Every finding on record at Good Samaritan Society Howard

Based on observation, interview, and policy review, the provider failed to ensure the staff followed standard infection prevention and control practices related to one of two certified nursing assistant (CNA) (I) who wore two pairs of gloves during one of one sampled resident's (30) cares and did not remove potentially soiled gloves before touching the resident's wardrobe and clean clothes.Findings include:1. Observation on 5/19/26 at 11:20 a.m. revealed that CNAs I and J were assisting resident 30 with changing his clothes after he was incontinent (involuntary urine or bowel leakage). Both CNAs were wearing gloves. With her potentially soiled gloves, CNA I walked over to resident 30's wardrobe, grabbed the handles and opened the doors, grabbed a pair of clean pants from the wardrobe, and closed the doors. She helped the resident put on his clean incontinence brief and pants and then removed and discarded her gloves in the trash can. She was wearing another pair of gloves underneath the first pair of gloves that she had removed and discarded.2. Interview on 5/19/26 at 11:27 a.m. with CNA I revealed that she was wearing two pairs of gloves during the above observation. She usually removed the outer layer of gloves after performing peri-cares (cleaning a person in the perineum area, the skin between the genitals and anus). She confirmed she did not remove the outer layer of gloves after performing peri-cares on resident 30. She touched the wardrobe door and handles, and resident 30's clean clothes with the soiled gloves. She said it was a normal practice at that facility to wear multiple pairs of gloves at one time.3. Interview on 5/20/26 at 2:54 p.m. with director of nursing B revealed that it was not their normal practice to wear multiple pairs of gloves at one time. She explained that it was not part of the provider's policy or good practice. She expected the direct care staff to remove their soiled gloves and perform hand hygiene (cleaning hands with soap and water or alcohol-based hand sanitizer) before touching the resident's clean clothes and wardrobe.4. Review of the provider's undated Personal Protective Equipment (PPE), Application and Removal, All Service Lines-Enterprise policy revealed that the policy did not include directions for wearing two pairs of gloves.5. Review of the provider's 11/13/25 Hand Hygiene-Enterprise policy revealed that All employees in patient care areas.will adhere to the 4 Moments of Hand Hygiene and 2 Zones of Hand Hygiene. 1. Entering Room. 2. Before Clean Task. 3. After Bodily Fluid/Glove Removal. 4. Exiting Room. 5. Zones: Patient zone and Health-care zones. HCW [Healthcare worker] will use waterless alcohol-based hand sanitizer or soap and water to clean their hands: .After removing gloves regardless of task completed .When entering healthcare zone (supply drawers, linen drawers or cupboards) Glove use: .Change gloves when moving from a dirty to a clean or sterile activity performing hand hygiene in between changing gloves.Hand hygiene must be performed after removal [of gloves] regardless of task.

Based on interview, observation, record review, and policy review, the provider failed to ensure an environment free from accident hazards for one of one sampled resident (24) with a diagnosis of hemiplegia (paralysis effecting one side of the body) following cerebral infarction (a stroke) who, while reaching for his call light, fell, hit his head, and sustained a laceration (a deep cut) to his left arm when left unattended in his bathroom, seated on the toilet, with a stand aid (a manual lift used to assist a person from a seated to a standing position) positioned in front of him, without the staff ensuring that the lift brakes were locked and that his call light was within his reach. Findings include: 1. Interview and observation on 5/19/26 at 10:48 a.m. with resident 24 in his room revealed he had fallen from the toilet in his bathroom onto the floor a couple of weeks ago. He had hit his head on the floor and received a cut on his left arm. He indicated that a certified nursing assistant (CNA) had taken him into the bathroom and left him on the toilet without his call light within his reach. He could not recall the name of the CNA who had transferred him to the toilet. He indicated that the stand aid (a manual lift used to assist a person from a seated to a standing position) was left in front of him when he was seated on the bathroom toilet, but the brakes were not locked, and the stand aid scooted forward when he lost his balance reaching for the call light cord to call for staff assistance, and fell. His bathroom was situated so that the toilet was in the southwest corner of the bathroom. If a person was sitting on that toilet, they would be facing to the east. The call light cord was attached to the wall on the northwest corner of the bathroom (situated to a person's left side if they were seated on the toilet), and the sink was in the northeast corner of the bathroom. He had a seat riser on the toilet and a grab bar that was on the right side of the toilet. Resident 24 had a stroke that resulted in him having left-sided weakness in his body, which potentially could have contributed to his fall as he had to lean over on his left side to reach the call light cord with his right hand. He confirmed he did not have to go to the emergency room for further treatment after his fall. 2. Review of resident 24's electronic medical record (EMR) revealed that he was admitted to the facility on [DATE]. He had medical diagnoses that included hemiplegia (paralysis of one side caused by brain damage) following cerebral infarction (stroke) of the left nondominant side, chronic obstructive pulmonary disease (COPD) (progressive long-term lung condition that causes obstructive airflow from the lungs), and atrial fibrillation (irregular heartbeat). On 11/19/25, his Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated his cognition was intact. His current undated care plan included that he was to transfer with one staff member using the white stand-aid, and that he was assessed and found to be at risk of falling with a history of falls. A care plan intervention added on 4/22/26 read, Educate/remind CNAs to give [the] resident [his] call light while in [the] restroom and educate/remind [resident 24] to ensure he has [the] call light before [the] CNA leaves [the] room. Resident 24's 4/21/25 Physical Therapy Treatment Encounter progress note read, Challenging patient's forward reach while sitting unsupported to both ipsilateral [on the same side of the body] and contralateral [on opposite side] sides reaching for objects 4 [four inches] above [the] floor with [his] right hand. Needs supervision for safety, able to bend forward with no loss of balance (LOB) instances. 3. Interview on 5/21/26 at 3:15 p.m. with CNA G regarding resident 24 revealed he transferred with assistance from the staff and the use of the stand aid. She would drape the call light cord over the bar frame of the stand aid, and the resident would hold onto the string and pull it to turn the call light on to indicate when he was finished using the bathroom. CNA G usually waited outside of the bathroom in the resident's room for the resident to finish in the bathroom, but the staff could keep the resident to the stand aid and leave the bathroom if the stand aid brakes were locked. Resident 24 could not fully grip the bar of the stand aid while the staff stood him up to transfer him, but rather, he rested his hand on the bar. She indicated that Physical Therapy and Occupational Therapy assessed the residents to determine which transfer machine they could safely use. 4. Interview on 5/21/26 at 3:52 p.m. with CNA F revealed that residents were left in their bathroom with the stand aid when they used the toilet, and the call light cord was draped over the stand aid for the residents to pull when they were finished and needed the staff to return to assist them. 5. Interview on 5/21/26 at 3:54 p.m. with CNA E revealed he did not leave the stand aid in the bathroom with resident 24. Instead, he would remove the stand aid from the bathroom until resident 24 needed assistance again. He reviewed the resident's Kardex (a report of the resident's care needs and interventions) to know how the resident transferred and what equipment the resident could use. He did not indicate how he ensured resident 24 was able to use the call light while in the bathroom. 6. Interview on 5/21/26 at 4:39 p.m. with director of nursing (DON) B revealed the incident that occurred on 4/22/26 at 6:19 a.m. with resident 24 was due to the resident overreaching for his call light cord while he was sitting on the toilet in his bathroom. The resident had fallen off the toilet and hit his head on the floor and received a laceration to his left upper arm. The resident was transferred with the white stand aid with staff assistance. She indicated that the staff could leave a resident in the bathroom with the call light cord within their reach and the stand aid in front of them if the resident was assessed to safely use the stand aid and if the stand aid brakes were engaged to prevent it from moving. She stated, I can't guarantee that they always use them correctly, when referring to the CNAs using the stand aids. Competency validation checklists were provided for all staff that were working the day of the incident indicated the staff were trained before the incident on 4/22/26 on how to use the stand-aid. 7. Interview on 5/21/26 at 6:16 p.m. with licensed practical nurse (LPN) H revealed that she was present on 4/22/26 when resident 24 was found on his bathroom floor at 6:19 a.m. He had hit his head on the floor and received a laceration to his left upper arm. She assessed him and followed the policy and procedures for resident falls. 8. Review of the provider's 4/8/25 Falls Resource Packet-Rehab/Skilled Policy revealed that Fall reduction begins with proactively recognizing potential fall risk factors and proceeds with communicating actions to reduce the possibility of falls. Early identification of each resident's risk for a fall and promptly communicating interventions to avoid falls is vital for resident safety. Common risk factors to consider and proactively address to reduce falls.Lower body weakness.Gait and balance problems.Newly admitted to the facility, room change, and room arrangement changes.

Based on observation, interview, record review, call light report review, resident council meeting, and policy review the provider failed to ensure that two of seven sampled residents (1 and 5) had their call lights answered in a timely manner. Findings include: 1. Observation and interview on 1/27/25 at 2:56 p.m. with resident 1 while in her room revealed: *She was in bed. *Her call light was attached to a blanket within her reach. *Staff used a total lift (a mechanical lift and sling used to lift a person's full body) to transfer her in and out of bed. *She had chronic pain. *Staff would come in her room and turn her call light off and tell her they needed to get another staff member to help with her transfer. *She stated she had waited over an hour for staff to answer her call light. Review of resident 1's call light report for January 2025 revealed: *There were 22 call light response times over 20 minutes. *Three of those call lights were on for over an hour. Review of resident 1's electronic medical record (EMR) revealed: *She had a brief interview for mental status (BIMS) assessment score of 15 which indicated she was cognitively intact. *She had diagnoses of: -Quadriplegia. -Major depressive disorder, recurrent severe without psychotic features. -Unspecified intracranial injury with loss of consciousness of unspecified duration. -Chronic pain due to trauma. *Her revised 11/1/24 care plan stated she had a history of not allowing staff to turn the call light to answered/off knowing that the call light system tracked times of cares and that was empowering to resident. 2. Observation and interview on 1/28/25 at 9:10 a.m. with resident 5 in her room regarding call light wait times revealed: *She was in bed. *Her call light was attached to a blanket within her reach. *She stated it took staff a long time to answer her call light at certain times of the day. *She had a BIMS assessment score of 15 which indicated she was cognitively intact. Review of resident 5's call light report for January 2025 revealed: *There were 13 call light response times over 20 minutes. *Two of those call lights were over an hour. Interview on 1/29/25 at 9:10 a.m. with administrator A and director of nursing (DON) B regarding call light times revealed: *They could review call light times by hallway, but not by individual resident room. *They were not able to print documentation for call light reports. *The DON reviewed and monitored call lights monthly, and it was very labor intensive. *Call light times were part of the quality assurance meetings. *They had created a performance improvement plan (PIP) in October for call lights *They had some high acuity residents that took a lot of time to care for. *They had increased staffing levels around mealtimes to try to meet the resident's needs. *Ancillary staff helped answer resident call lights, but they could not provide personal cares. *It was their expectation that resident call lights be answered in a timely manner. *They agreed call lights should be answered within 20 minutes. Interview on 1/29/25 at 10:38 a.m. with agency certified nursing assistant (CNA) D regarding call lights revealed: *They monitored call lights in the hallways and were to answer them when they come on. *A white light meant a resident needed assistance. *A green light meant staff were already helping a resident. *A red light meant a resident needed assistance in the bathroom. *She carried a walkie-talkie to communicate with other staff members about resident care needs, including call lights. Interviews on 1/29/25 at 1:28 p.m. with residents in a group setting regarding call lights revealed: *They waited longer before and after meals for call lights to be answered. *Some staff would answer the call lights but they had to get another staff member to help them, which increased their wait times. Interview on 1/30/25 at 10:08 a.m. with business office manager/quality assurance performance improvement (QAPI) C regarding resident call lights revealed *The QAPI team met monthly. *Call light times were reviewed at the meeting by DON B for specific trends. *They had been completing call light audits since October. *The call lights were on longer around mealtimes and during morning and evening cares for residents. *They had added staffing hours to try to address the longer resident call light times. Review of the provider's 7/29/24 revised call light policy revealed: *Purpose: To ensure resident always has a method of calling for assistance. *To promptly answer resident's call light. *Procedure: 1. New admission- explain and demonstrate the use of call light system. *2. When resident's call light is observed/heard, go to resident's room promptly. *3. Respond to request as soon as possible. Turn call light off and inquire about resident's request.

Based on record review, interview, and policy review the provider failed to ensure one of one sampled resident (37) who had an injury of unknown origin was thoroughly investigated and reported to the South Dakota Department of Health (SDDOH). Findings include: 1. Review of resident 37's electronic medical record revealed her: *Diagnoses included: Parkinson's Disease, schizophrenia, bipolar disorder, anxiety disorder, major depressive disorder, muscle weakness, mild cognitive impairment, and pain in her right knee. *Medications included: Haldol (used to treat mental/mood disorders) and risperidone (used to treat bipolar disorder and schizophrenia. *Care plan included that she: -Had communication problems related to her Parkinson's disease. -Used a wheelchair for mobility. -Required a mechanical lift and two staff members to assist in transferring between surfaces. -Required total assistance of a staff member for positioning when in bed. *On [DATE] a Suggestion or Concern form was completed that indicated certified nursing assistants (CNA) heard a popping sound when repositioning resident 37. -On [DATE]: --Resident 37 was interviewed and denied having had a fall or difficulty with transfers. --Two CNAs were interviewed and stated there had been no difficulty with transfers or with repositioning. --A charge nurse was interviewed and had knowledge of a popping sound while staff were providing care to her. --There had been no other identified concerns from the resident or staff. *Review of resident 37's medical record revealed: -A progress note dated [DATE] indicated: Resident continues to c/o [complain of] pain and states her legs hurt bad. Will continue to monitor and repositioned with the right leg on a pillow. Resident closes her eyes off and on. -On [DATE], at 10:14 a.m. the provider sent a facsimile to the primary care provider (PCP) that included the following: --When she had been repositioned on the night of [DATE] the staff heard a loud pop. --She complained of right knee into hip pain. -The PCP ordered an x-ray of her right knee to have been done on [DATE] due to her knee pain. -A nurse's progress note on [DATE] at 1:05 p.m. revealed she complained of an increase in pain in her right hip area to the fore right thigh. -A nurse's progress note on [DATE] indicated she had x-rays taken of her knee due to knee and hip pain. *On [DATE], the PCP noted knee xray reviewed and She has severe arthritis sometimes joints can make popping sounds with arthritis. *On [DATE], resident 37: -Had her gastrostomy tube displaced. -Was transported to the hospital via ambulance. -Was admitted to the hospital for a fracture of her right hip. *On [DATE], a radiology report noted Acute right subtrochanteric right femoral fracture. Interview on [DATE] at 3:07 p.m. with director of nursing (DON) B regarding resident 37 revealed: *She had used a full-body mechanical lift for transfers. *She had a feeding tube in place for her nutrition. *She went to the emergency roiagnom on [DATE] due to having pulled out her feeding tube and she was having high blood sugars, not for any pain or her hip. *She passed away on [DATE]. *We were waiting for some kind of information from hospital/final report. *The protocol for investigations was: -Investigations occurred when an incident on the premises, or a resident was out of the facility, or staff took a resident out and something happened was reported. -She had no knowledge of the hip fracture until after resident 37 had passed away. -She had not completed an investigation for the hip fracture. --She had not thought that a report needed to have been be filed with the SDDOH as resident 37 had passed away. -She agreed resident 37's hip fracture was an injury of unknown origin and should have been reported to the SDDOH. Interview on [DATE] at 4:14 p.m. with administrator (ADM) A regarding resident 37's fractured hip revealed: *The protocol was for any abuse or neglect allegation to have been reported to the SDDOH within two hours of notification of the allegation. -The ADM, DON, or social service designee would have completed and filed the report. -An investigation would have been started. -She was made aware of resident 37's hip fracture the day after she had died . -She had not reported the hip fracture to the SDDOH as they had not been aware if the fracture occurred while resident 37 was in the facility. -She stated, We had no incident, no trauma. -She agreed the hip fracture should have reported. Review of the provider's [DATE] Abuse and Neglect Policy revealed: *Purpose -To ensure that all identified incidents of alleged or suspected abuse/neglect, including injuries of unknown origin, are promptly reported and investigated. *Procedure *4. Notification procedures: -c. Designated agencies will be notified in accordance with state law, including the State Survey and Certification Agency. --If there is an allegation ., including injuries of unknown source ., then it will be reported immediately, but not later than two hours after the allegation is made.

Based on observation, record review, and interview, the provider failed to ensure residents: *Sitting at the same table were served at the same time for two of two meal services. *Who required assistance with eating received the necessary help for two of two randomly observed residents (7 and 27). *Who required assistance were not brought into the dining room after other residents were done eating and placed at unclean tables for two of two sampled residents (9 and 23). Findings include: 1. Observation on 2/4/19 from 5:30 p.m. through 6:20 p.m. of the dining room revealed: *At 5:30 p.m. residents 33 and 38 were sitting at the same table. *At 5:36 p.m. resident 33 was served her food. *At 5:45 p.m. resident 33 was done with one half of her sandwich and eating the other half. -Resident 38 had not been served her food yet. *At 5:52 p.m. resident 38 had been served her food. *There were six other residents sitting at another table. -The first resident got served his food at 5:42 p.m. -The last resident got served her food at 5:57 p.m. --The male resident sitting across from her was done eating at that time. *Throughout the observation there was no table that had all residents served at the same time. Observation on 2/5/19 from 11:10 a.m. through 12:19 p.m. in the dining room revealed: *At 11:10 a.m. resident 33 had been sitting at her table. *At 11:31 a.m. resident 38 sat down at that table. *At 11:37 a.m. resident resident 33 was served her food. *At 11:49 a.m. resident 38 was served her food. -That had been twelve minutes from when the first resident was served. *At the table with six residents: -The first resident got his food served at 11:46 a.m. --All the other residents were sitting at the table at that time. -The last resident at that table was served at 12:04 p.m. --That had been eighteen minutes from when the first resident had been served. 2. Observation on 2/4/19 from 5:40 p.m. through 6:04 p.m. of resident 7's and 27's table revealed an unidentified staff member had been assisting resident 7 throughout the meal. At 6:04 p.m. she wheeled over to resident 27 to help her with her meal. There had been no staff assisting resident 27 prior to that time. Review of resident 7's 11/22/18 Minimum Data Set (MDS) assessment revealed she required extensive assistance from one staff person for eating. Review of resident 27's 1/3/19 MDS assessment revealed she required limited assistance from one staff person for eating. Observation on 2/5/19 from 11:10 a.m. through 12:19 p.m. in the dining revealed: *Residents 7 and 27 sat at the same table. *There was another resident that sat in-between the two of them. *At 11:47 a.m. residents 7 and 27 had been served their food. -There had been no staff present at that table at that time. *At 11:50 a.m. certified nursing assistant (CNA) I was assisting resident 7. -She got up and went over to resident 27 to assist her. -She then returned and sat down with resident 7. --Resident 27 was not eating. *Between 11:50 a.m. and 12:19 p.m. she got up and down five times to assist resident 27. Interview on 2/5/19 at 12:19 p.m. with CNA I revealed: *They considered the table she was assisting the restorative table. *Both residents 7 and 27 required assistance to eat. *Resident 27 fluctuated some days on how much assistance she needed. -Some days she needed complete assistance with eating. *There was never more than one staff member assisting at that table. 3. Review of resident 9's medical record revealed: *He was admitted on [DATE]. *His [DIAGNOSES REDACTED].>-Unspecified intracranial injury with loss of consciousness greater than twenty-four hours without return of pre-existing conscious level. -Other specified intracranial injury without loss of consciousness. -Personal history of [MEDICAL CONDITION]. -Unspecified dysphasia. Review of resident 9's 11/27/18 MDS revealed: *He was totally dependant on one staff person for locomotion on and off the unit. *He required the extensive assistance of one staff member for eating. Review of resident 23's medical record revealed: *She was admitted on [DATE]. *Her [DIAGNOSES REDACTED].>-[MEDICAL CONDITION]. -Dementia. -[MEDICAL CONDITION]. -Hypertension. Review of resident 23's 12/17/18 MDS revealed she was totally dependent on one staff member for locomotion on and off the unit and eating. Observation on 2/4/19 at the following times of residents 9 and 23 at the assisted dining table revealed: *At 5:15 p.m. resident 9 was sitting in the foyer in front of the dining room in his wheelchair. *At 5:32 p.m. supper service began. *At 6:02 p.m. he was brought into the dining room. -He was pushed up to a table where other residents had earlier been assisted to eat their meal. -There were no other residents at the table. -The table had not been cleared and reset for him. *At 6:03 p.m. he was served his meal. *At 6:16 p.m. there were two residents who had not come to the dining room and one required assistance to eat. *At 6:16 p.m. resident 23 was brought into the dining room for supper. -She was pushed up to the same table that resident 9 was sitting at. -The table had not been cleared and reset for her. Interview on 2/4/19 with the certified dietary manager (CDM) and cook A during the above observations revealed residents who required staff assistance at meals were not brought to the dining room until someone was able to assist them. Interview on 2/5/19 at 1:48 p.m. with dietary aides C and D revealed: *Resident's seated at the same table were not served at the same time. *The cook filled meal orders based on the order the meal tickets were received. Interview on 2/5/19 at 2:00 p.m. with cook B revealed residents were served their meals in the order their menus were turned in. Interview on 2/5/19 at 2:05 p.m. with the CDM revealed: *The provider had an open dining concept. *The cooks filled meal orders in the order they were received. *Residents at the same tables were not served their food at the same time. Surveyor: 4. Interview on 2/6/19 at 4:18 p.m. with the director of nursing and the administrator revealed: *They stated they had an open dining concept. *They picked up and served the tickets the way the residents came into the dining room. *That was why residents sitting at the same table were not served at the same time. *They stated resident 27 only needed supervision and had not realized she required limited assistance from one staff member. -There should have been a staff member available to assist her. -CNA I should not have been getting up and leaving one resident to assist another. *Residents 9 and 23 were not able to make the decision when they would come into the dining room. -They relied on staff to help them into the dining room and to eat.

Based on observation, interview, and policy review, the provider failed to ensure infection control practices were followed for: *Appropriate hand hygiene and glove use during catheter care for one of one sampled resident (36). *Covering clean linen during transport during two observations in one of three hallways (200 wing). *Maintenance and storage of resident equipment in a sanitary manner in one of two long-term care shower rooms (400 wing). *Cleanliness of one of two long-term care shower rooms (400 wing). Findings include: 1. Observation on 2/5/19 at 2:15 p.m. revealed certified nursing assistant (CNA) E performing catheter care for resident 36. She washed her hands and put on gloves. With those gloves on she: *Moved a walker out of the way and opened a cupboard door to gather equipment including a brief, towels, soap, washcloths, and a graduate container for measuring urine. *Set those items on a bedside table. *Turned the sink faucet on and got two washcloths wet then shut the faucet off. *Placed those washcloths on two paper towels on the bedside table. *Pulled the electric wheelchair away from the bed. *Pulled the resident's pants and brief down. With those same gloves on she used one soapy washcloth in the following order to wash: *His abdominal fold. *The creases to both sides of his groin. *The catheter insertion site and down the catheter tubing. With those same gloves on she: *Used another soapy washcloth and cleaned the abdominal fold, groin creases, catheter insertion site, and tubing in the same order. *Used a towel to dry the body areas in the same order. CNA E then removed her gloves and washed her hands. She put on a clean pair of gloves and: *Opened a drawer to get powder and powdered the resident's groin. *Pulled up his brief and pants. *Drained the catheter bag into the graduate pitcher. She removed her gloves and put on another pair without washing her hands and: *Cleaned the catheter bag drain with alcohol. *Measured the urine and disposed of it. *Opened a drawer to remove a trash bag. *Placed the powder in the drawer. At that time she: *Removed her gloves and washed her hands. *Gathered the trash bag. *Opened the curtain and left the room. *Had not disinfected the bedside table. Interview on 2/6/19 at 1:10 p.m. with the infection control (IC) nurse regarding resident 36's catheter care revealed CNA E: *Had contaminated her gloves prior to beginning the catheter care. *Should have cleaned around the catheter insertion site first to prevent possible infection from cross-contamination. *Should have washed her hands between dirty and clean areas, and before applying clean gloves. Interview on 2/6/19 at 3:40 p.m. with the director of nursing (DON) confirmed CNA E had not followed appropriate infection control practices for catheter care. Review of the provider's (MONTH) (YEAR) Catheter Care policy revealed the employee was to: *Perform the beginning five. That process was not written in the policy. *Cleanse round the meatus of the the penis, then cleanse for four inches down the catheter, then clean the perineal area with a soapy washcloth and water, and dry the area with a towel. *Empty the drainage bag, Final five. The policy had not specified the directions for hand washing and glove use. Surveyor 2. Observation of linen being passed on 2/5/19 revealed: *At 9:33 a.m. There was a cart of laundry going down the 200 wing hallway. -There were two fleece blankets on top of the cover for the laundry. -The laundry was in a wire basket on wheels. -The laundry was only covered on the top; the sides and the bottom were not covered. *At 11:08 a.m. There was a laundry cart going down the hall. -The laundry was in a wire basket on wheels. -The laundry was only covered on the top; the sides and the bottom were not covered. Surveyor Observation and interview on 2/6/19 at 8:40 a.m. with laundry aide G regarding the laundry process revealed: *She used a rolling cart to transport the residents' clothing back to their rooms after they were washed. That cart was covered on the top, bottom, and sides as she wheeled it down the hall between rooms. *She used as small metal mesh cart to deliver linen including bed sheets and towels for resident use back to the clean linen storage areas. During that delivery: -She covered the top of the cart with a blanket. -The sides and bottom of the mesh cart remained uncovered. *She had a smaller mesh cart that had a plastic bin insert, but stated that cart was too small to carry the linen. *A large covered rolling cart stored the clean linens as she prepared them in the laundry room. -She stated that cart was too large to transport the linen. Interview on 2/6/19 at 11:10 a.m. with the laundry supervisor regarding the uncovered sides and floor of the mesh cart used for transporting linens confirmed: *The provider had not been using a fully covered cart to transfer linen. *All laundry should have been fully covered during transports. Interview on 2/6/19 at 1:20 p.m. with the IC nurse confirmed the linen was to have been covered when transporting it. Review of the provider's (MONTH) (YEAR) Laundering and Drying Clothes and Linens policy revealed: *Proper laundry and drying practices were to have been followed to prevent the spread of potential infectious disease and promote health and well-being of the residents. *Package, transport and store clean clothes and linens to ensure their cleanliness and to reasonably protect them from dust and soil. 3a. Observation on 2/5/19 at 3:00 p.m. of the shower room on the 400 unit revealed: *It had two shower stalls. *The west shower stall contained two commodes and one shower chair. -The shower chair had tan dried residue on the seat. -One commode's lid that covered the bucket had a dried layer of brown residue on it. -The second commode had dried brownish residue in the commode bucket. *The east shower stall contained two commodes. -The back of one commode leaned against a shower chair. A red-bagged (hazardous waste) trash can with a sign labeled dressing had been placed on top of the shower chair. -The second commode leaned against another red-bagged receptacle. --A small plastic table had been placed on top of that trash receptacle. -Unlabeled used boxes had been placed behind that equipment. b. Observation on 2/5/19 at 3:00 p.m. of shower room on the 400 unit revealed: *Two shower stalls. -Both stalls contained resident-use equipment and trash receptacles. --The trash receptacles were not in use. *The room was disheveled. *The floor of the room was unclean with grime and numerous bits of dust and crust. *A wheelchair scale had been placed beside the east shower stall. The floor of that scale had dirt caked on the painted bottom and bits of dust and dirt on the area meant to hold the wheelchair. Observation on 2/6/19 at 8:30 a.m. of the 400 wing shower room revealed the room was unchanged from the above observation. c. Interview on 2/6/19 at 9:30 a.m. with CNA/bath aide F regarding the 400 wing shower room revealed: *The room was not used routinely for showering, but it was used if there were problems with the 200 wing bathing area such as: -If the water temperatures were cold. -If the 200 room had other mechanical issues. *The 400 shower room was going to be used the next week while the 200 room was being remodeled. Interview on 2/6/19 at 11:00 a.m. with the housekeeping supervisor regarding the 400 shower room storage and cleanliness revealed: *She confirmed the room was not clean. *The room was mostly used for storage. *The housekeepers did not clean it. *The DON would be in charge of the room. Interview on 2/6/19 at 1:30 p.m. with the IC nurse regarding the 400 shower room and equipment storage revealed: *She would not know if the equipment stored in the shower room had been cleaned before it was placed in the room. *All resident equipment was to have been cleaned by the nursing staff after the resident had used it. *She stated: -She did not know if the nursing or housekeeping department were in charge of keeping the room clean. -She was not sure if there was a cleaning schedule for that room. Interview on 2/6/19 at 3:40 p.m. with the DON regarding storage and maintenance of the 400 shower room confirmed: *The room was not being cleaned regularly. *The resident equipment was not being stored in a sanitary manner. The DON had not clarified who was responsible for the cleanliness of the shower room. Review of the provider's (MONTH) (YEAR) Environmental Cleaning Principles policy revealed: *Environmental cleaning played an important part in an infection control program. *The spread of infections from contaminated surfaces was significant and supported the need for good procedures and practices related to cleaning and disinfecting. *All staff members played a role in cleaning. *Good communication between the nursing and housekeeping staff members was critical to successful environmental cleaning for the protection of the occupants. Review of the provider's (MONTH) (YEAR) Common Area Cleaning policy and procedure revealed: *Cleaning procedures in common areas was to have been developed and followed with a goal of minimizing the spread of infections. *Keep all common areas clean, neat, and free of litter. *Clean surfaces as often as necessary to keep furniture and equipment free of accumulations of dust, dirt, food particles, etc. *The provider was to have developed a schedule for routine cleaning and deep cleaning common areas and equipment. This surveyor requested but did not receive by the end of the survey a policy specific to equipment storage and maintenance from the IC nurse.

Based on observation, record review, interview, and policy review, the provider failed to offer and document individualized one-to-one activities for 5 of 12 sampled residents (4, 9, 13, 20, and 28). Findings include: 1. Review of resident 9's medical record revealed: *He was admitted on [DATE]. *His [DIAGNOSES REDACTED].>-Unspecified intracranial injury with loss of consciousness greater than twenty-four hours without return of pre-existing conscious level. -Other specified intracranial injury without loss of consciousness. -Personal history of [MEDICAL CONDITION]. -Unspecified dysphasia. Review of resident 9's 11/27/18 Minimum Data Set (MDS) revealed: *He was totally dependent on two staff for: -Bed mobility. -Transfers. -Dressing. -Toileting. -Personal hygiene. *He required extensive assistance of one staff person for locomotion on and off the unit. Review of resident 9's 2/5/19 care plan revealed: *Focus area: The resident is dependent on staff for activities, cognitive stimulation, social interaction R/T (related to) Cognitive deficits, Immobility, Physical limitations EB (evidence by) no wanting to attend activities, not being oriented, not being able to ambulate or get around, needs a wheelchair with help to ambulate. -Goal: Resident will maintain involvement in cognitive stimulation, social activities as desired through review date. Will attend group activities as he chooses. Will receive one to one visits. -Interventions: --Provide 1 to 1 bedside/in-room visits and activities if unable to attend out of room events. --Offer to turn on TV, music in room when resident chooses not to participate in organized activities: 1 to 1 visits about carpentry, electrician skills, and landscaping topics When weather is nice likes to sit outdoors. --Invite and assist him to music groups, parties, movies, readings. --Invite and assist resident to small men's group and visits about things in which he has an interest. Observations at the following times from 2/4/19 through 2/6/19 of resident 9 revealed on: *2/4/19 at 3:15 p.m. he was in bed with the TV on a music channel. *2/4/19 at 4:50 p.m. he was in the common area where activities were held. The TV was on, and no one was interacting with him. *2/5/19 at 9:39 a.m. he was in his bed with the TV on a music channel. *2/5/19 at 11:01 a.m. he was sitting in the foyer in front of the dining room. *2/5/19 at 12:14 p.m. he was sitting in the foyer in front of the dining room. *2/6/19 at 12:55 p.m. he was sitting in the foyer in front of the dining room. *2/6/19 at 1:30 p.m. he was in the common area where actives were held, with the TV on. *2/6/19 at 2:15 p.m. he was at the activity held in the dinning room. Interview on 2/6/19 at 12:55 p.m. with an anonymous staff member about resident 9 revealed: *He sat in his room a lot with the TV on. *He seemed to enjoy watching TV in the common area where other activities were held. *He was gotten up for meals and laid back down after meals. *He did not go many activities due to needing so much assistance. *She didn't feel like residents were included in activities if they could not actively participate in group activities. Interview on 2/6/19 at 1:39 p.m. with certified nursing assistant (CNA) H about resident 9 revealed, He doesn't really do activities. Interview on 2/6/19 at 3:15 p.m with the activities director about resident 9 revealed: *There were only nine one-to-one activities documented from 1/19/18 - 1/25/19. *He attended music activities and movies. *Sensory Stimulation and TV/Radio/iPod were documented as activities and those were when she turned on his TV. 2. Review of resident 13's medical record revealed: *He was admitted on [DATE]. *His [DIAGNOSES REDACTED].>-Personal history of [MEDICAL CONDITION]. -[MEDICAL CONDITION] disorder with psychotic features. -Autism spectrum disorder. Review of resident 13's 1/29/19 MDS revealed: *He was independent for eating. *He needed supervision or cueing from one staff person for: -Bed mobility. -Transferring. -Walking in room. -Walking in corridor. -Locomotion on and off the unit. -Dressing. -Personal hygiene. Review of resident 13's 2/5/19 care plan revealed: *Focus area: The resident has potential for activity deficit R/T depression, [MEDICAL CONDITION] E/B is unable to pursue activity interest, has difficulty initiating stimulation and socialization, chooses to say in his room and sleep on his bed, tells us to get out of his room when we remind him of activities. -Goal: Resident will maintain involvement in cognitive stimulation, social activities as desired through review date. Member of the Lutheran faith. -Interventions: STRENGTH: Resident prefers the following TV programs: Occasionally will sit and watch what is on. Says he has no favorite shows. Hang an activity calendar in his room where he can see it. Observations of resident 13 revealed: *On 2/5/19 at 11:18 a.m. he was sitting outside on a bench with the director of nursing (DON). *On 2/5/19 at 2:00 p.m. he was sitting outside on a bench with the social worker. Interview on 2/6/19 at 3:15 p.m with the activities director about resident 13 revealed: *There isn't going to be much documented because he doesn't come to activities. *He always yells for us to get out when we go to get him for activities. *He has conversations with his brother when his brother comes to visit. *Sensory Stimulation and TV/Radio/iPod were documented as activities, and those were when she turned on his TV or the news before breakfast. *She indicated she just learned he liked to go outside but stated I am not taking him outside until spring. *Her activity assessment indicated he preferred to do things independently, however she had not offered any activities for him in his room, other than TV. 3. Review of resident 20's medical records revealed: *She was admitted on [DATE]. *Her [DIAGNOSES REDACTED].>-[MEDICAL CONDITION]. -Dementia with behavioral disturbances. -Restlessness and agitation. -Hallucinations. Review of resident 20's 12/25/18 MDS revealed: *She required the extensive assistance of two staff members for: -Bed mobility. -Transfers. -Dressing. -Toileting. -Personal hygiene. *She required the extensive assistance of one staff member for locomotion on and off the unit. Review of resident 20's 2/5/19 care plan revealed: *Focus are: The resident has potential for activity deficit R/T dementia, [MEDICAL CONDITION], E/B is unable to pursue activity interest, has difficulty initiating stimulation and socialization. Needs reminding of activities and assist with her wheelchair. -Goal: Resident will maintain involvement in cognitive stimulation, social activities as desired thorough review date. Member of the Lutheran faith. Will attend music groups and parties. -Interventions: --Resident's preferred activities are: Music groups, physical games such as horseshoe. --Offer to turn on TV, music in room when resident chooses not to participate in organized activities: She does watch news and games. --Invite and remind resident of scheduled activities, assisting to and from locations as needed. Observations of resident 20 at the following times on 2/4/19 and 2/6/19 revealed on: *2/4/19 at 2:00 p.m. she was in her recliner with her eyes closed and did not respond to my knock on the door. *2/4/19 at 3:15 p.m. she was in the recliner with her eyes closed. *2/6/19 at 11:04 a.m. she was sitting in her recliner with her feet up and eyes closed. *2/6/19 at 2:15 p.m. she was laying in bed with her eyes closed and blanket on. 2 *2/6/19 at 3:13 p.m. she was laying in bed, her eyes were opened watching TV, and she greeted me when I looked into her room. Interview with the activities director on 2/6/19 at 3:15 p.m. about resident 20 revealed: *She is sick and likes to stay in bed. *Her family visits often. *Physical games were care planned as an enjoyment for the resident although they were not identified on the activity assessment. 4. Review of resident 28's medical record revealed: *He had been admitted on [DATE]. *His [DIAGNOSES REDACTED].>-[MEDICAL CONDITION]. -Unspecified diastolic (congestive) heart failure. -Unspecified [MEDICAL CONDITION]. -Long term use of anti-coagulants. -Long term use of [MEDICAL CONDITION]/antiplatelets. -Type 2 diabetes mellitus without complications. Review of resident 28's 1/6/19 MDS assessment revealed: *His Brief Interview for Mental Status score was fifteen indicating his cognition was intact. *It was very important to him to do the following: -Go outside. -Participate in religious services. *It was somewhat important for him to do the following: -Do his favorite activities. -Keep up with the news. *It was important, but he could not do the following due to his visual impairment: -Having books, newspapers, and magazines to read. Observation on 2/4/19 at 4:00 p.m. of resident 28 revealed he was sitting in his recliner in his room with his eyes closed. He remained sitting in his recliner until he went to supper at 5:30 p.m. Interview on 2/5/19 from 8:30 a.m. through 9:00 a.m. with resident 28 revealed: *He was sitting in his recliner, and his daughter had been visiting. *He did not go out to many activities, because he could not hear or see very well. *It would attend BINGO. *Staff would visit for short amounts of time but did not have any activities for him to do. *He would possibly like someone to read the newspaper to him. *His family had taken the TV out of his room, as he could not hear it very well. *He had never tried a pocket talker to see if he could hear better. -He would be willing to try it though. Review of resident 28's undated care plan revealed there had been no interventions for activities or one-to-one programming. Interview on 2/6/19 at 1:24 p.m. with the activities director regarding resident 28 revealed: *He came out for BINGO, and sometimes he came out for music activities. *She had done room visits but had not documented any of those visits. *His family visited often, and she considered that an activity. -When family visited she would consider that a social activity even though staff were not involved. *She had marked social activity on 1/25/19, 1/28/19, 1/30/19, 1/31/19, and 2/1/19. -She was unsure if any of those included staff visits. *He was going out to a funeral today with his family, and she would mark that as an outing. *She knew he was hard of hearing and had not attempted any interventions such as a pocket talker. Interview on 2/6/19 at 1:49 p.m. with the social service director regarding resident 28 revealed she had not attempted any interventions for his hearing. 5. Review of resident 4's medical record revealed he: *Was admitted on [DATE]. *Was on hospice. *Had [DIAGNOSES REDACTED].>-[MEDICAL CONDITION]'s disease. -Chronic lymphocytic [MEDICAL CONDITION]. -Major [MEDICAL CONDITION]. -Dementia with behavioral disturbance. -[MEDICAL CONDITION]. -Restlessness and agitation. -Anxiety disorder. -History of repeated falls. -[MEDICAL CONDITION] in right eye and low vision in left eye. -Abnormalities of gait and mobility. -Hypertension. - Pain, unspecified. Review of resident 4's 2/5/19 care plan revealed: *Focus area: The resident is dependent on staff for activities, cognitive stimulation, social interaction R/T [MEDICAL CONDITION]'s disease EB cognitive deficits and physical limitations, needs a wheelchair, needs to be watched in w/chair (wheelchair) to prevent falls. -Goals: Resident will maintain involvement in cognitive stimulation, social activities as desired through review date. Resident is a member of the Catholic faith. Resident will receive room visits and enjoy the music and memory program 2x's (two times) a week and when weather permits ride outside. -Interventions: Resident's preferred activities are sitting outside in the wheelchair with staff assistance. Does enjoy listening to (name) music. Room visit and play his favorite songs on his music & memory speaker. Take him to Catholic Services if he agrees. Hang an activity calendar in his room. Room visit and take outside for rides and visit with him. Staff read his weekly letter to him from Hospice and family. Review of resident 4's 1/1/19 through 1/31/19 interdisciplinary progress notes revealed three activity entries made by the activities director: *The 1/11/19 progress note indicated she read him a letter while he listened with his eyes open. *The 1/25/19 progress note indicated a music and memory blue tooth was placed in his room in the a.m. and he appeared to enjoy it. * The 1/28/19 progress note indicated he sat up and listened as she had read him a letter and talked about the person that sent it. No observations of one-to-one activities occurred at any time during the survey from 2/4/19 from 1:15 to 6:45 p.m., 2/5/19 from 7:30 a.m. to 5:00 p.m. and 2/6/19 from 7:30 a.m. to 6:15 p.m. Interview on 2/6/19 at 10:06 a.m. with the activities director regarding resident 4 confirmed: *He was to have one-to-one activities completed two times weekly. *She documented one-to-one activities in the interdisciplinary progress notes. *She had not documented activities consistently. 6. Review of the provider's 8/15/19 policy Implementing the activity program 1:1 (one-to-one) activity intervention revealed: Document the one-to-one program in PCC-P[NAME]. Document the following: activity type, activity topic, and result of 1:1.

Based on observation, record review, interview, and policy review, the provider failed to ensure 4 of 12 sampled residents (9, 13, 20, and 28) had individualized care plans regarding activities. Findings include: 1. Review of resident 28's medical record revealed his undated current care plan had not been updated to include individualized interventions for activities. Refer to F679, finding 4. 2. Review of resident 9's 2/5/19 care plan revealed it was not individualized or person-centered for activities. Refer to F679, finding 1. 3. Review of resident 13's 2/5/19 care plan revealed it was not individualized or person-centered for activities. Refer to F679, finding 2. 4. Review of resident 20's 2/5/19 care plan revealed it was not individualized or person-centered for activities. Refer to F679, finding 3. 5. Review of the provider's (MONTH) (YEAR) Care Plan policy revealed each resident would have an individualized, person-centered, comprehensive plan of care.

Based on observation, interview, record review, and job description review, the provider failed to ensure social service interventions were provided for one of one sampled resident (28) who was grieving several losses, and had hearing and vision problems. Findings include: 1. Review of resident 28's medical record revealed: *He had been admitted on [DATE]. *His [DIAGNOSES REDACTED].>-[MEDICAL CONDITION]. -Unspecified diastolic (congestive) heart failure. -Unspecified [MEDICAL CONDITION]. -Long term use of anti-coagulants. -Long term use of [MEDICAL CONDITION]/antiplatelets. -Type 2 diabetes mellitus without complications. Review of resident 28's 1/6/19 Minimum Data Set assessment revealed: *His Brief Interview for Mental Status score was fifteen indicating his cognition was intact. *He was minimally depressed. Observation on 2/4/19 at 4:00 p.m. of resident 28 revealed he was sitting in his recliner in his room with his eyes closed. He remained sitting in his recliner until he went to supper at 5:30 p.m. Observation and interview on 2/5/19 from 8:30 a.m. through 9:03 a.m. with resident 28 revealed: *Stated he was probably not sleeping yesterday when I stopped in. -He closed his eyes because they hurt, but he seldom napped during the day. *He was hard of hearing and had a visual impairment. *His daughter was visiting. *He liked BINGO but did not participate in many other activities because of his hearing and his vision. *He had never tried a pocket talker to see if he could hear better. -He would be willing to try it though. *Staff would visit for short amounts of time but did not have any activities for him to do. *He would possibly like someone to read the newspaper to him. *They had taken the TV out of his room, as he could not hear it very well. *He stated he enjoyed the visit, and The thirty minute conversation breaks up the monotony of my day. *He had pneumonia recently but was not hospitalized . *His wife passed away a year ago on the 21st of this month. *He stated he was upset with the doctors and became teary eyed. -He attempted to explain the situation that they had not diagnosed [MEDICAL CONDITION]. *He stated he missed her. *He also had a funeral tomorrow and stated it was his last cousin who had passed away. *He stated it was hard being his age, because many people he knew were now gone. Review of resident 28's undated care plan revealed: *Focus area: The resident is grieving R/T (related to) loss of wife and other family members E/B (evidenced by) statements of wishing he had passed away first, tearfulness. -Interventions included: --Describe to resident/family and caregivers the stages of anticipating grieving; initiated on 2/27/18. --Encourage resident to express feelings of anger and concerns as necessary; initiated on 2/27/18. --Assist resident to identify, access and use support systems; initiated on 2/27/18. --Encourage resident to recognize grief situation; initiated on 2/27/18. *Focus area: The resident has depression R/T [DIAGNOSES REDACTED]. -Interventions included: --Discuss with resident/family any concerns, fears, issues regarding health or loss of wife; initiated on 4/6/18. --Discuss resident's feelings relative to loss, unhappiness; initiated on 4/6/18. *Focus area: The resident has a behavior symptom R/T major [MEDICAL CONDITION] E/B statements and thoughts that he would be better off dead, thinking he is a burden on his family, being upset if family doesn't spend time with him when they are here and spending more time with his sister than him. -Interventions included: --Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed; initiated on 9/12/18. --Provide opportunity for positive interaction, attention; initiated on 5/2/18. --Assist resident to develop more appropriate methods of coping and interacting such as visiting with facility SW (social worker), visiting with family, visit other residents in the facility; initiated on 5/2/18. --Educate resident/family on successful coping and interaction strategies such as visiting with resident about family, past job, other activities he enjoys. Provide reassurance that resident is not a burden on his family and that they love him; initiated on 5/2/18. --Attempt non-pharmacological interventions; initiated on 11/13/18. --Consult with pharmacy, health care provider, etc. to consider dosage reduction when clinically appropriate; initiated on 5/2/18. *There had been no interventions for activities or one-to-one programming. Interview on 2/6/19 at 1:24 p.m. with the activities director regarding resident 28 revealed: *He came out for BINGO, and sometimes he came out for music activities. *She had done room visits but had not documented any of those visits. *His family visited often, and she considered that an activity. -When family visited she would consider that a social activity even though staff were not involved. *She had marked social activity on 1/25/19, 1/28/19, 1/30/19, 1/31/19, and 2/1/19. -She was unsure if any of those included staff visits. *He was going out to a funeral today with his family, and she would mark that as an outing. *She knew he was hard of hearing and had not attempted any interventions such as a pocket talker. Interview on 2/6/19 at 1:49 p.m. with the social service director regarding resident 28 revealed: *She knew he got emotional and depressed. *She was not sure what had been on the care plan for interventions. *She visited with him in his room sometimes. *She had not documented any of those visits. *She had not attempted any interventions for his hearing. *She had not made any referrals to any outside agencies. Interview on 2/6/19 at 2:12 p.m. with the director of nursing regarding resident 28 revealed: *He had a lot of loss in the past year. *She knew he had difficulty with the doctors who took care of his wife. *She agreed they should have provided more support and followed through with interventions for him. Review of the provider's 8/17/16 Director of Social Services job description review revealed: *Opportunity: Through essential duties and responsibilities, employees have the opportunity to improve the well-being of those served both directly and indirectly. *Outcome: Employees are held accountable for job performance. Employees are considered effective when those served, including coworkers, feel loved, valued and at peace.

Based on observation, interview, and policy review, the provider failed to ensure sanitary conditions were maintained for: *Overall kitchen cleanliness. *Appropriate storage of food items in one of one walk-in cooler, full-size refrigerator/freezer, and one of one flour bin. *One of one refrigerator/freezer in the main dining room with large amount of dried spills and built-up ice in the freezer compartment. *Three hand hygiene opportunities during two of two observed meals by two of two observed staff (A and B). *One of one dumpster overflowing with garbage and lid had not been closed. Findings include: 1. Observation on 11/6/17 from 4:05 p.m. through 4:20 p.m. in the kitchen revealed: *The main door leading into the kitchen had dried spills running down the front of it. *The hand washing sink had dried dirt around the edges. *The towel dispenser above the hand washing sink was dirty and grimy. *The soap dispenser beside the paper towel dispenser was dirty and grimy. *There were two finger nail brushes laying on the hand washing sink that were dirty. *The garbage can below the hand washing sink had build-up of a moderate amount of dirt and grime on the top and sides. *A large stand-up mixer had dried particles of food on it. *The walk-in cooler: -Had several cardboard ice cream containers that each contained leftover food including: dressings, tartar sauce, and dill pickles. -Had dust, small scraps of paper, and sticky areas on the floor. *The inside of the fullsize refrigerator/freezer had: -Dried on particles of food on the shelves. -Leftover canned fruit stored inside a cardboard ice cream container. *The outside of the full sized refrigerator/freezer had a moderate amount of dried on spills and grime on it. *The outside and inside of the microwave was dirty and grimy. *The large flour bin had a large amount of spilled flour on top of the lid. *The inside and outside of the large commercial stove was dirty and had a moderate amount of dried food particles on it. *On top of the commercial stove was a towel that contained dried stains. -On top of that towel were clean serving utensils, knives, and spatulas. *The convection oven had dried food particles and was dirty and grimy on the inside and outside of it. *Inside of multiple cupboard drawers were old food particles and dirt. *Multiple cupboard doors had dried spills and grime on them. *The outside of the ice machine was dirty. Observation on 11/6/17 from 4:21 p.m. through 4:28 p.m. in the main dining room revealed: *A small dorm size refrigerator/freezer with a moderate amount of old food particles in it. -The freezer had a large build-up of ice in it. *There were several containers of Imperial thickner on the tables. -On the outside of those containers were a large amount of dried on food particles. 2. Observation on 11/6/17 at 4:40 p.m. and again on 11/8/17 at 8:15 a.m. out the west exit door revealed: *A dumpster with a large amount of debris overflowing from the top of it. *The lid had not been shut to the top of that dumpster. 3. Observation on 11/7/17 at 11:25 a.m. in the kitchen with dietary cook A revealed: *She removed several pans of food from the convection oven and placed them onto a two-tiered stainless steel cart. *The cart had a small amount of dried spills on it. 4. Observation on 11/7/17 from 11:35 a.m. through 12:10 p.m. in the dining room during the noon meal with dietary cook A revealed: *She coughed into her right inner arm a total of four times. *Two of those four times she had not completed hand hygiene. *She had continued to serve the meal to the residents. 5. Observation on 11/7/17 at 5:45 p.m. in the dining room during the evening meal with registered nurse (RN) B revealed: *She had been delivering the meal trays to the residents. *She coughed into her left inner arm and without performing hand hygiene continued to deliver a meal tray to a resident. 6. Review of the August through October 2017 registered dietitian (RD) Food Safety and Sanitation Checklists revealed: *August 2017: Recommend getting more containers for storage and not old containers for already completed dish. *September 2017: Recommend buying storage containers. *October 2017: Ice machine needs cleaning on outside. Review of the September through November 7, 2017 kitchen cleaning logs revealed several unsigned areas indicating the cleaning had not been completed. Interview on 11/6/17 at 4:10 p.m. with dietary cook C in the kitchen confirmed left over food was stored in cardboard ice cream containers. Interview on 11/7/17 at 2:40 p.m. in the kitchen with the dietary manager revealed: *He agreed the kitchen was dirty and needed to be cleaned better. *The kitchen staff had not followed the cleaning schedule. *He did not know the cardboard ice cream containers were not made for multi-storage containers for food. Interview on 11/8/17 at 7:30 a.m. with the director of nursing (DON) regarding dietary cook A and RN B regarding performing hand hygiene after coughing into their inner arms revealed her expectations would have been for the two staff to: *Have performed hand hygiene after coughing into their inner arms. *Have performed hand hygiene before proceeding with food service. Interview on 11/8/17 at 7:35 a.m. with the DON and the administrator regarding the dumpster revealed: *The city picked up the garbage. *The garbage was to be picked up two to three times a week. *They had called the city to pick up the garbage. *They did not have a written contract with the city for garbage removal. Interview on 11/8/17 at 8:05 a.m. with the maintanance supervisor regarding the dumpster revealed: *The city picked up the garbage every three days. *He had checked into getting new lids for the dumpster. *He had educated the staff to discard garbage on both sides of the dumpster. Review of the provider's September 2017 Food Storage policy revealed: *Purpose: To ensure that food is stored properly. *Procedure: 6. Foods that have been opened or prepared are placed in an enclosed container, dated and labeled. *The policy had not included any information on what type of containers to have used. Review of the provider's September 2017 Cleaning Schedule policy revealed: *Purpose: -To promote a system that identifies cleaning tasks to be completed. -To provide guidelines to employees for proper cleaning of kitchen immobile equipment, such as refrigerators/freezers. Review of the provider's September 2017 Hand-Washing and Glove Use policy and procedure revealed: *Procedure: Hand-Washing: -When to wash hands: --e. After sneezing, coughing or blowing nose. Review of the in-service on Nutrition in Long Term Care presented by the RD on 6/21/17 revealed: *Foodborne illnesses: Cleaning schedules to be followed. *Dining Room: Not following good handwashing--after sneezing, sneezing into hand, touching nose, hair. Review of the providers's Trash Collection and Waste Removal procedure revealed: *Purpose: To provide procedures for the management of waste removal. *Procedure: -4. Keep all exterior waste containers properly shuta dn secured at all times for rodent control and to prevent trash from escaping the container. -7. Service contracts should allow for adjustments in frequency to ensure timely and adequate removal of waste.

Based on observation, interview, record review, and policy review, the provider failed to ensure ongoing assessments and interventions for safety were in place for one of one sampled resident (9) with a motorized device. Findings include: 1. Observation and interview on 11/7/17 at 6:00 p.m. in resident 9's room revealed: *He had been sitting in his chair. *There was a motorized scooter beside his chair. *He had an artificial prothesis attached to his left knee area. *He confirmed he used the motorized scooter to get around the facility. Review of resident 9's medical record revealed: *A readmission date of [DATE]. *[DIAGNOSES REDACTED]. The 8/24/17 quarterly Minimum Data Set assessment for resident 9 revealed he: *Had a Brief Interview for Mental Status examination score of fifteen indicating he was alert and oriented. *Required extensive assistance of two staff for bed mobility, transfer, and toilet use. *Had not ambulated. *Was independent after set-up assistance with locomotion on and off the unit. *Had upper and lower extremity impairments on both sides. *Used a wheelchair and had a limb prothesis. The 6/15/17 through 10/22/17 nurses progress notes for resident 9 revealed: *6/15/17: He uses a motorized w/c (wheelchair) as primary mode of locomotion as well as LLE (left lower extremity) prosthetic. *7/5/17: Drives motorized wheelchair too fast without slowing down. *8/8/17: Resident uses motorized wheelchair to get around facility. Goes uptown in motorized wheelchair. *8/30/17: CNA (certified nursing assistant) staff reported that around 1030 today, she was outside waiting to hold the door open for (resident's name) as he was outside. While he was driving his motorized w/c and holding a box at the same time, he ran into the left side of an employee's moped that was parked outside. It caused the moped to tip over on it's right side which scratched up the right side of the moped. *10/22/17 Have observed resident multiple times come around a corner in his power chair at a very fast speed without looking to see if anyone was there or coming, has had a few close calls with staff and residents but has not hit anyone. There had been no assessments completed for the use of a motorized device for resident 9. There was not a physician's orders [REDACTED]. Review of the 6/8/17 care plan for resident 9 revealed there was no focus area, goal, or interventions for the use of a motorized device. Interview on 11/8/17 at 9:45 a.m. with the director of nursing (DON) regarding resident 9 revealed: *He had been readmitted on [DATE] after a short stay at home. *He had been readmitted with the motorized scooter. *The motorized scooter had not been care planned for focus area, goals, or interventions for safety. *The motorized scooter should have been care planned. *Physical therapy (PT) or occupational therapy (OT) usually completed the assessments and evaluations for the use of motorized devices. *PT had not completed an assessment or evaluation for the use of a motorized device for the resident. *Motorized device assessments did not have to be done unless they met one of the three criteria that included: --After a safety incident. --At the request of a resident by PT. --Staff observation of a resident who is a high risk for injury or direct threat to self or others. Interview on 11/8/17 at 11:00 a.m. with the DON and administrator regarding resident 9 revealed: *They both agreed an assessment should have been done for the resident to use the motorized scooter. *The resident had met the criteria for an assessment to have been completed for the use of the motorized scooter. *The DON agreed the above should have been care planned. *An incident report had not been completed for the 8/30/17 incident. Review of the provider's April 2016 Motorized Mobility Devices in Skilled Nursing Facilities policy and procedure revealed: *Purpose: To establish procedures for the safe use of motorized mobility devices. *Policy: The safe use of motorized mobility devices will be promoted for residents in rehabilitation/skilled care locations. *Procedure: Staff members are responsible for the following: -Knowing when a motorized mobility assessment is/is not appropriate. -Providing a mobility device assessment once a safety issue has been noted. -After a safety issue has occurred, an order for [REDACTED]. *Development of individualized care plan approaches for the use of a motorized mobility device. Review of the provider's November 2016 Care Plan policy revealed: Each resident will have an individualized, person-centered, comprehensive plan of care that will include measurable goals and timetables directed toward achieving and maintainting the resident's optimal medical, nursing, physical, functional, spiritual, emotional, and psychosocial and educational needs.

Based on record review, interview, job description, and policy review, the provider failed to ensure seven of eight sampled residents (1, 3, 4, 5, 6, 7, and 8) had timely documentation entered into their medical records by the consulting registered dietician (RD). Findings include: 1. Review of resident 3's medical record revealed a revised RD assessment had been completed on 8/25/16. That had been entered into the medical record on 9/13/16. 2. Review of resident 4's medical record revealed an initial RD assessment had been completed on 10/2/15. No other RD assessments were found in the medical record. 3. Review of resident 5's medical record revealed: *RD assessments had been completed on: -4/20/16; That was entered into the medical record on 9/13/16. -5/19/16; That was entered into the medical record on 9/13/16. -6/15/16; That was entered into the medical record on 9/13/16. -7/13/16; That was entered into the medical record on 9/13/16. -8/25/16; That was entered into the medical record on 9/13/16. 4. Review of resident 1's medical record revealed RD assessments had been completed on: *6/15/16. The assessment had been entered into the medical record on 9/13/16. *7/13/16. The assessment had been entered into the medical record on 9/13/16. *8/25/16. The assessment had been entered into the medical record on 9/12/16. 5. Review of resident 8's medical record revealed RD assessments had been completed on: *4/20/16. The assessment had been entered into the medical record on 9/13/16. *5/19/16. The assessment had been entered into the medical record on 9/13/16. *6/15/16. The assessment had been entered into the medical record on 9/13/16. *7/13/16. The assessment had been entered into the medical record on 9/13/16. 6. Review of resident 6's medical record revealed an RD assessment had been completed on 4/20/16. That assessment had not been entered into the medical record until 9/13/16. 7. Review of resident 7's medical record revealed: *RD assessments had been completed on: -4/20/16; That was entered into the medical record on 9/13/16. -6/16/16; That was entered into the medical record on 6/24/16. -7/13/16; That was entered into the medical record on 9/12/16. -8/25/16; That was entered into the medical record on 9/13/16. 8. Interview on 9/14/16 at 10:30 a.m. with the administrator revealed: *He had recently reduced the number of hours the RD was consulting. -He wondered if that had contributed to her not getting her documentation done more timely. *He was unaware the RD documentation was not available in the medical record in a timely manner. *It was his expectation the RD assessments would be put into the medical record when the assessments were completed. Surveyor: Interview on 9/14/16 at 1:15 p.m. with the RD regarding the late entries of nutritional assessments revealed: *She agreed the residents' assessments had not been completed and entered in the medical record at the time the residents had been assessed. *She had been consulting at the facility twice monthly until the current administrator had been hired. Since then her time at the facility had been cut to once monthly. *She spent all her time at the facility in meetings or seeing the residents. *There was not enough time to enter her assessments into the medical record while she was in the facility. *The assessments had been entered into the computer from home. *Her expectation was the assessments should have been entered into the medical record when they were done. Interview on 9/15/16 at 2:30 p.m. with the dietary manager regarding the late entries of RD nutritional assessments revealed:*She was aware the RD nutritional assessments had not been entered into the medical record at the time the residents had been assessed. *The RD had left notes of meetings and some recommendations during her visits. *Her expectation was the RD nutritional assessments would have been completed at the time of the assessments. Surveyor: Review of the provider's February 2013 RD responsibilities policy revealed: *According to the American Dietetic Association Standards of Practice for Registered Dietitians in Nutrition Care, the RD is accountable and responsible for his or her practice and service to the location. *The RD will provide written reports to the location monthly regarding visit activities and recommendations -It is recommended that the Visit Report by Consultant RD and Medical Record Reviewed by Consultant RD be used for this purpose.

A. Based on observation, interview, manufacturer's instructions review, and policy and procedure review, the provider failed to follow manufacturer's instructions for disinfecting one of two whirlpool tubs (100 wing) during one of one observed whirlpool cleaning by certified nursing assistant (CNA) A. Findings include: 1. Observation on 9/13/16 at 9:30 a.m. with CNA A during disinfecting of the whirlpool tub down the 100 wing revealed: *She had: -Added approximately one gallon of pre-mixed disinfectant solution to the foot well of the whirlpool tub. -Added water in the foot well until it covered the water intake. -Turned the air jets on. -Sprayed the interior surfaces of the tub with pre-mixed disinfectant solution. -Scrubbed the interior surfaces of the tub with a brush for less than one minute. *The chair and some of the interior surfaces of the tub had dried at 9:35 a.m., five minutes after being sprayed. *She confirmed those areas were dry. Interview on 9/13/16 at 9:50 a.m. with CNA A revealed she: *Agreed the disinfecting directions on the container of the CLASSIC Whirlpool Disinfectant Cleaner revealed to Wet the surface thoroughly. Allow to remain wet for 10 minutes and then let air dry. *Stated she would not have monitored the whirlpool or chair surfaces to ensure they had remained wet for a ten minute contact time. Interview on 9/14/16 at 2:32 p.m. with the infection control supervisor confirmed: *Their Whirlpool Tub Disinfection policy and procedure did not follow the disinfectant manufacturer's instructions. *CNA A did not follow the correct procedure to disinfect the whirlpool tub according to the disinfectant manufacturer's instructions. Review of the provider's nondated Whirlpool Tub Disinfection policy and procedure revealed to Let disinfectant stay on surfaces for 10 minutes. (Or, as recommended by the instructions on the disinfectant concentrate container.). Review of the CLASSIC Whirlpool Disinfectant Cleaner instructions revealed to Wet all surfaces thoroughly. Allow to remain wet for 10 minutes and then let air dry.

Based on record review, interview, and policy review, the provider failed to ensure one of seven sampled residents (6) on antipsychotic medication had appropriate documentation to support the ongoing use of it. Findings include: 1. Review of resident 6's [DATE] Minimum Data Set (MDS) assessment revealed he: *Scored a 3 on a Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. -He had both long and short term memory loss and impaired decision making. *Was was easily distracted or had difficulty following what was occurring. *Had no hallucinations or delusions. *Had exhibited physical behaviors. -The behaviors had not put the resident or other residents at risk for physical injury. -They did not interfere with the resident's care. *Had not rejected care or wandered. Review of resident 6's physician's orders [REDACTED]. *[MEDICATION NAME] XR 28 milligrams (mg) in the evening for [MEDICAL CONDITION] unspecified; dementia in other diseases classified elsewhere with behavioral disturbance. It was started on [DATE]. *[MEDICATION NAME] tablet 10 mg daily for [MEDICAL CONDITION] unspecified; dementia in other diseases classified elsewhere with behavioral disturbance. It was started on [DATE]. *[MEDICATION NAME] tablet 25 mg daily for unspecified mood disorder. It was started on [DATE]. Review of resident 6's nursing mood/behavior documentation revealed there was behavior documented four times in the past year that included: *[DATE]; He had pushed another resident in wheelchair to get him out of the way and swore at him. *[DATE]; He had gotten up in the late evening claiming he had not eaten supper. Staff attempted to redirect him, but he repeatedly claimed he had not eaten supper. He became upset with staff, and told them to get out of his room. He did not strike out at staff. -There was no documentation he had been offered something to eat or if they had assessed if he was just hungry. *[DATE]; He was confused, and told staff he had seen his wife who was deceased . Staff attempted to redirect him by telling him repeatedly she was deceased . He went up and down hallways into residents' rooms looking for his wife. -There was no documentation they had tried to validate his feelings of missing his wife. [DATE]; He had wheeled his wheelchair backwards 'purposely' and tried to hit another resident. Review of resident 6's pharmacist medication regimen reviews from [DATE] through [DATE] revealed: *[MEDICATION NAME] had been reduced from 50 mg to 25 mg on [DATE]. *[DATE]; This resident has been on [MEDICATION NAME] XR 25 mg, [MEDICATION NAME] 10 mg daily and [MEDICATION NAME] 25 mg daily. Please evaluate the current dose and consider a gradual taper to ensure this resident is using the lowest possible effective optimal dose. -The physician had responded Patient has had good response to treatment and requires this dose for condition stability. Dose reduction is contraindicated because benefits outweigh risks for this patient and a reduction is likely to impair the residents function and or cause psychiatric instability. -On [DATE] the pharmacist stated Resident has a [DIAGNOSES REDACTED]. *No other gradual dose reductions had been recommended. Interview on [DATE] at 10:45 a.m. with registered nurse (RN) D regarding resident 6 revealed: *She did not work a lot of hours at the facility. *She was not aware of any significant behaviors the resident had exhibited. Review of resident 6's 2016 psychological services progress notes revealed: *He had been seen two times per month for the past year. *He received psychotherapy during those visits. *From January through August the risk factors addressed with their occurrence were: -Sexual Acting Out; none. -Aggressive Behavior; none. -Substance Abuse; none. -Suicidal/Self Injury; none. -Homicidal; none. Review of resident 6's psychiatric medication management review for the following dates revealed: *[DATE] - (Resident's name) has had a couple of incidents where he is a little confused and combative. He is now kind of wandering aimlessly into other people's rooms, but I don't think he is causing any harm doing that; it is just happening. *[DATE] - (Resident's name) is very much status quo. He is sleeping well. He's pretty much the I don't know interview when we talk to him. We had attempted to lower his [MEDICATION NAME] a while back and when he got off of that medicine just a little bit it resulted in decompensation. Therefore there is no reason we would discontinue that. He offers up no other complaints. He gets along with his roommate well enough probably because he has known him through the years; a local guy. Interview on [DATE] at 9:00 a.m. with the social services director and director of nursing (DON) regarding resident 6 revealed: *They were unaware of how or when the resident received the [DIAGNOSES REDACTED]. -Neither of them were employed at the facility at that time. *They were unable to find documentation for that diagnosis. *The surveyor offered to speak to the physician if the DON called him, but that was not done. *The DON confirmed the resident might have been started on the medication, and the [DIAGNOSES REDACTED]. -She was unsure. *The DON was unfamiliar with the regulatory guidelines regarding antipsychotic medications. *They confirmed the resident might not exhibit the behaviors to support the medication. -Their behavior documentation would not have supported the use of that medication. *They were unable to find documentation to support when the resident's behavior had decompensated in the past as had been stated above. Review of the provider's [DATE] psychpharmacological medications and sedative/hypnotics policy revealed: *Antipsychotic medications should only have been used for a list of conditions/diagnosis. *For a resident who is receiving an antipsychotic medication to treat behavioral symptoms related to dementia, the gradual dose reduction (GDR) may be clinically contraindicated if: -a.) The resident's target symptoms returned or worsened after the most recent attempt at a GDR. -b.) The physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior. *For a resident receiving an antipsychotic medication to treat a psychiatric disorder, the GDR may be considered contraindicated if: a.) The continued use is in accordance with relevant current standards of practice and the physician has documented the clinical rationale for why any attempted dose reductions would be likely to impair the resident's function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder.

Based on observation, interview, record review, and policy review, the provider failed to assess, develop, and implement interventions for pain management for one of one sampled resident (6) with uncontrolled pain during the residents' care. Findings include: 1. Observation on 10/14/15 at 4:30 p.m. revealed CNAs B and C went into resident 6's room and closed the door. At the above time while in the hallway by resident 6's room he could be heard for a full minute (was timed). He was crying out and yelling that hurts and stop multiple times along with moaning. After knocking on his door permission was gained to enter his room. Observation revealed: *The above CNA's were wiping his bottom to change his briefs in order to transfer him into his wheelchair. *He continued to moan and cry out and was grimacing while they continued with his care. *He stopped once they were done, and he was up in his chair. Interview immediately after the above observation with licensed practical nurse (LPN) D regarding resident 6 revealed: *She was in the hallway outside of the resident's room passing medications. *He had received his scheduled pain medication half an hour before the care started. *He received an extra as-needed (PRN) dose of pain medication that morning before his morning care to help with pain. *He had not received a PRN dose for his recent care to help with his pain. Interview five minutes later with resident 6 revealed when asked Do you hurt?, he replied My behind hurts the worse. Interview the same day at 5:00 p.m. with CNA C regarding resident 6 revealed: *He always screams like that. *When asked what she would do to help with his pain she replied I'm not sure what he gets for pain. Review of resident 6's medical records revealed: *He was admitted on [DATE]. *His [DIAGNOSES REDACTED]. *His last nursing pain assessment was on 8/29/15. *He received a scheduled pain medication three times a day. That was changed from PRN on 10/5/15 due to a pharmacist recommendation. *No further assessments had been found to evaluate the effectiveness of his pain medication. Review of resident 6's 8/2/15 Minimum Data Set assessment regarding pain revealed he: *Received scheduled and PRN pain medication and a non-medical intervention for pain. *Showed pain non-verbally, vocally, and by expression. *Had pain three to four days of the week. Review of resident 6's 10/14/15 care plan revealed: *The resident has potential for pain/discomfort . *Minimize potential of resident behavior problems by modifying pain before cares are given. *Attempt non-pharmacological (medication related) interventions: distraction. *Notify heath care provider if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain. *No specific plan for interventions except for distraction. Interview on 10/15/15 at 10:45 a.m. with the director of nursing services regarding resident 6 revealed: *She confirmed his PRN pain medication was changed to scheduled due to the pharmacist noting the resident was receiving the PRN frequently. No other interventions had been done. *There were no other pain assessments since 8/29/15. *She thought the above observation of the resident's behavior had a lot to do with his dementia. *She agreed residents with dementia could have pain. *She agreed he had no updated assessments to adequately evaluate and treat his pain during care. Review of the provider's September 2012 Pain Management policy revealed all residents would receive interdisciplinary consultations on assistance in managing pain. The registered nurse would review response to medication intervention and work closely with the physician to assist in the individualized pain measurement plan. Review of the provider's September 2015 Pain Data Collection and Assessment procedure revealed: *Purpose: to determine what pain relief interventions that are specific to the resident can be used and established to aide in maintaining a comfortable level of function and quality of life. *Residents identified to be at high risk for pain will be reviewed weekly by the RN (registered nurse) who will also work with the medical provider to update the individualized pain management plan.

Based on observation, record review, interview, and policy review, the provider failed to implement and follow interventions for one of one sampled resident (6) who developed two pressure ulcers (a skin injury caused by unrelieved pressure that resulted in damage to tissue) after admission to the facility. Findings include: 1. Review of resident 6's medical record revealed: *He had been admitted on [DATE]. *He developed a pressure ulcer to his right heel on 8/22/15. -That pressure ulcer was not yet healed. *He developed a pressure ulcer to his left buttock on 10/11/15. Review of resident 6's 7/27/15 Braden Scale for Predicting Pressure Sore Risk assessment revealed: *He had a score of twelve that meant he was at high risk for developing pressure ulcers. *The intervention guide included the following interventions: -Frequent turning with a planned schedule. -Supplement with small shifts in position. -Pressure reduction support surface (chair or bed). -Use foam wedge for 30 degree lateral (on side) positioning. -Maximal remobilization (as much movement as possible). -Protect heels. -Manage moisture. -Manage nutrition. -Manage friction and shear (rubbing against a surface that would cause a skin injury). Review of resident 6's 8/2/15 Minimum Data Set (MDS) assessment revealed: *His thinking ability was severely impaired. *He was at risk for development of pressure ulcers. *Interventions that had been checked as being applied included: -Pressure relieving device in his chair. -Pressure relieving device in his bed. -Turning/Repositioning program. -Nutrition or hydration intervention. -Ulcer care. -Nonsurgical dressing, other than feet. -Ointments/medications, other than feet. *He required extensive assistance of one staff person to eat. Review of resident 6's 8/6/15 care plan revealed: *A focus area stated The resident has pressure unstageable PU (pressure ulcer) on right heel R/T (related to) altered mental status, dehydration, disease process, immobility, incontinence (loss of bowel and bladder control), and poor nutrition. *Interventions had included: -Heel protectors started on 8/23/15. That had been after the development of the pressure ulcer to his heel. -Resident has air mattress on bed and cushion in wheelchair for pressure relief. an order for [REDACTED]. *A focus area of limited physical mobility with an intervention to turn and reposition every two hours. *A focus area for nutrition with an intervention of Offer additional 1-2 oz (ounce) of protein each meal. Offer 2 cal (protein supplement) BID (two times per day) due to open areas. That had been initiated on 9/14/15. That had been after the development of the pressure ulcer to the heel. *There were two interventions for eating that were contradictory. -One stated Resident requires hand over hand, reminding, prompting, cueing, assistance to eat. -The other intervention stated Provide supervision/observation, and assistance at meals. -This second intervention had not accurately reflected the MDS assessment. Observations on 10/14/15 throughout the day revealed staff had not provided extensive assistance of one person to resident 6 during meal times. Refer to F280. Observations on 10/14/15 from 7:55 a.m. through 12:30 p.m. of resident 6 revealed: *At 7:55 a.m. he had been in the dining room in his wheelchair (w/c). *At 8:50 a.m. he was still at the table in the dining room in his w/c. *At 9:15 a.m. he had been taken in his w/c into the dayroom to watch a movie. *At 9:50 a.m. he remained in the dayroom in his w/c. *At 10:30 a.m. he was still in the dayroom in his w/c. *At 10:40 a.m. he was still in the dayroom in his w/c. *At 11:30 a.m. he had been moved in his w/c to the front lobby to wait for lunch. *At 11:52 a.m. he was moved to his table and served food. *At 12:30 p.m. he was still in the dining room. *He had not been repositioned during the above observations. Review of resident 6's medical record revealed he developed a pressure ulcer to his left buttock on 10/11/15. There had been a fax sent to the physician on 10/11/15 requesting treatment. The physician had not answered the fax regarding the treatment. On 10/11/15 staff had applied DuoDerm (specific type) dressing without a physician's orders [REDACTED].>Interview on 10/14/15 at 9:00 a.m. with licensed practical nurse D regarding resident 6 revealed they were still waiting on the physician's orders [REDACTED]. Interview and record review on 10/14/15 from 4:00 p.m. through 4:45 p.m. with the director of nursing (DON) regarding resident 6 revealed: *Staff had not received a physician's orders [REDACTED]. *They should have called the on-call physician on 10/11/15 to get the order. *She thought DuoDerm might have been on the standing orders signed by the physician. Review of the standing orders for resident 6 revealed it was not part of those orders. *The MDS assessment was accurate, and he should have had staff assisting him with his meals. *She stated he was admitted on [DATE] and had been at a table with no staff assistance. They noticed he was not eating very well and moved him to a table with staff assistance for that reason. *He had a weight loss during that period of time and that was when they added the supplement. *She had not implemented a repositioning schedule for resident 6. *The orders for the heel protector and air mattress had been obtained after the development of the first pressure ulcer. *She could not recall if there had been an air mattress on his bed prior to the 8/21/15 physician's orders [REDACTED].>*They had not implemented the interventions suggested prior to the development of the first pressure ulcer. Interview on 10/15/15 at 12:30 p.m. with the DON revealed she had reviewed the pressure ulcer information for resident 6. She had found on 9/24/15 they had changed the treatment to the heel. There had not been any other changes. Review of the provider's July 2015 Physician/Practitioner Orders policy revealed Orders must be obtained for wound care including product to be used, when to change and when to reassess. Review of the provider's September 2012 Pressure Ulcer policy revealed the center would use prevention and assessment interventions to ensure that a resident who entered the facility without a pressure ulcer would not develop a pressure ulcer.

Based on observation, interview, and manufacturer's information review, the provider failed to ensure proper disinfection was done for one of one whirlpool bathtub on the 200 wing by one of one bath aide (A). Findings include: 1. Observation and interview on 10/14/15 at 9:10 a.m. of bath aide A cleaning the residents' Cascade whirlpool bathtub revealed she: *Had been in that position for a year. *Had rinsed the inside of the tub and placed the drain plug over the drain. *Pushed the button to add the disinfectant to the bathtub. *Added water until it was three-fourths full and started the air jets. *Scrubbed the interior surfaces then turned off the air jets. *Drained the bathtub then rinsed it with water. *Would leave the disinfectant on for a minute or so before rinsing. Review of the undated Cascade whirlpool tub cleaning information revealed: *'Release the disinfectant button after you see solution coming out of all the air jets and you have one to one and one half gallons of disinfectant solution in the foot well of the tub. -There was no mention of adding water to the bathtub and disinfectant solution as was done above. * Thoroughly scrub all interior surfaces of the tub and chair with the disinfectant solution. Let disinfectant stay on the surface for 10 minutes. *'Remove the plug from the drain. *Rinse the tub's interior surfaces thoroughly with the shower sprayer. *Press and hold the Rinse button located on the control panel until clear water runs from all the air jets. Then release the Rinse button. *Finish rinsing the interior surfaces of the tub with the shower sprayer. *Start the air blower by pushing the Aqua-Aire button. Allow it to run for 30 seconds. This pushes the rinse water out of the air injection system. Interview on 10/15/15 at 12:00 noon with the infection control nurse revealed she agreed bath aide A should not have added water to the disinfectant, did not leave it on long enough to properly disinfect the bathtub, nor ran the jets at the correct time to clean and remove the solution.

Based on record review, interview, and policy review, the provider failed to obtain a physician's order for a pressure ulcer (a sore caused by unrelieved pressure that resulted in damage to tissue) treatment for one of two sampled residents (6) with a pressure ulcer. Findings include: 1. Review of resident 6's medical record revealed he developed a pressure ulcer to his left buttock on 10/11/15. There had been a fax sent to the physician on 10/11/15 requesting treatment. The physician had not answered the fax regarding the treatment. On 10/11/15 staff had applied a DuoDerm (specific type) dressing without a physician's order. Interview on 10/14/15 at 9:00 a.m. with licensed practical nurse D regarding resident 6 revealed they were still waiting on the physician's order for the type of pressure ulcer treatment to use. Interview and record review on 10/14/15 from 4:00 p.m. through 4:45 p.m. with the director of nursing regarding resident 6 revealed staff had not received a physician's order for the DuoDerm dressing treatment for the pressure ulcer. They should have called the on-call physician on 10/11/15 to get the order. She thought DuoDerm might have been on the standing orders signed by the physician. Review of the standing orders for resident 6 revealed it was not part of those orders. Review of the provider's July 2015 Physician/Practitioner Orders policy revealed Orders must be obtained for wound care including product to be used, when to change and when to reassess.

Based on observation, record review, interview, and policy review, the provider failed to follow, update, and/or revise care plans for two of three sampled residents (6 and 8) who needed extensive assistance of one staff person. Findings include: 1. Review of resident 6's 8/2/15 Minimum Data Set (MDS) assessment revealed he required extensive assistance of one staff person to eat. His thinking ability was severely impaired. Review of resident 6's 8/6/15 care plan revealed there were two interventions for eating that were contradictory. One stated Resident requires hand over hand, reminding, prompting, cueing, assistance to eat. The other intervention stated Provide supervision/observation, and assistance at meals. The second intervention had not accurately reflected the above MDS assessment. Observation on 10/14/15 at 7:55 a.m. of resident 6 revealed he was at the dining table for breakfast. He had scrambled eggs, bacon, an English muffin with jam, and cheerios in milk. He was attempting to eat on his own but was struggling with picking up the silverware and food. He was very shaky. He had attempted several times to pick up the English muffin but was unable to pick it up. At 8:15 a.m. an unidentified certified nursing assistant (CNA) who had been assisting another resident at the same table sat next to resident 6 and fed him two bites. He ate them very well. She then got up and returned to help the other resident. She did not return to assist resident 6. At 8:50 a.m. he was still at the table attempting to eat without assistance. He had eaten a few bites of the cheerios and drank some of his beverages. Observation on 10/14/15 from 11:52 a.m. through 12:30 p.m. of resident 6 revealed he was in the dining room for lunch. He had been served spaghetti. There had been one staff person at the table to assist two other residents. He pushed away from the table and did not want to eat. The CNA at the table had not attempted to get him to return to eat. Observation on 10/14/15 from 5:45 p.m. through 6:40 p.m. of resident 6 revealed he was in the dining room for supper. He had been pushed up to the table and stated Back me out I don't want anything. He continued to attempt to give his food away to another resident at the table. CNA B had been at the table assisting two other residents. She had not spoken to resident 6 during that timeframe. He was attempting to drink his beverages. He was able to drink a few sips of his beverages but had not eaten anything. During the above observations the staff had not provided extensive assistance of one person as indicated on the 8/2/15 MDS. Interview on 10/14/15 from 4:00 p.m. through 4:45 p.m. with the director of nursing (DON) regarding resident 6 revealed the MDS assessment was accurate. He should have had staff assisting him with his meals. She stated he was admitted on [DATE] and had been at a table with no staff assistance. They noticed he was not eating very well and had moved him to a table with staff assistance for that reason. He had weight loss but they had added a supplement to his diet. The supplement had helped with the weight loss. 2. Review of resident 8's 8/27/15 MDS assessment revealed he required extensive assistance of one staff person to eat. Review of resident 8's 8/27/15 care plan revealed there were two interventions for eating. One intervention had been Resident is able to hold cup, feed self, eat finger foods, etc (and so forth) .independently, needs cueing and assist at times. The second intervention stated Provide supervision/observation, assistance at meals. Assist with set up help and remind resident to eat slowly. Those interventions had not accurately reflected the above MDS assessment. Observation on 10/14/15 at 7:55 a.m. and at 11:52 a.m. revealed resident 8 had one staff person assisting him with his meals. Observation on 10/14/15 at 5:45 p.m. of resident 8 revealed he did not have a staff person assisting him with his meal. He was able to eat with his fingers but ate in a hurry. Interview on 10/14/15 at 6:15 p.m. with CNA B regarding resident 8 revealed he did not need staff assistance and ate on his own. Interview on 10/15/15 at 3:30 p.m. with the DON regarding resident 8 revealed he sometimes could eat on his own, but staff should still have been there to assist him. 3. Review of the provider's August 2015 Comprehensive Care Plan and Care Conferences policy revealed the care plan should have been driven by identified resident issues/conditions and their unique characteristics, strengths, and needs. The interventions should have been individualized and realistic. They should have identified specifically what staff would do for the resident.

Based on observation, interview, product label review, and policy review, the provider failed to ensure: *Multiple use items (nail clippers and curlers) had been cleaned and disinfected between resident use in one of one beauty shop and one of one whirlpool tub room. *Resident care items (hair products) had been stored in a clean and sanitary manner in one of one beauty shop resulting in the potential for cross-contamination and infection. *A blood glucose (sugar) meter had been disinfected after registered nurse RN (B) checked one of one randomly observed resident's (11) blood sugar. Findings include: 1. Random observations on 8/26/14 through 8/27/14 in the whirlpool tub room and the beauty shop revealed: *Nail clippers were stored in a small plastic bin that had nail trimmings and debris both on the nippers and the bottom of the plastic bin. *Beauty shop curlers were found with large amounts of hair present and debris on them. *Resident care items (shampoos, conditioners, hair spray) had been stored behind the sink in a built-in hinged cupboard with a lid. The cupboard: -Was found to have large amounts of debris and hair in amongst the bottles. -The hinges were rusty, and the lid and cupboard were visibly dirty with hair and debris on them. Interview on 8/26/14 at 1:30 p.m. in the beauty shop with licensed beautician A revealed she: *Had not disinfected the hair curlers in between resident use. She estimated nine of twenty residents who received her services used the curlers. *Would clean the curlers on average once per month to once every two months. *Stored various resident use items in the built-in hinged cupboard behind the sink. *Was unaware who cleaned that cupboard. *Agreed the cupboard and the lid had been visibly soiled with hair and debris, and the hinges were quite rusty. *Was unaware she needed to disinfect curlers between resident use. Interview on 8/27/14 at 3:00 p.m. with the infection control coordinator revealed she: *Agreed multiple use items needed to be cleaned and disinfected between resident use. *Was unaware resident care items were stored in the cupboard behind the sink. *Expected the licensed beautician would be responsible for the cleaning of the multiple use items and the cupboard behind the sink. *Was unaware nail clippers had not been cleaned and expected those would also be cleaned and disinfected between resident use. Review of the provider's June 2012 Center Beauty Shops policy revealed all equipment must be sanitized between each resident use. 2. Observation and interview on 8/26/14 at 5:25 p.m. with registered nurse B while she checked resident 11's blood sugar revealed she: *Went into the residents room and obtained her blood sugar. *Brought the glucose meter to her medication cart that had been in the hallway. *Wiped the glucose meter with a Super-sani cloth for 5-10 seconds. *Put the glucose meter back into her medication cart. *Confirmed the blood glucose meter had been a multiple resident use item. Review of the Super-sani cloth label revealed the treated surface must remain visibly wet for two minutes. Use additional wipes to ensure continuous two minute wet contact time. Interview on 8/27/14 at 3:50 p.m. with the director of nursing revealed she would have expected the blood glucose meter to have been disinfected after each use. Review of the provider's Cleaning and Disinfecting Blood Glucose Meters policy/procedure revealed: *"It is preferable that each resident has his/her own glucose meter." *"After disinfecting is complete, using any of the methods listed above, the meter should be left for a few minutes to ensure it is dry."

Based on record review, interview, and policy review, the provider failed to ensure necessary care and services were provided to one of one sampled resident (10) who sustained an injury after a fall. Findings include: 1. Review of resident 10's physician's visit documentation on 5/1/12 revealed he: *Had a [DIAGNOSES REDACTED]. *Had been placed on hospice care on 3/16/12 for dementia, decline in activities of daily living, debilitation, [MEDICAL CONDITION], recent hospitalization , and hematuria (blood in the urine). Review of resident 10's Interdisciplinary notes revealed: *He had a fall on 5/18/12 at 10:50 p.m. *From 5/18/12 at 11:00 p.m. through 5/19/12 at 7:00 a.m. the only documentation had been "Occurrence report." *He fell out of bed and had been found lying face down on the floor on the left side of the bed, the fall mat was on the right side of the bed. -A neurological assessment had been initiated (assessment done after a head injury that includes vital signs, level of consciousness, how pupils react to light, and if they are equal in size). *There was no documentation the physician had been verbally notified. *There was no documentation hospice had been notified. *Further review of resident 10's interdisciplinary notes revealed: *On 5/19/12 from 11:00 p.m. through 7:00 a.m. "Occurrence report." *On 5/19/12 the following entries had been made: - 7:30 a.m."Resident R (right) and L (left) eye are bruised -steri strips intact but dry blood under them. [MEDICATION NAME] x (times) 2 this shift for comfort-did settle into sleep after 4 am -is resting now. 02 (oxygen) on per n/c (nasal cannula) but does not take this off. Will eat breakfast in bed - monitor wakefulness to rise later." -11:00 a.m."Neuro check et.(and) vs (vital signs) taken et. recorded. Is lethargic but responds by opening eyes when spoken to. Resting quietly-appears comfortable. B/P 170/80 R (respirations) 28. Did not eat breakfast. Repositioned et. mouth care every 2 hours." -12:40 p.m. "B/P 99/66 P (pulse) 135, 02 sat(saturation) (monitors the oxygen in blood) 60% (normal 02 saturation is kept above 90%) R 32. Skin cool et. clammy with some mottling noted in abdominal area. 02 mask applied. [MEDICATION NAME] given. Daughter-in-law notified of change in condition et. she will notify the rest of the family. Hospice notified of condition change also." -12:45 p.m. "02 increased to 4L (liters)/min. (minute) via mask-02 sat 65." -1:15 p.m. "Daughter-in-law ___ and granddaughter here @ (at) bedside. Resident turned et. repositioned. Skin cool et. clammy. Body flaccid (limp) et. resident is not responding to stimuli. Color pale. R 24." -2:25 p.m. "Attempted to check B/P with no reading. Respirations absent et. no heart beat auscultated (he had no heart beat). Daughter-in-law__ et. granddaughter @ bed side.___ stated she would notify the rest of the family." -2:30 p.m."On call ER (emergency room ) PA (physician assistant) notified of death. T.O (telephone order) received et. noted to release body to funeral home. Dr._____(the residents physician) faxed to notify of death." Review of the facsimile (fax) communication to resident 10's physician revealed: * On 5/19/2 at 3:14 a.m. the physician was notified by the nurse regarding the fall. *That was over four hours after the fall. *The nurse had described the incident as the following: "Found face down on floor 5/18/12 at 10:50 p.m. 1 centimeter (cm) laceration over right eye-cleansed-steri strips-0.25 cm bridge of nose laceration-cleaned and steri-striped-neuro's started, ice bag to forehead area - right eye bruising." *The directions on the top right of the flow sheet revealed: *Neuro-checks were to be performed with the following minimum frequency according to the directions on the neuro-check flow sheet: -Day 1: Every thirty minutes for four times then every shift. -Day 2: Every shift. -Day 3: Every shift or more frequently as directed by a physician. Review of resident 10's Neuro-Check flow sheet revealed: *On 5/18/12 neuro's had been done at 11:30 p.m., and 11:45 p.m. *On 5/19/12 neuro's had been done at 12:45 a.m., 1:45 a.m., 3:45 a.m., 9:30 a.m., 10:45 a.m., 12:30 p.m., and 1:45 p.m. *On 5/19/12 at 9:30 a.m. the resident's blood pressure (B/P) was 160/60, the pulse was 100 beats per minute, and respirations had been 24 per minute. The resident's level of consciousness had been alert and had followed commands. *On 5/19/12 at 10:45 a.m. the residents B/P was 180/80, the pulse was 120 beats per minute, respirations had been 24 per minute, the resident was alert and had followed commands. *On 5/19/12 at 12:30 p.m. the residents B/P was 99/66, the pulse was 135 beats per minute, respirations had been 32 per minute, the resident had become lethargic and drowsy but had awakened to stimuli. *On 5/19/12 at 1:45 p.m. the resident's B/P was 93/49. the pulse was 136 beats per minute, respirations were 32 per minute, he was in a coma, unresponsive, and could not be aroused. He did not open his eyes or speak. Review of the Required Nursing Facility Event Report revealed: *The director of nursing (DON) had concluded her investigation of resident 10's fall and death. *The report had been written by the DON as follows:"Conclusion of investigation resident was on hospice and had a fall from a low bed. Resident has been on steady decline for several months. Interviews with staff support care provided within the facilities policy and procedure. All staff providing care interviewed. Although on hospice, facility found physician was not contacted timely and disciplinary action was filed to the staff involved. Family satisfied with care provided to their family member." Interview on 7/11/12 at 9:50 a.m. with the administrator and the licensed practical nurse/health information manager revealed: *The nurse had failed to inform the medical doctor in a timely manner. *The documentation by the nurses was not complete. *If there was no documentation the care had not been done. *The nurse should have notified the physician by phone to ensure the resident's immediate needs had been taken care of. *Hospice should have been notified after the fall and injury of resident 10. *She felt there had been a misconception about resident 10's care, because he had been on hospice. Review of the provider's March 2011 Neurological Evaluation procedure revealed: *The purpose of the policy was to establish a baseline neurological status upon which subsequent evaluations may be compared and changes in neurological status may be determined following an un-witnessed fall (when a head injury may be suspected). *Notify the physician of the event, the initial findings, and baseline neurological evaluation. Review of the provider's February 2005 Notification of Change in Resident Status policy revealed: *It was to ensure the appropriate notification of change in resident's status. *The center would immediately inform the resident, if appropriate (except in a medical emergency or when resident was incompetent), and consult with the resident's physician and if known, notify the resident's family or legal representative in the following cases: -Resident accident which results in injury with a potential for requiring physician intervention. -Significant change in the resident's physical, mental or psychosocial status. -Need to alter treatment significantly. -Decision to transfer or discharge the resident from the center. Review of the provider's January 2009 Documentation policy revealed: *The purpose was to provide appropriate documentation expectations. *All documentation was expected to be legible, accurate, understandable, timely, and pertinent, and held in confidence. *Frequency of the documentation would be determined depending on the condition of the resident. Review of the provider's September 2010 Nursing Documentation Guidelines/ Timelines policy revealed the purpose was to ensure appropriate documentation was completed in a timely manner.