Every finding on record at Rib Lake Health Services

Based on observation and interview, the facility did not ensure each resident has a safe, clean, comfortable, and homelike environment, including, but not limited to, receiving treatment and support for daily living for 5 (R5, R6, R7, R8, and R9) of 7 residents who independently use the East Hall to receive therapy services. For 6 of 13 (R5, R13, R14, R15, R17, and R3) residents residing in the southeast hall who independently ambulate. For 20 of 32 (R5, R6, R10, R20, R11, R7, R4, R12, R13, R1, R8, R14, R9, R2, R15, R16, R17, R18, R19, and R3) residents who have the potential to independently ambulate to the dining room to use the vending machines. The east hall going to the therapy room had cracked, missing, and lifting flooring tiles which have the potential to be an uncleanable surface and a hazard for residents who ambulate independently and use assistive devicesThe southeast hall had missing flooring tiles which have the potential to be an uncleanable surface and a hazard for residents who ambulate independently and use assistive devices. The dining room had buckling and lifting flooring tiles near the vending machines which have the potential to be an uncleanable surface and a hazard for residents who ambulate independently and use assistive devices. This is evidenced [NAME] 07/29/26 at 9:30 AM, Surveyor observed on the east hall across from the conference room, 2 yellow caution standing floor signs. Between the 2 yellow caution signs there are 23 square tile floorings that are cracked, missing parts of the tile, and are buckling and move when Surveyor stepped on them. At the end of the east hall is the facility's therapy room. On 07/29/26 at 9:41 AM, Surveyor interviewed Housekeeping C about the broken and missing flooring tiles across from the conference room. Housekeeping C stated for about 1 to 2 years the tile had been pulling up with missing pieces of tile. Every hallway the flooring tiles are broken. Housekeeping C does not know if they are going to be replaced. On 07/29/26 at 10:32 AM, Surveyor interviewed Maintenance Director (MD) E asking if the tile flooring is going to be replaced. MD E stated the tile flooring is not in the building budget to be replaced. Surveyor asked if the missing and broken tiles could be replaced. MD E stated they don't have the same size tiles. Surveyor observed with MD E the missing tile on the southeast wing by the shower room door. The floor appeared to have residual glue remaining on the floor. On 07/29/26 at 11:25 AM, Surveyor observed in the dining room by the soda and candy vending machines, the tile flooring to be buckling and a missing tile that is approximately 4 inches by 4 inches. There are 4 tile strips about 3 feet long that are buckling up and moving when Surveyor steps on the tiles that are located in front of the soda machine. The soda machine had a note on it stating it was out of service. On the right side of the soda machine was a wheeled cart that covered more buckling tiles.On 07/29/26 at 11:30 AM, Surveyor interviewed R3 and R4 about the vending machines and tiles buckling. R3 and R4 stated the tiles have been buckling since they put the vending machines there. Residents will use the machines, but the soda machine is currently broken. On 07/29/26 at 11:45 AM, Surveyor interviewed Dietary Manager (DM) H about the flooring tile by the vending machines. DM H stated the vending machines were put in about a year ago and within a month or so the tiles started to bubble. DM H stated the heat from the machines are drying the tile and glue causing the tile to bubble. DM H stated they will keep a cart next to the machine, so no residents go by bubbling tiles.On 07/29/26 at 1:48 PM, Surveyor interviewed Nursing Home Administrator (NHA) A asking when the tiles will be replaced in the hallways and dining room. NHA A stated they had sent in a capital request for carpeting for the lobby and flooring for part of the nurse's station to be replaced. [NAME] President of Success (VP) K stated the capital request was completed on 07/14/26 and did not include replacement of tiles in hallways. NHA A talked with MD E about replacing tiles. NHA A stated they don't know if there are tiles available since they are very old. On 07/29/26 at 2:49 PM, Surveyor interviewed Physical Therapist (PT) L asking which residents who receive therapy services are able to be mobile without staff assistance to come to the therapy room. PT L stated R5, R6, R7, R8, and R9 are able to come to therapy independently by ambulating with assistive devices, by wheelchair or with a motorized wheelchair. On 07/29/26 at 2:59 PM, Surveyor interviewed Registered Nurse (RN) M about residents able to move independently by ambulating or with assistive devices on the southeast hall. RN M stated on the southeast hall R5, R13, R14, R15, R17, and R3 can move without staff assistance. Surveyor asked which residents in the facility would be able to use the dining room vending machines independently. RN M stated R5, R6, R10, R20, R11, R7, R4, R12, R13, R1, R8, R14, R9, R2, R15, R16, R17, R18, R19, and R3.

Based on interview and record review, the facility did not immediately inform the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status for 2 of 3 residents (R) reviewed. (R1 and R3).R1 became lethargic and confused and was sent to the emergency department. There is no evidence that representative/emergency contact was updated.R3 had severe abdominal pain, acute leukocytosis with concern of sepsis (life threatening condition) would progress, and was transferred to the emergency department. There is no evidence that representative/emergency contact was updated. The facility policy titled, Change in condition of the Resident, states, Documentation . 4. Notification of responsible party - include date, time, what was conveyed, any comments (each time notified).According to regulation S483.10(g)(14), Even when a resident is mentally competent, his or her designated resident representative or family, as appropriate, should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally, especially in the case of sudden illness or accident.Example 1R1 was admitted to the facility on [DATE] with diagnoses that include diabetes, weakness, proteinuria, heart disease, urinary retention, history of prostate cancer, left leg amputation, and presence of urogenital implants. R1 had a brief interview of mental status (BIMS) score of 15/15 indicating intact cognition.Surveyor reviewed R1's progress notes. Note dated 01/02/26 stated R1 had a change in condition, altered mental status, (weak, tired, confused or drowsy) different than usual, poor food and fluid intake, and a functional decline. On 01/02/26 at 6:05 PM, staff updated the physician that ordered stat labs and push fluids. Staff were unsuccessful in obtaining blood draw after several attempts. Physician was again updated and stated to send R1 to the emergency department if unable to increase fluids or any changes occur. At 10:32 PM, progress notes indicated that staff assessed R1 and noted oxygen saturation was 81%, blood pressure 62/40, and s/he could not keep fluids down. Physician was updated and R1 was sent to the hospital and was diagnosed with septic shock and Fournier's gangrene (rapid progression necrotizing infection). The National Institute of Health explains the rapid progression of the disease can damage tissue at a rate of 1 inch per hour. Both conditions are life threatening. At 10:42 PM, R1 left for the hospital via ambulance. There is no mention that R1's family was notified. On 02/04/26, Surveyor spoke to R1's family member (FM) C who reported being upset that the facility did not provide an update until almost 6:00 AM on 01/03/26. FM C stated that she lives a few hours away and could have been with R1 sooner during R1's time of need. FM C also stated that due to R1's severe condition, all were in agreement to palliative care, which was initiated, and R1 passed away on 01/06/26. FM C stated she received R1's death certificate that identified the primary cause of death was multiple system shut down and secondary cause of death was sepsis.On 02/04/26, Surveyor interviewed Licensed Practical Nurse (LPN) D and asked to explain when family members are updated if residents are sent to the hospital. LPN D stated if residents are their own person (cognitively intact), they offer to call the emergency contact. If residents are not able to communicate, they always update the emergency contact. Surveyor asked LPN D to show in the notes where the documentation is that R1's emergency contact was updated. LPN D looked in multiple areas of R1's electronic health record (EHR) and stated she did not find any notes indicating R1's emergency contact was updated and explained it should have been completed and documented.Example 2R2 was admitted to the facility on [DATE] with diagnoses that include weakness, stroke, diabetes, obstruction/reflux uropathy, and aphasia. R2 had a BIMS assessment completed on 12/11/25 that resulted in a score of 15/15 indicating intact cognition. Surveyor reviewed progress notes that indicated R2 developed severe abdominal pain on 01/05/26, staff updated the physician who ordered labs. Labs showed elevated white blood count. Progress notes on 01/06/26 indicates R1 has severe abdominal pain, acute leukocytosis with a concern to progression of sepsis (life threatening condition). Physician ordered R2 be sent to the emergency department. Surveyor could not find any evidence that R2's emergency contact was updated. R2's face sheet specifically notes to update R2's sibling if R2 goes to the ER. On 01/08/26, progress notes indicate a hospital update that R2 was diagnosed and being treated for a urinary tract infection and will be returning back to the facility. Surveyor attempted to interview R2; however, R2 declined due to not feeling well. Surveyor attempted and was unsuccessful with contacting R2's sibling for verification of notification. On 02/04/26 at 1:20 PM, Surveyor interviewed Director of Nursing (DON) B and asked what the expectation would be for staff to notify emergency contact of resident transfers to the hospital with potential life-threatening concerns. DON B stated she would expect staff to update any activated power of attorney, guardian, and if the resident chooses. If they are not able to choose, or understand for any reason, the emergency contact should be updated and documented in the resident's record. Surveyor asked DON B to show where in R1 and R2's medical record shows evidence that the staff notified emergency contacts for the hospitalization mentioned above. DON B stated she did not see any documentation that families were updated.

Based on observation and interview, the facility did not maintain a safe and sanitary environment in which food is prepared and distributed. This had the potential to affect all 38 residents in the facility.Facility staff did not label, date, or cover food.Facility is not protecting clean dishware from contaminants. Facility staff did not keep personal clothing from touching food when serving residents.Findings include:The 2022 FDS Food Code documents at 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food: Disposition .A date marking system may be used which places information on the food, such as on an overwrap or on the food container, which identifies the first day of preparation, or alternatively, may identify the last day that the food may be sold or consumed on the premises. A date marking system may use calendar dates, days of the week, color coded marks, or other effective means, provided the system is disclosed to the Regulatory Authority upon request, during inspections.4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles.(A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS,laundered LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES shall be stored: . (2) Where they are not exposed to splash, dust, or other contamination.2-304.11 Clean Condition.Food employees shall wear clean outer clothing to prevent contamination offood, equipment, utensils, linens, and single-service and single-use articlesThe United States Public Health Service, Food and Drug Administration Food Code 2-401 Food Contamination Prevention, states in part,. F. Facility-wide ConsiderationsIn order to have active managerial control over personal hygiene and cross-contamination, certain control measures must be implemented in all phases of the operation. All of the following control measures should be implemented regardless of the food preparation process used. Prevention of cross-contamination of ready-to-eat food or clean and sanitized food-contact surfaces with soiled cutting boards, utensils, aprons, etc.,On 9/29/25 at 8:25 AM, Surveyor conducted initial Kitchen tour with Dietary Manager (DM) K. During initial tour, Surveyor observed open bags of broccoli, peas, beans, and tater tots, as well as opened ice cream in the freezer without any information written on them. Surveyor also observed opened peaches in a container without any information labeled and uncovered chicken cutlets in a pan without any information on or near the container. DM K stated the chicken should be covered and all of the open food items should be dated when opened and stored. On 9/29/25 at 8:33 AM, Surveyor observed a fan positioned on a top shelf across from the clean dishes area, blowing on the clean dishes to dry them. DM K stated he did not know fan could not be used to dry the clean dishes and verbalizes understanding of how this exposes the dishes to dust and potential other contaminants. On 9/30/25 at 11:48 AM, Surveyor observed DM K dishing up food onto residents' plates. DM K leaned forward to dish up food, and while doing so, Surveyor observed DM K's soiled clothing touch top of residents' plates and at times, residents' food. DM K stated he did not wear an apron when cooking and was unaware his clothing was touching the resident's food and plates. Immediately after observation, Surveyor interviewed DM L, who stated the expectation would be the staff's clothing does not touch the residents' plates and/or food during serving of meals.

Based on interview and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (R9) who smoke in the facility.R9 did not have a smoking care plan, or a nicotine assessment completed.Findings:Facility policy titled, Smoking Policy date revised 9/10/24 stated in part: .3. Residents and family members will be notified of this policy during the admission process, and as needed.4. All residents will be asked about tobacco/nicotine use during the admission process, and during each quarterly or comprehensive minimum data set (MDS) assessment process.5. Resident who smoke or use nicotine or e-cigarettes will be further assessed, using the Nicotine Assessment UDA, to determine whether supervision is required for smoking, or if resident is safe to smoke at all .7. Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas (weather permitting), at designated times, and in accordance with his/her care plan .9. All safe smoking measures will be documented on each residents' care plan and communicated to all staff, visitors, and volunteers who will be responsible for supervising residents while smoking. Supervision will be provided as indicated on each residents' care plan .Resident (R) 9 was admitted to the facility on [DATE] with a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated R9 was cognitively intact.R9 had diagnoses of acute respiratory failure with hypoxia (the inability of the respiratory system to maintain an adequate blood oxygen level to preserve normal organ function), cerebral infarction (refers to a blood vessel blockage in the brain caused by atherosclerosis, or the hardening of arteries due to buildups of fatty deposits), and above the knee amputation of the left leg.R9 did not have a care plan to address smoking.R9 did not have a nicotine assessment in the medical chart.On 09/29/2025 at 8:39 AM, facility provided team with a list of residents in the facility who smoke. R9 was on the list of smokers.On 09/29/2025 at 9:46 AM, Surveyor asked R9 about the normal routine for smoking. R9 replied, I usually have to ask for my cigarettes. We go right out the front door to smoke. I can get from my bed to my chair pretty much on my own I just need someone here, so I don't end up on my nose.On 09/29/2025 at 1:43 PM, Surveyor was unable to find any care plan or nicotine assessment for R9 in the medical chart.On 09/30/2025 at 8:07 AM, Surveyor asked Registered Nurse (RN) I for a nicotine assessment and care plan for R9.On 09/30/2025 at 8:27 AM, RN I informed Surveyor that R9 did not initially smoke when he came in so the facility missed that assessment but have now completed that assessment so when R9 goes out again he will be ok.On 10/01/2025 at 12:44 PM, Surveyor asked License Practical Nurse (LPN) J, When did the facility know that [R9] was a smoker? LPN J replied, We knew probably a couple of days after he came to our facility. He did not go out and smoke before that that I know of. Surveyor asked LPN J, When was the nicotine assessment completed for R9? LPN J replied, I think recently that was completed. I know that all smokers are supposed to have a nicotine assessment.

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 to the administrator of the facility and to other officials in accordance with State law through established procedures for 1 resident (R8) reviewed.Facility failed to report R8's allegation of abuse/neglect to State Agency (SA) and law enforcement. Findings:The facility policy, titled Abuse, Neglect and Exploitation, revised 07/15/2022, states: Definition of Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.includes verbal abuse. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.Reporting/Response Part A(1a) states in part.reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other agencies (e.g., law enforcement when applicable) immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in bodily injury. R8 was admitted to the facility on [DATE], with diagnoses including abnormalities of gait and mobility, chronic obstructive pulmonary disease (COPD), morbid obesity, unspecified dementia and anxiety disorder. R8 has a BIMS score of 8/15, which indicates moderate cognitive impairment, and has an activated power of attorney for healthcare. On 10/01/2025 during record review of facility complaints, documentation of a grievance was found, dated 07/16/2025 and filed by Social Worker (SW) D on behalf of R8. Grievance report states:On 07/16/2025 (no time indicated), grievance was reported. Description of grievance states in part.Certified Nursing Assistant (CNA) E came in and threw off attitude with R8. CNA E then called another aide into the room to boost R8, and R8 asked not to because of some pain (from a fall R8 sustained earlier that day) and how R8 thought his leg was broken. The report further indicated R8 stating CNA E said, oh come on [R8]! and then proceeded to boost R8. R8 felt CNA E has a sour and poor attitude with R8 every time R8 needs something. On 07/22/2025, grievance report indicates SW D interviewed several other residents on southeast hall, inquiring about any concerns of abuse or neglect. No concerns of abuse/neglect identified. On 07/17/2025, R8's POA was notified of grievance regarding alleged abuse. On 08/06/2025, NHA H signed grievance reportOn 10/01/2025 at 11:45 AM, Surveyor interviewed R8 about alleged abuse/neglect incident on 07/15/2025. R8 did not recall all details of incident but did remember it happening and that CNA E was staff person involved. R8 denied having any harm as result of incident. R8 denies any further concerns of abuse/neglect with CNA E or other staff. R8 continues to allow CNA E to perform cares. R8 stated, They've had trouble with her before. She acts like she owns the place. On 10/01/2025 at 12:03 PM, Surveyor interviewed SW D about the grievance filed on 07/16/25 on R8's behalf of allegation of inappropriate interaction between CNA E and R8. SW D stated:On 07/15/25, late afternoon just prior to SW D's shift ending, CNA F and another CNA, whom SW D could not recall name for, presented with concerns of witnessing CNA E's rudeness towards R8 earlier in the day. SW D asked both CNAs to report concerns to nursing staff and to write up statements surrounding event and put reports under SW D's door to be addressed next day. SW D is not sure if CNAs did report incident to nursing staff.On 07/16/2025, at facility's routine morning meeting (SW did not recall the time) with interdisciplinary team members (IDT), SW D brought forward R8's concerns. Nursing Home Administrator (NHA) H, acting administrator at time of incident, informed SW D to speak with R8, as well as CNA E about tone of voice.On 07/16/2025, upon arrival to work, SW D had received a witness statement from CNA F. SW D states no statement from other CNA who reportedly witnessed incident on 07/16/2025 was received.On 07/16/2025, Housekeeping (HK) G arrived for shift and told SW D of overhearing CNA E speaking rudely to R8 on 07/16/2025. SW D asked HK G to write a witness statement. Statement from HK G was later received.On 07/17/2025 (SW D did not recall time), SW D interviewed R8 who stated CNA E was inconsiderate after R8 requested to not be boosted up in the bed because of pain. R8 told SW D that CNA E was rude and had no remorse. SW D asked if R8 preferred that CNA E no longer performs cares for him, and R8 stated, 'It's water under the bridge. I just wish she was more considerate. R8 declined SW D's offer for alternative staff to do cares. On 07/22/2025 (SW D did not recall time), SW D spoke with CNA E regarding grievance filed for incident on 07/15/2025. SW D could not recall entire conversation with CNA E but was instructed by NHA A to address CNA's mannerism and tone of voice toward R8.On 07/29/2025, SW D interviewed a surplus of residents down the Southeast Hall asking if they had any concerns with CNA E or any other staff. All residents interviewed denied having any concerns of abuse or neglect. On 10/01/2025 at 12:49 PM, Surveyor interviewed current NHA A what expectations are of staff to report any allegations of abuse/neglect. NHA A stated there is a facility policy for abuse and neglect in place and it is expected that all staff persons report abuse suspicions immediately to administrative staff or shift nurses. Shift nurses have been trained on the protocols for reporting abuse/neglect allegation immediately to the NHA/DON. NHA A stated all staff receive annual training on abuse and neglect. NHA A stated all allegations of abuse/neglect are to be reported to the state and appropriate authorities within 2 hours of acknowledgment, investigation of incident begins immediately with a completed follow up report done in 5 days. On 10/01/2025 at 1:15 PM, Surveyor interviewed former NHA H, who was acting NHA at time of incident, what expectations are of staff to report any allegation of abuse/neglect. NHA H stated if abuse/neglect was suspected, it would be reported to the state. At time of the incident, NHA H did not feel actual harm came to R8 because of the interaction between R8 and CNA E, so administration did not report the allegation of abuse or neglect to SA or law enforcement. NHA H stated SW D was asked to further interview both R8 and CNA E about their interaction, and CNA E was made aware that the interaction was interpreted as inappropriate by R8.

Based on interview and record review, the facility did not ensure alleged violations of abuse or neglect was thoroughly investigated, preventions for further abuse/neglect implemented, and corrective actions were taken as a result of investigation for 1 resident (R8) of 1 resident.Failure by the facility to thoroughly investigate R8's allegation of abuse/neglect denied protection of R8's health, welfare and rights as a resident to feel safe while residing at facility. Findings:The facility policy, titled Abuse, Neglect and Exploitation, revised 07/15/2022, states in part:Prevention of Abuse, Neglect and Exploitation - The facility will identify, correct and intervene in situations in which abuse, neglect.is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff to meet the needs of the residents.Identification of Abuse, neglect or Exploitation - The facility will have written procedures to assist staff in identifying the different types of abuse.Investigation of Alleged Abuse, Neglect and Exploitation - An immediate investigation is warranted when allegation or suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Identifying and interviewing all involved persons. focusing the investigation on determining if abuse/neglect has occurred, the extent, and cause.providing complete and thorough documentation of the investigation.R8 was admitted to the facility on [DATE] and has diagnoses that include abnormalities of gait and mobility, Chronic Obstructive Pulmonary Disease (COPD), morbid obesity, unspecified dementia and anxiety disorder.R8 has a BIMS score of 8, moderate cognitive impairment, and has an activated power of attorney for healthcare. On 10/01/2025 during record review of facility complaints, documentation of a grievance was found, dated 07/16/2025 and filed by Social Worker (SW) D on behalf of R8. Grievance report states:On 07/16/2025 (no time indicated), grievance was reported. Description of grievance states in part.Certified Nursing Assistant (CNA) E came in and threw off attitude with R8. CNA E then called another aide into the room to boost R8, and R8 asked not to because of some pain (from a fall R8 sustained earlier that day) and how R8 thought his leg was broken. The report further indicated R8 stating CNA E said, oh come on [R8]! and then proceeded to boost R8. R8 felt CNA E has a sour and poor attitude with R8 every time R8 needs something. On 07/17/2025, R8's POA was notified of grievance regarding alleged abuse.On 07/22/2025, grievance report indicates SW D interviewed other residents on southeast hall about any concerns of abuse or neglect. No concerns of abuse/neglect identified. It is noted the facility had no documentation to support who was interviewed for residents, or what was said. On 07/29/2025, grievance report documentation for actions taken to resolve grievance states SW D questioned CNA E about allegation and CNA E stated CNA E and R8 are fine and have been fine since the altercation. On 08/06/2025, NHA H signed grievance reportOn 10/01/2025, witness statement by CNA F, dated 07/15/2025, was reviewed and states that R8 told CNA F, I don't deserve to be treated poorly, talked to like I am nothing and argued with. CNA F's statement states R8 requested CNA E not to be allowed back in room because she is rough and does not care about us.On 10/01/2025, witness statement by HK G, dated 07/17/2025, stated while cleaning R8's room, R8 talked to HK G about knee pain and earlier that morning R8 told CNA E this. CNA E responded to R8, Oh [R8], it's not that bad and then turned off R8's call light and left room. R8 did not appreciate that kind of response when in pain. HK G offered to get another CNA to assist, however R8 declined. On 10/01/2025 at 11:45 AM, Surveyor interviewed R8 about alleged abuse/neglect incident on 07/15/2025. R8 did not recall all details of incident, but did remember it happening and that CNA E was staff person involved. R8 denied having any harm as result of incident. R8 denies any further concerns of abuse/neglect with CNA E or other staff. R8 continues to allow CNA E to perform cares. R8 stated, They've had trouble with her before. She acts like she owns the place.On 10/01/2025 at 12:03 PM, Surveyor interviewed SW D about the grievance filed on 07/16/25 on R8's behalf of allegation of inappropriate interaction between CNA E and R8. SW D stated:On 07/15/25, late afternoon just prior to SW D's shift ending, CNA F and another CNA, whom SW D could not recall name for, presented with concerns of witnessing CNA E's rudeness towards R8 earlier in the day. SW D asked both CNAs to report concerns to nursing staff and to write up statements surrounding event and put reports under SW D's door to be addressed next day. SW D stated not sure if CNAs reported incident to nursing staff.On 07/16/2025, at facility's routine morning meeting (SW did not recall the time) with interdisciplinary team members (IDT), SW D brought forward R8's concerns. Nursing Home Administrator (NHA) H, acting administrator at time of incident, informed SW D to speak with R8, as well as CNA E about tone of voice. It is noted there is no documentation to support participants in meeting, or issues addressed. There is no evidence that CNA E was removed from resident cares or that an investigation process was initiated. On 07/16/2025, upon arrival to work, SW D had received a witness statement from CNA F. SW D stated no statement from other CNA who reportedly witnessed incident on 07/16/2025 was received.On 07/16/2025, Housekeeping (HK) G arrived for shift and told SW D of overhearing CNA E speaking rudely to R8 on 07/16/2025. SW D asked HK G to write a witness statement. Statement from HK G was later received.On 07/17/2025 (SW D did not recall time), SW D interviewed R8 who stated CNA E was inconsiderate after R8 requested to not be boosted up in the bed because of pain. R8 told SW D that CNA E was rude and had no remorse. SW D asked if R8 preferred that CNA E no longer performs cares for him, and R8 stated, It's water under the bridge. I just wish she was more considerate. R8 declined SW D's offer for alternative staff to do cares. On 07/22/2025 (SW D did not recall time), SW D spoke with CNA E regarding grievance filed for incident on 07/15/2025. SW D could not recall entire conversation with CNA E but was instructed by NHA H to address CNA's mannerism and tone of voice toward R8On 07/29/2025, SW D interviewed a surplus of residents down the Southeast Hall asking if they had any concerns with CNA E or any other staff. All residents interviewed denied having any concerns of abuse or neglect. There is no supporting documentation of which residents were interviewedOn 10/01/2025 at 12:49 PM, Surveyor interviewed NHA A what expectations are of staff to report and investigate any allegations of abuse/neglect. NHA A stated there is a facility policy for abuse and neglect in place and it is expected that all staff persons report abuse suspicions immediately to administrative staff or shift nurses. NHA A stated all staff receive annual training on abuse and neglect recognition and reporting. NHA A stated all allegations of abuse/neglect are to be reported to the state and appropriate authorities within 2 hours of acknowledgment, investigation of incident begins immediately, which includes removal of accused staff personnel from resident care, and a completed investigative follow up report done in 5 days. NHA A was unable to provide proof of a facility reported incident for 07/15/2025, or documentation of a thorough investigation was implemented. On 10/01/2025 at 1:15 PM, Surveyor interviewed NHA H what expectations are of staff to report and investigate any allegation of abuse/neglect. NHA H stated if abuse/neglect was suspected, it would be reported to the state. At the time of the incident, NHA H did not feel actual harm came to R8 because of the interaction between R8 and CNA E, so it was not reported to appropriate agencies as abuse or neglect. NHA H stated SW D was asked to further interview both R8 and CNA E about their interaction. At time of interview, NHA H did acknowledge there was indication of abuse/neglect based off information provided by R8 and staff, and that this occurrence should have been reported to appropriate agencies with an investigative process implemented immediately.

Based on interviews and record review, staff did not follow the facility's post fall assessment for 1 out of 1 resident (R26) investigated for falls.The facility did not ensure post fall neurological (neuro) checks were performed as required following R26's unwitnessed fall. Findings include:The facility's policy titled, Fall Prevention and Management Guidelines reviewed on 7/18/24, states in part, .7. When any resident experiences a fall, the facility will: a. Complete a post-fall assessment and review: . 2) Neuro checks for any unwitnessed fall or witnesses fall where resident hits their head: Initially, then hourly x 3 then continue neuro checks every 4 hours x 6, then continue neuro checks every 8 hours x 6 or as indicated by physician.R26 was admitted to the facility on [DATE] with diagnoses, which include in part, Alzheimer's disease and focal partial symptomatic epilepsy. R26's care plan includes, in part, that R26 is at risk for falls due to history of falls, past history of syncope, and possible seizures. R26 most current Minimum Data set (MDS) on 8/2/25 indicated a Brief Interview for Mental Status (BIMS) was 4/15, indicating severe cognition deficit. R26 had no impairment with range of motion (ROM), independent with ambulation and use of walker, and required partial to moderate assistance with hygiene/ bathing/dressing.Record review indicated on 8/28/25 at approximately 3:15 PM, R26 had an unwitnessed fall outside the facility in front of the building. Vital signs were taken and were recorded as the following: blood pressure: 124/75, Temperature: 98.2, pulse: 124, and respirations: 18. Resident was brought back in the building. R26 was assessed by the Director of Nursing (DON). R26 had a laceration on her left upper arm/shoulder. Provider was notified. Documentation on 8/28/25 in R26's post assessment fall documentation, states in part. 8. Care Plan, 1. List new immediate interventions. Social Service Director spoke with Power of Attorney (POA) in regard to wander guard. 1-hour checks. Date and time of interventions 8/28/25 1:45PM.Surveyor interviewed Nursing Home Administrator (NHA) A, who stated, 1-hour checks were put in the assessment by mistake. No documentation of 1 hour wandering checks on R26 were completed.R26's record review indicated neurological checks were completed as follows:On 8/28/25, initially at 3:15 PM and hourly at 4:05 PM and 5:13 PM. Neuro checks were completed initially and then hourly two time, missing the third hourly neuro check around 6 PM.Neuro checks then should have been completed every 4 hours x 6 and were completed at 9:59 PM on 8/28/25 and then not checked again until 8/29/25 at 2:59 AM and 11:27 PM. The Neuro checks should have been done at 2 AM, 6 AM, 10 AM, 2 PM, 6 PM, and 10 PM on 8/29/25. There was no documentation of neuro checks done at those times.Neuro checks then should have been completed every 8 hours x 6 at around 6 AM, 2 PM, and 10 PM on 8/30/25 and documentation shows these were done at 4:30 AM, 2:34 PM, and 4:53 PM on 8/30/25. No documentation of neuro checks for 16 hours until on 8/31/25 at 9:52 AM and then again at 5:21PM.On 10/01/25 at 8 AM, Surveyor interview NHA A, who stated she is aware there are missing post fall neurological assessments from R26's fall on 8/28/25. Although the neuro checks completed were with in normal limits and R26 did not require hospitalization, there was a potential for R26 to have had harm due to the multiple missed neuro checks.On 10/1/25 at 11:50 AM, Surveyor interviewed DON B, who stated the expectation would be that staff follow the facility's Fall Prevention and Management Guidelines as indicated for post-fall assessments.

Based on observation, interview and record review, the facility did not prepare, distribute, and serve food in a manner that prevents foodborne illness. This has the potential for foodborne illness to all 35 residents (R) in the facility.The facility staff did not ensure proper hand hygiene when preparing and plating of food. The facility did not take internal food temperatures of all cooked foods before serving.Findings:The facility policy, titled Hand Washing - Food and Nutrition Services, dated 8/16/2022, states:Employees will wash hands as frequently as needed throughout the day using proper hand washing procedures,When to wash hands:f. After handling soiled equipment or utensils.g. During food preparation, as often as necessary to remove soil or contamination and to prevent cross contamination when changing tasks.i. Before donning (putting on) disposable gloves for working with foods and after gloves are removed. The policy General Food Preparation and Handling, dated 8/16/22, discusses food preparation, storage, and food service; however, it only addresses appropriate temperatures for cooling down foods and process. It does not address temperatures of food before serving. According to Food Safety.gov, a federal government website managed by the US Department of Health and Human Services, last updated 9/2/2023, states, FDA Food code requires nursing home kitchens monitor food temperatures to ensure potentially hazardous foods are kept at safe temperatures to prevent bacterial growth. Temperatures must be taken continuously for holding foods ., to confirm cooking is complete to the minimum internal temperature. Food temperatures should be checked with a calibrated thermometer during these critical control points. According to State Operations Manual-Appendix PP Long Term Care, dated 4/2025, which states, Hot foods are held at 135 F or higher on the steam table.Ensure proper final internal cooking temperatures (monitoring the foods' internal temperature for 15 seconds determines when microorganisms can no longer survey and food is safe for consumption) .Surveyors are to monitor the time food is put on the steam table and when meal service starts.This is evidenced by:Example 1On 9/3/25 at 6:42 AM, Surveyor entered kitchen and started to observe [NAME] D prepare breakfast. [NAME] D pulled the oatmeal container from a shelf, took out a metal pan and measuring cup, measured oatmeal and water, and set to cook on the stove top. [NAME] D went and washed her hands. [NAME] D donned gloves, opened a loaf of bread and started putting it through the industrial toaster. [NAME] D buttered toast and took off her gloves. [NAME] D did not wash her hands. [NAME] D then took toast to steamer table and put in steamer pan with contaminated hands and did not use tongs to place toast in the steamer pan. [NAME] D continued to get temperatures of food, only touching pans and thermometers. [NAME] D took omelets from steamer pan with a tong, placed on a plate, and carried to microwave. Omelets were overlapping and touching [NAME] D's contaminated hands. [NAME] D placed omelets in microwave. [NAME] D then carried overlapping omelets, which were touching contaminated hands to steamer pan and took the temperature of the omelets. [NAME] D then took remaining cold omelets (not overlapping) to microwave to be warmed. [NAME] D went to the sink and washed hands. [NAME] D went back to steamer table to start plating food for the unit carts. [NAME] D started to plate food at 7:07 AM. [NAME] D started plating food using different tongs for each food type and went through the dietary sheets with dietary aide, putting supplemental shakes and fruit on the plates as ordered. While making plates for first cart, [NAME] D went to the freezer, took out the box of omelets, touched freezer handle, box of omelets, and surfaces with her bare hands. [NAME] D put on gloves without washing hands first. [NAME] D took frozen omelets out of the box with gloved hands, placed on plate, and took them to the microwave. The scrambled eggs in microwave were taken out, temperature obtained and dumped into steamer table pan. [NAME] D took off gloves and did not wash hands. [NAME] D went to 3 compartment sink, touched handles, filled the sanitation buckets and water bucket with [NAME] D's bare hands. [NAME] D then put on new gloves without washing her hands, opened freezer door, and pulled bread bags from freezer. Using tongs, [NAME] D took a piece of gluten-free bread to toaster by the microwave. While bread was toasting, [NAME] D took out regular bread with same gloves and started toasting more bread with the industrial toaster. [NAME] D, using a pair of tongs, retrieved the gluten-free bread and directly put on a plate. [NAME] D took off her gloves and went to sink to wash her hands. [NAME] D started plating food for the second cart. [NAME] D did not step away from steamer table until all food was plated for the second cart. [NAME] D washed hands and took a moment to pull tickets before starting to plate food for residents in the dining room. Surveyor left kitchen and followed cart to the unit. On 9/3/25 at 8:52 AM, Surveyor interviewed [NAME] D and asked when hand washing is appropriate or necessary. [NAME] D stated when you clock in, wash when you go out, wash when you come back in, wash when you touch new product, go to a new job wash your site. If you touch raw meat, always wash.On 9/3/25 at 12:28 PM, Surveyor interviewed [NAME] D to get clarification and asked if handwashing is required if you use gloves in the kitchen. [NAME] D stated to use gloves anytime you work with raw meat. Wash hands before gloves and afterwards discard them and wash your hands every time such as when working with lettuce, tomatoes, cucumbers, or anything you prepare. Wear gloves when handling toast because it is difficult to use tongs. You should not be touching any food item with your bare hands. There should be tongs for each food item. Surveyor asked if it is gloves or handwashing or both. [NAME] D stated you must wash hands before and after gloves. Surveyor shared observations with [NAME] D. [NAME] D stated, I should have washed my hands.On 9/3/25 at 12:25 PM, Surveyor interviewed Dietary Manager (DM) E and asked what DM E's expectations are for hand washing. DM E stated the expectation is that staff should follow the procedure for hand washing, 20 seconds, dry hands, shut off faucet. Surveyor asked if it is ok to use gloves and not wash your hands. DM E stated no, hands should be washed before gloves are put on and when gloves are taken off.Example 2On 9/3/25 at 7:18 AM, Surveyor observed [NAME] D take and record temperatures for Cream of Wheat. [NAME] D wiped probe, air dried for 5 seconds, and left probe in food for 90 seconds. [NAME] D then proceeded to take temperature of the oatmeal following the same procedures. Temperatures were 180 for both items. [NAME] D then went to take temperature of omelets. [NAME] D stated she could tell they were cold, and with tongs, [NAME] D placed the omelets on a plate and took them to be microwaved. [NAME] D stated we do not put the omelets in the oven because then they (residents) complain they are crispy. After microwaving was complete, [NAME] D took temperature of omelets. They were 160 and [NAME] D put the omelets into the steamer pan and started plating food. On 9/3/25 at 7:30 AM, Surveyor observed [NAME] D lift the lid on the first set of steamer pans for the first time. Surveyor had been continuously monitoring the kitchen since 6:40 AM. [NAME] D pulled out a plastic bag with pancakes. [NAME] D ripped the bag open and with tongs put pancakes on a plate. [NAME] D then took another set of tongs and retrieved a fried egg from under same steamer pan lid. Neither of these items had a temperature obtained before serving and were in the steamer before 6:40 AM when Surveyor entered the kitchen to start observations. On 9/3/25 at 10:30 AM, Surveyor reviewed temperature logs. For the last 30 days prior to today, all food temperatures were taken and recorded.On 9/3/25 at 12:28 PM, Surveyor interviewed [NAME] D, who stated that all hot foods should be temped when they come out of the oven. Surveyor asked about the fried eggs and pancakes. [NAME] D stated, I didn't do that? I should have.On 9/3/25 at 12:43 PM, Surveyor interviewed DM E who stated DM's E expectations are that all food should be temped when it comes out of the oven, right before serving. When Surveyor told DM E that temps were missed this morning on fried eggs and pancakes, DM E stated a second time that all food that comes out of an oven should be temped.

Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect all 14 residents (R) living on the unit. R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18 Staff did not wear proper personal protective equipment (PPE) when interacting with residents on contact precautions (R5, R6, R7, R8, and R9).Staff entered rooms of residents on contact precautions (R5, R6, R7, R8, R9) without proper PPE and then passed food trays to residents not on contact precautions which had the potential to develop and transmit communicable disease and infections. Findings:The facility policy, titled Transmission- Based (Isolation Precautions), dated 9/24/24, states in part, 10. Contact Precautions-a. Intended to present transmission of pathogens that are spread by direct or indirect contact with the reside or the resident's environment .c. Healthcare personnel caring for residents on Contact Precautions were a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment.This is evidenced by:On 9/3/25 at 8:05 AM, Surveyor observed Certified Nursing Assistant (CNA) H and CNA G deliver breakfast trays to residents in the south unit. The south unit has residents currently on contact precautions and enhanced barrier precautions. CNA H and CNA G started delivering food at the end closest to the nurses' station and worked their way down towards the end. CNA G stated that all residents are on the unit eating in their rooms today. One resident was off unit and had gone to dialysis. Thirteen residents remained. CNA H was observed taking food to R5 and then to R6 without required PPE. Both R5 and R6 were on contact precautions. CNA H then proceeded into R11's room, who was not on contact precautions. CNA G took food to R7 and then to R9 without required PPE. Both R7 and R9 were on contact precautions. CNA H then took food to R12, who was not on contact precautions. On 9/3/25 at 10:25 AM, Surveyor interviewed Director of Nursing (DON) B regarding staff following contact precautions vs. enhanced barrier precautions. DON B stated she expects staff to follow precautions as ordered. DON B stated PPE goes on outside of room when on contact and can go on when they get in the room for cares when on enhanced. Contact precautions are followed whenever they go in their room, even passing trays. On 9/3/25 at 12:32 PM, Surveyor interviewed Assistant Director of Nursing (ADON) I, who stated the south unit is on lock down, because 5 residents have Gastrointestinal (GI) symptoms. Fourteen residents live on the hall. room [ROOM NUMBER] (R5), room [ROOM NUMBER] (R6), room [ROOM NUMBER] (R7), room [ROOM NUMBER] (R8), and room [ROOM NUMBER] (R9). ADON I stated that contact precautions mean you put on your PPE prior to entering. Enhanced barrier precautions, mean they have no GI symptoms but another reason for PPE during cares, like a catheter. You can put on your PPE when you get into the room. PPE should be put on prior to passing trays when resident is on contact precautions. On 9/3/25, at 12:28 PM, Surveyor interviewed CNA H who stated contact precautions are used for anyone that was sick. It means you put on your PPE before entering the room. Surveyor asked if that includes when going into their room to give them water or pass their food tray. CNA H stated that is including when passing trays; I missed one today. On 9/3/25 at 10:11 AM, Surveyor interviewed CNA G and asked CNA G if there is a difference between contact vs enhanced barrier precautions. CNA G stated that usually enhanced precautions means using PPE only with cares, but contact precautions is every time you go into a room. CNA G stated that rooms needing contact precautions are room [ROOM NUMBER] (R5), room [ROOM NUMBER] (R6), room [ROOM NUMBER] (R7), room [ROOM NUMBER] (R8), and room [ROOM NUMBER] (R9). Surveyor asked if CNA G wore a gown to deliver breakfast trays this morning and if she should have. CNA G stated probably not, I didn't think to do it until I went into R7's room.

Based on record review and interview, the facility did not revise resident care plans to reflect residents' current needs and to provide the needed direction to staff in providing necessary care and services. The facility practice affected 2 of 4 residents care plans reviewed (R3 and R4). R3's care plan directs staff with intervention on toileting schedule when R3 is fully incontinent and requires checking for incontinence, providing incontinent care and/or changing or brief if warranted. R4's care plan directs staff to remove her Hoyer sling when in wheelchair when current interventions include leaving R3's sling in place when up in her wheelchair for her safety. This is evidenced by: Surveyor requested and reviewed the facility policy titled Comprehensive Care Plan dated as most recently revised 9/23/2022. The policy in part read: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered plan for each resident . Policy Explanation and Compliance Guidelines: The comprehensive care plan will describe at minimum, the following: ~The services which are to be provided . ~Resident specific interventions . The comprehensive care plan will be reviewed and revised as appropriate by the interdisciplinary team after each comprehensive and quarterly MDS assessment, and as needed with changes in condition. Surveyor reviewed R3's record and noted the following: R3 most recent significant change in status Minimum Data Set (MDS) assessment completed 10/29/24 indicated R3 is always incontinent of bowel and frequently incontinent of bladder. R3's most recent Bowel/Bladder assessment dated [DATE] indicated Bladder: How long has resident been incontinent .Incontinent longer than a month, less than a year How often is resident wet .once or more per shift Resident is wet during .day and night time Amount of urine .Large Medications affecting elimination: antipsychotics Continent of stool .no Factors contributing to fecal incontinence .diarrhea, diet R3's care plan included: Focus: Urinary Incontinence r/t (related to) functional incontinence. Goal: will have no complications due to incontinence. Date initiated: 10/29/201 Revision on: 12/04/2023 Target date: 5/07/2025 Interventions/Tasks: ~Remind and assist as needed with toileting at routine times such as upon arising in am, before and after meals, activities, therapy and at bedtime. On 1/22/25 at 12:17 PM, Surveyor spoke with Director of Nursing (DON) B about R3's care plan for her incontinence care needs. DON B expressed R3 is always incontinent of bowel and bladder and a toileting schedule is no longer appropriate for R3. R3's care plan should have been revised with an intervention indicating she is to be checked/changed and provided incontinence care as needed every 2-3 hours and was not revised. Surveyor asked DON B about the facility process for revising resident plans of care. DON B expressed Registered Nurse/Resident Care Management Director (RCMD) E leads the facility process of MDS assessment and care plan development/revision. RCMD E works from home. DON B provided Surveyor with RCMD E's phone number. On 1/22/25 at 1:17 PM, Surveyor spoke with RCMD E via phone. RCMD E expressed during the MDS assessment process and with any resident change in status such as therapy recommendation the IDT (interdisciplinary team) meets to discuss and revise residents' care plans. R3's significant change in status MDS was done when hospice services were added. The bladder assessment was done as part of the assessment which showed R3 is incontinent of bowel and bladder. R3's care plan should have been updated to include she should be checked/changed and provided incontinent care every 2-3 hours as a toileting schedule is no longer appropriate. Example 2 Surveyor reviewed R4's most recent MDS which was a quarterly completed 12/01/24. The MDS indicated R4 understands, is understood and is cognitively intact. R3 is dependent on staff for transfer. Surveyor reviewed R4's comprehensive care plan and noted: Focus: urinary incontinence r/t impaired mobility. Goal: Will be free from skin breakdown Date Initiated: 11/04/2022 Date Revised: 6/15/2023 Target Date: 6/04/2025 Intervention: Remove sling from under resident when in bed or w/c (wheelchair). Surveyor observed R4 throughout the survey with her sling from her mechanical lift under her in her wheelchair. On 1/22/25 at 11:50 AM, Surveyor spoke with R4 about her sling observed under her in her wheelchair. R4 explained the sling is used with a lift to move her from bed to wheelchair and back. R4 expressed sometimes staff leave it under her in her wheelchair and sometimes staff remove it. R4 further expressed she is not sure why sometimes it is under her and sometimes it is not stating maybe cause it is sent to laundry. On 1/22/25 at 12:17 PM, Surveyor spoke with DON B about R4's care plan for her Hoyer sling. DON B expressed R4 needs her sling to remain under her when she is up in her wheelchair for safety reasons. It would be unsafe to remove the sling under R4 when she is up in her wheelchair and place it under R4 when she is in her wheelchair. The sling needs to remain in place for R4's safety. R4's care plan should have been revised indicating she requires her sling to remain under her for her safety and it was not revised. On 1/22/25 at 1:17 PM, Surveyor spoke with RCMD E about R4's care plan for her hoyer sling. RCMD E expressed R4 needs her sling to remain under her when she is up in her wheelchair for both her safety and staff safety. R4's care plan should have been revised indicating she requires her sling to remain under her for her safety and it was not revised.

Based on observation, record review and interview, the facility did not provide the necessary activities of daily living (ADLs) services for residents dependent on staff for care. The facility practice affected 1 of 4 residents reviewed for ADLs (R3). This is evidenced by: Surveyor requested and reviewed the facility policy tilted Perineal Care dated as most recently revised 4/04/2023. The policy in part read: Policy: It is the practice of this facility to provide perineal care to all incontinent residents .as needed to promote cleanliness and comfort . Policy Explanation and Compliance Guidelines: ~Gather supplies needed. ~Place water proof pad underneath resident. ~Reposition resident in supine position and continue with perineal care. Surveyor reviewed R3's record and noted the following: R3's most recent significant change in status Minimum Data Set (MDS) assessment completed 10/29/24 indicated R3 sometimes understands, sometimes is understood and has severe cognitive impairment. R3 does not reject care. R3 requires maximum assist for bed mobility and is dependent on staff for transfer. R3 is always incontinent of bowel and frequently incontinent of bladder. R3's diagnoses include memory deficit from known intra-cranial hemorrhage, hemiplegia and hemiparesis affecting right side. R3 has range of motion limitations of 1 upper and 1 lower extremity. R3's most recent Bowel/Bladder assessment dated [DATE] indicated Bladder: How long has resident been incontinent .Incontinent longer than a month, less than a year How often is resident wet .once or more per shift Resident is wet during .day and night time Amount of urine .Large Medications affecting elimination: antipsychotics Continent of stool .no Factors contributing to fecal incontinence .diarrhea, diet R3's care plan included: Focus: Urinary Incontinence r/t (related to) functional incontinence. Goal: will have no complications due to incontinence. Date initiated: 10/29/201 Revision on: 12/04/2023 Target date: 5/07/2025 Interventions/Tasks: ~Remind and assist as needed with toileting at routine times such as upon arising in am, before and after meals, activities, therapy and at bedtime. On 1/22/25 at 8:18 AM, Surveyor observed R3 up in her wheelchair in her room. R3 remained up in her wheelchair until 9:49 AM when Certified Nursing Assistants (CNA) C and D entered R3's room. On 1/22/25 at 9:47 AM prior to care observation, Surveyor spoke with CNA C about R3's routine and care provided by CNAs. CNA C indicted she cares for R3 routinely. R3 had gotten up per her usual around 6:20-6:30 AM this morning. R3 is dependent on staff for all care needs and is dependent on 2 staff via a Hoyer lift for transfers. CNA C expressed it is usual to check and change R3 as needed after meals, around this time each day. On 1/22/25 at 9:49 AM, CNA C and D entered R3's room and reclined R3 in her wheelchair. CNA C and D lowered R3's pants in front and checked her brief in the front for incontinence. CNA C and D expressed the strip in front of R3's brief indicated she was dry. CNA C and D pulled R3's pants up and inclined R3 in her chair. R3 was not transferred from her wheelchair to bed to allow for supine positioning to fully check R3 for incontinence. R3 remained up in her wheelchair and was not provided incontinent care or changing of her brief as warranted. Surveyor asked CNA C and D if the observed incontinence check is normal procedure. CNA C expressed staff check R3's brief in her chair; if the strip in front indicates she is wet she is transferred to her bed and provided incontinence care and changing of brief. On 1/22/25 at 12:17 PM, Surveyor spoke with Director of Nursing (DON) B about the observation. DON B expressed the manner of checking R3's brief for incontinence, as observed, is not sufficient to check R3 fully for incontinence. R3 should be transferred to bed and checked and changed with incontinent care as needed every 2-3 hours. Surveyor asked DON B about R3's intervention for toileting. DON B expressed R3 is always incontinent of bowel and bladder and a toileting schedule is no longer appropriate for R3. R3's care plan should have been revised with an intervention indicating she is to be checked/changed and provided incontinence care as needed every 2-3 hours.

Based on observation, record review and interview, the facility did not provide the necessary services for residents at risk for pressure injuries or residents with actual pressure injuries. The facility practice affected 1 of 4 residents reviewed (R3). R3 was not provided repositioning from her wheelchair to off-load pressure from 6:30 AM until Surveyor concluded observation at 12:10 PM. This is evidenced by: Surveyor requested and reviewed the facility policy titled Pressure Injury and Non-pressure Injuries dated as most recently revised 7/20/22. The policy in part read: Policy: This center will complete a comprehensive assessment to identify risk factors for the development of pressure injuries and put measures in place intended to achieve the goal of prevention of pressure injuries in our residents. Friction and Shearing: Friction is the mechanical force exerted on skin that is dragged across any surface. Policy Explanation and Compliance Guidelines: ~Complete the Braden Scale to assess risk of developing PI (pressure injury) . ~Care Planning: A comprehensive skin integrity care plan is based on resident history, review of skin assessments, Braden scoring .Consider the area of risk .Communicate risk factors and interventions to direct staff: Moisture: address cause of moisture . Activity: If a resident is chair bound . ~Schedule repositioning in the plan ~Develop turning/repositioning schedule based on resident needs and risk factors. Friction and Shear: ~Use lifting aides to move patient (slip sheet/lift sheet .) Surveyor reviewed R3's record and noted the following: R3's most recent significant change in status Minimum Data Set (MDS) assessment completed 10/29/24 indicated R3 sometimes understands, sometimes is understood and has severe cognitive impairment. R3 does not reject care. R3 requires maximum assist for bed mobility and is dependent on staff for transfer. R3 is at risk for the development of pressure injuries. R3's most recent Braden Scale for Predicting Pressure Score Risk dated 10/30/24 noted R3 scored a 13 which indicates R3 is at moderate risk for the development of pressure injuries. R3's risk factors include: Sensory Perception: Slightly limited: responds to verbal commands but can not always communicate discomfort or the need to be turned or has some sensory impairment Moisture: Occasionally moist: skin is occasionally moist . Activity: Chair fast: ability to walk severely limited or non-existent. Can not bear own weight and/or must be assisted to chair or wheel chair, Mobility: Very limited: makes occasional slight changes in body .unable to make frequent or significant changes independently. Nutrition: Probably inadequate . Friction and Shear: Problem: requires moderate to maximum assistance in moving .Complete lifting without sliding . R3's care plan included: Focus: At risk for alteration in skin integrity related to: contractures, diabetes, impaired mobility, incontinence, end of life, post CVA (stroke). Goal: minimize skin breakdown. Date initiated: 11/01/14 Target date: 5/07/2025. Interventions/Tasks: ~Encourage to reposition as needed; use assistive devices as needed. On 1/22/25 at 8:18 AM, Surveyor observed R3 up in her wheelchair in her room. R3 remained up in her wheelchair until 9:49 AM when Certified Nursing Assistants (CNA) C and D entered R3's room. On 1/22/25 at 9:47 AM prior to care observation, Surveyor spoke with CNA C about R3's routine and care provided by CNAs. CNA C indicted she cares for R3 routinely. R3 had gotten up per her usual around 6:20-6:30 AM this morning. R3 is dependent on staff for all care needs and is dependent on 2 staff via a Hoyer lift for transfers. CNA C expressed it is usual to check and change R3 as needed after meals, around this time each day. On 1/22/25 at 9:49 AM, Surveyor observed R3 up in her wheelchair in her room. CNA C and D entered R3's room and reclined R3 in her wheelchair. CNA C and D lowered R3's pants in front and checked her brief in the front for incontinence. CNA C and D expressed the strip in front of R3's brief indicated she was dry. CNA C and D pulled R3's pants up and inclined R3 in her chair. R3 was not transferred from her wheelchair and pressure was not off-loaded for R3. R3 remained up in her wheelchair until Surveyor concluded observation at 12:10 PM when Surveyor observed R3 in her room, in her wheelchair, with her lunch tray on bedside table in front of R3. On 1/22/25 at 12:17 PM, Surveyor spoke with Director of Nursing (DON) B about the observation. DON B expressed R3 should be transferred to bed to off-load pressure. The manner of reclining and incline of R3 in her wheelchair as observed could cause friction/shearing of R3's skin. R3 is at risk for pressure injuries. R3 is not able to reposition self in her wheelchair. Surveyor discussed R3's care planned interventions that indicated R3 should be repositioned as needed. DON B expressed R3 should be repositioned to prevent pressure injuries from developing.

Based on record review and interview, the facility did not take appropriate corrective action, educating all staff for 4 of 4 residents (R1, R2, R3, R4) reviewed for misappropriation of property. This is evidenced by: Surveyor reviewed the facility policy titled, Abuse, Neglect and Exploitation, revised on 07/15/22, which states, .It is the policy of this 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 . Staff: Includes employees, the medical director, contractors, caregivers who provide care and services to residents, including therapy, social and activity programs. Example 1 On 12/04/24, Surveyor reviewed a Facility Reported Incident (FRI) that noted on 10/03/24, R1 reported missing approximately $100.00. The facility reported and conducted an investigation with involvement of law enforcement and were unable to locate the money. On 12/04/24, Surveyor reviewed R1's record and noted the most recent quarterly Minimum Data Set (MDS) dated [DATE] indicated that R1 has a cognitive score of 13 out of 15, indicating normal cognition. Upon conclusion of investigation, the facility supplied re-education of abuse to nursing staff only. Example 2 On 12/04/24, Surveyor reviewed a FRI that noted on 10/05/24, R2 reported missing $287.00. The facility reported and conducted an investigation with involvement of law enforcement and were unable to locate the money. On 12/04/24, Surveyor reviewed R2's record and noted the most recent quarterly MDS, dated [DATE], indicated that R2 has a cognitive score of 14 out of 15, indicating normal cognition. Upon conclusion of investigation, the facility supplied re-education of abuse to only nursing staff. Example 3 On 12/04/24, Surveyor reviewed a FRI that noted on 10/25/24, R3 reported missing $150.00. The facility reported and conducted an investigation with involvement of law enforcement and were unable to locate the money. On 12/04/24, Surveyor reviewed R3's record and noted the most recent annual MDS, dated [DATE], indicated that R3 had a cognitive score of 15 out of 15, indicating normal cognition. Upon conclusion of investigation, the facility supplied re-education of abuse only to nursing staff. Example 4 On 12/04/24, Surveyor reviewed a FRI which noted on 10/09/24, R4's daughter reported missing $50.00. The facility reported and conducted an investigation with involvement of law enforcement and were unable to locate the money. On 12/04/24, Surveyor reviewed R4's record that noted on the most recent significant change MDS, dated [DATE], R4 has a cognitive score of 6 out of 15, indicating severe cognitive impairment. On 12/04/24 at 8:45 AM, Surveyor interviewed Account Manager (AM) C, regarding receiving education on abuse, including misappropriation of property. AM C was aware of R3 missing money and reported AM C had not received re-education of misappropriation. On 12/04/24 at 9:00 AM, Surveyor interviewed Hospice Certified Nursing Assistant (CNA) D regarding abuse including misappropriation of property. CNA D stated was not aware of any residents missing money and had not received any re-education regarding misappropriation. On 12/04/24 at 8:25 AM, Surveyor interviewed Housekeeper (HK) E regarding abuse including misappropriation of property. HK E stated was aware of R2 and R3 missing money and stated had not received any re-education regarding misappropriation. On 12/04/24 at 9:58 AM, Surveyor requested complete investigations of all 4 FRIs including all education provided to all staff following incidents of misappropriation. Surveyor received: 1. A training log for F557 Respect and Dignity which included education on staff searching a resident's body or personal possessions without the resident's or, if applicable, the resident's representative's consent. The information included dated signatures by nursing staff only. 2. A Course Completion History for education on Caregiver conduct. The information included dated signatures by nursing staff only. On 12/04/24 at 1:11 PM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding evidence of educating/re-educating all staff who may provide goods or services to residents. NHA A stated that education was not provided to contracted employees (dietary, housekeeping, laundry, and therapy), non-licensed staff (hospitality aides, activity aides, and maintenance), and others (beautician and volunteers) who provide care and services to residents.

Based on interview and record review, the facility did not establish an Infection Control Program under which it investigates, controls, and prevents infections in the facility, or a system for recording incidents identified under the facility's Infection Control Program, including corrective action in a timely manner, for both residents and staff. This has the potential to affect all 39 residents in the facility. -The facility did not have an adequate surveillance program in place for tracking and monitoring infectious disease for staff and residents. -Observations were made of facility staff not implementing proper infection control practices during and after resident cares for 1 of 1 resident on Enhanced Barrier Precautions (R2). Findings: Facility policy entitled: Infection Surveillance, with a last revised date of 03/08/23, states in part: .surveillance of communicable diseases and infections will include signs and symptoms of infection, a resident started on an antibiotic, microbiology testing, isolation precautions, microbiology test results show drug resistance. Facility policy entitled: Hand Hygiene, with a last revised date of 11/02/23, states in part: Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. Additional considerations: The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Infection surveillance: On 09/11/24, Surveyor reviewed the facility infection surveillance log for staff and residents for the period of 09/23-09/24 and noted the following: All residents listed did not include symptoms of illness. All residents listed did not include the date symptoms resolved. All residents listed did not include culture results, if applicable. All residents listed did not include type of isolation precautions implemented, date implemented, or date discontinued. On 04/03/24, R2's record review indicates a positive culture result of Methicillin-resistant Staphylococcus aureus (MRSA). This was not included on the infection surveillance log. On 09/11/24 at 7:17 AM, Surveyor interviewed Unit Manger (UM) I regarding infection surveillance logs. Surveyor asked UM I who was responsible for the infection surveillance logs. UM I stated that it is UM I's responsibility. Surveyor asked UM I to clarify the items that were to be monitored on the surveillance logs. UM I stated that each column on the list identifies what should be monitored. Surveyor asked UM I if the expectation is to have the surveillance log filled in entirely in all the documented columns. UM I stated yes. Surveyor asked why the columns of symptoms, symptom date of onset, symptoms resolution date, and transmission-based precautions (TBP) were all void of documentation. UM I stated the information was missing due to being new in this role and inexperience with this kind of documentation. Surveyor asked who was responsible for documenting and monitoring the infection surveillance log prior to UM I. UM I stated not being able to recall who had the role prior. UM I stated recognition of the infection surveillance log not being documented appropriately and is currently working to improve the practice. On 09/11/24 at 10:42 AM, Surveyor interviewed Director of Nursing (DON) B regarding the absence of R2 from the infection surveillance log for the MRSA infection noted on 04/03/24. DON B stated not being aware of a MRSA infection and directed Surveyor to speak with UM I. DON B stated further investigation of this would be completed and would get back to Surveyor with results. On 09/11/24 at 10:44 AM, Surveyor interviewed UM I regarding the absence of R2 from the infection surveillance log for the MRSA infection noted on 04/03/24. UM I stated not being aware of a MRSA infection but would try to find more information. On 09/11/24 at 12:50 PM, Surveyor interviewed UM I regarding the documentation of R2's MRSA infection. UM I stated being unable to find any additional information beyond a nursing note in R2's Electronic Medical Record (EMR) On 09/11/24 at 1:31 PM, Surveyor interviewed DON B, who is also the Infection Preventionist (IP), regarding infection surveillance logs. Surveyor asked DON B who is responsible for the infection surveillance log. DON B stated that she assists with the monitoring, but that UM I took over the responsibility 05/24. Surveyor asked DON B what items should be included on the infection surveillance logs. DON B stated that it should include symptoms, start/end date of symptoms, TBP start/end date if applicable, culture and test results, and any antibiotics prescribed. Surveyor asked if DON B was aware of the incomplete documentation on the infection surveillance log that was reviewed for the timeframe of 09/23-09/24. DON B stated she was aware and that it is one of the many projects to be included in improving. Surveyor asked DON B if there was a current plan of correction in place for the surveillance log. DON B replied that there was not. Example 2 R2 was admitted to the facility on [DATE] with pertinent diagnoses of diabetes mellitus type 2 and peripheral vascular disease. R2's most recent quarterly Minimum Data Set (MDS), dated [DATE], stated R2's Brief Interview for Mental Status (BIMS) score was 9/15, indicating moderately impaired cognition. R2 was identified as always incontinent of bowel and bladder. R2's comprehensive care plan, initiated 02/15/24, included in part: FOCUS Urinary incontinence r/t: impaired mobility, infection (UTI prior to admission), physical limitations On 09/10/24 at 7:19 AM, Surveyor observed Certified Nursing Assistant (CNA) L and CNA H complete personal cares for R2. R2 is on Enhanced Barrier Precautions (EBP) related to open wounds. Surveyor entered R2's room with CNA H, who completed hand hygiene and donned PPE that included a gown and gloves prior to entering room. Upon entering R2's room, CNA L was observed at bedside with R2, wearing only gloves. CNA H filled water basin and gathered supplies for R2's personal cares and placed items on R2's bedside table. CNA L began removing blankets and items from R2's bed to prepare for cares. CNA H asked CNA L to put on a gown and gloves as R2 was EBP. CNA L removed gloves and did not complete hand hygiene. CNA L donned a gown and gloves and returned to bedside. CNA H completed upper body cares with R2 following appropriate infection control practices of clean cloth for each new area cleansed and used the clean basin water appropriately. CNA L was observed completing peri cares on R2 using the same washcloth to clean and rinse area and repeatedly dipped the washcloth in the dirty water basin. After completing cares, CNA L applied zinc cream to R2's peri area and applied a new incontinence brief. CNA L did not change dirty gloves or complete hand hygiene between tasks. CNA L then assisted CNA H with repositioning R2 in bed and repositioning R2's clean bed sheets with same dirty gloves on. After cares were completed, CNA L reapplied R2's blankets without removing dirty gloves. CNA H removed supplies from R2's bedside table and did not disinfect table. CNA L and CNA H removed PPE and completed hand hygiene. On 09/10/24 at 7:44 AM, Surveyor interviewed CNA L and CNA H about cares provided. Surveyor asked both CNAs what the EBP sign on R2's door meant. CNA H stated that R2 had a wound, so staff needed to wear a gown and gloves when providing care. Surveyor asked both CNAs if they received education and training for infection control and EBP. Both CNAs stated yes. Surveyor asked CNA L what practices should be followed for EBP. CNA L stated hand washing, wearing a gown, and gloves. Surveyor asked if these practices were followed during R2's cares. CNA L stated not being sure and stated being new to the facility and usually works at another location. Surveyor asked if the other location was part of this facility's organization. CNA L stated it was. Surveyor asked CNA L if infection control training was provided at their location. CNA L stated not being sure but thinks it might have been during orientation a couple months ago when CNA L was hired. On 09/11/24 at 10:42 AM, Surveyor interviewed DON B regarding infection control practices during resident cares. DON B stated the expectation is for staff to follow standard precautions and any additional precaution identified for a resident. Surveyor informed DON B about the observations during cares for R2. DON B stated frustration and disappointment that CNA L did not follow infection control as they were only there helping at the facility for the day. DON B stated that all facility organization staff receive the same infection control education and CNA L should have followed proper hand hygiene and EBP policies while providing care for R2.

Based on observation, interview and record review, the facility did not distribute foods and beverages in a manner to prevent contamination. The facility practice has the potential to affect 28 of 39 residents who routinely eat in their rooms. Surveyors observed meal service for lunch on 9/09/24 and breakfast service on 9/10/24. Surveyor observed foods and beverages being distributed to residents from a food cart down the wings to their rooms without cover to prevent contamination. This is evidenced by: Surveyor requested and reviewed the facility policy titled Meal Distribution with most recent revision of 2/2023. The policy in part reads: Policy Statement: Meals are transported in dining locations in a manner that .protects against contamination. Procedure: All foods that are transported to dining areas that are not adjacent to the kitchen will be covered. On 09/09/24 at 12:09 pm, Surveyor observed the tray cart approximately one quarter down the North Hall with Nursing Home Administrator (NHA) A and Certified Nursing Assistants (CNA) C and D delivering the trays from the cart to resident rooms down the wing. Surveyor noted the main entree was covered on a plate with a plate cover. The strawberry shortcake, Jello and applesauce were observed in small bowls which were not covered. Surveyor observed staff pour beverages to glasses and cups that were placed on the trays and not covered during transport from the cart to resident rooms. Surveyor observed CNA C take the cart from North Hall to South Hall and placed the cart near the first rooms at the end of the hall. Again, Surveyor observed NHA A and CNA C and D transport meal trays from the cart up and down the hall. The beverages and the small dished items are not covered during transport up the hallway to resident rooms. Surveyor noted the cart does not have lids or saran wrap available to cover the items. Surveyor observed CNA E go to the cart and pour juice into cup, leave the wing with the glass which was not covered and deliver to a resident on the South Hall. On 9/10/24 at 7:38 am, Surveyor observed breakfast service on the South Hall. Surveyor observed the meal cart at the start of the hallway. Surveyor observed CNA F removing trays from the cart with main entree that was on a plate and covered. Surveyor observed CNA F pour beverages to glasses and place them on the meal trays. The beverages were not covered and were distributed to the residents in their rooms up the hallway. On 9/10/24 at 9:48 am, Surveyor interviewed CNA F about the observation. CNA F expressed it is normal practice for the meal carts to be brought to the end of the hallways and for staff to pour beverages to glasses/cups to place on the trays for delivery. CNA F further expressed beverages and other small items are not usually covered when transported from the cart to resident rooms. On 9/10/24 at 1:35 pm, Surveyor interviewed Dietary Manager (DM) G about the observation and the expectation related to covering foods and beverages during distribution. DM G expressed staff should use saran wrap to cover foods and beverages during distribution to prevent contamination. Surveyor requested a list of residents who routinely eat in their rooms. DM G provided Surveyor with a list that contained 28 residents who routinely eat in their rooms that have the potential to be affected by this practice.

Based on observation, interview and record review, the facility did not develop and implement a comprehensive person-centered care plan for 1 (R19) of 12 sampled residents to meet a resident's medical, nursing and psychosocial needs that are identified. R19 did not have a comprehensive person-centered care plan for the use of a high risk medication. Findings: The facility policy titled, Comprehensive Care Plan, revised 09/23/22, stated in part: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . 1. The care planning process will include an assessment of the residents' strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma informed . 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . f. Resident specific interventions that reflect the residents' needs and preferences and align with the residents' cultural identity, as indicated . g. Individualized interventions for trauma survivors that recognizes the interrelation between trauma and symptoms of trauma, as indicated. Trigger-specific interventions will be used to identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident. 5. The comprehensive care plan will be reviewed and revised as appropriate by the interdisciplinary team after each comprehensive and quarterly MDS assessment, and as needed with changes in condition Example 1 R19 was admitted to the facility on [DATE] with a Brief Interview of Mental Status (BIMS) of 15 which indicated R19's cognition was intact. R19 had a diagnosis of hemiparesis (one-sided muscle weakness) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). R19 had a medication order of apixaban 5 milligrams give one tablet two times a day for acute right hemiparesis. On 09/10/24 at 1:20 PM, Surveyor asked Director of Nursing (DON) B, Could you show me a care plan for this resident being on a blood thinner? On 09/10/24 at 1:22 PM, DON B informed Surveyor, I have no answer for you, this resident has no care plan for the apixaban medication.

Based on interview and record review, the facility did not provide care and treatment in accordance with professional standards of practice for 1 of 12 sampled residents (R2). On 03/16/24, R2 developed a fluid filled blister on left foot. On 3/19/24, a fluid filled blister developed on R2's right foot. Both blisters opened and resulted in a non-pressure injury, that was infected with Methicillin Resistant staphylococcus. (MRSA). A care plan was not implemented for the blister, and the facility did not follow through with the antibiotic order for the MRSA. Findings: Facility policy entitled: Pressure Injuries and Non pressure Injuries, most recently revised 07/20/22, stated in part: Develop interventions based on individual risk factors including, but not limited to, overall health status/comorbidities or presence of acute infections that may impact healing .In the context of clinical condition, the resident's care plan should establish relevant goals and approaches to stabilize or improve comorbidities aimed at limiting the effects of risk factors and what interventions will be in place to minimize risk to resident. R2 was admitted to the facility on [DATE], with pertinent diagnoses of diabetes mellitus type 2 and peripheral vascular disease. R2's most recent quarterly Minimum Data Set (MDS), dated [DATE], stated R2's Brief Interview for Mental Status (BIMS) score was 09/15, indicating moderately impaired cognition. The MDS skin assessment indicated R2 had no open lesions on the foot, no diabetic foot ulcers, and was receiving application of dressing to feet. R2's comprehensive care plan, with last revised date of 06/17/24, did not include a plan or interventions related to R2's non-pressure foot ulcers on the right and left feet. R2's orders: Apply skin prep to the intact blister to the top of the left foot. Wrap loosely with kerlix PRN as needed. START: 03/19/24 END: 04/03/24 Cleanse open area to the top of the right foot with wound cleanser. Apply foam dressing. Change PRN until healed as needed. START: 03/19/24 END: 04/06/24 Apply skin prep to the intact blister to the top of the left foot. Wrap loosely with kerlix QD and PRN in the evening. START: 03/20/24 END: 04/06/24 Cleanse open area to the top of the right foot with wound cleanser. Apply foam dressing. Change QD and PRN until healed in the evening. START: 03/20/24 END: 04/06/24 Sorbact swab dressing to bilateral dorsal feet ulcers and heels, cover with a ABD pad and cast padding to secure in place. Betadine apply to right 2nd toe eschar. Dermagrip compression stocking applied to bilateral extremities in the afternoon every Mon, Wed, Fri for wound care. START: 04/03/24 END: 04/16/24 R2's skin assessments: 02/15/24 - admission assessment: Left foot has three scabbed areas on dorsal side each measuring 0.5cm x 0.5cm. Bruise on top of foot just back from toes measuring 5.0cm x 2.0cm. Right foot. Top of foot has a scab 0.7cm x 0.5cm. Great toe has no deficit. 2nd and 3rd toes are webbed and have scabbed areas: 2nd toe 0.5cm x 0.8cm. 3rd toe 0.5 x 0.5cm. 4th toe has scab 0.5cm x 0.5cm. 03/16/24 - R2 developed a fluid filled blister to left foot. Foam border applied and feet elevated. 03/19/24 - Intact blister to the top of the right foot popped. Measures 3.0cmL x 2.8cmW and is a partial thickness wound. Peri wound is pink and blanches. Wound edges are intact. Area cleansed with wound cleanser and dressing applied. Intact blister to the top of the left foot. Measures 5.8CML x 8.0 CM W. Applied skin prep to the intact blister and wrapped loosely with kerlix. No update was made to R2's comprehensive care plan made to include interventions and treatment of bilateral non-pressure injuries of feet. The wound continued until R2 was admitted to hospice services on 05/17/24. R2's progress notes: 4/3/2024 11:23 Aspirus wound clinic called to ask for the phone number for Pharmerica (R2's pharmacy), as the wound culture had moderated growth of MRSA. They will be sending a script for ATB to Pharmerica. No order for a prescription was entered or administered by facility for R2. Surveyor was unable to find any further documentation regarding treatment of MRSA infection with antibiotics or follow-up of culture results. On 09/11/24 at 12:55 PM, Surveyor completed phone interview with Wound Clinic Nurse (WCN) K. WCN K stated that on 04/03/24 at 11:28 AM, the facility was notified of the wound culture results being positive for MRSA and an antibiotic prescription was called in directly to the pharmacy for R2. WCN K stated this was completed via telephone and was acknowledged by facility nursing staff. On 09/11/24 at 1:31 PM, Surveyor interviewed Director of Nursing (DON) B regarding the wound clinic culture results. DON B stated that after review of R2's record, DON B saw the note made on 04/03/24 by facility nursing staff receiving the phone call about the positive MRSA culture and subsequent antibiotic being ordered. DON B stated she was unaware of this and contacted the pharmacy to verify the order on 09/11/24. DON B stated there was a problem with the facility entering the order into R2's chart as the nurse who received the phone call from the wound clinic did not get the prescription information. As a result, the pharmacy did not send over the prescription because it was never entered into R2's order. The prescription stayed with the pharmacy and was never sent for administration for R2. DON B stated this was an error by the facility and acknowledged that not administering this medication could have resulted in delayed healing or harm to the resident. DON B acknowledged a care plan was not in place for the care of the blisters.

Based on observations, interviews and record reviews, the facility failed to ensure 1 of 1 resident (R26) reviewed for post-traumatic stress disorder (PTSD) received culturally competent trauma-informed care in accordance with professional standards of practice and accounting for each resident's experience and preferences in order to eliminate or mitigate re-traumatization. Findings: According to Substance Abuse and Mental Health Services Administration (SAMHSA, 2014) (https://www.ncbi.nlm.nih.gov/books/NBK207191/), The impact of trauma can be subtle, insidious, or outright destructive. How an event affects an individual depends on many factors, including characteristics of the individual, the type and characteristics of the event(s), developmental processes, the meaning of the trauma, and sociocultural factors. SAMHSA explains trauma causes immediate and delayed emotional, behavioral, physical, cognitive, and existential reactions. The facility's policy titled, Trauma Informed Care, date revised 10/18/2022, stated in part: It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization . Policy Explanation and Compliance Guidelines: 1. The facility will work to facilitate the principles of trauma informed care . 2. The facility will use a multi-pronged approach to identifying a resident's history of trauma. This will include asking the resident about triggers that may be stressors or ay prompt recall of a previous traumatic even, as well as reviewing documentation such as the history and physical, consultation notes, or information received from family/responsible party . 4. The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health care professionals (such as psychologists and mental health professionals) to develop and implement individualized care plan interventions. 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, as well as identify ways to mitigate or decrease the effect of the trigger on the resident and will be added to the resident's care plan . 8. In situations where a trauma survivor is reluctant to share their history, the facility will still try to identify triggers which may re-traumatize the resident and develop care plan interventions which minimize or eliminate the effect of the trigger on the resident. R26 was admitted to the facility on [DATE] with a Brief Interview of Mental Status (BIMS) of 10, which indicated R26 had moderately impaired cognition. R26's Minimum Data Set (MDS), dated [DATE], indicated that R26 had a diagnosis of PTSD. R26 had a Trauma-Informed Care Observation dated 03/23/22, that stated in part: B. Observation Detail . 1. Have you ever experienced, witnessed, learned about a natural disaster (e.g. flood, tornado, hurricane, earthquake, etc.)? Personally experienced. 2. Have you ever experienced, witnessed, learned about a serious accident (e.g. car accident, boat accident, train wreck, plane crash, work accident, home accident, recreational accident, fire/explosion, etc.)? Personally experienced . 4. Have you ever experienced, witnessed, learned about a life-threatening illness or injury (e.g. cancer, heart attack, AIDS, leukemia, multiple sclerosis, etc.)? Witnessed. 5. Have you ever experienced, witnessed, learned about a physical assault (e.g. attacked, hit, beaten up, etc.)? Witnessed. a. Was a weapon involved? Yes. 6. Have you ever experienced, witnessed, learned about combat or war-zone (e.g. combat in the military, as a medic, as a civilian, etc.)? Personally experienced. 7. Any other very stressful events or experience? Resident indicating his time in the service was very difficult mentally. C. Experience 1. Did any of these events bother you? Yes 2. Comment on events resident was bothered by: Resident did not wish to share details but stated his time in service was mentally exhausting. Resident stating, he signed up to be in the Marines for 3 years however at the end of his 3-year term he was told he had to do another year term in the Mojave Desert in hope to help him clear his mind of all the things he experienced while in active combat. D. Effects 1. How long were you bothered by the events? Resident noting it still bother him to this day. Resident became quite tearful during the assessment but did not wish to go into any details. Resident stating, he would not change being in the service but all he experienced during that time made him a different person. 2. How much did the events bother you emotionally? Very much. 3. What are the triggers that remind you of the event (e.g. loud noises, confined spaces, bathtubs, hot surfaces, siren, etc.)? Resident noting he does not have any triggers that he is aware of. Resident stating, he does not mind being asked about his service but wants people to understand if he shares only limited information. 4. How do you react when you are reminded of the events? I don't know how to answer that question. It was a different world back then. I didn't come home the same man . Additional Observer info: Resident did become tearful several times throughout assessment . On 09/09/24 at 9:24 AM, Surveyor asked R26 if R26 was in the military. R26 replied, I was with the first [NAME] division. We had to fight China and Russia to take this big reservoir. I enlisted with the Marines for 3 years and the government gave me a 4th year in the Mojave Desert. We killed so many people. When I came back from Korea things were not so good in my head. R26 began crying during this interview. On 09/09/24 at 11:56 AM, Surveyor asked the Director of Nursing (DON) B for specific triggers for R26's PTSD. On 09/10/24 at 7:57 AM, Surveyor noted there was no trauma informed interventions or triggers in the medical record or care plan provided. On 09/10/24 at 9:59 AM, DON B provided Surveyor with a trauma informed care plan dated 09/10/24 (today). On 09/10/24 at 11:09 AM, Surveyor asked MDS coordinator Registered Nurse (RN) J if this care plan was initiated today. RN J confirmed that it was. On 09/10/24 at 12:00PM, Surveyor reviewed assessments completed in R26's medical record. There was a Trauma-Informed Care Observation completed on 03/29/22 (date of admission) and a second one completed on 09/10/24 (today), after Surveyor asked questions about R26's PTSD. Surveyor noted no trauma informed plan to eliminate triggers that may cause re-traumatization for R26. On 09/11/24 at 8:42 AM, Surveyor interviewed Certified Nursing Assistant (CNA) F about R26's military service and PTSD. Surveyor asked CNA F, Do you know if R26 has any triggers regarding his PTSD? CNA F replied, He cries from time to time. I avoid talking about his history and change the subject.

Based on observations, interviews and record reviews, the facility failed to ensure 2 of 3 residents with indwelling Foley catheters (R14 and R3) received appropriate treatment and services to prevent urinary tract infections (UTIs) and restore continence to the extent possible. - R14 was admitted with an indwelling Foley catheter. The facility did not assess R14's continued need for the device, there was no medical justification located for the catheter, and there was no trial discontinuation followed by a comprehensive bladder assessment with an individualized toileting plan to determine if R14 could remain as continent as able without the device. Furthermore, R14 receives catheter changes every month without justification. - R3 has a recent history of a UTI and was observed to have the indwelling Foley catheter drainage bag lying on the floor, increasing the risk for the development of a UTI. This is evidenced by: According to the Centers for Disease Control and Prevention (CDC), UTIs are the most common type of healthcare-associated infections reported to the National Healthcare Safety Network (NHSN), of which 75% are associated with the use of a urinary catheter. The CDC further states the most important risk factor for developing a catheter-associated UTI (CAUTI) is prolonged use of the device. Therefore, the CDC recommends that catheters should only be used for appropriate indications and should be removed as soon as they are no longer needed. The CDC goes on to state, in part, under guidelines of Catheter Associated Urinary Tract Infections, .Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised . Furthermore, the CDC directs under Proper Techniques for Urinary Catheter Maintenance include .Keep the collection bag below the level of the bladder at all times. Do not rest the bag on the floor . Healthcare Infection Control Practices Advisory Committee (HICPAC) Guideline for Prevention of Catheter Associated Urinary Tract Infections, 2009 states in part, . Examples of Appropriate Indications for Indwelling Urethral Catheter Use includes: - Patient has acute urinary retention or bladder outlet obstruction. - Need for accurate measurements of urinary output in critically ill patients. - Perioperative use for selected surgical procedures: - Patients undergoing urologic surgery or other surgery on contiguous structures of the genitourinary tract. - Anticipated prolonged duration of surgery - Patients anticipated to receive large-volume infusions or diuretics during surgery. - Need for intraoperative monitoring of urinary output. - To assist in healing of open sacral or perineal wounds in incontinent patients. - Patient requires prolonged immobilization (e.g., potentially unstable thoracic or lumbar spine, multiple traumatic injuries such as pelvic fractures). - To improve comfort for end of life care if needed. Examples of Inappropriate Uses of Indwelling Catheters according to HICPAC include, - As a substitute for nursing care of the patient or resident with incontinence. - As a means of obtaining urine for culture or other diagnostic tests when the patient can voluntarily void. - For prolonged postoperative duration without appropriate indications (e.g., structural repair of urethra or contiguous structures, prolonged effect of epidural anaesthesia, etc.) Example 1 R14 has medical diagnoses that include, but are not limited to drug-induced secondary Parkinsonism, diabetes mellitus type II, morbid obesity, weakness and chronic kidney disease stage 3. According to the most recent Minimum Data Set (MDS) assessment which was an admission assessment dated [DATE], R14 is non-ambulatory and utilizes a mechanical lift for all transfers. R14 is cognitively intact, with a Brief Interview of Mental Status (BIMS) score of 15/15. Also according to the MDS, R14 requires extensive assistance of staff to meet her most basic daily tasks of bathing, dressing, toileting and personal hygiene. Surveyor reviewed the Comprehensive Care Plan (CCP) developed for R14. Included in the plan was Use of indwelling urinary catheter Foley needed due to: chronic use r/t (related to) retention (started 7/5/23 and last revised 7/6/23.) Included in the interventions for this CCP was Change urinary collection bag as needed. This was dated 7/5/23. In reviewing the Physician Orders written for R14, Surveyor noted the following: - Indwelling urinary catheter 16FR (French) 10cc (cubic centimeters) balloon for diagnoses retention in the afternoon starting on the 24th and ending on the 24th every month for urine retention; - Ciprofloxacin Oral Tablet 500 MG (Milligram), Give 500 mg by mouth in the morning starting on the 24th and ending on the 24th every month for prior to catheter change. (Start Date 7/24/2023 0800); - Change catheter system as needed for infection, obstruction, or leakage (start 7/6/23); and - Foley catheter care every shift every shift for Urine retention (7/5/23) Surveyor reviewed R14's previous hospitalization records with Director of Nursing (DON) B. DON B and Surveyor were unable to locate anywhere in R14's past or current medical record of R14 having a diagnosis of urinary retention or of R14 being seen by a urologist. On 9/05/23 at 11:04 AM, Surveyor interviewed R14 regarding the urinary catheter. R14 stated, I am not really sure why I have the catheter. I was living in my hometown at the nursing home there . I got a urine infection and they had to send me to the hospital because my temperature wouldn't come down. They put the catheter in there. On 9/06/23 at 4:30 PM, Surveyor interviewed R14. R14 stated that the problem is completely emptying her bladder, stating that some urine stays in her bladder and doesn't come out. She indicated that she has retention. R14 further stated, .I need to keep the catheter in until I can walk again otherwise I wet myself, and I don't want to do that . Initially, R14 stated that she wished to keep the catheter, as I can't stand yet and don't want to wet my pants . R14 also informed Surveyor that the catheter is changed every month. Further review of R14's records indicated the indwelling Foley catheter was changed on 7/18/23 while in the hospital for complaints of pelvic pain, and again on 8/20/23 at the facility. On 9/07/23 at 8:36 AM, DON B was interviewed regarding the use of indwelling Foley catheters. DON B stated the facility follows the CDC guidelines regarding changing of Foley catheters. DON B is very new in her position (8/4/23) and stated that catheter changes are on her list to update. She stated that she believed the facility was practicing the old standard to change them every month and she needs to update their practices to the new standard to change them only as needed. At 11:16 AM, Surveyor interviewed DON B on what the expectation of staff is when a resident is admitted with a Foley catheter. DON B stated, We need to find out why they have it and when it was inserted. We then would work with the Physician and Medical Director, and if there is no medical reason for the device, to get it discontinued. There is no indication in R14's record of being seen by a urologist to determine the need for the Foley or a evidence of a long-standing history of UTIs, and no medical diagnosis to justify its use. There have been no attempts to discontinue the device through a trial voiding data collection, and the development of an individualized toileting program to meet R14's needs. 46693 Example 2 On 04/17/23, R3 was diagnosed with urinary obstruction requiring the use of an indwelling Foley catheter to ensure excrement of urine. On 09/05/23 at 10:15 a.m., Surveyor observed R3 sitting up in bed with catheter bag lying directly on the floor uncovered and not protected from potential contamination by a dignity bag (cloth bag that covers the catheter bag). Surveyor reviewed progress notes which indicated on 06/19/23, R3 developed a urinary tract infection (UTI) with the bacteria Proteus Mirabilis. According to National Institute for Health, dated June 12, 2023, Proteus mirabilis is a gram-negative facultative anaerobe with swarming motility and an ability to self-elongate and secrete a polysaccharide which allows it to attach to and move along surfaces like catheters, intravenous lines, and other medical equipment. Surveyor reviewed R3's record, Minimum Data Set (MDS) dated [DATE], which states R3 has BIMS of 14 indicating that R3 is cognitively intact. MDS also identifies R3 has an indwelling Foley catheter. On 09/05/23 at 10:34 AM, Surveyor interviewed Certified Nursing Assistant (CNA) C who was caring for R3 that day. CNA C stated that the bag must have fallen on floor. CNA C then fixed the collection bag to the bed. CNA C stated, I know the bags are to be kept off the floor. Surveyor reviewed R3's care plan; was as follows: -Use of indwelling urinary catheter 16 French with 10 ml balloon needed due to: obstructive uropathy disease process Will have no acute complications of urinary catheter use CATHETER CARE (FYI) Shows on Kardex. Catheter collection bag placed in dignity bag holder on bed/ wheelchair . On 09/07/23 at 8:36 AM, Surveyor interviewed DON B who confirmed that the catheter bags should be securely placed and off the floor.

Based on interview and record review, the facility did not ensure 1 of 14 residents (R) R11, reviewed for comprehensive care plans had a developed care plan to include epilepsy (seizure disorder). R11 had a history of epilepsy and did not have a comprehensive care plan to include information concerning R11's history of epilepsy. This was evidenced by: R11 was admitted to the facility on [DATE] and had a diagnosis that includes epilepsy. R11's admission Minimum Data Set (MDS) assessment, dated 02/26/23 and the most recent MDS dated [DATE], were marked for seizure disorder/epilepsy as a medical condition. R11's care plan did not include information on anything pertaining to seizure disorder, to ensure staff would recognize and take correct action if a seizure were to occur. Provider order for R11 included Levetiracetam (Keppra) oral tablet 500 mg (milligram) by mouth two times a day for seizure disorder with a start date of 02/15/23. R11's order to monitor for seizure activity every shift was completed by the nurses with no seizure activity noted. On 09/06/23 at 2:30 PM, Surveyor interviewed Certified Nursing Assistant (CNA) E and asked if R11 had a history of seizures. CNA E said yes. Surveyor asked CNA E if R11 has had any seizures while at this facility. CNA E said no, not that she was aware of. On 09/06/23 at 2:32 PM, Surveyor interviewed Registered Nurse (RN) D concerning R11's history of seizures. RN D said she was unsure if R11 had a history of seizures, but that R11 does take Keppra. RN D said R11 has not had any seizure activity while here at this facility that she was aware of. On 09/07/23 at 8:40 AM, Surveyor interviewed R11 concerning his history of seizures. R11 said he does have a history of seizures, but that he had not had one in a while. R11 said the last time he had a seizure was before he was admitted at this facility. R11 said when he had a seizure, it hits him hard. On 09/07/23 at 12:48 PM, Surveyor interviewed Director of Nursing (DON) B concerning R11's diagnosis of seizures and no care plan for seizures was found in the electronic medical records for this. DON B went to look for any information in the care plan for seizures. On 09/07/23 at 2:30 PM, Surveyor interviewed DON B who said there was no care plan focus regarding seizures for R11. DON B provided Surveyor with the provider note from R11's hospital stay prior to admission to the facility dated 01/28/23 through 02/15/23. The note stated R11 was diagnosed with epilepsy and prescribed Keppra.

Based on interview and record review, the facility did not ensure that 3 of 7 sampled residents had an environment that was as free from accident hazards as possible. On 12/16/09, Resident #2 had a fall sustaining a neck and nasal fracture, closed head injury, lacerations and bruising. Resident #2 was hospitalized and subsequently returned to the facility. Since his return, Resident #2 has had 10 falls. After each fall, the facility did not critically analyze the fall to identify and evaluate potential hazards and risks to determine if other measures needed to be put in place to reduce Resident #2's falls. On 7/2/10, Resident #2 had a fall in his room and sustained a laceration to the back of his head which required him to be transported to the emergency room . Resident #2 received 8 staples to the back of his head. Resident #7 had several falls. After each fall the facility did not critically analyze the fall to identify and evaluate potential hazards and risks to determine if other measures needed to be put in place to reduce Resident #7's falls which were consistent with Resident #7's needs. Resident #3 sustained 8 falls since admission on 8/18/10. The facility did not develop and implement new interventions to meet Resident #3's individualized needs. The facility's failure to have a system in which it critically analyzed each fall to determine the root cause, to determine if care planned interventions had been implemented and to determine if other interventions were needed to prevent or to reduce the probability that further falls would occur placed residents in a situation of immediate jeopardy. The facility was notified of the immediate jeopardy on 11/4/10. The facility removed the jeopardy on 11/5/10, however, the deficient practice continues at a scope/severity level of E (potential for harm that is not immediate jeopardy/pattern) because the facility still has staff to train and needs to evaluate the effectiveness of the interventions put in place. This is evidenced by: On 10/26/10 at 8:30 a.m., Surveyor # requested the facility's fall policy and procedure. The Administrator provided a copy of "Clinical Guideline: Falls Management" dated 4/24/06, which includes a decision tree for Fall Risk/Post Fall Assessment Process. The Clinical guideline does not address identifying the root cause of the fall; evaluating and analysis of the fall; a system approach to the implementation of an intervention correctly and consistently; evaluating the effectiveness of interventions; modifying or replacing interventions as needed; and, evaluation of the effectiveness of new interventions to prevent further falls. Example #1: Resident #2 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. The current MDS (Minimum Data Set) dated 9/10/10 indicates Resident #2: ~Has short-term memory problems and his long-term memory is OK; ~Has severely impaired cognitive skills; ~Is easily distracted, has periods of altered perception, and his mental function varies over the course of the day; ~Has impaired vision; ~Requires the assistance of 1 person for transfers and walking; ~Is not able to complete a balance test without physical support; and, ~Has fallen in the past 30 days and past 31-180 days. The facility implemented a fall care plan at the time of Resident #2's admission. Resident #2's fall care plan dated 11/24/08 indicates, "...Potential for injury r/t (related to) falls...Resident is known to ambulate without assistance at times..." The fall approaches include "...Place call light within reach at all times and answer promptly...Bed alarm at night...Bed alarm on when in bed to alert staff..." The approaches are undated as to when they were implemented. ~An entry in the nurse's note dated 12/16/09 states, "...found resident lying prone...he was not using his walker..." Surveyor # completed a review of the post fall investigation completed by the facility. This indicates Resident #2 is independent in ambulation; at the time of the fall was not using his walker; and, was noted to trip on his feet. The investigation also indicates that Resident #2 has had a bed alarm since 6/09. Resident #2 was admitted to the hospital with [REDACTED]. Resident #2 was hospitalized for [REDACTED].#2 returned to the facility with orders for a C-collar (cervical collar) at all times and to ambulate with assistance. On 10/26/10 at 4:15 p.m., Surveyor # spoke with the DON (Director of Nursing). Surveyor # asked the DON what intervention was put into place after the fall of 12/16/09. The DON stated that staff are to remind Resident #2 to use his walker. There is no evidence that this approach has been added to Resident #2's plan of care. On 3/13/10, the facility updated Resident #2's care plan to include approaches of, "...Encourage resident to wear shoes or gripper socks at noc (night)...Ensure room is free from clutter..." ~An entry in the nurse's notes dated 3/14/10 states, "At 23:40 (11:40 p.m.) res (resident) was witnessed to have fallen with his back to the door of his room landing on his elbows...(nurse) heard res alarm sounding, went to check and noted the res falling to the floor...2 small; skin tears and bruising with some swelling on his rt (right) elbow..." Due to Resident #2's recent neck fracture, the physician ordered x-rays. There were no new fractures noted. On 3/18/10 the C-collar was discontinued. On 10/26/10 at 4:15 p.m., Surveyor # spoke with the DON regarding Resident #2's fall on 3/14/10. The DON indicated that Resident #2 had tripped on his feet while walking. The DON stated they completed a medication review and the physician subsequently discontinued an anti-anxiety medication. Resident #2 has fallen 2 times now because he tripped on his feet. There are no further interventions to reduce or eliminate Resident #2's falls aside from a medication review. ~An entry in the nurse's notes dated 5/9/10 states, "...found res on knees, and right elbow with right side of head up against bathroom door...nickel sized bruise on res right elbow..." On 10/26/10 at 4:15 p.m., Surveyor # spoke with the DON regarding Resident #2's fall on 5/9/10. The DON indicated that Resident #2 was going to the bathroom independently and lost his balance and fell . When asked what was done following this fall, the DON indicated the new intervention was to ensure that Resident #2 was settled in his room before staff left. The DON stated she also requested a therapy screen. There is no evidence that the new intervention of ensuring Resident #2 was settled in his room was added to Resident #2's plan of care. Resident #2 had also indicated that he needed to go to the bathroom. There is no evidence that Resident #2's toileting schedule has been addressed. The DON indicated therapy screened Resident #2. ~A nurse's notes on 5/20/10 states, "01:43 PM...assisted to his chair in his room. Alarm intact. He was found walking in the hall with his walker. He did lose his balance near the nurses station and landed on his buttock..." ~A second entry in the nurse's notes on 5/20/10 states, "Call for help was heard approximately 17:50 (5:50 p.m.) alarm sounding...found sitting on floor at end of bed with his back leaning against the bed...Walker was tipped over...stated that he was going to put the tissue box that was laying on the floor in the waste basket..." On 5/20/10, a note was written on Resident #2's fall care plan which states, "Resident fell - No injuries - was confused - lack of sleep." Although staff identified this as a problem, no new interventions were implemented. Surveyor # spoke with the DON regarding both of Resident #2's falls on 5/20/10. Surveyor # asked the DON if Resident #2's alarm was sounding when Resident #2 went from his room to the nursing station. The DON stated she did not know. Evaluation of whether care planned approaches have been implemented is essential to understanding the root cause or to determining if the approach itself is ineffective. Surveyor # also asked the DON when Resident #2's alarms were placed. The DON was unsure of the date that the alarm was implemented. Surveyor # asked the DON what new intervention was put into place to prevent another fall. The DON stated that after the therapy screen from the fall on 5/9/10, therapy started to see him. The DON also indicated that the physician completed a medication review and reduced Resident #2's antipsychotic medication. No new immediate interventions are added to Resident #2's plan of care to prevent further falls. ~A nurse's note on 5/24/10 states, "...saw res sitting on the floor with his legs cross at the ankles and leaning back against the recliner chair...stated he fell and hit his head on the floor...No injury noted..." A nurse's note on 5/26/10 states, "...reminding staff that res alarms should be answered, and that he is not supposed to be alone...Screen completed today per staff request d/t (due to) frequent falls...becoming more weak and unsteady on his feet..." Surveyor # spoke with the DON regarding Resident #2's fall on 5/24/10. The DON stated that they were unable to determine why Resident #2 fell . No new interventions are added to Resident #2's plan of care. ~An entry in the nurse's notes on 5/28/10 states, "...turned off alarm and came to desk and asked where his care keys were..." No new interventions are implemented following the 5/28/10 incidence of turning off the alarm. The use of alarms continued to be a care-planned approach for preventing falls, even though the resident had now demonstrated an ability to turn off the alarm. Resident #2 was seen by physical therapy from 6/1/10 through 6/16/10. Therapy notes indicate that when therapy ended, Resident #2 required stand by assistance and/or contact guard assistance of 1 for transfers and walking. ~An entry in the nurse's notes dated 7/2/10 states, "...res. fell in room; 3-4 cm (centimeter) laceration to R (right) occipital..." Resident #2 was transported to the emergency room . 8 staples were placed in the back of his head. Resident #2 returned to the facility with a cervical collar on until cervical x-rays could be viewed. The X-ray report indicated no fracture and on 7/15/10, the cervical collar was discontinued. Surveyor # spoke with the DON regarding Resident #2's fall on 7/2/10. The DON again indicated that Resident #2 tripped. Surveyor # asked the DON if Resident #2's alarm was sounding at the time of the fall. The DON indicated she did not know. Surveyor # asked what interventions were put into place after the fall. The DON indicated that gripper socks were added to his plan of care. The DON also stated the physician reviewed Resident #2's medications and on 7/15/10, made another medication change. Of note, the approach of gripper socks has been a care planned approach since 3/13/10. Surveyor # completed a review of the facilities "Post Fall Investigation Summary" dated 7/6/10. This is the summary completed after Resident #2's fall on 7/2/10. This form indicates, "...Ambulating s (without) Assistance per his norm; stated he was trying to go to the bathroom..." All evidence indicates that Resident #2 requires assistance for ambulating. There is no evidence that the facility reviewed Resident #2's toileting schedule. There are no new interventions added to Resident #2's plan of care. Surveyor # reviewed Resident #2's most current fall risk assessment dated [DATE]. The fall assessment indicates Resident #2: ~Has multiple falls in the past 180 days; ~Requires assistance for toileting; ~Has a decrease in muscular coordination, and has jerking or instability when making turns; ~Uses an assistive device for walking; and, ~Is on medications which could potentially affect balance. The fall risk assessment has a cumulative score of 20. According the facility's scoring system, a score of 20 puts Resident #2 at a high risk for falls. ~Nurse's notes on 8/18/10 states, "...heard pull alarm sound and then he yelled out 'help'...found...lying on left side of body in front of closet, head near heat run. thinks he bumped on floor...'I was going to the toilet'..." A follow-up note on 8/20/10 states, "...small scrapes on res knees...attributes to falls...bruising on his left forearm - with tiny scrapes...bruising on his left outer wrist..." Surveyor # spoke with the DON regarding Resident #2's fall on 8/18/10. The DON indicated they reviewed Resident #2's toileting times; however, there are no changes made to his current toileting schedule. There are no changes made to Resident #2's plan of care. ~An entry in the nurse's notes on 9/1/10 states, "...Is able to ambulate independently with wheeled walker. This is what he was doing prior to the fall in the hall near the nurses station...observed...hit the back of his head...small abrasion on his left side...also landed on his left elbow and has an eraser size blood blister there...stated 'my feet just wouldn't work together'..." This is the second documented instance where Resident #2 was up and ambulating independently after the facility had determined he requires assistance. On 10/26/10 at 4:15 p.m., Surveyor # spoke with the DON regarding Resident #2's fall on 9/1/10. The DON again stated Resident #2 had lost his balance. There was no evidence that new interventions have been put into place to reduce Resident #2's falls. Surveyor # asked the DON about Resident #2 ambulating independently. The DON stated she thought that Resident #2's plan of care indicated that he could be up independently as along as he was in the "eye sight" of staff. The DON later returned and indicated to Surveyor # that she was wrong and that Resident #2 requires stand by assistance or contact guard assistance for walking. ~A nurse's note dated 10/18/10 states, "...found on floor between bed and wheelchair...heard him calling out 'help me'...lying under wheelchair with back on floor..." On 10/26/10 at 4:15 p.m., Surveyor # spoke with the DON regarding Resident #2's fall on 10/18/10. The DON indicated Resident #2 was being treated for [REDACTED]. The DON indicated they again reviewed Resident #2's toileting schedule and indicated that staff are to ensure they are waking him up at night to take him to the bathroom. This intervention is not on Resident #2's care plan. When asked if the alarm had sounded, the DON indicated she was not sure if the alarm sounded at the time of the fall. There is no evidence that new interventions were added to Resident #2's care plan to prevent falls. ~An entry in the nurse's notes on 10/21/10 states, "...Found sitting on floor midway between bed and bathroom...Skin tear noted on R (right) elbow, bruise noted on L (left) shoulder...complaints of pain with movement in L shoulder...stated that he got up from his bed and was going to bathroom..." Resident #2 again indicated that he was going to the bathroom. There is no evidence that Resident #2's toileting schedule has been reviewed. There are no changes to Resident #2's plan of care. On 10/26/10 at 4:15 p.m., Surveyor # spoke with the DON regarding Resident #2's fall on 10/21/10. The DON indicated they had completed a medication review, the physician had ordered lab work, and they were encouraging Resident #2 to sit in a recliner in his room. On 10/26/10 at 3:10 p.m., Surveyor # spoke with CNA-B (Certified Nursing Assistant) about Resident #2's falls. CNA-B indicated that Resident #2 has fallen a lot. CNA-B stated that on one occasion, she was in another resident's room assisting a resident when Resident #2's alarm went off. CNA-B stated she could not leave the resident she was with. CNA-B stated she attended to this resident's cares as quickly as possible and ran down the hall to Resident #2's room because no one else was responding. CNA-B stated that by the time she got to Resident #2's room, he was on the floor. On 10/26/10 at 5:00 p.m., Surveyor # spoke with the DON regarding the facility's fall prevention program. The DON indicated that up until just recently, they had not been critically analyzing their falls. The DON stated the facility does have a fall team but they have not been meeting regularly. The DON also indicated the facility does have a form referred to as the "crime scene" form. The DON stated this form goes into greater detail on what should be looked at following a fall. The DON stated this form is only used at the discretion of the staff and is not required. Example #2: Resident #7 was admitted to the facility on [DATE] following a left hip fracture that was not surgically repaired. Additional admitting [DIAGNOSES REDACTED]. The current MDS assessment dated [DATE] indicates Resident #7: ~Has long-term memory problems and no short-term memory problems; ~Has moderately impaired cognitive skills; ~Vision is highly impaired; ~Requires extensive assistance for bed mobility and transfers, and does not walk; ~Has both sitting and standing balance problems; and, ~Has fallen within the last 31-180 days. Resident #7's falls care plan dated 11/27/09 has approaches which include, "...Place call light with in reach...answer promptly...Ensure room is free from clutter..." Resident #7's current fall risk assessment dated [DATE] indicated that Resident #7 has intermittent confusion; has had falls; is chair bound; has balance problems; utilizes an assistive device; and, takes medications which could affect her balance. The fall risk cumulative score was 16. According to the facility's scoring system, a score of 16 indicates Resident #7 is at risk for falls. The facility updated Resident #7s care plan on 3/25/10 with a handwritten approach of "Bed in low position/alarm on." ~A nurse's note on 3/28/10 states, "...alarm had been sounding...CNA's (Certified Nursing Assistants) found her on the floor...lying on her right side, head on the floor...lump forming on her right upper head--into the scalp area...small skin tear on her inner right elbow...bruise on her right elbow...has slightly slurred speech and her thought are confused..." Resident #7 was transported to the emergency room and was diagnosed with [REDACTED]. On 10/26/10 at 5:50 p.m., Surveyor # spoke with the DON (Director of Nursing) regarding Resident #7's fall on 3/28/10. The DON indicated that they could not determine why Resident #7 had fallen. The DON stated that after the fall, they placed Resident #7's bed against the wall and placed a mat on the floor next to Resident #7's bed when Resident #7 was in bed. According to the care plan, those approaches had been implemented on 3/25/10. ~A nurse's note on 6/18/10, "...resident was found in her room, had fallen out of her w/c (wheelchair)...Chair alarm was going off...was sitting on her buttock with her back against the door...w/c was in front of her. Resident reports she had crawled to the door from her bed..." There were no injuries noted. On 10/26/10 at 5:50 p.m., Surveyor # spoke with the DON regarding Resident #7's fall on 6/18/10. The DON indicated Resident #7 has recently become more active and is up in her wheelchair more often. Surveyor # asked the DON what new interventions were put into place after the fall. The DON indicated that they had reviewed Resident #7's current interventions and determined they were all appropriate. The DON also stated that the facility requested therapy to screen Resident #7. Resident #7 was noted to become more active and was up in her chair more often. Despite this, there is no evidence that the facility analyzed Resident #7's fall as it relates to her current condition. There were no changes made to Resident #7's care plan. ~A nurse's note on 9/29/10 states, "...wanted to get to bathroom, and did not want to wait...res (resident) stated she did not hit her head when she hit the floor with her buttocks...No bruising noted...Res had managed to get over the footrests and ambulated herself from just outside the bathroom to right in front of toilet then down she went..." ~A follow-up note on 9/30/10 states, "...appx (approximately) quarter sized bruise to her right upper buttocks area, this may be d/t (due to) her fall from yesterday..." On 9/29/10, an approach was added to Resident #7's care plan which states, "Toilet ASAP (as soon as possible) when res requests." Review of the fall history finds that Resident 7 does not consistently request assistance to the bathroom. On 10/26/10 at 5:50 p.m., Surveyor # spoke with the DON regarding Resident #7's fall on 9/29/10. The DON indicated they reviewed Resident #7's toileting pattern and determined that her current toileting plan is appropriate. The DON stated they also reviewed Resident #7's current interventions and determined that they are still appropriate. Surveyor # asked the DON what new interventions were put into place to prevent further falls. The DON stated that they added to Resident #7's care plan that staff are to assist Resident #7 right away when she needs to go to the bathroom. Example #3: On 10/26/10, Surveyor # reviewed Resident #3's medical record. Resident #3 was admitted on [DATE] with a [DIAGNOSES REDACTED]. The MDS dated [DATE] indicates Resident #3 has short and long term memory problems; poor decision making; requires extensive assist with assist of 2 for transfers and toilet use; and, has fallen in the past 30 days. A Fall Risk Assessment form indicates a score of 8. A score of 10 or greater is considered high risk. According to the nurse's notes and Change in Condition Report-Post Fall/Trauma form, Resident #3 has fallen 8 times since admission (8/20/10, 9/11/10, 9/16,10, 9/20/10, 9/21/10, 9/22/10, 9/27/10 and 10/17/10). On 8/30/10 a care plan was written addressing risk for falls. Approaches include bed in low position; assessment of wheelchair for appropriate size; gait belt with transfers; footwear to prevent slipping; toileting schedule; and, keep environment well lit and free of clutter. Review of the care plan finds that after the 9/11/10 fall, a clip alarm was implemented. Review of the Post Fall/Trauma reports reveal the following: ~9/16/10 at 6:50 a.m., Resident #3 was found in a semi-reclined on his back and buttocks on floor next to lowered bed, pants and depends off, soiled bed sheets. Alarm had been removed while string still attached to the alarm, therefore did not sound. Resident #3 sustained a skin tear on his right hand. Staff documented Resident #3 requires safety cues and that he was seen by the physician. There are no changes to Resident #3's care plan. ~9/20/10 at 6:30 p.m., Resident #3 ambulated without assistance and fell in the lounge with no apparent injuries. Staff documented a recommendation of "w/c (wheelchair) positioning." There are no changes to Resident #3's care plan. ~9/21/10 at 1:00 a.m., Resident #3 transferred unassisted and fell in the lounge without injury. Staff documented that the interventions in place prior to the fall would continue. There are no changes to Resident #3's care plan. ~9/22/10 at 4:45 p.m., Resident #3 transferred unassisted and fell in his room. "Sensor alarm turned on but not sounding." Staff documented that the interventions in place prior to the fall would continue and that the alarm was replaced. No changes are made to the care plan. ~9/27/10 at 9:25 p.m., Resident #3 transferred unassisted and fell in his room. There are no changes to Resident #3's care plan following this fall. ~10/17/10 nurse's note indicates that Resident #3 was lowered to the floor. No changes are made to Resident #3's care plan at this time. On 10/26/10 at 5:20 p.m., Surveyor # interviewed CNA-C who consistently takes care of Resident #3. CNA-C stated the only time Resident #3 fell on her watch was when he was in the bathroom and just sat down. On 10/26/10 at 8:35 a.m., Surveyor # observed Resident #3 sitting in the lounge area. Resident #3 was in a wheelchair with the alarm on. Surveyor # observed Resident #3's right eye was discolored. The facility's failure to have a system in place for reviewing and responding to falls so that future falls could be prevented or minimized created a finding of immediate jeopardy. The facility removed the immediate jeopardy on 11/5/10 by which time it had: ~ Begun educating all staff prior to beginning their next shift of work on identification of residents at risk for falls at admission and after a significant change of condition, and at quarterly MDS evaluation utilizing the Falls Assessment or the new Health Status form. ~ Begun inservicing staff on the fact that fall prevention interventions would be added to the care plan and the CNA care card and that a root cause analysis would be conducted after each fall, utilizing Post Falls Investigation, with interventions added to the care plan and to the CNA care card. ~ Revised and begun implementing procedures such that: -Post Falls Investigation would be conducted after each fall at Daily Clinical Start-Up to ensure root cause is addressed with appropriate interventions. - A weekly fall meeting would be held to review resident identified at high risk and to review any falls from the previous week. Minutes from these meetings would be reviewed at the monthly Quality Assurance meeting. - Auditing process would be conducted to maintain substantial compliance with the Fall Prevention process. ~ Identified twelve residents as being at high risk for falls (score of 10 or above on assessment tool), reviewed and updated their care plans.