Every finding on record at Fieldstone of Dewitt

Based on clinical record reviews, facility policy reviews, facility record reviews, resident and staff interviews, the facility failed to ensure call lights answered in a timely manner for 4 of 4 residents (Resident #14, Resident #15, Resident #23, Resident #30) reviewed for call lights. Facility reported a census of 63.Findings include: 1.Review of Resident #14 Minimum Data Set assessment dated [DATE] revealed intact cognition based on a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The diagnoses listed included a abnormalities of gait and mobility, fracture, and hypertension. The MDS indicated Resident #14 dependent for chair/bed-to-chair transfer and toilet transfer; dependent for toilet hygiene and required partial/moderate assistance for personal hygiene. During an interview on 5/19/2026 at 8:31 AM, Resident #14 stated that she had had to wait over an hour for staff to respond to her call light, and frequently has to wait more than 15 minutes. Resident #14 stated she used a hoyer lift (a mechanical lift, hoyer is a brand name and not identified as the brand used by the facility, rather it is generic trademark often used for a mechanical lift) which took 2 staff, when she needed to use the bedpan. Resident #2 noted the delays could cause her discomfort and the result in her being incontinent. She explained that she is normally able to use a bedpan and avoid being incontinent. Resident 14 described staff members coming into her room to turn off the call light and then leave, and then waiting for another half hour before they returned. A review of the facility provided call light log for Resident #14 revealed: a. On 4/21/2026 at 7:29 AM light activated for 26 minutes(m) 38 seconds(s). b. On 4/25/2026 at 8:28 AM light activated for 18m 24s. c. On 4/25/2026 at 10:56 AM light activated for 29m 55s. d. On 4/29/2026 at 4:30 PM light activated for 16m 15s. e. On 5/1/2026 at 1:41 PM light activated for 16m 20s. f. On 5/2/2026 at 6:54 AM light activated for 16m 40s. g. On 5/4/2026 at 6:10 AM light activated for 18m 3s. h. On 5/5/2026 at 7:07 AM light activated for 16m 34s. i. On 5/9/2026 at 7:48 AM light activated for 19m 4s. j. On 5/19/2026 at 7:02 AM light activated for 36m 43s. During an interview on 05/ 20/2026 at 12:10 PM, Staff B, Certified Nursing Assistant (CNA) stated that some call lights still took longer than 15 minutes to answer due to more intense resident needs. She explained that when the facility is at full capacity, there are typically two CNAs assigned to each Home, plus two float CNAs who move between the homes to help where needed. If a staff member calls in sick, a CNA is usually pulled from another area to cover multiple homes. Because the Homes are far apart, these floating staff members have to walk long distances, making it harder to provide timely care. She added that when residents turned their call lights back on shortly after receiving care, she had to inform them that it would take a while for staff to return because they had to care for other residents first. During an interview on 05/20/2026 at 2:55 PM, Staff C, Registered Nurse (RN) stated that the facility had been experiencing ongoing staffing shortages for some time, including during the current week despite a low number of residents. She stated that she was unable to take a break because she had to manage two separate resident Homes by herself. Staff C explained that because the units were located too far apart, it was difficult for staff to provide resident care in a timely manner. She stated that the workload was particularly heavy on Thursdays when two medical practitioners visited the building, as nursing staff had to spend extra time processing and updating new medical orders during patient rounds. Staff C explained that staff were trained to turn off the call light upon entering a room. If they could not assist the resident immediately, they would inform the resident that they had to help someone else first. Staff were then supposed to turn the call light back on before leaving the room to serve as a visual reminder to return later, but this often doesn't happen leaving the resident to wait for longer periods of time. She stated that during high workload times she would often request help from Nurse Managers, but they would rarely step in to assist. During an interview on 5/21/2026 at 10:36 AM, the Administrator stated that the facility sometimes does not meet their staffing targets. The Administrator explained that on Thursday's when providers are rounding, floor nurses can request assistance if they are feeling overwhelmed, and the Nurse Managers are required to help during those times. The Administrator stated management reviewed call light reports daily during huddles to identify unusual delays. 2. Review of the MDS for Resident #23 dated 3/1/26 revealed diagnoses of non-Alzheimer's dementia, Parkinson's disease, and restlessness and agitation. The MDS identified Resident #23 dependent for transfers and bathing, and required substantial/maximal assistance with hygiene and dressing. During an interview on 05/19/2026 at 4:23 PM, Resident #23 and their spouse reported concerns about the number of aides available for bathing, meals, and cares. The spouse stated a CNA recently told them she couldn't give the resident a shower when they wanted one because she was the only one there and they just had to wait for someone else to show up. The spouse reported staff were very kind, there were just not enough of them for residents with that much need. During an interview on 05/21/2026 at 10:15 AM Staff D, CNA reported residents and family had complained to her about not having enough staff. She stated it was hard to get everything done when it was just her and one other person for 16 residents and thought over half needed two people to help them transfer. A document provided by the facility titled Kardex Report as of 5/20/26 confirmed that 9 of 16 residents in Resident #23's household required the assistance of 2 staff. 3. Review of the MDS for Resident#15 dated 4/15/26, revealed diagnoses of osteoporosis, arthritis and anxiety disorder. A BIMS score of 15 out of 15 indicated intact cognition. The MDS identified Resident#15 dependent on staff for toileting hygiene, lower body dressing, and chair to chair or to bed transfers. Review of Resident #15 Care Plan revealed a Focus area to address The resident has an ADL (activities of daily living) performance deficit r/t (related to) Activity intolerance, confusion, impaired balance due to effects of spastic paraplegia, intractable right hip pain with need of assistance to complete most ADL tasks. Interventions included in part, Hoyer Lift; TOILET USE: The resident is incontinent and requires assist x 2 to complete management of incontinence. Does not transfer to the toilet at this time; BED MOBILITY: The resident needs assist x 1-2 with bed mobility, watch for pain. TRANSFER: The resident required Mechanical lift (hoyer) with 2 staff assistance for transfers. A review of the facility provided call light log for Resident #15 revealed: a. On 05/03/26 at 8:10 AM light activated for 31m 20s. b. On 05/09/26 at 1:19 PM light activated for 17m 3s. c. On 05/15/26 at 7:40 AM light activated 29m 4s. d. On 05/15/26 at 10:05 AM light activated 19m 18s. e. On 05/15/26 at 1:43 PM light activated 24m 11s. f. On 05/16/26 at 11:35 AM light activated 16m 13s. g. On 05/17/26 at 10:16 AM light activated 22m 16s. h. 05/18/26 at 7:36 AM light activated 22m 19s. i. 05/19/26 at 6:46 AM light activated 24m 49s. During an interview on 05/20/2026 10:36 AM, Resident #15 reported she put her call light on last night and it took 45 minutes before the staff got her to bed. She said she soaked through her pants. Resident#15 said the call lights on for over 15 minutes happens a few times a week on all the shifts. She reported the facility needed more staff. Resident #15 stated she's gone to the Resident Council meeting and has reported her concern. 4. Review of Resident #30 MDS dated [DATE], revealed diagnoses of heart failure, diabetes mellitus (DM) and malnutrition. The BIMS score of 12 out of 15 indicated a moderate cognitive impairment. The MDS indicated Resident#30 dependent on staff for toileting hygiene and toileting transfers. Review of the Care Plan for Resident #30 revised date 1/3/25 included a Focus area to address The resident has an ADL self-care performance deficit r/t Weakness and debility post hospitalization r/t pneumonia with respiratory failure, vision loss with need for assistance to complete most ADL tasks. Interventions included, in part: TOILET USE: The resident needs assist x 2 with Sara Steady (a type of mechanical lift) to transfer to and from the toilet. Assist with clothing and hygiene management. I prefer for staff to remain with me while using the Restroom. A review of the facility provided call light log for Resident #30 revealed: a. 05/09/26 at 11:15 AM light activated 18m 42s. b. 05/11/26 at 6:17 AM light activated 39m 3s. c. 05/13/26 at 9:22 PM light activated 25m 25s. d. 05/15/26 at 5:19 AM light activated 16m 26s. e. 05/17/26 at 7:04 AM light activated 17m 59s. f. 05/17/26 at 7:41 AM light activated 18m 44s. g. 05/18/26 at 6:46 AM light activated 20m 44s. h. 05/19/26 at 10:42 AM light activated 18m 5s. i. 05/19/26 at 12:45 PM light activated 17m 31s. During an interview on 5/20/26 at 10: 52 AM, Resident#30 reported staff came into her room in the morning to get her call light when she wanted to get up. The staff told her they needed to get two other residents up and then they would be back to help her. During an interview on 05/20/2026 at 2:42 PM, Staff J, Licensed Practical (LPN) said all the residents say not enough staff. Staff J reported they complain the staff float from one unit to the other and it is a big place, it takes time. Staff J said nurses float 2 wings. Staff J said the call lights alarm to the system and pop up on the phone and keeps going until they get the light, more than 15 minutes sometimes. During an interview on 05/20/2026 at 3:21 PM, Staff I, Assistant Director of Nursing (ADON) reported the call lights can go long. Staff I reported she expected the staff to get the all light in 10 minutes. Staff I stated they get a report and are to review call light logs daily. During an interview on 5/21/26 at 10:35 AM, the Resident Council President, Resident #13 reported residents in the meeting have reported at times they are put in the restroom and have to wait for 30 minutes before the staff comes back and helps them. During an interview on 05/20/2026 3:29 PM, Staff A, LPN stated they keep the phone in their pockets and can see the call lights. Staff A confirmed residents reported long call light times at least weekly. Review of Resident Council notes dated March 2026 revealed Administration concern: Would like more CNAs on each shift. The notes included a March 2026 Department Response page. The Administration section response to the concern read: Response: In response to the request for more CNA's: We understand how important consistent staffing is to your comfort and well-being. We staff each shift based on the number or residents we are serving, and the care needs of our community. We schedule to meet or exceed state-required expectations, and we build our schedules with enough team members to support quality care. However, when we experience unexpected team call-offs or no-call/no-shows at the start of a shift, it can create gaps that are difficult to fill on short notice. We consistently reach out to available team members or agency support as needed, but those options are not always immediately available – in which we will reorganize the staffing structure to best meet the needs of our community., In addition, we balance staffing within our budget to ensure that we are good stewards of our financial resources while prioritizing resident needs. We are actively working on improving attendance and reducing call-offs so that we can maintain consistent coverage across all shifts. Please continue to share suggestions at any time. Review of the facility policy titled Call System Use dated 2026 included Purpose section which included: To respond promptly to resident's call for assistance and To assure call system is in proper working order. The Procedure section directed, in part: a. Answer ALL call system calls promptly, whether or not you are assigned to the resident. b. Never make the resident feel you are too busy to give assistance; offer further assistance before you leave the room.

Based on observation, record review and staff interview the facility failed to maintain the cleanliness of kitchen equipment and the areas used for resident food prep in an effort to prevent food borne illness. The facility identified a census of 63 residents. Findings include: During an initial kitchen observation on 5/18/2026 at 9:50 AM:a. The vents over the stove noted to have a grease buildup, and oil stains noted at the base. b. Several small dried white splash-like areas noted on the floor near the stove.c. Black debris noted over the top of the stove and a grease build up observed at the back of the fryer. During an observation of the bistro kitchen on 05/20/2026 at 11:10 AM:a. Main kitchen area under hood of grill and fryers are splatters of dried substance.b. A buildup of debris noted on the bent above the grill on the front of stove.c. Runs of a dried substance on the front of the fryer.d. The freezer next to the fryer had a dried brown substance on the door, and on the back of the top prep area.e. A buildup of spills and dried runs of a substance on the lower half and side of the oven.f. Garbage can next to oven uncovered. g. Dried splashes of a substance noted on the refrigerator doors, and spills of a white substance on the inside and outside of the glass doors. h. Smeared, dried white and brownish red substance noted on the handles of the refrigerator. During an interview on 05/21/2026 at 10:56 AM, Staff K, [NAME] stated staff have a cleaning schedule. She explained The Bistro is cleaned every Sunday. Staff K stated staff sweep and mop and wipe down everything, every night. Staff K added on a weekly basis staff pull equipment, like the fryer and grill out and wipe down behind it. She stated Maintenance cleans the hood above the fryer and grill once every 3 months. Staff K explained the stove has to be disconnected from the gas to clean on the side of it and there is a large amount of food crumbs and debris on the floor. Staff K acknowledged there are spills going down the wall and on the side of the stove of dried food. During an interview on 05/21/2026 at 11:10 AM, the Dietary Manager stated he would expect the areas around the stove and grill/fryers to be clean. He stated there is a cleaning schedule posted on the wall in the Bistro. The side of the stove and the hood above are done by contracted staff. Review of the facility document titled Food and Safety Sanitation Checklist dated 10/20/24, directed staff to make sure food contact surfaces smooth, easily cleaned, and free of breaks, seams, cracks, chips, and pits. The checklist directed staff to check the refrigerator, range/oven, and fryer clean. It also directed for the hood to be cleaned professionally routinely. The checklist indicated garbage cans should be covered unless in use.

Based on observation, clinical record review, facility policy review, resident and staff interviews, the facility failed to assess and intervene with a high blood sugar result for 1 of 1 resident (Resident #76) reviewed. The facility reported a census of 63 residents.Findings include:The Minimum Data Set (MDS) assessment for Resident#76 dated 5/15/26, listed diagnoses of diabetes mellitus and osteoporosis. The Brief Interview for Mental States (BIMS) reflected a score of 15 out of 15, indicating intact cognition. The MDS did not identify any high-risk medications used by Resident #76. The MDS identified an admission date of 5/11/26. Review of Resident #76's Care Plan dated 5/20/26, revealed a Focus area to address The resident has Diabetes Mellitus. Interventions initiated on 5/20/26 included:a. Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. b. Monitor/document/report PRN (as needed) any s/sx (signs or symptoms) of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing, acetone breath (fruity smell), stupor, coma. c. Monitor/document/report PRN any s/sx of hypoglycemia: Sweating, Tremor, Increased heart rate (Tachycardia), Pallor, Nervousness, Confusion, slurred speech, lack of coordination, Staggering gait. d. Fasting serum blood sugar as ordered by doctor. Review of the May 2026 Medication Administration Record (MAR) revealed the following orders:a. Blood Sugar checks 4 times per day. ACHS (before meals and at bedtime) and PRN for diabetes mellituis. b. Insulin Lisp injection 100 units/milliliter (ML) subcutaneous (SQ, meaning injection into fatty layer under the skin) sliding scale (amount of insulin to be administered based on blood sugar reading) three times a day with meals: Blood sugar of 150-200=1 UNIT; 201-250=2 UNITS; 251-300=3 UNITS; 301-350=4 UNITS; and 351-400=5 UNITS.The Insulin Lisp order did not provide parameters of when to call the provider in the event of low blood sugar (typically below 70 mg/dl) or a high blood sugar (above 400 mg/dl)Review of the May 2026 MAR revealed a blood sugar reading of 500 mg/dl at 8:00 AM on 5/17/16. Review of the electronic health record (EHR) revealed a X-Orders Administration Note Progress Note entered on 5/17/26 at 8:57 AM which stated the MAR order for Insulin Lisp, and Registered HI - rechecked after insulin 323. During an interview on 5/19/2026 at 8:50 AM, Resident #76 stated she had not gotten her insulin yet.During an interview on 05/20/2026 at 2:40 PM, Staff J, Licensed Practical Nurse (LPN) stated if a resident had a blood sugar of 500 mg/dl she would assess the resident, call the Provider for what to do next. Staff J added this would need to be documented in the Progress Notes. During an interview on 05/20/2026 at 3:03 PM. Staff I, Assistant Director of Nursing (ADON) stated residents on sliding scale insulin needed parameters for when to notify the Provider of a high or low blood sugar. Staff I explained she and the other ADON check to make sure the parameters are in place on admission. Staff I stated they missed that for Resident #76. Staff I reported she expected the nurses to complete an assessment with a high blood sugar, notify the Provider for orders, inform the family and document in the progress notes. Staff I confirmed she failed to see an assessment, provider notification or orders in the progress note for Resident#76 on 5/17/26. Review of an undated facility tool titled Admit Audit Leadership included Diabetic - YES/NO and the options to indicate Insulin/MAR and BG (blood glucose) checks w/ (with) parameters. Review of the facility policy titled Hyperglycemia Guidance dated 11/2025, it directed staff to obtain accucheck (blood sugar). See accucheck order for parameters for physician notification. If no parameters outlined-notify Provider if results greater than 300.

Based on observation, clinical record review, manufacturer instructions, facility record review, facility policy review and staff interviews, the facility failed to prime an insulin pen as directed by the manufacturer for 1 of 1 resident (Resident #77) reviewed for insulin administration; and failed to ensure a resident only received medications prescribed to them for 2 of 2 residents (Resident #73 and Resident #35) reviewed for medication errors. The facility reported a census of 63 residents.Findings include: 1. Review of Resident #77's entry Minimum Data Set (MDS) assessment dated [DATE] revealed the resident admitted to the facility on the same date. Review of the electronic health record (EHR) Diagnosis List revealed, in part: Type 2 diabetes mellitus.and long term (current) use of insulin.Review of May 2026 Medication Administration Report (MAR) revealed an order for: Fiasp (type of fast acting insulin) flex inj[ection] touch inject 'SQ (subcutaneous, an injection made into the fatty tissue under the skin) per sliding scale (amount of insulin delivered based on blood sugar) before meals: Blood Glucose: 80-130=5 UNITS; 131-160=6 UNITS; 161-190=7 UNITS; 191-220=8 UNITS; 221-250=9 UNITS; 251-280=10 UNITS; 281-310=11 UNITS; 311-340=12 UNITS; 341-370=13 UNITS; 371-410=14 UNITS. Greater than 410 = 15 units. During an observation on 05/20/2026 at 7:11 AM, Staff H, Registered Nurse (RN) prepared the resident for her insulin by checking her blood sugar. The RN entered the blood sugar result of 118 mg/dl (milligrams/deciliter), into the EHR and determined Resident #77 required 5 units of insulin. Staff H sanitized her hands, donned clean gloves, checked the pen against the MAR, and turned the dial to 5. She asked the resident where she wanted her insulin and administered it to her stomach as requested. Staff H held the pen in place for a count of 4-5 seconds and removed it.During an interview with Staff H, RN at 7:19 AM on 05/20/2026, when asked if insulin pens needed to be primed (turning the dial to 2 and depressing the injector to 0 to remove air bubbles and ensure the resident received a full dose of insulin), she stated that particular insulin pen did not need to be primed like the resident's long-acting insulin pen did.A document provided by the facility titled Instructions on how to use Fiasp Flextouch directed, in part:2 Check the insulin flow (page 49 of 50) directeda. Always check the insulin flow before you start. This helps you to ensure that you get your full insulin dose.b. Turn the dose selector to select 2 units. Make sure the dose counter shows 2.c. Hold the pen with the needle pointing up. Tap the top of the pen gently a few times to let any air bubbles rise to the top.d. Press and hold in the dose button until the dose counter returns to 0. The 0 must line up with the dose pointer. A drop of insulin should appear at the needle tip. A small air bubble may remain at the needle tip, but it will not be injected. If no drop appears, repeat steps 2A to 2C up to 6 times. If there is still no drop, change the needle and repeat steps 2A to 2C once more. 4 Inject your dose (page 51 of 52) directed, in part:a. Keep the needle in your skin after the dose counter has returned to 0 and count slowly to b. If the needle is removed earlier, you may see a stream of insulin coming from the needle tip. If so, the full dose will not be delivered. During an interview on 5/21/26 at 10:20 AM, Staff E, Licensed Practical Nurse (LPN) stated insulin pens should be primed before every administration. She stated there was a cheat sheet in the medication room and that to her knowledge all insulin pens should be primed before administration to ensure the resident got the full dose of insulin.During an interview on 05/21/2026 at 10:34 AM, the Director of Nursing (DON) stated she expected the nurses to prime insulin pens before every administration, and facility policy was to hold the needle in the resident's skin for 5-10 seconds to insure an accurate dose. She reported that staff were educated on insulin pen use.2. Review of Resident #73's MDS assessment dated [DATE], revealed diagnoses of hypertension, Parkinson's disease, and chronic obstructive pulmonary disease. The BIMS score of 5 out of 15 indicated a severe cognitive impairment. Review of the October 2025 MAR revealed the following medications prescribed for Resident #73: carbidopa-levodopa 10-100mg, risperidone 0.25mg, furosemide 40mg, ticagrelor 90mg, and metoprolol succinate ER (extended release) 25mg. Review of a facility Medication Error report dated 10/1/2025 at 11:00 AM revealed Went into resident's [Resident #73] room to give morning medications, realized resident was on bedpan; placed medications on med cart with plan to return to room when resident available. Went into (name redacted, Resident #73) room to give morning medications. Had to leave room to get insulin pen needles, placed cup of pills in locked drawer. Returned to room and grabbed the medications off med cart and gave to (name redacted, Resident #73). Insulin was given and when returning pens to drawer realized cup of pills was still in drawer. Immediately called (name of medical provider redacted) and spoke with (name of nurse practitioner name redacted) received back from (NP name redacted) after reviewing medications. Order received to hold Metoprolol x 1 dose, hold Lasix x 1 dose, hold Brilinta x 1 dose. Check BP (blood pressure) and Pulse Q (every) 2 hours x 12 hours. Hospice was notified, no orders received. TC placed to daughter, message left, no answer. BP 110/62, Pulse 79. Resident awake and resting in bed3. Review of Resident #35's MDS dated [DATE], revealed a diagnoses list which included Parkinson's disease, non-Alzheimer's dementia, and anxiety. The Brief Interview for Mental Status (BIMS) score of 8 out of 15 indicated a moderate cognitive impairment. Review of the March 2026 MAR revealed Resident #35 prescribed the following medications to be taken during the morning medication pass: furosemide 20 mg, lisinopril 20 mg, potassium chloride 10 mEq (milliequivalents), amlodipine 10 mg, and carbidopa-levodopa 25-100 mg.Review of the EHR Progress Note dated 3/26/26 at 7:29 AM revealed, in part: This nurse gave resident [Resident #35] the wrong medication, call to Dr on call.Review of the EHR Encounter note dated 03/26/2026 revealed, in part: .Chief Complaint: Medication error.I received a phone call this morning noting that nurse made a medication error. Patient [Resident #35] given another patient's medications. He was given aspirin, Plavix, diltiazem 120, Lasix 80, potassium 10 mEq, probiotic, Tylenol. He has had no side effects.documented the chief complaint for the provider's visit was a medication error. During an interview on 05/21/2026 at 10:20 AM, Staff E, LPN stated she knew staff had training about medication errors. Part of the education was related to medication cards in the wrong drawer and how to prevent those errors. She thought that training was last year. Another education, maybe in February or March, included not leaving medications with residents and not leaving medication cups with medication in it on the carts in the hallway.During an interview on 05/21/2026 at 10:34 AM, the DON stated that only the nurses involved in the medication errors (r/t to Resident #35) received training. She said the incident with Resident #35 was a one-off situation and that nurse received counseling. When asked about the error with Resident #73 she stated there was a different DON at that time this error was made. She reported there was a skills fair later that year so all of the nurses would have been educated then.During an interview on 05/21/2026 at 11:11 AM, Staff F, Advanced Registered Nurse Practitioner (ARNP) stated she was able to follow up with both residents in person within a day or two. Both Resident #35 and Resident #73 required blood pressure monitoring and had to have their regular medications held. She did not think Resident #35 had any long-term impact. Resident #73 had initial fatigue and blood pressure monitoring had to be extended an extra 12 hours.In response to a request for documentation of Medication Administration education the facility provided an undated document for annually required training plans provided, which included: Quality Assurance and Performance Improvement, Dementia Care, Protecting Resident Rights, Alzheimer's Disease and Related Disorders: Communication, and Behavioral Health for Older Adults. Review of the facility policy titled Accident/Incident Investigation and Reporting Policy and Procedure documented the intent was to ensure the facility provided an environment that was free from accident hazards over which the facility has control. Medication errors were included as a type of accident/incident that required investigation.

Based on observation, policy review and staff interview the facility failed to utilize proper food handling to prevent potential cross contamination of food, ensure food maintained appropriate temperature to prevent food borne illness and proper hand hygiene/hand washing for 1 out of 1 meal observed. The facility reported of census 65 residents. Findings include: During continuous observation of puree process and meal service on 8/21/24 at 11:45 AM to 12:40 PM Staff D, Homemaker-Cook presented wearing black nitrile gloves upon surveyor arrival to the household kitchen. Staff D, Homemaker-Cook placed 1/2 half cup of potato salad in Cuisinart/blender. Staff D, Homemaker-Cook used a rubber spatula to scrap the potato salad into a small bowl. The bowl was covered with aluminon foil and placed in the refrigerator. Staff D, Homemaker-Cook brought the Cuisinart/blender container and placed the mixing container and lid in the sink. The blade was set on the counter to the right of the sink. Staff D, Homemaker-Cook used her gloved left hand to turn on the faucet and rinse the lid, rubber spatula, blade and Cuisinart/blender mixing container. Staff D, Homemaker placed the Cuisinart/blender mixing container on the base, installed the blade and set the lid and rubber spatula off to the side on the counter. Staff D, Homemaker-Cook using tongs placed 1 pork tenderloin patty into Cuisinart/blender. Staff D, Homemaker-Cook warmed chicken broth up in the microwave and added it to the pork tenderloin patty to puree. Staff D, Homemaker-Cook scrapped the pureed pork tenderloin using the rubber spatula into a bowl, covered with aluminon foil and set on top of the two steamwell food warmer. Staff D, Homemaker-Cook disassembled Cuisinart/blender mixing container and rinsed it under the faucet using gloved hands and rubber spatula. Staff D, Homemaker-Cook reassembled Cuisinart/blender mixing container and blade setting the lid off to the side. Staff D, Homemaker-Cook dried gloved hands with paper towels, pulled open trash container drawer with her left gloved hand and disposed of used paper towels. Staff D, Homemaker-Cook grabbed a bun with her left gloved hand from an open package on the counter. The bun was placed in the Cuisinart/blender and pureed with chicken broth. Staff D, Homemaker-Cook used the same spatula to scrape the pureed bun into a bowl. Bowl was covered with aluminon foil and placed on the steam food warmer lid. The Cuisinart/blender mixing container, blade, lid and spatula were placed in the sink. Staff D, Homemaker-Cook, went into the food prep area and grabbed an unwarpped onion, green pepper and red pepper from a black cart into the food prep area refrigerator. Staff D, Homemaker-cook wiped both gloved hands on the sides of her pants and walked back into the kitchen area. The refrigerator was opened with her right gloved hand and lemonade, iced tea and raspberry juice pitchers were placed on the counter. Staff D, Homemaker-Cook opened the ice bin and used a scoop to place ice cubes in stainless steel bowl. Staff D, Homemaker-Cook, with gloved hands used ice scoop to place ice in 13 8-ounce glasses and filled with beverages. Staff D, Homemaker-Cook placed filled glasses on a tray and passed drinks to residents touching the rim of the glasses with her gloved left hand. Staff D, Homemaker-Cook grabbed a paper towel and dried off the used beverage tray and placed pre-dished bowls of salad on the tray. Salads were passed to residents in the dining area. Staff D, Homemaker-Cook removed gloves and washed hands, turning the faucet off with her wet hands. Staff D, Homemaker-Cook donned gloves placed pureed meal on plate and brought to resident sitting at the table. She rinsed the Cuisinart/blender that was sitting in the sink under the faucet with her gloved hands touching the inside surface of the Cuisinart/blender mixing container. She placed the Cuisinart/blender mixing container on the base, dried her gloved hands with paper towels and pulled opened the drawer with her left gloved hand where the trash container was located to dispose of the used paper towels. Staff D, Homemaker-Cook placed used tongs to place two pork loins in the Cuisinart/blender to prepare mechanical soft meal for two residents. She used her left hand to grab a bun from the open package on the counter, used both gloved hands to tear open the bun and then used a spatula to portion out approximately 1/4 cup of mechanical soft pork loin on the bun. Staff D, Homemaker-Cook served ten residents pork tenderloin sandwich using her left gloved hand to take the bun out of the packaging. While holding the bun in her left gloved hand, she used her right gloved hand to tear the bun in half opening it up. The bun was placed on a plate. Tongs were used to place a pork tenderloin on the bun. Staff D, Homemaker-Cook used her left gloved hand was to place the top of bun on the pork tenderloin. Observed 4 times Staff D, Homemaker-Cook use her right gloved fingers to grab 2 pickles slices and placed them on the plate beside the sandwich. Staff D, Homemaker-Cook opened drawers to obtain condiment dishes and open refrigerator for condiments with gloved hands. Staff D, Homemaker-Cook removed peanut butter cookies from a parchment lined cookie sheet with the same gloved hands placing one cookie on a plate serving the13 residents in the dining area. Staff D, Homemaker-Cook failed to utilize hand washing. Observed Staff D, Homemaker-Cook removed her gloves two times and washed her hands. Staff D, Homemaker-Cook, turned on faucet, wet hands, applied soap and washed her hands. Staff D, Homemaker-Cook used her left hand to shut the faucet off and then reached for a paper towel to dry her hands. Staff D, Homemaker-Cook failed to use a dry paper towel to shut the faucet off. The faucet is a contaminated surface failing to prevent cross contamination of food. Observed Staff D, Homemaker-Cook recorded temperatures of pureed meat and mechanical ground meat prior to serving. One resident was served pureed pork loin with a temperature of 114 degrees Fahrenheit. Two residents were served the mechanical soft pork loin with a temperature of 123 degrees Fahrenheit. Staff D, Homemaker-Cook failed to reheat the pureed and mechanical soft meat to appropriate temperature to prevent food borne illness. A record review revealed two residents with pureed diets and five with mechanical soft diets. The temperature logs for the month of August 2024 revealed no columns for temperature recordings for the puree or mechanical ground diets. During an interview on 8/21/24 at 12:46 with Staff D, Homemaker-Cook, reported she had not received training on food handling. She stated her process for cleaning the Cuisinart/blender in between preparing mechanical soft or puree food items, is to rinse it under the faucet and replace it on the base of the unit for continued use. She stated that she normally does not use the Cuisinart/blender for mechanical soft diets. For the mechanical soft diet, she reported her normal practice is to use a knife and fork to cut items in small pieces. She reported that she received training on proper food temperature from her supervisor and instructed to bring food to the appropriate food temperature prior to serving. She acknowledged she should have reheated the mechanical soft and puree meat. She stated she has had training on hand washing technique. During an interview on 8/21/24 at 12:54 with Staff E, Director of Food and Beverage, revealed she did observe Staff D, Homemaker-Cook rinse the Cuisinart/blender mixing container, lid, blade and rubber spatula for continued use. She reported the expectation is to run the items through the dish machine between uses. Staff E, Director of Food and Beverage reported earlier today she reminded Staff D, Homemaker-Cook to bring pureed items to proper temperature before serving. The temperature of pureed and mechanical soft items are taken after the process has been completed and brought up to appropriate temperature prior to serving to the resident. The Food Safety Policy dated 07/2024 revealed cross contamination occurs when harmful substances are transferred from one source (i.e. hands, food contact surfaces, unsanitary cleaning cloths, raw foods) to the food. The policy failed to mention touching contaminated surfaces with gloves and contact with ready to eat food. The Hand Washing and Hand Hygiene policy dated 08/24 revealed hand hygiene to be completed before touching medication and food given to a resident. The undated Hand Hygiene Competency directed staff to use a clean, dry paper towel to turn off the faucet. Do not contaminate your hands by touching the surface of the sink or faucet. The Puree Policy dated 08/24 failed to address bringing hot puree food items to appropriate food temperatures to prevent food borne illness.

Based on observation, staff interview, and policy review the facility failed to handle soiled linens with the appropriate Personal Protective Equipment (PPE). The facility reported a census of 65 residents. Findings include: In an observation on 8/20/24 at 9:16 AM Staff A, Certified Nursing Assistant (CNA) put on gloves and failed to put on a gown when she took personal items from a resident's hamper and placed it in the washing machine. She then started the machine and removed her gloves. In an interview on 8/20/24 at 8:55 AM Staff B, CNA noted separate washing machines were used for personal items and household laundry. She explained staff wore gloves to put dirty laundry in the machine and again when switching over laundry to the dryers. Clean laundry is placed in a separate bin and then in a separate room. There are isolation settings for the washer machine and those items are washed separately. In an interview on 8/21/24 at 9:05 AM Staff C, Assistant Director of Nursing explained residents have laundry hampers in their rooms. She expected staff to wear gloves to put soiled laundry into the washer. For general soiled laundry gloves are all that is worn. For soiled laundry from a contact isolation room staff are to wear a gown as well. There are no other precautions. The facility document titled Updated Laundry Process, dated 3/22/24 failed to indicate PPE required when handling soiled laundry.

Based on observation, staff interview and record review the facility failed to provided a restorative nursing program for 4 of 5 residents reviewed (Resident #2, #13, #17 #41) . The facility identified a census of 66 residents. Findings include: 1. Resident #2's Minimum Data Set (MDS) Assessment, dated 12/13/19, showed the resident with [DIAGNOSES REDACTED]. The resident required total assistance with Activities of Daily Living (ADL's). The MDS showed the resident had received a restorative nursing program for passive range of motion. The Care Plan, revised on 10/28/18, showed the resident with limited physical mobility related to traumatic head injury with contractures. An intervention on the Care Plan showed a Restorative Program for passive range of motion to bilateral upper and lower extremities as tolerated 2-4 times per week. Review of the Follow Up Question Report dated 9/1/19 through 12/24/19 showed the resident did not receive the passive range of motion Restorative Program at least 2 times per week. Review of the Quarterly Restorative Assessment and progress note, dated 9/16/19, showed the resident received passive range of motion exercises with the restorative staff 2-4 times weekly. The progress note showed the resident showed resistance in their joints with range of motion. Review of the Quarterly Restorative Assessment and Progress note, dated 12/16/19, showed the resident received passive range of motion exercises with the Restorative staff 2-4 times per week. The progress note showed the resident with resistance in their joints with range of motion. An observation on 12/22/19 at 10:56 a.m. showed the resident had contractures of bilateral arms and hands. An interview on 12/23/19 at 3:05 p.m. the Household Coordinator, Registered Nurse (RN) reported the restorative documentation is located under the task section of the resident's electronic medical record. An interview on 12/24/19 on 7:03 a.m. Staff A, Certified Nurse Assistant, (CNA)/Certified Restorative Aide, (CRA), reported the Household Coordinator provided a list of the residents on a Restorative Program. She reported the list of residents is located in a binder along with the exercise programs for each of the residents. She remarked that most of the residents received their Restorative Program 2-4 times per week but there are some residents who received their Restorative Program 4-6 times per week and one resident received their Restorative Program daily. Staff A reported there is a paper in the restorative binder that showed the dates the Restorative Program is provided to each resident but the official documentation for the Restorative Program is in the residents' electronic medical record. Staff A explained if a resident refused the program there is a button to push in the electronic medical record to document the refusal. Staff A provided a documentation sheet that showed the dates each of the resident's received the Restorative Programs for the month. She reported the resident received restorative passive range of motion program on 12/13/19 according to the paper documentation. Staff A explained she did not know why the resident had not received the restorative program since 12/13/19 but that the resident had almost reached their goal of restorative 8 times per month. An interview on 12/24/19 at 7:20 a.m., the Household Coordinator reported the Restorative Programs are developed by the therapy department and given to the Household Coordinator. She reported she then provided the Restorative Nursing Assistants a copy of the exercise program and also made a copy of the restorative exercise program for the resident's room. She reported the standard practice of the facility is to provide Restorative Programs to the residents 2-4 times per week. She reported she audits the Restorative Program monthly to ensure the residents reached their goal for the month. The Household Coordinator reported she expected the residents to receive their Restorative Program at least 2-4 times per week every week. The Household Coordinator reported she did not know the reason the resident had not received their Restorative Program since 12/11/19. She reported if a resident refused the program the restorative staff would fill out a paper form and give it to her regarding the refusal and not document it in the residents record. An interview on 12/24/19 at 7:42 a.m. the Household Coordinator reported she did not have any refusal documentation for the resident's Restorative Program. An interview on 12/24/19 at 8:04 a.m. the Director of Nursing, (DON)/Administrator reported when a resident came to the facility and is not skilled level of care and did not have therapy the resident would have an assessment in the first 14 days at the facility. She reported the Household Coordinator looked at the resident's needs and individualize a Restorative Program for the resident. The DON/Administrator reported if therapy worked with resident, they would give recommendations for the resident's Restorative Program to the Household Coordinator. She remarked the Therapy Department will recommend the frequency of the program. The DON/Administrator reported the standard of practice for the frequency of a Restorative Program is 2-4 times per week or 8-10 times per month. The DON/Administrator remarked she would expect residents to have their Restorative Program 2-4 times per week each week dependent on the residents medical conditions. She reported she expected staff to document their restorative documentation in the task section of the electronic medical record. The DON/Administrator reported she expected staff to document Restorative Program refusals in the residents clinical record. 2. Resident #41's MDS assessment, dated 10/1/19, showed the resident with a Brief Interview of Mental Status (BIMS) score of 09 indicating a moderate cognitive impairment. The resident required extensive assist with dressing, toilet use and bathing. The resident documented with [DIAGNOSES REDACTED]. The Care Plan, revised 11/4/19, showed the resident with an activity of daily living self care performance deficit related to limited range of motion in the bilateral lower extremities and weakness. An intervention on the Care Plan showed the resident had a Restorative Program for active range of motion exercises to upper and lower extremities 2-4 times per week as tolerated. Review of the Follow Up Question Report dated 9/1/19 through 12/24/19 showed the resident did not receive the active range of motion exercises at least 2 times per week. Review of the Quarterly Restorative Nursing Assessment and Progress note, dated 11/5/19, showed the resident completed active range of motion exercises with the restorative staff to maintain strength as tolerated. An interview on 12/23/19 at 1:16 p.m., the Household Coordinator reported the resident will do the active range of motion exercises with the staff a couple times per week, and the resident also completed the exercises on their own throughout the week. She reported the resident is receptive to the exercises with staff, and when the resident transferred to Hospice the resident preferred to continue the exercise program. An interview on 12/24/19 at 7:52 a.m., the Household Coordinator reported the resident's Restorative Program was not developed by the Therapy Program, the resident requested to do the exercises. She reported the resident should receive the Restorative Program 2-4 times per week. She reported if the resident refused to do the program the staff have a form to fill out and give to her but there is no documentation in the resident's clinical record to show the resident refused the Restorative Program. She reported when she audited the Restorative Programs monthly she checks to see if the resident had received their program goal of 8 times per month, there is not audit to ensure the resident received the restorative program 2-4 times per week. The Restorative Nursing Program Policy, dated 7/1/2019, showed the Restorative Program focuses on the resident mobility and the prevention of complications in order to enhance well being and independence. The purpose of the policy is to provide Restorative Nursing Services to residents that will maximize functioning and promote the highest quality of life possible while a resident at the facility. The Practice and Procedure section of the policy showed the following: b. Residents selected for the Restorative Nursing Program will be individually assessed by the Restorative Nurse or designee and an evaluation completed. Goals will be realistic and reflect the resident's need to maintain function while promoting comfort during treatment. d. Documentation of the resident's individualized Restorative Program will be maintained in the resident's electronic medical record. e. A summary of the resident's progress will be made, not less than quarterly by the designated Restorative Nurse. Also, included will be revised goals if needed, and a determination of the appropriateness of the resident's continued participation in the program. f. Participation in the designated Restorative Nursing Program will be noted on the resident's Comprehensive Care Plan. 3. The Significant Change Minimum Data Set (MDS) Resident Assessment for Resident #13 documented the resident with [DIAGNOSES REDACTED]. The MDS documented that the resident scored 11 out of 15 for the Brief Interview for Mental Status (BIMS), indicating mild cognitive impairment. The resident required extensive assistance of one person for dressing, toileting, bed mobility, and the resident with impairment to both lower extremities. The MDS documented that the resident received Physical and Occupational Therapy on 9/27/19. The Physical Therapy Treatment Encounter Note dated 10/24/19, documented that the resident would be set up for a home exercise program. The Occupational Therapy Treatment Encounter Note dated 10/24/19, documented that the resident would be set up for a Restorative Program for left and right upper body strengthening. The Facility Follow Up Question Report dated 11/01/19 to 11/30/19 directed staff to provide the following; restorative for upper and lower extremity exercises 2-4 times weekly as tolerate. The report lacked documentation that the resident received exercises two times a week. The Facility Follow Up Question Report dated 12/01/19 to 12/31/19 lacked documentation that the resident received exercises two times a week. The Restorative Note dated 10/01/19 documented that the resident with limited range in bilateral lower extremities due to significant [MEDICAL CONDITION] in the lower legs, ankles, and feet. The resident fell on ce this last quarter when he rolled out of bed. The resident had been unsteady, needing staff assist when moved from a seated to a standing position, and when moved on and off the toilet, and other surface to surface transfers. The resident unsteady, but able to steady himself with walking short distances, and turning around. The resident checked on at regular times to make sure he is in a good position in the bed. During an interview on 12/24/19 at 7:42 a.m., the Restorative Nurse reported she lacked any documentation the resident had refused restorative exercises 4. Resident #17's MDS Quarterly Assessment completed 9/27/19 documented the following Diagnoses: [REDACTED]. The MDS identified the resident to be cognitively intact with a BIMS score of 15 out of 15, required extensive staff assistance with most activities of daily living and had impairment of both legs in range of motion. The Care Plan with the initiation date of 7/11/18 identified the resident with the problem of impaired physical mobility and dependent with activities of daily living due to the [DIAGNOSES REDACTED]. The resident does independent exercises with therabands throughout the day, please assist her with setting these up when she asks. A review of the documentation of restorative exercises provided on the follow up question reports revealed staff instructed to assist with range of motion exercises to arms 2-3 times weekly as tolerated. The documentation shown exercises completed as follows: a. In (MONTH) first week 4 times, second week once on the 11th, third week once on the 15th and the fourth week once on the 24th. b. In (MONTH) 1st week two times on the 1st and 4th, second week none completed, third week 3 times on the 16th, 17th & 18th, fourth week once on the 22nd, fifth week none from the 28th through the 31st. c. In (MONTH) 1st week once on the 2nd, second week twice on the 5th & 9th, third week once on the 13th, fourth week once on the 20th, fifth week twice on the 26th and 27th. d. In (MONTH) 1st week once on the 1st, second week none, third week twice on the 17th and 20th. The above reports and progress notes from Restorative Staff dated 10/2/19 and 12/24/19 contained no documentation to show the resident refused exercises. During an interview on 12/24/19 7:51 a.m., the Restorative Nurse reported the resident requested the staff to provide her restorative care and she dictated when she will get the restorative care. The Restorative Nurse also reported she audited charts and the goal is to have at least 8 sessions a month. The resident will let us know when she does not want the therapy, however, it is not charted when she refused.

Based on observation, record review and staff interview, the facility failed to provide a person centered Care Plan for two of seventeen residents reviewed with failing to address the use of [MEDICATION NAME] for Resident #21 and the [DIAGNOSES REDACTED].#46. The facility reported a census of 66 residents. Findings include: 1. Resident #21's Minimum Data Set (MDS) 10/4/19 documented the following Diagnoses: [REDACTED]. It also identified her to be cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, and required limited staff assistance with most activities of daily living. A review of the Physician Orders revealed the following orders: a. On 8/28/19 [MEDICATION NAME] 2 mg (milligrams) one tablet one time a day every Monday, Wednesday, Thursday, Friday, Saturday and Sunday for anticoagulation. b. On 9/6/19 [MEDICATION NAME] 3 mg give one tablet one time a day every Tuesday, Friday and Sunday for anticoagulation. c. On 9/6/19 [MEDICATION NAME] 2 mg give one tablet by mouth one time a day every Monday, Wednesday, Thursday and Saturday for anticoagulation. d. On 9/11/19 [MEDICATION NAME] 2 mg daily on Monday and 3 mg daily all other days. e. On 9/18/19 [MEDICATION NAME] 3 mg daily on Tuesday through Saturday and [MEDICATION NAME] 2 mg every Monday. f. On 9/23/19 [MEDICATION NAME] 3 mg on Tuesday, Wednesday, Thursday, Friday, Saturday and Sunday and [MEDICATION NAME] 2 mg on Monday. g. On 9/30/19 continue [MEDICATION NAME] 2 mg on Monday and [MEDICATION NAME] 3 mg rest of the week. h. On 10/3/19 may hold [MEDICATION NAME] for 5 days for tooth extraction. i. On 10/28/19 may hold [MEDICATION NAME] for 3 days for bridge work. j. On 11/7/19 [MEDICATION NAME] 3 mg daily for anticoagulation. k. On 12/2/19 Continue same dose of [MEDICATION NAME]. l. On 12/9/19 No change in [MEDICATION NAME], 4 mg on Monday and Friday and 3 mg on all other days. m. On 12/17/19 clarification [MEDICATION NAME] 3 mg daily. A review of the Care Plan for Resident #21 revealed no identification the resident with orders for [MEDICATION NAME]/[MEDICATION NAME]. In an interview on 12/23/19 at 11:02 a.m., Staff D, Assistant Director of Health Services (ADHS), reported she would expect [MEDICATION NAME] to be addressed on the Care Plan and that she would be responsible for updating the resident's Care Plan. During an interview on 12/22/19 at 11:38 a.m., Staff D, ADHS reported the original order for the [MEDICATION NAME] noted on 8/28/19. In an interview on 12/23/19 at 3:28 p.m., the Administrator/Director of Nursing (DON) reported she would not expect [MEDICATION NAME] to be addressed on the Care Plan as all Certified Nursing Assistant's (CNA's) would be expected to report any unusual signs of bleeding whether or not the resident has orders for [MEDICATION NAME]. 2. Resident #46's MDS Quarterly Assessment completed 11/8/19 documented the following Diagnoses: [REDACTED]. It also identified the resident as cognitively intact with a BIMS score of 15 out of 15, required extensive staff assistance with bed mobility, dressing, toileting and hygiene and received insulin. A review of the Care Plan for Resident #46 revealed the resident not identified to have the problem of diabetes mellitus. A review of the Physician Order Sheet and (MONTH) 2019 Medication Administration Record [REDACTED]. During an interview on 12/23/19 at 11:02 a.m., Staff D, ADHS, reported she would expect the [DIAGNOSES REDACTED].#46. In an interview on 12/23/19 at 3:28 p.m., the Administrator/DON reported she would expect the [DIAGNOSES REDACTED]. A review of the facility policy titled: Interdisciplinary Care Team Process/ Nursing Assessment of the Resident with the effective date of 7/1/19 directed nursing staff to participate in the resident Care Plan Conference and assist in developing the Interdisciplinary Plan of Care within 21 days of admission. Quarterly (not less than once every 3 months) MDS Nursing Reviews will be completed including physical assessment, review of significant events and Care Plan goal evaluation.

Based on observation, facility policy review and staff interview, the facility failed to ensure staff utilized proper handling of ready to eat resident food items and failed to ensure the temperature probe was sanitized between uses in order to prevent food-borne illness. The facility census was 67 residents. Findings include: 1. During observation of the noon meal service on 10/16/18 at 11:57 a.m., Staff E, cook used a temperature probe with gloved hands to obtain food temperatures after touching lids and steam table, picked up a carrot with gloved hand to insert thermometer probe and then placed carrot back into steam pan to be served. Staff E utilized the same temperature probe without cleansing between measuring the temperature of the potatoes and the temperature of the stewed tomatoes. Staff E utilized the same alcohol wipe, kept it in the palm of their hand to clean the probe between measuring the broccoli soup, gravy and ground meat. Staff E touched a peanut butter and jelly sandwich with gloved hands she had used to serve food and continued to touch the steam table, lids, pans and scoops. Staff E placed a pork loin chop on the attached full length cutting board sitting on the steam table and cut the chop with gloved hands. Staff E wearing the same gloves placed half the chop on the plate and the other half into the pork loin food pan. Staff E washed their hands, donned gloves, touched plates, scoops and the steam table and went on to touch crackers in a container. Staff E placed the crackers on the plate and changed gloves and opened the door to refrigerator, took out a tuna sandwich, directly touching it with the gloved hand and placed on plate. Staff E donned clean gloves, touched a plate and bread wrapper, directly took the bread out and set it onto the tray. The tray also had utensils and loaf of bread already placed on it. Using the same gloved hands, she touched cabinet handles, removed peanut butter and jelly packets from cabinet and opened them. With a knife held in one gloved hand and bread in the other gloved hand, spread peanut butter. She did the same procedure spreading the jelly. Staff E placed that sandwich onto a plate to be served. During interview on 10/17/18 at 2:25 p.m., Certified Dietary Manager (CDM) stated staff was to sanitize the probe for the food thermometer with a clean alcohol pad between each food measurement and to not touch the food with hands. CDM stated when they are actually touching food products they should have gloved hands, wash hands first and use gloves and if changes gloves should wash hands again and only touch one type of food product before changing gloves. Record review of the facilities Food Handling Guidelines revised 1/18 directed staff to use single use disposable gloves are worn when preparing foods that will not be cooked again (ready to eat foods) and while serving food. Gloves are to be placed over clean hands. Gloves are changed between tasks or if punctured or ripped. Disposable Glove Use policy revised 01/18 advises staff to change gloves and wash hands when gloves are dirty or ripped and when moving from one task to another, such as moving from handling dirty dishes to handling clean dishes. The facility was not able to provide a policy or procedure on proper way to obtain food temperatures.

Based on observation, clinical record review and staff review, the facility failed to follow physician orders for one of two residents reviewed receiving oxygen. (Resident #48) The facility census was 67 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #48 had [DIAGNOSES REDACTED]. A [DIAGNOSES REDACTED]. A Physician Order Statement (POS) dated 9/18/18, directed staff on 8/17/17 to administer oxygen via nasal cannula at 2 liters per minute as needed for symptoms of hypoxemia (low oxygen) or as desired and may increase it to 3 liters per minute if the sats (saturated oxygen) drops below 90 percent (%). A Hospital Discharge Order dated 9/4/18, directed staff to administer oxygen at 4 liters per minute per nasal cannula as needed. The Medication Administration Record (MAR) dated for 9/1/18 through 9/30/18, failed to show any documentation for the use of oxygen at 2 liters per minute per nasal cannula as needed. The Medication Administration Record (MAR) dated for 10/1/18 through 10/30/18, failed to show any documentation for the use of oxygen at 2 liters per minute per nasal cannula as needed, except for the 10/16/18 date. The oxygen level was not changed to 4 liters per minute as the latest order on the resident's medication record documented. The Care Plan revised on 6/13/18 failed to identify any need or usage for oxygen. Observation on 10/15/18 at 9:26 a.m., revealed the resident in the wheelchair wearing oxygen at 3 liters per nasal cannula. Observation on 10/16/18 at 10:30 a.m., revealed the resident having an episode of shortness of breath at the back nursing station. Staff A, Registered Nurse, RN checked the resident's oxygen saturation level with the pulse oximeter. The oxygen tank read at 4 liters per nasal cannula per minute. Approximately 30 minutes later staff wheeled the resident to the room and at that time the oxygen tank read 3 liters per nasal cannula per minute. Observation on 10/17/18 at 2:45 p.m., showed the resident resting in the recliner and the oxygen level registered at 3.5 liters per minute per nasal cannula. During interview on 10/17/18 at 3:00 p.m., Staff I, RN reported they have been monitoring the resident's oxygen level for over a year now. Staff I reported staff monitor the resident oxygen level at least 3 times a day and adjust the oxygen level as needed. Staff I did not know the Hospital Discharge Report directed staff to apply oxygen at 4 liters per nasal cannula and believed that could have been missed for the latest physician orders and would check it out. Staff I noted the oxygen level was not documented on the MAR's. During interview on 10/17/18 at 3:55 p.m., Staff I reported the physician order for [REDACTED]. Staff I believed the hospital order did not get properly transcribed by staff.

Based on observation, clinical record review, facility policy review and staff interview, the facility failed ensure the catheter tubing for two of four residents reviewed was not dragging on the floor in order to prevent infection. (Resident #39 & #45) The facility census was 67 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #45 had [DIAGNOSES REDACTED]. A Physician order [REDACTED]. During observation on 10/15/18 at 9:01 a.m., the residents catheter hung on the side of the bed with 6 inches of the Foley catheter tubing on the floor. During observation on 10/15/18 at 1:55 p.m., the resident was in bed and again 6 inches of the Foley catheter tubing was on the floor and the base of the Foley catheter bag was directly on the floor. During observation on 10/17/18 at 8:00 a.m., the resident was in bed with 3 inches of the catheter tubing on the floor. During observation on 10/17/18 at 12:58 p.m., four inches of the Foley catheter tubing was on the floor at the side of the bed. During interview on 10/17/18 at 2:14 p.m., Staff D, Registered Nurse, RN reported the catheter tubing should be off the floor if they can at all help it, the catheter drainage bag needed a dignity bag also. 2. The MDS assessment dated [DATE], documented Resident #39 had [DIAGNOSES REDACTED]. On 10/15/18 at 10:59 a.m., the resident was in the doorway leaning on his front wheeled walker (FWW) with his catheter bag hanging off the lower bar of his FWW and the tubing hanging on the floor as the resident stood. As the resident moved the catheter tubing dragged along the floor. On 10/15/18 at 12:02 p.m., the resident was sitting in the recliner waiting for lunch to be brought to him and noted FWW near him with the catheter bag hanging from it and the catheter tubing continued to lay on the floor. On 10/15/18 12:34 p.m., the resident was up standing in the doorway with the catheter tubing laying on the floor. On 10/15/18 at 4:00 p.m., the resident was in the doorway leaning on the FWW tray and the catheter tubing was laying on the floor. On 10/16/18 at 7:27 a.m., the resident was sitting in the recliner with approximately a foot of the catheter tubing is lying on the floor. On 10/17/18 at 1:17 p.m., the resident was in the doorway with the catheter hanging on the FWW and noted the resident to move out into the hallway so staff could bring a Hoyer lift into the room to transfer his roommate. As the resident walked out into the hallway, approximately 1 1/2 foot of the catheter tubing drug along the floor as the resident walked. During interview on 10/17/18 at 2:03 p.m., Staff B, CNA reported catheter tubing should not be on the floor as the floor was dirty and the tubing can become contaminated or the tubing can be stepped on by the resident. During interview on 10/17/18 at 2:10 p.m., Staff C, CNA reported the floor was dirty and it was not good to have the tubing lay on the floor. Review of the Catheter Care Policy last revised 7/12/18 stated the purpose to be to maintain infection control when performing catheter care to prevent infections within the facility. The policy directed the Nursing Staff through the procedure of catheter care, and when completed to place the drainage bag at bedside attached to bed frame, not side rail or assist bars.

Based on clinical record review and staff interview, the facility failed to inform one of three residents reviewed of their right to appeal the decision for discontinuation of skilled services. (Residents #50) The facility census of 67 residents. Findings include: 1. Clinical record review revealed Resident #50 was discharged from skilled care on 8/30/18. The facility issued a notice of medicare denial form on 8/27/18, but failed to issue a Notice of Medicare Non Coverage (NOMNC) form . SNF Notice of Non-Coverage Cheat Sheet from WPS (Wisconsin Physician Services) Government Health Administrators provided to surveyor by the administrator directed the facility to give the SNF ABN (form - ) and Notice of Medicare Non-Coverage(NOMNC) (form - ) when Beneficiary drops to a non-skilled level of care, benefits have not exhausted and beneficiary remains in the facility (Medicare Certified Bed or non - Medicare certified bed) During interview on 10/17/18 at 9:32 a.m., the Administrator stated they did not do the CMS - form for any skilled nursing facility discharges they were not aware they needed to complete both forms.

Based on observation, record review, and staff interviews, the facility failed to follow the planned menu for 3 of 3 pureed diets ordered by the resident's physicians for the noon meal observed. The facility identified a census of 60 residents. Findings include: The facility's Week 1 menu for lunch showed the Monday Meal for all residents included a dinner roll. The spreadsheet of the same meal, reviewed and approved by the Dietitian, identified the noon meal with a dinner roll for all diets except the pureed and liquid diets. The menu did show pureed corn to be served with the puree diets at noon. Observation of noon meal service on 7/17/17 from 12:00 p.m. to 12:35 p.m., revealed 3 residents with a puree diet did not receive pureed corn, as identified on the planned menu. During an interview on 7/17/17 at 12:50 p.m., the Dietitian and the Food Service Supervisor acknowledged the pureed corn had not been served to the 3 residents on a puree diet. The Food Service Supervisor remarked 'it was just missed'. Both remarked the pureed corn should have been served. The Dietician reported the pureed corn probably replaced the dinner roll for the puree diets. When asked why the puree diets did not list a dinner roll when all the other diets listed that, the Supervisor and Dietician had no comment.