Every finding on record at Pride TLC Therapy and Living Campus

Based on interview and record review, the facility did not electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the Centers for Medicare and Medicaid Services (CMS) System, within 14 days after completion of resident assessment for 3 of 3 sampled residents (R4, R5, R1).-R4's MDS assessment dated [DATE] was listed as export ready on 07/21/26.-R5's MDS assessment dated [DATE] was listed as in progress on 07/21/26.-R1's MDS assessment dated [DATE] was listed as export ready on 07/21/26.Findings include:Example 1On 07/21/26, Surveyor reviewed R4's Minimum Data Set (MDS) assessments. The most recent MDS assessment for discharge/return anticipated dated 07/01/26 had been completed but not exported to Centers for Medicare and Medicaid Services (CMS) and the status was listed as export ready.Example 2On 07/21/26, Surveyor reviewed R5's MDS assessments. The most recent assessment for Medicare/5-day dated 07/06/26 listed a status of in progress. The MDS assessment for admission dated 07/06/26 listed a status of in progress.Example 3On 07/21/26, Surveyor reviewed R1's MDS assessments. The most recent assessment for discharge/return not anticipated dated 06/19/26 had been completed but not exported to CMS and the status was listed as export ready.On 07/21/26 at 12:36 PM, Surveyor interviewed MDS Coordinator F regarding MDS assessments. When asked what the time frame is for completing and submitting an MDS assessment to CMS, MDS Coordinator F stated, We are behind, I'm not going to lie. MDS Coordinator F stated the corporate staff were supposed to make sure the MDS assessments had been exported. MDS Coordinator F stated MDS Coordinator F is still training and has not been taught how to do everything at this time. Surveyor asked MDS Coordinator F about the most recent assessments for R4, R5, and R1. MDS Coordinator F acknowledged they were not complete and should be.On 07/21/26 at 1:41 PM, Surveyor interviewed Director of Nursing (DON) B regarding the incomplete MDS assessments. DON B acknowledged the assessments should have been completed.

Based on observation, interview and record review, the facility failed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections with the potential to affect 17 of 17 residents. - Facility staff did not perform appropriate hand hygiene during cares and while serving meals. - Facility staff did not ensure a dropped cover to a milk jug from dining room refrigerator was properly cleaned before replacing it. - Facility did not ensure covers were available and utilized for transporting fluids to resident rooms.Findings include:Facility policy titled, Hand Hygiene Policy, last reviewed 04/2025, reads in part: Staff will perform hand hygiene by washing hands for fifteen-twenty seconds.under the following conditions.before moving from a contaminated body site to a clean body site.after providing direct resident care. If hands are not visibly soiled use an alcohol-based hand rub.after contact with inanimate objects in the immediate vicinity of the resident.Facility policy titled, Safe Food Handling and Sanitation, last reviewed 03/2025, reads in part: Examples of when hands must be washed.before setting tables or serving food.picking an item up off the floor.On 07/15/25 at 8:12 AM, Surveyor observed facility staff entering the dining room to retrieve drinks for residents eating in their rooms. Surveyor observed some staff did not perform hand hygiene prior to obtaining the cups/glasses and filling them after aiding residents or performing other tasks. Surveyor observed uncovered drinks delivered to resident rooms with no cover by multiple staff members. On 07/15/25 at 8:15 AM, Surveyor observed a staff member drop the cover of a milk jug on the dining room floor, pick it up, and immediately replace it on the milk jug. Surveyor observed the staff member did not sanitize hands and took the glass of milk down the hallway uncovered.On 07/16/25 at 7:10 AM, Surveyor observed Certified Nursing Assistant (CNA) F perform peri care. CNA F washed the buttocks area. CNA F did not change gloves or wash/sanitize hands after cares were completed. CNA F continued cares with the same pair of gloves to assist with clean undergarment and clothing. CNA F did not remove gloves until resident was in wheelchair.On 07/16/25 at 7:29 AM, Surveyor interviewed CNA F. CNA F stated if she were to pour a glass of milk and the milk jug cover fell on the floor, CNA F would ensure the cap was thoroughly cleaned prior to replacing it. CNA F also stated when taking drinks to resident rooms, CNA F would make sure they are covered before taking them to the rooms. CNA F also stated, I want to apologize for yesterday. We didn't have any covers out here.On 07/16/25 at 8:05 AM, Surveyor observed breakfast in dining room. Surveyor observed Physical Therapy Assistant (PTA) H did not perform initial hand hygiene upon entrance of dining room. Surveyor observed covers for drinks are now available and being used. Surveyor observed CNA D rub the back of two separate residents while talking to them and then grab a third resident's food tray to deliver it to their room. No hand hygiene performed in between.On 07/16/25 at 8:22 AM, Surveyor interviewed CNA D. CNA D stated she would throw away the cover of a milk jug if it landed on the floor. CNA D also stated she would contact dietary for an appropriate alternative container to put the rest of the milk in. CNA D stated if getting fluids for residents in their rooms she would sanitize her hands, check the dates, pour the drinks, make sure they are covered, verify the drinks are appropriate for that resident, and take them to the resident. CNA D also stated staff is to wash or sanitize their hands before and after resident contact.On 07/16/25 at 8:24 AM, Surveyor interviewed PTA H. PTA H stated if obtaining drinks for resident rooms, PTA H would go to the dining room, sanitize hands, pour the drinks, place covers on drinks, deliver the drinks, and sanitize hands again.

Based on interview and record review, the facility transferred a resident (R) (R29) to acute care and did not notify R29 or the Long-Term Care (LTC) Ombudsman of R29's discharge or provide a bed hold notice per the facility policy.Findings: The facility's Resident admission Agreement read in part, Before a resident is transferred to a hospital, the facility will provide written information to the resident that specifies the duration of the state bed-hold policy (up to 15 days). If the facility determines a resident who was transferred with the expectation of returning cannot return, the facility will issue a discharge notice.The facility's policy, Bed Hold Policy read in part, Upon hospitalization the resident shall be provided the right to a bed-hold via the facility's Bed-holding Agreement. The form will be filled out by the nurse and will be filed in the resident's chart and a copy given to the resident. All resident's, regardless of pay source, have the right to bed-hold for 15 days. If the resident waives their right to a bed-hold, this will be documented with a signature on the Bed-holding Agreement. R29 was admitted to the facility on [DATE], after hospitalization following fall at home. R29 was hospitalized from [DATE]-[DATE]. Diagnoses included low back pain, type 2 diabetes, hemiplegia following a stroke, and pain/numbness or weakness of low back. Minimum Data Set (MDS) assessment, completed on 05/20/25, confirmed R29 scored 15/15 during Brief Interview for Mental Status, indicating intact cognition. R29 makes his own medical decisions.R29's NURSING NOTES: -5/23/25 at 9:39 AM, R29 reported a fall in his bathroom. -05/23/25 at 1:22 PM, writer [ED] was informed of resident's fall from earlier this date, while in the bathroom. The nursing note from the fall report and the PT assessment indicates a change of condition that warrants an ER visit and work up.Writer called ER and spoke to RN. Writer provided report to RN regarding resident, hospitalization and fall today, which was described as: while finishing his toileting task and as he stood from the toilet, his legs gave out and he fell to the floor, hitting his buttock on the toilet stool, then landing on his buttock with his legs pointing out and sitting in front of the toilet Writer spoke to resident with NHA and DON, admission RN and discussed the course of action given his change of condition. Writer expressed that the attending provider, provided orders to facility for resident to be sent to the ER via non urgent EMS . Writer shared with resident the goal for him to be seen in the ER to determine if something changed in his back post fall, given his reported change in sensation. Writer did review that his time in the hospital was due to a protruded disc in his back and that they may have to do imaging or additional work up to determine what may be causing the change in sensation.Writer is assisting the facility and ER with transitional planning. There is no need for a bed hold, as resident was independent prior to this recent fall, which is indicated as an unexpected change in plane. -05/23/25 at 1:25 PM, EMS was contacted for non-ambulatory ambulance transportation to ER. On 07/16/25 at 7:11 AM, Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A stated bed-hold policy is discussed with residents at the time of admission. NHA A reported when a resident is transferred to the ER, the facility sends a transfer document, physician orders, and verbal communication is made with the ER. The bed-hold policy is again discussed with the resident and a signature is obtained. If the resident has Medicaid, the facility holds the resident's bed for 15 days. Surveyor requested and reviewed transfers and discharges NHA A made to the LTC Ombudsman. Surveyor noted R29 was not included in the update. NHA A acknowledged she did not add R29 to the transfers and discharges update to the LTC Ombudsman. On 7/16/25 at 7:13 a.m., Surveyor interviewed Executive Director (ED) C about the lack of information on the bed hold notice for R29. ED C acknowledged the documentation related to bed-hold discussion with R29 was not well documented in his record.

Based on observation, interview, and record review the facility did not ensure residents (R) received proper treatment and assistive devices to maintain hearing abilities for 1 of 1 resident reviewed. (R6)R6 did not have a recent audiologist screening and hearing aids were not working. This is evidenced by:R6 was admitted to the facility on [DATE] with pertinent diagnosis of unspecified hearing loss.R6's most recent quarterly Minimum Data Set (MDS) assessment, dated 05/08/25, noted a Brief Interview for Mental Status (BIMS) score of 02/15 indicating severe cognitive impairment. R6 was noted to have highly impaired hearing and has hearing aids.R6's care plan, dated 06/27/21, with a target date of 05/13/25, states: .communication problem related to hearing deficit with interventions of bilateral hearing aids, charge hearing aids daily, and make sure hearing aids are clean and batteries are working.R6's orders:08/30/23 May flush patient's ears with warm water 3/4 and peroxide 3% 1/4 ratio every 24 hours as needed for ear care.01/17/23 (new hearing aids - not chargeable) Ensure hearing aids are opened to disconnect battery QHS at bedtime.Surveyor reviewed R6's electronic medical record (EMR) and noted the last audiologist visit occurred on 12/27/22. Surveyor reviewed R6's progress notes and noted:06/25/25 contacted R6's Activated Power of Attorney (APOA) to let him know that left hearing aid is not working despite replacing with new battery.Of note: no further follow-up documented.On 07/14/25 at 12:31 PM, Surveyor observed R6 sitting in wheelchair in room. Surveyor knocked and introduced self. R6 repeated numerous times that she could not hear Surveyor. Surveyor observed hearing aids in place in both ears. Surveyor asked Certified Nursing Assistant (CNA) I to assist with ensuring hearing aids were working. CNA I looked at hearing aids and stated they haven't been working.On 07/15/25 at 1:56 PM, Surveyor interviewed Health Unit Coordinator (HUC) J regarding appointments. HUC J stated when residents have an appointment, nursing staff will alert HUC to schedule appointment and set up transport. Surveyor asked HUC J if R6 had any audiology appointments scheduled within the last year. HUC J stated no; family typically handles all of R6's appointments and transportations. Surveyor asked HUC J if this would be documented when family takes R6 to an appointment. HUC J stated yes, there should be a progress note entered.Of note: no progress notes were documented of family taking R6 to audiology appointment within the last 12 months.On 07/16/25 at 7:47 AM, Surveyor observed Certified Nursing Assistant (CNA) D assisting R6 with using bed pan. CNA D attempted to inform R6 when needing to roll from side to side and when putting on new brief. R6 was observed to become agitated during cares asking CNA D what she was doing. CNA D repeated numerous times each task, but R6 kept repeating, What? Surveyor asked CNA D if R6's hearing aids were working. CNA D then looked on bedside table for hearing aids; they were not there. CNA D then looked in R6's ears and stated they were still in her ears. CNA D stated that the nighttime aids must not have charged them.Of note: R6's hearing aids use batteries and do not require charging.On 07/16/25 at 9:08 AM, Surveyor interviewed CNA F regarding R6's hearing aids. CNA F stated that R6's hearing aids haven't been working for a while. Surveyor asked CNA F if anyone was notified of R6's hearing aids not working. CNA F stated the nurse was notified.On 07/16/25 at 9:18 AM, Surveyor interviewed Director of Nursing (DON) B regarding R6's hearing aids and audiology appointments. DON B stated that family insisted on handling all of R6's appointments. Surveyor asked if the facility follows up with family to ensure hearing appointments are conducted. DON B stated no. Surveyor asked DON B if any follow-up was done after notifying family R6's hearing aids were not working on 06/25/25. DON B stated being unsure as most communication is informal and not documented. DON B stated that better follow-up should be completed if no resolution or concern is not quickly addressed and that this process will be looked.

Based on observation, interview and record review, the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infections and prevent new ulcers from developing for 1 of 2 residents (R), (R5). This is evidenced by:The facility policy, titled Skin and Wound Management Program, last reviewed 4/2025, states in part, Ongoing Skin and Wound Assessment (6) Progress toward healing is monitored, Part C: The complexity of a resident's condition may affect responsiveness or tolerance to treatments, and this is considered in the review of the care plan and goals of treatment. Part D: Benefit and risk documentation shall occur as needed based on resident expressed preferences, choice and participation in skin and wound management recommended treatments and interventions. (7) Wounds are identified as avoidable or unavoidable through the facility QAPI review process Wound Management Principles (2) Wound management principles include and are not limited to: Part A: Control or elimination of causative factors such as: pressure, shear, friction, moisture, circulatory impairment.R5 was admitted to the facility on [DATE] and has diagnoses that include displaced fracture of base of neck of left femur resulted from fall, displaced intertrochanteric fracture of right femur resulted from fall, unspecified dementia with unspecified severity and with other behavioral disturbance, unspecified anxiety disorder.R5's admission Minimum Data Set (MDS) Assessment, dated 06/27/25, which indicated a Brief Interview for Mental Status (BIMS) of 3/15, meaning R5 has moderately impaired cognition. R5 has an appointed guardian, and requires substantial/maximum assist for ADLs, positioning in bed/wheelchair, and mobility. The MDS identifies a stage 3 PI.R5's care plan, dated 07/07/25, states: I have a potential for skin breakdown related to hip fracture and decreased mobility, dementia, potential for friction and shearing, coccyx and right buttock wounds present upon readmitting from hospital. Goal includes, My coccyx and buttocks wounds will heal or show signs of healing. Interventions include, Roho cushion, check for incontinence upon rising, before and after meals, before bed and prn during the night. Do peri-care when I am incontinent.complete my Braden Scale weekly and prn with skin checks to assess my potential for skin breakdown and any potential problems .encourage me to reposition myself in bed. Assess my ability to do independently or reposition me every 2 hours.R5's Braden Scale Assessment, completed 07/11/25, showed a Predicting Pressure Score Risk of 13, which indicated moderate risk for pressure injury development.Physician notes dated 7/14/25 in part: .Per nursing team patient has a pressure sore to his buttocks, this is currently being treated and skin interventions are in place .On 07/14/25 at 1:10 PM until 3:11 PM, Surveyor observed R5 seated on his buttocks. On 07/16/25 from 7:27 AM to 9:23 AM, Surveyor observed R5 sitting in BRODA chair in common area in front of TV with tray table and crossword puzzle in front of him without repositioning assistance performed by staff to relieve pressure on known PIs on coccyx and buttock areas for each of these dates. On 07/15/25 at 11:52 AM, Surveyor observed toileting assist of R5 with Occupational Therapy Assistant (OTA) K. R5 was cooperative during cares, when coccyx area was assessed. R5 stated, I hate when sitting and watching TV and something is digging into me, referring to buttock area. OTA K stated, I know, you do sit a lot. On 07/14/25 at 1:10 PM, Surveyor attempted to interview R5, but R5 did not respond to questions and was determined not interviewable.On 07/15/25 at 7:26 AM, following AM cares, Surveyor interviewed CNA F regarding R5's coccyx wound care which is indicated on CNA Care Delivery Guide (CDG). CNA F was not aware of PI area on coccyx or interventions being in place on CDG.On 07/15/25 at 1:20 PM, Surveyor interviewed CNA F and CNA L regarding CNA plan of care regarding repositioning interventions for R5. CNA L stated, We lay [R5] down in the afternoon. [R5] needs to always be in line of site (due to fall risk) and has been a bit more combative lately.That is why [R5] sits in wheelchair in common area. CNA F stated, [R5] often refuses to lay down, preferring to stay in wheelchair. [R5] becomes combative so we do not force [R5] to lay down. Surveyor asked CNA L how it is tracked when last time R5 was repositioned. CNA L showed Surveyor a binder kept in the common area to track certain residents' toileting and ambulating schedules to communicate to other staff. R5 was not listed in binder for communication of repositioning or toileting. Surveyor asked CNA L how repositioning is documented, or refusals to lay down or reposition. CNA L stated repositioning, or refusal to do so by R5, is documented in the progress notes and/or CNA tasks by CNAs. On 07/16/25 at 9:16 AM, Surveyor interviewed DON B what the expectations of staff are when a resident is at risk for pressure injury or has known pressure injury. DON B indicated all direct care staff do ongoing assessments and make sure pressure relieving devices are in place, repositioning is done, and preventative measures are established. Documentation consists of weekly assessments and interventions are placed in care plans for high-risk residents. DON B confirmed there is a repositioning program in place for residents as indicated in their policy and procedures for pressure injuries. DON B stated, CNAs should be repositioning residents based off their Care Delivery Guides. If a resident refuses repositioning, they attempt other approaches such as activities, and document refusals in charting. Surveyor asked DON B if interventions were in R5's care plan when behaviors interfere with repositioning attempts. DON B reported R5 is challenging for staff to comply with pressure injury management and was unable to confirm interventions were in place in the CDG.On 07/15/25 at 3:13 PM, record review did not show any nursing/CNA documentation in R5's chart of refusals to reposition while in wheelchair or lay down after long periods of sitting. CNA task documentation for repositioning showed R5 was repositioned on 07/04/25, 07/05/25 and 07/06/25 only. No care plan interventions are in place for repositioning R5 for pressure relief to coccyx area during daytime, nor acknowledgement to R5's tendencies to refuse or become combative when attempting to reposition. No alternative interventions or approaches have been developed if R5 refuses to allow staff to assist with repositioning.On 07/16/25 at 12:15 PM, DON B was unable to provide evidence of care plan interventions for repositioning in place for R5, or alternative interventions in recognition of R5's behaviors/refusals. DON B was also unable to provide documentation by staff in R5's chart of both completion and refusals of repositioning.

Based on observations, interviews and record review, facility did not ensure a resident with an identified decline in range of motion (ROM) received services and treatment to prevent further decline for 1 of 2 residents (R) (R6) reviewed. R6 had contracture with impaired ROM in right hand and did not receive therapy services.This is evidenced by:R6 was admitted to the facility on [DATE] with pertinent diagnoses of malignant neoplasm of temporal lobe, disorientation, left foot drop, localized edema, and unspecified hearing loss.R6's most recent quarterly Minimum Data Set (MDS) assessment, dated 05/08/25, noted a Brief Interview for Mental Status (BIMS) score of 02 indicating severe cognitive impairment. R6 has impaired ROM on one side in upper and lower extremities, uses a wheelchair, requires substantial assistance with oral hygiene, shower/bathe self, upper dressing, personal hygiene, and rolling left to right. R6 requires dependent assist with toilet transfers, lower body dressing, putting on footwear, sit to lying, sit to stand, and chair/bed transfers. R6 did not receive occupational or physical therapy services and no restorative nursing services.R6's care plan, initiated date of 04/11/22 and revised date of 05/14/24, with a target date of 05/13/25, states: .a mobility deficit with potential for falls with a goal to retain prior level of function and interventions to place foam wrapped in kerlix in contracted hand overnight as tolerated. Surveyor reviewed R6's orders:03/08/24 CONTRACTOR MANAGMENT: Soak Right hand to loose contractor and allow cleansing. Dry and place tan foam tubing with a light layer of kerlix into right hand. Leave as long as tolerated in the morning for wound care & contractor management AND one time only for wound care & contractor management for 1 Day.Surveyor reviewed R6's therapy notes:03/07/24 OT screen completed in regards to right finger contractures. Self-feeding without difficulty as R6 is left-handed. Wheelchair mobility also observed managing well. Had patient soak R hand in warm water followed by light massage to palmar MCPs which helped open fingers up a bit more. ROM is guarded to R D3 and D4 due to PIP flexion contractures. Able to extend small digit to nearly full range. Short piece of tan foam tubing with light layer of kerlix was placed in patient's R hand to open up MCPs. After soaking, did have quite a bit of dead skin come off with a slight odor to it. Recommend hand soak 1x daily with hygiene followed by placement of foam tubing in R hand to care plan. We will need to see how long she can tolerate keeping the foam tubing in there and add more kerlix to widen if it goes well. OT can look in to more of a resting hand splint to order if we are able to get her fingers extended more.Of note: this is the only documented therapy screen and evaluation documented. No additional assessments completed. No prior documentation of right-hand contracture noted.On 07/16/25 at 7:47 AM, Surveyor observed R6 lying supine in bed being assisted with AM cares. Surveyor observed R6's right hand to have a slight tremor and digits folded in with small movements in finger noted. Surveyor did not observe foam tube in R6's right hand. When R6 was rolled, R6 did not open hand or extend finger to use grab bar with right hand. On 07/16/25 at 9:02 AM, Surveyor interviewed Certified Nursing Assistant (CNA) D. CNA D stated that the foam roll gets placed in R6's hand at bedtime but falls out a lot of times during the night. Surveyor asked if this was communicated to OT for modification or changes. CNA D did not know.On 07/16/25 at 9:18 AM, Surveyor interviewed Director of Nursing (DON) B regarding R6's contracture treatment. DON B stated that R6 is currently on palliative care and therapy services are not being completed per R6's activated power of attorney (APOA). Surveyor asked for documentation of this. DON B stated not having it as most conversations are informal and not documented.On 07/16/25 at 11:04 AM, Surveyor interviewed Occupational Therapist (OT) E regarding R6's contracture. OT E stated no formal evaluation and treatment was completed for R6 as R6 is on palliative care. OT E confirmed there is no documentation to determine if contracture was present prior to the initial assessment on 03/07/24 and no further evaluations were completed after this date. OT E stated that R6 is seen frequently within the facility in an informal manner and is able to observe R6 completing ADLs with no decline. OT E stated that nursing staff will typically update therapy if there is a change or concern, but this is typically done informally with verbal communication. Surveyor asked OT E how they determine if R6 has had a decline. OT E stated by using observations. Surveyor asked OT E if formal assessments should have been completed after first documenting the contracture. OT E said yes. On 07/16/25 at 11:49 AM, Surveyor interviewed DON B. DON B stated recognition of facility's lack of documentation in assessments and communication in the treatment of R6's contracture.

Based on observations, record review and interview, the facility did not store and distribute foods in a sanitary manner. The facility practice has the potential to affect all 21 residents. This is evidenced by: Surveyor reviewed the facility policy titled Food Handling and Sanitation, most recently revised on 3/2024. The policy in part read: Policy: The food service department will comply with federal, state and county food codes to ensure food safety. Cover all equipment with a garbage bag when not in use and at the end of the business day: this includes but not limited to small and large equipment (utensils, can openers, mixers, blenders ect.) ~Hairnets shall cover 100% of the hairline, beards nets will be worn if not shaved. On 05/06/24 at 8:14 AM, Surveyor conducted the initial tour in the facility kitchen with Dietary Manager (DM) I. Surveyor observed a kitchen aide mixer with mixing bowl which was not inverted or covered on the food preparation counter. Surveyor observed a can opener and robo-coup food processor. The items were not in use or covered. Surveyor asked DM I if this is the normal way the equipment is stored and if the means of storage has a potential for contamination. DM I responded this was a normal means of storage and the means of storage is Pretty high potential for contamination. On 05/07/24 at 11:38 AM, Surveyor observed lunch service in the kitchen. Surveyor observed Cook F at the steam table plating foods for resident consumption. Cook F's hair was visibly hanging below the hair net at the back of the neck. Dietary Aide (DA) G was assisting with service by placing items on resident lunch trays. DA G had visible sideburns/beard with no beard net worn. DA G's hair net was only partially covering the hair in back. DA H was also observed in the kitchen assisting with tray line with hair hanging below the hair net at her ears and back of head. Surveyor asked DA G about hair restraint in the kitchen. DA G explained the facility has never provided him with a beard restraint stating, They are not used because they are not provided. Surveyor asked DM I about the expectation of hair restraint in the kitchen. DM I expressed all visible hair is to be covered in the kitchen. On 5/07/24 at 12:38 PM, Surveyor observed dishwashing and food preparation in the kitchen. Surveyor observed DA G loading dirty dishes to a rack, spraying the dishes and loading them to a tray which was loaded into the dish machine. DA G was wearing a hair net with visible hair at back of head and neckline and a surgical mask that was only partially covering the beard. DA H was observed unloading clean dishes with hair at sides of her face and back of head as DA H unloaded the clean dishes. DA H was observed walking throughout kitchen for various containers and lids and in and out of the walk in refrigerator. Surveyor observed Cook F taking clean shallow pans from rack at the 3 compartment sink. The pan was taken to the food preparation counter where Cook F scooped yogurt and coleslaw to individual containers. Cook F continued with visible hair at back of Cook F's head while completing food preparation.

Based on observation, interview and record review, facility staff did not ensure adequate supervision and safety to prevent accidents from occurring by not using a gait belt when warranted for a resident transfer affecting 1 of 3 residents (R) reviewed for transfer and falls (R7). This is evidenced by: Facility policy titled Transfer and Body Mechanics Policy, dated as most recently revised on 12/03/23 was reviewed by Surveyor. The policy in part reads: Procedure: The intent of this policy is to ensure every resident receives specialized rehabilitive services as determined by their comprehensive plan of care to assist them to attain, maintain or restore their highest practicable level . Protocol: Guidelines and tips for using proper body Mechanics: ~Use a gait belt at all times. Surveyor reviewed R7's Admission Minimum Data Set (MDS) completed on 4/20/24 which noted R7 understands, is understood and is cognitively intact. R7's admission diagnoses included vertigo (a sensation of motion or spinning that is often described as dizziness) and displaced left hip fracture. R7 has a fall history prior to her admission. R7 requires partial to moderate assistance of one staff for transfers sitting to standing, toilet transfer, and shower transfer. Surveyor reviewed R7's care plan and noted the following: I have a mobility deficit with potential for falls R/T (related to) hip fracture s/p (status post) nailing and weakness. Goal: I will regain my prior level of function and will not have a fall with injury through the review date. Review Date: Overdue Interventions: My mobility devices are W/C (wheelchair), FWW (front wheeled walker) My weight bearing status is: WBAT LLE (weight bearing as tolerated, left lower extremity) I ambulate assist of one using FWW I transfer assist of one I need assist of one for toileting On 5/07/24 at 7:19 AM, Surveyor observed Certified Nursing Assistant (CNA) C assist R7 with morning care. CNA C offered R7 the toilet and took R7 to the bathroom via her wheelchair. CNA C assisted R7 to stand at the toilet, lowered R7's brief and assisted R7 to sit on the toilet. CNA C did not use a gait belt (transfer belt) when assisting R7 with her transfer. CNA took R7's wheelchair from the bathroom and brought in her walker. CNA C placed a gait belt around R7's waist and assisted her to stand and take a few steps with the walker to a shower chair in the shower in R7's bathroom. CNA C assisted R7 with the shower and told R7 the gait belt that had been removed from R7 had gotten wet from the shower spray. CNA C told R7 she needed to obtain a dry gait belt and proceeded to assist R7 in drying off from her shower. CNA C did not obtain a dry gait belt and proceeded to dry R7's feet. CNA C placed a towel on the shower floor and brought R7's walker closer to R7. CNA C assisted R7 to stand without the use of the gait belt. CNA C dried R7's back, applied lotion to R7's back and barrier cream to the buttocks as R7 stood with the walker. CNA C pulled up R7's brief/pants and transferred R7 to her wheelchair. No gait belt was used. On 5/07/24 at 9:55 AM, Surveyor interviewed Certified Nursing Assistant (CNA) C about the observation and expectation related to use of a gait belt with residents who need staff assistance to transfer. CNA C responded she should have used a gait belt as it is a facility expectation to not move residents without one as you would not want residents to fall when moving them. On 5/07/24 at 10:04 AM, Surveyor interviewed Physical Therapist (PT) D about R7's transfer abilities, the observation and the facility expectation related to gait belt use. PT D expressed the expectation is a resident would need a gait belt whenever it is indicated in a resident care plan that staff assistance is required for transfer. Physical Therapy does ongoing evaluation of resident transfer abilities and informs staff verbally as well as updated resident care plan. Staff should always use a gait belt when resident care plan specifies assist of one for transfers. It is important for both resident and staff safety. On 5/07/24 at 10:12 AM, Surveyor spoke with Nursing Home Administrator (NHA) A about the observation and the facility expectation regarding gait belt use. NHA A indicated gait belts are absolutely required for all resident transfers requiring one or two staff persons. All nursing staff are trained on this expectation including CNA C.

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. Staff did not perform hand hygiene when warranted while providing care to 1 of 3 residents (R) observed for care (R7). This is evidenced by: Surveyor requested and reviewed the facility policy titled Hand Hygiene Policy. The policy in part reads: This policy will provide staff for hand washing and hand hygiene techniques that will aid in the prevention of the transmission of infections. Hand washing with soap and water: Staff will perform hand hygiene by washing their hands .under the following conditions: Before moving from a contaminated body site to a clean site during resident care; for example: after providing peri care, before applying moisture barrier cream . After providing direct resident care. Using alcohol-based gel: If hands are not visibly soiled, use an alcohol-based hand rub for all the following: Before applying gloves and after removing gloves . Before moving from a contaminated body site to a clean body site during resident care; example: after providing peri care, before applying barrier cream After contact with inanimate objects in the immediate vicinity of the resident On 5/07/24 at 7:19 AM, Surveyor observed Certified Nursing Assistant (CNA) C provide care to R7. CNA took R7 to the bathroom via her wheelchair and donned gloves in the bathroom. CNA C did not perform hand hygiene before donning the gloves. CNA assisted R7 to stand, lowered her brief and transferred R7 to the toilet. R7 urinated in the toilet and CNA C assisted R7 to stand and wiped her peri area with a wipe. With the same gloved hands CNA C assisted R7 to walk to shower chair in her shower and assisted R7 to sit in the chair. CNA C assisted R7 with removing her gown and slippers, adjusted the shower water and handed the shower hose to R7 to spray herself. CNA C wet R7's back and hair and proceeded to shampoo, apply conditioner and rinse R7's hair. CNA C applied soap to a cloth and washed and rinsed R7's back and underarms. CNA C proceeded to wash R7's body, legs and feet. CNA C dried her gloved hands and brought R7's walker closer to R7. CNA C placed a clean towel on floor and assisted R7 to stand. CNA C washed and rinsed R7's peri area and provided R7 a clean towel to dry her front. CNA C dried R7's back, legs and feet and assisted R7 back to shower chair. CNA C obtained lotion from counter, removed her gloves and donned clean gloves. CNA C did not perform hand hygiene. CNA C applied lotion to R7's back and gave R7 deodorant to apply. CNA C provided R7 with a clean shirt that she put on. CNA C applied clean tubi-grip stockings after lotion was applied to R7's legs. CNA C placed a clean brief, clean pants and slippers on R7. CNA C removed her gloves and donned clean gloves with no hand hygiene after drying water from R7's bathroom floor. CNA C assisted R7 to stand to apply barrier cream to her buttocks. CNA C pulled up R7's brief and pants and assisted R7 to transfer to her wheelchair. CNA C brought R7 into her room and provided her with a comb. CNA C returned to the bathroom to bag dirty linens. CNA C removed her gloves and performed hand hygiene. This is the first hand hygiene Surveyor observed during R7's care. On 05/07/24 at 9:55 AM, Surveyor interviewed CNA C about the facility expectation for hand hygiene and R7's morning care observation. CNA C expressed she should have performed hand hygiene prior to donning gloves, when removing gloves and when going from dirty to clean. Hand hygiene is important to not move germs from one place to another. On 5/08/24 at 9:15 AM, Surveyor spoke with Registered Nurse (RN) E about the observation. RN E is the facility's Infection Control Preventionist (ICP). RN E expressed RN E would expect hand hygiene before donning gloves. RN E would expect staff to perform hand hygiene after removing gloves and expect staff to remove gloves, do hand hygiene and don clean gloves every time when going from dirty to clean to prevent the spread of infection.

Based on observation, interview, and record review, the facility did not quarantine R1 for 14 days after admission, and staff did not wear appropriate personal protective equipment (PPE) as warranted. R1's visitor did not wear PPE while visiting. This has the potential to affect all 12 residents. Example 1: R1 was admitted [DATE]. R1 should have remained on 14 day quarantine through 12/13/21. Certified Nursing Assistant (CNA)-D assisted R1 for breakfast in the facility dining room without a gown, gloves, or N95 respirator. Licensed Practical Nurse (LPN)-C provided R1 medications in the dining room without gown, gloves, or N95 respirator. Occupational Therapist (OT)-G and Physical Therapist Assistant (PTA)-F did not have on goggles in the dining room where encounters with R1 are likely. Family Member H did not have on a mask while in R1's room with her. This is evidenced by: Surveyor requested and reviewed the facility policy titled, Covid Policy with a revised date of February 23, 2021. The policy in part reads: Purpose: to provide guidance to Pride TLC employees . on how to safely manage patients with suspected or confirmed coronavirus, as well as keep other patients and staff from becoming infected. All new admissions are to be reviewed for quarantine per CDC and CMS guidelines as follows: ~Residents will be quarantined to their room, unless clinical needs indicate that patient needs to be at supervised dining, in line of sight for fall prevention . When providing care for residents with suspected or confirmed coronavirus: Implement contact and droplet precautions . R1 was admitted [DATE]. R1 should have remained on 14 day quarantine through 12/13/21. Surveyor reviewed R1's medical record. The care plan contained no direction to staff for quarantine or PPE expectations and source control measures when R1 was not in her room. The nurse's notes were reviewed from admission to present. The notes also contained no mention of PPE requirements and source control measures while caring for R1. On 12/07/21 at 8:00 a.m., Surveyor observed CNA-D provide R1 breakfast in the facility dining room. CNA-D brought R1's breakfast tray to her and provided set up of her breakfast tray. CNA-D returned to R1's side several times after obtaining various items from the counter and to provide R1 cueing to eat. CNA-D had on a mask and goggles. CNA-D did not have on a gown, gloves, or N95 respirator as expected when caring for a resident on quarantine. During the observation, Surveyor observed OT-G and PTA-F enter the dining room to obtain various items on the counter which was in close proximity to R1. OT-G and PTA-F were wearing a face mask but did not have on goggles. Although OT-G and PTA-F did not have direct contact with R1, encounter with R1 could not be anticipated. OT-G and PTA-F should have had on goggles for source control of COVID-19 virus. At 8:07 AM, LPN-C went to R1's side in the dining room and provided R1 with medications by scooping medications from a cup and providing R1 medications via a spoon. LPN-C had on a mask and goggles. LPN-C did not have on gloves, gown, or N95 respirator. After the observation, Surveyor asked LPN-C about R1's quarantine status and expected PPE when assisting R1. LPN-C indicated there are no residents on quarantine at the facility at this time. LPN-C further expressed residents on quarantine should stay in their room and all PPE should be worn when providing care such as medication administration. Surveyor asked LPN-C how staff know when residents are on quarantine. LPN-C explained a sign is on the resident's room door indicating start and end of quarantine as well as PPE expectations. Surveyor and LPN-C went to R1's room and observed a sign that read Admit: 11/29/21, 14-day quarantine date: 12/13/21. Pride TLC staff to wear full PPE when in this room during dates above. LPN-C expressed R1 should be isolated to her room and staff should wear full PPE when providing R1 any care. On 12/07/21 at 8:19 AM, Surveyor spoke with Nursing Home Administrator (NHA)-A via phone and Director of Nursing (DON)-B about the facility's expectation related to PPE. NHA-A explained R1 is the only resident in the facility who is not fully vaccinated and on 14 day quarantine. R1 will not stay in her room and is on line of sight due to safety reasons. Staff are to wear full PPE when providing any care to R1. NHA-A further expressed all staff in clinical areas are to wear face masks and goggles for source control measures. NHA-A further indicated the facility was in outbreak of Covid 19 from 11/01/21 through 12/03/21 and the county transmission rate is considered high. On 12/07/21 at 8:25 a.m., Surveyor and DON-B spoke with OT-G and PTA-F regarding PPE expectations while in clinical areas for source control measures. OT-G and PTA-F indicated full PPE is required when providing care to residents on quarantine. A face mask is required in clinical areas. Surveyor asked PTA-F and OT-G if resident encounters are expected in clinical areas. OT-G and PTA-F indicated resident encounters can be expected in clinical areas and not always anticipated. On 12/07/21 at 9:41 a.m., Surveyor spoke with CNA-D regarding the observation in the dining room and her understanding of PPE requirements when assisting R1. CNA-D expressed she forgot R1 was on quarantine. When the facility ended outbreak measures she stopped wearing full PPE. On 12/07/21 at 10:51 a.m., Surveyor observed Family Member (FM)-H, R1's spouse, sitting in a chair beside R1 in her room. FM-H did not have a mask on. Surveyor observed FM-H to sit beside R1 reading a book as R1 dozed in a chair. At no time did FM-H don a mask. After the observation, Surveyor spoke with FM-H regarding his understanding of PPE requirements while visiting his wife. FM-H expressed he was told he needed to wear a mask when entering the facility and whenever he is out of R1's room. FM-H further expressed he was unaware of the need to wear a mask when visiting his wife in her room. FM-H further expressed he has visited a couple of times since her admission and no one has told him the mask was required in the room. Surveyor asked FM-H if staff have come into R1's room to assist her, while he was visiting. FM-H expressed staff have come into the room each time he has visited and provided R1 assistance. Surveyor asked FM-H if staff wear a gown, gloves, mask, and goggles when assisting R1 in her room. FM-H indicated some staff wear some but not all staff and not all personal protective equipment. On 12/07/21 at 11:41 a.m., Surveyor spoke with DON-B regarding the observation. DON-B indicated R1's spouse and daughter have been allowed to visit since 12/03/21 due to R1's safety and psychological needs. FM-H needs to wear a mask whenever visiting including visiting in R1's room.

Based on observations, interviews, and record reviews the facility failed to properly prevent the possible transmission of COVID 19. The facility was not quarantining new admissions with unknown COVID 19 status for 14 days after admission, and residents were not wearing face coverings for source control outside of their rooms, which could have led to the spread of COVID 19 throughout the facility. 10 of 15 residents (R215, R161, R210, R61, R60, R1, R211, R162, R62, R163) were currently within 14 days of admission. Five of 15 residents (R2, R160, R213, R214, R212) were outside of the 14 days of admission, however were not quarantined when admitted . All residents (15 of 15) could be affected by residents not wearing face coverings. This is evidenced by: The Centers for Disease Control and Prevention (CDC) recommends long term care facilities create a plan for how the facility will manage new admissions and readmission for those residents whose COVID 19 status is unknown. Guidance has included quarantining these residents in separate rooms for 14 days. When staff are working with these residents they are to be wearing all necessary PPE (personal protective equipment) that includes a gown, gloves, goggles or face shield, and a N95 Respirator (a surgical mask is acceptable if N95 respirators are not available). A person may spread the disease in the pre-symptomatic stage, or can be asymptomatic throughout their illness. People have developed symptoms up to 14 days after known or unknown exposure. By quarantining residents with unknown COVID 19 status, the risk of transmission by these two scenarios is greatly reduced. The CDC also recommends implementing universal source control. This includes having staff, residents, and anyone entering the facility wear a well-fitting face covering. Residents should wear face coverings when outside of their rooms, such as being in the halls, to not only protect themselves, but to protect others from them if they are pre-symptomatic or asymptomatic. The survey team entered facility at approximately 8:20AM, 2/22/21. Upon entering, surveyor asked NHA-A (Nursing Home Administrator) if there were any COVID positive residents. NHA-A replied no. Surveyor asked about new or readmission who were on 14 day quarantine. NHA-A replied the facility does not quarantine anyone after admission. On 2/22/21 at 8:40AM, Surveyor conducted the Entrance Conference with NHA-A, and again asked about quarantining new admissions. NHA-A stated that the facility has the hospitals conduct a COVID 19 test within 24 hours of discharge to the facility. If the resident is positive the facility will hold off the admission. If the resident is negative, the facility will admit and not quarantine based on that negative test. On 2/22/21 at 2:06PM, Surveyor interviewed CNA-C (Certified Nursing Assistant) who stated new admissions are not quarantined. They are tested for COVID 19 when they discharge from the hospital and if positive are not admitted , if negative they are admitted . No quarantine after admission. CNA-C also stated if the residents start developing symptoms they would be kept in their rooms and closely monitored until a COVID 19 test result came back. On 2/23/21 at 7:47AM, Surveyor interviewed NHA-A who stated the facility had been quarantining residents for the 14 days prior to their outbreak. They halted all admissions during their outbreak; however, as the county was dealing with increasing cases and the hospitals were filling up she was getting pressure to start taking admissions again. NHA-A stated she was in constant contact with Marathon County public health, the hospitals, and had some contact with a DHS (Department of Health Services) IP (Infection Preventionist). NHA-A stated the DHS IP had completed an ICAR (Infection Control Assessment and Response) and had even made an onsite visit with no concerns. NHA-A stated the facility struggled with coming up with a process due to the population they serve being short stay rehab. She stated the facility does still have other measures in place like social distancing and mask wearing. The NHA-A interviewed continued again on 2/23/21 at approximately 10:40AM. NHA-A stated their first case of COVID 19 was 10/1/20. The DHS IP conducted the ICAR with the facility's IP on 10/16/20 during which they talked about planning for those new admission residents with unknown COVID status. NHA-A was under the impression that the DHS IP was good with their plan for testing out of the hospital and not quarantining new admissions because they were only planning to take COVID negative admits. NHA-A again stated she had multiple contacts with county public health about their plans and public health did not seem to have concerns. NHA-A stated the hospitals are not quarantining patients, but utilizing the least restrictive measure. NHA-A stated on 11/5/20 the DHS IP visited the facility and talked about infection prevention. Again, NHA-A was under the impression the DHS IP had no concerns with their plans. On 02/23/21 at approximately 8:40 a.m. Regional Infection Preventionist (RIP) M was contacted. RIP M indicated they did not give the facility this direction nor was public health giving this instruction. RIP M indicated that new admissions were to be quarantined for 14 days per CDC guidance. On 2/24/2021 at 9:20AM Surveyor interviewed OTR-H (Registered Occupational Therapist). When asked what the protocol for PPE and new admissions was, OTR-H responded that they do not need to wear gowns for new admissions since they went down on COVID frequency. The county level dropped down, new admits are not in quarantine. The new admissions are tested prior to coming in and they don't admit people who don't test negative. On 02/24/21 at 11:34AM, Surveyor again spoke with OTR-H regarding PPE required when caring for residents who have been admitted in the past 14 days. OTR-H indicated mask and eye protection and often gloves are worn. OTR-H expressed she has not been fitted for an N95 respirator. The surveyor asked if a gown is worn. OTR-R explained a while back the facility stopped requiring staff to wear gowns and gloves with resident care unless the task was personal hygiene such as toilet assistance. On 02/24/21 at 12:02PM, Surveyor spoke with COTA-K regarding the observation and PPE requirements with care of residents admitted in the past 14 days. COTA-K explained a face shield or goggles and a standard mask is required. Gloves are required if assisting with a hygiene task. COTA-K further expressed at one time the facility required staff to wear full PPE in the care of residents. Every time staff entered a resident room they were required to don full PPE. Staff were expected to remove the PPE and wash their hands when exiting resident rooms. When the facility no longer had residents who were positive with the Covid-19 virus staff no longer were required to wear full PPE. On 2/24/2021 at 9:26AM Surveyor interviewed CNA-G (Certified Nursing Assistant) regarding new admission protocols. CNA-G was asked what kind of PPE is required for new admissions. CNA-G responded that just surgical mask and eye protection is worn. During an outbreak they used to wear a gown, N95, and gloves. There were signs on the doors and carts were in the vestibule of the rooms and there were dedicated garbage bins. On 2/24/21 at approximately 12:00PM, Surveyor interviewed DON-B (Director of Nursing) who stated they used to quarantine new admits but their process changed when they began to admit again as their outbreak was coming to an end in mid-December. DON-B stated she and the facility IP worked with county public health on their new process and that public health had told them other facilities in the area were not quarantining their new admits and that they were actually going above and beyond those other facilities by asking for a COVID test. The facility went forward with their new process of not quarantining new admits based on these types of conversations and decreasing community spread. DON-B and the facility IP also looked through CDC and CMS (Centers for Medicare and Medicaid) memos and did not find specific language about quarantining new admissions. Facility IP was unavailable during survey. General observations were made by all surveyors on the team throughout the survey of those residents who would have been considered within their 14 days after admission out of their rooms, some with masks, some without masks. There were no transmission based precautions supply carts in halls, or rooms. Staff were not wearing all necessary PPE when working with these residents. General observations made by all surveyors on the team throughout the survey of residents walking in the halls with both nursing staff and therapy staff without having a face covering on. Review of facility's COVID policy speaks to the testing necessary 24-48 hours prior to facility admission. Policy also speaks to masking of residents outside of their rooms. Review of facility's COVID timeline showed their outbreak began 10/1/20 and ended 12/14/20. Example #1 On 02/22/21 at 9:57AM, Surveyor spoke with R60. R60 indicated she was admitted to the facility a few days ago from a hospital. The surveyor asked R60 if staff that care for her wear personal protective equipment when assisting her with personal care. R60 explained staff wear a face mask and eyewear. The surveyor asked R60 if staff wear gowns or gloves with her care such as transfers, toilet assistance and mobility. R60 responded staff do not wear gowns and rarely wear gloves. Gloves are only worn with help with her toilet needs. The surveyor noted no bin of personal protective equipment in R60's room or outside R60's room. The door to R60's room did not contain signage alerting staff to don PPE when entering room. The surveyor verified in R60's record she was admitted [DATE] from hospital after knee replacement surgery. R60's record noted R60 was alert and oriented to person, place and time. R60's care plan did not indicate she was on precautions and PPE should be donned by staff when caring for R60. On 02/22/21 at 9:58AM, Surveyor observed COTA-K (Certified Occupational Therapy Assistant) enter R60's room. COTA-K is wearing a standard mask and goggles. COTA-K removes R60's blanket and pillow from under her knee and assists R60 to and from the bathroom using a sit to stand lift. COTA-K was not wearing a gown, gloves or N95 respirator when caring for R60. On 02/23/21 at 9:05AM, Surveyor observed PTA-L (Physical Therapy Assistant) ambulating R60 from her room, into hallway. PTA-L was wearing a face mask and eye protection. PTA-L was not wearing the required PPE when assisting R60. On 02/23/21 at 12:47PM, Surveyor observed CNA-C and RN-D (Registered Nurse) enter R60's room wearing eye protection and face masks. R60's ice pack from knee was adjusted by RN-D as CNA-C stood by R60. RN-D and CNA-C did not have on required Personal protective equipment (PPE) for caring for R60. On 02/23/21 at 12:59PM, Surveyor observed CNA-C assisting R60 with transfer from wheelchair to bed. CNA wore a standard face mask and eye goggles. CNA-C placed a gait belt on R60, assisted R60 to stand with a sit to stand machine and lowered her to bed. CNA-C assisted R60 to lay in bed, removed the gait belt, placed a rolled towel between her knees and covered her with a blanket. CNA provided R60 with bedside table, television remote and call light. CNA-C washed her hands prior to exiting R60's room; however, CNA-C did not wear the required personal protective equipment for caring for a resident on quarantine. On 02/24/21 at 11:01AM, Surveyor spoke with CNA-C regarding the observations and her understanding of PPE requirements. CNA-C indicated she was not aware full PPE is required in care of residents who were admitted in the past 14 days. CNA-C further indicated some time ago staff donned full PPE with care of residents due to positive Covid cases in the building. When the facility no longer had residents who tested positive they no longer required staff to wear gown or gloves with cares. Gloves are only required with personal hygiene cares such as incontinence care. Example #2 On 02/22/21 at 10:33AM, Surveyor spoke with R61. R61 expressed he was admitted to the facility a few days after the Super Bowl. R61 expressed he receives therapy in room and requires some assistance from staff. R61 further expressed staff wear face mask and goggles in his room when providing therapy and assistance. No gowns or gloves are worn when care is provided. The surveyor noted no PPE available for staff in R61's room or outside R61's room. There was no signage at the room door instructing staff R61 was on quarantine and PPE should be worn. The surveyor reviewed R61's record and noted he was admitted [DATE] after falling at home and fracturing his back. R61's 5-day admission Minimum Data Set (MDS) noted R61 understood, understands and is cognitively intact. He requires extensive assistance of 2 staff for bed mobility, transferring and toilet use. R61's care plan was reviewed by the surveyor. The care plan did not indicate R61 was on precautions and PPE should be worn when assisting R61 with care or therapy. Example #3: On 02/22/21 at 3:28PM, Surveyor observed R62 sitting in the lounge with no mask on. The lounge is an open area that is centralized where the three units meet. On 02/22/21 at 4:00PM, Surveyor spoke with R62. R62 expressed he often sits in the lounge with another male resident to converse. R62 further expressed sometimes staff will ask him to wear a mask when taking him to the lounge or dining room. However, often times they do not and there are no masks in his room for him to put on prior to leaving his room. R62 indicated if staff were to offer him or bring him masks he would wear them outside his room. The surveyor asked R62 if staff wear personal protective equipment when providing his care. R62 expressed therapy staff assist him with walking and he requires assistance with care. Staff wear mask and goggles or face shield with care. Staff do not wear gowns or gloves when assisting him with walking or providing care. On 02/23/21 at 8:46AM, Surveyor observed R62 sitting in the lounge area with no face cover. On 02/23/21 at 12:37PM, Surveyor observed R62 sitting in lounge with no mask covering. The surveyor confirmed R62 was admitted [DATE] in his record. R62's quarantine of 14 days should have been in place through 2/23/21. Example #4: Between 2/22/21 and 2/24/21 throughout the survey, Surveyor observed the room in which R215 resided. R215 had been admitted to the facility on [DATE]. R215's room did not have a transmission precautions sign on door, nor were there gowns, gloves, masks or eyewear available for staff to don prior to entering room. There were no receptacles present in the room to doff gowns and gloves when exiting even though R215 was a new admission and within the required 14 day quarantine timeline for new residents. Example #5: Between 2/22/21 and 2/24/21 throughout the survey, Surveyor observed the room in which R210 resided. R210 had been admitted to the facility on [DATE]. R210's room did not have a transmission precautions sign on the door, nor were there gowns, gloves, masks, or eyewear available for staff to don prior to entering room. There were no receptacles present in the room to doff gowns and gloves when exiting even though R210 was a new admission and within the required 14 day quarantine timeline for new residents. On 2/23/21 at 1:03PM, Surveyor observed Housekeeper-J enter room [ROOM NUMBER] without donning a gown or gloves even though R210 who resides in room [ROOM NUMBER] was within the 14 day quarantine time required for new-admissions. On 2/23/21 at 1:05PM, Surveyor interviewed Housekeeper-J. When asked by Surveyor what kind of PPE they wear going into rooms, Housekeeper-J responded that when the facility had active COVID cases they were required to wear gowns, masks, shields, and gloves when entering rooms. They had to remove gloves, do hand hygiene, remove gown, and sanitize shield before exiting the rooms and then do hand hygiene again. They were not doing this now, as there were no active COVID cases in the building. Example #6: Between 2/22/21 and 2/24/21 throughout the survey, Surveyor observed the room in which R211 resided. R211 had been admitted to the facility on [DATE]. R211's room did not have a transmission precautions sign on the door, nor were there gowns, gloves, masks, or eyewear available for staff to don prior to entering room. There were no receptacles present in the room to doff gowns and gloves when exiting even though R211 was a new admission and within the required 14 day quarantine timeline for new residents. On 2/24/2021 at 9:13AM, Surveyor observed CNA-I enter R211's room without donning a gown or gloves. On 2/24/21 at 8:49AM, Surveyor interviewed CNA-I regarding PPE required. When asked what PPE is required at this time in the facility CNA-I stated that when the facility has an active case of COVID they gown and glove and remove these when leaving the room. CNA-I was asked what happens when a new resident enters the facility. CNA-I stated they make sure they have a shield and mask on, and do handwashing. They do not wear gowns and gloves unless they have an infection. Nothing different is done for new admissions. Example #7: R161 was admitted to the facility on [DATE] and would have been in the 14 day quarantine period. Between 2/22/21 and 2/24/21, Surveyor made observations of R161's room area. No noted PPE cart or trash receptacle in or around the room for staff to readily don and doff necessary PPE. No noted signage in or around room to alert staff or others. Observations made of staff entering room without necessary PPE for a resident on quarantine. Example #8: R162 was admitted on to the facility on [DATE] and would have been in the 14 day quarantine period. Between 2/22/21 and 2/24/21, Surveyor made observations of R162's room area. No noted PPE cart or trash receptacle in or around the room for staff to readily don and doff necessary PPE. No noted signage in or around room to alert staff or others. Observations made of staff entering room without necessary PPE for a resident on quarantine. Between 2/22/21 and 2/24/21, Surveyor observed R162 in common area sitting in recliners. R162 was without a mask during all times out of room on 2/22/21 and 2/23/21. R162 would eat meals in the dining room for staff observation. R162 would be out of room without a mask from breakfast through lunch. After lunch R162 would nap in room for a while and then be back out in the common area again from Mid-afternoon through supper. On 2/24/21 R162 did have a mask on while in the common area. At approximately 11:15AM Surveyor asked R162 about wearing the mask and if any staff had encouraged R162 to wear it. R162 stated feeling it was just a good day to wear a mask. R162 stated that no staff had told him to wear it. Example #9: R163 was admitted to the facility on [DATE] and would have been in the 14 day quarantine period. R163 was discharged back to the Assisted Living portion of the campus shortly after entrance . On 2/22/21 at approximately 9:00AM, Surveyor made observations of R163's room area. No noted PPE cart or trash receptacle in or around the room for staff to readily don and doff necessary PPE. No noted signage in or around room to alert staff or others. Example #10: On 2/24/21 at 7:30AM, Surveyor observed CNA-G pushing R210 down hall in a wheelchair to be weighed before breakfast. R210 was not wearing a face covering. On 2/24/21 at approximately 7:45AM, Surveyor interviewed CNA-G about residents wearing face coverings. CNA-G stated that residents are to be encouraged to wear masks and R210 is generally one that will comply. CNA-G stated she had simply forgot to remind R210 about wearing a mask at that time. On 2/24/21 at 7:30AM, Surveyor observed CNA-C pushing R214 down the hall in a wheelchair to be weighed before breakfast. R214 was not wearing a face covering. On 2/24/21 at 10:42AM, Surveyor interviewed CNA-C about residents wearing face coverings. CNA-C stated she usually encourages residents to wear a mask when they are outside of their rooms. CNA-C stated she realized she had forgotten to ask R214 that morning. On 2/24/2021 at 08:48 AM Surveyor observed R213 walking in the hall with a therapist without a face mask on. R213 saw Surveyor walking down the hall, and then took their mask out of their pocket and put it on.

Based on record review and interview the facility did not ensure MDS (Minimum Data Set) assessment accuracy for 2 out of 8 (R1 and R111) sampled residents. R1 had coding errors in section A0310, the reason for assessment was coded incorrectly. R111 had coding errors in section N, the anti-depressant and anti-coagulation medications R111 received daily were not coded. This is evidenced by: Example 1: R1 was admitted to the facility on [DATE]. The facility completed an admission MDS assessment for R1 with an assessment reference date of 11/04/18. R1 was transferred to the hospital on [DATE] with return anticipated according to RN-A (Registered Nurse). The facility completed a discharge return not anticipated MDS assessment for R1 instead of return anticipated. On 12/17/18, R1 returned to the facility. The facility again selected the wrong type of MDS assessment when the facility completed a significant change in status assessment for R1. In addition, the facility did not code R1 as a reentry but rather an admission under section A1700. On 02/07/19 at 9:54 a.m., Surveyor interviewed RN-A who stated she had completed R1's MDS assessments. RN-A stated she should have coded R1 as a discharge return anticipated and then completed a significant change in status upon his return to the facility on [DATE]. Example 2: R111 was admitted to the facility on [DATE] following a fall and a fracture. Review of the physician orders [REDACTED]. Review of the MAR (Medication Administration Record) from 01/22/19 through 01/31/19 noted R111 received [MEDICATION NAME] and eliquis daily. The facility completed an admission MDS assessment for R111 with an assessment reference date of 01/29/19. Review of section N Medications noted R111 received zero anti-depressants and zero anti-coagulants. On 02/07/19 at 9:54 a.m., Surveyor interviewed RN-A regarding R111's admission assessment. RN-A confirmed R111 did receive 7 days of the anti-depressant and 7 days of the anti-coagulant during the admission MDS assessment. RN-A stated she was unsure how the error was.

Based on observation, interview, and record review, the facility did not ensure standards of practice were maintained for 1 (R112) out of 8 sampled residents. CNA (Certified Nursing Assistants) are not allowed to apply creams or lotions to nonintact skin. This tasks must be completed by a licensed nurse as part of the assessment of the skin integrity. CNA-A applied Baza barrier cream to R112's nonintact buttock. This is evidenced by: R112 was admitted to the facility on [DATE] with the following, but not all inclusive, Diagnoses: [REDACTED]. The facility completed an admission MDS (Minimum Data Set) assessment on 04/24/18 for R112 with the following data noted: ~able to make self understood and understands others. ~BIMS (brief interview for mental status) exam was 11 out of 15 indicative of mild cognitive deficits. ~rejected care 1 to 3 days out of 7. ~required extensive staff assistance for bed mobility, transfers, locomotion, dressing, hygiene, toilet use, and bathing. ~frequently incontinent of bladder. ~occasionally incontinent of bowel. ~weight was 313#. ~at risk for pressure ulcer development. ~had moisture associated skin damage. ~received a pressure reducing device in bed and chair. ~on a turning and repositioning program. Review of the CAA (care area assessment) for pressure ulcers noted R112 had a history of [REDACTED]. The wound nurse determined R112's buttock area was moisture associated. Review of the skin assessment completed at the time of admission noted R112 had intact skin on both right and left buttocks. The skin was purple, intact, and nonblanchable. Review of R112's care plan titled I have potential for skin breakdown R/T (related to) decreased mobility dated 04/13/18 had a goal of no new skin breakdown through the next review date of 07/23/18. The interventions included Braden skin assessments weekly, incontinence care every 2 hours, adequate fluid intakes, adequate nutritional intakes, and to reposition every 2 hours. Review of R112's care plan titled I have potential for urinary incontinence . dated 05/01/18 included an intervention to assist with incontinence care to prevent skin breakdown. Review of the physician orders [REDACTED]. The Baza was ordered on [DATE] and the [MEDICATION NAME] was ordered on [DATE]. Review of R112's nurses notes identified skin breakdown, but with varying causes. For example: ~on 04/11/18 RN (Registered Nurse)-C documented decubitus ulcers, stage 2, on both buttocks are healing well. ~admission skin assessment completed also on 04/11/18 noted skin was intact but nonblanchable. ~on 04/23/18 the DON documented partial thickness due to moisture associated skin damage on the right buttock that measures 0.6 cm (centimeters) by 0.6 cm. ~on 04/27/18 RN-C documented abrasions noted to right buttock. ~on 04/30/18 the DON documented partial thickness due to moisture associated skin damage to the right buttock that measures 0.5 cm by 0.3 cm. The facility completed the Braden skin at risk assessment upon admission and noted R112 to be rarely moist and slightly limited mobility. The facility completed another Braden skin at risk assessment on 04/18/18 and noted R112 to be constantly moist. On 04/30/18 at 9:59 a.m., Surveyor observed CNA-A provide incontinence care to R112. R112 had been incontinence of a large amount of urine as evidenced by a saturated adult brief. CNA-A and CNA-D assisted R112 to a standing positioning using the EZ stand mechanical lift. CNA-A washed R112's buttock twice and then applied Baza barrier cream to both right and left buttocks. Surveyor noted the left buttock was excoriated and the right buttock was excoriated and also had a small open area. CNA-A covered the excoriated areas as well as the open area with Baza barrier cream. CNA-A did not remove gloves, perform hand hygiene, and don a clean pair of gloves prior to applying the Baza barrier cream. On 05/02/18 at 1:46 p.m., Surveyor interviewed the DON (Director of Nurses) regarding R112's skin problem. The DON was also a wound certified nurse. The DON stated wound rounds are completed by herself every Wednesday. The DON stated R112's skin condition on the buttock was a moisture associated skin problem due to incontinence. The DON stated she first observed R112's buttock on 04/21/18 and noted the open areas had maceration due to incontinence and other moisture sources. The DON stated in addition to the moisture, the location of the open areas were not on any bony prominence, thus the DON concluded the skin problem was moisture associated. The DON stated there was evidence of long standing skin problems with scar tissue present as well as chronic discoloration of the buttock. The DON stated on 4/23/18 R112's buttock wound was again assessed and the DON recommended to use a [MEDICATION NAME] barrier cream twice daily and as needed. The DON stated orders were received and R112 continued to receive the [MEDICATION NAME] barrier cream twice daily as well as the Baza cream as needed. The DON stated as of 05/02/18, R112's buttock wound remained open and measured 0.5 cm by 0.5 cm on the right buttock. The left buttock was closed. The DON stated any nonintact skin must be assessed by the licensed nurse followed by the treatment ordered. The DON stated CNA staff are not allowed to apply any creams, lotions, or powders to nonintact skin. The DON stated CNA staff are allowed to apply barrier cream and lotions to clean and intact skin as a means to prevent skin problems. The DON stated in addition to treating and healing the skin problem, staff are to consider causes and contributing factors and attempt to alleviate or reduce these factors and causes. For example, frequent repositioning, good incontinence care, keep skin clean and dry, provide good nutrition/hydration, and provide pressure reducing devices in the chair and in bed. The DON stated R112 preferred to sleep and to sit in a recliner and would rarely lay in the bed on either side to alleviate pressure. The recliner did not have any pressure reducing devices present. The recliner is a standard recliner with no pressure reducing characteristics according to the DON. The DON stated pressure was a factor that contributed to the buttock wound and needed to be addressed with frequent repositioning along with good incontinence care, a pressure reducing device, and skin protection. On 05/03/18 at 8:14 a.m., Surveyor interviewed CNA-A who stated she had been a CNA for [AGE] years. CNA-A stated she was never told she was not allowed to apply creams, lotions, or powders to nonintact skin. CNA-A stated she had often applied creams, lotions, and powders to nonintact skin under breasts and under abdominal folds as well as barrier cream to nonintact skin on resident buttocks. CNA-A stated R112's buttock was open but very small. CNA-A stated she would never apply any creams or lotions to any large or deep ulcer. CNA-A stated the Baza barrier cream was kept in R112's drawer for staff use. CNA-A confirmed R112's buttock was open on the right side and excoriated on both sides when she applied the Baza cream. CNA-A also confirmed she did not remove gloves, perform hand hygiene, and don clean gloves before applying Baza cream. CNA-A stated she should have changed gloves between washing R112's buttock and applying the Baza barrier cream.

Based on observation, interview, and record review the facility did not ensure the provision of quality care for 1 (R112) out of 8 sampled residents. R112 was not offered assistance to repositioned or toilet assistance for 3 hours and 20 minutes. R112 had been incontinent and currently had moisture associated skin damage on buttock. CNA (Certified Nursing Assistant) applied cream to R112's excoriated and open bilateral buttock using dirty technique. This is evidenced by: R112 was admitted to the facility on [DATE] with the following, but not all inclusive, Diagnoses: [REDACTED]. The facility completed an admission MDS (Minimum Data Set) assessment on 04/24/18 for R112 with the following data noted: ~able to make self understood and understands others. ~BIMS (brief interview for mental status) exam was 11 out of 15 indicative of mild cognitive deficits. ~rejected care 1 to 3 days out of 7. ~required extensive staff assistance for bed mobility, transfers, locomotion, dressing, hygiene, toilet use, and bathing. ~frequently incontinent of bladder. ~occasionally incontinent of bowel. ~weight was 313#. ~at risk for pressure ulcer development. ~had moisture associated skin damage. ~received a pressure reducing device in bed and chair. ~on a turning and repositioning program. Review of the CAA (care area assessment) for pressure ulcers noted R112 had a history of [REDACTED]. The wound nurse determined R112's buttock area was moisture associated. Review of the skin assessment completed at the time of admission noted R112 had intact skin on both right and left buttocks. The skin was purple, intact, and nonblanchable. Review of R112's care plan titled I have potential for skin breakdown R/T (related to) decreased mobility dated 04/13/18 had a goal of no new skin breakdown through the next review date of 07/23/18. The interventions included Braden skin assessments weekly, incontinence care every 2 hours, adequate fluid intakes, adequate nutritional intakes, and to reposition every 2 hours. Review of R112's care plan titled I have potential for urinary incontinence . dated 05/01/18 included an intervention to assist with incontinence care to prevent skin breakdown. Review of the physician orders [REDACTED]. The Baza was ordered on [DATE] and the [MEDICATION NAME] was ordered on [DATE]. Review of R112's nurses notes identified skin breakdown, but with varying documentation of the cause. For example: ~on 04/11/18 RN (Registered Nurse)-C documented decubitus ulcers, stage 2, on both buttocks are healing well. ~admission skin assessment completed also on 04/11/18 noted skin was intact but nonblanchable. ~on 04/23/18 the DON (Director of Nurses) documented partial thickness due to moisture associated skin damage on the right buttock that measures 0.6 cm (centimeters) by 0.6 cm. ~on 04/27/18 RN-C documented abrasions noted to right buttock. ~on 04/30/18 the DON documented partial thickness due to moisture associated skin damage to the right buttock that measures 0.5 cm by 0.3 cm. The facility completed the Braden skin at risk assessment upon admission and noted R112 to be rarely moist and slightly limited mobility. The facility completed another Braden skin at risk assessment on 04/18/18 and noted R112 to be constantly moist. On 04/30/18 at 9:59 a.m., Surveyor observed CNA-A provide incontinence care to R112. R112 had been incontinence of a large amount of urine as evidenced by a saturated adult brief. CNA-A and CNA-D assisted R112 to a standing positioning using the EZ stand mechanical lift. CNA-A washed R112's buttock twice and then applied Baza barrier cream to both right and left buttocks. Surveyor noted the left buttock was excoriated and the right buttock was excoriated and also had a small open area. CNA-A covered the excoriated areas as well as the open area with Baza barrier cream. CNA-A did not remove gloves, perform hand hygiene, and don a clean pair of gloves prior to applying the Baza barrier cream. On 05/02/18 beginning at 7:30 a.m., Surveyor began a continuous observation of R112. R112 was seated in the recliner wearing 2 hospital gowns and his legs covered with a blanket with feet on the floor. R112 also had on yellow gripper socks and oxygen was running. At 8:25 a.m., Surveyor observed RN-E enter room and administer medications to R112. Immediately after RN-E left room, CNA-F entered room to check R112's blood pressure. Neither RN or CNA offered R112 an opportunity to reposition or use to toilet. R112 continued to eat breakfast and watch television after CNA-F left room. At 9:17 a.m., a housekeeper entered room then exited in less than 3 minutes. The housekeeper had no interaction with R112. At 9:40 a.m., Surveyor noted R112's blanket that was covering his legs had fallen to the floor. R112's legs were exposed to passerby's in the hallway. At 9:47 a.m., the NHA (Nursing Home Administrator) entered room and looked in R112's refrigerator. The NHA assisted R112 by placing the blanket over his legs again. At 9:55 a.m., CNA-F entered room and donned R112's support hose. At 9:59 a.m., RN-C entered R112's room and completed a head to toe nursing assessment. RN-C removed the support hose and instructed CNA-F to apply lotion and replace the support hose. At 10:03 a.m., CNA-B entered R112's room with the EZ stand mechanical lift. CNA-B began washing R112's face. R112 reported pain behind both ears and CNA-B exited room and returned to room with the DON and RN-C. Both RNs assessed R112's sore ears. At 10:22 a.m. all staff exited room. R112 continued to be seated in the recliner with both feet resting on the floor. At 10:24 a.m., the nurse practitioner entered R112's room to assess sore ears. At 10:34 a.m., the nurse practitioner exited R112's room. At 10:38 a.m., RN-C entered R112's room and removed the urinal. At 10:42 a.m., RN-E entered R112's room to assist RN-C with the intravenous medication. At 10:50 a.m., the DON and CNA-B entered room. CNA-B began to provide frontal incontinence care for R112. CNA-B attempted to place the EZ stand mechanical lift sling around R112's waist to continue with rear incontinence care but R112 declined to get out of the recliner. The DON informed R112 he needed to be repositioned out of the recliner and provided incontinence care as his brief and chair pad were soiled with urine. R112 stated he wanted to rest in the recliner as he had been unable to do so for quite some time. R112 stated he has had multiple staff in the room since breakfast and requested to rest for a short time. The DON again educated R112 of the importance of repositioning and incontinence care. R112 stated he would complete all of the staff requests after he had rested. R112 agreed for CNA-B to return later and complete hygiene and repositioning. All staff left the room at 10:58 a.m. and R112 remained seated in the recliner under a wet brief and chair pad with his feet on the floor. At 11:30 a.m., CNA-B had completed R112's hygiene and incontinence care and had assisted R112 into the wheelchair. R112 was pleased with CNA-B's care. R112 went 3 hours and 20 minutes before staff offered assistance with repositioning or incontinence and provided education following R112's decline. On 05/02/18 at 1:46 p.m., Surveyor interviewed the DON regarding R112's skin problem. The DON was also a wound certified nurse. The DON stated wound rounds are completed by herself every Wednesday. The DON stated R112's skin condition on the buttock was a moisture associated skin problem due to incontinence. The DON stated she first observed R112's buttock on 04/21/18 and noted the open areas had maceration due to incontinence and other moisture sources. The DON stated in addition to the moisture, the location of the open areas were not on any bony prominence, thus the DON concluded the skin problem was moisture associated. The DON stated there was evidence of long standing skin problems with scar tissue present as well as chronic discoloration of the buttock. The DON stated on 4/23/18 R112's buttock wound was again assessed and the DON recommended to use a [MEDICATION NAME] barrier cream twice daily and as needed. The DON stated orders were received and R112 continued to receive the [MEDICATION NAME] barrier cream twice daily as well as the Baza cream as needed. The DON stated as of 05/02/18, R112's buttock wound remained open and measured 0.5 cm by 0.5 cm on the right buttock. The left buttock was closed. The DON stated any nonintact skin must be assessed by the licensed nurse followed by the treatment ordered. The DON stated in addition to treating and healing the skin problem, staff are to consider causes and contributing factors and attempt to alleviate or reduce these factors and causes. For example, frequent repositioning, good incontinence care, keep skin clean and dry, provide good nutrition/hydration, and provide pressure reducing devices in the chair and in bed. The DON stated R112 preferred to sleep and to sit in a recliner and would rarely lay in the bed on either side to alleviate pressure. The recliner did not have any pressure reducing devices present. The recliner was a standard recliner with no pressure reducing characteristics according to the DON. The DON stated pressure was a factor that contributed to the buttock wound and needed to be addressed with frequent repositioning along with good incontinence care, a pressure reducing device, and skin protection. The DON agreed adding a pressure reducing cushion in the recliner would be an appropriate intervention. On 05/03/18 at 8:14 a.m., Surveyor interviewed CNA-A who stated she had been a CNA for [AGE] years. CNA-A stated R112's buttock was open but very small. CNA-A stated the Baza barrier cream was kept in R112's drawer for staff use. CNA-A confirmed R112's buttock was open on the right side and excoriated on both sides when she applied the Baza cream. CNA-A also confirmed she did not remove gloves, perform hand hygiene, and don clean gloves before applying Baza cream. CNA-A stated she should have changed gloves between washing R112's buttock and applying the Baza barrier cream.

Based on observations, staff interviews and record review the facility did not include non pharmacological individualized interventions and individualized behavioral monitoring for the use of psychoactive medications for 2 of 4 residents reviewed for psychoactive medications (R5 and R3). R5 receives scheduled [MEDICATION NAME] and [MEDICATION NAME] and as needed [MEDICATION NAME]. R5 has no individualized non pharmacological approaches for the use of these medications and does not have individualized behavioral monitoring related to the use of these medications. R3 receives [MEDICATION NAME] regularly scheduled and as needed and Mirtazepine for anxiety, sleep and depression. R3 has no individualized non pharmacological approaches for the use of these medications. R3 has no individualized behavioral monitoring related to the use of these medications. This is evidenced by: Example 1: R5 was admitted to the facility on [DATE] receiving Quetiapine [MEDICATION NAME] ([MEDICATION NAME]) 25 milligrams a day (antipsychotic), [MEDICATION NAME] 25 milligrams as needed and 25 milligrams a day (anti-anxiety) and [MEDICATION NAME] 10 milligrams a day (antidepressant). R5's current signed physician's orders [REDACTED].>~[MEDICATION NAME] Tablet 0.25 mg (milligrams) Give 1 tablet by mouth every 12 hours as needed for anxiety. ~[MEDICATION NAME] Oxalate Tablet 10 mg Give 1 tablet by mouth in the morning for anxiety. ~Quetiapine [MEDICATION NAME] Tablet 25 mg Give 1 tablet by mouth one time a day for Delusional Disorder OK to use home supply per . ~[MEDICATION NAME] by mouth 1 tablet (0.25 mg) twice daily give at 1000 and 1600 (10 am and 4 pm) 05/01/17. R5's most recent Minimum Data Set Assessment ((MDS) dated [DATE] reveals no mood or behavioral issues. On 05/01/17 at 2:30 p.m., Surveyor observed R5 seated in a wheelchair in a central lounge area. A staff person was seated next to her. R5 was observed breathing very heavily in a huffing and puffing sound. R5 was observed to briefly cry. At 2:40 p.m., the staff person assisted R5 in walking with a wheeled walker. at 2:55 p.m., R5 was back sitting in the lounge area. Some huffing and puffing was observed. At 3:15 p.m., R5 was still observed seated in the central lounge area with a staff person seated next to her. R5 was talking with the staff person in a whisper. On 05/03/17 at 3:20 p.m., Surveyor spoke with CNA A (Certified Nursing Assistant). CNA A indicated R5 has periods of anxiety where R5 will breath very fast and heavy. CNA A indicated when R5 does this, it may mean that she has to use the bathroom. CNA A also indicated R5 sometimes has a hard time falling asleep. On 05/04/17 at 6:25 a.m., Surveyor spoke with RN C (Registered Nurse) RN C said R5 will hyperventilate (heavy breathing) when she is anxious and they recently got an order for [REDACTED].>On 05/04/17 at 8:45 a.m., Surveyor spoke with the Director of Nursing (DON). The DON indicated R5 was admitted on the [MEDICATION NAME] and [MEDICATION NAME] for anxiety. The DON said they also give as needed [MEDICATION NAME] for anxiety, (heavy breathing). The Surveyor and the DON reviewed R5's current care plan dated 03/20/17 for the use of these medications and for non pharmacological approaches related to R5's anxiety and heavy breathing. The DON indicated they did not have any non pharmacological approaches for the use of these medications. The DON and Surveyor reviewed R5's individualized behavioral monitoring on the medication and treatment records. R5's individualized monitoring does not include the anxious heavy breathing. Review of the Nurse Aide Assignment Sheet dated 05/02/17 does not include any approaches and interventions to minimize R5's anxiety-heavy breathing. Example 2: R3 was admitted to the facility on [DATE] and readmitted on [DATE]. R3 was admitted with orders for [MEDICATION NAME] as needed and 1 milligram a day of regularly scheduled for anxiety; and Mirtazepine 7.5 milligrams a day for anxiety and depression. R3's scheduled Mirtazepine was increased to 15 milligrams and [MEDICATION NAME] was decreased to .5 milligrams a day. Review of R3's most recent MDS dated [DATE] reveals no mood or behavioral concerns. R3's current physician's orders [REDACTED].>~[MEDICATION NAME] Tablet 0.5 mg (milligrams) Give tablet by mouth as needed for anxiousness 1 tablet po (by mouth) twice daily as needed for anxiety. ~[MEDICATION NAME] Tablet 0.5 mg Give 1 tablet by mouth at bedtime for anxiety. ~[MEDICATION NAME] Tablet 15 mg Give 1 tablet by mouth at bedtime for mood and appetite stimulant. On 05/04/17 at 6:00 a.m., Surveyor spoke with the DON. The DON said R3's scheduled and as needed [MEDICATION NAME] as well as the Mirtazepine were ordered upon admission. The DON said R3 has anxiety, sleep problems and depression. The DON said R3's [MEDICATION NAME] was reduced and the Mirtazepine was increased. The DON and the Surveyor reviewed R3's most recent care plan (04/28/17) related to non pharmacological approaches related to the anxiety, sleep and depression area's and the use of the medications. The DON indicated that R3 did not have any non pharmacological approaches. Review of R3's Nurse Aide Assignment Sheet dated 05/02/17 does not reveal any non pharmacological approaches related to R3's anxiety, sleep and depression. The DON also indicated that R3 does not have individualized behavioral monitoring related to her sleep and anxiety.

Based on observation, interview, and record review, the facility did not ensure 1 of 25 residents received their medications as prescribed and in accordance with manufacturers recommendations. R4 had orders for Cosopt eye drops for glaucoma. One RN (Registered Nurse) did not instill the eye drops in accordance with R4's physician orders, nor in accordance with manufacturers recommendations. This is evidenced by: Cosopt is a medication used to treat increased eye pressure caused by glaucoma. The medication itself can cause adverse reactions if it is absorbed systemically (into the blood stream). Manufacturers recommendations include once Cosopt is instilled, to place slight pressure with a finger on the tear duct for one minute. This is necessary to prevent systemic absorption of Cosopt. On 5/3/17 at 8:23 a.m. Surveyor observed RN B administer R4's Cosopt eye drops. RN B gathered Cosopt eye drops and entered R4's room. RN B handed R4 a Kleenex and instilled one drop of Cosopt into R4's left eye. R4 dabbed his eye with the Kleenex. RN B removed her gloves, washed her hands, and exited R4's room. According to R4's physician orders [REDACTED]. There was no pressure applied to R4's tear duct to prevent systemic absorption. On 5/4/17 at 8:30 a.m. Surveyor spoke with RN C regarding the facility's practice for administering Cosopt eye drops. RN C was unaware of the need to place pressure to the tear duct to prevent systemic absorption. On 5/4/17 at 9:40 a.m. Surveyor spoke with the DON (Director of Nursing). The DON indicated they utilize the Lipincott Manual for their standards of practice. The DON referenced the manual and indicated any eyes drops with the same chemical composition as Cosopt, including Cosopt, should have pressure to the tear duct for 1 to 2 minutes to prevent systemic absorption. The DON indicated she would expect all nurses to follow their standards of practice.

Based on record review and interview the facility did not ensure the individuals taking care of the residents were Certified Nursing Assistants (CNAs) and listed on the Wisconsin CNA Regsitry. This has the potential to affect all residents. This is evidenced by: Review of the staffing schedules found times when PTAs (Physical Therapy Assistants) and COTAs (Certified Occupational Therapy Assistances) were used in place of CNAs for resident care: ~9/4/16 on the evening shift COTA-D was on duty for an 8 hours shift one CNA. The census was 10. ~9/5/16 evening shift PTA-B was on duty for an 8 hour shift with one CNA. The census was 11. ~9/15/16 on the evening shift PTA-C was on duty for an 8 hour shift with one CNA and another CNA that worked only 6 hours. The census was 18. When taking the ~9/18/16 on the evening shift PTA-C and COTA-D both worked 8 hour shifts with one CNA that worked 4 only hours. The census was 17. ~9/21/16 on the evening shift PTA-B worked 8 hours with 2 CNAs. The census was 18. ~9/22/16 on the evening shift COTA-A worked 5 hours with one 8 hour CNA and another CNA that worked only 6 hours. The census was 19. ~10/1/16 on the day shift COTA-A worked 4 hours with one 4 hour CNA and another CNA that worked only 5 hours. The census was 18. ~10/6/16 on the evening shift PTA-C worked six hours with 1 CNA and one nurse technician (NT) that split an 8 hour shift. The census was 18. When taking the PTA out of the equation; there was one aide for 18 residents. On 11/9/16 at 3:35 p.m. Surveyor interviewed COTA-A about working the floor as a direct care staff person. COTA-A stated that she has worked the floor but that when she did, there were 2 CNAs scheduled and she would, .volunteer to support. I have my own agenda and I will jump in when I'm needed for patient care. COTA-A stated she would work on the units when there were admissions and stated she did so last week when there were 2 CNAs scheduled but there were 2 new admissions. COTA-A stated her duties were to help with morning cares, showering, dressing and activities of daily living (ADLs) but stated that the goals are function based and part of her daily interactions with the patients. On 11/10/16 at 10:28 a.m. Surveyor interviewed PTA-B. PTA-B stated he had been a PTA since 2009 and his 3 year training included the basics of personal hygiene, toileting, and perineal care however the main focus of his training was increased independence of the individual and proper instruction for personal cleaning. PTA-B stated he has had formal training with a mannequin and a return demonstration for perineal cleansing. At 10:43 a.m. Surveyor interviewed PTA-C. PTA-C stated she had been a PTA since 2010 and her 2 1/2 year training included clinical practice on the job where she had to demonstrate skills and be checked off to know proper ADLs, skin care, dressing, bathing, perineal care and toileting. PTA-C stated she was a CNA in the past however had not kept her certification up since becoming a PTA. At 11:17 a.m. Surveyor interviewed COTA-D. COTA-D stated she had been a COTA for over 11 1/2 years after 2 1/2 years of training. COTA-D stated that in addition to her education and training in ADLs, feeding, bathing, dressing, and perineal cleansing; she also needs 24 credits to kept her stat certification and these trainings include transfers and working with patients with dementia. At 11:20 a.m. Surveyor spoke to the NHA (Nursing Home Administrator) regarding the education and training of the PTAs and COTAs. The NHA stated that with their enhanced skills and college education over the CNAs 9 months of training this made them an invaluable part of the rehabilitation and care goals of the facility. However, these skills are not in alignment with the training and goals of CNA.

Based on record review and interview the facility did not ensure 1 of 1 allegation of drug diversion was thoroughly and immediately investigated. This is evidenced by: The state survey agency recevied an allegation that RN-FF (Registered Nurse) had diverted medications while employed at the facility. Part of the allegation is the potential diversion was reported to the facility with no actions taken. A review of the facility's investgations found the facility had investigated RN-FF for altering a prescription for narcotic pain medications, but there was no indication an investigation into actual diversion had occurred. On 6/25/16 at 9:40 a.m., 2:00 p.m., and 3:28 p.m., Surveyor # interviewed the INHA (Interim Nursing Home Administrator) about the 5/20/16 investigation and the allegation of diversion. The INHA stated a call was received by the facility on 7/15/16 but the caller hung up prior to giving details and evidence of the allegations to the DON (Director of Nursing). The INHA indicated he had spoken to another staff member, RN-GG. The INHA stated she was able to verify the identity of the caller through the use of Caller ID. The INHA stated she did not attempt to call the person back or question RN-GG. When asked why, the INHA indicated the caller was malicious. On 7/25/16 at 3:10 p.m. Surveyor # interviewed RN-GG. The INHA was present as well. RN-GG stated that on 7/15/16 she received a call from a man. RN-GG stated the identity of the caller appeared on the Caller ID. The caller told her to write down that RN-FF, who used to work at the facility was taking pills from the residents, that he had proof, and was going to call the State. RN-GG stated she told the man on the phone that he needed to speak to the DON but the caller stated that he did not want to. The INHA stated this was the first time she had heard RN-GG explain the call in person.

Based on record review and interview the facility did implement their policies and procedures to prevent caregiver misconduct for 1 of 10 sampled residents. The facility reasonable suspicion that RN-FF (Registered Nurse) committed a crime when she altered Resident #24's prescription for a narcotic pain medication. The facility did not report law enforcement or the State Survey Agency as required by section 1150B of the Social Security Act. This is evidenced by: The facility has a policy and procedure dated 11/30/15 titled Reporting Reasonable Suspicion of a Crime. The procedure states, .Covered individuals must report any reasonable suspicion of crime against residents in the facility. Reports must be made to the Wisconsin Department of Quality Assurance and to one or more local law enforcement entities .within 24 hours . The policy and procedure are consistent with Section 1150B of the Social Security Act with guidance provided in Survey & Certification memo 11-30. Review of the facility ' s investigation found that on 5/14/16 Resident #24 ' s physician had ordered an increase in her [MEDICATION NAME]([MEDICATION NAME] sulfate) to 45 mg twice a day. The facility investigation of 5/20/16 concluded that RN-FF had altered the original prescription from the doctor ' s office from 15 mg to 45mg. The facility ' s investigation discovered the resident was already receiving 30 mg and this addition of 15 mg would equal 45 mg. The forgery was discovered after the facility ' s pharmacy questioned the dosage and a comparison was made of the altered script to the doctor ' s note and carbon copy of the script. Included in the investigation was record of a conversation with RN-FF on 5/20/16 in which she confessed to altering the prescription to the physician ' s office and the INHA (Interim Nursing Home Administrator). Included in the investigation was a review of the narcotic MEDICATION ORDERS FOR [REDACTED]. On 7/25/16 at 9:40 a.m. Surveyor # interviewed the INHA about the investigation. The INHA stated the conclusion that RN-FF had altered the prescription came at the same time that RN-FF confessed to doing so. The INHA stated that the physician was notified and a letter of apology was written to the physician. The INHA stated she did not report it as the resident received the right medication and therefore no crime was committed against Resident #24. Anytime a person exploits a resident and their condition for personal gain is considered a crime against the resident.

Based on observations, interviews, and record reviews, the facility failed to maintain appropriate sanitizing temperatures in the automatic high-temperature dish washer resulting in risk of serious harm and death to all residents of the facility. Surveyor # along with the Dietary Manager (DM), observed ware washing in the facility kitchen. The sanitizing temperature was noted to not rise above 91 degrees for at least 2 cycles. The DM did not intervene with the exception of tapping on the gauge. Surveyor # intervened and stopped the ware washing process. The gauge was replaced. The following day, surveyor reviewed the rinse temperatures documented for the remainder of 5/10/16 and 5/11/16, which included supper on 5/10/16 and breakfast and lunch on 5/11/16. The temperatures again did not reach the appropriate level. The improperly sanitized dishes were used to serve food to residents of the nursing home for 3 meals. Review of the facility's temperature logs back to May 2015 found multiple entries of below minimum temperatures with no actions taken to correct the issue. The Immediate Jeopardy began on 10/1/15 when rinse temperatures were consistently below the minimum with no evidence that the DM took actions to correct the issue. The NHA was notified of the Immediate Jeopardy on 5/12/16 at 11:25 a.m. The Immediate Jeopardy was removed on 5/12/16 but noncompliance remained at the lower scope and severity level of F (potential for more than minimal harm that is not immediate jeopardy/widespread) as the facility needs to fully implement a correction plan. In addition to the Immediate Jeopardy, the following deficient practices were also identified: The facility did not: ~Ensure all staff, including the DM uses appropriate hair restraints in the food prep area; ~Have a process for ensuring leftovers and other foods are cooled to appropriate temperatures within specified guidelines to reduce the chance of foodborne illness; ~Ensure the food preparation equipment and surfaces free of dirt, grease splatters, and spills, and soil; ~Have a system to consistently monitor and record temperatures of every refrigerator located in resident rooms. This is evidenced by: Example #1: On 05/10/16 at 9:05 a.m., Surveyor # conducted the initial kitchen tour with the DM. During the tour, Surveyor # noted the dish machine was in use. The specifications on the CMA-180 dish machine indicated the wash temperature must reach 155 degrees Fahrenheit and the rinse temperature must reach 180 degrees Fahrenheit for proper and complete sanitization of dishes. Surveyor # noted the temperature on the wash cycle reached 160 degrees Fahrenheit, but the temperature on the rinse cycle was only 91 degrees Fahrenheit. The DM was standing behind the Surveyor. DA-V (Dietary Aide) was taking the dish racks from the clean side and putting the dishes on a cart. DA-V noted the rinse temperature gauge was not moving with each cycle then stated she would contact maintenance regarding the gauge. The DM stepped up to the gauge and tapped on the gauge but the gauge continued to read only 91 degrees Fahrenheit. Surveyor # instructed DA-V the dishes that were just washed must not be used until properly sanitized. Surveyor # also instructed DA-V to stop washing breakfast dishes until the dish machine was working correctly. DA-V placed an irreversible temperature indicator strips on a rack filed with dishes and put the rack through the dish machine. The indicator strip turned from blue to orange/gray. This test strip did not turn a solid orange as per the manufacturer instructions. DA-V repeated the test strip process with the same results. The indicator strip instructs staff if the blue indicator strip turns orange, the rinse temperature was 180 degrees Fahrenheit and the test was positive for sanitizing. DA-V stated the irreversible temperature indicator strips were to be checked weekly then attached to the temperature log. There were no irreversible temperature indicator strips done for the month of May, 2016 as of 05/10/16. On 05/11/16 at 9:15 a.m., Surveyor # interviewed MS-S (Maintenance staff) regarding the dish machine. MS-S stated he had replaced the gauge connected to the rinse cycle on the dish machine on 05/10/16 and he further stated the water was reaching the desired temperatures. On 05/11/16 at 11:06 a.m., Surveyor # returned to the kitchen and reviewed the dish machine temperature log. Temperatures since 5/10/16 found the rinse temperatures were still too low at 160-170 degrees. The facility had used these unsanitized dishes for supper on 05/10/16, breakfast and lunch on 05/11/16. On 05/11/16, Surveyor # requested copies of all the dish machine temperatures logs beginning 05/11/16 back to May, 2015. The facility provided Surveyor # with logs for the following months in 2015: May, June, September, October, November, and December. The facility provided Surveyor # with logs for the following months in 2016: January, February, March, April, and May. Review of the dish machine temperature logs noted the following problems: ~May 2015 had 5 days that did not meet the required wash/rinse temperatures and there were no irreversible temperature indicator strips completed. ~June plus July 1 2015 had 31 days that did not meet the required wash/rinse temperatures and there were no irreversible temperature indicator strips completed. ~September 2015 all days met the required wash/rinse temperatures, but there were no irreversible temperature indicator strips completed. ~October 2015 had 31 days that did not meet the required wash/rinse temperatures and there were no irreversible temperature indicator strips completed. ~November 2015 had 30 days that did not meet the required wash/rinse temperatures and there were 2 irreversible temperature indicator strips completed. The test strips were not dated. ~December 2015, had 31 days that did not meet the required wash/rinse temperatures and there was only 1 irreversible temperature indicator strips completed. The test strip was not dated. ~January 2016, had 31 days that did not meet the required wash/rinse temperatures and there were no irreversible temperature indicator strips completed. ~February 2016 had 29 days that did not meet the required wash/rinse temperatures and there were 4 irreversible temperature indicator strips completed. The test strips were not dated. ~March 2016 had 31 days that did not meet the required wash/rinse temperatures and there were 4 irreversible temperature indicator strips completed. The test strips were not dated. ~April 2016 had 29 days that did not meet the required wash/rinse temperatures and there were 5 irreversible temperature indicator strips completed. The test strips were not dated. ~May 2016 had 11 days that did not meet the required wash/rinse temperature and there were 2 irreversible temperature indicator strips completed. Both of the test strips were done on 05/10/16, but not dated. Surveyor # noted all of the nonreversible test strips were not orange in color, but rather a grayish color. The manufacturer's directions indicate that when the surface temperature of the dish reaches the appropriate temperature, the strip should turn orange. The used strips do not provide evidence that the rinse temperature reached appropriate levels. On 05/11/16 at 4:20 p.m., Surveyor # interviewed the DM regarding dish machine temperatures. The DM stated the dish machine wash temperature must reach 160 and the rinse temperature must reach 170. In order to assure proper sanitation is occurring, the dish surface must reach a minimum temperature of the water temperature, which is measured by the external gauge, must reach a minimum of 180 degrees. This temperature is required in order to assure the surface temperature of the dishes is reaching a minimum of 160 degrees, which is measured by the nonreversible test strip. (Food and Drug Administration, Food Code, 4-703.11(b).) The DM stated the nonreversible temperature indicator strips should be completed weekly. The DM stated he had observed the dish machine earlier on 05/11/16 and the temperatures had reached the required temperatures for sanitization of the dishes. The DM stated CTL/NAASCO company comes monthly and checks the dish machine. The DM stated he was unaware of any concerns from the outside company. The DM stated he spends approximately 2 hours/day in the kitchen and the remainder of his time is as the assistant administrator for the assisted living section. On 05/16/16 at 2:30 p.m., Surveyor # interviewed the RD (Registered Dietician). The RD stated she spends approximately 8-12 hours/week in the facility. The RD stated most of her time is spend doing clinical assessments, care plans, and resident interviews. The RD stated she does monthly audits looking at dish machine temperatures, food temperatures, and refrigerator logs. The RD stated the only concern she identified with the dish machine was that staff had not completed the weekly irreversible temperature indicator strips. The RD states she does attend staff meetings and conduct staff observations as well. The RD stated she does not monitor cleaning schedules. The RD states when concerns are identified such as the irreversible temperature indicator strips not completed weekly, she would bring that information to the DM. The Immediate Jeopardy that began on 10/1/15 was removed on 5/11/16 when the facility ~Trained all staff including the DM prior to the start of their next shift on appropriate temperatures of the dishmachine; ~Developed a system whereby the DM will audit temperatures daily with oversight by the RD; and ~Weekly audit of dishwashing temperatures by the NHA. The non compliance remains at the lower scope and severity level of F (potential for more than minimal harm that is not immediate jeopardy/widespread) as outlined by the following examples: Example #2: On 05/10/16 beginning at 9:05 a.m., Surveyor # was conducting the initial kitchen tour with the DM (Dietary Manager). The DM had a full beard and was not wearing a beard net. The DM and the Surveyor were in all the areas of the kitchen including the food preparation areas. The DM asked the Surveyor if hats were allowed as hair restraints and the Surveyor directed the DM to the facility policy. The Surveyor then stated facial hair was to be covered as well. The DM asked Cook-T where the beard nets were located and the DM retrieved and donned a beard net before returning to the kitchen tour. Example #3: Food must be rapidly cooled to 70 degrees Fahrenheit within 2 hours and 41 degrees Fahrenheit within another 4 hours to be considered safe to serve as leftovers. On 05/11/16 at 10:55 a.m., Surveyor # noted a container of leftover lasagna and a bag of leftover sausage links in the refrigerator. Lasagna was served for lunch on 05/10/16 and sausage links were served for breakfast on 05/11/16. Surveyor # asked Cook-U what was done with leftover food and Cook-U stated leftovers were used for mechanically altered diets or for resident requests. Surveyor # asked Cook-U and Cook-T how foods were cooled. Cook-T stated the facility does not log the cooling process. Cook-U stated the lasagna and sausage links were placed in the refrigerator and no temperatures were taken once in the refrigerator. Surveyor # asked the DM to see the cooling log. The DM stated the facility does not keep leftovers. Surveyor # informed the DM that both full time cooks stated otherwise. The DM stated the only leftover foods kept would be soups. Surveyor # was provided cooling logs dated 04/01 (no year) through 08/04 (no year). The logs did not include the year and it is unclear what year these cooling logs represent. The logs had 8 columns across and 14 columns down. The first column noted the date, the next column was the food item, the next column was the start temperature of the food item, the next column was the temperature after 2 hours, the next column was the temperature after 4 hours, the next column was another start time, the next column was temperature after 4 hours, and the final column was corrective actions taken and cooks initials. Review of the cooling logs noted 34 entries. Of the 34 entries listed, 22 of the entries did not follow the cooling requirements. Items on the cooling logs included rice, beef, soups, meat loaf, ham, vegetables, pork, chicken, chili, beef stew, eggs, and turkey. Example #4: During the initial tour which started on 05/10/16 at 9:05 a.m., Surveyor # noted the following items that were dirty, sticky, soiled, or with grease splatter: ~three white plastic bins filled with flour, sugar, and pasta had a yellow sticky film on all lids. ~a stainless steel 2 hole plate warmer had a yellow sticky film around both wells. The black lids that covered the plates were greasy and sticky as well. ~2 Imperial ovens one with a flat grill top and the other with 6 burners. Both ovens were dirty with grease splatter on the backsplash, cook top, and front doors. ~a deep fryer that had burnt crumbs along side of the grease well and as old grease and dirt splatter on the sides and front. ~a 4 well steam table that had crumbs and grease splatter along side of the wells, on the front, top, and sides of the steam table. ~2 Imperial convection ovens stacked one on top of the other. Both ovens had dirt and grease splatter on the front and sides. ~a Lolo Steamer on top of a 3 tier metal cart. The steamer and metal cart were covered in dirt and grease splatter. On 05/11/16 at 4:20 p.m., Surveyor # requested a copy of the cleaning logs from the DM. The Surveyor asked the DM who was in charge of the cleaning scheduled and the DM stated Cook-T was in charge of the cleaning schedule and weekly staff inservice. The DM stated at the weekly staff inservices Cook-T usually addressed any concerns with the cleaning schedule Review of the weekly kitchen cleaning log noted the log was dated 03/10/16 through 05/11/16. The log identified most items not being cleaned since 03/10/16 and some items not being cleaning prior to that date. Items not cleaned at all or since 03/10/16 included oven #1 and #2, flat top grill, walls, freezer, drains, steamer, cooler, doors, bins, stock room floor, shelves, steam table, and food carts. Example #5: Resident room refrigerators must be clean and monitored daily for proper temperatures. During the general observation task conducted on 05/11/16 beginning at 7:40 a.m., Surveyor # noted the following rooms without any daily temperature logs: ~room 81 refrigerator was empty. ~room 91 refrigerator had jello, yogurt, boost, gatorade, applesauce, ice cream, and soda ~room 96 refrigerator had boost, fruit, soda, and a ziploc plastic container of snacks from home. ~room 95 refrigerator was empty. ~room 71 refrigerator had water, yogurt, and a ziploc plastic container with snacks from home. ~room 74 refrigerator was empty. ~room 88 refrigerator had applesauce, ensure, and plus 2 supplement. ~room 86 refrigerator had soda and coffee creamer. On 05/11/16 at 9:15 a.m., Surveyor # interviewed MS-S regarding temperatures of room refrigerators. MS-S stated every room refrigerator has a thermometer hanging and temperatures are taken daily. MS-S was unsure what discipline was responsible for checking refrigerator temperatures. MS-S stated he was notified if the temperature was abnormal and would follow up as needed. On 05/11/16 at 9:30 a.m., Surveyor # interviewed MD-R (Maintenance Director) regarding room refrigerators. MD-R stated the nursing staff was responsible to check and log refrigerator temperatures daily. On 05/11/16 at 4:30 p.m., Surveyor # interviewed the DM regarding room refrigerators. The DM stated housekeeping was responsible to check and log refrigerator temperatures daily. The DM stated dietary staff was not responsible for the resident room refrigerators.

Based on medical record review and interviews, the facility did not ensure that staff consulted a physician when there was a significant change in condition resulting in delay in treament for apparant injuries which lead to 2 additional surgeries and ultimately the death of 1 of 4 residents reviewed for falls. Resident #9 was admitted on [DATE] after having a left hip replacement. On [DATE] at 6:15 a.m., he had an unwitnessed fall and was found on his knees beside the bed. Documentation in the medical record finds Resident #9 had extreme pain rated at a 12 out of 10 beginning the time of the fall. Resident #9's spouse and Physical Therapy staff identified Resident #9 had rotation in the left leg. Although there were several calls placed to physicians regarding pain, there is no indication that any physician was informed of the fall and consulted about the physical findings. On [DATE], 4 days later was seen in the clinic for a routine follow-up appointment. Documentation finds the clinic staff immediately identified Resident #9's left leg was rotated indicating possible injury to the recent surgical site. Resident #9 was found to have a left hip dislocation. Resident #9 was taken to surgery the next day for closed reduction of the left hip (put it back into socket). 3 days after surgery, Resident #9's previous incision was leaking and prompted a third surgery for [REDACTED]. Due to complications during surgery, Resident #9 required mechanical ventilation/life support. Ventilation was removed per family wishes and Resident #9 expired. The Immediate Jeopardy began on [DATE] when facility staff did not consult with the physician regarding the fall and any physical findings and was identified on [DATE]. The Interim Nursing Home Administrator was notified of the immediate jeopardy at 10:30 a.m. on [DATE]. The Immediate Jeopardy was removed on [DATE], but noncomplaince remains at the lower scope and severity level of D (potential for more than minimal harm that is no immediate jeopardy/isolated) as the facility still needs to fully implement a correction plan. This is evidenced by: Resident #9 was admitted on [DATE] following a left total hip arthroplasty (left hip replacement). The surgery was to treat osteonecrosis which had left Resident #9 unable to walk for 2 years prior to the surgery. Other [DIAGNOSES REDACTED]. Progress note on [DATE] states, Nursing staff called to resident's room this morning by CNA (Certified Nursing Assistant). Upon entering room, NOC RN (Night Registered Nurse) and day RNS (Registered Nurses) observed resident kneeling on the floor next to hip (sic) bed. When asked what he was trying to do, resident stated, 'I had to go to the bathroom so I was trying to go.' Resident assessed wityh no injury noted to face or head or hip. Only noted injury is scuff to left knee. MD-H (Medical Doctor) (on call for Resident #9's primary care physician) was notified and spouse notified .Hip painful with movement. Weakness and confusion continues .Resident not bearing weight to left d/t (due to) pain . On [DATE], Surveyor # spoke with Resident #9's wife, Family-M. Family-M stated that after Resident #9's fall, she notied Resident #9's left leg was turned out. Family-M stated that she reported this to the nursing staff, but no one did anything about it. The facility completed a fall assessment dated [DATE] which stated, RN was called to patients (sic) room by CNA stating that Resident #9 was on his knee next to bed. No injuries were noted, patient denies pain other that (sic) his left hip, which is not new . On [DATE] at 9:46 a.m., Surveyor # interviewed MD-H by phone. MD-H confirmed that he was on call for Resident #9's PCP on [DATE]. MD-H stated he did not recall the case. MD-H stated any nurse who calls the on call physician really needs to know the resident's background, We rely on the nurse for their assessment. If I would have been called and informed that this person was a new hip replacement and had fallen I most likely would have ordered an x-ray to rule out any injury. The facility also can have a portable x-ray completed at the facility. All on call discussions are documented. MD-H indicated there was no record of any call being recieved that day regarding Resident #9's fall. On [DATE] at 1:35 p.m., Surveyor # interviewed MA-E (Medical Assistant) who works with Resident #9's PCP (Primary Care Provider) and asked if anyone had been consulted regarding Resident #9's fall on [DATE]. MA-E stated that if a call is made before business hours (before 8:00 a.m.), the facility would call the Triage Nurse who would place a note in the resident's online record. MA-E reviewed the record and found no evidence that a call was placed/physician was consulted on [DATE] following the fall. Nurse's note continue: [DATE] at 9:04 a.m., Assess pain q (every) 4 hours and offer pain medications as needed every 24 hours for pain. Rating pain in left hip and knee a ,[DATE]. [DATE] at 11:40 a.m., .Patient states pain in left leg is a 12 out of 10, but declines pain meds. Physical Therapy notes documented by PTA-K (Physical Therapy Assistant) on [DATE] at 3:49 p.m. state, .Residents LLE (left lower extremity) tends to externally rotate when seated and in supine (lying down) . External rotation of the left leg is indicative of a possible injury, especially after a recent hip replacement. There is no evidence that PTA-K reported the observation to nursing for a full assessment of potential injury. On [DATE], Resident #9 was seen in the Orthopedic Clinic for a routine post-surgical follow up. The clinic note states, .Patient reports he did fall on Saturday night hitting a wastebasket and landing mainly on his right side. He reports he had a spike in pain at the time and noted more pain thereafter when being turned in bed. He denies that an xray was done at the (facility). (Orthopedic Physician's) office had not been informed of event .Based on recent fall and patient reports of severe hip pain with logrolling in bed, (Orthopedic Physician) ordered a hip xray which documented hip dislocation. Patient is admitted to St. Clare's (hospital) for closed reduction . Hospital documentation on [DATE] states the following: .came with pain in the left hip due to dislocation of recently placed left hip arthroplasty .(Orthopedic surgeon) performed a closed reduction of hip dislocation. Subsequently patient had some leaking from the wound and taken again to OR (operating room) for revision of left total hip arthroplasty which was done on [DATE] .On [DATE] possibly had aspiration and was bradycardic (slow heart rate) and went into asystole (no cardiac activity) and had CPR (cardio [MEDICAL CONDITION] rescusitation). After that he was intubated (tube inserted through the mouth and into the trachea) in the ICU (Intensive Care Unit) and mechanically ventilated .(wife) requested comfort care and withdrawl of the mechanical ventilation .The patient was not in distress and died peacefully after he was extubated . On [DATE] at 10:43 a.m., Surveyor # interviewed RN-I who is Resident #9's Orthopedic Nurse. RN-I stated the facility usually calls the orthopedic clinic if a resident falls after a recent hip replacement. RN-I stated the surgeon first found out Resident #9 had fallen when he (Resident #9) was at his 9 day status [REDACTED]. On [DATE] at 3:00 p.m., Surveyor # interviewed RN-C who has worked as a Registered Nurse for [AGE] years. RN-C stated after completing her head to toe assessment, she would directly talk with the physician about the fall and always err on the side of reinjury after surgery, then document the discussion along with his response. On [DATE] at 3:30 p.m., Surveyor # interviewed the Interim Director of Nurses who stated that her expectations would be that nursing complete a head to toe assessment, check range of motion, check pain with any changes, and leg differential. Once the assessment is completed, the nurse should notify the physician, document the findings and the physician response. Surveyor # showed the IDON the [DATE] note that physician was notified with no other documentation on what was discussed or if any further treatment was needed. The IDON stated, We don't know what the physician said, we need better documentation. The RN who cared for Resident #9 on [DATE] is no longer employed by the facility and could not be reached for an interview. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility: ~Developed policies and procudres to ensure physician consultation is completed via telephone; ~Developed a system of audits to ensure physicians are consulted regarding changes in condition including falls; ~Began training for all nursing staff on the new policies and procedures prior to beginning their next scheduled shift; and ~Increased oversight of the nursing department by the nursing leadership team. The noncompliance remains at the lower scope and severity level of D (potential for more than minimal harm that is not immediate jeopardy/isolated).

Based on observations, interviews and medical record review, the facility failed to implement a falls prevention program resulting in serious injury and death to 1 resident (Resident #9) out of 4 residents reviewed for falls. In addition to the resident in immediate jeopardy, the faciliyt failed to ensure the residents' environement was free from accident hazards and/or devices to prevent falls/mitigate injury were provided for 14 residents. Resident #9 was admitted to the facility following left hip replacement surgery. The hospital discharge summary indicates fall precautions of a bed and chair alarm were used during his hopsital stay. Upon admission to the facility, nursing and therapies identified Resident #9 was at high risk for falls. Although a care plan for falls was developed, the only intervention was to keep the call light in place. 3 days after admission, Resident #9 was found kneeling on the floor next to his bed. Following the fall, nursing documented there were no injuries except for an abrasion on the left knee. This abrasion is indicative Resident #9's impact was to the leg affected by surgery. A comprehensive post-fall assessment was not documented. Immediately following the fall, Resident #9's wife reported to staff that the left leg looked shorter. Therapy documented the left leg was externally rotated. Both are signs/symptoms that an injury ocurred to the left hip. In addition, Resident #9 was experiencing significant, uncontrolled pain. Despite this, facility staff did not complete a comprehensive assessment nor did they consult Resident #9's primary physician or orthopedic surgeon of the fall. During Resident #9's 9 day follow-up with the surgeon, staff identified the left leg was rotated and Resident #9 reported he had fallen. X-rays revealed Resident #9's left hip was dislocated and required surgery to put the joint back into socket the next day. 3 days later, Resident #9 had drainage from the surgical incision and underwent a third surgery for [REDACTED]. During surgery, Resident #9 went into cardiac arrest and was placed on mechanical ventilation. Family later withdrew the ventilation and Resident #9 expired on [DATE]. The Immediate Jeopardy began on [DATE] when facility staff identified Resident #9 as being at risk for falls, yet did not implement any deveices to prevent falls or reduce the chance for injuryand was identified on [DATE]. The Interim Nursing Home Administrator was notified of the immediate jeopardy at 10:30 a.m. on [DATE]. The Immediate Jeopardy was removed on [DATE], but noncomplaince remains at the lower scope and severity level of E (potential for more than minimal harm that is no immediate jeopardy/pattern) as additional violations of this regulation were identified on this survey. Resident #4 care plan clearly indicates that he is not to be left alone in the bathroom. Surveyor # observed him in the bathroom on the toilet with no staff within the line of sight. Resident #2 has experienced falls in the facility and has a fall history. Resident #2 has a care planned approach for mats to be placed a bedside in attempt to prevent injury if a fall should occur. Resident #2 was observed lying in bed with no mats beside his bed. Surveyor # checked 12 out of 24 rooms and found water temperatures ranging from 118.0 to 130.9 degrees Fahrenheit. Of the 12 rooms checked, 8 were occupied with a resident. This has the potential to affect all residents. This is evidenced by: Example #1 Resident #9 was [AGE] years old and admitted to the facility on [DATE] following a left hip replacement. The surgery was to treat osteonecrosis which had left Resident #9 unable to walk for 2 years prior to the surgery. Other [DIAGNOSES REDACTED]. Hospital discharge summary dated [DATE] indicated Resident #9 was at risk for falls while in the hospital and hospital staff used a chair pull alarm and a bed sensor alarm. On [DATE], PT (Physical Therapy) assessment stated, Wife states he (Resident #9) hasn't walked for 2 years .Due to documented physical impairments and associated functional deficits, the pt (patient) is at risk for falls and further decline in function. On [DATE], OT (Occupational Therapy) assessment stated, This gentleman is incredibly debilitated, certainly one of the weakest individuals treated by this writer . On [DATE] RN-L (Registered Nurse) completed the Admission Assessment. Section M includes the Fall Risk Assessment. The assessment indicated Resident #9: ~Took diuretics, antihypertensives, benzodiazepines, narcotics; ~Unable to stand independently; ~Requires hands-on assistance to move from place to place. The assessment scored Resident #9 at an 8 indicating moderate risk for fall. Under the section Interventionsthe person completing the form is to, Identify all intervention being used to prevent fall and/or to promote safety (THESE NEED TO BE ADDED TO CARE PLAN). RN-L documented, Writer does not agree with assessment. Writer feels Resident is high risk for falls due to lack of strength, resident cannot support his own (sic), writer feels Resident should be in the high risk category. RN-L did not identify individualized interventions to prevent falls and/or injuries. Resident #9's care plan dated [DATE] includes a problem of The resident has actual/or potential for a fall/or at risk to fall. Only 1 intervention was listed, Keep call bell within reach. Progress note on [DATE] states, Nursing staff called to resident's room this morning by CNA (Certified Nursing Assistant). Upon entering room, NOC RN (Night Registered Nurse) and day RNS (Registered Nurse Supervisor) observed resident kneeling on the floor nest to hip (sic) bed. When asked what he was trying to do, resident stated, 'I had to go to the bathroom so I was trying to go.' Resident assessed wityh no injury noted to face or head or hip. Only noted injury is scuff to left knee. MD-H (Medical Doctor) (on call for Resident #9's primary care physician) was notified and spouse notified .Hip painful with movement. Weakness and confusion continues .Resident not bearing weight to left d/t (due to) pain . On [DATE], Surveyor # spoke with Resident #9's wife, Family-M. Family-M stated that after Resident #9's fall, she notied Resident #9's left leg was turned out. Family-M stated that she reported this to the nursing staff, but no one did anything about it. The facility completed a fall assessment dated [DATE] which stated, RN was called to patients (sic) room by CNA stating that Resident #9 was on his knee next to bed. No injuries were noted, patient denies pain other that (sic) his left hip, which is not new . On [DATE] at 9:46 a.m., Surveyor # interviewed MD-H by phone. MD-H confirmed that he was on call for Resident #9's PCP on [DATE]. MD-H stated he did not recall the case. MD-H stated any nurse who calls the on call physician really needs to know the resident's background, We rely on the nurse for their assessment. If I would have been called and informed that this person was a new hip replacement and had fallen I most likely would have ordered an x-ray to rule out any injury. The facility also can have a portable x-ray completed at the facility. All on call discussions are documented. There is no record regarding that MD-H was consulted. On [DATE] at 1:35 p.m., Surveyor # interviewed MA-E (Medical Assistant) who works with Resident #9's PCP (Primary Care Provider) and asked if anyone had been consulted regarding Resident #9's fall on [DATE]. MA-E stated that if a call is made before business hours (before 8:00 a.m.), the facility would call the Triage Nurse who would place a note in the resident's online record. MA-E reviewed the record and found no evidence that a call was placed/physician was consulted on [DATE] following the fall. Nurse's note continue: [DATE] at 9:04 a.m., Assess pain q (every) 4 hours and offer pain medications as needed every 24 hours for pain. Rating pain in left hip and knee a ,[DATE]. [DATE] at 11:40 a.m., .Patient states pain in left leg is a 12 out of 10, but declines pain meds. [DATE] at 5:51 p.m., .Verbalized no pain upon assessment . Physical Therapy notes documented by PTA-K (Physical Therapy Assistant) on [DATE] at 3:49 p.m. state, .Residents LLE (left lower extremity) tends to externally rotate when seated and in supine (lying down) . External rotation of the left leg is indicative of a possible injury, especially after a recent hip replacement. There is no evidence that PTA-K reported the observation to nursing for a full assessment of potential injury. On [DATE], Resident #9 was seen in the Orthopedic Clinic for a routine post-surgical follow up. The clinic note states, .Patient reports he did fall on Saturday night hitting a wastebasket and landing mainly on his right side. He reports he had a spike in pain at the time and noted more pain thereafter when being turned in bed. He denies that an xray was done at the (facility). (Orthopedic Physician's) office had not been informed of event .Based on recent fall and patient reports of severe hip pain with logrolling in bed, (Orthopedic Physician) ordered a hip xray which documented hip dislocation. Patient is admitted to St. Clare's (hospital) for closed reduction . Hospital documentation on [DATE] states the following: .came with pain in the left hip due to dislocation of recently placed left hip arthroplasty .(Orthopedic surgeon) performed a closed reduction of hip dislocation. Subsequently patient had some leaking from the wound and taken again to OR (operating room) for revision of left total hip arthroplasty which was done on [DATE] .On [DATE] possibly had aspiration and was bradycardic (slow heart rate) and went into asystole (no cardiac activity) and had CPR (cardio pulmonary rescusitation). After that he was intubated (tube inserted through the mouth and into the trachea) in the ICU (Intensive Care Unit) and mechanically ventilated .(wife) requested comfort care and withdrawl of the mechanical ventilation .The patient was not in distress and died peacefully after he was extubated . On [DATE] at 3:00 p.m., Surveyor # interviewed RN-C who has worked as a Registered Nurse for [AGE] years. RN-C stated after completing her head to toe assessment, she would directly talk with the physician on the fall and always error on the side of reinjury after surgery, then document the discussion along with his response. On [DATE] at 3:30 p.m., Surveyor # interviewed the Interim Director of Nurses who stated that her expectations would be that nursing complete a head to toe assessment, check range of motion, check pain with any changes, and leg differential. Once the assessment is completed, the nurse should notify the physician, document the findings and the physician response. Surveyor # showed the IDON the [DATE] note that physician was notified with no other documentation on what was discussed or if any further treatment was needed. The IDON stated, We don't know what the physician said, we need better documentation. The RN who cared for Resident #9 on [DATE] is no longer employed by the facility and could not be reached for an interview. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility: ~Developed policies and procudres to ensure acurate admission assessments are completed and a care plan is developed; ~Developed a system of audits to ensure all falls and cooresponding investigations are reviewed by the Interdisciplinary Team; and, ~Began training for all nursing staff regarding the facility's policies and procedures prior to beginning their next scheduled shift. The noncompliance remains at the lower scope and severity level of F (potential for more than minimal harm that is not immediate jeopardy/widespread) as additional examples were identified during the survey. Example #2: Resident #4 was admitted with a [DIAGNOSES REDACTED]. The admission MDS dated [DATE] indicates that Resident #4 requires extensive assistance of 2 staff for bed mobility, transfers, dressing, hygiened and toilet use. History of falls prior admission. The Care Area Assessment (CAA) regarding to falls indicate that he is aware of limitations but can be forgetful at times. Has a low bed and mat of the floor. Staff to anticipate needs. The Admission Fall Risk assessment dated [DATE] indicate a score of 12 (,[DATE] points) moderate risk. Interventions implemented: frequent monitoring, potentially low bed with mats if attempts out of bed. Resident #4's Comprehensive Care Plan dated [DATE]: Focus Resident is at risk for fall related to dx (diagnosis), h/o (history of) fall, abnormalities of gait and mobility, and weekness. Interventions included, XXX[DATE] Please keep in line of sight and do not leave unattended during toileting .Frequent checks q ,[DATE] hrs XXX[DATE] Keep in line of sight when in w/c-patient may be alone in room if in recliner or bed . The CNA Assignment sheet indicate under toileting: Assist x1 for sit to stand pivot transfer-please keep within line of sight and do not leave unattended during toileting. On [DATE] at 10:58 a.m., Surveyor # observed Resident #4 sitting on the toilet with no staff within the line of site. Surveyor # spoke with RN-D who stated that Resident #4 can now be left alone in the bathroom. RN-D then went into the bathroom to applied ointment to resident's groin area. On [DATE] at 11:08 a.m., Surveyor # spoke with CNA-O who stated that earlier she toileted Resident #4. CNA-O stated that he could be left alone on the toilet. On [DATE] at 2:15 p.m., Surveyor # spoke with CNA-W regarding Resident #4 care needs. CNA-W stated that Resident #4 cannot be left alone while on the toilet. On [DATE] at 6:45 a.m., Surveyor # spoke OT-CC (Occupational Therapist) and stated that Resident #4 is not to be left alone on the toilet and the care plan does list this. Example #3: Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #2's most recent MDS (Minimum Data Set) dated [DATE] indicated: ~he had a recent fall with no injury ~he is dependent on staff for bed mobility and transfer ~He is severely cognitively impaired Resident #2's care plan dated [DATE] include a focus, At risk for for falls. Interventions/Tasks: .Mats at bedside . Resident #2's CNA Care card also indicated mats at bedside. Nurses Notes indicated Resident #2 experienced a fall as recent as [DATE]. He was found on the floor in his room attempting to transfer from his wheelchair to bed. Resident #2 experienced no injury. The facility responded by having Resident #2 in common areas when he is not in bed. On [DATE] at 10:00 a.m. # observed Resident #2 lying in bed. He did not have mats placed at his bedsides. Resident #2 was observed again at 10:30 a.m. and 11:00 a.m He remained in bed without mats beside the bed. On [DATE] at 11:00 a.m. Surveyor # spoke with CNA-A (Certified Nursing Assistant) who was responsible for Resident #2's care. Surveyor # asked about Resident #2's routine. CNA-A explained Resident #2 gets up in the morning for breakfast at varying times. After breakfast, around 9:00 or 9:30 a.m., he is laid down in bed and remains in bed until around 11:30. Resident #2 is laid back down in the afternoon after lunch. Surveyor #2 asked CNA-A about Resident #2's fall precautions. CNA-A responded he is to have his bed in a low position. Surveyor # asked CNA-A if Resident #2 is to have mats beside his bed when he is in bed. CNA-A explained she has worked at the facility for 2 months and has taken care of Resident #2 since she started. CNA-A further indicated Resident #2 has never had mats beside his bed since she started. Surveyor # asked CNA-A what Resident #2's care card indicated. CNA-A and Surveyor # reviewed the care card dated [DATE]. The card indicated mats at bedside. On [DATE] at 11:15 a.m. Surveyor # spoke with the RN-Z about Resident #2's fall risk and fall precautions. RN-Z indicated Resident #2 is at risk for falling due to cardiac issues, confusion, his inability to recall and attempts to transfer without staff assistance. RN-Z reviewed Resident #2's care planned approaches for fall precautions which included mats at bedside. Surveyor # informed RN-Z Resident #2 was observed in bed without mats beside him. On [DATE] at 11:30 a.m. Surveyor # was accompanied by RN-Z to Resident #2's room. Resident #2 was observed in bed with mats at both sides of his bed. Surveyor # asked CNA-A about the mats. CNA-A indicated the mats were retrieved from storage. Example #4: The facility had a census of 19 with no residents sharing a room. The facility had 13 private rooms and 11 semiprivate rooms. There was a total of 24 rooms. Of the 19 residents, 3 had a [DIAGNOSES REDACTED]. During a random check of the facility's rooms which was conducted on [DATE] beginning at 7:40 a.m., Surveyor # found the following rooms with high water temperatures: ~room 71 water temperature was 130.9 degrees Fahrenheit. ~room 81 water temperature was 119.3 degrees Fahrenheit. ~room 86 water temperate was 122.0 degrees Fahrenheit. ~room 91 water temperature was 124.1 degrees Fahrenheit. On [DATE] Surveyor # found additional rooms with elevated water temperatures. Those rooms were: ~room 75 water temperature was 120.0 degrees Fahrenheit. ~room 82 water temperature was 118.0 degrees Fahrenheit. ~room 83 water temperature was 120.0 degrees Fahrenheit. ~room 87 water temperature was 118.0 degrees Fahrenheit. On [DATE] at 9:15 a.m., Surveyor # interviewed MS-S (Maintenance Staff) regarding water temperatures. MS-S stated he randomly checks water temperatures monthly. MS-S stated all rooms have a bathroom sink, a shower, and a main sink. MS-S stated each sink has its own mixing valve. MS-S stated the goal of the water temperatures was to be between ,[DATE] degrees Fahrenheit. On [DATE] at 9:30 a.m., Surveyor # interviewed MD-R (Maintenance Director). MD-R stated the water temperatures should be below 115 degrees Fahrenheit. The Surveyor and MD-R went to rooms 71, 86, and 91 and confirmed the water temperatures to be as previously noted above or very close to the previous temperature. MD-R stated the water temperature in these rooms was too high and would be adjusted immediately. Surveyor # requested a copy of all water temperature logs back to [DATE]. Surveyor # was provided with 4 temperature logs. The logs were titled Weekly Hot Water Temperature Readings. One log was dated [DATE] and another log was dated [DATE]. The other 2 logs were not dated. Review of the facility water temperature log dated [DATE] noted room 71 with a temperature of 129.3. Review of the other 2 undated logs noted room 98 had a water temperature of 128.0, the housekeeping room on 70's hall had a water temperature of 126.0, and the bathroom on the 80's hall had a water temperature of 118.1. The 4 logs reviewed noted the facility had identified rooms with water temperature too high. There was no evidence of what was done to correct the water temperatures and was there any follow up. On [DATE] at 10:50 a.m., Surveyor # interviewed MD-R regarding the logs. MD-R stated the logs do not show what was done to correct the identified problems, but MD-R stated he was sure the MS-S would have adjusted the temperature or replaced the mixing valves. MD-R stated he was only able to locate 4 pages of temperature logs even though, according to the log, temperatures should be taken weekly.

Based on interview and record review the facility did not ensure that 1 of 4 sampled residents received adequate pain control and. viewed for pain received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The facility failed to develop, implement, monitor, or modify pain management interventions. Resident #9 was admitted following hip replacement surgery and with [DIAGNOSES REDACTED]. In addition, Resident #9 had a fall 3 days after admission with increased complaints of pain. The facility did not develop a comprehensive pain management program that included medications and non-pharmacological interventions, did not monitor the effectiveness of pain medications, and did not consistently offer or provide any pain relieving medications and/or nonpharmacological interventions that Resident #9 identified as being effective. This is evidenced by: Resident #9 was admitted to the facility on [DATE] following a left total hip replacement. In addition, Resident #9 had [DIAGNOSES REDACTED]. The Admission Nursing assessment dated [DATE], completed by RN-L, indicates under pain: ~Resident #9 verbalizes/shows pain. Stated, he was given 5 mg (milligrams) of [MEDICATION NAME] IR (Immediate Release) and 650 mg Tylenol 2 hours prior to arrival. Pain is ,[DATE]. ~Has pain almost all day. ~Pain is sharp. ~On a scale of 1 to 10 (with 10 being the worst pain), Resident #9 rated his pain at a 12. ~Resident #9 indicated his pain goal is a 4. ~Alleviating factors include Biofreeze and ice. ~Aggravating factors include movement or putting any wight on it (left leg). ~Pain keeps him awake. Resident #9's physician orders [REDACTED]. ~Assess pain every 4 hours and offer pain medications as needed; ~[MEDICATION NAME] 300 mg, 2 capsules, 2 times a day; ~[MEDICATION NAME] HCl 5 mg, 1 tablet every 4 hours as needed for pain 1 or 2 tablets po (by mouth) every 4 to 6 hours; ~[MEDICATION NAME] HCl 5 mg, Give 2 tablets by mouth every 6 hours as needed for pain ,[DATE] tablets every ,[DATE] hours. Resident #9's Care Plan includes a problem of The resident has pain/or has potential for pain which is dated [DATE]. The care plan outlines goals including Resident #9 will verbalize adequate pain relief and no have an interruption in normal activities due to pain. However, no individualized interventions were identified to assist Resident #9 in reaching his goals. Review of Resident #9's MAR (Medication Administration Record), NN (Nursing Notes), PT (Physical Therapy) and OT (Occupational Therapy) notes finds the following entries: [DATE] ~MAR-Pain rated at a 9, 1 tablet of [MEDICATION NAME] given at 4:18 p.m. which was effective. Pain rated at an 8 at 8:00 p.m., no medication given. ~NN-Gave 1 tablet of [MEDICATION NAME] at 4:18 p.m., documented as effective at 7:28 p.m. There were no entries related to Resident #9's pain rating of 8 at 8:00 p.m. and no evidence that pain medication was offered or refused. [DATE] ~MAR Pain Assessments - 12:00 a.m., 3; 4:00 a.m., 3; 8:00 a.m., 5; 12:00 p.m., 7; 4:00 p.m., 7; 8:00 p.m., 7. ~MAR Medication Administration - 1:50 a.m., 2 [MEDICATION NAME] tablets for a pain rating of 10, which was effective. 1:08 p.m., 2 [MEDICATION NAME] tablets for a pain rating of 7, which was ineffective. ~NN [DATE] at 10:05 a.m., (Pain rating) ,[DATE] with any movement. 12:10 p.m., Call placed to (Primary Care Physician) office regarding resident's pain. Having ,[DATE] with no relief from current regimen. Waiting call back. From 4:00 p.m. on [DATE] through 12:00 p.m. Resident #9 could have received 6 doses of pain medication. According to the MAR, he only received 3 with only 1 entry indicating the medication was ineffective. There was no evidence that Resident #9 refused pain medications. There is also no evidence that non-pharmacological interventions identified by the resident as being effective (biofreeze and ice) were tried. On [DATE] at 12:59 p.m., the facility received a Physician's Telephone Order to add [MEDICATION NAME] (muscle relaxant) 750 mg, three times a day to Resident #9's pain medications. According to www.drugs.com, side effects of [MEDICATION NAME] include but are not limited to: ~joint or muscle pain; ~loss of consciousness; ~loss of memory; ~pain, tenderness, or swelling of foot and leg; ~problems with memory; ~sleepiness; and, ~unusual weakness or tiredness. [DATE] ~MAR Pain Assessments - 12:00 a.m., 3; 4:00 a.m., 3; 8:00 a.m., 5; 12:00 p.m., 7; 4:00 p.m., 7; 8:00 p.m., 7. ~MAR Medication Administration - There were 6 opportunities to provide as needed [MEDICATION NAME]. None was administered. ~NN 9:11 a.m., Pain rated 10 out of 10. There is no indication that pain medications were offered or that Resident #9 refused pain medications. ~NN 3:58 p.m., Call placed to on call for (Orthopedic Surgeon) regarding pain control medication. There is no other information indicating what prompted the call to the physician. ~NN 5:44 p.m., On call MD for (Orthopedic Surgeon) returned call and suggested cutting the [MEDICATION NAME] in half for this evening for pain control. He will also send an order for [REDACTED].#9 had received 3 doses. Even though Resident #9 had not been provided with any pain medications since 1:08 p.m. on [DATE] (28 hours earlier) and there was no evidence of non-pharmacological interventions attempted, facility staff called the physician to change Resident #9's pain medication regimen. [DATE] ~MAR Pain Assessments - 12:00 a.m., 2; 4:00 a.m. 7; 8:00 a.m., 10; 12:00 p.m., 10; 4:00 p.m., 5; 8:00 p.m., 4. ~MAR Medication Administration - Resident #9 received no [MEDICATION NAME] the entire day. The order for [MEDICATION NAME] referenced in the [DATE] nurse's note, was not received until [DATE]. Resident #9 has not received any pain medication since 1:08 p.m. on [DATE]. ~NN 6:15 a.m., RNS (Registered Nurses) were called to Resident #9's room stating that he was on his knee at bedside. Resident #9 was lowered to the floor .no injuries noted .Dr. and wife notified .Pain continues to be only located in the left hip. (Refer to F157 and F323.) ~NN 7:05 a.m., .Hip painful with movement .Resident not bearing weight to left d/t (due to) pain . ~NN 9:04 a.m., .Rating pain in left hip and left knee a 12 out of 10. ~NN 11:33 a.m., .Patient states pain in left leg is a 12 out of 10, but declines pain meds. Despite the refusal of medication, there is no evidence that non-pharmacological interventions were offered or provided. ~NN 12:08 p.m., .Resident with c/o (complaints of) pain to left hip that is fairly controlled with pain medication but medication does cause mentation changes. MD notified yesterday and he will send script (prescription) for [MEDICATION NAME] to pharmacy . The entry stating Resident #9's pain is fairly well controlled is contradicted by other nurse's notes and MAR indicated [REDACTED]. Despite the fall at 6:15 a.m., Resident #9 received no pain medication and/or non-pharmacological interventions. On [DATE], the facility received a new physician's orders [REDACTED]. [DATE] ~MAR Pain Assessments - 12:00 a.m., 6; 4:00 a.m., 7; 8:00 a.m., 10; 12:00 p.m., 3; 4:00 p.m., 3; 8:00 p.m., 3. ~MAR Medication Administration - [MEDICATION NAME] administered at 7:17 a.m. for a pain rating of 10. The follow up indicates the medication was effective, however, the pain assessment documented at 8:00 a.m., indicates a pain rating of 10. This is the only pain medication provided since 1:08 p.m. on [DATE]. ~MAR - A new order was placed on the MAR, [MEDICATION NAME] (Tylenol) 500 mg, take 2 tablets as needed for pain management. A second new order states, .ice every 2 hours for pain management . Even though Resident #9 identified ice helps to alleviate pain on admission, the facility first added this to the MAR indicated [REDACTED] ~PT - .Resident's L LE (left lower extremity) tends to externally rotate when seated or supine . External rotation of the left leg could be indicative of an injury to the newly replaced joint. (Refer to F323.) [DATE] ~MAR Pain Assessments - 12:00 a.m., 4; 4:00 a.m., 3; 8:00 a.m., 4; 12:00 p.m., 10; 4:00 p.m., 7; 8:00 p.m., 7. ~MAR Medication Administration - [MEDICATION NAME] administered at 4:40 p.m. for a pain rating of 7. The follow up indicates the medication was ineffective. [MEDICATION NAME] administered at 11:34 a.m. for a pain rating of 10. The follow up indicates the medication was effective. Ice was applied every 2 hours according to the MAR. ~NN 8:24 a.m., .is refusing pain meds and will not say if he in having pain. Face look as if in pain, enc (encourage) to take Tylenol . There was only 1 other entry ([DATE]) indicating Resident #9 had refused pain medications. There was no indication that other non-pharmacological interventions ~NN 9:15 a.m., Tyelnol given and was ineffective. ~NN 11:34 a.m., [MEDICATION NAME] given and was ineffective. However, the MAR indicated [REDACTED].) ~NN 4:40 p.m., [MEDICATION NAME] given and was ineffective. ~PT at 9:01 a.m., .Resident unable to attempt slide board transfer or ez-stand transfer today d/t fatigue level and increased pain .Resident cries out in pain with minimal movement of R (sic) LE and becomes angry telling his wife to 'pack our bags we are out of here.' .Resident refused Tylenol this morning however agreed to take [MEDICATION NAME] at start of session. ~OT at 1:38 p.m., .decreased participation noted during session/increased fatigue/pain RN notified. Pain with movement noted during session today . [DATE] ~MAR Pain Assessments - 12:00 a.m., 0; 4:00 a.m., 7; 8:00 a.m., 6; 12:00 p.m., 4; 4:00 p.m., 3; 8:00 p.m., 2. ~MAR Medication Administration - [MEDICATION NAME] 1 tablet administered 8:29 a.m. for a pain rating of 6 which was effective. ~NN 12:28 a.m., .Resident prefers APAP (Tylenol) than the strong narcotics. Please use APAP first . ~Pain Assessment indicated Resident #9 had: Occasional labored breathing; Short periods of hyperventilation; Occasional moan or groan; Low-level speech with a negative or disapproving quality; and, Facial grimacing. [DATE] ~MAR Pain Assessments - 12:00 a.m., 0; 4:00 a.m., 2; 8:00 a.m., 4; 12:00 p.m., 4. The remainder of the day is blank. ~MAR Medication Administration - [MEDICATION NAME] 2 tablets administered at 2:15 a.m. for a pain rating of 5 which was effective. [MEDICATION NAME] 1 tablet administered at 8:45 a.m., for a pain rating of 4 which was effective. ~NN 12:45 p.m., Resident went out for f/u (follow up) appt (appointment) with ortho (orthopedics). Facility received call that resident was being admitted to hospital and having surgery on [DATE] According to hospital documentation, Resident #9 was found to have a dislocated left hip and underwent a closed reduction (put the joint back into the socket) on [DATE]. The incision started draining, and Resident #9 had a third surgery to replace the left hip again. Resident #9 expired following the third surgery. Throughout the 7 day stay, Resident #9's care plan was not updated to include any interventions related to pain relief. Pain medications were changed even though the effectiveness could not be evaluated as the medications were not given. On [DATE] at 7:30 a.m., Surveyor # spoke with RN-G (Registered Nurse) who works the night shift. RN-G stated that there is herself and one CNA (Certified Nursing Assistant) on the night shift. RN-G stated Resident #9 was alert and oriented and made his needs known. He was fine unless you moved him, then he was in a lot of pain. I know we had a hard time controlling the pain. He was sleeping a lot in his wheelchair. RN-G stated at night, staff do a quick pain assessment using the scale of ,[DATE], check the last time someone had pain medication and give it if within the time limits. If not effective, staff will try repositioning or ice. RN-G stated that the day shift does the more comprehensive pain assessments.