Every finding on record at Good Samaritan Society - Howard Lake

Based on observation and interview, the facility failed to ensure staff implemented infection prevention practices by offering assistance, encouragement, or reminders for residents to sanitize their hands prior to dining. This had the potential to affect all residents eating in the dining room.Findings include:During observation of the dining room on 02/10/2026 at 4:35 p.m., residents were seated at tables where containers of Sani-Hands hand sanitizing wipes were visibly placed in the center of each table. Residents proceeded to eat their meals without staff offering assistance, reminders, or encouragement to sanitize their hands prior to eating. No staff were observed directing residents to the hand sanitizer or assisting residents who required cues or assistance due to physical or cognitive limitations. During observation of the dining room on 02/11/2026 at 4:37 p.m., residents were seated at tables where containers of Sani-Hands hand sanitizing wipes were visibly placed in the center of each table. Residents again proceeded to eat their meals without staff offering assistance, reminders, or encouragement to sanitize their hands prior to eating. No staff were observed directing residents to the hand sanitizer or assisting residents who required cues or assistance due to physical or cognitive limitations. During interview on 02/10/2026 at 6:26 p.m., Dietary Aide (DA)-A stated the sanitizing wipes placed on dining room tables were intended to be used at every meal and residents typically sanitized their hands independently. Dining room staff or the staff who assisted residents into the dining room were responsible for assisting dependent residents with hand sanitization. DA-A did not offer reminders or provide assistance to any residents with hand sanitization during the evening meal. During interview on 02/10/2026 at 6:32 p.m., Cook-A stated the sanitizing wipes placed on dining room tables were for resident use. Independent residents were expected to sanitize their hands independently and dependent residents received staff assistance. Cook-A stated nursing assistants were expected to assist residents who required help with hand sanitization. Cook-A further stated hand sanitization should have occurred prior to the meal, as the meal primarily consisted of finger foods and residents were using their hands to eat. During interview on 02/11/2026 at 4:55 p.m., nursing assistant (NA)-B stated she did not assist any residents with hand sanitization prior to the meal. NA-B stated assisting residents with hand sanitizing was the responsibility of all staff. During interview on 02/11/2026 at 12:04 p.m., NA-A stated it was the responsibility of the staff who assisted residents into the dining room to assist residents or provide reminders to use sanitizing wipes before and after meals. During interview on 02/12/2026 at 1:30 p.m., the dietary manager (DM) stated staff were expected to encourage residents to use hand sanitizing wipes prior to meals. Hand sanitization should have occurred for infection prevention purposes, particularly when meals included finger foods. A facility infection prevention and control policy related to hand hygiene during meals was requested but was not received.

Based on observation, record review and interview, the facility failed to ensure food and beverages were handled and served in a sanitary manner to prevent contamination for residents receiving meals in the dining room. Additionally, the facility failed to consistently monitor dishwasher temperatures for rinse cycles and take timely action to correct the process to assure temperatures were within the desired range for the rinse cycle for 1 of 1 dishwashers observed. This had the potential to affect all 28 current residents, as well as staff, who ate food served from dishes and tableware that were cleaned in the dishwasher. Further more, the facility failed to ensure proper measures were implemented with meal preparation to ensure food was handled and prepared for service in a sanitary manner to prevent contamination of food products. This had the potential to affect residents, guests, and staff receiving meals served from the kitchen.Findings include: During observation of the evening meal service on 02/10/26 at 4:35 p.m., dietary aide (DA)-A was observed delivering beverages to multiple residents in the dining room without wearing gloves. DA-A was observed entering and exiting the kitchen, multiple times, to obtain beverages for individual residents and was observed touching the kitchen keypad and door handle during each entry and exit DA-A was also observed touching dining room tabletops, counters, water pitchers, and the ice machine between beverage deliveries without performing hand hygiene. While carrying the beverages, DA-A was observed placing bare fingers around the rim of multiple Cook-A was observed transporting four plated meals at one time from the kitchen to the dining area without wearing gloves. Two of the plates were observed in direct contact with the cook's shirt while being carried. The plates were subsequently served to residents without being re-plated or discarded. During observation of the evening meal service on 02/11/26 at 4:37 p.m., DA-B was observed delivering beverages to multiple residents in the dining room without wearing gloves. DA-B was observed multiple times entering and exiting the kitchen to obtain beverages for individual residents and was observed touching the kitchen keypad and door handle during each entry and exit. DA-B was also observed touching dining room tabletops, counters, water pitchers, and the ice machine between beverage deliveries without performing hand hygiene. While carrying the beverages, DA-B was observed placing bare fingers around the rim of multiple drinking glasses, directly contacting the area where residents' mouths contact during consumption. The beverages were delivered directly to residents without corrective action, hand hygiene, or replacement of the glasses. During an interview on 02/10/26 at 6:26 p.m., DA-A stated she prepared beverages individually as residents arrived in the dining room and delivered the drinks to residents. DA-A stated she did not wear personal protective equipment (PPE), including gloves, when delivering beverages. DA-A confirmed her fingers contacted the rim of the drinking glasses in the area where residents' lips contact during consumption. DA-A stated gloves should be worn during beverage service due to the potential for cross-contamination when assisting multiple residents during meal service. During an interview on 02/10/26 at 6:32 p.m., Cook-A stated he typically served meals by carrying multiple plates at one time. Cook-A confirmed he carried four plates simultaneously, with some plates resting against his shirt on his chest and stomach. The cook stated he usually wore gloves during meal service but confirmed he was not wearing gloves at the time of observation and acknowledged gloves should have been worn. During an interview on 02/12/26 at 1:30 p.m., the dietary manager (DM) stated staff did not routinely wear gloves when delivering food and beverages. The DM stated staff should not touch the tops or rims of drinking glasses due to the risk of contaminating food contact surfaces. The DM stated plates should not contact staff clothing during service due to the risk of contamination. Staff were expected to use gloves during meal service and that glove use was encouraged. Review of the facility's Hand Washing and Glove Use – Food and Nutrition Services policy, dated 06/06/25, indicated the facility provided guidelines regarding hand hygiene and glove use to reduce the risk of cross-contamination when serving highly susceptible populations. The policy indicated employees were not to touch food with bare hands and were to use proper utensils, including tissue, spatulas, tongs, or single-use gloves, when handling food. The policy further indicated employees involved in food preparation, distribution, and service were required to consistently utilize proper hygienic practices and techniques. Dishwasher On 2/9/26 at 7:11 a.m. an initial tour and interviews were completed. The dishwashing area was observed with cook-B. Cook-B stated the current dishwasher was a steam dishwasher and was temperature based, with the wash temperature to be at 150 degrees Fahrenheit (F), and rinse cycle at a temperature of 180 degrees Fahrenheit. A review of the February temperature log of both wash and rinse cycles temperatures was completed and were noted to have been consistently tracked. All temperatures were noted to be within the desired range, except for the following dates on the morning shift: 2/1/26 morning rinse cycle of 170 degrees F.; 2/4/26 morning rinse cycle of 174 degrees F.; and on 2/5/26 morning rinse cycle of 175 degrees F. Cook-B stated when she worked, she would run loads through when completing morning prep. Cook-B stated when this occurred, she would advise the dietary manager (DM)-A. Cook-B stated she had been informed to run additional racks through at that time to bring the temperatures up by DM-A. [NAME] B stated she was unaware to run racks through prior to checking the temperatures to ensure the temperature was at the desired temperature. The January temperature log was reviewed, and it was noted to have been completed on 30 of 31 days. A review of the temperature entries indicated the temperatures were within the desired temperature range for both wash and rinse cycles, with the exception of 10 of the 30 morning rinse temperatures being below 180 degrees F., with the range of those temperatures being between 170-179 degrees F. During interview on 2/12/26 at 10:18 a.m., the contracted service technician (CST)-A was working on the dishwasher. CST-A stated the temperature of the water in the rinse cycle needed to get up to 180 degrees to achieve the desired surface temp of 160 degrees F. CST-A stated a secondary test, using either a temperature strip or lollipop thermometer should be used periodically to assure the accuracy of the dishwasher thermometer. On 2/12/26 at 10:41 a.m., DM-A stated when monitoring temperatures, they had both temperature strips and the lollipop thermometer available for comparison to assure dishwashing machine thermometers remained accurate. DM-A stated it was important to ensure the dishwasher was at the appropriate temperature to prevent illness in residents. DM-A went on to state The high temperature is used to kill the bacteria and germs. The facility policy, titled Warewashing- [sic] Mechanical and Manual-Food and Nutrition, last reviewed 3/27/25, identified Warewashing [sic]means the cleaning and sanitization of utensils and food-contact surfaces of equipment. The policy outlines for staff the wash and rinse cycles are to be monitored and recorded on the Dish Machine Temperature Log. The policy directs staff if temperatures are outside acceptable parameters, employees notify the director of food and nutrition services (DFN) before proceeding with ware washing. The documentation provided by the Dishmachine [sic] Rental Program, provided by the facility, outlines the minimum temperature of the water for wash was 150 degrees F., and the minimum rinse cycle temperature was 180 degrees F. Meal Prep During observation and interview on 2/12/26 at 10:24 a.m., cook-C was observed during meal prep. Cook-C was observed to have hairnet/restraint in place; however, bangs were noted to be outside of the restraint of the hairnet. After washing her hands with soap and water, cook-C proceeded to set up strawberry ice cream for dessert. Cook-C removed the cover off of the large round container of strawberry ice cream. Cook-C placed a disposable glove on her right hand and picked up the ice cream scoop. Cook-C used her right hand to scoop the ice cream from the container, while resting her left hand on the edge of the ice cream container. Once the ice cream was scooped, cook-C used her ungloved hand to hold onto the dish and placed a scoop of ice cream in each dish. While securing the container of the ice cream, when the ice cream required more effort to scoop, cook-C's pointer finger was observed to slide down into the container. While scooping with the right, gloved, hand, cook-C was observed to roll the scoop up the side of the container where ungloved finger had been resting. Cook-C was observed to use a paper towel to wipe off her left hand on one occasion while scooping the ice cream. Once ice cream was served, it was covered with saran wrap and placed in the freezer. Cook-C was then observed to remove her right glove, and disposed of it into the garbage can, and wash her hands. Upon completion of task on 2/12/26 10:38 a.m., cook-C was interviewed about use of only one glove. Cook-C stated it would be preferable to wear gloves on both hands and was unsure why she had only put on one glove. Cook-C stated hairnets are used to prevent hair from going into the food served to others. Cook-C stated she normally had all hair contained in hairnet and stated hairnet seemed to ride up on me. During interview on 2/12/26 at 1:27 p.m. dietary manager (DM)-A stated when completing food preparation, gloves should be used on both hands. DM-A stated this was important for infection control. DM-A stated hairnets were important to prevent hair in food items. The facility policy, Hand Washing and Glove Use-Food Nutrition Services, last reviewed 6/6/25, identified Employees do not touch any food with bare hands – ready-to-eat or otherwise. Proper utensils such as tissue, spatula, tongs, and single-use gloves should be used for food handling to reduce the risk of cross-contamination. The facility policy, Employee Hygiene and Dress Code-Food and Nutrition Services, last reviewed/revised 5/27/25, identified Hairnets or hair restraints and beard nets or beard restraints are used: a. When cooking, preparing, assembling food or ingredients. This includes dish rooms and storage areas. See specific state guidelines. Hair is to be covered completely.

Based on observation and interview, the facility failed to ensure residents received care and services in accordance with professional standards of practice to prevent avoidable harm for 1 of 1 resident (R1) observed during wheelchair transport.Findings include:R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment and required assistance with activities of daily living (ADLs). R1's diagnoses included pneumonia (a lung infection), arthritis (joint inflammation causing pain and limited mobility), non-Alzheimer's dementia (a condition affecting cognition and functional abilities), malnutrition (inadequate nutritional status), localized edema (fluid-related swelling), adult failure to thrive (characterized by weight loss and functional decline), and disorientation (impaired awareness of person, place, or time). The MDS also indicated R1 required occasional assistance with locomotion and utilized a wheelchair for mobility. During observation on 2/9/26 at 7:52 a.m., R1 was being assisted to the dining room in a wheelchair. Nursing assistant (NA)-A pushed R1's wheelchair in the hallway. R1's wheelchair did not have foot pedals in place. R1's feet were observed bouncing off the floor on three occasions. During observation on 2/10/26 at 4:02 p.m., activity aide (AA)-A pushed R1, in the wheelchair, down the hallway. Foot pedals were not in place on R1's wheelchair. R1's feet were observed sliding on the floor. During observation on 2/10/26 at 4:40 p.m., AA-A was pushing R1, in the wheelchair, down the hallway toward the dining room without foot pedals in place. R1's feet were sliding on the floor. NA-C approached, stopped AA-A, and stated R1 should not be pushed unless foot pedals were in place. NA-C asked R1 whether he preferred to continue propelling himself to the dining room or if staff should obtain the foot pedals. R1 stated he would continue to self-propel to the dining room independently. This observation demonstrated differing staff practices regarding the use of foot pedals during wheelchair mobility. During review of R1's electronic medical record (EMR) on 2/11/26, R1's comprehensive care plan, print date of 2/12/26, revealed the care plan did not address the resident's locomotion status, including wheelchair use and whether foot pedals were required for safe mobility. There was no documented guidance outlining how staff were to assist the resident when R1 was in a wheelchair. During interview on 2/12/26 at 12:04 p.m., Nursing Assistant (NA)-A stated the resident's care plan should identify the level of assistance needed for transfers and wheelchair mobility, including whether foot pedals were required. NA-A reported the resident did not like using foot pedals and typically self-propelled himself throughout the facility. NA-A further stated that when staff assisted the resident by pushing his wheelchair, the resident's feet would sometimes slide or bounce off the floor. During interview on 2/12/26, Nursing Assistant (NA)-B stated that if staff were pushing a resident in a wheelchair, foot pedals should be in place. NA-B further stated the resident should have foot pedals because his feet would sometimes slide on the floor when staff pushed the wheelchair. During interview on 2/12/26 at 12:24 p.m., Registered Nurse Manager (RN)-B stated the use of foot pedals was determined by the resident's care plan and acknowledged some residents did not like foot pedals in place. RN-B stated foot pedals could be kept in the resident's room for staff use when assisting the resident. RN-B reviewed R1's care plan and confirmed wheelchair use and foot pedal use were not addressed. RN-B further stated any floor nurse could update care plans and that RN-B served as the final reviewer to ensure care plans were entered correctly and accurately. During interview on 2/12/26 at 1:39 p.m., the Director of Nursing (DON) stated wheelchair mobility depended on the individual resident; however, staff were advised not to push a resident in a wheelchair while the resident's feet were on the floor. The DON stated foot pedals should be in place when staff pushed a resident in a wheelchair and that this expectation should be addressed in the resident's care plan. The DON further stated nurses, care managers, and the DON were able to revise and add information to residents' care plans as needed. Facility policy related to wheelchair use was requested but was not received. The facility failed to ensure staff followed professional standards of practice for safe wheelchair transport, resulting in the potential for avoidable harm to the resident.

Based on record review and interview, the facility failed to ensure comprehensive care plans were developed and updated to address identified needs for 2 of 2 residents (R1 and R4) reviewed for development of care plans.Findings include:R1:R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had severe cognitive impairment and required assistance with activities of daily living (ADLs) including transfers. R1's diagnoses included pneumonia, arthritis, non-Alzheimer's dementia, malnutrition, adult failure to thrive, and disorientation. The MDS also identified R1 required occasional assistance with locomotion and utilized a wheelchair for mobility.R1's comprehensive care plan, print date of 2/12/26, failed to address R1's locomotion status, including wheelchair use or the need for foot pedals for safe mobility. r1's care plan failed to include guidance outlining how staff were to assist R1 with transfers or wheelchair mobility.R4:R4's quarterly MDS dated [DATE], identified R4 had moderately impaired cognition and required assistance with ADLs. R4's diagnoses included non-traumatic brain dysfunction, urinary tract infections (UTIs), non-Alzheimer's dementia, and malnutrition. The MDS identified a history of urinary tract infections, and indicated an ongoing clinical condition which required monitoring and preventative interventions.R4's comprehensive care plan, print date of 2/12/26, failed to include problem, goal, or interventions addressing R4's history of UTIs.During interview on 2/12/26 at 12:04 p.m., nursing assistant (NA)-A stated a resident's care plan should identify the level of assistance needed for transfers and wheelchair mobility, including whether foot pedals were required. R1 did not like foot pedals and typically self-propelled throughout the facility. When staff assisted R1 by pushing R1 in the wheelchair, R1's feet would sometimes slide or bounce off the floor while being pushed down the hallway. NA-A was not aware of R4's history of UTIs.During interview on 2/12/26, NA-B stated the use of foot pedals should be identified on the care plan and if staff were pushing a resident in a wheelchair, foot pedals should be in place. R1 should have foot pedals because R1's feet sometimes slid on the floor when staff pushed the wheelchair. NA-B stated R4 had a history of UTIs and required staff reminders to drink fluids. NA-B stated interventions related to UTIs should be included on the care plan for staff to follow.During interview on 2/12/26 at 12:24 p.m., the registered nurse manager (RN)-B stated the use of foot pedals was determined by the resident's care plan and acknowledged some residents did not like foot pedals. Foot pedals could be kept in the resident's room for staff use when assisting with mobility. RN-B reviewed R1's care plan and confirmed wheelchair use and foot pedal use were not addressed. Floor nurses were able to update care plans. RN-B served as the final reviewer to ensure care plans were entered correctly and accurately. RN-B also stated R4 had a history of UTIs and, upon review of the care plan, stated R4 did not have an active UTI at the time and the issue was considered resolved. RN-B acknowledged R4's history of UTIs should be addressed on the care plan so staff were aware and could monitor for recurrence. RN-B expected the care plan included R4's history of UTIs.During interview on 2/12/26 at 1:39 p.m., the director of nursing (DON) stated wheelchair mobility depended on the individual resident; however, staff were advised not to push a resident in a wheelchair while the resident's feet were on the floor. The DON stated foot pedals should be in place when staff were pushing a resident in a wheelchair for resident comfort and safety. DON expected wheelchair mobility was addressed in the resident's care plan. The DON further stated nurses, care managers, and the DON were able to revise and add information to residents' care plans as needed. The DON also stated the facility addressed only active UTIs on care plans and did not address residents' history of UTIs, adding a resident's history of UTIs should be included on the care plan for prevention purposes.The facility's Care Plan policy, dated 12/1/25, indicated residents would receive the necessary care and services to attain or maintain the highest practicable well-being in accordance with the comprehensive assessment. The policy further indicated each resident would have an individualized, person-centered, comprehensive care plan that included measurable goals and timetables to address identified medical, nursing, physical, functional, and psychosocial needs.

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was completed and closed in accordance with federal requirements for 1 of 1 resident (R26) for accuracy of assessments. Findings include: R26's Medicare 5-day Minimum Data Set (MDS) assessment was initiated on [DATE], but was not completed or closed following the resident's transfer to the hospital. Record review indicated R26 was transferred from the facility to the hospital on [DATE]. R26 expired and did not return to the facility. Review of the MDS tracking system on [DATE], indicated the assessment remained open and exceeded 120 days without completion or closure. The MDS tracking system failed to include documented evidence the facility completed a required discharge assessment or took action to close the MDS following the resident's hospital transfer and death. During interview on [DATE] at 12:24 p.m., the Registered Nurse Manager (NM) stated the MDS assessment should have been closed or the Assessment Reference Date (ARD) changed following the R26's emergent hospitalization. R26 was transferred emergently to the hospital and the MDS should have been closed and left incomplete. The NM further stated a Medicare 5-day assessment should not have been completed. The NM reported being on vacation at that time, which NM stated may have contributed to the MDS not being closed appropriately. Review of the facility's MDS 3.0 RAI Policy, dated [DATE], indicated when a resident is hospitalized or discharged after a Medicare assessment has been opened but not completed, the facility must determine whether the MDS assessment is required for Medicare payment and take appropriate action to complete or close the assessment.

Based on record review and interview, the facility failed to ensure the Office of the Ombudsman for Long-Term Care was notified of a resident's transfer to the emergency room (ER) on two separate occasions for 1 of 3 residents (R4) for transfer from facility.Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE], identified R4 had moderately impaired cognition and required assistance with activities of daily living (ADLs). R4's diagnoses included non-traumatic brain dysfunction (impairment of brain function affecting cognition or behavior not caused by physical injury), hypertension (chronically elevated blood pressure), urinary tract infections (infection of the urinary system), hyponatremia (abnormally low serum sodium levels), non-Alzheimer's dementia (progressive cognitive decline not attributed to Alzheimer's disease), and malnutrition (insufficient nutritional intake resulting in impaired health status). Review of R4's electronic medical record (EMR) on 02/11/26, indicated R4 was transferred from the facility to the emergency room on two separate occasions, 4/17/25 and 6/21/25. R4's transfer documentation, progress notes, and facility's Ombudsman notification logs failed to include documentation the Office of the Ombudsman for Long-Term Care was notified of either transfer. During interview on 02/11/26 at 3:37 p.m., the Health Information Manager (HIM) stated she reported unplanned hospital transfers to the Office of the Ombudsman for Long-Term Care and planned transfers were communicated in advance and coordinated with the Ombudsman. The HIM stated unplanned transfers were faxed to the Ombudsman on a monthly basis. The HIM reviewed facility records for hospital transfers dated 04/17/25 and 06/21/25 and verified both transfers were missing from her system. The HIM confirmed the transfers were not included in the monthly reports faxed to the Ombudsman and acknowledged the notifications were missed. The facility's Discharge and Transfer policy, dated 01/15/26, indicated when a resident was temporarily transferred on an emergency basis to an acute care center, a notice of transfer was required to be provided to the resident and resident representative as soon as practicable before the transfer. The policy further indicated copies of notices for emergency transfers must also be sent to the Office of the Ombudsman for Long-Term Care and may be provided when practicable, including as part of a monthly listing.

Based on observation, interview, and record review, the facility failed to ensure a resident was treated with dignity and respect during the dining experience for 1 of 1 resident (R4) reviewed for dignity. Findings include:R4's quarterly Minimum Data Set (MDS) dated [DATE] identified R4 had moderately impaired cognition and required assistance with activities of daily living (ADLs). R4's diagnoses included non-traumatic brain dysfunction (impairment of brain function affecting cognition or behavior not caused by physical injury), hypertension (chronically elevated blood pressure), urinary tract infections (infection of the urinary system), hyponatremia (abnormally low serum sodium levels), non-Alzheimer's dementia (progressive cognitive decline not attributed to Alzheimer's disease), and malnutrition (insufficient nutritional intake resulting in impaired health status). During continuous observation on 2/10/26 from 4:35 p.m. through 4:54 p.m., R4 had been assisted into the dining room by staff and had been seated at a table with two other residents. At 4:39 p.m., the tablemates had been served their meals and had begun eating; however, R4 had not received her meal at that time and had remained seated without a meal while the other residents had continued eating. At 4:48 p.m., R4 had still not received her meal and had asked the other residents, Was the food good? after they had finished eating. At 4:54 p.m., R4's meal had been delivered; however, by that time, the other residents at the table had completed their meals, resulting in R4 waiting approximately 15 minutes or longer. During interview on 2/10/26 at 6:26 p.m., dietary aide (DA)-A was unable to provide an explanation for why R4's meal was delayed while other residents at the table were served in a timely manner. DA-A stated residents were served on a first-come, first-served basis. During interview on 2/10/26 at 6:32 p.m., the cook stated he typically served residents as they entered the dining room and ensured drinks were provided. He stated he asked residents what they would like to eat and served meals as residents arrived. He further stated, once dining room activity slowed, he attempted to serve meals by table, as he did not like seeing residents waiting while others were eating. The cook confirmed R4's tablemates had been served their meals and R4 was the last resident seated at that table. He further confirmed he forgot to serve R4's meal initially and did not realize R4 had not received her meal until later. He stated R4 had been sitting without a meal for quite awhile before her meal was delivered. During interview on 2/11/26 at 10:59 a.m., R4 stated watching other residents eat while she waited for her meal made her feel increasingly hungry and caused her to sit wondering when her meal would be served. The facility Dining Service Standards policy, dated 12/18/25, indicated the facility would provide assistance with dining in a manner that promoted independence, maintained dignity, and focused on quality of life. The facility Resident Dignity policy, dated 12/18/25, indicated the facility would promote care for residents in a manner and environment that maintained or enhanced each resident's dignity and respect in full recognition of his or her individuality.

Based on record review and interview, the facility failed to ensure the resident's physician was notified of change in condition and significant clinical events in accordance with provider orders for 1 of 1 resident (R20) reviewed for change in condition. Findings include: R20's admission Minimum Data Set (MDS) dated [DATE], identified R20 had intact cognition and required assistance with activities of daily living (ADLs). R20's diagnoses included acute on chronic combined systolic and diastolic heart failure (a condition in which the heart experienced both acute worsening and long-standing impairment of its ability to pump and fill effectively), coronary artery disease (narrowing or blockage of the coronary arteries supplying blood to the heart), heart failure (a chronic condition in which the heart was unable to pump sufficient blood to meet the body's needs), gastroesophageal reflux disease (GERD) (backflow of stomach contents into the esophagus causing irritation and discomfort), hyperlipidemia (elevated levels of fats or cholesterol in the blood), lymphedema (chronic swelling caused by impaired lymphatic drainage), fluid overload (excess fluid in the body with the potential to worsen cardiac and respiratory status), history of falling (previous episodes of loss of balance resulting in falls), edema (swelling caused by excess fluid in body tissues), hypokalemia (abnormally low potassium levels in the blood with the potential to affect heart rhythm and muscle function), and morbid obesity (excessive body weight associated with increased risk of serious health conditions). R20's physician orders printed on 2/12/26, indicated a provider order requiring staff to obtain daily weights in the morning for congestive heart failure (CHF) protocol and to notify the provider of a weight increase of three or more pounds within 24 hours or five or more pounds within one week. The physician orders also indicated a provider order for Nitroglycerin 0.4 mg sublingual (under the tongue) to be administered every five minutes as needed for chest pain or other signs or symptoms of acute angina, after the initial dose, the medication could be repeated every five minutes for up to two additional doses. If chest pain or acute angina was not relieved after three doses, staff were to contact the provider; if the provider could not be contacted, staff were to call 911 immediately unless contrary to the resident's advance directives. R20's electronic medical record (EMR) reviewed 1/1/2026 through 2/11/2026, indicated R20 experienced a weight gain greater than three pounds in one day on three separate occasions, including 1/21/26, 2/3/26, and 2/11/26. R20's nursing notes, weight logs, and physician communication records failed to include documentation the provider was notified of these weight changes as required by the provider order. R20's EMR also indicated Nitroglycerin was administered to R20 on five separate occasions, including 1/21/26, 1/23/26, 1/29/26, 2/1/26 (two doses administered 10 minutes apart), and 2/10/26. Review of the medical record, Medication Administration Records (MARs), and physician communication documentation indicated no evidence the provider was notified following Nitroglycerin administration prior to 2/10/26. During interview on 2/12/26 at 8:27 a.m., the nurse practitioner (NP) stated she expected nursing staff to follow all provider-established parameters and to notify the provider using a portal message. NP expected the message would include a nursing assessment. Staff were expected to report weight gain, lung assessment findings, and the presence of edema. While notification of weight gain depended on the resident's baseline weight and clinical presentation, in the presence of CHF and increased edema she would have considered prescribing a diuretic, as R20 had previously required diuretic medication for fluid management. NP stated the last time she had been notified of weight gain for R20 was 12/23/25. NP stated she had been notified of one dose of Nitroglycerin administered to R20 on 2/10/26; however, NP was not aware the resident had received five doses prior to that date. NP stated she should have been notified of the repeated administration of Nitroglycerin, as it was considered a higher-risk medication. Had NP been aware of the multiple doses, she would have evaluated the situation more closely, including reviewing potential contributing factors, and noted the timing coincided with the discontinuation of R20's Protonix (used to reduce stomach acid production). During interview on 2/12/26 at 8:56 a.m., registered nurse (RN)-A stated nursing assistants (NA)'s obtained daily weights for residents with CHF and either documented the weights in the medical record or reported them to the nurse. If weight parameters were met, nursing staff were expected to notify the provider and include recent weight trends in the notification. RN-A also stated the provider should be notified in the event of chest pain or administration of Nitroglycerin. During interview on 2/12/26 at 9:13 a.m., NP stated the provider should be notified whenever Nitroglycerin was administered. NP did not believe the weight gain resulted in harm and did not consider the event significant; however, if the provider had been notified, additional interventions or follow-up would have been implemented. During interview on 2/12/26 at 12:04 p.m., NA-A stated NA's obtained residents' weights and either provided the weights to the nurse or entered them into the EMR. During interview on 2/12/26 at 12:10 p.m., NA-B stated NA's obtained residents' weights, entered them into the EMR, and reported them to the nurse. During interview on 2/23/26 at 12:24 p.m., the registered nurse manager (NM) stated if a resident experienced chest pain and Nitroglycerin was administered, staff were expected to obtain a full set of vital signs, including heart rate and blood pressure, ensure the resident was seated or lying down, apply oxygen as indicated, and assess the resident's signs and symptoms. The provider should be notified when Nitroglycerin was administered so the provider could determine whether additional doses or further interventions were needed. NM further stated NA's and nurses were expected to obtain daily weights promptly in the morning and document them in the medical record. Nurses were responsible for notifying the provider when weight changes met provider-established parameters. During interview on 2/12/26 at 1:39 p.m., the Director of Nursing (DON) stated she expected staff to obtain daily weights and notify the provider in accordance with provider-established parameter orders. Staff were expected to inform the provider if the resident was retaining fluids or if cardiac function appeared compromised. Regarding Nitroglycerin administration, the DON stated staff were expected to follow provider orders, obtain blood pressure and other vital signs prior to administration, and notify the provider when Nitroglycerin was administered. The DON confirmed the physician order required provider notification. The DON further stated, after the provider was notified of the resident's weight gain by the surveyor earlier that morning, the provider prescribed additional Lasix (diuretic) for five administrations and restarted Protonix on 2/12/26. During follow-up interview on 2/12/26 at 2:33 p.m., the DON stated staff relied on the provider order as written in the electronic medical record, which directed staff to contact the provider after three doses of Nitroglycerin had been administered. She further stated that although nursing staff were expected to notify the provider of chest pain or Nitroglycerin administration, this expectation was not consistently followed in practice, as staff deferred to the wording of the electronic order rather than notifying the provider with each administration. The facility Change in Condition policy, dated 4/6/25, indicated nursing judgment was to be used when determining the urgency of contacting the provider.

Based on observation, interview, and document review the facility failed to accurately complete a comprehensive Minimum Data Set (MDS) assessment for 1 of 1 resident, (R23), who was reviewed for dental status Finding include: R23's Admission assessment Minimum Data Set (MDS), dated [DATE], identified R23 had significant cognitive impairment, however, was independent with eating and oral hygiene. The MDS indicated R23 required assistance with dressing, personal grooming (outside of oral hygiene), and required full assistance with mobility. R23's medical diagnoses included a joint replacement, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), multiple sclerosis (MS-a disease process which has been known to cause numbness, weakness, trouble walking, vision changes and other symptoms), anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), atrial fibrillation (an irregular and often very rapid heart rhythm), heart failure (a progressive heart disease that affects pumping action of the heart muscles, which may cause fatigue, shortness of breath.), hypertension (high blood pressure), and end stage renal (kidney) disease. The MDS indicated R23 had no concerns with broken or missing teeth, or abnormal mouth issues and indicated None of the above were present. R23's quarterly MDS assessment of 10/30/24 lacked entry for dental status of R23. A subsequent MDS of 12/18/24 indicated there were no dental concerns identified. R23's care plan, dated 8/8/24, identified R23 experienced a self-care deficit related to hip fracture. The care plan identified R23 had his own teeth, was able to brush his teeth independently once set up, and was able to eat independently. The care plan directed staff to assist in dressing, grooming, mobility, with a goal to improve current level of function. A review of the record lacked indication R23 was missing the upper portion of his teeth on both the upper and lower jaw, with only the lower portion of teeth remained present. On 1/6/25, at 12:59 p.m., R23 was observed in his room following the noon meal. On the tray, it was noted there were two slices of bread with only the outer crusts remaining, with the center absent. R23 was observed to have only partial teeth on the upper and lower jaw. The lower portion of the teeth remained, however, there were no biting surfaces in place, and appeared to be only the pulp and roots remaining. R23 stated he was aware he needed to go to the dentist, although denied pain. On 1/8/25, at 3:59 p.m., a review was completed with registered nurse (RN)-A of the dental assessments on the MDS' of 8/14/24, 10/30/24, and 12/18/24. RN-A verified the documentation reviewed indicated there were no dental concerns identified. A review of the care plan at this time also lacked any indication of dental concerns. RN-A stated this data is automatically entered from the [NAME] (Nursing Admit Re-Admit Data Collection) form completed form the time of admission. RN-A was requested to evaluate the R23's dental status and follow up after investigation completed. At 5:26 p.m., RN-A identified R23 was noted to have broken/missing teeth in the center of the upper and lower jaw. RN-A stated dental assessments were completed initially upon admission, and quarterly thereafter, and the dental assessments should have reflected the status of the resident. RN-A stated she had conferred with the director of nursing (DON), who had attended the resident care conference on 12/12/24, at which time R23's dental status was reviewed. The notes reflected plans were made for dental status review at a follow up medical appointment on 1/7/25. Although identified at the care conference, this was not reflected in the care plan. RN-A stated with the concern identified, she would anticipate it would have been identified within the care plan. On 1/9/25, at 3:30 p.m., the DON stated it was her expectation for the MDS to accurately reflect the status of the resident. Additionally, DON stated it was her expectation the care plan be reflective of resident status, and direct staff as to resident needs for assistance and care. The facility policy, MDS 3.0 (Minimum Data Set) RAI (Resident Assessment Instrument)-Rehab/Skilled & Therapy and Rehab, last reviewed/revised 8/27/24 was reviewed. The policy identified during the observation period, each team member will review the EMR (electronic medical record) to determine if there is accurate documentation to support coding for the MDS. The policy directs that if, while reviewing the medical record, the time finds conflicting information, a clarifying note was to be written as part of a supportive documentation note. The guidelines indicated the staff were to attempt to conduct interviews with all residents. The facility policy, Denture and Oral Care, Dental Health Assessment, Dental Services, last reviewed and revised on 6/3/24, identified multiple purposes, which included to observe the oral cavity for abnormalities, provide comfort and well-being, and to maintain healthy condition of teeth and oral cavity. The policy outlines dental assessments are conducted upon admission, quarterly, and with the annual MDS, or with any other oral changes. The purpose of these assessment was identified as early identification and evaluation of any dental/oral health problems for treatment by a dentist or other health professional.

Based on interview and document review, the facility failed to ensure an elopement incident was reported to the State Agency (SA) not later than 24 hours for 1 of 1 residents (R32) reviewed for elopement. Findings include: R32's admission Minimum Data Set (MDS) dated [DATE], indicated R32 had severe cognitive impairment and required extensive assistance with cares. R32 had diagnoses which included amputated toes of left foot, peripheral vascular disease, diabetes, and muscle weakness. R32's care plan revised 6/1/24, identified R32 had potential for elopement related to elopement 5/31/24 (completed after the reported incident). R32's progress notes were reviewed and identified the following entries: - 5/31/2024, at 8:10 p.m. assisted with toileting about 7:30 p.m. refused medications and blood sugar check. When staff went to check on resident at about 8:00 p.m. room door did not open. - 5/31/2024, at 8:15 p.m. family updated was refusing medications, door to room wouldn't open and was observed from his window to be covering up with covers in bed. - 5/31/2024, at 9:00 p.m. daughter arrived, resident did not answer family through the door. It was found that the window to room was open, the screen had been cut and resident was not in the room. Family left immediately to look for him while staff called 911. While staff on the phone with 911, family returned to report resident was at home with his family, that someone had given him a ride home from the bowling alley. A Facility Reported incident was submitted to the SA on 6/3/24, at 5:00 p.m. (approximately 68 hours after resident eloped out window) which identified R32 a non-elopement risk resident left the building through window in room. Locked door with cell phone cord and placed pillows in the bed to make it appear he was laying in it. Proceeded to walk to the roadway next to the building, flag down a motorist and got ride to his home. When interviewed on 1/09/25, at 3:59 p.m. director of nursing (DON) stated R32 was supposed to discharge to home the week before the incident, facility had discharge orders from the provider at that time. Family had convinced him to stay longer. R32 had gone to an appointment the morning of the incident , believed he was going to go home afterward but the family had brought him back to the facility. The nurse went to attempt medication administration again after he had initially refused, was not able to open the door to the room and R32 was not responding to the nurse so she went outside to look through the window observing R32 laying down in bed and covering up. Nurse had called the family for assistance since he was not responding to her, family arrived about 45 minutes later. R32 did not respond to the family who then went to the window discovering the window open and screen cut, resident was no longer in the room. Facility staff called 911 while the family left and located him at his residence in town. the nurse talked to the good samaritan that R32 flagged down, had not felt comfortable with driving him anywhere but someone from the bowling alley had overheard and gave R32 a ride. Was not reported at the time of the incident as did not feel that this was an elopement, had an order the week prior to discharge, he had a destination and arrived to that destination. Family brought him back later that night. Facility policy titles Abuse and Neglect - Rehab/Skilled, Therapy and Rehab revised 7/22/24, indicated if there is an allegation that does not involve abuse and there is no serious bodily injury, then it will be reported not later than 24 hours after the allegation is made.

Based on observation, interview and record review the facility failed to maintain proper records of kitchen dishwasher temperature logs. This had the potential to affect all 27 residents. Findings include: During observation on 11/6/23 at 11:30 a.m., temperature logs were unable to be located during intital kitchen tour. During observation on 11/7/23 at 2:16 p.m., rinse temp on dishwasher test during kitchen tour with certified dietary manager (CDM-A), reached 175 dgrees on final rinse. When interviewed on 11/7/23 at 2:20 p.m., CDM-A stated she did not know why the temperature was not reaching full temperature and if the gauge was accurate. CDM-A said she could not find previous temp logs but would look. During observation on 11/7/23 at 5:20 p.m., with facility Administrator, the facility dishwasher was able to reach temperature with a temperature test strip. When interviewed on 11/7/23 at 5:30 p.m., facility Administrator stated the dishwasher had just been reviewed by the lease company Eco-labs, and that the temperatures of the dishwasher should be recorded and logged. When interviewed on 11/8/23 at 9:45 a.m., Eco-lab representative, (ELR-C) stated and demonstrated that the facility dishwasher was reaching temperatures of 180 degrees for rinse appropriately and would be reviewing for a newer temperature gauge. ELR-C stated it would be easier to monitor function with up-to-date temperature logs. When interviewed on 11/8/23 at 2:41 p.m., dietary cook (DC-A) stated she usually records the dishwasher temperatures on the log, and that she could see it had not been done for the first 6 days in November. DC-A stated it is important to record the dishwasher temperatures to show proper functioning, otherwise a resident could get sick. When interviewed on 11/8/23 at 2:43 p.m., CDM-A stated that she had located dishwasher temperature logs and showed that multiple days and months had been missing in the last quarter. CDM-A stated she did see this as an issue, and we don't want anyone to get sick from a misfunctioning dishwasher. CDM-A stated that she had reviewed the policy, updated the records, and began staff education on proper recording after the surveyor made her aware of the concern. Facility documents, titled 2023 Dish Machine Temperature Log for the months of November, October, September, and August indicated 6 missing entries to date in November, 9 missing entries for September, and unable to produce records for October or August for the year 2023. Facility document, titled Dishmachine Failure, revised on 2/1/2023 indicated, the senior living director or person in charge monitors the temperature/chemical logs on a periodic basis (a minimum of monthly) to ensure the data is within recommended guidelines.

Based on observation, interview, and document review, the facility failed to ensure a comprehensive care plan was developed and available to help outline services and care provided while on hospice for 1 of 1 residents (R4) reviewed for skin issues. Furthermore, the facility failed to ensure a comprehensive care plan was developed and available to help outline services and care provided while on hospice for 1 of 3 residents (R13) reviewed for communication / sensory issues. Findings include: R4's Admission Record (undated) indicated R4 had the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's annual Minimum Data Set (MDS), dated [DATE], indicated R4 was extensively dependent on staff for most of her activities of daily living and was severely cognitively impaired. In a review of the facility's wound measurement record, the area measured 0.5 centimeters (cm) x 0.50 cm x 0.1 cm). The physician orders, dated 9/15/21, directed the facility to Monitor Pilonidal cyst on upper right buttocks every shift for [signs and symptoms] of infection, including [CONDITION(S)] and warmth. The orders directed staff to keep covered with [MEDICATION(S)] and continue to allow to drain. This was to be completed with every shift monitoring of draining cyst. In review of R4's Care Plan indicated concerns of the potential for Impaired Skin Integrity (last updated 5/6/21) and the potential for pressure ulcer development (last updated 7/21/21). However, the care plan lacked any documentation of R4's pilonidal cyst and the treatment ordered. R13's Admission Record (undated) indicated R13 had the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R13's admission MDS, dated [DATE], indicated R13 was extensively dependent on staff for most of her activities of daily living and was severely cognitively impaired. In review of R13's In-House audiology services report, dated 5/25/21, indicated possible decrease in hearing sensitivity bilaterally. The report indicated R13 was wearing hearing aids upon arrival to appointment. A review of R13's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] do NOT place bilateral hearing aides per audiologist. they do not work. Keep in med cart. every morning and at bedtime for hearing aid use. In review of R13's Care Plan (last revised 8/24/21) lacked any indication R13 was hard of hearing and required hearing aids. During interview on 10/21/21, at 10:32 a.m. the director of nursing (DON), after reviewing the care plans of both R4 and R13, stated she verified that neither R4's pilonidal cyst, nor R13's hearing difficulty had been addressed on their care plans. DON stated the missing information for both R4 and R13 would be important for facility staff to be aware of for the provision of care. In review of the facility's policy, entitled: Care Plan - Rehab / Skilled (last revised 9/17/21) defined the Comprehensive Care Plan as: includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The policy further indicated, under the definition of a Person-Centered Care as: a focus on the resident as a [focus] of control and supporting the resident in making his / her own choices and having control over their daily life.

Based on observation, interview and document review, the facility failed to ensure the primary provider reviewed the ongoing effectiveness of medications as recommended by the mental health consultant to ensure the highest practicable well-being was achieved for 1 of 1 residents (R1) reviewed for mood and behavior. Findings include: R1's annual Minimum Data Set (MDS) dated [DATE], identified diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated R1 was cognitively intact, and had not reported symptoms of depression or concerns regarding behavior. R1's care plan, revised on 8/2/21, printed on 10/21/21, identified R1 had depression related to disease process, functional impairments, and multiple comorbidities. R1's goal statement was for R1 to be free from signs and symptoms of distress, symptoms of depression, anxiety or sad mood. The care plan directed staff to seek consultation with pharmacy, health care provider, etc. to consider dosage reduction when clinically appropriate. It also identified talk therapy (counseling) biweekly (twice a month) with the Associated Clinic of Psychology (ACP/mental health care provider). During the initial interview on 10/19/21, at 9:30 a.m. when asked if they experienced depression or lack of interest in day to day activities, R1 responded, That's my normal state. R1 went on to say watching TV took their mind off of their mood, however, they thought they were becoming, immune to the medications they were taking for their mood. R1 stated they met with a person for their mood and felt this helped. R1 was neat and well groomed in appearance. On 8/24/21, R1 was seen by licensed social worker (LSW)-A, from ACP. In the narrative note, R1's mood/affect was described as flat/depressed, and behavior as withdrawn and identified R1 remained despondent, with a low mood. LSW-A identified R1 continued to have a low mood overall, and indicated, examining the effectiveness of the current depression medication may be beneficial. This note was signed off as, Noted on 8/25/21 by registered nurse (RN)-B. An additional set of initials of LEC-A (Life Enrichment Coordinator) which lacked the date or other notation. On 9/28/21, R1 was again seen by LSW-A, and their mood/affect was again described as flat/depressed with withdrawn behavior. The note identified R1 continued to have days with chronic health issues which caused them to be moody and fatigued. In the progress note, it indicated R1 shared with LSW-1 they were concerned others would feel they [R1] were making it up and using it [their illness] as an excuse. On 9/8/21, R1 was seen for routine follow up by their primary provider. In the 9/8/21 progress note, it identified R1 was seen for chronic medical conditions. The section titled Past Medical History identified R1 had a major depressive disorder, recurrent, mild, however, it lacked review of current medications for treatment or their effectiveness. During interview on 10/21/21, at 12:46 p.m. director of nursing (DON) indicated R1 had historically described their mood state as kind of a, [NAME] and gloom attitude. DON stated upon review of the progress notes from the provider, it lacked documentation to reflect the medications prescribed for mood and behavior were reviewed for ongoing effectiveness. DON was unsure as to why the review of effectiveness of medications was not relayed to, and addressed by, the primary provider. A written policy was requested for the process of review and follow up on recommendations made by ACP but was not received. DON stated she could verbally provide the information for review of the ACP visit notes and follow up, however, did not have a written policy. DON stated the ACP progress notes were completed following the visit. The reports were then faxed to the facility in follow up and were received and reviewed by the LEC, and then passed onto to RN-B for review and follow up. Once this was completed, the dictated notes were provided to DON for review and follow up if indicated. DON stated this follow up had not been completed with the above listed notes.

Based on observation, interview, and document review, the facility failed to follow up on audiology recommendations for communication ability of 1 of 1 resident (R13) who was hard of hearing with hearing aids requiring repair. Furthermore, the facility failed to follow up on optometrist recommendations for follow-up appointments of 1 of 1 resident (R20) who was reviewed for vision issues. Findings include: R13's Admission Record (undated) indicated R13 had the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R13's admission Minimum Data Set (MDS), dated [DATE], indicated R13 was extensively dependent on staff for most of her activities of daily living and was severely cognitively impaired. In review of R13's In-House audiology services report, dated 5/25/21, indicated R13 was wearing hearing aids upon arrival to appointment. However, noting that the hearing aids were not functioning, the audiologist recommended the following: 1. Attempt testing [noise volume] so as to hopefully be able to obtain new hearing aids for patient. 2. Use PocketTalker type device to aid patient in communication; this will be discussed with [Director of nursing]. During a telephone interview on 10/20/21, at 9:03 a.m. R13's guardian (FM)-A stated she was aware R13's hearing aids were not working back in May 2021. However FM-A stated she was unaware of what the facility and / or the audiologist were doing about the repairs. An interview on 10/20/21, at 12:47 p.m. registered nurse (RN)-A stated that R13 was not wearing the hearing aids while staff would frequently find R13's hearing aids in her mouth and chewing on them. RN-A stated the staff were concerned that R13 might swallow the batteries. RN-A knew the facility had PocketTalker devices, but was unaware if the device had been tried with R13. A further interview on 10/20/21, 1:14 p.m. nursing assistant (NA)-A stated she was aware of R13's dementia and hearing difficulties. When asked how the facility staff communicated with R13, with NA-A stating they show R13 offer cares and needs by pointing to items. NA-A is unaware if a PocketTalker device has ever been tried with R13. During an interview on 10/21/21, at 9:48 a.m. the director of nursing stated she had thought the previous Life Enrichment Director had attempted a trial with a PocketTalker device. However, after review of progress notes, there was no indication of that taking place. R20's Admission Record (undated) indicated R20 had the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R20's significant change MDS, dated [DATE], indicated R20 had adequate vision, however, listed [CONDITION(S)] as an active diagnosis. The MDS further indicated R20 was cognitively intact. During interview on 10/18/21 2:57 p.m. R20 stated thought she had her vision checked over a year ago, but would like to go to the eye clinic in Cokato. R20 denied any current vision issues other than wishing a vision check and newer glasses. In review of R20's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] Solution ([MEDICATION(S)]) 0.2-0.5% (used to reduce pressure inside the eye used to treat [CONDITION(S)] or ocular hypertension) 2. [MEDICATION(S)] Solution ([MEDICATION(S)]) 0.01% (reduction of elevated intraocular pressure in patients with open angle [CONDITION(S)] or ocular hypertension) In review of R20's In-House vision exam services report, dated 3/22/21, indicated R20 [return to clinic] 3 months for [intraocular pressure] check only. In a review of R20's medical progress notes, there lacked evidence R20 was ever scheduled for the return visit to have her eye pressure re-evaluated. During an interview on 10/21/21, at 9:48 a.m. the director of nursing stated earlier in the year it was her understanding that R20 did not wish to go to her medical appointments, so both Hospice and the facility canceled them. However after review of R20's medical records, lacked documentation on whether the return in 3 months appointment was made and/or canceled. Although the facility had policies and procedures for the receiving and transcriptions of physician / other healthcare providers orders, the facility did not have a formal policy / procedure for appointment arrangements / cancellations.

Based on observation, interview, and document review the facility failed to ensure staff consistently implemented proper glove use and hand hygiene while providing resident care for 1 of 3 (R18) residents observed for provision of cares. Findings include: R18's quarterly Minimum Data Set ((MDS) dated [DATE], identified R18 had moderate cognitive impairment and required extensive assistance with activities of daily living (ADLs). During observation on 10/30/19, at 8:32 a.m. after closing the door, nursing assistant (NA)-A and NA-C applied gloves, NA-A opened R18's incontinent brief and washed R18's peri-area and around catheter tubing with a washcloth, NA-C assisted R18 to turn to her side, NA-A used disposable wipes to cleanse fecal matter from R18's rectal area. Without changing gloves or completing hand hygiene NA-A used a washcloth to cleanse rectal area and apply barrier cream to buttocks. Without removing soiled gloves or completing hand hygiene, NA-A then untangled R18's call light cord and placed a clean incontinent brief under R18. NA-A removed soiled gloves, without completing hand hygiene NA-A opened door to the room, walked into hallway, brought in hoyer lift. At 8:44 a.m. NA-A applied clean gloves with no hand hygiene completed, obtained a plastic graduate and emptied R18's catheter drainage bag, emptied graduate into toilet, rinsed graduate with water then washed hands with soap and water. At 8:59 a.m. NA-A removed soiled bedding from R18's bed without applying gloves, NA-A then applied gloves without completing hand hygiene brushed R18's lower denture, removed soiled gloves and without completing hand hygiene, placed R18's oxygen tubing into nostrils. NA-A then washed hands with soap and water. When interviewed on 10/30/19, at 9:11 a.m. NA-A stated hand hygiene was to be done going in to a room, after picking up garbage, before leaving a room, after cleaning up stool, before emptying a catheter drainage bag, when going from dirty to clean. NA-A further stated I did not do hand hygiene, was going to wait until she was in her chair, should have done it for infection control. When interviewed on 10/31/19, at 9:43 a.m. registered nurse (RN)-A stated hand sanitizer could be used up to three times then hands needed to be washed with soap and water or if hands were visibly soiled hands had to be washed with soap and water before entering a room, when leaving a room and anytime gloves were removed. When interviewed on 10/31/19, at 2:49 p.m. director of nursing stated staff hand washing competencies had just been done, hand washing or hand sanitizer was to be done when entering and leaving a room, and after removing gloves. Adding, proper hand hygiene and glove use was most important step staff could take to help decrease risk of spread on infection. A facility Hand Hygiene and Handwashing policy revised 1/2018, identified hand hygiene was to be completed after removing gloves, before and after direct resident contact after touching equipment with soap and water or alcohol based hand rub.

Based on observation, interview and document review the facility failed to implement recommendations and subsequent provider orders for reduction of medication for 1 of 5 residents (R22) reviewed for unnecessary medications. Findings include: R22's quarterly Minimum (MDS) data set [DATE], identified R22's medical [DIAGNOSES REDACTED]. R22's care plan most recently revised on 7/28/19, indicated nutritional problem or potential nutritional problem related to type 2 diabetes mellitus and self reported gastrointestinal (GI) issues. The care plan identified R22 was to receive a therapeutic diet. Staff were directed to honor R22's choices and do not offer food which has caused GI issues. The care plan lacked identification of the use of medication management of GERD. R22's medication orders indicated R22 was ordered [MEDICATION NAME] Capsule (A medication used to treat certain stomach and esophagus problems (such as acid reflux, ulcers) which works by decreasing the amount of acid your stomach makes), delayed release 20 mg (milligram) one daily for GERD. This order was started on 12/1/18. A review of consulting pharmacist notes, titled Pharmacist Recommendations to Providers, of 8/26/19 identified R22 was observed to have used the [MEDICATION NAME] for greater than 120 days which posed an increase risk for [MEDICAL CONDITION] (c. diff) infections (An infection of bacterium that causes diarrhea and [MEDICAL CONDITION] (an inflammation of the colon)), [DIAGNOSES REDACTED] (Low magnesium level in the blood), [DIAGNOSES REDACTED] (Low calcium in the blood), bone fractures and CAP (community acquired pneumonia). This recommendation was reviewed by the provider on 8/30/19 and the handwritten narrative indicated this decrease was done on 8/17/19 and was discontinued on 8/31/19. This was signed off as Noted by registered nurse (RN)-A on 8/30/19. A review of the narrative note of the consultant pharmacist of identified the PPI (Proton pump inhibitors-acid reducing medications) recommendations as outlined with the recommendations for taper and discontinuation. A review of the (MONTH) electronic medication record (EMAR) of (MONTH) 2019 lacked indication of dosage reduction with subsequent discontinuation. A review of the Medical Director Summary of 9/29/19 indicated there was a recommendation to taper and discontinue [MEDICATION NAME] on 8/26/19, with a response that it was done on 8/14/19, however, it was noted by the consultant pharmacist the medication continued to be noted on the EMAR. A review of the narrative progress notes of the pharmacist identified: [MEDICATION NAME] taper was ordered but was continued per EMAR,without a taper of dosage. A subsequent review of the Medical Director Summary of 10/25/19 indicated the previous recommendations had been made and addressed, however, the medication continued to be given. Additionally, it identified the documentation was not reflective of why this medication was continued. A review of the narrative progress notes of the consulting pharmacist identified: On 8/26/19, there was an order to taper the [MEDICATION NAME]. This was not implemented, Recommendations made and sent to the MD(Medical doctor). A review of the (MONTH) EMAR identified R22 continued to receive the [MEDICATION NAME]. On 10/31/19, at 2:00 p.m. the director of nursing (DON) reviewed the consulting pharmacist information provided regarding the order for taper and subsequent discontinuation of [MEDICATION NAME] as had been noted by RN-[NAME] A review of the EMAR from (MONTH) identified the taper had not been initiated or completed. A review of the (MONTH) EMAR indicated R22 continued to receive this medication. DON stated it was her expectation all orders received from the provider would be transcribed and implemented. Additionally, the DON stated it was her expectation staff reviewing the Pharmacist Recommendations to Providers would assure the recommendations were implemented as prescribed. A call was placed to the consulting pharmacist in follow up who indicated the recommendations were made with written recommendations filed with the facility. A facility policy was requested for review of Pharmacist Recommendations to Providers but was not received.

Based on observation, interview and document review, the facility failed to coordinate dental follow up for 1 of 1 resident initially seen by the dentist with recommendations made. Findings include: R1's quarterly Minimum Data Set of 7/31/19, indicated R1 has intact cognition and received extensive assistance of staff to perform personal cares, including grooming and oral hygiene. R1's care plan, initiated 10/28/18, indicated ADL (Activities of daily living-dressing, grooming, bathing, etc .) deficit as evidenced by need for assistance with cares. The care plan instructed R1 was able to brush his own teeth with set up. The care plan also identified R1 had his own teeth, with several which were broken and needed repair, however care plan update of 10/30/19 indicated resident did not desire repair. The Bedside Kardex Report, printed 10/31/19, indicated staff were to provide set up for oral care to allow resident to complete independently. On 10/28/19, at 4:44 p.m. R1 stated he had missing and broken teeth and had seen a dentist while at the nursing home, however, stated this had never been followed up on. R1 stated this needed to be taken to the next level. On 10/30/19, at 7:13 a.m. R1 was observed to be up and dressed and seated in his room in his wheelchair. R1 stated he had only a handful of teeth, as some were missing, and others were decayed or broken. R1 again stated he had been seen by a dentist, however, follow through had not been completed. R1 was noted to have pronounced morning breath when speaking. A progress note of 7/11/19, at 9:10 p.m. indicated R1 was seen by the dentist and was to receive full mouth debridement, The documentation then referred to the dental notes. A patient note from dental provider was completed after assessment of 7/11/19 which identified R1 had Lots of issues. The dental recommendation identified a full mouth debridement was needed. The note also indicated a pre-authorization would be done AFTER debridement and restorative. The plan indicated R1 was to receive full mouth debridement, followed by restorative. Following this, a pre authorization was to be done for partials. A review of R1's Admission Record, printed on 10/31/19 indicated R1 received Medicaid coverage. On 10/30/19, at 11:55 a.m. registered nurse (RN)-B reviewed R1's dental evaluation and recommendations dated 7/11/19 and identified this had not been completed. RN-B stated coordination of appointments was generally completed by the Health Information Director (HI-D), however, RN-B was unable to find documentation this had been completed. RN-B stated the dentist did not specify when resident was to be seen, however, the note did identify debridement was to be done before a prior authorization would be submitted for additional dental care. RN-B stated we should have contacted the dentist in follow up to clarify the plan and an appointment should have been scheduled. On 10/31/19, at 9:47 a.m. HI-D stated R1's records had been reviewed and did not indicate follow through from the visit of 7/11/19 had been completed. HI-D stated this should have done after the dental evaluation when recommendations had been made. A facility policy titled Dental/Oral Health Services and Assessments revised 10/17 indicated residents were assisted in making dental appointments and with coordination of transportation.

Based on observation, interview and record review, the facility failed to complete an accurate oral assessment for 1 of 1 residents(R1) reviewed for dental concerns. Findings include: R1's quarterly Minimum Data Set of 7/31/19, indicated R1 had intact cognition and received extensive assistance of staff to perform personal cares, including grooming and oral hygiene. R1's care plan, initiated 10/28/18, indicated ADL (Activities of daily living-dressing, grooming, bathing, etc .) deficit as evidenced by need for assistance with cares. The care plan instructed R1 was able to brush his own teeth with set up. The care plan also identified R1 had his own teeth, with several which were broken and needed repair, however care plan update of 10/30/19 indicated resident did not desire repair. The Bedside Kardex Report, printed 10/31/19 indicated staff were to provide set up for oral care to allow resident to complete independently. On 10/28/19, at 4:44 p.m. R1 stated he had missing and broken teeth and had seen a dentist while at the nursing home, however, stated this had never been followed up on. R1 stated this needed to be taken to the next level. On 10/30/19, at 7:13 a.m. R1 was observed to be up and dressed and seated in his room in his wheelchair. R1 stated he had only a handful of teeth, as some were missing, and others were decayed or broken. R1 again stated he had been seen by a dentist, however, follow through had not been completed. R1 was noted to have pronounced morning breath when speaking. A patient note from dental provider was completed after assessment on 7/11/19, which identified R1 had Lots of issues. The dental recommendation identified a full mouth debridement was needed. The note also indicated a pre-authorization would be done AFTER debridement and restorative. The plan indicated R1 was to receive full mouth debridement, followed by restorative. Following this, a pre authorization was to be done for partials. An Oral/Dental Assessment-V2 dated 10/28/18, completed by registered nurse (RN)-C , indicated resident had his own teeth, with obvious or likely cavity or broken natural teeth. The assessment indicated R1 had halitosis (Chronic bad breath) and had few missing upper and lower molars. A subsequent Oral/Dental Assessment-V2 dated, 10/28/19 by RN-A, indicated R1's last dental exam was unknown and identified R1 had no concerns with missing or broken teeth, halitosis, mouth pain or discomfort. The document indicated R1 did not request a dental appointment. On 10/30/19, at 11:55 a.m. (RN)-B reviewed R1's dental exam recommendations from 7/11/19. RN-B confirmed there had not been any follow up from the dental exam and stated she would follow up on the recommendations. On 10/31/19, at 8:52 a.m. RN-B stated she had reviewed the Oral/Dental Assessment-V2 dated, 10/28/19 and completed an accurate second evaluation of R1's dental status with an oral exam which identified R1 had missing and broken teeth, as well as halitosis. A subsequent appointment for dental care was also scheduled for R1. On 10/31/19, at 2:10 p.m. the director of nursing (DON) stated the purpose of completing an oral /dental assessment was to determine if there were areas of concerns which required follow through and intervention. The assessment should review the current resident status through visualization, a review of recommendations made, and initiation of any follow through as indicated. The facility policy Dental/Oral Health Services and Assessments revised 10/2017 identified the purpose of assessments were to ensure dental needs of all residents are met in a timely manner to maintain good oral hygiene. Additionally, the policy identified the assessments were performed so early identification and evaluation of any dental/oral health could occur.

Based on observation, interview and document review, the facility failed to ensure oxygen equipment received routine filter maintenance for 2 of 2 residents (R6 and R18) reviewed for oxygen therapy. Findings include: R6's annual Minimum Data Set (MDS) completed on 8/29/19 indicated R6 had moderate cognitive impairment and received extensive assistance with ADL's (Activities of daily living-dressing, grooming, and bathing, etc .). R6's medical [DIAGNOSES REDACTED]. [MEDICAL CONDITION] (MS-a potentially disabling disease of the brain and spinal cord), anxiety, and asthma (A condition in which your airways narrow and swell and produce extra mucus). The MDS also identified R6 received oxygen therapy and receives services with hospice. R6's care plan revised on 9/28/17, identified R6 had shortness of breath related to asthma which is triggered by laying flat while in bed. The care plan directs staff to elevate the head of the bed for optimal breathing. Additionally, the care plan interventions include oxygen therapy as needed to keep oxygen saturation levels great than 90% (A measurement of your blood oxygen level (SpO2), with abnormal reading typically between 95 and 100 percent. On 10/28/19, at 1:52 p.m. was observed resting in her bed with the head of her bed elevated. R6 respirations were easy, without cough or wheeze heard. R6 had an oxygen concentrator (A machine which condenses room air for oxygen administration) in her room, with a humidifier bottle and tubing in place which was dated 10/26/19. R6 stated she used this machine when she had an upper respiratory infection. Upon removal of concentrator filter from the back of the unit, it was dated 8/2017. The machine was labeled as being the property of Hospice. The removable filter was observed to have to have two darkened spots, gray/black in color which measured approximately 1.5 cm in diameter. On 10/31/19, at 11:35 a.m. registered nurse (RN)-D stated resident oxygen tubing and humidifier bottle was changed weekly on the weekend. RN-D stated the filters are cleaned weekly also, indicating a small black filter on the NewLife elite oxygen machine. RN-D was unaware of any other filters in place. On 10/31/19, at 11:40 a.m. Respiratory Services representative (RS)-A stated the concentrators which had disposable filters in place had date of service required label on the front of the machine. RS-A stated when the date presented for service, the concentrators were traded out, with the concentrator which required service to be returned to the company for service. On 10/31/19, at 2:29 p.m. the director of nursing stated the concentrators oxygen tubing and humidifier bubblers were changed on a weekly basis on the weekend. The DON stated concentrator filters were to be cleaned at that time also. DON stated the machine provided by the respiratory company were labeled with date recommended for service, however, she was uncertain as to the process for the the machines provided by Hospice. R18's quarterly minimum data set ((MDS) dated [DATE], identified R18 had moderate cognitive impairment and required extensive assistance with activities of daily living (ADL's). R18's care plan revised 4/4/19, identified continuous oxygen therapy related to [MEDICAL CONDITIONS] ( lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing). On 10/29/19, at 12:42 p.m. R18's filter located on back of oxygen concentrator (a medical device that concentrates oxygen from environmental air and delivers it to a patient in need of supplemental oxygen) covered in thick layer of gray debris which covered entire surface of black foam filter, filter approximately four inches by five inches and approximately 1 inch thick. On 10/29/19, at 2:58 p.m. oxygen concentrator continued to have thick layer of gray debris covering it. On 10/30/19, at 8:03 a.m. oxygen concentrator continued to have layer of gray debris. When interviewed on 10/30/19, at 1:21 p.m. nursing assistant (NA)-B stated NA's did not take care of oxygen equipment, only the nurses did. When interviewed on 10/31/19, at 9:43 a.m. registered nurse (RN)-A stated oxygen concentrator bubbles and tubing were changed on Saturday evenings and was not aware of any filters on the machines. Observed R18's oxygen concentrator 10/31/19, at 1:53 p.m. with RN-[NAME] Instruction sticker located on front of concentrator identified important air intake filter must be washed weekly. RN-A stated gray debris was approximately 0.1 centimeters (cm) thick and stated we have not been washing filters weekly. A facility policy, Oxygen Administration with Nasal Cannula, Face Mask, or Face Tent (or [MEDICAL CONDITION] or Endotracheal Tube), dated 10/17 indicated disposable equipment should be changed weekly or according to manufacturer's instructions. New equipment is to be labeled with the date changed and initials of staff performing. An AirSep Corporation service manual revised 2/2014, identified to ensure accurate output and efficient operation the air intake filter must be washed weekly in warm soapy water and rinsed.

Based on observation, interview and document review, the facility failed to ensure medications were administered in accordance with physician's orders/manufacturer's recommendations for 1 of 9 residents (R11) observed to receive medication during the survey. This resulted in a facility error rate of 6.67% (percent). Findings include: R11's (MONTH) (YEAR), Medication Administration Record [REDACTED] - [MEDICATION NAME] (drug which reduces the amount of acid in your stomach) 40 mg (milligram) one capsule daily in the morning, for [MEDICAL CONDITION] reflux (GERD) without esophagitis (inflammation/or irritation of the esophagus) with instructions to give at least 30 minutes prior to meals. - [MEDICATION NAME] (medication used when the [MEDICAL CONDITION] does not produce enough [MEDICAL CONDITION] hormone). 75 mcg (microgram) daily in the morning, for [MEDICAL CONDITION]. The manufacturers package insert for [MEDICATION NAME] revised 12/17, identified [MEDICATION NAME] should be given on an empty stomach, one-half to one hour before breakfast. During observation on 11/6/18, at 7:47 a.m. registered nurse (RN)-A was observed preparing medication for R11 which included [MEDICATION NAME] 40 mg and [MEDICATION NAME] 75 mcg. After preparing the medications RN-A administered the medications to R11, who was seated in the dining room, eating toast and cereal. During interview on 11/6/18, at 12:59 p.m. RN-A stated the morning medications could be administered one hour prior to the meal and up to one hour after breakfast meal. RN-A did not identify the [MEDICATION NAME] and [MEDICATION NAME] should be given at least a half-hour prior to eating. On 11/6/18, at 1:03 p.m. the director of nursing (DON) stated both medications should be given on an empty stomach, at least 30 minutes before eating. The DON stated the order for [MEDICATION NAME] specifically stated to give a half hour before meals. On 11/7/18, at 2:42 p.m. the consultant pharmacist (CP) stated [MEDICATION NAME] and [MEDICATION NAME] was to be given from a one-half hour to one and one-half hours before meals. The facility policy Medication Administration, Including Scheduling and Medication Aides dated 10/17, identified medication scheduling was to completed to maximize the effectiveness of the medication and to avoid potential significant medication interactions such as medication-food or medication-medication interactions.

Based on observation, interview and document review, the facility failed to comprehensively reassess and develop interventions to provide adequate supervision and safety with unsupervised smoking for 1 of 1 residents (R8) identified to have [MEDICAL CONDITION] their clothing and skin. This resulted in an immediate jeopardy (IJ) situation, substandard quality of care, for R8 who remained at risk [MEDICAL CONDITION] serious injury with unsupervised smoking. The IJ began on 11/28/17, when it was identified R8 had sustained repeated incidents of [MEDICAL CONDITION] his clothing and skin from unsupervised smoking. Although direct care staff had knowledge of these incidents, they had not been addressed and R8 was not comprehensively reassessed and interventions developed to provide adequate safety with independent, unsupervised smoking. On 11/29/17, at 5:06 p.m. the director of nursing (DON) and director of environmental services (DES) were notified of the IJ for R8. The IJ was removed on 12/1/17, at 2:19 p.m., however, non-compliance remained at an isolated scope and severity which indicated no actual harm with potential for more than minimal harm (Level D). Findings include: R8's annual Minimum Data Set ((MDS) dated [DATE], identified R8 had intact cognition, displayed verbal behavioral symptoms (i.e. yelling, cursing) and did not display any episodes of rejection of care. R8's medical [DIAGNOSES REDACTED]. Further, R8 required extensive assistance with activities of daily living (ADLs), total assistance from staff for transfers, and currently used tobacco products, however, displayed no skin tears,[MEDICAL CONDITION](2nd or 3rd degree) or other open [MEDICAL CONDITION] on his skin. Further, R8's Medical [DIAGNOSES REDACTED]. R8's last completed Tobacco Use assessment dated [DATE], identified R8 currently used tobacco and smoked over 10 times a day during all hours (i.e. morning, afternoon, night) with no desire to quit. R8 was able to make decisions regarding daily life independently and demonstrated no vision impairment(s), however, did have dexterity concerns which, would affect his/her ability to smoke or use tobacco products according to the assessment. The assessment did not identify what R8's identified dexterity concerns were, nor any information on how they would be addressed. R8 displayed no physical limitations which would interfere with their ability to get outside or back in the center. The assessment listed a section labeled, Safety, which identified R8 was able to light his own cigarette and contained a question of, Resident need for adaptive equipment, along with several choices to select including a smoking apron, cigarette holder, supervision, one to one assistance. The option for, None of the above, was checked. Further, the assessment identified R8 had no history or incidents with dropping the cigarette, falling asleep while smoking, burning himself or clothing, or other unacceptable tobacco-related behavior(s) in the past. The assessment lacked any information on physical location for R8's smoking, his ability to hold a cigarette or ash during use, or any history of attempted interventions which had been refused or unsuccessful for R8. R8's care plan printed 11/29/17, identified R8 had bilateral hand contractures due to a spinal cord injury along with limited physical mobility related to [MEDICAL CONDITION]. R8 was unable to transfer without staff assistance and a mechanical lift device, and demonstrated potential mood concerns along with notation he, easily angers towards staff. Further, the care plan identified R8 used tobacco products off facility grounds and listed a goal of, (R8) will safely use tobacco products in designated area. I will be free from burns. The only intervention listed to help meet this goal was identified as, I am independent with tobacco use, cigarettes and lighter are in a pouch on my wheelchair and always with me. The care plan lacked any further information, including any past offered or refused interventions, pertaining to R8's unsupervised smoking. On 11/28/17, at 1:58 p.m. R8 was observed to smoke. R8 wheeled himself out of his room in an electric wheelchair and proceeded down the hallway. R8 had visible contractures of his fingers on both hands. R8 proceeded to wheel himself past the reception desk in the main lobby of the facility and did not sign himself out of the facility prior to exiting the nursing home and going down to the end of the driveway, however, he remained on the nursing home property. R8 removed an opened package of cigarettes from his gray colored hooded sweatshirt front pocket and turned it upside down on his lap exposing a cigarette and standard lighter with a plastic body and metal sparkwheel. R8 picked up the cigarette using his thumb and pointer finger and placed it into his mouth, the rest of his fingers being contacted inwards towards his palm(s). R8 attempted several times to light the cigarette in his mouth using the lighter, however, was unable to after several attempts. R8 stated he had, lots of years practice, lighting his cigarettes in the wind and removed it from his mouth. R8 then used his right hand to hold the cigarette with his thumb and first finger as the remaining fingers were contracted inwards towards the palm. R8 used his opposite hand to hold the lighter. R8 then pressed into his abdomen with both hands while flicking the lighter several times with visible sparks and open flame being held immediately next to his sweatshirt as he attempted to light the cigarette and bring it to his mouth. R8 lit the cigarette and used his right hand to bring it to his mouth. R8 stated he smokes several times a day often going outside on his own to smoke, once every hour and a half or so. R8 stated he has burned himself before while smoking as ash or the cigarette cherry (red hot ash on the end of the lit cigarette) will fall off and he is unable to feel it on his skin due to poor sensation from his shoulders downward. R8 stated he last burned himself a couple weeks prior and showed the surveyor a visible, light brown colored scabbed area surrounded by light pink colored skin on the inner aspect of his first finger of his right hand. The area was approximately 0.5 centimeters (cm) in diameter and R8 added he had sustained burns, just like the one he showed, before. In addition, R8 then lifted up his gray colored sweatshirt and showed a visible, approximately 2.5 cm in diameter, hole in the center of the front side of the sweatshirt. R8 stated it was from a cigarette ash which had fallen on it from awhile prior. R8 stated none of the staff had spoken to him about his smoking, nor do they come outside with him while he smokes, however, when questioned about a smoking apron being used he replied, heck no. R8 stated if he were to have a complication or potentially start his clothing on fire, he would use his cell phone to call the nursing home and ask for help. R8 finished smoking his cigarette at 2:08 p.m. and removed it from his mouth using his right hand and tossed the remaining filter and butt into the street. R8 did not extinguish the cigarette before disposing of it. R8's most recently completed Skin Observation - V2 dated 11/21/17, identified R8 had a chronic pressure ulcer on his gluteal fold(s), however lacked any [MEDICAL CONDITION] skin injuries on his right hand. When interviewed on 11/28/17, at 2:24 p.m. nursing assistant (NA)-A stated R8 goes out to smoke after he gets up for the day and then is typically gone a few hours around town. NA-A stated she had never personally helped or gone outside to observe R8 while smoking, however, had noticed burn holes in his clothing before. The most recent burn holes being on his winter jacket, however, NA-A stated she was not sure if these were old or new burn holes though as he owned the coat for awhile. Further, NA-A stated R8 was independent with his smoking and staff did not help him, nor did R8 wear or use any adaptive devices while smoking to her knowledge. During interview on 11/28/17, at 2:28 p.m. NA-B stated R8 smoked independently and staff were, not supposed to, help him as if a resident wanted to smoke while living at the nursing home, they had to be able to do it without staff assistance because, That's just the policy here. NA-B stated she had noticed R8 to have [MEDICAL CONDITION] his hands before because it gets too hot and creates a blister, adding this happened every couple months. NA-B stated she last observed a burn on R8's hand approximately three months prior when completing range of motion on his hand(s) further adding, that's how I always notice them. Further, NA-B stated she had reported [MEDICAL CONDITION] the nurse(s), however, was unable to recall anyone specific it had been reported to. On 11/28/17, at 2:34 p.m. the surveyor and NA-B attempted to visit with R8 to observe his burn and go through his clothing to check for additional burn holes, however, R8 had left the facility and was not available. During interview on 11/29/17, at 8:49 a.m. laundry assistant (LA)-A stated she completed all personal laundry for R8 and was aware he smoked adding his hands aren't 100 percent functional. LA-A stated she had never noticed burn holes in his clothing before, however, added she doesn't look at them that close. LA-A turned and removed several pieces of clothing which had been hanging on a rack in the laundry room. R8 had a plain green colored shirt with several holes in the front. LA-A stated she felt these were wear holes though. LA-A removed the gray colored sweatshirt R8 had worn the day prior, when observed to smoke by the surveyor, and inspected it. LA-A verified a hole in the front of the sweatshirt and stated, I would say that was a cigarette burn. Further, LA-A stated she currently was not inspecting R8's clothing when completing his laundry, however, added I guess I should be checking (his) clothes better. When interviewed on 11/29/17, at 9:33 a.m. trained medication aide (TMA)-A stated R8 was a smoker and goes down to the end of the property to smoke after he gets up for the day. TMA-A stated R8 was independent with smoking and was able to safely use cigarettes and a lighter without assistance. TMA-A was unaware of [MEDICAL CONDITION] R8's skin or clothing, however, stated staff should report it right away to the charge nurse and complete an Stop-and-Watch (an 'early warning tool' used when a change is identified while caring for a resident). TMA-A stated she would assume R8 would just put out the cigarette and/or fire, if one occurred, while he was smoking as R8 took full responsibility for himself when smoking. R8 was to check in and out using a paper log when going outside to smoke. TMA-A showed this log to the surveyor which identified several empty spaces when R8 failed to sign himself back into the facility when he returned. TMA-A reviewed the record and stated R8 should be filling out the sign in/out record as he's been told to use it. Further, TMA-A stated staff did not inspect R8's skin when he returned from smoking or from his outings around town. An undated, blank Stop and Watch Early Warning Tool was provided. The form listed instructions to complete one when, you have identified a change while caring for or observing a resident, then to provide the form to a nurse for follow-up. Some examples provided on the form to be [MEDICAL CONDITION] for included, Seems different than usual, and, Change in skin color or condition. R8's medical record lacked any evidence one of these had been completed for [MEDICAL CONDITION] his skin or clothing. R8's medical record was reviewed. A handwritten progress note dated 4/16/13, identified R8 to smoke and did not want to pursue quitting at the time further adding him to, understands risk/benefit of all education and choices that he makes. The note lacked any information on what information related to safe smoking had been provided, nor what interventions, if any, were discussed and/or refused to ensure safe unsupervised smoking. An electronic progress note dated 6/21/17, identified R8 continues to be safe to smoke his cigarettes independently and hold them and the lighter at all times. The note lacked any observation, assessment or dictation to describe how this determination had been made of R8's unsupervised smoking abilities. R8's physician progress notes [REDACTED]. R8 was identified as a current smoker on each of the visits. On 2/14/17, R8 was identified as having [MEDICAL CONDITION] and needed to remain on [MEDICATION NAME] (medication used to treat anxiety and muscle spasms) for control of spasms. All of the provided notes lacked any dictation regarding smoking related injuries or his unsupervised smoking abilities. Further, the medical record lacked any identified reassessment of R8's unsupervised smoking abilities despite [MEDICAL CONDITION] clothing and skin described by NA-A and NA-B; any history of occupational therapy (OT) interventions for his smoking; nor evidence of other attempted interventions to promote safety with unsupervised smoking. In addition, the record lacked any documented or recorded incident report(s) related to the [MEDICAL CONDITION] on his clothing and skin as described by NA-A and NA-B, nor any evidence the facility had attempted to provide on-going collaboration with R8 to develop and implement interventions or therapies related to his unsupervised smoking. The facility provided no additional notes or medical record entries regarding these items during the survey. During interview on 11/29/17, at 12:47 p.m. NA-E stated she was aware R8 smoked and added it was the first thing he does when he goes and gets up. R8 was independent with his smoking and when he leaves to smoke, he is responsible for himself then. NA-E had never noticed or been told of [MEDICAL CONDITION] R8's skin or clothing before; nor had she ever seen him wear a smoking apron before, however, felt it would be a nice thing to have as R8 was not someone to report incidents, like dropping the cigarette or burning himself, to the staff. When interviewed on 11/29/17, at 12:54 p.m. NA-F stated staff don't help him (R8) with smoking. R8 goes outside and smokes on the street and, whatever happens outside of this building, we don't know it. Further, NA-F stated staff were not completing any formal skin checks or other interventions upon his return, but merely asking him how was it? On 11/29/17, at 1:03 p.m. registered nurse (RN)-C was interviewed and identified R8 was a quadriplegic, had poor sensation and contracted fingers on both hands and was supposed to sign himself out of the building each time he wanted to smoke as he was unable to smoke on facility grounds. RN-C was unaware of [MEDICAL CONDITION] R8's clothing or skin resulted from cigarette smoking as nothing got reported. RN-C stated if staff are [MEDICAL CONDITION] his clothing and skin, it should be reported to the nurses immediately so the physician can be updated and an incident report can be completed. Further, RN-C stated R8 was independent with using his cigarettes and lighter, however, added she had never watched him smoke personally nor was she aware how he had been assessed to be safe with smoking before the survey. During interview on 11/29/17, at 1:27 p.m. RN-B stated she had worked at the facility for approximately two and a half years and R8 had smoked since he came to the nursing home years prior. R8 typically gets assisted out of bed and then does his own thing in the community as he is unable to smoke on the campus grounds, however, RN-B added at times R8 will just go down to the end of the driveway and smoke in the later evening hours. RN-B stated she would assume a smoking assessment had been done on admission for R8, however, was not sure adding she had never assessed him with safe unsupervised smoking before. RN-B stated she was unaware R8 had been sustaining [MEDICAL CONDITION] his clothing and skin as it had not been reported to her or raised as a concern until now. RN-B stated she did not think OT had ever been consulted in the past to help address R8's unsupervised smoking adding, not since I've been here. Further, RN-B stated R8 burning himself while smoking made her feel like I should do something right now to help him as we got to be keeping him safe. When interviewed on 11/29/17, at 1:55 p.m. RN-D stated she was aware R8 goes outside to smoke, however, added she did not know the physical location(s) he was smoking when outside as, I don't feel like I'm his babysitter. R8 was his person when he left the facility. RN-D stated she was unaware R8 had a current cigarette burn on his hand, nor was she aware he had burn holes being observed in his clothing by staff. RN-D felt with R8's paralysis and poor sensation contributed that he, might not know its (cigarette burning his skin or clothes) happening, and NA staff should be reporting those things to nursing so it could be addressed for the resident's safety. On 11/29/17, at 2:15 p.m. the assistant director of nursing (ADON) was interviewed. ADON stated she had worked at the nursing home for nearly four years and R8 had smoked during that entire time. R8 was last assessed by ADON for smoking in September 2016 (assessment dated [DATE]), and she felt he was safe at the time. ADON stated R8 uses his thumbs a lot with everything including lighting his cigarettes, however, she was unable to recall how R8 lit the cigarette in 2016 when she last assessed him. ADON stated she was unaware R8 had been burning his clothes and skin with his cigarettes adding the NA staff had never reported those concerns to her. If the NA staff identify a new concern with a resident, like [MEDICAL CONDITION] clothing and/or on their skin, a stop-and-watch tool should have been completed so it could be addressed and R8 could be reassessed for his safety with smoking. Further, ADON stated she was unaware if anyone had discussed the risk [MEDICAL CONDITION] R8, nor had OT ever been consulted to help develop interventions to ensure R8 was safe with his unsupervised smoking. A provided UDA (user defined assessments) Reference Guide dated 12/1/17, was provided which identified it had been in use at the facility prior to survey. The guide listed several assessments along with their use, purpose and when to complete them. The Tobacco Use Assessment was listed which should be completed by a registered nurse or social worker, . on admission for residents who use tobacco products; required for all residents who smoke or use tobacco products when not previously completed; or when there is a change in cognitive ability, judgment, manual dexterity, and/or mobility. Further, the guide directed the assessment should be completed when an incident occurred and listed, smoking injury as an injury type. During interview on 11/29/17, at 2:28 p.m. OT-A stated she was new to the nursing home and unaware of the facility's policies and procedures regarding having a smoking safety assessment completed. OT-A reviewed the therapy record and stated there was no history of OT being consulted for R8 for his unsupervised smoking, however, OT-A stated there were definitely some compensatory methods which could be used so R8 did not have use his abdomen or chest to light his cigarettes and potentially burn himself or start his clothing on fire; including assessing his cognition, looking at his dexterity and handling skills while using a cigarette and just do a comprehensive assessment. R8 had impaired sensation and OT-A questioned, Does he (R8) even know he's being burned? Further, OT-A stated if someone with impaired dexterity and sensation was sustaining [MEDICAL CONDITION] unsupervised smoking, it would be OT appropriate to review them so as to assess functional deficits and safety. On 11/29/17, at 2:45 p.m. the director of nursing (DON) was interviewed regarding R8's unsupervised smoking. DON stated she started working at the nursing home in June 2017, and to her knowledge R8 had always refused interventions from staff for his smoking. R8 was his own person and will do whatever he dang well pleases, and had a history of [REDACTED]. DON stated the interventions offered to him in the past with his smoking were done as in passing conversations and they just had not been documented. DON stated she was unaware R8 had been burning himself while smoking as it had not been reported, however, if NA staff noticed [MEDICAL CONDITION] his clothing or on his skin, they should have completed a Stop-and-Watch so [MEDICAL CONDITION] be treated and staff can be looking at it. Further, DON stated the facility was ultimately responsible to ensure R8 was safe, however, when he signs himself out and leaves, he was his own person. During a follow up interview on 11/29/17, at 5:06 p.m. DON stated a report was made to the State agency (SA) regarding potential neglect for R8 since he had been sustaining [MEDICAL CONDITION] unsupervised smoking. A facility Smoke-Free Locations policy dated 3/2016, identified it applied to skilled care and smoking inside Good Samaritan Society (GSS) buildings was not permitted. The policy directed, All residents/clients who smoke or use tobacco products will be assessed. A procedure was listed which directed staff members would designate acceptable outdoor locations for resident smoking which must be readily visible for staff member observation. Upon admission, residents who use tobacco will have a Tobacco Use Assessment completed. Further, additional assessments would be completed if a resident has a change in cognition, judgment, manual dexterity or mobility. The policy lacked any direction or procedure for staff to implement on how to address cigarette burn(s) on clothing and/or skin, should they occur. A Smoking and Tobacco Use policy dated 4/2017, identified it applied to skilled care and listed a purpose of reaffirming the GSS commitment to a safe and healthy environment for employees, residents and visitors. The policy directed smoking shall be done away from the main entrance of the facility in spaces which were readily visible to staff. Further, Residents who smoke must not pose a safety hazard to themselves or others. The policy lacked any direction or procedure for staff to implement on how to address safety with smoking nor cigarette burn(s) on clothing and/or skin, should they occur. No further policies or procedures related to smoking safety or unsupervised smoking were provided. The IJ which began on 11/28/17, was removed on 12/1/17, at 2:19 p.m. after the facility successfully implemented a removal plan which included the following: - R8 was reassessed by nursing for unsupervised smoking which identified he required a smoking apron, cigarette holder, supervision and one on one assistance. R8 refused all of these interventions, however, R8 agreed to (OT evaluation for safety). Further, the assessment identified R8 to now have a history of smoking related incidents including a self reported incident of burning his finger which he failed to report as it was not a big deal. A subsequent progress note for R8's smoking reassessment dated [DATE], at 6:45 p.m. was authored by ADON. ADON explained to R8 they had reported the burn(s) for potential neglect of care while R8 demonstrated how he smoked. R8 was identified as reporting he had a[***]y lighter when observed by the surveyor on 11/28/17, and should have gotten a different one, instead of fighting with the[***]y one and almost burning my shirt. - An OT consultation was made for R8 to screen, assess and develop interventions for safe, unsupervised smoking. A provided OT Daily Treatment Note dated 12/1/17, identified R8 as having an incomplete SCI (spinal cord injury) at C5 - C7 (vertebrae), who had impaired sensation, impaired upper body strength and impaired motor control. OT completed a smoking evaluation which identified R8 was able to strike the lighter away from his body, however, (his) thumb still very near flame when lighting. Will need to further explore options to reduce risk of burn. Further, R8 agreed to trying a plastic-smoking adaptor and e-cigarettes, along with throwing out the cigarette mid-way before hot end nears hand. - Educating all staff on ensuring cigarette burn(s) on clothing and/or skin were immediately reported and documented. On 12/1/17, from 2:01 p.m. to 2:18 p.m. nursing and direct care staff were interviewed to ensure training had been provided related to R8's unsupervised smoking including ensuring R8's skin and clothing was routinely monitored for potential burn injuries, use of the Stop-and-Watch tool and communicating changes in resident conditions timely, and documentation standards pertaining to a change in condition.

Based on observation, interview, and document review, the facility failed to ensure each resident was provided with ambulation services when recommended, and assessed when ambulation ability declined for 1 of 3 residents (R2) reviewed for ambulation services. This practice resulted in actual harm for R2, when she experienced an avoidable decline in ability to ambulate. Findings include: R2's [DIAGNOSES REDACTED]. R2's care plan dated 11/28/12, directed staff to assist with a restorative nursing program to include ambulation, with one assist and rolling walker, to and from all meals as tolerated. In addition, the care plan directed staff to assist with a daily exercise program to include: the use of a Restorator (an exercise machine) as tolerated and/or standing alternate marches 20 repetitions total with upper extremity use on walker. Step up onto wooden box of six inches, and/or 3 pound seated exercises 20 repetitions bilateral. Pulleys for 5 minutes and red pegs and putty. R2's Physical Therapist Progress & Discharge Summary dated 5/10/13, included physical therapy (PT) had worked with R2 4/15/13 through 5/10/13, due to a decline in ability to transfer in and out of bed. The summary directed nursing staff to continue her ambulation program. The "Current Level of Function," concluded R2 was able to ambulate 60 to 100 feet, with a front wheedled walker, with minimum assistance to hold onto R2 and pull the wheel chair behind. R2's Care Plan Approaches Report from May 1, 2013 through October 31, 2013, showed R2 had the opportunity to ambulate to and from meals as directed by the care plan 655 times. The documentation showed R2 only actually ambulated to and from meals 103 times. R2 had refused 113 times. There was no evidence R2 had been offered assistance to ambulate to and from meals the other 439 times during this time frame. There was no documentation to indicate why R2 had not ambulated these 439 times. R2's Care Plan Approaches Report from July 1, 2013 through October 31, 2013 showed R2 had not participated in the exercise program with the Restorator, standing marches, pulleys or pegs exercises at all. R2 should have been offered this program daily for the 123 days in this time period. There was no documentation to indicate why it was missed for all 123 days. On 10/28/13, at 5:02 p.m. R2 was sitting in the dining room in her wheel chair. At 6:10 p.m. she was propelled out of the dining room in her wheel chair by an unknown staff person. At 6:50 p.m. R2 was observed in her room sitting in her wheelchair watching television. When interviewed on 10/30/13, at 11:30 a.m. nursing assistant (NA)-B stated she works as a dining aide in the mornings and does the restorative programs in the afternoons. NA-B said the facility use to have a full day restorative nurse aide, but that had changed in April 2013, to just half a day. NA-B stated there is not enough time to do everyone's restorative program, but verified she had not reported this to anyone. NA-B had never assisted R2 to do her exercise program that was care planned to occur every day. She had not been instructed to do so. When interviewed on 10/31/13, at 1:31 p.m. R2 stated she use to walk to and from all the meals and that she requires assistance from staff to do this. R2 stated that about six months ago, staff just stopped asking her to walk and now they just automatically take her to meals in her wheel chair. R2 did not know about doing any exercises, and said she had not been offered any. On 10/31/13, at 1:42 p.m. R2 was sitting in her wheelchair in her room. R2 requested to lie in bed. Nursing assistant (NA)-A and trained medication aide (TMA)-A assisted R2 into bed, with two person assist. NA-A stated R2 had not ambulated to and from lunch today. NA-A stated that since she had started working in the facility in June 2013, she had never seen R2 ambulate to and from meals. NA-A was unaware R2's care plan directed staff to assist her to ambulate to and from meals. NA-A was not aware of any other exercise program R2 was supposed to participate in either. On 11/1/13, at 9:19 a.m. R2 was in the hallway next to the dining room sitting in her wheelchair, using the hallway grab bars to pull herself down the hall. R2 was asked by the physical therapist (PT)-A if she could watch her walk. R2 replied, "I can't walk anymore." R2 agreed to attempt to ambulate. NA-A and NA-D assisted R2 to stand with a transfer belt and front wheeled walker. R2 was able to ambulate 20 feet with weight bearing assistance of two nursing assistants who were also pulling the wheel chair behind her. PT-A stated in May 2013, R2 was able to ambulate 60 to 100 feet with only one assist, for balance. PT-A stated R2 had declined in her ability to ambulate. PT-A stated staff needed to encourage R2 to ambulate more. When interviewed on 11/1/13, at 9:43 a.m. NA-C stated R2 use to ambulate to meals, but could not anymore, "it is too hard for her to move her feet." NA-C stated this change occurred over the past six months, but NA-C confirmed she had not reported this change to anyone. NA-C further stated the nursing assistant assigned to do the restorative programs often gets pulled from doing that duty to work on the floor indicating this happens when staff call in sick, or when they are "just short." R2's Interdisciplinary Assessments and Summary Quarterly review dated 8/7/13, included "Resident has goals of participation in AMB (ambulation) and OT/PT (occupational therapy and physical therapy)...Resident continues to AMB (ambulate) (with) assist of (two) to get up then (one) assist to AMB (ambulate). Often refuses with no other reason than "I'm [AGE] years old." Will continue goals..." R2's Quarterly review dated 10/21/13, included, "... Goal of ambulating to all meals not met r/t (related to) refusals. Simply states, "I'm a hundred, I shouldn't have to..." When interviewed on 11/1/13, at 10:05 a.m. the assistant director of nursing (ADON) stated she does the reviews on each resident's restorative nursing program every month, but was unaware R2 had not been participating with the restorative nursing programs including exercise and ambulation as directed by the care plan. The ADON said if R2 was refusing, it should be documented and reported to her. The ADON stated she should review the Care Plan Approaches Reports and speak with nursing assistants when she reviews the restorative programs, but had not. The ADON did not know why her Interdisciplinary Assessment and Summary reviews did not address the exercise program R2 had been care planned to do. R2's Therapy Screen Form dated 11/1/13, included R2 had a change in condition and this change required modification of the functional maintenance program. When interviewed on 11/1/13, at 10:33 a.m., the Director of Nursing (DON) stated they had a restorative aid who quit in January 2013, and they had hired staff to complete the restorative programs, but was not aware the programs were not being implemented. The DON stated R2 has refused to ambulate at times, she was not aware it wasn't being offered. The DON stated she did not know R2 had never received the exercise program which could have helped with R2's strength and endurance. The facility's Restorative Nursing Program/ Restorative Nursing Documentation policy, last revised 1/2013, indicated the purpose is to document restorative nursing appropriately. "... for re-screens, document if a functional change has occurred; upon comparison with last screen, do follow-up and make referral to therapists as necessary... lack of progress and reason as well as any increase/ decrease in goals."