Every finding on record at Ellsworth Health Services

Based on observation, interview and record review, the facility did not maintain a safe and sanitary environment in which food is prepared and distributed. This had the potential to affect all 29 residents.Facility staff did not keep personal clothing from touching food when serving residents.Facility's dishwasher records indicate dishwasher is not consistently reaching required temperatures to ensure adequate sanitization.Facility is not maintaining a sanitary environment for clean dishware.This is evidenced by:The facility's policy titled, Ware washing, dated 12/2024, states in part, 2. All dish machine water temperatures will be maintained in accordance with the manufacture's recommendations for high temperature or low temperature machines. 3. Temperature and/or sanitizer concentration logs will be completed, as appropriate.The United States Public Health Service, Food and Drug Administration Food Code 2-401 Food Contamination Prevention, states in part,. F. Facility-wide ConsiderationsIn order to have active managerial control over personal hygiene and cross-contamination, certain control measures must be implemented in all phases of the operation. All of the following control measures should be implemented regardless of the food preparation process used,. Prevention of cross-contamination of ready-to-eat food or clean and sanitized food-contact surfaces with soiled cutting boards, utensils, aprons, etc.,On 08/26/25 at 12:03 PM, Surveyor observed [NAME] D dish up foods to plates sitting on edge of steam table. When leaning forward, [NAME] D's t-shirt would touch residents' food and plates. On 08/26/25 at 12:05 PM, Surveyor interviewed, District Dietary Manager (DDM) E, who also observed [NAME] D's shirt touching the plated food. DDM E reported the expectation would be that the staff wear aprons to keep cross contamination from occurring.On 08/26/25 at 12:10 PM, Surveyor observed Dietary Manager (DM) F prepare an alternative food option after washing dirty dishes in the dirty dish washing area without wearing an apron. Surveyor observed notable splashed water and debris on DM F's clothes when returning to cooking/serving area to make a sandwich for a resident.On 08/26/25 at 12:15 PM, Surveyor reviewed log of recorded internal dish washing temperature thermometer and noted several entries were below the specified range of High Temp wash: 150- 165 degrees F and rinse of 180 -194 degrees F, per the standards specified on the facility's tracking log. DM stated she was unaware of the below standard temperature, and this should have been reported to her per the instructions on the facility's log. Surveyor asked DM F how she knows dishwasher is getting up to the correct temperature. Surveyor then observed DM F remove a dirty recycle bin from in front of dishwasher, directly under clean dish area, in order to read the digital thermometer on dish washer. DM F reports back up monitoring of dishwashing temperatures are not being documented. DM F was not able to demonstrate that the disc used to check that dishwasher was coming up to the standards to assure adequate sanitization of the dishes. DM F reported they were using the disc to verify accuracy but will now go back to using strips. On 08/26/25 at 12:20 PM, Surveyor observed an uncovered plastic rectangular bin full of cloudy, dirty water on the floor, directly under the dishwasher. DM F did not know why it was there and agreed that it should not be there.On 08/26/25 at approximately 12:30 PM, Surveyor interviewed DDM E, who stated staff should be wearing a designated apron for dishes when doing dirty dishes and the recycle bin and the open dirty tote of water should not be in the clean dishes area. DDM E agreed these practices are not in compliance with the sanitary regulations that would be the facility's expectations.Surveyor requested policy for kitchen operation/sanitation/cleaning. DM F offered vague policies.On 8/27/25 at approximately 2:30 PM, Surveyor interviewed DM F, who stated what she provided the Surveyor for policies is what she could find. The facility is working on getting some guidelines in place. DM F agreed the policies provided to Surveyor were not specific to this facility. DM F stated, With the switch over, we really don't have anything that gives direction, and we are working on this.

Based on observation, interview and record review, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (R) 21 reviewed.This is evidenced by: Facility's policy titled Fall Prevention and Management Guideline revised date 07/18/24, read in part. Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized plan of care to minimize the likelihood of falls or reduce the possibility/severity of injury. R21 was admitted to the facility on [DATE]. R21's current diagnoses include hemiplegia and hemiparesis following cerebral infarction (CVA) affecting right dominant side, dysphagia, and cognitive communication. Minimum Data Set (MDS) dated [DATE] a quarterly assessment, documented a Brief Interview for Mental Status (BIMS) score of 8 out of 15, meaning R21 has moderate cognitive impairment. R21 has impairment to one side of upper and lower extremities. R21 is dependent on staff for toileting, lower body dressing, personal hygiene, bed mobility, and transfers. Care plan dated 04/22/25, states: The resident is at risk for falls R/T (related to) CVA right side weakness right hand flaccid Unable to ambulate Uses w/c with total assist. Interventions: 08/06/25 Bed in lowest position at HS or when in bed, FALL RISK - FALL MAT. On 08/28/25 at 10:09 AM, Surveyor observed R21 in bed. The bed was in the low position and no fall mat was on the floor next to bed. Surveyor interviewed Certified Nursing Assistant (CNA) C about what interventions should be in place when R21 is in bed. CNA C stated the bed should be in low position and the fall mat on the floor next to the bed. CNA C stated she did not put R21 in bed this morning. Surveyor asked CNA C to verify what interventions are in place for R21. CNA C entered room and stated the fall mat was not on the floor and R21 is in a low bed. CNA C placed the fall mat on the floor next to the bed. On 08/28/25 at 11:05 AM, Surveyor interviewed Director of Nursing (DON) B about the fall interventions for R21 and the observation of the fall mat was not in place and verified with CNA C. DON B stated understanding, and the fall mat should be in place.

Based on observation, interview and record review, the facility failed to ensure residents (R) receive treatment and care in accordance with professional standards of practice for residents experiencing changes in condition for 1 of 4 residents (R10) reviewed for changes in condition regarding congestive heart failure. This is evidenced by: According to the National Institutes of Health (NIH) Congestive Heart Failure (CHF): Nursing Diagnosis, 2023, indicates nurse assessment of CHF is to assess current symptoms such as dyspnea, fatigue, orthopnea, peripheral edema, vital signs, cardiovascular examination such as (abnormal heart sounds, jugular venous distention), respiratory examination such as (auscultate lung sounds for crackles or wheezing and assess respiratory effort), daily weights, edema assessments, dietary habits, weight changes, medication adherence and any side effects related to diuretics or blood pressure medications, and assess emotional well-being related to potential anxiety or depression related to the chronic nature of CHF. R10 was admitted to the facility on [DATE], and had diagnoses that included in part: CHF, hypertensive heart disease, mitral valve stenosis, pulmonary hypertension, nonrheumatic aortic valve stenosis, peripheral venous insufficiency, chronic kidney disease (CKD) stage 4 of 5, and diabetes. R10's care plan, dated 1/11/23, states: .The resident has altered cardiovascular status related to CHF, mitral valve stenosis, pulmonary hypertension, hypertensive heart with heart failure, aortic valve stenosis. Interventions include (in part): o Assess for chest pain Enforce the need to call for assistance is pain starts. Start date 1/11/23. o Assess for shortness of breath and cyanosis. Start date 1/11/23. o Monitor VITAL SIGNS per order. Notify MD (Medical Doctor) of significant abnormalities. Start date 1/11/23. o Monitor/document/report PRN (as needed) any signs and symptoms of Congestive Heart Failure: dependent edema of legs and feet, periorbital edema, SOB (shortness of breath) upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation of the lungs, orthopnea, weakness and/or fatigue, increased heart rate (Tachycardia) lethargy and disorientation. Start date 4/19/23 . R10's provider note dated 2/19/24 stated weight continues with slow increase, however no increase in edema or change in respiratory status, likely related to increase caloric intake from snacking. Dietary working with resident to make healthier snack choices. R10 with mild bilat LE (lower extremity) edema. Currently on Bumex 3mg BID (twice a day). Metolazone 2.5mg twice weekly had been d/c (discontinued) due to increased BUN/creatinine (kidney function tests). Current weight increased by about 20 pounds in 4 months, however no increase in edema or change in respiratory status. Plan: continue to monitor weight, edema, and respiratory status, with update if indicated. Encourage healthy snack choices. Cardiology follow up 6/2024. Restart Metolazone 2.5mg 30 minutes before first Bumex dose weekly on Wednesday. Recheck BMP (lab for kidney function/ electrolytes) on 2/29/24. R10's lab levels were checked on a regular basis by the provider due to CKD history and on diuretics. Tubi socks (help with compression for edema) were documented as on during the day as ordered. R10's medical administration record (MAR) documentation of edema and monitor SOB when flat, at rest, and exertion each shift was documented by the nurses. R10 had chronic 1+ pitting edema with some increase to 2+ pitting edema in the afternoons for the month of April 2024. R10 had SOB during exertion, lying flat, and at rest documented more frequently in the month of April 2024. The nurse's documentation on R10's MAR only indicated if the SOB or level of pitting edema was present. The nurses did not document a cardiovascular examination such as abnormal heart sounds, jugular venous distention or respiratory examination such as auscultate lung sounds for crackles or wheezing and assess respiratory effort. R10's progress notes in part: On 3/05/24 Weight Note: CBW (current body weight): 169 pounds. Resident triggers for significant weight gain of 5.6% in 30 days, 8.3% in 3 months and 19% in 6 months. BMI (body mass index) 26.5; healthy for age . RD has no concern with weight gain as resident is at healthy weight for age, as long as resident has no issues with SOB or increased edema; updated nursing during WAR (weekly at risk) meeting with IDT (Interdisciplinary Team) today. Resident has potential for weight fluctuation r/t (related to) fluid shifts r/t edema BLE (bilateral lower extremity) and diuretic use and changes to diuretic medications. RD remains available for consult as needed. On 3/05/24 General Note: Weekly at-risk meeting-5.6% weight gain in 30 days, weight is healthy for her age, will monitor for SOB and edema. Continues to eat snacks of choice in her room. On 4/02/24 Weight Note: CBW: 173 pounds Resident triggers for significant weight gain of 8.5% in 3 months and 17.7% in 6 months. BMI 27; healthy for age. Weight more stable the past month at ~170# +/- .RD has no concern with weight gain as resident is at healthy weight for age, as long as resident has no issues with SOB or increased edema. Resident has potential for weight fluctuation r/t fluid shifts r/t edema BLE and diuretic use. Resident had elevated TSH back on 2/29/24 which can impact weight. RD remains available for consult as needed. R10's assessment completed 4/04/24 indicated R10 was independent for most activities of daily living with no decline. Cardiopulmonary assessment indicated no oxygen used, regular heart rate, no respiratory distress, respirations are even and unlabored. Edema (mild) present. R10's assessment completed 4/04/24 did not include auscultation of lung sounds or heart sounds, or assessment of jugular venous distention. The standard pitting scale of 1-4 + pitting edema was not utilized. On 4/10/24, R10's Nutrition Assessment Note: Current weight: 174.4 pounds - 4/8/2024 Scale: Standup scale. BMI: 27.3. Significant weight change present. Weight history- 1 month ago: 168 pounds, 3 months ago: 164 pounds, 6 months ago: 149 pounds. 16.8% weight gain in 6 months. Gradual weight gain of ~10 pounds in the past 3 months. Skin condition: No skin issues noted. Edema present. 0-2+ Summary: . Resident has potential for weight fluctuation r/t fluid shifts. Resident continues with weight gain, likely r/t to a combination of edema and excess calories and sodium in diet .Continue current nutrition plan of care. Care plan reviewed and updated. On 4/10/24, R10's Summary Note: Resident is alert and orientated x 4 . is currently on RA (room air), VSS (vital signs stable) . Recent vitals: Temperature: T 97.8 - 3/27/2024 10:08 Route: Forehead (non-contact) Pulse: P 68 - 3/27/2024 10:08 Pulse Type: Regular Blood Pressure: BP 129/59 - 3/27/2024 10:08 Position: Sitting Respirations: R 18.0 - 3/27/2024 10:08 O2 Sat: O2 95.0 % - 3/27/2024 10:08 Concerning R10's summary note above, the nurses did not document a cardiovascular examination such as abnormal heart sounds, jugular venous distention or respiratory examination such as auscultate lung sounds for crackles or wheezing and assess respiratory effort. From 4/10/24 until 4/19/24, when R10 was sent out to the cardiology appointment, there were no assessments documented. The facility stated they document on exception meaning if there were no concerns, nothing would be documented. The facility lacked a complete cardiovascular and respiratory assessment on a regular basis to assess for fluid overload due to CHF. On 4/19/24 Nursing Note: Resident went out to cardiology appointment today. Son called and stated that resident was sent to the hospital from appointment to have fluid taken off of her and she will be out a couple of days. R10 attended the cardiology appointment on 4/19/24. The cardiologist determined at that appointment to send R10 to the hospital. R10 was hospitalized from 4/19/24 through 4/24/24 with diagnosis of acute on chronic diastolic congestive heart failure and CKD stage 4. R10's cardiology visit 4/19/24 provider note stated: R10 was here for worsening edema. Over the past 2-3 months R10 notes worsening shortness of breath, cough, edema, and weight gain. R10 was on Bumex 3mg twice daily and metolazone was restarted but she hasn't responded. Weight was 164 pounds in December now up to 185 pounds. She has a cough and notes orthopnea (shortness of breath when lying down) as well. Impression: 20 pounds weight gain in 3 months, worsening dyspnea on exertion, orthopnea/edema despite high dose diuretic. Reviewed vitals from nursing home. Weight has been steadily increasing. Creatinine worsened. Discussed admission to hospital for intravenous diuretic, echocardiogram and x-ray given lack of response to oral diuretic. R10 and son in agreement. No telemetry (cardiac monitoring) beds open yet, so patient will be transported to the emergency room . R10's hospitalization progress notes: History and Physical Note: R10 was admitted on [DATE] with CHF exacerbation. Patient seen earlier today at cardiology clinic with worsening lower extremity edema. She notes also that she has had increased dyspnea (SOB) on exertion. Notes that when she is ambulating from dining room to bathroom. Weight was 164 pounds in December now 185 pounds. She failed diuresis with oral diuretics as an outpatient and was directed to the emergency department for inpatient admission. Laboratory evaluation notable for hemoglobin 9.9, BNP (CHF indicator) 2204, troponin elevation of 30 with no significant change in delta troponin. Chest x-ray impression stated lungs are hypoinflated with bibasilar atelectasis. No focal consolidation, pleural effusion, or pneumothorax. Principle Problem: Acute on chronic heart failure with preserved ejection fraction. Admit inpatient, given 3mg of IV Bumex in emergency department. Of note, IV Bumex on national shortage. Will switch to IV furosemide infusion. Monitor intake and output. Consult cardiology. Check echo. Interviews: On 06/10/24 at 2:17 PM, Surveyor interviewed R10 who said she was in the hospital recently for fluid overload/heart failure. R10 said the staff weigh her every day. R10 with compression socks on both legs. R10 said she was aware to elevate legs to help with swelling. On 06/12/24 at 9:05 AM, Surveyor interviewed Certified Nursing Assistant (CNA) C and asked if she had worked with R10 in March and April this year before the hospital admission. CNA C said yes, she worked with R10 in March/April 2024 before the hospital stay. Surveyor asked CNA C if R10 had any concerns such as difficulty breathing or increased swelling before the hospital admission. CNA C said yes, R10 had increased swelling to her legs and had increased difficulty walking with trouble breathing. CNA C said we weighed R10 regularly. Surveyor asked CNA C if the nurses were aware of this. CNA C said yes, they were aware. On 06/12/24 at 9:08 AM, Surveyor interviewed R10 and asked if she remembered how she was before she was admitted to the hospital on 4/19/24. R10 said they took off 15 pounds of fluid while I was in the hospital. Surveyor asked R10 how she felt now. R10 said she felt much better. On 06/12/24 at 9:12 AM, Surveyor interviewed Registered Nurse (RN) D and asked how R10 was prior to hospitalization on [DATE]. RN D said R10 always had edema. R10 did not have any shortness of breath or indicators of CHF exacerbation prior to admit. RN D said we would update the provider on a regular basis and was aware of the gradual increase of weight. That was why the provider wanted to get R10's cardiology appointment moved up sooner. R10 did not show any signs or symptoms that indicated she needed to be sent out to the hospital sooner. On 06/12/24 at 9:45 AM, Surveyor interviewed Director of Nursing (DON) B and asked how R10 was prior to hospitalization on [DATE]. DON B said we were monitoring R10's weights and signs symptoms of heart failure. R10 eats salty snacks that she has in her room. We have educated the resident on salt intake. The provider was adjusting R10's diuretics and monitoring the labs because R10 also had CKD stage 4. R10 was doing fine with no indicators that she needed to be sent out to be evaluated at the hospital. The primary provider here at the facility wanted to get R10 seen by the cardiologist to have her medications adjusted as it was hard to adjust due to her poor kidney function. We also were keeping a close eye on R10 for any change in symptoms and discussed her case at our weekly at risk (WAR) meetings. Surveyor informed DON B the concern of incomplete assessments for CHF in the week prior to the hospitalization . Surveyor asked DON B for CHF assessments, that would include lung sounds and cardiovascular assessment during this time frame. DON B said the nurses documented the edema and shortness of breath symptoms on the MAR and review documentation during the WAR meetings. On 06/12/24 at 10:04 AM, Nursing Home Administrator (NHA) E provided R10's MAR documentation. Surveyor asked NHA E what the 1 and 2 meant for documentation of edema. NHA E said it meant the pitting edema levels. No WAR documentation for R10 for the month of April was provided. On 06/12/24 at 10:53 AM, DON B provided the cardiology note from R10's clinic visit on 4/19/24. DON B said the note stated over the past 2-3 months, R10 notes worsening shortness of breath, cough, edema, and weight gain. DON B said R10's primary provider was aware of this. DON B said there were no indications that R10 needed to be sent out to the hospital due to her symptoms of baseline edema, shortness of breath and weight gain. DON B said as an improvement, they could change their order batch to indicate what to do for a thorough assessment if increased SOB or edema and how staff should respond to the data found. On 06/12/24 at 12:30 PM, Surveyor interviewed R10's Medical Doctor (MD) F and asked what the expectation was for staff to do with the findings from the MAR documentation of 1-2+ edema and increasing shortness of breath. MD F said he was at the facility every week and was looking at R10's respiratory status, weights, edema and if there were any other indicators of CHF exacerbation. MD F said he was aware of the gradual weight gain, and he decided to wait to see what cardiology would do before adding more interventions due to R10's kidney function. MD F said he had adjusted R10's diuretics but was hesitant to push the diuretic any further due to R10's kidney function that he was closely monitoring with lab work. MD F said he had requested the cardiology appointment be moved up closer due to this. Surveyor asked MD F what the expectation was for lung assessments. MD F said he was not relying on the nurse's assessments; he was relying on his own assessments of R10 and looking at R10's weights. Surveyor asked MD F if he felt R10 needed to be sent out to the hospital sooner before the 4/19/24 cardiology appointment. MD F said obviously it was not needed to send R10 out sooner because R10 was not in any distress. MD F said it was unexpected that R10 was admitted to the hospital. MD F said he was expecting R10 to be seen by the cardiologist who could adjust the oral diuretics and get the weight off at the facility. The cardiologist must have felt R10 was not responding to oral diuretics and needed IV diuretics instead. MD F said R10 was not in any acute distress while at the facility. On 06/12/24 at 1:00 PM, Surveyor interviewed DON B and NHA E concerning R10's condition prior to hospital admit on 4/19/24. DON B and NHA E both said R10 was assessed by the primary provider weekly, and our nurses assess R10 all the time. We did not feel R10 needed to be sent to the hospital sooner as R10 had baseline edema and shortness of breath upon exertion. Just because the nurses checked yes to shortness of breath on the MAR, it did not indicate concern to send R10 out to the hospital. DON B and NHA E were unsure what they should have done differently due to keeping the provider well informed, assessment of R10 on a regular basis and charting if there were concerns, moving the appointment for cardiology up sooner to have medications adjusted and see if other interventions were warranted. Nurses chart by exception and if there were no concerns, nothing would be documented. Surveyor asked what standards the facility follows to determine immediate versus non-immediate response for a resident presenting with CHF symptoms and what tool was used for pitting edema assessment. DON B said she will provide these items. Facility utilized the following tool to indicate pitting edema measurements: 1+ = 2mm depression, barely detectable. 2+ = 4mm deep pit, a few seconds to rebound. 3+ = 6mm deep pit, 10-12 seconds to rebound. 4+ = 8mm very deep pit, >20 seconds to rebound. Surveyor asked what standards the facility follows to determine immediate vs non-immediate response for a resident presenting with CHF symptoms. The facility provided the Interact tool for shortness of breath which indicated the following: Immediate - abrupt onset of shortness of breath with pain, fever, or respiratory distress, or with progressive leg edema. Non-immediate - recently progressive or persistent minor shortness of breath without other symptoms. On 06/12/24 at 2:00 PM, Surveyor interviewed RN D who said R10 was at baseline with no need to send her out to the hospital. If R10 did need to be sent out to the hospital, a change in condition would have been completed if warranted, but R10 did not warrant this. RN D said she spoke with MD F often to update on R10. RN D said they were all surprised that R10 was admitted to the hospital from her cardiology clinic appointment on 4/19/24. After R10's hospital admission, the facility did not provide education or training to the nurses concerning cardiac/respiratory assessments with a resident who had CHF concerns.

Based on observation and interviews, the facility did not prepare and distribute food under sanitary conditions. This has the potential to affect 27 of 27 residents. -Staff were not properly hand washing -Staff were using contaminated gloves -Cleaning schedule not being completed On 05/23/23 at 11:13 AM, Surveyor observed Dietary Manager (DM) G wet hands, put soap on hands and rub hands together for 3 seconds, DM G then shut off water faucet with wet hands and then dried hands with paper towels. Surveyor observed DM G empty the garbage and take it outside. When DM G returned, she washed her hands, turned on the water, rubbed hands together with soap and water for a few seconds, turned off the water with wet hands, then grabbed the paper toweling to dry her hands. At 11:40 AM, Surveyor observed Dietary Aide (DA) H put on gloves, no hand washing reached into the bread bag and butter slices of bread for lunch. DA H removed gloves, no hand washing, put on a new pair of gloves then started to dish up lunch plates with same gloved hands opening up utensil drawers, touching resident food slips, then grabbed buttered bread with the contaminated gloves from the container and put on resident's lunch plate. DA H then removed contaminated gloves, no hand washing put on a new pair of gloves, continued dishing up lunch plates then removed gloves and washed hands with soap and water. At 12:02 PM, DM G was assisting DA H. DM G removed the gloves she had on, no handwashing put on a new pair of gloves, reached in the bread bag and buttered 2 pieces of bread, went to the cooler, opened the door with same gloved hands and grabbed some cheese from the cooler for a grilled cheese with the same gloved hands. On 05/24/23 at 9:12 AM, Surveyor asked DM G what they expect staff to do in-between changing gloves. DM indicated they are supposed to wash hands in-between use. Upon visits to the kitchen during the survey period, Surveyor noted unclean and unkept areas. The steam table in the dining room has a plexi-glass splash guard that has visible splashes with dried on substance dripping down the whole length of the splash guard. Areas of the walls in the kitchen had sheet-rock that was cracked and falling off. The can opener when Surveyor observed it and looked at the pointed part had a hardened particle of food on it. The blender that is used daily has a layer of dust on it that has not been wiped down. When DM G moved the blender, the area under the blender had a substance that was smeared under it that has not been cleaned up and was dried on. Surveyor asked DM G if there was a cleaning schedule. DM G provided Surveyor with a, Cooks Checklists and an Aides Checklist. On the cooks checklist number 3 reads in part steam table wipe clean, number 11 reads in part counters washed and sanitized. Surveyor asked DM G who checks on these lists. DM G indicated she did. There was no evidence the cleaning had been completed.

Based on observation, interview and record review, the facility did not perform appropriate reprocessing of reusable resident medical equipment. Observations of staff not sanitizing the mechanical lift between resident use, which had the potential to affect 3 of 3 residents who required the mechanical lift. This was evidenced by: On 05/24/23 at 9:30 AM, Surveyor observed Certified Nursing Assistant (CNA) C and CNA D transfer R5 from the wheelchair into bed with the use of a mechanical lift. Staff did not sanitize the lift after use. CNA D moved the lift out of R5's room and placed the lift right outside the room in the hall. There were no sanitizing wipes on the lift, but there was an empty bag hanging from the lift. Surveyor watched the lift from use of R5 until used on the next resident. Staff did not sanitize the lift before use on the next resident. On 05/24/23 at 9:40 AM, Surveyor observed Registered Nurse (RN) E ask CNA C if she was done with the mechanical lift that was right outside R5's room. CNA C said yes, and RN E took the lift from the hall, so Surveyor followed RN E with the lift into R7's room. Staff did not sanitize the lift before use. Surveyor observed RN E and CNA C transfer R7 from the wheelchair into the bed with the use of the mechanical lift. Staff did not sanitize the lift after use. CNA C moved the lift just outside the room into the hallway and then walked away without sanitizing the lift. Surveyor asked CNA C what the process was for cleaning the mechanical lift. CNA C said she cleans the lift a few times a shift and tries to clean it after each use. On 05/24/23 at 9:47 AM, Surveyor asked CNA D what the process was for cleaning the mechanical lift. CNA D said the lifts are cleaned daily and they should be cleaned after use. CNA D said the wipes are hanging on the lift or in the storage area. On 05/24/23 at 9:58 AM, Surveyor asked the Nursing Home Administrator (NHA) A and the Director of Nursing (DON) B when multi-use equipment like the mechanical lift was cleaned. NHA A and DON B said the use of disinfectant wipes are used to disinfect the equipment after each use. NHA A said the disinfectant wipes container was located on the mechanical lift in a bag that was hanging from the lift with extra containers of disinfectant wipes stored in the storeroom. Surveyor advised NHA A and DON B concerning the observation of staff use of a mechanical lift with no sanitizing of the lift after use. Surveyor advised NHA A and DON B that the mechanical lift used by the staff did not have any disinfectant wipes on it. DON B stated she will get the wipes placed on the lifts now. Surveyor asked for a copy of the facility's policy and procedure for sanitizing multi-use equipment. On 05/24/23 at 11:08 AM, NHA A said they do not have a policy or procedure on cleaning the mechanical lifts after each use. It is an expectation that staff do this. NHA A said there are three residents who use the mechanical lift in the facility: R4, R5, and R7. On 05/24/23 at 1:30 PM, Surveyor reviewed the facility policy, entitled Infection Prevention and Control Program, dated 03/14/23, stated: .Equipment Protocol: Nursing staff/designee will decontaminate reusable equipment with a germicidal detergent prior to storing for reuse .

Based on observation, interview and record review, the facility did not ensure 1 of 12 (R20) residents reviewed for comprehensive care plans had a developed care plan to include respiratory. R20 had a history of respiratory issues, along with the use of continuous oxygen, and did not have a comprehensive care plan to include respiratory. This was evidenced by: On 05/23/23 at 8:27 AM, Surveyor observed R20 currently on oxygen at three liters per minute via nasal cannula. On 05/23/23 at 11:10 AM, Surveyor reviewed R20's medical record. R20 was admitted to the facility on [DATE] with diagnoses included, but not limited to acute respiratory failure with hypoxia, and heart failure. R20's physician's order included oxygen at 1-2 liters at rest, and up to 4 liters with activity, titrate to keep oxygen saturation 90-92% with a start date of 11/28/22. Review of R20's recent Minimum Data Set (MDS) assessment on 04/26/23 indicated oxygen use. A review of R20's care plan shows there was nothing written concerning respiratory such as assessments, care, or treatments. On 05/23/23 at 1:41 PM, Surveyor spoke with NHA (Nursing Home Administrator) A asking for R20's care plan of oxygen/respiratory as there was no current care plan for this seen in the electronic medical record. On 05/23/23 at 2:26 PM, Corporate NHA F said R20 did not have a care plan for oxygen/respiratory at this time. NHA F said they will enter oxygen/respiratory care plan for this resident. On 05/24/23 at 9:00 AM, NHA A provided a copy of R20's care plan that included (date initiated 05/23/23), R20 was at risk for hypoxia/respiratory failure due to a diagnosis of acute respiratory failure and heart failure. R20 will maintain acceptable levels of comfort and breathing. Interventions included Furosemide as ordered to maintain fluid balance and subsequent breathing ability, Guaifenesin as ordered to control chest congestion, hospice team involved as necessary to assist in comfort goals, and oxygen as ordered by the Physician.

Based on interviews and record review, the facility did not ensure 3 of 3 residents (R) reviewed for hospitalization were notified in writing of the reason for transfer from the facility. (R15, R28, and R4) R15, R28, and R4 were transferred to the hospital and neither the resident nor their representative received written notice of the reason for the transfer. Findings include: Facility Transfer to Hospital checklist states, in part, .Fill out Notice of Transfer or Discharge form, attach to checklist, turn in to medical records box .Documentation in chart .Patient Transfer Form . Example 1: R15 was hospitalized from 03/01/23 to 03/04/23 for low heart rate with symptoms. On 05/22/23 at 6:58 PM, Surveyor interviewed R15 who stated they did not remember getting any written notice of a reason for transfer to the hospital when sent to the emergency room (ER) in March. No written notice of reason for transfer was identified during review of R15's medical record. Surveyor requested a copy of the written notice of reason for transfer. On 05/24/23 at 8:44 AM, Nursing Home Administrator (NHA) A reported they did not have a copy of a written notice of transfer on R15's medical record when R15 was transferred to theER on [DATE]. Surveyor asked NHA A what the facility policy was for notice of transfer. NHA A stated they had a discharge/transfer packet with a check list. The packet contained a notice of discharge or transfer form that was to be completed at the time of the transfer. A copy of that document was supposed to be attached to the resident's chart. NHA A stated they just discovered that form was not getting completed according to their expected procedure. Example 2: R28 was transferred to theER on [DATE] due to increased flank and lower back pain. R28 was admitted to the hospital with an abscess on the spine. No written notice of reason for transfer was identified during review of R28's medical record. Surveyor requested a copy of the written notice of reason for transfer. On 05/24/23, Surveyor requested the written notice of transfer form for R28's hospitalization on [DATE]. NHA A stated they did not have a copy of that form on R28's medical record. 46693 Example 3 R4 was admitted to the facility on [DATE] with diagnosis that includes, in part, diabetes, morbid obesity with hypoventilation, and obstruction in the urinary tract. R4's Minimum Data Set (MDS) indicated a Brief Interview for Mental Status (BIMS) score of 14 that indicates that R4 is cognitively intact. On 03/12/23, R4's kidney drain was found to have fallen out. The doctor was called, and an order was given to send R4 to the hospital. On 05/23/23, Surveyor reviewed R4's medical record which confirmed transfer to the hospital and the facility completed an MDS indicating a discharge with return anticipated on 03/12/23. Surveyor was unable to locate the written notice requirements before transfers and discharges. Interview with DON B confirmed that R4 did not receive the written required notifications at the time of transfer to the hospital.

Based on record review and interview, the facility did not provide written notice of bed hold policy for 3 of 3 residents (R) reviewed for transfer to the hospital. (R15, R28, and R4) At the time of transfer to the hospital all 3 residents, or their representatives, did not receive written notice of bed hold policy. Findings include: Facility Transfer to Hospital checklist states, in part, .Fill out Notice of Transfer or Discharge form, attach to checklist, turn in to medical records box .Documentation in chart .Patient Transfer Form . The Notice of Transfer or Discharge form includes the facility bed hold policy. Example 1: R15 was hospitalized from 03/01/23 to 03/04/23 for low heart rate with symptoms. On 05/22/23 at 6:58 PM, Surveyor interviewed R15 who stated they did not remember getting any written notice of bed hold policy when sent to the emergency room (ER) in March. No written notice of bed hold policy was identified during review of R15's medical record. Surveyor requested a copy of the written notice of bed hold policy. On 05/24/23 at 8:44 AM, Nursing Home Administrator (NHA) A reported they did not have a copy of a written notice of bed hold policy on R15's medical record when R15 was transferred to theER on [DATE]. Surveyor asked NHA A what the facility policy was for written notice at the time of transfer. NHA A stated they had a discharge/transfer packet with a check list. The packet contained a Wisconsin Bed Hold and Notice of Transfer form that was to be completed at the time of the transfer. A copy of that document was supposed to be attached to the resident's chart. NHA A stated they just discovered that form was not getting completed according to their expected procedure. Example 2: R28 was transferred to theER on [DATE] due to increased flank and lower back pain. R28 was admitted to the hospital with an abscess on the spine. No written notice of bed hold policy was identified during review of R28's medical record. Surveyor requested a copy of the written notice of bed hold policy. On 05/24/23 Surveyor requested the written notice of bed hold policy for R28's hospitalization on [DATE]. NHA A stated they did not have a copy of that form on R28's medical record. 46693 Example 3 Surveyor reviewed R4's medical record and noted R4's Minimum Data Set (MDS) assessment dated [DATE] documented discharged with return anticipated. R4's medical record did not document a written bed hold notice. Director of Nursing (DON) B confirmed that bed hold notification was not given at time of transfers.

Based on observation, interview and record review, the facility failed to store and distribute food under sanitary conditions on two of three days of survey. Frozen foods were observed to be stored in packaging that was not intact or labeled with the date they were opened or package contents. Staff was observed to touch ready to eat foods with contaminated gloves. This is evidenced by: The facility policy, entitled Food Storage, dated effective April 2020, states in part: Foods will be stored and handled to maintain the integrity of the packaging until ready for use. All foods should be covered, labeled and dated. The facility policy, entitled Bare Hand contact with food and use of Plastic Gloves, dated effective May 2020, states in part: Gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed and hands must be washed. Food Storage On 05/02/22 at 10:55 AM during the initial kitchen tour, Surveyor observed within the freezer a package of tube shaped meat on the top shelf in an opened plastic bag. The bag was not sealed, not dated, and not labeled for contents. Surveyor asked Dietary Cook (DC) D about the package. DC D identified it as sausage links. DC D stated, We just got it last Tuesday. After conferring with Dietary Manager (DM) C, they decided it arrived on the 26th. DC D stated it hasn't been opened for long, but she was unable to identify how long. DC D then wrote on the package with a magic marker, the contents and the date. On another shelf was a plastic bag of white crumbly contents, that had no date on it when it was opened, no label for contents. When asked, DC D identified this as cooked chicken crumbles. DC D again spoke with DM C and they concluded part of it was used in chicken salad last Tuesday - also the 26th. DC D wrote on it with marker, as to the contents and date. DC D indicated there was a small smudge in marker on the bag, staff stated, it may have been dated at some point, but that it rubbed off. Also observed in the freezer was an open plastic bag with large bag of hot dogs in it. The plastic bag's Ziploc type seal is not closed, and did not seal. DC D pulled out the bag to view it and said the opened edge is on the bottom and placed the open bag back in freezer. When asked if that is how it should be, DM C took the bag back out of the freezer and stated the plastic bag should be shut, sealed. Surveyor observed lots of crystallized ice in the bag, by the hot dogs. Food Distribution Glove Use On 05/02/22 at 12:05 PM, Surveyor observed DC D serving food. DC D was observed to walk around the dining room taking residents' orders for the noon meal with gloved hands. As she did this, DC D touched the tables and the order slips and used a pen to write on the slips. When she completed this, DC D began to plate food. DC D did not change her gloves or wash her hands prior to plating food. As DC D plated food she would occasionally pull down her shirt, at one point she touched the door jam going into the kitchen with her gloved hands. DC D then reached into a plastic bag of rolls, with her contaminated gloves, pulled the rolls apart and placed them onto plates and served the food to residents. DC D did this multiple times. DC D would take the plates to residents at the table. DC D was also observed to cut a resident's sandwich by placing her contaminated gloved hand flat on the surface of the bread to hold it as she cut it with a knife. The last resident was observed to be served at 12:24 PM. On 05/03/22 at 11:55 AM, Surveyor observed Dietary Cook (DC) E serving food. DC E was observed to walk around the dining room taking residents' orders for the noon meal with gloved hands. As she did this, DC E touched the tables and the order slips and used a pen to write on the slips. When she completed this, DC E began to plate food. DC E did not change her gloves or wash her hands prior to plating food. As DC E did this she would reach her contaminated gloved hand into a bag of rolls and pull them apart and place them on plates for residents to eat. The last resident was observed to be served at 12:26 PM On 05/04/22 at 1:49 PM, Surveyor interviewed DM C and relayed the above concerns. DM C acknowledged that all frozen food packaging should be sealed properly then dated and labeled with contents. DM C stated that staff are trained to take residents' orders at meal time without wearing gloves. DM C stated after taking orders, staff should then wash their hands and put on clean gloves prior to serving food at the tray line. DM C stated if staff touch anything besides serving utensils, or any time their gloves become contaminated, they need to change their gloves, rewash their hands and reglove.

Based on observations, interviews, and policy review, the facility failed to establish and maintain an infection prevention and control program to help prevent or contain the development and transmission of communicable diseases such as COVID 19, which had the potential to affect 23 of 23 residents. Staff did not follow proper hand hygiene procedures during wound care procedure. This occurred for one of one wound care observations, resident (R) 273. Facility staff did not wear properly positioned facemasks for 3 of 3 days which had the potential to affect 23 of 23 residents. Staff did not don appropriate PPE for 1 of 2 residents on transmission based precautions, R19. Findings include: Example 1: Review of the Facility Policy dated September 2013, titled Dressing, Dry/Clean; reads in part .each time gloves are removed wash and dry hands thoroughly. On 03/29/21 Surveyor observed Director of Nursing (DON) B complete wound care on Resident (R) 273 at about 1:15 PM. DON B donned Personal Protective Equipment (PPE), sanitized the surface of the bed side table, and placed paper towels down on the sanitized table, set out bandage, gauze and derma rite. DON B then raised the bed to waist height and laid R273 flat to get to right lateral heel. DON B removed R273's sock; DON B cleansed the wound with Derma Rite and dried with gauze. DON B removed her gloves, washed hands with soap and water and put on new gloves. DON B then measured the wound, applied skin prep around the wound, removed her gloves and put on new gloves without washing and drying hands before putting on a new pair of gloves. DON B then applied bordered foam and dated it with today's date. DON B then removed gloves and put on new gloves without washing and drying hands before putting on a new pair of gloves. DON B then applied lotion to R273's foot, removed gloves and put on new gloves without washing and drying hands before putting on a new pair of gloves. DON B put R273's sock back on, then his blue boot, lowered the bed and raised the head of the bed, then DON B removed gloves and went to the bathroom and washed with soap and water. 03/31/21 08:50 AM Surveyor interviewed DON B at 8:05 am and reviewed the steps DON B took while doing wound care and asked DON B if it was DON B's standard of practice to change out gloves without hand sanitizing or hand washing in between changing gloves. DON B said No I should have washed my hands before putting on new gloves. Example 2: R19's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R19 was admitted to the facility from the hospital on 03/26/21. On 03/30/21 at 08:15 a.m., Surveyor accompanied Registered Nurse (RN) C while she assisted with R19's oral medication administration. After washing her hands, RN C entered R19's room without donning PPE. RN C assisted R19 with oral medication administration. After assisting R19 with oral medication assistance, RN C performed hand hygiene and left the room. Surveyor reviewed signs posted outside of R19's room. The signs read, in part, Contact precautions don gown, mask, gloves, eyewear .before entering room . Plastic drawers outside of the residents' room contained masks, gowns, gloves, and faceshields. Surveyor interviewed RN C. RN C confirmed that R19 was on contact precautions due to admission on 03/26/21. RN C stated I just don't know what I was thinking .I just forgot. Example 3. Face Masks The facility policy and procedure guide for donning and doffing a facemask (based on CMS guidance dated 04/02/2020) instructs staff in part to: Mold or pinch the stiff edge to the shape of your nose. Pull the bottom of the mask over your mouth and chin. On 03/29/21, at 08:45 a.m., Surveyor performed an initial kitchen tour. Dietary Manager (DM) H's face mask was covering only his mouth, leaving his nose exposed. On 03/30/21, at 11:35 a.m., Surveyor observed DM H during meal service. DM H's face mask was covering only his mouth, leaving the nose exposed. On 03/30/21, at 12:10 p.m., Surveyor observed DM H. DM H's mask was below his nose and mouth. On 03/29/21 at 11:12 AM, Surveyor observed RN C walking down the hall with face mask not covering her nose. Several residents and other staff members were in the hallway at the time. On 03/29/21 at 11:31 AM, Surveyor observed RN C with surgical mask not covering her nose assist a resident back to her room in her wheelchair. On 03/29/21 at 12:55 PM, Surveyor observed CNA E go into a resident room to pick up a lunch tray. CNA E's surgical face mask was not covering her nose. On 03/30/21 at 8:05 AM, Surveyor interviewed RN C. RN C's surgical face mask was below her nose during the entire interview. On 03/30/21 at 8:42 AM, Surveyor interviewed CNA E. CNA E's surgical face mask was below her nose during the entire interview. Observations on 03/29/21 at 11:22 AM included RN C walking down hall and into residents' bedrooms, while wearing a face mask that fell just below the level of her nose, covering only her mouth, and chin. CNA E was observed on 03/29/21 at various times through out the day shift to go up and down hall, in and out of residents rooms with her face mask worn below her nose. Observations on 03/30/21 made between 7:30 AM and 11:46 AM at varied times, CNA E was observed to wear her face mask below her nose, covering only her mouth and chin. CNA E was observed to be walking up and down the hall while assisting residents. Going into and out of resident rooms. In the dining room, talking with residents and other staff while closer than 6 feet apart. At breakfast CNA E was observed to pull her face mask down under mouth (covering only her chin) at times to speak with others. Observations on 03/31/21 at 8:17 AM CNA E was observed to wear her face mask below her nose and upper lip. CNA E walked through the dining room stopping to speak to R17 and 2 other residents whose masks were off as they were actively eating. CNA E asked the residents how breakfast was and made other small talk while within 1 foot of the residents. CNA E then went into hall with her face mask in the same position. Interview on 03/31/21 at 12:06 PM with NHA A, surveyor explained the above observations and asked how face masks should be worn. NHA A stated face masks should be worn over the nose and mouth at all times to be effective. NHA A stated that is how staff are trained to wear their face masks.

Based on observation and interview the facility did not ensure that food was prepared to conserve nutritive value. The Dietary Manager did not prepare pureed foods to maintain the nutritive value of pureed foods for 1 of 1 residents (R) 4 who received a pureed diet. This is evidenced by: On 03/30/21, at 11:53 a.m., Surveyor observed meal preparation and service. The steam table contained meat, green beans, and noodles. No pureed item was placed on the steam table. At 12:00 p.m., Surveyor interviewed DM H. DM H stated that he purees the food fresh so that it will not sit on the steam table. At 12:10 p.m. Surveyor observed pureed meal preparation of beef tips and noodles: Noodles/Meat: Meat and noodles were mixed with water (1 ladle of meat mixture with water to blender (Robocoup) no specific amount) beans 1 ladle .unmeasured amount of water added, and a pre-prepared bread substance. DM stated he has not had training regarding how to prepare pureed diets and that he has had experiences in Assisted Living but nobody has told him how exactly to do it. DM H stated that he adds water to obtain pureed consistency, unmeasured, but will add milk depending on the food type, such as a doughnut. DM H stated I haven't been here that long, and I'm learning as I go along. DM H stated that the dietician was responsible for providing training to new Dietary Managers. DM H did not follow a recipe to make the pureed food to maintain the nutritional value of the food for R4. 03/30/21 02:00 p.m. Surveyor interviewed Dietician I. The dietician stated that she has Reviewed expectations, standard precautions, and clinical expectations with DM H. D I stated There are pureed recipes in the kitchen with spreadsheets. Surveyor asked D I if she provided training to DM H regarding pureed diets and recipes. D I stated No, I haven't worked with him on that yet. I was going to today. Surveyor reviewed DM H's hire date. DM H has been the Dietary Manager since 02/02/21. Surveyor reviewed pureed diets which contained alternate recipes. The diets are kept in a binder and stored in the kitchen. Surveyor reviewed the facility diet textures. R4 was the only resident who was currently receiving a pureed diet. Surveyor reviewed R4's weights. No significant weight loss since admission.

Based on observation and interview, the facility did not ensure drugs and biologicals were labeled in accordance with currently accepted professional principles, and did not ensure expired medications were removed from stock supply. Two medications were not labeled with resident's name and prescription information in 1 of 1 medication carts reviewed for storage. Eight expired medication bottles were identified in 1 of 1 medication storage rooms reviewed. Findings include: On 03/31/21 at approximately 09:30 AM, Surveyor reviewed medication storage on one medication cart with Director of Nursing (DON) B. In bottom drawer of medication cart, Surveyor identified an opened bottle of [MEDICATION(S)] nasal spray in a plastic bag with no label for which resident it belonged to. In the same drawer, Surveyor noted an Incruse/ellipta inhaler in a plastic bag with no resident name. Registered Nurse (RN) C stated those two medications belong to Resident (R) 1. RN C stated the medications came in a box with the resident's name/label, but that was discarded when the medication was taken out of the box. RN C stated she just knows they belong to R1 because only two residents' medications are kept in the bottom drawer, and they just place all of one resident's medications together in the drawer. DON B stated each medication container should be labeled with the resident's name and prescription label from the pharmacy. On 03/31/21 at approximately 09:40 AM, Surveyor reviewed medication storage in the medication storage room with DON B. In the stock medication cupboard, Surveyor identified 4 bottles of [MEDICATION(S)] 5 mg tablets that had an expiration date of August, 2020. Surveyor identified 2 bottles of Geri-[MEDICATION(S)] liquid with an expiration date of January, 2021. Surveyor identified 2 bottles of saline nasal spray with an expiration date of December, 2020. DON B removed those from the stock, and stated expired medications should be removed from the stock supply and disposed of. DON B stated the contracted pharmacy was not coming into the facility to check the stock medication supply due to the COVID-19 visitor restrictions.

Based on observation, interview, and policy review the facility failed to ensure visual personal privacy of a resident's body for 1 of 14 (R)1 sampled residents R1 was observed on 2 of 3 days of survey to be exposed from the waist down, and visible from the hallway. This is evidenced by: The facility policy entitled Resident Rights, dated 09/26/2017, states in part: always provide privacy by .pulling a curtain around the bed, . closing the door and draping the resident's body appropriately.' Based on the reasonable person concept, a person whom is unable to provide for their own personal privacy of their body, would want their privacy to be provided by staff. This would include ensuring that a persons body be covered in a way to protect them from the view of others. Including the private, normally covered areas of their body. R1 was admitted to the facility with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 is currently a hospice patient. R1 takes routine medications for pain and anxiety. R1's progress notes reveal R1 is maintained with multiple doses of Lorazepam and [MEDICATION(S)] daily. R1's level of consciousness and abilities vary with medication use and as R1's health declines. Observations on 03/29/21, at 9 AM and 11 AM, Surveyor observed R1 from the hallway. The lower half of R1's body from approximately the waist down was visible from the hallway. R1 wore a blue diaper type incontinent product, and nothing else. R1 was sleeping at the time and was exposed clearly from the hallway. Observations at 1:44 PM revealed that a privacy curtain by the doorway, was drawn a bit, but R1's lower half of the body was still exposed and visible from the hallway. Observations on 03/30/21, at 9 AM and 11 AM, Surveyor observed R1 to be exposed and visible from hallway. The lower half of R1's body from approximately the waist down was visible from the hallway. R1 wore a blue diaper type incontinent product, and nothing else. R1 was sleeping at the time. On 03/29/21 and 03/30/21 staff was observed to go up and down the hallway, at times even entering R1's room, and did not do anything to ensure R1's physical privacy was maintained. Surveyor attempted to interview R1 on 03/29/21, 03/30/21 and on 03/31/21 about the above observations. R1 would mumble a few unintelligible words in response to questions and would fall back to sleep. On 03/31/21, at 12:06 PM, surveyor interviewed NHA A, who stated when asked about the above observations, that R1 should be covered to maintain his dignity. NHA A stated that normally R1 closes his bedroom door. Surveyor and NHA A discussed R1's current increasing weakness and fluctuating levels of alertness. When asked if staff should ensure R1's privacy if R1 did not close the door or pull the curtain. NHA A stated that staff should.

Based on interview and record review, the facility did not ensure that the Advanced Directives information related to resuscitation status was clearly identified on residents' medical records to ensure their life-sustaining wishes would be honored. This occurred for 3 of 4 residents (R) reviewed for Advanced Directives. (R8, R14, and R20) The facility had multiple places in the medical record that list the resident's resuscitation or code status, and all three examples had discrepancies in the code status on the medical record. Findings include: Facility Policy entitled, Living Will/Advanced Directives/Life-Sustaining Treatment Orders states, in part: 2. Residents will be given the option of completing a Living Will or Advance Directive if they have not already done so. This option will be presented to a resident on admission to the facility. Advance Directives allows the resident to ask for no life saving measures without the need for a terminal diagnosis. The Living Will or Advance Directives will be then noted on the resident's medical record. Example 1: R20 was admitted to the facility on [DATE]. Review of R20's medical record identified the profile on the opening screen of the medical record stated Do Not Resuscitate (DNR). The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Advanced Directive status on the resident's comprehensive care plan stated Full Code or Cardiopulmonary Resuscitation (CPR). The resident desired a code status of DNR. On [DATE] at 8:05 AM Surveyor interviewed Registered Nurse C, who reported a resident's code status (wishes for resuscitation) is located in a red binder titled Code Book at the nurses station. Surveyor reviewed the Code Book and identified a cover page with the resident roster and each resident's code status listed after their name. R20's name was not on the resident roster page. Behind the W tab in the binder, Surveyor located a copy of the state of Wisconsin DNR form signed by R20 and a physician. On [DATE] at 8:27 AM Surveyor interviewed Licensed Practical Nurse (LPN) F who reported a resident's CPR or code status was located in a CPR binder at the nurses station, on the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN F stated LPN F would go by the resident's physician orders. Surveyor reviewed R20's medical record and CPR book with LPN F. Surveyor pointed out to LPN F that R20's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN F stated R20 was a resident in the facility in the past and possibly the code status from the previous admission filtered through onto the current care plan. Surveyor asked LPN F who is responsible to make sure a resident's code status is correct. LPN F stated the nurses and the Minimum Data Set (MDS) Coordinator all work together to update a resident's code status in all of the areas of the medical record. On [DATE] at 8:42 AM Surveyor asked Certified Nursing Assistant (CNA) E where CNA E would look to determine a resident's code status. CNA E would look for a resident's code status in the CPR book at the nurses station. On [DATE] at 11:00 AM Surveyor interviewed MDS Coordinator G about who is responsible to put the resident's code status on the care plan. MDS Coordinator G stated the code status usually gets entered into the resident's medical record as a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS Coordinator G stated she enters that on the care plan. Surveyor asked MDS Coordinator G if there was a discrepancy between physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS Coordinator G stated she guessed she was responsible for that. MDS Coordinator G stated as soon as she was aware of any discrepancies, she would correct it. MDS Coordinator G stated the resident's code status is reviewed quarterly and updated on the care plan. Surveyor asked MDS Coordinator G if there is a system in place to catch any errors or discrepancies sooner than quarterly. MDS Coordinator G did not think there was a system in place to check for discrepancies. On [DATE] at 08:26 AM Surveyor interviewed Director of Nurses (DON) B and Clinical Services Director (CSD) D about facility policy on Advanced Directives. Surveyor asked where a resident's code status was recorded, and where staff look to determine what a resident's code status was. Both DON B and CSD D acknowledged they had identified the facility had a problem with their system. They stated there were too many locations in the medical record to document the resident's code status, and that contributed to possible errors or discrepancies. Surveyor reviewed with DON B and CSD D, the discrepancies found on R20's medical record, of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . DON B and CSD D acknowledged this was an error on R20's medical record that could lead to a serious mistake in honoring R20's wishes if R20 had a [CONDITION(S)]. Example 2: R8 was admitted to the facility on [DATE]. Review of R8's medical record identified physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R8's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Code Book in the nurses station identified a document signed by R8 and a physician that stated Full Code or CPR. The resident desired a code status of CPR. On [DATE] Surveyor reviewed with DON B and CSD D, the discrepancies found on R8's medical record, of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . DON B and CSD D acknowledged this was an error on R8's medical record that could lead to a serious mistake in honoring R8's wishes if R8 had a [CONDITION(S)]. Example 3: R14 was admitted to the facility on [DATE]. Review of R14's medical record R14's profile indicated CPR, the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders for code status on the POLST were opposite to everything else in R14's medical record. R14's request was for CPR. Surveyor interviewed DON B and Director if Clinical Services about the above discrepancies in charting of code status and they both agreed there was a problem and could lead to a mistake in honoring R14's wishes for CPR if R14 had a [CONDITION(S)].

Based on interviews and record review, the facility did not have evidence all allegations of abuse or mistreatments are thoroughly investigated. This occurred for 1 of 3 residents reviewed for abuse, Resident (R) R1. R1 made an allegation of rape. The facility did not do a thorough investigation into the incident. This is evidenced by: R1 was admitted to the facility [DATE] with a [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) documents a Brief Interview for Mental Status Score of 14, meaning R1 is alert and oriented and able to answer questions. R1 does have an activated power of attorney for health care due to the intellectual disability and poor decision making. R1's Care Plan Resident alleged that she was raped prior to entering the care center (first initiated [DATE]). Goal: Resident will feel safe in her environment and free to verbalize thoughts, feelings, and fear as she feels comfortable. Interventions: Social worker will provide support and monitor for signs of anxiety and or depression .A sign will be placed on door directing all visitors to nurses station. All male visitor (except guardian) will need to be supervised .A report was made to county sheriff, . County Human Services, NHA, DON and resident's guardian. (updated [DATE]). This is the date Surveyor was onsite. Surveyor reviewed the medical record and noted the hospital admission notes include in part, Pt had reported to nurse that she was raped .was able to give some detail as to what happened to her and she reports that two different men had tried to rape me last week. Pt declined for RN to physically examine her and collect evidence .Pt denied that a penis was put inside of her .Pt did report that both men's penis was out of their pants . The hospital filed a vulnerable adult report. On [DATE] at 8:45 a.m., Surveyor asked the Nursing Home Administrator (NHA) and the Director of Nursing (DON) for any self reports that are in progress or abuse investigations. Surveyor was told they do no have any recent investigations. On [DATE] at 9:30 a.m., Surveyor interviewed R1 and asked how things were going. R1 said, Not good. Surveyor asked if R1 wanted to talk about it. R1 said, No. R1 stated she was leaving the facility. On [DATE] at 9:40 a.m., Surveyor interviewed Certified Nursing Assistant (CNA) C to ask about any behaviors of R1. CNA C indicated R1 gets upset easily, very emotional and does not like the restrictions of no visitors due to Covid. CNA C stated that R1's roommate passed away a few months ago and since then R1 is very emotional. Surveyor asked if R1 has made any allegations of sexual abuse. CNA C stated, No. Surveyor reviewed the nurses' notes for any additional information from social services. A note on [DATE] includes in part: Received call from .adult protection .regarding resident and allegations she made while at hospital.Resident has made these allegations in the past in which facility and pierce county launched an investigation. During previous investigation into incident, it was found out that the incident had occurred many years ago and the individual who had sexually assaulted resident is now deceased . Informed adult protective services she has not had any visitors due to Covid -19 .resident has not made these allegations while at the facility since April when writer started position. Writer will look back in notes and see if there is anything that can be reported .at this time social worker at .county and writer agree that it can be assumed the allegations resident made while at hospital are relating to a past experience .Social services will continue to monitor situation for any behavior or statements that relate to the situation and will report any findings to the adult protection social worker. No other questions or concerns at this time. On [DATE] at 1:10 p.m., Surveyor interviewed Social Services Director (SSD) D asking what SSD D was aware of about R1's allegations. SSD D indicated the hospital had called and talked with SSD D most likely on [DATE]. SSD D stated the hospital told the facility a report had been filed with adult protective services. Surveyor asked what happened after that. SSD D stated that on [DATE] the county Social Worker called to go over the case. The worker had a similar case from this resident from approximately 1 year ago. SSD D stated she looked back in R1's record and could see no visitors have been allowed in that could have done anything due to Covid restrictions. SSD D stated the county social worker was going to call the Power of Attorney. SSD D stated she has not heard anything back at this point. SSD D stated that she and the county social worker agreed it was most likely trauma being brought up from the past due to the surgery at the hospital. Surveyor asked if the facility had interviewed the resident. SSD D stated she has worked at the facility for two months. R1 is very particular about who she talks to. SSD D is told to leave the room after one or two sentences. Surveyor asked if the facility interviewed other alert and oriented female residents for any misconduct occurring. SSD D stated no. Surveyor asked if the facility had interviewed staff to see if they heard or saw anything, or if R1 had reported this to other staff. SSD D stated, No, we are starting the interviews today. On [DATE] at 1:55 p.m., Surveyor interviewed NHA A about the above incident. Surveyor asked what was done when the facility was notified about the sexual abuse allegation. NHA A stated the power of attorney had been called who indicated this relates back to an older incident that R1 experienced many years ago. The names alleged are now deceased . NHA A stated that an interview was conducted today with R1 by NHA A and that R1 stated no one in the facility has hurt her. NHA A stated she would look for any other soft files relating to the investigation that may have been completed. On [DATE] at 5:38 p.m., Surveyor received an email that said, This is what I have. The email contained the admission assessment including skin assessment. Evidence of a thorough investigation into the rape allegation was not provided. Surveyor reviewed a facility policy entitled, Abuse Prevention Program. The policy, dated [DATE], states the following, in part: .5. Investigation .The facility's immediate response is to protect the alleged victim. To protect the alleged victim, the facility has clear delineated roles of those responsible for investigating and will respond to ensure protection of the alleged victim, identify any other alleged victims, ensure the safety of all other residents and the integrity of the investigation. Procedures: The components of an internal investigation will be initiated immediately and may include .an initial evaluation and interview .a psychosocial evaluation .and interviews with potential witnesses .collecting of evidence .documentation. Collection of evidence and documentation will be ongoing until determination is made. All involved persons will be identified including the victim, alleged perpetrator, witness(es) and others with any information about the incident .6. Protection .Staff will respond immediately to protect the alleged victim, all residents .The alleged perpetrator will immediately be removed from the facility and denied access to the alleged victim and all other residents .

Based on interview, record review and policy review, the facility did not have evidence that all allegations of abuse or mistreatment to residents were reported in accordance with state survey agency requirements. This occurred for 1 of 3 residents reviewed for abuse, Resident (R)1. R1 alleged she was raped during a hospital admission from facility on [DATE]. The facility did not report the allegation of sexual abuse to the state agency. This is evidenced by: R1 was admitted to the facility [DATE] with a [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) documents a Brief Interview for Mental Status Score of 14, meaning R1 is alert and oriented and able to answer questions. R1 does have an activated power of attorney for health care due to the intellectual disability and poor decision making. Surveyor reviewed the medical record and noted the hospital admission notes include in part, Pt had reported to nurse that she was raped .was able to give some detail as to what happened to her and she reports that two different men had tried to rape me last week. Pt declined for RN to physically examine her and collect evidence .Pt denied that a penis was put inside of her .Pt did report that both men's penis was out of their pants . The hospital filed a vulnerable adult report. On [DATE] at 8:45 a.m., Surveyor asked the Nursing Home Administrator (NHA) and the Director of Nursing (DON) for any self reports that are in progress or abuse investigations. Surveyor was told they do no have any recent investigations. Surveyor reviewed the nurses' notes for any additional information from social services. A note on [DATE] includes in part: Received call from .adult protection .regarding resident and allegations she made while at hospital. Resident has made these allegations in the past in which facility and county launched an investigation. During previous investigation into incident, it was found out that the incident had occurred many years ago and the individual who had sexually assaulted resident is now deceased . Informed adult protective services she has not had any visitors due to Covid -19 .resident has not made these allegations while at the facility since April when writer started position. Writer will look back in notes and see if there is anything that can be reported .at this time social worker at .county and writer agree that it can be assumed the allegations resident made while at hospital are relating to a past experience Social services will continue to monitor situation for any behavior or statements that relate to the situation and will report any findings to the adult protection social worker. No other questions or concerns at this time. Surveyor reviewed the facility policy Abuse Prevention Program dated [DATE] that includes in part: 7. Reporting/Responding .The facility must report alleged violations related to .abuse .and report the results of all investigation to the proper authorities within the prescribed time frames .Results of the investigation will be reported to the state survey agency within 5 working days of the initial allegation . On [DATE] at 1:10 p.m., Surveyor interviewed Social Services Director (SSD) D and asked when the facility was made aware of the incident. SSD D indicated the hospital called the facility on [DATE] and informed the facility. On [DATE] at 1:55 p.m., Surveyor interviewed NHA A and asked if the facility has filed a report with the state agency since being aware of the incident on [DATE]. NHA A stated, No.

Based on interview, record review and observation, the facility has not established a surveillance plan to identify, track and monitor infections on an ongoing basis for early detection and to manage potentially infectious diseases; this has the potential to affect all 33 residents residing in the facility. Additionally, the facility did not implement appropriate transmission-based precautions for a resident with active [MEDICAL CONDITION]-Resistant Staphylococcus Aureus (MRSA) for 1 of 1 residents reviewed with an active infection, Resident (R) 13. Surveillance data did not include all residents with symptoms of infection unless the resident was prescribed an antibiotic. R13 has a history of [MEDICAL CONDITION] infection. On 09/10/19 and 09/11/19, transmission based precautions were not in place for R13. This is evidenced by: 1. On 9/11/19 at 1:30 PM, Surveyor interviewed Interim Director of Nursing (DON), who is currently overseeing the facility Infection Control program. DON stated he is employed by a staffing agency and has been serving as Interim DON since (MONTH) 2019. DON stated the facility follows McGeer's criteria for infection prevention and control. Surveyor asked what system is in place for monitoring infections. DON stated he checks the computer every morning and receives a pop-up anytime a new antibiotic is ordered, alerting him to a new infection. DON stated the resident would at that time be added to the log sheet to be monitored. Surveyor asked how symptoms are tracked on a daily basis. DON stated whenever there is a change in condition he is notified and completes a risk assessment and contacts the physician. Surveyor asked how DON would identify if an outbreak were occurring. DON stated he doesn't know off the top of his head what criteria would constitute an outbreak, but once an outbreak was declared, he would isolate residents and report it. The facility's corporate office would send down protocols at that time. Monthly Infection Surveillance Log reviewed for past 3 months. Log contains names, location, symptoms, organism and precaution listing of residents who have been prescribed an antibiotic. It does not contain any daily surveillance of residents that would allow early detection of symptoms. On 9/12/19 at 1:49 PM, Surveyor interviewed Nursing Home Administrator (NHA). Surveyor relayed concerns regarding the absence of a system to identify symptoms for early detection of infections on a daily basis. NHA stated during the morning meeting the 24-hour list is reviewed and if symptoms are noted they should be put onto a daily surveillance list. NHA stated she will try to get a copy to show Surveyor this is being done. Surveyor asked if NHA is aware of what type of training and credentials DON has to qualify him to oversee the facility's infection control and prevention program. NHA stated she does not know, but stated someone from the corporate office came to the facility and gave DON training upon his hire. On 9/12/19 at 2:31 PM, Surveyor interviewed DON for clarification of Monthly Infection Surveillance Log. Surveyor asked if log only contains residents who were started on an antibiotic. DON stated yes, that is correct. Surveyor asked where was any other tracking of symptoms the resident was having prior to the antibiotic being ordered or a log that indicates symptoms that led to the physician being contacted for an antibiotic order. DON stated there is no other tracking recorded; the information would have to be found in the nurses notes. Surveyor asked what type of training DON has received for his role overseeing the infection control and prevention program. DON stated he has his experience in the nursing field and his on-the-job knowledge. DON stated he is enrolled in the Infection Preventionist training through the Centers for Disease Control, but has not yet started. Surveyor asked if facility had provided him any training upon hire and DON replied no. On 9/12/19 at 3:15 PM, NHA and DON brought Surveyor a printed copy of a log sheet that would allow for daily recording of symptoms. NHA stated DON was not aware of this and NHA was hesitant to provide this information because it was part of the facility's Quality Assurance and Performance Improvement (QAPI) program. Surveyor asked how this information would be accessible. NHA stated it would not have been accessible, but from this point on they will record daily symptom tracking on a log similar to the one being used to track antibiotic use. 2. During the initial tour on 09/10/19, Surveyor interviewed R13 at 1:25 PM in the resident room. There were no precaution carts or signs indicating transmission based precautions were needed. R13 indicated she has [MEDICAL CONDITION] infection which started about one week ago on the crease of her leg and labia. R13 stated, I had another infection [MEDICAL CONDITION] that started three months ago on my behind with three boils. R13 stated, I saw the doctor today who kept me on the antibiotics I have been on and gave me ointment to put on there. Medical record documents R13 has history [MEDICAL CONDITION], has been treated with antibiotics and sees a physician routinely for follow up at a dermatology clinic. R13 was seen on 09/10/19 for [MEDICAL CONDITION] infection. Physician orders [REDACTED].>Mupirocin Ointment 2 % Apply to buttocks topically two times a day for Rash for 2 Weeks and nares. Pharmacy Active 9/10/2019 14:00. [MEDICATION NAME] Liquid 4 % ([MEDICATION NAME]) Apply to neck down topically one time a day every Wed for Rash do not apply to broken skin Pharmacy Active 9/11/2019 18:00 9/10/2019 Follow up appointment .at Forefront Dermatology on 9/26/19 @1330 . The skin integrity care plan in part, The resident has skin infection r/t [MEDICAL CONDITION] The resident will not display any complications related to skin infection. Educate resident/family on precaution policies at facility. Follow facility policy for implementation of any precautions r/t active infection. Staff to follow standard precautions and transmission precautions when appropriate .Use Contact PRECAUTIONS per isolation Surveyor observed no precautions in place during 09/10/19 or 09/11/19. On 09/11/19 at 1:30 p.m., Surveyor interviewed the interim DON. The DON stated R13 has been active [MEDICAL CONDITION] and has had several rounds of antibiotics, recently finishing them. The DON indicated R13 saw a doctor yesterday for new treatment. Surveyor stated transmission based precautions sign or cart with personal protective equipment has not been seen or used by staff for the past two days of survey. The DON stated it should be colonized at this time so no precautions or cart were by R13's room. Surveyor asked how that determination was made. The DON stated the physician could be contacted to clarify. Surveyor asked if the DON could contact the MD and confirm that [MEDICAL CONDITION] is not active. At 2:45 p.m., the DON came to Surveyor and stated the doctor stated R13 is active [MEDICAL CONDITION] infection and should still be on transmission based contact precautions. The DON will put the cart in place at this time.

Based on observation, interview and record review, the facility did not ensure each resident's care plan is reviewed and revised, based on the residents' needs and comprehensive assessment. This occurred for six of 19 residents whose care plans were reviewed (Residents (R) 11, 29, 21, 26, 13, and 19). R11's care plan was not updated to identify the use of bedrails, anti-rollback brakes and the correct type of walker the resident uses. R29's care plan was not updated to identify the correct diet texture, type of mattress or use of bedrails. The care plan was not updated to identify fall interventions were no longer in use. R21's care plan was not updated to identify the resident did not want to be woken up by staff in the early hours, and a particular staff member was no longer to enter the resident's room. R13 and 26's care plans were not updated and revised with instructions on certain caregivers not caring for them. R19 and R26's care plan were not updated with pertinent information on the type of bedrail, purpose for the bedrail, or when and how to use the bedrails. This is evidenced by: 1. On 09/10/19, Surveyor reviewed R11's medical record. The resident has [DIAGNOSES REDACTED]. The resident is legally blind. R11's Brief Interview for Mental Status (BIMS) score, dated 07/14/19, was a 12 out of a possible 15 points. According to the BIMS assessment, a score of 12 indicates the resident has moderately impaired cognition. On 09/10/19 at 10:30 a.m., Surveyor observed the resident lying in bed. The resident had bilateral (both) one-half bedrails near the head of the resident's bed. An anti-rollback brake device was located on the back of R11's wheelchair, and a front-wheeled (or regular-type) walker was located in the resident's room. On 09/11/19 at 6:58 a.m., Surveyor observed the resident lying in bed. The resident had bilateral one-half bedrails near the head of the resident's bed. An anti-rollback brake device was located on the back of R11's wheelchair, and a front-wheeled walker was located in the resident's room. At 7:21 a.m., R11 was observed to be self-propelling in a wheelchair towards the facility dining room. The anti-rollback device was located on the back of the resident's wheelchair. Surveyor reviewed a facility Side Rail Assessment, dated 05/14/18. The assessment indicates R11 requires one-half side rails (bedrails) on the left and right sides of the bed, to assist the resident with bed mobility. A physician's orders [REDACTED]. The medical record identifies the resident is to walk to and from meals with staff assistance and a walker. Surveyor reviewed R11's comprehensive care plan and Certified Nursing Assistant (CNA) care plans. The comprehensive care plan states in part, .The resident has limited physical mobility .Revision on: 06/25/2019 .Interventions .AMBULATION/L[NAME]OMOTION-FOUR WHEELED WALKER .TRANSFER-FRONT WHEELED WALKER . Neither care plan identifies the resident has bedrails or an anti-rollback device on the wheelchair. On 09/12/19 at 8:57 a.m., Surveyor interviewed Registered Nurse (RN) A, and asked if a resident's bedrails are normally identified on the care plan. RN A replied the use of bedrails are something the facility normally identifies on the resident's care plan. RN A stated R11's anti-rollback brakes are not identified on the care plan. During the continued interview, RN A stated R11 used a four-wheeled walker in the past, and is now supposed to use a front-wheeled walker, which is located in the resident's room. RN A stated she updates the resident's care plans at least quarterly, or with any changes. 2. On 09/11/19, Surveyor reviewed R29's medical record. The resident has [DIAGNOSES REDACTED]. According to the resident's MDS, dated [DATE], the resident has short and long term memory deficits, and has fluctuating disorganized thinking. The resident requires the assistance of staff for transfers and eating. R29's medical record identifies the resident fell , on 08/22/19, and sustained a left femur fracture. A physician's orders [REDACTED]. The resident's medical record identifies, on 08/28/19, an air mattress was delivered to the resident. On 09/10/19 at 12:02 p.m., Surveyor observed the resident sitting up in a Broda wheelchair (a brand of wheelchair which uses tilt-in-space positioning) in the facility dining room. There was no tray located on the resident's wheelchair. On 09/11/19 at 6:59 a.m., Surveyor observed R29 lying in bed, sleeping. An air mattress, without raised edges, was located on the resident's bed, and the resident had bilateral one-half bedrails near the head of the bed. There was no bed alarm or fall mats located next to the resident's bed. At 8:42 a.m., Surveyor observed two staff members transfer R29 from the Broda wheelchair to the resident's bed. At the end of the observation, staff left the room and R29 was observed to be lying in bed. An air mattress, without raised edges, was located on the resident's bed, and the resident had bilateral one-half bedrails near the head of the bed. There was no bed alarm or fall mats located next to the bed. Surveyor reviewed a facility Side Rail Assessment, dated 11/19/18. The assessment indicates R29 requires one-half side rails on the left and right sides of the bed, to assist the resident with positioning. Surveyor reviewed R29's comprehensive and CNA care plans. The comprehensive care plan states the following, in part, .The resident is at risk for falls .Revision on: 06/16/2019 .Interventions .FALL RISK-BED ALARM .FALL MAT .RAISED EDGE MATTRESS .The resident has had an actual fall with no injury. Date Initiated: 08/22/2019 .The resident had a [MEDICAL CONDITION] ([MEDICAL CONDITION]/Stroke) affecting left side .Has 1/2 lap tray on left arm rest of w/c (wheelchair) for resident to rest her arm on .The resident is at nutritional risk .Revision on: 11/29/2018 .Interventions .DIET TEXTURE-REGULAR . The care plan does not identify the resident has bedrails. R29's CNA care plan identifies the resident uses a bed alarm, a fall mat, a raised edge mattress, has a regular diet texture, and has a wheelchair table. On 09/12/19 at 8:57 a.m., Surveyor discussed R29's comprehensive and CNA care plans with RN [NAME] The RN stated since the resident's fall, on 08/22/19, the resident no longer uses a fall mat, bed alarm or raised edge mattress. RN A stated R29 fell and sustained a femur fracture, on 08/22/19, which should be updated on the resident's care plan. The RN indicated the 1/2 wheelchair tray was once used by R29, until the resident was enrolled in hospice care, on 06/10/19. RN A further stated the resident's diet texture must be updated in the care plan to reflect the pureed diet. During the continued interview, RN A stated R29's bed rails are not identified on the care plan. RN A stated she updates the resident's care plans at least quarterly, or with any changes with the residents. At 11:04 a.m., Surveyor discussed R29's care plan updates with the Nursing Home Administrator (NHA), and the Director of Nursing (DON). The NHA stated R29 does not have the fall mat, bed alarm, raised edge mattress, wheelchair tray, and the resident's diet is now pureed. 3. On 09/10/19, Surveyor reviewed R21's medical record. The resident has [DIAGNOSES REDACTED]. R21's BIMS score, dated 08/08/19, was an 11 out of a possible 15 points. According to the BIMS assessment, a score of 11 indicates the resident has moderately impaired cognition. According to the resident's medical record, the resident requires assistance of staff for personal hygiene and toileting. On 09/10/19 at 9:15 a.m., Surveyor interviewed R21. When Surveyor asked if the resident is able to make choices about their daily life, R21 replied, No. R21 explained CNA D enters the resident's room between 4:00 a.m. and 5:00 a.m. and will rearrange the resident's items in the room (i.e. straightens out the incontinence pads, etc.). The resident further explained CNA D will wake up the resident, to ask R21 if the resident has to use the bathroom. R21 stated she has told CNA D, I tell her to not wake me up (and) I didn't ring for you. The resident stated she will then ask the CNA to leave the room. R21 stated she has reported this to Licensed Practical Nurse (LPN) C, but the resident stated CNA D has come into R21's room in the early hours at least three times since it was reported to the LPN. R21 further stated, She (CNA D) keeps coming in here and I don't want her in here in the mornings. On 09/11/19 at 3:18 p.m., Surveyor spoke with LPN C. The LPN stated approximately seven to ten days ago, he was given a note, by Registered Nurse (RN) B, which mentioned CNA D should no longer go into R21's room. LPN C explained at that time, the LPN spoke with R21 regarding some concerns the resident had about CNA D. LPN C explained, according to R21, one of the concerns was CNA D was entering the resident's room at 3:00 a.m. to 4:00 a.m. which woke up the resident. Cross reference F609. At 3:25 p.m., Surveyor asked RN B about the note the RN left for LPN C. RN B explained, according to R21, the resident did not want CNA D to come into the resident's room. RN B stated she passed this onto LPN C, and this occurred about two weeks ago. Surveyor reviewed R21's care plan. The care plan does not identify CNA D, or other staff, should not enter the resident's room in the early hours to wake up the resident, or CNA D should not be in the resident's room, per the resident's request. On 09/11/19 and 09/12/19, Surveyor discussed the above resident and nurse staff interviews with the NH[NAME] 4. R13 was admitted [DATE]. The most recent quarterly MDS, dated [DATE], indicates R13 has a BIMS score of 13, meaning she is alert and oriented and able to answer questions accurately. R13 has [DIAGNOSES REDACTED]. On 09/10/19 at 1:15 PM, Surveyor interviewed R13, asking how she was treated in the facility. R13 indicated CNA D came in and was mean. Surveyor asked R13 to explain how CNA D was mean. R13 stated CNA D slapped her to wake her up, used a very mean tone and was nasty and rough. Surveyor asked if R13 had reported this to the NH[NAME] R13 stated she had and at this time CNA D is not to work with her. R13 expressed a fear of retaliation if CNA D was allowed in her room. On 09/11/19, Surveyor interviewed the NH[NAME] The NHA stated there was an incident months ago and an investigation was completed. The resolution to the concern was R13 requested CNA D not work with her anymore. Surveyor reviewed the care plan prior to this interview. R13's Self Performance Deficit care plan was reviewed on 09/10/19 which includes in part: The resident has a self-care performance deficit r/t (related to) H/O (history of) Fractured Acetabulum Right pubis sacrum, Repeated falls pain, Constipation H/O UTI, [MEDICAL CONDITION]. Stress right ankle fracture. The resident will improve current level of function in ADL'S through the review date. 2 staff at all times during cares. Allow to do for self BATHING/SHOWERING - ASSIST - ONE DRESSING - ASSIST - ONE DRESSING - GRABBER/REACHER DRESSING: Allow resident to choose clothing DRESSING: Allow sufficient time for dressing and undressing. EYE CARE - GLASSES DAILY PERSONAL HYGIENE/ORAL CARE - ASSIST - ONE Praise all efforts at self care. The care plan does not identify any specifications about certain staff members that can not work with R13. 5. R26 was admitted to the facility in 2014. R26 has [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] documents R26 has total dependence on staff for all transfers, bed mobility and personal hygiene needs. BIMS score is 15, meaning R26 is alert and oriented and can answer questions accurately. Surveyor was made aware of abuse allegations about CNA D on initial tour. On 09/11/19 at 9:30 a.m., Surveyor interviewed the NH[NAME] The NHA was aware of this and had done a complete investigation into the situation; abuse was not substantiated. The NHA told Surveyor there are certain residents CNA D can not work with. The NHA stated R26 was one of them. The resident has a self-care performance deficit care plan that was reviewed by Surveyor on 09/10/19 that includes in part, Will allow staff to perform cares BATHING - Prefers BATH. Tub Bath on Sundays and Thur . BATHING/SHOWERING - ASSIST - BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. DRESSING - ASSIST - TWO DRESSING: Allow resident to choose clothing No male caregiver ORAL CARE - OWN LOWER/UPPER TEETH PERSONAL HYGIENE/ORAL CARE - ASSIST - ON Resident requests to stay up for 1/2 hr after meals before she lays down. The care plan does not identify that CNA D is not to work with this resident, but does identify no male caregivers for R26. On 09/11/19 at 3:18 p.m., Surveyor interviewed RN B and LPN C. LPN C stated there are some resident rooms in which CNA D cannot go in. When Surveyor asked for who these residents are, LPN C and RN B provided names of R21, R13, R16 and stated there are no other residents the CNA cannot work with. Staff were not aware of R26 not wanting CNA D to care for her. On 09/12/19 at 12:45 p.m., Surveyor interviewed R26 asking about concerns with CNA D. R26 stated that CNA D had been rough with her with cares when turning her, and spoke to her rudely. R26 indicated she does not want CNA D in her room. The quarterly MDS dated [DATE] documents R26 has total dependence on staff for all transfers, bed mobility and personal hygiene needs. BIMS score is 15, meaning R26 is alert and oriented and can answer questions accurately. During the initial tour on 09/10/19 at 10:32 AM, Surveyor interviewed R26, who has limited mobility due to a [DIAGNOSES REDACTED]. The care plan states, Bed Mobility - Assist Rail Left, Assist Rail Right. The medical record did not contain a physician order, indicate the medical symptom the rails were being used for, or how and when they are to be used. The care plan contains no instruction on how and when to use the bedrails. On 9/12/19 at 1:00 p.m., Surveyor interviewed RN A about the use of the bedrails, asking how staff know how and when they are to be used. Surveyor asked if there are any interventions in place to address potential complications such as physical and/or psychosocial changes related to the use of the bedrails, such as increased incontinence, decline in ADLs or ROM, increased confusion, agitation, and depression. RN indicated there are no interventions to address the use of the bedrails, complications for the use of the bedrails or how the interventions are evaluated for effectiveness. RN A indicated she would update the mobility care plan with this information. 6. R19 was admitted [DATE] having [DIAGNOSES REDACTED]. R19 has severe cognitive impairment from dementia. The quarterly MDS dated [DATE] documents R19 needs total assist for all bed mobility, transfers and personal hygiene. Observations Surveyor noted bedrails on R19's bed on 09/10/19 at 9 a.m. during the initial tour, as R19 was lying in bed. 09/10/19 02:36 PM Left bedrail, is up. R19 lying in bed, not moving she is on her back. 09/11/19 11:07 AM R19 lying in bed on her back, left bedrail is up. On 09/12/19 at 9:00 a.m., Surveyor interviewed CNA J asking about use of the bedrails such as when they are to be used or released. CNA J indicated it is not on the care plan, and there is no specific plan for the use of the bed rails. Surveyor reviewed the comprehensive care plan, CNA care plan and the physician orders. There was no documentation of the purpose of the bedrails or when and how to use the bedrails. On 09/12/19 at 1:00 p.m., Surveyor interviewed RN A who updates the care plans. Surveyor asked if R19 had any care plan information for the use of her bed rails. RN A looked on computer and stated, No. Surveyor asked if staff knew which medical need would be met through the use of bedrails, how often the bedrail is applied, duration of use, and the circumstances for when it is to be used. RN A indicated none of that information was on the care plan. RN A indicated R19's care plan does cover mobility; the bedrail use should be updated in that area. Surveyor asked if there are any interventions in place to address potential complications such as physical and/or psychosocial changes related to the use of the bedrails, such as increased incontinence, decline in ADLs or ROM, increased confusion, agitation, and depression. RN indicated there are no interventions to address complications for the use of the bedrails.

Based on observation, record review and interview, the facility did not ensure 1 of 1 residents who was reviewed who required the use of a hearing aide, was provided with the proper assistance for a hearing aide replacement, Resident (R) 7. R7 is hard of hearing and is to use bilateral hearing aides. R7's hearing aide was broken since 04/04/19. The facility did not assist R7 with following through with an audiologist appointment to repair his hearing aide. As of 09/12/19, R7 does not have the hearing aide repaired and stated he is having trouble hearing conversations. Findings include: R7 was admitted on [DATE]. The quarterly Minimum Data Set ((MDS) dated [DATE] documents R7 has minimal difficulty hearing with the use of a hearing aide. On 09/10/19 at 9:33 AM, Surveyor interviewed R7 during the initial tour. Surveyor asked if R7 wears glasses. R7 indicated he uses reading glasses. Surveyor noted R7 was having a hard time hearing the questions. Surveyor asked if R7 has hearing aides. R7 stated, I have hearing aides but I don't wear them because I am waiting for it to get fixed. R7 indicated he can not drive at this time so can not get to the ear doctor in the nearby town to take care of this. Surveyor asked how long the hearing aide has been broken. R7 indicated it has been months. Care plan in part, The resident has/potential for a communication problem. R/T (related to) HOH (hard of hearing) lost one hearing aide and has one hearing aide here. Resident states that he does not always wear them. The resident will maintain current level of communication function through the review date. Will continue to express needs COMMUNICATION - LEFT HEARING AIDE broken, (dated 04/04/19) COMMUNICATION - RIGHT HEARING AIDE COMMUNICATION: HARD OF HEARING Has L&R hearing aides. Nurse has them on the med cart . Staff to assist with putting hearing aides in and puts in med cart at night` Resident stated that one of the Hearing aides is broke . · Provide a quiet setting · Refer to Audiology for hearing consult as ordered. · Speak face on · Speak on an adult level, speaking clearly and slower than normal. · Speak slow/distinct On 09/11/19 at 7:08 AM, Surveyor interviewed Administrative Assistant (AA) M who also works as a Certified Nursing Assistant. AA M was making R7's bed. Surveyor asked if AA M helped R7 with cares. Surveyor observed R7 is not wearing hearing aides this morning. AA M indicated yes, she helps on the floor. Surveyor asked if R7 has hearing aides. AA M stated, Not that I am aware of. I never see them. R7 spoke up and said that he does but they are broken and locked up at the nurses station. R7 said he can't get anywhere to get them fixed, so they are not able to be used. On 09/11/19 at 10:00 a.m., R7 attended the group meeting. R7 kept on saying he could not hear the questions as he held his hand over his ear. R7 told the group it is because his hearing aides are broken. He indicated they are locked up at the nurses station and that he can not drive and get to the ear doctor to get them fixed. Surveyor had to move next to R7 so he could participate in the group interview, and repeat questions as needed. On 09/11/19, Surveyor interviewed the Director of Nursing (DON) and asked about R7's hearing aides. The DON stated he does not know if R7 has hearing aides of if they are working. On 9/11/19 at 2:20 p.m., Surveyor went to Social Worker (SW) K to ask if she was aware of the hearing aide problem. SW K indicated she is new so is not familiar with R7's needs. Surveyor asked when SW K started her position. SW K indicated it was the end of (MONTH) 2019. At 2:47 p.m., SW K came to Surveyor with a set of hearing aides and stated they have been locked up at the nurses station, but that they work. Surveyor went to R7's room with SW K. SW K helped R7 put the left hearing aide in. R7 stated it is not working because the battery is dead. R7 found batteries in his room. SW K put a new battery in. R7 looked at the right hearing aide and said, It's broken like I said, the part to turn on and off is missing. SW K looked at the hearing aides and said, Maybe it is just a different style. R7 was assisted to put a new battery in the right hearing aide and put in R7's right ear. Surveyor could hear a continual beeping noise. R7 stated that it is not working, I can't listen to that, and took it out. Surveyor asked if R7 would wear hearing aides if they were working. R7 stated, Of course I would. I was wearing them before I came here. R7 then said, I can't get to the ear doctor when I'm in here. I don't drive. Surveyor indicated that SW K would help him. R7 stated, Really well what's taken 9 months to figure this out. SW K stated I don't think its been that long. R7 stated it has been months since I've had my hearing aides. (The care plan documents the hearing aide has been broken since 04/04/19.) SW K stated she would make an appointment and get this taken care of. On 09/12/19 at 1:50 p.m., Surveyor interviewed the Nursing Home Administrator (NHA) about the above concerns asking if any appointments had been made to repair the hearing aide. The NHA indicated SW K was working on it.

Based on interview and record review, the facility did not ensure all alleged abuse violations are reported immediately, but not not later than 2 hours, to the administrator or their designated representative. This occurred for one of two residents reviewed for allegations of abuse (Resident (R) 11). The Nursing Home Administrator (NHA) was not notified of a resident's allegation of verbal abuse by staff. This is evidenced by: On 09/10/19, Surveyor reviewed a facility policy entitled, Abuse Policy Requirements. The policy, dated 07/17/17, states the following, in part: .The center will ensure that all alleged violations involving abuse .or mistreatment .are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse .to the administrator of the center .PR[NAME]EDURE: INTERNAL REPORTING: a. Team members .residents .will receive orientation and education on the center Abuse Policy and reporting requirements. Team members must always report any 'abuse' or suspicion of 'abuse' immediately to the Administrator. **Note: Failure to report can make employee just as responsible for the abuse in accordance with State Law .all persons at (name of facility) are individually responsible to follow this policy and cooperate in the communication, investigation and resolution of resident grievances as well as related reporting requirements . On 09/10/19, Surveyor reviewed R11's medical record. The resident has [DIAGNOSES REDACTED]. The resident is legally blind. R11's Brief Interview for Mental Status (BIMS) score, dated 07/14/19, was a 12 out of a possible 15 points. According to the BIMS assessment, a score of 12 indicates the resident has moderately impaired cognition. The resident's care plan states the following, in part, .The resident has limited physical mobility r/t (related to) back pain and [MEDICAL CONDITION] and repeated falls unsteady gait .Revision on: 06/25/19 .Interventions .AMBULATION/L[NAME]OMOTION-ASSIST-ONE (staff member) .TRANSFER-ASSIST-ONE cue resident for directions. Supervision for standing CGA (Contact Guard Assist) Resident should not be in w/c (wheelchair) in room in order to prevent self transfer . R11's room is next door to R21. On 09/10/19 at 9:15 a.m., Surveyor interviewed R21, and asked the resident how staff treat the resident. R21 stated about three weeks ago, her neighbor (R11) was using a walker at bedtime when CNA D entered R11's room. R21 stated she overheard CNA D say to R11, Why don't the hell you get your ass back in bed or I'll put you there . R21 stated she reported this to Licensed Practical Nurse (LPN) C. At 1:08 p.m., Surveyor informed the NHA of the above interview with R21. The NHA stated she was not aware of the alleged incident between R11 and CNA D, and the facility has no investigation regarding this alleged abuse. During a resident interview with R13, conducted on 09/10/19, R13 had a allegation of physical and verbal abuse by CNA D, on 02/28/19. This was investigated by the facility, on 02/28/19. At approximately 4:00 p.m., Surveyor reviewed CNA D's facility personnel file. The CNA's personnel file contained a Progressive Discipline Form Work Performance/Behavior/Conduct Form, dated (MONTH) 2019. The form states the following, in part: .Team Member Name: (Name of CNA D) .Date of Last Discipline: 7-17-17 Date of Situation giving rise to Discipline: (MONTH) (2019) This Corrective Discipline is: Step 4: Suspension, Date: (To Be Determined) .Identify the policy or policies violated by the deficient performance/behavior/conduct: Team Member Handbook, Specific Policy .List the facts to support unsatisfactory performance/behavior/conduct .Code of conduct-Residents have right to direct care, need to be mindful of Mannerism. Maintaining a positive Attitude toward residents (and) staff does not Always occur. Sleeping while working .Was the team member working to the best of his/her ability? No. Explain: (Left blank) .Identify how the actions supporting the discipline affect the center/community, team members or residents .Residents prefer you not work with them .List the Corrective Action to be taken by the Team Member .2. Be Mindful of voice tones (and) Mannerisms 3. Be Positive at all times at work-if having issues address with DON (Director of Nursing) 4. Cannot fall Asleep while working. Do we need to look at your schedule (and) reduce hrs (hours)? .Team Member Comments: (Left blank) . This form was signed by the NHA on 06/10/19, CNA D on 06/19/19, and the DON on 06/19/19. There is no documentation as to why this progressive discipline was conducted. On 09/10/19 at 4:19 p.m., Surveyor discussed CNA D's (MONTH) 2019 disciplinary form with the NH[NAME] The NHA stated she does not have a list, and does not know which residents who do not want CNA D to work with them (as indicated in the disciplinary form). The NHA stated the DON may have a list of these residents. Surveyor asked what prompted the NHA to complete CNA D's disciplinary form in (MONTH) 2019, and asked if residents and/or staff had complained about the CNA's care and/or performance. The NHA stated she would look into this. On 09/11/19 at 9:33 a.m., Surveyor met with NH[NAME] The NHA stated there are only two residents in the facility who do not want CNA D to work with the residents; R13 and R26. The NHA stated there were no previous allegations of abuse between R13 and R26 and CNA D, and the NHA has no grievances of CNA D from these or other residents. During the continued meeting, the NHA stated CNA D's (MONTH) 2019 disciplinary form was completed due to the administrator looking at things as a whole; the CNA was nodding off while charting and CNA D may have been given too many hours. Surveyor asked if CNA D was suspended as a result of this progressive discipline, as indicated on the signed form. The NHA stated she was unsure if CNA D was suspended as a result, and the NHA stated she would have to look into this. Surveyor asked if the facility increased supervision of CNA D while working with residents, after the (MONTH) 2019 discipline. The NHA stated a night shift nurse oversees CNA D, keeps the CNA on task, and the NHA speaks with this nurse quite a bit. Surveyor asked if the facility has followed-up with R13 and R26 to determine if CNA D has worked with them since (MONTH) 2019. The NHA stated she followed-up with R13 on 09/10/19, and she will speak with R26 today. Cross reference F657. On 09/11/19 at 3:18 p.m., Surveyor spoke with LPN C. The LPN stated approximately seven to ten days ago, he was given a note, by Registered Nurse (RN) B, which mentioned CNA D should no longer go into R21's room. LPN C explained at that time, the LPN spoke with R21 regarding some concerns the resident had about CNA D. LPN C explained, according to R21, one of the concerns the resident had was CNA D was loud, yelling and, getting after (first name of R11). LPN C stated he reported R21's concerns to RN [MI] LPN C stated he could not remember the exact words R21 said she heard CNA D say to R11; but the LPN stated R21 thought CNA D was yelling at R11. LPN C stated he did not report R21's allegation to the NHA or DON. The LPN further stated, in retrospect, I should have called them. At 3:25 p.m., Surveyor asked RN B about the note the RN left for LPN C. RN B explained, according to R21, the resident did not want CNA D to come into the resident's room. RN B explained, according to R21, the resident reported CNA D was getting rough verbally with R11. RN B stated she passed this onto LPN C, and this occurred about two weeks ago. On 09/12/19 at 11:04 a.m., Surveyor met with the NHA and the DON, and the above interviews with LPN C and RN B were discussed. The NHA stated the abuse policy is reviewed by staff, and nursing staff will immediately be educated on the facility abuse policy.

Based on observation, interview and record review, the facility did not ensure the resident environment remains as free from accidents as possible for 2 of 3 residents who use power chairs (Residents #5 and #8) and 1 of 4 residents who receive oxygen via tanks (Resident #8). The facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 4 residents observed for transfers and ambulation (Residents #3 and #1). Power chairs Resident #5 uses a power wheelchair for mobility. On 04/26/16, Resident #5 slid out of the power wheelchair outside when going down a grassy hill. On 05/02/16, Resident #5 fell out of the power wheelchair when a therapist directed Resident #5 to go down a hill so she could assess the resident for safe use of the power wheelchair. Resident #5 fractured her ankle and required surgery. The facility did not initially assess the safe use of the power wheelchair, was not aware that the manufacturer did not recommend the use of the chair on grassy slopes, did not re-educate the therapist related to what to do differently to prevent reoccurrence and did not re-educate all staff related to Resident #5's practice of unsafe behavior with the power wheelchair. Resident #8 uses a power scooter. The facility has not assessed the safe use of the power scooter. Oxygen tanks Resident #8 receives oxygen via e tank. Resident #8 was observed on a power scooter receiving oxygen. The e tank of oxygen was not placed in a holder and was standing free, unsecured on the front of the scooter between the legs of Resident #8. Gait belts Resident #3 was transferred and ambulated by staff with no gait belt. Resident #1 needs assist with pivot transfers. The Certified Nursing Assistant (CNA) did not use a gait belt during the observed transfers. This is evidenced by: 1. On 07/20/16 at 9:45 a.m., Surveyor reviewed Resident #5's medical record. Resident #5 has a [DIAGNOSES REDACTED]. Resident #5 is not ambulatory, is alert and oriented and is her own decision maker. The quarterly Minimum Data Set, dated dated [DATE], documented Resident #5 scored a 15 on the Brief Interview for Mental Status determining the resident was cognitively intact. Resident #5 was totally dependent on two staff for hoyer mechanical transfers, did not ambulate and required staff supervision and set up off the unit. Resident #5 used a power wheelchair. Resident #5 had functional limitations in range of motion of the upper extremity on one side and both lower extremities. The current interdisciplinary care plan states Resident #5 is transferred via a full body lift with assist of two staff and uses an electric wheelchair. The Fall Risk Assessment, dated 03/15/16, stated, Resident has a history of a CVA. Resident does have limited mobility on her left side. Resident is obese. Resident does take medication that increase the risk of falls. Resident does wear appropriate foot wear. Resident is at risk for falls. Fall #1 Nurse's note, dated 04/26/16 late entry 4:36 p.m., stated, (Resident #5's name) had a Witnessed Fall Incident on 04/26/16 at 3:15 p.m. Incident details: AM nurse was leaving work in her car when she was flagged down by a cna student secondary to resident had slide down in her electric wheelchair. Resident was half in and half out of her electric wheelchair with her legs and feet bent under her electric wheelchair. with the electric wheelchair still on. Resident continued to slid and staff assisted her down onto the grass. Residents electric wheelchair was stuck in the grass and had to be pushed back manually by staff. The following injuries or first aide noted: Abrasion to rear L (left) thigh 17 x 0.5 cm (centimeters) in size, a bruise to the inner L elbow approx (approximately) 0.5 cm in size and a bruise to the inner R (Right) ankle approx 1 x 2 cm in size there is no swelling noted to the ankle but resident does c/o (complain) discomfort to the area . Immediate care plan intervention: Resident was instructed to not go on unlevel or rough surface and to ask for assist. Note sent to OT (Occupational Therapy) to eval use of the WC (Wheelchair) . Nurse's note, dated 04/26/16 at 8:15 p.m., stated, Resident has apparently slid out of her electric WC while she was outside. She was on the lawn at the time. The fire dept was called and several firemen arrived to assist resident back in to the facility. Resident was instructed to not take her WC out on unlevel and rough ground. resident sustained [REDACTED]. Nurse's note, dated 04/27/16 at 1:21 p.m., stated, Incident IDT Committee Meeting Note-Description- Res was outside in electric wheelchair when Res came to a grassy area at the top of hill and went down the sloped area in her wheelchair. The student CNA cautioned her that it was unsafe. She slid out of her w/c unto the grassy area. She was assisted by Fire Dept off the ground and into building. Past interventions: nonskid strips removed from side of bed, electric scooter turned off before transfers, one assist to transfer, call light within reach. Res is receiving PT (Physical Therapy). Care plan interventions: dycem on her seat of w/c. OT eval for electric scooter safety. Summary of incident: Res slipped out of w/c on lawn area. Res was assisted back to her room via stretcher and 6 firemen. Res sustained a 17 cm x 0.75 cm abrasion to the back of L thigh, a 0.5 cm bruise to the inner arm above the elbow and a very light bruise to inner R ankle .(Physician names, Nursing Home Administrator (NHA) and Director of Nursing (DON) names) notified of fall. New intervention- Dycem on seat of w/c and OT eval w/c safety . Cognitive functioning- Resident is alert and oriented. Physical Functioning: Resident is independent with mobility once up secondary to having an electric wheelchair that she uses to get to destinations of her choice. Care Plan interventions: IDT members met on 04/27/16 to discuss (Resident #5's name) fall. Res was outside in her electric W/C with CNA student who was helping her pick up pinecones for a project. Res. decided to take a short cut across the lawn. Res came to a grassy areas at the top of the hill and went down the sloped area in her W/C. The student cautioned her that it didn't seem safe and (Resident #5's name) replied, I do this all the time. As she was going down the hill the student CNA put her hand on the wheelchair handle. (Resident #5) started to slip out of the chair. AM nurse leaving work in her car was flagged down by cna student. Res was half in and half out of her wheelchair with her legs and feet bent under the W/C. Res continued to slide and staff assisted her down onto the grass. Res was assisted back to her room via stretcher and 6 firemen. Res sustained a 17 cm x 0.75 cm abrasion to the back of her L thigh, a 0.5 cm bruise to the inner arm above the elbow and a very light bruise to inner R ankle .New interventions; Res instructed to only use her elec W/C on level ground. Dycem placed on seat of w/c. Orders for OT to eval electric wheelchair safety. Root cause: Res is her own person, is alert and oriented, used poor judgement to go down grassy hill in her electric W/C. Care plan updated to reflect current changes. The Unusual Occurrence/Injury of Unknown Source investigation report, dated 04/27/16, stated in part, IDT members met on 04/27/16. Res was outside in her electric wheelchair with (CNA L initials) who was helping her pick up pinecones for a project. Res decided to take a short cut across the lawn. Res came to a grassy area at the top of hill and went down the sloped area in her wheelchair. The student CNA cautioned her that it didn't seem safe and (Resident #5's name) replied, I do this all the time. As she was going down the hill the student CNA put her hand on the wheelchair handle. (Resident #5's name) started to slip out of the chair. AM nurse, (Licensed Practical Nurse (LPN) M's initials) leaving work in her care was flagged down by cna student, (CNA Student L's initials) . On 04/26/16 at 3:40 p.m., written statement by CNA L stated, Request by (Resident #5's name) from instructor to accompany (Resident #5's name) outdoors to pick up pine cones for a craft project. Exited through employee door and cross parking lot and approached grassy area at the top of large hill. As (Resident #5 name) proceeded writer cautioned her that it didn't seem safe and she replied with I do this all the time As she proceeded down hill writer felt like she would bounce out of chair head first, writer put hand on wheelchair handle. (Resident #5's name) started to slip out of chair. I waved down a staff member that was in her car. On 04/26/16 a written note by the NHA stated, Further clarification: I talked with (CNA L) regarding her putting her hand on wheelchair handle. She stated she never touched the joystick. (Resident #5's name) was in control of that. She put her hand on the handle of the wheelchair only. On 04/26/16, Resident #5's signed statement stated, I was on the asphalt driveway and I was going onto the lawn, it had rained the last couple of days, so when I went onto the grass my wheelchair sunk down in the ground causing it to tilt forward and then I started sliding out of my wheelchair. Two staff assisted me to the ground. The fire department was called and they assisted me to my bed. I only obtained a scratch on my back at the time and I did not even realize that I had scratched my back until the staff rolled me onto my side and saw it, when I was in bed. Fall #2 The Unusual Occurrence report, dated 05/02/16, stated in part, (Resident #5's name) 05/02/16 Was outside with occupational therapist on the lawn of Atrium Post Acute Care of Ellsworth. Resident interview: Resident stated that OT (Occupational Therapy) was assessing her for safety to go down the hill behind the facility. Witnesses: (OT C's name). IDT members met on 05/03/16 to discuss (Resident #5's name) fall. Res was being assessed by OT for safety with her power w/c. Res verbalized to the therapist where and how she had frequently gone down the hill to sit by the trees. Res was able to explain to the therapist how she positions her w/c and the location on the hill which is less steep that she uses to go down onto the lawn. OT attempted to have her try going down the hill. Resident moved her foot rests and tilted her wheelchair back, she kept at a slow pace but resident did slide out of wheelchair landing on the ground in a supine position. Resident was assessed for injuries and had c/o pain in her right ankle. The paramedic's were called to assist in getting (Resident #'5's name) up secondary to her size but upon examination by (Physician Assistant (PA) N's name) who was at the building and the paramedic's it was deemed appropriate for resident to be transported to the hospital for eval and treatment of [REDACTED]. Res instructed to only use her elec W/C on level ground. Diacem placed on seat of w/c. OT to eval electric wheelchair safety. All were in place at time of fall. New intervention: Education done with therapy staff, diacem applied between hoyer sling and resident . What appears to be the initial root cause of the fall? Not safe to take w/c out on grass. Describe initial interventions to prevent future falls: Resident will not be allowed to locomote over grass in motorized w/c in future. The Inservice Training Note, dated 05/03/16, documented inservice training with OT C. The note stated, On 05/03/16 discussed with therapist when receiving orders for therapy to evaluate and treat for Electric wheelchair safety that therapy would seek clarification on what type of evaluation the nursing department is looking for. Written statement signed by Occupational Therapist (OT) C, dated 05/02/16 at 1:43 p.m., stated, Resident name: (Resident #5's name) Time of incident: 1:00 p.m. May 2, 2016. Resident injury: Fall out of power wheelchair in yard behind facility. Witness - (OT C's name). (Resident #5's name) had OT assessment for safety with power w/c. (Resident #5's name) reports in summers going down hill in her w/c to sit by the trees. She had recent fall and had orders to assess safety in w/c. (Resident #5's name) verbalized to therapist where and how she has frequently gone down hill to sit by trees. Explained to therapist how she positions w/c and location on hill less steep that she uses to go down. Pt. (Patient) reported to therapist plans to go down hill and how she has done it before without incident. Pt reports recent fall being due to ground being soft, foot rest stuck in ground and CNA student present with her moved joystick forward instead of back causing her to slide. Pt reports no prior incidents sliding out of chair at location it was assessed at today. To assess if it was safe for continuing in future OT attempted to have her try going down hill. Pt moved footrests and tilted w/c back to keep hips back prior to going down hill. She kept at slow pace but did slide out of w/c. Therapist attempted her to do down hill based on her prior history of doing so and plans to do it again this summer. During incident with w/c mobility to do down hill, therapist was next to pt in w/c. Pt was controlling joystick and was going at a very slow speed. She was verbalizing knowing to go at slow speed. Prior to attempting going down hill pt tilted w/c back approx 45 degrees. Pt reported where on hill she has gone down hill successfully in past and position of w/c at those times. Pt reported she has gone down the hill on many occasions safely and reported having plans to continue to do so as she enjoys sitting by the trees. Upon sliding out of chair pt landed on ground in supine position. She slid forward and landed on ground in quick motion. Signed statement by Resident #5, dated 05/02/16, stated, OT took me out and we went back to the lawn by the tree and she then wanted me to demonstrate what had happened the last time I slid out of my wheelchair. I told her that I would rather stay on the asphalt But she wanted me to show her what I had done the last time and was persistent about it. So I went onto the grass towards the tree, and I fell out of my wheelchair and landed on my right leg. The fire department was called and they started to move me and my right ankle was killing me. The lifted me off the ground and carried me to the ambulance. We went to Regions hospital first stopping by the River Falls hospital. She was persistent about it because she said she had to write an accident report. Social service note, dated 05/03/16 at 12:18 p.m., stated, I spoke with (Resident #5's name) today. She has been admitted to Regions and is awaiting surgery on her right ankle. (Resident #5's name) stated she broke her ankle in 3 places, 2 in her large bone and once in her small bone. Per the hospital discharge summary, dated 05/05/16, stated Resident #5 had an open reduction internal fixation of a right trimalleolar ankle fracture. X-ray report on 05/03/16 at the hospital stated status [REDACTED]. On 07/20/16 at 10:05 a.m., Resident #5 told Surveyor , I got dumped out of my wheelchair. Before I slid out of my wheelchair outside. The ground was soft. We were re-enacting the scene and I fell out of the wheelchair under the tree and broke my ankle. I didn't want to go down the hill. The therapist was insistent I go down the hill because she had to fill out a report on me. I had a plate and ten screws put in. On 07/21/16 at 6:55 a.m., Surveyor interviewed the NHA. The NHA stated Resident #5 had no similar incidents before 04/26/16. The NHA stated Resident #5 is alert and oriented and deemed safe to go outside in her power wheelchair by herself with no supervision. The NHA stated the student CNA did not touch the joystick on the first fall. The resident was in control of the joystick. The NHA stated Resident #5 had taken the same path before and it had rained a lot. The wheelchair got stuck due to the rain. The ground was greasy and we pushed the wheelchair up the hill. The corrective action after the first fall was to add dycem to the wheelchair and have OT eval for safe use of the power wheelchair. The second fall was outside when accompanied by OT. The NHA stated Resident #5 likes to go outside and sit by the trees and wanted to continue to do this. The NHA further stated OT was trying to assess her safety in going down the hill off terrain. The NHA stated Resident #5 is now safe to go outside with her electric wheelchair. Surveyor requested a copy of safety assessment for the use of the power wheelchair prior to the falls. The NHA stated she could find no initial assessment for the safe use of the power wheelchair except a therapy note, dated 02/09/15, stating Resident #5 came into the facility with the power wheelchair and used it independently. On 07/21/16 at 7:40 a.m., Surveyor and the NHA walked the path Resident #5 took on both falls. Resident #5 left the side door by the therapy department in her power wheelchair and went approximately 177 feet down a cement sidewalk to a paved street to a parking lot and then went up hill into another parking lot to a grassy hill. Resident #5 was attempting to reach a grove of pine trees approximately one block from the parking lot. The NHA pointed out to the surveyor the site of the first fall which was on a steep slope about 1/4 of the way down on the hill. The NHA pointed out the site of the second fall, which was on the same hill, that was less steep but was still steep. On 07/21/16 at 10:15 a.m., Surveyor interviewed OT C who stated she got an order to assess safety of Resident #5's use of the power wheelchair. The week before Resident #5 had been with a CNA student and had gone down a hill and slid from the wheelchair. This prompted the facility to get an OT order to assess the wheelchair. OT C stated she checked safety in the building and outside in the sidewalks and parking lot with Resident #5. Resident #5 had used the chair for years. Resident #5 told OT the incident occurred when going downhill. Resident #5 reported she had gone downhill several times and likes to sit in the shade by a tree. Resident #5 reported plans to continue to do this. Part of the assessment was to decide if this was safe for Resident #5 to do. Resident #5 demonstrated now she tilted her wheelchair up and adjusted her foot rests. We found a slope with less slope. Resident #5 stated how she does it frequently. Resident #5 explained it as they did it. OT C stated Resident #5 slid part way down and slid from the wheelchair. Resident #5 had tilted her wheelchair back to make herself in a more upright position tilted back. Resident #5 was running the joystick. OT C stated she was standing along side Resident #5 and was not operating the wheelchair. OT C stated the grass was not wet at the time. OT C stated Resident #5 stated she planned to continue to do this. Resident #5 had been navigating safely on sidewalks and parking lots prior to going on the grass. OT C stated, It was not something to try for the sake of trying. It was due to her saying she had done this before and would continue, that's why I tried it. OT C further stated, I needed to know if it was safe for her to do this. OT C stated her assessment completed on 05/02/16, was that Resident #5 should not take the power wheelchair on grassy areas. Surveyor and OT C reviewed the therapy notes and could find no initial safety assessment for the use of the power wheelchair. On 07/25/16 at 11:15 a.m., Surveyor interviewed OT C, who stated the facility spoke with her related to what happened but did not tell her what to do differently. Surveyor questioned OT C if the wheelchair was safe to use off terrain. OT C stated she did not know. OT C stated the chair is big and sturdy. Surveyor questioned OT C if she had checked with the manufacturer if the chair was safe to use on grassy slopes prior to taking Resident #5 outside to demonstrate on the hill. OT C stated she hadn't researched it. On 07/25/16 at 9:40 a.m., Surveyor interviewed the DON, who stated she had spoken to OT C after the fall about what needed to be done in an OT eval whether it is an assessment for use inside or outside. The DON stated, My thought process was why did you take her down the hill. (OT C's name) her process was she does this all the time, that's why she made her go down. The DON stated no assessment was completed initially for the safe use of the power wheelchair. Surveyor questioned if the facility had completed other education after the falls with other facility staff. The DON stated, No. Surveyor reviewed the manufacturer's book that accompanied the power wheelchair. The book states the following: Outdoor Driving surfaces- Your power chair is designed to provide optimum stability under normal driving conditions- dry, level surfaces composed of concrete, blacktop, or asphalt. However, Pride recognizes that there will be times when you will encounter other surface types. For this reason, your power chair is designed to perform admirably on packed soil, grass and gravel. Avoid driving on uneven terrain and/or soft surfaces. Avoid tall grass that can tangle the running gear. If you feel unsure about a driving surface, avoid that surface. On 07/25/16 at 11:25 a.m., Surveyor interviewed Pride Corp Customer Service Rep O who stated the power wheelchair used by Resident #5 is not recommended to be used on grassy slopes. The Pride Corp Customer Service Rep O further stated uneven and soft surfaces and surfaces with grades should be avoided. On 07/25/16 at 11:30 a.m., Surveyors , and observed the grassy hill where the two falls occurred. The surveyors observed the slope of the grassy hill to be steep with ground that was soft and soggy. 2. On 07/21/16 at 2:45 p.m., Surveyor observed Resident #8 seated in his power scooter chair. Resident #8 was operating the chair independently. On 07/25/16 at 9:30 a.m., Surveyor interviewed the DON. The DON stated the facility had just completed an assessment for safe use of Resident #8's power scooter chair on 07/22/16. The DON stated she would check to see if any previous assessments had been completed. On 07/25/16 at 1:30 p.m., the DON stated she had no initial assessment for safe use of the power scooter chair for Resident #8. Oxygen Tanks 3. The facility policy entitled, Compressed Gas (E-cylinder) Overview, undated, states in part, Purpose: To provide general knowledge on the use of compressed gas E-cylinder units. 12. Compressed oxygen cylinders must be in a cart, rack or chained to a wall at all times to prevent tipping over. These cylinders are under high pressure and must be protected from damage due to dropping or mishandling. On 07/21/16, Surveyor reviewed Resident #8's medical record. Resident #8 has [DIAGNOSES REDACTED]. Per the quarterly Minimum Data Set, dated dated [DATE], Resident #8 scored a 15 on the Brief Interview for Mental Status meaning intact cognition. Per the current physician orders, Resident #8 receives oxygen at 2 liters at night via mask and 2 liters every hour as needed via cannula and 2-3 liters as needed for shortness of breath via cannula. On 07/21/16 at 11:30 a.m. and 12:45 p.m., Surveyor observed Resident #8 in his power chair with the oxygen tank unsecured standing upright between Resident #8's legs. On 07/21/16 at 2:45 p.m., Surveyor observed Resident #8 seated in his power chair with oxygen on. The e-cylinder was free standing, unsecured resting between Resident #8's legs. Surveyor informed the DON and the NHA of the observation. The DON stated the oxygen tank should be secured. Resident #8 told Surveyor that he had a holder for the tank but three weeks ago when the electricity went off, someone took his holder and he never got it back. The facility found a holder and secured the oxygen tank. On 07/25/16 at 7:25 a.m., the NHA told Surveyor that the facility had offered a holder to Resident #8 and he refused it. On 07/25/16 at 12:40 p.m., Resident #8 told Surveyor that he has never refused to have a oxygen holder on his power chair. Resident #8 stated someone took his holder three weeks ago when the electricity went out and they needed it for someone else. Resident #8 said they never brought his holder back. Gait Belts 4. The facility policy entitled, Transfers/Gait Belts, dated 12/19/12, states in part, Purpose: To promote resident comfort and safety and to prevent employees injuries, transfer belts will be used. All nursing staff and the rehabilitation team will utilize a transfer belt for resident mobility when the resident requires one or more to assist he/her during a transfer or ambulation. The facility will provide transfer belts for the staff on each unit B. When a resident's transfer or ambulation requires one or more assist, or a resident who is unsteady on their feet, utilize the transfer belt. On 07/20/16 at 10:15 a.m., Surveyor reviewed Resident #3's medical record. Resident #3 has a [DIAGNOSES REDACTED]. Per the Minimum Data Set, dated dated [DATE], Resident #3 required extensive assistance of one staff person with toileting and hygiene. Resident #3 had balance problems, was not steady and only able to stabilize with staff assistance. Resident #3's current interdisciplinary care plan and Certified Nursing Care plan states the resident requires assistance of one staff with personal hygiene and ambulation. On 07/20/16 at 7:50 a.m., Surveyor observed CNA B transfer Resident #3 from the bed to the bathroom using a wheeled walker and no gait belt. After using the toilet, CNA B assisted Resident #3 to stand with a wheeled walker and no gait belt. Resident #3's legs were shaking when first standing. CNA B ambulated Resident #3 out of the bathroom to a wheelchair with a wheeled walker and no gait belt. On 07/25/16 at 9:40 a.m., Surveyor informed the DON of the surveyor's observation of staff not using a gait belt for transfers and ambulation with Resident #3. The DON stated the CNA should have used a gait belt with Resident #3. 5. Resident #1's care plan, The resident has a self care performance deficit related to [DIAGNOSES REDACTED]. The focus note, dated 07/15/16, in part: Resident transfers (pivot) with one assist.requires staff assist on/off toilet . Observation On 07/20/16 at 8:30 a.m., Surveyor observed CNA D transfer Resident #1 into her wheelchair and onto the toilet. No gait belt was used. After cares, CNA D told Resident #1 to stand up. Resident #1 stood part way up, in a stooped position and then sat back down, unable to stand. CNA D let Resident #1 rest a few minutes and then had Resident #1 stand up again. Resident #1 was very unsteady and remained in a stooped posture. CNA D had to quick grab the wheelchair and pull it closer. CNA D grabbed onto Resident #1's pants and under Resident #1's left arm to get Resident #1 in the wheelchair. CNA D did not use a gait belt. On 07/25/16 at 10:20 a.m., Surveyor interviewed the DON about the above observation. Surveyor asked if Resident #1 needed assistance of a CNA for transfers, since the care plan was not clear. The DON replied, Yes. Surveyor shared the observation of the unsafe transfer by CNA D. The DON acknowledged that a gait belt should have been used.

Based on observation, record review and interview, the facility did not provide an environment that maintains and enhances resident quality of life for 1 of 5 residents reviewed (Resident #1). As evidenced by: On 10/14/15 at approximately 10:00 a.m., Surveyor reviewed the medical record for Resident #1 and noted the following: - Resident #1 is [AGE] years old and has a [DIAGNOSES REDACTED]. - Current physician orders [REDACTED]. - Minimum Data Set's (MDS), dated [DATE] and 08/24/15, states Resident #1 is alert and oriented and has a BIMS score of 15, MDS states Resident #1 requires extensive assistance from facility staff for all ADL needs and currently takes an antidepressant and hypnotic medication. - Comprehensive nursing care plan, received 10/14/15, states Resident #1 has limited physical mobility and requires extensive assistance from facility staff for all ADL needs. Activities care plan states Resident accepts invitation to activities and is involved in activities in the facility. The care plan states resident uses an antidepressant medication related to a [DIAGNOSES REDACTED]. Care plan states Resident is to be offered oral cares. - Nursing notes from 09/02/15 - present did not indicate if Resident #1 was being monitored for depression and did not reflect depressive mood or statements. On 10/14/15 at 10:15 a.m., Surveyor interviewed Resident #1 in his room. Resident #1 was laying in bed in pajamas watching television. Resident #1's floor had multiple yellow stains, empty plastic soda containers and an open bag of Cheetos on the floor next to a large yellow stain. Resident #1's room was observed to be unclean. During the interview, Resident #1 stated he was depressed and felt isolated by the facility. Resident #1 stated the facility does not come into his room to talk with him and are scared of him due to his diagnosis. Resident #1 stated they don't sit down with me and don't talk to me .Social Worker only talks to me if I have a meeting. Resident #1 states this makes him very sad, lonely and depressed stating, I just want to get out of here .don't like this place .I'm very lonely .sometimes no longer want to live. Resident #1 stated he has nine cats at his home and they are the most important thing to him and he misses his cats. Resident #1 stated his sister, Family Member (FM) E had brought in one of his cats in a little over a month or so ago and it ended up nipping a staff member and himself. Resident #1 stated he was told the cat was no longer allowed to enter the building due to potential harm. Resident #1 stated all of his cats are current with their vaccinations and he and FM E explained this to the NHA. During this interview with Resident #1, FM E called Resident #1 at 10:30 a.m. via Facetime on Resident #1's Iphone. At this time with Resident #1 permission, FM E joined the interview. FM E stated she received a letter in the mail from the facility shortly after 09/08/15 which contained guidelines titled, Pet Therapy Guidelines. The guidelines state, Visiting pets are a wonderful asset to our residents and should be encouraged .However, for the safety and comfort of residents, staff and visitors, the following guidelines should be followed: Prior to or at the time of the visit: 1. The pet owner needs to verbally verify the pet is up to date on all required shots prior to facility access. 2. The pet owner needs to be informed: F. Pet visits are to be of a reasonable length of time as not to disrupt resident/staff schedules .General guidelines: 5. Pet owners who cannot verbally verify up to date shots for the pet, should not be allowed access with the pet. 6. Any pet causing injury to a person(s) within the facility is to be immediately removed and will not be allowed to return. FM E stated she had a conversation with the facility and permission was granted to bring a different cat to the facility to visit with Resident #1. FM E stated that at around end of September, she had brought a cat into the facility to visit Resident #1. After 15 minutes of having the cat in Resident #1's room, a facility staff member entered the room and told both Resident #1 and FM E that having the cat in the facility was against facility policy and FM E would have to take the cat out of the building. FM E stated she immediately spoke with the DON and stated the DON confirmed that the cat would have to leave the building. FM E stated she verbalized the cat was not the same cat which had previous nipped Resident #1 and a staff member and that the cat was up-to-date on all of it's vaccinations. FM E stated the DON stated the cat had to leave the building. FM E stated Resident #1's whole demeanor changed and he immediately became withdrawn and depressed. FM E stated the weather on this date was very nice so she took Resident #1 outside where he then was allowed to hold the cat and visit with it. FM E stated when she left the facility with the cat, Resident #1 was very sad and depressed. FM E stated when she spoke to Resident #1 the next day, he said staff kept coming into his room to ask him if he and FM E had smuggled the cat back into the room and questioned him if the cat was still there. FM E stated this made Resident #1 very depressed and this was very upsetting to her to know facility staff would question and accuse Resident #1 in this manor. FM E stated herself, Resident #1 and the NHA all spoke, via Facetime on Resident #1's Iphone, shortly after this incident to discuss Resident #1 being able to visit with his cats which was very important to him. FM E stated the NHA told them that she would have to speak with the facility's corporate office in regard to current pet guidelines. FM E stated the NHA did apologize to both her and Resident #1 for staff enforcing that they remove the cat from the building and felt the staff were wrong and did not follow current pet guidelines. FM E stated the NHA told both herself and Resident #1 that she could bring the cat to visit but it could not be every day and the cat could only stay for 3 hours and would then have to leave due to the cat causing disruption to both therapy and facility staff members. FM E and Resident #1 discussed concerns with only being allowed to see the cats on a limited time frame violated his rights. Surveyor asked Resident #1 if he had spoken to the facility's social worker in regard to his depression. Resident #1 stated he only sees the social worker at meetings and has not seen her in a long time. Resident #1 stated he had recently told the NHA that he was depressed about his cats and has also told multiple staff members that he was depressed. Resident #1 stated he felt the facility did not care about his depression. During this interview with both Resident #1 and FM E, Resident #1 stated, no one has come in today to help me with my morning cares .this is normal .if I need help I have to use my call light for staff to come in here and sometimes I have to wait a long time. Resident #1 stated he felt very isolated and lonely. Resident #1 then turned on his call light at 10:50 a.m. At 10:57 a.m., Certified Nursing Assistant (CNA) D knocked on the door and entered Resident #1's room. Surveyor asked CNA D if she was responsible for Resident #1's cares and CNA D stated she worked on the hall and it was both her responsibility along with CNA C's responsibility to take care of assisting Resident #1's cares. Surveyor asked CNA D if she had been in Resident #1's room today since starting at 6:00 a.m. to assist Resident #1 with his cares and CNA D stated no. At this time CNA C entered the room to assist CNA D with cares. Surveyor asked CNA C if she had been in Resident #1's room at all during her shift and CNA C stated no. Resident #1 stated staff used to ask if he needed assistance but have stopped coming into his room. Resident #1 stated there have been days when he spends all day in bed in his pajamas. Surveyor observed Resident #1 ask both CNA's to provide morning personal cares. After personal cares were observed, neither CNA offered or provide oral cares. On 10/14/15 at 11:15 a.m., Surveyor interviewed CNA C in regard to Resident #1's personal cares not being done until 11:00 a.m. and no one entering his room until his call light was turned on at 10:50 a.m. CNA C stated, it's normal for staff not to enter his room. and felt that staff should be going in there to ask him if he wants personal cares done. On 10/14/15 at approximately 11:20 a.m., Surveyor interviewed Registered Nurse (RN) B in regard to staff not entering Resident #'1 room to assist with cares until 11:00 a.m. RN B felt the staff should be going in his room to offer cares in the morning and felt by not going into his room was wrong. RN B stated, staff should be offering AM cares for Resident #1 and not waiting for him to use his call light to ask. On 10/14/15 at approximately 11:22 a.m., Surveyor discussed concerns with the Director of Nursing (DON) and Nursing Home Administrator (NHA) in regard to CNA C stating it was normal for staff not to enter Resident #1's room to assist with ADL's. Both the NHA and the DON agreed this was not appropriate. Surveyor discussed concerns that no oral care was offered or provided by either CNA D or C during or after personal cares were provided. Both the DON and the NHA agreed that oral cares should have been provided. On 10/14/15 at 9:30 a.m., Surveyor interviewed the NHA in regard to Resident #1. The NHA stated FM E had brought in a cat into the facility (date not provided), that had bitten a staff member and the resident. The NHA stated the staff freaked out over the incident and the family was then told the cat(s) could no longer enter the facility. Surveyor asked why the staff would freak out over the incident and the NHA stated because the staff were concerned about Resident #1's blood. Surveyor asked the NHA if the staff had been educated on blood borne illness and the NHA indicated all nursing staff were educated on Resident #1's condition and to use universal precautions in June, 2015 (education provided). The NHA stated the staff were afraid at the time of the incident but she is not aware of any concerns at the moment. The NHA stated at the time of the incident the facility did not have pet visit guidelines and after the incident had occurred she had spoken to the corporate office and guidelines were implemented. The NHA stated she had sent out the new guidelines to all family members the week of 09/08/15 and discussed these guidelines with both Resident #1 and FM E via a Facetime interview. The NHA stated she had discussed a limit of 3 hours with the cat to due to not wanting to disrupt staff with cares and stated both Resident #1 and FM E were in agreement of this time frame. The NHA stated she was aware of Resident #1 being very sad over not being able to visit with his cats and noted he had stopped coming out of his room like he use to after the incident had occurred. The NHA stated prior to the above noted incident, it was normal for her to see Resident #1 go by in his motorized wheelchair in the hallway and they would say hello to each other. The NHA stated she noted Resident #1 was not attending Bingo, which he enjoy a lot, and not coming out of his room as much so one day (date not provided) she entered his room and attempted to encourage him to come out. On 10/14/15 at 12:35 p.m., Surveyor interviewed Social Worker (SW) A in regard to Resident #1. SW A stated she was not made aware by facility staff that Resident #1 had signs and symptoms of depression. SW A stated the last assessment completed for depression was on 08/25/15 and did not trigger for depression. SW A stated Resident #1 desperately does not want to live in the facility. SW A stated, typically staff will let me know if someone is feeling bad. SW A stated the NHA had not come to her with information that Resident #1 was not coming out of his room and attending activities. SW A stated she felt she should have been notified. SW A stated no interventions to assist with Resident #1's recent depression were implemented and no outside services have been recommended. SW A stated the facility has an inhouse therapist that rounds in the facility and stated Resident #1 was has not been referred to this therapist for depression. SW A stated the inhouse therapist recently underwent surgery and was not currently available but felt the facility should have had a backup plan and did not. SW A agreed that signs and symptoms are apparent and would immediately assess Resident #1. SW A stated Resident #1 loved to go to the facility run Bingo program and was such a joy for him. SW A stated Resident #1 does not attend Bingo as much anymore and feels like the facility should have done more to help him. On 10/14/15 at approximately 1:00 p.m., Surveyor interviewed the NHA in regard to Resident #1's signs and symptoms of depression and no assessment or interventions had been implemented. Surveyor discussed concerns of staff not entering Resident #1's room to assist with cares or visit which then makes him feel lonely and isolated. Surveyor discussed concern that Resident #1 stating he feels so depressed and sometimes no longer wants to live. Surveyor also discussed concerns in regard to facility limiting cat visit times due to causing disruption to the staff in regard to cares. The NHA stated she didn't know why 3 hours was implemented for visits and felt that was a reasonable amount of time for Resident #1 to visit with the cat. Surveyor discussed concerns with Resident #1 eating his meals in in room and if the cat was visiting with him in his room there should not be a disruption to the staff in regard to cares. The NHA stated if the Resident #1 had said he needed more than 3 hours with the cat the facility would have obliged. The NHA stated the facility did not ask Resident #1 if 3 hours was long enough or if he needed more time with the cat. The NHA stated she was not made aware of staff statements of accusing Resident #1 of smuggling the cat into the facility. Surveyor discussed Resident #1's room not being cleaned, having multiple yellow stains on the floor, open food containers and opened soda bottles on the floor. The NHA stated she would have housekeeping go in immediately to clean the room.

Based on record review and interview, the facility did not ensure appropriate interventions were put into place to prevent future falls and did not complete a root cause and analysis for cause of fall(s) for 2 of 12 sampled residents (Resident #3 and #1) reviewed for falls. Resident #3 had a fall and no intervention was put into place to prevent future falls and no root cause and analysis were completed to determine reason for fall(s). Resident #3 then had another fall which resulted in a fracture. Resident #11 had multiple falls and no root cause and analysis were documented to determine reason for falls. As evidenced by: Facility policy titled, "Fall Assessment," dated 08/01/1999, states, "When a resident falls the nurse is to: A. Select "Tasks" highlight "Fall Assessment", click "Load" then "Go." B. Complete the Fall Assessment by clicking on all pertinent information. Summarize finding and develop a plan to prevent future falls. Identified interventions shall be placed on the resident's care plan and the CNA worksheet. C. The Director of Nurses or designee is to review the fall assessments daily and add any additional comment and interventions as needed. D. Fall Committee to review fall assessments weekly, at a minimum." 1. Resident #3 On 06/25/2014 at 2:05 p.m., Surveyor # reviewed the medical record for Resident #3 and noted the following: - Resident #3 has a [DIAGNOSES REDACTED]. - Minimum Data Set (MDS), dated [DATE], indicates Resident #3 is cognitively impaired, requires extensive assistance from one staff member for transfers and requires the use of a walker, has had prior falls (one with injury) and is at risk for falls. - MDS, dated [DATE], indicates Resident #3 is cognitively impaired, is totally dependent upon staff for transfers and requires the use of a wheelchair. The MDS does not indicate prior falls with or without injury. - Comprehensive Care Plan, dated 06/25/2014, titled, "Self-Care," states Resident #3 requires assistance from facility staff for all ADLs (Activities of Daily Living) due to dementia, osteoporosis, macular degeneration and visual deficit. - Comprehensive Care Plan, dated 06/25/2014, titled, "Mobility," states Resident #3 requires extensive assistance from facility staff for bed mobility, ambulation and transfers. Care plan states Resident #3 is unsteady, has had recent fall(s) and has a visual deficit. Care plan states Resident #3 is to have have grippy socks on when in bed, has a bed sensor alarm, requires the use of a full body lift, to keep resident in sight of staff when up in wheelchair, has a velcro seat belt alarm and pressure pad alarm while in recliner and a pressure pad alarm in wheelchair. Care plan also states staff are to follow hip precautions by not allowing Resident #3 to cross legs, to place a pillow between legs when turning, to use pillows between legs or abduction pillow between legs at all times when in bed and is non-weight bearing. - Certified Nursing Care Plan, dated 06/25/2014, states Resident #3 is required to wear grippy socks while in bed, to assist directly from room to bath tub, has a bed sensor alarm, requires the use of a full body lift for transfers, keep in sight of staff when up in wheelchair, to follow hip precautions, and uses a velcro seat belt alarm and pressure pad alarm in recliner. Care plan also states Resident #3 has a pad alarm in wheelchair and floor mats on each side of the bed. On 06/25/2014, Surveyor # reviewed the nursing notes for Resident #3 from 01/01/2014 - 06/25/2014 and noted the following information: -01/07/2014: Resident #3 had a fall while wheeling herself in her wheelchair from the beauty shop back to her room and then attempting to self transfer from her wheelchair. Prior interventions included: grippy socks while in bed, walker, two side rails, bed alarm, alarmed velcro seatbelt and pressure alarm in recliner and in any chair and to remove bed spread before laying down. The facility added a new intervention of assisting Resident #3 back to her room after attending the beauty shop and then to assist into her recliner. - 03/12/2014: Resident #3 had a fall in her room. Resident #3 had unbuckled her seat belt and then rehooked it behind her and then attempted to self transfer herself to her bed and fell . The notes indicated the alarm sounded and the care plan had been followed. The new intervention put into place stated Resident #3 was to be placed on 15 minute checks for 24 hours. No other intervention was provided. - 04/19/2014: Resident #3 had a fall in her room. Notes indicate facility staff responded to Resident #3's alarm and found her on the floor. Resident #3 was then sent to the emergency room and was diagnosed with [REDACTED]. On 06/26/2014, Surveyor # reviewed the fall investigations for the above mentioned falls. All fall investigations contained the above information. On 06/26/2014 at 8:15 a.m., Surveyor # interviewed RN (Registered Nurse) B, who is the MDS nurse. This surveyor and RN B reviewed the falls for Resident #3 dated, 01/07/2014, 03/12/2014 and 04/19/2014. This surveyor asked RN B if he was on the facility Fall Committee and RN B stated, "Yes." RN B stated he, along with the Director of Nursing (DON) and Nursing Home Administrator (NHA), review all falls daily during morning meeting. This surveyor asked RN B if the intervention for the fall that had occurred on 03/12/2104, which was placing Resident #3 for 15 minute checks for 24 hours, was the only intervention put into place and RN B stated, "Yes." This surveyor asked RN B how 15 minute checks for only 24 hours would prevent Resident #3 from falling again. RN B stated, "I don't know...I do not have a good answer to that." RN B stated the facility should have incorporated a more appropriate intervention for Resident #3 when she fell on [DATE] and placing the Resident on 15 minute checks for only 24 hours at the time of the fall did not assist in preventing future falls. This surveyor asked RN B if a root cause and analysis had been completed on 03/12/2014 fall. RN B stated, ''No." RN B stated a root cause analysis should have been done. RN B stated Resident #3 had self-removed her alarmed velcro seatbelt and then rehooked it again behind her. RN B stated Resident #3 has always been able to undo her seatbelt and reattach it again on her own since it was incorporated well over a year ago. This surveyor asked RN B if this information was made available on the resident's care plan and if staff had been educated on the fact the resident could remove her own seatbelt and then reattach it back. RN B stated it was not on the care plan and staff was not educated on the subject. On 06/25/2014 at 3:15 p.m., Surveyor # interviewed the DON. This surveyor asked the DON why Resident #3 had a velcro seatbelt and a pressure alarm while in the chair if the resident could easily remove the seatbelt and then reattach it, which would then turn the alarm off. The DON stated the seatbelt had an odd sound and, even for just a few seconds, would alert staff of the resident attempting to stand up. This surveyor reviewed the above mentioned falls for Resident #3 with the DON. The DON stated the facility has been "stumped" on providing fall interventions for Resident #3 and are "struggling with her." The DON stated 15 minute checks for only 24 hours for the fall on 03/12/2014 was not appropriate and another more appropriate intervention to prevent future falls should have been implemented. On 06/26/2014 at 12:00 p.m., Surveyor # discussed the above mentioned falls for Resident #3 with the NHA and the facility not implementing appropriate interventions for the fall that occurred on 03/12/2014. The NHA agreed that a more appropriate intervention should have been implemented, which could have possibly prevented the fall on 04/19/14 which resulted in a hip fracture. The NHA stated she would investigate further to see if the facility had any further information available to assist with the investigation. On 06/30/2014 at 9:00 a.m., Surveyor # interviewed the DON. The DON stated the facility did not have any further information on the above mentioned falls. No further information was provided. 2. Resident #11 Resident #11 was admitted to the facility with [DIAGNOSES REDACTED]. The MDS documented the resident had two falls with no injury. Per the care plan, dated 04/15/13, the following fall interventions were in place: if resident noted to be picking at floor or wallpaper, attempt to divert resident's attention with an activity, start 15 minute checks until resident is asleep. Fall #1 - resident found on knees in the hallway. Incident report, dated 05/23/13 at 2:50 p.m., stated Resident #11 was found on her knees in the hallway. The resident had no injuries. Resident #11 was independent in ambulation at the time of the fall. The new intervention added, per the incident report, was to start 15 minute checks until the resident was asleep in bed that evening. On 07/01/14 at 7:55 a.m., Surveyor reviewed the incident report with the DON. The surveyor requested additional information related to root cause analysis and other interventions put into place to prevent further falls. No further information was provided. Fall #2 - resident found on her knees in the hallway. Incident report, dated 05/27/13 at 3:00 p.m., stated Resident #11 was found on her hands and knees on the floor in the hallway. Resident #11 had slight pinkness to her right knee that measured 4 centimeters. The new intervention added, per the incident report, was to start 15 minute checks for 24 hours. On 07/01/14 at 7:55 a.m., Surveyor reviewed the incident report with the DON. The surveyor requested additional information related to root cause analysis and other interventions put into place to prevent further falls. The DON provided information that the physician decreased Seroquel to 25 milligrams to be given at hour of sleep on 05/28/13 (which was five days after the first fall). No other information related to new interventions or root cause analysis was provided to the surveyor. Fall #3 - resident was attempting to slide her slacks down and squat towards the floor. Falls Committee note, dated 08/08/13 at 11:30 a.m., stated Resident #11 was attempting to slide her slacks down and squat towards the floor when she slid against the wall onto the floor. The resident had no injuries. The new intervention per the committee notes stated, "If noted pulling slacks down assist to toilet." There is no documentation of other new interventions put into place or root cause analysis of the fall. Fall #4 - resident found on floor sitting on buttocks. Written Statement of Witness/ Others, dated 08/15/13 at 3:00 p.m., stated that Resident #11 was found on the floor on 08/15/13 at 9:00 a.m. The resident was found sitting on her buttocks in the dayroom. The resident called out, "Oh my arm" and appeared to have her arm on the wheelchair as she sat down on the floor. The resident had no other complaints. There was no investigation attached to this witness statement. There is no root cause analysis as to the cause of the fall. The care plan was updated to assist back to room after each meal. On 07/01/14 at 7:55 a.m., Surveyor reviewed the incident reports with the DON. The surveyor requested additional information related to root cause analysis and other interventions put into place to prevent further falls. The DON provided the surveyor with a copy of a physician order [REDACTED]. Fall #5 - resident leaned on a walker that did not have brakes locked and tripped and fell to the floor. Incident report, dated 09/12/13 at 7:40 a.m., stated Resident #11 had walked into the dining room and was talking to another resident. Resident #11 was leaning on the other resident's walker that was not locked. Resident #11 tripped on the walker and fell hitting her head on the wheelchair. At the time of the fall, the resident was independent with ambulation. The resident did not have her eyeglasses on at the time of the fall. The new intervention implemented, per the report, was to make certain the resident had her glasses on before going to the dining room. On 07/01/14 at 7:55 a.m., Surveyor reviewed the incident report with the DON. The surveyor requested additional information related to root cause analysis and other interventions put into place to prevent further falls. The DON provided the surveyor with a copy of a physician order [REDACTED]. Fall #6 - resident was found lying face down on the floor in the hallway. Incident report, dated 10/30/13 at 9:30 a.m., stated Resident #11 was found lying face down on the floor in the hallway. The resident had discoloration to her left cheek and a laceration on the right cheek measuring 2 cm and one by the upper brow measuring 3 cm. The resident received first aid with steri strips applied. The resident, at the time of the fall, was independent in ambulation. The new intervention put in place after the fall was 30 minute checks for the next 24 hours. On 07/01/14 at 7:55 a.m., Surveyor reviewed the incident report with the DON. The surveyor requested additional information related to root cause analysis and other interventions put into place to prevent further falls. The DON provided the surveyor with information that was added to the care plan on 11/28/13 (29 days after the fall). The new intervention added was using a wheelchair for transfers if the resident was unsteady or having difficulty with transferring. On 01/07/14, the resident's care plan was updated stating the resident was to be ambulated and transferred with assist of one staff and a gait belt to all destinations. The MDS, dated [DATE], documented the resident continued to have short and long term memory problems with moderate impairment in decision making. The resident now required extensive assistance of one staff with transfers, ambulation, eating, toileting and dressing. Fall #7 - resident slid out of wheelchair. Incident report, dated 02/28/14 at 4:30 p.m., stated Resident #11 was reaching for the couch or a picture when she slid out of the wheelchair and ended up lying on the floor. The resident had no injuries. The new intervention, per the report, was 15 minute checks for 48 hours. Interventions added on 03/03/04 (three days later) were: may use wheelchair but transfer to recliner chair in the day room and do not leave in the wheelchair unattended. On 07/01/14 at 7:55 a.m., Surveyor reviewed the incident report with the DON. The surveyor requested additional information related to root cause analysis and other interventions put into place to prevent further falls. Surveyor questioned the DON if the facility had implemented interventions such as occupational therapy (OT) evaluation for wheelchair positioning or the addition of dycem to the wheelchair. The DON stated she would look for more information. No further information was provided. The MDS, dated [DATE], documented the resident continued to have short and long term memory problems with moderate impairment in decision making. The resident now required extensive assistance of one to two staff with transfers, ambulation, eating, toileting and dressing. Fall #8 - resident fell from the toilet. Incident report, dated 05/29/14 at 5:10 a.m., stated Resident #11 fell off the toilet. The nurses' notes, dated 05/29/14, stated the resident later complained of pain in the hip. The resident had hip and pelvic rays and a fracture could not be determined. The new intervention added, per the incident report, was to not leave the resident unattended on the toilet and to not use a toilet riser. On 07/01/14 at 7:55 a.m., Surveyor reviewed the incident report with the DON. The surveyor requested additional information related to root cause analysis and other interventions put into place to prevent further falls. No further information was provided.