Every finding on record at Lutheran Home

3.) On 6/09/25, at 9:52 AM, Surveyor observed a wound treatment on R77. There was a sign for Enhanced Barrier Precautions, which directs gown and gloves with touching R77 body. The wound treatment was performed by Registered Nurse (RN) -C. R77 has 3 wounds and RN-C did not utilize a gown for personal protective equipment (PPE) during the wound treatments. RN-C set-up wound supplies on the over bed table. The RN-C did not have a gown and wore a surgical mask and gloves. R77 has a pressure injury of eschar on the left heel. RN-C removed pressure relief boot and sock from the left foot. The RN-C applied a skin prep wipe to the left heel eschar area. RN-C performed the treatment without a PPE gown. R77 has a pressure injury, stage 4 wound, on the right outer ankle. RN-C performed the treatment without a PPE gown. RN-C re-applied R77 socks and pressure relief boots. R77 has a Foley catheter for their bladder. RN-C unfastened R77 incontinence brief and assisted in turning R77 on their side. RN-C did not utilize a PPE gown. R77 has a pressure injury, stage 3 wound, on the sacrum. RN-C performed the treatment without a PPE gown. On 6/09/25. at 10:36 AM, Surveyor interviewed RN-C. RN-C stated They forgot to wear the PPE gown. On 6/9/25, at 3:10 PM, at the facility exit meeting with Nursing Home Administrator (NHA) -A and Director of Nurses (DON-B. Surveyor shared the concerns with the observation with R77's wound care. Based on observation, interview, and record review, the facility did not maintain an infection and control program designed to provide safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases for 4 (R87, R12, R77 and R528) of 26 residents reviewed for Infection Control practices. * Surveyor observed Wound Medical Doctor (MD)-O, Nurse Manager-J, and Wound tech-P perform wound care for R87 without wearing proper Personal Protective Equipment (PPE). *Surveyor observed Certified Nursing Assistant (CNA)-K provide bowel incontinence care for R87 and did not change gloves and wash hands prior to performing peri care/catheter care. *Surveyor observed Advanced Practice Nurse Practitioner (APNP)- Q assess R87's right lower leg wound without proper PPE. *Surveyor observed Wound MD-O not wearing a glove while performing wound debridement for R12's wound care. *Surveyor observed PPE not worn while providing incontinence cares for R12. *PPE not used for R528 while performing tube feeing cares. *PPE not used during wound care for R77. Findings: The Facility's policy titled Enhanced Barrier Precautions (EBP), dated 05/01/2024, documents in part . PROCEDURE: . 5. Staff caring for residents in EBP will need to wear proper PPE with high contact resident care activities. High contact resident care activities include bathing, dressing, transfers, toileting, hygiene, changing linen wound care or device care. 6. Gowns and gloves MUST be worn when performing any high-contact resident care activities: a. Dressing, bathing, showering, hygiene b. Transferring c. Changing linens or briefs d. Toileting e. Device care: central line, urinary catheter, feeding tube, etc. f. Wound care . 1.) R87 was admitted to the facility on [DATE], with diagnoses including [NAME]-[NAME] syndrome (a rare autoimmune disorder of the neuromuscular junction where the immune system attacks nerves and muscles, leading to muscle weakness and other symptoms), neuromuscular dysfunction of bladder (a condition where the nerves controlling bladder function are damaged or not functioning properly, leading to difficulty in controlling urination), pain, cellulitis (a bacterial skin infection affecting the deeper layers of the skin and underlying tissue, often caused by bacteria like Streptococcus or Staphylococcus entering through a break in the skin) of right lower limb and urine retention (the inability to fully or completely empty the bladder, resulting in a buildup of urine). R87's quarterly Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact) for R87, that R87 is able to understand and be understood, is dependent on staff for toileting hygiene, substantial/maximal assistance with shower/bathing and has an indwelling urinary catheter. On 06/04/2025, at 11:35 AM, Surveyor noted an Enhanced Barrier Precaution (EBP) sign on R87's door. Surveyor was speaking with R87 in R87's room, when Wound MD-O, Nurse Manager-J, and Wound tech-P came into R87's room, Surveyor noted none of the staff were not wearing gowns. Surveyor observed Wound MD-O measure and clean R87's right lower leg wound without gloves. Surveyor left the room with Wound MD-O, Nurse Manager-J, and Wound tech-P. Surveyor noted Wound MD-O began typing on his computer and did not wash or sanitize his hands. On 06/04/2025, at 11:46 AM, Surveyor interviewed Wound MD-O. Surveyor asked Wound MD-O why Wound MD-O did not don EBP PPE to perform wound care for R87. Wound MD-O indicated that Wound MD-O was early, and the nurse was not ready. On 06/09/2025, at 06:50 AM, Surveyor observed CNA-K provide bowel incontinence care and catheter care for R87. Surveyor noted that R87's bowel movement was a loose consistency and was covering R87's peri area as well. CNA-K cleaned R87's bowel movement. CNA-K then began cleaning R87's peri area and providing catheter care with unchanged dirty gloves. Surveyor observed CNA-K begin to put R87's clean brief on with unchanged dirty gloves. Surveyor intervened and encouraged CNA-K to change gloves, perform hand hygiene and re-clean R87's peri area and catheter. Surveyor observed CNA-K clean R87's peri area and noted fecal matter being cleaned that was left behind. On 06/10/2025, at 10:04 AM, Surveyor observed APNP-Q, and student, enter R87's room to assess R87's right lower leg wound. Surveyor noted that neither staff were wearing gowns for EBP PPE. Surveyor observed APNP-Q and student remove R87's wound bandage and assess R87's wound. Once APNP-Q was done assessing R87, Surveyor asked APNP-Q if R87 is on EBP, APNP-Q indicated yes. Surveyor asked APNP-Q why APNP-Q did not follow EBP, APNP-Q informed Surveyor that it was an oversight. On 06/09/2025, at 12:50 PM, Surveyor interviewed NHA-A, DON-B and ANHA-M of the concerns for R87. DON-B indicated that EBP should be followed for wounds and catheters and is expectation to be worn when providing cares. DON-B indicated that proper PPE would include gown and gloves. On 06/10/2025, at 10:19 AM, Surveyor informed NHA-A and DON-B of above findings. No further information was provided at time of write up. 2.) R12 was admitted to the facility on [DATE], with diagnoses which include need for assistance with personal cares, pressure ulcer (a skin and soft tissue injuries caused by prolonged pressure on the skin, often leading to tissue death and open wounds) of right heal, scoliosis (a condition where the spine curves abnormally, often appearing as an S or C shape) and adult failure to thrive (a condition where a child's physical growth and development slow down or stop, usually due to inadequate nutrition). R12 admission MDS, dated [DATE], documents that R12 is able to understand and be understood, a BIMS (brief interview for mental status) of 13 (cognitively intact), that R12 is at risk for pressure ulcers/injuries and that R12 has unhealed pressure ulcers/injuries. On 06/04/2025, at 11:41 AM, Surveyor observed an EBP sign on R12's door. Surveyor observed Wound Tech-P enter R12's room without a gown and assist R12 into bed and removed R12's wound dressing. On 06/04/2025, at 11:54 AM, Surveyor observed Wound MD-O and Nurse Manager-J come into R12's room wearing gowns. Surveyor noted Wound MD-O only had one glove on his left hand. Surveyor observed Wound MD-O perform wound debridement of R12's wound using Wound MD-O 's ungloved right hand. On 06/04/2025, at 11:58 AM, Surveyor asked Wound MD-O again why Wound MD-O did not use a glove while performing wound debridement for R12. Wound MD-O indicated that gloves are to protect yourself and not to protect the resident. Surveyor asked Wound MD-O if not wearing proper PPE during wound cares is common practice for Wound MD-O. Wound MD-O indicated that EBP are to prevent transmission of bacteria from one patient to another, and that nothing actually touched the patient. On 06/09/2025, at 07:21 AM, Surveyor observed CNA-K provide incontinence cares for R12 and observed CNA-K did not wear a gown during this high contact care activity. Surveyor observed CNA-K clean R12's peri area with the same washcloth, and unchanged dirty gloves CNA-K used to clean fecal matter. CNA-K started to put a new brief on R12, Surveyor intervened CNA-K and encouraged CNA-K to change gloves and perform hand hygiene. CNA-K changed gloves, preformed hand hygiene and re-washed R12's peri area with a clean washcloth. On 06/09/2025, at 11:42 AM, Surveyor interviewed Infection Preventionist (IP)-N regarding the concerns for R12 and R87. IP-N indicated that any resident with a urinary catheter, tube feed, chest tube, intravenous line or chronic wounds is on EBP. IP- indicated that the expectation is that gown and gloves are worn during high contact activities and any staff performing any type of cares for those residents should be using PPE. IP-N indicated that it would be expected that staff wear gloves during wound care and there is never a time where it is ok to not wear gloves during wound care. On 06/09/2025, at 12:50 PM, Surveyor interviewed NHA-A, DON-B and ANHA-M of the concerns for R12. DON-B indicated that EBP should be followed for wounds and catheters and is expectation to be worn when providing cares. DON-B indicated that proper PPE would include gown and gloves. On 06/10/2025, at 10:19 AM, Surveyor informed NHA-A and DON-B of above findings. No further information was provided at time of write up. 4.) R528 was admitted to the facility on [DATE] with diagnosis of malignant neoplasm of tongue, Barrett's esophagus without dysplasia, dysphasia, adult failure to thrive, cachexia. R528's admission Minimum Data Set (MDS) assessment, dated 5/22/2025, documented a Brief Interview Mental Status (BIMS) score of 15, indicating cognitive awareness. Section B, documents that R528 is understood and understands. R528's (requires enhanced barrier precautions) care plan, dated 5/17/2025, documents: Resident requires enhanced barrier precautions related to Percutaneous Endoscopic Gastrotomy (PEG) tube. Surveyor observed no sign on R528's door indicating a need for enhanced barrier precautions with cares. On 6/5/2025, at 8:37 AM, Surveyor observed Licensed Practical Nurse (LPN)-S, flushing R528's tube feeding. LPN-S did not have on a gown. Surveyor interviewed LPN-S who indicated that if Personal Protective Equipment (PPE) was needed it would indicate it on the door. LPN-S stated that with R528 being a tube feeding resident, that a sign should be there. LPN-S indicated that with all residents with tube feeding that they should have a sign and PPE should be worn. On 6/10/2025, at 9:38 AM, Surveyor interviewed the Unit Manager, Registered Nurse (RN)-C, who stated that during cares with the tube feeding that staff needs to wear PPE. RN-C indicated that would include a gown and that per facility policy a sign should be on the door to notify staff of enhanced barrier needs. RN-C indicated that last week there was an extra sign for enhanced barrier on the treatment cart and believes that might be when the sign fell off R528's door. On 6/10/2025, at 12:16 PM, Surveyor informed Nursing Home Administrator (NHA)-A, of the concern with R528's enhanced barrier not being followed per care plan and policy. No additional information received as to why R528 had cares completed with no gown being used by staff and no sign on the door to notify staff of need for enhanced barrier PPE.

3.) On 2/11/25, the nurses note indicates R54 was experiencing a change in condition and was sent to the hospital. The nurses note on 2/11/25 indicates R54 was being admitted to the facility due to influenza and needing dialysis. On 6/9/25 at 3:10 p.m., during the daily exit meeting with NHA(Nursing Home Administrator)-A and DON (Director of Nursing)-B, Surveyor asked for a copy of the transfer and bedhold notice given to R54 for the 2/11/25 hospitalization. On 6/10/25 Surveyor received the transfer and bedhold notice dated 2/12/25 for R54. The transfer and bedhold notice does not include email address for state agency and facility and does not include information regarding the Ombudsman and how to contact the ombudsman. On 6/10/25 at 10:45 a.m. Surveyor interviewed NHA-A. NHA-A stated she understood the concern and had no additional information. Based on record review and interview, the facility did not provide the required documentation with resident transfers to the hospital. This was observed with 4 (R22, R86, R54, and R77) of 5 resident hospitalization reviews. * R22, R86, R54, and R77 were transferred from the facility to a hospital. The facility Transfer Notice did not include contact information of the Office of the State Long-Term Care Ombudsman. The Appeals contacts did not include emails of the contacts and resident transfers were not sent to a representative of the Office of the State Long-Term Care Ombudsman. Findings include: The facility does not have a specific Transfer Notice Requirements policy and procedure On 6/09/25 at 9:40 AM, Surveyor interviewed the Social Worker (SW)- D, who is responsible for notifying the Ombudsman with resident transfers. SW-D stated they will look for a notification of when a resident transfers. SW-D stated the facility will call the Emergency Contact with a Bed Hold Notice and mail the notice to the emergency contact. SW-D did not create the Bed Hold and Transfer documentation that is provided. Surveyor reviewed the facility's transfer notices and noted that there is no contact information for the Office of the State Long-Term Care Ombudsman, and no email contacts for the Appeals Agencies. On 6/09/25, at 12:01 PM, Nursing Home Administrator (NHA)-A, Director of Nurses (DON)-B spoke with Surveyor. NHA-A informed Surveyor that NHA-A did not realize the Ombudsman was not being identified on the Transfer Notice. NHA-A stated The Social Worker thought the Ombudsman is notified with discharges and not transfers. 1.) R22's medical record was reviewed by Surveyor. R22 was transferred to the hospital on 2/11/25 and returned to the facility on 2/17/25. R22's Transfer Notice did not have documentation including: The email of the State entity which receives such appeal hearing requests; The name, address (mailing and email), and phone number of the representative of the Office of the State Long-Term Care ombudsman. Surveyor noted that the transfer notice was not sent to a representative of the Office of the State Long-Term Care Ombudsman. R22 was transferred to the hospital on 3/6/25 and returned to the facility on 3/11/25. R22 Transfer Notice did not have documentation including: The email of the State entity which receives such appeal hearing requests; The name, address (mailing and email), and phone number of the representative of the Office of the State Long-Term Care ombudsman. Surveyor noted that the transfer was not sent to a representative of the Office of the State Long-Term Care Ombudsman. 2.) R86 was transferred to the hospital on 2/19/25 and returned to the facility on 3/3/25. R86 Transfer Notice did not have documentation including: The email of the State entity which receives such appeal hearing requests; The name, address (mailing and email), and phone number of the representative of the Office of the State Long-Term Care ombudsman. Surveoyr noted that the transfer notice was not sent to a representative of the Office of the State Long-Term Care Ombudsman. R86 was transferred to the hospital on 3/24/25 and returned to the facility on 3/26/25. R86 Transfer Notice did not have documentation including: The email of the State entity which receives such appeal hearing requests; The name, address (mailing and email), and phone number of the representative of the Office of the State Long-Term Care ombudsman. Surveoyr noted that the transfer notice was not sent to a representative of the Office of the State Long-Term Care Ombudsman. R86 was transferred to the hospital on 3/18/25 and returned to the facility on 3/21/25. R86 Transfer Notice did not have documentation including: The email of the State entity which receives such appeal hearing requests; The name, address (mailing and email), and phone number of the representative of the Office of the State Long-Term Care ombudsman. Surveoyr noted that the transfer notice was not sent to a representative of the Office of the State Long-Term Care Ombudsman. No additional information was provided. 4.) On 6/10/2025, Surveyor reviewed R77's nursing progress note dated 4/17/25 indicating x-ray results positive for displaced fractur of distal femur. Surveyor observed orders to send out to the hospital. On 6/10/2025 Surveyor reviewed the transfer and bed hold notice dated 4/17/2025 for R77. surveyor noted that the transfer and bed hold notuce did not include an email address for state agency and facility and does not include information regarding the Ombudsman and how to contact the ombudsman. On 6/10/2025, at 12:16 PM, Surveyor informed Nursing Home Administrator (NHA)-A of the concern with R77's bed hold document. NHA-A stated she understood the concern and had no additional information.

Based on observation, interview, and record review the facility did not ensure each resident receives, and the facility provides food prepared by methods that conserve nutritional value, flavor, and appearance. This deficient practice had the potential to affect 8 residents receiving a puree diet. The recipe for preparing pureed diet was not followed to ensure puree food is prepared by methods that conserve nutritional value, flavor and appearance. Findings include: The facility policy and procedure titled General Food Preparation reviewed 6/2025 documents (in part) . . Policy Statement: All food must be prepared in a manner that maintains its safety, quality, and nutritional value. Proper food handling techniques must be followed at all times to prevent forborne illness and ensure resident satisfaction. 3. Special Diets and Resident Needs: Follow individualized dietary plans as ordered by the registered dietician or physician. Ensure consistency-modified diets (e.g., pureed, mechanical soft) are prepared correctly to reduce the risk of choking. 1.) On 6/5/25 at 9:00 AM, Surveyor observed Cook-F prepare pureed greens. Surveyor observed the recipe on the table and Cook-F looked at the recipe before preparation. Cook-F informed Surveyor he is making enough for 10-12 servings. Using a metal strainer, cook-F removed a scoop of greens from the metal cooking tub. Surveyor noted the strainer to be approximately 1/2 - 3/4 full. Cook-F placed the greens in the food processor. Surveyor asked how much greens were added, Cook-F pointed to the strainer and said, That's a quart. Cook-F then picked up a metal pitcher containing a white powder and added the contents all at once into the food processor. Surveyor asked what the white powder was. Cook-F replied thickener. Surveyor asked how much thickener was in the container that was added. Cook-F stated I don't know, it was maybe a 1/4 full. Cook-F then poured water from a pitcher into the food processor, mixed the contents together, looked in and added more water. Surveyor asked if there is a specific measured amount of thickener to add. Cook-F stated No, I just add it and then keep checking it. Surveyor asked if there is a specific measured amount of water to add. Cook-F stated No, I just keep adding it as I need to for it to get to like pudding or mashed potatoes. Surveyor asked if he adds anything besides water to achieve the desired consistency. Cook-F stated, No, when I was trained I was told to add water. Surveyor stated So you just add as much thickener as you think you will need and then as much water as you think you will need to get to the desired consistency. Cook-F stated Yes. Surveyor noted nothing else was added to the food processor. Surveyor reviewed the Dining Manager recipe used titled Pureed Greens copyright 2025 which documented: Ingredients: Greens 10 servings - 1 qt (quart) 1 cup. Margarine, solids - 1/4 cup Place prepared vegetables and margarine in a washed and sanitized food processor; blend until smooth. *Note: Any liquid specified in the recipe is a suggested amount of liquid (if needed). Some recipes items will require no liquid added to achieve the desired consistency. 1. If product needs thinning, gradually add an appropriate amount of liquid (NOT WATER) to achieve a smooth, pudding or soft mashed potato consistency. 2. If the product needs thickening, gradually add a commercial or natural food thickener (ex, potato flakes or baby rice cereal) to achieve a smooth, pudding or soft mashed potato consistency. 3. Follow any facility policies/procedures, such as the puree volume method procedure, to ensure a correct portion is served. Top pureed foods with appropriate sauces or gravies, as needed, to ensure adequate moisture for safe consumption and enhance flavor. On 6/5/25 at 9:17 AM, Surveyor spoke with Dining Director-G. Surveyor advised the recipe for pureed greens did not indicate an amount of how much thickener should be added. Dining Director-G stated I would think that would be listed on there somewhere. Surveyor advised the recipe indicates to add liquid (not water in capital letters) if product needs thinning, and asked what liquid should be used to thin. Dining Director-G stated Like a vegetable based broth or something similar to that. Surveyor asked if the strainer used to remove the greens has an amount on it to indicate how much it holds. Dining Director-G replied I don't think so. Surveyor advised Dining Director-G of observation and concern the recipe for pureed greens was not followed. The amount of greens was not measured, margarine was not added, the amount of thickener was not measured, was added all at once (not gradually as recipe indicates), amount of water was not measured, was added all at once (not gradually as recipe indicates), and the recipe indicates in capital letters not to use water to thin. Dining Director-G reported she believed there is another more detailed recipe that is kept in binders, and she will look for it. Surveyor advised this is the recipe cook-F followed during observation. On 6/5/25 at 10:29 AM, Dining Director-G advised Surveyor she spoke to the company that creates the recipes. She reported they do not specify the amount of thickener because it varies, and they recently discussed liquid for thinning. Dining Director-G stated Going forward they will specify what liquid to use for thinning, for example broth, water, milk. Dining Director-G advised Surveyor cook-F is currently going through ServSafe training. On 6/5/25 at 11:05 AM, Surveyor advised Assistant Director of Nursing (ADON)-I of the above concerns regarding observation of the recipe not followed during pureed food preparation. No additional information was provided. On 6/10/25 at 8:12 AM, Surveyor spoke with Executive Chef-H and viewed the strainer that was used to remove the greens for puree food preparation. Surveyor advised cook-F reported the strainer was a quart size. Surveyor asked how do you know this holds a quart. Executive Chef-H stated I don't know, I did look at it after and could not find any measurement on it, maybe it is worn off or something. Surveyor confirmed there was no measurement indicated on the strainer to to confirm it is indeed a quart. Executive Chef-H stated No, not unless we put something in it to verify the measurement. No additional information was provided.

Based on observation, interview and record review the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 3 resident unit refrigerators in the facility. This deficient practice had the potential to affect 46 residents residing on the affected unit. Residents' food stored in the refrigerator was not labeled and/or dated. The refrigerator temperature was not within the recommended temperature for safe food storage. Findings include: The facility policy and procedure titled Food Storage-Resident reviewed 1/29/24 documents (in part) . Policy statement: All perishable food items brought in by family and visitors must be refrigerated and labeled. 1.0 Perishable food brought in by family or visitors will be labeled by nursing staff and refrigerated. 2.0 Labels will state residents name, date received/opened and discard date. 3.0 A food chart is maintained on each refrigerator indicating the discard date for each food item. Any questions regarding discard dates should be directed to Dining and Hospitality. 4.0 All food items must be monitored daily by nursing staff to ensure food items are within labeled dates. 5.0 Daily temperature logs will be maintained by nursing staff to ensure proper temperature of refrigerators. 6.0 Any items found outside of the discard date will be discarded and the resident and/or family will be notified. The facility policy and procedure titled General Food Preparation reviewed 6/2025 documents (in part) . 3. Label and date all prepared and stored meals for specific residents. 4. Food Storage. Label all foods with the date of receipt and/or preparation. Maintain proper refrigeration and freezer temperatures: Refrigerator </= (less than or equal to) 41 degrees F (Fahrenheit). 6. Maintain temperature logs for food storage and cooking. Conduct routine audits and inspections to ensure compliance with policy. 1.) On 6/4/25 at 9:35 AM, Surveyor observed the unit refrigerator on 3 North [NAME] (NW). Surveyor noted the temperature gauge inside the refrigerator read 68 degrees Fahrenheit. Inside the refrigerator, Surveyor located a plastic bag with 2 Styrofoam containers containing food which was not labeled with a name and was not dated. Surveyor observed a plate covered with with aluminum foil labeled with R111's name which was not dated. Surveyor noted a log on the side of the refrigerator was complete for temperature checks dating back to January 2025. The top of the form documents: Daily Food Refrigerator Temperature Monitoring. Temperature should be kept between 37-41 degrees Fahrenheit. By initialing below you are acknowledging the temperature is within range, the fridge is clean and all resident food is labeled/unexpired. Surveyor reviewed the temperature log from January though June 2025. January: All temperatures documented were greater than (>) 41 degrees. February: All temperatures documented were >41 degrees. March: All temperatures (with exception of 3 dates) documented were >41 degrees. April: All temperatures (with the exception of 3 dates) documented were >41 degrees. May: All temperatures documented were >41 degrees. June all temperatures documented were >41 degrees. The documented temperatures ranged from 48-52 degrees from 6/1 through 6/4/25. On 6/4/25 at 11:15 AM, Surveyor recheck of the 3NW unit refrigerator and noted the thermometer read 58 degrees Fahrenheit. On 6/4/25 at 1:58 PM, Surveyor asked Nurse Manager (NM)-J to view 3NW refrigerator temperature with Surveyor. The temperature gauge inside the refrigerator read 58 degrees. Surveyor advised the log indicates the temperature to be kept between 37-41 degrees. Surveyor asked what is the protocol if the refrigerator temperature is this high. NM-J stated They should be turning the temperature down so that it's within the range. Surveyor advised NM-J of the resident food containers inside the refrigerator that are not labeled and/or dated. NM-J stated I will throw that out because anything that doesn't have a name or date should be thrown out. Surveyor advised NM-J of the temperature log dating back to January 2025 documentation of temperatures above the recommended range. NM-J stated I think this log was from the old fridge that wasn't working, this might be a new fridge from like a month ago, but don't quote me. On 6/4/25 at 2:00 PM, During the daily exit meeting, the facility was advised of concern regarding the 3NW unit refrigerator temperature above the recommended range and resident food items not labeled and/or dated. On 6/5/25 at 8:30 AM, Surveyor noted the 3NW unit refrigerator had been removed. No additional information was provided.

Based on observation, interview, and record review, drugs used in the facility were not labeled in accordance with currently accepted professional principles, to include the expiration date when applicable for 2 of 2 medication rooms and 1 of 3 medication carts observed. Medication rooms and carts contained insulin that was expired, and insulin and eye drops that were not dated when opened. Findings include: The facility policy and procedure titled Medication and Vaccine Storage effective date [DATE] documents (in part) . . Policy statement: Medications will be stored safely, securely and properly. The medication supply will only be accessible to licensed nursing personnel, pharmacy personnel, and staff members authorized to pass medications. 5. Outdated or contaminated medications or those in cracked or soiled or without secure closures are removed from the medication cart and disposed of properly. Medications will be reordered as needed. 9. Medications will be stored in their original packing until ready for administration. If multi-dose, medication should be dated. 11. Insulin is to be refrigerated until opened. Once open, insulin can remain at room temperature until expiration, based on guidelines for specific product. The facility provided a Health Direct Pharmacy Services form Titled Insulin Expiration Dates: Update dated [DATE], which documented (in part) . . All insulin's should be stored in the refrigerator until opening and protected from light. Once opened or removed from the refrigerator for storage in the medication cart, the insulin should be dated as it will expire in a specific time per manufacturer. The facility provided a Health Direct Pharmacy Services form titled Ophthalmic Medication Beyond Use Date Guide dated [DATE], which documented (in part) . . It is good standard of practice to date an ophthalmic (eye) medication upon opening, as the date should be tracked according to the facility policy to reduce the risk of using contaminated products. 1.) On [DATE] at 12:26 PM, Surveyor observed the 2nd floor medication room. Inside the refrigerator, Surveyor located a Lispro insulin vial belonging to R52 dated opened 5/5 expired 6/2. On [DATE] at 1:00 PM, Surveyor observed the 3 North [NAME] medication room. Inside the refrigerator, Surveyor located the following: A Novolin 70/30 insulin vial belonging to R45 which was open and used, but not dated when opened. The label read expires 28 days after opening. A plastic bag containing 3 Lantus insulin pens belonging to R55. Two of the insulin pens were open and used, but not dated when opened. The label read expires 28 days once opened. A bottle of Brimonidine 0.2% eye drop solution belonging to R55, which was open and used, but not dated when opened. The label read expires 28 days after opening. A Lantus insulin vial belonging to R25, dated opened [DATE] expired [DATE]. 2.) On [DATE] at 1:14 PM, Surveyor observed the 3 North [NAME] medication cart. Inside the cart, Surveyor located a bottle of Prednisolone 1% eye drop solution belonging to R71, which was open and used, but not dated when opened. The label read expires 28 days after opening. Surveyor showed Licensed Practical Nurse (LPN)-E all the above medications. LPN-E reported all of the medications should have been dated when opened and thrown away once expired. On [DATE] during the daily exit meeting, the facility was notified of the above concerns regarding insulin and eye drops that were not dated when opened and/or were expired. No additional information was provided.

Based on interview and record review, the facility did not ensure that 2 (R59 and R96) of 5 residents reviewed were provided pain management services consistent with professional standards of practice, including completing comprehensive assessment, developing a comprehensive person-centered care plan and evaluating the resident's goals and preferences. Findings include: On 6/9/25, the facilities policy and procedure titled Pain Management dated 1/16/19 was reviewed and documented: The 0-10 pain scale will be used for the alert resident. A pain data collection tool will be completed at a minimum on admission, readmission, quarterly and with any change of condition. The pain data tool will include: pain history, description of pain, non-pharmacological approaches that work for the resident. Location of pain, Resident's goal of pain management. Care plan is to include the residents underlying diagnosis or conditions that are causing or contributing to pain, residents goal for pain management, and pharmalogic and non-pharmalogic interventions, 1.) R59 was admitted to the facility on [DATE] with diagnosis of unspecified pain and fibromyalgia (pain disorder). R59's Annual Minimum Data Set (MDS) dated [DATE] documented that R59 was on scheduled pain medication, as needed pain medication and received a non-medication intervention for pain. The MDS also documented R59 had almost constant pain over the past 5 days. The worst pain R59 indicated was an 8 on a scale of 1-10. R59's brief interview for mental status on this assessment documented a score of 14 (cognitively intact). The MDS did trigger for a pain care area assessment (CAA)which documented: R59 verbalizes pain related to fibromyalgia/chronic pain that is almost constant, and disturbs sleep, and limits day to day activities at times. R59 states pain can get up to a 9 on a 0-10 pain scale. Resident states pain is decreased with medications which include scheduled medications for neuropathic pain as well as scheduled and prn (as needed) opioid analgesics. The MDS documented a care plan should be developed for R59's pain. On 6/5/25 at 8:22 AM, R59 was interviewed in her room and indicated she could only have pain medication every 4 hours and it wears off in 2.5 hours. R59 indicated she's never been offered anything but medication for pain and that she would be open to trying non-pharmaceutical interventions. R59 indicated her pain is not well controlled and is severe at times. On 6/5/25, R59's care plan was reviewed and no care plan for pain or any interventions for pain were found on the current care plan. On 6/5/25, R59's current physician orders were reviewed and documented and included: Oxycodone/acetaminophen 10-325 milligrams (MG) every morning and bedtime related to pain with a start date of 6/25/24. Oxycodone/acetaminophen 10-325 MG every 4 hours as needed related to pain with a start date of 5/20/24. Gabapentin 300 MG give once a day for pain with a start date of 4/16/24. On 6/9/25, R59's Medication Administration Record (MAR) was reviewed from 3/1/25 to 6/9/25. R59's March 2025 MAR indicated she received as needed oxycodone/acetaminophen 10-325 MG 60 times with a pain rating of 5-9 all 60 times before administration. The MAR does indicated the medication was effective each time but does not give a pain rating. R59's April 2025 MAR indicated she received as needed oxycodone/acetaminophen 10-325 MG 62 times with a pain rating of 5-10 all 62 times before administration. The MAR documents the medication was effective 53 times but does not give a pain rating and ineffective 9 times but does not indicate was was done about the continued pain. R59's May 2025 MAR indicated she received as needed oxycodone/acetaminophen 10-325 MG 63 times with a pain rating of 5-10 all 63 times before administration. The MAR documents the medication was effective 57 times but does not give a pain rating and ineffective 6 times but does not indicate was was done about the continued pain. On 6/9/25, R59's Long Term Care Evaluation dated 2/19/25 was reviewed and documented: pain level 4. No change. Generalized aching, multiple times a day. Scheduled pain medication. None of the questions's relating to how the pain is affecting R59 or what is the worst pain R59 experiences is filled out. The assessment also does not indicate that R59 takes as needed pain medication. On 6/10/25 at 10:00 AM, Director of Nursing (DON)-B was interviewed and indicated there was nothing else for R59's pain care plan or assessment of R59's pain. Surveyor asked if DON-B thought R59 had a comprehensive care plan and assessment for her pain. DON-B would not answer. On 6/9/25 at 3:00 PM, during the daily exit meeting, the above findings were shared with the Nursing Home Administrator (NHA)-A and DON-B. Additional information was requested, if available as to why R59 did not have a comprehensive plan of care and assessment for her pain. None was provided. 2.) R96 was admitted to the facility on [DATE] with diagnoses that included unspecified pain, low back pain and dysuria (pain with urination). On 6/5/25, R96's Annual Minimum Date Set (MDS) dated [DATE] was reviewed and documented R96 was on scheduled pain medication and received a non-medication intervention for pain. R96's brief interview for mental status on this assessment documented a score of 13 (cognitively intact). The MDS did not trigger for a pain care area assessment. On 6/5/25 at 8:47 AM, R96 was interviewed and indicated she had pain in her neck and back mainly and that her current pain medications did a good job controlling her pain. R96 indicated she was never offered anything but medication for her pain and indicated a hot pack once in awhile may help. On 6/5/25, R96's care plan was reviewed and the only interventions for pain management were listed under the care plan titled Self Care Deficit. No problems or goals related to pain were documented and the interventions included documented Non pharmalogical interventions for pain management; rest, repositioning with a start date of 8/7/24 and plan for pain management. Resident is receiving scheduled Tylenol three times a day and as needed. Staff to report any episodes of unrelieved pain to Medical doctor. Able to use pain scale 0-10 with a start date of 8/7/24. (Care plan only mentions Tylenol bur R96 also receives Lidocaine and Gabapentin daily). On 6/5/25, R96's current physician orders were reviewed and documented and included: Lidocaine pad 4%. Apply to left knee and left hip every morning for pain with a start date of 4/30/24. Tylenol two 325 milligram (MG) tablets 3 times a day for low back pain with a start date of 3/1/24. Gabapentin 100 MG give 2 capsules by mouth every morning and bedtime for pain with a start date of 4/30/24. On 6/9/25, R96's Vitals and Pain Only Evaluation dated 2/27/25 was reviewed and documented 1/14/25. R96 was asked id she had pain in the last 5 days and indicated yes and that it was frequent. R96 indicated her worst pain on a scale of 1-10 was a 5. No documentation was made as to a location of R96's pain, location of pain, acceptable level of pain or if current interventions were effective. On 6/9/25, R96's Medication Administration Record (MAR) was reviewed from 3/1/25 to 6/9/25. No pain levels using the 0-10 scale were found. R96's pain medications were documented as given daily. On 6/10/25 at 10:00 AM, Director of Nurses (DON)-B was interviewed and indicated there was nothing else for R96's pain care plan or assessment. The Surveyor asked if DON-B thought R96 had a comprehensive care plan and assessment for her pain. DON-B would not answer. The above findings were shared with the Administrator-A and DON-B on 6/9/25 at 3:00 PM. Additional information was requested, if available as to why R96 did not have a comprehensive plan of care and assessment for her pain. None was provided.

2.) R20 was admitted to the facility on [DATE] with diagnoses of dementia, CHF (congestive heart failure) and type 2 diabetes. R20's nurses note dated 5/25/25 documents that R20 developed a pressure injury. The nurses note documents, staff noted open area to left gluteal fold during cares. Cleansed with NS (normal saline) pat dry. Skin prep applied to peri wound. Medi Honey applied and covered with foam dressing. Resident was repositioned to side. Air mattress in place. Will continue to monitor for s/s (signs and symptoms) of infection. R20's annual MDS dated [DATE] documents R20 has severe cognitive impairment and is dependent for moving in bed and transfers. R20's CAA dated 4/15/25 documents: R20 triggered r/t (related to) staff giving assist with her adl's (activity of daily living) and mobility. she is weak and deconditioned and has cognitive deficit and needing staff to assist with her adl's/transfers and mobility. w/c for mobility and ez stand for transfers . Staff provide pressure reducing interventions. skin remain intact / staff provide dressing to sacrum for protection. and skin care given see TAR (treatment administration record). R20's alteration in skin integrity care plan date initiated 8/7/2024 revised date 5/28/25, documents the following interventions: Encourage resident to wear socks in bed as tolerated initiated 5/19/25 Pressure reducing measures: Staff to assist with repositioning every 2-3 hours while in bed. Encourage resident to keep pressure off of her bottom as she prefers to lay on back while in bed. Resident to wear pressure relieving boots on bil (bilateral) feet as tol (tolerated) while in bed. Resident may remove them from her feet independently. Staff should attempt to suspend heels off of bed with pillow while in bed if boots are not worn. Date initiated 8/7/24 revision on 10/23/24. Resident was provided w(with)/roho cushion for w/c (wheelchair) and low air loss mattress for bed. Prostat was ordered for wound healing. Staff to complete txs (treatment) to pressure injury on bottom per order. Date initiated 8/7/24 and revision on 10/23/24. Staff encouraging resident to wear pressure relieving boots at all times on left foot. Does decline to wear at times. Date initiated 8/7/24. Staff to continue to keep shoes off at this time due to hx (history) blistered areas on bilateral heels. Date initiated 8/7/24. On 5/28/25, Wound MD-O assessed R20 pressure injury on the left ischium as Stage 3 pressure injury measuring 2.9 cm (centimeter) by 2.4 cm by 0.2 cm with 30% slough and 70% granulation tissue. On 6/4/25, Wound MD-O assessed R20 pressure injury on the left ischium as healing Stage 3 measuring 1.6 cm by 2.8 cm by 0.2 cm with 30% slough and 70% granulation tissue. On 6/9/25, Wound MD-O assessed R20 pressure injury on the left ischium as healing Stage 3 measuring 1.6 cm by 2.8 cm by 0.2 cm with 30% slough and 70 % granulation tissue. The treatment order dated 5/25/25 documents cleanse pressure ulcer with NS , pat dry . Apply skin prep to peri wound . Apply MediHoney , cover with Foam dressing. Change daily and PRN (as needed). This order remains the same. On 6/9/25 at 9:38 a.m. Surveyor observed Nurse Manager-R provide treatment to R20 pressure injury. R20 was observed with bilateral boots on her feet. Surveyor observed R20 pressure injury and there was no signs of odor or drainage. After the treatment R20 was repositioned on her right side to off load. On 6/9/25 at 3:10 p.m., during the daily exit meeting with DON (director of nursing)-B and NHA (nursing home administrator)-A, Surveyor asked for the initial comprehensive wound assessment for R20. On 6/10/25, DON-B provided Surveyor with the facility incident form dated 5/25/25. The incident form documents, Staff noted open area to left gluteal fold. Open area noted about 3.5 cm by 4.5 cm, irregular shape wound bed noted clean. The incident form does not provide a comprehensive assessment of the pressure injury On 6/10/25 at 10:45 a.m., Surveyor interviewed DON-B. Surveyor explained R20 developed a pressure injury on 5/25/25 and a comprehensive assessment was not completed. DON-B stated she understood the incident form did not include an assessment of the wound bed, peri wound and staging of the pressure injury. DON-B understood the concern and had no additional information. Based on record review, interview and observation, the facility did not ensure residents with pressure injuries received the necessary treatment and services, consistent with professional standards of practice, to promote hearling, prevent infection and prevent new ulcers from developing for 2 (R112 and R20) of 7 residents reviewed with pressure injuries. * R112 was transferred to the hospital with a pressure injury. Upon readmission, R112's pressure injury was not comprehensively assessed until 3 days later. R112 did not have a comprehensive plan of care related to a comprehensive assessment. *R20 developed a pressure injury in the facility that was not comprehensively assessed. The facility's policy and procedure titled Skin Care Program and dated 6/17/2019, documents: -The policy is for every resident who enters the facility will be evaluated within 8 hours to prevent the formation of pressure injuries. -Measuring Wounds As Follows: size, length, width, top of wound, depth and any undermining/tunneling; location, stage and measurements, wound base, periwound, drainage, pain/tenderness and wound edges. Findings include: 1.) On 6/04/25 at 10:31 AM, Surveyor interviewed R112 while R112 was in bed. R112 was laying on their side with an air mattress on the bed. R112 had no concerns with the wound treatment to their sacrum. R112 verbalized their bottom is better. R112 was admitted to the facility on [DATE] with a diagnoses of Cancer. R112 admission Minimum Data Set (MDS) assessment was completed on 3/11/25 and documented that R112 is a risk for a pressure injury and has no current pressure injuries. R112 has no cognitive impairments. R11's Care Area Assessment (CAA) for Pressure Injury documents: Resident had no pressure related open area initially but post Assessment Reference Date (ARD) resident does have an area to the coccyx that upon admission was healed but has reopened. Area has a treatment in place and staff monitors it with dressing changes. Resident has a pressure relieving wheelchair cushion and pressure reducing mattress. Resident is at risk r/t (related to) decreased mobility d/t (due to) weakness r/t diagnosis that include CA s/p (cancer status post) radiation to right thigh for myxofibrosarcoma. At this time staff assist with bed mobility and transfers at a supervision/touching to partial moderate assistance for bed mobility and transfers. On 3/16/25, R112 develops a pressure injury to the sacrum. This is a re-opened area and is appropriately assessed with treatment. The last assessment, before R112's hospital stay, was from the Wound Medical Doctor (MD) on 3/19/25 that documented R112's wound as a stage 3 to the coccyx. The wound size is documented as (Length x Width x Depth): 2.6 x 0.7 x 0.2 cm, drainage is Light Sero - sanguinous with granulation tissue of 100 %. The assessment documents that the pressure ulcer re-opened. A treatment is ordered, along with recommendations for healing the wound. This includes: Off-Load Wound ; Reposition per facility protocol ; Limit sitting to 60 minutes. R112 plan of care (POC) documents: The resident has potential/actual impairment to skin integrity of the coccyx related to fragile skin and incontinence with a start date of 3/16/25. Under the Interventions it documents: -Start date 3/17/25 Alternating air mattress requested. -Start date 5/29/25 Treatment to wound per providers order. There is no documentation of additional interventions to prevent, and promote, skin integrity. On 3/21/25, R112 was transferred to the hospital with a change in condition. R112 returned to the facility on 4/4/25. R112's 5-day entry MDS assessment completed on 4/10/25 documents a stage 4 pressure injury for R112. There are interventions documented for pressure relief devices with positioning. R112's nurses note date 4/7/25 written by Registered Nurse (RN)-C documents: A 1.7 x 0.7 cm unstageable wound remains on Sacrum, with mod serosang drainage on dressing. Wound edges defined and attached, base 100% slough and 1 x 0.7 cm abrasion on right buttock. Bilateral buttocks significant dry flaky skin from excoriation. Will continue Medi-honey gel TX until seen by wound physician. R112's Wound MD (medical doctor) notes on 4/9/25 document a stage 4 pressure injury to R112's sacrum. The wound size is documented as (L x W x D): 3.9 x 2.7 x 0.3 cm; with drainage of light sero- sanguinous; characteristics of slough 40%, granulation tissue 40%, intact normal skin 20% this was exacerbated from hospital stay. This wound was debrided on 4/9/25 with this assessment. Recommendations are to off-load wound ; reposition per facility protocol ; limit sitting to 60 minute. R112's pressure injury was not comprehensively assessed with readmission on [DATE]. The POC for the pressure injury did not reflect an actual pressure injury, along with comprehensive interventions. R112's Treatment Administration Record (TAR) for April 2025 documented a treatment to the sacrum with readmission on [DATE]. R112's pressure injury to the sacrum was assessed by the Wound MD on 6/4/25. The Wound MD assessed the wound as resolved and to continue zinc oxide to the area. On 06/09/25, at 10:37 AM, Surveyor interviewed Registered Nurse (RN)-[NAME]. RN-C stated The nurses do skin assessments with admissions and readmissions and I personally try to assess the resident the next day. Wound MD usually follows up on the wound weekly. The plan of care for R112 was comprehensive before the hospital transfer. Someone must have modified the care plan with readmission. On 6/09/25 at 1:52 PM, Director of Nurses (DON)-B provided Surveyor R112's Nurse admission Screen for 4/4/25. Surveyor noted that the screen is not a comprehensive assessment of the coccyx wound and that it only has wound measurements. Surveyor noted that a comprehensive assessment and care plan of R112's pressure injuries was not provided. On 6/9/25, at 3:15 PM, at the facility exit meeting with, Surveyor informed Nursing Home Administrator(NHA)-A and DON-B of the concerns with R112 pressure injury. On 6/10/25, at 9:07 AM, NHA-A provided Surveyor R112's plan of care for skin. Their were no changes from the original plan of care. The skin assessments provided to Surveyor only have measurements and not characteristics of the sacrum wound. R112 did not have a documented comprehensive wound assessment, along with a comprehensive plan of care. No additional information was provided.

2.) R87 was admitted to the facility on [DATE], with diagnoses including [NAME]-[NAME] syndrome (a rare autoimmune disorder of the neuromuscular junction where the immune system attacks nerves and muscles, leading to muscle weakness and other symptoms), neuromuscular dysfunction of bladder (a condition where the nerves controlling bladder function are damaged or not functioning properly, leading to difficulty in controlling urination), pain, cellulitis (a bacterial skin infection affecting the deeper layers of the skin and underlying tissue, often caused by bacteria like Streptococcus or Staphylococcus entering through a break in the skin) of right lower limb and urine retention (the inability to fully or completely empty the bladder, resulting in a buildup of urine). R87's quarterly Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact), is able to understand and be understood, is dependent on staff for toileting hygiene, substantial/maximal assistance with shower/bathing and has an indwelling urinary catheter. R87's Annual MDS, dated [DATE], documents that it is very important for R87 to choose between a tub bath, shower, bed bath, or sponge bath. Surveyor reviewed R87's care plan which documents in part, R87 has an ADL self-care performance deficit and documents R87 prefers showers with an extensive assist of 1. Surveyor reviewed R87's physician orders in R87's electronic health record, and noted R87 is to have a shower every Monday. On 06/09/2025, at 06:50 AM, Surveyor observed Certified Nursing Assistant (CNA)-K assist R87 with getting out of bed for the morning. CNA-K informed Surveyor that R87 will stay in R87's night gown because today is R87's shower day. CNA-K indicated that there is a shower aide who provides showers to residents on their shower days. On 06/09/2025, at 08:33 AM, Licensed Practical Nurse (LPN)-L informed Surveyor that the shower aide left sick, and R87 would have to reschedule R87's shower. LPN-L indicated that LPN-L informed R87 of this as well. On 06/09/2025, at 08:59 AM, Surveyor spoke with R87 regarding R87's shower. R87 informed Surveyor that R87 was not informed that R87 would not be receiving a shower today. R87 voiced concern that R87 did not want to wait to have a shower since R87 did not receive a shower last week either. R87 indicated that R87 requires assistance to shower and has no choice but to wait until staff are able to assist R87 with a shower. Surveyor reviewed R87's bathing/shower task document and noted that R87's last documented shower was on 05/29/2025 and documented R87 was dependent on staff to bathe/shower. On 06/09/2025, at 01:04 PM, Surveyor informed Director of Nursing (DON)-B of concerns regarding R87's showers. DON-B informed Surveyor that DON-B would get back to Surveyor on that. No additional information was provided as to why the facility did not provide R87 with showers or baths per R87's preferences and physician orders. Based on interview and record review the facility did not ensure 2 (R77, R87) of 26 residents needing assistance with Activities of Daily Living (ADL) cares, received the necessary services for cares. *R77 did not receive nail care per care plan, policy and resident's preference. *R87 did not receive scheduled shower per care plan and resident's preference. Findings include: The Facilities Policy titled, Standards of Care at Lutheran Home. Revised 6/1/2023. Documents: Policy Statement: Lutheran Home will provide routine interventions for all residents. These interventions do not to be addressed on the resident's individual care plan or care card. If the standard is different for a resident, the individual plan of care will reflect the variance. Standards: . Resident will receive a weekly shower or bath. Regular nail care provided as needed. 1) R77 was admitted on [DATE] with diagnosis of Type 2 diabetes mellitus with diabetic neuropathy, polyneuropathy, difficulty in walking, need for assistance with personal care. R77's admission Minimum Data Set (MDS) completed on 4/28/2025 documents a Brief Interview for Mental Status (BIMS) score of 9, indicating that R77 is cognitively intact. R77 section B in the MDS documents that R77 is understood and usually understands. R77's (diabetes Mellitus) care plan, dated 4/10/2025, documents: Refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails. On 6/9/2025, at 1:34 PM, Surveyor observed R77 nails on her feet, they nails were long and surveyor asked R77 if she liked her toenails to be long. R77 indicated that she preferred them short, and stated we should cut them, if they are long, they should be cut. On 6/9/2025, at 3:43 PM, Surveyor interviewed Registered Nurse (RN)-T, who stated R77's nails were long and that they look like they need to be trimmed, RN-T stated R77 is diabetic and should be seen by podiatry for nail trimming. On 6/9/2025, at 3:59 PM, Surveyor interviewed Unit manager RN-C, who stated that podiatry comes every 60 days and that R77 son will be called as podiatry needs consent from POA to see R77. RN-C indicated not knowing how long R77's nails were long, as staff will go directly to unit secretary to add residents to the podiatry list and not include RN-C on those residents. On 6/10/2025, at 9:38 AM, Surveyor interviewed unit manager RN-C, who stated R77 is not on the list currently to see podiatry, RN-C acknowledged R77's toenails were long and stated she did clip R77's toenails. On 6/10/2025, at 9:48 AM, RN-C informed surveyor that POA of R77 will be coming into the facility today to sign the paperwork for R77 to see podiatry. On 6/10/2025, at 12:16 PM, Surveyor informed Nursing Home Administrator (NHA)-A, of the concern with R77's long toenails and no podiatry visit per care plan and policy. No additional information received as to why R77 had long toenails and no received services from podiatry services.

Based on interview and record review the facility did not provide a comprehensive care plan for 1 (R96) of 5 residents reviewed for bowel and bladder incontinence. R96 is incontinent of bowel and bladder and did not have a comprehensive care plan for incontinence. Findings include: 1.) R96 was admitted to the facility on [DATE] with diagnoses that included Chronic Kidney Disease Stage 3, and Dysuria (pain with urination) On 6/5/25, R96's Annual Minimum Date Set (MDS) dated [DATE] was reviewed and indicated R96 was frequently incontinent of bladder. R96's brief interview for mental status on this assessment documented a score of 13 (cognitively intact). R96's MDS triggered for urinary incontinence and was selected to continue to care plan. R96's Care Area Assessment (CAA) for urinary incontinence dated 3/24/25 triggered and documented resident needing assistance with toileting including transfers, clothing adjustment and toileting hygiene. Resident is frequently incontinent of bladder. Staff provides substantial/max (maximum) assist for toileting hygiene and partial moderate assistance for toilet transfer with 1 helper. On 6/5/25 at 8:47 AM, R96 was interviewed in her room and indicated she uses a brief to urinate in at times as she doesn't always feel the need to urinate. and sometimes doesn't get to the toilet on time and requests assistance when needed. On 6/5/25, R96's complete care plan was reviewed and the only documentation of R96's bladder incontinence interventions were under self care deficit with a start date of 8/7/24 with the intervention of offer toileting every 2-3 hours and as needed. Wears small/med brief. The care plan does not document any reasons for urinary incontinence, type of urinary incontinence, goals for urinary incontinence care or any other interventions for urinary incontinence care. R96 has no documentation in the self deficit care plan that indicates she had renal disease or dysuria. On 6/10/25, R96's Certified Nursing Assistant (CNA) care card was reviewed and the only instructions for R96's bowel and bladder incontinence documented: offer toileting every 2-3 hours and as needed. Wears small/med brief. On 6/10/25 at 10:00 AM, Director of Nursing (DON)-B was interviewed and indicated there was nothing else for R96's bowel and bladder incontinence care plan. The Surveyor asked if DON-B thought R96 had a comprehensive care plan for her incontinence. DON-B would not answer. On 6/9/25, The facilities policy and procedure titled Careplans and Carecards dated 10/4/19 documented: The careplan will include at a minimum: goals, assistance with activities of daily living, considerations of risks affecting the residents health. On 6/9/25 at 3:00 PM, the above findings were shared with the Nursing Home Administrator (NHA)-A and DON-B. Additional information was requested, if available as to why R96 did not have a comprehensive plan of care for her urinary incontinence. None was provided.

4.) R14 was admitted to the facility on [DATE] with diagnoses of CHF(congestive heart failure), Parkinson's disease, dementia, schizophrenia, bipolar and anxiety. R14's significant change MDS (minimum data set) dated 9/16/24 documents under Section A1500 that R14 does not have a serious mental illness. The PASRR (preadmission screeen and resident review) level 1 screen dated 9/28/18 indicates R14 has a serious mental illness. The PASRR level 2 screen was completed 10/22/18 and indicates R14 is not in need of specialized services or specialized psychiatric rehabilitation services at this time. On 6/10/25 at 10:55 a.m. Surveyor interviewed DON-B and NHA-A. Surveyor explained the concern with the incorrect assessment on the significant change MDS dated [DATE]. Surveyor explained on the MDS, R14 was assessed as not having a serious mental illness. Surveyor explained R14 has diagnoses of mental illness and a PASRR level 1 and 2 was completed which reveals R14 has a serious mental illness. DON-B stated R14 does have a mental illness and understood the MDS was incorrectly assessed. No additional information was provided. 3.) R52 was admitted to the facility on [DATE] with a diagnoses of Bipolar, Anxiety and Depression. R52 had a Preadmission Screening and Resident Review (PASSR) level one and level two completed due to mental illness. Per R77's PASSR level 2 screening, does not require specialized services for their mental illness. R77's 4/1/25 Minimum Data Set (MDS) assessment, completed 4/1/25, does not document that R77 had a PASSR screening completed. Section A that contains this information was completed by Social Worker (SW) -D. On 6/09/25, at 9:46 AM, Surveyor interviewed SW-D. The SW-D stated They made a mistake on the MDS assessment. On 6/9/25, at 3:10 PM, at the facility exit meeting with Nursing Home Administrator (NHA)-A and the Director of Nursing (DON)-B, Surveyor informed the concerns with R52's MDS assessment. No additional information was provided. Based on record review and interview, the facility did not ensure assessments accurately reflected residents' status for 4 (R55, R59, R52, and R14) of 4 reviewed for Preadmission Screening and Resident Review (PASRR) with serious mental illness diagnosis. *R55, R59, R52, and R514 had PASRR Level I and Level II completed, and had diagnosis of serious mental illnesses, but this was not documented into the Minimum Data Set (MDS) comprehensive assessment at section A1500. Findings include: 1.) R55 was admitted to the facility on [DATE] with diagnoses of major depression, auditory and visual hallucinations, and anxiety. On 6/9/25, R55's Annual Minimum Data Set (MDS) dated 11/6//24 section A1500 documented R55 does not have a serious mental illness. Section I labeled active diagnosis documented R59 has diagnosis of anxiety, depression, and psychotic disorder. This MDS was completed by Social Worker-T. On 6/9/25, R55's preadmission screen and resident review (PASRR) level 1 screen dated 8/25/20 indicates R55 has a serious mental illness. The PASRR level 2 screen was completed 9/30/20 and indicates R55 is not in need of specialized services or specialized psychiatric rehabilitation services at this time. On 6/10/25 at 10:30 AM, Social Worker-T was interviewed and indicated R55's Annual MDS dated [DATE] was coded wrong and R55 did have a serious mental illness at the time of the assessment. The above findings were shared with Nursing Home Adminstrator (NHA)-A and Director of Nursing (DON)-B on 6/10/25 at 3:00 PM. Additional information was requested, if available as to why R55's MDS was coded incorrectly. None was provided. 2.) R59 was admitted to the facility on [DATE] with diagnosis of anxiety, major depression, post traumatic stress disorder, and psychotic disorder with hallucinations. On 6/9/25, R59's Annual Minimum Data Set (MDS) dated [DATE] section A1500 documents R59 does not have a serious mental illness. Section I labeled active diagnosis documents R59 has diagnosis of anxiety, depression, psychotic disorder and post traumatic stress disorder. This MDS was completed by a Social Worker-U who is no longer employed by the facility. On 6/9/25, R59's preadmission screen and resident review (PASRR) level 1 screen dated 8/3/23 documents R59 has a serious mental illness. The PASRR level 2 screen was completed 9/5/23 and indicates R59 is not in need of specialized services or specialized psychiatric rehabilitation services at this time. On 6/10/25 at 10:30 AM, MDS Coordinator-V was interviewed and indicated R59's Annual MDS dated [DATE] was coded wrong and R55 did have a serious mental illness at the time of the assessment. The above findings were shared with Administrator-A and Director of Nurses-B on 6/10/25 at 3:00 PM. Additional information was requested, if available as to why R59's MDS was coded incorrectly. None was provided.

Based on observation, record review and interview, the facility did not ensure staff were trained to safely use a hoyer lift with support bars. This was observed with 1 (R2) of 1 residents using this type of Hoyer Lift. R2 obtained a bruise by their eye due to staff using the Hoyer Lift incorrectly. Findings include: The facility's policy and procedure, Safe Transfers, revision date of 7/1/2021. The Policy documents: Residents admitted to Lutheran Home will be assessed to ensure appropriate and recommended transfer techniques are in place to direct safe resident transfers. On 2/3/25, at 9:03 AM, Surveyor spoke with R2 in their room. R2 stated they had a bruise by their eye from the hoyer lift. R2 stated this happened on 12/28/24 and their eye still hurts. Surveyor reviewed R2's medical record. R2 is their own person. The most recent MDS (minimum data set) assessment is a Significant Change in Status completed 11/16/2024. This MDS documents R2 does not have any cognitive impairments and is dependent on staff for transfers. R2's CNA (Certified Nursing Assistant) Kardex, dated 2/3/2025 documents under Transferring: R2 requires 2-3 staff, a full-body sling and the hoyer lift with swinging bars on the side. R2's medical record documents on 12/28/24, at 1:39 PM, R2 left side of face was accidentally bumped while transferring into bed. R2 has a small hematoma. There was a cold compress applied. The correlating Incident Report regarding the transfers documents: Staff assisting R2 from their bed into a broda chair. The hoyer lift used has bars on each side that hang down and can swing up. Staff reported the bar was in the upright position, and one of the staff moved their position, the bar came down and hit R2 on the left side of their face. R2 obtained a hematoma and did not need to go out of the facility for treatment. Surveyor notes the documentation does not include the staff involved and there is no documentation of preventive interventions put into place to prevent future injuries. On 2/3/25, at 2:33 PM, Surveyor interviewed Assistant Nursing Home Administrator (ANHA)-H and Assistant Director of Nurses (ADON)-B. Surveyor requested, and received, information related to the staff involved with R2's hoyer lift injury. ADON-B stated the staff involved were CNA-C and CNA-D. The Nurse that assessed R2 after this event is no longer employed at the facility. The (Unit Manager) UM-E would have reviewed the incident and talked to the staff involved. ANHA-H and ADON-B did not have any additional documentation related to the incident. On 2/4/2025, at 8:03 AM, Surveyor interviewed Staff Development (SD)-F. SD-F stated she was not directed to conduct training on the hoyer lift used for R2. SD-F did not conduct any staff training with the hoyer after this event on 12/28/24. On 2/4/25, at 9:10 AM, Surveyor interviewed UM-E. UM-E stated they just spoke with CNA-C about the hoyer incident. The UM-E did not speak to the other CNA involved, CNA-D. UM-E stated this Hoyer has arms that are on the side. UM-E stated R2 has used this hoyer for a long time and was their preference. The UM-E felt this incident was isolated. The UM-E stated they did not know what the arms were for on the Hoyer. Surveyor and UM-E then observed the hoyer lift. The hoyer lift has side bars that hang vertical in a downwards position. When the arms are raised they do not lock in a straight vertical position upwards. UM-E stated they did not know what the bars were for and did not implement preventative measure(s) to prevent a reoccurrence. On 2/4/25, at 9:38 AM, Surveyor interviewed CNA-C. CNA-C stated the hoyer arm does not lock in place in the upwards position. CNA-C stated when you transfer R2 you need to hold the bar up. They had to raise the bar due to positioning the hoyer and transferring R2. CNA-C stated they were not trained on this type of hoyer lift before, or after, this incident. On 2/4/25, at 9:40 AM, Surveyor interviewed CNA-D. CNA-D stated the hoyer bar does not lock in the upward position. When R2 requested them to go behind them, they bumped the raised bar and it fell down. R2 left side of their eye was bumped. CNA-D stated they float on the units and was not familiar with this hoyer lift. CNA-D stated they did not receive training on this lift before, or after, this incident. On 2/4/25, at 11:52 AM, SD-F and UM-G, spoke with Surveyor. UM-G stated R2 used to be on their unit and UM-G trained staff a couple years ago. UM-G stated they trained staff on the unit today. UM-G stated the hoyer bars are for support and not for the function of the hoyer. UM-G stated they did not complete staff training when this incident occurred on 12/28/24. UM-G stated they talked to staff on the unit today because they heard about the incident with R2. SD-F stated they do not have staff competencies for this particular hoyer lift. This hoyer lift was originally from the Veterans Administration and remained at the facility. R2 has been using this lift per their choice for a long time. SD-F will supply Surveyor with the operation manual for this hoyer lift. Surveyor reviewed the instruction manual for use for the Golvo 9000 mobile lift. The armrests are for support only when moving in the lift to another room. The side arms hang in a downward vertical position. When moving the lift, the side bars can flip over to a horizontal position. To provide arm support for moving in the lift. The side arms do not lock upwards and are not for function of the lift. On 2/4/25, at 12:05 PM, Surveyor shared the hoyer lift concerns with Nursing Home Administrator (NHA)-A, ANHA-H and ADON-B. Surveyor shared the concerns of staff competency, and environmental safety using the hoyer lift. Surveyor shared the concern of no documentation of interventions to prevent this from reoccurring.

Based on observations, interviews, and record review the facility did not ensure food was stored and served in accordance with professional standards for food safety. *Staff did not test Sentinel sanitizing solution per manufacturer's instructions when testing the sanitizing sink used for dishwashing. Staff did not log or document testing results. This affected 136 out of 136 residents who receive food prepared by the facility kitchen. *The Unit refrigerator on 2E had multiple food items that were not labeled with resident's name. Open food was not dated. The refrigerator was unclean. There was not a current temperature log posted on the refrigerator and temperatures were not being documented since December of 2023. This had the potential to affected 41 of 41 residents who can use the Resident's unit refrigerator on 2E. Findings include: 1.) On 3/12/24 at 10:53 AM, Surveyor toured the dishwashing area with the Dining and Hospitality Director (Director-L) and the Executive Chef (EC-K). Surveyor noted the facility's 3-compartment sink. Surveyor asked that the sanitizing sink be tested . EC-K retrieved a strip to test the sanitizing water. EC-K placed the strip into the sanitizing water through the foam layer on top of the water. EC-K kept the strip in the water for 10 seconds and then removed the strip. EC-K reviewed the strip to determine the result. EC-K stated that the result was 500ppm. Surveyor asked what the desired result would be for the sanitizing sink. EC-K stated that the sink should test at 200ppm before using the water to sanitize dishes. Surveyor asked how often the sink is tested . EC-K stated that it is tested daily. Surveyor asked to review the testing log for the sanitizing sink. Director-L and EC-K indicated that the facility did not log the results of testing. Director-L stated that they will start logging the results of the testing. On 3/12/24 at 11:49 AM, Director-L returned to surveyor. Director- L stated that they reached out to (name of company) who is the company that provides guidance for the sanitizing sink. Director-L stated that (name of company) has a representative that will come to the facility, check the sanitizing sink, and adjust the sink if needed. Director-L indicated that the earlier result could be skewed if the testing was not completed correctly. Director-L stated that the (name of company) representative informed Director-L of the proper way to test the sanitizing sink. Surveyor observed Director-L testing the sanitizing sink. Director-L took a strip to test the sink, cleared some of the foam layer on top of the water and placed the strip into the sanitizing water for 10 seconds. Director-L removed the strip. Director-L reviewed the strip and stated that they would read the results at 200ppm. Surveyor reviewed the strip and noted areas on the strip that continued to read at 500ppm. Director-L stated that kitchen staff are being trained on new equipment in the kitchen. Director-L indicated that during that training, they will include the process of testing the sanitizing sink and the new log that was created to document the testing. On 3/13/24 at 8:50 AM, Director-L provided Surveyor with manufacturer's instructions for the Sentinel sanitizer used in the sanitizing sink. Director-L also gave surveyor a document that is posted by the 3-compartment sink. Surveyor reviewed the manufacturer's instructions. Under the title, Directions for use, was: Consult your (name of company) for proper use instructions. Surveyor reviewed the document posted by the 3-compartment sink. Under the title, Third Sink, was: Fill with water and sanitizer to the correct concentration. Sanitizer should read 200ppm. On 3/13/24 at 10:19 AM, Surveyor interviewed (name of company) Representative (NR-M) who provides local facilities with proper instructions for use of the sanitizing sink. NR-M stated that they had recently emptied and refilled the sanitizing sink before Surveyor arrived at the dishwashing station. NR-M reviewed how to test the sanitizing sink with the surveyor. NR-M stated that staff should never test through the foam on top of the water in the sink, the foam should be moved aside before testing. NR-M stated that the test strip should be placed in the water and kept still for 10 seconds. NR-M tested the newly mixed sanitizing sink. NR-M stated the result was 200ppm. Surveyor reviewed the testing strip and noted that the strip did result at 200ppm with no areas of a higher reading. Surveyor asked what the results should read to ensure that the dishes are being sanitized correctly. NR-M stated that 200ppm is the ideal result, but an acceptable range is 150-400ppm. Surveyor asked how often the sanitizing sink should be tested . NR-M stated that the sink should be tested every 4 hours and should only be emptied and refilled if the sink does not test correctly. Surveyor noted that the facility was not following the manufactures instructions for the process of testing and for the timing of testing. EC-K tested through the foam on 3/12/24. NR-M stated that staff should not test through the foam on top of the water. On 3/12/24, EC-K stated that the sanitizing sink should be tested daily. NR-M stated the sink should be tested every 4 hours. On 3/13/24 at 10:30 AM, Surveyor interviewed Director-L. Director-L stated that they added a spot to log the sanitizing sink results to the daily log. Surveyor reviewed the posted log on a board in the kitchen. Surveyor noted a newly added spot for one result a day to be posted. Surveyor informed Director-L of the ongoing concern regarding the sanitizing sink. Director-L stated they understood. Director-L indicated that they have already made changes and that they will be more prepared for the next survey. On 3/13/24 at 3:08 PM, Chief Executive officer (CEO-C), Assistant Administrator (AA-I) and Director of Nursing (DON-B) were informed of concerns with the sanitizing sink. No other information was provided. 2.) On 3/13/24 at 1245 PM, Surveyor observed a resident refrigerator located in a clean utility room on the 2E unit. Posted on the front of the refrigerator door was, Resident foods only. Please label all resident food with name and dates. Surveyor opened the refrigerator and observed a plastic food service container with pickle spears, a jar of prune juice, 3 bottles of salad dressings, and a bottle of coffee cream that did not have a resident label or date on it. Surveyor noted that 3 shelves in the refrigerator had stains of old food on them and liquid was draining out of the plastic container with pickles. Surveyor noted that the freezer and the refrigerator did have a thermometer. Surveyor located a temperature log hanging on the side of the refrigerator. The log was dated with the year of 2023 and documentation indicated that the temperatures were being recorded up until November of 2023. Surveyor could not locate any documentation for temperature recordings from December of 2023 to current time. On 3/13/24 at 12:50 PM, Surveyor interviewed Registered Nurse (RN-N). Surveyor asked who was responsible for taking temperatures and cleaning the refrigerator? RN-N state that the night shift staff are supposed to log the temperatures and make sure the refrigerator is clean. Surveyor asked who was responsible for making sure that the night shift was completing their duties. RN-N stated she would get the manager. On 3/13/24 at 1:07 PM, Surveyor interviewed Nursing Unit Manager (UM-J). Surveyor asked what the protocol was for maintaining the resident unit refrigerator. UM-J stated that she will clean out the refrigerator every day and will toss out any unlabeled food or any food without a date on it. Surveyor alerted UM-J to the containers in the refrigerator with no name or date. UM-J began grabbing the pickle container and dressing bottles and stated that they would be thrown away. Surveyor asked if the prune juice had a name or date on it. UM-J stated No. Surveyor asked if the coffee cream had a name or date on it. UM-J stated No but indicated that they know it is for a resident, but she could not recall which resident. Surveyor asked what the protocol was for recording refrigerator temperatures. UM-J stated that the night shift is responsible to log the refrigerator temperatures daily. Surveyor asked for a current log of temperature. UM-J looked at the log hanging on the side of the refrigerator. UM-J acknowledged that the log was from 2023. UM-J stated that they will make sure that they put a new one on the refrigerator and make sure that it is checked every day. On 3/13/24 at 2:06 PM and on 3/14/24 at 9:25 AM, Surveyor asked DON-B if the facility had a policy regarding the maintaining of resident unit refrigerators. DON-B stated they did not have a policy for unit refrigerators. On 3/13/24 at 3:08 PM, CEO-C, AA-I and DON-B were informed of concerns with the 2E resident refrigerator. No other information was provided. 49435

Based on observation, interview, and record review the facility did not ensure that food was prepared to conserve nutritive value. This has the potential to effect 8 of 8 residents on pureed diet. The Cooks Helper (CH-H) did not follow a recipe for preparing texture and modified consistency diet for pureed food. Findings include: The facility's policy and procedure, entitled SUBJECT: International Dysphagia Diet Standardization Initiative (IDDSI) Terminology for Food Textures and Drink Thickness, dated 11/21/2023, states: The [facility] will follow the IDDSI framework meant to provide a common terminology for describing food textures and drink thickness to improve safety for individuals with swallowing difficulties. Surveyor reviewed the IDDSI framework for preparing pureed food on the IDDSI website https://iddsi.org. Surveyor noted the IDDSI method includes testing the texture of the food before serving. IDDSI outlines the procedure for testing the food. For pureed food, IDDSI uses the fork test. Pureed food can be tested by assessing whether the food flows through the tines/prongs of a fork. Once the pureed food is prepared, staff can put a scoop of food onto a fork. The food should sit in a mound or pile above the fork. A small amount of food may flow through and form a short tail below the fork, but the food should not dollop, flow or drip continuously through the fork prongs. On 3/12/24 at 10:33 AM, Surveyor observed CH-H preparing puree food. CH-H indicated there are a total of 8 residents that receive a pureed diet. CH-H put 5 Chicken fried steaks into the blender. CH-H took a pitcher of hot water and poured an unmeasured amount of water into the blender. Surveyor asked if CH-H needed to measure the water. CH-H stated they judge how much to put in by checking and rechecking if it is the correct texture. CH-H added an unmeasured amount of a thickening agent powder to the blender. Surveyor asked if CH-H needed to measure the thickening agent. CH-H indicated there is no specific amount, but they add it slowly and will check to see if more is needed. CH-H took a spatula to check the consistency. CH-H stated they needed to add more water to make the food a pudding consistency. CH-H poured an unmeasured amount of water into the blender. CH-H took a spatula to check the consistency. CH-H stated that the consistency is better. CH-H poured the pureed food into 2 containers, placed foil on the containers and put them in the warmer. Surveyor asked if CH-H uses a recipe when pureeing food. CH-H stated they have a recipe binder. CH-H retrieved the recipe binder from a counter in the kitchen. CH-H indicated the recipe book has a recipe, but the serving size is for 200 people and that is why CH-H did not use it for the preparation today. CH-H indicated they just eye it to make sure the consistency is correct. Surveyor noted CH-H used 5 Chicken fried steaks to feed 8 residents. Surveyor noted a recipe was not followed. Surveyor noted CH-H did not follow the IDDSI method for testing pureed food. Surveyor noted a broth or other liquid with nutritious value was not used in preparing the pureed food. On 3/12/24 at 1040 AM, Surveyor reviewed the recipe binder. Surveyor noted all the recipes reviewed in the binder have a prepared serving of 200 people. On 3/12/24 at 10:42 AM, Surveyor interviewed Executive Chef (EC-K) and Director of Dining and Hospitality (Director-L). Surveyor asked if staff use recipes for preparing pureed food. Director-L stated EC-K prints the recipes and places them in the recipe binder. EC-K indicated staff should be using the recipes to prepare the food. Surveyor informed Director-L, and EC-K that CH-H did not use a recipe in preparing pureed food because the recipe serving size is too large. EC-K stated they will adjust the recipe for the correct number of residents who receive pureed food. Surveyor asked what liquid is used for pureeing food. EC-K indicated they use water with other seasonings to help with taste. Surveyor asked about using a liquid with nutritious value. EC-K indicated that they will sometimes use a broth. On 3/12/24 at 11:49 AM, Director-L returned to Surveyor. Director-L stated EC-K was already working on adjusting the recipes for the pureed binder so that it would include measurements for preparing food for 5, 10, 15, and 20 residents. On 3/13/24 at 3:08 PM, Chief Executive Officer (CEO-C), Assistant Administrator (AA-I) and Director of Nursing (DON-B) were informed of concerns with the preparation of pureed food. No other information was provided.

Based on observation, interview and record review, the facility did not provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. Licensed Practical Nurse (LPN) - E did not safely administer Insulin to 1 (R58) of 1 resident observed for insulin administration. Findings include: R58 was admitted to the facility 5/6/20 with diagnoses that included Alzheimer's Disease, Chronic Kidney Disease and Type 2 Diabetes Mellitus. Surveyor reviewed R58's MD orders. Documented with a start date of 12/12/23 and an administration time of 7:00 AM to 10:00 AM was Novolin 70/30 U-100 Insulin (insulin ph and regular human) [OTC] suspension; 100 unit/mL (70-30); amt: Per Sliding Scale; If Blood sugar is less than 70, call NP/PA. If Blood Sugar is 71 to 100, give 20 Units. If Blood Sugar is 101 to 400, give 30 Units. If Blood Sugar is greater than 400, call NP/PA. subcutaneous Special Instructions: BREAKFAST [DX: Type 2 diabetes mellitus with diabetic chronic kidney disease] Once A Day; 07:00 - 10:00 On 3/14/24 at 8:23 AM Surveyor observed Licensed Practical Nurse (LPN)-E administer insulin to R58. LPN-E stated to Surveyor R58 would get 30 units of Novolin 70/30 based on the blood glucose of 107 taken earlier. LPN-E sanitizes hands, removes cap and draws back 30 units of insulin. LPN-E does not recap needle and holds in right hand without cap on. LPN-E then puts on left glove with uncapped needle in right hand. Uncapped needle is waved in air. LPN-E gathered alcohol wipe and locked cart. LPN-E walked in R58's room with uncapped needle. Approached R58 and donned right glove with uncapped needle still in hand, switched hands to don glove. LPN-E then opened alcohol wipe and wiped back of arm with uncapped needle still in hand. LPN-E then injects insulin in back of arm, pulled out needle and turned around before putting safety cap on. LPN-D discarded needle in sharps container. On 3/14/24 at 10:43 AM Surveyor interviewed Director of Nursing (DON)-B and Registered Nurse (RN)-G. Surveyor asked what was the correct procedure to administer insulin from a multi-dose vial. DON-B stated alcohol the top of the bottle, draw back syringe to units needed, insert needle and put air into vial, draw back and verify correct amount in syringe, recap the needle and bring it to patient, alcohol wipe area they want insulin administered, administer insulin, safety cap and discard in sharps. Surveyor asked if staff have been trained on safety with the needles? DON-B stated I believe so. Surveyor asked should staff always be recapping the syringe after drawing up insulin. DON-B stated yes. Surveyor expressed safety concerns with LPN-E not recapping the insulin needle.

Based on observation, interview and record review, the facility did not ensure 3 (R61, R66 & R63) of 5 sampled residents with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections and provide dignity for residents. *R61 was observed multiple times with their catheter drainage bag system uncovered and laying on the floor. *R66 was observed multiple times with their catheter drainage bag system uncovered. *R63 was observed multiple times with their catheter drainage bag system uncovered and with drainage system port uncovered directly on the floor. Findings include: 1. R61 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease stage 3, muscle weakness and sepsis. R61's admission MDS (Minimum Data Set) assessment dated [DATE] indicated R61 had moderately intact cognition with a BIMS (brief interview for mental status) score of 12. R61 was noted to require maximal assist with 1 person for incontinence cares. R61 requires use of a urinary catheter for bladder elimination. R61's care plan with an initiation date of date of 2/3/24 reads Resident has a foley catheter r/t (related to) urinary retention. Interventions include the following: Do not allow tubing or any part of drainage system to touch the floor .store collection bag inside a protective dignity pouch. On 3/11/24 at 10:51 AM, Surveyor noted R61's catheter bed bag to be directly on the floor next to their bed. Surveyor did not observe a privacy bag or any barrier between drainage system and floor. On 3/11/24 at 11:57 AM, Surveyor noted R61's catheter bed bag to be directly on the floor next to their bed. Surveyor did not observe a privacy bag or any barrier between drainage system and floor. On 3/11/24 at 1:45 PM, Surveyor observed R61's catheter bed bag to be directly on the floor next to their bed. Surveyor did not observe a privacy bag or any barrier between drainage system and floor. On 3/14/2024 at 10:51 AM, Surveyor interviewed DON (Director of Nursing)-B who stated catheter drainage bags should have a cover over them for privacy. Surveyor shared Surveyor's multiple observations of R61's catheter drainage system observed being uncovered and laying directly on the floor on 3/11/24. The facility was unable to provide additional information at this time. 2. R66 was admitted to the facility on [DATE] with diagnoses including urinary tract infection R66's significant change Miminum Data Set (MDS) assessment dated [DATE] indicated R66 has intact cognition with a Brief Interview for Mental Status (BIMS) of 14. R66 was noted to require maximal assist with 1 person for incontinence cares. R66 requires use of a urinary catheter for bladder elimination. A care plan dated 1/5/24 with a revision date of 3/8/24 reads: Potential for Infection r/t (related to) recent UTI/infection and needing IV (intravenous) abt (antibiotic). Care plan intervention listed reads Nursing staff will monitor for further s/s (signs or symptoms) of infections. On 3/11/24 at 10:45 AM, Surveyor observed R66's catheter drainage system to be hanging on R66's bed frame. Surveyor noted approximately 300 cc of blood tinged urine in the drainage system bag. Surveyor did not observe a privacy bag or any barrier between drainage system and bedframe. On 3/11/24 at 11:47 AM, Surveyor observed R66's catheter drainage system to be hanging on R66's bed frame. Surveyor noted approximately 325 cc of blood tinged urine in drainage system bag. Surveyor did not observe a privacy bag or any barrier between drainage system and bedframe. On 3/11/24 at 1:40 PM, Surveyor noted R66's catheter drainage system to be hanging on R66's bed frame. Surveyor noted approximately 100 cc of blood tinged urine in drainage system bag. Surveyor did not observe a privacy bag or any barrier between drainage system and bedframe. On 3/14/2024 at 10:51 AM, Surveyor interviewed DON (Director of Nursing)-B who stated catheter drainage bags should have a cover over them for privacy. Surveyor shared Surveyor's multiple observations of R66's catheter drainage system observed being uncovered on 3/11/24. The facility was unable to provide additional information at this time. 47094 3. R63 was admitted to the facility on [DATE] and has diagnoses that include Alzheimer's, Dementia, chronic kidney disease stage 3, Type 2 Diabetes Mellitus, Polyneuropathy, spinal stenosis, benign prostatic hyperplasia with lower urinary tract symptoms, urine retention, neuromuscular dysfunction of the bladder and has a history of having urinary tract infections (UTI). R63's quarterly minimum data set (MDS) dated [DATE] indicated R63 had intact cognition with a brief interview for mental status (BIMS) score of 13 and the facility assessed R63 needing maximal assist with 1 person for incontinence cares. R63 had a foley catheter and was frequently incontinent of bowel and wore and adult brief. R63's Alteration in bladder elimination related to diagnoses of urinary retention with chronic indwelling foley catheter care plan initiated on 7/13/2020 and last revised on 1/3/2024 with the following interventions: Goal: Resident's foley catheter will remain patent and will continue to drain without difficulty. Will be free of signs and symptoms of UTI (urinary tract infection). -Toileting program: staff to empty catheter q (every) three hours to prevent pulling on penis and PRN (as needed). Staff to change catheter monthly per order. Has order for 20 french coude catheter. Staff may irrigate catheter PRN if obstructed. Staff to monitor resident for signs and symptoms of UTI that may include change in color, cloudiness, foul odor, etc . staff to update MD/NP (medical doctor/nurse practitioner) if UTI suspected. -incontinence product- briefs. Surveyor made the following observations of R63's foley catheter during the survey: On 3/11/2024 at 10:15 AM Surveyor observed R63's catheter drainage bag was hanging from the side of the bed uncovered. On 3/13/2024 at 8:05 AM Surveyor observed R63's catheter drainage bag was inside a privacy bag and the privacy bag was on the floor. R63's catheter tubing was slightly pulled so there was no slack on the tubing. Surveyor asked R63 how R63 was feeling. R63 stated R63 felt fine and did not feel like the catheter tubing was pulling. On 3/14/2023 at 8:18 AM Surveyor observed R63's catheter drainage bag hanging on the side of R63's bed uncovered. The drainage valve on the catheter drainage bag was hanging down and the tip of the tubing was touching the floor. On 3/14/2024 at 8:35 AM Surveyor interviewed Unit Manager (UM)-D who stated staff empty R63's foley catheter drainage bag frequently to prevent tension on the catheter tubing. On 3/14/2024 at 10:51 AM Surveyor interviewed Director of Nursing (DON)-B who stated catheter drainage bags should have a cover over them for privacy. Surveyor shared Surveyor's observations of R63's catheter bag being uncovered on multiple occasions and the drainage valve tubing touching the ground. DON-B had no further questions or information and this time.

Based on interview and record review, the facility did not ensure proper antibiotic use for 1 (R46) of 4 resident's reviewed for antibiotic use. *R46 was prescribed an antibiotic prior to obtaining a respiratory panel. Results of the respiratory panel documented R46 was infected with the para-influenza virus, which does respond to antibiotics. Findings: POLICY STATEMENT: [name of the facility], in conjunction with the medical director, consultant pharmacist, and administration will promote effective management and utilization of antibiotics prescribed to residents. This policy provides guidelines for the healthcare staff caring for our older adults, to recognize infection and initiate appropriate evaluation and treatment in a timely fashion, thereby improving outcomes of care. The [name of the facility] will utilize McGeer's [sic] definitions as one of the surveillance tool for infection tracking. Older adults who symptoms do not meet the guidelines for an infection should receive an intervention aimed at resolving symptoms without the unnecessary use of antibiotics. Atypical signs and symptoms of an infection in the older adult must be acknowledged and have been incorporated into the McGeer's [sic] definitions a: criteria for management of infection. Final diagnosis and treatments are determined by the provider. PROCEDURE: When the licensed nurse receives notification of a resident with signs and symptoms of infection, the following process must take place: Residents are placed on the 24-hour report. The provider or designee is notified of signs and symptoms and interventions that are initiated. Family/HCPOA is updated on resident's change of condition. If the resident does not meet the surveillance definitions of an infection, the provider or designee should consider doing lab work such as a CBC (complete blood count), or alternative interventions such as increase fluid intake . At any time that the resident's condition deteriorates or requires immediate medical intervention, the provider will be notified. Residents who have a suspected or confirmed infection will be documented on list on the unit. Antibiotics that continue into the next month do not need to be reflected on the line list for the second month. The line list includes resident symptoms, laboratory, or radiological test. If a resident does not meet the criteria for infection based on McGeer's [sic] criteria, the provider should be notified and documentation in the medical record should occur. The medical director will be consulted and intervene as needed. The provider MUST provide a diagnosis, duration of treatment and/or indication for the use of an antibiotic. Every shift the nursing supervisor or manager will review the antibiotic line list to ensure appropriateness of antibiotic. Supervisor/manager will review for trends or outbreaks and report to infection preventionist or designee. A floor map will also be completed to monitor for possible outbreaks. Final culture results should be reported to provider to ensure appropriate treatment is prescribed . R46 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease with late onset; Hypertensive heart disease without heart failure; Major depressive disorder, single episode, unspecified and Anxiety disorder, unspecified. R46's most recent Minimum Data Set Assessment (MDS), dated [DATE] documented R46 had a Brief Interview for Mental Status (BIMs) of 99 indicating R46 did not respond and/or did not respond appropriately to four or more questions; R46 had taken antibiotics in the previous seven days. Surveyor reviewed R46's nursing progress notes and noted the following: On 11/12/2023 at 10:54 AM, a nurse documented, Cough and congestion present at this time. [name of physician] updated. Orders received to start resident on Azithromycin (Z-pack) 250 mg (milligrams) daily x (for) 5 days. Resident to receive 2 tabs now followed by one tab daily for a total of a 5 day treatment. Orders given to obtain a respiratory panel, and a Covid swab. Resident remained in bed this AM shift. VSS (vital signs stable) . On 11/13/2023 at 8:40 PM, a nurse documented, Resting in bed. Respiration is normal. No indication of having respiratory distress. Noted with occasional nonproductive cough. Lung sounds diminished. No other complaints presented. Remains on ABT (antibiotic therapy). No adverse reactions noted. Afebrile. Remains on droplet precautions and observed for Para Influenza. Surveyor noted the following order in physician's orders: Azithromycin tablet; 250 mg (milligrams); amt (amount): one tab; oral Special Instructions: x (for) 4 days after first dose of 500mg on 11/12/23 for a total of 5 days treatment. Surveyor could not locate documentation the facility followed up with R46's prescribing physician regarding the results of R46's respiratory panel which was positive for the para-influenza virus. On 03/13/24 at 12:42 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-G and Director of Nursing (DON)-B. ADON-G informed Surveyor the facility uses the McGreer's criteria to identify infections. Per ADON-G, the nurses would notify the physician with a resident's change in condition and then follow the physician's orders which could include a chest X-ray, laboratory work, and/or cultures. Per ADON-G the facility would not normally treat the influenza virus with antibiotics. Surveyor asked why was R46 prescribed antibiotics for the influenza virus? Surveyor asked for documentation the physician was made aware of the results of the respiratory, education by the facility regarding using antibiotics for viral infections and the reasoning behind the physician's continued order for the z-pak antibiotics. Prior to the end of the day on 03/13/24, DON-B provided Surveyor with a copy of the physician's handwritten note dated 11/13/23. This note documented R46 had cough, sore throat, low grade temperature and R46's nasal swab was positive for the para-influenza virus. This note does not document any conversation had with the facility regarding the antibiotic use or the physician's reasoning behind continuing to treat a viral infection with an antibiotic. At 03/13/24 at 3:00PM during the end of the day meeting with DON-B, Chief Executive Officer-C and ADON-G, Surveyor relayed the above concerns regarding R46 receiving antibiotics for a viral infection. Surveyor asked for any additional information. No additional information was given.

Based on observation, record review and interview, the facility did not ensure that its medication error rate was not 5 percent or greater. During observation of medication administration, the facility staff made medication errors with 2 (R58 and R10) of 7 residents observed for medication administration for a total of 2 errors of 31 opportunities for an error rate of 6.45%. ~ R58 was administered Novolin insulin that was expired. ~ R10 was administered Aspirin where the expiration date was illegible and was unable to be confirmed if it was expired or not. Findings include: Surveyor reviewed Medication and Vaccine Storage policy with an effective date of [DATE]. Documented was: .5. Outdated or contaminated medications or those in cracked or soiled or without secure closures are removed from the medication cart and disposed of properly. Medications will be reordered as needed . 11. Insulin is to be refrigerated until opened. Once open, insulin can remain at room temperature until expiration, based on guidelines for specific product. 1. R58 was admitted to the facility [DATE] with diagnoses that included Alzheimer's Disease, Chronic Kidney Disease and Type 2 Diabetes Mellitus. Surveyor reviewed R58's MD orders. Documented with a start date of [DATE] and an administration time of 7:00 AM to 10:00 AM was Novolin ,d+[DATE] U-100 Insulin (insulin ph and regular human) [OTC] suspension; 100 unit/mL (,d+[DATE]); amt: Per Sliding Scale; If Blood sugar is less than 70, call NP/PA. If Blood Sugar is 71 to 100, give 20 Units. If Blood Sugar is 101 to 400, give 30 Units. If Blood Sugar is greater than 400, call NP/PA. subcutaneous Special Instructions: BREAKFAST [DX: Type 2 diabetes mellitus with diabetic chronic kidney disease] Once A Day; 07:00 - 10:00 On [DATE] at 8:23 AM Surveyor observed Licensed Practical Nurse (LPN)-E administer insulin to R58. LPN-E stated to Surveyor R58 would get 30 units of Novolin ,d+[DATE] based on the blood glucose of 107 taken earlier. LPN-E sanitizes hands, removes cap and draws back 30 units of insulin. LPN-E handed vial of insulin with box to Surveyor. Written in blue ink on label was opened [DATE]. There was no discard date written on the label. LPN-E walked in R58's room and administered insulin in back of left arm. Surveyor reviewed Novolin N Prescribing Information found on Drugs.com. Documented was: Table 2: Storage Conditions and Expiration Dates for NOVOLIN N 10 mL multiple-dose vial . In-use (Opened) Room Temperature (see temperature below) Until expiration date 42 days up to 77 F (25 C) (Do not refrigerate) https://www.drugs.com/pro/novolin-n.html#s-,d+[DATE] Surveyor noted the insulin would have been expired and past 42 days. On [DATE] at 10:43 AM Surveyor interviewed Director of Nursing (DON)-B and Registered Nurse (RN)-G. Surveyor asked how long is insulin good for after opening. DON-B stated 28 days unless the label says different. Surveyor asked if the nurses should be checking expiration dates before administration. DON-B stated yes. Surveyor asked should the insulin be labeled with the discard date. DON-B stated yes. Surveyor noted LPN-E administered Novolin to R58 past the manufacturer's expiration days of 42. DON-B stated she should have not administered that. 2. R10 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, Metabolic Encephalopathy, Hypertensive Heart Disease without Heart Failure, Hyperlipidemia and Type 2 Diabetes Mellitus. Surveyor reviewed R10's MD Orders. Documented with a start date of [DATE] and an administration time of 7:00 AM to 10:00 AM was: aspirin [OTC] tablet, chewable; 81 mg; amt: 1 tablet; oral [DX: Hyperlipidemia, unspecified] Once A Day; 07:00 - 10:00 On [DATE] at 7:54 AM Surveyor observed LPN-F administer medications to R10. LPN-F popped blister packs of medications into a medication cup. LPN-F poured one house stock 81 mg Chewable Aspirin tablet into bottle top and then poured it into the med cup with other medications. LPN-F handed the bottle to Surveyor. Surveyor could not find expiration date on bottle. LPN-F gave the medication cup to R10 who took the pills whole with water. Surveyor handed the bottle back to LPN-F and asked what the expiration date was for the 81mg aspirin. LPN-F stated she did not see it. Surveyor asked if she would check the expiration before you give it. LPN-F stated yes, she usually does. Surveyor asked what would happen if she noted prior that she could not read it. LPN-F stated I am going to have to get rid of it. On [DATE] at 10:43 AM Surveyor interviewed Director of Nursing (DON)-B and Registered Nurse (RN)-G. Surveyor asked what nurses should be checking before administering medications. DON-B and RN-G stated the 5 rights that included right person, right medication, right route, right time and right dose. Surveyor asked if the nurse should be checking expiration dates for medications to make sure they are not expired. DON-B stated yes. Surveyor asked if the expiration date is illegible and worn out on the bottle, what should the nurse do. DON-B stated discard the bottle and get a new one. Surveyor explained the concern with the Aspirin administered to R10.

Based on interview, record review and observation, the facility did not assure drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles and include the expiration date when applicable in 3 of 3 Medication Carts and 2 of 2 Medication Storage Rooms reviewed for compliance. Surveyor observed undated, opened eye drops in 2NW Cart 1. Surveyor observed undated and unlabeled medications in 2NW Cart 1. Surveyor observed insulin that should have been refrigerated in 2NW Cart 1. Surveyor observed expired insulin in 2NW Cart 1. Surveyor observed 2 medications stored in latex gloves in 2NW Medication Room. Surveyor observed a salad in the medication fridge in the 2NW Medication Room. Surveyor observed nose spray with no opened on date in 3NW Cart 1. Surveyor observed 2 unlabeled tubes of ointment in the same container in 3NW Cart 1. Surveyor observed undated, opened eye drops in 3NW Cart 1. Surveyor observed undated and unlabeled medications in 3NW Cart 1. Surveyor observed expired eye drops in 3NW Cart 1. Findings include: Surveyor reviewed Medication and Vaccine Storage policy with an effective date of 9/26/19. Documented was: POLICY STATEMENT: Medications will be stored safely, securely, and properly. The medication supply will only be accessible to licensed nursing personnel, pharmacy personnel, and staff members authorized to pass medications. PROCEDURE: .5. Outdated or contaminated medications or those in cracked or soiled or without secure closures are removed from the medication cart and disposed of properly. Medications will be reordered as needed. 6. Medication storage areas are kept clean, well - lit, and free of clutter and extreme temperatures and humidity . 9. Medications will be stored in their original packing until ready for administration. If multi-dose, medication should be dated . 11. Insulin is to be refrigerated until opened. Once open, insulin can remain at room temperature until expiration, based on guidelines for specific product . TEMPERATURE: .2. Medications requiring refrigeration are kept in a refrigerator at temperatures between 36 F and 46 F with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label. Controlled substances that require refrigeration are stored within a lock box that is attached to the refrigerator . On 3/14/24 at 10:55 AM Surveyor observed the 2 Northwest Cart 1 with Registered Nurse (RN)-G who is also the Infection Preventionist. Surveyor observed Polyvinyl AL eye drops with no opened on date belonging to R108. Surveyor observed Systane eye ointment with no opened on date belonging to R57. Surveyor observed brimonidine timolol eye drops with no opened on date belonging to R50. Surveyor observed Genteal eye drops with no opened on date belonging to R69. Surveyor observed Alphagan eye drops with no opened on date belonging to R65. Surveyor observed Novolog insulin belonging to R57 that had not been opened but printed on front was refrigerate until opening. Surveyor observed Novolog insulin belonging to R57 that had expired 3/12/24. Surveyor observed an opened box of Acetylcysteine 4mg vials with no name or date opened on it. On 3/14/24 at 11:10 AM Surveyor asked RN-G what will be done with the eye drops. RN-G stated she had directed the nurse on the cart to reorder all the unlabeled medications including the insulin. RN-G stated they will be sent back to pharmacy to be destroyed. RN-G stated she was unsure who the Acetylcysteine belonged to but it should be labeled. On 3/14/24 at 11:15 AM Surveyor observed the 2 Northwest Medication Room with RN-G. Surveyor observed a tube of Procto Med HC inside a latex glove and also a Hydrocortisone cream inside a latex glove. Surveyor opened the medication fridge and a salad in a plastic to go container was in the refrigerator. On 3/14/24 at 11:18 AM Surveyor asked RN-G if medications should be stored in gloves. RN-G stated no, they should be stored in Ziplock bags. Surveyor asked about the salad in the medication fridge. RN-G stated that should be thrown away, that shouldn't be in there. On 3/14/24 at 11:25 AM Surveyor observed the 2 Northwest Cart 2 with RN-G. Surveyor observed Polyvinyl AL eye drops with no opened on date belonging to R39. On 3/14/24 at 11:27 AM RN-G stated she will also have those eye drops reordered. On 3/14/24 at 11:31 AM Surveyor observed the 3 Northwest Cart 1 with RN-G. Surveyor observed Fluticasone with no opened on date belonging to R72. Surveyor observed Muro 128 in container with 2 tubes inside, one old and one new with no opened on date belonging to R1. Surveyor observed Moxifloxacin eye drops with no opened on date belonging to R6. Surveyor observed Travaprost eye drops with no opened on date belonging to R118. Surveyor observed Systane eye ointment with no opened on date belonging to R43. Surveyor observed an open tube of triamcinolone cream with no name on it. Surveyor observed an expired Latanoprost eye drop container belonging to R118. On 3/14/24 at 11:39 AM Surveyor observed RN-G instruct the unit nurses to reorder all the unlabeled and expired medications found in 3 Northwest Cart 1. On 3/14/24 at 11:43 AM Surveyor observed the 3 Northwest Medication Room with RN-G. Surveyor observed the Medication Refrigerator thermometer to read 55 degrees and handed the thermometer to RN-G to verify. Surveyor observed an expired bottle of Lactulose belonging to R30. Surveyor observed house stock bottles of Tab A Vite that expired 2/24 and Docusate Calcium that expired 11/22. Surveyor observed an open bottle of Pepsi and open bag of Hot Stuff potato chips on the counter behind the sink. On 3/14/24 at 11:48 AM Surveyor asked RN-G what the temperature in the Medication refrigerator should be. RN-G stated 37 to 40 degrees is what it is supposed to be. RN-G stated they will fix that right away. RN-G put the expired medications in the bin to go back to pharmacy to be destroyed. Surveyor asked what the food and soda was doing in there. RN-G stated it should not be in there. Surveyor noted the concerns with all the carts and med storage rooms. RN-G stated she understood. Surveyor requested and received the medication storage policy.

Based on interview, record review, policy review and review of facility documents, the facility failed to ensure two (Residents (R)1 and R3), of ten sampled residents were free of accidents. Specifically, R1 fell to the floor while unsupervised and sustained a fracture requiring surgical intervention, and R3 fell to the floor while unsupervised which resulted in a head laceration requiring medical treatment. In addition, both R1 and R3 were not provided individual interventions on their care plans to prevent the falls from occurring. The failure to provide adequate supervision and individual fall risk interventions placed R1 and R3 at risk for falls with injury. Findings include: Review of the facility's policy titled Falls with a revision date 05/17/23 indicated Residents have the right to be mobile and free from physical restraints with minimal risk for injury. The goal is to reduce falls as much as possible, and to reduce the risk of serious injury . all residents will be assessed for their fall risk upon admission . risk factors will be identified . interdisciplinary interventions will be identified and included on the plan of care. 1. Review of R1's Face Sheet located in the Electronic Medical Record (EMR) under the Resident tab indicated R1 was admitted on [DATE] with diagnoses including subcortical compression of the brain, generalized muscle weakness with lack of coordination, left-side paralysis, and cognitive communication deficit. Hospital records provided to the facility during R1's hospitalization post stroke indicate in the physical therapy details: (Name of R1) .she requires max assist x (times) 2 and verbal cues for task sequencing, but able to assist with her right upper extremity. Remaining deficits include impaired cognition, decreased insight into current deficits, impaired safety awareness, impulsivity, impaired judgement, pain, weakness, impaired balance, and limited activity tolerance . The admission Fall Risk Data Collection Tool dated 06/20/23 located in the EMR under the Reports tab, indicated R1 was High Risk for falls due to intermittent confusion, confined to chair, totally unable to ambulate without assist, history of falls, and wheelchair with footrests needed during transport. The fall risk data collection tool also indicates R1 has cardiovascular issues - cardiac dysrhythmia, Neuromuscular/functional issues - loss of limb movement, decline in functional, incontinence, hypotension, CVA (cerebral vascular accident), hemiplegia/hemiparesis, parkinson's, seizure disorder, syncope, unsteady gait, Psychiatric or cognitive - delirium, decline in cognitive skills, manic depression, alzheimer's disease, other dementia, Orthopedic - joint pain, fracture of hip, missing limb, osteoporosis - contributing factors scoring - 4 or more present. The assessment section for indicate care plan action taken indicates continue plan of care: description notes indicate: Staff aware of resident being high fall risk. Maintain low bed at all times. fall mat in place with LAL (low air loss) mattress/bolsters. PRN (as needed) Lorazepam for restlessness and agitation - hospice patient. The baseline admission Care Plan dated 06/21/23 located in the EMR under the RAI tab indicated, Resident is at risk for falling related to decrease in mobility secondary to left sided weakness and an initial fall score at high risk . client will remain free from injury. Approaches included, encourage resident to assume a standing position slowly, keep call light in reach at all times, give verbal reminders not to ambulate/transfer without assistance, keep personal items within reach and obtain therapy consult for strength training, positioning, transfer training, gait training, and mobility devices. Based on the information gathered by the facility upon admission and the fall risk assessment, the baseline Care Plan included approaches that did not meet the cognitive and physical needs of R1's fall risk. R1 could not stand, could not use a call light, and could not cognitively be reminded to ask for assistance due to diagnoses listed on admission. (refer to F655) Surveyor noted the baseline care plan did not include the interventions of maintain low bed at all times, fall mat in place with LAL (low air loss) mattress/bolsters. PRN (as needed) Lorazepam for restlessness and agitation - hospice patient. or include interventions for R1's restlessness/agitation. Additionally, the baseline care plan did not address the deficit unawareness or impulsivity that was included in the hospital discharge paperwork regarding R1 as a possible risk factor for R1 falling. R1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/25/23, located in the EMR under the RAI tab, indicated R1's Brief Interview for Mental Status (BIMS) score was 11 out of 15 which indicated R1's cognition was moderately impaired and was dependent on staff for bed mobility and transfer. R1 was unable to ambulate due to left-side paralysis. R1 was transferred with a Hoyer lift. During an interview on 10/17/23 at 10:17 AM, R1's attending physician stated The resident (referring to R1) fell at home, was high risk for falls on admission due to cognitive loss and general weakness due to the brain injury. The resident was not aware that independent ambulation is not possible. R1's record indicates on 6/23/23 R1 experienced a change in condition that included R1's oxygen levels to drop to 86% with a low grade temperature. R1 was provided with oxygen at 4L (liters) via a nasal cannula. Orders were obtained for a stat chest x-ray, blood cultures, CBC (complete blood count), and BMP (basic metabolic panel) labs. Lung sounds were clear at this time. Oxygen levels improved and the oxygen was lowered to 2L via nasal cannula and a rapid covid test was negative. It is noted the facility activated R1's power of attorney for healthcare on this date. R1 was placed in isolation at this time. Surveyor noted there was no review of R1's need for supervision or assessment for possible changes to fall risk with the change in condition and need for isolation. The Event Report provided by the Administrator dated 06/23/23 at 3:30 PM indicated R1 had an unwitnessed fall from a recliner while in the bedroom. According to the Event Report R1 was found face down on the floor with a bump on the head and complained of left hip pain. During an interview on 10/17/23 at 11:30 AM, Registered Nurse (RN) 3 stated R1 was unable to communicate because of confusion and cognitive loss. RN3 stated that prior to the fall, nursing staff used a mechanical lift for transfers and R1 was unable to walk due to left-side paralysis. During an interview on 10/18/23 at 8:00 AM, the Director of Nursing (DON) stated, The fall (referring to the event report dated 06/23/23) was unwitnessed. The resident was in the bedroom in a recliner and was found face down on the floor. I'm not sure how it happened, the first X-ray taken of the hip showed no fracture but a few days later she had swelling and bruising above the left knee and a second X-ray showed a fracture. We try to keep residents who are high risk for falls in the common area where there is more supervision especially during staffing challenges. Resident Progress Notes dated 06/23/23 at 05:10 PM located in the EMR under Resident tab indicated, Was called to resident's room at 1520 and upon arrival to room, nurse manager, RN on unit and LPN (licensed Practical Nurse) assisting resident to transfer resident off the floor to bed with the use of a Hoyer lift. Per staff resident was found face down. Noted about a quarter size bump/bruise to left forehead and faint bruise to right forehead. Resident is alert and denies pain. No c/o (complaint of) headache, no nausea/vomiting. No other injury noted. Ice pack applied. Neuro check is within normal. Has left sided weakness d/t hx (history) of CVA (cerebral vascular accident) and recent stroke. Bed in low position, and floor mat next to bed. Call light clip to chest and reminded to call for assistance as needed. Spoke with (name of) NP (nurse Practitioner) updated on the event with head injury, no new order. Spoke with POAHC (power of attorney for health care), stated she knew it that she would fall because resident is forgetful and tries to get up and walk unassisted. Resident just had a recent fall before she went to the hospital. Informed her that we need to keep resident then in the common area d/t history of fall and impulsiveness. She was ok to keep resident in place that needed supervision. The Summary of Incident dated 06/27/23 provided by the Administrator, indicated on 06/27/23 the resident complained of left knee pain. Upon assessment the knee was observed to be swollen with bruising on the inner aspect. An X-ray was ordered and completed on 06/28/23 and showed an acute distal femoral fracture. According to the Summary of Incident the resident was transferred to the hospital. The summary indicated Based on the findings of the investigation, it was determined that the injury to the left knee is consistent with resident falling on 06/23/23, R1 was transferred to the hospital on 06/28/23. Review of a hospital Patient Report dated 06/28/23 located in the EMR under the reports tab indicated Left Knee . Acute distal femoral fracture. Orthopedic evaluation is recommended. Progress Notes dated 07/05/23 at 5:33 PM located in the EMR under the RAI tab indicated, Client readmitted to facility from hospital via ambulance. Client s/p [status post] ORIF [Open Reduction Internal Fixation]. According to the Treatment Administration Record (TAR) dated 07/05/23 located in the EMR under the Orders tab, R1 was readmitted to the facility following orthopedic surgery and had staples to the left hip/knee [thigh]. During an interview on 10/19/23 at 8:30 AM the DON stated, The admission care plan did not include the use of Dycem, a Broda chair in the reclining position or increased supervision in the common area because these approaches were not added until 6/26/23, after R1's fall on 06/23/23. 2. R3's Face Sheet located in the EMR under Resident discharged chart, indicated an initial admission on 08/08/14 with a re-admitted [DATE] and diagnoses included dementia and polyosteoarthritis. R3's quarterly MDS with an ARD of 04/28/23 found in the EMR under the RAI indicated a BIMS score of 99 which indicated R3 was unable to be interviewed, had memory loss with moderately impaired cognitive skills. R3 was unable to walk and was totally dependent on staff for dressing, eating, toilet use, personal hygiene, and bathing. R3 used a wheelchair for mobility with assistance from staff. Review of R3's Care Plan dated 04/17/23 located in the EMR under the RAI tab indicated, Potential for injury safety related to history of falls, immobility, weakness, and diagnosis of corticobasal degeneration . resident will be free of injuries due to falls, target date 11/30/23. Approaches included: 4/17/23 bed in lowest position when not completing cares. 1/23/22: unwitnessed fall from Broda chair - staff to monitor resident's position in Broda chair. Staff should lower the height of Broda chair after meals . 2/3/15 Mat to be placed on the floor next to bed when resident is in bed. 9/17/14: Dicem (sic) placed on recliner/Broda chair seat. Staff to keep soft touch call light in lap or clipped to arm rest of recliner/Broda chair. Review of a Fall Risk Data Collection Tool dated 05/10/23 located in the EMR under the Report tab indicated R3 was high risk for falls due to mental status, visual impairment, transfer dependency, orthopedic condition, arthritis pain and neuromuscular status. Review of a Falls Event dated 07/09/23 at 2:50 PM provided by the facility indicated R3 was found in the room on the floor next to a Broda chair -head toward the bathroom door, prone with right side of head on floor, right arm under her torso. Prior to the fall R3 was up in Broda chair watching TV, was last observed at 1410 and last toileted at 1200. R3 exhibited pain in the head with laceration. The Falls Event indicated Were proper precautions taken prior to the fall? Yes or no. The No box was checked and indicated Sitting upright in Broda chair. Safety measures already in place included Dicem (sic), low bed, mat on floor next to bed, and other- recline Broda chair. Interventions to prevent recurrence include: staff to keep resident in common area when up in Broda chair. Surveyor noted the falls event does not include review of whether other relevant interventions were in place including if there was Dycem in the seat of the chair to prevent slipping and whether R3 had the call light in place as care planned or had activated it prior to the fall. Review of Resident Progress Notes dated 07/09/23 at 3:31 PM located in the EMR under the Resident tab indicated Was called to resident's room and observed resident lying on the floor with unit nurse applying pressure to the right side of forehead laceration. Also noted right cheekbone is slightly swollen. Able to control bleeding and dressing applied . order received to send resident to ER [emergency room ] for evaluation. Review of Resident Progress Notes dated 07/11/23 at 06:43 PM located in the EMR under the Report tab indicated Client readmitted from hospital via ambulance . discharge diagnosis unwitnessed fall with forehead laceration . resident has 4 or 5 sutures to right side of forehead . sutures to be removed in 7-10 days. During an interview on 10/18/23 at 2:50 PM the DON stated the Fall Event dated 07/09/23 was discussed at the morning meeting the day after the fall. The box that was checked No was discussed regarding the Broda chair not being reclined before the resident fell . The DON stated, I could not verify if the chair was reclined as interviews with staff some said yes and some said no. The DON agreed that the reclining Broda chair was an intervention that was indicated as a proper precaution not in place on the Falls Event dated 07/09/23. According to all of the operating manuals for the different Broda seating models under hazards: 2.5 Hazards 2.5.1 Position of Chair - Danger of Falling After a resident is transferred into a chair, assess the amount of tilt required. We recommend that the chair's seat be tilted sufficiently to help prevent the resident from sliding or falling forward off the chair. The amount of seat tilt used should be determined by the resident's caregiver who is responsible for seating. 2.5.2 Position of Seat Tilt - Danger of Tipping We recommend that the chair's seat be tilted sufficiently to prevent an agitated resident from tipping the chair forward or backward, or from slumping and sliding in the chair. The amount of seat tilt used should be determined by the resident's caregiver who is responsible for seating. Always ensure that the resident is properly positioned before operating the seat tilt. 2.5.3 Location of Chair - Danger of Tipping or Falling Objects We recommend that when a resident has been moved to their destination, the chair is placed where the resident cannot reach handrails or other objects, fixed or movable. This is to prevent the resident from pulling the chair over or pulling themselves off the seating surface and to prevent the resident from pulling movable objects onto the chair and themselves. We recommend that the chair be used in a supervised area to prevent untrained residents, caregivers, or third parties from unauthorized operation, movement, or unsafe actions such as sitting or leaning on the reclined back, elevated footrest, or the armrests. These actions, if not prevented, put the chair at risk of tipping or damage to the chair. We recommend that a chair only be located on a level surface to minimize the risk of tipping over. 2.5.4 Total Lock Wheel Brakes - Danger of Falling The special casters found on the BRODA chair have total lock brakes which prevent the wheels from turning and swiveling. The brakes must always be applied when: 1) the chair is not in use; 2) a resident is being transferred (moved) into or out of the chair. It is important to note that if the wheel brakes are applied while the resident is in the chair, that the caregiver does not leave the resident unattended, especially those residents who have the capability or tendency to move the chair and/or those who may be agitated. This could cause harm to the resident if they attempt to move the chair while the wheel brakes are applied. Note that removing and attaching the footrest may be easier for the caregiver with the brakes applied Failure to follow these instructions will unnecessarily increase the risk of serious falls by residents, caregivers, or third parties caused by the chair unintentionally moving. 2.5.5 Re-Positioning of Resident - Danger of Clamping BRODA Pedal Chairs offer the benefits of seat tilt and height adjustable arms. During the movement of any of these functions, the following safety measures must be observed:

Based on interview, record review, policy review and review of facility event reports, the facility failed to develop a baseline care plan to include individual approaches and interventions to prevent a fall for one (Resident (R) R1) of 10 sampled residents. Specifically, R1 fell to the floor while unsupervised which resulted in R1 sustaining a fracture requiring surgical intervention. Findings include: Review of the policy titled Falls with a revision date 05/17/23 indicated Residents have the right to be mobile and free from physical restraints with minimal risk for injury. The goal is to reduce falls as much as possible, and to reduce the risk of serious injury . all residents will be assessed for their fall risk upon admission . risk factors will be identified . interdisciplinary interventions will be identified and included on the plan of care. Review of R1's Face Sheet located in the Electronic Medical Record (EMR) under the Resident tab indicated R1 was admitted on [DATE] with diagnoses including subcortical compression of the brain, generalized muscle weakness with lack of coordination, left-side paralysis, and cognitive communication deficit. Hospital records provided to the facility during R1's hospitalization post stroke indicate in the physical therapy details: (Name of R1) .she requires max assist x (times) 2 and verbal cues for task sequencing, but able to assist with her right upper extremity. Remaining deficits include impaired cognition, decreased insight into current deficits, impaired safety awareness, impulsivity, impaired judgement, pain, weakness, impaired balance, and limited activity tolerance . The admission Fall Risk Data Collection Tool dated 06/20/23 located in the EMR under the Reports tab, indicated R1 was High Risk for falls due to intermittent confusion, confined to chair, totally unable to ambulate without assist, history of falls, and wheelchair with footrests needed during transport. The fall risk data collection tool also indicates R1 has cardiovascular issues - cardiac dysrhythmia, Neuromuscular/functional issues - loss of limb movement, decline in functional, incontinence, hypotension, CVA (cerebral vascular accident), hemiplegia/hemiparesis, parkinson's, seizure disorder, syncope, unsteady gait, Psychiatric or cognitive - delirium, decline in cognitive skills, manic depression, alzheimer's disease, other dementia, Orthopedic - joint pain, fracture of hip, missing limb, osteoporosis - contributing factors scoring - 4 or more present. The assessment section for indicate care plan action taken indicates continue plan of care: description notes indicate: Staff aware of resident being high fall risk. Maintain low bed at all times. fall mat in place with LAL (low air loss) mattress/bolsters. PRN (as needed) Lorazepam for restlessness and agitation - hospice patient. The baseline admission Care Plan dated 06/21/23 located in the EMR under the RAI tab indicated, Resident is at risk for falling related to decrease in mobility secondary to left sided weakness and an initial fall score at high risk . client will remain free from injury. Approaches included, encourage resident to assume a standing position slowly, keep call light in reach at all times, give verbal reminders not to ambulate/transfer without assistance, keep personal items within reach and obtain therapy consult for strength training, positioning, transfer training, gait training, and mobility devices. Based on the information gathered by the facility upon admission and the fall risk assessment, the baseline Care Plan included approaches that did not meet the physical needs of R1's fall risk. R1 could not stand, could not use a call light, and could not cognitively be reminded to ask for assistance due to diagnoses listed on admission. (refer to F655) Surveyor noted the baseline care plan did not include the interventions of maintain low bed at all times, fall mat in place with LAL (low air loss) mattress/bolsters. PRN (as needed) Lorazepam for restlessness and agitation - hospice patient. or include interventions for R1's restlessness/agitation. Additionally, the baseline care plan did not address the deficit unawareness or impulsivity that was included in the hospital discharge paperwork regarding R1 as a possible risk factor for R1 falling. Review of R1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/25/23, located in the EMR under the RAI tab, indicated R1 had cognitive impairment, was dependent on staff for bed mobility and transfer. R1 was unable to ambulate due to left-side paralysis. During an interview on 10/17/23 at 10:17 AM R1's attending physician, stated The resident (referring to R1) fell at home, was high risk for falls on admission due to cognitive loss and general weakness due to the brain injury. Review of an Event Report provided by the Administrator dated 06/23/23 at 3:30 PM indicated R1 had an unwitnessed fall from a recliner while in the bedroom. According to the Event Report R1 was found face down on the floor with a bump on the head and complained of left hip pain. During interview with the attending physician on 10/17/23 at 10:17 AM, she stated that R1 tried to get up because she thought she could walk due to the stroke. The event report showed she fell from a recliner in her room. During an interview on 10/17/23 at 11:30 AM Registered Nurse (RN) 3 stated The resident can't communicate because of confusion and cognitive loss. A lift was used for transfer and the resident was unable to walk due to left-side paralysis. During an interview on 10/18/23 at 8:00 AM, The Director of Nursing (DON) stated The fall (referring to the event report dated 06/23/23) was unwitnessed. The resident was in the bedroom in a recliner and was found face down on the floor. I'm not sure how it happened. The first X-ray taken of the hip showed no fracture but a few days later she had swelling and bruising on the left knee and a second X-ray showed a fracture. We try to keep residents who are high risk for falls in the common area where there is more supervision especially during staffing challenges. During an interview on 10/18/23 at 9:30 AM, the Administrator stated, If the fall investigation stated 'recliner' then it was the regular recliner and not a Broda chair that the resident was in when she fell . Resident Progress Notes dated 06/23/23 at 05:10 PM located in the EMR under Resident tab indicated, Was called to resident's room at 1520 and upon arrival to room, nurse manager, RN on unit and LPN (licensed Practical Nurse) assisting resident to transfer resident off the floor to bed with the use of a Hoyer lift. Per staff resident was found face down. Noted about a quarter size bump/bruise to left forehead and faint bruise to right forehead. Resident is alert and denies pain. No c/o (complaint of) headache, no nausea/vomiting. No other injury noted. Ice pack applied. Neuro check is within normal. Has left sided weakness d/t hx (history) of CVA (cerebral vascular accident) and recent stroke. Bed in low position, and floor mat next to bed. Call light clip to chest and reminded to call for assistance as needed. Spoke with (name of) NP (nurse Practitioner) updated on the event with head injury, no new order. Spoke with POAHC (power of attorney for health care), stated she knew it that she would fall because resident is forgetful and tries to get up and walk unassisted. Resident just had a recent fall before she went to the hospital. Informed her that we need to keep resident then in the common area d/t history of fall and impulsiveness. She was ok to keep resident in place that needed supervision. Review of Summary of Incident dated 06/27/23 provided by the Administrator, indicated on 06/27/23 the resident complained of left knee pain. Upon assessment the knee was observed to be swollen with bruising on the inner aspect. An X-ray was ordered and completed on 06/28/23 and showed an acute distal femoral fracture. According to the Summary of Incident the resident was transferred to the hospital. The summary indicated Based on the findings of the investigation, it was determined that the injury to the left knee is consistent with resident falling on 06/23/23, R1 was transferred to the hospital on 06/28/23. Review of a hospital Patient Report dated 06/28/23 indicated Left Knee . Acute distal femoral fracture. Orthopedic evaluation is recommended. Review of Progress Notes dated 07/05/23 at 5:33 PM, indicated, Client readmitted to facility from hospital via ambulance. Client s/p [status post] ORIF (Open Reduction Internal Fixation). According to the Treatment Administration Record (TAR) dated 07/05/23 located in the EMR under the Orders tab. R1 was readmitted to the facility following orthopedic surgery and had staples to the left hip/knee, (thigh). During an interview on 10/19/23 at 8:30 AM, the DON stated, The approaches were revised on the care plan after the resident fell . The admission care plan did not include the use of Dycem, a Broda chair in the reclining position or increased supervision in the common area. We don't have a policy for the base line care plan. The nurses write the care plan on admission and make a care card for the nurse aides to follow. The care card is placed on the door of the resident's room. We discarded the admission care card when we revised it.

Based on a complaint received at the Southeastern Regional Office, interview and record review, the facility did not ensure that 1 of 4 sampled residents (R2) received an RN (Registered Nurse) assessment and appropriate medical care when R2 had a significant change in her medical condition. On [DATE] following the lunch meal, R2 vomited in the dining room. Licensed Practical Nurse (LPN)-D obtained the first set of vital signs prior to staff taking R2 to her room. LPN-D called Optum call center to give a message to the nurse practitioner. The Optum note at 1:31 PM documents lungs clear to auscultation, oxygen saturation of 96% on room air and temperature of 98.2. After staff took R2 to her room, R2 had loose stool and another emesis. LPN-D obtained a second set of vital signs approximately 15 minutes later, which LPN-D documented in the nurses notes at 1:30 p.m. as, Congestion noted at this time. SpO2 (peripheral capillary oxygen saturation) at 82% oxygen started at 2 liters. Skin warm to touch. ABD (abdomen) soft and non tender. Bowel sounds present. Bp (blood pressure) ,[DATE], Resp (respirations) 20, Pulse 68, Temp (temperature) 100.6 Axillary. LPN-D did not call Optum back with the second set of vital signs that showed a significant change in R2's condition. LPN-D notified NS (Nursing Supervisor)-B but NS-B did not assess R2. R2 was not assessed, until approximately 3 hours later by RN-R when the family requested R2 be sent to the emergency room . On [DATE], R2 arrived at the emergency room at 5:50 p.m. Within an hour of arrival to the emergency room R2 was placed on ventilator and was subsequently admitted to the ICU (intensive care unit). R2 remained on the ventilator until [DATE]. On [DATE], R2 started receiving hospice services until she expired on [DATE]. The facility's failure to complete an immediate RN (Registered Nurse) assessment and for failing to call Optum back to report changes in R2's condition created a finding of Immediate Jeopardy beginning on [DATE]. Director of Nursing (DON)-A and ADON (Assistant Director of Nursing)-N were informed of the Immediate Jeopardy on [DATE] at 1:52 p.m. The Immediate Jeopardy was removed on [DATE]. This deficient practice continues at a scope/severity of D (potential for harm/isolated) as the facility continues to implement its action plan. Findings include: R2's [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) with an assessment reference date of [DATE] documents R2 has short & long term memory and is severely impaired for cognitive skills for daily decision making. R2 required extensive assistance with two plus person physical assist for bed mobility, dependent with two plus person physical assist for transfers, dependent with one person physical assist for toilet use, extensive assistance with one person physical assist for dressing, eating, & hygiene and did not ambulate. Surveyor reviewed R2's oxygen sats listed under the vital sign tab in the electronic record and noted on [DATE], [DATE], and [DATE] R2's oxygen sats are documented as 95%. According to https://www.mayoclinic.org, Normal pulse oximeter readings usually range from 95 to 100 percent. Values under 90 percent are considered low. On [DATE] at 10:45 a.m., Surveyor spoke with CNA (Certified Nursing Assistant)-C. CNA-C informed Surveyor R2 was throwing up in the dining room on [DATE] and the nurse told them to put her to bed. R2 had diarrhea, they cleaned her up then R2 threw up. Surveyor inquired how R2 had been in the morning. CNA-C informed Surveyor R2 was good and ate all her pancakes. Surveyor asked if the nurse came into R2's room. CNA-C informed Surveyor LPN (Licensed Practical Nurse)-D came in after they finished cleaning R2 up. Surveyor asked CNA-C if R2 could tell them if anything was wrong with her. CNA-C replied, no. On [DATE] at 11:39 a.m., CNA-E informed Surveyor R2 was in the dining room and threw up after lunch on [DATE]. LPN-D told them to lay R2 down. CNA-E informed Surveyor she helped CNA-C clean R2 up as she had loose stools and then R2 had emesis all over. CNA-E informed Surveyor R2's breathing wasn't normal and it was different. CNA-E indicated LPN-D told them to elevate R2's head and she was going to get vital signs. CNA-E informed Surveyor after they were done LPN-D went down to R2's room with the cart & blood pressure machine. Surveyor asked CNA-E if she recalled any other nurse going to R2's room other than LPN-D. CNA-E replied no and explained they were laying other residents down before the end of their shift. Surveyor asked CNA-E how R2 was the day before. CNA-E informed Surveyor there was nothing the day before with R2, it came on suddenly and R2 was eating pancakes. On [DATE] at 11:03 a.m. Surveyor spoke with LPN-D regarding when R2 had a change of condition on [DATE]. LPN-D informed Surveyor that one of the CNAs told her R2 threw up at lunch. Surveyor inquired who told her R2 threw up. LPN-D informed Surveyor she doesn't remember but told the CNA to take R2 to her room but don't lay her down. LPN-D indicated after staff cleaned R2 up they had to put her back to bed because she had loose stool and had an emesis while in bed. LPN-D informed Surveyor she took R2's vital signs prior to having the CNAs take R2 to her room; after taking the vital signs she placed a call to Optum on call Nurse Practitioner (NP) and waited for them to call back. The Optum on call communication note dated [DATE] at 1:31 p.m. documents, nurse states pt (patient) was eating lunch and after lunch, she had a large emesis. They took her to her room, cleaned her up and put her back to bed and she had another large emesis She did have a large regular BM (bowel movement) this am (morning). Abdomen is soft, NTND (non tender, non distended) with BS (bowel sounds) +x4 (positive times four). Nurse reports stomach virus in building on another floor and there is 1 other resident with similar symptoms on same floor that started earlier in the week. LCTA (lungs clear to auscultation). VS (vital signs) ,[DATE] 72 18 98.2 96% RA (room air). Call disposition escalated call to NP-T via jabber. NP-T to call back. Informed nurse. Thanked nurse. Approximately 15 minutes later, after staff had cleaned up R2, LPN-D took a second set of vital signs. The nurses note dated [DATE] at 13:30 (1:30 p.m.) documents, Emesis/Loose Stools: Writer called to residents room after lunch. Resident noted to have two large emesis and two large loose stools. Congestion noted at this time. SpO2 (peripheral capillary oxygen saturation) at 82% oxygen started at 2 liters. Skin warm to touch. ABD (abdomen) soft and non tender. Bowel sounds present. Bp (blood pressure) ,[DATE], Resp (respirations) 20, Pulse 68, Temp (temperature) 100.6 Axillary. Contact Isolation initiated at this time. On call Optum updated. On call stated that NP (Nurse Practitioner)-O is aware and will be calling writer back. Nursing Supervisor and the Manager on duty made aware. This note was written by LPN (Licensed Practical Nurse)-D. On [DATE] at 11:03 a.m. LPN-D informed Surveyor after the 2nd emesis R2 had a temperature, her oxygen was low and she placed oxygen on R2. LPN-D informed Surveyor she informed NS (Nursing Supervisor)-B and called 2nd POA-P. Surveyor asked LPN-D if Optum NP called her back. LPN-D replied, not on my shift. LPN-D informed Surveyor she also informed RN (Registered Nurse)/ADON (Assistant Director of Nursing)-F who was Manager on Duty. Surveyor asked LPN-D if she recalled anything else. LPN-D informed Surveyor she checked to see if R2 had an order for [REDACTED]. LPN-D informed Surveyor she thinks she did. Surveyor asked where the vital signs would be documented. LPN-D informed Surveyor they should be in the vital section or notes. Surveyor informed LPN-D Surveyor did not locate any further vital signs. LPN-D informed Surveyor it was close to end of the shift. The next nurses note is dated [DATE] at 13:46 (1:46 p.m.) documents, Resident's daughter 2nd POA (power of attorney)-P updated on residents status, and that there is a call out to the NP. This note was written by LPN-D. The next nurses note is dated [DATE] at 15:31 (3:31 p.m.) documents, Isolation placed outside resident's room. Resident has had 1 loose stool and one emesis so far this shift. This note was written by RN (Registered Nurse)-R. There is no evidence RN-R assessed R2 at this time. The next nurses note is dated [DATE] at 16:10 (4:10 p.m.) documents, Staff reported to writer that resident had another emesis and a loose stool, went to assess resident, and noted to be congested, O2 (oxygen) was 82% 2L/NC (two liters per nasal cannula), raised O2 to 4.5 and changed to oxy (oxygen) musk (mask) and oxygen level fluctuates from 84 to 89% then resident's family in bed side (daughter stated I can't stand seeing her likes this) and requested that resident be sent to ER (emergency room ) for further evaluation. Spoke to resident's POA-Q and he agreed to hospitalization . Supervisor updated and came to assess resident. This note is written by LPN-H. The next nurses note is dated [DATE] at 16:31 (4:30 p.m.) documents, Writer in to assess resident, SpO2 remains at 82% on 4.5 L (liter) O2 via oxy mask with respirations of 50. Ronchii to all lung fields. Call placed to Optum on call NP-S with new order received to transport to Froedtert Hospital for evaluation. Daughters remain at bedside and will follow ambulance. This note was written by RN-R. The next nurses note is dated [DATE] at 17:00 (5:00 p.m.) documents, Call placed to [NAME] ambulance to request transport to Froedtert. Writer then spoke with POA-Q to update. This note was written by RN-R. The next nurses note is dated [DATE] at 17:38 (5:38 p.m.) documents, [NAME] ambulance just left unit with resident after making 2 unsuccessful attempts to start an IV (intravenous). Call for another rig to come assist. Taking resident out to the ambulance where they plan to make another attempt to start IV before transport. Daughter will follow to hospital. This note was written by RN-R. Review of R2's hospital records document R2's arrival date as [DATE] at 1750 (5:50 p.m.) The emergency room admission [DIAGNOSES REDACTED]. The emergency room final [DIAGNOSES REDACTED]. Surveyor noted within an hour of arrival to the emergency room R2 was placed on ventilator and was subsequently admitted to the ICU (intensive care unit). R2 remained on the ventilator until [DATE]. On [DATE] R2 started receiving hospice services until she expired on [DATE]. On [DATE] at 11:50 a.m. Surveyor spoke with RN/ADON-F to inquire who was the manager on duty on [DATE]. RN/ADON-F replied me. Surveyor asked what are the duties of the manager on duty. RN/ADON-F explained they are visible in the building to assist with admissions, she'll speak with Residents who recently were admitted , and they are an extra set of eyes. Surveyor asked RN/ADON-F if she received a call regarding R2. RN/ADON-F informed Surveyor she didn't receive a call. Surveyor asked RN/ADON-F if anyone asked her to assess R2. RN/ADON-F replied no and explained there was an RN Supervisor on duty that day. On [DATE] at 11:56 a.m., Surveyor spoke with NS (Nursing Supervisor)-B via the telephone. Surveyor asked NS-B if she remembered R2 and the day she was discharged to the hospital on [DATE]. NS-B replied, can't say for sure. Surveyor informed NS-B Surveyor did not see any documentation in R2's medical record from her. NS-B informed Surveyor she didn't remember and would have to check her worksheets. NS-B then stated to Surveyor she thinks R2 went out on the evening shift. Surveyor asked NS-B if she did an assessment on R2 would this assessment be documented in R2's medical record. NS-B replied, should be. Surveyor asked NS-B how often she works at the Facility. NS-B informed Surveyor she works just day shift every other weekend. NS-B informed Surveyor if it's the same person she is thinking of the LPN was waiting for the NP to get back to the Facility and the next day they said she was sent to the hospital. Surveyor again asked NS-B if she assessed R2. NS-B informed Surveyor she didn't as it was the end of the shift and she gave report. Surveyor asked who she gave report to. NS-B replied, RN-R. On [DATE] at 12:05 p.m., RN/ADON-F informed Surveyor she wanted to clarify the conversation with Surveyor earlier. RN/ADON-F informed Surveyor when Surveyor asked if anyone called her regarding R2 they didn't but she was at the nurses station doing something else when LPN-D said to NS-B who was sitting next to her R2 had an emesis and sounded a little congested. RN/ADON-F indicated she told LPN-D to check her pulse ox and LPN-D came back stating she was going to start oxygen. Surveyor asked RN/ADON-F if LPN-D said what R2's pulse ox was. RN/ADON-F replied, something in the 80's. Surveyor asked RN/ADON-F if she remembered what time this was. RN/ADON-F replied, not exactly, late morning. Surveyor asked what time R2's unit has lunch. RN/ADON-F informed Surveyor between 11:30 a.m. to 12:00 p.m. On [DATE] at 1:22 p.m., Surveyor spoke with Optum APRN (Advanced Practice Registered Nurse)-G who is the Optum nurse for the Facility. Surveyor inquired if R2 was one of APRN-G's residents. APRN-G informed Surveyor R2 was one of her patients. Surveyor asked APRN-G if she wasn't in the building and received a call from the Facility when should the Facility receive a call back. APRN-G informed Surveyor typically calls back are in 15 minutes or so. Surveyor asked if this would be the same on the weekends. APRN-G informed Surveyor that it would depend how many calls are in the Q. Surveyor asked when APRN-G is at the Facility. APRN-G explained she is at the Facility Monday thru Friday. APRN-G explained on nights and weekends there is on call staff. Surveyor asked APRN-G if the Facility calls the on call staff regarding one of her Residents would they then call her. APRN-G informed Surveyor she is not involved at all in the on call and they wouldn't call her. Surveyor read APRN-G R2's [DATE] nurses note at 1:30 p.m. to APRN-G. APRN-G informed Surveyor the on call staff wouldn't know R2's history and she would have been concerned about aspiration pneumonia as R2 is high risk for aspiration. On [DATE] at 1:57 p.m. Surveyor asked LPN-D when she called Optum did she speak to the nurse. LPN-D replied no and explained when she called it's like a call center, spoke with the receptionist and informed them R2 had emesis and needed to speak to the NP about congestion and temperature. On [DATE] at 2:58 p.m., Surveyor spoke with LPN-H regarding when R2 had a change of condition on [DATE]. LPN-H informed Surveyor at the start of her shift around 3:30 p.m. to 4:00 p.m. CNA-U reported to her R2 had emesis. LPN-H informed Surveyor she told CNA-U to clean R2 up and she would be right there. LPN-H indicated she noticed R2 was congested, took vitals her oxygen sats were ,[DATE] and was on nasal cannula so she said she was going to change the oxygen to a mask, went to get the mask and put the mask on. LPN-H informed Surveyor 2nd POA-P and another daughter, whom she didn't know her name, was in R2's room. LPN-H informed Surveyor she asked 2nd POA-P if she wanted her mother to be sent out. 2nd POA-P told LPN-H I can't stand seeing her like this. LPN-H indicated she told 2nd POA-P she would call POA-Q but the other daughter was on the phone with POA-Q, gave her the phone, she explained the situation and asked POA-Q if he wanted R2 sent to the hospital which POA-Q said yes. LPN-H informed Surveyor she called the Supervisor and RN-R came to assess R2. Surveyor asked LPN-H if she told anything about R2 in report. LPN-H informed Surveyor R2 had emesis and loose stool. Surveyor asked if anything was mentioned about congestion or oxygen. LPN-H replied, ya she probably mentioned it, yes congestion can't remember. Surveyor asked LPN-H if after report did she go and check R2. LPN-H informed Surveyor after report she goes room to room. Surveyor asked LPN-H if she went into R2's room. LPN-H replied, No, just peeked. On [DATE] at 10:55 a.m., Surveyor spoke with LPN-D to inquire if she documented on the 24 hour report on [DATE] for the day shift. LPN-D informed Surveyor she did. Surveyor asked what the circle meant next to MD and family on the 24 hour report. LPN-D replied, needs to be updated. Surveyor then asked for clarification as to why there are different vital signs and documentation on the Optum note dated [DATE] at 1:31 p.m. and her documentation on this date at 1330 (1:30 p.m.). LPN-D explained the vital signs in the Optum note are the first set of vitals for R2. LPN-D informed Surveyor after R2 had an emesis in the dining room she took a set of vitals in the lounge before staff took R2 to her room. LPN-D informed Surveyor after staff took R2 to her room she had loose stool and another emesis. LPN-D stated she took vitals, placed O2 on R2, looked for a breathing treatment and gave Tylenol. Surveyor asked if the second set of vitals is what is documented in R2's record. LPN-D indicated they were. Surveyor asked what was the time span between the first set of vital and second set of vitals. LPN-D replied probably good 15 minutes. Surveyor asked LPN-D if she called Optum back after the 2nd set of vitals, which LPN-D had documented congestion, O2 at 82% and a temperature. LPN-D informed Surveyor she didn't call back as she already had a call out and was trying to make R2 comfortable. LPN-D stated, Probably could have called them back. On [DATE] at 11:23 a.m., Surveyor asked DON-B if she would expect a nurse to recheck vitals if when taking a resident's vitals they have a temperature or their oxygen sats are low. DON-B replied yes and explained after an intervention such as giving Tylenol or administering oxygen. Surveyor showed DON-B LPN-D's note at 1:30 on [DATE] and no further documentation from LPN-D. DON-B informed Surveyor, What you see is what I see. On [DATE] at 11:48 a.m., Surveyor spoke with Optum CSM (Clinical Services Manager)-I to inquire after placing a call to Optum when a Facility should receive a call back. CSM-I informed Surveyor they should be calling facilities back within 15 minutes and if a Facility doesn't receive a call back they should call Optum again. CSM-I informed Surveyor she spoke with the on call center manager who looked into whether the Facility received a call back from Optum on [DATE] and stated someone definitely screwed up. CSM-I indicated the call center RN escalated the phone call to an NP but the Facility did not receive a call back. CSM-I stated Facilities are informed if they don't get a call back they are instructed to call Optum back. CSM-I informed Surveyor they have an after hours on call process which each Facility is provided and would e mail this to Surveyor. At 11:54 a.m. Surveyor received via e mail Optum's after hours on call process. Surveyor noted at the bottom of this form documents, Every attempt will be made to return your urgent messages within 15 minutes. If you do not receive a call back within 15 minutes please call again and follow above prompts. On [DATE] at 12:48 p.m. DON-B informed Surveyor she (DON-B) spoke with RN-R via the phone. DON-B informed Surveyor RN-R had informed her she was told during report with NS (Nursing Supervisor)-B R2 had a change of condition, had loose stool and is on oxygen. RN-R informed DON-B she went down to the unit and went by R2's room around 3:00 or 3:15 p.m., she noticed the cart was outside the door, the daughter was in the room, and she eye balled R2 but did not go in the room because she had other people to see first and R2 was on isolation. DON-B informed Surveyor RN-R had told her R2's daughter said her mother was fine and she could come back to do the assessment. RN-R informed DON-B LPN-H was going to check R2's vitals. On [DATE], the facility's failure to ensure an immediate RN assessment of this resident and for failing to call Optum back to report the change in the resident's condition in a 15-minute period of time prevented R2 from receiving timely medical intervention and created a finding of immediate jeopardy for R2. The facility removed the immediate jeopardy on [DATE] when the facility implemented the following; The specific resident identified in the immediate jeopardy is no longer residing at our facility. The facility reviewed and updated the following policies: a. Notification of Resident's Change in Condition b. Nursing Documentation The Registered Nurse will be notified immediately with a change of condition and will complete assessment immediately but no later 30 minutes of the change of condition. If condition warrants, 911 will be contacted immediately. Protocol for Nurse Practitioner/physician (NP/MD) notification will be: a. Immediate contact to NP/MD or 911 depending on the severity of the change of condition. b. If no return call in 15 minutes another call will be placed to the NP/MD c. If no return call in the next 15 minutes, the Medical Director will be notified. Staff received training on the following: a. All changes of condition will be assessed and documented by a RN. b. An appropriate intervention may be applied depending on the severity of the condition. c. If the condition warrants, an abnormal vital signs may be rechecked after no more than 30 minutes after a reasonable intervention has been applied. The licensed nurse must then update the MD/NP on the resident's condition with the intervention applied. d. Immediate physician notification is warranted upon discovery of an abnormal vital sign unresponsive to intervention or that poses a significant threat to the resident's well-being, I.E.: severe bleeding, decreased oxygenation, severe vascular changes, major injury, and loss of consciousness. e. The MD/NP will be contacted promptly with all changes of condition. If MD/NP does not return call within 15 minutes another call will be placed. If no return call, the Medical director will be contacted if primary MD is not returning call. 911 may be called in cases requiring emergency intervention. f. Licensed nursing staff (RN and LPNs) received training starting on [DATE] and received training prior to working their next shift with an in person in-service or on the phone. Audits will be performed on every change of condition for 3 months and reported to Quality Council in (MONTH) to determine if further auditing needed.

Based on record review and staff interviews the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents. Resident #1 was being transported to her room in her wheelchair after breakfast without having footrests on the wheelchair and fell forwards out of the wheelchair hitting her head. Resident #1 sustained cervical fractures (C1 and C2 of the neck), a right distal femur fracture (broken bone in knee) and a laceration to her forehead. Resident #1 was admitted to Vitas Hospice on [DATE] and expired on [DATE]. Findings include: Resident #1 was a [AGE] year old female who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On [DATE] at 2:50 p.m., Surveyor # reviewed the closed medical record of Resident #1. Review of the most recent quarterly MDS (Minimum Data Set) dated [DATE] notes under activities of daily living that Resident #1 was totally dependent on staff for bed mobility, transfers, locomotion on and off unit, dressing, toilet use, personal hygiene and bathing. Resident #1 needed extensive assistance with meals. The MDS indicates under Balance in regards to surface to surface transfer (transfer between bed and chair or wheelchair) Resident is indicated as "Not steady, only able to stabilize with human assistance." Review of Resident #1's nurses care plan, snapshot date is [DATE]. Under "Potential for Injury Safety r/t (related to) HX (history) of falls" it states under approach, Staff to position resident closer to dresser, as she likes to go into drawer to look at her things. Do not place her in middle of room where she has to reach for her bed or her dresser drawer. Bed/Chair alarms. Under "Impaired Mobility related to pain and weakness" approaches include to assist resident to lounge area when restless or agitated, dycem applied to wheelchair seat ([DATE]), transfer with assist 2 person transfers with Hoyer lift. There is no mention of placing footrests to wheelchair in care plan. On [DATE] at 2:50 p.m., Surveyor # reviewed the nurses notes on [DATE] for Resident #1 which state: Resident had witnessed fall from WC (wheelchair) after breakfast at 0840. Staff was propelling resident back to her room when resident leaned forward and fell out of WC hitting head on floor. Resident obtained a R (right) forehead laceration and scant blood noted on her mouth between lower R jaw and inside lip. Active bleeding was stopped with pressure. Resident did not loose consciousness. Alert, mentation per usual. Anxious verbalizing, "Am I going to go to the hospital?" Resident did not verbalize any pain or discomfort. No facial grimace, guarding or groan. ROM (range of motion) WNL (within normal limits) per her norm, as she has rigid posturing to all extremities. Resident was transported to Froedert ER for eval and treat per protocol. MD updated and her daughter aware. On [DATE] at 2:50 p.m., Surveyor # reviewed the facility investigation and Unusual Occurrence form (incident report) for Resident #1 dated [DATE]. There is no mention of Resident #1 having footrests on her wheelchair or not throughout the investigation for proper positioning in the wheelchair. On [DATE] at 3:05 p.m., Surveyor # interviewed Assistant Director of Nursing (ADON)-C regarding the facility's investigation. The ADON-C stated the pictures that were attached to the investigation were from a reenactment of the fall that Resident #1 had. ADON-C stated the wheelchair in the pictures was Resident #1's wheelchair. This wheelchair showed a cushion with dycem on it but, had no wheelchair footrests on it for Resident #1 to rest her feet on. ADON-C stated that the Quality Assurance (QA) committee met the next morning and discussed the fall of Resident #1. ADON-C provided an outline of what the committee discussed (not the minutes of QA). The outline had the following on it: * Incident was isolated * Fall witnessed * Immediate interventions according to fall protocol * Transporter (witness) states resident had legs out not under wheelchair-were not dragging * Facility had (prior to and at the time of incident) strong systems & policies in place to assure a safe environment for residents: Immediate protection of all other residents can be validated because of systems in place- there was not a lacking or non-existent system. * Red tag system * Each resident has his/her own wheelchair * Leg/footrest carry bags on wheelchairs used for residents who vary in use of these attachments *Audits to assure care directive compliance. The ADON-C stated that the RED tag system has been in place for a couple years. On [DATE] at 8:20 a.m., Surveyor # interviewed the Physical Therapist Manager-D regarding Resident #1. The Physical Therapist Manager-D stated that Resident #1 was quite debilitated and had severe arthritis in the knees. Surveyor # asked the Physical Therapist Manager-D if Resident #1 was to have footrests on her wheelchair at all times. The Physical Therapist Manager-D stated if the resident's feet didn't touch the floor or feet are not planted on the floor the resident should have footrests on the wheelchair. Surveyor # asked if he had completed a positioning assessment on Resident #1 regarding footrests being on the wheelchair and he stated not for footrests but for bed positioning a while ago. On [DATE] at 9:55 a.m., Surveyor # interviewed Med Tech/CNA-E regarding the morning of [DATE] when she assisted with the transfer of Resident #1 from the bed to the wheelchair and if footrests were placed onto the wheelchair prior to transporting Resident #1 to the dining room. The Med Tech/CNA-E stated that when she assisted CNA-G with transferring (Resident #1) from the bed to the wheelchair, she knew that CNA-G knew what she was doing as a CNA because she (CNA-G) had the same group of resident's the day before. Med Tech/CNA-E was unaware of (Resident #1) not having her footrests on her wheelchair because after transferring to the wheelchair CNA-G still needed to comb (Resident #1's) hair so Med Tech/CNA-E left the room to tend to her own residents. Med Tech/CNA-E stated that (Resident #1's) wheelchair footrests should have been placed onto the wheelchair by CNA-G. That it was routine for (Resident #1) to have footrests on. Then stated if she had (Resident #1) that morning the footrests would have been placed on prior to transporting (Resident #1) to the dining room for breakfast because she is to have them on when in the wheelchair. Med Tech/CNA-E stated there are residents that do not want them on because they self propel their wheelchair so we don't put them on. Med Tech/CNA-E stated that after (Resident #1) had fallen out of the wheelchair that morning, staff were all spoken to and re-inserviced on the importance of using resident's equipment properly, expressing the use of footrests. On [DATE] at 10:25 a.m. Surveyor # interviewed CNA-F regarding the incident on [DATE], CNA-F was the CNA that was transporting Resident #1 back to her room when Resident #1 fell forward out of the wheelchair onto the floor. CNA-F stated that she was not the primary caregiver for (Resident #1) that morning and that CNA-G was. CNA-F stated that she knows (Resident #1) and when she gets anxious in the dining room that means (Resident #1) wants to return to her room. CNA-F stated that she observed (Resident #1) leaning to the side and she and another staff member repositioned (Resident #1) in her wheelchair. At this time CNA-F noticed that (Resident #1) did not have her footrests on and the chair alarm was not connected, so the alarm would not have worked because the connector box was missing. CNA-F decided to take (Resident #1) back to her room to place the footrests on and connect the alarm box properly. CNA-F stated when she was passing room 3113 she saw CNA-G assisting a resident with their meal and CNA-F stopped to tell CNA-G that (Resident #1) didn't have her footrests on or that the chair alarm was not connected properly, and CNA-G stated OK. CNA-F stated she proceeded down the hall to room 3110 and just prior to the room (Resident #1) just went forward and fell to the floor hitting her head, it happened so fast I couldn't stop her from falling. There was a lot of blood from the head. CNA-F called for the nurses and they came real fast. (Resident #1) was just lying there asking if she was going to go to the hospital. CNA-F stated in a short time the Paramedics were there and transferred (Resident #1) to the hospital. CNA-F stated (Resident #1) didn't come back to the nursing home but, went to the Hospice section on 3rd floor. Surveyor # asked CNA-F why she didn't just go get the footrests from Resident #1's room and bring them back to the dining room and place them onto the wheelchair before transporting Resident #1 to down the hallway to her room. CNA-F stated she just wanted to get the footrests on and the alarm connected properly. CNA-F stated that (Resident #1) could not place or plant her feet firmly on the floor because she had a thick cushion with decem on the cushion, so her feet couldn't touch the floor at all. CNA-F stated that (Resident #1) always had footrests on when in the wheelchair. That it was routine for (Resident #1) to have footrests. CNA-F stated that Resident #1 couldn't self propel her wheelchair so she needed the staff to wheel her anywhere she was going so (Resident #1) needed wheelchair footrests. CNA-F stated that (Resident #1) sat much better in the wheelchair with the footrests because she was more relaxed because, (Resident #1's) feet were resting on the pedals. CNA-F stated that after (Resident #1) fell from the wheelchair the staff were all re-inserviced about the proper use of residents equipment and the use of their equipment. On [DATE] at 2:25 p.m., Surveyor # interviewed Registered Nurse/Infection Control-H who stated that she went down to 3NW and 2NW units at approximately 10:00 a.m. on [DATE] and spoke to each CNA and nurse regarding making sure footrests are on when transporting residents, and if a resident refused to have footrests on they are to inform the Social Worker immediately. RN-H stated that residents that don't want to use footrests is care planned and that these residents have a RED tag on their wheelchair noting that it is ok for resident not to have footrests on and that CNA-G should have known this from orientation. RN-H also stated that she went to rooms on 2 different units that residents needed footrests on their wheelchairs and just observed that staff knew they had to put the footrests on for these residents. On [DATE] a 2:30 p.m. Surveyor # interviewed the Director of Nursing (DON)-B regarding the use of footrests not being on the nurses or CNA's care plan. The DON-B stated that they place footrests by exception, meaning if a resident needs to be pushed in the wheelchair or needs assist with transport anywhere then that resident needs to have footrests on. On [DATE] at 3:00 p.m. the Administrator-A stated that CNA-G was a float and the care card for Resident #1 doesn't give the specification for use of footrests and that the fall (Resident #1) had was witnessed so the facility did not report this incident to the state. The Administrator-A also stated that the facility initiated an audit for checking all personal equipment such as; wheelchairs, cushions, decem, footrests, within a couple of days after (Resident #1) fell . On [DATE] at 10:00 a.m. Surveyor # called CNA-G (as she resigned [DATE]) and interviewed her regarding the incident on [DATE] with Resident #1 falling from her wheelchair. Surveyor # asked CNA-G why she didn't put footrests onto (Resident #1's) wheelchair prior to transporting Resident #1 to the dining room. CNA-G stated the care plan did not have footrests on it and at the time of the fall she was not with (Resident #1). CNA-G stated that she was a float and it was her first day off orientation. CNA-G stated that while she was assisting another resident with her meal in her room, Med Tech/CNA-E came to the room and stated why didn't you put the footrests and alarm on (Resident #1), she was very rude. Then CNA-F came to the door and also told me she was taking (Resident #1) to her room to put the footrests on and also the alarm because I didn't put them on and I told her I was sorry and OK. CNA-G stated that if the staff came and told her that she didn't put the footrests on she would have went to (Resident #1's) room and got the footrests and placed them on while (Resident #1) was in the dining room. (Resident #1) was safe in the dining room between the wheelchair and the table. This could have been avoided if the staff would have just told me before they wheeled (Resident #1) out of the dining room. CNA-G stated she did not know about the RED tag being on residents wheelchairs that didn't need footrests. On [DATE] in the morning, Surveyor # reviewed the facility's policy and procedures for wheelchair mobility effective date [DATE]. POLICY: It is the policy of Lutheran Home to keep all resident's safe and to protect them from injury. Residents who require a wheelchair for mobility will be provided a wheelchair and wheelchair foot pedals. If the resident requires staff to propel the chair, foot rests will be placed on the wheelchair. PROCEDURES: * Residents, who require a wheelchair for mobility, will be provided a wheelchair and wheelchair foot pedals. If the resident requires staff to propel the chair, foot pedals MUST be placed on the wheelchair. * If a resident declines the use of foot pedals for transport, notify the social worker. The social worker will then discuss the risks and benefits of foot pedals with the resident and/or POA and have a waiver signed. If the resident of POA chooses not to use the foot pedals, a red wheelchair band will be placed on the arm rest of the wheelchair by the social worker. * Residents will be assessed on admission by the licensed nurse to determine if foot pedals are appropriate or not. Questions regarding appropriateness of foot pedals can be directed to therapy as needed. * Foot pedals may be removed to enable the resident to get closer to the table for meals. The foot pedals must be replaced prior to transporting the resident back to their room. * If the resident is unable to use their arms to propel the chair, the foot pedals may be removed. This will enable the resident to use their feet to walk the chair. If the resident becomes fatigued, the staff member MUST place the foot pedals on the chair prior to pushing them to their destination. * Footpedals will be used for ALL transports out of the facility. * Residents who use broda chairs or gerchairs have foot rests in place. If the resident or POA declines the use of the foot rest, the social worker will follow the same process as listed above in regards to the waiver and wheelchair red band. On [DATE], the facility stated that over the weekend all residents were assessed for the use of footrests and all care plans were updated to reflect the use of footrests.