Every finding on record at Plum City Care CTR

Based on interview and record review, the facility did not ensure staff consulted with the resident's physician per physician orders when laboratory values are out of parameters for 1 of 12 residents (R22) reviewed.The facility did not notify the provider when R22's blood sugars were outside of parameters per physician order.This is evidenced by:Facility policy titled, Physician Notification - Consultation Parameters, with a reviewed date of 12/2023, states: .Non-immediate Notification: The attending physician should be informed of the event during normal office hours, and generally no later than the next regular office day.R22 was admitted to the facility on [DATE] with a diagnosis of type 2 diabetes mellitus.R22's physician orders include:Blood glucose checks every other day AM. Notify physician if blood sugar <80 or >250 mg/dL.Blood glucose checks every other day PM. Notify physician if blood sugar <80 or >250 mg/dL.Surveyor reviewed R22's blood sugars:04/19/2026 8:13AM: 68 mg/dL03/24/2026 8:06AM: 70 mg/dL03/22/2026 7:14AM: 76 mg/dL03/16/2026 6:46AM: 72 mg/dL02/10/2026 7:56AM: 77 mg/dL02/08/2026 7:35AM: 79 mg/dL01/31/2026 7:22AM: 64 mg/dL01/23/2026 8:36AM: 278 mg/dL12/18/2025 8:14AM: 72 mg/dL-Of note: Surveyor reviewed R22's medical record and was unable to find documentation notifying the provider of R22's blood sugar results outside of ordered parameters.On 04/22/26 at 8:14 AM, Surveyor interviewed Licensed Practical Nurse (LPN) D regarding notifying provider of blood sugar results. LPN D stated that if a provider orders parameters, it would be expected for the nurse to call the provider and document the notification in a nursing note.On 04/22/26 at 8:41 AM, Surveyor interviewed Director of Nursing (DON) B regarding provider notification of blood sugars outside of ordered parameters. DON B stated she was unable to provide documentation notifying the provider of any of R22's blood sugars outside of the ordered parameters. DON B stated that the expectation would be for the nurses to follow the provider's order to notify the provider of the blood sugar results and to document the communication in a nursing note in the resident's medical record.

Based on record review and interview, the facility did not ensure residents/representatives were notified of the rate to reserve the resident's bed in the Wisconsin Bed Hold Notice and did not include the specific reason for transfer. This has the potential to affect all 39 residents.R4 received a bed hold notice with no daily rate documented and transfer notice did not specify reason for transfer.This is evidenced by:R4 was admitted to the facility on [DATE].On 10/11/25, R4 was transferred to the hospital. The WI Bed-Hold was signed by R4 and did not include the daily rate to hold R4's bed. The Transfer Notice noted reason for transfer was due to R4 requesting a transfer. No specific reason for transfer was documented.On 01/08/26, R4 was transferred to the hospital. The WI Bed-Hold was signed by R4 and did not include the daily rate to hold R4's bed. The Transfer Notice noted reason for transfer was due to R4 requesting a transfer. No specific reason for transfer was documented.On 03/06/26, R4 was transferred to the hospital. The WI Bed-Hold was signed by R4 and did not include the daily rate to hold R4's bed. The Transfer Notice noted reason for transfer was due to R4 requesting a transfer. No specific reason for transfer was documented.On 04/03/26, R4 was transferred to the hospital. The WI Bed-Hold was signed by R4 and did not include the daily rate to hold R4's bed.On 04/21/26, Surveyor interviewed Social Worker (SW) E regarding bed-holds and transfer notices. SW E stated being unaware of having to include the daily rate for bed-hold notices. SW E stated a new transfer notice form does include an area to document reason for transfer, but had not printed off new copies for nursing staff to use.

Based on observation and interview, the facility did not treat a resident (R) with respect and dignity and care for the resident in a manner that promotes maintenance or enhancement of his or her quality of life.-R8 wanted to utilize a urinary leg bag to increase his quality of life and improve his independence and dignity with his mobility and transferring.Findings include:R8 was admitted to facility on 07/29/25, with a diagnosis including acute infective endocarditis, congestive heart failure, and obstructive and reflux uropathy.Most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R8 had an indwelling catheter. R8 scored 13/15 during Brief Interview for Mental Status (BIMS), indicating intact cognition.R8's care plan indicates impaired mobility, . foley catheter for urinary retention. R8 is dependent on staff for all activities of daily living (ADL's). R8 will participate in cares as he is able.On 4/20/26 at 11:46 AM, Surveyor observed R8 struggle with moving his urinary bed bag from underneath his wheelchair to his bed after transferring himself to sit on the bed. R8 then tried to cover the exposed tubing with his pant leg. R8 told Surveyor he had wanted a leg bag because the bed bag made it more difficult when he was up walking and it would be still hooked to his wheelchair behind him, and it would be easier for him when he independently transfers out of the wheelchair. R8 reported a nurse did use a leg bag on him one time but they made her take it off. R8 did not know why or who said he could not use a urinary leg bag with his indwelling catheter.On 4/21/2026 at 8:13 AM, Surveyor observed Certified Nurse Assistant (CNA) G empty R8's catheter bag. CNA G does not know why R8 is not able to use a urinary leg bag. CNA G stated, I know he has asked for one before.On 4/22/2026 at 7:27 AM, Surveyor interviewed Nursing Home Administrator (NHA) A, who reported R8 had asked for a leg bag in the past. NHA A had a conversation with R8 on his increased risk of infection due to disconnecting the bed bag to put on the bed bag every day. NHA A reported she did discuss risk versus benefits. NHA A stated it was decided not to use a leg bag. NHA A stated there was no documentation of this conversation. On 4/22/2026 at 7:55 AM, Surveyor interviewed CNA F, who reported there are not any other residents currently in the facility using a leg bag.

Based on observation, interview and record review, the facility did not ensure a resident with limited mobility receives appropriate restorative services, and assistance to maintain or improve mobility with the maximum practicable independence for 1 out of 1 sampled resident (R8). -R8 was not provided care and assistance to walk 3 to 4 times a day, as indicated in R8's Physical Therapy (PT) plan. This is evidenced by:Per Appendix PP of the State Operations Manual (SOM), regulation F688 reads, .The facility must develop resident care policies in collaboration with the medical director, director of nurses, and as appropriate, physical/occupational therapy consultant. This includes policies on restorative/rehabilitative treatments/services, based on professional standards of practice. The care plan must identify the type of treatments, frequency, and duration, as well as the measurable objectives and resident goals.R8 was admitted to facility on 07/29/25, with a diagnosis including acute infective endocarditis and heart failure. Most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R8 scored 13/15 during Brief Interview for Mental Status (BIMS), indicating intact cognition. On 4/20/26 at 11:40 AM, R8 told Surveyor he would like the opportunity to walk more. R8 stated his doctor was supposed to make it so he could walk more and that he would like to get stronger and possibly go home. R8 told Surveyor he only gets assistance with walking a few times a week but not every day. Record review indicated R8 was seen by Physical Therapy (PT) and on 10/22/25 an order indicated to Ambulate with 2 wheeled platform walker with caregiver assist (CGA) and wheelchair (w/c) follow 3-4 times a day.R8's care plan of 3/26/26, indicated R8 has a self care deficit related to Impaired mobility. with a goal to regain some strength and endurance. Nurse Aide intervention included, . Ambulation: 2 assist, CGA with platform walker and w/c to follow 3-4 x daily.On 4/21/26 at 8:17 AM, Surveyor interviewed Certified Nurse Assistant (CNA) G, who reported R8 is walked most days and provided Surveyor with R8's Restorative Nursing Program, Care Plan and Flow Record.Review of R8's records indicated in February 2026, R8 was offered and ambulated 2 times a day on 17 of the 28 days and once a day on the remaining 11 days in February.In March 2026, R8 was offered and ambulated two times a day on 9 out of the 31days, once a day on 19 days, and not at all on 3 days.As of April 21, 2026, records indicated R8 has been offered and ambulated twice a day on 6 days, once a day on 7 days, and not at all on 4 of the 20 days thus far in April.Provider documentation on 3/26/26 states, His [R8] only concern is he would like to get more exercise.On 4/21/26 at 10:04 AM, Surveyor interviewed Nursing Home Administrator (NHA) A, who stated it does not look like R8 is getting ambulated as often as he should and as indicated in the PT orders and in his care plan.

Based on interview and record review, the facility failed to ensure pain management was consistent with resident centered care plan and goals and preferences for 2 of 2 residents (R22 and R23) reviewed for pain management. -R22 received scheduled and as needed (PRN) pain medications. The facility did not implement pain assessments to monitor and evaluate efficacy of interventions.-R23 has orders for scheduled and PRN pain medications. The facility did not evaluate R23's acceptable level of pain or implement pain assessments. Facility policy titled, Pain Recognition and Management, with a revised date of 04/2025, states: Purpose: In order to help a resident attain or maintain his or her highest practicable level of well-being and to prevent and/or manage pain, the facility, to the extent possible, will: Recognize when the resident is experiencing pain and identify circumstances when pain can be anticipated; evaluate the existing pain and the cause(s); and prevent or manage pain – consistent with the comprehensive assessment and plan of care, current clinical standards of practice, and the resident's goals and preferences. Protocol: . 5. Assessment of Pain: .iii. Characteristics of pain, such as: (intensity, pattern, location, frequency, and duration); iv. Impact of pain on quality of life;.ix. The resident's goals for pain management and his or her satisfaction with the current level of pain control.8. Quality Assurance/Performance Improvement Considerations: a. For residents experiencing ongoing/unresolved moderate to severe pain, review the resident's current pain medication regimen to determine if changes in the regimen are necessary. i. Chart the resident's daily pain level in ECS, using an appropriate care planned pain scale. Example 1 R22 was admitted to the facility on [DATE] with wedge compression fracture of second thoracic vertebra, lumbago (pain) with sciatica, bilateral primary osteoarthritis of hip, disease of spinal cord, radiculopathy (nerve pain) of lumbar region, and cervical disc disorder with myelopathy (compression of spinal cord). R22's most recent quarterly Minimum Data Set (MDS) assessment, dated 02/07/26, noted a Brief Interview for Mental Status (BIMS) score of 13/15, indicating cognition is intact. R22 indicated pain was frequently present and occasionally affects day-to-day activities. R22's care plan, dated 03/28/26, with a target date of 3 months, states: Alteration in comfort related to weakness, severe cervical stenosis, cervical myopathy, degenerative joint disease, spinal stenosis, compression fracture of L2, chronic paresthesia, severe spinal cord narrowing, and moderate disc osteophyte has a goal for R22 to rate pain at a 4 or less. R22's physician orders: Tramadol HCL 50 mg three times daily with a therapeutic goal to report a decrease in pain of 3 or less within 1 hour after administration. Acetaminophen 1,000 mg three times daily with a therapeutic goal of pain in shoulders to be 3 or less on 0-10 scale within 1 hour of administration. -Of note: Surveyor reviewed R22's medication administration record (MAR) and noted R22's pain level was not consistently documented prior to administration of PRN medications and follow-up efficacy not recorded. All of R22's scheduled pain medications did not include a pain assessment prior to or after administration. On 04/20/26 at 1:27 PM, Surveyor interviewed R22 in his room. R22 stated having excruciating pain in his shoulders that have limited day-to-day activities and participating in activities. Surveyor asked R22 if the facility was aware of the severity of the pain. R22 stated yes and a few different things had been tried, but he is still in horrible pain. Surveyor reviewed R22's medical record for pain assessments and noted no daily pain assessments documented. On 04/21/26 at 11:40 AM, Surveyor interviewed Registered Nurse (RN) C regarding pain assessments. RN C stated that typically, pain assessments are only completed when giving a PRN pain medication. Surveyor asked RN C how nursing staff monitor and assess chronic pain. RN C stated daily assessments aren't typically done unless the provider orders it. On 04/22/26 at 7:45 AM, Surveyor interviewed Director of Nursing (DON) B regarding R22's pain assessments. Surveyor asked DON B if R22's pain was being assessed and monitored as outlined in the care plan and therapeutic goal included in the physician orders. DON B stated no and this should have been completed. Example 2 R23 was admitted to the facility on [DATE] with diagnosis including heart failure and Bell's palsy. Resident was placed on Hospice care on 3/27/26. R23's most recent quarterly Minimum Data Set (MDS) assessment, dated 03/05/26, noted a Brief Interview for Mental Status (BIMS) score of 13/15, indicating cognition is intact. R23's care plan, dated 3/27/26 states: Goal: will remain comfortable at the end of his life. Interventions include, . monitor for change in behavior, grimacing, moaning, or resistance with cares that may indicate discomfort. collaborate with family and MD for comfort needs. R23's physicians orders as of date:Acetaminophen 1000mg by mouth three times a day for painMorphine Sulfate 1.3 ml / 5.2mg by mouth every 4 hours as needed for comfort for end of life with a therapeutic goal of an acceptable level of painAcetaminophen 650mg by mouth every 6 hours as needed for pain with a therapeutic goal of an acceptable level of pain. Surveyor reviewed R23's medical record and noted no pain assessments indicating R23's acceptable level of pain or daily pain assessments. On 4/20/26 at 1:58 PM, R23's family told Surveyor R23 had complained of intense pain a couple of days ago and expressed concerns with how the facility is providing R23's pain medication. R23's family is concerned R23 will not use call light and ask for pain medication even though he [R23] is in pain and they had asked facility to give him [R23] more pain medication on a regular basis. On 4/22/2026 at 7:55 AM, Surveyor interviewed CNA F, who reported R23 does moan and groan with movement. CNA F stated she would report to nurse. On 4/22/2026 at 8:00 AM, Surveyor spoke with DON B and asked how does staff know if and when R8 is having pain and what R23 finds to be an acceptable level of pain if they have not done a pain assessment for him [R23]. DON B reported they were going to do a pain assessment on him [R23] today. On 4/22/2026 at 8:56 AM, DON B reported when R23 is asked he typically denies pain, although he is not asked daily. DON B reported family has concerns with R23's comfort level and CNA's have reported R23 moan and groans with movement, but they thought it was just due to moving not pain. DON B agreed conducting a pain assessment is needed to determine R23's level of acceptable pain and when he might be experiencing pain.

Based on observation, interview and record review, the facility did not ensure that food was stored, prepared, distributed, and served food in accordance with professional standards for food service safety. The facility did not label opened dry goods with an open date to ensure food safety for residents. This has the potential to affect all 37 of 37 residents (R) residing in the facility. Findings include: Facility policy titled, Food Storage Standards revised November 2024, states, The dietary director shall ensure that standards for refrigerated, frozen, and dry foods are followed . Policy: follow the criteria below for all types of food storage . 3. Criteria for Dry Food Storage: . A dry food storage timeline chary is available and followed. (http://www.ag.ndsu.edu/pubs/yf/foods/fn579.pdf) . Dry food stock rotation follows the FIFO [First In First Out] principle . Staff receive training on the proper dry food storage time and temperature. North Dakota State University (NDSU), FN579 titled, Food Storage Guide reviewed January 2023, states, Many staples and canned foods have a relatively long shelf life, but buy only what you can expect to use within the time recommended in the chart. Date food packages and use the oldest first .Cupboard Storage Chart . - spaghetti, macaroni, etc. unopened stored for 2 years opened stored for 1 year . egg noodles unopened stored for 2 years and opened stored for 1-2 months. Once opened, store in an airtight container. On 01/07/25 at 11:52 AM, Surveyor observed dry storage area and noted that some products had open dates and some products did not. Surveyor observed three bags of noodles that were opened and did not have open dates; other bags of noodles in the same area were also opened and did have open dates. The three bags of noodles were open and still in original packaging, not in an airtight container. On 01/07/25 at 12:00 PM, Surveyor interviewed Dietary Manager (DM) H regarding food storage procedure. DM H would expect that staff put an open date on the noodles, so they know if they need to be thrown out. DM H said they planned to toss the noodles now because they did not know when they were opened and did not feel comfortable serving the noodles after not seeing open dates.

Based on observations, interviews and record reviews, the facility did not ensure 4 of 4 residents (R5, R34, R28 and R3) reviewed for moderate to high risk of Pressure Injury (PI) development received the necessary treatment and services to promote healing of existing skin impairments or prevent new pressure injuries from developing. -R5 is at moderate risk for the development of PIs. R5 was observed for 5 hours and 13 minutes sitting in a Broda chair without staff offering or attempting to offload body surface. -R34 was admitted with multiple PIs and was at risk for PI development. The facility did not reposition R34 for several hours and did not provide repositioning to off-load the coccyx and hip as ordered. -R28 was at risk for PI development. The facility failed to evaluate the effectiveness of current interventions R28 had in place. The facility did not apply prevalon boot to R28's right heel as ordered to off-load heels. -R3 was at moderate risk for PI development. R3 was not repositioned for 5.5 hours and did not have pressure relieving cushion in Broda chair as ordered. This is evidenced by: According to the National Pressure Injury Advisory Panel (NPIAP) 2019, page 115, . Repositioning and mobilizing individuals is an important component in the prevention of pressure injuries. The underlying cause and formation of pressure injuries is multifaceted; however, by definition, pressure injuries cannot form without loading, or pressure, on tissue. Extended periods of lying or sitting on a particular part of the body and failure to redistribute the pressure on the body surface can result in sustained deformation of soft tissues and, ultimately, in tissue damage . According to Wound Care Education Institute (WCEI), 2018 states in part: there are three levels to skin breakdown . The second phase of skin breakdown is tissue ischemia, which begins within 2-6 hours of sustained pressure, depending on various factors (shearing, friction, moisture or incontinence, immobility, medical conditions, nutrition, mental status, etc.). and age. Tissue ischemia is marked by deep redness over the skin surface. It takes approximately 36 hours to dissipate once the pressure is removed. The facility Policy and Procedure titled: Skin Care Management, last revised on 09/24, states: It is the policy of this nursing home to provide skin care to residents that includes assessment, prevention of skin breakdown, management of pressure injury and other skin integrity concerns. Under section Protocol Section 3 states in part, The Braden Scale pressure injury risk assessment will be completed to identify risk factors . the risk assessment scoring, along with comprehensive clinical evaluation, will assist the interdisciplinary team for the development of the care plan. .#5. The tissue tolerance protocol will be completed to determine which repositioning interval best reduces resident risk for developing pressure injuries. This test will be completed upon new admission, readmission if a problem exists, annually, and if there is a significant change in the resident's condition, acuity or alterations to their skin. #7. When a resident is admitted with or develops a pressure injury or any other open area, immediate treatment will be initiated. d. A weekly assessment will be done by the nurse and all ongoing wound documentation will be entered into the pressure-injury assessment folder in ECS. f. The nurse will notify the residents responsible party of any skin integrity issues and/or changes in treatment and document this in the nursing progress notes . Example 1 R5 was admitted to the facility on [DATE] and has diagnoses that include but are not limited to Alzheimer's disease and venous insufficiency. R5's Minimum Data Set (MDS) assessment, dated 10/23/24, indicated: -R5 is totally dependent on staff to meet the most basic daily tasks of bed mobility, transfer, dressing, toilet use and personal hygiene. -R5 is non-ambulatory and is transferred with the use of a mechanical lift. -R5 is always incontinent of bladder function and bowel function. -R5 has short-term and long-term memory impairment and severely impaired daily decision-making abilities. On 07/24/24, the facility completed a Braden Scale for Predicting Pressure Sore Risk Assessments for R5 indicating a score of 14 (moderate risk). On 07/24/24, the facility completed a Tissue Tolerance Protocol per policy which indicated R5 requires repositioning at an interval of every 2 hours. R5's care plan, dated 01/06/25, with a target date of 3 months, states: Problem: Tissue integrity impairment r/t impaired mobility, urinary incontinence, cognitive deficits . manifested by dependent on others for position changes and personal hygiene . intervention includes: assist with position changes every 2-3 hour. On 01/07/25, Surveyor observed the following: -7:40 AM, Surveyor observed R5 sitting in Broda chair at 45-degree position at breakfast table. -8:04 AM, R5 repositioned by staff to 90-degree position to eat. -8:35 AM, R5 brought to room and remained sitting at a 90-degree position. -9:45 AM, R5 observed continuing sitting in room at a 90-degree position. -10:39 AM, R5 brought to dining room for church service remaining at a 90-degree position. -11:17 AM, R5 placed in dining room in front of television after church service. -11:51 AM, R5 wheeled to dining table for lunch. -12:29 PM, R5 brought out of dining room into hallway across from nurses station. -12:53 PM, R5 transferred to bed. Surveyor observed 2 staff members conducting check and change peri care, noting R5's buttocks to be reddened after removing wet incontinent product (taking approximately 2-3 minutes). On 01/07/25 at 12:55 PM, Surveyor interviewed Certified Nursing Assistant (CNA) C who stated R5 was transferred to bed for a check and changed for incontinence before church. On 01/07/25 at 3:13 PM, Surveyor interviewed Director of Nursing (DON) B regarding expectation of turning, repositioning and offloading residents who have pressure injury or are at moderate to high risk for pressure injuries. DON B stated, The expectation would be to turn and reposition approximately every 2 hours and should be off loaded for at least 1/2 hour to 1 hour. DON B also stated that R5 should probably have been laid down after breakfast and gotten back up to go to church service. 48793 Example 2 On 01/06/25, Surveyor reviewed R34's medical record. R34 was admitted to the facility on [DATE] with diagnoses including unspecified Alzheimer's disease, failure to thrive, chronic kidney disease stage 3, type 2 diabetes mellitus with hyperglycemia, overactive bladder, and encounter for palliative care. R34's Minimum Data Set (MDS) assessment, dated 01/09/24, had a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicated R34 had severe impaired cognition. R34's MDS section GG for functional ability indicated R34 is totally dependent on staff for transfers, repositioning, and personal hygiene. MDS indicated that R34 was admitted with three stage 1 PIs and one stage 2 PI, and no stage 3 PIs noted. R34 is currently on hospice care. Surveyor reviewed R34's physician orders, which stated in part: -Check drive air mattress set at 200 and marked with a sticker. Air mattress set on normal pressure, static. Check 3 times a day. Surveyor reviewed R34's tissue integrity impairment care plan dated 01/05/25: -needs 2 assist and slip sheet for position changes every 2 hours. -keep off left hip as much as possible -float heels while in bed -air mattress on bed check every shift -heel protectors on at all times -dressing on both hips -document on coccyx PI area weekly On 01/07/25 at 7:15 AM, Surveyor observed R34 lying in bed on back slightly leaned to right side, sleeping. Surveyor observed lower back and coccyx flat against R34's bed, not offloading the PI. On 01/07/25 at 9:23 AM, Surveyor observed R34 lying in bed on back with slight lean towards right side and a pillow behind R34's upper back. Surveyor observed lower back and coccyx flat against R34's bed, not offloading the PI. On 01/07/25 at 10:35 AM, Surveyor observed CNA D and CNA G go into R34's room. CNA D and CNA G pulled covers down to R34's waist. Surveyor observed R34 on R34's right side slightly leaned to the right but with lower back and coccyx touching the mattress. Surveyor did not observe CNA D and CNA G reposition R34 off R34's coccyx. On 01/07/25 at 11:58 AM, Surveyor observed R34 lying on back in bed with lower back and coccyx against the mattress, not offloading the PI. Surveyor observed CNA D and CNA G transfer R34 out of bed into wheelchair for lunch. On 01/07/25 at 12:52 PM, Surveyor interviewed CNA G and asked how often is R34 to be repositioned and is R34 supposed to be completely off R34's coccyx. CNA G indicated that every resident should be repositioned for the most part every 2 hours. CNA G indicated that all staff try to reposition R34 off coccyx and off left hip as much as possible. On 01/07/25 at 1:13 PM, Surveyor started to observe R34 when placed in bed via Hoyer lift. CNA D and CNA G placed R34 on left side with pillow between legs. Surveyor did continuous observation of R34. On 01/07/25 at 3:53 PM, Surveyor observed R34 lying in bed on left side with pillow between legs. Surveyor did not observe staff reposition R34 during 1:13 PM-3:53 PM observation. On 01/08/25 at 11:33 AM, Surveyor interviewed Director of Nursing (DON) B and asked about expectations for staff to reposition R34. DON B indicated that CNAs should be repositioning R34 within 2 hours of being in bed since R34 is at high risk and has stage 3 PI on coccyx. On 01/13/25 at 3:30 p.m., Surveyor interviewed Regional Director of Operations (RDO) I asking if the PI was unavoidable. RDO I provided physician documentation that R34 has severe aortic stenosis, and audible severe heart murmur that affects circulation and healing. Physician stated that the area was not expected to heal due to R34's end of life condition. Example 3 On 01/06/25, Surveyor reviewed R28's medical record. R28 was admitted to the facility on [DATE] with diagnoses including acute on chronic systolic heart failure, chronic atrial fibrillation, and nonrheumatic mitral valve insufficiency. R28's Minimum Data Set (MDS) assessment, dated 09/25/24, had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated R28 had moderate impaired cognition. R28's MDS section GG for functional ability indicated R28 needs substantial/maximal assistance from staff for transfers, repositioning, and personal hygiene. Admission MDS indicated that R28 was admitted with unstageable pressure injury to the right heel but current MDS from 09/25/24 indicates right heel PI healed. Surveyor reviewed R28's physician orders, which stated in part: -Apply foam boot and float right heel when in bed every shift. Surveyor reviewed R28's tissue integrity impairment care plan dated 01/04/25: -Encourage to lift off surfaces to prevent shearing -Geo ultra gel mattress on bed -Encourage frequent positions changes 2-3 hours -Prevalon boots in bed and elevate feet Surveyor reviewed R28's skin assessments: -On 09/25/24, Braden scale assessment score was 17, indicating at risk for pressure injury. On 01/06/25 at 11:19 AM, Surveyor observed R28 sleeping in bed. Surveyor observed prevalon boot in wheelchair and not on R28's feet. On 01/08/25 at 9:48 AM, Surveyor observed R28 lying in bed without prevalon boot on right heel. Surveyor did not observe pillow under right heel to off-load. Surveyor observed prevalon boot lying in recliner beside the bed. On 01/08/25 at 10:16 AM, Surveyor interviewed CNA D and asked why R28's prevalon boot was in recliner in room instead of on R28's right heel. CNA D indicated that prevalon boot should be on while R28 is lying in bed. CNA D indicated to Surveyor that CNA D is unsure who laid R28 down in bed after breakfast. On 01/08/25 at 10:18 AM, Surveyor interviewed CNA C and asked if CNA C laid R28 down after breakfast. CNA C indicated that CNA C laid R28 down in bed after breakfast around 8:50 AM. Surveyor asked CNA C if CNA C applied prevalon boot on R28's right heel when CNA C laid R28 down after breakfast. CNA C indicated that CNA C did not apply the prevalon boot to R28's right heel and CNA C should have. On 01/08/25 at 11:33 AM, Surveyor interviewed DON B and asked about expectations for staff to apply prevalon boot to R28's right heel. DON B indicated that CNAs should always apply R28's prevalon boot to right heel whenever R28 is in bed. Example 4 On 01/06/25, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease with early onset, contracture right and left hand, contracture right and left elbow, contracture right and left wrist, contracture left shoulder, and Post Traumatic Stress Disorder (PTSD). R3's Minimum Data Set (MDS) assessment, dated 10/01/24, indicated Brief Interview for Mental Status (BIMS) could not be completed due to R3 being nonverbal. R3's MDS section GG for functional ability indicated R3 is totally dependent on staff for transfers, repositioning, and personal hygiene. Surveyor reviewed R3's care plan dated 01/06/24, which stated in part: -Dependent on staff for all cares, and transfers with 2 assists and Hoyer lift -Lay down between meals -Up in Broda chair with pommel wedge cushion for locomotion -Currently is unable to make any position changes independently Surveyor reviewed R3's Braden scale assessment, which stated in part: -On 12/27/24, Braden scale score 14 which indicates R3 is at moderate risk of skin breakdown. On 01/07/25 at 7:35 AM, Surveyor observed R3 in Broda chair sitting up at a 90-degree angle. Surveyor did not observe R3's pommel wedge cushion in place under R3. On 01/07/25 at 8:26 AM, Surveyor observed staff assisting R3 with breakfast. R3 was sitting in Broda chair at 90-degree angle. Surveyor did not observe R3's pommel wedge cushion in place under R3. On 01/07/25 at 8:50 AM, Surveyor observed Certified Nurse Assistant (CNA) E propel R3 in Broda chair to R3's room. CNA E parked R3 in room to watch television and attached call light to R3's chair. Surveyor did not observe CNA E reposition R3 in Broda chair and Surveyor did not observe R3's pommel wedge cushion in place under R3. On 01/07/25 10:05 AM, Surveyor observed R3 in Broda chair sitting up at a 90-degree angle. Surveyor did not observe R3's pommel wedge cushion in place under R3. Surveyor did not observe any staff members go into R3's room to assist in repositioning R3. On 01/07/25 at 11:03 AM, Surveyor observed R3 sleeping in Broda chair sitting up at a 90-degree angle. Surveyor did not observe R3's pommel wedge cushion in place under R3. Surveyor did not observe any staff members go into R3's room to assist in repositioning R3. On 01/07/25 at 12:02 PM, Surveyor observed CNA E wheel R3 out of R3's room and to the dining room. Surveyor observed R3 in Broda chair sitting up at a 90-degree angle. CNA E parked R3 at the dining room table and placed clothing protector on R3. Surveyor did not observe R3 repositioned. Surveyor did not observe R3's pommel wedge cushion in place under R3. On 01/07/25 at 1:15 PM, Surveyor observed CNA D and CNA G lift R3 into Hoyer lift and transfer to bed. CNA D and CNA G performed peri cares on R3. Surveyor observed golf ball size red mark on R3's right outer elbow where R3's elbow was pressed against the side of the Broda chair for a length of time. Surveyor observed wrinkle creases in skin on R3's lower back and coccyx area. Surveyor interviewed CNA D and CNA G and asked what time CNA D and CNA G transferred R3 out of bed this morning for breakfast. CNA D indicated around 6:40 AM. CNA D indicated that CNA D and CNA G were going to lay R3 down in bed after breakfast, but CNA G was waiting to offer a snack since R3 was pocketing food at breakfast and did not eat breakfast. CNA D and CNA G indicated that CNA D and CNA G decided to just keep R3 up for the day. Surveyor asked if R3 had been repositioned or position changed since R3 did not lay down in bed to off-load. CNA G indicated R3's Broda chair has been repositioned back a little earlier this morning but unsure what time. CNA G indicated that CNA G should have probably laid R3 down earlier. On 01/07/25 at 3:41 PM, Surveyor interviewed DON B and asked about repositioning R3. DON B indicated that all residents should be repositioned every 2 hours if at risk of skin breakdown. Surveyor asked DON B about R3's pommel wedge cushion that is ordered for R3 to be placed in wheelchair. DON B indicated that DON B would need to look into the cushion for R3.

Based on record review and interview, the facility did not ensure that 1 of 1 resident (R) reviewed received appropriate respiratory care during administration of respiratory therapy (R32). Facility did not perform pre and post respiratory assessments for R32 when administering nebulizer treatments. Findings include: On 01/06/25, Surveyor reviewed R32's medical record. R32 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), anxiety disorder, pneumonia, and chronic respiratory failure with hypoxia. R32's Minimum Data Set (MDS) assessment, dated 11/20/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R32 had intact cognition. Surveyor reviewed R32's physician orders, stated in part: -Albuterol Sulfate HFA 90 mcg, give two puffs inhalation every four hours as needed for COPD and breathing comfort. -Ipratropium-Albuterol neb 0.5mg/3ml give every six hours with pre-neb and post-[NAME] assessment. -May take medications whole. Do not leave at bedside. Observe taking all medications. On 01/06/25 at 11:35 AM, Surveyor observed R32 sitting in recliner. Surveyor observed R32 start R32's own nebulizer machine. Surveyor interviewed R32 and asked if the normal process was for R32 to start R32's own nebulizer for treatment. R32 indicated R32 started own nebulizer machine and that staff will bring nebulizer medication in and leave on bedside table if not ready to take medication. Surveyor did not observe a nurse go in and complete pre nebulizer treatment assessment. On 01/07/25 at 10:55 AM, Surveyor observed nebulizer machine on bedside table with some medication in the nebulizer compartment. Surveyor interviewed R32 and asked who manages the nebulizer machine such as filling the nebulizer compartment with medication, cleaning, rinsing, and drying it for the next use. R32 indicated it stays on bedside table and it is R32's personal nebulizer machine that R32 manages. On 01/07/25 at 12:35 PM, Surveyor heard nebulizer going and Registered Nurse (RN) F in R32's room sitting on bed conversing with R32. Surveyor observed RN F exit R32's room and walk down the hallway. Surveyor did not observe RN F complete pre nebulizer treatment assessment. Surveyor interviewed RN F and asked what RN F's process is for administering nebulizers to R32. RN F indicated that RN F will sometimes bring the nebulizer medication down to R32 and place in nebulizer machine. RN F indicated that RN F sometimes assesses oxygenation saturation with oximeter. RN F indicated RN F should auscultate lungs as well. Surveyor asked RN F if RN F assessed R32's lungs pre nebulizer treatment and RN F indicated that RN F did. Surveyor did not observe RN F perform pre nebulizer treatment or observe a stethoscope in R32's room or around RN F's neck. On 01/07/25 at 12:41 PM, Surveyor observed R32 shut nebulizer machine off and set the nebulizer on the bedside table. Surveyor did not observe RN F go back into R32's room to confirm nebulizer medication was finished accurately. Surveyor interviewed R32 and asked if RN F had listened to R32's lungs pre nebulizer treatment. R32 indicated that RN F did not listen to R32's lungs before R32 started R32's own nebulizer treatment. R32 indicated that R32 manages R32's own nebulizer treatments. On 01/07/25 at 12:41 PM-1:11 PM, Surveyor observed continuous observation that RN F did not perform post nebulizer respiratory assessment. On 01/07/25 at 1:53 PM, Surveyor interviewed Director of Nursing (DON) B and asked DON B's expectations for nursing staff to complete pre and post nebulizer assessments if R32 is self-administering the nebulizer treatment. DON B indicated that nursing staff should still be auscultating R32's lungs and performing the respiratory assessment pre and post nebulizer treatment. Surveyor asked DON B's expectation of time frame post nebulizer treatment for assessment of respiratory status. DON B indicated within 15-30 minutes post nebulizer treatment a respiratory assessment should be completed. Surveyor requested documentation of respiratory assessment pre and post nebulizer treatment for 01/07/24. Surveyor reviewed nurse progress notes and could not find consistent respiratory assessments pre and post nebulizer administrations.

Based on observation and interview, the facility did not ensure the accurate receiving and dispensing of all drugs and biologicals. Expired medications were observed in 1 of 4 medication storage areas medicine carts/rooms inspected. The facility did not administer medications accurately for 1 resident (R) (R32) of 1 sampled resident observed. -Facility did not destroy R15's Lorazepam after medication was discontinued. -Facility did not destroy R35's Lorazepam after medication was discontinued. -R32 had medications left at bedside and did not have an assessment to self-administer medication. Findings include: Example 1 The facility policy, titled Destruction of Medications, reviewed July 2024, states: .3. Disposal of all drugs will occur within 72 hours of a physician's order discontinuing its use, the resident's death or passage, its expiration date or as outlined in state specific policy . Surveyor reviewed R15's physician orders, which stated in part: -On 11/14/24, ordered Lorazepam 2mg/ml Give 0.25ml orally every four hours as needed for anxiety. Surveyor reviewed R35's physician orders, which stated in part: -On 12/17/24, ordered Lorazepam 2mg/ml Give 0.25ml orally every two hours as needed for anxiety. On 01/07/25 at 9:36 AM, Surveyor toured medication storage room with Director of Nursing (DON) B. On 01/07/25 at 9:43 AM, Surveyor observed two Lorazepam 2mg/ml bottles unopened labeled for R15 and R35 for use as needed. R15's bottle was prescribed 11/14/24. R35's bottle was prescribed to R35 12/17/24. DON B indicated the two bottles of lorazepam are not supposed to be in fridge anymore as the physician orders were only good for 14 days and both orders have been discontinued for a while. Surveyor interviewed DON B and asked why the bottles were still in fridge and who is responsible for auditing and removing controlled medications that are no longer in use. DON B indicated that DON B is the one who audits controlled medications and makes sure controlled medications that are discontinued are no longer in the facility. DON B apologized and stated DON B would remove controlled medications right away. Example 2 On 01/06/25, Surveyor reviewed R32's medical record. R32 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), anxiety disorder, pneumonia, and chronic respiratory failure with hypoxia. R32's Minimum Data Set (MDS) assessment, dated 11/20/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R32 had intact cognition. Surveyor reviewed R32's physician orders, which stated in part: -Albuterol Sulfate HFA 90 mcg, give two puffs inhalation every four hours as needed for COPD and breathing comfort. -Ipratropium-Albuterol neb 0.5mg/3ml give every six hours with pre-neb and post-[NAME] assessment. -May take medications whole. Do not leave at bedside. Observe taking all medications. On 01/06/25 at 11:35 AM, Surveyor observed R32 sitting in recliner. Surveyor observed R32's nebulizer medication in nebulizer machine on bedside table. Surveyor observed R32 start R32's own nebulizer machine. Surveyor interviewed R32 and asked if the normal process was for R32 to start R32's own nebulizer for treatment. R32 indicated R32 started own nebulizer machine and that staff will bring nebulizer medication in and leave on bedside table if not ready to take medication. During interview Surveyor observed two Ventolin HFA inhalers with tops off located on bedside table near R32's recliner. On 01/07/25 at 10:55 AM, Surveyor observed R32 sitting in recliner after transferring from commode to recliner. R32 was short of breath and had a red inhaler in left hand shaking getting ready to use the inhaler. Surveyor interviewed R32 and asked if R32 was ok and once done using the inhaler, may Surveyor see the inhaler to read the label. R32 indicated to Surveyor that the inhaler is fine, and R32 manages own medication with the rescue inhalers in R32's room. R32 indicated that R32 always keeps inhalers at bedside in R32's room. Surveyor observed nebulizer machine on bedside table with some medication in the nebulizer compartment. Surveyor interviewed R32 and asked who manages the nebulizer machine such as filling the nebulizer compartment with medication, cleaning, rinsing, and drying it for the next use. R32 indicated it stays on bedside table and it is R32's personal nebulizer machine that R32 manages. On 01/07/25 at 12:35 PM, Surveyor heard nebulizer going and Registered Nurse (RN) F in R32's room sitting on bed conversing with R32. Surveyor observed RN F exit R32's room and walk down the hallway. Surveyor interviewed RN F and asked what RN F's process is for administering nebulizers to R32. RN F indicated that RN F will sometimes bring the nebulizer medication down to R32 and place in nebulizer machine. RN F indicated that R32 does not always want the nebulizer right away so RN F will leave nebulizer medication on bedside table until R32 is ready to use. RN F indicated the facility has deemed R32 to be ok to administer nebulizer to self. On 01/07/25 at 12:41 PM, Surveyor observed R32 shut nebulizer machine off on R32's own and set the nebulizer on the bedside. Surveyor did not observe RN F go back into R32's room to confirm nebulizer medication was finished accurately. On 01/07/25 at 1:53 PM, Surveyor interviewed Director of Nursing (DON) B and asked DON B's expectations for staff leaving medications with residents. On 01/07/25 at 2:17 PM, DON B indicated to Surveyor that R32 did not have an assessment to self administer medications so the nurse should not have left the medication at bedside.

Based on observation and interview, the facility did not ensure all drugs and biologicals were stored in accordance with currently accepted professional principles. This occurred for 1 of 7 resident (R32) medication administration/storage observed. During the three-day survey, 1 of 7 observations were made of medications left unattended and out of view of staff. Findings include: On 01/06/25, Surveyor reviewed R32's medical record. R32 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), anxiety disorder, pneumonia, and chronic respiratory failure with hypoxia. R32's Minimum Data Set (MDS) assessment, dated 11/20/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R32 had intact cognition. Surveyor reviewed R32's physician orders, which stated in part: -Ipratropium-Albuterol neb 0.5mg/3ml give every six hours with pre-neb and post-[NAME] assessment. -Do not leave at bedside. Observe taking all medications. On 01/06/25 at 11:35 AM, Surveyor observed two Ventolin HFA inhalers with tops off located on bedside table near R32's recliner. On 01/07/25 at 10:55 AM, Surveyor observed R32 sitting in recliner after transferring from commode to recliner. R32 was short of breath and had a red inhaler in left hand shaking getting ready to use the inhaler. Surveyor interviewed R32 and asked if R32 was ok and once done using the inhaler, may Surveyor see the inhaler to read the label. R32 indicated to Surveyor that the inhaler is fine, and R32 manages own medication with the rescue inhalers in R32's room. R32 indicated that R32 always keeps inhalers at bedside in R32's room. On 01/07/25 at 1:53 PM, Surveyor interviewed Director of Nursing (DON) B and asked DON B's expectations for R32 self-administering Ventolin inhalers and storage of R32's inhalers. DON B indicated that all medications are to be stored in medication carts or medication storage room. DON B indicated that R32 should not be using Ventolin inhalers freely in room without supervision from nursing staff.

Based on observation, record review and interview, the facility staff did not conduct hand hygiene during resident (R) cares for 1 out of 5 (R34) observations. Certified Nursing Assistant (CNA) E did not perform hand hygiene when warranted when providing peri care to R34. This is evidenced by: The facility policy, titled Infection Prevention and Control dated 2/2024 states: 5. Hand Hygiene a. The World Health Organization (WHO) guidelines are followed for hand hygiene for all employees. The WHO Guidelines, titled WHO Guidelines on Hand Hygiene in Health Care dated 01/15/2009 states on page 92 under the section Indications for hand hygiene: My five moments for hand hygiene. Moment 1- Before touching a patient. Moment 2- Before a procedure. Moment 3- After a procedure or body fluid exposure risk. Moment 4- After touching a patient. Moment 5- After body fluid exposure risk The WHO Leaflet, titled Glove Use Information Leaflet states under section Inappropriate glove use: The use of contaminated gloves caused by inappropriate storage, inappropriate moments, and techniques for donning and removing, may also result in germ transmission. On 01/07/2025 at 9:02 AM, Surveyor observed CNA E conduct hand hygiene before transferring R34 via Hoyer lift to R34's bed. CNA E donned gloves, and no hand hygiene was observed prior to donning gloves. CNA E proceeded to remove urine wet brief, conducted peri care and placed new brief. CNA E proceeded with contaminated gloves to pull up and adjust R34's pants, adjust pillow under head, place pillow behind back for support and adjust blanket. On 01/08/2025 at 12:40 AM, Surveyor interviewed Director of Nursing (DON) B regarding expectation of hand hygiene. DON B stated the expectation would be to conduct hand hygiene after contact with residents, personal items, or equipment used to care for them.

Based on observation, interview and record review, the facility did not ensure all drugs and biologicals were stored in accordance with currently accepted professional principles and did not ensure only authorized personnel had access to medication carts. This had the potential to affect 1 of 12 sampled residents (R) R138. Findings include: The facility policy entitled, Controlled Substance Policy, dated 12/21 stated in part: 3. MEDICATION STORAGE & SECURITY a. All carts must be locked when not in visual presence of the nurse. b. Nurse must have the medication keys in their control at all times . R138 was admitted to the facility on [DATE] with a Brief Interview of Mental Status (BIMS) score of 15. Diagnoses include atrial fibrillation, congestive heart failure and hypertension. On 12/06/23 at 8:30 AM, Surveyor observed a medication cart sitting in the dining room. The medication cart was unlocked with the keys lying on top of the medication cart. Surveyor also observed a medication card for R138 for Metoprolol on top of the cart face up. On 12/06/23 at 8:32 AM, Surveyor observed RN F return to the medication cart. Surveyor asked if the cart was unlocked, and RN F indicated that it was. Surveyor asked if these medications lying on top for R138 should be on top of the cart, and RN F replied, No, but I had to step away quickly. On 12/07/23 at 9:26 AM, Surveyor asked Director of Nursing (DON) B, What are your expectations regarding unattended medication carts being locked? DON B replied, The medication carts need to be locked if unattended. Surveyor asked DON B, What are your expectations regarding residents' medications on top of unattended cart lying face up? DON B replied, That practice is not ok. The nurses need to keep the medications stored in the medication cart when unattended.

Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help to prevent the development and transmission of communicable diseases and infections. Staff did not wear appropriate Personal Protective Equipment (PPE) during observation of incontinence care for R15 who is on Enhanced Barrier Precautions (EBP). Staff did not change gloves or perform hand hygiene during observation of incontinence cares for R15 and R26. Findings include: Surveyor reviewed policy entitled Standard and Transmission-Based Precautions which states in part .Enhanced barrier precautions expands the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug resistant organisms (MDRO) to staff hands and clothing. Examples of high-contact resident care activities requiring gown and glove use for enhanced barrier precautions include dressing, providing hygiene, changing briefs, or assisting with toileting. Surveyor reviewed policy entitled Standard and Transmission-Based Precautions which states in part .Hands shall be washed with soap and water when visibly soiled with dirt, blood, or body fluids after direct or indirect contact with such. In the absence of visible soiling of hands, alcohol-based rubs are preferred. Example 1 R15's care plan and Certified Nursing Assistant (CNA) care card updated on 10/26/23, indicates enhanced barrier precautions to be worn for direct cares due to bacteria in urine. On 12/06/23 at 7:03 AM, Surveyor observed upon entering R15's room an Enhanced Barrier Precaution sign posted outside of the door and PPE hanging on the back of R15's door. Surveyor observed CNA C setting up to provide morning cares. During observation of providing cares to R15, which included incontinence care, CNA C was not wearing appropriate PPE. CNA C did not have a gown. On 12/06/23 at 7:05 AM, Surveyor interviewed CNA C, who stated unawareness of R15 being on precautions and believes the PPE hanging on the door is old. On 12/06/23 at 1:39 PM, Surveyor interviewed Licensed Practical Nurse (LPN) E, who indicated R15 is on enhanced barrier precautions due to bacteria in urine. Staff need to gown before doing incontinence/toileting care. LPN E indicated information is also on the CNA card. On 12/06/23 at 3:20 PM, Surveyor shared observation with Director of Nursing (DON) B who indicated the expectation would be for staff to wear personal protective equipment (PPE) which includes gown and gloves, during care of a resident on enhanced precautions as posted outside of a resident's door. Example 2 On 12/06/23 at 7:14 AM, Surveyor observed CNA C conduct morning cares on R15 which included incontinence care. CNA C did not remove gloves and conduct hand hygiene after completing incontinence care and proceeded to wear contaminated gloves contaminating R15's: clean t-shirt, clean sweatshirt, and shoes. CNA C, still wearing the contaminated gloves, put CNA C's arm around the back of R15's shoulders and repositioned R15 to sit on side of bed, assisted R15 to stand to pull up R15's clean pants. CNA C proceeded touching R15's walker handle, wheelchair, and applied a sweater on R15, prior to removing contaminated gloves. On 12/06/23 at 7:14 AM, Surveyor interviewed CNA C regarding appropriate time to conduct hand hygiene. CNA C stated before cares, after peri care and after completion of cares. Surveyor indicated that no observation of hand hygiene after peri care was observed. CNA C confirmed CNA C had not removed gloves and conducted hand hygiene until the task was completed. Example 3 On 12/06/23 at 7:35 AM, Surveyor observed Nursing Assistant (NA) D assist R26 to stand after toileting and conduct peri care. Using contaminated gloves, NA D pulled up R26's pants, straightened shirt, touched walker handle, and held gait belt to transfer R26 to wheelchair. On 12/06/23 at 7:45 AM, Surveyor Interviewed NA D regarding observation of no hand hygiene conducted after peri care, NA D confirmed not removing gloves and conducting hand hygiene after incontinence care. On 12/06/23 at 3:20 PM, Surveyor shared the 2 observations of staff not conducting proper glove removal and hand hygiene. DON B stated the expectation of conducting hand hygiene care during incontinence care would be to remove gloves and conduct hand hygiene after incontinence care and before proceeding with cares.

Based on observation and interview, the facility did not store, prepare, distribute and serve food in a safe and sanitary manner. This has a potential to affect all 39 residents. Kitchen staff did not test the dishwashing machine's chemical sanitization solution to ensure it is maintained at the correct concentration to prevent a potential chemical contamination of the food served to the residents. This is evidenced by: The following are general recommendations according to the U.S. Department of Health and Human Services, Public Health Services, Food and Drug Administration Food Code for each method. Low Temperature Dishwasher (chemical sanitization): o Wash - 120 degrees F; and o Final Rinse - 50 ppm (parts per million) hypochlorite (chlorine) on dish surface in final rinse. The chemical solution must be maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines. On 10/24/22 at 10:50 a.m., Surveyor conducted the initial tour of the kitchen. Surveyor observed the dishwasher being in operation with the Dietary Manager (DM) C. Surveyor interviewed DM C asking about the type of dishwasher sanitization process. DM C indicated it is a low temperature chemical sanitization. Surveyor interviewed Dietary Aide (DA) D asking when the dishwasher sanitization is tested . DA D indicated it is tested at breakfast or lunch. Surveyor asked DM C for the logs of the tests completed for the level of Parts Per Million (PPM) of the chemical sanitization. DM C indicated not being aware of logs being kept. Surveyor asked for DA D to test the chemical sanitization level. DA D appeared to be unsure of how to test. DM C asked where the litmus strips were located and gathered strips from the 3-compartment sink area. When tested , the strip was a dark blue color. Surveyor asked if the litmus strips were the correct type for a low temperature sanitization chemical. DM C was unable to determine if they were the correct litmus strips. Surveyor asked if there is any documentation of the type of strips with a color reference chart. DM C showed Surveyor the bucket the litmus strips came from and there was no label or color reference chart. DM C indicated it appeared the litmus strips may have gotten wet before. DM C indicated he will be contacting the company to get the strips and start logging the results. On 10/26/22 at 3:00 p.m., Surveyor reviewed the observation with Nursing Home Administrator (NHA) A. NHA A indicated education and training will be provided to DM C as he is new to the position.

Based on observation, interview, and record review, the facility did not implement effective interventions to ensure that a resident maintain an acceptable parameter of nutritional status. This occurred for 1 of 3 residents, Resident (R) R93. The facility did not have a system to monitor or ensure accurate weights for R93, care plan for nutritional interventions, or ensure R93 had an evaluation by speech therapy. This is evidenced by: The facility policy, entitled Weight Management, dated 05/16, states .An accurate body weight obtained at individually assessed intervals is one of the most reliable, inexpensive and non-invasive ways to identify when a resident is not obtaining adequate nutrition and/or hydration .If resident's weight has changed more than 3 pounds from the previous weight, immediately reweigh the resident .The licensed nurse notifies the Dietary Director/Registered Dietician (RD) of residents with a specific weight loss .1 month significant 5% .greater than 5% severe .The Dietary Director/RD assesses each resident with a significant or severe weight loss and makes appropriate recommendations to physicians and updates the residents' plan of care . R93 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R93's Minimum Data Set (MDS), dated [DATE], indicated that R93 experiences coughing or choking during meal, has difficulty with chewing. Weight is 184#. R93's clinical record does not include a nutrition related care plan. The Certified Nursing Assistant plan of care indicates that R93 is able to feed self after set up assistance. R93's nutrition assessment, completed 06/25/21, showed that R93's weight was 184#, with intake at meals 26-75%. Physical and mental functioning noted that R93's food texture needed to be evaluated by speech therapy, as well as feeding guidelines, since R93 was not able to feed self, was coughing between swallows and not remembering how to swallow at the time of the Registered Dietician (RD) evaluation on 06/25/21. Surveyor reviewed and confirmed that R93's consistent intakes, as documented by the facility, are frequently greater than 75%, occasionally 100%, meal and fluid consumption. A review of R93's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R93 was also receiving this medication in the hospital by IV. Hospital weight on 06/24/21 was #185.2. R93 was admitted to the facility the next day. Weights ranged as follows: 06/25/21: 184# 07/06/21: 159# 07/12/21: 158# 07/17/21: 158# 07/18/21: 154# 07/21/21: 154# 07/27/21: 154# On 06/25/2021, the resident weighed 184#. On 07/27/2021, the resident weighed 154 pounds which is a 16.30% loss, and considered a severe weight loss. On 07/14/21, at 11:36 a.m., RD C noted: Admission weight entered as 184# . Weight dropped to 159# on 07/06/21, and down to 158# on 07/12/21 .resident may be a poor historian, so will attempt to gather more background from spouse or family . The facility did not reweigh R93 after obtaining a weight on 07/06/21 showing a 25 pound weight loss until 07/12/21. On 07/26/21, at 12:15, Surveyor observed R93 during the noon meal. R93 was able to eat independently after set up by staff. No obvious coughing during the meal observation. R93 consumed most of his meal and fluids. On 07/28/21, at 03:35 p.m., Surveyor interviewed DON B. Surveyor asked DON B how the facility ensures that resident weights are accurate and to explain the system for reporting and monitoring weight loss. DON B stated, Sometimes when they (a new admission) comes in, the staff get the weight and I don't know if it is accurate .the admission weight is entered into the computer. No, there is not a system for the staff to compare a resident's previous weight to the current weight .No system for monitoring weight loss .Our Dietary Manager used to do it but now she is gone. The weights are not followed as closely since she left. The new Dietary Manager hasn't started to learn how to do this yet. Surveyor asked DON B if a referral was placed to speech therapy for evaluation of swallowing. DON B stated that she was not aware that a speech evaluation was recommended by RD C. DON B confirmed that no speech therapy evaluation was performed for R93 since RD C recommended it on 06/25/21. On 07/28/21, at 04:15 p.m., Surveyor interview RD C. Surveyor asked RD C to describe the system for discussing weight reviews, if there is a discrepancy noted, with the facility, or any other dietary concerns. RD C told Surveyor that she did not discuss R93's weights or swallowing concerns with the facility. RD C stated, They were aware of this weight discrepancy at the time I wrote the note. Staff was truly aware. They are able to view my note.

Based on interview and record review, the facility did not coordinate with the appropriate, State-designated authority, to ensure that individuals with a mental disorder, or an intellectual disability receive care and services in the most integrated setting appropriate to their needs that is identified in the Preadmission Screen and Resident Review (PASARR) screens. This occurred for 1 of 1 resident (Resident (R) 38 reviewed for PASARR screens. R38 has a [DIAGNOSES REDACTED]. This is evidenced by: On 06/24/2019 at 10:30 AM, R38's record includes [DIAGNOSES REDACTED]. On 06/24/19 at 3:29 PM, a social service note, dated 04/14/14, provided information from R38's brother who stated R38 had a history of [REDACTED]. The resident's brother stated R38 had treatment for [REDACTED]. Upon further record review: fax order sheet to the physician, dated 04/12/2019, states under patient background: [MEDICAL CONDITION]. PASARR Level I screening was reviewed. The screening was completed on 04/03/14. The form states R38 is not suspected of having a serious mental illness or a developmental disability. On 06/25/2019 at 11:00 AM, Surveyor spoke with Social Worker (SW) D. Surveyor asked SW D if a PASARR Level II screen was completed for R38. SW D stated there was no Level II screen done, because R38's admission paperwork never had a mental health diagnosis. Surveyor reviewed the medical record, and no PASARR Level II screening was found. Surveyor reviewed the Minimum Data Set (MDS) records, from 04/16/14 through 06/05/19, and the [DIAGNOSES REDACTED]. On 06/26/19 at 8:21 AM, Surveyor spoke with the Director of Nursing (DON). Surveyor asked the DON where the [DIAGNOSES REDACTED]. The DON said she would check. On 06/26/19 at 9:30 AM, the DON provided a [DIAGNOSES REDACTED]. One visit note, dated 07/10/14, lists a [DIAGNOSES REDACTED]. The DON provided a [DIAGNOSES REDACTED]. The DON stated she thought this information was where the [DIAGNOSES REDACTED]. On 06/26/19 at 10:14 AM, Surveyor spoke with MDS Coordinator C. Surveyor asked where the [DIAGNOSES REDACTED]. MDS-C thought the [DIAGNOSES REDACTED]. MDS-C stated the Medical Director initialed some [DIAGNOSES REDACTED]. Surveyor asked when and how did the [DIAGNOSES REDACTED]. MDS-C stated she would look in the record. On 06/26/19 at 11:06 AM, MDS-C provided coding information she used and stated that from the [DIAGNOSES REDACTED]. MDS-C stated this is where she probably came up with the [MEDICAL CONDITION] code in the MDS.

Based on observation and interview, the facility did not ensure pureed foods are prepared by methods that conserve nutritive value, flavor, and appearance for 5 of 5 residents. (Resident (R) 13, 15, 8, 28, 36) Dietary staff did not measure the water that was added to the food that was pureed and facility does not have recipes to follow to prepare pureed foods. On 06/24/19 at 11:17 a.m., Dietary Cook (DC) B indicated the facility has five residents on pureed food R36, R13, R15, R8 and R28. Surveyor observed DC B take six scoops of noodles and added water from the coffee maker, which was not measured, then blended. DC B took five scoops of meatloaf and added water from the coffee maker, which was not measured, then blended. DC B took five scoops of cooked vegetables with juice and blended. Surveyor interviewed DC B about the pureed foods. DC B indicated she has worked at the facility for a long time and knows about how much water needs to be added to be the right consistency. DC B indicated she does not follow a recipe for pureed foods. 06/25/19 10:16 a.m., Interview with Dietary Manager (DM) A indicated could not find recipes for yesterday's meal. DM A indicated staff should use milk or chicken broth to get to consistency for puree or if thickener is needed. Will look for policy on what to use to make pureed foods. On 06/25/19 at 10:49 a.m., DM A gave Surveyor policy for Puree Process Method - RPH with the revised date of 01/16 which read in part: STEP 3 ONLY IF NECESSARY, add liquid or thickener to obtain desired consistency. An example of a food that might require thickener is watermelon. If thinning a food is required, use liquids that add to the nutritional value as well as the flavor of the food item. Appropriate liquids include milk, fruit juice, vegetable juice, or low sodium broths, gravies or cream sauces. Example of appropriate liquids with menu items include: milk with oatmeal, pancakes or muffins; orange juice with mandarin oranges; vegetable juice with stuffed green pepper; low sodium chicken broth or chicken gravy with baked chicken, etc. STEP 4: Measure the total volume of pureed food after it is pureed. STEP 5: Divide the total volume of pureed food by the original number of portions On 06/25/19 at 3:00 p.m., Surveyor interviewed DM A and reviewed above concern. DM A indicated education will be completed tomorrow with all dietary cooks.

Based on interview and record review, the facility did not maintain resident medical records which are complete. This occurred for one of 16 residents (Resident (R) 31) whose medical records were reviewed. The facility did not have complete and thorough documentation in R31's medical record of previous interventions for wandering, discharge planning and discussions with the resident's power of attorney. This is evidenced by: On 06/24/19, Surveyor reviewed R31's medical record. The resident has [DIAGNOSES REDACTED]. The resident's Brief Interview for Mental Status (BIMS) score, dated 02/05/19, was a 03 out of a possible 15 points. According to the BIMS assessment, a score of 03 indicates R31 has severe cognitive deficits. The resident has an activated Power of Attorney for Healthcare (POAHC) agent, who is the resident's daughter. The resident is able to walk independently in the facility. On 06/25/19 at 1:15 p.m., Surveyor conducted a resident group interview. During the group interview, R23 stated R31 previously threatened to hit R23, but R31 did not follow through to hit R23. Surveyor reviewed R31's nurses' notes, from 01/29/19 to 06/24/19. The nurses' notes identify R31 wandered into the rooms of other residents, on at least sixteen different days, between 02/02/19 to 06/21/19. The alleged incident between R31 and R23 was not documented in R31's medical record. A note, dated 04/12/19, states the following, in part, .MD (Doctor of Medicine) updated on wandering and other behaviors, especially at HS/N[NAME] (Hour of Sleep/Night Shift) .MD verbalized understanding .stated that he feels resident would do best in a dementia unit. Updated him that facility is working with (name of managed care organization) on finding alternate placement but have not been able to find up til this point . There is no documentation in R31's medical record alternate placement was pursued for the resident, prior to 05/22/19. Surveyor reviewed R31's social services notes, from 01/29/19 to 06/24/19. The alleged incident between R31 and R23 was not documented in R31's social service notes. The social services notes state the following, in part: -05/08/19: .Quarterly Review .family visits as able and are attentive to needs .BEHAVIORAL ISSUES: Resident wanders around facility, in others rooms .Resident is not able to sit still for any length of time .He continues to be restless .REFERRALS/OUTSIDE RESOURCES: Daughter asks that she be asked about return to community on comprehensive assessments only. Has Care Wisconsin (managed care organization) workers . -05/22/19: (Name of worker) from (name of another nursing facility) called this writer to request information on resident. They were contacted by Resident's Care WI worker .to evaluate for admission to their facility. SW (Social Worker) faxed requested information. SW will await for determination. SW to continue to be available as needed . There is no further documentation in R31's medical record if the other nursing facility accepted or denied the resident for alternate placement. -06/10/19: Discharge planning .(name of memory care facility and name of worker) came and evaluated resident on this date for Memory care. She felt he would be a good fit. (Name of worker) said that I (SW) would hear from Care WI worker if resident is accepted and family is in agreement . There is no further documentation in R31's medical record if the resident was accepted into this memory care facility, or if the resident's POAHC was in agreement with this transfer. There is no documentation of the resident's care conferences, including if the POAHC or members of the managed care organization are in attendance, since R31 was admitted to the facility, on 01/29/19. Surveyor reviewed R31's Certified Nursing Assistant (CNAs) care plan. The CNA care plan states the following, in part, .06/24/19 .SPECIAL CARE REMARKS .is alert but forgetful .monitor where abouts .attempts to wamder in other rooms, monitor for this and redirect-often is looking for snack or toilet .door camoflauge (sic) placed on doors on 100 wing near his room to deter him from wandering into these rooms . R31's comprehensive care plan states the following, in part, PROBLEM .Alteration in Thought processes, Potential for Ineffective coping, Limited mental function .MANIFESTED BY .Resident wanders around facility, in others rooms .05/08/2019 .involve Care Wisconsin team to assist with placement in memory care facility. Thus far, residents (sic) daughter wants him close to her in .Staff use redirection when wandering in other's rooms . On 06/26/19 at 8:20 a.m., Surveyor interviewed the Director of Nursing (DON), and R23's statements from the resident group interview were discussed. The DON stated R31's POAHC/daughter does not want the resident moved to the memory care unit, which assessed the resident for placement, on 06/10/19. The DON indicated the facility currently is using large posters on the doors of other resident's rooms, to deter R31 from entering these rooms. The DON indicated the facility previously used purple magnetic signs on the outside of other resident's doors to deter R31 from entering these rooms; however, the DON stated R31 removed these signs. It is noted, the use of the purple magnetic signs, including the dates and efficacy of the signs, are not documented in R31's medical record. At 8:48 a.m., Surveyor interviewed SW D. The SW stated R31's POAHC/daughter declined to have the resident moved to the memory care facility, which assessed the resident on 06/10/19. SW D stated she did not write a follow-up note regarding this. SW D stated R31 would be better suited in a memory care facility, and the facility staff and the workers of the managed care organization have educated R31's POAHC/daughter regarding the resident's wandering behaviors, as well as the benefits of a memory care unit. SW D stated there is probably nothing more documented about this education than what is already in the notes. It is noted, there is no documentation in R31's medical record regarding the above education provided to the POAHC. During the continued interview, SW D stated R31's POAHC/daughter has not come to the resident's care conferences, so the SW stated she does not write a note in the medical record about the conferences unless something comes up. Surveyor discussed R23's statements from the resident group interview. SW D stated she was aware of the incident with R23, and R23 was moved after this incident. This incident is not documented in the resident's medical record.

Based on staff interview and record review, the facility did not ensure 3 of 3 sampled residents (R9, R22 and R28) were prevented from receiving unnecessary PRN (give as needed) [MEDICAL CONDITION] medications beyond 14 days without documentation in the resident's record to include the rationale as to why the medication should go beyond the 14 days, and indicate the duration for the order. The physician ordered [MEDICATION NAME] PRN (give as needed) for R9. The physician did not document the rationale for the use of the medication beyond 14 days and did not document the duration of the order. Resident (R) 22 and R28 have orders for an as needed (PRN) anti-anxiety medication which has gone beyond 14 days and did not include the duration for the medication ordered and did not include a rationale for using the medication beyond the 14 days. This is evidenced by: 1. On 06/19/18 at 10:15 a.m., Surveyor reviewed R9's medical record. R9 has [DIAGNOSES REDACTED]. Surveyor could find no documentation in the medical record of the rationale as to why the [MEDICATION NAME] was used beyond the 14 days and indication of the duration of the order. On 06/19/18 at 2:30 p.m., Surveyor interviewed the Director of Nursing (DON) about PRN [MEDICATION NAME] ordered for SOB/anxiety. Surveyor requested documentation by the physician of rationale for PRN [MEDICATION NAME] ordered beyond 14 days and duration for the PRN order. Per the Medication Administration Record [REDACTED]. The DON stated she would check with Mayo Hospice to see if they had any documentation. The DON stated she felt this order was left over from the resident being on hospice. Surveyor asked when R9 was on hospice. The DON stated she would look for that documentation. On 06/19/18 at 3:00 p.m., the DON stated R9 was on Mayo hospice and went off hospice around 12/22/17 to palliative care. The DON said she was not aware the regulation applied to hospice/palliative residents. The DON stated their pharmacist said hospice would take care of this order. The DON stated she would check with Mayo Hospice to see if they had the documentation. No documentation was provided. 2. R22 has [DIAGNOSES REDACTED]. Review of R22's medical record on 06/19/18 revealed a physician's orders [REDACTED]. Further review of the medical record did not locate a reason for the medication to be used beyond 14 days, and did not indicate duration for the order. Surveyor met with the DON at 4:40 p.m., on 06/19/18, and requested further information in relation to the above matter. The DON stated R22 has significant anxiety and the medication helps to relieve this effectively for her. The DON stated she would look for further information. Interview with the DON on 06/20/18 at 1:40 p.m. revealed, R22 takes the anti-anxiety PRN medication almost every day for her anxiety, and gets good relief from this. The DON did not provide any information related to the duration of the medication ordered, or a justification for using the PRN medication beyond the 14 days. 3. R28 has [DIAGNOSES REDACTED]. R28 is currently on hospice care. Review of R28's medical record on 06/19/18 revealed a physician's orders [REDACTED]. Further review of the medical record, did not locate a reason for the medication to be used beyond 14 days, and did not indicate duration for the order. Surveyor met with the DON at 4:40 p.m., on 04/19/18, and requested further information in relation to the above matter. The DON stated R28 has significant mental health history including anxiety. The DON stated she would look for further information in hospice documentation as they may have it in their records. On 06/20/18 at 1:20 p.m., the DON provided a document dated 06/20/18 which indicated a physician had reviewed the medication usage and wrote a justification for the use of the medication beyond the 14 days and duration of the order Interview with the DON on 06/20/18 at 1:40 p.m. revealed, R28 takes the anti-anxiety PRN medication once or more, on every other day to every third day, and gets good relief from this. The DON indicated the document dated 06/20/18 was written today to provide the needed information, as pointed out by the surveyors.

Based on observation, interview and record review, the facility did not ensure it was free of medication error rates of five percent or greater. During the medication administration task there were 2 errors observed out of 32 opportunities. This identified a medication error rate of 6.25% affecting Resident (R) 40. -The nurse did not cue R40 to swish and expectorate following the use of an inhaler. -The nurse did not mix the fiber powder with enough water, causing R40 to not receive the entire dose. This is evidenced by: On 06/19/18 at 7:55 a.m., Surveyor observed Licensed Practical Nurse (LPN) A administer medications to R40 in the dining room. R40 had a physician order [REDACTED]. R40 then swallowed the water. Nursing (YEAR) Drug Handbook states administration recommendations for Breo Ellipta, After use have patient rinse mouth without swallowing to help reduce the risk of oropharyngeal candidiasis. On 06/19/18 at 7:55 a.m., Surveyor observed LPN A administer Fiber Powder to R40. R40 had a physician order [REDACTED]. The Fiber Powder became thickened during this process and approximately one teaspoon of medication was remaining in the bottom of the cup. LPN A did not offer to mix additional water to the cup of thickened Fiber Powder. R40 did not receive the entire dose of Fiber Powder. On 06/20/18 at 8:45 a.m., Surveyor interviewed the Director of Nursing (DON). Surveyor reviewed findings of medication pass observation with a medication error rate of 6.25%. Surveyor reviewed the two medication errors with the DON.

Based on observation, interview and record review, the facility failed to ensure the resident environment remains as free from accidents as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 3 of 6 (#1 and #3) residents reviewed. Resident #1 fell while attempting to get out of bed, resulting in a pelvic fracture. Resident #1's fall preventions were not in use. Resident was moved off the floor prior to doctor notification regarding pain on right side. The fall was not thoroughly investigated and was not self reported. Resident #3's did not have new interventions for falls, fall interventions were not followed and were not on the care plan. Resident #2 who is at risk for falls, was observed to not have the intervention of the call light within reach. This was not provided as Resident #2 sat in his room alone. This is evidenced by: Resident #1 has a [DIAGNOSES REDACTED]. According to the 09/05/14 quarterly MDS, Resident #1 required extensive assist of one staff for bed mobility, transfers and toileting. The nurse's note on 11/28/14 states Resident #1, Has a pressure alarm in bed and wheelchair, has poor safety awareness and a history of falls at home. At 3:00 p.m., staff observed Resident #1 on the floor in the bathroom on her left side. Resident #1 had transfered herself to use the bathroom. Resident #1 experienced discomfort to her right shoulder and right hip. The nurse's note further stated, Seat alarm was not on at change of shift, re-educated staff to check alarms at change of shift. On 11/29/14, Resident #1 experienced pain and bruising and was transferred to the hospital for evaluation and x-rays. It was discovered she had a fractured pelvis in three places. Surveyor reviewed the fall investigation report written by the Nursing Home Administrator (NHA). The investigation states that at 3:00 p.m. on 11/28/14, Registered Nurse (RN) M was informed by a facility visitor that Resident #1 was lying on the floor. RN M assessed the resident and noted pain on her right side. Resident #1 stated she needed to use the bathroom. Resident #1 was assisted off the floor with assist of three and Hoyer lift. The physician was updated (after she was moved off the floor) and stated to observe for bruising and pain. Family was updated and stated they would be in the next day to decide on x-rays. Resident #1 was transported to the emergency roiagnom on [DATE]. The x-rays showed fracture of the superior pubic rami bilaterally and associated fracture of the inferior pubic ramus. Resident #1 was not a surgical candidate. The investigation further states that day staff were interviewed. The interviews identified the resident had no unusual behaviors or agitation. The investigation concludes the resident attempted to transfer herself and lost her balance. The facility investigation does not address the alarm and whether it was sounding or not. On 08/13/15 at 10:54 a.m., Surveyor interviewed the NHA. The NHA states the fall was not self reported to the state agency. During a further interview at 2:15 p.m. with the NHA, she agreed the investigation should have included more details. The NHA indicated that if the nurses' notes said the alarm wasn't on, she is sure that's what happened; however, she wasn't aware of it. The NHA agreed the incident should have been self reported. The NHA did not have documentation of staff retraining regarding alarms and stated the nurse on duty that night probably re-educated those staff that were working. 2. Resident #3's [DIAGNOSES REDACTED]. Resident #3's Bief Interview for Mental Status (BIMS) was 7, indicating severe cognitive impairment. On 08/17/15, Surveyor reviewed Resident #3's fall history as outlined in documentation and incident report review. The falls are as follows: 01/27/15 at 11:00 p.m., Resident #3 was found sitting on the floor beside her bed. No injuries were noted. The resident had a tab alarm on. The facility intervention was to place the tab alarm on the right side of the bed to ensure the alarm triggered when the resident moved to get up. This intervention was not added to the care plan. 01/28/15 at 10:15 a.m., Resident #3 was found on floor in the bathroom while attempting to toilet self. No injuries. The facility's new intervention in response to this fall was to relocate the resident to a room that would be closer to the nurses' station to increase staff monitoring. When the facility contacted the Power of Attorney for Health Care (POAHC), the POAHC refused to give permission to the facility to change rooms. The facility did not develop alternative interventions upon POAHC refusal for the resident to change rooms. 04/11/15 at 5:00 p.m., Resident slid out of her chair in the dining room. No injuries. The incident report documents the resident was to have a non-slip lining added to her broda chair to prevent injuries. This intervention (the addition of non-slip material to be placed on the broda seat) was added as an intervention on 04/01/15, but the resident did not have the non-slip material on the chair on 04/11/15 at the time of the fall. 05/03/15 at 2:00 a.m., Resident slid out of bed. No injury. The facility did not develop additional interventions or increase staff monitoring of resident. Interventions implemented stated, Continue with current plan of care. 08/06/15 at 9:00 p.m., Resident was found sitting on floor. No apparent injuries. The intervention initiated at that time was to assist resident to the bathroom, then resident was given a pillow and blanket and assisted into her broda chair. After this intervention, the resident was able to rest. No new interventions were placed on the care plan. On 08/12/15 at 1:15 p.m., Surveyor observed Resident #3 as she was napping in her room. Surveyor noted the divider curtain was pulled, which obstructed the staff's view from the hall. The resident was lying in bed fully dressed, except for shoes, with a blanket covering her body. On 08/13/15 at 9:30 a.m., Surveyor observed Resident #3 as she was napping in her room. Surveyor noted the divider curtain was pulled, which obstructed the staff's view from the hall. The resident was lying in bed fully dressed, except for shoes, with a blanket covering her body. On 08/17/15 at 9:10 a.m., Surveyor observed Resident #3 as she was napping in her room. Surveyor noted the divider curtain was pulled, which obstructed the staff's view from the hall. The resident was lying in bed fully dressed, except for shoes, with a blanket covering her body. Surveyor reviewed Resident #3's plan of care. The plan of care stated the curtain divider was to be left open for increased staff monitoring. This intervention had been added on 03/30/15 after Resident #3 sustained a fall from bed without injury. 3. Resident #2 was observed at 2:30 p.m. on 08/12/15 in his wheelchair, with his head down asleep in his room. Resident #2 was positioned approximately three feet from his bed, where his call light laid curled in the center of the bed. Resident #2 remained in his room alone in this position until 3:40 p.m., when staff entered the room and repositioned the resident. Review of Resident #2's medical record by Surveyor on 08/12/15 revealed that Resident #2 is at risk for falls. Resident #2's most recent fall occurred on 08/02/15. Resident #2's care plan identifies Resident #2 as having impaired mobility, unsteadiness, poor safety awareness, potential for falls and increased confusion. An approach, dated 07/10/15, states to keep call light within reach. Six other approaches, the most recent dated 08/03/15, also include keeping the call light within reach for Resident #2. Interview with RN D at 2:35 p.m. on 08/13/15 revealed that Resident #2 is at risk for falls and should have his call light within reach, in order to help prevent future falls.