow was below R41's knees and R41's heels were sideways in the bed. LPN-C adjusted the pillow and R41 was agreeable to the adjustment. On 3/26/25 at 1:04 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed if the order to float R41's heels was entered on 3/18/25, R41's care plan and Kardex should have been updated right away. 2. From 3/24/25 to 3/26/25, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had diagnoses including schizoaffective disorder and dementia. R10's MDS assessment, dated 12/27/24, had a BIMS score of 15 out of 15 which indicated R10 was not cognitively impaired. R10 had a court-appointed Guardian. From 3/24/25 to 3/26/25, Surveyor reviewed R37's medical record. R37 was admitted to the facility on [DATE] and had diagnoses including cognitive impairment. R37's MDS assessment, dated 12/30/24, had a BIMS score of 13 out of 15 which indicated R37 was not cognitively impaired. On 3/24/25 at 12:38 PM, Surveyor interviewed R10 who indicated R37 (who lived across the hall from R10) is mean to everyone including the staff. R10 indicated one day R10 was in R37's way and R37 tapped R10 on the shoulder. R10 indicated R10 turned around and did it back to R37. R10 indicated R37 won't move for staff or the paramedics if R37 is in the way and swears at staff. In a subsequent interview, R10 was asked if R10 wanted to move to a different room. R10 indicated R10 is not going to move. R10 indicated R10 avoids R37 and does not like the way R37 treats people. On 3/25/25 at 1:48 PM, Surveyor interviewed CNA-E who works on R10 and R37's unit regularly. CNA-E indicated CNA-E was not aware of any physical aggression and indicated it was only verbal banter. CNA-E indicated R10 and R37 live across the hall from each other and R10 likes to keep R10's doors open. CNA-E indicated staff intervene and redirect if they see R10 and R37 in the hall together On 3/25/25 at 2:06 PM, Surveyor interviewed LPN-C who confirmed R10 and R37 do not like each other and have yelled at each other. LPN-C indicated it was worse on the PM shift. LPN-C indicated management is aware. LPN-C indicated R37 is usually gruff and crabby. On 3/25/25 at 4:33 PM, Surveyor interviewed CNA-F who is familiar with R10 and R37 and works the PM shift on their wing. CNA-F confirmed R10 and R37 have a conflict with each other, however, CNA-F had never heard or seen anything physical. CNA-F indicated R10 and R37 yell at each other and staff intervene. On 3/26/25 at 11:07 AM, Surveyor interviewed Social Worker (SW)-G who indicated R10 and R37 do not like each other. SW-G indicated if R10 does not like someone, R10 makes mean comments. SW-G indicated R37 is direct and gruff and will tell R10 to get out of the way. SW-G indicated it is a normal conflict of two people who do not like each other. SW-G was not aware of any physical altercations and stated R10 and R37 try to avoid each other. SW-G stated SW-G has had conversations with R10 and R37 and staff inform SW-G when there is an issue. SW-G indicated R10 and R37 have conflicts with other residents as well. SW-G stated R10 and R37 have been offered to move but both declined and feel the other should move. SW-G indicated R10 and R37's conflicts are not usually documented or care planned. On 3/26/25 at 11:11 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated R10 and R37 are matter of fact and boisterous. R10 bothers R37 when R10 yells from R10's room. R37 does not like anyone to get in R37's path and tells R10 that R10 is in the way. NHA-A indicated both residents raise their voices but there has not been any physical aggression. NHA-A indicated NHA-A has spoken frequently to R10 and R37 about their conflict. NHA-A did not feel the interactions were verbally abusive but were personality conflicts. NHA-A indicated neither resident wants to move. Surveyor indicated Surveyor could not locate any documentation of a conflict between R10 and R37 and what staff should do in either of R10 or R37's care plans. Surveyor also informed NHA-A that R10 stated R37 tapped R10 on the shoulder approximately a month ago and R10 did the same thing back. NHA-A was not aware of the incident. NHA-A indicated the conflict between R10 and R37 could be addressed in their care plans.

Based on staff interview and record review, the facility did not ensure range of motion exercises were completed in accordance with a range of motion program for 1 resident (R41) of 20 sampled residents. Documentation for R41's range of motion (ROM) program was not completed accurately and/or was not completed. Findings include: From 3/24/25 to 3/26/25, Surveyor reviewed R41's medical record. R41 was admitted to the facility on [DATE] and had diagnoses including schizoaffective disorder, bipolar type, dementia, patients non-compliance with medical treatment and regimen, muscle weakness, bilateral primary osteoarthritis of knee, peripheral vascular disease (PVD), and pain in right and left knee. R41's Minimum Data Set (MDS) assessment, dated 3/15/25, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R41 had moderately impaired cognition. R41 had a corporate Guardian for decision making. A care plan (revised 12/19/24) indicated R41 had limited physical mobility related to schizophrenia, obesity, and dementia. The care plan contained an intervention (dated 4/11/24) for ROM daily. On 3/26/25 at 12:24 PM, Surveyor interviewed Therapy Director (TD)-J who indicated R41 was seen by therapy from 3/21/24 to 4/10/24. The goal for therapy was to get R41 to sit up in bed more. TD-J indicated R41 was discharged from therapy on 4/10/24. A daily ROM daily program was implemented on 4/11/24. The ROM program included heel slides, straight leg raises, hip abductions, and dorsal flexions. TD-J indicated the therapy note stated staff were trained, however, therapy staff put examples of exercises in the room for staff to reference. TD-J indicated any type of ROM for R41 would be good. On 3/26/25, Surveyor reviewed the ROM task in R41's medical record which indicated: Lower extremity ROM bilateral - heel slides, dorsiflexion/plantarflexion, hip flexion, and hip abduction 10 reps daily. Certified Nursing Assistant (CNA) staff were asked: Task completed? Staff could choose: 0 = Yes, 1 = No, 2 = Resident not available, 3 = Resident refused, or 4 = Not applicable. ROM documentation for R41 from 1/1/25 through 3/25/25 indicated the following: ~ Six days had no documentation ~ Seven days indicated NA (4) ~ Thirty five days indicated No (1) ~ Thirty days indicated Yes (0) ~ Four days indicated R41 refused (3) Surveyor noted Certified Nursing Assistant (CNA)-E frequently documented a 1 on the task which indicated ROM was not completed. On 3/26/25 at 12:56 PM, Surveyor interviewed CNA-E about consistently documenting No for R41's ROM task. CNA-E indicated R41 usually refused ROM. When Surveyor asked why CNA-E did not document that R41 refused instead of indicating ROM was not completed, CNA-E indicated CNA-E was not aware there was an option for refused. On 3/26/25 at 1:04 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed documentation should be completed daily. DON-B also indicated the documentation should be accurate. DON-B indicated if R41 refuses, the documentation should indicate the refusal.

Based on staff interview and record review, the facility did not ensure 1 resident (R) (R56) of 5 sampled residents received influenza and COVID-19 vaccines as indicated. Upon admission to the facility, R56's Power of Attorney for Health Care (POAHC) signed a consent form for R56 to receive influenza and COVID-19 vaccines. The vaccines were not administered. Findings include: The facility's Seasonal Influenza Vaccine Policy, revised 9/19/24, indicates: The Centers for Disease Control and Prevention (CDC) guidelines and recommendations are followed for the prevention and control of seasonal influenza .6. For residents and/or legal representatives consenting to receiving the seasonal influenza vaccine, the facility shall obtain a physician's order for the administration of the vaccine .8. Administration of the vaccine will be done upon a signed consent and valid physician's order and shall be recorded in the medical record. The facility's COVID-19 Vaccine Policy, revised 9/19/24, indicates: The CDC recommends residents of long-term care facilities receive a COVID-19 vaccine to help save the lives of those who are most at risk of dying from COVID-19 .6. For residents and/or legal representatives consenting to receiving the COVID-19 vaccine, the facility shall obtain a physician's order for the administration of the vaccine .8. Administration of the vaccine will be done upon a signed consent and valid physician's order and shall be recorded in the medical record. On 3/25/25, Surveyor reviewed R56's medical record. R56 was admitted to the facility on [DATE] and had diagnoses including eosinophilia, Alzheimer's disease, dementia, and cognitive communication deficit. R56's Minimum Data Set (MDS) assessment, dated 1/22/25, had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R56 had moderate cognitive impairment. R56 had an activated POAHC who assisted with healthcare decisions. R56's medical record included a consent form to receive an influenza vaccine signed by R56's POAHC on 1/16/25. R56's medical record also contained a consent form to receive a COVID-19 vaccine signed by R56's POAHC on 1/16/25 and 3/24/25. On 3/25/25 at 4:14 PM, Surveyor interviewed Director of Nursing (DON)-B who verified R56's POAHC signed a consent for R56 to receive the influenza vaccine on 1/16/25 and signed a consent for R56 to receive a COVID-19 vaccine on 1/16/25 and 3/24/25. DON-B stated staff did not obtain physician orders for the influenza and COVID-19 vaccines and R56 did not receive the vaccines. DON-B stated it is the facility's practice to obtain an order to administer a vaccine after consent is obtained for a single dose vaccine within 1 business day. DON-B stated the facility had an influenza clinic on 2/13/25 but R56 did not receive the vaccine.

Based on observation, staff interview, and record review, the facility did not provide a safe, functional, sanitary, and comfortable environment for residents on 3 of 3 units. Utility rooms on all 3 units contained dust, debris, stains, and an odor of bodily waste, In addition, Surveyor observed risks of cross-contamination. Findings include: On 8/21/24, Surveyor completed a tour of the facility, including the soiled utility rooms (enclosed spaces meant to remove waste generated by resident care and soiled cleaning materials). On 8/21/24 at 11:31 AM, Surveyor toured the soiled utility room on unit 2. Upon opening the door, Surveyor noted an odor of human waste. Surveyor observed two uncovered trash containers that contained garbage bags with resident waste. Surveyor also observed dust, debris, and stains on the floor, stains on the walls, and several small garbage cans stacked to the side with an empty soda bottle. On 8/21/24 at 11:38 AM, Surveyor toured the soiled utility room on unit 4. Upon opening the door, Surveyor noted an odor of human waste. Surveyor observed two brooms with clumps of dust on the bottom and a dirty dust bin hung on the wall. The room contained a utility hopper sink (meant for proper and safe disposal of contaminated material) that was half-full of brown water and a pink plastic biohazard bag that covered the handles. On top and in front of the sink were two resident commodes. There was a raised sink next to the utility sink that contained dust and debris and a clogged drain. There was an open ceiling tile above the standard sink with exposed ceiling pipes that contained dust and debris. Surveyor also observed three plastic storage bins that contained personal protective equipment (PPE) (used by staff for infection prevention and control). There was brown liquid, a brief, and other soiled material on top of one of the bins and the floor contained dust, debris, and stains. On 8/21/24 at 1:10 PM, Surveyor and Nursing Home Administrator (NHA)-A toured the soiled utility room on unit 1. Surveyor observed and NHA-A confirmed the utility room contained dust, debris, and stains on the floor and had an odor of human waste. The room also contained two sinks. One sink was lined with a black garbage bag that contained a roll of clear garbage bags and appeared stuck to the sink when lifted by NHA-A. The second sink also contained a roll of clear garbage bags. Surveyor and NHA-A then toured the soiled utility rooms on units 2 and 4 and Surveyor's concerns were acknowledged by NHA-A who stated there was turnover in the housekeeping department and the facility hired a new housekeeping manager the previous week. On 8/21/24 at 1:55 PM, Surveyor interviewed NHA-A who provided cleaning schedules and the housekeepers' checklists. Surveyor noted the unit cleaning list included Utility Closet-Take Out Garbage. NHA-A stated NHA-A instructed housekeeping staff to immediately clean the soiled utility rooms. NHA-A stated the ceiling tile was replaced and the sinks were emptied and cleaned by maintenance staff. NHA-A stated NHA-A also spoke with staff regarding the concern that clean PPE was stored in the soiled utility room and instructed staff to wipe down and throw out all material in the bins. NHA-A stated the housekeeping manager should audit the housekeeping task list to ensure tasks are being completed appropriately.

Based on observations, record review and staff and resident interviews, the facility did not ensure that 2 Residents (R) (R1 and R2) of 18 sampled resident environments remained as free of accident hazards as possible. R1 was assessed to have poor safety awareness/poor health care decision making skills but was still deemed as own decision maker. R1 had a continual, non re-directable behavior of wheeling electric wheel chair very close to the front of the bedroom heater wall unit with the unit thermostat set on the highest heat setting (85 degrees F (Fahrenheit)), and blocking the intake air flow to the unit, which caused the air temperature at the unit's air discharge area to rise to unsafe levels. R1 would often fall into a deep sleep and the right hand was noted on several occasions to be resting on top of the unit. R1 had a [DIAGNOSES REDACTED]. R1 had recently been readmitted after a hospital stay for urosepsis and was receiving IV (Intravenous) infusion of antibiotics. On 3/9/19, R1 presented with significant second [MEDICAL CONDITION] the back of the right hand related to prolonged contact with the heating unit in R1's room. No changes to R1's plan of care were initiated prior to the injury when R1 continually sat next to the heat unit and was not able to be redirected away from the heating unit, and no appropriate and effective preventative interventions were implemented after the burn occurred so like injuries would not occur in the future. (This incident caused actual harm to the resident and is being cited at a scope/severity of G.) R2 attempted to close the closet door (bifold) and the closet door fell off the hinge because of the design of the closet doors. R2 sustained a contusion to the left hip. The doors remained a safety hazard to other residents. Additionally, R2 did not have a care plan related to potential for falls prior to the fall even though R2 had falls noted prior to admission. The design of the bi-fold closet doors had the potential to affect 9 of the 13 residents on the 400 wing who are ambulatory and who could access the closet. Findings include: 1. The Standard Guide for Heated System Surface Conditions That Produce Contact Burn Injuries, C 1055-03, reapproved in 2014, by The American Society For Testing Materials, indicates the following: 1.1 This guide covers a process for the determination of acceptable surface operating conditions for heated systems. The human burn hazard is defined, and methods are presented for use in the design or evaluation of heated systems to prevent serious injury from contact with the exposed surfaces. 1.2 The maximum acceptable temperature for a particular surface is derived from an estimate of the possible or probable contact time, the surface system configuration, and the level of injury deemed acceptable for a particular situation. 1.3 For design purposes, the probable contact time for industrial situations has been established at 5 s (seconds). For consumer products, a longer (60-s) contact time has been proposed by Wu (1)2 and others to reflect the slower reaction times for children, the elderly, or the infirm. 1.4 The maximum level of injury recommended here is that causing first [MEDICAL CONDITION] the average subject. This type of injury is reversible and causes no permanent tissue damage. For cases where more severe conditions are mandated (by space, economic, exposure probability, or other outside considerations), this guide may be used to establish a second, less desirable injury level (second degree burns), where some permanent tissue damage can be permitted. At no time, however, are conditions that produce third [MEDICAL CONDITION]. 3.1.5 burns: 3.1.6 first degree burn-the reaction to an exposure where the intensity or duration is insufficient to cause complete necrosis of the epidermis. The normal response to this level of exposure is dilation of the superficial blood vessels (reddening of the skin). 3.1.7 second degree burn-the reaction to an exposure where the intensity and duration is sufficient to cause complete necrosis of the epidermis but no significant damage to the dermis. The normal response to this exposure is blistering of the epidermis. 5.4 This guide is meant to serve only as an estimation of the exposure to which an average individual might be subjected. Unusual conditions of exposure, physical health variations, or nonstandard ambients all serve to modify the results. X1.2.3.2 The lowest temperature where epidermis (outside skin layer) damage occurs is approximately 44°C (Celsius) (~111 degrees F) when it is sustained for approximately 6 h (hours). It is possible to extrapolate this result to conclude that longer exposures might cause damages at temperatures below 44°C. X1.2.3.3 As the temperatures of contact increase above 44°C, the time to damage is shortened by approximately 50% for each 1°C rise in temperature up to about 51°C (~124 degrees F). Figure 1: Temperature-Time Relationship [MEDICAL CONDITION] the above referenced document indicates that contact skin temperatures of 124 degrees F (~51.1 degrees C) can produce first [MEDICAL CONDITION] an average individual in approximately 2 minutes and could result in a second degree burn in less than 10 minutes. 1. R1 was readmitted to the facility on [DATE] after a hospital stay for treatment of [REDACTED]. R1 had [DIAGNOSES REDACTED]. The resident was own decision maker. R1 presented with poor safety awareness and poor health care decision making skills as evidenced by review of nursing entries and current plan of care. These indicated R1 would often be seated in electric wheel chair for up to 36 hours at a time; banging into walls with electric wheel chair; unsafe smoking practices; use of alcohol and illegal substances; not donning a coat when exiting the facility in extreme cold weather; refusal of bowel incontinence cares; refusal of supra pubic catheter cares; refusal of personal hygiene; and refusal to be redirected when R1 would continually sit directly in front of the heating unit in room blocking the heater air intake vents; and constantly requesting staff turn heater up to maximum thermostat setting of 85 degrees F. (This practice, when combined with placing wheel chair in front of the intake vents which blocked the air vents, caused the air temperature at the unit's air discharge area to rise to unsafe levels.) When staff attempted redirection regarding these behaviors, R1 would become verbally abusive and resist all attempts at redirection related to these unsafe behaviors. It was noted that R1 was unable to turn the wall heater unit on or adjust the temperature control without assistance of staff or family members. R1's most recent quarterly MDS (Minimum Data Set) dated 2/7/19, indicated R1 was assessed by the facility to score a 14 of 15 on the cognitive screen (the higher the score, the more cognizant) and had range of motion deficits of both upper and lower extremities. R1's most current safety plan of care and care kardex reviewed by the Surveyor on 3/12/19, noted that the safety concern regarding R1's behavior of sitting directly in front of the wall heating unit blocking the air intake vents, often falling into a deep sleep with right hand directly on top of the unit where heated air blows out of the unit, was not listed with interventions to prevent the unsafe behavior. The current plan of care also did not list effective ways of how staff were to redirect R1 when the resident consistently requested staff to turn the heating unit to the maximum air temperature while seated directly in front of the unit. R1's progress notes in the medical record indicated several documented notes beginning on 12/27/19 that noted R1 was sitting directly in front of the bedroom wall heater unit with the air temperature thermostat reading set at the highest level of 85 degrees F. Some of the entries indicated staff attempted to redirect R1 away from the heater and turn down the heat which R1 refused to comply with and other entries did not document that R1 had been redirected away from the safety hazard. On 3/12/19 at 8:15 a.m., the Surveyor interviewed both CNA (Certified Nursing Assistant)-C and CNA-D. Both staff verified to the Surveyor that R1 continually sits next to the heating unit in room blocking the air intake vents with electric wheel chair with heat turned up to the maximum temperature and constantly asks staff to turn the temperature up to the maximum setting. Staff both verified that they attempt to redirect R1 away from the heating unit and tell R1 it is not a good idea to turn the heat all the way up but R1 becomes very agitated and verbally abusive so staff will not move R1 away from the unit and turn up the temperature as requested. On 3/12/19 at 9:10 a.m., the Surveyor interviewed COTA-G via the telephone. COTA-G stated, I observed (R1) while walking by room on 3/9/19. (R1) isn't on my case load at this time but I can tell when (R1) is sleeping in (R1's) chair by (R1's) posture. I went in there late morning and noticed (R1) was sitting right in front of the wall heater with right hand directly on the top of the heater. (R1) was in such a deep sleep that I could not wake (R1). When in that deep of a sleep, (R1) has a tendency for right arm to slip off wheel chair arm. I put (R1's) arm back into (R1's) lap. Just shortly after lunch, I noticed (R1) in the same position sleeping next to wall heater with right hand directly on top of heater unit so I moved it again and told the CNA staff about it. I have removed (R1's) hands several times in the past off the heater but have never noticed any burns. I know I talked to staff about this in either (MONTH) or (MONTH) of 2019. I was concerned because I know (R1) can't feel much in the upper extremities. When (R1) is napping, you cannot wake (R1) up. (R1) was very 'out of it' on 3/9/19 when I tried to wake (R1). (R1) just opened (R1's) eyes, then the eyes rolled back in (R1's) head and (R1) closed eyes again. I couldn't get a verbal response at all from (R1) either time I entered (R1's) room that day. I will have to look at my notes because I know I charted that I talked to staff about this before 3/9/19 and also on 3/9/19. There was a CNA in the room at one point and that CNA saw me move (R1's) hand off the heat unit, but I can't remember that staff member's name. (On 3/13/19 at approximately 2:30 p.m., NHA-E was interviewed by the Surveyor via telephone and relayed that COTA-G could not locate the above noted documentation in the record but indicated COTA-G knew the information had been documented.) The Surveyor interviewed NHA (Nursing Home Administrator)-E on 3/12/19 at 7:45 a.m. NHA-E stated, On 3/9/19, (R1) fell asleep in front of the heater in room. (R1) had been told constantly not to sit in front of the heater. Staff were in (R1's) room several times that day offering to lay (R1) down, but (R1) refused. (R1) gets very angry and verbally abusive when redirected. The staff placed (R1's) right arm back on lap several times because the hand had slipped off onto the heater. (R1) presented with a second degree burn to the back of the right hand. We initiated 30 minute checks of (R1) after that and started an investigation but that didn't include to check what the heat was set at. We checked all heaters in the building. (R1) asks staff and family and friends to turn the heat up to the maximum temperature. We had discussed placing a cage over the heater but were concerned about resident rights. During the time (R1) got burned, the air thermostat was set at 85 degrees F. All heaters are now set at a maximum temperature of 76 degrees F. Besides the frequent checks, we also tell (R1) to move away from the heater, but (R1) is very defiant. A nursing entry documented in R1's medical record dated 3/9/19 at 6:36 p.m. indicated, Resident reported fluid filled blisters right third, fourth and fifth finger. 0.6 cm (centimeters) x 0.4 cm x 0.3 cm smallest and 1 cm x 1.6 cm x .5 cm largest. Surrounding skin red/pink measures 9 cm x 8.5 cm. Resident stated had glove on with metal on it and fell asleep by heater. On call physician updated. New order for [MEDICATION NAME] cream and non adhesive dressing twice daily. Refused offer of Tylenol. Stated pain was 7 of 10 (the higher the pain number, the more pain; 7 indicates severe pain). On 3/12/19 at 1:30 p.m., the Surveyor interviewed RN (Registered Nurse)-B via the telephone. RN-B had completed the assessment of R1's burn on 3/19/19. RN-B stated, I was alerted at about 3:00 p.m. about (R1's) hand. I did a brief assessment and there was no blistering at that time, the top of the hand was just red/pink. (R1) insisted on leaving the facility so when the resident came back at approximately 6:00 p.m., I assessed the hand again and noted the blisters, so I notified the physician on call and received treatment orders. Review of black and white photographs obtained from R1's family member of the top of R1's right hand indicated the entire hand and all five digits were very [MEDICAL CONDITION] (swelling due to excess fluid) with two large fluid filled blisters on the little finger; one very large fluid filled blister on the fourth finger; three small fluid filled blisters on the third finger; one small fluid filled blister on the second finger; and two large and two small fluid filled blisters on the top of the hand. On 3/12/19 at 8:00 a.m., the Surveyor entered R1's room and observed R1 was in bed. The Surveyor observed the wall heating unit in R1's room. The unit was on the wall under the window at approximately upper thigh height and the air temperature was set at 76 degrees F. The entire unit was made of plastic. Intake air flow vents were located across the entire front of the unit. The Surveyor interviewed R1 and R1 stated had fallen asleep next to the room heater on 3/9/19 and had awakened due to the feeling that right hand was hot. R1 then alerted staff. R1 indicated R1 likes to sit right up next to the heater with electric wheel chair sideways next to the heater because, I'm always cold. R1 verified to the Surveyor that R1 has limited movement of both upper extremities and has little to no sensation in upper extremities. R1 also stated, I ask my mom or the staff to turn up the heat for me and they do it. On 3/12/19 at 8:30 a.m., the Surveyor interviewed NP (Nurse Practitioner)-F. NP-F verified to the Surveyor having examined R1 on 3/11/19 and R1 did have second [MEDICAL CONDITION] top of right hand which staff communicated to the NP were due to R1 falling asleep with right hand on top of the heater in room. NP-F indicated had ordered a right hand x-ray due to unusual bruising of top of hand. The x-ray was completed on 3/12/19 and was negative with the exception of soft tissue swelling of the fifth finger. On 3/12/19 at 9:40 a.m., the Surveyor interviewed MS (Maintenance Supervisor)-O. MS-O stated, We do occasional audits of the air temperature settings in the resident rooms and feel the top of the heating units. The thermostats are set for a range of 60-85 degrees F and are electric heat units. If the unit becomes extremely hot, there is a thermal overload unit that will kick the unit to off. I did investigate on 3/11/19 what could be done to (R1's) heat unit with the manufacturer of the unit. They gave me five options: Educate the resident, set heat limit to 76 degrees F but that won't regulate how hot the unit gets, it will just not run as often; use of a guard (physical barrier around unit); we could move the resident to a room that has electric baseboard heat unit with a guard on it; and to instruct staff to increase number of times rooms checks are done. My feeling is that if R1 is parked next to the unit and blocking the air intake vents with the wheel chair, the unit can't get enough airflow so the air coming out of the top of the unit will be a lot hotter, but if it gets too hot, it would kick off due to the thermal overload. I don't know how hot it would get before that happens. I would have to call the manufacturer. I have not checked yet exactly what the temperature of the air is coming out of the the top of the unit, but it only has a maximum air temperature of 85 degrees F. I didn't think to do that. The Surveyor requested that MS-O obtain the appropriate temperature reading device and check R1's heat unit air temperature. MS-O obtained a laser light thermometer. As the Surveyor observed, MS-O checked the air temperature blowing from the top of the unit when the air temperature was set at 76 degrees F. After temperature readings were completed for several minutes along the entire top of where heat was blowing out of the unit, the reading was 108 degrees F (~42.2 degrees C). When two-thirds of the the air intake vents were blocked with two clip boards and the air temperature thermostat was set at 76 degrees F, temperature readings were completed for several minutes along the entire top of where heated air was blowing out of the unit. The highest temperature reading recorded was 124 degrees F (~51.1 degrees C). MS-O stated, The temperature of the heat blowing from the top of the unit would be the same if the air temperature was set at 86 degrees F, it just wouldn't run as long as it would if the air temperature was set at 76 degrees F. On 3/12/19 at 11:20 a.m., NHA-E verified to the Surveyor that on the evening of 3/9/19 after R1 had sustained a significant second degree burn to top of right hand, the NHA had instructed staff to initiate 30 minute checks on R1 but no documentation of those checks had been completed. NHA-E stated, There wasn't even a check list sheet made out. Nursing entries in R1's medical record dated 3/10/19 at 8:49 p.m. indicated that staff had found R1 again seated in front of the heater multiple times throughout shift. R1 was educated. An entry dated 3/11/19 at 1:36 a.m. indicated R1 was still up in wheel chair in front of heater. R1 was asked to back away from heater but stated (R1) liked the heat to blow on face. Staff will continue to monitor. An entry dated 3/11/19 at 3:17 a.m. indicated that staff was passing by R1's room and saw that R1 was sitting in front of the heater. Writer advised R1 to move away from the heater to avoid getting a burn on legs. Heater thermostat was set at 76 degrees F. A Risk versus Benefits form was completed on 3/10/19 at 9:09 p.m. for R1 regarding recommendations that R1 move away from heater with the risk of choosing not to follow recommendations listed as burn. The conclusion indicated, Resident continues to refuse to stay away from heater. The facility indicated an investigation into R1's burn on 3/11/19. Out of five staff interviewed, four noted R1 sitting in front of the heat unit in room on 3/9/19 prior to a report of R1 receiving a second degree burn on the right hand. One of the staff interviewed indicated having had talked to R1 multiple times about not having heat set above 75 degrees F in room prior to the burn incident but R1 always demanded heat be turned up higher or became verbally abusive. 2. R2 was admitted to the facility with [DIAGNOSES REDACTED]. R2's admission MDS assessment dated [DATE], documented R2's cognition was 15 out of 15 (the higher the score, the more cognizant), R2 required extensive assistance with transfer and ambulation, and had a history of [REDACTED]. R2 did not have a care plan related to falls until R2 had an actual fall although R2 had a history of [REDACTED]. A Fall Review Summary regarding R2 dated 3/3/19 at 8:50 PM, indicated R2 attempted to get clothing out of R2's closet without assistance. Education was provided on the call bell system. Closet door was fixed. Anticipate R2's needs. R2 ambulated with a walker. R2 was leaning on the closet door when it came off hinges and fell on R2. R2 ambulated to the closet door and attempted to close the door. The door came off the hinge while R2 was using the door to hold self up. When the door fell , R2 fell . R2 was sent to the ED (emergency department) on 3/3/19 and diagnosed with [REDACTED]. On 3/12/19 at 9:25 AM, the Surveyor interviewed R2 regarding the fall. R2 indicated R2 went to shut the closet door on 3/3/19 and the closet door came off the hinge making R2 fall. R2 verified R2 was sent to the ED after the fall and was diagnosed with [REDACTED]. No fracture. Hip still hurts. R2 verified R2 was offered pain medication, but declined the offer. On 3/12/19 at 9:50 AM, the Surveyor interviewed MS-O regarding the closet doors and R2's fall related to the closet doors. MS-O stated, The top point slid off when (R2) fell . (R2) was using (the) closet door to hold self up, not designed to stabilize self. The following day and throughout that week (of R2's fall), I checked for stability of doors in other resident rooms on the 400 unit. MS-O stated checks were still in process and rooms with residents have been completed while empty rooms still needed to be looked at. On 3/12/19 at 1:00 PM, the Surveyor interviewed MS-O regarding the closet doors on the 400 unit. MS-O and the Surveyor toured the 400 unit, which is the only unit with bifold closet doors. MS-O indicated the facility can secure points of the doors with fasteners, but if a resident lifts up on the doors, the resident could still pull the door off/out and fall. MS-O stated, It's a very poor design for a building like this and still a safety hazard. MS-O stated that the facility had, fixed as much as can be without remodeling. It's a poor design. The rails on top are only going to hold so much, no matter how many screws we throw at it, it's still a safety hazard. No matter what we do to them, they're going to be a problem. I wish we could take them all down and put curtains up. Sliding doors are safer like we have in the rest of the facility. MS-O confirmed the closet doors had already been removed from another resident's room (R1) due to a safety concern related to falls. On 3/12/19 at 1:45 PM, the Surveyor interviewed DON-A regarding a potential for falls care plan for R2 prior to falling at the facility. DON-A verified R2 should have had a care plan related to having a potential for falls prior to the actual fall as R2 had a history of [REDACTED]. On 3/12/19 at 2:33 PM, the Surveyor interviewed DON-A regarding the number of residents that were able to access closet doors on the 400 unit independently. DON-A verified there were 9 of 13 residents on the 400 unit who could access closet doors independently who would be at risk for falls.

Based on observation, interview, and record review, the facility did not ensure 4 (resident #4,#6, #7 and #9) of 13 sampled residents reviewed for falls received the necessary interventions to prevent accidents. Resident #4 had a history of [REDACTED]. The resident was to have an alarmed seatbelt on to alert staff when the resident would attempt to stand independently. The resident was left unattended with the alarm turned off when the resident attempted to self-transfer, fell , and suffered a hip fracture. Resident #6 was assessed to be at risk for falls and per the plan of care had a sensor pad alarm while in bed. During observations of the resident, the alarm box was not connected to the sensor pad to alert staff if the resident attempted to self transfer. The plan of care intervention was not consistently implemented. Resident #7 was assessed to be at risk for falls and per the plan of care had a motion sensor alarm next to bed to alert staff if the resident attempted to self transfer from the bed. Resident #7 was able to ambulate to the bathroom without staff supervision after the alarm sounded and staff were not on the unit. Resident #9 was assessed to be at risk for falls. An intervention on resident #9's plan of care indicated a clip alarm was to be used while the resident was in bed to alert staff to the residents attempts to rise. The clip alarm was not secured to the bed per manufacturer's recommendations. Findings include: 1. According to the face sheet dated 7/22/14, resident #4 had a history of [REDACTED]. The change of condition MDS (Minimum Data Set) assessment dated [DATE], indicated resident #4 had cognitive impairment, required extensive assist with transfers, did not ambulate, and suffered one fall with a fracture in the facility. On 7/15/13, the facility initiated a "Risk for injury" care plan for resident #4. The care plan indicated the resident was unaware of safety needs, had a history of [REDACTED]. The care plan directed staff to implement multiple interventions including a seat belt alarm. The seat belt alarm intervention began on 7/15/13 and was determined not to be a restraint for this resident. The fall incident report dated 3/27/14 documented resident #4 had attempted to stand up from a seated position in the wheelchair. The fall was witnessed and no injuries occurred. The resident's seatbelt alarm was in place, however did not alarm because the resident or a family member turned it off. The facility updated the resident's care plan to direct staff to place the alarm under the wheelchair to discourage the resident or family from disabling the alarm. The fall incident report dated 5/14/14 documented resident #4 had an unwitnessed fall in the resident's room. The resident was heard calling for help. Staff found the resident on the floor next to the wheelchair with no alarm sounding. The resident immediately complained of left groin pain and was sent to the emergency room where the resident was diagnosed with [REDACTED]. The investigation indicated the CNA (Certified Nursing Assistant) did not know how to operate the alarm appropriately and did not turn the alarm on when the resident was seated in the wheelchair prior to the fall. The investigation indicated all staff were educated on how to operate the different alarms residents in the facility utilize. On 10/2/14 at 3:00 p.m., RN (Registered Nurse)-A verified to surveyor # the purpose of resident #4's alarm was to alert staff if the resident removed the seatbelt, so staff could try to prevent a fall. On 10/2/14 at 3:10 p.m., DON (Director Of Nursing)-B verified to surveyor # , the resident's fall possibly could have been prevented if the alarm was turned on. DON-B indicated the purpose of the alarm was to alert staff to get to the resident in time to prevent a fall. DON-B provided inservice information provided to staff. The inservice forms were undated, but signed by direct care staff, and directed staff how to appropriately activate resident alarms. 2. On 10/1/14, surveyor # reviewed resident #6's medical record. Resident #6's face sheet, dated 5/13/14, indicated the resident was admitted to the facility with multiple [DIAGNOSES REDACTED]. Resident #6's quarterly MDS assessment dated [DATE], indicated resident #6's cognition was moderately impaired. The MDS also indicated resident #6 required extensive assistance from staff with transfers, ambulation in room, and did not ambulate in the hall. Resident #6 had a fall risk evaluation completed on 7/11/14 which indicated the resident was at risk for falls. Resident #6's plan of care, dated 5/15/13, titles "Risk for injury: falls related to cognition, acute process, musculoskeletal impairment, pain, medication, history of falls, ambulation/elimination status, vision, gait/balance disturbance, blood pressure predisposing diseases." An approach, dated 7/21/14, was added to the care plan and indicated resident #6 was to have a sensor pad alarm in bed and wheel chair. On 10/2/14 at 10:00 a.m., surveyor # observed resident #6 in bed. The sensor pad alarm box was clipped to the handle of the nightstand, but was not attached to the sensor pad on the bed. At 12:55 p.m., CNA (Certified Nursing Assistant)-L went in the resident's room to bring the resident water because the resident "won't get out of bed today." At 1:32 p.m., surveyor # asked LPN (Licensed Practical Nurse)-J to observed the resident's alarm box. LPN-J verified resident #6 has a sensor alarm in bed and that the alarm box was not attached to the sensor pad. LPN-J located the cord to the alarm under the mattress near the head of the bed and attached the cord from the sensor pad to the alarm box. LPN-J tested the alarm to make sure the alarm would sound to alert staff if the resident attempted to self transfer. LPN-J then stated "she must have pulled it out...going to ask who put (the resident) to bed." 3. On 10/1/14, surveyor # reviewed resident #7's medical record. Resident #7's annual MDS assessment dated [DATE], indicated resident #7's cognition was intact, but has disorganized thinking, and inattention that comes and goes. The MDS also indicated resident #7 required supervision with transfers, ambulation in the room and did not ambulate in the hall. Resident #7 had a fall risk evaluation completed on 6/19/14 which indicated the resident was at risk for falls. Resident #7's plan of care, dated 9/11/13, titled "Risk for injury: falls related to medications, ambulation/elimination status, gait/balance, incontinence, infections, history of seizures and falls." An approach, dated 9/18/13, was added to the care plan and indicated resident #7 was to have a wall sensor alarm next to the bed. On 10/2/14 at 10:42 a.m., surveyor # observed staff go in resident #7's room because the alarm was sounding when the resident attempted to self transfer out of bed. On 10/2/14 at 1:20 p.m., surveyor # heard resident #7's motion sensor alarm sounding. Resident #7 ambulated past the motion sensor alarm and went in the bathroom. The alarm stopped sounding after the resident reached the bathroom. The surveyor did not see any staff on the unit to respond to resident #6's motion sensor alarm that was sounding. At 1:25 p.m., resident #7 remained in the bathroom when LPN-J came back to the nurses' station. Surveyor # advised LPN-J that resident #7 had self transferred to the bathroom. LPN-J stated "I wasn't here for that, I was off the unit." LPN-J then went to the resident's room. At 1:29 p.m., LPN-J assisted resident #7 from the bathroom back to bed. As LPN-J and resident #7 ambulated back to the bed, the motion sensor alarm sounded when they walked in front of the alarm. LPN-J then assisted the resident back to bed and left the resident's room. CNA-K and CNA-L were walking by the resident's room in the hall. LPN-J asked the CNAs "where were you?" The CNAs stated "off the unit." 4. On 10/1/14, surveyor # reviewed resident #9's medical record. Resident #9's quarterly MDS assessment dated [DATE], indicated resident #9's cognition was severely impaired, was dependent on staff for transfers and does not ambulate. Resident #9's last fall was documented on 9/13/14 with no injuries noted. Resident #9 had a fall risk evaluation completed on 8/21/14 which indicated the resident was at risk for falls. Resident #9's plan of care, dated 11/21/13, titled "Risk for injury: falls related to decreased cognition, ambulation/elimination status, gait/balance, psych med use, incontinence." An approach, dated 11/21/13, was added to the care plan and indicated resident #9 was to use body alarms as appropriate. On 10/6/14 at 10:49 a.m., surveyor # observed CNA-K and CNA-L provide incontinence cares for resident #9. After the cares were completed, CNA-K attached the clip of an alarm to resident #9's shirt on the right shoulder area. The alarm box was under the resident's pillow on the right side. Surveyor # asked about the alarm box under the pillow. CNA-L stated "yes, that's how it is, under pillow just laying on bed." CNA-K then stated "if (the resident) turns, it'll (the alarm) sound." The resident "usually doesn't move." CNA-K and CNA-L left the resident's room with the alarm box laying under the resident's pillow rather than attached to the head of the bed. On 10/6/14 at 11:15 a.m., surveyor # interviewed LPN-J and asked the LPN to observe resident #9's alarm box which was laying under the resident's pillow. On entrance to the resident's room, surveyor # interviewed LPN-J if the alarm box should be laying under the pillow. LPN-J removed the alarm box from under the pillow and while attaching the alarm box to the head of the bed with a clip, stated, "No, it should be up here." The manufacturer guidelines for the Personal Sentry Fall Monitoring System which resident #9 utilized, indicated the monitor (alarm box) is mounted to either a chair or bed using the clip on the back of the monitor or using the optional Universal Mounting Bracket or Chair Strap. Place the magnetic disk from the pull string to the metallic disk on the front of the monitor and attach the locking clip to the resident's garment at the top of the shoulder or back of the neck.

Based on record review and staff interviews, the facility did not ensure that 2 (resident #1 and #2) of 14 sampled residents were free of significant medication errors. Resident #1 had physician orders [REDACTED]. On 8/30/14, RN (Registered Nurse)-A administered 100 units of [MEDICATION NAME] to the resident. As a result, the resident required a 2.5 day hospital stay to monitor for signs and symptoms of [DIAGNOSES REDACTED] (low blood sugar). During the hospital stay, the resident was on a continuous IV (Intravenous) infusion of D5 ([MEDICATION NAME]) and required an additional IV infusion of 50% [MEDICATION NAME] 14 hours after the insulin overdose had occurred, due to plummeting blood sugars. All staff had not been in serviced so like medication errors would not occur in the future. In this citation, Resident #1 is considered at actual harm, isolated (G level); Resident #2 is considered less than actual harm, isolated (D level). Resident #2, who was admitted to the facility on [DATE], had admission orders [REDACTED]. The resident did not receive this medication on 7/12/14 and 7/13/14. Entries on the resident's MAR (Medication Administration Record) indicated the medication was unavailable; however, [MEDICATION NAME] was kept in the facility's contingency stock. Findings include: The Nursing Drug Handbook, published in 2013 by Lippincott, Williams and Wilkins indicated that [MEDICATION NAME] is classified as a long acting Insulin whose onset of action is 1 hour, peak of action is unknown and duration of action is 24 hours. Adverse reactions to the medication include [DIAGNOSES REDACTED], which is the most common adverse effect of insulin. Early symptoms may be different or less pronounced in patients with long duration diabetes, diabetic nerve disease, or intensified diabetes control. Monitor glucose level closely in these patients because severe [DIAGNOSES REDACTED] may result before the patient develops symptoms. The American Diabetes Association defines [DIAGNOSES REDACTED] (low blood sugar) as levels usually less than 70. [DIAGNOSES REDACTED] may also be referred to as insulin reaction or insulin shock. Severe [DIAGNOSES REDACTED] has the potential to cause accidents, injuries, coma, and death. 1. Resident #1's readmission face sheet, post hospitalization dated 9/2/14 indicated the resident had [DIAGNOSES REDACTED]. The resident was [AGE] years old and had a current documented weight of 107 pounds. Resident #1's most recent MDS (Minimum Data Set) assessment dated [DATE], indicated that the facility had assessed the resident to be severely cognitively impaired. Resident #1's care plan included the problem 'Risk for complications related to [DIAGNOSES REDACTED]. Approach included to "administer anti-diabetic medications as ordered. See MAR for specific instructions." Review of the resident's medication regime pre-hospitalization (prior to 8/30/14) indicated the resident had been prescribed the long acting insulin [MEDICATION NAME], 15 units daily at bedtime, dated 3/28/14. Review of a communication form, located in the resident's medical record dated 8/30/14, indicated resident #1 had received 85 units of [MEDICATION NAME] over the prescribed 15 units to equal receiving 100 units of [MEDICATION NAME]. The Insulin overdose had been administered to the resident by RN (Registered Nurse)-A. The time of the error was listed as 8:00 p.m. RN-A immediately notified the supervising nurse, blood sugars for the resident were completed and documented as 148 at 9:00 p.m., 134 at 9:50 p.m. and 217 at 10:15 p.m. A physician was notified and an order was obtained for the resident to be sent to the hospital for evaluation and treatment. Review of the hospital admission history and physical dated 8/31/14 at 12:01 a.m., indicated: "The resident had past medical history significant for diabetes mellitus presenting with unintentional insulin overdose. One of the staff at the nursing home was supposed to give the patient 15 units of [MEDICATION NAME] and they gave her 100 units of [MEDICATION NAME]. Patient was brought to emergency room by ambulance for further evaluation. [MEDICATION NAME] 100 units was administered at 8:30 p.m. By 10:30 p.m., blood sugar was 270. By the time emergency medical services checked blood sugar it was 170. In the emergency room , blood sugar was 166. Patient had no mental status changes beyond baseline and was able to eat. Recommendation was made for observation admission. An IV of D5 1/2 normal saline was initiated at 100 ml (milliliters) per hour. Blood sugar checks every 2 hours. Hold scheduled insulin. [MEDICATION NAME] gel 25 grams IV when necessary if blood sugars less than 60. Diagnosis: [REDACTED]. Would like to see blood sugars into the 200's on D5 prior to discharge." Review of the resident's hospital blood sugars and medication administration record indicated the following: * 8/30/14 at 11:13 p.m. - 166 * 8/31/14 at 2:09 a.m., - 136 * 8/31/14 at 4:36 a.m., - 134 * 8/31/14 at 6:05 a.m., - 107 * 8/31/14 at 8:09 a.m., - 100 * 8/31/14 at 10:05 a.m., - 76. The resident received one dose of IV [MEDICATION NAME] 50% (25 grams) on 8/31/14 at 10:29 a.m. * 8/31/14 at 12:06 p.m., - 173 * 8/31/14 at 2:25 p.m., - 153 * 8/31/14 at 4:01 p.m., - 95 * 8/31/14 at 6:06 p.m., - 111 * 8/31/14 at 8:40 p.m., - 156 Resident #1's IV order changes included: * [MEDICATION NAME] 5%/sodium chloride 0.45% at 100 ml/hour IV on admission and discontinued at 9:10 a.m. on 8/31/14. * [MEDICATION NAME] 5%/sodium chloride 0.45% at 75 ml/hour IV then discontinued at 1:29 p.m. on 9/1/14. * [MEDICATION NAME] 5%/sodium chloride 0.45% at 50 ml/hr IV then discontinued at 8:22 a.m. on 9/2/14. On 9/2/14 in the morning, the resident was discharged back to the facility. Review of the medication error report for resident #1 dated 8/30/14 indicated, "Nurse educated on insulin and reading orders, doing second and third check before administration. Doses of med's highlighted in pink." Review of resident #1's MAR for September of 2014, indicated that the scheduled [MEDICATION NAME] dose was highlighted with a pink marker. Surveyor # reviewed resident #1's June/2014, July/2014 and August/2014 MARs and noted that the scheduled [MEDICATION NAME] dose was either underlined in black ink or circled in black ink. On 9/11/14 at 2:15 p.m., surveyor # interviewed RN-A via the telephone. RN-A stated, "I read the order ([MEDICATION NAME] for resident #1) wrong off the MAR. I read the quantity of 100 units/ml versus what the prescribed dose was. (On 8/30/14) When I went back to the cart to sign the medication in the MAR, I realized the error had occurred and I alerted the charge nurse and she took over. The facility is having me retrain with another nurse with medication pass for two shifts, and I will be touching base with the education coordinator (RN-C) weekly." On 9/11/14 at 3:15 p.m., RN-C verified to surveyor # that RN-A had been re-educated regarding insulin administration prior to working another shift, after the medication error that had occurred with resident #1's [MEDICATION NAME] dosing. RN-C further verified to the surveyor that no other re- education or in-servicing had been completed for any of the other facility licensed staff, regarding the incident, so medication errors regarding insulin dosing would be less likely to occur in the future and stated, "I was unaware of the need to in-service all staff when an incident like this occurs." RN-C further verified to the surveyor that all licensed staff had attended a nursing skills fair on 7/10/14 and 7/11/14 which had included education on time frame to administer different types of insulin depending on peak and onset of action, making sure MARs are complete and accurate and double checking all orders regardless of the medication before administering that medication. During the investigation, 7 residents (including resident #1) were noted to have not received proper dosing of sliding scale insulins per documented blood sugar parameters both before and immediately following the medication error that had occurred on 8/30/14 with resident #1's [MEDICATION NAME]. Refer to the citation text at F 425 for further information. 2. Resident #2 was readmitted to the facility with [DIAGNOSES REDACTED]. The resident's most recent MDS assessment dated [DATE], indicated the resident was cognitively intact with no behavior or [MEDICAL CONDITION]. The MDS also indicated the resident took anticoagulant medication for the previous 7 days; however, the resident's MAR indicated the resident received that medication for 5 of the previous 7 days. The resident's Medication care plan, dated 3/21/14, indicated the resident was at risk for bleeding and/or bruising related to the use of Aspirin, [MEDICATION NAME] and [MEDICATION NAME]. On 9/11/14, surveyor # reviewed the medical record for resident #2 and noted the resident was re-admitted to the facility on [DATE] following hospitalization on [DATE] for chest pain, [MEDICAL CONDITION] a possible [MEDICAL CONDITION] infarction ([MEDICAL CONDITION]). Further evaluation determined the resident was in [MEDICAL CONDITION] flutter with a rapid ventricular response and periods of [MEDICAL CONDITION]. The resident had been hospitalized in the past for similar issues and was discharged to the facility with orders to include [MEDICATION NAME] 50 mg subcutaeously daily until INR is greater than or equal to 2.0. Review of the resident's July 2014 MAR indicated the resident did not receive [MEDICATION NAME] on 7/12/14 and 7/13/14. The initials NA, indicating "not available", were noted where the medication is signed out when given. Surveyor # reviewed the facility's medication error report, dated 7/14/14, and noted the report indicated 3 doses of [MEDICATION NAME] were not given. LPN (Licensed Practical Nurse)-E was given a written warning and instructed to check the MAR after each medication pass. An additional intervention indicated the facility would spot check the MARs after the LPN-E's shift. On 9/11/14 at 2:00 p.m., surveyor # interviewed DON (Director of Nursing)-D regarding the facility's contingency medication stock. When asked if the facility had [MEDICATION NAME] in contingency, DON-D answered, "Yes." On 9/11/14 at 2:15 p.m., surveyor # interviewed RN-C regarding the medication error report. RN- C stated, "(LPN-E) said she didn't know it ([MEDICATION NAME]) was in contingency. She said she wasn't aware." When asked about the number of doses missed, RN-C reviewed both the report and MAR and stated, "I guess (resident #2) just missed 2 doses. It was given on the 14th and I re-wrote the order for PM (evening) because we usually give [MEDICATION NAME] then." RN-C indicated LPN-E was the only staff educated regarding contingency medication. RN-C agreed facility-wide education for nursing staff would be useful as there may be other nursing staff not aware of what medications are kept in contingency.

Based on observation, record review and staff interview, the facility did not ensure that residents are free of any significant medication errors for 1 (resident #1) of 7 sampled residents. Resident #1 was administered insulin despite an accucheck result below the physician's specified parameters for administration of the medication. Findings include: The facility's Insulin Administration policy dated 2/16/11 states: Purpose/Preparation 3. The type of insulin, dosage requirements, strength, and method of administration must be verified before administration to assure that it corresponds with the order on the medication sheet and the physician's orders [REDACTED]. 4. The nurse shall notify the Director of Nursing Services and the Attending Physician of any discrepancies before giving the insulin. Resident #1: 1. According to the resident's face sheet, resident #1 was admitted to the facility on [DATE] for short- term rehabilitation with [DIAGNOSES REDACTED]. The resident's initial MDS (Minimum Data Set) indicated the resident was alert and oriented but required extensive assistance with bed mobility, transfers and personal cares. The resident's most recent CAA (Care Area Assessment) summary indicated the resident had been in acute care due to hypoglycemic responses to medications and was undergoing [MEDICAL CONDITION]. A history and physical admission note from a local hospital, dated 2/8/13 and prior to the resident's nursing home admission indicated the resident was admitted with low magnesium and [MEDICAL CONDITION] following a [MEDICAL CONDITION] infusion. The resident complained of fatigue, shortness of breath and frequent episodes of [DIAGNOSES REDACTED] and was subsequently diagnosed with [REDACTED]. Upon review of the resident's medical record, surveyor # noted a fax sent to the physician on 2/15/13 that stated, "Please provide blood sugar parameters so we know when to contact you for abnormal values." A fax was sent to the facility from the physician on 2/15/13 with the order, "Call if BS (blood sugar) <80 or >350." On 7/18/13, surveyor # reviewed resident #1's MAR (Medication Administration Record) and observed a handwritten order at the top of the MAR indicated [REDACTED]." On the next line, surveyor # observed an order for [REDACTED].# noted a handwritten order that stated, "Call MD if BS <80 or >350." According to the MAR, surveyor # noted resident #1's HS accucheck on 2/16/13 yielded a result of 73 which was below the physician's specified parameter of 80. Surveyor # also noted the resident's HS [MEDICATION NAME] order was signed out as given. On 7/18/13 at 10:45 a.m., surveyor # showed DON (Director of Nursing)-A resident #1's MAR. DON-A stated, "RN (Registered Nurse)-B gave insulin on 2/16 with blood sugar at 73. I would've expected her to call the physician. I would expect the staff nurses look at the whole MAR...they would be expected to know the parameters for the blood sugar. She signed it out in such a way that I'm wondering if she actually gave it. This is the only documentation." DON-A was unable to provide documentation to surveyor # indicating the physician was notified of the resident's blood sugar prior to administration of the insulin. A nurses' note dated 2/17/13 indicated the resident's blood sugar was checked at 7:30 a.m. with a result of 44. A re-check was done with a result of 46. The resident was observed to be groggy with slurred speech and displayed "out of norm" behaviors. A timeline attached to an SBAR (Situation, Background, Assessment, Recommendation) form dated 2/17/13 gave the following information regarding the low blood sugar reading on this date: 0730 - Blood glucose was 46; upon re-check was 39. 0745 - Contacted charge nurse and checked sugars again with a result of 69. 0750 - Charge nurse gave more juice and blood sugar noted to be 169. Call placed to physician. 0815 - While on phone with MD (Medical Doctor), blood sugar checked with a result of 33. Doctor gave order to send to hospital. 0820 - Call placed to 911. 0830 - Paramedics arrived to take resident to local hospital. 1150 - Spoke with hospital and resident will not return to facility today. Message left with wife. 1215 - Called ER (emergency room ) for report. Resident admitted with [DIAGNOSES REDACTED]. A nurses' note dated 2/17/13 included more details following the timeline of the SBAR ...After orange juice and sugar packets were given, the resident's blood sugar was re-checked with a result of 69. After administering more juice and sugar, the resident's blood sugar was re-checked with a result of 169. The physician was called and the resident's blood sugar was re-checked with a result of 39. The physician ordered the resident be sent to the hospital. A nurses' note dated 2/17/13 at 7:45 a.m., indicated the resident's blood sugar was 69 and staff was administering juices. The resident appeared fatigued but was able to follow commands, answer questions appropriately and drink fluids independently. A nurses' noted dated 2/17/13 at 8:15 a.m. indicated the resident's blood sugar was 169. The resident was "alert and oriented and answering questions appropriately but appeared sluggish in verbal responses with slurred speech." Following a blood sugar re-check with a result of 33, more juices were offered and the facility called 911. A nurses' noted dated 2/17/13 at 8:30 a.m. indicated the paramedics arrived to transport the resident to a local hospital. Facility follow up: On 7/18/13 at 11:30 a.m., surveyor # spoke with RN-B via telephone. RN-B stated, "I don't recall the incident. If I signed out the MAR, the med was given. Was it not to be given? I don't remember. Usually all the diabetics have parameters and if they don't, we call to get them. Nobody said anything to me. I don't remember this (resident #1's) name at all." RN-B also could not remember if the physician was notified prior to administration of the insulin. On 7/18/13 at 11:25 a.m., surveyor # spoke with DON-A regarding any training or in servicing with nursing staff regarding the insulin issue. DON-A stated, "This month I had a nurses' meeting on 7/11 and reviewed my med errors...did an in-service. I've talked to RN-B before regarding cares and medication errors. I have RN-B's write-ups if you need them. Surveyor # reviewed a medication error write-up for RN-B dated 6/26/13 which referred to insulin parameters and physician notification. On 7/19/13 at 10:20 a.m., surveyor # interviewed DON-A regarding the specific types of medication errors discussed during the 7/11 nursing in-service. When surveyor # asked if insulin administration and physician notification related to accucheck results and blood sugar parameters were discussed, DON-A responded, "Actually, what I did...it was transcription errors...I did the 5 medication rights and gave other examples of medication errors. It was an open forum with examples, questions and answers. If we talked about accuchecks, insulin...I can't tell you that for sure. I was more concerned with the transcription errors which were the biggest thing." DON-A also indicated she was unaware that resident #1's blood sugar level was below the physician ordered parameters on 2/17/13 and that RN-B administered insulin without notifying the physician until surveyor # brought it to her attention on 7/18/13. DON-A stated the resident's insulin administration was not reviewed by the facility following the resident's hypoglycemic incident on 2/17/13.