Every finding on record at Fairway View Neighborhoods

Based on observation, interview, and document review, the facility failed to include the resident censes on the facility nurse staff posting. This deficient practice had the potential to affect all 49 who resided in the facility and any visitors who may have wished to view the information. During an observation on 7/20/26 at 3:46 p.m., nurse staff posting dated 7/20/26, was observed on a bulletin board by the director of nursing (DON) office. The staff posting included the total number of nursing staff hours, broken down into sections of day shift, evening shift, and overnight shift, with spaces in each section for registered nurse (RN), licensed practical nurse (LPN), trained medication aide (TMA), and certified nursing assistant (NA). The posting lacked information on the resident census. During an interview on 7/20/26 at 4:00 p.m., DON indicated that the process was for the night shift to post the nurse staff posting. DON verified that the census area was blank and should have been included in the posting. DON indicated that it is important to list the censes and staffing in order to have the information available to residents and visitors. Facility policy titled Posting Direct Care Daily Staffing dated 9/27/22, identified the information recorded on the form shall include the name of the facility, the date for which the information is posted, the resident census at the beginning of the shift for which the information is posted. The direct care daily staffing lacked the census information.

Based on interview, observation and document review, the facility failed to ensure 1 of 1 resident (R1) was free from neglect when R1 had a fall, intentionally not reported by staff, which delayed necessary medical care for two hours. This resulted in an immediate jeopardy (IJ) for R1 when, as a result of the fall, she was treated at the emergency department (ED) where she was diagnosed with a laceration to her forehead, an abrasion, bruising, concussion and a fracture of the sternum. The IJ began on 12/15/25 at 7 p.m., when nurse aide (NA)-A transferred R1 alone (care plan directs assist of two) and R1 fell off the edge of the bed which resulted in bleeding laceration on her forehead and NA-A intentionally did not report the fall or seek appropriate medical care until two hours later. The administrator, director of nursing (DON), and primary care provider medical doctor (MD) were notified of the IJ on 12/23/25 at 4:30 p.m. The facility implemented corrective action by 12/18/25, prior to the start of the survey, and therefore is issued as past non-compliance. Findings include: R1's significant change Minimum Data Set (MDS) dated [DATE], indicated severely impaired cognition, with disorganized and incoherent thinking (rambling, unclear, illogical flow of ideas, or irrelevant conversation) altered level of consciousness, and long and short-term memory loss. She was dependent (required assistance of two or more staff to complete) personal hygiene, bathing/shower, sit to stand, all transfers, and used a manual wheelchair for mobility. Her medical diagnoses included Alzheimer's Disease, dementia, and anxiety. Since admission she had two falls without injury and one with injury (except major). R1's Face Sheet identified diagnoses history of falling and transient ischemic attack (TIA) (stroke)/cerebral infarction (area of necrotic (death of) tissue in the brain due to disrupted blood supply), and osteoporosis (caused bones to become weak and brittle.) R1's care plan dated 11/5/25, identified R1 had difficulty understanding others due to dementia. Staff were directed to speak clearly, repeat phases as needed, and ask simple yes or no questions. She required 24-hour supervision and care which placed her at a greater risk for abuse and neglect. She had altered ability to care for herself due to cognition, unable to walk, dependent upon staff for all transfers, and may use EZ stand as needed with a medium sling. She was at risk for falls due history of falls, staff were directed to give verbal reminders not to ambulate, transfer without assistance, bed in lowest position, observe frequently and place in supervised area when out of bed, pressure sensor when in bed to alert staff when trying to get out of bed, and call light within reach always. She had impaired decision making due to dementia and staff were directed to provide cues, supervision, determine if decisions made by her endangered herself or others and intervene if necessary. On 12/18/25, R1's care plan was updated to include stand pivot transfer (SPT) with assist of two if alert, Hoyer lift, and assist of two with medium sling. Physical therapy (PT) evaluation and plan of treatment dated 10/27/25, identified referral was made due to change in cognition and mobility status. Staff reported hard to transfer with assist of one to two with pivot transfers due to resident unable to understand completion of task. Staff reported the use of EZ stand had been difficult due to resident unsure of the task and hard to explain to her. She was identified as high risk for falls due to cognitive status and unable to follow cueing for safety. Clinical impression of evaluation: a cognitive decline was identified, a hard time with constant movement and conversation causing limitations in orientation to task. She was able to complete the SPT from wheelchair to chair with moderate assistance but attempted to sit in the middle of transfer and required maximum assistance to reposition. EZ stand transfer was completed and required assist of two throughout to attend to task, keep safely of extremities, and allow for best maneuver of transfer. PT discussed with staff on this date, will maintain SPT and EZ stand, with discussion on addition of Hoyer as needed in upcoming sessions. R1's order start date 10/27/25 through 12/18/25, listed under activities of daily living (ADL) flow sheet, identified activity as tolerated; SPT assist of two or EZ stand transfer with assist of two per patient cognition and ability to follow cues (this had not been added to R1's care plan). R1's order start date 12/18/25, listed under ADLs flow sheet, identified activity as tolerated; stand pivot transfer with assist of two if alert. Hoyer lift due to fracture and medium sling. R1's fall risk assessment dated [DATE], identified intermittent confusion, poor recall judgment, and safety awareness. R1 had balance problems with standing, impaired mobility, and required the use of wheelchair. Fall risk score was 18 (16-20 had high likelihood of a fall occurring) and indicated high risk for falls. R1's progress notes from 12/15/25, through 12/19/25, identified: -On 12/16/25 12:19 a.m., nurse was called to R1's room at about 9:00 p.m. (12/15/25). She had a hematoma and discoloration on right side of face around eyebrow, large gash about 3 centimeters (cm) long on top left side of head, and partially dry blood running down left side of head. R1 was snoring heavily while nurse wiped blood away using gauze to check the size of the cut, left eye was rolled back, and right pupil was pinpoint. R1 was difficult to wake, a second nurse was called over, DON contacted, and vitals taken. Staff stated she was put to bed about 7:00 p.m., checked at about 9:00 p.m., which was when the gash was found. Sternal rub used at which time she arose and asked what we wanted, and why her name had been called. Her eyes returned to normal, though pupils remained small. DON notified family who consented for transfer to hospital. Ambulance called; resident left for hospital. She returned to facility at 11:50 p.m. with five staples in forehead laceration. Hourly checks are being completed on resident. -On 12/16/25 at 1:06 a.m., (recorded as a late entry) nurse evaluated R1, and DON arrived at facility. She responded to DON but due to advanced Alzheimer's did not respond to questions appropriately. R1's blood pressure noted to be slightly elevated (158/99) and son requested she be sent to ER to be evaluated. DON met ambulance at the hospital and stayed with her while she was evaluated, then accompanied her back to facility. R1 had complained of pain with movement. Two staff assisted her back to bed with gait belt and she hollered out with transfer. Morphine was administrated and staff were instructed to complete hourly checks, check bed alarm placement, and ensure bed was in lowest position. -On 12/16/25 at 7:27 a.m., R1 was restless in bed, assisted up and propelled self in wheelchair. Verbalized complaints of pain; rubbed head and sternum area with movement. -On 12/16/25 at 8:00 a.m., Call placed to on-call provider at hospital regarding increased pain and current morphine orders, will return call. -On 12/16/25 at 8:45 a.m., Difficulty with speech related to Alzheimer's repeats J-e-a n-n. Moving about in wheelchair independently on unit. Stopped frequently and rested head in palm of hand, closed eyes while rocking back and forth in chair. -On 12/16/25 at 8:51 a.m., Hospice updated. Continued to have some discomfort with abrupt movement/turning and twisting in sternal area. Rubbing at chest and head at times stating ow. (as if in pain) -On 12/16/25 at 12:01 p.m., skin inspected: mid upper forehead laceration 3.5 cm with 5 staples. Right eyebrow with a 1 x 0.6 cm purple contusion that had a surrounding area 5 x 2 cm lighter in color. Right radial side of wrist had 4 small lacerations with some small areas of redness. Left knuckle of first finger 0.2 x 0.5 cm contusion. Left great toe 1 x 0.5 cm bruise. -On 12/16/25 at 1:34 p.m., hourly checks completed. Mid shift sleeping in wheelchair with head resting in palm of hand. Assisted to recliner then to bed. -On 12/16/25 at 2:00 p.m. Snoring while she laid in bed and difficult to arouse. -On 12/16/25 at 11:48 p.m. Condition/Status: too sleepy to get up for supper. Ate apple sauce and pocketed her medications in mouth. -On 12/18/25 at 9:00 a.m. left for appointment. -On 12/18/25 at 11:08 a.m. informed son imaging was completed without sedation. -On 12/18/25 at 1:03 p.m. Returned from clinic. Restless while she sat in wheelchair. Occasionally grimacing and stating, ow while moving back and forth. Orders received to increase morphine dose. -On 12/18/25 at 3:00 p.m. informed son of computed tomography (CT) scan imaging. Lidocaine patch will be placed on sternum. R1's ER visit on 12/15/25 at 10:18 p.m. identified diagnoses: laceration of scalp measured 3.5 cm, contusion of face, and multiple abrasions. R1 was placed in bed at 7:00 p.m. At 9:00 p.m. during rounds found in bed by staff with large laceration to mid upper forehead, bruise and swelling to right eyelid, and abrasion to right wrist area. She was lethargic. History of Alzheimer's unable to follow commands, provide any history of injury or answer questions (baseline according to staff present) due to advanced dementia. Received Seroquel at approximately 7:00 p.m. per staff. Dried blood noted to laceration area. Laceration was irrigated with normal saline solution, skin closure completed with five staples, and antibiotic ointment applied. Tolerated procedure well. R1's CT scan with contrast dated 12/18/25, identified acute nondisplaced (the bone breaks but maintains proper alignment) fracture (a sudden break in a bone due to a traumatic injury) of manubrial (upper part of the sternum/breastbone) (usually caused by high impact trauma such as from motor vehicle accidents, falls from heights or direct blow to the chest). Big Stone County Sheriff's Office Incident Report dated 12/24/25, identified on 12/16/25 at approximately 11:50 a.m., he was made aware of a Minnesota Adult Abuse Reporting Center (MAARC) report. Information was received and identified an investigation was warranted, cannot determine how R1 received the gash on her head or the bruising on her arm/hand. On 12/16/25 police officer (PO) completed the first interview with NA-A and identified: NA-A and NA-B had transferred R1 around 7:00 p.m., bed alarm checked and was working. At 7:45 p.m., NA-A checked on R1 sleeping, shortly before 9:00 p.m. NA-A entered R1's room and found her on the floor with cut on her head conscious and communicating, cleaned R1 up, changed her clothes, got her back to bed and sought help from trained medication aide (TMA). NA-A stated she did not immediately call for help because she was scared and did not know what to do, never got blood on her clothes, and threw the bloody rags and R1's clothing in the trash (big garbage). NA-A's second interview completed on 12/17/25 at 9:53 a.m. and identified after supper she brought R1 to her room, completed evening cares and used the lift to transfer her to toilet and to bed. NA-B completed a shower on a resident. Later that evening opened R1's door, checked on her, did not see anything unusual and closed the door. Unsure why bed alarm did not alarm or activate when R1 fell out of bed. NA-A stated she took out trash at some point (6:40 p.m.) and then placed R1's clothes in the trash after that. NA-A returned to R1's room at 8:40 p.m. and TMA arrived at R1's room at 8:53 p.m. He found it unlikely NA-A could have cleaned up R1, placed her back in bed and taken out bloody clothing/rags to the trash in less than 8 minutes. NA-A then recanted statements and informed PO what happened. R1's fall occurred after she placed her on the edge of the bed between 6:30 p.m. and 7:00 p.m. while she returned lift to bathroom and heard a thud. Wet rags were applied to stop the bleeding on R1's forehead, changed pajamas, placed her back into bed and stayed with her until she fell asleep. NA-A stated she did not immediately report the incident, feared getting in trouble for assisting R1 along, as care plan required two staff. She was afraid of losing her job, made decisions based on that fear, and did not intentionally harm R1. She later decided to report the incident because she felt it was the right thing to do. Review of NA-A's personnel file identified termination on 12/18/25, related to dishonesty. She stated she had assistance of another staff when a resident was transferred. It was discovered false and deemed a violation of the resident's care plan. It was discovered she initially disposed of the resident's bloody clothing which impacted the facility's ability to conduct an honest and ethical investigation. Camera footage also revealed she had later hidden her own hoodie which had blood on it from caring for the resident at the time of injury. She provided misinformation to cover up a wrongdoing, was unacceptable, and can cause harm to the residents. Facility 5-day report dated 12/19/25 at 3:36 p.m., identified NA-B stated she had assisted R1 with cares and placed her in bed with assist of NA-A around 7:00 p.m. At 9:00 p.m. licensed practical nurse (LPN)-A was called to R1's room for head injury. Found hematoma and 1 inch gash with bleeding. Unable to arose until sternal rub was used to stimulate her. Pupils normal and sent to ER. To ensure resident safety, her care plan was updated to include stand pivot transfer with assist of two if alert. Hoyer lift assist of two, use medium sling. R1's cognition was severely impaired. Report identified physical abuse did not occur, however concluded NA failed to follow the resident's care plan. NA-A was suspended until further notice then terminated following the conclusion of the investigation. During an observation on 12/19/15 at 1:30 p.m., R1's door was closed to her room. Knocked on the door. A female family member (FM) opened the door. R1 laid on her back in the bed, covered with blanket, with head of bed up to approximately 90 degrees, face was pale, and eyes were closed. There were at least eight people gathered in her room and FM stated she wasn't doing very well. Surveyor left the area and provided family privacy. At 1:55 p.m. R1 passed away. During an interview on 12/22/25 at 12:18 p.m. NA-C stated R1's cognition was poor, confused, and unable to communicate her needs without cues. She was not safe with assist of one staff and the EZ stand. She was uncomfortable and restless in the EZ stand, and we were expected to have two assists with transfers to be safe. She was unable to have sat on edge of bed by herself. Staff were expected to report any falls to the nurse immediately, do not move them until the nurse completed an assessment. During an interview on 12/22/25 at 1:33 p.m. NA-B stated R1 was forgetful, incredibility unsafe to be transferred with only one assist, she had taken her hands off the bars while she stood in the lift, sleepy, and had poor cognition. From 6:00 p.m. to 6:30 p.m. she gave a resident a bath. She had assisted another resident from 6:30 p.m. to 7:00 p.m. At 7:05 p.m. NA-A came out of R1's room and acted kind of weird. She asked if she was ok, and she stated she was, grabbed her sweatshirt, wrapped it around her shoulders/head and said she was hot. She asked her to assist another resident to bed and walked away. At 9:15 p.m. NA-B walked by R1's room, heard snoring, and entered the room. R1 had a huge gash on her forehead with dried blood in her hair, blood dripped down her face. NA-A stated she did not know what happened and maybe she had hit her head over there (pointed to the bar of the bed by the nightstand). R1 looked so bad. During the conversation, NA-A pointed at NA-B and said you and me transferred her together. NA-B said she stated, oh yeah, I guess we did. NA-B said when they left the room, NA-A asked her to lie. N A-B wrote up her report and lied. R1's blood was dried onto her face, which had to have happened before 7:00 p.m. both NA-A and NA-B worked together from 7:00 p.m. to 9:00 p.m. and were not apart for more than 10 minutes. NA-A called her before there was an investigation and asked her why she freaked out and stated she did not know what happened. As soon as NA-B figured out NA-A had lied, she called the facility, told them she had lied and wanted to come clean. During an interview on 12/22/25 at 10:15 a.m., MD stated he was made aware of R1's incident/fall on 12/16/25, during a staff meeting. There were two NAs involved; one tried to cover up the fall for the other one. The staff would have been expected to follow the facility policy and report the fall and injures right away and did not happen. It was disappointing to hear how this happened, the NAs were not truthful right away. The police department was contacted and completed their own investigation. NA-A was in R1's room, transferred her, R1 then fell off the bed, and that did not get reported until two hours later. NA-A attempted to cover up the fall, changed R1's clothing, and cleaned her up. R1 ended up with a fracture to the sternum which most likely was caused by this fall, a laceration to her forehead and bruise to her eye. She was sent to ER for treatment and received stitches to her forehead. A fall with an elderly person was more serious due to possible damage to the soft tissue and fractures and would have taken longer to heal. The fall may have affected her mortality, hard to tell for sure, but was suspicious when she passed away on 12/19/25 (4 days later). During an interview on 12/22/25 at 2:25 p.m., NA-A stated R1 required assistance with all cares, safe for the most part when transferred with the EZ stand. Staff were expected to transfer R1 with assist of two for safety reasons, she struggled with understanding what was going on and required cues. She assisted R1 with supper and was administered her evening medications between 6:00 p.m. and 6:30 a.m. then fell asleep at the table. At 6:45 p.m., she pushed R1 to her room in the wheelchair and placed pajamas on her. NA-A hooked her up to the EZ stand and transferred her from wheelchair to the toilet in the bathroom alone. NA-B knew if she waited too long to put R1 to bed she would get too sleepy. She knew it was hard to understand why she transferred R1 without assistance of another staff but did it to help her. The EZ stand transfer went ok from wheelchair to toilet and toilet to bed. She kept R1 distracted which helped avoid her from becoming agitated due to lack of understanding of what was going on. NA-A lowered R1 onto the edge of the bed and removed the loops from the lift. She walked away from the bed while R1 sat alone with feet on the floor and pushed the lift machine into the bathroom. She would have been safe on the edge of the bed unattended with how awake she was and had not planned to be away from her for more than one minute. She saw R1 fall off the bed to her left side and head towards the foot of the bed and heard a thud. She ran back to the bed, rolled her over onto her back and saw blood on her forehead coming down her face by her eyebrow, and placed a pillow underneath her head. NA-A grabbed wash clothes, threw them in the bathroom sink, ran cold water over them, and placed them on R1's forehead to stop the bleeding, unsure how long, then removed them to make sure bleeding stopped. NA-A assisted R1 to sit up, R1 mumbled and asked for her sister. She removed R1's blood-stained pajama shirt and pants and replaced them with clean ones. She assisted her to a sitting position, informed her she needed to stand up, placed her heels/feet on the floor and held her back side. She positioned herself behind R1, scooped her arms underneath R1's armpits, quickly lifted her onto the bed, lifted feet up, and pivoted her into the bed onto her back. NA-A sat next to her bed, held her hand, talked to her as R1 moved her legs and mumbled. NA-A stated she just responded in the moment with a fight or flight response, felt she would have noted if she caused R1 more harm when she assisted her back to bed by herself and really thought she was ok. After that, NA-A stated she cleaned up the room, wiped four blood spots off the floor with a washcloth, bagged all her bloody clothing and wash clothes, turned off the lights, exited the room, then placed the bag in the garbage rather than launder it. At some point later NA-A indicated she went back to R1's room, touched her shoulder, she moved her leg and gave her reassurance she was ok. Then at approximately 9:00 p.m. when she was going to be leaving for the night, she knew she could not leave her with a cut on her forehead and told the first staff she saw, TMA-A. NA-A indicated she stayed with R1 while TMA-A went and found a nurse. She was asked what happened and NA-A stated she did not know. She was scared and panicked, she knew she should have got a nurse and should not been moved R1 from the floor after the fall until assessed by a nurse in case she had an injury such as a fracture. NA-A stated then NA-B entered the room and asked what happened and she was told no one knew. The registered nurse (RN)-B then asked NA-B is R1 was okay when we (NA-A and NA-B) put R1 to bed, and NA-B stated yes. RN-B and TM-A then left the room and called the director of nursing (DON). NA-A stated she then said, you pretty much told them you helped put R1 to bed, to NA-B. NA-A indicated was asked to provide a handwritten statement prior to leaving the building. On 12/16/25, DON called and placed her on leave, and following that, she completed an interview with the city police department. On 12/19/25, she was informed she no longer had a job and was terminated. During an interview on 12/23/25 at 10:20 a.m., physical therapist (PT) stated R1 was difficult to redirect, no memory recall, and unable to carry on a constructive conversation. She had a history of falls, lacked safety awareness, and was not cognitively appropriate for therapy. The PT orders dated 10/27/25, after the evaluation was completed included assist of two with the EZ stand and was not included in the care plan. She would have not been safe sitting on the edge of the bed independently. Based upon her lack of safety awareness, she would have tried to get up and transfer herself unaware to stop herself and placed her at risk for a fall. R1 was hard to test for strength due her declined cognition. Cognition ability is what limited her to be safe in the middle of a transfer, standing, increased her risk for a fall, and the reason she required two assists with transfers. During an interview on 12/23/25 at 11:00 a.m., radiologist MD-B stated R1's results of CT scan with contrast dated 12/18/25, identified non-displaced manubrial fracture. The scan showed the fracture was acute (a break in the bone that happened recently and suddenly), no healing seen, happened within a week based on what appeared in the scan. Possibly caused by her fall directly to the floor and usually caused by direct trauma. During an interview on 12/23/25 at 3:30 p.m., RN-B stated she was called to R1's room around 9:00 p.m. regarding a fall. When she arrived in R1's room she noted a hematoma and bruising on right side of face located around the eyebrow. There was a large gash on the top of her forehead located by the hairline approximately 3 cm in length with dried blood on it and partially dried blood running down the left side of her face. She attempted to clean the gash with a gauze to better visualize the size. R1 was snoring loudly at the time, she called her name and was unable to arouse her. RN-B described R1's left eye as rolled back, and right pupil was pinpoint. RN-B stated NA-A informed her R1 was placed in bed at 7:00 p.m. and checked on at 9:00 p.m. when the gash on her head was discovered. She indicated a sternal rub was used to arouse R1 and when she woke her eyes returned to normal except the pupils remained small. The ambulance was called and R1 transferred to ER. Staff would have been expected to report the fall as soon as it happened. R1 had severely impaired cognition due to her dementia and Alzheimer's. She was an assist of two staff for transfers due to a decline in her condition and strength for safety reasons. During an interview on 12/24/25 at 8:29 a.m., DON stated R1 had advanced dementia with a recent decline and had been placed on hospice. She would not have been safe sitting on edge of bed unsupervised/independently due to the recent decline, as she was sleepy and leaning a lot. Staff were expected to provide assist of two for all transfers. R1 was not weight bearing was known to let go of the hand grippers on the EZ stand. Additionally, she was assessed by PT on 10/27/25, and identified she was two assists for transfers, but that had not gotten transcribed onto her care plan. Staff were made aware of this change during shift change rounds and verbal report. R1 required constant cueing, and mental cognition was worse in the evening. She was notified of the R1's incident on 12/15/25 at 9:10 p.m. and arrived at the facility at 9:23 p.m. R1 was evaluated, had laceration on her head, required medical treatment, cognition was poor, she mumbled the letters, GEG, GEG frequently (normal behavior). She was transferred to ER via ambulance. Staff were expected to report a fall as soon as possible to the nurse, evaluation/assessment completed prior to moving, repositioning, or transferring them to make sure there are no injuries or neurological abnormalities. During an interview on 12/24/25 at 8:14 a.m., PO stated he interviewed NA-A on 12/16/25 and 12/17/25 and she had changed her story. Initially NA-A wrote down NA-B assisted her with R1's transfer to bed, checked on her at 7:45 p.m. was ok, at 9:00 p.m. felt blood and reported it. PO came into facility and investigated, tested the alarms and reviewed the log. If R1 had fallen out of bed the alarm should have gone off and did not. NA-A admitted she was not truthful, stated R1 was found on the floor, which still did not make sense. He reinterviewed NA-A and she admitted she had completed a single person assisted lift. NA-A's final story identified she transferred R1 to bed, while she sat on edge of bed, placed lift in bathroom, and then heard a thud which was R1 hitting the floor. She cleaned up R1, placed her back into bed, sat with her for approximately two hours, then waited until 9:00 p.m. and reported she was injured. Based on what NA-A said PO felt the fall happened when she was on the stand lift, bruising on the back made him believe she slid through the lift and did not fall off the bed. It was believed to be an accident she attempted to cover up. During an interview on 12/24/25 at 9:35 a.m., nurse leader RN-A stated physical therapy orders were entered into the medical record system: SPT with assist of two or may use EZ stand with assist of two as needed (PRN) with a medium sling dated 10/27/25. She was responsible to enter the changes in R1's the care plan but was not completed due to human error. Staff were informed in report and aware of the need to transfer her with assist of two for safety reasons. Additionally, this information was placed on the white board by PT for staff to view. R1's MDS indicated she was dependent for transfers which indicated assist of two staff. Facility policy Falls, Fall Risk Managing dated 3/31/25, identified based on previous evaluation and current data, the staff will identify interventions related to resident risks and causes to try to prevent the resident from falling and minimize complications from falling. Resident fall risk factors that may contribute to the risk of falls include delirium and other cognitive impairment, poor grip strength, medication side effects, functional impairments, and lower extremity weakness. Facility policy Abuse Prevention dated 10/29/24, identified all residents will be free from abuse, neglect, and exploitation. Abuse was defined as the deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury harm. Neglect was defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately to administrator, licensed social worker, and the Office of Health Facility Complaints within specified time frames. Internal reporting: employees 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. Staff education dated 12/16/25, Abuse, Neglect/Accident reporting and following care plan. Incident Overview: Allegation of neglect, delayed injury reporting and not following care plan. Reporting Delay: Not reported immediately to supervisor or location leaders. Details: Staff did not follow the care plan for type of lift required for resident transfers resulting in resident injury and not reported to supervisors/leaders immediately. For any injury to a resident, always report immediately to ensure proper assessment, first aid and necessary notifications to physician, family, and possible authorities. In the event of resident fall or accident with any lift, do not move resident, stay with resident and summon the licensed nurse. A nurse must observe the resident and perform a full-body exam to determine if there maybe suspected injury and direct whether to move the resident. Nursing staff are expected to follow the resident care plan for guidance on assistance with daily activities, including transfers: type of lift, size of sling or harness, and number of staff required to assist the resident to reduce risk of injury. The past noncompliance immediate jeopardy began on 12/15/25. The immediate jeopardy was removed and the deficient practice corrected by 12/18/25 after the facility implemented a systemic plan that included the following actions: -Investigated the circumstances around R1's injuries and implemented immediate resident protection. -R1's Care Plan was revised to include stand pivot transfer with assist of two if alert. Hoyer lift, assist of two with medium sling. -Re-educated the staff on Abuse/Neglect/Accident Reporting, providing safe and appropriate care, and resident protection. -Education verified through interview and training records. The facility implemented corrective actions prior to the start of survey on 12/19/25 and therefore this is issued in past noncompliance.

Based on observation, interview and document review, the facility failed to ensure fire suppression pipes located directly above the deep fat fryer, and stove top grill surface were free from accumulation of dirt and grease. This buildup had the potential to contaminate food being prepared and served. In addition, the facility failed to ensure 1 of 1 meat slicer was appropriately cleaned and sanitized following use. These deficient practices had the potential to affect all 51 residents who received food prepared in the facility kitchen. Findings include: During an observation and interview on 5/12/25 at 12:33 p.m., with the certified dietary manager (CDM) identified the vent hood located above the stove top grill and deep fat fryer, contained metal pipes identified as the fire suppression system, which were coated with a black fuzzy substance the CDM identified as dirt and grease buildup. Both the pipes and light fixtures in the hood had multiple areas identified as rust. The CDM stated she had only been in her position for two weeks and had not noticed the buildup on the ends of the fire suppression pipes. CDM indicated she would have the area cleaned immediately due to the potential for contamination of food being prepared. Observation of a meat slicer identified as last used on 5/11/25, to slice ham was on a counter and covered with plastic. When the plastic was removed, food particles were observed on the shield behind the blade, on the platform, and there was buildup of food particles on the sides and grooved surface of the unit. The CDM confirmed the meat slicer had not been cleaned and sanitized appropriately following use and would need to be cleaned prior to being used again. During an interview on 5/12/25 at 12:45 p.m. , the CDM identified her expectation was for cleaning schedules to be followed and identified the need for improvement and monitoring of cleaning and sanitation of food preparation equipment located in the facility kitchen. CDM stated the vented hood was due for an annual cleaning however, confirmed she had not noticed the buildup on the pipes located above the food preparation surfaces. A policy for scheduled kitchen maintenance/cleaning was requested, but not provided by the end of the survey period. Review of the 2008 policy for cleaning slicers identified the slicer was to be cleaned and sanitized after each use. All parts of the slicer were to be disassembled and washed in the pots and pans sink or dish machine. All parts were to be sanitized in a chemical sanitizer, or in the dishwasher. The remaining parts of the slicer that could not be placed in the dishwasher were to be washed with hot water and soap, rinsed and allowed to dry. Special attention was to be paid to any moveable parts, especially the blade. The parts were to be sanitized and allowed to dry, the slicer was to be reassembled and covered. The counter where the slicer was located was also to be washed and sanitized with each use of the slicer.

Based on observation, interview, and document review, the facility failed to ensure the common use blood glucometer machines were disinfected according to current manufacturer's guidelines between resident use for 2 of 3 residents (R44 and R1) reviewed who received blood glucose testing in the facility. Findings include: Observation on 5/12/25 at 5:27 p.m. with trained medication aide (TMA)-A as she prepared to check a blood glucose for R44. TMA-A took the glucometer from the charging station located at the nursing station, collected her necessary supplies, and proceeded to R 44's room where she donned personal protective equipment (PPE) of gown and gloves. TMA-A obtained a clean towel which she placed on the bedside table and placed the glucometer and supplies on the towel. She then washed her hands, put on new gloves, scanned the bottle of test strips and placed a strip into the glucometer. TMA-A wiped R44's finger with an alcohol pad, allowed to dry and utilized a lancet (A lancet is a small, sharp surgical instrument used to make small incisions, typically for drawing blood samples. It is commonly used in diabetes management) to obtain a blood sample which she collected with the test strip. TMA-A placed a cotton ball on R44's finger and after obtaining a reading disposed of the used items in the sharp's container in R44's bathroom. She removed her PPE and performed hand hygiene. TMA-A went out of the room to her cart positioned outside the room and proceeded to wipe off the glucometer, and bottle of strips with alcohol pads. She stated she would need to clean the glucometer and bottle of strips again as she had contaminated them when she was removing her PPE. TMA-A returned to the nursing station, retrieved alcohol pads, and wiped off the glucometer and bottle of strips with the alcohol pads and returned to the docking station. When asked, she confirmed the glucometer was disinfected and ready to use for the next test. During an observation and interview on 5/12/25 at 5:50 p.m., with registered nurse (RN)-A as she retrieved the common use glucometer and identified she was going to check a blood sugar and administer R44's insulin. RN-A obtained her supplies, used hand sanitizer and proceeded to the area outside R44's room where she donned PPE of gown and gloves. RN-A took a gray labeled Sani Cloth, wiped over the surface of the common use glucometer and set aside to dry. RN-A stated the glucometer needed to remain wet for three minutes however, did not leave the meter in contact with the cloth and confirmed the meter was dry within a little more than a minute. RN-A reported she had not ensured the meter remained wet for the three minute time period and had never checked to determine how long it took for the solution to dry after wiping the surface. During an interview on 5/12/25 at 5:55 p.m., TMA-A stated she was not aware that alcohol was not the correct product to use for disinfecting the common use glucometers, and that she was not aware of how the manufacturer and/or policy directed the meter to be cleaned and disinfected following use. RN-A who was also in attendance, confirmed to TMA-A the glucometer was supposed to be disinfected using the gray labeled Sani cloth wipes and reported she had just realized the solution needed to remain wet on the surface for three minutes to disinfect the surface. 40550 During an observation and interview on 5/12/25 at 12:03 p.m., TMA-B cleansed hands and applied gloves prior to checking resident blood sugars. TMA-B placed a test strip into the common use glucometer, cleansed R1's middle right finger with an alcohol wipe, used a lancet to prick her finger and dropped the sample of blood onto the test strip. At 12:08 p.m., TMA-B sanitized the common use glucometer with a single use Sani wipe by wiping the front and back briefly and placed the glucometer on her cart. When interviewed, TMA-B stated she believed the glucometer was sanitized after wiping it as she had. TMA-B removed gloves and sanitized her hands. TMA-B entered the results into R1's electronic medical record and moved her cart down the hallway to the hallway located to the right of the dining room. At 12:12 p.m., TMA-B was bringing R9 to a private area to check her blood sugar when surveyor stopped her and asked her to review the manufacturer's guidelines for the Sani wipe she used for sanitizing the glucometer. TMA-B reviewed the instructions and did confirm the instructions identified the glucometer was to remain wet for three minutes to ensure proper sanitization. TMA-B confirmed she had not done that as instructed. TMA-B removed a new Sani wipe, wiped the glucometer down on each side and wrapped the wipe around the glucometer as instructed before she continued on with further blood sugar checks. During a telephone interview on 5/14/25 at 10:08 a.m., infection preventionist (IP) stated the common use glucometers required sanitization between each resident's use. IP identified staff wre expected to use the Sani wipes by wiping three times horizontal and three times vertical and ensure the glucometer remained wet for three minutes. IP stated that may mean staff were to re-wipe the glucometer if needed to ensure it remained wet for three minutes. IP indicated it was the facility's expectation staff would follow the wet time as indicated to prevent the spread of blood-borne pathogens. During an interview on 5/13/25 at 1:15 p.m. the director of nursing (DON) identified her expectation for the common use glucometer was to be cleaned and disinfected after each use according to the policy and manufacturer's instructions. DON identified alcohol wipes were not the appropriate solution for disinfection of the meter and the gray labeled Sani Cloths were available for that purpose. Review of manufacturer's instructions for Sani-Cloth AF3 Germicidal Wipes General Guidelines for Use dated 2019, instructed staff to unfold a clean wipe and thoroughly wet the surface. Allow treated surface to remain wet for three minutes and let air dry. Review of the January 27, 2025, Nova StatStrip Meter Procedure identified according to Infection Prevention (IC) the meter's exterior was to be cleansed between each patient. The decontamination preparation approved was identified as Sani-Cloth AF3-grey lid. The strip port was to be cleansed by lab staff only. Do not immerse meter or hold the meter under running water. Do not spray with a disinfectant solution.

Based on observation, interview and document review, the facility failed to ensure an insulin SoloStar Insulin pen was appropriately primed prior to insulin administration for 1 of 2 residents (R30) who received 25 units of Lantus insulin daily. Findings include: During an observation and interview on 5/12/25 at 5:50 p.m., licensed practical nurse (LPN)-A prepared to administer R30's ordered dose of Lantus insulin. The current physician orders for Lantus Solostar insulin identified he was to receive 25 units subcutaneously (subcutaneous injections are used to administer medications between skin and muscle) once per day, with a special note which identified the insulin was to be administered between 4:00 p.m. and 6:00 p.m. daily per resident request. LPN-A checked the pen against the Medication Administration Record (MAR), performed hand hygiene, removed the pen cap, wiped the end of the pen with an alcohol pad, attached the needle, dialed the pen to one unit and depressed the plunger, no insulin was observed exiting the needle. LPN-A then dialed the pen to 25 units, retrieved a new alcohol pad and proceeded to R30's room to administer the dose of insulin. LPN-A was interrupted, and she and the surveyor exited the room, where LPN-A was asked about her procedure for priming (removes the air from the needle and cartridge that may collect during normal use. This ensures ensures receiving the full dose) the insulin pen. She replied her normal procedure was to prime the pen with one or two units, and then dial to the ordered dose of insulin. LPN-A stated she was not aware of what the manufacturer's directions instructed for priming the pen by dialing to two units after attaching the needle. LPN-A wasted the dose of insulin, dialed the pen to two units, demonstrating the insulin coming through the needle, performed hand hygiene, applied gloves, and proceeded to administer R30's insulin in his left lower abdomen. LPN-A stated she had always primed insulin pens in that manner and was not aware she needed to prime with two units to remove air from the needle. During an interview on 5/13/25 at 8:30 a.m., the director of nursing (DON) stated her expectation for licensed nursing staff administering insulin was to follow the manufacturer's instructions and the facility policy for priming pens with two units prior to administration of the ordered insulin dose. Review of the manufacture's instruction sheet: How to use your Lantus SoloStar pen: - a short version of the instruction leaflet included in the Lantus SoloStar pen box. The pamphlet detailed the importance of following the listed steps to help ensure an accurate dose of insulin was received. 1.) Remove the pen cap with clean hands. Check the reservoir to ensure it is clear and colorless and has no particles. 2.) Wipe the pen tip (rubber seal) with an alcohol swab. 3.) Remove the protective seal from the new needle, line the needle up straight with the pen and screw the needle onto the pen. 4.) After attaching the needle, remove the outer needle cap and save to remove the needle after the injection. 5.) Remove the inner needle cap and discard. 6.) Dial the pen to 2, hold the pen upright, tap the reservoir to bring any bubbles to the top, depress the plunger and ensure insulin exits the needle. The dial will automatically return to zero. 7.) Check to ensure the dial returned to zero, and then dial to the ordered dose of insulin. 8.) Clean the injection site with an alcohol pad, Hold the pen straight, insert the needle into the skin, depress the plunger and wait 10 seconds before releasing the plunger and removing. 9.) Replace the outer needle cap over the needle and remove the needle from the pen and dispose in a sharps container. Review of the Revised September 2014 Med-Pass, Inc policy Insulin Administration identified nursing staff were to have access to manufacturer's instructions for all types of insulin administration devices prior to use. The policy identified steps for use of an insulin pen: Verify the physician orders for the type and dose of insulin to be administered; Prime the pen with 2 units of insulin; dial the pen to the ordered dose; administer the insulin in the identified body location; and wash hands following administration of the medication.

Based on observation, interview and document review, the facility failed to provide assistance with routine grooming cares which included facial hair removal for 1 of 1 residents (R14) reviewed for activities of daily living (ADLs) who required assistance with grooming and personal hygiene. Findings include: R14's significant change Minimum Data Set (MDS) dated [DATE], identified R14 had moderate cognitive impairment and diagnoses which included: Alzheimer's disease, arthritis and hypertension. Indicated R14 required partial/moderate assistance for personal hygiene and dressing. R14 required maximum assistance with bathing. Identified R14 had physical and verbal behavior symptoms one to three days and did not exhibit rejection of cares. R14's care plan revised 6/18/24, identified R14 required assistance with ADLs related to Alzheimer's disease. R14's care plan approaches identified R14 required extensive assistance with bathing and dressing. In addition, R14 required cueing, set up and extensive assistance with grooming, which included brushing teeth and combing hair. R14's care plan lacked an approach for facial hair removal. During an observation on 7/8/24 at 12:28 p.m., R14 was seated in her recliner in her room. R14 had six to eight white facial hairs eight to twelve millimeter (mm) long on the front of her chin, and three to four white facial hairs above and beside her lips. During a telephone interview on 7/8/24 at 3:06 a.m., family member (FM)-A indicated it bothered her that R14 would have facial hair present and expected staff to assist with removing it. FM-A stated she was unaware if it bothered R14. During an observation on 7/9/24 at 8:45 a.m., R14 was dressed in street clothes and seated in her recliner in her room. R14 continued to have six to eight white facial hairs eight to twelve mm long on the front of her chin and three to four white facial hairs above and beside her lips. During an observation and interview on 7/9/24 at 9:36 a.m., nursing assistant (NA)-B stated her usual practice was to remove facial hair when observed. NA-B indicated she was aware R14 had long facial hairs on her chin. NA-B indicated R14's pen razor quit working a couple of weeks ago and her family was going to order one however, was unsure if R14 had a new one yet. NA-B stated it depended on R14's mood when they would assist R14 with cares and if needed, would leave her alone then re-approach later to complete cares. At 9:50 a.m. NA-B knocked and entered R14's room and located R14's razor in R14's drawer in her bathroom. NA-B asked R14 if she could shave her and R14 agreed. NA-B then removed R14's facial hair with the electric pen razor without difficulty and confirmed R14 had multiple facial hairs present that she had removed. During an interview on 7/9/24 at 10:09 a.m., registered nurse (RN)-B stated the nursing staff were expected to assist residents with facial hair removal if they were agreeable to it. RN-B indicated she was aware R14 had facial hairs present that morning and had planned to go back and shave R14 later that day. RN-B confirmed it appeared R14's facial hairs had been present more than a couple of days. RN-B stated R14 usually agreed to having her facial hair removed however, if she did refuse, staff would just re-approach her at another time. RN-B indicated it was important to assist R14 to remove facial hair as that was a dignity issue and could have been embarrassing to her. During an interview on 7/9/24 at 11:57 a.m., neighborhood nurse leader RN-C confirmed R14 required assistance with ADLs. RN-C indicated her expectation was staff would assist residents to remove facial hair and it was important to do so to promote dignity. RN-C stated R14 refused cares at times however, expected staff to re-approach R14 if refused. During an interview on 7/9/24 at 4:38 p.m., director of nursing (DON) indicated it was her expectation nursing staff removed facial hair for residents if they were agreeable. DON confirmed her expectation was if a resident refused to allow staff to remove the facial hair, the nursing staff would re-approach, and if continued to refuse to report to the nurse who would document in the progress notes. DON indicated if the resident continued to refuse, she would expect it would have been care planned. DON stated it was important to assist residents to remove facial hair for dignity purposes. The facility policy titled Shaving The Resident revised 3/14/24, identified the purpose was to promote cleanliness and to provide skin care. The policy instructed staff to notify the supervisor if the resident refused the procedure.

Based on observation, interview and document interview, the facility failed to conduct an accurate and timely smoking assessment for 1 of 1 residents (R16) who currently smoked. Findings include: R16's admission Minimum Data Set (MDS) dated [DATE], indicated R16 was cognitively intact and was independent with mobility, transfers, toileting, and required limited assistance with dressing. Identified R16 had hypertension (high blood pressure), arthritis and a wound infection. R16's care plan updated 7/8/24, indicated R16 was a current smoker and was at risk for injury related to smoking. Identified R16 demonstrated safety with smoking and disposed cigarette butts in the appropriate designated location. R16's initial smoking assessment dated [DATE], was completed by therapy staff and indicated R16 was a safe smoker, was able to get to/from smoking location and demonstrated safe use/disposal of cigarette butts. During an observation and interview on 7/8/24 at 2:53 p.m., R16 indicated it was hard to go from the building to the smoking area and R16 was unable to get down the lip of the driveway to the road where R16 was supposed to be smoking. R16 revealed she was unable to reach the smoking butt receptacle so she placed her cigarette butts in her right pants' pocket and would dispose of them in the trash in her room. R16 smoked one cigarette, put the cigarette out on the right metal arm of her wheelchair and put the cigarette butt in her pocket. R16 obtained another cigarette and repeated the process. R16 obtained the third cigarette and repeated the process. During a continuous observation on 7/8/24: -6:29 p.m., R16 was seated in her wheelchair at the corner of the parking lot leading to the road. R16 put her cigarette out on the right metal arm of her wheelchair and placed the cigarette butt in her right pants' pocket. -6:39 p.m., R16 obtained another cigarette, lit and smoked it, put it out on the right metal arm of her wheelchair, twisted the end of the cigarette and placed the cigarette butt in her right pants' pocket. -6:48 p.m., R16 obtained the third cigarette, lit and smoked it, put her cigarette out on the right metal arm of her wheelchair, twisted the end of the cigarette and placed the cigarette butt in her right pants' pocket. During an observation on 7/8/24 at 6:56 p.m., R16 was seated in her wheelchair at the corner of the parking lot leading to the road. R16 put her cigarette out on the right metal arm of her wheelchair, twisted the butt of her cigarette and placed the cigarette butt in her right pants' pocket. During an interview on 7/10/24 at 7:04 a.m., R16 stated it would be easier if the facility moved the cigarette butt receptacle closer to the end of the driveway so R16 could throw her cigarette butts away outside. R16 confirmed she placed her cigarette butts in her right pants pocket and threw them away in the trash in her room when she went back into the facility. R16 indicated she did not even try to dispose of her cigarette butts in the receptacle since she was not able to reach it from where she sat. During an interview on 7/10/24 at 9:53 a.m., physical therapy assistant (PTA) indicated R16 was discharged from physical therapy (PT) on 7/5/24, as she met her goal of becoming independent. PTA stated PT was working with R16 and PT would occasionally go outside with R16 to smoke. PTA stated R16 never mentioned she was not able to get to the cigarette butt receptacle and PT never saw R16 place cigarette butts in her right pants pocket. During an interview on 7/10/24 at 11:29 a.m., registered nurse (RN)-D revealed R16 was admitted [DATE], and a smoking assessment was not completed upon admission. RN-D stated R16's smoking assessment was not completed until 7/8/24. RN-D indicated she was not aware R16 was putting her cigarettes out on the right metal arm of her wheelchair and placing them in her pocket to dispose of them in the facility. In addition, RN-D stated she was not aware R16 could not reach the cigarette receptacle to properly dispose of her cigarette butts. During an interview on 7/10/24 at 11:47 a.m., director of nursing (DON) indicated she was not aware a smoking assessment had not been completed on R16 upon admission. DON stated she was not aware R16 could not reach the cigarette butt receptacle and was placing her cigarette butts in her right pants' pocket to dispose of them in the facility. DON stated her expectations were if staff knew a resident smoked upon admission, a smoking assessment should have been completed at that time. Facility Policy titled Smoking Policy revised 2/14/24, if a resident strongly felt smoking added to their quality of life they would be allowed to continue to smoke. They must be assessed for safety upon admission, annually, or after a significant change.

Based on observation, interview and document review, the facility failed to ensure proper hand hygiene during a medication pass for 3 of 7 (residents R44, R15, R48 ) observed for medication administration and during personal cares for 1 of 4 residents (R45) observed for captivities of daily living (ADL's). In addition, the facility failed to implement appropriate donning/doffing of personal protective equipment (PPE) practices and to ensure PPE was readily available for use to prevent the spread of infection for 1 of 5 residents (R16) observed for enhanced barrier precautions (EBP) (an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). Findings include: HAND HYGIENE/MEDICATION PASS R44's quarterly Minimum Data Set (MDS) dated [DATE], identified R44 had intact cognition and diagnosis which included: hypertension (elevated blood pressure) Diabetes and glaucoma. Identified R44 required limited assistance with activities of daily living (ADL's) which included bed mobility, transfers, and personal hygiene. R44's care plan dated 11/13/23, identified R44 required limited assistance with ADL's. R44's care plan lacked an approach for medication administration. R15's significant change MDS dated [DATE], identified R15 had intact cognition and diagnosis which included anemia (a condition in which blood doesn't have enough healthy red blood cells and hemoglobin) Atrial fibrillation (rapid heart rate that causes poor blood flow), and Alzheimer's Disease. Identified R15 required limited assistance with ADL's which included bed mobility, transfers, and personal hygiene. R15's care plan dated 5/19/24, identified R15 required limited assistance and a walker for ambulation related to her cognition. R48's significant change MDS dated [DATE], identified R48 had intact cognition and diagnosis which included hypertension (elevated blood pressure) hyperlipidemia (elevated cholesterol) and Alzheimer's Disease. Identified R48 required limited assistance with ADL's which included bed mobility, transfers and personal hygiene. R48's care plan dated 5/18/24 identified R48 required limited assistance with ADL's. R48's care plan lacked interventions for medication administration. During an observation on 7/8/24 at 5:21 p.m., trained medication aide (TMA)-A entered R44's room with Timoptic (Eye drops used to treat elevated pressure in the eyes) eye drops in her hand. R44 was seated in her recliner and TMA-A proceeded to place gloves on both hands and while touching R44's face used her left hand to pull down on each of R44's eye lids as she administered the eye drop to each eye with her right hand. TMA-A removed her gloves and proceeded to dish up medications for R15. TMA-A administered R15's medications and then handed R15 her water pitcher. TMA-A proceeded to place a transfer belt around R15's waist and walked with her to supper. TMA-A removed the transfer belt from R15 and pushed R15's wheelchair up tot he table. TMA-A proceeded to dish up medications for R48. TMA-A placed gloves on both hands and broke one of R48's medications in half and administered medications to R48 after obtaining a bottle out of R48's fridge and handing it to R44 to take her medications with. TMA-A wheeled R48 in her wheelchair to the dining room. At no time during the above observation had TMA-A performed hand hygiene. During an interview on 7/8/24 at 5:41 p.m., TMA-A confirmed the above observation and that she had not performed hand hygiene. TMA-A stated she should have performed hand hygiene after administering R44's eye drops and before assisting any other residents. TMA-A stated hand hygiene was important to reduce the spread of infection. 48583 EBP Centers for Disease Control and Prevention (CDC) guidelines dated 4/2/24, PPE use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDROs). Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities was indicated for nursing home residents with wound and/or indwelling medical devices regardless of MDRO colonization. Resident roster dated 7/9/24, lacked identification of R16 being on EBP. R16's admission MDS dated [DATE], indicated R16 was cognitively intact and was independent with mobility, transfers, toileting and required limited assistance with dressing. Identified R16 had hypertension (high blood pressure), arthritis, a wound infection, and a peripherally inserted central catheter (PICC). R16's care plan dated 7/8/24, indicated R16 was to receive intravenous (IV) antibiotics for an infection. R16's care plan lacked documentation R16 was on EBP. R16's provider progress notes dated 7/8/24, indicated R16 was in the nursing home due to an unexpected discovery of pyogenic arthritis when she received a hip replacement. R16 had required IV antibiotics and consultation with infectious disease. R16's treatment administration history dated 6/7/24 to 7/10/24, indicated R16 was to receive Ceftriaxone (antibiotic) one gram via IV route one time daily, change PICC caps every three days, measure arm circumference daily, PICC line dressing change every week, flush both PICC ports with 10 milliliters (ml) daily, and Vancomycin (antibiotic) 1000 milligrams (mg) via IV route one time daily. During an observation on 7/9/24 at 8:40 a.m., R16 was seated in her wheelchair in her room working on her computer. Registered nurse (RN)-E gathered supplies to administer R16's Vancomycin one gram in 200 ml solution via IV. RN-E washed her hands, applied gloves, opened an alcohol wipe, removed current IV tubing and cleansed the IV hub. RN-E flushed the port with 10 ml normal saline (NS). RN-E left the syringe hooked to the port while she opened the antibiotic and spiked the bag. RN-E primed the tubing, placed the tubing into the IV pump, removed the syringe, cleansed the hub with alcohol, attached the tubing to the port and programmed the pump. IV antibiotics began running. RN-E removed her gloves and washed her hands. RN-E was not observed to be wearing a gown as indicated for EBP. There was no signage present on the door identifying R16 was on EBP. In addition, there was no PPE available inside or outside the room for EBP. During an observation on 7/09/24 at 2:24 p.m., there continued to be no EBP PPE inside or outside R16's room. Additionally, there continued to be no signage indicating R16 was on EBP. During an interview on 7/10/24 at 7:04 a.m., R16 revealed staff only wore gloves when they were assisting her. R16 indicated staff had never worn a gown or any additional PPE when assisting R16. During an interview on 7/10/24 at 11:29 a.m., registered nurse (RN)-D confirmed R16 was to be on EBP and was not aware R16 did not have any PPE inside or outside of R16's room. 48740 HAND HYGIENE R45's admission MDS dated [DATE], identified R45 had mildly impaired cognition and was diagnosed with hypertension, dementia, and osteoporosis. R45 needed moderate assistance with transferring on and off the toilet, maximal assistance with perineal hygiene, moderate aid with dressing, and substantial assistance with personal hygiene. During an observation on 7/10/24 at 8:09 a.m., NA-A sanitized hands, and applied gloves. NA-A had R45 sit on the toilet. NA-A removed pajamas and brief. NA-A placed the brief in the garbage and applied a clean brief and pants while R25 was seated on the toilet. NA-A had R45 stand up and used a wet washcloth with soap and provided perineal hygiene using a circular wiping motion from front to back. NA-A took a moist washcloth without soap and washed R45's perineal area from front to back. NA-A took a dry towel and dried R45's perineal area from front to back. NA-A assisted R45 to a standing position, pulled up R45's briefs and pants. NA-A removed gloves and asked R45 to walk to the sink. NA-A combed R45's hair and assisted R45 with applying toothpaste to the toothbrush. NA-A asked R45 to sit in the wheelchair, wheeled R45 out of the room. At that time, NA-A used hand sanitizer that was located outside of the door and brought R45 to the dining room. During an interview on 7/10/24 at 8:25 a.m., NA-A verified she did not remove gloves between handing the soiled brief and the clean brief. NA-A verified hands were not sanitized between perineal care and oral hygiene care. NA-A verified not removing gloves and sanitizing hands could lead to cross-contamination. During an interview on 7/10/24 at 8:26 a.m., registered nurse RN-A stated her expectation would be for staff to change gloves after perineal care to prevent cross-contamination. During an interview on 7/10/24 at 11:00 a.m., infection preventionist (IP) stated hand hygiene was important after removing gloves to prevent the spread of infection. IP stated her expectation was that staff always performed hand hygiene after removing gloves. In addition, IP stated staff were expected to remove gloves, perform hand hygiene and apply clean gloves after performing perineal cares to prevent cross-contamination. During an interview on 7/10/24 at 11:05 a.m., IP indicated the facility implemented the EBP process in April 2024, and confirmed R16 should have been on EBP due to wound care and a PICC in place. IP stated staff were educated last week about R16 being on EBP. IP indicated she was not aware R16 did not have any PPE inside or outside of R16's room. IP stated she would expect staff to follow EBP guidelines when they completed high-contact care with residents who were in EBP. During an interview on 7/10/24 at 11:14 a.m., director of nursing (DON) stated her expectation would be for staff to change gloves after removing dirty briefs and to change gloves after perineal care. DON stated she would have expected staff to perform hand hygiene before oral cares and hair care were completed to prevent cross-contamination. During an interview on 7/10/24 at 11:32 a.m., DON stated her expectation was staff would have washed their hands after removing gloves and before assisting any other residents. During an interview on 7/10/24 at 11:43 a.m., DON confirmed the above findings and stated her expectations were staff were to follow the EBP guidelines. DON stated staff were to have gowns/gloves on and were to sanitize/wash their hands before and after cares. Facility policy titled Wound Care revised date 3/14/24, the following equipment and supplies would be necessary when performing this procedure: personal protective equipment (e.g. gowns, gloves, mask, etc., as needed). Facility policy titled Enhance Barrier Protection revised 4/19/24, Fairway View - Long Term Care to implement enhanced barrier precautions for the prevention of transmission of multidrug resistant organisms. An order would be obtained for residents with any of the following: wounds and/or indwelling medical devices including central lines. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities. High contact care activities include: device care or use and wound care. Requested a policy on PICC care and dressing change, however one was not provided. A policy titled Hand Hygiene-Ortonville dated 2/13/24 revealed when to perform hand hygiene moving from contaminated body site to clean body site during patient care, after removing gloves. Change gloves when moving from a dirty to a clean site during patient care and perform hand hygiene after glove removal.

Based on interview and document review, the facility failed to report an allegation of physical abuse by a staff member to the state agency (SA) within the two-hour requirement for 1 of 3 (R1) residents reviewed. Findings include: Review of facility reported incident (FRI) to the SA on 7/21/23 at 11:55 a.m., indicated staff received notification of R1 reporting a nursing assistant (NA)-A was rough with cares and refusing to assist R1 with putting her legs into bed. A skin assessment was completed and there were no findings of bruises or red marks. R1's annual Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses of anxiety, depression and had severe cognitive impairment. Additionally, R1 required staff assistance with activities of daily living. During an interview on 7/25/23 at 12:03 p.m, R1 indicated during the night on 7/26-7/27/23 NA-A was the NA-A that handled her roughly. R1 explained after NA-A assisted her to the bathroom, she could not able to lift her legs back up into bed. NA-A lifted them and threw them onto the bed. R1 could not remember what time the incident occurred, only that it happened during the night shift. During an interview on 7/26/23, at 1:33 p.m. NA-A indicated on 7/21/23 around 5:00 a.m. R1 had been upset because she was still waiting for her Tylenol she had requested from the nurse around 1:30 a.m. NA-A sent a text message to LPN-B requesting Tylenol for R1. NA-A stated she assisted R1 to the bathroom again. R1 told her she was too rough with her cares. NA-A stated at 5:45 a.m. she reported to LPN-B R1 had told her she was too rough during cares, LPN-B told her a written statement was not needed. At 6:15 a.m. NA-A again asked LPN-B if she wanted her to document the incident, LPN-B again told her no. During an interview on 7/26/23 at 10:47 a.m., licensed practical nurse (LPN)-B indicated R1 historically has alleged rough handling in a joking manner. LPN-B stated on 7/21/23, between 5:15 a.m. and 5:30 a.m. NA-A reported to her R1 told her she was too rough during cares. LPN-B indicated she then went to talk to R1, however she was sleeping. When she did talk to R1, R1 reported to her NA-A had been too rough during cares. LPN-B explained she then reported R1's concerns to the adminstrator at 10:30 a.m. LPN-B stated that she did not know of the two-hour time frame until conversation with the administrator. During an interview on 7/26/23 at 9:52 a.m. administrator indicated she was made aware of the incident from LPN-B at 10:30 A.M., and immediately started her investigation and removed AP from the schedule. Administrator indicated that she reported the incident within 2 hours of knowledge of the incident. Facility policy titled Abuse Prevention Policy dated 6/1/23, indicated the facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made.

Based on interview and document review, the facility failed to ensure resident current wishes for resuscitation status were accurately documented in the medical record for 1 of 51 residents (R11) reviewed for advanced directives. Findings include: R11's quarterly Minimum Data Set (MDS) dated [DATE], indicated R11 had severe cognitive impairment and had diagnoses which included: Parkinson's, diabetes mellitus, (DM), and dementia. Identified R11 required extensive assistance with activities of daily living (ADL's) which included: bed mobility, transfers, and toileting. R11's current care plan dated [DATE], identified R11's advance directives were (do not resuscitate) DNR. Review of R11's electronic health record (EHR) identified the following: -R11's physician orders dated [DATE], identified R11 had an order for DNR. -R11's dashboard profile on the computer screen identified R11's status was DNR. -R11's Advance Directive dated [DATE], identified R11's status was a DNR. Review of R11's paper health record identified the following:-R11's choices sheet dated [DATE], identified R11's status was a DNR. -R11's face sheet undated identified R11 was a full code status. The paper health record identified a discrepancy of R11's wishes for resuscitation. During an interview on [DATE], at 8:18 a.m. registered nurse (RN)-A stated her usual practice in verifying a resident's code status was to first review the choices sheet which was located in the front of each resident's paper chart. In addition, RN-A stated there was a face sheet which identified the resident's code status located behind the choices sheet in each resident's paper chart. RN-A stated she would review the face sheet after the choices sheet. During a telephone interview on [DATE], at 2:05 p.m. nurse manager (NM) stated her usual practice in verifying a resident's code status was to review the choices sheet of the paper chart first. Secondly, she would review the face sheet of the paper chart. During an interview on [DATE], at 2:10 p.m. RN-B stated her usual practice in verifying a resident's code status was to review the resident's choices sheet which was located in front of the paper chart and then the face sheet which was located directly behind the choices sheet. RN-B confirmed R11's choices sheet in the paper chart identified R11 was a DNR. In addition, RN-B confirmed R11's face sheet in the paper chart identified R11 was a full code verifying a discrepancy. RN-B stated she was uncertain why the face sheet in the paper chart had not been updated to reflect the accurate status of DNR. During an interview on [DATE], at 2:15 p.m. director of nursing (DON) confirmed there was a discrepancy in R11's paper chart in which the choices sheet identified R11 was a DNR code status and the face sheet in the paper chart indicated R11 was a full code status. DON stated the facility's process in determining a resident's code status was to review the choices sheet in the paper chart. DON indicated the face sheet in the hard chart would have been a secondary place to look. DON stated her expectation would have been the choices sheet and the face sheet in R11's chart would have matched since the discrepancy had the potential to misdirect staff on whether or not cardiopulmonary resuscitation (CPR) should have been provided or not when an emergency situation occurred. A facility policy titled Advance Directives revised [DATE], indicated Advance Directives and choices of Limited Treatment form would be respected in accordance with state law and facility policy. Policy stated a copy of Advance Directive and choices of Limited Treatment would have been kept in paper form in the chart as well as scanned into the resident's chart.

Based on observation, interview and document review, the facility failed to properly clean and disinfect reusable equipment shared among residents for 4 of 4 residents (R20, R26, R9, R3) observed having temperatures checked with a no touch infrared forehead thermometer and oxygen levels checked by an oximeter (small medical device clipped to the finger to check oxygen levels in the blood). This had the potential to affect all 14 residents who resided on Orton's Crossing wing in the facility. Findings include: On 4/7/21, at 2:35 p.m. trained medication aide (TMA)-A approached R20 while she was sitting in the common area. TMA-A checked R20's temperature by holding the thermometer up to her forehead and placed the oximeter on her right forefinger. TMA-A set the equipment on her cart and left the area. TMA-A did not disinfect the equipment after use with R20 and proceeded to push her cart to the hallway near R26's room. TMA-A entered R26's room with the thermometer and oximeter. TMA-A was observed leaving the room and placed the equipment on her cart. TMA-A did not disinfect the oximeter or thermometer after use with R26. At 2:38 p.m. TMA-A washed her hands in the sink in the dining room and entered R9's room with the oximeter and thermometer. TMA-A placed the oximeter onto R9's right forefinger and checked his temperature. TMA-A left R9's room and placed the equipment on her cart. TMA-A did not disinfect the equipment after use with R9. At 2:41 p.m. TMA-A entered R3's room carrying the thermometer and oximeter, placed the oximeter on R9's right finger and checked her temperature. TMA-A left the room and placed the thermometer and oximeter in her pocket. TMA-A did not disinfect the equipment after use with R3. On 4/7/21, at 3:05 p.m. TMA-A stated she had been taking resident temperatures and oxygen saturations for COVID -19 screenings for all the residents on Orton's Crossing wing. TMA-A indicated she had 3 residents left to complete screenings on. TMA-A stated she had not disinfected the equipment between use with the residents. TMA-A indicated her usual practice was to disinfect the equipment after she completed her screenings at the end of her shift and not between each resident use. TMA-A stated she had not received any training on disinfecting equipment commonly shared between residents. On 4/8/21, at 11:39 a.m. clinical manager (CM)-A indicated her expectation was for all equipment to be wiped down after use between each resident with the alcohol wipes or Vindicator ( a cleaning product used to clean, deodorize and disinfect to prevent the spread of infection) disinfectant. CM-A stated this expected practice was important to prevent the spread of infection. CM-A indicated she would expect the thermometer and oximeter to be wiped down between resident use. CM-A stated she had not performed any recent audits to assure equipment was being cleaned and disinfected between resident use on the unit. On 4/8/21, at 11:45 a.m. infection preventionist (IP)-A indicated she expected all equipment to be wiped down between each resident using sani-wipes or Vindicator disinfectant. IP-A stated this was important to prevent the possible spread of infection from one resident to another. IP-A indicated staff on each wing were responsible for audits to assure disinfecting of equipment between residents was completed. IP-A stated she completed audits for hand hygiene and personal protective equipment. On 4/8/21, at 11:49 a.m. director of nursing (DON) confirmed her expectation was all equipment be disinfected between resident use. DON indicated they had alcohol wipes to use on the thermometer and oximeter. DON indicated all equipment should be sanitized to prevent transmission of possible infection from one resident to another. DON stated IP-A completed audits for infection prevention and all staff had received education on sanitizing equipment between residents. The facility policy titled Cleaning Disinfect Equipment reviewed/revised 12/13/18, identified resident-care equipment, would be cleaned and disinfected according to current CDC (Centers for Disease Control and Prevention) recommendations for disinfection and the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogens Standard. The policy further identified reusable items were cleaned and disinfected between residents. The policy identified reusable resident care equipment would be decontaminated and/or sterilized between residents according to manufacturers' instructions.

Based on observation, interview, and documentation review the facility failed to follow recommendations from the Centers for Disease Control (CDC) to prevent the spread of COVID-19 in long term care facilities. The facility failed to ensure staff demonstrated proper gown use for 1 of 1 (R4), who was on 14 day quarantine due to recent hospitalization and admission to the facility. The deficient practices had the potential to affect all 40 residents who currently reside at this facility including staff. Findings include: R4's current face sheet dated 12/2/20, listed [DIAGNOSES REDACTED]. R4's progress note dated 12/3/20, at 12:00 p.m. indicated R4 was placed into quarantine x (times) 14 days for routine quarantine for COVID-19. admitted for potential short term for dementia care. R4 was recently in the hospital on observation status due to a urinary tract infection [MEDICAL CONDITION]. During an interview on 12/7/20, at 12:45 p.m. with a homemaker (H)-A she indicated when she cleaned a 14 day quarantine room she put on a cloth gown hanging on the wall in the resident's room. H-A indicated she picked any gown hanging on the wall, and indicated staff members shared PPE (personal protective equipment) sometimes such as a cloth gown, and also put on double pair of gloves. H-A stated after cleaning the room, the first set of gloves were taken off, then the gown and was hung up on one of the hooks in the room. H-A stated she removed the second pair of gloves, discarded them and sanitized her hands. On 12/3/20, at 1:05 p.m. a sign was observed on the outside of R4's door which listed enhanced droplet precautions started 12/3/20 at 10:00 a.m. isolation precautions discontinued 12/17/20, at 10:00 a.m. On 12/3/20, at 1:50 p.m. just inside of R4's room on left hand side of wall were 3 hooks attached to the wall. On the first hook was a face shield, on the second hook a reusable gown with a face shield and on the third hook a faceshield. The 3 faceshield's and gown were not labeled with staff names. There were no labels on the individual hooks, in addition to no labels on each piece of PPE. On 12/7/20, at 2:05 p.m. R4 started walking out of her room and was immediately redirected by activity director (AD)-A who was present in the hall, to go back to the room. The staff put on gloves and grabbed the one yellow gown hanging on the wall in the resident's room and put it on. AD-A entered the room, stood near R4 where she sat in her recliner by the window and talked to her, picked up the remote control, and adjusted the television channel. AD-A readjusted the bedside table and moved it away from R4. Staff moved closer to the resident, stood next to the recliner, and continued her conversation. AD-A repositioned a stack of papers on the table, picked up R4's phone and attempted to get it to work, adjusted the wires while talking to R4, then walked to the other side of the bed to look for a phone cord. She walked back to the side by the resident and attached a cord to the phone. AD-A proceeded to remove her gloves and gown, place the gown back on the middle hook where it previously hung and exited room. She sanitized hands, removed a mask from a cabinet in hallway and took off her mask, put on the clean mask, then walked over to the dinning room to discard the mask in garbage can, then sanitized her hands. AD-A exited the resident's room at 2:25 p.m. When staff was getting ready to walk away she commented to surveyor and indicated I had to get to that resident quickly and encourage her to get back into her room so I just grabbed what supplies I could. During an observation on 12/7/20, at 2:30 p.m. H-A stood at the entrance to R4's room, wore goggles and mask, and applied gloves to both hands. H-A opened R4's door and reached for the one yellow gown in the residents room hanging on the middle hook. The gown and three face shields on the wall hooks were not labeled with a staff name. H-A put the yellow gown on, fastened the ties, and went into room. H-A gathered the three bags of garbage and tied each bag shut. H-A then went into the bathroom and sprayed liquid cleaner into the toilet, swished the toilet brush around in the bowl and put it back into holder. She took the tied garbage bags and placed them on the floor outside of the resident's room. H-A then removed the yellow gown and placed it on the end hook furthest away from the door over a face shield hanging there. She then removed her gloves, exited the room, and sanitized her hands. H-A did not label the gown. During an interview on 12/7/20, at 4:21 p.m. activity director (AD)-A indicated when entering an isolation room she used hand sanitizer first, applied gloves then put on a gown inside the room located on the hook. AD-A indicated as long as no cares were being done she could use the gown that was hanging in the room. She indicated at times she assisted with resident cares, but did not assist often. AD-A indicated she had toileted someone a while ago but usually does not assist with toileting. AD-A stated she thought it would be an expectation for the activity staff to assist if needed. When doing cares AD-A stated she would take a new disposable gown from the cabinet outside the room or a washable one. AD-A indicated the hooks in the room are used for each NA (nursing assistant) for the day. She also indicated all staff had education on PPE and isolation rooms. AD-A stated she hung the gown back up on the hook because she did not have any physical contact with the resident. AD-A indicated they should have been labeled but not sure if they were or not. AD-A also stated she did not know if that was a new gown hanging there or not. During an interview on 12/7/20, at 3:25 p.m. Infection preventionist (IP)-A indicated when a resident was in quarantine staff were required to put on full PPE but we use PPE conservation. IP-A stated that meant instead of getting a new gown each time the staff use the same gown for their duration of their shift, but do not share gowns, they hang those gowns up inside the patient room. IP-A stated each neighborhood does it a bit different but the expectation is that they label their hooks. IP-A indicated some units use labeling slips and the shield hanging with the gown should belong to the same staff. IP-A stated we have extra shields. IP-A also indicated the expectation would be that staff get a new gown and shield if it is not labeled. During a follow up interview on 12/9/20, at 2:09 p.m. IP-A stated the facility had sufficient supply of PPE and presently no shortage. We have different venders, the coalition group, a safety officer that kept track of Redcap and sometimes had ordered PPE supplies from there. Review of the facility Basic PPE Training PowerPoint, provided to all staff November 2020, per IP-A during an interview on 12/9/20, at 10:30 a.m. indicated on the 6th slide PPE precautions, do not safe (sic) your mask, or gown to keep using throughout the day, always dispose of right away. Review of facility Standard Precautions document dated 12/13/08, Personal Protective Equipment -Using Gowns indicates use gowns only once and then discard into appropriate receptacle in the exam or treatment room. Reusable gowns shall be laundered after each use in accordance with established laundry procedures. The CDC Isolation Precautions updated April 2019, includes: -Standard Precautions indicates before leaving the patient's room or cubicle, remove and discard PPE. Do not reuse gowns, even for repeated contacts with the same patient. -Contact Precaution indicates after gown removal, ensure that clothing and skin do not contact potentially contaminated environmental surfaces that could result in possible transfer of microorganism to other patients or environmental surfaces.

Based on observation, interview and document review, the facility failed to follow the manufacturers instructions when using a mechanical lift for 2 of 2 residents (R1 and R2) who utilized a full body mechanical lift for transfers. R1 fell from the lift, hit her head and sustained a hematoma. This resulted in an immediate jeopardy situation for R1 and R2, when the facility failed to educate staff on how to properly use the mechanical lift to prevent accident hazards. The immediate jeopardy began on 10/8/20, at 4:50 p.m. when it was identified staff continued to transfer residents with the mechanical lifts, without training on the use of full body mechanical lifts. The director of housing, and the director of nursing (DON) were notified of the IJ on 10/8/20, at 4:50 p.m. The IJ was removed on 10/12/20, at 12:06 p.m. but noncompliance remained at the lower scope and severity level D-isolated, scope and severity, which indicated no actual harm with the potential for more than minimal harm, that is not immediate jeopardy. Findings include: R1's quarterly Minimum Data Set (MDS), dated [DATE], included severe cognitive impairment with a diagnosis of Alzheimer's disease. R1 required extensive assistance of 2 plus persons for transfers and had no falls since the prior assessment. R1's care plan, revised 10/4/20, included risk for falls, and staff were directed to use a full body lift with a medium sling per manufacturers guidelines, or to transfer with one-two manual assist. R1's Event Report dated 10/2/20, identified R1 was being transferred from her bed to a wheel chair, the straps of the sling were not crossed between her legs and she slid to the floor with assistance from staff. R1 sustained a, bump, and bruising. The report identified the staff operating the mechanical lift were inexperienced with the use of the equipment and education was needed. R1's progress note dated 10/2/20, at 4:33 p.m. included, Writer called to resident's room where resident was laying on the floor beneath the hoyer [mechanical lift] lift with her head on a pillow. Staff had attempted to transfer her from the bed to the w/c [wheel chair] with the use of the hoyer and the straps from the hoyer lift sheet were not crossed underneath her. She slid from the lift onto the floor, staff helped to ease her to the floor but she did hit her head, the left side, base of the skull. No other injuries noted. Assisted to standing position using 3 staff and a transfer belt. Resident did not grimace with this movement and did not grimace while bearing weight on legs. Seated in w/c and VS [vital signs] obtained, neuro checks show no abnormality. Family and physician notified. Staff re-educated on how to properly use the hoyer lift, nurse will accompany staff into resident's room for the next transfer to ensure they are properly using the lift. R1's progress note dated 10/3/20, at 12:58 p.m. included, F/U [follow up] Fall: Pain noted from fall this a.m. scheduled pain gel put on. R1's progress note dated 10/4/20, at 9:40 p.m. included, Hematoma less swollen with no c/o [complaints of] when touched. Some grimacing noted after the evening meal so did give Tylenol at HS [bedtime] and within a half hour she was asleep. R1's progress note dated 10/5/20, at 9:22 p.m. included, There is still some bruising to the left side of her neck towards the base of the skull. R1's progress note dated 10/8/20, at 8:47 a.m. included, During a.m. cares staff noted discolored bump area to right inner foot approx. [approximately] 2 cm [centimeters] below ankle. Area discolored purple and appears to be fading, 2.5 cm round in size. During observation on 10/7/20, at 1:41 p.m. nursing assistant (NA)-G and NA-H assisted R1 with toileting, transferring with a mechanical standing lift. R1 had a large green colored bruise to the left side of her neck. When interviewed on 10/7/20, at 2:00 p.m. NA-G stated R1 had the bruising on her neck because she fell out of the full body lift sling on 10/2/20. NA-G had watched a video on the use of the lifts and at change of shift today staff were going to do a demonstration of how to use the lift. R1 uses the standing lift, on good days, and will use the full body lift when weaker. During observation on 10/7/20, at 2:15 p.m. nine staff went into an empty resident room with the full body lift and NA-F played a video on the laptop computer on the appropriate use of the full body lift, then NA-F demonstrated using one of the staff present to be transferred in the full body lift, stressing the importance of the crossing of the straps between the legs. No other staff participated in the hands on training. When interviewed on 10/7/20, at 3:03 p.m. NA-I stated she was not aware of any training on lifts over the years. NA-I stated she had the training in class when she was certified, but that was so long ago. When interviewed on 10/7/20, at 2:32 p.m. NA-D stated he was working with R1 on 10/2/20, with NA-C. NA-D stated he and NA-C were transferring R1 with the full body lift from her bed to her wheel chair when, like slow motion, R1 slid out of the sling and down NA-C's leg to the floor. NA-D stated R1 had sustained bruise on her neck. NA-D stated he was told how to use the lift verbally after R1's fall and later the nurse came into R1's room to help with the transfer to show the proper way to use the full body lift. NA-D stated he was still not comfortable using the full body lift and this was the first training he had received on the full body lift since he started in August of 2020. NA-B stated R1 was transferred previously with assist of two staff and a gait belt. During a follow-up interview with NA-D on 10/8/20, at 10:35 a.m. NA-D stated he learned the reason for R1 falling out of the lift was that the straps were not crossed between her legs. NA-D explained he had done some on-line training prior to starting on the floor as an aide, and six-seven shifts with a mentor on the floor before he was able to work independently. NA-D stated he completed a check off sheet of skills during this time, and was able to complete all but the full body lift and bedpans. NA-D will be able to take the certification test after he has gained experience and feels ready to take the exam, but is not a certified nursing assistant at this time. When interviewed on 10/8/20, at 3:15 p.m. NA-C stated R1 had been using the standing lift, but on 10/2/20, NA-F told her to use the full body lift and asked if she could teach NA-D how to use it. NA-C stated she did not think she would be training anyone as this was her first assignment and had only been working at the facility for a couple of months. NA-C stated she was never asked if she knew how to use the lift, just if she would teach NA-D. NA-C stated she did tell NA-F, ok, to teaching NA-D. NA-C stated while transferring R1, she slid out of the sling. NA-C stated she noticed the straps between R1's leg were not crossed about the same time registered nurse (RN)-A showed up to the room and pointed it out. NA-C stated a nurse did assist with the transfer of R1 later that night with her and NA-D. NA-C stated no other training has been provided to her. NA-C explained when she started with the facility two months ago, she did a few shifts on the floor with a mentor and had to complete two exams with, Medical Solutions [a staffing agency] before working in any facilities. NA-C stated the test with Medical Solutions was general questions, but no questions on the use of mechanical lifts, and she has not had training with lifts for several months, when she had worked in another state. When interviewed on 10/7/20, at 2:45 p.m. RN-A stated she was called to R1's room on 10/2/20, R1 was on the floor with her head on the inside leg of the full body lift and her feet were toward the door. The full lift was next to the bed. Staff explained R1 had slipped out of the sling during the transfer. RN-A stated she noticed the straps of the sling were not crossed and R1 had a hematoma on the left base of her skull at the hairline. RN-A stated she did an assessment of R1 and updated the family and the physician. RN-A stated she told NA-D and NA-C not to do another transfer with the full body lift until a nurse could assist them. RN-A stated she did a verbal teaching at the time when she noticed the straps not crossed for the legs and RN-B was able to assist later in the evening when they assisted R1 to bed. When interviewed on 10/7/20, at 2:00 p.m. NA-E stated she was working as a homemaker on 10/2/20, making cookies, when NA-D came into the dining room asking for help. NA-E stated she went to R1's room and saw R1 on the floor with the full body lift parallel to the bed. NA-E stated she asked NA-C to put a pillow under R1's head and the nurse came to the room to assist. NA-E stated she received training on the lifts annually and during the nursing assistant classes when they get certified. However NA-E was unable to recall the last training she attended on lifts. When interviewed on 10/8/20, at 10:00 a.m. the director of nursing (DON) stated she was informed that R1 was being transferred in the full body lift by NA-D and NA-C when R1 slipped out of the sling and was supported to the floor by staff, hitting her head on the foot of the lift. DON also stated she was aware that the nurse was present for the transfer later in the shift to ensure it was done appropriately. DON stated that it is her expectation that all staff be trained before using the full body lifts and the straps be crossed between the legs of the resident during the transfer so the resident transfers safely. R2's annual MDS dated [DATE], included, severe cognitive impairment with a diagnosis of Alzheimer's disease. R2 was totally dependent upon 2 plus staff for transfers and had 2 plus falls since the prior assessment. R2's care plan revised 8/3/20, included the need for total staff assistance for transfers with a full body mechanical lift and medium sling. During observation on 10/8/20, NA-A and NA-B assisted R1 with a transfer from bed to the wheel chair using the full body mechanical lift. As NA-B was lowering R2 toward the wheel chair, NA-A tipped the wheel chair off the two front wheels bracing the wheel chair with her leg. After R2 was seated in the wheel chair NA-A lowered the wheel chair to the floor. When interviewed on 10/8/20, at 11:45 a.m. NA-A stated she tipped the wheel chair back to position R2 correctly in the wheel chair. NA-F also stated she has done training on the lift via computer yearly, but has never participated in a demonstration. During a follow up interview with NA-A on 10/8/20, at 1:49 p.m. NA-F stated she usually does tip the wheel chair back when transferring R2. NA-A stated she knows she, probably shouldn't, and doesn't always do it, it just depends on the day. She had not been taught to do transfers this way. When interviewed on 10/8/20, at 1:50 p.m. the DON stated, it would never be safe to tip the wheel chair back during a transfer and there are handles on the sling to aid in positioning of the residents. DON confirmed the facility currently has two residents (R1 and R2) who utilize full body lifts. When interviewed on 10/8/20, at 10:00 a.m. the DON stated training on the mechanical lifts with staff were done on hire and annually in a classroom setting with the therapy department to demonstrate the proper use of the full body lift and the standing lift. This training was over 2-3 days and was mandatory to all staff. The last training was in November of 2019 and the next one will be before the end of the year. The DON stated the training planned for the licensed nurses and aids following the fall of R1, are a training video that has a follow up test, a live demonstration, and a return demonstration by the staff. This training was started and on 10/8/20, and 8 staff had completed the live demonstration and 10 had completed the video with the follow up test. This is out of the 68 total staff needing the training. The return demonstration piece of the training is planned to start on 10/9/20. The DON provided a sign in sheet for the, live demonstration, which showed 8 out of 68 staff had participated so far. Tests were provided and showed 10 of 68 staff had taken the exam. When interviewed on 10/8/20, at 1:25 p.m. the sales representative from EZ way [mechanical lift brand name] stated, when transferring a resident using the full body lift it doesn't matter how you cross the straps between the legs, as long as they are crossed and it would absolutely never be appropriate to tip the wheel chair back to correctly position a resident. She further stated if positioning was not correct, then the sling was not positioned correctly under the resident in the first place. NA-D's training records dated 8/28, no year, included a check off list of training's. A video training entitled, hoyer, was not checked off. No training was found for the mechanical lifts. No competency training on mechanical lifts was available for NA-C. NA-C worked for the staffing agency Medical Solutions. The Medical Solutions contract dated 11/16/16, identified training on any equipment was the responsibility of the facility. The EZ Way Smart Lift instructions dated 8/10/18, identified, For safe operation of the EZ Way Smart Lift, operators should watch the training video, read through this manual, complete the competency checklist, and practice on a fell ow staff member. The manual describes the need to individualize the sling size and method to each resident and to cross the sling between the legs. The IJ that began on 10/8/20, was removed on 10/12/20, when the facility ensured all staff were trained prior to providing direct care of the residents and had a plan to have all new employees trained prior to working on the floor. Laminated instructions were placed in all three of the full body lifts in the building and three ring binders with the instructions were placed at all three nurses stations. Care plans were reviewed and updated for R1 and R2 and training was completed for 43 of the 68 staff, with the remainder of the staff to be trained prior to their next shift. However, the noncompliance remained at the lower scope and severity level of D-isolated, scope and severity, which indicated no actual harm with there potential for more than minimal harm that is not immediate jeopardy.

Based on interview and document review the facility failed to cancel all group activities per Centers for Medicare and Medicaid Services (CMS), Coronavirus Disease 2019 (COVID-19) guidance for 17 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, and R17) identified by the facility as routinely in attendance of group activities in the facility. This deficient practice had the potential to affect all 50 residents who resided in the facility and staff. Findings include: The CMS, Center for Clinical Standards and Quality/Quality, Safety & Oversight Group, QSO memo 20-14 Guidance for Infection Control and Prevention of COVID-19 for nursing homes, revised 3/13/20, provided guidance to cancel all group activities, both internal and external group activities. On 5/7/20, at 10:43 a.m. life enrichment assistant (LEA) indicated she had conducted small group activities of about 7 residents on the household. The LEA confirmed the facility continued to hold small groups of bingo, and happy hour activities in the dining room weekly, with one resident at each table. LEA stated she had scheduled a group happy hour activity gathering in the dining room for that afternoon. On 5/7/20, at 10:55 a.m. nursing assistant (NA)-A indicated the facility had small group gatherings for activities including bingo in the dining room. NA-A indicated the residents were socially distanced with one resident at each table. On 5/7/20, at 11:05 a.m. registered nurse (RN)-A confirmed the facility continued to hold group bingo activities in the dining room. On 5/7/20, at 11:45 a.m. director of nursing (DON) confirmed the facility conducted some small group activites in the neighborhood dining rooms, with 4-6 residents at a time in the groups. On 5/7/20, at 2:01 p.m. during a telephone interview with infection preventionist registered nurse (IPRN) she stated she had not been aware the facility had been holding communal activities. The IPRN stated the facility staff had received education in March of 2020, to stop all group activities. She indicated she had been under the impression all resident activites were held in resident rooms or on a 1:1 basis with resident and a staff member. The facility forms titled Life Enrichment Daily Attendance Sheets Fairway View Neighborhoods 201 Mark Dr. Ortonville MN, May 2020, identified 17 residents documented as attending group activites. The attendance sheets listed: R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, and R17 had attended activities in the facility in May. On 5/8/20, at 2:16 p.m. during a follow up telephone interview, the DON confirmed the facility continued to hold group activities of four (4)-six (6) residents in the neighborhood, in common areas about two (2) times a weekly. On 5/12/20, at 1:41 p.m. during a telephone interview, the Activity Director (AD)-A confirmed 17 of the 50 residents routinely attended the small group activities of three to five residents for bingo, happy hour, and special events when food was served. AD-A defined a group activity as when the residents would gather together in the same spot, several people at a table engaging in an activity. AD-A indicated she felt bingo with residents at individual tables was an independent activity. AD-A confirmed they had been providing small group activities in the neighborhood common areas for the past 6 to eight (8) weeks. The facility policy titled Infection Prevention Emerging Threats-Acute Respiratory Syndromes Coronavirus-Ortonville, revised 4/9/20, identified one of it's purposes was to minimize the number of individuals who came into contact with COVID-19, but lacked direction for resident activities. The untitled facility provided document effective March 10, 2020, identified restrictions on group activities at Fairway View Senior Communities. The document indicated there were no group activities happening in the facility, and instructed staff to ensure residents in common areas of the neighborhoods were socially distanced at least 6 feet apart.

Based on observation, interview and document review the facility failed to routinely provide ambulation services according to therapy recommendations to maintain function for 1 of 1 residents (R29) reviewed for ambulation. Findings include: R29's annual Minimum Data Set ((MDS) dated [DATE] indicated R29 had severe cognitive impairment and [DIAGNOSES REDACTED]. The MDS identified R29 required supervision with eating, limited assistance to walk in her room, and extensive assistance with all other activities of daily living (ADL). R29's MDS further indicated R29 had walked in the hallway only once or twice during the seven-day MDS assessment period. R29's Care Area Assessment (CAA) dated 1/30/19 indicated R29 required limited assistance of one staff with walking in room and hallway. The CAA further indicated staff would continue to offer R29 help to accomplish ADLs daily, while making sure ADLs were completed safely. The CAA directed staff to encourage R29 in the FMP (Functional Maintenance Program) (a program to help maintain a residents functional status) as designed/ordered, work with R29 to help with walking with staff frequently as ordered, and get R29 to participate in other activities R29 enjoyed. R29's care plan revised 3/6/19 indicated R29 was limited in her ability to accomplish ADLs daily related to diagnoses, which included dementia with cognitive loss. The care plan listed various interventions, which included the need for limited assist of one staff for walking in the room and hall as R29 tolerated with a gait belt and four-wheeled walker (FWW). The care plan further indicated R29 did not go in the hallway much, was on the walking list twice a day as R29 allowed/agreed to, and please help R29 with walking to keep up her leg strength. On 3/4/19, at 3:21 p.m. R29 was observed seated in a wheelchair and propelled herself in a common area of the unit with her feet. R29 lightly bumped the wheelchair into pillars in the common area as she peddled around. R29 was alert as she made eye contact with others around her. On 3/4/19, at 7:31 p.m. during a phone interview with family member (FM)-A stated R29's balance could be off in the mornings and R29 needed to be reminded to stand tall, complete her exercises and walking. FM-A indicated they were unaware if staff were walking R29, and was something FM-A asked the staff to make sure they were doing. FM-A further stated R29's wheelchair was her main mode of transportation. On 3/4/19, at 7:33 p.m. R29 was seated in a wheelchair and propelled herself down the hallway of the unit. R29 was alert as she looked into other residents' rooms, but did not enter them. On 3/6/19, at 7:47 a.m. R29 was laying in a low bed, on her back, with eyes closed, curtains pulled and the lights were off. At 8:23 a.m., R29 remained laying in the bed. At 8:51 a.m. nursing assistant (NA)-A opened R29's door and walked out with two tied plastic bags and walked down the hall. R29 was seated in her wheelchair and pedaled herself from the room to the middle of the hallway. At 8:53 a.m., R29 remained seated in the wheelchair in the hallway and NA-A approached and asked R29 if she was ready for breakfast. R29 indicated she was, and NA-A pushed her wheelchair to a table in the dining room. On 3/6/19, at 12:47 p.m. R29 was seated in the wheelchair in the dining room at the noon meal. At 12:57 p.m., after R29 had finished the noon meal, she propelled the wheelchair with her feet and sat outside her bedroom door. R29 was alert and looking around the unit. On 3/7/19, at 8:09 a.m. R29 was laying in a low bed, on her back, with eyes closed and window curtains pulled shut. At 8:53 a.m., R29 remained lying in bed. At 9:19 a.m., R29 was seated in the wheelchair and propelled self out of the room and straight to the dining room table for the breakfast meal. Review of Therapy Communication/Screen Form, dated 1/22/19, indicated, family/staff have noticed that resident seems weaker in transfers. She has not been walking much. Please assess for transfers and ambulation and give recommendations. The form indicated, by circling no, that R29 was not a candidate for a physical therapy evaluation. The physical therapist (PT)-A commented (R29) cont. (continues) to be A (assist) x (times) 1 @ (at) this time. Staff has been encouraged to cont(inue) to walk c (with) res(ident). Review of R29's Point of Care History, Miscellaneous Tasks: Walk 150-350 FT (Feet) with FWW CGA (Contact Guard Assist) of 1 (staff) with W/C (wheelchair) to Follow Cue For Stride Length, Distance As Tolerated (Twice A Day), from 12/1/18, through 3/7/19, revealed the following: -From 12/1/18, through 12/31/18, the question if R29 walked as above was marked as unanswered 30 times, marked as Done 27 times, and marked as Not Done five times due to refusal, combative or deferred due to condition. -From 1/1/19, through 1/31/19, the question if R29 walked as above was marked as unanswered 28 times, marked as Done 31 times, and marked as Not Done three times due to refusal or deferred due to condition. -From 2/1/19, through 2/28/19, the question if R29 walked as above was marked as unanswered 21 times, marked as Done 31 times, and marked as Not Done four times due to refusal. -From 3/1/19, through 3/7/19, the question if R29 walked as above was marked as unanswered five times, marked as Done seven times, and marked as Not Done two times due to refusal. On 3/6/19, at 1:28 p.m. NA-A stated R29 required extensive assistance with ADLs and walked with staff at times. NA-A stated some of her duties included walking residents, whom were able, to and from meals. NA-A stated some residents required extra walking in the hall and the extra walking was charted in the electronic health record (EHR). NA-A reviewed the Point of Care (P[NAME]) charting for R29 and confirmed R29 required extra walking. On 3/7/19, at 9:34 a.m. NA-D stated R29 required extensive assistance for ADLs, and walks with staff one to two times per day, on a good day. NA-D indicated R29 was to walk twice a day, and stated, She is supposed to be, I don't know if it gets done when I am not here. NA-D indicated R29 would walk from the bed to the bathroom and to the dining room. NA-D stated R29 walked to the bathroom from the bed that morning, and added, She is stiff this morning. On 3/7/19, at 10:12 a.m. NA-E indicated she was directed to walk with the residents that were able to walk to the dining room and back. NA-E stated R29 required extensive assistance of one staff for walking with a gait belt and FWW, and two staff if R29 was tired. NA-E indicated she would walk R29 to the bathroom from her bed, and to the dining room. NA-E stated R29 was to walk at least two times per day, and indicated she had not had the chance to walk R29 in the hallway much. NA-E indicated R29 does not refuse walking, but if R29 was tired, staff would not attempt to walk with R29. NA-E reviewed P[NAME] walking instructions for R29 in the EHR, and was unable to determine how far 150 to 350 feet would be on the unit. On 3/7/19, at 10:30 a.m. registered nurse (RN)-A stated R29 abilities varied, and required one to two staff to walk, with a gait belt and FWW and wheelchair to follow to walk. RN-A stated R29 would walk from her room to the bathroom and to the dining room. RN-A stated she had not seen staff walk R29 down the hallway. On 3/7/19, at 10:48 a.m. nurse manager (NM)-C indicated R29's walking program was separate from the facility's Functional Maintenance Program (FMP) and the unit staff completed R29's walking program. NM-C stated the facility had a walk to dine program where staff were to walk residents to meals. NM-C stated R29's room was extremely close to the dining room and indicated the walk to dine program did not account for the closeness to the resident's room from the dining room. NM-C reviewed R29's P[NAME] instructions to walk R29 150-350 FT (Feet) with FWW CGA (Contact Guard Assist) of 1 (staff) with W/C (wheelchair) to Follow Cue For Stride Length, Distance As Tolerated (Twice A Day), and documentation, and verified missing documentation in R29's walking program. NM-C indicated R29's alertness varied, but staff had the ability to chart refusals and would have to accommodate R29. NM-C stated the normal procedure for a resident refusing was for staff to document the refusal, update the nurse and reapproach the resident. NM-C stated she was unaware who reviewed R29's walking program, and indicated R29 would be at risk for a decrease in range of motion and increased fall risk. On 3/7/19, at 12:19 p.m. therapy site coordinator (TSC)-A stated therapy typically did not include walking on a resident's FMP, with hopes nursing staff were walking the resident to the dining room and the bathroom. TSC-A stated if R29 had specific instructions to walk 150 to 350 feet twice a day, it would have been a recommendation from therapy. TSC-A stated with R29's room being so close to the dining room, she would expect nursing staff to be walking R29 the 150-350 feet distance as well. TSC-A stated R29 would be at risk for a decrease in transfer ability and decrease in functional strength. On 3/7/19, at 3:03 p.m. director of nursing (DON) indicated R29 had varying levels of alertness, and added R29 had days, which she would sleep most of the day, but also R29 had multiple days in a row, which she was awake and alert. DON stated she would expect staff to walk R29 per instructions, and start R29's walk further from the dining room to increase the walking distance. The DON indicated the NM should be reviewing R29's walking to dine program. A policy on walk to dine/walking program was requested, however one was not provided.

Based on observation, interview and document review the facility failed to routinely provide range of motion services according to therapy recommendations to maintain function for 2 of 3 residents (R29, R45) reviewed for range of motion (ROM). Findings include: R29's annual Minimum Data Set (MDS), dated [DATE], indicated R29 had severe cognitive impairment, and had [DIAGNOSES REDACTED]. The MDS identified R29 required supervision with eating, limited assistance to walk in her room, and extensive assistance with all other activities of daily living (ADL). R29's MDS further indicated, R29 had walked in the hallway only once or twice during the seven day MDS assessment period. R29's Care Area Assessment (CAA) dated 1/30/19, indicated R29 required limited assistance of one staff with walking in room and hallway. The CAA further indicated staff would continue to offer R29 help to accomplish ADLs daily, while making sure ADLs were completed safely. The CAA directed staff to encourage R29 in the FMP (Functional Maintenance Program) (a program to help maintain a residents functional status) as designed/ordered and get R29 to participate in other activities R29 enjoyed. R29's care plan, last revised 3/6/19, indicated R29 was limited in her ability to accomplish ADLs daily related to [DIAGNOSES REDACTED]. The care plan listed various interventions which included R29 would participate with therapies as ordered to the best of her ability, including establishing FMP after therapies are done, encourage R29's participation in the program and reapproach R29 if initially refuse or was uncooperative. On 3/4/19, at 3:21 p.m. R29 was observed seated in a wheelchair and propelled herself in a common area of the unit with her feet. R29 lightly bumped the wheelchair into pillars in the common area as she peddled around. R29 was alert as she made eye contact with others around her. On 3/4/19, at 7:31 p.m. during a phone interview with family member (FM)-A stated R29's balance could be off in the mornings and R29 needed to be reminded to stand tall, complete her exercises and walking. FM-A indicated they were unaware if staff were walking R29, and was something FM-A asked the staff to make sure they were doing. FM-A further stated R29's wheelchair was her main mode of transportation. On 3/4/19, at 7:33 p.m. R29 was seated in a wheelchair and propelled herself down the hallway of the unit. R29 was alert as she looked into other residents' rooms, but did not enter them. On 3/6/19, at 7:47 a.m. R29 was lying in a low bed, on her back, with eyes closed and curtains pulled and the lights were off. At 8:23 a.m. R29 remained laying in the bed. At 8:51 a.m. nursing assistant (NA)-A opened R29's door and walked out with two tied plastic bags and walked down the hall. R29 was seated in her wheelchair and peddled herself from the room to the middle of the hallway. At 8:53 a.m. R29 remained seated in the wheelchair in the hallway and NA-A approached and asked R29 if she was ready for breakfast. R29 indicated she was, and NA-A pushed her wheelchair to a table in the dining room. On 3/6/19, at 12:47 p.m. R29 was seated in the wheelchair in the dining room at the noon meal. At 12:57 p.m. after R29 had finished the noon meal, she propelled the wheelchair with her feet and sat outside her bedroom door. R29 was alert and looking around the unit. On 3/7/19, at 8:09 a.m. R29 was lying in a low bed, on her back, with eyes closed and window curtains pulled shut. At 8:53 a.m. R29 remained lying in bed. At 9:19 a.m. R29 was seated in the wheelchair and propelled self out of the room and straight to the dining room table for the breakfast meal. On 3/6/19, at 1:28 p.m. NA-A stated R29 required extensive assistance with ADLs and walked with staff at times. NA-A stated, nursing assistants do not complete resident's FMP on the units. NA-A stated, staff may complete a little stretching of hands in the room, but the facility had restorative therapy staff and they complete FMPs. On 3/7/19, at 9:34 a.m. NA-D stated R29 required extensive assistance for ADLs, and walks with staff one to two times per day, on a good day. NA-D indicated R29 had a FMP and restorative therapy aide (RA) would work with R29 once in a while. NA-D stated, there are some days we (staff) do not get RA down on the unit, and staff make sure to complete walking with R29. NA-D stated R29 walked to the bathroom from the bed that morning, and added she is stiff this morning. On 3/7/19, at 10:30 a.m. registered nurse (RN)-A stated R29 abilities varied, and required one to two staff to walk, with a gait belt and four wheeled walker and wheelchair to follow, to walk. RN-A stated RA staff completed all resident's FMP. RN-A indicated an RA was available Monday through Friday, and NA floor staff were not trained to complete a resident's FMP. On 3/7/19, at 10:48 a.m. nurse manager (NM)-C indicated after R29 completed therapy, therapy ordered a FMP to assist in maintaining R29's functional mobility. NM-C stated after FMP orders were received, they are placed into R29's orders and into her care plan. NM-C stated R29's FMP was reviewed monthly by the night shift, licensed practical nurse (LPN)-A. NM-C reviewed R29's monthly FMP progress note from LPN-A and indicated R29's FMP was completed 8 times last month. NM-C stated she would expect R29's FMP to be completed as instructed, and if not, R29 was at risk for a decrease in ROM, increased fall risk, and contractures. On 3/7/19, at 11:55 a.m. restorative therapy aide (RA)-A stated she was one of two RAs responsible for completing resident's FMP. RA-A confirmed restorative therapy (RT) was completed Monday through Friday at the facility, and usually only one RA worked per day. RA-A stated the facility currently had 37 FMP programs, and if the RA could not get to a resident, due to not having enough time, the RAs were instructed to chart the resident as unavailable. RA-A stated if a resident was sleeping, with company or an activity she would then put in a comment as to why the FMP was not done that day. RA-A confirmed R29 had a FMP, and stated R29 did not refuse often, and if R29 did refuse, she would add refuse to the comments. Review of R29's FMP documentation from 1/1/19, to 3/7/19, was completed and revealed resident unavailable was documented 70 times in January, 70 times in February, and 28 times in March. On 3/7/19, at 12:19 p.m. therapy site coordinator (TSC)-A stated a resident's FMP was set up after therapy was complete, to maintain balance and ROM. TSC-A stated R29 does participate with her FMP when in the therapy room with RA-A. TSC-A stated R29 last received therapy from 10/19/18, through 11/1/18, and therapy recommended different activities R29 could complete safely in the dining room, and for R29's FMP to continue. TSC-A indicated if R29's FMP was not completed, R29 would be at risk for a decrease in functional strength and increased risk for contracture. On 3/7/19, at 2:24 p.m. during a follow up interview, NM-C stated facility NAs were not trained to complete resident's FMPs and only two RA staff were trained to complete the FMPs. NM-C stated she was unaware of a time the RT staff reported to her that they were unable to complete R29's FMP. On 3/7/19, at 3:03 p.m. director of nursing (DON) indicated R29 had varying levels of alertness, and added R29 had days which she would sleep most of the day, but also R29 had multiple days in a row which she was awake and alert. The DON stated she was responsible for the facility's FMP, and her expectation for R29's FMP would be RT staff follow the orders from the chart. DON stated two RT aides were trained to complete FMPs, and no other staff. The DON indicated if the RAs were unable to complete the required FMPs for each day, the RAs would tell her. She was unaware residents were not being provided their FMPs as ordered. The DON stated moving forward resident's FMPs would be completed in groups so RA staff can complete all FMPs. R45 R45's significant change Minimum Data Set ((MDS) dated [DATE] indicated R45 was cognitively intact and had [DIAGNOSES REDACTED]. R45 required extensive assist of one person with bed mobility, transfers, dressing, toileting, and locomotion on/off the unit. In addition, R48 needed supervision with personal hygiene. R45's significant change Care Area Assessment (CAA) dated 2/18/19, identified R45 had [MEDICAL CONDITION] bowel and bladder related to [MEDICAL CONDITION]. As a result, R45 was occasionally incontinent of bowel and bladder and needed extensive assistance from one staff to toilet, provide incontinence cares, and assist with dressing. The CAA further identified R45 was at a risk for falls related to [MEDICAL CONDITION] drug use of [MEDICATION NAME] taken for depression, and [DIAGNOSES REDACTED]. R45's care plan dated 2/21/19, addressed numerous areas including chronic pain from arthritis, severe headaches, as well as muscle cramping/freezing pain from [MEDICAL CONDITION]. The care plan instructed staff to use non-medicated pain relief measures including physical therapy, stretching, strengthening exercises. The care plan also addressed R45's fall risk and included various interventions. In addition, the care plan addressed R45's need for assistance with activities of daily living (ADL)s and indicated he required extensive assistance from 1-2 staff with ambulation in his room or hallway using a front wheeled walker. Further, the care plan instructed staff to provide a functional maintenance program (FMP) to help maintain strength and mobility. On 3/7/19, at 9:06 a.m. R45 was interviewed with family member FM-B present in the room. R45 stated he had fallen a couple of times, and was not supposed to transfer himself but indicated he had to wait 5-10 minutes for staff sometimes, and stated that was often too late. FM-B stated R45 has had physical therapy in the past and indicated R45 currently had a functional maintenance program (FMP) 2-3 times per week to help maintain his strength and balance. FM-B indicated she did not think staff was offering R45 the FMP. R45 stated he was willing to go any time, stated he was not allowed to stand to urinate independently, indicated he did not like the motion sensor alarm in his chair and wished he could stand to urinate independently. R45 and FM-B stated they had expressed the concern for use of the chair alarm, and staff stated it was for safety. FM-B stated they had a therapy evaluation done a couple of weeks ago to address the concerns with wanting to stand to urinate independently, but indicated that insurance would not cover the cost of therapy and they had opted to use the FMP instead. R45 stated he had not been offered FMP exercises. On 3/7/19, 9:27 a.m. restorative aide (RA)-A entered the room and stated she had worked with R45 in the past but indicated it had been a long time. RA-A stated she had R45 on her schedule for the last few months, and indicated she could come get him later for the FMP exercises. Review of R48's restorative therapy FMP documentation from 12/1/18 to 3/7/19, was completed and revealed resident unavailable was documented 32 times in December, 71 times in January, 36 times in February, and 15 times in (MONTH) which indicated he had not been offered the FMP exercises in his restorative therapy program. On 3/7/19, at 9:43 a.m. the physical therapy assistant (PTA) - A stated R45 was in therapy after a hospital stay in (MONTH) 11/22/18, and was discharged from physical therapy (PT), occupational therapy (OT), and speech on 12/4/18. A review of R45's discharge summary indicated at the end of therapy he was able to walk 10-30 feet with FWW, contact guard assist up to minimal assist. PTA-A indicated R45 was at risk for falls and decline in mobility related to his [DIAGNOSES REDACTED]. PTA-A stated R45 was set up with a FMP on 12/5/19, and indicated the plan included doing large amplitude movements, toe taps, NuStep, walking in the parallel bars to encourage more fluid movements and less freezing episodes. PTA-A reviewed R45's restorative documentation and stated R45 usually refused resident unavailable, and indicated if he continued to refuse restorative therapy he would be discharged from the program. PTA-A explained that R45 could have a more progressive decline in his mobility without the FMP, and stated restorative therapy can delay the progression of his [MEDICAL CONDITION] symptoms. PTA-A verified the RA's documentation resident unavailable and stated she would interpret that as a refusal, but indicated the restorative aide could clarify the information documented. PTA-A stated if R45 was refusing the FMP the restorative aide should communicate if there was any concern of decline in mobility and function, and indicated she was not aware of any decline with R45 at this point. On 3/7/19, at 9:48 a.m. during a group interview, director of nurses (DON) and RN-A indicated R45 had been on the restorative program 3 times per week since the hospital stay in (MONTH) and indicated the felt resident frequently refused, or was unavailable. On 3/7/19, at 10:43 a.m. RA-A who verified R45 was on her list for the FMP 3-5 times per week. RA-A verified she had not offered R45 restorative therapy this week, and indicated she had 37 other resident on the list. RA-A stated she did not have time to get to him this week yet, and stated R45 had not refused. RA-A stated she did not have time to get to everyone on her list every week, and indicated she would choose the residents on her list who are likely to accept first. RA-A stated she could on average see 11-12 residents each day, and stated that if she was unable to get to someone on the list she was instructed during restorative training to document resident unavailable. RA-A confirmed documentation in restorative FMP resident unavailable meant the restorative aide did not get to the resident and FMP was not offered. On 3/7/19, at 11:19 a.m. DON stated she would expect the RA to communicate with her if a resident refused or if they were not able to get to someone. The DON stated the workflow should be changed, and she expected that every resident in the FMP should have it offered. The DON stated she was not aware that people were not being offered the FMP, and indicated the RA had stated I was not able to get to everyone I wanted to today but did not know that it meant she was not getting to the residents at all. The DON was not aware of any concerns with a resident decline in ADL function. On 3/7/19, at 2:47 p.m. nursing assistant NA-C stated the restorative aides have a list of people they walk or do exercises with, and it had not communicated to her if they were not able to get to someone on the list. NA-C stated the residents to be walked popped up on their task list and they do walk those residents but indicated they are not trained to complete the FMB restorative aides' duties. NA-C stated R45 required extensive assistance of one staff with toileting/transfers and stated she does not walk R48 due to his shuffled gait, and indicated she transferred R45 into his wheelchair then took him to the bathroom. During a follow up interview on 3/7/19, at 3:03 p.m. the DON stated she would expect to offer, reapproach, then document the refusal and update the nurse. The DON indicated she was in charge of the restorative program, and indicated they coordinate with big stone therapy to develop and update the FMP. The DON stated licensed practical nurse (LPN)-A reviews the charts and documentation on a weekly basis, looking for increase in refusals, and stated the FMP may get discontinued if there is a change in condition and the FMP was not appropriate or if the resident did not participate. The DON stated if the RA was unable to complete workload, she would expect them to notify her. The DON stated LPN-A may have interpreted unavailable as a refusal and indicated she was not aware that the RA documentation resident unavailable meant the FMP restorative program was not offered. The DON stated she would expert if RA staff cannot get to everyone in a day that it would be communicated clearly to the DON and unit leaders. The facility provided policy titled Restorative Therapy Program reviewed on 9/2018, indicated the purpose of the restorative program was to provide residents a planned therapy program that promoted each resident to maintain the highest level of function and independence. The policy indicated that a resident who refused the restorative therapy program for 3 consecutive months would be discharged from the program.

Based on observation, interview and document review the facility failed to follow manufacturer's guidelines for the proper use of a wheeled walker to prevent accident hazards for 1 of 1 resident (R3) who utilized a walker for ambulation. Findings include: R3's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R3 had intact cognition and [DIAGNOSES REDACTED]. The MDS further indicated R3 required limited assistance with transfers and walking, extensive assistance with bed mobility, toileting, dressing, and personal hygiene and utilized a walker. R3's care plan, revised 3/6/19, indicated R3 was at risk for falls due to balance problems, weakness and had fallen in the past. R3's care plan listed various interventions which included keeping R3's walker at bedside when in bed, education on ways to reduce falls and verbal reminders not to ambulate/transfer without assistance. On 3/6/19, at 3:08 p.m. R3 was observed seated on the seat of a four wheeled walker (FWW), with feet off the ground, and was being pushed backwards as she sat on the FWW, down the hall of the unit by activity director (AD)-A. R3 was pushed, as above, from outside the unit's door, down the hall and into R3's room. AD-A stated she was unaware if R3's FWW was safe to operate as a wheelchair or to transport R3. AD-A stated R3 had attended a Church service and organ music activity in the facility's theater. She stated R3 began to walk back to her room, got tired and sat down on the seat of the FWW. At 3:22 p.m. AD-A stated a sticker on R3's FWW indicated not to use the FWW for resident transport, and stated she was a former occupational therapy assistant, and added I know better. At 3:24 p.m. director of nursing (DON) stated her expectation for FWW was staff would not transport a resident seated on a FWW. The DON indicated R3's FWW was not owned by the facility, and would and would have to locate the manufacture's recommendations. The DON stated R3 would be at risk for tipping and falling if staff utilized her FWW as a seat to transport her. On 3/6/19, at 3:30 p.m. R3's FWW was observed in her room. The green and black, Nova Zoom 20 walker, Item number 4220GN had a Warning sticker on the right side frame by the wheels which indicated, Do not use as a w/c (wheelchair) or transport someone. On 3/7/19, at 9:12 a.m. nursing assistant (NA)-E indicated R3 and other residents would sit on their FWW and request staff transport them to locations. NA-E stated she had pushed R3 while seated on the FWW once, but had seen other staff do this as well. NA-E stated she had received education on safety risk of using a FWW for resident transport in the past. On 3/7/19, at 9:31 a.m. NA-D stated R3 utilized a wheelchair for long distances, and a FWW otherwise. NA-D stated we (staff) do not use the FWW as a seat to transport her very often, maybe once or twice. NA-D was unaware of any education not to use a FWW for resident transport, and was unaware of any safety risks for doing so. On 3/7/19, at 10:22 a.m. team lead (TL)-B stated R3 used a wheelchair for distances and a FWW on and off the unit. TL-B stated staff were not to push residents seated on FWW, as it was not stable and when pushing them, they could tip over and fall. On 3/7/19, at 10:46 a.m. nurse manager (NM)-C stated staff were educated not to use FWW to transport residents as it was a tipping hazard and risk for falls. On 3/7/19, at 2:05 p.m., physical therapist (PT)-A stated FWW were not recommended to be used as a transport device for residents as it increased the risk of falls. Review of Nova FWW Rolling Walker User Guide, last revised 3/24/17, directed uses under Safety Warning Instructions, DO NOT use as a wheelchair or to transport someone. The User Guide indicated, Failure to follow these instructions can lead to serious injury or result in death.

Based on observation, interview and document review, the facility failed to ensure eye drop medications were discarded after 28 days after opening per standard of practice for 3 of 4 residents (R20, R11, R5) observed during the medication storage review of the Harvest Trail medication storage closets. Findings include: On [DATE], at 8:20 a.m. the Harvest Trail household medication storage closets were observed with trained medication aid (TMA)-A. The following were noted: -At 8:23 a.m., R20's medication storage closet was observed to have a bottle of [MEDICATION NAME] eye drops (a medication to prevent pressure in the eye) with an opened date of [DATE], written in pen on the label. - At 8:23 a.m., TMA-A verified the bottle of [MEDICATION NAME] were labeled for use by R20 and the label identified the open date as [DATE], and R20 currently received the eye drops from the bottle. R20's Physician order [REDACTED]. R20's Medication Administration Record [REDACTED]. - At 8:25 a.m., R11's medication storage closet was observed with TMA-A to have a bottle of [MEDICATION NAME] eye drops which had a very small amount of medication remaining in the bottle. The bottle lacked a hand written date the medication bottle was opened. The medication refill date of [DATE] was on the pharmacy printed label. - At 8:25 a.m., TMA-A verified the bottle of [MEDICATION NAME] was labeled for use by R11, the label lacked a hand written date of opening; however, identified the refill date as [DATE]. TMA-A verified R11 currently had an order for [REDACTED]. R11's Physician order [REDACTED]. R11's MAR indicated [REDACTED]. - At 8:43 a.m. R5's medication storage closet was observed with TMA-A to have a bottle of [MEDICATION NAME] eye drops with an opened date of ,[DATE], written in pen on the label, and a bottle of [MEDICATION NAME] eye drops which lacked a hand written date the medication bottle was opened. The [MEDICATION NAME] medication had a refill date of [DATE], printed on the pharmacy label. - At 8:43 a.m. TMA-A verified the bottle of [MEDICATION NAME] was labeled for use by R5 and had a hand written open date of ,[DATE]. TMA-A further identified the [MEDICATION NAME] eye medication was labeled for use by R5 and lacked a hand written date of opening; however, identified the refill date as [DATE]. TMA-A verified R11 currently had orders for [MEDICATION NAME] eye drop to both eyes daily and [MEDICATION NAME] eye drop to the left eye twice a day. R5's Physician order [REDACTED]. R5's MAR indicated [REDACTED]. [MEDICATION NAME] 0XXX,[DATE].5% instill one drop in the left eye twice daily. On [DATE], at 9:03 a.m. the nurse leader (NL)-A reviewed the eye drop medications listed above. NL-A indicated staff typically do label eye drop medications when opened; however, if not labeled when open, would use the medication fill date printed on the pharmacy label as the opened date. NL-A indicated the above-mentioned eye medications possibly were expired. NL-A identified the facility had delegated the night shift to routinely review all resident medication storage closets to ensure medications were not in use after the expiration dates. On [DATE], at 9:45 a.m. NL-A entered the director of nursing's (DON) office and stated, she had called a facility's pharmacy and was informed to follow the expiration dates printed on the medication. On [DATE], at 9:47 a.m. the director of nursing (DON) indicated the facility used the expiration date printed on all eye drop medication including [MEDICATION NAME] and [MEDICATION NAME]. The DON indicated in the past these medications were to be discarded 28 days after opening, but they no longer were on the list provided by the pharmacy. On [DATE], at 12:40 p.m. a call was placed to the pharmacy consultant with a message to return the call. A return call was not received during the survey. Review of the facility provided medication packaging for [MEDICATION NAME] Ophthalmic (eye) Solution 0.25% and 0.5%, and [MEDICATION NAME] brimodine [MEDICATION NAME]/[MEDICATION NAME] ophthalmic solution 0.2 % / 0.5%. did not identify the expiration date after the medication was opened. On [DATE], at 1:44 p.m. the Allergan information line was utilized. The Medical information specialist (MIS) verified [MEDICATION NAME] 0.25% and 0.5% was to be discarded in 28 days after opening, sooner if it became contaminated. The MIS verified the [MEDICATION NAME] eye medication was also to be discarded 28 days after opening the bottle. On [DATE], at 2:04 p.m. the DON verified the facility utilized a list of medications which expired sooner than the printed expiration date, provided by the facility pharmacy consulting company. The DON verified the facility used that guide and would call the local pharmacy with questions. The DON indicated the facility would not consult the medications manufacturer, but would leave that up to the local pharmacy if they didn't have the answers. The facility form titled Medication Expiration Dating, dated ,[DATE], identified, If an item is not on the list below use manufacturers OR pharmacy label expiration. The requested facility policy was not provided.

Based on observation, interview, and document review, the facility failed to ensure nursing staff were trained and assessed for competency following current manufacturer's recommendations for disinfection of glucometer machines in 3 of 3 neighborhoods (Granite View, Orton's Crossing, Harvest Trail), for 18 residents (R2, R5, R6, R11, R12, R13, R15, R16, R18, R22, R29, R30, R31, R34, R38, R39, R42, R100) who received blood glucose testing in the facility. Findings include: On 5/2/18, at 11:36 a.m. R100 was seated in a chair in his room. Registered nurse (RN)-A entered the room, with a light gray, plastic box labeled Stat Strip and gathered supplies to perform a blood glucometer test for R100. RN-A donned gloves, cleansed R100's finger using an alcohol wipe, obtained a sample of R100's blood finger and obtained a blood glucose reading from the Stat Strip glucometer. RN-A proceeded to set the glucometer on R100's bathroom counter and discard the used blood glucose testing supplies into a sharps container in the bathroom. RN-A picked up the glucometer, exited R100's room and walked to a computer cart located in the hallway. RN-A placed the glucometer between her upper arm and side while she cleaned her hands with hand sanitizer. RN-A then held the glucometer and opened an individual packet labeled Covidien Webcol 70% [MEDICATION NAME] alcohol swab and removed a 2-ply non-woven sponge, wiped the front portion of the glucometer and the test strip port and set the glucometer on the rolling computer cart outside of R100's room and rolled the cart to the nurses station. On 5/2/18, at 11:40 a.m. RN-A stated nursing staff always used alcohol pads to wipe off the glucometers and confirmed the Nova Stat Strip glucometer was now clean and ready to use for other residents on Orton's Crossing, as the glucometer was used to test blood samples on al residents who required blood glucose testing on the unit. On 5/2/18, at 11:43 a.m. R11 was seated in a chair in her room. RN-B entered the room, RN-B washed hands in R11's bathroom, donned gloves, cleansed R11's finger using an alcohol swab, used lancet to puncture R11's skin, placed the glucometer strip near the blood on R11's finger and obtained a sample of blood on the testing strip. RN-B obtained the blood glucose level from the glucometer, removed the testing strip and placed the strip, alcohol swab and used lancet in the sharps container in R11's bathroom. RN-B then wiped the glucometer with one alcohol swab and set the glucometer in a plastic bin on the computer caddy. On 5/2/18, at 11:48 a.m. RN-B stated nursing staff had always used an alcohol swab to clean the Nova Stat Strip glucometers, and confirmed the glucometer was a common use glucometer in the Harvest Trail Neighborhood. On 5/2/18, at 12:13 p.m. R2 in a wheelchair in his room with RN-A present. RN-A donned gloves, gathered supplies to perform a blood glucometer check for R2. RN-A cleansed R2's finger with an alcohol swab, and obtained a sample of blood on the testing strip. RN-A disposed the used blood sugar testing supplies in a sharps container in the bathroom and exited the room. RN-A walked to the computer cart in the hallway, wiped the outside of the glucometer with one alcohol swab and placed the glucometer on the computer cart. On 5/2/18, at 12:16 p.m. RN-A stated she always used alcohol swabs to clean the Nova Stat Strip glucometer and confirmed it was a common use glucometer. On 5/2/18, at 1:08 p.m. director of nursing (DON) stated the policy for cleaning the Nova Stat Strip glucometers had recently been updated and referred directly to the updated policy. The DON stated the glucometers should be cleaned after each use with either a 10 % (percent) bleach solution or 70% [MEDICATION NAME] alcohol (rubbing alcohol) solution. The DON confirmed all facility glucometers were common use and could be used on any resident with blood glucose testing orders. She confirmed she was aware the usual facility practice was for staff to use alcohol wipes to disinfect the common use glucometers. On 5/2/18, at 1:28 p.m. the DON provided the Stat Strip Glucose Hospital Meter, Instructions for Use Manual, dated 6/2011. The manual's Table of Contents showed, 6.3 Cleaning the Meter. 6.3 Cleaning the Meter instructed the user to use a 10% bleach solution or 70% [MEDICATION NAME] alcohol solution to clean the glucometer. On 5/2/18, at 1:41 p.m. during a phone interview, Nova Biomedical Technician (NBT)-A stated the Nova Stat Strip glucometer should be cleaned utilizing a 10% bleach wipe, but other approved cleaning products could be used and would provide the approved Stat Strip cleaning product list. On 5/3/18, at 9:41 a.m. the DON reviewed the Nova Biomedical Customer Information Bulletin dated 12/4/12, regarding the cleaning and disinfection procedure for the Stat Strip glucometer. The bulletin indicated Clorox Healthcare Bleach Germicidal Wipes were the only product validated for use with the Stat Strip system. The bulletin further indicated hospitals that utilized an alternate germicidal product and disinfection, should select a product on the Environmental Protection Agency (EPA) List D. The DON reviewed the EPA List D and indicated 70% [MEDICATION NAME] alcohol was not included on the list. On 5/2/18, at 3:04 p.m. RN-C stated the common use glucometers were cleaned after use on the Granite View Neighborhood by using two by two alcohol swabs to wipe the glucometer. RN-C stated the last education she had received regarding glucometers was when they moved to the new facility last year. RN-C stated the education provided by the facility included the use of alcohol wipes to clean the common use glucometers. RN-C stated she was unsure what the current standard of practice for glucometer cleaning was. On 5/3/18, at 8:46 a.m. clinical manager (CM)-B stated she expected staff to disinfect the common use glucometers with Cavi wipes (a disinfecting wipe, on EPA List D) . She indicated she was unaware staff were using the alcohol wipes, stated she was surprised and stated that method has been out of practice for years. On 5/3/18, at 10:14 a.m. infection preventionist (IP) for the facility, who also identified herself as the associated hospital's infection preventionist, indicated the facility staff had questioned how to disinfect the glucometers and she had reviewed the manufacturer's guidelines for disinfection. IP stated she had trained nursing staff to use the [MEDICATION NAME] alcohol swabs for cleaning the common use glucometers between each resident. The facility policy titled Nova Meter Cleaning and Disinfection, last revised 3/8/16, indicated the glucose meters that are used for more than one resident must be cleaned and disinfected after each use. A 10% bleach solution or 70% [MEDICATION NAME] alcohol solution should be used to disinfect the Nova glucose meter.

Based on observation, interview and document review the facility failed to dispose of garbage in a sanitary manner to prevent facilty contamination areas, including the kitchen, which had the potential to affect all 50 residents who resided in the facility. Findings include; On 4/30/18, at 2:20 p.m. a kitchen tour was completed with dietary manager (DM)-A which included the kitchen's garbage disposal area. DM-A indicated the kitchen staff disposed of the kitchen garbage by bringing closed bags to the maintenance room across the hall from the kitchen area. The room had two areas, with an open door between the areas. In the back area there was a small dumpster in the right corner and a garbage compactor machine next the the dumpster. An area approximately 2 feet in front of the dumpster and compactor was soiled with brown liquid spills, food partials and a few small white pieces of plastic. DM-A indicated the maintenance staff would use the garbage compactor and then transport the garbage to the large dumpster's outside the facility near the garage area. At 6:35 p.m. DM-A confirmed the floor was dirty in front of the dumpster and compactor in the maintenance room. DM-A indicated kitchen staff routinely were in the room and agreed it was a problem for kitchen staff stepping on the soiled floor and returning to the kitchen area. DM-A indicated maintenance staff were responsible for cleaning the area and were not available at that time for interview. On 5/1/18, at 9:58 a.m. director of clinical operations (DCO)-A indicated she had been informed of the condition of the floor in the maintenance room near the dumpster and had spoken to the maintenance staff who had cleaned the area that morning. DCO-A and surveyor toured the area and the floor was no longer soiled. DCO-A indicated the facility plan was to remove the compactor from the facility to the garage to help keep the area clean. DCO-A confirmed the area was soiled prior to being cleaned that morning. On 5/02/18, at 10:20 a.m. DCO-A confirmed the facility had no cleaning schedule for the floor to be cleaned near the dumpster and compactor area. A facility policy titled Fairway View Garbage Disposal, dated 3/16/18, indicated garbage bags were brought to the EVS (environmental services )room. EVS staff would place trash in compactor for compacting, then remove the compacted trash to the dumpster for removal. EVS staff would clean compactor and compactor area periodically.