Every finding on record at Randolph Health Services

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This has the potential to affect all 60 residents. Dish washing was completed without testing for dishwasher temperature.DA G (Dietary Aide) was observed stacking wet dishes without allowing them ample time to dry. Evidenced by:The facility's Warewashing policy, dated 9/2017, states: All dishware, serviceware, and utensils will be cleaned and sanitized after each use. 1. The Dining Services staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine, and proper handling of sanitized dishware. 2. All dish machine water temperatures will be maintained in accordance with manufacturer recommendations for high temperature or low temperature machines.4. All dishware will be air dried and properly stored.2022 Food and Drug Administration (FDA) Food Code states:4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) Except as specified in (B) of this section, in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90 degrees Celsius (C) (194 degrees Fahrenheit (F)), or less than: (1) For a stationary rack, single temperature machine, 74 degrees C (165 degrees F); or (2) For all other machines, 82 degrees C (180 degrees F).Example 1On 3/11/26 at 12:25 PM, Surveyor observed DA H (Dietary Aide) perform dishwashing. Surveyor did not note any checks being performed of the high-temperature dishwasher's temperatures. Surveyor asked DA H if there are any checks of the machine before beginning dishwashing. DA H stated no, we check the temperature on the yellow disk at the end of dishwashing. Surveyor asked DA H if the water temperature at the start of dishwashing was known to ensure that dishes were being sanitized. DA H stated, I don't know; should we be doing this before we start?On 3/11/26 at 12:46 PM, Surveyor interviewed RDM I (Regional District Manager) and asked if temperatures are not tested prior to dishwashing, can you tell if the dishes were sanitized. RDM I stated I don't know; maybe we should start doing temperatures before the start of dishwashing.Example 2On 3/11/26 at 12:34 PM, Surveyor observed DA G (Dietary Aide) remove 2 pans from the dishwasher and place the pans together on top of other pans. Surveyor asked DA G if the pans were dry. DA G stated no, they were wet. DA G stated dishes should be dry prior to stacking them or it could cause mold.On 3/11/26 at 12:46 PM, Surveyor interviewed RDM I (Regional District Manager) who stated that wet-stacking of dishes is not allowed. Dishes need to be dry before stacking.

Based on observation, interview, and record review the facility did not ensure that residents with an indwelling catheter received the appropriate care and services to prevent infections or complications for 1 of 3 Residents (R45) reviewed for catheters.R45's urinary drainage bag was noted uncovered and sitting on the floor on two separate occasions.Evidenced by:The facility's Catheter Care policy, dated 3/15/23, states, in part: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use.2. Privacy/dignity bags will be available and catheter drainage bags should be covered or shielded at all times while in use.R45 admitted to the facility on [DATE] and has diagnoses that include: Urinary Tract Infection; Obstructive and Reflux Uropathy (a blockage of the urinary tract preventing proper drainage and backward flow of urine toward the kidneys).R45's Care Plan Report states, in part: Focus: Use of indwelling urinary catheter-foley r/t (related to) BPH (Benign Prostatic Hyperplasia-an enlargement of the prostate gland), retention, outlet obstruction.Interventions/Tasks: .Catheter collection bag placed in dignity bag holder on bed/wheelchair.On 3/10/26 at 10:39 AM, Surveyor observed R45 lying in bed with urinary drainage bag uncovered and resting on the floor.On 3/10/26 at 10:41 AM, Surveyor interviewed CNA E (Certified Nursing Assistant) and asked about a CNA's responsibility with a catheter. CNA E stated empty as needed, hang in a bag from the wheelchair or bedrail, ensure it is not touching floor. Surveyor asked CNA E about the placement of R45's catheter bag. CNA E confirmed it was on the floor and stated it should not be on the floor and it should be in a bag.On 3/12/26 at 7:55 AM, Surveyor observed CNA F entering R45's room. R45 was lying in bed with urinary drainage bag uncovered and resting on the floor. Surveyor asked CNA F about the positioning of the catheter bag. CNA F confirmed that the bag was on the floor and stated it should not be; it should be in a bag or a basin.On 3/12/26 at 8:30 AM, Surveyor interviewed DON B (Director of Nursing) and asked about catheter bags. DON B stated they need to be covered and cannot be on the floor.

Based on interview and record review, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 5 residents (R26) R26's surgical wound care was not completed as ordered.This is evidenced by:On 3/12/26, Surveyor requested a policy for following physician orders and treatments. NHA A (Nursing Home Administrator) stated the facility follows the Board of Nursing, Standards of Practice for Registered Nurses and Licensed Practical Nurses, which includes: N6.03(2)(d) Perform delegated acts under the general supervision or direction of provider.R26 admitted to the facility on [DATE] with diagnoses including resident reported skin cancer.R26's Minimum Data Set (MDS) dated [DATE], indicates R26 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R26 is cognitively intact.On 3/10/26 at 9:53 AM, Surveyor interviewed R26. Surveyor observed a wound to R26's head on the right side that had exposed bone. R26 stated he had a mole removed from the right side of his head because of skin cancer.On 3/11/26 at 10:19 AM, Surveyor interviewed LPN C (Licensed Practical Nurse) regarding R26's right side head wound. LPN C stated R26 had a [NAME] procedure done to the right side of his head.(Mohs procedure is used to treat common skin cancers by removing layers of skin until only cancer-free tissue remains)On 2/9/26, R26's faxed order from Dermatology related to R26's [NAME] Surgery states in part: Wound care for [NAME] site on scalp: Wash daily and apply Vaseline to entire wound. Wound does not need to be covered with bandage. Continue to wash daily and keep wound covered with Vaseline until new tissue has filled in and the area is healed.R26's February 2026 and March 2026 physician orders include Wound care for right scalp where [NAME] procedure was performed: Clean drainage on the skin around the wound with water and a soft cloth daily. **DO NOT USE SOAP AS IT CAN DRY THE WOUND and there is exposed bone** Clean the wound bed and wound edges with tap water two times a week. Apply LARGE amount of Vaseline to the wound every day. Keep wound covered when showering.R26's February 2026 and March 2026 Treatment Administration Record (TAR) includes clean drainage on the skin around the wound with water and a soft cloth daily. **DO NOT USE SOAP AS IT CAN DRY THE WOUND and there is exposed bone** Clean the wound bed and wound edges with tap water two times a week. Apply LARGE amount of Vaseline to the wound every day. Keep wound covered when showering. every day shift every Tue (Tuesday), Fri (Friday)Of note, the TAR only displays the treatment order on Tuesdays and Fridays and does not display the treatment to be completed on any other day. The treatment was signed as being completed only on Tuesdays and Fridays. The order from 2/9/26 indicates R26's treatment is to be done daily. On 3/11/26 at 3:52 PM, Surveyor interviewed RN D (Registered Nurse). RN D reviewed R26's TAR and treatment order and stated the treatment for R26's right side head wound is completed on Tuesdays and Fridays. RN D indicated if the Vaseline is to be completed daily, it should show on the TAR every day, not just Tuesdays and Fridays.On 3/11/26 at 4:09 PM, Surveyor interviewed DON B (Director of Nursing). DON B indicated the order was entered into the computer incorrectly and should have been entered as daily. DON B indicated the facility should have been completing R26's wound care daily and they were not.

Based on interview and record review, the facility did not ensure that all alleged violations involving misappropriation of resident funds/personal property are reported immediately to the administrator of the facility, the State agency, and to other officials, including local law enforcement, in accordance with State law through established procedures for 1 of 3 sampled residents (R3) reviewed for abuse. Facility did not report an incident of suspected resident theft/misappropriation of resident monetary funds to the local law enforcement. Evidenced by: The facility policy, entitled Abuse, Neglect, and Exploitation, reviewed 7/15/22, includes It is the policy of the facility to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property . The facility will implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property . Establish policies and procedures to investigate any such allegations; and . Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, reporting procedures, and dementia management and resident abuse prevention; and . Establish coordination with the QAPI (Quality Assurance Performance Improvement) program . Reporting/Response: The facility will have written procedures that include: Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies, for example law enforcement when applicable, within specified timeframes . Immediately, but no later than two hours after the allegation is made, if events that cause the allegation involve abuse or result in serious bodily injury, or not later than twenty four hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury . The facility policy, reviewed 8/16/22, includes: . Definitions: Crime- Section 1150 B (b) (1) of the Social Security Act provides that a crime is defined by law of the applicable political subdivision where the facility is located. A political subdivision would be a city, county, township, village, or any local unit of government created by or pursuant to State law. Policy explanation and compliance guidelines: The facility will coordinate with state and local law enforcement entities to determine what actions are considered crimes in the facility's political subdivision and will work with law enforcement to determine which crimes are reported. Example of situations that would be considered crimes in all subdivisions include, but are not limited to murder, manslaughter, rape, battery, sexual abuse, theft/robbery, drug diversion ., fraud/forgery, certain cases of abuse, neglect, and exploitation . others as required by local jurisdiction and/or specific circumstances of the incident . The facility will follow policies regarding staff treatment of residents to assure the facility is doing all that is within its control to prevent occurrences of resident abuse .misappropriation of property. This includes policies for reporting such incidents . R3 admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, type 2 diabetes mellitus with hyperglycemia, aphasia, anxiety disorder, post-traumatic stress disorder, and major depressive disorder. R3's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 4/15/25 indicates R3 is cognitively impaired with a BIMS (Brief Interview for Mental Status) score of 5 out of 15. Facility Self-Reported Incident Report, submitted 4/25/25, includes Date and Time of incident: unknown. Date discovered: 4/24/25 . Summary of Incident- Law Enforcement was not contacted. The resident was asked if he would like law enforcement to be contacted and he did not feel the need to contact law enforcement . The Administrator and Social Services Director searched the resident's room for the missing funds, with the approval of the resident and his activated power of attorney. $200 was found in a pocket of the resident's jacket, in the form of $20 bills. The resident states that this is not the money that was missing. The resident stated to the social worker on 4/24/25 that he was missing $60.00. In the same conversation, he told her that he was missing $80. In the same conversation he told her he was missing $70. When the administrator spoke with him on 4/25/25, the resident stated that he was missing $38. The resident also stated that he had a coin purse that was approximately 3 inches long. No coin purse was found by the administrator and social worker when the residence room was searched. When the administrator spoke with the activated power of attorney, he stated that the resident had a $20 bill in his night stand and some quarters in a green pill bottle. No $20 bill was found in the residence night stand. The green pill bottle was found but no quarters were in the pill bottle. The resident has funds in a safe provided by the son, and that are tracked by the facility. The only withdrawal from the account was the one most recent withdrawal for $31 that went directly to the resident. The facility is conducting resident interviews to determine if any other residents have been missing property. No other residents with missing property have been identified at this time, however, interviews are still ongoing. The facility is also collecting statements from staff who were notified of the missing funds. The facility is also interviewing staff at our facility to determine if they have seen the money in the resident's room, or if they have any indication that the money was taken from the resident. Investigation Summary, dated 4/29/25, includes Resident was admitted to the facility on [DATE] . He has an activated power of attorney . Description of Incident: On 4/24/25 Licensed Practical Nurse C, Social Services Director D, Housekeeper F, and Housekeeper E were notified that R3 was missing monetary funds that were kept in his room. R3 initially shared . it was $60 missing. In the same conversation he noted it was $80 missing, and later in the conversation noted that $70 was missing. The administrator was notified that the resident was missing monetary funds that were kept in his room. R3 shared with the administrator that $31 was unaccounted for. The Administrator and Social Services Director searched for the funds in the resident's room with permission from the resident, while the resident was in the room. The search of the room was unsuccessful in finding the monetary funds. R3 was notified that the center would be submitting a report to the state on the incident, asked if he felt someone had taken the funds, and asked if he would like law enforcement to be notified. R3 stated that he did not want to notify law enforcement. Results of investigation: the administrator and social services director performed random resident interviews for residents residing in all sections of the skilled nursing facility to determine if any other residents were missing monetary funds or other items of personal property. The administrator also obtained statements from staff who were notified of the missing funds on 4/24/25. The administrator spoke with the residents power of attorney . and the power of attorney notified the administrator that there was a $20 bill in the top drawer of his night stand and some quarters in a green bottle in the top shelf. It was found that the resident pulled $31.00 from his funds that his power of attorney leaves in the facility safe for the resident if he needs or wants it. It cannot be determined if these funds were used by the resident or if the funds were in his room. These funds were unable to be located. The power of attorney noted that he would not like law enforcement to be notified. The power of attorney was notified that the administrator submitted a report to the state and would be performing an investigation in house to hopefully determine the cause of the missing funds. Conclusion: Based on interviews and the investigation the facility cannot establish that there is any evidence of non-compliance. After an exhaustive search and thorough investigation, it could not be determined if money was ever in the residence possession, if money was taken from the residence room, if so, by whom, and how much was actually missing. The facility will continue to closely monitor resident and resident activity that may indicate theft of resident property. The resident has been reminded that his monetary funds can be kept in the safe at the facility for safekeeping. The resident is content with the results of this investigation and will be informed if any further information is found. Facility Self-Reported Incident Report, submitted 4/30/25, includes Date occurred- (unknown) . Date discovered- 4/24/25 . The administrator and social services director searched the resident's room for the missing funds, with the approval of the resident and his activated POA. R3 initially shared with Social Services Director D that it was $60 missing. In the same conversation he noticed it was $80 missing, and later in the conversation noted that $70 was missing. When the administrator spoke with him, the resident stated that he was missing $38. When the administrator spoke with the activated power of attorney ., he stated that the resident had a $20 bill in his nightstand and some quarters in a green pill bottle. No $20 bill or quarters were found in the resident's nightstand. The facility conducted staff and resident interviews and gathered some staff statements. After an exhaustive search and thorough investigation, it could not be determined if money was ever in the resident's possession, if money was taken from the resident's room, if so, by whom, and how much was actually missing . The resident was initially upset by the encounter. However, shortly after, the resident expressed that it was just a little bit of money. I am not worried about it. The resident expressed that he would not like law enforcement to be notified and that he was not concerned over the incident. The resident's son (Power of Attorney) also expressed that he is not upset by the incident, and that he would not like law enforcement to be notified. Upon learning of the incident, the administrator and social services director interviewed numerous residents to identify if any other residents were missing personal property. The administrator and social services director also received written statements from the staff who were notified of the incident and interviewed other staff to determine if any staff members have seen money in the resident's room. It was found that no staff members interviewed had seen money in the resident's room. On 5/6/25 at 11:00 AM NHA A (Nursing Home Administrator) indicated R3 thought someone may have taken his money and she never reported it to local law enforcement. On 5/6/25 at 11:39 AM NHA A indicated stealing is a crime. NHA A indicated it was only $20 and R3 and his power of attorney did not want the facility to call local law enforcement. NHA A indicated she was not sure how much money missing would warrant a call to local law enforcement. NHA A indicated the facility has never coordinated with the local law enforcement to create a policy and procedure for reporting crime in their jurisdiction. NHA A indicated she does not need family or resident's permission to follow the facility abuse policy and procedures. NHA A indicated she understands that the local law enforcement is a resource for the residents and by calling them, she would be giving the local law enforcement a chance to decide whether they would conduct an investigation on behalf of the resident, or if they would just document it, or if they would not get involved at all. NHA A indicated by not calling local law enforcement to report, the resident is denied the resource of having local law enforcement involved.

Based on observation, interview, and record review the facility did not ensure the resident environment remains as free of accidents/hazards as is possible for 2 of 2 sampled residents (R56, R23) reviewed for accidents/hazards and 3 supplemental residents (R111, R37, R7). R56 is a cognitively impaired resident who fell out of bed onto the heat register and was there for an unknown amount of time, unable to remove herself off of the register, and sustained second- and third-degree burns. The facility made a policy for beds to remain more than 18 inches from the heat register. Surveyors observed R23, R111, R37, and R7 lying in beds that were less than 18 inches away from the heat register in the room. The facility also failed to implement a system for monitoring the surface temperature of the heat registers after the incident occurred. The facility's failure to ensure all staff follow proper safety interventions and the facility's policy of keeping residents who are in bed at least 18 inches from the heat registers and failure to implement a system of monitoring the surface temperatures of the registers led to a finding of immediate jeopardy that started on 10/15/24. Surveyor notified NHA A (Nursing Home Administrator) and DON B (Director of Nursing) of the Immediate Jeopardy on 12/12/24 at 11:29 AM. The Immediate Jeopardy was removed on 12/12/24; however, the deficient practice continues at a scope/severity of an E (potential for more than minimal harm/pattern) as the facility continues to implement its removal plan. Evidenced by: R56 admitted to the facility on [DATE] with the following diagnoses: Congestive Heart Failure, AFIB (atrial fibrillation/arrhythmia of the heart), coronary artery disease, a history of heart attack, peripheral vascular disease (decreased circulation), Cognitive Communication Deficit, and anxiety disorder. R56's Comprehensive Care Plan, initiated 7/7/22, includes nursing will provide assistance as needed for transfers and ambulation. Uses walker and wheelchair for long distance . repositioning: 1 assist . Resident needs assistance with all aspects of care . Resident requires 2 staff assist with gait belt to transfer . Alternating pressure air mattress applied to bed on 9/25/24 . R56's Immediate Plan of Care, dated on 9/20/24 . Advancing disease process, generalized debilitation, resident will remain comfortable and maintain adequate/desired level of physical, mental, and spiritual comfort through either verbal or nonverbal expressions and/or family/responsible person's communication with staff. R56's Nurse Note, dated 9/23/24, includes Resident is alert and oriented x1, not able to make needs known, staff regularly checks on resident. Heart is regular, 2+ pitting edema to BLE (bilateral lower extremities) despite elevating feet. Lungs are clear, no congestion noted - resident does not take deep breaths and as an occasional cough. Resident is requiring 3 liters per minute of oxygen to maintain saturations . Resident transfers with a 1-person pivot to wheelchair. Resident has increasing weakness d/t decline and has been in bed for the day, resident is repositioned every 2 hours and as needed. Resident is on a mech soft diet with thin liquids but has a poor appetite. Resident is drinking well. Resident has no verbal complaints of pain, but prior to getting her scheduled morphine appears to be uncomfortable. R56's Care Plan entry, added 9/25/24, indicates an alternating pressure air mattress was applied to R56's bed. R56's Nurses Notes, dated 9/30/24, includes Resident has been resting comfortably in bed for shift. Repositioned every 2 hours and as needed. Fluids have been encouraged; appetite is poor. She did take all medications this shift. R56's Nurses Notes, dated 10/2/24, includes Resident slept majority of the shift today. Was repositioned every 2 hours and as needed. Resident is encouraged to drink fluids but has very poor appetite. Resident did not get out of bed this shift. R56's Nurses Notes, dated 10/6/24, includes Resident continues to decline . Family visiting most of the day. No food accepted and only small amounts of fluids . Resident is side to side repo every 2 hours. Staff anticipate needs. R56's Post Fall Assessment, dated 10/15/24, includes date and time of fall-10/15/24 at 7:05 AM . safety measures in place at time of the fall- proper footwear, scoop mattress . R56's Emergency Department Notes, dated 10/15/24, include Patient presents for evaluation of burns to the right side of her body. She lives at (Facility Name). She has an extensive past medical history and . is currently . comfort measures only . the patient (had a) fall . she was leaning against the register for an unknown period of time when she was found by her daughter who actually works there as a cleaner . the patient arrives by ambulance. The daughter is here with her. The daughter wishes to have her burns evaluated and treated. She is not interested in evaluation for any of her other multiple chronic problems which she is already on comfort measures for. Patient is nonverbal and unable to provide any type of history. Patient is already on lorazepam and morphine as per comfort measures protocol. Assessment/plan: wound 1: partial thickness burns of right upper arm. Order: Emollient Ointment . one application topical two times a day . wound 2: partial thickness burn of multiple sites of trunk. Order: Emollient Ointment . one application topical two times a day . 3. Partial thickness burns of right thigh . Order: emollient ointment one application topical 2 times a day . Medication administered during visit valiant cream one application topical and morphine 30 milligrams oral . R56's Wound MD (Medical Doctor) Note, dated 10/16/24, includes: Site 1 Burn wound of the right arm partial thickness: wound size 23.5cm (centimeters) by 8cm by 0.1 centimeters . exudate: light serosanguinous . Treatment plan: primary Xeroform gauze . once daily for 30 days . secondary ABD pad (type of medical dressing) once daily for 30 days . Site 2 burn wound of right hip partial thickness: wound size 18cm by 25cm by 0.1cm . exudate light serosanguinous . Treatment plan: primary Xeroform gauze . once daily for 30 days . secondary ABD pad once daily for 30 days . Site 3 burn wound of right abdomen full thickness: wound size 17cm by 9cm by 0.05 cm . exudate: none . Treatment plan: triple antibiotic ointment once daily for 30 days . (It is important to note R56 current evaluation of R56's abdominal wound now a full thickness burn.) On 12/11/24 at 11:48 AM, RR P (Resident Representative) indicated she found R56 on the floor between the bed and the wall with the right side of her body in contact with the bed and the heat register. RR P indicated R56 was face down on her forearms and her knees. RR P indicated she then went to the hallway where the nurse was located and retrieved her. On 12/11/24 at 12:18 PM, RN H indicated RR P asked her to come check on R56 and when she got there, she found R56 on the floor pinched between her bed and the wall/ RN H indicated R56's right side of her body was in direct contact with the heat register. RN H indicated she and a CNA (Certified Nursing Assistant) moved the bed away and turned R56 to her side and then on her back and slid a pillow under her head for support. RN H indicated she could see reddened areas on R56's knees, forearms, and burns on her right side. RN H stated, The bed and the register held her upright and was not able to move herself away from the heat source. RN H indicated staff are to keep the beds at least 18 inches away from heat registers. On 12/11/24 at 9:24 AM, Surveyor asked Maintenance Director M for an infrared thermometer. Maintenance Director indicated the facility did not have one. Maintenance Director M indicated he was not monitoring the surface temperature of the heat registers. On 12/11/24 at 9:25 AM, Surveyors observed surface temperatures of the heat registers by touching the register with their hand and recording after 1 minute, after 3 minutes, and after 5 minutes. In total 5 heat registers were hot to the touch. Surveyors also observed a total of 11 beds that were closer than 18 inches to the heat register. Of the 11 beds observed 4 residents were in their bed at the time of the observation. They are as follows: R111 admitted to the facility on [DATE]. Her diagnoses include cutaneous abscess of left lower limb and weakness . R111's Activities of Daily Living (ADLs) Care Plan, initiated 12/10/24, includes ADL self-care deficit as evidenced by weakness related to left thigh abscess . Bed mobility: Assist of 1 . may need assistance getting legs into bed . On 12/11/24 at 9:26 AM, Surveyor observed R111 in bed and R111's bed to be about 12 inches away from the heat register. On 12/11/24 at 9:30 AM, Surveyor observed Scheduler Q enter R111's room and move her bed farther away from the heat register. On 12/11/24 at 9:41 AM, R111 motioned for Surveyor to enter room and told Surveyor that staff just came in and moved the bed while she was in it to be away from the heating unit. On 12/11/24 at 1:00 PM, Scheduler Q indicated she moved R111's bed further away from the heat registers because she saw Surveyors measuring distance and recording surface temperatures of the heat registers. Scheduler Q indicated beds are to be at least 18 inches away from the heat registers. R7 admitted to the facility on [DATE]. Her diagnoses include complication of internal fixation device of left femur, COPD (Chronic Obstructive Pulmonary Disease), and Chronic respiratory failure with hypoxia. R7's ADLs Care Plan, initiated 11/22/24, includes ADL self-care deficit as evidenced by weakness related to recent hip surgery . underwent left total hip replacement for failed intramedullary nailing of left hip from fracture (situation where a surgical procedure to fix a broken hip using an intramedullary nail has not been successful) . Bed mobility: assist of 1. On 12/11/24 at 9:26 AM, Surveyor observed R7 in bed. R7's bed was located less than 18 inches away from the heat register. On 12/11/24 at 1:00 PM, Scheduler Q indicated she moved R7's bed, further away from the heat registers because she saw Surveyors measuring distance and recording surface temperatures of the heat registers. Scheduler Q indicated beds are to be at least 18 inches away from the heat registers. R37 admitted to the facility on [DATE]. His diagnoses include Alzheimer's disease, unsteadiness on feet, muscle weakness, dementia, and dysphagia. R37's ADLs Care Plan, initiated 6/27/22, includes Resident has impaired functional mobility as evidenced by chronic condition (Congestive Heart Failure Exacerbation), cognitive deficit . Resident requires sit to stand lift with transfers and the blue sling . On 12/11/24 at 9:27 AM Surveyor observed R37 in bed and his bed was about 12 inches from the heat register. On 12/11/24 at 1:00 PM Scheduler Q indicated she moved R37's bed further away from the heat registers because she saw Surveyors measuring distance and recording surface temperatures of the heat registers. Scheduler Q indicated beds are to be at least 18 inches away from the heat registers. R23 admitted to the facility on [DATE]. Her diagnoses include hemiplegia and hemiparesis, scoliosis, polyneuropathy, generalized anxiety disorder, psychotic disorder, vascular dementia, and obesity. R23's ADL Care Plan, initiated 5/26/21, includes Resident has impaired functional mobility as evidenced by . fall resulting in femur fracture, obesity, depression, anxiety, insomnia, chronic pain, hemiplegia/hemiparesis post CVA (stroke), . Resident requires 2 staff assist for transfer . (This care plan does not include bed mobility status) . On 12/11/24 at 9:35 AM Surveyor observed R23 to be in her bed and her bed to be closer than 18 inches to the heat register. On 12/11/24 at 10:09 AM R23 told Surveyors that Scheduler Q had come in after them and moved her bed away from the heat register without an explanation. On 12/11/24 at 1:00 PM, Scheduler Q stated, I moved R23's bed because it has to be 1.5 tiles away from the register. I saw you guys in there and saw it was too close. Scheduler Q indicated the beds get moved when CNAs (Certified Nursing Assistants) use mechanical lifts and forget to move them back. On 12/11/24 at 1:04 PM, CNA N and CNA O indicated sometimes the registers are hot, especially the bathroom registers. CNA N and CNA O indicated they move the beds at times to fit a mechanical lift in the space and forget to move them back away from the heat register. On 12/12/24 at 11:29 AM, NHA A (Nursing Home Administrator) and DON B (Director of Nursing) indicated the facility does not have a system in place for monitoring the surface temperature of the heat registers. DON B and NHA A indicated staff are to keep the beds at least 18 inches away from the heat registers. The facility's failure to ensure surface temperatures of heat registers are at a safe temperature, ensure all staff follow proper safety interventions and keeping residents who are in bed at least 18 inches from the heat registers. These failures created a reasonable likelihood for serious harm to occur, thus leading to a finding of immediate jeopardy. The immediate jeopardy was removed on 12/12/24 when the facility began implementing the following: Environmental rounds were completed by the ED/designee on 12/12/2024 to ensure no bed was in close proximity to heating unit. In consultation with the DON, rooms were rearranged if necessary. One resident with immobility and obesity issues was relocated to a private room to allow for larger safety perimeter between bed and heating unit. Resident's care plan was updated to reflect rationale for private room. One resident with obesity and multiple co-morbidities bed was moved out further to allow for a larger safety perimeter between bed and heating unit. Resident's care plan was updated to reflect rationale for this. ED/designee to complete environmental rounds/audits daily x 2 weeks then 3x per week through the remainder of the heating season to ensure beds/chairs/furniture not close to heating units where a resident's skin could come in contact. Results of rounds/audits will be brought to QAPI for tracking/trending and further recommendations, as necessary and appropriate. Discussion regarding noted concern and removal plan reviewed with Medical Director and ad hoc QAPI meeting held on 12/12/2024. Re-education initiated on 12/12/2024 with center staff (including PRN and agency staff if applicable) to reinforce that anytime the side of a bed is noted to be too close to a heater/heating unit (where a resident's skin could come in contact with the unit), to move it away and to alert the ED/DON for follow up. If bed needs to be moved to accomplish cares, be sure to move bed back away from the heater upon completion of cares. This re-education will be completed by the DON/designee and will be completed prior to the next scheduled shift. On 12/12/2024, ED/VPS, DON, and Maintenance Director reviewed policy Accidents and Supervision. Policy meets current standard of practice. ED/designee to complete environmental rounds/audits daily x 2 weeks then 3x per week through the remainder of the heating season to ensure beds/chairs/furniture not close to heating units where a resident's skin could come in contact. Results of rounds/audits will be brought to QAPI for tracking/trending and further recommendations, as necessary and appropriate. Discussion regarding noted concern and removal plan reviewed with Medical Director and ad hoc QAPI meeting held on 12/12/2024.

Based on observation, interview, and record review, the facility did not ensure that residents admitted without a pressure injury (PI) did not develop pressure injuries unless clinically unavoidable and did not ensure residents are provided cares and services consistent with professional standards of practice to prevent the development of PI for 1 of 4 residents (R22) reviewed for pressure injuries. R22 developed a stage 3 PI on his coccyx. The facility failed to implement a turning/ repositioning schedule that staff adhered to in order to prevent a stage 3 pressure injury and a second pressure injury from developing. Staff also did not implement the wound care treatment orders that were ordered by the physician. Evidenced by: The American Medical Directors Association (AMDA) clinical practice guideline entitled, 'Pressure Ulcers and Other Wounds,' dated 2017, states in part: .A pressure ulcer (Injury) is localized damage to the skin or underlying soft tissue, usually over a bony prominence or related to a medical or other device. The ulcer may present as intact skin or as an open ulcer and may be painful. The ulcer occurs as a result of intense or prolonged pressure or pressure in combination with shear .Recognition: Early recognition of pressure ulcers and of any risk associated with the development of pressure ulcers and other wounds is critical to their successful prevention and management .Assessment: The purpose of the assessment is to collect enough information to evaluate the patient's general condition, characterize a pressure ulcer; and identify related causes and complications. The National Pressure Injury Advisory Panel (NPIAP) at www.NPIAP.com defines PIs in the following categories: Category/Stage II: Partial thickness loss - Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or serosanguinous filled blister. Category/Stage III: Full thickness skin loss - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The facility's policy titled Pressure Injuries and Non pressure Injuries last reviewed on 7/20/2022, states in part .Stage 3 Pressure Injury: Full- thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present .Additional Skin Impairment Definitions: Moisture Associated Skin Damage: inflammation of the skin and erosion from prolonged exposure to moisture and its [sic] contents. Common sources of moisture include urine and stool, perspiration, wound exudate, and effluent from an ostomy .2. Weekly: a. Complete a head-to-toe skin check and document findings on the Skin Review .If new areas are present: i. notify MD (Medical Doctor) ii. Notify resident/ responsible party iii. Initiate treatment per order . R22 was admitted to the facility on [DATE] with diagnoses that include heart failure, chronic kidney disease stage 2 (long term condition where the kidneys become damaged), and peripheral vascular disease (disorder that affects blood vessels). R22's most recent Minimum Data Set (MDS) dated [DATE] states that R22 has a Brief Interview of Mental Status (BIMS) of 11 out of 15, indicating that R22 is mildly cognitively impaired. R22's MDS also indicates that R22 is dependent on staff for toileting, bathing, lower body dressing, and transfers and requires substantial/ maximal assistance in rolling from side to side in bed. R22's care plan dated 6/15/23 states in part: .Focus: At risk for alteration in skin integrity related to: limited mobility. Goal: Skin will remain intact, free from erythema (redness of the skin), breakdown, or bruising until next review. Interventions/ Tasks: Air Mattress (date initiated: 11/12/24). Barrier cream to peri area/ buttocks as needed. Encourage to reposition as needed; use assistive devices as needed. Float heels as able. Use pillows/ positioning devices as needed. Wheelchair arm adjustment, reassess with padding needs . R22's care plan dated 11/13/24 states in part: .Focus: The resident has a pressure ulcer on sacrum r/t (related to) immobility. Goals: The resident's pressure ulcer will show signs of healing and remain free from infection by/ through review date. Interventions/ Tasks: Administer medications as ordered. Monitor/ document for side effects and effectiveness. Administer treatments as ordered and monitor for effectiveness. Educate the resident/ family/ caregivers as to cause of skin breakdown; including: transfer/ positioning requirements; importance of taking care during ambulating/ mobility, good nutrition, and frequent repositioning. Follow facility policies/ protocols for the prevention/ treatment of skin breakdown. If the resident refuses treatment, confer with the resident, IDT (Interdisciplinary Team) and family to determine why and try alternative methods to gain compliance. Document alternative methods. Inform the resident/ family/ caregivers of any new area of skin breakdown. Monitor dressing every shift and PRN (as needed) to ensure it is intact and adhering. Report lose [sic] adhering dressing to treatment nurse . The facility's document titled Repositioning Tracker B Wing is a document completed by the CNAs on the unit and lists the residents name, need, Night Aides & Nurse, Day Aides & Nurse, and PM Aides & Nurse. The form instructs staff to indicate the times that the residents were repositioned (R), toileted (T), toileted and repositioned (T/R), and if heels were floated (F). It is important to note that the documentation provided does not include what task was provided for R22. The standard of practice is to reposition every 2 hours. The Repositioning Tracker for R22 states that the need is to check/ change/ repo (reposition) Q (every) 2 hrs. (hours). The following is documentation of non-compliance (it is important to note the night shift is listed first on the document): October 4, 2024: 4:00 AM, 6:30 AM, 9:00 AM, 11:10 AM, 12:45 PM, 4:20 PM, 6:30 PM, 8:45 PM. October 5, 2024: 11:30 PM . 10:00 AM, 12:30 PM, 2:30 PM, 4:50 PM, 6:00 PM, 8:00 PM October 6, 2024: 11:00 PM .6:15 AM, 8:40 AM .3:30PM, 6:00 PM October 7, 2024: 6:45 AM, 9:30 AM .1:15 PM, 3:45 PM, 5:00 PM, 7:30 PM, 9:40 PM October 8, 2024: 11:30 PM, 2:00 AM, 4:30 AM .10:00 AM, 12:30 PM October 9, 2024: 11:30 PM, 2:10 AM .6:30 AM, 9:00 AM, 10:45 AM, 11:00 AM, 4:00 PM October 10, 2024: 11:35 PM, 2:05 AM, 4:15 AM, 6:30 AM, 9:30 AM October 11, 2024: 11:05 PM, 1:35 AM, 4:05 AM, 7:30 AM, 9:40 AM, 11:50 AM, 12:20 PM, 1:05 PM, 3:25 PM October 12, 2024: 8:00 AM, 10:15 AM .3:00 PM, 5:30 PM, 7:30 PM, 9:30 PM October 13, 2024: 12:00 AM .6:45 AM, 9:00 AM, 11:15 AM, 1:15 PM, 4:30 PM October 15, 2024: 11:05 PM, 1:35 PM, 4:05 AM .10:00 PM October 16, 2024: 1:00 AM, 3:30 AM October 17, 2024: 11:05 AM, 1:35 AM, 4:10 AM, 6:20 AM .3:00 PM, 5:25 PM, 8:00 PM, 9:15 PM October 18, 2024: 12:00 AM, 2:00 AM, 4:00 AM, 6:05 AM .10:00 PM October 19, 2024: 12:00 AM, 2:30 AM, 5:00 AM .2:00 PM, 4:45 PM, 6:50 PM, 8:50 PM October 20, 2024: 11:00 PM .12:00 PM, 2:30 PM .9:00 PM October 21, 2024: 11:10 PM, 1:15APM, 3:15 AM, 5:30 AM, 7:30 AM, 9:15 AM, 4:00 PM, 7:00 PM, 9:00 PM October 22, 2024: 12:00 AM, 2:30 AM, 5:00 AM .12:30 PM, 3:00 PM, 5:30 PM October 24, 2024: 6:00 AM, 8:40 AM, 10:00 AM, 12:30 AM .4:00 PM, 6:20 PM .9:30 PM October 25, 2024: 12:00 AM .6:00 AM, 8:30 AM, 11:00 AM October 26, 2024: 4:00 AM, 6:20 AM .12:20 AM, 2:30 AM, 4:50 AM .8:30 PM October 27, 2024: 11:05 PM, 1:30 AM, 3:50 AM, 6:00 AM, 12:30 PM, 2:00 PM, 4:10 PM, 6:10 PM, 9:10 PM October 28, 2024: 12:00 AM, 2:30 AM, 5:00 AM, 7:30 AM, 9:00 AM, 11:45 AM October 29, 2024: 11:05 PM, 1:35 AM, 3:50 AM, 7:00 AM .4:00 PM, 7:00 PM October 31, 2024: 6:10 AM, 8:15 AM, 10:45 AM .8:30 PM November 1, 2024: 12:00 AM, 2:30 AM, 5:00 AM November 2, 2024: 7:00 AM, 10:00 AM, 12:30 PM November 3, 2024: 6:00 AM, 8:30 AM November 4, 2024: 9:00 AM, 12:00 PM .9:00 PM November 5, 2024: 12:00 AM .9:15 AM, 11:30 AM November 8, 2024: 11:05 PM, 1:35 AM, 3:50 AM, 7:00 AM, 9:30 AM November 9, 2024: 3:55 AM, 6:15 AM, 8:30 AM November 10, 2024: 12:15 AM, 4:35 AM, 2:05 PM, 4:15 PM, 6:30 PM, 8:50 PM- (it is important to note that the entire day shift row is documented with a check mark and no times.) November 11, 2024: 7:30 AM, 9:45 AM November 12, 2024: 12:00 AM, 2:30 AM, 6:00 AM .10:00 PM November 13, 2024: 12:10 AM .6:45 AM, 9:15 AM November 15, 2024: 12:00 AM, 2:30 AM, 5:00 AM, 7:30 AM, 9:45 AM November 16, 2024: 12:50 PM, 3:00 PM November 18, 2024: 12:00 AM, 2:30 AM, 5:00 AM, 7:30 AM November 20, 2024: 5:30 AM, 8:00 AM November 22, 2024: 6:00 AM, 8:15 AM, 10:30 AM, 12:45 AM November 23, 2024: 1:00 AM, 3:30 AM .6:45 AM, 9:30 AM, 12:30 PM November 24, 2024: 1:00 AM, 4:00 AM November 25, 2024: 6:35 AM, 9:15 AM, 11:30 AM, 1:25 PM, 4:00 PM November 26, 2024: 4:00 AM, 6:10 AM, 8:40 AM, 10:00 AM, 12:15 PM November 27, 2024: 6:00 AM, 8:30 AM .10:00 PM November 28, 2024:12:10 AM, 2:10 AM, 4:10 AM, 8:00 AM .11:30 AM, 2:00 PM November 29, 2024: 1:10 AM, 3:40 AM, 6:00 AM November 30, 2024: 11:00 PM, 1:40 AM, 3:55 AM, 6:15 AM, 9:00 AM, 12:45 AM, 4:00 PM December 2, 2024: 12:10 AM, 2:40 AM, 5:10 AM .9:00 PM December 3, 2024: 12:10 AM, 2:40 AM, 5:10 AM, 6:00 AM, 9:00 AM .3:00 PM, 7:00 PM December 4, 2024: 11:10 PM, 1:40 AM, 4:10 AM, 8:00 AM, 10:45 AM .9:00 PM December 5, 2024: 11:45 PM, 2:15 AM, 4:45 AM, 6:50 AM, 8:15 AM, 10:20 AM December 6, 2024: no documentation provided. December 7, 2024: 6:00 AM, 9:00 AM, 11:00 AM, 1:10 PM .9:00 PM December 8, 2024: 12:00 AM .7:00 AM, 10:00 AM, 12:45 AM December 9, 2024: 6:30 AM, 8:45 AM, 10:30 AM, 1:10 PM December 10, 2024: no documentation provided. December 11, 2024: 2:00 AM, 4:30 AM, 6:00 AM, 8:30 AM December 12, 2024: 4:00 AM, 6:20 AM, 9:20 AM Weekly skin assessment dated [DATE] does not indicate that R22 had any redness to his coccyx. Weekly skin assessment dated [DATE] states that resident has redness to his coccyx. Nurse's note dated 11/7/24 at 1:31 PM states in part .Resident noted to have excoriated areas to sacrum from incontinent dermatitis. Peri-wound is pink and blanchable. MD updated and new tx (treatment) order noted . MD order dated 11/7/24 states Cleanse excoriated areas to sacrum and apple [sic] small pieces of calcium AG and cover area with sacral dressing every day shift every 3 days for Incontinent Dermatitis. It is important to note that Calcium alginate dressings are used in advanced wound care for the management of highly draining wounds. These dressings are derived from seaweed and are highly absorbent, making them ideal for wounds with moderate to heavy exudate. They conform to wound beds easily and gel upon contact with wound fluid, providing a moist environment conducive to healing. The fibers swell in response to moisture, transforming into a gel-like material that promotes moisture balance and facilitates natural healing. They are typically applied to diabetic wounds, venous wounds, burns, ulcers, and other wound types. There is no indication of having moderate to heavy exudate from the area or if the excoriated area itself was blanchable. Weekly skin assessment dated [DATE] states that resident has a small open area to his coccyx. Wound measurements and documentation completed by the Wound MD and ADON (Assistant Director of Nursing) are as follows: On 11/13/24: .Stage 3 Pressure Wound Sacrum Full Thickness: .Wound size (L (Length) x W (Width) x D (Depth)): 4.5 x 2.5 x 0.2 cm (centimeters). Surface Area: 11.25cm. Exudate: Moderate sero-sanguinous. Thick adherent devitalized necrotic tissue: 10%. Granulation tissue: 90%. Expanded Evaluation Performed: .Recommend upgrading off-loading devices in bed and/ or chair .Dressing Treatment plan: leptospermum honey apply once daily for 30 days. Alginate calcium apply once daily for 30 days .Gauze Island w/ bdr (border) apply once daily for 30 days . It is important to note that the leptospermum honey was not added to R22's treatment orders, therefor was not performed. 11/20/24: .Stage 3 Pressure Wound Sacrum Full Thickness: .Wound size (L x W x D): 3 x 1 x 0.2 cm. Surface Area: 3.0 cm. Exudate: Moderate sero-sanguinous. Thick adherent devitalized necrotic tissue: 10%. Granulation tissue: 90% . Dressing Treatment plan: leptospermum honey apply once daily for 23 days. Alginate calcium apply once daily for 23 days .Gauze Island w/ bdr (border) apply once daily for 23 days . It is important to note that the leptospermum honey has not been added to R22's treatment orders, therefor was not performed. 11/27/24: .Stage 3 Pressure Wound Sacrum Full Thickness: .Wound size (L x W x D): 2.8 x 0.7 x 0.2 cm. Surface Area: 1.96 cm. Cluster wound: open ulceration area of 1.57 cm. Exudate: Moderate sero-sanguinous. Granulation tissue: 80%. Skin: intact normal color 20% .Dressing Treatment plan: leptospermum honey apply once daily for 16 days. Alginate calcium apply once daily for 16 days .Gauze Island w/ bdr (border) apply once daily for 16 days . It is important to note that the leptospermum honey was not added to R22's treatment orders, therefor was not performed. 12/4/24: .Stage 3 Pressure Wound Sacrum Full Thickness: .Wound size (L x W x D): 3.0 x 0.5 x 0.2 cm. Surface Area: 1.50 cm. Cluster wound: open ulceration area of 1.20 cm. Exudate: Moderate sero-sanguinous. Granulation tissue: 80%. Skin: intact normal color 20% .Dressing Treatment plan: leptospermum honey apply once daily for 9 days. Alginate calcium apply once daily for 9 days .Gauze Island w/ bdr (border) apply once daily for 9 days . It is important to note that the leptospermum honey was not added to R22's treatment orders, therefor was not performed. 12/11/24: .Stage 3 Pressure Wound Sacrum Full Thickness: .Wound size (L x W x D): 2.7 x 0.5 x 0.2 cm. Surface Area: 1.35 cm. Cluster wound: open ulceration area of 1.08 cm. Exudate: Moderate sero-sanguinous. Granulation tissue: 80%. Skin: intact normal color 20% .Dressing Treatment plan: leptospermum honey apply once daily for 30 days. Alginate calcium apply once daily for 30 days .Gauze Island w/ bdr (border) apply once daily for 30 days . It is important to note that the leptospermum honey was not added to R22's treatment orders, therefor was not performed. Of note, R22 developed and additional pressure injury below the original pressure injury and is labeled as a cluster wound. Additionally, the cluster wound is not captured on the facility's Pressure Injury Weekly Tracker. On 12/12/24 at 8:55 AM, Surveyor interviewed CNA E (Certified Nursing Assistant). Surveyor asked CNA E how often R22 is to be repositioned. CNA E reviewed R22's Kardex and reported that R22 should be repositioned every 1.5- 2 hours. Surveyor asked CNA E if they document every time R22 is repositioned, CNA E reported yes. Surveyor asked CNA E what time R22 was last repositioned, CNA E stated that the night shift CNA repositioned R22 at 6:20 AM and that she has not repositioned him since. Surveyor asked CNA E what time should R22 have been repositioned, CNA E stated 8:20 AM. On 12/12/24 at 10:20 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what steps are taken when a resident is noted to have a new skin concern, DON B reported that staff should assess it, update the MD and family, get a treatment order, complete a RCA (Root Cause Analysis) on it, and put in place interventions. Surveyor asked DON B when it was noted that R22 had redness to his coccyx, would she expect the nurse to complete an assessment, DON B stated yes. Surveyor asked DON B if, on 11/7/24, when it was documented that R22 had an excoriated area related to incontinent dermatitis, if the documentation indicates that the excoriated area was blanchable, DON B stated no. Surveyor asked DON B what the standard of practice treatment is for MASD (Moisture Associated Skin Damage), DON B states a barrier cream and good peri-care with incontinence episodes. Surveyor asked if calcium alginate is typically used for MASD, DON B stated usually not. Surveyor asked DON B if there was any documentation on the characteristics of the area between 11/7/24 and 11/13/24, DON B stated no. Surveyor asked DON B when the pressure injury was noted to be open, DON B stated that she was unsure. Surveyor asked DON B what the expectation is for repositioning R22, DON B reported that according to the Kardex, R22 should be turned and repositioned every 1.5- 2 hours. Surveyor asked DON B if she would expect that to be done, DON B stated yes. Surveyor asked DON B where the CNAs document repositioning, DON B provided Surveyor with Repositioning Tracker B Wing. Surveyor reviewed the documentation and noted that several dates had all residents on the hall being repositioned at the same time, as well as R22 frequently being repositioned longer than every 2 hours. Surveyor asked DON B if she would expect the CNAs to document accurately, DON B stated yes. Surveyor reviewed the Repositioning Tracker with DON B and asked how it would be possible for all the residents to be repositioned at the exact same time, DON B reported that she was not sure. On 12/12/24 at 11:14 AM, Surveyor completed a wound care observation with UM F (Unit Manager). During wound care, Surveyor noted that R22 had 2 pressure injuries to his coccyx, one below the other. Surveyor asked UM F if R22 has 2 pressure injuries, UM F stated yes, one upper and one lower on the coccyx. Surveyor asked UM F what stage the 2 pressure injuries were, UM F stated that she couldn't really say. Surveyor asked UM F if she was aware that R22 had 2 open areas prior to wound care, UM F stated no. It important to note that UM F is Wound Care Certified. On 12/12/24 at 11:25 AM, Surveyor interviewed IP C (Infection Preventionist), who is also the ADON (Assistant Director of Nursing) and accompanies the Wound Care MD on weekly wound rounds. Surveyor asked IP C if she knew that R22 had a new pressure injury, IP C stated that she did not know because she was holding R22 but stated that the MD may have mentioned something about a cluster wound. Surveyor asked IP C if the documentation indicates that R22 has 2 open areas, IP C stated that it has always been her understanding that there has only been 1 area. On 12/12/24 at 1:24 PM, Surveyor interviewed UM G. Surveyor asked UM G how often should R22 be repositioned, UM G reviewed R22's Kardex and reported that R22 should be repositioned every 1.5- 2 hours. Surveyor asked UM G if she would expect the CNAs to document accurately, UM G stated yes. Surveyor asked UM G if she would expect that R22 be repositioned every 1.5- 2 hours, UM G stated yes. On 12/12/24 at 1:53 PM, Surveyor interviewed DON B. Surveyor asked DON B if she would expect staff to know that R22 has 2 open areas on his coccyx, DON B stated yes. The facility failed to implement a turning/ repositioning schedule that staff adhered to in order to prevent a stage 3 pressure injury and a second pressure injury from developing. Staff also did not implement the wound care treatment orders that were ordered by the Wound care physician.

Based on observation, interview, and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect all 58 residents. The facility does not maintain a resident infection control line list that contains residents displaying signs and symptoms of potential infection. The facility's COVID Outbreak 3/2024 summary is not complete or accurate. R31 had a breach in infection control during medication administration observation when a nurse picked up the resident's nasal cannula for oxygen from the floor and placed it into the bag on the portable oxygen tank. This is evidenced by: The facility's Infection Prevention and Control Program policy, dated 7/23/24, states in part: Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.3. Surveillance: a. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards.9. Equipment Protocol: a. All reusable items and equipment requiring special cleaning or disinfection shall be cleaned in accordance with our current procedures governing the cleaning of soiled or contaminated equipment. 10. Supplies Protocol: .d. Non-sterile supplies are stored and maintained as clean prior to use. The facility's Infection Surveillance policy, dated 3/8/23, states, in part: Policy: A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections.6. The facility will collect data to properly identify possible communicable diseases or infections before they spread . The facility's Infection Outbreak Response and Investigation policy, dated 2/26/23, states, in part: Policy: The facility promptly responds to outbreaks of infectious disease within the facility to stop transmission of pathogens and prevent additional infections.Policy Explanation and Compliance Guidelines: .d. An outbreak will be reported to the local and/or state health department in accordance with the state's reportable diseases website.3. Outbreak investigation: .f. A summary of the investigation should be documented . Guidance for COVID-19 for health care providers from Wisconsin Department of Health Services website, https://www.dhs.wisconsin.gov/covid-19/providers.htm , states, in part: Reporting guidance As of November 1, 2023, only COVID-19-associated hospitalization and COVID-19-associated pediatric mortality are reportable. COVID-19 outbreaks are also reportable . Example 1 The facility's Line Listing of Resident Infections, dated September 2024, shows 9 residents on antibiotics. The line listing shows no residents with signs and/or symptoms of infection without ordered antibiotic. The facility's Line Listing of Resident Infections, dated October 2024, shows 9 residents on antibiotics. The line listing shows no residents with signs and/or symptoms of infection without ordered antibiotic. The facility's Line Listing of Resident Infections, dated November 2024, shows 7 residents on antibiotics. The line listing shows no residents with signs and/or symptoms of infection without ordered antibiotic. On 12/12/24 at 8:02 AM, Surveyor interviewed IP C (Infection Preventionist) and DON B (Director of Nursing) and asked how the facility determines what residents are going onto the line list. IP C stated that residents with any signs and/or symptoms of infection go onto the line list; cough, shortness of breath, fever, urinary frequency, painful urination, etc. Surveyor showed IP C and DON B that September, October, and November did not show residents with signs and symptoms and the lists showed only residents with ordered antibiotics. DON B stated we have inserviced our nurses on the need to document each new symptom. Surveyor asked if the line lists showed overall surveillance of the residents. DON B stated no. Surveyor asked if the facility should have daily overall surveillance of all the signs and symptoms of infection. DON B stated yes Example 2: The facility's Line Listing of Resident Infections dated March of 2024 shows 5 residents (R112, R113, R114, R11, and R47) with COVID 19 infection. There are no resolved dates listed for these residents. The facility's COVID Outbreak 3/2024 summary indicates 4 residents (R112, R113, R11, and R47) were in the outbreak. R114 is not included in the summary. The summary states that infection control audits were started, but does not include when they were done or what the audits included. The facility did not provide documentation of these audits. The summary states that residents and staff with close contact to COVID positive residents were tested , but does not list who was tested or the results of those tests. The facility did not provide documentation of these tests. The summary does not include whether the medical director and/or public health was updated on the outbreak. On 12/12/24 at 8:02 AM, Surveyor interviewed DON B and asked if all COVID positive residents from the March line list should be included in the outbreak. DON stated yes. Surveyor asked for additional documentation regarding audits and resident/staff testing from the COVID outbreak. No additional documentation was provided. Surveyor asked if the COVID summary should be complete and accurate. DON B stated yes. Example 3: On 12/11/24 at 8:09 AM, Surveyor observed LPN D (Licensed Practical Nurse) pick up the nasal cannula for R31's portable oxygen tank from the floor, wind up the tubing, place it into the bag on the portable oxygen tank and leave R31's room. Surveyor asked when R31 uses his portable oxygen. LPN D stated he uses it when he leaves his room for meals. Surveyor asked if R31 uses the nasal cannula attached to the portable tank. LPN D said yes. Surveyor asked if a nasal cannula should be on the floor. LPN D said no, it is contaminated. On 12/12/24 at 8:02 AM, Surveyor completed Infection Control interview with IP C and DON B and asked if a nasal cannula on the floor is contaminated. IP C and DON B stated yes. Surveyor asked what should be done with a contaminated nasal cannula. IP C and DON B indicated that the nasal cannula should be thrown away and replaced. Surveyor asked if IP C and DON B would expect staff to throw away a nasal cannula that was laying on the floor. IP C and DON B stated yes.

Based on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored and distributed. This has the potential to affect all 58 residents who reside in the facility. Surveyor observed the facility's stove hood, located directly above food being prepared, to have dust covered sprinklers inside of it and 2 dust covered fixtures on the outside. Surveyor observed dented cans in circulation. Surveyor observed two gallon size milks opened and expired. Evidenced by: Example 1 Facility policy, entitled Food Storage Chart, revised ,d+[DATE], includes: Milk, half and half and cream to be used within 4 days from open date, never longer than manufacturer expiration date. On [DATE] at 8:48 AM, Surveyor observed an opened gallon of 2% white milk without an open date and an expiration date of [DATE]. Surveyor also observed an opened gallon of chocolate milk with expiration date of [DATE]. DM J (Dietary Manager) indicated staff served this milk at breakfast but should not have since it expired the previous day. On [DATE] at 12:52 PM, District Food Service Manager L indicated milk should not be served after the manufacturer's stamped date. Example 2 Facility policy, Hoods and Filters, reviewed [DATE], includes: Stove hoods and filters will be cleaned according to a cleaning schedule, or at least monthly . Clean the interior and exterior of the hood, use a clean cloth soaked in soapy detergent water. Rinse thoroughly and air dry. On [DATE] at 8:48 AM, Surveyor observed sprinklers inside of the facility's stove hood to have a thin layer of dust covering them. Surveyor also noticed to fixtures that were on the outside of the stove hood to have a thicker layer of dust covering them. Both the sprinklers and the fixtures were directly above food being prepared. DM J indicated she is not sure who is responsible for cleaning these areas and there is potential for the dust to dislodge and fall into the food being prepared. On [DATE] at 12:52 PM, District Food Service Manager L indicated the stove hoods are cleaned 2 times a year and the maintenance department is supposed to clean it in between these times. Example 3 Facility policy, entitled Dry Storage Area, implemented ,d+[DATE], includes: Leaking or severely dented cans and spoiled foods should be disposed of promptly to prevent contamination of other food. On [DATE] at 8:48 AM, Surveyor observed two dented cans in circulation. DM J indicated these should be pulled and tossed in the garbage. On [DATE] at 12:52 PM, District Food Service Manager L indicated dented cans should be pulled off of the shelf.

Based on interview and record review, the facility did not ensure that a resident who displays or is diagnosed with a mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder (PTSD), receives appropriate treatment and services to correct the assessed problem or attain the highest practical mental and psychosocial well-being for 1 of 1 residents reviewed for PTSD (R14). R14 was listed as having a diagnosis of PTSD and his care plan is not person centered, as it does not specify triggers, symptoms to monitor for or interventions to use to ensure R14 is reaching his highest practical mental and psychosocial well-being. This is evidenced by: Per the Centers for Medicare and Medicaid Services (CMS), .Although PTSD is commonly viewed as a disorder experienced only by military veterans, it is not exclusively a consequence of combat or war zone exposure. Individuals who have been physically or sexually assaulted or who experienced a terrorist attack or natural disaster, among other things may also be affected by PTSD. The facility's policy titled Trauma Informed Care dated 10/18/22 states in part, .2. The facility will use a multi-pronged approach to identify a resident's history of trauma. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as reviewing documentation such as the history and physical, consultation notes, or information received from family/ responsible party .5. The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger- specific interventions will identify ways to decrease the resident's exposure to triggers which re- traumatize the resident and will be added to the resident's care plan . R14 was admitted to the facility on [DATE] with diagnoses that include PTSD, anxiety disorder (significant and uncontrollable feeling of anxiety), major depressive disorder (persistantly low or depressed mood), and hemiplegia and hemiparesis (total or nearly complete paralysis of one side) following a cerebral infarction affecting the right side (stroke with right sided weakness). R14's most recent Minimum Data Set (MDS) dated [DATE] states that R14 has a Brief Interview of Mental Status (BIMS) of 6 out of 15, indicating that R14 has severe cognitive impairment. R14's MDS section I also states that R14 has PTSD, anxiety, and depression. R14's care plan dated 6/4/24 states in part: .Focus: At risk for retraumatization of past event or experience where reminders/ triggers of event or experience may cause behavioral changes and/ or emotional distress. History of assault, mental disorder, PTSD, confirmed by [Psychiatrist name] on initial evaluation of resident. Goal: Reminder/ triggering events will be avoided with minimal impact during stay with in the facility. Resident will use coping techniques in coordination with individualized interventions to minimize impact of potential retraumatization. Interventions/ Tasks: Determine as able, the triggers of traumatic event or experience, such as sights, smells, sounds and touch, which may lead to a set of emotional, physiological and behavioral responses that arise in service of survival and safety. Determine individualized de- escalation preferences. Monitor for increased withdrawal, anger, or depressive opportunities to avoid. Provide a safe environment. Provide choice- making activities. Remove/ avoid situations that may trigger retraumatization. Staff will work to accommodate resident with a private room . It is important to note that R14's care plan is not individualized to ensure that staff is aware of R14's specific type of trauma, how his trauma manifests, specific behaviors to monitor for, what triggers R14 has, individualized de- escalation preferences/ interventions, and what coping techniques are effective. On 12/10/24 at 1:47 PM, Surveyor interviewed R14. Surveyor asked R14 about his diagnosis of PTSD, R14 reported that he was in Vietnam and that he has flashbacks and nightmares. Surveyor asked R14 if he has any triggers that he is aware of, R14 stated no. On 12/11/24 at 2:14 PM, Surveyor interviewed SSD K (Social Services Director). Surveyor asked SSD K what the source of R14's PTSD was, SSD K stated that it was something with the military and the psychiatrist was able to find out about a sexual assault he experienced while in the military. SSD K reported that the psychiatrist recommended that R14 have a private room as having a roommate is a trigger for him. Surveyor asked SSD K if R14's care plan reflects his trauma, triggers, and has individualized interventions related to his PTSD, SSD K stated no.

Based on observation, interview, and record review, the facility did not ensure residents were treated with dignity and respect in an environment that promotes an enhanced quality of life which affected 1 of 15 residents reviewed (R1). R1 reported to Surveyor that her vision is poor and that she clinks her glass against her plate in order to know where to set it, but she is unable to do that because the facility had given her a Styrofoam plate. Evidenced by: The facility's policy titled Resident Rights last reviewed on 7/2022 states in part, .12. The resident has a right to live in this facility and receive services with reasonable accommodation of needs and preferences except when to do so would endanger the health and safety of the resident or other residents . R1 was admitted to the facility on [DATE] with diagnoses that include vascular dementia (decline in cognitive function), glaucoma (eye condition that damages the optic nerve), and age- related Macular Degeneration- bilateral (vision impairment in both eyes caused by deterioration of the retina). R1's most recent Minimum Data Set (MDS) dated [DATE] states that R1 has a Brief Interview of Mental Status (BIMS) of 8 out of 15, indicating that R1 has moderate cognitive impairment. The MDS also indicates that R1's vision is highly impaired and wears glasses. R1's care plan dated 10/2/23 states in part: .Focus: Impaired vision as evidenced by need for glasses and assistance r/t (related to) glaucoma, Macular Degeneration. Goal: Will have ADL (Activities of Daily Living) needs met with staff assistance as needed. Interventions/ Tasks: Encourage to wear glasses .Glasses. Provide ADL assistance as needed .Resident has tendency of wearing glasses on head and then forgets where she put them. Staff remind her of this when it happens . On 12/10/24 at 11:39 AM, Surveyor was making an observation of the lunch meal. R1 reported to Surveyor that she missed having a glass dessert plate so she knows where she is placing her milk glass, so she doesn't spill. R1 reported that she taps the glass against the plate. Surveyor noted that R1's dessert was on a Styrofoam plate. On 12/10/24 at 11:45 AM, Surveyor interviewed DA I (Dietary Aide). Surveyor asked DA I why some residents are using Styrofoam plates and others are using glass plates, DA I stated that she just wanted to make sure that there would be enough glass plates for the hall carts. On 12/11/24 at 4:01 PM, Surveyor interviewed DM J (Dietary Manager). Surveyor asked DM J if she was familiar with R1 and if she had any deficits, DM J stated that R1 cannot see very well. Surveyor asked DM J if the dietary staff were aware of R1's poor vision, DM J stated yes and that staff tell R1 where her food is located on the plate, cut up food, and gets R1 lots of chocolate milk. Surveyor asked DM J how staff is made aware of a resident's preferences, DM J stated that they are usually listed on their diet slips. Surveyor reviewed R1's diet slip with DM J; no preferences were listed on R1's diet slip. Surveyor asked DM J if the kitchen had enough glass plates for every resident, DM J stated yes. Surveyor asked DM J if she was aware of R1's preference for a glass plate, DM J stated that all residents should have glass plates. R1's preference is to have a glass plate and R1 was served dessert on a Styrofoam plate.

Based on observation, interview, and record review, the facility did not ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 20 (R22) reviewed for abuse. R22 was noted to have a significant bruise to his right eye. The facility failed to report an injury of unknown origin to the State Agency. Evidenced by: The facility's policy titled Abuse, Neglect and Exploitation last reviewed on 7/15/22 states in part, .IV. Identification of Abuse, Neglect, and Exploitation .B. Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse. 2. Physical marks such as bruises or patterned appearances such as a handprint or ring mark on a resident's body. 3. Physical injury of a resident, of an unknown source .VII. Reporting/ Response .1. Reporting of all alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes: a. Immediately, but no later than 2 hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in bodily injury . R22 was admitted to the facility on [DATE] with diagnoses that include heart failure, chronic kidney disease stage 2 (long term condition where the kidneys become damaged), and peripheral vascular disease (disorder that affects blood vessels). R22's most recent Minimum Data Set (MDS) dated [DATE] states that R22 has a Brief Interview of Mental Status (BIMS) of 11 out of 15, indicating that R22 is mildly cognitively impaired. R22's MDS also indicates that R22 is dependent on staff for toileting, bathing, lower body dressing, and transfers and requires substantial/ maximal assistance in rolling from side to side in bed. On 12/10/24 at 9:27 AM, Surveyor interviewed R22. Surveyor noted that R22 had a bruise to his right eye that went from the upper corner of his eye down to underneath his eye. The bruise is yellow green at the upper corner and purple underneath R22's eye. Surveyor asked R22 how he got the bruise to his eye, R22 stated it just showed up. Surveyor requested the facility's investigation documentation of R22's bruise. The facility's investigation indicates that they interviewed 2 CNAs and 2 nurses. The interviews are as follows: 11/24/24 at 1:30 PM - CNA: Interview Summary: Unsure- if rolling from side to side his outer eye may have hit the rail. 11/24/24 at 2:00 PM - CNA: Interview Summary: Maybe when someone was cleaning his eyes. 11/24/24 at 10:00 PM - RN: Investigation Summary: Writer and other RN in at 5:00 AM to give suppository PR (per rectum). No bruise observed this AM. Resident holds siderail with turns. Head was not near siderail. 11/25/24 at 10:00 AM - DON B (Director of Nursing): Res (resident) has long thick fingernails. He may have scratched his eye with them, also has severe coughing episodes every AM, may have broke [sic] a blood vessel. On 12/11/24 at 10:52 AM, Surveyor interviewed RN H (Registered Nurse). Surveyor asked RN H what she knows about the bruise on R22's right eye, RN H stated that she was unsure how he got it, but R22 is turned and repositioned a lot so he may have bumped it. Surveyor asked RN H how she was made aware of the bruise, RN H stated that it was passed on in report. On 12/11/24 at 10:58 AM, Surveyor interviewed DON B. Surveyor asked DON B what the process is when a resident is noted to have a bruise. DON B stated that when it gets reported, the facility investigates, identify possible ways that the resident got the bruise, ask the resident about the bruise, ask about staff treatment, update the MD (Medical Doctor) and family. DON B reported that if they are able to figure out how the bruise was obtained, they add interventions to the care plan and educate staff. Surveyor asked DON B if R22's bruise would be considered an injury of unknown origin, DON B stated that in the beginning it probably was. Surveyor asked DON B if R22's bruise was reported to the State Agency, DON B stated that after completing their investigation, they decided that it didn't need to be reported. Surveyor asked DON B what the timeframe is for reporting potential abuse, DON B stated within 2 hours. The facility failed to report an injury of unknown origin to the State Agency.

Based on observation, interview, and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment, that alleged violations are thoroughly investigated for 1 of 20 residents (R22) reviewed for abuse. R22 was noted to have a significant bruise to his right eye. The facility failed conduct a thorough investigation. Evidenced by: The facility's policy titled Abuse, Neglect and Exploitation last reviewed on 7/15/22 states in part, .IV. Identification of Abuse, Neglect, and Exploitation .B. Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse. 2. Physical marks such as bruises or patterned appearances such as a handprint or ring mark on a resident's body. 3. Physical injury of a resident, of an unknown source .V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when allegation or suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigation include: 1. Identifying staff responsible for the investigation .3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation(s); 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/ or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation . R22 was admitted to the facility on [DATE] with diagnoses that include heart failure, chronic kidney disease stage 2 (long term condition where the kidneys become damaged), and peripheral vascular disease (disorder that affects blood vessels). R22's most recent Minimum Data Set (MDS) dated [DATE] states that R22 has a Brief Interview of Mental Status (BIMS) of 11 out of 15, indicating that R22 is mildly cognitively impaired. R22's MDS also indicates that R22 is dependent on staff for toileting, bathing, lower body dressing, and transfers and requires substantial/ maximal assistance in rolling from side to side in bed. On 12/10/24 at 9:27 AM, Surveyor interviewed R22. Surveyor noted that R22 had a bruise to his right eye that went from the upper corner of his eye down to underneath his eye. The bruise is yellow green at the upper corner and purple underneath R22's eye. Surveyor asked R22 how he got the bruise to his eye, R22 stated it just showed up. Surveyor requested the documentation of the facility's investigation of R22's bruise. The facility's investigation indicates that they interviewed 2 CNAs and 2 nurses. The interviews are as follows: 11/24/24 at 1:30 PM - CNA: Interview Summary: Unsure- if rolling from side to side his outer eye may have hit the rail. 11/24/24 at 2:00 PM - CNA: Interview Summary: Maybe when someone was cleaning his eyes. 11/24/24 at 10:00 PM - RN: Investigation Summary: Writer and other RN in at 5:00 AM to give suppository PR (per rectum). No bruise observed this AM. Resident holds siderail with turns. Head was not near siderail. 11/25/24 at 10:00 AM - DON B (Director of Nursing): Res (resident) has long thick fingernails. He may have scratched his eye with them, also has severe coughing episodes every AM, may have broke [sic] a blood vessel. On 12/11/24 at 10:58 AM, Surveyor interviewed DON B. Surveyor asked DON B what the process is when a resident is noted to have a bruise. DON B stated that when it gets reported, the facility investigates, identify possible ways that the resident got the bruise, ask the resident about the bruise, ask about staff treatment, update the MD (Medical Doctor) and family. DON B reported that if they can figure out how the bruise was obtained, they add interventions to the care plan and educate staff. Surveyor asked DON B if R22's bruise would be considered an injury of unknown origin, DON B stated that in the beginning it probably was. Surveyor asked DON B if she had interviewed any staff from the previous shifts, DON B stated that they didn't because they determined that it was fine and that nothing had happened and that R22 stated that nothing had happened. Surveyor asked DON B if they had interviewed any other residents, DON B stated no. The facility failed to complete a thorough investigation regarding the bruise to R22's eye, including interviews from additional staff and other residents.

Based on interview and record review, the facility failed to ensure that services provided by the facility meet professional standards of quality for 2 of 5 residents (R26 and R23) reviewed for unnecessary medications. R26 is receiving Melatonin for sleep and did not have a sleep assessment, sleep tracking, or a sleep care plan. R23 is receiving Melatonin for sleep and did not have a sleep assessment, sleep tracking, or a sleep care plan. This is evidenced by: Example 1: R26 was admitted to the facility on [DATE] with diagnoses that include, in part: Anxiety disorder (significant/uncontrollable feelings of anxiety); vascular dementia (type of dementia (decline in cognitive abilities) caused by decreased blood flow to the brain), without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and Bipolar Disorder. R26's Minimum Data Set (MDS) dated [DATE] indicates a Brief Interview for Mental Status (BIMS) of 6, indicating severe cognitive impairment. R26's physician orders include, in part: Melatonin 10mg (milligrams) by mouth at bedtime for insomnia related to bipolar disorder-order date 10/24/24. R26's care plan does not include a problem, goal, and interventions for sleep. Surveyor requested a policy on sleep and R26's sleep assessment and monitoring documentation. Documentation was not provided. On 12/12/24 at 1:19 PM, Surveyor interviewed DON B (Director of Nursing) and asked if residents receiving medication for sleep have an assessment and tracking of their sleep. DON B stated yes, for anyone on a prescription medication, not for over the counter medications. Surveyor asked if DON B would expect that residents receiving Melatonin would have a comprehensive sleep assessment, sleep tracking, and a care plan for sleep. DON B stated yes. 50698 Example 2 R23 was admitted to the facility on [DATE] and has the following diagnoses which include: generalized anxiety disorder (significant/uncontrollable feelings of anxiety), insomnia (difficulty falling or staying asleep), post traumatic stress disorder (response to trauma), and vascular dementia (type of dementia (decline in cognitive abilities) caused by decreased blood flow to the brain). R23's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 11/15/24 indicates R23's cognition is intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. R23's Physicians Orders as of 12/12/24 includes in part: Melatonin oral tablet, 10mg (milligrams) by mouth at bedtime for insomnia. Start date 10/24/23 . On 12/12/24 at 10:00 AM, Surveyor reviewed R23's Medical Record and observed the record does not contain a comprehensive sleep assessment or tracking/monitoring of sleep. On 12/12/24 at 10:30 AM, Surveyor also reviewed R23's care plan and observed at that time the care plan did not contain goals or interventions related to use of Melatonin, creating a positive sleep environment, or monitoring for sleep. On 12/12/24 at 1:19 PM, Surveyor interviewed DON B (Director of Nursing). DON B indicated she would expect a comprehensive sleep assessment to be done, expect to have a care plan completed about sleep, and would expect to have sleep monitoring for residents on Melatonin.

Based on observation, staff interview and record review, the facility did not ensure staff performed proper hand hygiene for 2 Residents (R) (R2 and R3) of 2 residents observed during the provision of cares. On 2/8/23, Certified Nursing Assistant (CNA)-D did not consistently perform appropriate hand hygiene during the provision of perineal care for R2. On 2/8/23, Graduate Nurse (GN)-F did not consistently perform appropriate hand hygiene during the provision of wound care for R3. Findings include: The facility's Hand Hygiene policy, dated 11/2/22, contained the following information: All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility .Hand Hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR) .Staff will perform hand hygiene when indicated, using proper techniques consistent with accepted standards of practice .Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table .Attached Hand Hygiene Table indicated: Either Soap and Water or Alcohol Based Hand Rb (ABHR is preferred) was to be performed before applying and after removing personal protective equipment (PPE), including gloves and after handling items potentially contaminated with blood, body fluids, secretions or excretions. On 2/8/23, Surveyor reviewed R2's medical record. R2 was admitted to the facility with diagnoses to include chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and dementia with behavioral disturbance. On 2/8/23, Surveyor reviewed R3's medical record. R3 was admitted to the facility with diagnoses to include chronic kidney disease (gradual loss of kidney function), COPD and diabetes mellitus (a disease in which blood sugar levels are too high). On 2/8/23 at 11:03 AM, Surveyor observed CNA-D don gloves and provide perineal care for R2. Without removing gloves and cleansing hands following perineal care, CNA-D opened a drawer to obtain barrier cream and applied barrier cream to R2's posterior peri area. CNA-D then removed CNA-D's right glove and, without performing hand hygiene, fastened R2's brief and put R2's pants and shoes on. CNA-D then removed CNA-D's left glove and, without performing hand hygiene, assisted R2 to a sitting position at the edge of the bed. With the assistance of CNA-E, CNA-D applied a gait belt to R2 and assisted R2 to stand and pivot into a chair. CNA-D then removed the gait belt, positioned R2's feet onto the platform of the chair and tilted the chair to a proper position. CNA-D then turned on R2's alarm, straightened R2's bed linens and removed a soiled garbage bag from a garbage can. CNA-D placed a clean bag in the garbage can and then washed CNA-D's hands. On 2/8/23 at 11:15 AM, Surveyor interviewed CNA-D who verified CNA-D should have performed hand hygiene immediately after glove removal and before touching other objects. CNA-D verified CNA-D should not have touched R2's drawer or barrier cream with the same gloved hands used to perform perineal care. CNA-D verified CNA-D's uniform pocket contained hand sanitizer. On 2/8/23 at 12:13 PM, Surveyor observed GN-F don gloves and provide wound care for R3. GN-F removed a dressing from R3's left heel and removed GN-F's gloves. Without performing hand hygiene, GN-F donned clean gloves, cleansed R3's left heel wound and applied a clean dressing. With the same gloved hands, GN-F put a sock on R3's left foot, obtained a pillow and placed the pillow under R3's left arm. GN-F then removed gloves. Without performing hand hygiene, GN-F exited R3's room to obtain additional supplies. On 2/8/23 at 12:21 PM, Surveyor observed GN-F don gloves and complete wound care for R3. GN-F removed a dressing from R3's elbow, removed GN-F's gloves and, without performing hand hygiene, donned clean gloves. GN-F applied a clean dressing to R3's elbow, removed GN-F's gloves and, without performing hand hygiene, placed a walker in front of R3. Without performing hand hygiene, GN-F exited R3's room to obtain an additional staff for assistance and returned to R3's room with CNA-D. GN-F and CNA-D performed hand hygiene, donned clean gloves, assisted R3 to a standing position and pulled R3's clothing down. GN-F cleansed the open wound on R3's left buttock and removed gloves. Without performing hand hygiene, GN-F donned clean gloves, applied a dressing to the open wound, performed perineal care and removed gloves. Without performing hand hygiene, GN-F donned clean gloves, cleaned R3's chair cushion and assisted CNA-D in redressing R3. After assisting R3 into a chair, CNA-D and GN-F removed gloves and cleansed hands. On 2/8/23 at 12:39 PM, Surveyor interviewed GN-F who verified GN-F did not perform hand hygiene following glove removals. On 2/8/23 at 12:43 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-C who stated staff should definitely perform hand hygiene immediately with glove removal. On 2/8/23 at 2:42 PM, Surveyor interviewed Director of Nursing (DON)-B who, following a discussion of the above observations, verified hand hygiene should be performed immediately following glove removal.

Based on Record Review and Interview, the facility did not ensure medical records contained accurate and complete information for 2 Residents (R) (R21 and R24) of 17 Residents sampled. R21 had missing documentation in R21's medical record related to treatments. R24 had missing documentation in R24's medical record related to treatments. Findings include: 1. R21 was admitted to the facility on [DATE] and had a Brief Interview of Mental Status Score (BIMS) a brief verbal screening that indicates an individual's cognitive functioning level) of 15/15 which indicates that R21 was cognitively intact. R21 was receiving the following treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] On 9/20/22 at 10:36 AM, Surveyor interviewed R21 who had no concerns related to wound care. ~Wound vac to wound skin prep Periwound area apply wound vac dressing @125 mm Hg (millimeters of mercury - a measurement of the amount of pressure) using green [MEDICATION(S)]. Gently place foam into wound cavity ensuring contact with all wound surfaces. Foam should not be in contact with skin. Every day shift, Every Tuesday, Thursday, Saturday for Sacral Wound. Start date of 7/9/22. On 9/21/22, Surveyor reviewed R21's Medical Record and noted missing documentation on 10 out of 22 opportunities between 8/1/22 and 9/21/22 for the above wound treatment. Days missing documentation were as follows: 8/4, 8/11, 8/18, 8/20 and 9/3, 9/5, 9/8, 9/10, 9/13, 9/20. 2. R24 was admitted to the facility on [DATE] and had a BIMS score of 13/15 which indicated that R24 was cognitively intact. R24 had related diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/22/22, Surveyor was reviewing R24's medical record and noted that R24 was missing documentation related to the following treatments. R24's areas of treatment were not worsening. ~Cleanse open areas to RLE (Right lower extremity) and LLE (Left lower extremity), apply xeroform gauze and cover with nonadherant dressing and wrap with kerlix every day shift starting 9/7/22. There were 5 of 16 treatments missing documentation (9/7/22, 9/9/22, 9/13/22, 9/14/22, 9/20/22) ~Monitor skin tear and change dressing daily until healed every day shift from 8/17/22 to 9/21/22. Skin tear had healed. In September there were 4 of 20 treatments missing documentation (9/3/22, 9/13/22, 9/14/22, 9/20/22). On 9/22/22 at 9:18 AM, Surveyor interviewed Director of Nursing (DON-B) who indicated the expectation that treatments should be documented on when completed and would begin an investigation. 09/22/22 at 10:54 AM Interview with Assistant Director of Nursing (ADON-C) indicated that schedules showed it was 2 different nurses. Both indicated the treatments were completed. ADON-C indicated that the 2 staff were educated.

Based on observation, interview and record review the facility did not develop and implement a Comprehensive Resident-Centered Care Plan for 1 of 19 sampled residents reviewed (R417). R417 is using CBD (Cannabidiol) cream, New Vomica lip balm and [MEDICATION NAME] which are not care planned for use and monitored for effectiveness. Evidenced by: R417's [DIAGNOSES REDACTED]. R417's Admission MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 5/8/19, indicates R417's BIMS (Brief Interview for Mental Status) score is 14, indicating R417 is cognitively intact. Section G: Functional Status indicates R417 requires 2 assist for bed mobility and transfer. Section J: Pain indicates R417 has occasional pain which makes it hard to sleep at night and limits her day-to-day activities. R417 rated her pain as a 5. R417's Progress Note, dated 8/12/19 at 9:19 PM, includes, in part: CBD Clinic Revolutionary Pain Relief Cream - (MONTH) keep at bedside. Check bedside use every evening shift for pain up to 3 x (times) day to affected areas: shoulders, knee. R417 is not using CBD. R417's Progress Note, dated 8/13/19 at 8:29 PM, includes, in part: CBD Clinic Revolutionary Pain Relief Cream - (MONTH) keep at bedside. Check bedside use every evening shift for pain up to 3 x (times) day to affected areas: shoulders, knee. R417 is not using CBD. R417's Progress Note, dated 8/23/19 at 5:58 PM, includes, in part: Call from MD (Medical Doctor) gave permission for R417 to have [MEDICATION NAME] Essential Oils at bedside. Also will be receiving Homeopathic supplement provided by family, Nux Vomica 30 x 2 tablets PO (Oral) Q (Every) 4 hours PRN (When necessary) for nausea or anxiety. (Of note: Surveyor observed an open bottle of [MEDICATION NAME] 30 x tablets with a quantity of 250 tablets per label, a tube of New Vomica lip balm, and CBD cream at bedside sitting in a basket.) R417's care plan for pain, dated 5/13/19, includes, in part: has pain or the potential for pain evidenced by: Chronic Pain to right shoulder. At risk for pain. admitted for short term therapy. R417 has hx (history) of arthritis, with past hx of episodes of related back pain. Has orders for scheduled and prn [MEDICATION NAME]. Alert and able to verbalize her needs. R417 will communicate needs for pain medication and will verbalize adequate relief of pain or ability to cope with pain as specified by pain level goal. Administer [MEDICATION NAME] per MD orders. Give prior to treatments, therapy or cares. Anticipate R417's need for pain relief and respond as soon as possible to any complaint of pain. Ask R417 about which positions are comfortable, encourage frequent repositioning. Document pain on 1-10 scale or using pain faces. Monitor response to [MEDICATION NAME] and pain alleviation measures. Explore non pharmacological pain alleviating interventions such as heat, ice, massage, elevation, relaxation, repositioning and food. Monitor/document for side effects of pain medication - i.e. constipation, drowsiness. Update Physician on effectiveness of [MEDICATION NAME] and pain treatments as necessary. (Of note: The above care plan does not address the use of homeopathic supplements.) Review of R417's Self- administration-pain relief cream-CBD clinic or equivalent care plan, dated 6/12/19, includes, in part: R417 will safely administer medications. Confirm and document the medications administered. Periodic safety assessment/evaluation of patient's ability to dispense medications. On 10/8/19 at 9:27 AM, Surveyor asked R417 if she was having any pain. R417 indicated yes, my right arm hurts. Surveyor asked R417 if the facility gives her anything for the pain. R417 indicated they put pain reliever cream on and R417 takes pain pills. (Of note: R417 has an order for [REDACTED].>On 10/8/19 at 9:33 AM, Surveyor observed the following supplements at bedside. New Vomica lip balm, [MEDICATION NAME] 30 x tablets and CBD cream. Surveyor asked R417 if she records the supplements used and notifies the nurse. R417 indicates she does not tell the nurse when she uses these items and does not record them. On 10/10/19 at 1:17 PM, Surveyor interviewed RN [NAME] (Registered Nurse) regarding R417's order for [MEDICATION NAME]. RN [NAME] indicated the [MEDICATION NAME] is not on the MAR (Medication Administration Record), nor is there an order for [REDACTED].>R417's Physician Orders, signed 6/12/19, includes, in part, the following: R417 would like to have CBD clinic revolutionary pain relief ointment at bedside to apply to affected areas - shoulder - knees as needed up to 3 times per day. MD indicates ok as above on 6/12/19. The facility did not create a Homeopathic Supplement Care Plan to address the use and monitoring of the supplements that R417 is taking.

Based on observation, interview and record review, the facility had 3 medication errors out of 25 opportunities for a medication error rate of 12.0 % involving 1 of 8 residents (R15) observed during medication pass. LPN C (Licensed Practical Nurse) did not shake the bottle of [MEDICATION NAME] (eye drops) or [MEDICATION NAME] (Nasal spray) prior to administering to R15. LPN C also administered Refresh eye drops with an open date of [DATE] to R15. Findings include: The facility policy, General Guidelines for Administration Medication via Enteral Route, with a revision date of ,[DATE], does not include verifying placement of the enteral tube prior to medication administration. The facility Medication Administration Policy, dated ,[DATE], includes, in part: #21. Return expired or outdated medications promptly to the pharmacy. According to Drugs.com: for [MEDICATION NAME] eye drops: Shake the bottle well before each use. Tilt your head back and, pressing your finger gently on the skin just beneath the lower eyelid, pull the lower eyelid away from the eye to make a space. Drop the medicine into this space. Let go of the eyelid and gently close your eye. Do not blink. Keep the eye closed and apply pressure to the inner corner of your eye with your finger for 1 or 2 minutes to allow the medicine to be absorbed by the eye. [MEDICATION NAME] nasal spray - Shake the nasal spray just before each use. On [DATE] at 7:55 AM, Surveyor observed the med pass observation with LPN C. LPN C instilled 10 cc (cubic centimeter) of air into the enteral tube and did not aspirate for stomach contents to verify tube placement prior to administering R15's enteral tube medications. LPN C placed one drop of [MEDICATION NAME] ophthalmic solution into R15's right eye and did not shake the bottle prior and did not apply pressure to the inner canthus. LPN C instilled 2 sprays of [MEDICATION NAME] into R15's bilateral nares. LPN C did not shake the bottle of the [MEDICATION NAME] prior to administering. LPN C instilled Refresh tears 1 gtt (drop) left eye per R15's request. Surveyor observed the open date of [DATE] on the label. On [DATE] at 2:17 PM, Surveyor interviewed RN D (Registered Nurse) regarding R15's medications. Surveyor asked RN D if she would do anything in particular with the [MEDICATION NAME] or the [MEDICATION NAME] prior to administration. RN D indicated she would shake the bottles before administering. Surveyor took RN D to R15's room and asked RN D to look at the Refresh tears that were on R15's bedside table. RN D indicated the eye drops were open for way to long. Surveyor asked RN D if anything should be done prior to administering the enteral medications. RN D indicated the nurse should flush the tube with water and it is appropriate to instill air. RN D indicated the nurse should have aspirated for stomach contents. On [DATE] at 2:42 PM, Surveyor interviewed DON B (Director of Nursing) regarding the expectation of enteral medication administration. DON B indicated to gurgle 10 ml (milliliter) air and then aspirate. Surveyor asked DON B if the [MEDICATION NAME] eye drops and [MEDICATION NAME] should be shaken. DON B indicated yes, the [MEDICATION NAME] should have been shaken prior to administration.

Based on record review and interview the facility did not ensure personal privacy for 1 of 12 total residents reviewed (R2). R2 was not permitted to visit with his family in private. This is evidenced by the following: R2's [DIAGNOSES REDACTED]. R2 was admitted to the facility as an anticipated short stay resident. At the time of admission R2's HCPOA (Health Care Power of Attorney) was activated naming a friend as the HCPOA. R2's record shows that R2 began to have visits from his family around 9/16/16. On this date R2's family was informed they could not take R2 off the premises without permission from R2's HCPOA. At this time family members provided a second HCPOA form, dated 9/16/16, naming family members as activated HCPOA. R2's record shows that the facility, after receiving counsel from their corporate attorney, would honor the original HCPOA, naming the friend as the HCPOA, until clarification could be made. R2's record documents on 9/28/16 at 6:50 pm that SS (Social Services) Staff C spoke with R2. This documentation states: When resident was asked if he wished to have visits with his (family member) he said yes and when asked where he would like to have these visits he stated Wherever it is comfortable. R2's record contains an additional SS Staff C note on 9/28/16 at 7:06 pm which states: Writer talked to resident's activated HCPOA today about visits from resident's (family member) on Monday and what transpired during the duration of the meeting. Resident's HCPOA (name) was also informed about phone call from the Ombudsman today and what she told DON (Director of Nursing) and SS about concerns that were presented to her from a third party. Explained to HCPOA about family visits and how they are not part of a healthcare decision and they are to carry forth with allowing family to visit without supervision . Director called corporate attorney with writer and discussed several things and got advice and direction as to what the best course of action is for us as the facility where this resident resides and our obligation to make sure his best interest are being met. Advice was given and director will follow up with this SS's assistance. On 2/9/17 at 2:25 pm Surveyor spoke with SS Staff C regarding R2, his POA, family visits and his subsequent discharge from the facility. SS Staff C stated that R2's family member had been in the facility 1 - 2 times before 9/16/16. SS Staff C stated that after 9/16/16 the facility began working with R2, R2's family, R2's HCPOA, Ombudsman, and the facility's corporate attorney to clarify who R2's activated HCPOA was, as there was confusion since the facility now had 2 HCPOA papers; one naming a friend, and the more recent one naming the family member. SS Staff C stated when R2 was asked by facility who he wished to assist him in important health decisions R2 would respond (his friend). SS Staff C stated R2 would respond with different answers when asked, depending on to whom R2 was talking. SS Staff C stated R2 was a lovely man who did not want to hurt anyone's feelings, but until 10/7/16 he always told the facility he wished to have his friend as his HCPOA. SS Staff C stated while all of this was going on it was felt that supervised visits (with R2 and his family members) would be in the best interest of R2 as the facility was responsible for R2's safety and at the time they did not know the family well. SS Staff C stated in her previous work as a Social Worker, supervised visits meant she, as the SS Staff, was to remain there during the visit to be able to directly monitor the visits. SS Staff C stated when she was to supervise R2's visit with his family she would bring her work with her into the room and sit right there and work during the visit and monitor what was going on and being said. SS Staff C stated she knows the family was appalled at this, and she apologized, but stated this is what she needed to do for the best interest of R2. Surveyor asked SS Staff C what days this was when she sat in the room with R2 and his family during their visits. SS Staff C stated she could not recall, but it was sometime after 9/16/16 and before the facility was informed they could not do this (9/28/16). SS Staff C stated it was only that 1 time that she had supervised the visits. SS Staff C stated when NHA A learned what and how she was supervising the visits she (SS Staff C) was instructed to stop and some of the restrictions were lifted. On 2/9/17 at 2:50 pm Surveyor spoke with NHA A regarding R2, his POA, family visits and his subsequent discharge from the facility. NHA A stated R2's visits with his family members were supervised in the beginning stating: When I told (SS Staff C) to supervise (the visits), she took it a totally different way. It was not what I meant at all. I should have explained better what I meant. I take full responsibility for that and I did apologize.

Based on interview and record review the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures in 2 of 3 investigations reviewed for potential abuse involving Residents 10 and 11 . R 10 stated to ST (Speech Therapist) E that she had been raped. The allegation was not reported to the State Agency, was not fully investigated and R 10 was not immediately protected. In addition this allegation was found to have been reported earlier that day to CNA (Certified Nursing Assistant) F that she had been raped, CNA F did not immediately report the incident. The facility did not fully investigate and immediately report to the State Agency when it was noted that R11 verbalized he was afraid a staff member was going to hit him and was hostile. Evidenced by: Example 1 The facility's Verification of Investigation form, dated 2/1/17, included, in part, the following information: Resident Name: (R 10). Date/Time of Occurrence: 2/1/17 approximately 10:00 AM. Provide Detailed Description of Event/Allegation: Resident was seen by the Speech Therapist (ST E) and she reported to the therapist that she had been raped last noc (night). Therapist immediately reported allegation to nurse and nurse reported to Clinical Manager. Administrator immediately interviewed resident. Resident stated a male resident who had their night clothes on assisted her with placement of the bedpan while she was in bed. Wiggled bedpan back and forth crumpling up sheets and night gown. R 10's Progress Notes includes the following entry: 2/1/17, 11:40 (AM): When approached CNA on unit to inform about resident's statement, CNA said she knew resident told her this am and she forgot to tell writer. On 2/9/17 at 12:00 PM Surveyor interviewed NHA (Nursing Home Administrator) A. NHA A stated she did not send in the allegation to the State Agency because she knew within an hour that it never happened. On 2/9/17 at 4:15 PM Surveyor interviewed NHA A. NHA A stated CNA F should have informed her nurse immediately when R 10 stated she had been raped and R 10 should have been protected immediately at the time R 10 reported the allegation to CNA F. NHA A stated she should have reported the incident immediately to the State Agency. NHA A stated she should have interviewed CNA F and other staff who work on R 10 unit regarding R 10's allegation. Example 2 The facilities Verification of Investigation dated 9/30/2016 at 4:10pm states in part .stated CNA (certified nursing assistant) had been very rude to him. Resident was very upset .Resident interview summary: R11's call light was on, his underwear was wet. CNA D said I need to start learning to use the urinal. She said I am tired of you. She left me sitting in my wet underwear. I was kind of afraid she was going to hit me. She was hostile and she stormed out of the room . immediate resident protection initiated CNA D did not work with resident for the rest of the shift .State agency notified checked No. 09/30/2016 at 6:44PM nurses note states: Resident upset during cares provided before supper. Incontinence care was provided. On 02/09/2017 at 3:15PM Surveyor interviewed DON (Director of Nursing) B regarding R11's allegation. DON B indicated that R11 has a history of being demanding and fabricating stories. DON B indicated an investigation was started and CNA D was taken away, from R11 and did not care for him the rest of the night after interviewing CNA D to get her side of the story. DON B indicated there was no evidence CNA D was ever mean to R11 or abused R11 based on CNA D's interview and R11's interview and his history of fabricating and lying. DON B indicated if it was anyone else, but R11, it would have been reported to the state agency. DON B indicated she was not aware of CNA D's location during the beginning of the investigation. DON B indicated CNA D was moved to another assignment. DON B indicated if there was any suspicion it was true, DON B would send the employee home. DON B indicated she did not send CNA D home or remove her from providing cares to other residents. R11's behaviors of fabricating stories and lying were not care planned until 10/3/2016 when the incident occurred on 09/30/2016.

Based on observation, interview and record review the facility did not ensure that a resident with a limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 7 of 10 residents (Residents 2, 4, 6, 7, 8, 9 and 10). The facility did not consistently implement the restorative programs for Residents 2, 4, 6, 7, 8, 9 and 10. This is evidenced by the following: On 2/4/16, at 9:15 AM, Surveyor interviewed Certified Nursing Assistant (CNA) D. CNA D stated she does the schedule and restorative and sometimes she works on the floor when needed. CNA D confirmed she was working on the floor today. CNA D stated every CNA is responsible for doing restorative especially if she is working on the floor like today and tomorrow. On 2/4/16, at 10:02 AM, Surveyor interviewed Registered Nurse (RN) E. RN E confirmed she is the nurse in charge of the restorative program. RN E stated there are forms on each unit for the CNAs to document when the restorative program is done. RN E stated she reviews the sheets and if there are blanks in the documentation she will go back and follow up with the staff to determine why. RN E stated she usually does this at the end of the month. RN E also stated this new program started in December 2015. RN E stated she has not reviewed any of the sheets for December or January as she has not had time but she should have. Surveyor and RN E reviewed the restorative sheets and RN E stated there should not be that many blanks. On 2/4/16, at 10:50 AM, Surveyor interviewed Director of Nursing (DON) B who stated CNA D does most of the restorative programs and the other CNAs do some of it. DON B stated when CNA D is working the floor the other CNAs on each wing are responsible for the restorative. DON B stated she expects the restorative programs to be followed and it should be charted. Example 1 Resident 2's restorative program is to ambulate to meals with 1 staff assist, walker, gait belt and follow with wheelchair. Resident 2's restorative documentation indicates: December 2015: 93 opportunities to ambulate to meals. Did not occur 49 times. January 2016: 93 opportunities to ambulate to meals. Did not occur 58 times. February 1-3rd 2016: 9 opportunities to ambulate to meals. Did not occur 8 times. On 2/4/16, at 10:16 AM, Surveyor interviewed Resident 2 who stated she took herself to the dining room in her wheelchair this morning. Resident 2 stated staff do not offer to walk with her to the dining room. Resident 2 stated the staff used to walk with her to all the meals but they don't do that anymore. At 10:48 AM, Surveyor interviewed CNA C about assisting Resident 2 to meals. CNA C stated Resident 2 self-propelled her wheelchair to the dining room for breakfast. CNA C stated she did not offer to walk with Resident 2 because it just did not occur to her. CNA C confirmed that Resident 2 is supposed to walk with staff to all meals. At 11:40 AM, Surveyor observed Resident 2 self-propelling her wheelchair into the dining room. Resident 2 again confirmed no staff offered to walk with her to the dining room for lunch. On 2/4/16 at 11:42 AM, Surveyor interviewed CNA F who was working on Resident 2's hall. CNA F stated there is a restorative paper that indicates who needs to walk and it is on the care card. CNA F stated she was not sure how Resident 2 gets to lunch but she has not walked with any residents to lunch today. Example 2 Resident 6's restorative program is to ambulate to meals with 1 staff assist, walker, gait belt and follow with wheelchair. Resident 6's restorative documentation indicates: December 2015: 93 opportunities to ambulate to meals. Did not occur 47 times. January 2016: 93 opportunities to ambulate to meals. Did not occur 52 times. February 1-3rd 2016: 9 opportunities to ambulate to meals. Did not occur 8 times. On 2/4/16, at 11:40 AM, Surveyor interviewed Resident 6 who stated she uses her wheelchair to get to meals. Resident 6 stated on occasion staff will walk with her in the hall maybe 1 or 2 times a day but it depends on the day. On 2/4/16 at 11:42 AM, Surveyor interviewed CNA F who was working on Resident 6's hall. CNA F stated there is a restorative paper that indicates who needs to be walked and it is on the care card. CNA F stated she walked with Resident 6 from the bathroom to the hall this morning. CNA F stated she did not walk with Resident 6 to the dining room. Example 3 - 7 for residents 4, 7, 8, 9, and 10 A review of the restorative documentation indicates the following additional examples: Resident 4's restorative program is Passive Range of Motion to lower extremities 10 repetitions twice daily. Resident 4's restorative documentation indicates: December 2015: 62 opportunities. Did not occur 20 times. January 2016: 62 opportunities. Did not occur 23 times. February 1-3rd 2016: 9 opportunities. Did not occur 1 time. Resident 7' restorative program is to ambulate in hallway with 1 staff assist, walker, gait belt and follow with wheelchair Day shift and PM shift. Resident 7's restorative documentation indicates: December 2015: 62 opportunities to ambulate. Did not occur 22 times. January 2016: 62 opportunities to ambulate. Did not occur 30 times. February 1-3rd 2016: 9 opportunities to ambulate. Did not occur 4 times. Resident 8's restorative program is to ambulate to meals with 1 staff assist, walker, gait belt and follow with wheelchair. Resident 8's restorative documentation indicates: December 2015: 93 opportunities to ambulate to meals. Did not occur 54 times. January 2016: 93 opportunities to ambulate to meals. Did not occur 60 times. February 1-3rd 2016: 9 opportunities to ambulate to meals. Did not occur 7 times. Resident 9's restorative program is Passive Range of Motion to all extremities 10 repetitions twice daily. Resident 9's restorative documentation indicates: December 2015: 62 opportunities. Did not occur 34 times. January 2016: 62 opportunities. Did not occur 14 times. February 1-3rd 2016: 9 opportunities. Did not occur 1 time. Resident 10's restorative program is to ambulate to meals with 1 staff assist, walker, gait belt and follow with wheelchair. Resident 10's restorative documentation indicates: December 2015: 93 opportunities to ambulate to meals. Did not occur 38 times. January 2016: 93 opportunities to ambulate to meals. Did not occur 29 times. February 1-3rd 2016: 9 opportunities to ambulate to meals. Did not occur 2 times.