Every finding on record at Riverview Health Services

Based on record review and interview, the facility did not ensure nursing staff had the appropriate competencies and skills sets to provide nursing and related services to ensure resident safety for 3 of 30 residents (R1, R4, and R8). Licensed Practical Nurses (LPNs) assessed R1 after a fall, without contacting a Registered Nurse (RN), the Director of Nursing (DON), or R1's provider prior to moving R1 for 5 of 8 falls. No documentation to support that the LPN contacted an RN prior to moving R8 after a fall.LPN did not report a change of condition in R4 to an RN.Per the Wisconsin LPNs Standard of Practice (N 6.04), -LPNs must work under the general supervision of an RN or direction of a provider. -LPNs provide basic nursing care, including collecting data and recording it. -LPNs must report changes in a patient's condition to the appropriate person. -LPNs must consult with a provider if they know a delegated act may harm a patient. The facility's policy titled, Fall Prevention and Management Guidelines, read in part.7. When any resident experiences a fall, the facility will: -Complete a post-fall assessment and review: 1) Physical assessment with vital signs. Example 1 R1 admitted to the facility on [DATE], after falling at home and laying on the ground for several days. R1's diagnoses included dementia. On 11/20/25, a Minimum Data Set (MDS) assessment confirmed R1 scored 04/15 during Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. R1's care plan included the following: -At risk for falls due to dementia, poor safety awareness, and history of falls. Interventions included bed in low position, 11/24/25. Fall mat on right side of bed, 11/24/25. Wide scoop mattress, 01/02/26. Bolster mattress, 01/25/26. On 01/26/26, Surveyor reviewed R1's falls. Surveyor noted R1 had eight falls since admission. Surveyor noted 5 of 8 fall assessments were completed by LPNs and did not include documentation the LPN updated an RN, DON, or provider prior to moving R1, per the following: -11/17/25, LPN J, Resident found on the floor by floor CNA at approx. 0430. Resident apparently rolled out of the right side parallel to his bed. Resident was in the supine position with head pointed towards the wall and feet towards the bathroom door. No new injuries noted and no increase or unusual pain noted. Resident assessed for injuries. ROM x's 4, right and left hip flexed without pain or discomfort, no new bruising, no new abrasions, and no new skin tears. Resident assisted off of the floor with a mechanical lift and 2 floor CNA's. Neuro checks initiated per facility protocol and WNL's. Awaiting call back from [clinic]. -11/24/25, LPN J, At approx. 0240, resident found side laying on his right side to the right side of bed. Resident had apparently rolled out of bed and rolled onto the floor. Resident unable to articulate how or why resident rolled onto the floor. Resident does have an alternating air mattress. Intervention is to ensure resident is in the center of the bed. Resident assessed for new injuries. None apparent. ROM x's 4, right and left hip flexed without pain or discomfort, right andleft leg are equal and symmetrical, no new bruising, no new skin tears, no new abrasions, and no new scratches. Resident denies any unusual pain or discomfort. Resident stated that he was having usual aches and pains and requested medication. Hydrocodone/APAP 5/325mg administered at 0300. Neuro checks initiated and are WNL's. Call currently out to [clinic] to update. Resident is currently center of bed resting comfortably at this time. -11/25/25, LPN J, Writer could hear a faint call for help coming from the west hallway. Writer went to investigate and found resident right side laying to the right side of bed. Identical fall as previous. Resident assessed for injury and no new injuries noted. ROM x's 4, resident does complain of pain in right arm which is a chronic problem for this resident, no new scratches, no new bruises, no new abrasions. Right and left hip flexed without pain or discomfort. Neuro checks initiated and are WNL's. Hydrocodone/APAP 5/325mg administered for a pain rating of 5 out of the 1-10 pain scale. Call out to [clinic] and awaiting call back at this time. Resident is currently in bed resting at this time. 15 minute checks in place as an intervention to prevent further incidents. -01/02/26, LPN K, Res. Was calling out and staff found him laying on his back next to bed on the mat with head positioned elevated from the floor pointing to the direction of the head of the bed. Able to move all extremities without any changes in mobility. No c/o pain. No injury from this fall. VSS. Neuro's WNL. Res. Alert and talking loudly per his usual. He did state he slid off the side of the couch. We did explain to him he was in a bed, he did ask where he was and informed his of his location. He was quite calm with interaction as usually he is yelling. Assisted him back into bed and positioned him for comfort and safety. Placed call light and gave him instructions to place call light on if he needed assist. His level of comprehension is impaired. Informed administrator of res. Fall. [NP from clinic] was informed and will follow facility protocol for fall. Also called res. LG and left detailed message. -01/25/26, LPN J, Resident found on the floor with head against wall just below TV and legs extended towards the bed in room. Resident was on his back with gripper socks on both feet, tee shirt on, and soiled adult disposable brief. Resident stated, I had to go to the bathroom. Resident assessed for injuries, none apparent. ROM x's 4, right and left hip flexed without pain or discomfort, BLE are equal and symmetrical, no bruising, no skin tears, and no abrasions noted. Neuro checks initiated and are WNL's. On 01/27/2026 at 7:31 AM, Surveyor interviewed LPN L. LPN L stated LPNs cannot start intravenous (IV)s or administer IV medications but are able to assess. Surveyor asked LPN L if there is a difference between RN and LPN scope of practice. LPN L then stated, Oh yes, by assess I meant gather the data, VS, etc, then let RN know. Our DON is on call 24/7 so the LPN would call her if there was no RN in the building. If DON is not available or on PTO, there is a backup plan, such as an RN or DON from another building, or also contact provider prior to moving the resident. On 01/27/2026 at 7:37 AM, Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A stated, The DON is on call 24/7, and the LPN would collect the information, call DON, and DON would take over the role or the judgement. NHA A reported understanding the Surveyor's concern of an LPN assessing a resident after a fall and moving the resident prior to contacting an RN, DON, or provider. Surveyor requested any additional information the facility may have to demonstrate compliance. On 01/27/26 at approximately 9:00 AM, Surveyor received a handwritten note from DON G, which read, We follow the WI Administrative Code N 6, Standards of Practice for RNs and LPNs. Example 2 R8 was admitted to facility on 11/03/25 with diagnosis of Parkinson's disease with dyskinesia fluctuation (difficulty in performing or controlling voluntary movements). R8's admission Minimum Data with target date of 11/09/25 and documented on 11/13/25 indicates:R8 has a BIMS of 7/15 (moderately impaired).R8 has a history of falls prior to admission and had one fall since admission to facility. On 01/04/26 at 10:24 AM, facility documented R8 tipped over in wheelchair and sustained a fall without injury and documented Resident [R8] appears to have slid down causing the chair to tip. No apparent injuries noted. Resident [R8] denied pain or discomfort. Resident [R8] denied hitting his head & was able to lift his bottom to get into the Hoyer sling. Resident [R8] unable to offer much information regarding fall but when asked if he hit his head he told the nurse No. Resident [R8] assisted back to his wheelchair via Hoyer & 2 staff members. No documentation to support the LPN contacted an RN prior to removing R8 off the floor to concur with findings from the fall. Example 3 R4 was admitted to facility on 08/08/2025, and has diagnoses of anxiety disorder, fracture of unspecified part of neck right femur, Parkinson's disease, dementia, unspecified severity, without behavioral disturbance. R4's Minimum Data Set (MDS) assessment, dated 08/08/2025, indicated that R4 has a Brief Interview for Mental Status (BIMS) score of 00/15, which means severe cognition impairment. R4 has an activated power of attorney for healthcare decision making. R4's care plan, dated 08/28/2025, with a target date of 03/25/2026, states in part: I have difficulty communicating related to: decline in cognitive status.Interventions include mirror residents facial expression/body language to communicate your understanding of emotion being expressed. Care plan states in part: I am at risk for complications due to musculoskeletal problems related to fracture right hip.Interventions include.at times I am non-compliant with hip abductor pillow. On 01/27/2026 at 9:02 AM, Surveyor interviewed R4's husband (legal representative) and asked if any concerns were identified during R4's residence at facility between dates 08/08/2025 and 10/13/2025. R4's husband stated R4 sustained a right hip fracture from a fall at home requiring a stay at the facility for rehabilitation. The discharge goal was for R4 to be able to return home. R4's husband stated it was discovered on 10/13/2025, during a previously scheduled routine follow up orthopedic visit, that R4 has a dislocated right hip. It is to be noted that R4 had two prior right hip dislocations following fracture surgery, both requiring immediate intervention. R4's husband arrived in the morning of the appointment on 10/13/2025 and found R4 sitting in the commons area crying. R4's husband spoke with a nurse - he could not recall name - who told him R4 would be evaluated at the orthopedic appointment later that day. R4's husband indicated how upset he was that no one from facility addressed R4's obvious discomfort from right hip dislocation and intervened sooner. During R4's hospital admission, husband decided against further surgical interventions and R4 returning to facility. Following a brief stay at another skilled nursing home, R4 was discharged to home on hospice. On 01/27/2026, record review of R4's medical record found the following: R4 was admitted to the facility following right hip arthroplasty for a hip fracture resulted from fall at home. R4's goal was to be able to return home to live On 09/01/2025 at 1:55 PM, R4 had suffered a fall at the facility resulting in a mildly displaced fracture across right femoral neck with shortening of the right femoral neck. A total hip arthroplast was done on 09/20/2025 for repair of fracture and R4 returned to facility on 09/25/2025. On 09/29/2025 and 10/08/2025, R4 was diagnosed by xray (radiographic imaging) to have recurring right hip/femoral head dislocations. R4 was treated with external reductions in the emergency department (ED) and returned to the facility. Record review of R4's medical record had several documented incidences of R4's noncompliance with maintaining proper right hip alignment and allowing placement of an abductor pillow because of R4's dementia. On 10/12/2025 at 8:48 PM, LPN I documented [R4] has some slight swelling noted tonight in right hip. No complaint of pain except when staff is placing abductor pillow in bed. There is no documentation found in R4's medical record of LPN I notifying a provider, RN or R4's legal representative of R4's change in condition. There is no further documentation by nursing staff in R4's medical record of further assessments or notifications surrounding right hip swelling and pain. On 10/13/2025 at 3:44 PM, DON B documented in R4's medical record R4's husband called facility to inform them an x-ray done at orthopedic's office revealed a right hip dislocation. R4 was admitted to the hospital with tentative surgery planned. R4 did not return to facility for readmission. On 01/17/2026 at 10:03 AM, Surveyor interviewed DON G and [NAME] President of Success (VPS) F about facility expectations for practicing LPNs' notification of a resident's change in condition. VPS F stated an LPN, after discovering a change in a resident's condition, is expected to notify an RN and/or provider immediately, regardless of time of day. DON G, who is the acting DON at facility while current DON out on sick leave, stated all nurses provide an oncoming/off going shift report on every resident. Shift changes happen at 6:00 AM, 2:00 PM, and 10:00 PM. DON G could not provide documentation of assessment or notification of R4's change in condition for 10/12/2025 8:41 PM to 10/13/2025 9:30 AM. DON G did not work at this facility (DON for partner facility), however was aware of R4's history of dementia and recurring hip dislocations, indicating a need for close monitoring and notification of status changes.

Based on interview and record review, the facility did not ensure pain management was provided to residents, consistent with the comprehensive person-centered care plan, and the resident's goals and preferences for 1 resident (R4) of 2 residents reviewed for pain management in a sample of 13. Facility did not develop and implement a care plan on pain management for R4 with a known diagnosis of dementia. R4 may not normally recognize and verbalize when having pain resulting in a prolonged status of discomfort while experiencing a hip dislocation. This is evidenced by:The facility policy, titled Pain Management, last revised 08/09/2022, states in part: The interventions for pain management will be incorporated into the components of the comprehensive care plan, addressing conditions or situations that may be associated with pain or may be included as a specific pain management need or goal.Non-pharmacological interventions will include but are not limited to.cold compress, warm shower/bath, massage, turning and repositioning, cognitive/behavioral interventions such as music, diversions, relaxation techniques.R4 was admitted to facility on 08/08/2025 and has diagnoses of anxiety disorder, fracture of unspecified part of neck right femur, Parkinson's disease, dementia, unspecified severity, without behavioral disturbance. R4 was discharged from facility on 10/13/2025. R4's Minimum Data Set (MDS) assessment, dated 08/08/2025, indicated that R4 has a Brief Interview for Mental Status (BIMS) score of 00/15, which means severe cognitive impairment. R4 has an activated power of attorney (POA) for healthcare decision making. R4's care plan, dated 08/28/2025, with a target date of 03/25/2026, states in part: I have difficulty communicating related to decline in cognitive status.Interventions include mirror residents facial expression/body language to communicate your understanding of emotion being expressed. Care plan states in part: I am at risk for complications due to musculoskeletal problems related to fracture right hip.Interventions include.at times I am non-compliant with hip abductor pillow.On 01/27/2026 at 9:02 AM, Surveyor interviewed R4's husband (legal representative) and asked if any concerns were identified during R4's residence at facility between dates 08/08/2025 and 10/13/2025. R4's husband stated R4 sustained a right hip fracture from a fall at home requiring a stay at the facility for rehabilitation. The discharge goal was for R4 to be able to return home. R4's husband stated it was discovered on 10/13/2025, during a previously scheduled routine follow up orthopedic visit, that R4 had a dislocated right hip. It is to be noted that R4 had two prior right hip dislocations following fracture surgery, both requiring immediate intervention. R4's husband arrived in the morning of the appointment on 10/13/2025 and found R4 sitting in the commons area crying. R4's husband spoke with a nurse - he could not recall name - who told him R4 would be evaluated at the orthopedic appointment later that day. R4's husband indicated how upset he was that no one from facility addressed R4's obvious discomfort from right hip dislocation and intervened sooner. During R4's hospital admission, husband decided against further surgical interventions and R4 returning to facility. Following a brief stay at another skilled nursing home, R4 was discharged to home on hospice. On 01/27/2026, record review of R4's medical record found the following: On 09/01/2025 at 1:55 PM, R4 had suffered a fall at the facility resulting in a mildly displaced fracture across right femoral neck with shortening of the right femoral neck. A total hip arthroplasty was done on 09/20/2025 for repair of fracture and R4 returned to facility on 09/25/2025. On 09/29/2025 and 10/08/2025, R4 was diagnosed by x-ray (radiographic imaging) to have recurring right hip/femoral head dislocations. R4 was treated with external reductions in the emergency department (ED) and returned to the facility. On 10/12/2025 at 8:48 PM, LPN I documented [R4] has some slight selling noted tonight in right hip. No complaint of pain except when staff is placing abductor pillow in bed. There is no documentation found in R4's medical record of LPN I notifying a provider, an RN or R4's legal representative of R4's change in condition. There is no further documentation by nursing staff in R4's medical record of further assessments or notifications surrounding right hip swelling and pain. R4 received scheduled dose of Tylenol per facility medication administration record (MAR) but no additional pain medications such as the hydrocodone/acetaminophen (Vicodin - a scheduled II narcotic for pain control) as ordered if needed for additional pain control. On 10/13/2025 at 3:44 PM, DON B documented in R4's medical record R4's husband called facility to inform them an x-ray done at orthopedic's office revealed a right hip dislocation. R4 was admitted to the hospital with tentative surgery planned. R4 did not return to facility for readmission. On 09/30/2025, physician ordered Tylenol oral tablet 325mg, give 650mg by mouth three times a day for pain related to difficulty in walking. R4's MAR consistently shows medication administration as ordered, along with pain level evaluation. On 09/25/2025, physician ordered Hydrocodone/acetaminophen 5/325mg (also known as Vicodin, a scheduled II narcotic used for pain control), one tablet by mouth every 6 hours as needed for post-surgical pain. Medication was administered to R4 once on 09/29/2025, once on 10/03/2025 (pain score of 2) and once on 10/08/2025 (pain score of 10). On 01/27/2026 at 10:03 AM, Surveyor interviewed Director of Nursing (DON) G on how nursing assesses for pain on residents who have dementia and cannot necessarily recognize or express pain in the conventional manner. DON G stated the facility uses the PAINAD (Pain Evaluation in Advanced Dementia) measuring tool. PAINAD uses observation of behaviors to measure pain levels in dementia residents. These observations include breathing; negative vocalizations such as moaning, calling out, crying; facial expressions such as grimacing, smiling; body language such as tenseness, pacing, fidgeting; and resident's ability to be consoled. R4's MAR indicated once daily PAINAD assessments on alternating shifts. Pain levels were documented prior to each Tylenol administration, ranging from level 0 to level 10. R4's medical record had several documented incidents by nursing and providers of R4's noncompliance with maintaining proper right hip alignment and allowing and/or keeping placement of an abductor pillow between legs. There are several daily skilled note entries by nursing indicating R4 had episodes of agitation and restlessness. No interventions for agitation and restlessness documented, which are behavioral indicators of possible pain according to the PAINAD measuring tool the facility uses for pain assessment. Record review of R4's medical record did not indicate development of a comprehensive care plan with interventions for R4's pain assessment and management including the observation of nonverbal indicators utilizing the PAINAD measuring tool. R4's care plan was not updated to include history of recurring right hip/femoral head fractures and right hip dislocations, and monitoring cues with interventions for detection of possible recurrences. R4's care plan does not include pharmaceutical interventions (beyond scheduled Tylenol) as ordered by physician for management of severe pain. R4's care plan did not include interventions to monitor agitation and restlessness type behaviors as possible exhibitions of discomfort being experienced by R4.

Based on record review and interview, the facility did not conduct a Level II Preadmission Screening and Resident Review (PASARR) for 1 of 4 residents reviewed (R33) within 30 days of admission to ensure individuals with a serious mental disorder received care and services in the most integrated setting possible. This is evidenced by:The facility policy, titled Resident Assessment - Coordination with PASARR Program, with a date implemented of 11/10/25, reads in part, The Level II resident review must be completed within 40 calendar days of admission.Surveyor reviewed R33's record and noted R33 was admitted on [DATE] with a diagnosis of major depressive order.R33's original order included Quetiapine Fumarate 25MG once daily and Duloxetine HCl 30 MG twice a day. R33's Quetiapine Fumarate was discontinued and on 1/26/26 R33's Duloxetine HCl was increased to 60MG in the morning and 30MG at bedtime.Surveyor noted on 11/6/25, a Level I PASRR screening noted R33 had a major mental disorder and has taken psychotropic medications to treat symptoms or behaviors of a major mental disorder, indicating a Level II PASRR should be completed. Screening indicated a short-term hospital discharge exemption, 30-day maximum.Surveyor reviewed R33's record and could not locate a Level II PASRR screening.On 1/27/2026 at 10:45 AM, Surveyor interviewed Social Services Director (SSD) H, who is responsible in part for the facility's PASRR screening process. SSD H confirmed a Level II PASRR was not completed for R33. SSD H reported R33 was not expected to stay beyond 30 days for care and a Level II PASRR should have been done in November 2025. SSD H acknowledged the facility does not have a system in place to ensure a PASRR II is completed for residents that stay past the 30-day window.

Based on record review and interviews, the facility did not ensure residents/representatives received written or verbal consent of Bed Hold reserved payment at time of transfer and the notice of transfer prior to discharge or transfer did not include written specific reason the specific for transfer for 2 of 3 residents (R4 and R14). R4 was sent to the hospital via ambulance on 09/19/25 for a change in condition. R4's representative was provided with a Bed Hold Request form that did not contain the written specific reason for transfer and was dated 09/22/25 of receiving verbal consent.R14 was sent to hospital via ambulance on 12/27/2025 for a change in condition. R14's representative was provided with a Bed Hold Request form that did not contain the written specific reason for transfer and was dated 12/29/25 of verbal consentThe facility policy, titled Bed Hold Notice, dated 04/23/25, states: It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold practices both well in advance, and at the time of a transfer for hospitalization.The facility policy further states: In the event of an emergency transfer of a resident, the facility will provide written notice of the facility's bed-hold policies to the resident and/or the resident representative within 24 hours.R4 was sent to the hospital via ambulance on 09/19/25 for a change in condition. R4's representative was provided with a Bed Hold Request form that did not contain the written specific reason for transfer and was dated 09/22/25 of receiving verbal consent.R14 was sent to hospital via ambulance on 12/27/2025 for a change in condition. R14's representative was provided with a Bed Hold Request form that did not contain the written specific reason for transfer and was dated 12/29/25 of verbal consent.On 01/26/26 at 2:42 PM, Surveyor interviewed facility's Business Office Manager (BOM) E regarding process of providing bed hold information to a resident or resident representative who is being transferred/discharged . BOM E stated the information regarding bed hold and notice of transfer is completed as soon as BOM E is aware of transfer or discharge.

Based on interview and record review, the facility did not notify a physician and/or RN about a significant change in a resident's physical status for 1 resident (R4) of 13 residents reviewed in a sample of 13.Documentation in R4's medical record by Licensed Practical Nurse (LPN) I indicated a change in R4's physical condition during an evening shift.LPN I did not notify a physician or a Registered Nurse (RN) for further guidance, resulting in R4's prolonged discomfort resulting from a dislocated hip.R4's medical record did not include further documentation of assessment by licensed staff following LPN I's initial documentation of a physical change in R4's status, resulting in delayed intervention for a dislocated hip. This is evidenced by: The facility policy, titled Change in Condition: When to report to the MD/NP/PA, adapted from AMDA Clinical Practice Guidelines 2003, states in part: Immediate notification.any symptom, sign or apparent discomfort that is: acute or sudden in onset, and a marked change in relation to usual symptoms and signs, or unrelieved by measures already prescribed.marked localized bruising, swelling, or pain over joint or bone, with or without recent fall.based on Wisconsin's Nurse Practice Act - Standards of Practice for registered nurses and licensed practical nurses, chapter N6.LPNs must be trained on: what constitutes a change in condition, including but not limited to:.pain changes or decline in function.Who to notify and when: notify RN immediately, MD/NP/PA R4 was admitted to facility on 08/08/2025 and has diagnoses of anxiety disorder, fracture of unspecified part of neck right femur, Parkinson's disease, dementia, unspecified severity, without behavioral disturbance. R4's Minimum Data Set (MDS) assessment, dated 08/08/2025, indicated that R4 has a Brief Interview for Mental Status (BIMS) score of 00 which means severe cognition impairment. RN has an activated power of attorney for healthcare decision making. R4's care plan, dated 08/28/2025, with a target date of 03/25/2026, states in part: I have difficulty communicating related to: decline in cognitive status.Interventions include mirror residents facial expression/body language to communicate your understanding of emotion being expressed. Care Plan states in part: I am at risk for complications due to musculoskeletal problems related to fracture right hip.Interventions include.at times I am non-compliant with hip abductor pillow. On 01/27/2026 at 9:02 AM, Surveyor interviewed R4's husband (legal representative) and asked if any concerns were identified during R4's residence at facility between dates 08/08/2025 and 10/13/2025. R4's husband stated R4 sustained a right hip fracture from a fall at home requiring a stay at the facility for rehabilitation. The discharge goal was for R4 to be able to return home. R4's husband stated it was discovered on 10/13/2025, during a previously scheduled routine follow up orthopedic visit, that R4 has a dislocated right hip. It is to be noted that R4 had two prior right hip dislocations following fracture surgery, both requiring immediate intervention. R4's husband arrived in the morning of the appointment on 10/13/2025 and found R4 sitting in the commons area crying. R4's husband spoke with a nurse - he could not recall name - who told him R4 would be evaluated at the orthopedic appointment later that day. R4's husband indicated how upset he was that no one from facility addressed R4's obvious discomfort from right hip dislocation and intervened sooner. During R4's hospital admission, husband decided against further surgical interventions and R4 returning to facility. Following a brief stay at another skilled nursing home, R4 was discharged to home on hospice. On 01/27/2026, record review of R4's medical record found the following:R4 was admitted to the facility following right hip arthroplasty for a hip fracture resulted from fall at home. R4's goal was to be able to return home to liveOn 09/01/2025 at 1:55PM, R4 suffered a fall at facility. No injuries noted and R4 was up and about her usual activity according to RN nursing documentation. R4's husband, clinic and director of nurses (DON) notified of incident.On 09/04/2025 an x-ray (radiographic image) of right hip done per request of physical therapy due to R4 having difficulty bearing weight on right leg. Xray indicated no findings of right hip/leg fractures or dislocations.On 09/19/2025, R4's husband requested a repeat x-ray of right hip be done due to R4 showing nonverbal cues of pain with hip after 09/01/2025 fall. It is documented by RN that R4 is an extensive assist of 2 with transfers. Xray revealed a mildly displaced fracture across right femoral neck with shortening of the right femoral neck. Nurse practitioner (NP) notified and requested R4 be transferred to emergency department (ED) for evaluation. R4 transferred to ED at 9:30 PM. R4's husband aware of transfer.On 09/20/2025, R4 had a right total hip arthroplasty done. R4 was readmitted to facility on 09/25/2025.On 09/29/2025, the NP rounding states, R4's right leg is slightly internally rotated and she is complaining of increased pain. Xray ordered by NP and done. Xray resulted as no acute fracture or dislocation identified. However, there is a superior dislocation of right femoral head across right hip joint. R4 was transferred to the ED for evaluation at 9:35 PM. R4's husband was aware of transfer to ED. On 09/20/2025 at 12:40 AM, R4 returned to facility after dislocation of neck of right femur was reduced. On 10/08/2025, R4's husband voiced concerns to an RN about R4 having some right hip swelling and internal rotation of right hip. R4's husband requested R4 be transferred to the ED for evaluation. R4's provider updated. ED informed facility RN on 10/08/2025 at 10:13 AM that R4's right hip was again dislocated and was able to be maneuvered back in place. ED MD informed RN it was recommended a follow up with orthopedic surgeon (after ED MD consulted with orthopedic MD) be made for R4. ED MD had been in contact with R4's husband.On 10/09/2025, R4's medical record states her husband set up an appointment for R4 to see orthopedics on 10/13/2025 at 9:45 AM.On 10/12/2025 at 8:48 PM, LPN I documented [R4] has some slight swelling noted tonight in right hip. No complaint of pain except when staff is placing abductor pillow in bed. There is no documentation found in R4's medical record of LPN I notifying a provider, RN or R4's legal representative of R4's change in condition. There is no further documentation by nursing staff in R4's medical record of further assessments or notifications surrounding right hip swelling and pain. On 10/13/2025 at 3:44 PM, DON documented in R4's medical record R4's husband called facility to inform them an x-ray done at orthopedics' office revealed a right hip dislocation. R4 was admitted to the hospital with tentative surgery planned. R4 did not return to facility for readmission. Record review of R4's medical record had several documented incidences of R4's noncompliance with maintaining proper right hip alignment and allowing placement of an abductor pillow because of R4's dementia. R4's care plan had no updates or interventions in place regarding recurring hip dislocations and alternatives for maintaining hip alignment when R4 was not able to comply. On 01/17/2026 at 10:03 AM, Surveyor interviewed DON G and [NAME] President of Success (VPS) F and asked what the facility's expectations are for practicing LPNs giving notification of a resident's change in condition. VPS F stated an LPN, after discovering a change in a resident's condition, is expected to notify an RN and/or provider immediately, regardless of time of day. DON G, who is the acting DON at facility while current DON out on sick leave, stated all nurses provide an oncoming/off going shift report on every resident. Shift changes happen at 6:00 AM, 2:00 PM, and 10:00 PM. DON G could not provide documentation of assessment or notification of R4's change in condition for 10/12/2025 8:41 PM to 10/13/2025 9:30 AM. DON G did not work at this facility (DON for partner facility), however was aware of R4's history of dementia and recurring hip dislocations, indicating a need for close monitoring and notification of status changes.

Based on observation, interviews, and record review, the facility failed to ensure each resident has the right to a dignified existence, self-determination, and communication by ensuring the ability to communication interventions were in place for 1 of 4 residents (R8).Surveyor observed R8 sitting in lounge area without the jingle bell R8 uses to communicate with staff when R8 needs something.R8 was admitted to facility on 11/03/25 with diagnosis that include Parkinson's disease with dyskinesia fluctuation (difficulty in performing or controlling voluntary movements).R8's admission Minimum Data with target date of 11/09/25 and documented on 11/13/25 indicates:R8 has a BIMS of 7/15 (moderately impaired).R8 has no speech sometimes understood and sometimes understands.R8's care plan, I have difficulty communicating as evidenced by whispered/soft voice, initiated on 11/03/25.R8's ADL care plan intervention labeled and dated 11/07/25 Communication states: Uses jingle bell when not in bed.On 01/26/2026 at 9:18 AM, Surveyor observed R8 sitting in facility's TV lounge area with Life Enrichment ([NAME]) D and was unable to visualize the jingle bell.Surveyor approached and interviewed [NAME] D regarding the jingle bell. [NAME] D stated R8 had the jingle bell the day prior, but R8 does not have it now.On 01/26/2026 at 9:24 AM, Surveyor interviewed Certified Nursing Assistant (CNA) C regarding the jingle bell whereabouts. Surveyor observed the following: CNA C went to R8's room to search for the jingle bell and was unable to locate the jingle bell. CNA C came back out to lobby to talk to [NAME] D who told CNA C where it was located the day before in R8's room. CNA C went back to R8's room and found the jingle bell between several large containers of R8's snacks and brought it to R8.On 01/26/2026 at 11:21 AM, Surveyor observed [NAME] D respond to R8 ringing jingle bell at lunch table, and after R8 and [NAME] D had a conversation (of note, Surveyor was unable to hear), R8 placed jingle bell on dining table. On 01/26/2026 at 11:25 AM, Surveyor observed R8 fidgeting in chair at dining table and R8 picked up and rang the jingle bell. [NAME] D responded immediately to the ringing and talked with R8 who became relaxed.On 01/26/2026 at 12:43 PM, Surveyor interviewed CNA C and asked what the expectation is for R8's jingle bell. CNA C stated that whoever assists R8 out of room should make sure the jingle bell is in R8's possession. CNA C stated she was not aware who got R8 up this morning.Surveyor further asked CNA C if R8 uses the jingle bell. CNA C stated R8 does know how to use it appropriately. On 01/26/2026 at 1:00 PM, Surveyor interviewed [NAME] D regarding earlier observation of responding when R8 used the jingle bell during lunch. [NAME] D stated R8 was having a difficult time communicating due to diagnosis. [NAME] D stated R8's ability to communicate as the day goes on and believes it is due to medication administration. On 01/26/2026 at 1:19 PM, Surveyor reviewed Hospice binder and noted documentation dated 01/26/26 in the morning, that staff from Hospice gave R8 a shower and documented following task, that R8 was taken to common lounge. On 01/26/2026 at 4:04 PM, Surveyor informed NHA A regarding observation of R8 not having the jingle bell intervention in place per plan of care when out of room. NHA A was made aware a staff member from Hospice had completed R8's care that morning and brought R8 out to lounge. NHA A stated the expectation is for R8 to have his jingle bed when out of room by staff and Hospice agency. NHA A stated that the care Kardex is available behind door in resident rooms to refer to.On 01/27/2026 at 11:36 AM, Surveyor interviewed R8's Spouse M via phone, who stated R8 is supposed to have the bell when not in room and stated R8 does not always have it, and it is left in room. Spouse M stated R8 may not always remember to use the bell, but feels if R8 was able to visually see the bell, then R8 would utilize it more.

Based on interview and record review, the facility did not ensure menus were followed to meet the nutritional needs of each resident. This practice had the potential to affect all 38 residents residing in the facility. Meals were not provided as listed on the menu. The facility did not consult with the Registered Dietitian when changes were made to the menu to ensure nutritional adequacy. Findings: According to The Academy of Nutrition and Dietetics, The menu must meet the Recommended Dietary Allowances, but the actual amount of food served to an individual resident should meet her/ his needs, not exceed them. Food is an essential component of quality of life; an unpalatable or unacceptable diet can lead to poor food and fluid intake, resulting in malnutrition and related negative health effects. On 11/04/24 at 8:11 AM, Surveyor completed initial tour of the kitchen with Dietary Manager (DM) F. DM F reported to Surveyor she will be changing menu items this week. DM F reported the planned menu for Wednesday's lunch and Thursday's dinner will be substituted with a soup and sandwich. DM F explained the facility will be changing menu items approximately twice weekly due to budgeting concerns. Surveyor asked DM F if the facility's Registered Dietitian (RD) approved menu changes and/or substitutions. DM F stated she logs the substituted items, and the RD approves the substitutions when she is on-site every month. On 11/04/24 at 12:51 AM, Surveyor interviewed RD H. RD H reported the facility's menus are approved by corporate dietitians. RD H confirmed she is on-site in the facility monthly. RD H confirmed dietary staff keep a log of substituted food items, and RD H signs off on the log when she is on-site. Surveyor asked RD H if there was risk to the residents if the menu changes were approved up to 30 days after being served. RD H confirmed menu substitutions could impact the nutritional value, based on what the planned item was versus the substitution. RD H acknowledged an RD should be approving menu substitutions prior to being served to ensure nutritional value is not altered.

Based on observation, interview and record review, the facility did not ensure proper sanitization and food handling practices to prevent the outbreak of foodborne illness for all 38 residents (R). The facility did not measure the internal temperature of the dishwasher. Dietary staff did not wear appropriate hair restraints. Findings: DISHWASHER The Food and Drug Administration (FDA) Food Code requires that commercial dishwashers achieve a utensil surface temperature of 71 C (160 F) as measured by an irreversible registering temperature indicator. On 11/04/24 at 1:23 PM, Surveyor observed Dietary Aide (DA) E washing dishes using a commercial dishwasher. DA E stated the dishwasher was a high temperature dishwasher. Surveyor noted the dishwasher's temperature log was not completed on 11/02/24 and 11/03/24. DA E stated sometimes he forgets. Surveyor asked DA E how dietary staff check to ensure the dishwasher's temperature is reaching the appropriate temperature for sanitization. DA E stated they were using test strips but had not been doing this. DA E was not able to find the test strips. On 11/04/24 at 1:25 PM, Surveyor interviewed Dietary Manager (DM) F. DM F reported the facility used an electronic probe that measures the internal and surface temperature of the dishwasher. DA E and DM F both acknowledged the test strips or the data logger had not been used to ensure the dishwasher was reaching the required temperatures to ensure sanitization. HAIR RESTRAINT The facility's policy titled, Staff Attire, read in part, All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. On 11/04/24 at 7:29 AM, Surveyor completed an initial tour of the kitchen. Surveyor observed DA E moving throughout the kitchen, preparing for breakfast. DA E was preparing coffee, opening refrigerator doors to obtain cold beverages, and rolling silverware in cloth napkins. Surveyor observed DA E's hairnet was not completely covering his hair, and hair was exposed at the sides and the back of his head. Surveyor observed DA E had facial hair that was not covered. On 11/04/24 at 8:11 AM, Surveyor interviewed DM F. DM F stated she was unaware DA E was not wearing a beard net to cover his facial hair. DM F confirmed all hair is to be covered when in the kitchen.

Based on observation and interview, the facility did not ensure staff followed procedures for the accurate administration of insulin. Staff did not complete a safety check by priming the needle on an insulin pen to ensure the injectable pens were dispensing insulin before administration for 1 of 2 residents (R), (R3). Findings include: Manufacturer's instructions for insulin pens state in part, .Step 3. Perform a Safety test. Always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by: ensuring that pen and needle work properly. Removing air bubbles. A. Select a dose of 2 units by turning the dosage selector. B. Take off the outer needle cap and keep it to remove the used needle after injection. Take off the inner needle cap and discard it. C. Hold the pen with the needle pointing upwards. D. Tap the insulin reservoir so that any air bubbles rise up towards the needle. E. Press the injection button all the way in. Check if insulin comes out of the needle tip. You may have to perform the safety test several times before insulin is seen. On 11/05/24 at 7:17 AM, Surveyor observed Registered Nurse (RN) G take a Glarigine insulin pen out of the medication cart and verify the label with the orders. RN G took a needle out of the drawer, wiped the end of the insulin pen with an alcohol wipe, and attached the needle to the insulin pen. RN G dialed the pen to 22 units per the order on the Medication Administration Record (MAR). RN G picked up the insulin pen to approach R3 when Surveyor stopped RN G and asked about priming the needle. RN G stated, I don't need to with this one, except if it is new. I do it with the other ones. RN G then primed the needle with 2 units twice until insulin was visibly coming out of the needle. RN G then dialed the pen to the 22-unit dose. This verified the pen was working correctly and ensured R3 received the correct dose of insulin. On 11/05/24 at 9:17 AM, Surveyor interviewed Director of Nursing (DON) B and asked what the facility policy and procedure was for priming insulin pens prior to administering the prescribed dose. DON B stated all nurses should prime the needle with at least 2 units, until the insulin is coming out, prior to dialing the pen to the prescribed dose. Surveyor explained the observations of RN G almost administering insulin with a pen to R3 without priming the needle. DON B stated RN G was not following the correct procedure and will educate RN G right away.

Based on interview and record review, the facility did not ensure one of five residents (R15) reviewed for unnecessary medications had appropriate monitoring and indication for use of an antipsychotic medication. R15 was prescribed risperidone for a diagnosis of dementia with behaviors. Behavior monitoring did not include the behaviors the medication was being used to treat. This is evidenced by: The facility policy titled, Psychotropic Medications read in part, Residents should not receive psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinic record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Psychotropic medications can affect behavior, mood, thoughts, and perceptions. Psychotropic medications include antipsychotic medications. Risperidone is an antipsychotic medication used to treat schizophrenia and bipolar disorder. R15 was admitted to the facility on [DATE]. Diagnoses included dementia with behavioral disturbance, depression, and Pick's disease (frontotemporal dementia). R15's Minimum Data Set (MDS) assessment, dated 08/03/24, confirmed R15 scored 00/15 during Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. MDS indicated R15 had no behaviors. R15's Power of Attorney is activated to assist with decision making. R15's physician orders included the following: -01/30/24, Risperidone 0.5 mg two times daily for dementia with behaviors. -05/02/24, BEHAVIORS: monitor for itching, picking at skin, restlessness, hitting, biting, spiting, kicking, cussing, elopement, stealing, delusions, hallucination, aggression, refusal of cares, every shift. If any NEW behaviors observed, document in progress notes. R15's care plan included in the following, in part: -02/14/24, At risk for adverse effects related to use of antipsychotic medication. -Evaluate effectiveness of medication. -Non-pharmacological interventions. -Target behaviors: crying, yelling out, agitation. On 11/06/24 at 12:31 PM, Surveyor interviewed Registered Nurse (RN) G. RN G stated R15 did not have any behaviors. On 11/06/24 at 12:36 PM, Surveyor interviewed Director of Nursing (DON) B. DON B stated R15 had a history of food behaviors prior to her admission. R15's behaviors included eating others' food and eating soap. DON B confirmed R15 did not exhibit these behaviors at the facility. On 11/06/24 at 12:49 PM, Surveyor interviewed Nurse Practitioner (NP) I. NP I explained R15 had food aggression behaviors prior to her admission to the facility. NP I described R15's behaviors as, She would take what she wanted. NP I stated R15's daughter and POA reported risperidone worked well to reduce R15's food aggression and insisted R15 continue the medication when admitted to the facility. NP I verified R15 had a diagnosis of Pick's disease and symptoms of Pick's disease included compulsive behaviors, and changes in diet, or mouth-centered behaviors. NP I confirmed R15 was receiving risperidone related to a diagnosis of Pick's disease with food aggression. On 11/06/24, Surveyor reviewed R15's behavior monitoring in her treatment administration record. Surveyor noted behavior monitoring included itching, picking at skin, restlessness, hitting, biting, spitting, kicking, cussing, elopement, stealing, delusions, hallucination, aggression, and refusal of cares. Surveyor noted R15's behavior monitoring reflected she did not exhibit any of these behaviors. Surveyor noted food aggression was not listed as a behavior. It was determined R15 was receiving risperidone related to food aggressive behaviors. Because food aggression was not listed as one of R15's behaviors, the behavior monitoring is not an accurate assessment to determine if risperidone is a necessary medication.

Based on observation, record review and interview, the facility did not perform hand hygiene when warranted during resident cares. The facility practice affected 1 of 3 residents observed for cares (R10). Certified Nursing Assistant (CNA) C did not perform hand hygiene after performing R10's peri care and before proceeding to touch presumably clean items. Findings Include: Surveyor requested and received the facility policy titled Hand Hygiene dated 11/02/22. The policy in part read: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Definitions: Hand Hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated using proper technique consistent with accepted standards of practice. Additional Considerations: a. 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. Surveyor also received and reviewed the Facility policy titled Hand Hygiene Table dated 11/02/24. The table indicated hand hygiene with soap and water or ABHR is required: ~After handling items potentially contaminated with blood, body fluids . ~Before applying and after removing personal protective equipment (PPE) including gloves. On 11/05/24 at 9:51 AM, Surveyor observed CNA C and CNA D assist R10 with morning cares. Surveyor observed CNA C and CNA D wash their hands and don gloves to provide R10 a bed bath. CNA C removed R10's soiled bedding and R10's soiled brief. CNA C removed gloves and donned clean gloves. CNA C did not perform hand hygiene. CNA C indicated R10 was incontinent of bladder and bowel. CNA C wiped R10's buttocks with peri wipes to remove a small amount of bowel movement and washed, rinsed and dried R10's buttocks. CNA C applied barrier cream to R10's buttocks and placed a clean brief on R10 without removing her gloves, performing hand hygiene or donning clean gloves. CNA C removed the remainer of R10's soiled brief and soiled bedding, removed her gloves and donned clean gloves. CNA C did not perform hand hygiene and proceeded to place a clean sheet and clean pad on R10's bed and adjusted R10's clean brief. CNA C covered R10 with a clean blanket and took the basin to the bathroom to empty, removed her gloves and performed hand hygiene. On 11/05/24 at 10:19 AM, Surveyor interviewed CNA C about the observation. CNA C indicated R10 was incontinent of bladder and a small amount of bowel. CNA C expressed she should have removed her gloves, performed hand hygiene and donned clean gloves after she performed peri-care and before she proceeded to handle R10's clean items to prevent cross contamination. CNA C expressed she did not have hand sanitizer in her pocket to perform hand hygiene at bedside. CNA C further stated she should carry hand sanitizer in her pockets to make hand hygiene at bedside easier to ensure hand hygiene is done when needed. On 11/05/24 at 3:47 PM, Surveyor interviewed Director of Nursing (DON) B regarding the observation. DON B indicated staff should have hand sanitizer in their pockets to have it available for hand hygiene at bedside. Staff should remove their gloves, perform hand hygiene and don clean gloves when going from a dirty task to a clean task to prevent cross contamination and the spread of infection.

Based on observation, interview and record review, the facility did not prepare and store foods in a sanitary manner. The facility practices had the potential to affect all 50 residents. The facility does not have a system in place to verify the internal hot water temperature of the hot water sanitizing dishwasher. During the initial tour of the kitchen, Dietary Manager (DM) G and Dietary Aide (DA) H were observed with facial hair at sides and below surgical mask that were being worn. DM G did not perform hand hygiene after contaminating his hands with dirt and grime. DM G proceeded to tour the kitchen with Surveyor, touching presumable clean surfaces and food items with his contaminated hands. Potentially hazardous food and drinks were stored in the kitchen refrigerator and were not dated with open by and use by dates. DM G was observed spraying dirty dishes in the dish room with his shirt being sprayed with contaminated water. DM G proceeded to prepare and serve foods at counter and steam table. DM G's contaminated shirt was observed contacting clean food surfaces. The refrigerator that stores resident foods brought into the facility was not monitored daily for safe food storage temperatures, and resident food items were not dated. This is evidenced by: Example 1 On [DATE] at 9:36 a.m., Surveyor observed DA H washing dishes in the dish room. DM G indicated the dish machine was a hot water sanitizing dish washer. Surveyor observed dishwasher logs for wash and rinse temperatures. Surveyor inquired about the facility process for verifying the internal dish washer temperatures. DM G expressed the internal dish machine temperatures are not being monitored as he needs to order strips for monitoring the internal temperatures. DM G further expressed there are no logs as the facility has not been verifying the internal temperature. DM G expressed he is aware internal temperatures should be verified and will be ordering the strips. Surveyor requested and received the facility policy titled Ware washing dated as most recently revised on ,d+[DATE]. The policy in part reads: ~Procedure: All dish machine water temperatures will be maintained in accordance with manufacturer recommendations for high water temperature and low temperature machines. Surveyor requested the manufacturer guidance for the hot water sanitizing dish machine related to verifying the internal temperature of the facility's dishwasher. DM G indicated he does not have the guidance but is aware the internal dish machines should be monitored. Example 2 On [DATE] at 9:36 a.m., Surveyor conducted the initial tour of the kitchen with DM G, who has been on staff a few weeks. DM G was observed wearing a surgical mask covering his nose and chin. DM G's face mask did not restrain his beard that was observed hanging below and at sides of the surgical mask. DA H was also observed in the kitchen with a surgical mask on his face. DA H's facial hair was visible and not restrained below his chin. On [DATE] at 8:47 a.m., Surveyor spoke with DM G about the observation. DM G expressed kitchen staff hair needs to be restrained in the kitchen including beards to not contaminate the foods. Surveyor requested and received the facility policy titled Staff Attire dated as most recently revised on ,d+[DATE]. The policy in part reads: ~Procedure: All staff members will have their .facial hair properly restrained. Example 3 During the initial tour, Surveyor noted the sink for handwashing with visible dirt and grime in sink. DM G wiped the grime with his fingers and swiped a paper towel across his fingers in attempt to remove the dirt and grime. DM G indicated the sink was not clean nor is it on the cleaning list to be routinely cleaned. DM G did not wash his hands before proceeding with the initial tour with Surveyor and touched presumably clean surfaces and food items with his contaminated hands. On [DATE] at 8:47 a.m., Surveyor spoke with DM G about the observation. DM G indicated the sink needs to be added to the kitchen cleaning list. DM G also expressed he should have stopped and washed his hands before proceeding with Surveyor. His hands were not clean when he touched various clean surfaces and resident food items. Surveyor requested and received the facility policy titled Environment dated as most recently revised on ,d+[DATE]. The policy in part reads: Procedure: The Dining Services Director will ensure routine cleaning schedule is in place for all cooking equipment, food storage areas and surfaces. Example 4 During the initial tour, Surveyor noted numerous food and drink items in the refrigerator with one set of dates. Surveyor noted 2 gallons of white milk and one gallon of chocolate milk with no dates. Eggs in the original container with manufacturer expiration date of [DATE] with no open by or use by dates. Surveyor also noted bagged grated yellow cheese with one fourth of bag remaining with no dates. Surveyor observed various other food items with either no date or one set of dates. Surveyor asked DM G if the dates were open dates or use by dates for the food items with one set of dates. DM G indicated he was unsure, and food and drink should have an open date and a use by date, so staff know when food is expired. DM G further expressed the items will be discarded. Surveyor requested and received the facility policy titled Food Preparation dated as most recently revised on ,d+[DATE]. The policy in part reads: ~All TCS (time/temperature control for safety) foods that are held for more than 24 hours at a temperature of 41 degrees Fahrenheit or less will be labeled with a prepared by (day1) and use by date (day 7). On [DATE] at 8:47 a.m., Surveyor spoke with DM G about the food and drink that was not properly labeled in the refrigerator. DM G expressed all food and drink that has been opened or prepared needs a date the item was opened or prepared and a use by date so no outdated foods are served. Example 5 On [DATE] at 11:45 a.m., Surveyor observed preparation for lunch service in the kitchen. Surveyor observed DM G at the stove stirring gravy in a pan. DM G emptied the gravy to a pan for the steam table and proceeded to the dish room. DM G sprayed the pan and placed it on a dish rack. Surveyor observed the overspray of the dirty water contaminating DM G's t-shirt as no apron was worn. DM G repeated this with a pan used for noodles and a pan vegetables were cooked in. DM G proceeded to prepare and serve foods with his contaminated t-shirt coming into contact with food preparation surfaces and the steam table where resident foods were placed. On [DATE] at 8:47 a.m., Surveyor spoke with DM G about the observation. DM G indicated he should not have sprayed the dirty dishes while preparing and serving foods. The dishes should be done separately with staff wearing an apron, so their clothes do not become contaminated. DM G further expressed he understands his shirt was dirty and coming into contact with clean surfaces which caused cross contamination. Surveyor requested the facility policy regarding clean versus dirty and cross contamination. At time of exit no policy was provided. Example 6 On [DATE] at 9:40 a.m., Surveyor and DM G observed a refrigerator and freezer in the resident dining room. DM G indicated the refrigerator is used to store foods brought into the facility for residents. Surveyor noted the log with refrigerator and freezer temperatures that was not completed after [DATE]. Surveyor also noted many of the food items had no dates or resident names. One food item was dated [DATE]. Surveyor asked DM G about the facility policy regarding safe storage of resident foods brought into the facility. DM G expressed foods should be labeled with resident name, date the food is brought in and a use by date. The foods should be discarded after 3 days. DM G also expressed the refrigerator and freezer temperatures should be monitored daily to ensure safe storage temperatures. Surveyor requested and reviewed the facility policy titled Use and Storage of Food Brought in by Family or Visitors dated [DATE]. The policy in part reads: Policy Explanation and Compliance Guidelines: All food items that are already prepared by the family or visitor brought in must be labeled with content and dated .The prepared food must be consumed by the resident within 3 days.

Based on observation, interview and record review, the facility did not prepare foods in a manner that maintained the nutritional value and palatability of foods. The facility practice has the potential to affect 14 of 50 sampled and supplemental residents (R20, R14, R45, R22, R25, R9, R12, R26, R27, R31, R21, R35, R15 and R7). Dietary Manager (DM) G was observed preparing lunch items of altered consistency without using a recipe or instructions to ensure nutritional values were maintained. This has the potential to affect 11 residents of 50 who are served an altered consistency diet (R20, R14, R45, R22, R25, R9, R12, R26, R27, R31 and R21). R35 indicated the foods served are often bland in taste and the meats are too tough to chew. R15 expressed that the food was cold and indicated it was not good. R250 expressed that the food was cold and said it was hard to eat. R7 complained about the beef tips for lunch. R7 stated he had to chew and chew. This is evidenced by: Example 1 On 9/26/23 at 11:45 a.m., Surveyor observed DM G preparing lunch. Surveyor observed DM G pour green beans and bean juice into a robo-coup food processor to alter the food consistency to pureed. DM G did not measure the green beans or bean juice. Surveyor asked DM G how he knows how much beans and juice is needed to ensure proper nutrition and portion size. DM G responded, Recipes are in his desk but he usually just eyeballs what's needed. Surveyor observed DM G place chunks of beef and gravy into the robo-coup food processor to puree and make mechanically soft altered beef. Again, nothing is measured. Surveyor asked DM G about portion amounts and maintaining nutritional values of foods. DM G responded, Did not measure, going off feeling not by the book. Surveyor asked DM G how he knows what amount of beef is needed to ensure enough beef or other foods are cooked to serve all residents. DM G responded he usually runs out of food before all residents are served almost daily as the previous dietary manager did not order enough food and honestly he does not know how to figure out the amount needed. On 9/27/23 at 8:47 a.m., Surveyor spoke with DM G about the observation and maintaining nutritional values of foods. DM G expressed the facility has recipes and therapeutic menus that are in his office that should be used when modifying food consistency. This is to ensure the foods are the right consistency, nutritional value and right portion size. The facility also needs to order additional scoops of various portion sizes to ensure residents are being served the proper portions. On 9/27/23 at 2:10 p.m., Surveyor spoke with Registered Dietician (RD) I about maintaining nutritional values when altering food consistency. RD I explained the facility uses the national dysphagia diet guidance to ensure proper consistency when modifying foods. The facility has recipes, guidance and instructions that should be used for proper diet extensions to ensure the nutritional values and proper consistency when foods are altered for residents. Surveyor requested and received a list of residents who are on an altered consistency diet. The list included R20, R14, R45, R22, R25, R9, R12, R26, R27, R31 and R21. Surveyor requested and received policy titled Therapeutic Diets dated as last revised on 9/2017. The policy in part states: ~Diets are prepared in accordance with the guidelines in the approved diet manual . Surveyor also received policy titled Menus also dated as most recently reviewed on 9/2017. The policy in part reads: ~Policy Statement: Menus will be planned in advance to meet the nutritional needs of the residents/patients in accordance with established guidelines . Procedure: A Registered Dietician/Nutritionist (RDN) or other clinically qualified nutrition professional reviews and approves the menus. Example 2 On 9/26/23 at 1:32 p.m., Surveyor observed the room tray lunch cart leave the facility kitchen. Surveyor observed the last resident lunch tray served at 1:40 pm. Surveyor conducted a test tray for food temperatures and palatability after the last resident tray was served. Surveyor noted the beef temperature at 136.5 degrees Fahrenheit. The beef could not be cut with a fork and was very difficult to cut with knife. Surveyor found the beef very difficult to chew and bland in taste. On the plate were noodles which were not covered with the beef and gravy. Surveyor found the noodles to be rubbery and cool. The noodles temperature was 122.5 degrees Fahrenheit. Surveyor also found the green beans that were served to be bland and barely warm in temperature. The green beans temperature was noted to be 128.0 degrees Fahrenheit. On 9/26/23 at 1:45 p.m., Surveyor spoke with R35 about her satisfaction with her lunch. R35 expressed she did not eat much as the food was bland and it would take a chainsaw to cut the meat. Surveyor reviewed R35's most recent Minimum Data Set, dated dated dated [DATE] which notes she understands, is understood and is cognitively intact. 47807 Example 3 R15 was admitted to the facility on [DATE]. R15's Minimum Data Set (MDS) assessment, dated 08/09/23, indicated that R15 has a Brief Interview for Mental Status (BIMS) of 15 indicating resident is cognitively intact. On 09/26/23 at 11:01 AM, Surveyor interviewed R15 about that morning's breakfast. R15 said the breakfast was blah and they said breakfast was cold that morning. On 09/26/23 at 1:59 PM, Surveyor observed R15 being served lunch of potatoes, mixed veggies, and a small amount of beef tips. Surveyor interviewed R15 asking about the lunch meal. R15 stated the meat was tough and the food was not great. Example 4 R250 was admitted to the facility on [DATE], with a diagnosis of a recent stroke. The facility had not completed the admission MDS. R250 is their own decision maker and is considered cognitively intact. On 09/26/23 at 1:59 PM, Surveyor observed R250 being served a lunch of potatoes, mixed veggies, and a small number of beef tips. Surveyor interviewed R250 asking about the meal. R250 stated the meat was tough to chew, they did not get the roll that was on the menu, the cake was supposed to be frosted and was dry, and the food was lukewarm at best. R250 then said that the beef tips were tough to chew. R250 showed Surveyor the meal ticket on their tray, indicating they were to receive frosted cake and a wheat roll. On 09/27/23 at 8:54 AM, Surveyor interviewed R250 about breakfast. R250 stated the food was not good this morning. There was no jam for the toast, the food was colder than they would have liked, the oatmeal was lukewarm, and the food itself was just colder than they would like. Even though the oatmeal was colder than preferred, they felt it was the best tasting, so they ate it and left the eggs and sausage on their plate. 44863 Example 5 R7 was admitted to the facility on [DATE]. Diagnoses include fracture of left tibia and fibula, muscle weakness, and abnormal gait and mobility. Minimum Data Set (MDS) assessment, dated 07/14/23, confirmed R7 scored 15/15 during Brief Interview for Mental Status (BIMS), indicating intact cognition. On 09/26/23 at 2:05 PM, Surveyor interviewed R7. R7 complained about the beef tips for lunch. R7 stated he had to chew and chew and told Surveyor to look at the tray. Surveyor observed R7's lunch tray and did observe R7 ate all of the meal except for the beef which was chewed up and spit out on the plate.

Based on interview and record review, the facility did not ensure that 3 of 3 sampled residents (R7, R18, R35) did not receive care and services to maintain and/or improve their highest level of range of motion (ROM). R7 did not receive assistance to ambulate twice daily per his restorative program. R18 did not wear hand brace at night as recommended by occupational therapy (OT). R35's care plan was not updated to indicate independence with walker. Findings include: R7 was admitted to the facility on [DATE]. Diagnoses include fracture of left tibia and fibula, muscle weakness, and abnormal gait and mobility. Minimum Data Set (MDS) assessment, dated 07/14/23, confirmed R7 scored 15/15 during Brief Interview for Mental Status, indicating intact cognition. On 09/25/23 at 11:41 AM, Surveyor interviewed R7. R7 reported he has not received therapy services in two weeks. On 09/27/23 at 9:00 AM, Surveyor interviewed Certified Nursing Assistant (CNA) J regarding the brace that R18 was supposed to be wearing per therapy. CNA J, who worked from 2AM to 10PM this day, said she did not take a brace off and doesn't believe R18 has used a brace for at least a couple weeks. On 09/27/23 at 10:11 AM, Surveyor interviewed R18 about the brace and R18 did not know what the Surveyor was talking about. R18 raised his hand to show no brace was on. Surveyor asked if a brace was worn at night. R18 was not sure and couldn't remember but he didn't think so. On 09/26/23 at 11:17 AM, Surveyor interviewed Physical Therapy Assistant (PTA) C. PTA C showed Surveyor therapy communication book kept at the nurse's station. PTA C reported therapy staff write therapy recommendations in the communication book for nursing staff. Surveyor observed therapy recommendations for sampled residents: 07/17/23, R7-Restorative; Encourage to ambulate with 1-2 aides with wheelchair and 2-wheeled walker, perform in the morning and the afternoon. Encourage to walk per resident tolerance. 09/13/23, R18-Left hand splint on at night. 08/10/23, R35-Independent in room with walker. Independent in hallway with 2-wheeled walker. During record review, Surveyor noted R7, R18 and R35's care plans were not updated with therapy recommendations. On 09/26/23 at 11:29 AM, Surveyor interviewed Certified Medication Technician (CMT) D. CMT D stated a resident's care plan is updated with therapy recommendations; however, she was not sure who was responsible to update the care plan. On 09/26/23 at 11:44 AM, Surveyor interviewed Certified Nursing Assistant (CNA) E. CNA E reported licensed nurses are responsible for updating a resident's care plan with therapy recommendations. CNA E stated when the care plan is updated the CNAs will see the update in the CNA electronic charting. CNA E confirmed R7, R18 and R35 did not have any restorative tasks assigned in the CNA charting. On 09/26/23 at 3:16 PM, Surveyor interviewed Licensed Practical Nurse (LPN) F. LPN F reported R7 did not have a restorative program that she knew of. LPN F reported she is not sure who is responsible to update the care plan with recommendations from therapy. On 09/27/23 at 9:39 AM, Surveyor interviewed Nursing Home Administrator (NHA) A. NHA reported the facility identified a concern with communication of therapy recommendations. The facility created a performance improvement plan (PIP) on 09/22/23 but had not yet implemented identified actions.

Based on interview and record review, the facility did not ensure 8 of 13 residents (R7, R16, R20, R27, R44, R22, R32 and R45A) and/or responsible party participated in the development of their person-centered plan of care. Additionally, the facility did not include all members of the Interdisciplinary team for care planning conferences. Findings Include: 9/06/22 at 10:56 AM, interview with R44. R44 stated that he would like to be closer to home so that his family can visit more often. Surveyor asked R44 if this had been discussed at his care conference. R44 reported that he has not had a care conference and is not sure what a care conference is. 9/07/22 at 10:36 AM, interview with Social Worker (SW) C. SW C stated that she has not been holding care conferences quarterly and is behind. SW C stated that she does not have time to document in resident charts. 09/08/22 at 8:39 AM Surveyor met with SW C again regarding care conference meetings. SW C stated she has held some of the meetings but her documentation hasn't been done. I know I need to do better on that. I have kept notes in a binder but didn't document in the resident's record. I know we have had them. I just didn't write any notes on them in the IDT Progress Notes . 09/08/22 at 11:10 AM, Surveyor interviewed Director of Nursing (DON) B regarding care plan conferences and their purpose. DON B stated, Care Plan Conferences are a meeting with nursing, social services, dietary, therapies, anyone involved in the resident's care and the resident and/or families, to discuss the cares and goals, discharge planning or anything in need of discussion, how things are going for the resident or how we can assist them. DON B further stated that care plan conferences should be done each quarter or every three months. Surveyor reviewed facility Admission Agreement, which stated in part .Resident care conferences are held shortly after admission and every three months thereafter. The care plan team consists of team members from nursing, social services, life enrichment, dietary and therapy. The intent of the conference is to identify needs, establish goals, and determine how the team will assist you to meet your goals. You and your support system are an integral part of this process and will be invited to actively participate in each care plan conference. EXAMPLE 1 R7 was admitted to the facility on [DATE]. R7 has an appointed guardian and Brief Interview for Mental Status (BIMS) score is 1. During record review there was no documentation that R7 has had a care conference since admission. R7's admission assessment was completed 3/30/22 with subsequent quarterly assessments. EXAMPLE 2 R16 was admitted to the facility on [DATE]. R16 has an activated Power of Attorney (POA) and BIMS score is a 3. During record review there was no documentation that R16 has had a care conference since admission. R16's admission assessment was completed on 1/28/22 with subsequent quarterly assessments. EXAMPLE 3 R20 was admitted to the facility on [DATE]. R20 has an activated POA and BIMS score of 0. During record review there was no documentation that R20 has had a care conference since admission. R20's admission assessment was completed on 1/12/22 with subsequent quarterly assessments. EXAMPLE 4 R27 was admitted to the facility on [DATE]. R27 has an activated POA and a BIMS score of 1. R27's admission assessment was completed on 4/19/22 with subsequent quarterly assessments. During record review it was noted that R27 had a care conference on 4/26/22, which indicated that R27, POA, SW C, therapy department, MDS Coordinator, Business Office Manager, and Nursing Home Administrator (NHA) attended care conference. There are no other care conferences documented. EXAMPLE 5 R44 was admitted to the facility on [DATE]. R44 makes his own healthcare decisions and has a BIMS of 15. R44's admission assessment was completed on 2/28/22 with subsequent quarterly assessments. During record review it was noted that R44 had a care conference on 3/27/22, which indicated that R44, SW C, managed care organization and therapy department attended care conference. Example 6 R22 was admitted to the facility 1/5/2022. According to the most recent Minimum Data Set Assessment, which was a quarterly assessment dated [DATE], R22 scored 14/15 on the Brief Interview of Mental Status (BIMS) assessment, indicating he is cognitively intact. On 9/8/22 at 9:34 AM, Surveyor interviewed R22 regarding his direction in his care and his input into the care planning process. R22 asked, What the heck is a care plan conference? Surveyor then explained what a care planning conference is, who participates and certain topics of discussion that incorporate his choices in the direction of his care. R22 stated, I don't remember any such meeting. I don't think I ever had one, and yes I would like some input into my care. In reviewing R22's medial record, Surveyor noted that R22 had no documented care plan conference with the Interdisciplinary Team incorporating his input into his plan of care. There was a Behavioral meeting held on 1/19/22, but there was no indication that R22 was present and had input into this discussion. At 10:18 AM, Surveyor interviewed SW C regarding R22's Care Plan Conferences. SW C presented a printed out Transaction report that speaks of money and collections. This was dated 7/19/22 and states, Writer, SSD (Social Services Director), and BOM (Business Office Manager) met with resident for care conference and to discuss his substantial balance . unlikelihood of him being able to safely return home and explained the Medicaid process . The note continues to discuss properties resident has and bank accounts but does not include any care discussions. It was documented by NHA A. At 10:52 AM, Surveyor interviewed NHA A regarding the discussion held at the above meeting. NHA A stated the meeting was not a care discussion, that it only dealt with his balances and the budget. Example 7 R32 was admitted to the facility 5/16/22. According to the most recent Minimum Data Set Assessment, which was a quarterly assessment dated [DATE], R32 scored 0/15 on the Brief Interview of Mental Status (BIMS) assessment, indicating severely impaired decision-making abilities. In reviewing the Interdisciplinary Team Progress (IDT) Notes from admission 5/16/22 to present day, Surveyor noted no entries regarding care plan conferences or meetings with the family and IDT team. On 9/8/22 at 8:39 AM, Surveyor interviewed SW C regarding care plan conferences for R32. SW C stated she knows R32's family has been kept up to date with issues that arise, but she had no evidence a care plan conference was held for R32. Example 8 R45A was admitted to the facility on [DATE] from home with Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/7/22 at 5:00 PM, Surveyor called Family E to discuss R45A and her concerns with his care. Family E was a daughter to R45A. Family E's main concern was that there was no care conference held to update family on how R45A's care was going. She felt the family was left in the dark about everything. In reviewing the Interdisciplinary Team Progress (IDT) Notes from admission, there was only one entry made in reference to Care Plan Conferences. This entry was dated 5/12/22 and stated, Care conference with daughters, wife, BOM (Business Office Manager) and SS (Social Services). Family would like a Medicaid application started as resident will be long term. Wife visits resident daily. Family placed a white board with pictures on it in residents room. Writer and BOM to begin Medicaid application ASAP. Note: This entry does not indicate care needs were discussed, only finances.

Based on observation, interview and record review, the facility did not ensure that a resident received treatment and care in ordinance with professional standards of practice and according to physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R37 has orders to complete skin treatment to bilateral left lower leg and left groin. Registered Nurse (RN) D did not complete the treatment per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Surveyor reviewed policy titled Handwashing/Hand Hygiene, with revised date of August 2019, read in part: . 7. Use an alcohol- based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . b. before and after direct contact with residents; . d. before performing any non-surgical invasive procedures. g. Before handling clean or soiled dressings, gauze pads, etc.; . j. After contact with blood or bodily fluids; k. After handling used dressings, contaminated equipment, etc.; l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; m. After removing gloves; . 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare- associated infections . R37 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/11/22, R37 attended a follow up appointment and was started on [MEDICATION(S)], an antibiotic, for possible wound infection. R37's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/11/22 documented R37 had a Brief Interview of Mental Status (BIMS) score of 14 indicating R37 is cognitively intact. Section G of the MDS indicates that R37 requires supervision and physical assist of one staff for bed mobility, transfers, and toileting, limited physical assist of one staff for walking, supervision and set up for dressing, and independent with set up help for eating and personal hygiene. Section M indicates R37 has surgical wounds and is receiving wound treatments. R37's September physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Morning dressing change to left groin incision, apply [MEDICATION(S)] Advantage and cover with 4x4 gauze. Order date 08/26/22. Morning dressing change to left lower extremity, use [MEDICATION(S)] solution 1% place dampened, not dripping, 4X4 gauze into bilateral left lower leg wounds cover with dry 4X4 gauze, and use abdominal pad over top, then Coban wrap to lower leg. Order date 08/19/22. R37's initial care plan indicates in part; wound care, pain management, surgical incision, and skin treatment per order. Progress note dated 08/11/22 in part: Resident returned to facility from f/u with leg surgery. Labs done, awaiting culture results. New order for [MEDICATION(S)] 100mg twice a day for 10 days and [MEDICATION(S)] 200mg twice a day. Start Probiotic 2 tabs twice a day. Follow up appointment for next week on 08/18/22. On 09/07/22 at 9:58 a.m., Surveyor observed RN D complete wound care for R37. RN D sanitized hands before entering room and cleaned overbed table with appropriate hospital grade sanitizer. RN D placed supplies on barrier on clean table, closed door with foot, and applied clean gloves. R37 stood at bedside, removed pants, and then laid on bed. RN D cut old dressing off left lower leg with bandage scissors then removed gloves and did not sanitize hands. RN D then applied new gloves, removed the old abdominal pads and 4x4 gauze that was placed over the wounds and discarded them in the garbage. RN D grabbed more clean supplies off dresser with soiled gloves. R37's used dressing was approximately 50% absorbed with serosanguinous fluid (serum and blood) that drained from the wound. Wound bed on to the outside lower left leg is pink with granulation noted. Toward the inside incision site to lower left leg has sutures intact, however edges are not well approximated. There is a 2-3mm gap and no drainage noted on that dressing. RN D removed gloves, did not sanitize hands, opened 3 abdominal pads, kerlix, and 2 non-woven 4x4 sponges, then again not sanitizing hands, reapplied clean gloves. RN D opened 3 more 4x4 gauze packages and showed surveyor a bottle of 0.9% Normal saline and said this is the [MEDICATION(S)] R37 gets on there. RN D then removed gloves, did not sanitize hands, and applied new gloves. RN D laid abdominal pads under both sides of leg, dampened 4x4's with normal saline and applied 4x4s over bilateral surgical wounds. RN D grabbed the abdominal pads to cover the 4x4's when Surveyor stopped RN D and explained that the bottle she showed was normal saline and not the [MEDICATION(S)]. RN D thanked Surveyor then removed the saline soaked 4x4's, reopened 4 more 4x4 gauze, soaked them in the [MEDICATION(S)] solution, and pressed excess fluid out of the gauze. RN D then placed [MEDICATION(S)] containing 4x4's over incisions, wrapped left lower leg with Kerlix, removed gloves, did not sanitize hands, opened and applied coban. R37 pulled underwear down just enough to expose the left groin surgical site. RN D retrieved wound cleanser and [MEDICATION(S)] advantage. RN D did not sanitize hands, applied clean gloves, sprayed wound cleanser on gauze, dabbed dry incision site to left groin, and discarded gauze. RN D removed gloves and again did not sanitize hands. RN D applied new gloves, trimmed [MEDICATION(S)] strip with scissors that cut off old lower leg dressing without sanitizing them, placed dry [MEDICATION(S)] strip on left groin incision site, and covered with 4x4 gauze. RN D removed gloves and did not sanitize hands then taped 4x4 in place, placed supplies back on dresser in closet, put on clean gloves to remove trash. RN D removed right hand glove, did not sanitize hand, opened door of room with right hand, opened doors to trash room and utility room down the hall and discarded soiled linen and trash items. RN D then sanitized hands. Of note, RN D would not have applied the ordered [MEDICATION(S)] solution if Surveyor did not stop her. She failed to read the solution bottle to ensure she was applying the correct solution to the gauze. In addition, RN D did not sanitize hands after numerous times gloves were removed which creates a potential for cross contamination and infection of R37's leg and groin wounds. On 09/08/22 at 10:43 a.m., Surveyor interviewed Director of Nursing (DON) B. Surveyor reviewed with DON B the observation of RN D using the normal saline and not the ordered [MEDICATION(S)] solutions and asked what DON B's expectations are of staff during dressing changes. DON B stated RN D reported to her that she made the normal saline error because she was nervous. DON B stated, staff should wash hands before, during treatments, and after glove changes and that it should occur 2-3 times or more if needed like if they become visibly soiled. DON B stated that it is ok to use hand sanitizer, and they do education and in-services all the time. The facility failed to ensure proper wound treatments were completed as ordered by prescriber and hand hygiene was completed per standards of practice.

Based on observations, interviews and record reviews, the facility did not ensure pain management was achieved for 1 of 12 residents reviewed for pain (R22). R22 has frequent complaints of pain for which he receives [MEDICATION(S)] and Tylenol. There is no Comprehensive Pain Assessment or Care Plan to address R22's pain. This is evidenced by: R22 has medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Prior to admission to the facility, R22 was hospitalized from 11/17/21 - 1/5/22 related to abdominal pain. Tests revealed pneumoperitoneum pneumatosis in which immediate surgical intervention was performed. Further pathological testing revealed a Grade 1 Follicular [CONDITION(S)] and R22 underwent [CONDITION(S)] treatment. Also noted was a Thoracic Vertebral 5 mass causing spinal cord compression. He was admitted to this facility on 1/5/22. In reviewing the most recent Minimum Data Set (MDS) Assessment completed for R22, which was a quarterly assessment dated [DATE], the following was noted: - Brief Interview of Mental Status score 14/15, indicating R22 is cognitively intact - No issues with vision, hearing and speech, no behaviors or mood tendencies - Pain was scored as occasional 6/10, indicating moderate pain Note: According to the pain review section of this assessment, pain does not affect R22's sleep or day-to-day activities. Therefore, Section J0700 was also coded as no staff pain assessment was needed to be conducted. On 9/7/22 at 1:21 PM, Surveyor interviewed Director of Nursing (DON) B regarding pain control expectations and process. DON B stated, We only use Opioids for moderate to high, first try Tylenol for 1-4 levels. The first step is to assess location, duration, anything that happened to cause the pain, etc. We then try nonpharmacy measures (ice, heat, positioning or activities) first, then we will try Tylenol and update the doctor. If these are not helping, try [MEDICATION(S)] and opioids lastly. DON B further stated, The process is always assessment as the first step. A pain care plan should be triggered through the MDS Assessment and additional assessments if completed. The care plan should include nonpharmocological interventions to try prior to administering PRN (as needed)Opioids. Always interview the resident on what has worked for them in the past and options they would like to try to alleviate their pain . On 9/7/22 at 2:09 PM, Surveyor interviewed R22 regarding his pain control and preferences for management. R22 stated that no staff have ever really questioned him on his pain. I worked sometimes 20 hour days picking Ginseng and my work is now catching up to my body. I have pain every day, it isn't always in the same spot. Right now, it's in my left knee, sometimes it's all over and many times I will rate it 8-10 because it just throbs and can be excruciating . it sometimes affects my sleep. At times, I will lay awake all night because it just throbs. Some days, I will just stay in bed because of no sleep the night before . When asked about his approaches to pain management in the past and any non-pharmaceutical interventions he attempted to relieve his pain, R22 stated, In the past, I practically lived on pain medication and am now down to [MEDICATION(S)] and Tylenol, which is a step in the right direction, but I would be open to trying other things. I have never tried applying heat, that may feel pretty good, maybe along with the [MEDICATION(S)], I might get some relief. It never really goes away . In completing a review of the care plan devised to direct R22's care, Surveyor noted there was no plan of care to address the management and prevention of pain for R22. There also was no comprehensive nursing assessment of pain for R22. Surveyor then approached DON B and requested any pain assessments conducted for R22. DON B stated, If you can't find it, it probably was not completed, but I will look. In reviewing R22's orders for pain medication, Surveyor noted that on 5/5/22, his physician ordered an opioid medication, [MEDICATION(S)] Tablet 50 MG, Give 1 tablet by mouth every 6 hours as needed for pain. Surveyor then reviewed PRN dosing of [MEDICATION(S)] for the past three months and noted the following: - June: R22 received the [MEDICATION(S)] 19 times for ratings 3-10 with effectiveness noted - July: R22 received the [MEDICATION(S)] 30 time for ratings 2-10 with effectiveness noted - August: R22 received the [MEDICATION(S)] 33 times for ratings 4-10 with effectiveness noted A Pain Interview with R22 was completed on 7/21/22 with R22 indicating a pain goal of 4/10. At 2:58 PM, DON B approached Surveyor regarding R22 and his pain care plan. She stated that R22 did not have a care plan. I put it in today. Back in April we did have it QAPI (Quality Assurance and Performance Improvement) for nursing to complete pain assessments. This was to be audited, but it was not. Going forward, we will be auditing all residents for pain control and management. I also just educated nurses on duty to complete pain assessments. R22 has no pain assessment or care plan for pain prevention and management, staff are unable to holistically prevent and/or manage pain. This also prevents staff from incorporating non-pharmacological interventions to manage or prevent pain, that are consistent with a comprehensive assessment, a plan of care and R22's goals and preferences to help him attain or maintain his highest practicable level of well-being to prevent or manage his pain.

Based on interview and record review, the facility did not provide at least 8 hours of Registered Nurse Coverage during a 24 hour period. This has the potential to affect all residents. The facility did not provide Registered Nurse (RN) coverage for at least 8 hours each day on 33 days since 01/01/21. This is evidenced by: The surveyor reviewed the nurse schedules for Licensed Practical Nurses (LPN) and Registered Nurses (RN) from 01/01/21 to present. The schedule is done by day (24 hours) and shifts of am, pm, and nights. The following days did not have 8 hours of RN coverage during the 24 hour period. Saturday 1/16/21 Sunday 1/17/21 Saturday 3/20/21 Sunday 3/21/21 Saturday 3/27/21 Sunday 3/28/21 Saturday 4/03/21 Saturday 4/17/21 Sunday 4/18/21 Saturday 4/24/21 Sunday 4/25/21 Saturday 5/01/21 Sunday 5/02/21 Saturday 5/08/21 Sunday 5/09/21 Saturday 5/15/21 Sunday 5/16/21 Saturday 5/22/21 Sunday 5/23/21 Saturday 5/29/21 Sunday 5/30/21 Saturday 6/05/21 Sunday 6/06/21 Saturday 6/12/21 Sunday 6/13/21 Saturday 6/19/21 Sunday 6/21/21 Saturday 6/26/21 Sunday 6/27/21 Saturday 7/03/21 Sunday 7/04/21 Saturday 7/10/21 Sunday 7/11/21 On 07/22/21 at 11:00 a.m. the surveyor spoke with Director of Nursing (DON)-B regarding the Nurse staff schedule. DON-B expressed she is often the RN for a minimum of 8 hours each day Monday through Fridays. Often times her shift is up to 16 hours. On weekends there is often no RN during a 24 hour period. The facility has one RN on staff that is part time who works the night shift. The facility has had difficulties recruiting and retaining Registered Nurses, thus they have been unable to cover the nurse schedule with RNs for a minimum of 8 hours each day. On 7/22/21 at 11:29 a.m. the surveyor spoke with the Nursing Home Administrator (NHA)-A regarding RN coverage. NHA-A expressed he became aware of the shortage of RNs on staff when he started 5/28/21. The facility has sign on bonuses, referral bonuses, job postings out, and has increased the wage. The facility has not been successful in recruiting RNs.

Based on observation, interview, and record review, the facility did not prevent the spread of suspected Covid-19 virus by ensuring staff don appropriate personal protective equipment when entering the room of 1 of 1 residents who is newly admitted and not fully vaccinated (R127). This has the potential to affect 13% of residents in the building who are not fully vaccinated. R127 was admitted [DATE]. R127 is not fully vaccinated against the Covid-19 virus. Staff entered R127's room without donning all appropriate personal protective equipment. This is evidenced by: On 7/19/21 at 7:30 p.m. the surveyor noted signage on R127's door indicating droplet and contact precautions. The surveyor also noted a cart outside R127's room containing personal protective equipment. On 7/19/21 at 7:35 p.m. Surveyor asked Licensed Practical Nurse (LPN)- E about the signage and cart. LPN-E responded R127 was newly admitted and had not been vaccinated against Covid-19. Surveyor reviewed R127's record and noted she was admitted [DATE]. Her record does not include immunization against the Covid-19 virus. On 7/20/21 at 07/20/21 7:54 a.m. Surveyor observed breakfast trays being passed to residents in their rooms. Surveyor observed Certified Nursing Assistant (CNA)-F knock and enter room [ROOM NUMBER]. There is signage on door indicating droplet and contact precautions and a cart of personal protective equipment outside the room. CNA-F delivered R127's breakfast tray to R127 who was in bed. CNA-F placed the tray on the bedside table and went to R127's bedside to converse with R127. CNA-F was wearing a standard face mask and eye protection. CNA-F did not don a gown or gloves before entering R127's room. Upon exiting the room CNA-F proceeded to the North wing. CNA-F used hand gel and continued to pass breakfast trays to residents on the north wing. When CNA-F was finished passing breakfast trays the surveyor asked CNA about staff expectation when entering R127's room, given the signage and cart outside her room. CNA-F explained she did not pay attention to the sign on the door. CNA-F stated R127 is a new admission and CNA F was unaware of R127's vaccination status. On 7/22/21 at 11:15 a.m. Surveyor spoke with Director of Nursing-B who is the facility's Infection Control Preventionist. Surveyor asked DON-B about the facility's expectation related to staff donning personal protective equipment when residents are on droplet and contact precautions. DON-B indicated staff are expected to wear a N95 respirator, if they have been fitted. If not fitted and not cleared to wear one then a regular surgical mask would be expected as well as gloves, gown, and eye protection. This should happen whenever entering the room. The surveyor asked DON-B for a list of unvaccinated residents currently in the building. DON-B indicated 4 residents are not fully vaccinated.

Based on observation, record review, and interview, the facility did not provide adequate supervision for 1 of 4 residents reviewed for falls. R13 was not provided supervision and adequate assistance with toilet use, consistent with his plan of care, when observed on the toilet on 7/19/21. R13 is at high risk for falls and has fallen at the facility; including a fall with major injury. This is evidenced by: On 7/19/21 Surveyor observed R13 was placed on toilet and left without supervision. On 07/22/21 at 10:26 a.m. Surveyor spoke with the Director of Nursing (DON)-B regarding R13's falls and the facility's expectation of staff supervision for R13 with toilet use. DON-B expressed R13's care plan for toilet use indicates he requires extensive assistance of 1 staff. This is due to the need for staff to stay with him while on the toilet. R13 is impulsive and has poor safety awareness, he has stood up and fallen when staff were not with him. R13 is high risk for falls. He has fallen in the past, including falls with major injuries, including a fracture. R13 requires extensive staff assistance with toilet use to provide him safe supervision and assistance to prevent him from falling. The surveyor reviewed R13's record and noted: R13's Quarterly MDS dated [DATE] notes: ~Usually understands/usually understood with impaired cognition ~Requires extensive assistance to walk, transfer, and use toilet ~Has fallen causing minor injury or no injury R13's Significant Change in status Minimum Data Set (MDS) dated [DATE] notes: ~Usually understands/usually understood with impaired cognition ~Requires extensive assistance to transfer and use the toilet ~Has fallen with no injury R13's most recent fall risk assessment dated [DATE] notes: Risk Factors: Medication taken more than 3x/week: Antihypertensive, Narcotics Has fallen 1-2 times in the past 180 days to 6 months Is at risk for falls R13's care plan notes: Focus: I have a physical functioning deficit related to mobility and self care impairment related to left hip fracture, non-surgical intervention, [CONDITION(S)], hypertension, dementia, [CONDITION(S)] (low potassium)asthma, [CONDITION(S)] (high cholesterol), history of stroke. Goal: I will improve my current level of physical functioning, Date Initiated: 9/15/20, Revised on: 6/28/21, target date: 9/14/21 Interventions in part include: ~Extensive assist of one with toileting Focus: at risk for falls related to recent fall with left hip fracture, history of falls, dementia, medications, hypertension, asthma, history of stroke, [CONDITION(S)] (low potassium), [CONDITION(S)], [CONDITION(S)] and assistance needed with transferring. Goal: No falls, date initiated: 10/07/20, Revised on: 6/28/21, target date: 9/14/21 Interventions: Activity programing as desired, anti-roll backs on wheel chair, assess pain as needed, assess wheel chair for appropriate size, bed alarm, bed positioned against the wall, call light and personal items available and easy to reach, dycem in wheel chair, foot wear to prevent slipping, gripper pad in wheel chair, keep environment well lit and free of clutter, lip mattress, mat on the floor, observe for side effects of medications, pressure sensitive call light in room, resident may kneel bedside to pray on mat, will call for help using call light, therapy referral as needed, visual cues use call light/lock wheel chair, Weight bearing as tolerated to lower extremities, assist of one. The surveyor reviewed R13's fall Investigations in the past 10 months since his admission. R13 had a history of falls occurring when self transferring as follows: 1/17/21: 1:47 p.m.: Resident transferring self in bedroom when lost balance, falling onto shoulder and hitting head to floor. Taken to hospital with fracture of right shoulder. IDT met to discuss fall, Root cause analysis; continued impulsiveness related to Alzheimer Dementia, care conference held to discuss current status and the possibility of hospice. Was last toileted 15-20 minutes prior. Had a change in medication and PT orders, to be picked up in PT-evaluation and treat, Pharmacy review with adjustment in [MEDICATION(S)] sulfate (iron). 4/18/21: found on the floor in room next to the second bed, Resident calling for assistance, stated he was looking for something. x-ray of hip negative, no injury. Occupational and Physical Therapy evaluation, Pressure sensitive call light added 6/30/21: alarm sounding and resident found on the floor with no injury Resident was searching for book, kneeled at bedside looking for book. Care Plan updated: resident may kneel at bedside on mat. The surveyor reviewed R13's historical care plan to ensure changes were made per fall investigations, root cause analysis, and follow up by the facility. The surveyor found that all falls were related to poor safety awareness and impulsivity. On 07/22/21 at 10:26 a.m. Surveyor spoke with the Director of Nursing (DON)-B regarding R13's falls and the facility's expectation of staff supervision for R13 with toilet use. DON-B expressed R13's care plan for toilet use indicates he requires extensive assistance of 1 staff. This is due to the need for staff to stay with him while on the toilet. R13 is impulsive and has poor safety awareness, he has stood up and fallen when staff were not with him. R13 is high risk for falls. He has fallen in the past, including falls with major injuries, including a fracture. R13 requires extensive staff assistance with toilet use to provide him safe supervision and assistance to prevent him from falling. DON-B went on to say R13's care plan reads extensive assistance of 1 staff for toilet use due to his safety and care needs. Staff are expected to remain with him during toilet use to supervise and ensure he does not stand unassisted. Surveyor shared the incident noted above with DON-B. DON-B expressed she would expect staff to remain with R13 while he is on the toilet to ensure his safety, provide him needed assistance and to prevent him from falling, as stated in his care plan for toilet use.