Every finding on record at Glenhaven

Based on observation, interview, and record review, the facility did not ensure that 1 of 3 residents (R) reviewed for pressure injuries (PI) (R2) received care consistent with professional standards of practice to prevent further deterioration and promote healing of an existing PI. R2 was at risk for PI development. The facility failed to provide adequate and consistent wound care treatments, comprehensive interventions to R2's care plan, and did not document progression of staged PI. Findings include: Facility policy titled Pressure Areas, last revised 01/22, stated in part, .1. Area in question is assessed by nurse and temporary care plan initiated with initial intervention to reduce pressure. #2. New Braden scale to be completed by nurse.#3. Area documented with size, shape, color, presence of slough or eschar, texture, odor, depth, prevalence of pain, peri-wound, drainage, location as well as any noted factors that may be causing the pressure.#4. Area staged according to National Pressure Ulcer Advisory Panel.#5. MD is notified of area and provided documentation.#8. Dietary is notified to determine if supplements are needed for wound healing. R2 was admitted to the facility on [DATE] with diagnoses including in part, urinary tract infection, klebsiella pneumoniae, parkinsonism, depression, anxiety, hyperlipidemia, type 2 diabetes, neuromuscular dysfunction of bladder, gastro esophageal reflux disease without esophagitis, and insomnia. R2's Minimum Data Set (MDS) assessment, dated 10/29/25, identified R2 required substantial maximal assistance for toileting and toilet transfer. Partial moderate assistance for bed mobility, rolling left to right, sitting to lying, and chair to bed. MDS indicated R2 was at risk for PIs.Surveyor reviewed R2's ADL care plan initiated on 11/07/25 which stated in part:-Bed mobility requires extensive assistance of 1 staff with the use of bedrail for bed mobility. Surveyor reviewed R2's skin integrity care plan. R2 has potential for pressure ulcer development related to immobility initiated on 11/10/25 which states in part:-The resident will have intact skin, free of redness, blisters or discoloration by/through review date. -Administer medications as ordered. Monitor/document for side effects and effectiveness.-Administer treatments as ordered and monitor for effectiveness.-Follow facility policies/protocols for the prevention/treatment of skin breakdown.-Monitor nutritional status. Serve diet as ordered, monitor intake and record.-Obtain and monitor lab/diagnostic work as ordered. Report results to MD [Medical Doctor] and follow up as indicated.-The resident requires supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing.-Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. Surveyor reviewed R2's physician orders:-On 02/27/26, Right buttock dressing, cleanse with wound cleanser, pat dry, cover with border foam every day shift every other day.-On 01/08/26, Skin assessment weekly every evening shift every Thursday. Surveyor reviewed R2's Braden and skin assessments:-On 10/22/25 at 12:31 PM, Initial admission assessment of normal skin, warm, temperature dry bilaterally equal, normal turgor, no open areas.-On 11/19/25 at 12:52 AM, Braden scale scored 16 at risk for skin breakdown.-On 02/19/26 at 4:08 PM, has no skin issues.-On 02/26/26 at 8:52 PM, Skin issue #1: An open sore to the left buttock measuring 0.5x0.5cm with purulent drainage.-On 02/28/26 at 8:40 PM, Braden scale scored 18 at risk for skin breakdown. Surveyor reviewed R2's progress notes, which stated in part, .-On 11/20/25 at 1:10 PM, Note: patient backside is reddened but intact at this time.-On 01/05/26 at 10:45 AM, Communication- With PhysicianNote Text: Nurse called with report as [R2] is returning to us from hospital. Patient also has some skin break down to his bottom which is covered with a Mepilex and has been struggling in the hospital with yeast to his groin area as well they sent him with a cream -Lotrimin to apply. Patients use 2 assists to get up and transfer. We will use sit to stand here at this time. -1/5/26 at 9:13 PM, Skilled Evaluation: Skin: Skin color is WNL. Skin warm / dry to touch. Decreased skin turgor.Skin note: Resident has redness/yeast in groin and redness to his coccyx. -1/5/26 at 9:19 PM, Skin onlySkin Evaluation: Skin color is WNL [within normal limits]. Mucous membranes are moist. Skin warm/dry to touch. Decreased skin turgor. Resident has current skin issues.Skin Issue: Pressure Ulcer / Injury. Skin issue location: Sacrum Pressure Ulcer / Injury Stage: Stage I - Non-blanchable erythema. Wound exudate: None. Peri wound condition: Erythema. Dressing saturation: None. Wound odor: No. Tunneling: No. Undermining: No. Tissue: Warm.Note / Notification / Education: Skin note: Mepilex placed on coccyx to protect against further breakdown.Provider Contacted: Already aware.Person Contacted: Already aware.-On 1/6/26 at 1:06 PM, Skin/Wound NoteNote Text: [R2] had large BM [bowel movement] today and when I was cleaning him up, I removed [R2's] Mepilex and did not have a new one available at that time. I was unable to replace it, however skin under dressing was reddened but intact without open sores. I did apply Lotrimin to [R2's] groin as ordered and have explained this to the CNAs [Certified Nursing Assistants] and also [R2's] wife that we address this area and apply new dressing net time we stand [R2] up.-On 1/7/26 at 10:28 AM, Skin/Wound NoteNote Text: Sacral Mepilex removed as it got soiled with feces, unable to apply new one as it was not available at the time. Writer did notice that right in the crack of [R2's] buttocks, [R2] had a layer of skin that appeared to have peeled off but not really an open area. It just appeared to be dry skin that flaked. Writer applied zinc barrier cream. Will monitor and pass on to next shift.-On 1/11/26 at 1:38 PM, Skin onlySkin Evaluation: Skin warm & dry, skin color WNL, mucous membranes moist, turgor normal. [R2] has current skin issues.Skin Issue: Discoloration. Skin issue location: Buttock Length: 1.5 cm red, blanchable Width: 1.0 Tissue: Painful.Note / Notification / Education: Skin note: Area on buttock measuring 1.5 x 1 cm. Red and blanchable. Put a protective coccyx Mepilex on buttock at this time.-On 1/11/26 at 2:15 PM, Health Status NoteNote Text: [R2] has a deep red, blanchable area measuring 1 cm x 1.5 cm. Recorder cleansed area and placed Mepilex. Daughter was in room when area was found, so she is aware. Recorder faxed PCP [primary care provider] for a dressing change order.-On 1/13/26 at 3:49 PM, Order NoteNote Text: Fax sent to MD that [R2] has a dark red, blanchable area measuring 1 cm x 1.5 cm on right buttock. Ok for dressing change daily, cleanse site, skin prep, Mepilex until area has resolved, returned signed ok [name of physician].-On 1/13/26 at 9:09 PM, Temporary Care Plan NoteNote Text: New dressing orders for R [right] buttock. No signs of worsening or delayed healing at this time.-On 1/14/26 AT 9:10 PM, Temporary Care Plan NoteNote Text: No new wounds or wound worsening on resident's R buttock. Continuing to follow dressing change orders.-On 1/15/26 at 9:53 PM, Skin onlySkin Evaluation: Skin warm & dry, skin color WNL, mucous membranes moist, turgor normal. Resident has current skin issues.Skin Issue: Discoloration. Skin issue location: Buttock Length: 1.5 Width: 0.6 Tissue: Painful.Note / Notification / Education: Skin note: area on buttock red, blanchable. Cleansed area, placed skin prep, placed Mepilex. Will continue to monitor per facility protocol.Resident / Responsible Party aware of diagnosis and plan of care: No. Resident education provided R/T [related to] new diagnosis: No. Resident education provided R/T new order: No.-On 1/21/2026 at 11:53 AM, Temporary Care Plan NoteNote Text: TCP for buttock wound dressing changed discontinued. Wound healed, no need for dressing.-On 1/24/2026 at 12:13 AM, Skilled EvaluationSkin: Skin warm & dry, skin color WNL and turgor is normal.Skin note: has protective dressing over sacrum, area is opportunistic for break down due to resident sliding down in recliner causing shearingSpecial Care:Safety: Call light is within reach.Functional: Able to move all extremities.-On 1/28/2026 at 1:18 PM, Skin/Wound NoteNote Text: Resident [R2] has small open area in intergluteal crest that appears to be from shearing. Writer applied zinc cream and a Mepilex to protect the area. No s/sx [signs/symptoms] of infection.-On 1/28/2026 at 1:19 PM, Temporary Care Plan NoteNote Text: TCP [antiseptic] started for small wound in intergluteal crest. Will monitor site for signs and symptoms of infection as well as encouraging resident to spend less time in his recliner and more time on his bed to offload pressure. Zinc cream and Mepilex foam dressing applied and to be changed daily and PRN [as needed]. Goal for wound to heal without signs/symptoms of infection.-On 1/29/2026 12:55 AM, Braden Scale for Predicting Pressure Ulcer RiskBraden Evaluation:Result: At RiskScore: 18.0.-On 2/5/2026 at 8: 27 PM, Skin onlySkin Evaluation: Skin warm & dry, skin color WNL, mucous membranes moist, turgor normal. No current skin issues noted at this time.-On 2/19/2026 at 4: 08 PM, Skin onlySkin Evaluation: Skin warm & dry, skin color WNL, mucous membranes moist, turgor normal. No current skin issues noted at this time.-On 2/25/2026 at 7:07 AM, Order NoteNote Text: New order from Hospice [name of physician]: Wound care to right buttock cleanse with wound cleanser & pat dry, cover with border foam dressing change every other day & PRN if dressing becomes loose or soiled.-On 2/25/2026 at 10:16 AM, Temporary Care Plan NoteNote Text: TCP started for right buttock wound. Staff to cleanse wound with wound cleanser and pat dry. Cover with bordered foam dressing and change every other day and PRN if dressing becomes soiled or loose. Will monitor for signs or symptoms of infection. Goal: wound healing.-On 2/26/2026 at 8: 52 PM, Skin onlySkin Evaluation: Skin warm & dry, skin color WNL, mucous membranes moist, turgor normal. Resident has current skin issues.Skin Issue: Other skin issue. Other skin issue: open sore Skin issue location: left buttock Length: 0.5 Width: 0.5 Wound exudate: Purulent. Wound odor: No. Tunneling: No. Undermining: No.-On 2/28/2026 at 8:40 PM, Braden Scale for Predicting Pressure Ulcer RiskBraden Evaluation:Result: At RiskScore: 18.0 . Surveyor reviewed R2's Hospice progress notes, which stated in part, On 02/24/26 at 2:00 PM, Wound assessment note: Onset date of wound 02/24/26, pressure ulcer, stage 2, wound measurements1.5cm x 1cm. Treatment: Cleanse with soap and water, dress with foam dressing, every other day. Additional; care: Moisture control and turning/repositioning program. Safety measures: Risk for skin breakdown. DME/Assistive devices: Roho cushion recommended, will obtain from Hospice office. Narrative note: Facility nurse reporting skin breakdown to [R2's] buttocks, probably shear injury, area assessed, wound added to flow sheet, wound care orders provided to facility, writer to check on availability of Roho cushion. Facility nurse asking about APM, but since [R2] spends most time in recliner will reassess need if [R2] begins lying in bed frequently.-On 02/26/26 at 2:31 PM, Visit notes: Stage 2 pressure ulcer, 0.5cmx0.5cm, follow wound care per care plan, wound assessment data obtained from facility note. No new interventions, follow plan of care. On 03/03/26 at 9:15 AM-11:55 AM, Surveyor observed R2 lying in recliner at a 45-degree angle with R2's buttocks touching the recliner. Surveyor observed Certified Nursing Assistant (CNA) E transfer R2 up to wheelchair for lunch at 11:55 AM. Surveyor did not observe a pressure relief cushion in R2's chair for off-loading. On 03/03/26 at 1:32 PM, Surveyor observed CNA E come out of R2's room with EZ-stand. Surveyor observed R2 lying in recliner at a 45-degree angle with R2's buttocks touching the recliner. Call light in reach. On 03/04/2026 at 10:55 AM, Surveyor observed CNA E don Personal Protective Equipment (PPE) and enter R2's room. CNA E transferred R2 to the toilet due to an incontinent BM. Surveyor observed CNA E cleanse BM off R2's buttocks. CNA E noted that R2's dressing on buttock area had fallen off. CNA E continued cleaning R2's buttocks and then called Registered Nurse (RN) D into re-dress the wound on R2's buttocks. Surveyor observed R2 grimace and stated, My butt hurts. CNA E reported that R2 has been having some loose incontinent BMs the last few days, and that it is not normal for R2 to have so many BMs. On 03/04/2026 at 11:03 AM, Surveyor observed RN D enter R2's room with PPE and a Mepilex for R2's wound. RN D began cleaning R2's buttocks with wipes as R2 had more BM that needed to be clean. R2 stated to RN D, My back side hurts bad. RN D looked at R2's buttocks and stated, I don't know how I am going to get this big Mepilex on [R2's] buttocks. CNA E stated to RN D, Maybe just do zinc oxide since the dressings fall off all the time. RN D stated to CNA E, That is what I will do. Surveyor assessed R2's wound and noted that R2 had an open wound on the left inner buttock, the wound bed could not be visualized, and Surveyor observed 100% slough. RN D applied zinc oxide to open wound on R2's left buttock with contaminated gloves. CNA E and RN D transferred R2 back to wheelchair. Surveyor did not observe RN D doff contaminated gloves and complete hand hygiene before applying zinc oxide to R2's open wound on buttocks. On 03/04/2026 at 11:22 AM, Surveyor observed R2 sitting in wheelchair in lounge on unit D in front of television shaking, complaining of severe pain on R2's bottom and in groin area. Surveyor interviewed CNA E and asked if R2 has pressure relieving devices in wheelchair and recliner. CNA E reported that R2 does not have any pressure relieving devices in recliner but R2 does have them in wheelchair. On 03/04/2026 at 11:27 AM, Surveyor observed RN D approach R2 to gather vitals. Upon requesting to sit forward, Surveyor observed R2 clench hold of the wheelchair and started shaking stating, I am in pain. RN D gathered vitals on R2 due to R2 being in so much pain. Vitals were within normal range, and R2 was febrile. RN D reported that RN D will be notifying R2's Hospice RN F and Hospice RN F will be at facility shortly. On 03/04/2026 at 11:34 AM, Surveyor interviewed CNA E, RN D, and Assistant Director of Nursing (ADON) C and asked what the expectation is for staff to reposition R2 as Surveyor has observed R2 sitting directly on buttocks either in recliner or wheelchair the last two days. RN D and ADON C reported expectations would be repositioning R2 at least every 2 hours. Surveyor asked ADON C for expectation of pressure relieving device in R2's recliner. ADON C reported that Hospice RN F was supposed to order this offloading device for R2 a week ago. Surveyor asked if anyone has followed up on the pressure relieving devices. ADON C reported to Surveyor that ADON C will do this now. On 03/04/2026 at 11:52 AM, Surveyor observed CNA E transfer R2 to bed to try to offload R2's buttocks. Surveyor observed CNA E complete another brief change as R2 had more BM on R2's buttocks and groin area. Surveyor observed R2 clenching and pushed against the wall when CNA E was cleaning R2's buttocks. Surveyor observed R2's buttocks to be very red and irritated. Surveyor observed no wound dressing on R2's open wound on left buttock. Surveyor observed CNA E apply a new brief on R2 but did not apply zinc oxide as ordered. Surveyor observed CNA E roll R2 back to supine position on R2's buttocks. CNA E exited R2's room. On 03/04/2026 at 12:02 PM, Surveyor interviewed CNA E and asked if R2 was lying on back in supine position with buttocks touching the mattress and was that enough to off load pressure for R2. CNA E reported to Surveyor that CNA E did not know if it was off loading or not. Surveyor never observed CNA E or any other staff go back into R2's room to reposition. On 03/04/2026 at 12:07 PM, Surveyor interviewed RN D and asked about wound dressing change and following wound care orders. RN D reported that RN D decided to just do the zinc oxide as the facility does not have small enough Mepilex to place on R2's open wound. Surveyor asked RN D if leaving an open wound is common practice. RN D reported that RN D was just doing what she could at that moment and afterward went and asked ADON C what steps should have been done. Surveyor reported to RN D that Surveyor observed RN D clean BM off R2's buttocks, and then RN D applied zinc oxide with contaminated gloves unto R2's buttocks, contaminating the open wound on R2's left buttock. RN D reported that RN D should have removed contaminated gloves and performed hand hygiene before donning a new pair of gloves, but RN D did not change contaminated gloves. On 03/04/2026 at 12:20 PM, Surveyor interviewed ADON C and asked expectation of wound dressing changes for R2. ADON C stated to Surveyor, Yes [RN D] came and spoke with me after [RN D] completed cares on [R2]. I educated [RN D] about importance of following physician orders. ADON C reported to Surveyor that RN D should have placed Mepilex on R2's buttocks as ordered. Surveyor asked ADON C for expectation of hand hygiene during wound dressing change. ADON C reported that RN D should have doffed the contaminated gloves, sanitized hands, and then donned new gloves during dressing change on R2. Surveyor asked ADON C once R2 developed open wound concerns on R2's buttocks how come interventions were not put into place on R2's care plan to decrease the chance of skin breakdown. ADON C reported to Surveyor that ADON C is unsure, but ADON C will be following up on off-loading interventions for R2 going forward. On 03/04/2026 at 1:05 PM, Surveyor observed Hospice RN arrive and enter R2's room. On 03/04/2026 at 1:43 PM, Surveyor interviewed Hospice RN F and asked Hospice RN F to explain when R2 was admitted to hospice and when did Hospice RN F assess R2's left buttock wound to start. Hospice RN F reported that when Hospice RN F admitted R2 on 02/24/26, R2 had an open area to left buttock. Hospice RN F documented the left buttock as a Deep Tissue Injury (DTI) of the left buttock stage 1. The stage 1 wound measured 1.5cm x 1cm. Surveyor asked Hospice RN F what kind of interventions were put into place to off-load and to minimize further breakdown. Hospice RN F reported that Hospice RN F verbally told staff to off-load, but there were no interventions put into place at that time in the medical record or care plan. Hospice RN F then reported that on 02/26/26 R2's left buttock DTI deteriorated further and opened which was assessed as a stage 2 measuring 0.5cm x 0.5cm. Hospice RN F reported there were no new interventions put into place and that interventions stayed as is. Hospice RN F reported to Surveyor that on 03/04/26, Hospice RN F assessed R2's DTI on left buttock. Hospice RN F stated to Surveyor, [R2's] DTI continues to deteriorate, measures 0.9cm x 0.7cm and is now unstageable with 100% slough, little erythema, no drainage and no odor at this time. Surveyor asked Hospice RN F what interventions are going to be put into place going forward. Hospice RN F reported that Hospice RN F is reaching out to the provider, but new interventions will be off-loading device to recliner, alternating air mattress to R2's bed, and new dressing change orders. Surveyor requested R2's hospice progress notes from Hospice RN F. On 03/09/26 at 3:40 PM, Surveyor emailed Hospice RN F for the documentation from hospice visit with R2 on 03/04/26. Surveyor is waiting for documentation. On 3/13/26 at 10:34 AM, Surveyor received via email R2's hospice progress notes. Hospice note dated 3/4/26 at 1:00 PM, PI midline inner buttocks gluteal fold Assessment states, PI stage 2, wound bed 100% slough, wound edges attached, peri wound skin-erythema, drainage-none, odor-none, wound status-deteriorating measurements are 0.9cm x 0.7 cm. Wound care/dressing change as per order: wound to right buttock. PI cleansed with wound cleanser and patted dry. PI covered with border foam dressing.

Based on observation, interview, and record review, the facility failed to provide palatable food served at safe appetizing temperatures. This has the ability to affect all 31 of the facility's residents. Review of resident council minutes and the resident council meeting reveal residents' concerns over meal temperatures. Observation at meals time revealed that foods were not held at proper holding temperatures; hot foods were not held hot, and cold liquids were not held cold. This is evidenced by: On 03/03/2026 at 2:00 PM, Surveyor reviewed Resident Council Meeting Minutes from December 2, 2025, which state in part; Food temps are cold. Resident Council Meeting Minutes from January 26, 2026, state in part: Food temps are on the colder side, and February 23, 2026, Resident Council Meeting Minutes state in part: Food temps are on the colder side. On 03/03/2026 at 9:42 AM, Surveyor interviewed R25 and asked if there were any concerns. R25 reported that R25's food is always cold. During the resident council meeting held by Surveyor on 03/04/2026 at 10:10 AM, the residents stated, Sometimes food is too cold. On 03/04/2026 at 12:05 PM, Surveyor observed the meal cart arriving to the unit. Items were placed in the hot holding area. Cranberry juice, lemonade, water, milk and other juices were passed on a cart from unit to unit without any temperature control measures. On 03/04/2026 at 12:13 PM, Dietary Aide (DA) H took temperatures of food items in the hot holding table. The cheese steak sandwich temperature was 98 degrees. Carrots' temperature was 130 degrees. The pureed food items were set on top of the counter with no temperature control in place. DA H took the temperature of the pureed potatoes; they were 70 degrees. DA H took the temperature of another pureed starch which was 47 degrees. DA H did nothing to bring the temperatures of the food items up to the proper holding temperatures prior to service. DA H continued to plate food until 12:47 PM. At 1 PM, staff began to place the fluids back into the refrigerator. Surveyor had staff take the temperature of one of the fluids; it was 71 degrees. On 03/04/2026 at 2:36 PM, Surveyor interviewed Dietary Director (DD) G. Surveyor relayed the above observations, to which DD G responded, That is not ok. Food should have been reheated to 165 degrees or higher prior to service. When asked why some of the food is just sitting on the counter with no temperature control, DD G stated, All food is supposed to be in the warmer, but with the current census there is more food than will fit. DD G stated we will be moving serving into the different households which will accommodate holding food in the warmers. When asked how long this problem of keeping things at the proper temperature has been going on, DD G stated the past 6 weeks or so. DD G stated she would provide the facility guidelines for holding temperatures. On 03/04/26 at 3:00 PM, DD G provided temperature logs with guidelines for hot holding which state, All hot foods should be held at 140 degrees or above. COLD HOLDING: All cold foods should be held at 41 degrees F or below.

Based on observation, interview, and record review, the facility failed to prepare and distribute food under sanitary conditions. This has the ability to affect all 31 of the facility's residents.Staff washing dishes contaminated their uniform. Staff doing dishes were observed going between dirty and clean items with no hand antisepsis. Staff were observed to change gloves with no hand antisepsis.Staff were observed to touch ready to eat foods with contaminated gloves.Food was carried down halls and from unit to unit uncovered then delivered to residents. Food not stored in its original container was not labeled with identifying information or open date. Open food not labeled with an open or use by dates.Scoop was found in food container, increasing food's risk for contamination.This is evidenced by:Example 1 The facility policy titled Cleaning Dishes and dish machine sanitization states in part; Person loading dirty dishes should not handle clean dishes unless apron is changed and hands are washed thoroughly and wearing thoroughly clean new gloves before moving from dirty to clean dishes. The facility policy titled Handwashing states in part: Dietary staff will wash hands before starting work, when returning to work. and at other times hands have been soiled. Dishwashers should always wash their hands before handling clean dishes. On 03/03/2026 at 1:54 PM, Surveyor observed Dietary Aide (DA) H doing dishes. DA H sprayed dirty dishes, getting water and debris on the front of her uniform. DA H did not wear an apron as described in the facility policy. DA H was observed going from handling dirty dishes to clean without changing gloves or performing hand hygiene. DA I was observed to be working in the dietary department and was observed to take off her gloves and put on clean gloves with no hand hygiene. On 03/04/2026 at 11:18 AM, Surveyor interviewed Dietary Director (DD) G about the above observations. DD G stated that staff are to, Wear a disposable apron, and they need to have a dirty person and a clean person when doing dishes, or they need to stop and wash their hands prior to handling the clean dishes. Example 2 The facility policy titled Single-Use Glove Policy states in part: gloves must be worn by all dietary staff when handling ready to eat foods, Hands must be thoroughly washed and dried before putting on a new pair of gloves . Hands must be washed immediately after removing gloves to remove any moisture or bacterial build up that occurred while wearing them .Gloves are task specific and must be discarded and replaced.as soon as they become soiled.before beginning a different task .before handling ready to eat foods. On 03/04/2026 at 7:37 AM, Surveyor observed Dietary Aide (DA) H had gloves on, and DA H grabbed utensils and milk container. Surveyor then observed DA H grab cooked toast out of toaster with contaminated gloved hands and buttered the toast. DA H placed contaminated toast on R17's breakfast tray. DA H grabbed R17's breakfast tray and delivered it to R17. Surveyor observed DA H grab door of dining room with contaminated gloves and continued prepping and serving other residents' food with same contaminated gloves. On 03/04/2026 at 7:40 AM, Surveyor observed DA H pouring fluids for breakfast into cups with gloves on. Surveyor observed DA H grab bread with contaminated gloves and place in the toaster. DA H waited for toast to cook then grabbed with same contaminated gloves and spread butter and jelly on toast. DA H placed contaminated toast on R25's breakfast tray and delivered breakfast tray to R25. On 03/04/2026 at 8:02 AM, Surveyor observed DA H preparing breakfast. DA H handled bread with gloved hands, got a knife from drawer, cut and plated fresh fruit, then got more bread out with the same gloved hands. DA I was observed making pancakes; at one point she changed gloves without performing hand antisepsis. On 03/04/2026 at 12:22 PM, Surveyor observed DA H making grilled cheese sandwiches. DA H reached into bag with gloved hands, got out bread, handled container of butter, and spread butter. DA H was observed to wipe the counter with a paper towel and then wiped the rim of a bowl of soup with the paper towel. DA H placed the bowl into the microwave, warmed the soup, temped the soup and put it on the plate, then she pushed over the cheese sandwich on the plate with her gloved hands. A short time later DA H carried a whole tray of individual cups of ice cream from one living unit to the C living unit uncovered. On 03/04/2026 at 9:37 AM, Surveyor interviewed DA H and asked if it was common practice to use the same contaminated gloves the entire time for prepping and serving meals to residents. DA H reported to Surveyor that DA H has only been here for couple weeks, but DA H probably should have changed gloves throughout touching utensils and other surfaces. Surveyor asked DA H if it is normal to touch food with bare hands or with contaminated gloves. DA H reported to Surveyor that the kitchen has lots of tongs and probably should have used tongs to pick up bread for breakfast. On 03/04/2026 at 11:18 AM, Surveyor interviewed Dietary Director (DD) G about the above observations. When asked about changing gloves, DD G stated any time they change tasks hands should be washed, and gloves should be changed. Example 3 On 3/3/26 at 8:55 AM, Surveyor asked for policies related to food storage, refrigeration, and leftover use. Surveyor only received the following two policies. The facility policy titled Use of Leftovers, not dated, states: 2. Leftovers will be covered, labeled, and dated; then stored appropriately. The facility policy titled Food Storage, dated 12/31/24, states: Sufficient storage facilities are provided to keep foods safe, wholesome and appetizing. Food is stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination. 4. Plastic containers with tight-fitting covers must be used for storing. All containers must be accurately labeled and dated. 6. Scoops must be provided for four, sugar, cereals, dried vegetables, and spices. Scoops are not to be stored in the food containers but are kept covered in a protected area near the containers. Scoops are to be washed and sanitized on a weekly basis, or as needed. The State Operation Manual for Long Term Care titled Appendix PP, dated states: 483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. Food handling risks associated with food stored.include but are not limited to:. Food left in refrigerators beyond use by dates (including, but not limited to foods that have been opened but were not labeled.) On 3/3/26 at 8:17 AM, Surveyor conducted an initial tour with the Dietary Director (DD). DD G provided a tour to Surveyor of the dry storage, refrigerator, freezers, and kitchen area. During the tour, Surveyor observed beige chunks floating in liquid in an unlabeled container in the refrigerator. DD G stated could not find a label when asked and stated they are pears. I am going to throw them away. Surveyor observed the container of salt with a scoop in it. DD G's expectation is no scoops left in the containers; it can cause cross contamination. Surveyor observed the containers of sugar, flour and brown powder. DD G was unable to find a label when asked. DD G stated I don't know what this is. They know better. I'm throwing this away. Surveyor observed a half open loaf of bread and open package of hamburger buns. DD G was unable to find a label. DD G stated we go through that daily, but they should have been labeled with an open date. In 3/3/26 at 8:52 AM, DD G stated that all things should be labeled when open. We do not have to label with a use by date if it has an expiration date. Example 4 The facility policy titled Plate Cover Policy states in part: to ensure food is served at the proper temperature, protected from environmental contamination.trays must remain covered during transport.covers should be removed just prior to placing the plate on the table to minimize heat and exposure On 03/03/2026 at 1:06 PM, Surveyor observed Certified Nurse Assistant (CNA) S walking down hallway with uncovered tray of desserts. CNA S delivered uncovered tray full of desserts to unit C. Surveyor observed CNA S set tray of desserts on table uncovered. Surveyor observed CNA S walk down hallway with uncovered tray full of desserts. On 03/03/2026 at 1:08 PM, Surveyor observed CNA S walk into R25's room with uncovered dessert tray and ask if R25 wanted dessert. CNA S walked out of R25's room down the hallway and into R28's room. CNA S exited R28's room and then walked into R35's room, which is on EBP, and asked if R35 wanted dessert. CNA S exited R35's room with uncovered dessert tray and continued down hallway with uncovered dessert tray. Surveyor observed CNA S walk down hallway and enter R33's room with uncovered dessert tray and ask if R33 wanted dessert. CNA S then exited R33's room and walked down hallway with uncovered dessert tray. On 03/03/2026 at 1:11 PM, Surveyor interviewed CNA S and asked if delivering uncovered dessert tray to residents on C unit is normal practice. CNA S reported to Surveyor that CNA S had to go get the desserts because the kitchen forgot to deliver the desserts to residents who already were served their lunch trays. Surveyor asked CNA S if the food tray needs to be covered. CNA S stated to Surveyor, I guess it does, but kitchen forgot to deliver desserts.

Based on record review, observation, and interview, the facility did not ensure the residents remain free of possible accidental hazards. Facility did not ensure staff were applying the correct size Hoyer (mechanical full body lift) sling to prevent accidents for 3 residents (R) requiring Hoyer full body lifts. (R5, R13, R23).R13 is dependent for rolling, repositioning, and mobility and was lifted with a one person assist mechanical lift which goes against policy and Occupational Safety and Health Administration (OSHA) nursing home standards of practice. R23 was lifted with a one personal assist mechanical lift which goes against Occupational Safety and Health Administration (OSHA) nursing home standards of practice. Lack of supervision of thickened liquids for R14 who was at risk of choking. Findings include: The facility policy, titled Safe Resident Lifting and Transferring Program, dated 1/3/26, states: Purpose: 4. Safely lift a resident who is unable to assist in transfer by pivoting out of bed and into a chair, Geri-chair, or wheelchair using a gait belt. Policy: Glenhaven, Inc employees will follow the Safe Resident lifting and Transferring Program guidelines for all resident lifts and transfers. 7. Total lifts are used for resident who are non-weight bearing and who have fallen on the floor and cannot get up on their own. A one-person transfer can be performed if the lift is designed for one person operation. Ther person ca be positioned appropriately with one person. If the person is predictable and without behaviors. If the staff is trained appropriately A backup is available if needed for safety concerns. 8. Be mobility such as rolling, boosting a resident, should be performed in teams of two. At no time should a Glenhaven, Inc. employee attempt to maneuver a resident individually, unless a resident is able to assist with the process. The Occupational Safety and Health Administration (OSHA) document, Guidelines for Nursing Homes, revised March 2009, states: The standard practice for Hoyer lifts in nursing homes requires at least two trained staff members for safe transfer, ensuring the correcting sling size and type are used . Sling Application: Choose the correct sling size; too large risks slipping, while to small causes discomfort or falls. Manufacturer's guidelines for EZ Way Smart Lift state the EZ way Smart Lift was designed to be operated safely by one person. However, with some patients it is best to use two people. Guidelines do not make a statement or clarify the factors that would make up some patients. Manufacturer's guidelines document. Sling Sizing Charts states: Small sling 70-100lbs, Max distance from patient's tailbone to base of neck 21inches, Medium Sling 90-220, Max distance from patient's tailbone to base of neck 24inches, Large Sling Size 190-320lbs. Max distance from patient's tailbone to base of neck 26inches, XL Sling Size 280-450lbs. Max distance from patient's tailbone to base of neck 29inches . Example 1 R13 was admitted to the facility on [DATE], and has diagnoses that include unspecified mood disorder, essential tremors, hearing loss, dementia, and high blood pressure. R13's Minimum Data Set (MDS) assessment, dated 12/8/25, indicated that R13 has unclear speech, is never understood and rarely understands the conversation. R13's Brief Interview for Mental Status (BIMS) indicated resident was unable to respond to the questions. R13 has impaired mobility bilaterally in both the upper and lower extremities. R13 is dependent for rolling left to right, and assessment did not attempt to have R13 sit up himself or try to stand. R13 is dependent of a mechanical lift for all transfers and a wheelchair for mobility. R13 is dependent for all activities of daily living (eating, hygiene, dressing). R13's Certified Nursing Assistant (CNA) Kardex (guide to care) for 3/4/26 found in CNA binder states, Ensure proper positioning in w/c. observe for signs of slouching; maintain prepositioning in bed. Transfer: dependent 1-2 assist, full body/Hoyer lift. Use size medium sling. On 3/4/26 at 7:10 AM, Surveyor observed only CNA T transfer R13 using a Hoyer (mechanical) lift and sling to transfer R13 from bed to his wheelchair. CNA T rolled R13 from side to side to place the Hoyer sling under him. R13 could not assist with the roll. Surveyor was surprised that CNA T was able to do that and made comment. CNA T stated I have to do this (roll resident) all the time. On 3/4/26 at 7:20 AM, Surveyor interviewed CNA T who stated, It was crazy when I moved here, they allow one person lifts. CNA T stated that she came from another facility and there they had assist of 2 with all Hoyer lifts. CNA T stated she thought that was standard. CNA T stated it is in the binder how to transfer residents and what sling to use. On 3/4/26 at 11:19 AM, Surveyor interviewed CNA T who stated the size of the sling used matters; it is in our book and on the care plan what is needed. CNA T stated there are extra slings in the laundry room; we wash as needed. CNA T stated slings stay with the resident, and we know the size because the edge is a different color, and it is listed on the tag. On 3/4/26 at 2:30 PM, Surveyor reviewed R13's electronic medical record for weights and height or documentation on size assessment for Hoyer sling. R13 weighed 185.4 lbs. (pounds) on 12/10/25, 189.6 lbs. on 2/4/26, and 191.2 lbs. on 3/4/26. There is no height documented in the electronic medical record. There was no progress note or assessment record for determining Hoyer sling size. Example 2 R5 was admitted to the facility on [DATE] with diagnoses of aphasia (difficulty swallowing), history of stroke, cellulitis of right lower limb, hemiplegia and hemiparesis, morbid obesity, seizure disorder, type 2 diabetes mellitus, muscle weakness, hypertension (high blood pressure), dementia, and depression. R5's MDS assessment, dated 12/15/25, indicated that R5 has unclear speech and is sometimes understood but usually understands, missing part of the message but comprehends most conversation. R5 needs substantial assistance to depends on assistance for all mobility. Due to R5's communication a BIMS was not done with R5. Assessment with staff and those that know R5 indicated R5 knows where he is, recognizes faces, but cognitively is severely impaired. R5's CNA Kardex, dated 3/24/26, states: Transfers: The resident requires total assistance by 1-2 staff to move between bed and wheelchair utilizing the Hoyer lift. Use size Large Sling. Resident utilizes the EZ stand to transfer between wheelchair and toilet Bed Mobility: The resident requires extensive assistance by 1-2 staff to turn and repositioning bed . On 3/4/26 at 1:50 PM, Surveyor observed CNA V and CNA T use a Hoyer lift and transfer R5 back to bed. CNA V and CNA T used the large Hoyer sling. Example 3 R23 was admitted to the facility on [DATE] and has diagnoses that include progressive neurological condition, coronary artery disease, heart failure, high blood pressure, non-Alzheimer's dementia, anxiety, depression, and asthma. R23's MDS assessment, dated 1/27/25, indicated that R23 has unclear speech, can sometimes make self-understood and misses some part/intent of the message but comprehends most conversations and is severely cognitively impaired. R23 has no extremity impairment, requires a wheelchair for mobility, and is dependent on full assistance for transferring to the toilet, shower, and for transfers to from chair to bed and vice versa. R23 is able to roll self in bed and sit up with touching assistance. On 3/4/26 at 7:48 AM, Surveyor observed only CNA V use a Hoyer lift and sling to transfer R23 from bed to his wheelchair. Surveyor observed CNA V place Hoyer sling under R23, giving R23 a little push when R23 rolled. On 3/4/26 at 7:52 AM, Surveyor interviewed CNA V who stated that they try to use two staff when they lift residents with a Hoyer lift, but the lifts are safe to use with one and sometimes it is too busy. We use the sling size that is on the plan. On 3/4/26 at 12:32 PM, Surveyor observed sling sizes used with R5, R13 and R23 with CNA T's assistance. R13 was sitting on a cross-body sling with a beige trim, R5 was sitting on a cross-body sling with burgundy trim, and R23 was sitting on a full body sling with beige trim. CNA T stated it is because R23 squirms and tries to put it out from under him and then we can't get it under him to transfer him out of his chair. On 3/4/26 at 3:33 PM, Surveyor reviewed EZ sling sizing guidelines. Surveyor noted there is overlap in weight ranges for different sizes. Residents could fit in two different slings resulting in one being too large or small. Leadership Interviews: On 3/4/26 at 10:14 AM, Surveyor interviewed Assistant Director of Nursing (ADON) C who stated that if a resident is working with therapy, they help determine the transfers. If there is a change, we usually get therapy involved. On 3/4/25 at 10:26 AM, Surveyor interviewed Physical Therapist (PT) U who stated if a resident is new, the facility gets the initial transfer status from the hospital. Then once here PT or Occupational Therapy (OT) go in and assess how much cuing is needed and strength the resident has. PT U stated that Hoyer lifts always take 2 staff to transfer in my experience. PT U stated that it is standard to have 2. PT U said R13's physical therapy deemed R13 as dependent. Per PT U's last therapy note stated R13 was dependent in all transfers and requires max assist with bed mobility. R13's orders do not say Hoyer directly but that is what dependent means. PT U states we do not determine the sling size, that is the nursing staff. On 3/5/26 at 10:52 AM, Surveyor interviewed ADON C who stated ADON C determines the sling size for residents. ADON C stated sling size is determined on weight, if overweight we would consider height and the two factors, using a larger size. Surveyor showed ADON C the manufacturer's guidelines where this is a chart for size of sling based on two factors, weight and measurement from patient's tailbone to base of neck. Guidelines state, A proper fit will depend on factors other than weight, including height and girth of a patient. ADON C stated let's be honest they have that note in there, so they are not liable. We base it off weight. If the CNA says this is not feeling right, then there is a new assessment. Example 4 R14 was re-admitted to the facility on [DATE] with diagnoses including in part, cerebral infarction, glaucoma, osteoarthritis, hypertension, edema, flaccid hemiplegia affecting ride dominant side, constipation, depression, muscle weakness, lymphedema, facial weakness following cerebral infarction, and urinary tract infection. R14's MDS assessment, dated 02/11/26, identified R14 required set up and supervision during eating. R14's BIMS dated 02/11/26 was 12/15, which indicates R14 had moderately impaired cognition. Surveyor reviewed R14's care plan for nutrition which states in part, -Provide, serve diet as ordered--Regular/Puree Texture/Honey thick liquids. -Set up and supervise meals. -Monitor intake and record q meal. -ST Evaluation and Treatment as indicated. Surveyor reviewed R14's ST order in CNA binder on unit, dated 02/18/26: Liquids MT2 (Nectar Thick) in 2 nosey cups. Continue with PU4 (Purees) for foods. Surveyor reviewed kitchen demographic sheet for R14. Surveyor observed diet IDDSI 4 (Pureed), nectar thick liquids in nosy cup, dislikes thickened water, green pureed food, and uses a divided plate. Surveyor reviewed R14's progress notes: -On 01/06/26, Nutrition/Dietary Note Late Entry:Note Text: Q3 Nutrition Assessment:Oral: Reports difficulty swallowing at times with coughing and choking during meals or when swallowing. Eating: admission Performance: Supervision or touching assistance at meals. No complaints of thirst.- Continue diet of Fluids and fluids as desired texture with honey consistency texture- Ensure appropriate pureed consistency preparation for all foods- Additional training provided to dietary staff on correct puree consistency preparation following incident- Monitor swallowing difficulties and coughing episodes during mealsWill review/update care plan. Will continue to monitor and follow closely. -On 2/5/2026, communication with Physician. Note Text: Fax sent to MD with request for ST Services following screen provided by physical therapy services.Response: OK for ST to eval and treat as indicated for dysphagia. -On 2/5/2026, Note Text: Notified resident that she has a new order for ST to eval and treat for dysphagia. -On 2/27/2026, Note Text: Fax sent to MD ST evaled & recommend nectar thick liquids with nosy cup for all liquids, continue with IDDSI 4 (puree) diet, returned signed ok with above. -On 2/27/2026, Communication with Family/POA, Note Text: Spoke with POA on the phone regarding new order for nectar thick liquids in a nosey cup rather than honey thick liquids in the nosey cup. POA agreeable to order change. Interviews/Observations: On 03/03/26 at 2:00 PM, Surveyor interviewed Family Member (FM) P and asked if FM P had any concerns with eating and diet. FM P reported that FM P feels facility is handling R14's diet correctly. FM P stated, Mom chokes a lot and sounds like Speech Therapy (ST) wants to change her diet a little to help with eating, so she is puree with thickened liquids. On 03/04/2026 at 7:43 AM, Surveyor observed Registered Nurse (RN) D administer medications for R14. Surveyor observed thickened water in a cup sitting on R14's bedside table when RN D and Surveyor entered R14's room. Surveyor observed RN D grab thickened water and hand to R14 to swallow medications. Surveyor interviewed RN D and asked if R14 is supposed to have fluids in room since R14 is on thickened liquid and puree diet. RN D stated to Surveyor, Oh, I think it is ok as long as it is out of reach as [R14] does not use her arms and can't reach the glass, but I am unsure at this time. On 03/04/2026 at 8:11 AM, Surveyor observed R14 at the dining room table for breakfast. Surveyor observed R14 grab R14's spoon and feed self. On 03/04/2026 at 12:29 PM, Surveyor observed Speech Therapy (ST) assessing R14 during lunch time for swallowing. On 03/04/2026 at 12:50 PM, Surveyor interviewed ST Q and asked what R14's diet is and expectation for R14 during feeding and drinking fluids. ST Q reported that R14 should be always supervised with feeding and drinking of thickened fluids. Surveyor asked if ST Q allows fluids in room. ST Q reported that R14 can have fluids in room if supervised but never left alone with fluids. ST Q reported that ST Q's company is new with the facility, and ST Q is performing much needed education regarding diets and supervision. On 03/05/2026 at 9:06 AM, Surveyor entered R14's room and observed thickened liquids in a clear cup sitting on bedside table. On 03/05/2026 at 9:17 AM, Surveyor interviewed CNA O and asked CNA O to enter R14's room. Surveyor asked CNA O if R14 having thickened liquids in room was appropriate. CNA O reported to Surveyor that usually R14 does not have thickened water in room and that today was maybe the second time CNA O has seen water in R14's room. CNA O reported to Surveyor that R14 needs supervision with food and water. On 03/05/2026 at 9:23 AM, Surveyor interviewed RN J and asked RN J's expectation of fluids in R14's room. RN J reported that all residents should have access to fluids. Surveyor asked RN J what R14's diet and intake orders are. RN J reported there has been some confusion about what type of fluids R14 is on. RN J reported that facility has been giving her honey thickened liquids for a while, but diet says nectar is thick, so RN J is unsure. RN J reported to Surveyor that RN J has been questioning this frequently with no direct affirmative answer. On 03/05/2026 at 9:43 AM, Surveyor interviewed ADON C and asked what diet R14 is. ADON C reported there has been some confusion about diet and fluids. Surveyor showed ADON C that ST's orders were Liquids MT2 (Nectar Thick) in 2 nosey cups. Continue with PU4 (Puree's) for foods on 02/18/26 but through interviews from staff, staff are still giving honey thick to R14. ADON C stated, That is a concern and needs to be fixed. ADON C reported that since we have switched to a different ST there needs to be more education on touching base with ADON C after ST recommends diet changes. Surveyor asked ADON C if R14 is supposed to be supervised. ADON C reported to Surveyor that ADON C will need to communicate with ST if in fact she needs supervision with food and liquids. ADON C stated at this time ADON C is unsure, but expectation is for all staff to monitor residents on thickened liquids if ST ordered supervised.

Based on staff and resident interview and record review, the facility did not ensure 2 residents/resident representative (R) (R2 and R30) of 2 residents reviewed for hospitalization received the proper notice of transfer, reason for transfer, or name and address with telephone number of the Office of the State Long-Term Care Ombudsman.Transfer Discharges Notices do not contain a specific reason for transfer.Findings include: On 3/12/26 at 2:32 PM, when completing offsite work, Surveyor identified there was no discharge/transfer policy in the pile of papers. Surveyor reached out to Assistant Director of Nursing (ADON) C and provided an opportunity to supply a policy. On 3/12/26 at 3:13 PM, ADON C sent email with documented titled Notice of Transfer or Discharge 2016 attached. Surveyor opened attachment and found a blank copy of the Notice of Transfer or Discharge form, Resident's Rights to Appeal a Transfer or Discharge document, Contact Numbers sheet and Notice of Bed-Hold Policies. These are blank versions of the forms used during the following listed hospitalizations. Per the Long-Term Care State Operations Manual (SOM), dated 7-23-25, regulation 483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must- (i) notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. 483.15(c)(5) Content of Notice. The facility's notice must include all the following at the time notice is provided: The specific reason for the transfer or discharge. Example 1 R30 was admitted to the facility on [DATE], and has diagnoses that include high blood pressure, high cholesterol, chronic fatigue, squamous cell carcinoma of skin, type 2 diabetes with chronic kidney disease, communication disorder, bipolar disorder, dementia, and Alzheimer's disease. R30's Minimum Data Set (MDS) assessment, dated 2/28/26, identified R30 is cognitively impaired and unable to make her own decisions. R30 requires substantial assistance with personal hygiene, bathing and dressing and partial assist with transferring to sit to lying position required substantial maximal assistance for toileting and toilet transfer. Partial moderate assistance for bed mobility, rolling left to right, sitting to lying, and chair to bed. On 3/4/26 at 1:32 PM, Surveyor reviewed notice of transfers for R30's hospitalizations on 1/7/26 and 4/12/25 which showed no specific reason for transfer to a higher level of care. Form had the following non specific reasons as option for discharge transfer: Resident choice. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. The resident's health has improved sufficiently that the resident no longer needs the services provided by this facility. The safety of individuals in the facility is endangered by the resident being here. The health of individuals in the facility would be endangered by the resident being here. The resident has failed, after appropriate notice, to pay for a stay in this facility. Immediate transfer/discharge as required by the resident's urgent medical need. On 3/5/26 at 3:43 PM, Surveyor interviewed ADON C who stated the forms tell families why they are being transferred. Surveyor reiterated that the regulation states specific reasons, and listed reasons are vague. The form should provide specific information to the family representative and ombudsman in writing. The options on the form of immediate transfer/discharge as required by the resident's urgent medical need, resident choice, necessary for the resident's welfare and the resident's needs cannot be met in the facility are not specific. ADON C stated I guess, I see. Example 2 R2 was admitted to the facility on [DATE] with diagnoses including in part, urinary tract infection, Klebsiella pneumoniae, parkinsonism, depression, anxiety, hyperlipidemia, type 2 diabetes, neuromuscular dysfunction of bladder, gastro esophageal reflux disease without esophagitis, and insomnia. R2's Minimum Data Set (MDS) assessment, dated 10/29/25, identified R2 required substantial maximal assistance for toileting and toilet transfer. Partial moderate assistance for bed mobility, rolling left to right, sitting to lying, and chair to bed. R2's Brief Interview for Mental Status (BIMS) dated 10/22/25 was 8/15, which indicates R2 had mild to moderate cognitive impairments. On 03/03/26 at 12:20 PM, Surveyor reviewed notice of transfers for R2's hospitalization on 11/10/25 and 12/27/25 which showed no reason for transfer to a higher level of care.

Based upon interview, policy review and record review, the facility did not ensure allegations of sexual abuse were thoroughly investigated or prevent further potential abuse from occurring while the investigation was in progress for resident (R) (R2) and other undocumented residents, which has the potential to affect all 11 residents on the D unit. Facility did not protect R2 when allowing Certified Nursing Assistant (CNA) M to continue to work with R2 when accused of sexual abuse.Facility did not complete a thorough investigation of R2's accusation against CNA M.Findings include:Facility policy titled Abuse Prevention Policy, last revised 04/07/25, stated in part,-E. Investigation: The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed.Investigation of abuse: i. Who was involved. ii. Residents statements. iv. Involved staff and witness statements of events. v. A description of the resident's behavior and environment at the time of the incident. vi. Injuries present including a resident assessment. vii. Observation of residents and staff behaviors during the investigation. viii. Environmental considerations.e. More investigative protocols: The results of the investigation will be recorded and attached to the report.-G. -F. Protection: Procedures must be in place to provide the residents with a safe, protected environment during the investigation. i. The alleged perpetrator will immediately be removed and residents protected. Employees accused of alleged abuse will be immediately removed from facility and will remain removed pending the results of a thorough investigation. iv. Examine, assess, and interview the residents and other residents potentially affected immediately to determine any injury and identify any immediate clinical interventions necessary. Notify resident physician. vii. Notification of law enforcement and/or State Agency as indicated. viii. A medical, evidentiary, or sexual assault exam should be completed as soon as possible, as appropriate .R2 was admitted to the facility on [DATE] with diagnoses including in part, urinary tract infection, Klebsiella pneumoniae, parkinsonism, depression, anxiety, hyperlipidemia, type 2 diabetes, neuromuscular dysfunction of bladder, gastro esophageal reflux disease without esophagitis, and insomnia. R2's Minimum Data Set (MDS) assessment, dated 10/29/25, identified R2 required substantial maximal assistance for toileting and toilet transfer. Partial moderate assistance for bed mobility, rolling left to right, sitting to lying, and chair to bed. R2's Brief Interview for Mental Status (BIMS) dated 10/22/25 was 8/15, which indicates R2 had mild to moderate cognitive impairments.Surveyor reviewed R2's progress notes in R2's medical record, which states in part,On 01/29/26 at 10:01 PM, CNA informed recorder that resident has complained about inappropriate sexual touching from another CNA. Recorder asked resident about the incident, resident stated CNA came into room last night and touched his penis while he was sleeping. Recorder asked clarifying question, Was it on top of the brief or under it? Resident stated, it was on top, and he slid his hand up and down. Recorder asked if it was possible that he was trying to see if resident was dirty? Resident stated no and he was going to call his son and be out of here by morning. Recorder notified DON of conversation, DON advised to get statements from everyone and obtained statement from POA. Recorder called POA and told her of resident sexual accusation. POA said residents have made these statements before and they are not true. He just doesn't like him. He doesn't like anyone. He said that CNA gets in bed and lays with him and I know that doesn't happen. POA then said when she was there CNA took him to the bathroom and was working with him while having good conversations. I just don't want him getting in trouble, he didn't do anything wrong. Recorder relayed this information to DON. DON she will make a note in care plan that resident makes false accusations and to not have this CNA go into residents' room anymore. Recorder relayed that information to POA. POA is okay with this plan and will discuss it at the next care conference. Recorder had both CNAs from D unit write statements and put under DONs door.Surveyor reviewed facility Analysis and Action Plan Worksheet, dated 01/29/26, which stated in part, .Actions: -On 01/29/26, Notification of POA, administration, and DON. -On 01/29/26-02/01/26, Staff interview and resident interviews completed. -On 01/30/26, ID care team monitoring.Statement from CNA incidence was reported to completed.Statement from POA completed.Statement from [CNA M] completed.Conclusion: In light of POA stating that [R2] has made comments/accusations previously to her and that she knows they are not true, no state report is being submitted. [R2] will be care-planned as having history of false accusations, and [CNA M] will no longer be assigned to care for resident per residents' preference.Out of precaution, all residents were questioned regarding any inappropriate touching. Those unable to answer were assessed for any changes to behaviors that may suggest any inappropriateness is occurring.Surveyor reviewed CNA M's timecard that states in part, .Worked 01/29/26 from 6:00 PM-6:23 AM, 01/30/26 from 6:01 PM-6:31 AM, 01/31/26 from 5:59 PM-6:36 AM.On 03/05/2026 at 1:10 PM, Surveyor interviewed R2's POA about incident with accusation of CNA M inappropriately touching R2's penis. POA N felt that R2 was hallucinating so POA N told facility not to worry about the accusation. Surveyor asked if there were any other steps facility might have taken to protect R2 from any potential sexual abuse concerns. POA reported to Surveyor that POA is unsure at this time.On 03/05/2026 at 1:38 PM, Surveyor interviewed CNA O and asked CNA O to explain how CNA O knew about R2's accusation of CNA M inappropriately touching R2's penis. CNA O stated, I came on day shift next morning and in report from [CNA M], [R2] had accused [CNA M] of a sexual concern. Surveyor asked CNA O if CNA M continued to work with R2 for the rest of CNA M's nightshift. CNA O reported that CNA M continued to take care of R2 that night as CNA M reported off to CNA O about cares completed for R2 through the night. CNA O stated, [CNA M] continued to care for all other residents on D unit. Surveyor asked if CNA O has heard any other concerns with CNA M's performance while working at facility and if any residents reported any sexual abuse concerns to CNA O. CNA O reported that CNA O has not heard any other complaints at this time. On 03/05/2026 at 1:51 PM, Surveyor interviewed Director of Nursing (DON) B about investigation of R2's sexual abuse concerns. DON B reported that DON B completed an investigation, and facility felt the accusation was not accurate. Surveyor asked how DON B investigated R2's accusation of CNA M inappropriately touching R2's penis. DON B reported that R2 hallucinates a lot, so facility had called POA N with updated hallucination, and POA N told facility that it was probably not accurate. DON B reported to Surveyor that DON B revised R2's care plan with intervention that R2 hallucinates. Surveyor asked if DON B interviewed all other potential sexual abuse concerns with other residents and were head to toe assessments completed for R2 and all other residents CNA M provided cares to. DON B reported that most residents were interviewed. DON B reported that DON B could not provide a head-to-toe assessment on R2 for any potential physical concerns of sexual abuse nor could DON B provide any other assessments for cognitively impaired residents who were cared for by CNA M. Surveyor asked DON B if CNA M was removed from providing immediate cares of residents until full investigation was performed and completed. DON B reported that DON B was unsure. Surveyor requested CNA M's timecard that showed CNA M continued to work the rest of 01/29/26 and then the next 2 days. Surveyor asked DON B if any further action was taken to protect R2 from potential sexual abuse concerns and if DON B provided education to CNA M after the incident. DON B reported to Surveyor that DON B did not perform education to CNA M. Surveyor reported to DON B that during interviews, CNA M is still providing care to R2 presently. DON B reported that DON B should have completed a more thorough investigation.

Based on interview and record review, the facility did not report 1 of 1 (R2) potential misconduct incidents to the State Agency (SA) via the State's Misconduct Incident Reporting (MIR) system immediately upon learning of the incident.R2 reported to facility staff that a male Certified Nurse Assistant (CNA) M had inappropriately touched R2's penis. Findings include:Facility policy titled Abuse Prevention Policy, last revised 04/07/25, stated in part,-F. Protection: Immediately upon receiving a report of alleged abuse, the Administrator, and or designee will coordinate delivery of appropriate medical/and or psychological care and attention. a. vii. Notification of law enforcement and/or State agency, Crisis Response, Poison Control, etc.as indicated.-G. Reporting and Response: Abuse policy requirements indicate any abuse allegations are reported per Federal and State Law. Facility will ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. In addition, local law enforcement will be notified of any reasonable suspicion of a crime against a resident in the facility .R2 was admitted to the facility on [DATE] with diagnoses including in part, Urinary tract infection, Klebsiella pneumoniae, parkinsonism, depression, anxiety, hyperlipidemia, type 2 diabetes, neuromuscular dysfunction of bladder, gastro esophageal reflux disease without esophagitis, and insomnia. R2's Minimum Data Set (MDS) assessment, dated 10/29/25, identified R2 required substantial maximal assistance for toileting and toilet transfer. Partial moderate assistance for bed mobility, rolling left to right, sitting to lying, and chair to bed. R2's Brief Interview for Mental Status (BIMS) dated 10/22/25 was 8/15, which indicates R2 had mild to moderate cognitive impairments.Surveyor reviewed R2's progress notes in R2's medical record, which states in part, On 01/29/26 at 10:01 PM, CNA informed recorder that resident has complained about inappropriate sexual touching from another CNA. Recorder asked resident about the incident, resident stated CNA came into room last night and touched his penis while he was sleeping. Recorder asked clarifying question, Was it on top of the brief or under it? Resident stated, it was on top, and he slid his hand up and down. Recorder asked if it was possible that he was trying to see if resident was dirty? Resident stated no and he was going to call his son and be out of here by morning. Recorder notified DON of conversation, DON advised to get statements from everyone and obtained statement from POA. Recorder called POA and told her of resident sexual accusation. POA said residents have made these statements before and they are not true. He just doesn't like him. He doesn't like anyone. He said that CNA gets in bed and lays with him and I know that doesn't happen. POA then said when she was there CNA took him to the bathroom and was working with him while having good conversations. I just don't want him getting in trouble, he didn't do anything wrong. Recorder relayed this information to DON. DON she will make a note in care plan that resident makes false accusations and to not have this CNA go into residents' room anymore. Recorder relayed that information to POA. POA is okay with this plan and will discuss it at the next care conference. Recorder had both CNAs from D unit write statements and put under DONs door.Surveyor reviewed facility Analysis and Action Plan Worksheet, dated 01/29/26, which stated in part, Notification of law-Na and Notification of MD-Na. On 03/05/2026 at 1:38 PM, Surveyor interviewed Director of Nursing (DON) B about investigation of R2's sexual abuse concerns that were reported to facility staff on 01/29/26. Surveyor asked DON B if R2's accusation of CNA M inappropriately sexually touching R2 was reported to law enforcement or to the State OCQ division. DON B reported that DON B did not report to state or law enforcement as DON B was supposed to.

Based on record review, observation and interview, the facility did not ensure a resident who required substantial assistance for repositioning and toileting received timely assistance for 1 of 1 resident (R) reviewed for Activities of Daily Living (ADLs) (R13).R13, who is dependent for cares and incontinent of urine, did not have his brief changed for about 7 hours; prior to 7:10 AM until 2:02 PM. Findings include:On 3/4/26 at 2:22 PM, Surveyor asked for policies regarding incontinence care, ADL dependency and repositioning, whether it was all in one policy or individual polices. At 3:33 PM, Director of Nursing (DON) B came back to Surveyor and said DON B could not find a policy on incontinence care and repositioning. The National Institute of Health states, Best practice for changing incontinence briefs in nursing homes requires checking every 2 hours, with changes occurring immediately upon soiling to prevent skin breakdown . High absorbency products may last 5-12 hours, but active monitoring is required for quality of care.R13 was admitted to the facility on [DATE], and has diagnoses that include unspecified mood disorder, essential tremors, hearing loss, dementia, and high blood pressure. R13's Minimum Data Set (MDS) assessment, dated 12/8/25, indicated that R13 has unclear speech, is never understood and rarely understands the conversation. R13's Brief Interview for Mental Status (BIMS) indicated resident was unable to respond to the questions. R13 has impaired mobility bilaterally in both the upper and lower extremities. R13 is dependent for all mobility and on a mechanical lift for all transfers and a wheelchair for mobility. R13 is dependent for all activities of daily living (eating, toileting hygiene, personal hygiene, dressing).R13's Kardex (certified nursing assistant plan of care), states R13 is incontinent. Check and change every two hours and as needed.R13 incontinence care plan, printed 3/4/26 states:FOCUS:INCONTINENCE The resident has bowel and bladder incontinence r/t immobility and cognitive loss. Date initiated 1/12/25 revision on: 6/11/25.Goal:Resident will not have skin breakdown related to incontinence. Date initiated: 1/12/25 Target date: 3/1/26.Interventions: Check resident every two to three hours for incontinence Date Initiated:1/12/25 Revision 1/12/25. Provide peri care after each incontinent episode Date Initiated: 1/12/25.On 3/4/26 at 7:10 AM, Surveyor observed Certified Nursing Assistant (CNA) T transfer R13 to his wheelchair using a Hoyer lift. CNA T stated R13's cares had been previously done. Surveyor continuously observed R13 from 7:10 AM to 10:02 AM. During this time R13 was sitting out in the great room, sitting in front of the fireplace before breakfast, and by window after breakfast. From 8:36 AM to 9:28 AM, R13 was at breakfast table.On 3/4/25 at 10:02 AM, Surveyor observed R13 start coughing and making noises. CNA T came over by R13, greeted him and wheeled him back to his room. CNA T pulled his blanket off his lap, pulled the waist band away from his waist, looked in R13's pants, stated there was no marking, he is dry, let waist band go, and put blanket back on his lap. CNA T did not change R13's brief.At 10:03 AM, R13's wheelchair was pushed from his room back in front of the fireplace. At 10:08 AM, CNA T pushed R13 out to the activities area where he stayed while BINGO was going on.On 3/4/26 at 11:17 AM, Surveyor observed R13, sitting out at BINGO in the middle of the U shape formation of tables, sleeping. R13 had not left the area.On 3/4/26 at 11:46 AM, Surveyor observed BINGO was over and R13 was sitting out in activity area with 3 other residents. Residents were being brought back to their units. At 11:48 AM, Surveyor observed CNA T take R13 from Registered Nurse (RN) R who had started to push R13 back to the unit. CNA T pushed R13 back into the unit and pushed R13 directly to great area and parked R13 wheelchair in front of the fireplace. R13's brief was not checked. R13 was at his lunch table from 12:08 PM to 1:26 PM. At 1:26 PM, R13 was placed back in front of the fireplace. At 1:39 PM, RN R pushed R13 back to his room because he started coughing and making noises and resident next to him was getting agitated. RN R pushed R13 just into his room, visible through the open door. Surveyor stood in hall where Surveyor could continue to observe residents in great room and R13 in R13's room.On 3/4/26 at 1:54 PM, Surveyor interviewed CNA V and CNA T about repositioning, changing briefs and the brief products used. CNA V stated that the rep for the briefs said until about 75% they are good, you watch the lines. Surveyor was unclear what she meant and asked CNA V for clarification. CNA V took a clean brief and showed Surveyor the yellow markings. CNA V pointed at the middle of brief and said that would be 50% so about here is 75%. The yellow markings will change to blue to indicate the brief is wet. CNA T stated normally we don't wait; we change if we see the lines and they are wet. CNA T stated nonverbal residents should be changed every 2 hours unless they are dry. We check every two hours. Surveyor asked if a resident can communicate, how long do they go without being checked. CNA T stated we ask after breakfast, and when we come to get them for lunch. On 3/4/26 at 2:02 PM, Surveyor observed CNA V and CNA T transfer R13 back to bed via Hoyer. CNA V and CNA T rolled resident and removed Hoyer sling from under R13, then changed R13's brief and provided peri-care. R13's brief was saturated and ready to break. CNA V took off brief, and Surveyor observed that all markings were blue indicating full saturation. CNA V held up brief to look at it, and CNA T stated when CNA T saw R13 this morning he had no lines. He was dry. On 3/4/26, Surveyor continuously observed R13 from 7:10 AM until 2:02 PM. CNA T took resident back to his room at 10:02 AM; in one minute, she allegedly checked R13 for dryness. At 10:03 AM, she was pushing him back out on floor. R13 was not checked for incontinence again until 2:02 PM. On 3/4/26 at 2:22 PM, Surveyor interviewed Assistant Director of Nursing (ADON) C who stated that R13 should have been checked before lunch if R13 was checked at 10. Generally, it is a 2-hour check. Our continence products are good for quite some time. We don't push it here. If checked and dry, we would not check again for 2 hrs. If it was bowel that's a different situation. Usually there is an odor and change them then, otherwise we would check at the two-hour limit. On 3/4/26 at 3:33 PM, DON B brought in requested paperwork to Surveyor. DON B stated we would expect them to be changed and repositioned every 2 hours or as care planned.

Based on interviews and record reviews, the facility did not complete and submit Minimum Data Set Assessments (MDSAs) in the required time frames for 2 of 2 sampled residents for hospitalizations. (R2, R30)R30's MDS assessment was completed late on 1/12/25, 11/19/24, 218/25, 4/23/25, and 8/19/25. R30's MDS dated [DATE] transmission timeframe was greater than the 14 days from due date. 1/12/26 MDS transmission to the Centers for Medicare & Medicaid Services (CMS) national database was 51 days late.R2's MDS assessment was completed late on 10/29/25, 1/12/26, and 2/6/26.R2's MDS dated [DATE] transmission timeframe was more than 14 days from due date. 10/22/25 MDS transmission to the CMS national database was 19 days late.Findings include:The RAI (Resident Assessment Instrument) 3.0 User's Manual, dated October 2024, states in regard to the timing for completing the MDSAs in Section 5.2: - For all non-admission MDSAs, the MDS Completion Date must be no later than 14 days after the previous ARD (Assessment Reference Date). This would include Annual Assessments.- For all admission Assessments, the MDS Completion Date must be no later than 13 days after the Entry Date (Date of admission plus 13 days)- Quarterly Assessments: The Assessment Reference Date and MDS Completion Dates must be no later than 92 days from previous ARD and the Transmission Date must be no later than 14 days from the Completion Date.Example 1R30 was admitted to the facility on [DATE], and has diagnoses that include high blood pressure, high cholesterol, chronic fatigue, squamous cell carcinoma of skin, type 2 diabetes with chronic kidney disease, communication disorder, bipolar disorder, dementia, and Alzheimer's disease.On 3/5/26 at 2:22 PM, Surveyor conducted a review of R30's MDSs submitted for R30 during this survey period; 12/11/24 to 3/5/36. Surveyor noted the following late MDS assessment and record submission.Comprehensive - Completed on 1/12/26 and submitted on 1/23/26 with assessment completed 1/19/26.The admission assessment is more than 13 days after admission 1/5/26.Annual Comprehensive: Completed on 11/19/24 and submitted on 12/20/24 with assessment completed 12/10/24. Assessment late; the assessment completion date of 12/10/24 is more than 14 days after 11/19/24 assessment reference date. Quarterly Assessment: Completed on 2/18/25 and submitted on 3/24/25 with assessment completed 3/13/25. Assessment late; the assessment completion date of 3/13/25 (assessment completion date) is more than 14 days after 2/18/25 assessment reference date.PPS Assessment: Completed on 4/23/25 and submitted on 5/15/25 with assessment completed 5/14/25.Assessment late; the assessment completion date of 5/14/25 is more than 14 days after 4/23/25 assessment reference date.Quarterly Assessment: Completed on 8/19/25 and submitted on 9/16/25 with assessment completed 9/15/25.Assessment late; the assessment completion date of 9/15/25 is more than 14 days after 8/19/24 assessment reference date.Tracking (entry/death record) completed on 1/12/26 and submitted on 3/4/26.Record submitted late; the submission is more than 14 days after 1/12/26. Example 2R2 was admitted to the facility on [DATE] with diagnoses including in part, urinary tract infection, Klebsiella pneumoniae, parkinsonism, depression, anxiety, hyperlipidemia, type 2 diabetes, neuromuscular dysfunction of bladder, gastro esophageal reflux disease without esophagitis, and insomnia. On 3/5/26 at 2:22 PM, Surveyor conducted a review of R2's MDS submitted for R2 during this survey period; 12/11/24 to 3/5/36. Surveyor noted the following late MDS assessment and record submission.Tracking (entry/death record): admitted on [DATE] and submitted on 11/10/25.Record submitted late: the submission date is more than 14 days after admission: [DATE].Comprehensive: Admission/Medicare 5 days: Completed on 10/29/25 and submitted on 11/10/26 with assessment completion on 11/7/25.The assessment completion date 11/7/25 is more than 13 days after 10/22/25 admission date.Discharge return anticipated/end of PPS Part A stay: Completed on 12/28/25 and submitted on 1/12/26. Accurate timing.Tracking (entry/death record): Completed on 01/05/26 and submitted on 1/12/26. Accurate timing. Admission/Medicare 5 day - Comprehensive - Completed on 1/12/26 and submitted on 1/23/26 with assessment completed 1/19/26.The admission assessment is more than 13 days after admission 1/5/26.PPS/Part A Discharge (End of Stay) - Completed on 2/6/26 and submitted on 3/4/26 with assessment completed 2/26/26.The assessment completion date of 2/26/26 is more than 14 days after 2/6/26.On 3/4/26 at 7:46 AM, Surveyor interviewed Assistant Director of Nursing (ADON) C, who is also the MDS coordinator, regarding R30, who was not in the system when surveyors entered the facility on 3/3/26. Facility had readmitted R30 at the facility on 1/12/2026. ADON C stated they caught that yesterday. ADON C realized something wasn't clicked and it did not go through on 1/12/26. For this reason, R30 would not have been in the system to be pulled for this recertification survey. On 3/5/26 at 3:30 PM, Surveyor interviewed ADON C regarding MDS. ADON C is the MDS coordinator and the lead for completion and submission. ADON C was made aware of late assessment and records submissions found. ADON C was surprised to learn that there were late assessments. ADON C also stated that she did not realize that reentry MDSs are to be completed within 7 days of being readmitted . Surveyor referred her to the timeline chart found in the RAI manual. ADON C wrote a note regarding the reference.

Based on observation and interview, the facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles. This occurred for 1 of 3 medication carts/storage rooms observed. During the recertification survey, 1 of 3 observations were made of R15's liquid Morphine bottle open with no open date label in medication cart on unit E. Surveyor observed controlled medication Lorazepam not double locked on unit E.Findings include:Facility policy titled Controlled Substance Medication Storage, last revised 05/2018, stated in part,B. Schedule II-V medications and other medications subject to abuse or diversion are stored in a permanently affixed double locked compartment sperate from all other medications or per state regulation .Example 1On 03/04/26 at 9:10 AM, Surveyor observed medication cart on unit E with Registered Nurse (RN) R. Surveyor observed a bottle of morphine sulfate oral concentration 100mg/5ml, give 0.25ml by mouth every 2 hours as needed, opened with no open date label. The morphine was dispensed on 12/26/25 and R15 used 2 doses on 02/14/26 and 02/17/26. The bottle was in a bag with R15's identification but no open date label. On 03/04/26 at 9:33 AM, Surveyor interviewed Assisted Director of Nursing (ADON) C and asked if ADON C is aware that R15 has morphine concentration located in medication cart on unit E that has been opened with no open date label. ADON C reported to Surveyor that all liquid medications should be labeled with open date as soon as they are opened. ADON C reported that ADON C will discard the morphine and obtain a new bottle with correct labeling. Example 2On 03/04/26 at 9:12 AM, Surveyor observed a locked cabinet on unit E with RN R. In the locked cabinet was a fridge that RN R opened. Surveyor observed Lorazepam vial located in the fridge with insulin pens and flu vaccinations. Surveyor interviewed RN R and asked if Lorazepam is supposed to be double locked. RN E reported that RN E was unsure and would need to ask ADON C. On 03/04/26 at 9:33 AM, Surveyor interviewed ADON C and asked if Lorazepam is supposed to be double locked. ADON C reported that Lorazepam should be locked and thought that it was double locked over the years but would fix immediately.

Based on interview and record review, the facility did not ensure 1 of 12 sampled residents' (R25) medical records clearly identified the resident's advanced directives, regarding code status.The facility did not ensure R25's medical record was clear in identifying her advanced directives, regarding code status on admission.Findings include:Facility policy titled, Advanced Directives, includes, in part: Advanced Directives is a written instruction, such as living will or durable power of attorney for health care, recognized by State law, relating to the provisions of health care when the individual is incapacitated A. Upon admission, identify if the resident has an advance directive. D. All advanced directive document copies will be obtained and located (identify the same section of the resident's medical record that would be readily retrievable by any facility staff) . E. Resident wishes will be communicated to the staff via care plan and to the resident physician.R25 was admitted to the facility following a hospitalization on [DATE]. R25's Brief Interview for Mental Status score dated [DATE] was 15/15, which indicates R25 had no cognitive impairments.Review of admission physician's orders on [DATE], R25's medical record identified no order for code status.Review of current physician's orders on R25's medical record identified on [DATE], Do Not Resuscitate (DNR) status completed.On [DATE] at 9:41 AM, Surveyor reviewed R25's medical record and found no advance directive scanned into computer and a physician order for DNR status ordered 7 days later in R25's medical record. Surveyor observed that R25 went 7 days without a code status in place.On [DATE] at 10:01 AM, Surveyor interviewed R25 about R25's wishes for CPR or code status. R25 reported to Surveyor that R25 is a DNR. On [DATE] at 9:23 AM, Surveyor interviewed Registered Nurse (RN) J and asked where RN J would find code status and the process for new admissions. RN J reported that the floor nurse that receives the new admission will make sure code status is addressed within 24 hours of R25 being in facility. RN J reviewed R25's record and could see that R25 was admitted on [DATE] but did not have a code status then. RN J reviewed physician orders that stated R25 is DNR on [DATE]. RN J looked at top of screen in medical record and stated R25 is DNR but when you click on advance directives there is no documentation to show the signed document for DNR status. On [DATE] at 10:21 AM, Surveyor interviewed Director of Nursing (DON) B and asked the expectation of time and accuracy of code status for R25. DON B reported to Surveyor that the process begins on admission by Administrative Assistant K who completed the admission paperwork, then the document is printed and given to DON B, Assistant Director of Nursing (ADON) C, or Health Unit Coordinator L and the document is then given to the provider to sign. DON B stated, One of us 3 will place a heart on resident's name on door to show Full Code status. DON B stated to Surveyor, I screwed up and was under the impression [R25] was a Full Code. It wasn't until [DATE] when [Health Unit Coordinator L] returned from vacation that staff realized [R25] was a DNR status. Surveyor asked DON B why there was no scanned documentation in R25's medical record pertaining to R25's code status. DON B reported that DON B would need to search for the code status document.On [DATE] at 10:45 AM, DON B brought Surveyor the advance directive document clarifying R25's code status of DNR but admitted that the document was not scanned into R25's medical record yet but would do this right away.

Based on observation, interviews, and record review, the facility did not ensure that residents with an indwelling catheter received the appropriate care and services for 1 of 2 residents (R2) reviewed for catheters.Findings include:Facility policy titled Indwelling catheter insertion and care, last revised 04/07/25, stated in part,-5. t. Secure the catheter to the client's thigh using the securement device.u. Secure the urine collection bag lower than the client's position.-6. f. Maintain unobstructed urine flow by: i. Keeping the catheter and collection tubing free from kinking.ii. Always keep collection bag below the level of the bladder.R2 was admitted to the facility on [DATE] with diagnoses including in part, urinary tract infection, Klebsiella pneumoniae, parkinsonism, depression, anxiety, hyperlipidemia, type 2 diabetes, neuromuscular dysfunction of bladder, gastro esophageal reflux disease without esophagitis, and insomnia. R2's Minimum Data Set (MDS) assessment, dated 10/29/25, identified R2 required substantial maximal assistance for toileting and toilet transfer. Partial moderate assistance for bed mobility, rolling left to right, sitting to lying, and chair to bed. R2's Brief Interview for Mental Status (BIMS) dated 10/22/25 was 8, which indicates R2 had mild to moderate cognitive impairments.Surveyor reviewed R2's indwelling catheter care plan:The resident has an Indwelling Catheter due to Neurogenic bladder.History of failed voiding trials and ongoing UTI's due to not being able to fully empty bladder.-Catheter: The resident has 16f coude tip catheter with 20cc balloon. Position catheter bag and tubing below the level of the bladder and away from entrance room door.-Monitor and document intake and output as per facility policy.-Monitor for signs and symptoms of discomfort.-Monitor/document for pain/discomfort due to catheter.-Monitor/record/report to MD for signs and symptoms of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns.On 03/04/2026 at 10:55 AM, Surveyor observed Certified Nurse Assistant (CNA) E don Personal Protective Equipment (PPE) and enter R2's room. CNA E transferred R2 to the toilet due to an incontinent Bowel Movement (BM). Surveyor observed R2 had a leg bag in place but was sitting above R2's knee, kinked and wrapped around R2's knee. Surveyor observed the catheter was pulling tight from R2's cornea of penis. Surveyor did not observe catheter stabilization to R2's thighs. Surveyor observed R2 to have hematuria in the leg bag. On 03/04/2026 at 11:22 AM, Surveyor observed R2 sitting in wheelchair in lounge on unit D in front of TV shaking, complaining of severe pain on bottom and in groining area. Surveyor interviewed CNA E and asked about R2's catheter and why it was kinked with the leg bag and no stabilization to R2's thigh to keep R2's catheter tubing from pulling at R2's penis. CNA E reported that the hospice CNA is the one who got R2 up this morning and provided cares for the day. CNA E reported that CNA E is unsure why the leg bag is so short and has no stabilization on thigh. On 03/04/2026 at 11:27 AM, Surveyor observed Registered Nurse (RN) D approach R2 to gather vitals. Upon requesting to sit forward Surveyor observed R2 clench hold of the wheelchair and started shaking stating, I am in pain. RN D gathered vitals on R2 due to R2 being in so much pain. Vitals were within normal range, and afebrile. RN D reported that RN D will be notifying R2's Hospice RN F and Hospice RN F will be at facility shortly. On 03/04/2026 at 1:54 PM, Surveyor interviewed Hospice RN F and asked for information pertaining to R2's catheter, hematuria, and the stabilization of catheter. Hospice RN F reported to Surveyor that R2 has a history of ESBL in urine, was admitted to hospital in December of 2025 for sepsis, and Urinary Tract Infection (UTI) but has not had hematuria and that is a new symptom today. Hospice RN F reported that R2's catheter should be secured to the thigh as well as proper tubing for the leg bag during the day so that it isn't kinked. Hospice RN F reported that when Hospice RN arrived at facility she was assessing R2 and noticed that R2's catheter was pulling at R2's penis. Hospice RN F applied thigh stabilization to R2's catheter and reported to Surveyor the expectation is that the catheter is always secured. On 03/04/2026 at 2:21 PM, Surveyor interviewed Assistant Director of Nursing (ADON) C and asked ADON C for expectation of securement of catheterization for R2. ADON C reported that R2's catheter should be secured to the thigh as well as proper tubing for the leg bag during the day so that it isn't kinked.

Based on observation, interview and record review, the facility did not ensure 2 of 2 residents (R13 and R5) received necessary care and treatment. R13 and R5 are dependent on assistance for repositioning and mobility. R13 and R5 were not repositioned per care plan and standards of care.Findings include:On 3/4/26 at 2:22 PM, Surveyor asked for policies regarding incontinence care, ADL dependency and repositioning, whether it was all in one policy or individual polices. At 3:33 PM, Director of Nursing (DON) B came back to Surveyor and said DON B could not find a policy on incontinence care and repositioning. Example 1R13 was admitted to the facility on [DATE], and has diagnoses that include unspecified mood disorder, essential tremors, hearing loss, dementia, and high blood pressure. R13's Minimum Data Set (MDS) assessment, dated 12/8/25, indicated that R13 has unclear speech, is never understood and rarely understands the conversation. R13's Brief Interview for Mental Status (BIMS) indicated resident was unable to respond to the questions. R13 has impaired mobility bilaterally in both the upper and lower extremities. R13 is dependent for all mobility and on a mechanical lift for all transfers and a wheelchair for mobility. R13 is dependent for all activities of daily living (eating, toileting hygiene, personal hygiene, dressing).R13's Kardex (certified nursing assistant plan of care), states: INCONTINENT: check and change every two hours and as needed.BED MOBILITY: dependent on 1-2 staff. Nurse Aide- anticipate needs as resident is no longer able to make them known, assist with repositioning.Kardex does not provide any guidance of frequency to reposition R13.On 3/4/26 at 7:10 AM, Surveyor observed Certified Nursing Assistant (CNA) T transfer R13 to his wheelchair using a Hoyer lift. On 3/4/26, Surveyor continuously observed R13 in his wheelchair from 7:10 AM to 2:02 PM. R13 was not repositioned or placed back into bed, or in his recliner to offload pressure to his buttocks.On 3/4/26 at 2:02 PM, Surveyor observed CNA V and CNA T lift R13 by Hoyer lift, provide peri-care and lay resident in bed on his back. Example 2R5 was admitted to the facility on [DATE] with diagnoses of aphasia (difficulty swallowing), history of stroke, cellulitis of right lower limb, hemiplegia and hemiparesis, morbid obesity, seizure disorder, type 2 diabetes mellitus, muscle weakness, hypertension (high blood pressure), dementia, and depression.R5's MDS assessment, dated 12/15/25, indicated that R5 has unclear speech and is sometimes understood but usually understands, missing part of the message but comprehends most conversation. R5 needs substantial assistance to depends on assistance for all mobility. Due to R5's communication a BIMS was not done with R5. Assessment with staff and those that know R5 indicated R5 knows where he is, recognizes faces, but cognitively is severely impaired. R5's skin assessment in MDS reports R5 has history of one pressure injury and is at risk of developing others. R5's CNA Kardex, dated 3/24/26, states: Reposition: Resident for comfort Ensure resident is transferred to bed between meals (following exercise bike if applicable) in order to offload from buttock.Turn and repositioned every 2 hours and PRN, Keep body in good alignment.Bed Mobility: The resident requires extensive assistance by 1-2 staff to turn and reposition in bed . On 3/4/26, Surveyor continuously observed R5 from 8:36 AM to 1:50 PM. R5 was not repositioned or placed back into bed, or in his recliner to offload pressure to his buttocks.On 3/4/26 at 1:52 PM, Surveyor interviewed CNA T who stated R5 is repositioned every 2 hours. CNA T stated she asked R5 after breakfast if R5 wanted to use the bathroom. CNA T said R5 said no. Surveyor asked if that was about 9:45 AM. CNA T said I think so. Surveyor asked if R5 had been up in his chair all day, if this was his first time back in bed. CNA T stated yes. We should have asked him again.On 3/4/26 at 2:00 PM, Surveyor interviewed CNA T while she waited for CNA V and the Hoyer lift. CNA T stated that the residents unable to move themselves should be repositioned every 2 hours. Surveyor asked if R5 and R13 can move themselves. CNA T stated R5 shifts his weight, but I suppose that is not repositioning. R13 can't move himself. Surveyor asked should they have been repositioned today. CNA T was hesitant but stated, yes, they should have been. On 3/4/26 at 2:22 PM, Surveyor interviewed Assistant Director of Nursing (ADON) C who stated the expectation is that someone who is not able to reposition themselves should be checked every couple hours, that is just baseline. If there is an issue we put it in the CNA tasks. R5 requires assistance but is not always a willing participant. He prefers to be one way and does not want to be other way. R5 can shift around in his chair. They should be offering to move him. They should not have gone 8-10 hours in one position. R13 needs assistance with repositioning. On 3/4/26 at 3:33 PM, Director of Nursing (DON) B stated we would expect them to be changed and repositioned every 2 hours or as care planned.

Based on observations, interview and record review, the facility did not ensure the resident environment remains free from accident hazards as possible and each resident receives adequate supervision and assistive devices to prevent accidents for 1 of 3 residents (R) reviewed. (R1)R1 had multiple bruises to arms and legs. The facility did not find root cause of the arm bruises or put interventions in place to prevent reoccurrence and did not educate staff on ways to prevent injury or recurring bruises.Federal regulation states facilities must ensure that resident's environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents.R1 was admitted on [DATE] with diagnoses that include dementia with anxiety and behaviors, atrial fibrillation, obesity, fibromyalgia, insomnia, and low back pain. R1's minimum data set (MDS), dated [DATE], notes R1 has severe cognitive impairment, is independent with bed mobility and ambulation using a wheeled walker. R1 requires supervision or touching assistance with transfers, toileting, and eating. Surveyor spoke with R1 who could not articulate well enough to communicate effectively.On 08/25/25, Surveyor reviewed the facility self-report that identified Certified Nursing Assistant (CNA) C gave R1 a shower on 08/17/25 and discovered multiple bruises:-3 bruises on right forearm: 3 x 3 cm, 0.7 x 0.6 cm, 0.5 x 0.5 cm.-2 bruises on eft upper arm: 6 x 4.5 cm, 1 x 0.4 cm-1 bruise on left calf: 6.3 x 4.2 cm-1 bruise of right calf: 5 x 4.5 cm-1 bruise behind left knee: 7.7 x 10 cm-1 bruise behind right knee: 14 x 9 cmThis was immediately reported to Registered Nurse (RN) D who assessed R1, updated Director of Nursing (DON) B, R1's activated Power of Attorney, and the on-call physician. RN D obtained statements from all staff working at that time and interviewed residents on if they were hurt or feel safe. -Assessment identified: R1 is alert and oriented to person only, has impaired memory, unstable walking, and was not able to remember how bruising would have occurred. RN D noted that no staff saw how bruises would have occurred and R1 receives blood thinning medication.-Statement written by CNA C on 08/17/25 mentioned the cause could have been from rolling up compression stockings. There was no evidence that the facility addressed this issue to prevent possible recurrence of bruising.Surveyor reviewed the facility self-report, critical event form, and R1's electronic health record and found no documentation how the bruising on the arms possibly occurred and no intervention was added to the care plan to prevent recurrence of arm bruising. A critical event form was completed by the interdisciplinary team (IDT) on 08/17/25 that indicated, The toilet is a hard seat, a shower chair potentially as well. There is no evidence that an assessment or interventions were completed to address the toilet seat and shower chair to prevent recurrence of bruising.Critical event form also noted education was completed on 08/18/25; however, no education regarding interventions to prevent bruising was found following the incident on 08/17/25. Surveyor asked Registered Nurse (RN) E who verbalized calling DON B and reported back that they have no proof the education was completed after the incident. Surveyor reviewed R1's progress note dated 08/15/25. Note stated R1 hit staff multiple times during toileting. The staff had to finish up her cares, apply new pad, and pull up pants. They then assisted R1 to bed to rest. This was not investigated as potential reason for bruising and no new intervention was added to the care plan regarding how to mitigate combativeness during care for R1 to prevent further injury and bruising.On 08/25/25, Surveyor asked RN E why there was no interventions in place to protect R1's skin from recurrent bruising from the toilet, shower chair, or compression stockings that were identified as possible causes, and no interventions were added to address arm bruises. RN E requested to get back to Surveyor. RN E returned stating she called DON B and felt addressing the INR and the dining room chair was sufficient but understands they need to prevent recurring injury and bruising for R1.

Based on interview and record review, the facility did not ensure possibility of abuse was thoroughly investigated for 1 of 3 residents (R), R1 reviewed.R1 obtained multiple bruises of unknown origin; the facility did not complete a thorough investigation of the incident.Federal regulation states, 483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: S483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.R1 was admitted on [DATE] with diagnoses that include dementia with anxiety and behaviors, atrial fibrillation, obesity, fibromyalgia, insomnia, and low back pain. R1's minimum data set (MDS), dated [DATE], notes R1 has severe cognitive impairment, is independent with bed mobility and ambulation using a wheeled walker. R1 requires supervision or touching assistance with transfers, toileting, and eating. Surveyor spoke with R1 who could not articulate well enough to communicate effectively.On 08/25/25, Surveyor reviewed the facility self-report that identified Certified Nursing Assistant (CNA) C gave R1 a shower on 08/17/25 and discovered multiple bruises:-3 bruises on right forearm: 3 x 3 cm, 0.7 x 0.6 cm, 0.5 x 0.5 cm.-2 bruises on eft upper arm: 6 x 4.5 cm, 1 x 0.4 cm-1 bruise on left calf: 6.3 x 4.2 cm-1 bruise of right calf: 5 x 4.5 cm-1 bruise behind left knee: 7.7 x 10 cm-1 bruise behind right knee: 14 x 9 cmThis was immediately reported to Registered Nurse (RN) D who assessed R1, updated Director of Nursing (DON) B, R1's activated Power of Attorney, and the on-call physician. RN D obtained statements from all staff working at that time and interviewed residents if they were hurt or feel safe. No concerns were identified; however, there were no skin checks completed to observe for bruising for non-interviewable residents to ensure this was not abuse.-Assessment identified: R1 is alert and oriented to person only, has impaired memory, unstable walking, and was not able to remember how bruising would have occurred. RN D noted that no staff saw how bruises would have occurred and R1 receives blood thinning medication.-Physician ordered CBC and INR labs to be drawn on 08/18/25.-Statement written by CNA C on 08/17/25 mentioned the cause could have been from rolling up compression stockings. There was no evidence that the facility investigated this as a possible cause. DON B began a misconduct investigation on 08/17/25 and noted the following: DON reviewed previous skin assessments from 08/03/25 of which were negative for any acute findings. R1 had an INR on 08/14/25 that was 4.2 with orders to hold the coumadin dose that evening and resume coumadin therapy on 08/15/25. It is noted that R1 sits on hard wooden chairs at meals; secondary to her elevated INR, DON is resolving this report claim.The facility assumed the cause of the bruising was the high INR and resident sitting hard on the wooden chair in the dining room. Surveyor observed the chair did have a cushion that would protect the back of residents' legs and back; however, nothing was noted how the bruising on the arms possibly occurred. A critical event form was completed by the interdisciplinary team (IDT) on 08/17/25 that indicated, The toilet is a hard seat, a shower chair potentially as well. There is no evidence that an assessment or interventions were completed to address if the toilet seat and/or shower chair was the root cause.Surveyor reviewed R1's progress note dated 08/15/25. Note stated R1 hit staff multiple times during toileting. The staff had to finish up R1's cares, apply new pad, and pull up pants. They then assisted R1 to bed to rest. This was not investigated as potential root cause of the arm bruising. On 08/25/25, Surveyor asked RN E why this was not completed. RN E reported calling DON B who said once they found a high INR, they felt they did not need to look any further.

Based on record review and staff interviews, the facility did not ensure that an alleged violation involving abuse by a Resident (R1) was reported immediately to the Nursing Home Administrator (NHA) and to the State Survey and Certification Agency. An incident involving R1 and R2 occurred on 02/27/25. R1 hit R2 with a closed fist. The facility did not report the abuse to the State Survey and Certification Agency. Findings Include: Facility policy titled, Abuse Policy, shows a most recent review date of 10/04/16, stated, Law Enforcement: All reports of suspected crime and/or alleged sexual abuse must be immediately reported to local law enforcement to be investigated. Facility staff will fully cooperate with the local law enforcement designee. R1 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's, chronic kidney disease, dementia, difficulty in walking, unsteadiness on feet, and cognitive communication deficit. R1's most recent [NAME] Data Set (MDS) assessment dated [DATE] indicated that R1 was able to ambulate independently and has a Brief Interview for Mental Status (BIMS) score of 05/15, which indicates severe cognitive impairment. R2 was admitted to the facility on [DATE] with diagnoses that include dementia, major depressive disorder, and fibromyalgia. R2's most recent MDS assessment dated [DATE] indicated that R2 has a BIMS score of 1/15, which indicates severe cognitive impairment. Facility reported incident submitted to state agency on 02/27/25 states, On 2/27/25, [R1] and [R2] were present in the E household living area. [R2] was walking past [R1] as she sat in the living room. [R1] commented to [R2] to wipe that look off your face. (resident [R2] had a flat look on her face). [R2] got closer to [R1] and stated: why don't you mind your own business?!. This upset [R1] and she struck [R2] in the upper right arm with a closed fist. [R2] became more upset after being struck and raised right hand as if to strike back. Staff was able to intervene before this happened. There were no other residents in the living area or dining area at the time of the incident in which to witness it. [staff] that did see the incident and was able to intervein [sp]. Both residents were agitated at that point. [Staff] assisted [R1] to her room to decompress as it was less stimulating. [R1] did kick [staff] during that process. [R2] remained in the dining room and drank some cocoa. The facility completed an investigation on 02/27/25 that included notification to both residents' power of attorney, notification to medical director, facility investigation, and notification to state agency. There was no evidence of notification to police regarding the potential crime of assault. On 04/01/25 at 11:05 AM, Surveyor interviewed Director of Nursing (DON) B regarding the lack of local law enforcement involvement. DON B said they felt this situation did not require it. On 04/02/25 at 1:10 PM, Surveyor asked DON B if they felt this incident could have been a potential crime. DON B said they did not think so. R1 hit R2 softly and they did not find any injury, so they felt it was not assault or some other crime.

Based on interview and record review, the facility did not ensure, in response to resident-to-resident physical abuse, a thorough investigation was conducted to prevent further potential abuse for 1 of 2 (R1) residents reviewed for abuse. The facility did not conduct a thorough investigation of the resident-to-resident-altercation that occurred to R2 on 02/27/25. The facility did not conduct other resident interviews for potential abuse. Findings include: Facility policy titled, Abuse Policy, shows a most recent review date of 10/04/16, stated, Examine, assess and interview the resident and other residents potentially affected immediately to determine any injury and identity and immediate clinical interventions necessary. R1 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's, chronic kidney disease, dementia, difficulty in walking, unsteadiness on feet, and cognitive communication deficit. R1's most recent [NAME] Data Set (MDS) assessment dated [DATE] indicated that R1 was able to ambulate independently and has a Brief Interview for Mental Status (BIMS) score of 05/15, which indicates severe cognitive impairment. R2 was admitted to the facility on [DATE] with diagnoses that include dementia, major depressive disorder, and fibromyalgia. R2's most recent MDS assessment dated [DATE] indicated that R2 has a BIMS score of 01/15, which indicates severe cognitive impairment. Facility reported incident submitted to state agency on 02/27/25 On 2/27/25, [R1] and [R2] were present in the E household living area. [R2] was walking past [R1] as she sat in the living room. [R1] commented to [R2] to wipe that look off your face. (resident [R2] had a flat look on her face). [R2] got closer to [R1] and stated: why don't you mind your own business?!. This upset [R1] and she struck [R2] in the upper right arm with a closed fist. [R2] became more upset after being struck and raised right hand as if to strike back. Staff was able to intervene before this happened. There were no other residents in the living area or dining area at the time of the incident in which to witness it. [Staff] that did see the incident and was able to intervein [sp]. Both residents were agitated at that point. [staff] assisted [R1] to her room to decompress as it was less stimulating. [R1] did kick [staff] during that process. [R2] remained in the dining room and drank some cocoa. The facility completed an investigation on 02/27/25 that included notification to both residents' power of attorney, notification to medical director, facility investigation, and notification to state agency. There was no evidence of interviews with other residents to ensure they were also not targeted by R1 or R2. On 04/02/25 at 1:10 PM, Surveyor interviewed Director of Nursing (DON) B regarding the lack of interviews with other residents. DON B said they felt like this was an isolated event and they did not think other residents were affected. When asked if R1 or R2 had access to other residents DON B said yes, but they know their residents well and there were no changes. DON B also stated that after conversations with surveyor they did go and interview other residents to ensure they were not targeted.

Based on interview and record review, the facility did not ensure the resident environment remained as free of accidents hazards as possible. The facility did not update resident's care plan after each event of a fall. This has the potential to affect 1 of 3 residents (R) (R1) reviewed for accidents. Facility did not update R1's care plan after R1's fall risk score increased from 12 to 16 on 02/16/25, and did not update care plan following a bruise noted on 03/05/25 from a fall. Findings include: The facility policy titled, Falls reviewed October 2023, states, 2. When notified a fall has occurred, the licensed nurse will: . R. fill out a care plan update sheet with new interventions for the MDS coordinator S. Make sure intervention and fall are reported through the 24 hr report sheet. t. [Director of Nursing] DON or designee will bring incident report to morning meeting where management team will review to make sure intervention is new, appropriate, documented and accessible to all staff. R1 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's, chronic kidney disease, dementia, difficulty in walking, unsteadiness on feet, and cognitive communication deficit. R1's most recent [NAME] Data Set (MDS) assessment dated [DATE] indicated that R1 was able to ambulate independently and has a Brief Interview for Mental Status (BIMS) score of 05/15, which indicates severe cognitive impairment. On 01/17/25, facility performed a falls risk assessment for R1 where R1 scored a 12.0 indicating they were at risk for falls. On 02/16/25, facility performed a fall risk assessment for R1 where R1 scored a 16.0 indicating that fall risk was increasing. There was no change to resident's care plan as the risk of falls increased. On 03/05/25, progress notes indicated that R1 was discovered to have bruising and pain on left foot. R1 said they believe they fell in the restroom of their room. After fall IDT team reviewed and replaced intervention that previously worked. The facility added a pressure alarm to R1's bed. On 03/08/25 at 9:41 AM, progress note related to new fall stated, Residents bed alarm was alarming, CNA, went in to check the alarm at 6:38, Resident was kneeling on the floor mat next to the bed. Boot was on the left foot. No complaints of pain noted nonvisible bruising. Record review of incident revealed that R1's interventions on the care plan were not changed; there were no new care plan updates or strategies to insure R1's safety. Care plan only indicated that resident is likely to try and ambulate. On 04/02/25 at 1:10 PM, Surveyor interviewed DON B regarding the lack of interventions after R1's most recent fall. DON B said they felt the intervention that was already in place was ok and emphasizing that staff need to get to R1's room as they are prone to falling when they get out of bed due to forgetting they are wearing a walking boot for a broken foot. Surveyor then asked if there were any other interventions the facility could have implemented. DON B said they did not think so; staff need to get to the room when the bed alarm goes off. Facility failed to update R1's care with interventions to ensure no further incidents of falls.

Based on observation, interview and policy review, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. When staff heated up Resident (R) 124's food in the microwave, staff did not check to ensure the food was at safe eating temperatures. In the kitchen refrigerator there was food that was not dated appropriately to ensure food safety. This has the potential the affect all 19 of 19 residents (R) residing in the facility. Findings include: Example 1 Facility Policy titled, Food temperatures, states, 6. To take hot food temperature, insert the thermometer at 45 degree angle to the middle of the food items taking care not to touch the container or bone if it has one. Wait for the thermometer to rise to the maximum temperature, read and record the temperature and then remove the thermometer from the food item and immediately clen with a fresh alcohol swab. Repeat this process until all hot food temperatures have been taken . 15. Leftovers must be, labeled, covered, cooled and stored (within ,d+[DATE] hour after cooking or service) in a refrigerator. Prior to re-serving, leftover foods must be reheated to a minimum internal temperature for 165 degrees Fahrenheit for a minimum of 15 seconds. On [DATE] at 12:22 PM, Surveyor observed Dietary Aide (DA) L heating up R124's lunch of hamburger and mashed potatoes in the microwave. After being in the microwave for 90 seconds DA L did not temp the food to ensure safe food temperatures before serving to R124. Surveyor asked DA L why they did not temp it and they were not sure. DA L said they do the same thing every day and they did wonder that, but what they did know is that R124 likes the food steaming hot or will ask it to be heated up again. DA L has always put it in for a minute and a half. DA L agreed that temping the food would make sense for resident safety. On [DATE] at 12:31 PM, Surveyor interviewed Dietary Manager (DM) K regarding not temping food out of the microwave. DM K said, Oh yes, that makes sense we should be temping the food to make sure it is not too hot. They did not have a known time management system to ensure heating, but facility will implement soon as possible. 47657 Example 2 On [DATE] at 9:15 AM, Surveyor conducted an initial tour of the facility's kitchen and noted the following: *A plastic zip bag with uncooked hotdogs dated [DATE] and unlabeled with expiration or discard date in facility cooler *2 plastic sealed containers of canned cranberries labeled with prep date of [DATE] and unlabeled with expiration date or discard date in facility cooler *A 3-tier cart with a sealed plastic container that later was identified as breadcrumbs by DM K unlabeled and undated. *A deep fryer uncleaned and pieces of French fries and crumbs. On [DATE] at 9:35 AM, Surveyor interviewed DM K regarding findings. DM K stated that the bag of hotdogs and container of cranberries should have been labeled with expiration or discard date and that both items should have been discarded after 3 days. DM K stated the container of breadcrumbs should have been labeled and dated with discard or expired date. DM K immediately removed container and disposed of contents. DM K stated they used the deep fryer the evening prior for cooking French fries and indicated the fryer should have been cleaned immediately after use.

Based on interview and record review, the facility did not ensure the mandatory staffing data that had been submitted from 01/01/24-09/30/24 was complete, accurate, and auditable. The submitted data from 01/01/24-09/30/24 was not complete, accurate, or auditable. This has the ability to affect all 19 of 19 residents in the facility. This is evidenced by: The Payroll Based Journal (PBJ) Staffing Data Reports that were generated quarterly document that the facility triggered No RN Hours for the dates of 01/08/24 (MO), 02/02/24 (FR), 03/15/24 (FR), 03/29/24 (FR). The PBJ Staffing Data Reports that were generated quarterly document that the facility triggered Failed to have Licensed Nursing Coverage 24 Hours/Day for the dates of 05/13/24 (MO), 05/16/24 (TH), 05/17/24 (FR), 06/02/24 (SU), 06/03/24 (MO), 06/09/24 (SU), 06/30/24 (SU), 07/06/24 (SA), 08/03/24 (SA), 09/06/24 (FR), 09/29/24 (SU). Surveyor completed record review of daily postings for infraction dates, including nursing schedules, Director of Nursing pay stubs, and Multiple Data Set (MDS) Coordinator pay stubs. Surveyor did not find any dates where the facility did not have 24 hour nursing coverage of no registered nurse coverage for at least 8 hours. On 12/11/24 at 1:15 PM, Surveyor interviewed Administrator Assistant (AA) M regarding PBJ data reporting. AA M determined that on the dates of infraction the MDS Coordinator or Director of Nursing covered as the registered nurse for the facility, and they were not coded as the registered nurse even though they were covering that position. Both the Director of Nursing and MDS Coordinator are registered nurses. They would expect that PBJ data be submitted accurately, and they might have to do more manual submissions to ensure that.

Based on observations, resident and staff interviews and record review, reveals the facility did not provide the necessary supervision to prevent falls, determine the root cause of the falls and develop new interventions following each fall for 2 of 4 residents reviewed for falls (R14 and R16). The facility did not assess the ability to safely use electric lift chairs for 2 of 2 residents reviewed with electric lift chairs (R14 and R16). 1. R14 who has a [DIAGNOSES REDACTED]. Many of the falls resulted in head injuries, and overnight hospitalization on [DATE] into 12/19/17 and a possible broken nose. The facility did not provide the necessary staff supervision to prevent these falls, did not determine the root cause and did not develop new interventions after many of these falls in an attempt to prevent further falls. R14 who is cognitively impaired and has [DIAGNOSES REDACTED] had a near fall from an electric lift chair in his room on 04/03/18. The facility did not assess his ability to safely and independently operate this electric lift chair. 2. The facility did not implement new interventions after R16's falls. The facility did not assess the resident's power lift recliner for safe use, and the use of the power recliner was not identified on R16's care plan. This is evidenced by: Surveyor review of R14's medical record reveals [DIAGNOSES REDACTED]. Surveyor review of R14's most recent Minimum Data Set Assessment ((MDS) dated [DATE] indicates the following: falls with injury, moderately impaired vision, BIMS (Brief Interview of Mental Status) 0, bed mobility and transfer extensive assistance of 2, not steady moving from seated to standing position, uses a wheelchair for locomotion, extensive assistance for locomotion, frequently incontinent of bladder and continent of bowel, no toileting program and dementia. Review of R14's most recent bowel and bladder assessment dated [DATE] reveals that R14 is sometimes aware of toileting needs, has functional incontinence. This assessment also reveals that R14 is not on a toileting program to manage urinary incontinence. It also indicates that R14 is always continent of bowels and currently a toileting program is not used to manage bowel incontinence. Surveyor review of R14's current physician's orders [REDACTED]. N[NAME] AM PM. Supportive device: Fall detection unit when in a chair N[NAME] AM PM. Surveyor review of R14's CNA Assignment Card, printed 07/16/18, reveals the following approaches under the Problem area of Falls: Nurse Aide: Encourage to ask for assistance Call button in reach Assist with ambulating, transferring, toileting. Anticipate needs-especially at night. Sensor alarm: to bed and chairs. Nonskid footwear, remind to pick feet up and extend his stride while walking. Encourage to turn his head and look where he is going while walking. Report pain indicators Keep door to . closed when not in it to deter from self transferring. Also under the problem area are the following: I have a history of a fall with facial fractures. I use a scoop mattress on my bed with a floor mat for safety r/t frequent falls. On 07/16/18 at 11:36 AM, Surveyor spoke with R14's family member R23. R23 indicated that R14 has had falls with injuries. R23 said that R14 had broken his nose following one of the falls. On 07/16/18 at 12:28 PM, Surveyor observed R14 wheeled into dining room in wheelchair. R14 was observed to have a visible scar above his right eye brow. Surveyor review of R14's nurses' notes reveal the following falls: Fall 1: ~12/09/17 6:30 p.m., unwitnessed in the bathroom. Injury: laceration, one to nose 3mm L Shaped, and one 4 mm to upper lip. (millimeter). First aid: Stopped bleeding of lacerations, cleansed area to see where lacerations were, applied steri strips on MD order. I interventions for falls: fall mat grippy socks night light in bathroom and instructed resident on using call light. Fall 2: ~12/18/17 9:35 a.m., witnessed fall in resident room. resident's room; was standing up to go to the bathroom, from his recliner chair; I had just walked him back into the room from the dining room [ROOM NUMBER] minutes prior to this happening, and asked if he wanted to go to the bathroom on the way back, and he had told me nope 5 minutes later his wife put on her call light because she saw him standing up to walk to the bathroom on his own (from his recliner chair) and then the CNA's pager also went off because his chair alarm was going off; she went in to help him, and he said he needed to go to the bathroom, and was already standing up in front of his recliner chair when she walked in; he started to try to move his foot like he was taking a step (I saw it out of the corner of my eye from the med island), and started leaning, and then quickly just fell forward, did not trip; his whole body, landed inside his walker, on his front his arms on the outside of his walker and down at his side, and landed on his face/nose, (did not put his arms out to catch himself) on top of his walker; immediately a very large puddle of blood beneath his face; he did mumble something to me when I told him that we were going to try to turn him to see what was going on; three of us log rolled him to his back, while steadying his neck/head, and put just a small towel flat on the floor under his head; his entire face was covered in blood, running in his eyes, coming out of his nose/mouth; his nose is very swollen out to both sides, and very flat at the bridge of the nose, and has a 4 cm (centimeter) laceration across the bridge of his nose; .orders to transfer resident to the ER . Possible cause: unsteady gait/balance, the CNA had just gotten there to try to help him to the bathroom (his chair alarm was going off). R14 ended up in the hospital overnight on 12/18/17. Returned on 12/19/17. No interventions to prevent further falls were noted. Surveyor review of R14's MDS (Minimum Data Set) Assessment, dated 12/26/17, after the hospitalization reveals the following: Other Fracture and [MEDICAL CONDITION]. Fall 3: ~Fall 02/15/18: 6 45p.m., Note: Resident bed alarm went off to alert staff., When staff approached, found resident on bathroom floor, in prone position with arms outstretched in front of him. Able to move all extremities. Staff rolled him over to backside, small abrasions noted as stated above. Ice pack and [MEDICATION NAME] applied to abrasion above eyebrow. Injury: 2 x 1 cm above left eyebrow with small bump, 3 x 4 cm abrasion to left shoulder, 4 cm linear abrasion to right knee 2 x 1 cm abrasion to left knee. Possible cause: without staff assist, slipped on floor no shoes/grippy socks on. Intervention: alarm to alert staff of self transferring. unable to educate resident. This intervention of the alarm was already in place. Fall 4: ~03/09/18 at 7:40 a.m., unwitnessed fall bathroom. Was attempting to stand in bathroom and fell into his w/c which was found next to him on its side folded up. Appears that he hit the right side of his head on the bathroom counter, was found lying on his back next to his sink. Injury: laceration to right cheek bone (2 cm) with 2 cm surrounding swelling, inside right ear (1.7 cm), outer top ear (1.5cm), abrasions to top of head (0.5 and 1.5 x 1.5 cm), right temporal area abrasion (area is 5 x 3cm). C/O tenderness with assessment. Able to move all extremities per norm. Will be seen in clinic for sutures. Resident states he needed to use the bathroom. Root Cause analysis: was attempting to stand in bathroom and fell into his w/c. Intervention: none noted. Fall 5: ~Fall 03/11/18 at 3:30 p.m.: unwitnessed in resident room. Wife R23 witnessed, states resident got up from recliner and took her walker and began waking toward bathroom where he fell in door way, falling over forward. Writer was coming through the household and heard the fall. Call light was not on for assistance, but pressure alarm in chair did go off. Injury: 5 cm abrasions 3 minor abrasions across nasal bridge bleeding from the mouth unable to assess this. Possible broken nose. Transported non emergent ambulance. Possible root cause: walking without staff assistance, unsteady gait restless. Intervention: Alarm to alert staff of self transferring. resident education: none due to dementia. This intervention was already in place. Fall 6: Fall 03/29/18 at 6:39 p.m.: unwitnessed fall in resident room. Injury: laceration lateral to right brow, laceration above start of right eye brow this one appeared quite deep, possible laceration under right eye. Activity at the time: resident must have gotten up from bed without assistance and hit head on night stand. sent in to ER. Possible Root Cause: transferred without assist device. Intervention: None noted. Fall 7: ~ 04/12/18: witnessed near fall. Resident was standing in room and CNA entered room and was able to lower unsteady resident to floor at 6:30 p.m. Nurse was called to room. Resident did not actually fall. He was lowered and sitting on lap of CNA. No injuries. Intervention: none noted. Resident was admitted for Hospice Care on 05/16/18. The Hospice [DIAGNOSES REDACTED]. Fall 8: ~ 05/21/18: unwitnessed fall in resident room. 2:15 a.m. Nurse and CNA were in dining room and heard the resident fall and responded before bed alarm had even gone off. 2.5 inch laceration to right forehead proximal to eyebrow. Has small cut on left side of tongue, no longer bleeding. Root cause analysis: Nurse believes resident was attempting to self transfer. Wife R23 who shares a room with him stated he had been making attempts to self transfer all day. Resident found lying with head at the foot of the bed (on the floor) with his feet at the head of the bed. Intervention: None noted. Fall 9: ~06/30/18: 1:30 p.m., unwitnessed: in bathroom. He had wheeled himself to his room and into the bathroom in the dark, from the dining room table; all staff was in with other residents at the time, his fall/chair alarm was not going off, the battery was dead. The CNA had come out of a room and went to see if someone else had put him to bed, and found him lying on the bathroom floor in shower area over the drain, on his left side; denies pain No injury. Possible root cause: transferring without staff assist. Intervention: Alarm to alert staff of self transferring, new batteries put in alarm, now working again; has fall mat. Resident education: instructed resident on waiting for staff help (we do give reminders and he will just smile). Staff education: to check alarms, batteries to make sure they are working; it would not have prevented this fall, but we may have been alerted earlier. Fall 10: ~ 07/02/18 1:03 p.m., common area in household. Had been sitting in green chair prior to falling. When staff found him he was on the floor. Must have gotten up and attempted to walk. Equipment involved: Chair alarm under him but did not alert staff upon investigation batteries had jiggled out of place just enough to not work. Injury: Laceration to right forehead above right eyebrow jagged and appeared to be full depth of facial tissue. With a length of approx 2.5 inches; abrasion over left knee that was 3 inches around, no skin flap left, just red wound bed. Nose appears more crooked and swollen, small trickle of blood from nose present, and he had blood in his mouth. Did not notice any loose teeth. Writer assessed resident shoulders, hips, knees and he made no grimaces. Asked if he had pain and the only place he pointed to was his forehead. Sent in by ambulance, for stitches. Root Cause: without assist device without staff assist. Intervention: Resident had two other falls this weekend. Staff had positioned him in common area to keep closer eye on him to keep him safe and he still managed to fall. On 07/18/18 at 10:00 AM, Surveyor spoke with the Director of Nursing (DON) regarding the facility procedure related to falls. The DON indicated that if the fall is unwitnessed, staff go and get the nurse to assess. Staff should not move the resident until the nurses assess. A lift is used to get the resident off the floor. Staff write an incident statement on what happened etc. The DON said that some of those statements were not found for some of R14's falls. Surveyor asked the DON for root cause analysis and interventions put into place for R14's falls that occurred on 12/18/17, 02/15/18, 03/29/18, 04/12/18, 05/21/18, 06/30/18 and 07/02/18. 07/18/18 10:57 AM Surveyor review of facility information related to R14 falls reveals no resident incident staff statement which includes knowledge of the statement, what happened, equipment, events, could it have been prevented etc. for the falls on 02/15/18, 03/11/18, 03/29/18 and 05/21/18. Per the DON they do not have any new interventions for R14 's falls from 12/18/17, 02/15/18, 03/29/18, 04/12/18, 05/12/18, 06/30/18 (and they put a new battery in the alarm after the 06/30/18 fall) and 07/02/18. The Surveyor asked the DON if they have a system to check the batteries and the functioning of the alarms. The DON said they do not. The DON gave Surveyor a copy of the facility policy and procedure with the subject of Falls dated 01/2012. This policy indicates to do a root cause analysis and include interventions and complete an incident report. On 07/18/18 at 1:40 PM, Surveyor spoke with Registered Nurse (RN) D. RN D said that R14 is very quick and often times he is trying to go to the bathroom and has [DIAGNOSES REDACTED]. RN D said that with R14's last fall they had placed him in a common area and he still managed to walk from the chair and fell by the fire place and hit his head. Electric Lift Chairs: Example 1: Surveyor review of the nurses notes for Resident # 14 indicates a nurses note from 04/03/18 which indicates the following note: Just heard Resident (#23) Resident #14's wife yelling/screaming at him, You're going to fall went in to check, and he had his recliner chair all the way up in the up position, was almost in a standing position, and starting to slide off of his chair. The CNA's now have him in the bathroom with the EZ stand On 07/18/18 at 9:55 AM, Surveyor spoke with the DON regarding safety assessment for resident electric lift chairs. The DON said that nursing does not do the assessment, will check with therapy to see if they do a lift chair safety assessment. The DON said that some of the lift chairs are facility chairs and some of them are resident owned chairs. On 07/18/18 at 12:45 PM, the DON said they don't have any electric lift chair assessment for R14. The DON said that she spoke with (Occupational Therapy) OT and they said they can assess the resident's ability to use the lift chair. On 07/18/18 at 2:25 PM, Surveyor observed R14's living room. R14 was observed to have an electric lift chair along with his wife R23 in their room. On 07/18/18 at 2:39 PM, the DON gave a list of the facility residents that currently use electric lift chairs. The facility identified 22 of 33 residents currently use lift chairs. 3 of the 22 residents are identified as having cognitive impairments (R14, R16). This list includes R14 and R16. Surveyor reviewed R16's medical record. The resident has [DIAGNOSES REDACTED]. The resident's Brief Interview for Mental Status (BIMS) score, dated 05/29/18, was a 07 out of 15 possible points. According to the BIMS assessment, a score of 07 indicates R16 has severe cognitive impairment. Surveyor reviewed the resident's care plan. The care plan states the following, in part: 02/02/2018 PROBLEM (ADLs (Activities of Daily Living) .I have hx (history) of frequent falls from my bed .I am of advanced age .APPROACH .12/20/2017 .non-ambulatory at this time .12/29/2017 .BED MOBILITY: 1 (staff) assist .TOILETING: 2 assist . 12/21/2017 PROBLEM (COGNITIVE LOSS): I have a dx (diagnosis) of age-related cognitive loss and cognitive communication deficit .I am known to have an increase of confusion later in the afternoon and at night . 12/21/2017 PROBLEM (FALLS) .I have a hx of urinary urgency. I am frequently incontinent of urine. I require 2 assist using sit to stand lift for all transfers .I am also known to have falls from my recliner in my room. My family reports they believe I will keep falling d/t (due to) my want for independence .I use a sensor alarm to my bed and chair at all times .APPROACH .12/29/2017 .Bedside mat. Scoop mattress. Offer toileting/urinal (every) 3hrs (hours) throughout the night . Surveyor reviewed R16's fall reports and nurses' notes, from 01/15/18 to 07/16/18. The notes state the following, in part: -01/19/18 at 11:45 a.m.: R16 fell in his room out of the power lift chair/recliner. The resident reported he was reaching for his lip balm when his feet slipped. The note states the resident placed the recliner at a 45 degree angle; and the chair alarm did not go off after the resident fell . There are no new interventions implemented after this fall to prevent future falls from occurring. There is no power lift chair safety assessments found in the medical record, and it is not identified on R16's care plan if the resident is safe to use the power recliner. There is no documentation in the resident's medical record if R16's chair alarm was inspected or replaced with a new alarm after this fall. -04/09/18 at 2:45 p.m.: R16 fell out of the wheelchair in his room, while reaching for the television remote. The facility provided a reacher tool for the resident. The reacher was not identified as a fall intervention on the resident's care plan. -04/16/18 at 6:30 p.m.: The resident slid out of his wheelchair in his room, while trying to close a dresser drawer. Staff reminded the resident to use the call light. There are no new interventions implemented after this fall to prevent future falls from occurring. -04/29/18: A nurses' note states the nurse spoke with a Physical Therapist on this date. The nurse was questioning if therapy had another cushion to keep R16 from sliding out of the wheelchair. There is no documentation in the resident's medical record an anti-slip mat or different cushion was placed in the resident's wheelchair, in order to prevent future falls from occurring. -06/28/18 at 10:15 p.m.: R16 slid out of bed trying to use the bathroom in order to have a bowel movement. The note states, in part, .ROOT CAUSE ANALYSIS FALLS: Stated he needed to use the restroom, restless and confusion. Unable to remember that he is unable to get up independently . RESIDENT EDUCATION: unable to proved (sic) resident with education d/t cognitive status . There are no new interventions implemented after this fall to prevent future falls from occurring. On 07/17/18 at 8:55 a.m., Surveyor observed the resident's room, which R16 was not present in at this time. A power lift recliner is located in a corner of the room. There is no anti-slip matting in the recliner. A black reacher tool is located in the room. At 8:57 a.m., Surveyor observed R16 sitting in a high-back wheelchair in the dining room. There is a black, thick cushion with which the resident is currently sitting. There is no anti-slip matting between the cushion and the resident to prevent the resident from sliding out of the wheelchair. On 07/18/18 at 9:50 a.m., Surveyor asked the DON if the facility had a power lift recliner safety assessment for R16. The DON replied the facility does not have a lift recliner safety assessment for the resident. At 10:45 a.m., Surveyor interviewed RN F. The RN stated R16 does not have an anti-slip matting in the resident's lift chair or on the resident's current wheelchair cushion. During the continued interview, RN F stated R16 is able to use the resident's power lift chair controller, but the resident is not to have the controller unless family is present. RN F stated the resident will sometimes put the lift chair up too high, in which the resident could potentially fall out of the chair. RN F stated staff will tuck the controller behind the chair so R16 cannot find the controller. RN F further stated R16 will sometimes get mad when he cannot find the chair controller, but will then forget about it. At 1:12 p.m., Surveyor interviewed CNA G. The CNA stated R16 is able to work the power lift chair controller. CNA G stated when staff seat the resident in the power chair, staff usually place the chair controller in the side pocket, so the resident is unable to use and see the controller, in order to keep the resident safe. It is noted, placing the lift chair controller in locations in which R16 cannot find or see the controller, has not been assessed and is not identified on the resident's care plan. At 1:27 p.m., Surveyor interviewed the DON, and R16's falls were discussed. The DON stated no new interventions were implemented after the resident's fall, on 01/09/18. The DON further stated she did not identify R16's chair alarm did not sound after the resident slid from the chair, so the alarm was not inspected or replaced after this fall. During the continued interview, the DON stated no new interventions to prevent future falls were implemented after R16's falls, on 04/16/18 and 06/28/18. The DON indicated the reacher tool is not identified on the resident's care plan. The DON indicated R16's family members do not want the resident to have access to the power lift chair controller, due to safety concerns. The DON stated the facility has not assessed use of the lift chair for this resident and has not identified the safety concerns or the use of the controller on R16's care plan.

Based on observation, interview, medical record review, and policy review, the facility did not ensure a resident who enters the facility without a pressure ulcer does not develop an avoidable pressure ulcer, and receives necessary treatment and services to promote healing of the pressure ulcer. This deficient practice was identified for 1 of 3 residents reviewed for pressure ulcers, Resident #4. Resident #4 was admitted to the facility with venous stasis ulcers on her lower legs. At the time of admission, the facility documented her heels were intact. On 06/23/11, ten days after admission, Resident #4 was found to have a fluid-filled blister, identified as a stage II pressure ulcer on her right heel. The day of admission, the facility had identified Resident #4 as at high risk for pressure ulcers. A standard pressure reduction mattress was put in use at the time of admission; other interventions were not implemented to prevent pressure ulcer development in a resident the facility had identified as being at risk for pressure ulcer development, until after a stage II pressure ulcer was found on Resident #4's right heel on 06/23/11. Following a hospital stay, the facility staff did not assess the right heel ulcer until two days after she had returned from the hospital. The right heel pressure ulcer had progressed to an unstageable pressure ulcer with black eschar present. The facility did not follow their policy for skin assessments that directed a skin assessment within 24 hours of admission. This is evidenced by: As identified in the Code of Federal Regulations (CFR) 483.35(c), "Because a resident at risk can develop a pressure ulcer within 2 to 6 hours of onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers." The facility policy titled "Skin Assessments" dated January 2010, read in part: "Policy: The goal of this policy is to ensure the resident's skin integrity remains intact. "Procedure: Resident's skin is assessed with [REDACTED]." Review of Resident #4's medical record beginning on 08/02/11 by Surveyor identified Resident #4 was admitted to the facility on [DATE]. Upon admission Resident #4 had [DIAGNOSES REDACTED]. A nurses' note entry dated 06/13/11 at 3:41 p.m. identified Resident #4 had been assessed using a Norton Plus Pressure Ulcer Scale, which is an assessment that identifies residents who are at risk for developing pressure ulcers. Resident #4 was assessed to have a score of 10. A score of 10 or less means the resident is at high risk for development of a pressure ulcer. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 as being at risk for pressure ulcers. Despite the resident ' s high risk for developing pressure ulcers, the facility did not identify any approaches on the care plan for preventing pressure ulcers on the heels. Medical record review by Surveyor on 08/03/11 identified a nurses' note dated 06/13/11 with the time of 10:21 p.m. written by Licensed Practical Nurse (LPN) Y that read in part, "Heels intact." On 06/23/11, ten days after admission, a nurses' note identified a fluid-filled blister, 4 cm (centimeters) long by 4 cm wide, a stage II pressure ulcer as identified by the facility, was found on Resident #4's right heel by Registered Nurse (RN) E while doing wound rounds. A nurses' note dated 06/23/11 written by RN E read, "She is going to have an air mattress and she is going to be wearing podus (also documented as Prevalon and blue) boots at all times." These interventions were put in place after the pressure ulcer was found. Review of Resident #4's nurses' notes by Surveyor on 08/03/11 identified her right heel was assessed by RN E on 07/20/11, the day before she was admitted to the hospital. This assessment identified the right heel was a stage 2 fluid-filled blister. There was no drainage and it was intact. The surrounding tissue was dark purple. On 07/20/11, RN E obtained the following measurements of the right heel ulcer, 3 cm in length by 4.5 cm in width and 0.1 cm. in depth. During observation of personal cares on 08/03/11 beginning at 7:17 a.m., Surveyor observed Resident #10's heels and noted an area of black eschar tissue, approximately the size of a 50-cent piece on Resident #4's right heel. Beginning at 10:25 a.m. on 08/03/11, Surveyor observed RN E and Licensed Practical Nurse (LPN) P perform wound care to Resident #4's right lower extremity venous stasis ulcers and measure the right heel pressure ulcer. RN E determined the right heel pressure ulcer measured 3 cm by 3.5 cm. Surveyor asked RN E and LPN P what treatment is being done for the right heel ulcer. RN E replied, "Just the boots and the air mattress." On 08/03/11, Surveyor reviewed Resident #4's history and physical (H&P) from her 07/21/11 hospital admission. It read, "She also complains of having some significant pain in the right heel and I do believe that she has an ischemic ulcer there." (The right heel is the site of the pressure ulcer.) The H&P also read, "The right lower extremity reveals some skin excoriation with concerns regarding [MEDICAL CONDITION] and there is also black eschar in the right heel which is significantly tender upon palpation...The patient has a black eschar in the right heel and it is extremely painful and tender. I believe the source of infection definitely could be considered from this." A document titled "Wound Care" received from the hospital and dated 07/31/11 identified the pressure ulcer on the right heel was "Unstageable." On 08/04/11 beginning at 10:30 a.m., Surveyor interviewed the DON, RN E and LPN P in the presence of Surveyor regarding Resident #4's right heel pressure ulcer. Surveyor stated Resident #4 was admitted with venous ulcers on her lower extremities, she had [DIAGNOSES REDACTED]. Surveyor asked what preventive measures where put in place right away when she was admitted [DATE]. RN E stated they used the foam dressings, her legs were wrapped with gauze, a pressure reduction mattress, skin checks, repositioning and she was working with therapies. Surveyor pointed out there was nothing on Resident #4's care plan related to the right heel ulcer, including the measures put in place after the pressure ulcer was found on the right heel. RN E stated they used the air mattress and the podus boots. Surveyor asked when the podus boots and air mattress were put in place. RN E stated on the 23rd (06/23/11) after they found the pressure ulcer. There was no care plan or CNA assignment sheet that addressed if her heel(s) were being floated on a pillow. A nurses' note of 06/15/11 with a time of 10:54 p.m. read in part, "Pain assessment. Legs rest on pillows at night." It doesn't identify if her heels were free of pressure with the use of the pillow under her legs. The care plan did not identify other measures in use to prevent ulcer development. During the above interview, Surveyor asked if Resident #4 was on a turning/repositioning schedule. They indicated information would be provided. Surveyor indicated Resident #4's 06/20/11 MDS identified she required extensive assistance of two staff for bed mobility. Resident #4's care plan for self-care deficit dated 07/01/11 read, "REPOSITIONING: Uses grab bar to assist with mobility." Surveyor stated Resident #4 was already compromised as she had the venous ulcers of her lower extremities, [MEDICAL CONDITION], diabetes and had been identified by the facility as being at risk for pressure ulcer development. On 08/04/11, Surveyor further reviewed Resident #4's medical record. The following nurses' notes regarding bed mobility were documents: 06/13/11 - 3:15 p.m. - "BED MOBILITY: Resident requires one aide assist for bed mobility to usually cue the resident to turn and/or offer encouragement, to provide extremity movement assist without weight bearing." 06/14/11 - 2:51 a.m. - "BED MOBILITY: resident repositions independently in bed." 06/14/11 - 10:32 a.m. - "BED MOBILITY: Resident requires one aide assist for bed mobility to usually cue the resident to turn and/or offer encouragement." 06/17/11 - 11:40 p.m. - "BED MOBILITY: Resident requires no help from staff for bed mobility, resident repositions independently in bed." 06/21/11 - 3:37 p.m. - "BED MOBILITY: Resident requires one aide to assist for bed mobility to usually cue the resident to turn and/or offer encouragement." This note was two days prior to the right heel ulcer being discovered. The documentation provided regarding bed mobility for Resident #4 for the time period of 06/13/11-06/23/11 varied from being independent with bed mobility to needing extensive physical assistance of one person on the night shift, extensive assistance of one to two persons on the day shift and dependent with physical assistance of two persons on the evening shift. Staff on the night shift identifying the resident as independent with bed mobility and not cuing the resident to turn and reposition, could have contributed to the development of the right heel pressure ulcer. During the above interview, Surveyor stated Resident #4's right heel ulcer had black eschar present but the nurses' note written by RN E on 08/03/11 read in part, "ONSET/DISCOVERY DATE: 08/01/11. Noted on admission. (The 08/01/11 date was a readmitted ; the right heel pressure ulcer was present prior to this hospital stay. It had been found at the facility on 06/23/11), WOUND TYPE: Stage 2. TISSUE TYPE: intact blister. WOUND TISSUE: purple." Surveyor asked RN E if she still considered the pressure ulcer a Stage II since there was black eschar present. RN E said, "It's probably unstageable." During this same interview, Surveyor asked the DON, RN E and LPN P why the pressure ulcer occurred. LPN P responded, "I suppose pressure." The DON stated, "I don't think that we weren't taking care of her, it has to do with nutrition and how she is physically." The DON was asked by Surveyor to explain why the ulcer was unavoidable. The DON did not have an answer. It was again stated they had the air mattress in place. Surveyor reminded them that measure was put in place after the right heel ulcer was found. LPN P commented, "I can't believe it got black so fast." RN E stated it wasn't black and hard, it was purple and fluid filled, soft dark purple." Surveyor noted the assessment of the right heel done 07/20/11 at the facility identified a fluid-filled blister and the H&P done 07/21/11 at the hospital identified the right heel ulcer had black eschar present. Surveyor requested to see the skin assessment completed for Resident #4 upon her return from the hospital 08/01/11. The DON provided Surveyor a copy of the "NURSING COMPREHENSIVE ADMISSION DATA COLLECTION AND ASSESSMENT" dated 08/01/11. Part of this document included a section titled "Skin Assessment" that read, "Complete Admission Skin Assessment and initiate Skin Integrity Assessment: Prevention and Treatment Plan of Care for all residents." The section for feet identified the following: "Color: pink, Temperature: cool to the touch, Alterations:" There was a place to identify if a pressure area/ulcer was present and devices to be used, also abrasions, bruises, a rash or other. "None" was x'd (indicated). This document does not contain a signature of the nurse who completed it on 08/01/11. LPN C, the nurse that worked the evening shift of 08/01/11, told Surveyor during the phone interview on 08/04/11 she had not looked at Resident #4's heels/feet as Resident #4 had the podus boots on. The DON was unable to locate documentation Resident #4's heels had been checked prior to RN E checking them on 08/03/11. During the above interview, Surveyor referred to a nurses' note from 08/01/11 written by LPN P that read, "The right heel continues to have the quarter size black spot." During the above interview, LPN P was asked by Surveyor if she had personally looked at Resident #4's right heel upon her return from the hospital on [DATE]. LPN P informed Surveyors and she had not looked at Resident #4's heels. LPN P was asked where she received the information regarding the right heel having the quarter-size black spot she charted. LPN P stated she must have gotten it in report from the hospital. On 08/04/11 beginning at 12:42 p.m., Surveyor interviewed LPN C via speaker phone with the DON present. Surveyor confirmed with LPN C that LPN C was the nurse on the evening shift Monday, 08/01/11, working with Resident #4, the day Resident #4 returned from the hospital. Surveyor asked LPN C if she had checked Resident #4's heels as part of her skin check. LPN C stated, "No, she had podus boots on them; I was told during her dressing changes the rest of skin would be getting done." Surveyor asked LPN C if she knew when the dressing change was due to be done. LPN C stated she thought they were due to be done Wednesday (08/03/11). LPN C informed Surveyor , "That was my very first skin check, I got thrown into it." LPN C stated she had only worked at the facility a couple months. Surveyor asked LPN C if she had training about what to do when a resident who is admitted or readmitted to the facility. LPN C stated, "Minimal, some, it was very busy that day." On 08/04/11, Surveyor reviewed Resident #4's nurses' notes from 08/01/11-08/03/11 to determine if facility staff had documented Resident #4's heels had been checked or assessed prior to RN E assessing them the morning of 08/03/11. There was no documentation to show they had checked Resident #4's heels until 08/03/11.

Based on observations, interviews, record reviews, and a review of the facility's infection control program, the facility did not establish an infection control program under which it investigated, controlled, and prevented infections in the facility; decide what procedures, such as isolation, should be applied to an individual resident; and maintain a record of incidents and corrective actions related to infections. The facility did not implement their infection prevention and control program and did not: ~Assure that the individual responsible for infection prevention and control received adequate training to implement the program. ~Follow their policies and did not implement their established procedure for tracking all residents with signs/symptoms of acute gastroenteritis as well as all residents with confirmed infections who were not on an antibiotic. ~Follow their policies to immediately implement appropriate precautions when multiple residents on a common unit presented with symptoms of acute onset of diarrhea and/or vomiting. ~Restrict staff with signs/symptoms of acute gastroenteritis from resident contact until forty-eight hours after symptom cessation nor did they restrict personnel movement between units. ~Suspend resident gatherings for dining and activities to ensure that residents who were not ill and had no symptoms were not exposed to residents who were presenting with signs/symptoms of acute gastroenteritis and to prevent further transmission of a potentially infectious agent. ~Assure that housekeeping was using the proper concentration of cleaning solution, that items used for cleaning were not shared between rooms, and that more intensive cleaning procedures were being done for high touch areas; ~Limit new admissions when a confirmed and/or suspected outbreak was occurring in the facility. The facility has a bed capacity for 40 residents with an environmental layout that includes two resident wings. The number of symptomatic residents during the month of December, 2010, was identified as 34/44 (77%) with the number of symptomatic staff identified as 33/86 (40%). Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, and #34 as well as numerous staff were identified in the subsequent investigation on survey to have presented and/or continued with signs/symptoms of gastroenteritis in November, 2010, and/or in December, 2010, and/or in January, 2011, and/or in February, 2011. These failures had the potential to affect all residents of the facility. The facility's failure to immediately implement appropriate procedures to limit the transmission of disease, which can be particularly serious for individuals with compromised conditions or multiple co-morbidities, created a situation of Immediate Jeopardy which began on 11/24/10 when residents and staff presented with a commonality of signs/symptoms of GI illness. The facility did not suspect and take appropriate action related to the outbreak until 12/07/10, and then did not consistently continue to implement appropriate procedures to limit the transmission of disease. The facility was notified of the finding of Immediate Jeopardy on 02/03/11. The facility removed the immediate jeopardy by the conclusion of the survey, on 02/03/11, by putting in place appropriate interventions that included surveillance of signs/symptoms of potentially infectious organisms and staff notification of the importance of infection prevention and control. The deficiency continues at a scope/severity of "F" as the facility did not correct the problem to include that all necessary policies and procedures are reviewed and/or revised, that all staff are educated on an infection control program that investigates, controls, and prevents infections in the facility, with appropriate isolation precautions applied to all individual residents according to accepted standards, and with a record of incidents and corrective actions related to infections properly maintained. This is evidenced by the following: NOROVIRUS IN WI LTC FACILITIES On November 14, 2010, the Department of Health Services, Division of Quality Assurance sent out via email list serve an announcement that directed providers to the link <http://www.dhs.wisconsin.gov/rl_DSL/Publications/pdfmemos/10-033attach.pdf> to view DQA Memo 10-033/Recommendations for the Prevention and Control of Viral Gastroenteritis Outbreaks in WI Long-Term Care Facilities (LTCF). This document notes the following; It is the responsibility of the of the LTCF to implement aggressive infection control measures quickly and to notify the appropriate agencies of the outbreak or suspected outbreak. Facilities are required to maintain an infection prevention and control program that includes a surveillance program for infections common to LTCFs including viral gastrointestinal disease. An outbreak of viral gastroenteritis should be suspected when two or more residents and/or staff develop new onset of vomiting and/or diarrhea within one to two days. On 12/15/10 the Division of Public Health (DPH) subsequently changed the definition to the following: 3 or more cases of illness among residents and/or staff within a 72-hour period with vomiting and/or diarrhea (3 or more loose stools in a 24-hour period) in a resident or a staff member and whose symptoms have no other apparent cause. Recommendations include but are not limited to; I. Limit transmission when initial cases of viral gastroenteritis are suspected A. Notification1. Each resident unit should immediately report any resident(s) or staff member(s)with a sudden onset of symptoms suggestive of viral gastroenteritis to the personin-charge and infection control practitioner who should immediately takeappropriate action. The medical director should be consulted anytime the facilitysuspects an outbreak.2. New cases should be recorded daily using a line list 3. Notify the local health department of any suspected or confirmed outbreak.Consult with the local health department about laboratory testing.4. Notify " sister " facilities that may share staff/resources with the affected facility sothey can put proper control measures in place and monitor for illness. B. Management of Residents and Staff1. Immediate isolation of the resident and restricting access to affected areas isessential.2. Confine symptomatic residents to their rooms until 48 hours after symptomscease. Symptomatic residents should be cohorted (e.g., residents with the sameinfection may share a room).3. Exclude non-essential staff from entering room.4. Require symptomatic staff, visitors and volunteers to stay home until they aresymptom-free for at least 48 hours.5. Discontinue "floating" staff from the affected unit to non-affected units, ifpossible.6. Discontinue "floating" staff from affected units to food service.7. Consider discontinuing use of common dining areas and instituting in-roomdining.8. If the outbreak continues, facility staff in consultation with their medical directorshould consider closing the unit/neighborhood or facility to new admissions aswell as referring facilities such as other nursing homes or hospitals.9. Suspend discharges/transfers to other facilities. C. Management of Staff1. Staff assignmentsa. Maintain the same staff to resident assignments, if possible.b. Limit staff from moving between affected and unaffected units.c. Discontinue "floating" staff from affected units and other facilities to foodservice.d. Provide education and DPH Disease Fact Sheets on viral gastroenteritis to allstaff. Include symptoms, transmission prevention precautions, and workexclusion guidelines.2. Implement "contact precautions":a. Wear personal protective equipment to include gloves, and gown (mask andgoggles or face shield if vomitus present) upon entry to the room and when incontact with the symptomatic resident (CDC, 2004). D. Management of Ill Staff1. A staff illness policy outlining the duty to inform requirements for exclusion andthe circumstances for returning to work (48 hours) should be developed andimplemented and all employees should be educated about the policy. Considerdeveloping a sick leave policy that provides compensation or other non-punitiveapproaches to encourage self-reporting of ill staff and appropriate exclusion.2. During an outbreak, staff should exclude themselves from resident care and/orfood service duties at the onset of symptoms including nausea, vomiting,abdominal pain and/or diarrhea. Such exclusions shall remain in effect until theemployee is asymptomatic and free of symptoms for 48 hours. Testing fornorovirus is not required before staff return to work. E. Management of Environment1. Increase the frequency of routine environmental cleaning including bathroomsand the area surrounding the resident's living space. Particular attention shouldbe given to cleaning objects that are frequently touched such as faucets, doorhandles, light switches and bed rails.2. Clean and disinfect vomit and fecal spills promptly. All individuals cleaningsurfaces soiled with vomitus or fecal material should wear a gown, gloves, and asurgical or procedure mask. After glove and gown removal and hand hygiene,ensure that hands and clothes do not touch potentially contaminatedenvironmental surfaces or items in the resident's room. Exposed food items suchas candy, fruit, cups or glasses with straws should be discarded.3. CDC recommends that chlorine bleach should be applied to hard, non-porous,environmental surfaces at a minimum concentration of 1000 ppm. Thisconcentration has been demonstrated in the laboratory to be effective against surrogate viruses with properties similar to those of norovirus. Healthcare facilitystaff should use appropriate PPE (e.g. gloves and goggles) when working withbleach. In areas with high levels of soiling and resistant surfaces, up to 5000 ppmchlorine bleach may be used. (See Appendix 1, page 11). The reliability ofdisinfectants other than those containing chlorine to kill norovirus is uncertain,although recent studies by the Nebraska Cooperative Extension and the USDAhave shown that certain oxidizing agents registered by the U.S. EPA (e.g.,Virkon), are effective virucidal agents. The effectiveness of other EPA-approveddisinfectants or norovirus clean-up is uncertain.4. Norovirus may remain viable for up to 12 days in carpeting or otherenvironmental surfaces. Therefore, a thorough cleaning of carpets, curtains, walls,and all equipment is essential. Steam cleaning should be used for all carpeting andsoft furnishings. Dry vacuuming has the potential to re-circulate the viruses and isnot recommended.5. Enhanced cleaning and disinfection should continue for at least 72 hours after thelast documented case. F. Laundry Concerns1. Do not shake soiled linens and laundry. Aerosols created may pose a risk fortransmission. Soiled linens should be placed directly into a bag at the point ofremoval. Minimize the number of staff handling this material.2. Contaminated pillows should be laundered as infected linen unless they arecovered with an impermeable cover, in which case they should be disinfectedwith a hypochlorite solution (See Appendix 1).3. Ensure proper segregation of clean and soiled laundry.4. Ensure laundry personnel are made aware of the potentially infected linen and areprovided with appropriate PPE.G. Management of Visitors1. Post signage that the facility is experiencing an increase in gastrointestinalillness.2. Visits to symptomatic residents should be discouraged, especially by children,the elderly and persons with underlying medical conditions.3. If visitation is necessary, health care workers should instruct visitors on theappropriate procedure for putting on and removing gowns, gloves and masks (ifthe resident is vomiting) and hand hygiene, and provide education and DPHNorovirus Disease Fact Sheets FACILITY POLICIES AND PROCEDURES Surveyor interviewed the DON on 02/02/11 at 12:15 p.m. who identified she had been in her position for approximately 3 years, that she was the facility's infection control nurse (responsible for infection prevention and control), that the standard used was APIC, 2009, "Infection Prevention Manual for Long-Term Care Facilities," and that the ICSL was the system used by the facility to track infections. Surveyor interviewed the DON on 02/03/11 at 1:35 p.m. who confirmed she received no formal training related to the facility's infection control program. Section I of the facility's infection control manual included the following: ~Policies, procedures, and guidelines will serve as a reference for all departments and the manual will serve as a tool to enhance surveillance for the infection preventionist; ~The infection preventionist is responsible for the quality of resident care as it relates to investigation, control, and prevention of infection which includes to perform surveillance to identify individual infections in residents and staff and to identify clusters of infection in a timely manner, to track trends in infection, to identify infection control issues and make recommendations for corrective action, to monitor infection prevention and control practices and employee compliance, to maintain infection prevention and control policies/procedures for all departments, to conduct outbreak investigation and initiate control measures, and to provide education related to infection prevention and control for all staff; ~"It is the policy of this facility to closely monitor all residents who exhibit signs/symptoms of infection. The nurse or nursing assistant will notify the infection preventionist of suspected infections and record the information on the infection prevention and control surveillance form..." It was identified that monitoring and documentation was based on McGeer's definitions; ~It was identified that monitoring and documentation was based on McGeer's definitions; McGeer's definition for GI infection identifies that a person must have "one" of the following: 2 or more loose or watery stools above what is normal for the resident in a 24-hour period, or 2 or more episodes of vomiting in a 24-hour period, or both a positive stool culture for a pathogen and 1 sign/symptom of GI illness); ~A monthly form which was separated by "sites" of potential infections and was to be used for any resident who "you suspect may have an infection," has antibiotics prescribed, or has had a culture obtained or ordered, as well as instructions for calculation of infection (incidence) rates; ~"The elderly are at increased risk of infectious gastroenteritis due to age-related decrease in gastric acid." Section II of the facility's infection control manual included the following related to employee health: ~"It is the policy of this facility to offer employees immunization against influenza every year between October and March...influenza is a serious risk for the elderly...the vaccine is recommended for them and for their caregivers..." ~"All employees are responsible for [MEDICATION NAME] good infection prevention and control measures...All employees are responsible for promptly reporting to their supervisor any infections they have come in contact with..." ~"Isolation procedures must be carried out as directed in the infection prevention and control manual. It is important to separate residents with certain infections from other residents to prevent the transmission of infection from one person to another." ~"Food handling is a very important aspect of infection control." Section V of the APIC, 2009, "Infection Prevention Manual for Long-Term Care Facilities," used as a standard by the facility, identified that standard precautions could be used for most gastroenteritis infections, except for[DIAGNOSES REDACTED] and Rotavirus for which contact precautions were to be used. It was also identified that for all gastroenteritis infections, "Use Contact Precautions for diapered or incontinent persons for the duration of illness or to control institutional outbreaks..." FACILITY SURVEILLANCE SYSTEM FOR TRACKING/TRENDING On 02/03/11, at 11:50 a.m., Surveyor reviewed the facility's ICSL for July, 2010, through January, 2011. The logs contained only residents with confirmed infections and/or treated with an antibiotic or other medication and did not include residents with suspected infections. A calculation of infection (incidence) rates was done by the DON using all the infections in a given month, but the incidence rate for specific "sites" of infection was not calculated. Following the survey, the facility provided quarterly data comparing infections by the site of the infection and the location of the infection, but the numbers of infections were provided, not the incidence rate. The facility has a bed capacity for 40 residents with an environmental layout that includes two resident wings, east and west, separated by a large dining room and central nurses' station. Connected to the dining room is a large front entry/activity area for residents. Surveyor reviewed records from the WI Division of Public Health (DPH) which identified that on 12/07/10, the facility made an initial call to the local public health department (PHD) related to an outbreak of GI illness in residents and staff. The local PHD advised that 4 stool specimens be sent to the State DPH for testing which subsequently confirmed norovirus in 3 of the 4 residents' stool specimens sent. The number of symptomatic residents during the month of December, 2010, was subsequently identified as 34/44 (77%) and the number of symptomatic staff was identified as 33/86 (40%). The case definition used by the DPH was "Vomiting and/or diarrhea (3 or more loose stools in a 24-hour period) in a resident or staff member and whose symptoms have no other apparent cause." Based on surveyor review of facility ICSL for November and December 2010, and January, 2011, the facility did not track those residents with signs/symptoms that met the McGeer's definition for GI infection. NOVEMBER, 2010 Based on Surveyor 's review of sampled residents' records to include nurse's notes and bowel records and review of the facility's November, 2010 ICSL (tracking system), West Wing Residents (#15, #8, #12, #5, #1, #19 listed in chronological date order) and East Wing Residents (#6, #32, #24 listed in chronological date order) who developed sign/symptoms that met the McGeer's and WI DPH definition of a potential GI infection were not recorded on the facility's November, 2010 ICSL. The facility did not follow their own policy for identifying suspected GI infections and did not follow their policy for tracking potential GI infections. Consequently, the facility did not identify they had a potential outbreak of GI infection. NOVEMBER, 2010, WEST WING Resident #15, age 89, (continent/incontinent) was noted to meet the definition of a GI infection on 11/06/10, 11/13/10, 11/20/10, and 11/22/10 with signs/symptoms that met McGeer's definition and the WI DPH definition of a potential GI infection. Resident #8, age 90, (continent) was noted to meet the definition of a GI infection on 11/16/10 and 11/22/10 with signs/symptoms that met McGeer's definition and the WI DPH definition of a potential GI infection. Resident #12, age 89, (continent/incontinent) was noted to meet the definition of a GI infection on 11/21/10 with signs/symptoms that met McGeer's definition and the WI DPH definition of a potential GI infection. Resident #5, Age 95, (continent) was noted to meet the definition of a GI infection from 11/25/10 through 11/29/10 (GI hemorrhage noted on 11/30/10) with signs/symptoms that met McGeer's definition and the WI DPH definition of a potential GI infection. Resident #1, Age 91, (incontinent) was noted to meet the definition of a GI infection on 11/28/10 with signs/symptoms that met McGeer's definition and the WI DPH definition of a potential GI infection. Resident #19, Age 93, (incontinent) was noted to meet the definition of a GI infection on 11/29/10 with signs/symptoms that met McGeer's definition and the WI DPH definition of a potential GI infection. NOVEMBER, 2010, EAST WING Resident #6 (Age 86) East Wing (This is the first resident on the "east" wing identified to have presented with signs/symptoms of a potentially infectious organism in November, 2010.) 11/14/10. Incontinent of 2 large loose stools. 11/20/10. Incontinent of 3 medium to large loose stools. ~The resident had episodes of frequent loose stools as well as more normal stools (a subsequent nurse's note stated the resident normally had loose stools but there were no diagnoses identified that supported this). The resident continued with loose stools in December (see December documentation below) and was subsequently identified as having the "flu" during the time of the norovirus outbreak. Resident #32 (Age 83) East Wing 11/19/10. Continent of 2 large loose stools. 11/22-24/10. Incontinent and continent of medium to large loose stools (2 on 11/23/10). 11/30/10. Incontinent of 3 large loose stools. ~Loose stools continued on 12/01/10 (see December documentation below). Resident #24 (Age 90) East Wing 11/28/10. Incontinent of 2 large loose stools. ~Loose stools continued with 2 or more noted on 12/07/10 (see December documentation below). According to APIC Infection Prevention Manual for Long-Term Care Facilities, 2nd Edition, 2009 Procedure for Outbreak Investigation (standard used by the facility) - When a commonality of symptoms is evident among residents or staff with common person, place, time, or event, suspect an outbreak. DECEMBER, 2010 When Surveyor requested and reviewed the facility's ICSL on 02/02/11 at 11:50 a.m., it was identified that the December log did not include any GI-related illnesses, except for[DIAGNOSES REDACTED] identified for Resident #20. The DON stated she did not include the recent norovirus outbreak in December, 2010, as part of her ICSL, but had it in a separate folder, which was subsequently provided. Based on Surveyor 's review of sampled residents' records to include nurse's notes and bowel records, review of the facility's December, 2010 ICSL (tracking system), and a review of the facility's correspondence with the local PHD, 18 West Wing Residents and 16 East Wing Residents who developed sign/symptoms that met the McGeer's and WI DPH definition of a potential GI infection were recorded on a "line list" provided by the local PHD, but not recorded on the facility's December, 2010 ICSL. The facility did not follow their own policy for identifying suspected GI infections in a timely manner and did not follow their policy for accurately tracking potential GI infections. Consequently, the facility did not promptly identify they had a potential outbreak of GI infection and maintain accuracy of the information. DECEMBER, 2010, WEST WING LINE LIST On 02/02/11 - 02/0911, Surveyor reviewed the following sample resident records to include nurse's notes and bowel records. Resident #15, Age 89, (continent/incontinent) was noted to meet the definition of a GI infection on 11/06/10, 11/13/10, 11/20/10, and 11/22/10, was not added to the "line list" until 12/08/10, and was removed from the "line list" on 12/10/10, even though the resident's signs/symptoms met McGeer's definition and the WI DPH definition of a potential GI infection before being placed on, and after being removed from the "line list." Resident #8, Age 90, (continent/incontinent) was first noted to meet the definition of a GI infection on 11/16/10, was not added to the "line list" until 12/06/10, and was removed on 12/10/10, even though the resident's signs/symptoms met McGeer's definition and the WI DPH definition of a potential GI infection before being placed on, and after being removed from the "line list." This resident who had signs/symptoms that met the definition of a GI infection was allowed to socialize with other residents thereby increasing the risk of transmission to other residents. Resident #12, Age 89, (incontinent) was first noted to meet the definition of a GI infection on 11/21/10, was not added to the "line list" until 12/08/10, and was removed on 12/10/10, even though the resident's signs/symptoms met McGeer's definition and the WI DPH definition of a potential GI infection before being placed on, and after being removed from the "line list." Resident #5, Age 95, was admitted from the hospital on [DATE] with a recent history of loose stools which persisted daily after admission, and diagnoses that included constipation related to irritable bowel syndrome. The resident (continent/incontinent) was noted to meet the definition of a GI infection on 11/25/10, was diagnosed with [REDACTED]. The resident was not added to the "line list" until 12/06/10 and was removed on 12/09/10, even though the resident's signs/symptoms met McGeer's definition and the WI DPH definition of a potential GI infection before being placed on, and after being removed from the "line list." Resident #1, Age 91, (incontinent) who had diagnoses that included diabetes mellitus (DM), history of stroke, acute anxiety, and chronic constipation was first noted to meet the definition of a GI infection on 11/28/10, was added to the "line list" on 12/07/10, and was removed from the "line list" on 12/11/10, even though the resident's signs/symptoms met McGeer's definition and the WI DPH definition of a potential GI infection before being placed on, and after being removed from the "line list." There was no entry on the "line list" or on the December, 2010, ICSL (tracking system) related to the resident's confirmed norovirus. Based on information Surveyor obtained from the WI DPH, this resident tested POSITIVE for norovirus on 12/14/10 from a stool sample that had been collected on 12/08/10. This resident who had signs/symptoms that met the definition of a GI infection was allowed to socialize (on 12/13/10) with other residents thereby increasing the risk of transmission to other residents. Resident #19, Age 93, (continent/incontinent) was first noted to meet the definition of a GI infection on 11/29/10, was added to the "line list" on 12/12/10, even though the resident's signs/symptoms met McGeer's definition and the WI DPH definition of a potential GI infection before being placed on the "line list." Resident #7, Age 96, (continent/incontinent) was noted to meet the definition of a GI infection on 12/01/10, was not added to the "line list" until 12/06/10, and was removed on 12/09/10, even though the resident's signs/symptoms met McGeer's definition and the WI DPH definition of a potential GI infection before being placed on, and after being removed from the "line list." Resident #10, Age 99, (continent/incontinent) was noted to meet the definition of a GI infection on 12/02/10, and was not added to the "line list" until 12/07/10, even though the resident's signs/symptoms met McGeer's definition and the WI DPH definition of a potential GI infection before being placed on the "line list." Resident #13, Age 89, (continent/incontinent) was noted to meet the definition of a GI infection on 12/03/10, was not added to the "line list" until 12/08/10, and was removed on 12/09/10, even though the resident's signs/symptoms met McGeer's definition and the WI DPH definition of a potential GI infection before being placed on, and after being removed from the "line list." Resident #9, Age 87, (continent) was noted to meet the definition of a GI infection and added to the "line list" on 12/06/10, but was removed from the "line list" on 12/09/10, even though the resident's signs/symptoms met McGeer's definition and the WI DPH definition of a potential GI infection after being removed from the "line list." Resident #3, Age 95, (incontinent) who had diagnoses that included ischemic heart disease, renal disease, duodenitis, constipation, depression, and dementia was noted to meet the definition of a GI infection. The resident was added to the "line list" on 12/07/10 and removed from the "line list" on 12/09/10, as the resident's signs/symptoms met McGeer's definition and the WI DPH definition of a potential GI infection. However, there was no entry on the "line list" or on the December, 2010, ICSL (tracking system) related to the resident's confirmed norovirus. Resident #11, Age 53, (incontinent) was noted to meet the definition of a GI infection and added to the "line list" on 12/07/10, but was removed from the "line list" on 12/09/10 (again added for 1 day on 12/17/10), even though the resident's signs/symptoms met McGeer's definition and the WI DPH definition of a potential GI infection after being removed from the "line list" for the second time. Surveyor interviewed Resident #11 on 02/03/11 at 3:05 p.m. Resident #11 stated she recalled having the "flu"( in December, 2010), and identified that the headaches were the worst part of it. Resident #11 stated she also had vomiting and diarrhea. When asked if there was anything that helped her to feel better during that time, she answered, "to get rid of it." Resident #17, Age 75, (continent) was noted to meet the definition of a GI infection, added to the "line list" on 12/08/10 and removed from the "line list" on 12/10/10, as the resident's signs/symptoms met McGeer's definition and the WI DPH definition of a potential GI infection. Surveyor interviewed Resident #17 on 02/03/11 at 5:15 p.m. Resident #17 stated she stayed in her room a day or 2, was sick to her stomach, and had some diarrhea. Resident #14, Age 87, (continent/incontinent) was noted to meet the definition of a GI infection and added to the "line list" from 12/08/10 to 12/10/10, and again added from 12/18/10 to 12/19/10 as the resident's signs/symptoms met McGeer's definition and the WI DPH definition of a potential GI infection. Resident #20, Age 67, (incontinent) was noted to meet the definition of a GI infection on 12/09/10 (after an antibiotic for[DIAGNOSES REDACTED] was discontinued on 12/05/10), was not added to the "line list" until 12/10/10, and was removed on 12/12/10. The facility's ICSL (tracking system) for December, 2010, identified the resident had an onset of signs/symptoms including foul smelling diarrhea on 12/15/10 and that the antibiotic for[DIAGNOSES REDACTED] was initiated on 12/18/10, however, there was no entry on the ICSL related to the resident's signs/symptoms that met McGeer's definition and the WI DPH definition of a potential GI infection from 12/09-15/10. [DIAGNOSES REDACTED] was again confirmed on 12/19/10 and an antibiotic was completed on 12/29/10. Resident #16, Age 69, (continent/incontinent) was noted to meet the definition of a GI infection and added to the "line list" on 12/09/10, but was removed from the "line list" on 12/10/10, even though the resident's signs/symptoms met McGeer's definition and the WI DPH definition of a potential GI infection after being removed from the "line list." This resident who had signs/symptoms that met the definition of a GI infection was allowed to socialize by visiting the attached assisted living facility and by going out to dialysis (without documented evidence the dialysis unit was informed of the outbreak at that time) thereby increasing the risk of transmission to individuals outside the facility. Surveyor interviewed Resident #16 on 02/03/11 at approximately 4:30 p.m. Resident #16 stated he was sick with the "flu" (in December, 2010) for a "couple of days" and identified he had the diarrhea during that time. Resident #16 confirmed that he did go to dialysis during the illness. Resident #16 stated that he always wears an incontinence product to dialysis, in case of "an accident" (incontinence). Resident #16 stated that he did not have an accident when he went to dialysis during his "flu" illness, but added that he was worried that it might happen. Resident #16 identified that he visits his wife daily at the attached assisted living unit, after supper, but did not go for a couple of days when he had the "flu." Resident #2, Age 90, (incontinent) who was hospitalized from [DATE] to 12/13/10 for suspected cardiac problems with subsequent diagnoses of Congestive Heart Failure (CHF) and chronic lung disease, was noted to meet the definition o