Every finding on record at Shawano Health Services

Based on observation, staff interview, and record review, the facility did not ensure appropriate treatment to promote healing of a pressure injury was provided for 1 resident (R) (R6) of 1 sampled resident.R6 had a stage 2 pressure injury on the right heel which was present upon re-admission to the facility. During an observation of wound care, Registered Nurse (RN)-F used soiled scissors to cut a clean dressing that was applied to R6's right heel pressure injury. Findings include:The facility's Clean Dressing Change policy, revised 1/19/26, indicates: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross contamination.From 2/15/26 to 2/17/26, Surveyor reviewed R6's medical record. R6 had diagnoses including a stage 2 pressure injury on the right heel, diabetes, Alzheimer's disease, and venous insufficiency. R6's Minimum Data Set (MDS) assessment, dated 12/13/25, had a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicated R6's cognition was severely impaired.R6's medical record contained dressing change instructions (dated 2/3/26) for a stage 2 pressure injury on R6's right heel that indicated to cleanse the wound with antiseptic solution 0.25% moistened gauze, gently pat dry, cover with antibacterial foam dressing, cover with an ABD pad, wrap with Kerlix (gauze dressing), secure with tape, and change twice daily and as needed.On 2/16/26 at 9:32 AM, Surveyor observed RN-F provide wound care for R6's right heel. RN-F cut R6's soiled outer Kerlix dressing with scissors and set the soiled scissors outside of the clean field that contained R6's clean wound dressings. RN-F removed the soiled dressings and cleansed the wound. Without cleaning the scissors used to remove the soiled dressing, RN-F used the scissors to cut a clean antibacterial foam dressing to size, put the dressing over R6's wound, and completed wound care as ordered.On 2/16/26 at 9:48 AM, Surveyor interviewed RN-F who confirmed RN-F should have cleansed the scissors to prevent wound contamination prior to cuting the antibacterial foam dressing that was applied to the wound.On 2/16/26 at 1:29 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed RN-F should have cleansed the scissors between dirty and clean wound care procedures.

Based on observation, staff interview, and record review, the facility did not ensure 1 resident (R) (R5) of 3 sampled residents received appropriate care and services to prevent urinary tract infections (UTIs).The facility did not provide catheter care for R5 in a manner that decreased R5's risk for infection. Findings include:The facility's Catheter Care policy, revised 3/15/23, indicates: It is the policy of this facility to ensure residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use .Privacy/dignity bags will be available and catheter drainage bags should be covered or shielded at all times while in use .On 2/15/26, Surveyor reviewed R5's medical record. R5 had diagnoses including benign prostatic hyperplasia (BPH) with lower urinary tract symptoms, other obstructive and reflux uropathy, and personal history of malignant neoplasm of bladder. R5's Minimum Data Set (MDS) assessment, dated 11/13/25, had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated R5 had severe cognitive impairment. R5 had an activated healthcare decision maker.A care plan indicated R5 required an indwelling Foley catheter due to bladder cancer and BPH secondary to urinary obstruction. The care plan indicated R5's catheter collection bag should be in a dignity bag holder on R5's bed/wheelchair. The care plan also indicated R5 was at risk for infection due to an indwelling Foley catheter. The care plan contained an goal that R5 would be free from infection through the review date.R5's medical record indicated R5 was prescribed macrobid (an antibiotic) for five days for a UTI on 1/6/26.On 2/15/26 at 9:51 AM, Surveyor observed R5 asleep in a recliner. R5's catheter bag was hung from a Hoyer sling that was behind R5. Surveyor noted R5's catheter bag was in contact with the floor without a barrier or dignity bag. On 2/15/26 at 9:58 AM, Surveyor interviewed Registered Nurse (RN)-C who verified R5's catheter bag was in contact with the floor. RN-C indicated the catheter bag should be in a dignity bag and stated RN-C would ensure a dignity bag was provided and the bag was hung off of the floor.

Based on observation, staff and resident interview, and record review, the facility did not provide pharmaceutical services to meet the needs of 3 residents (R) (R2, R42, and R1) of 7 sampled residents.R2 received a 750 milligram (mg) calcium carbonate chewable tablet during the 3:00 PM medication pass on 2/15/26. R2 should have received a 500 mg calcium carbonate chewable tablet.R42's polyethylene glycol 3350 was left at the bedside on 2/16/26. R42 did not have a self-administration of medication assessment or a physician's order that indicated R42 could safely and accurately self-administer the medication. R1 had an order for ipratropium-albuterol inhalation solution 0.5-2.5 mg inhaled via nebulizer four times daily for chronic obstructive pulmonary disease (COPD). On 2/15/26, R1 administered the nebulizer independently. R1 did not have a self-administration of medication assessment or a physician's order that indicated R1 could safely and accurately self-administer the medication. Findings include: The facility's Medication Administration General Guidelines policy, dated January 2025, indicates: Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices, and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Medication Administration: 1. Medications are administered in accordance with the written orders of the prescriber .5. The person who prepares the dose for administration is the person who administers the dose .15. Residents are allowed to self-administer medication when specifically authorized by the prescriber, the nursing care center's Interdisciplinary Team (IDT) and in accordance with procedures for self-administration of medication and state regulations. 1. From 2/15/26 to 2/17/26, Surveyor reviewed R2's medical record. R2 had diagnoses including dementia, dysphagia, chronic obstructive pulmonary disease (COPD), heart failure, depression, anxiety, and gastroesophageal reflux (GERD) without esophagitis. R2's Minimum Data Set (MDS) assessment, dated 12/16/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R2 had intact cognition. R2 had a legal Guardian who assisted with decision making. R2's medical record contained an order for calcium carbonate 500 mg chewable tablet by mouth four times daily for GERD (started on 12/18/25). On 2/15/26 at 3:04 PM, Surveyor observed Registered Nurse (RN)-G put a 750 mg chewable calcium carbonate tablet in a medication cup to administer to R2. RN-G verified the medication was a 750 mg fruity chewable tablet. At approximately 3:05 PM, Surveyor observed RN-G administer the tablet to R2. On 2/16/26 at 1:25 PM, Surveyor interviewed Director of Nursing (DON)-B who verified R2 should have received a calcium carbonate 500 mg chewable tablet instead of a 750 mg chewable tablet. 2. From 2/15/26 to 2/17/26, Surveyor reviewed R42's medical record. R42 had diagnoses including progressive multiple sclerosis, paraplegia, hypertension, and depression. R42's MDS assessment, dated 2/9/26, had a BIMS score of 12 out of 15 which indicated R42 had moderately impaired cognition. R42 made R42's own medical decisions. R42's care plan, dated 2/9/26, did not indicate R42 could self-administer medication. R42's medical record did not contain an order or assessment for self-administration of medication. On 2/16/26 at 7:20 AM, Surveyor observed Licensed Practical Nurse (LPN)-H leave polyethylene glycol 3350 mixed with water in a cup at R42's bedside. LPN-H left R42's room and continued to administer medication to other residents. On 2/16/26 at 8:27 AM, Surveyor returned to R42's room and noted the cup of polyethylene glycol 3350 was empty and on R42's breakfast tray. On 2/16/26 at 8:31 AM, Surveyor interviewed LPN-H who stated LPN-H was not sure if R42's polyethylene glycol 3350 could be left at the bedside. On 2/16/26 at 1:26 PM, Surveyor interviewed DON-B who verified R42 did not have an order or assessment for self-administration of medication and polyethylene glycol should not have been left at the bedside. 3. On 2/15/26, Surveyor reviewed R1's medical record. R1 had diagnoses including COPD and chronic respiratory failure with hypoxia. R1's MDS assessment, dated 12/2/25, had a BIMS score of 15 out of 15 which indicated R1 had intact cognition. R1 was R1's own decision maker. A care plan indicated R1 had an activities of daily living (ADL) deficit and nursing staff should visually inspect R1's mouth after medication administration to ensure medications were swallowed. The care plan also indicated R1 received steroid therapy to treat congestive heart failure (CHF)/COPD exacerbation and was at risk for adverse effects. The care plan contained an intervention to administer steroid therapy per physician orders. R1's medical record contained an order for ipratropium-albuterol inhalation solution 0.5-2.5 mg inhaled orally via nebulizer four times daily for COPD. The order did not indicate R1 could self-administer the medication. R1's medical record did not contain a self-administration of medication assessment. On 2/15/26 at 9:31 AM, Surveyor observed R1 in a recliner administering a nebulizer treatment independently. There were no nursing staff in the room or in the hallway. On 2/15/26 at 10:03 AM, Surveyor interviewed R1 who stated staff set up the nebulizer, R1 administers the medication, and staff return after the treatment is completed. On 2/15/26, Surveyor requested a self-administration of medication order and assessment for R1 from Nursing Home Administrator (NHA)-A. On 2/15/26 at 5:44 PM, Surveyor received email from NHA-A that indicated the facility did not have a self-administration of medication order or assessment for R1 and all medication should be administered by nursing staff. On 2/16/26 at 1:27 PM, Surveyor interviewed DON-B who indicated in order to self-administer medication, R1 should have a self-administration of medication assessment that indicates R1 can safely and accurately self-administer medication. DON-B confirmed R1 did not have a self-administration of medication assessment and stated nursing staff should remain with R1 while the nebulizer is administered.

Based on observation, staff interview, and record review, the facility did not ensure physician-ordered diets and menus were followed to meet nutritional needs for 3 residents (R) (R22, R14, and R5) of 3 sampled residents.R22, R14 and R5 had orders for a pureed diet. Staff did not ensure the required serving size of pureed items were served to meet R22, R14, and R5's nutritional needs.Findings inlcude:The facility's (contracted company's) Therapeutic Diets policy, revised 9/2017, indicates: All residents have a diet order, including regular, therapeutic, and texture modification, that is prescribed by the attending physician, physician extender, or credentialed practitioner in accordance with applicable regulatory guidelines .Diets are prepared in accordance with the guidelines in the approved diet manual and the individualized plan of care .On 2/16/26, Surveyor reviewed R22's medical record. R22 had diagnoses including dementia and type 2 diabetes mellitus. R22's Minimum Data Set (MDS) assessment, dated 2/26/26, had a Brief Interview for Mental Status (BIMS) score of 3 out of 3 which indicated R22 had severely impaired cognition. R22 had a court-ordered Guardian for healthcare decisions.A care plan indicated R22 was at risk for nutritional status change related to altered mental status, type 2 diabetes, and obesity and required a mechanically-altered diet. The care plan indicated R22 had significant weight loss on Hospice care and had increased nutrient needs related to wound healing, including an open area on the right buttock and a blister on the right lateral foot. The care plan contained a goal that R22 would experience no significant weight changes x 30-180 days per MDS criteria. The care plan contained an intervention to provide diet as ordered.R22's medical record contained an order for a pureed diet.A nutritional assessment, dated 2/3/26, indicated R22 had an order for a mechanically-altered diet and had skin conditions, including an abrasion on the right elbow, a fluid-filled blister on the right lateral foot, and an open area on the right buttock.R22's total caloric daily need was 1400-1700 calories and total protein daily need was 69-83 grams. R22's average meal intake average was 51%-100%.On 2/16/26, Surveyor reviewed R14's medical record. R14 had diagnoses including Alzheimer's disease, type 2 diabetes mellitus, dysphagia, and unspecified severe protein-calorie malnutrition. R14's MDS assessment, dated 1/23/26, had a BIMS score of 0 out of 15 which indicated R14 had severely impaired cognition. R14 had an activated healthcare decision maker.A care plan indicated R14 was at risk for nutrition related to Alzheimer's disease, major depressive disorder, type 2 diabetes, and anemia and had a history of significant weight loss and a need for pureed-texture meals and honey-thickened liquids. The care plan contained goals that R14's skin would show signs/symptoms of healing by the review date and R14 would maintain weight as evidenced by no significant weight changes (>/= 5% in 30 days, >/= 7.5% in 90 days, or >/= 10% in 180 days). The care plan contained an intervention to provide diet as ordered. The care plan also indicated R14 was at risk for nutritional status change related to Alzheimer's/dementia, dysphagia, hypertension, and Hospice care and indicated R14 had inadequate oral intake related to poor appetite and significant weight loss in the past month.R14's medical record contained an order for a pureed diet.A nutritional assessment, dated 1/20/26, indicated R14 had an order for a mechanically-altered diet and weight maintenance was beneficial. R14 had skin conditions, including moisture-associated skin damage (MASD) on the right buttock. R14's total caloric daily need was 1300-1600 calories and total protein daily need was 65-78 grams. R14's meal intake average was 51%-100%.On 2/16/26, Surveyor reviewed R5's medical record. R5 had diagnoses including Alzheimer's disease, dementia, and dysphagia. R5's MDS assessment, dated 11/29/25, had a BIMS score of 0 out of 15 which indicated R5 had severely impaired cognition. R5 had an activated healthcare decision maker.A care plan indicated weight management was beneficial related to Hospice care and R5 was at risk for nutritional status change related to Alzheimer's/dementia, dysphagia, hypertension, and Hospice care. The care plan indicated R5 had an inability to manage self-care related to dementia and Alzheimer's disease and inadequate oral intake related to poor appetite as evidenced by significant weight loss in the last month (dated 1/6/26). The care plan contained an intervention to provide diet as ordered.R5's medical record contained an order for a pureed diet.A nutritional assessment, dated 11/18/25, indicated R5 had an order for a mechanically-altered diet. R5's total caloric daily need was 1400-1700 calories and total daily protein need was 69-83 grams. R5's average meal intake was 25-100%.On 2/16/26 at 7:22 AM, Surveyor observed [NAME] (CK)-E serve breakfast from the steam table. Surveyor observed CK-E serve R22, R14 and R5 pureed egg bake with a 3 ounce (oz) scoop. The menu indicated the serving size for pureed egg bake was 4 oz. During an observation that began at 11:27 AM on 2/16/26, Surveyor observed CK-E prepare pureed food for lunch. CK-E put three 4 oz scoops of ravioli in a food processor to puree. CK-E indicated CK-E takes three 4 oz scoops of food for each resident on a pureed diet and uses the scoop to put an appropriate amount on each resident's plate. CK-E then portioned ravioli on plates for R22, R14, and R5 with a 4 oz ladle. The menu indicated the serving size for ravioli was 6 oz.On 2/16/26 at 1:00 PM, Surveyor interviewed Dietary Manager (DM)-D who confirmed CK-E served lunch to R22, R14, and R5 with the wrong size scoop and provided R22, R14, and R5 with the wrong portion of ravioli.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect more than 4 of the 42 residents residing in the facility. (One resident received nutrition via tube feeding.) During multiple observations, Dietary Manager (DM)-C did not wear a beard net in the kitchen. Findings include: The facility's dining services' Staff Attire policy, revised 10/2023, indicates: All employees wear approved attire for the performance of their duties .1. All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained . During a continuous kitchen observation that began at 9:12 AM on 2/4/25, Surveyor observed DM-C in the kitchen assisting with kitchen prep. DM-C's beard was not covered with a beard net. During a continuous observation of lunch service that began at 11:43 AM on 2/4/25, Surveyor observed DM-C assist with lunch trays, weigh meat loaf prior to service at the steam table, and cut meatloaf into serving sizes without wearing a beard net. Surveyor interviewed DM-C who indicated the Food Code does not have a regulation that indicates beard nets need to be worn. DM-C was not sure if the facility had a policy regarding beard nets but stated DM-C would look and obtain the policy for Surveyor if possible. On 2/4/25 at 1:35 PM, Surveyor entered the kitchen and observed DM-C cooking food on the stove without a beard net. DM-C indicated DM-C found the facility's policy on hair restraints. Surveyor and DM-C reviewed the policy in DM-C's office. DM-C confirmed the policy indicated beard hair nets were required and showed Surveyor that DM-C had a bag full of beard nets. On 2/5/25 at 10:17 AM, Surveyor entered the kitchen with DM-C who was not wearing a beard net and did not obtain or apply a beard net. Surveyor observed DM-C speak with kitchen staff at the stove. Throughout the observation, Surveyor did not observe DM-C restrain DM-C's beard with a beard net.

Based on staff and resident interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 resident (R) (R1) of 4 sampled residents. On 10/19/24, the facility discovered missing doses of narcotic medication for R1 which raised concerns of potential drug diversion and possible exploitation. The facility did not report the suspected crime to the State Agency (SA) or local law enforcement. Findings include: The facility's Reporting Abuse to Facility Management policy, with a revision date of December 2013, indicates: It is the responsibility of our employees, facility consultants, attending physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management .1. Our facility does not condone resident abuse by anyone, including staff members, physicians, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends, or other individuals. 2. To help with recognition of incidents of abuse, the following definitions of abuse are provided: .j. Exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion .6. Any staff member or person affiliated with this facility who has witnessed or who believes that a resident has been a victim of mistreatment, abuse, neglect, or any other criminal offense shall immediately report, or cause a report to be made of, the mistreatment or offense .7. Staff members and persons affiliated with this facility shall not knowingly: a. Attempt, with or without threats or promises of benefit, to induce another to fail to report an incident of mistreatment or other offense; b. Fail to report an incident of mistreatment or other offense. The facility's Report Reasonable Suspicion of a Crime policy, with an implementation date of 9/1/22, indicates: It is the policy of this center, pursuant to Section 1150B of the Social Security Act, to report any reasonable suspicion of a crime committed against a resident of this facility .1. The facility will coordinate with state and local law enforcement entities to determine what actions are considered crimes in the facility's political subdivision and will work with law enforcement to determine which crimes are reported. Examples of situations that would be considered crimes in all subdivisions include, but are not limited, to: .g. Drug diversion for personal use or gain .i. Certain cases of abuse, neglect, and exploitation .3. Any covered individual can report any reasonable suspicion of a crime without fear of retaliation. On 11/4/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including after-care from surgical amputation of right lower leg below knee, cognitive communication deficit, and diabetes mellitus. R1's Minimum Data Set (MDS) assessment, dated 10/21/24, stated R1's Brief Interview for Mental Status (BIMS) score was 15 out of 15 which indicated R1 was not cognitively impaired. R1's medical record indicated R1 was responsible for R1's healthcare decisions. R1's medical record contained notes, dated 10/19/24, that indicated R1 was seen at a clinic for a surgical follow-up visit on 10/18/24. A prescription for 60 tablets of hydrocodone/acetaminophen (also known as Norco) 7.5 mg/325 mg (milligrams) (a controlled substance narcotic used to treat moderate to severe pain) was sent to a local pharmacy. The notes indicated the facility did not have any Norco to administer to R1 and R1's spouse picked up the prescription from the pharmacy. R1 told staff that R1 was unable to get in touch with R1's spouse because R1's spouse's phone was accidentally left with R1. R1 refused staff's offer to call law enforcement to obtain the medication from R1's spouse and indicated R1's adult child would try to get in touch with R1's spouse. The notes indicated R1's spouse went to the facility on [DATE] at 11:45 AM. R1 and facility staff informed R1's spouse the medication needed to be brought to the facility for nursing staff to lock up and administer to R1 as needed. R1's spouse expressed understanding. On the afternoon of 10/19/24, R1 told a Certified Nursing Assistant (CNA) to give a bag with a local pharmacy emblem to the nurse. The bag contained two bottles of medication, one of which was a bottle of Norco 7.5 mg/325 mg with the label partially ripped off. Two nurses counted 14 pills in the bottle. When a nurse asked R1 about the other 46 pills, R1 indicated R1 owed them to other people. The nurse immediately reported the information to the Director of Nursing (DON). On 11/4/24 at 9:31 AM, Surveyor interviewed R1 who indicated R1 did not have any stored medication in R1's room. R1 indicated the physician would no longer prescribe narcotic pain medication to R1 since R1 got it all screwed up. R1 indicated at R1's clinic appointment, R1 had Norco refilled at a local pharmacy like R1 did when R1 was at home. R1 would not provide any further details. R1 was satisfied with pain management provided by the facility and had no care concerns. On 11/4/24 at 10:45 AM, Surveyor observed law enforcement at the facility for an event with residents. Surveyor interviewed Police Officer (PO)-D who indicated the facility should report to law enforcement any crime committed against a resident. PO-D verified if a resident was suspected of selling their narcotic medication, it was considered a reportable crime. On 11/4/24 at 11:11 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A and DON-B. NHA-A indicated the facility was never in possession of the medication. DON-B indicated R1 had an appointment and the physician prescribed 60 Norco tablets. The facility thought the order was sent from the clinic to the facility's pharmacy. DON-B indicated R1 called the clinic after the appointment and requested the order be sent to a different pharmacy for R1's spouse to pick up. DON-B indicated when the facility became aware, staff were unable to get in touch with R1's spouse. DON-B indicated R1's spouse came to the facility and provided 14 Norco tablets. When R1's spouse was asked about the rest of the tablets, R1's spouse did not answer. DON-B indicated R1's physician then discontinued R1's narcotic orders. DON-B again indicated the facility did not have possession of the missing narcotic medication and verified staff were mandatory reporters of suspected crime. NHA-A indicated corporate management informed NHA-A the situation was not reportable to the SA or local law enforcement since the facility never had possession of the missing narcotics. When asked what the facility suspected happened to the missing narcotics, NHA-A indicated it was thought that R1's spouse kept the medication. Following a discussion of R1's nursing note on 10/19/24 that indicated R1 stated R1 owed the missing pills to everyone else, NHA-A and DON-B indicated they were unaware of the wording of the note. When asked what NHA-A and DON-B would have done if they were aware of the wording, NHA-A indicated they would have questioned R1 more as to what R1 meant by that. On 11/4/24 at 12:04 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-E via phone. LPN-E verified LPN-E worked the 10/19/24 AM shift on R1's unit and documented the above notes. LPN-E indicated LPN-E placed a note in the paperwork sent to the clinic on the day of R1's surgical follow-up appointment to let the physician know R1 was out of Norco and needed a prescription sent to the facility's pharmacy. When LPN-E reported to work on the morning of 10/19/24, LPN-E asked the previous shift nurse if R1's Norco had arrived. The previous shift nurse indicated it had not. LPN-E reviewed R1's clinic notes which indicated 60 tablets of Norco were prescribed, but the prescription had gone to a local pharmacy instead of the facility's pharmacy. LPN-E recalled that before R1 returned from the appointment, the facility received a call from R1's physician group and instructed staff to give the surgical clinic phone number to R1 because R1 had called the physician group by mistake and wanted the phone number for the surgical clinic. LPN-E indicated LPN-E assumed R1 had intercepted the prescription and changed the pharmacy because LPN-E did not know how else the prescription was sent to the other pharmacy. On 10/19/24, R1 told LPN-E that R1's spouse was supposed to pick up the medication from the pharmacy and stated, (R1's spouse) is a user and I can guarantee there won't be 60 of them when (R1's spouse) brings them. LPN-E immediately reported the incident to DON-B. When asked if LPN-E informed DON-B of the specific wording used by R1, LPN-E indicated yes. When asked if the facility asked LPN-E to provide a written statement, LPN-E indicated LPN-E provided a written statement. LPN-E indicated R1 stated R1's spouse left their phone at the facility and R1's adult child found R1's spouse asleep in a car. LPN-E indicated R1's spouse came to the facility and gave LPN-E a funny look when LPN-E asked for the Norco. LPN-E was unsure when R1's spouse left the facility and indicated a person came to the desk a short time later and asked for a room number on a different unit. The person then returned to the desk and told LPN-E they were looking for R1 and were given the wrong room number. LPN-E directed the person to R1's room where they stayed for approximately 4 minutes and then left the facility. A CNA gave LPN-E a bag that contained a bottle of Norco from R1's room. LPN-E and another nurse counted 14 tablets in the bottle. When LPN-E asked R1 about the missing medication, R1 indicated R1 owed them to people. When LPN-E asked if R1 owed pills to the person who had just visited, R1 indicated yes. LPN-E then contacted DON-B. LPN-E indicated when R1's covering physician and surgical physician were notified of what happened, R1's narcotic medication was discontinued. LPN-E indicated staff monitored R1 for indications of pain, however, R1 had not exhibited signs of pain. On 11/4/24 at 12:43 PM, Surveyor interviewed DON-B who provided Surveyor with copies of written staff statements. DON-B indicated the facility did not have any other investigative documentation. On 11/4/24, Surveyor reviewed a typed and hand-signed statement from LPN-E, dated 10/19/24, that stated, . There were 14 pills in the bottle. Writer went and questioned the resident. Writer asked 'where did the other 46 pills go?' Resident responded (R1) 'owed them to everyone else'. Writer asked resident is that what that (person) was doing in your room? Resident responded 'yes'. I asked how many pills (R1) gave the (person) and (R1) replied 8. Writer asked what about all the others? Resident stated they went to everyone else (R1) owed . On 11/4/24 at 1:31 PM, Surveyor interviewed NHA-A. Following a discussion that the facility should have notified law enforcement of the suspected crimes of drug diversion and possible exploitation, NHA-A indicated NHA-A was instructed by corporate staff not to.

Based on observation, staff and resident interview, and record review, the facility did not ensure accurate and safe administration of pharmaceuticals for 3 residents (R) (R2, R1, and R3) of 4 sampled residents. On 11/4/24, multiple oral medications and an inhaler were left unattended by staff in R2's room. R2 was not assessed as able to self-administer medication. On 11/4/24, R1 indicated nurses sometimes left 2 Tylenol (used to treat mild to moderate pain) at R1's bedside for R1 to take if R1 had pain during the night. R1 was not assessed as able to self-administer medication. On 11/4/24, medication was left unattended by staff in R3's room for R3 to self-administer. R3 was not assessed as able to self-administer medication. Findings include: The facility's Medication Administration policy, dated 1/23, indicates: To administer oral medications in an organized, accurate, and safe manner .10. Administer medication and remain with the resident while medication is swallowed. Do not leave medication in a resident's room without orders to do so along with documentation of self-administration. Use caution with residents who have difficulty swallowing. 1. On 11/4/24, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses including pneumonia and diabetes mellitus. R2's Minimum Data Set (MDS) assessment, dated 11/4/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R2 had no cognitive impairment. R2's medical record indicated R2 was responsible for R2's healthcare decisions. On 11/4/24 at 9:19 AM, Surveyor observed R2 (through an open door from the hallway) sitting upright in a recliner, tying R2's shoes, and talking to a housekeeper who was cleaning R2's room. Surveyor observed an inhaler and medication cup with several oral medications on a table near R2. There was no food on the table. On 11/4/24 at 9:20 AM, Surveyor observed R2 put some of the medications in R2's hand and swallow the pills one by one while taking sips of liquid from a cup with a straw. Surveyor noted the medication cup still contained several medications. On 11/4/24 at 9:25 AM, Surveyor interviewed R2 who indicated a nurse left the medications a short time ago and stated, I have to work at it. There are so many. R2 indicated the inhaler was the same type of inhaler R2 used at home and was left in R2's room at all times. R2 indicated the nurses only left AM medications with R2 to take unattended. R2 indicated R2 received less medication at other times of the day and took those medications in front of the nurse. R2 did not have a roommate. A Self-Administration of Medication Approval form that was signed and dated by R2 on 10/31/24 indicated R2 wished to have medication administered to R2. On 11/4/24 at 9:39 AM, Surveyor observed R2 put more medications in R2's hand and swallow the pills one by one while taking sips of liquid from a cup with a straw. Surveyor noted the medication cup still contained medication. Surveyor reviewed R2's November 2024 Medication Administration Record (MAR) which indicated R2's AM medications on 11/4/24 included the following: ~ Aspirin (used to prevent blood clots) oral tablet Give 81 milligrams (mg) once daily .take with food ~ Calcium plus Vitamin D (used as a supplement) 600-200 mg 1 tablet once daily ~ Fexofenadine HCl (hydrochloride) (used to treat seasonal allergies) oral tablet Give 180 mg once daily ~ Metoprolol Succinate ER (extended release) (used to treat high blood pressure) oral tablet 25 mg Give 1 tablet by mouth once daily ~ Multivitamin with Minerals (used as a supplement) Give 1 tablet once daily ~ Omega-3 (used to treat high cholesterol) oral capsule Give 3000 mg once daily ~ Polyethylene Glycol 3350 (to promote bowel movement) powder Give 17 grams by mouth once daily .mix with 6-8 ounces (oz) of fluid ~ Spironolactone (used to treat high blood pressure) oral tablet Give 25 mg once daily ~ Vitamin C (used as a supplement) oral tablet Give 500 mg once daily ~ Vitamin D (used as a supplement) oral tablet Give 2000 units once daily ~ Vitamin E (used as a supplement) oral capsule Give 180 mg once daily ~ Acidophilus (used to prevent loose stools) oral capsule Give 1 capsule two times daily ~ Cefuroxime Axetil (used to treat infection) oral tablet 500 mg Give 1 tablet two times daily ~ Fluticasone-Salmeterol (used to treat asthma) Inhalation Aerosol Powder Breath Activated 250-50 mcg/act (micrograms per activation) 1 inhalation two times daily On 11/4/24 at 10:27 AM, Surveyor noted the medication cup and inhaler were no longer on R2's bedside table and observed R2 sitting on the edge of the bed with the bedside table close by. On 11/4/24 at 10:55 AM, Surveyor interviewed Registered Nurse (RN)-C who indicated if a resident was assessed as able to self-administer medication, the medication would be locked in the resident's room for the resident to self-administer. RN-C indicated the facility did not have any residents who were assessed as able to self-administer medication. Following a discussion of the above observations, RN-C indicated R2 told RN-C to leave the room when RN-C delivered R2's AM medication. RN-C verified RN-C should not have left the medication with R2. RN-C indicated RN-C usually worked a different unit and did not know whether or not R2 could self-administer medication. 2. On 11/4/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including after-care from surgical amputation of right lower leg below knee, cognitive communication deficit, and diabetes mellitus. R1's MDS assessment, dated 10/21/24, stated R1's BIMS score was 15 out of 15 which indicated R1 had no cognitive impairment. R1's medical record indicated R1 was responsible for R1's healthcare decisions. On 11/4/24 at 9:31 AM, Surveyor interviewed R1 in R1's room. Surveyor did not observe medication in the room. R1 indicated R1 did not store medication in the room but stated, Sometimes the nurse will give me two Tylenol and leave them in my room in case I need them at night. R1 indicated it depended on which nurse was working. R1 did not have a roommate. Surveyor reviewed R1's November 2024 MAR which included a physician order for acetaminophen (Tylenol) 325 mg Give 2 tablets every 4 hours as needed (PRN) for pain/fever. The MAR indicated R1 received doses of PRN Tylenol on 11/1/24 at 7:05 AM, on 11/2/24 at 11:09 AM and 8:00 PM, and on 11/3/24 at 8:03 AM and 8:35 PM. All doses were documented as effective. Surveyor reviewed two Self-Administration of Medication Approval forms in R1's medical record, signed and dated by R1 on 9/19/24 and 10/14/24, that indicated R1 wished to have medication administered to R1. On 11/4/24 at 11:11 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B. NHA-A indicated residents were asked to sign a form upon admission regarding whether or not they wished to self-administer medication. NHA-A indicated if a resident wanted to self-administer an inhaler, the resident would first be assessed by staff for the capability to self-administer the inhaler. NHA-A indicated the facility provided a locked box at the bedside of any resident able who self-administered medication and indicated there were no residents who were assessed as able to self-administer medication. Following a discussion of the above observations and interviews, NHA-A and DON-B indicated they were unaware staff left medication at the bedside and verified the practice was against the facility's policy. 51043 3. On 11/4/24, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease (COPD), chronic pain, and arthropathic pain. R3's MDS assessment, dated 10/21/24, had a BIMS score of 15 out of 15 which indicated R3 had no cognitive impairment. On 11/4/24 at 9:18 AM, Surveyor observed 2 capsules in a medication cup on R3's beside table which were later identified by R3 as Tylenol (used for pain). R3 indicated staff gave R3 the capsules but R3 fell asleep and did not take them. R3 had a roommate (R4). R3's November 2024 MAR indicated R3 was administered PRN Tylenol at 4:28 AM. On 11/4/24 at 10:40 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-F who provided a Self-Administration of Medication Approval form from R3's medical record that was signed and dated by R3 on 4/28/24. The form indicated R3 wished to have R3's medications administered to R3. LPN-F indicated LPN-F did not see medication at R3's bedside, but stated, I know the night shift nurse said she gave it (referring to Tylenol) around 4:30 AM. On 11/4/24, Surveyor reviewed R4's medical record. R4 had diagnoses including Parkinson's disease, cognitive communication deficit, and dysphagia (difficulty or discomfort in swallowing). R4's MDS assessment, dated 10/21/24, had a BIMS score of 14 out of 15 which indicated R4 had no cognitive impairment. On 11/4/24, Surveyor interviewed RN-C. When asked about the Tylenol at R3's bedside, RN-C indicated R3 stated R3 was going to take the Tylenol, however, RN-C didn't see R3 take it. RN-C indicated the facility's medication administration process included making sure residents took their medication. On 11/4/24 at 12:01 PM, Surveyor interviewed DON-B. When asked if any residents self-administered medication, DON-B indicated there were no residents who self-administered medication. When asked DON-B's expectations regarding medication administration, DON-B indicated DON-B expected staff to stay with residents to ensure they took the meds, didn't drop the meds, and swallowed the meds safely.

Based on staff interview and record review, the facility did not ensure the appropriate parameters for administering a bowel medication were met and did not document bowel movements or abnormal blood pressures for 1 Resident (R) (R1) of 14 sampled residents. R1 was given Miralax (a laxative used to treat constipation) on 8/9/24 after two documented episodes of diarrhea. In addition, R1 had episodes of diarrhea and low blood pressure that were not documented in R1's medical record. Findings include: On 8/28/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses of post operative care for kidney/ureter/bladder removal, kidney disease, type 2 diabetes, hypertension, and chroic obstructive pulmonary disease (COPD). R1's most recent Minimum Data Set (MDS) assessment, dated 8/20/24, stated R1's Brief Interview for Mental Status (BIMS) score was 15 out of 15 which indicated R1 had intact cognition. R1 was R1's own decision maker and discharged home on 8/24/24. Surveyor reviewed R1's progress notes, hospital notes, Medication Administration Record (MAR), and vital signs. R1's medical record indicated R1 was hospitalized from 8/1/24 to 8/8/24 for removal of a kidney and part of the bladder and ureter. R1 developed an ileus (inability of the intestine (bowel) to contract normally and move waste out of the body) while in the hospital; however, R1's bowels were functioning normally when R1 was discharged on [DATE]. R1 was admitted to the facility with an order for Miralax 17 grams by mouth as needed (PRN) to promote bowel movements. On 8/9/24, Certified Nursing Assistant (CNA) charting indicated R1 experienced two episodes of watery diarrhea at approximately 1:15 AM and 3:30 AM. On 8/9/24 at 1:50 PM, Licensed Practical Nurse (LPN)-C administered PRN Miralax and noted it was effective. On 8/9/24 at 4:08 PM, R1 was sent to the emergency room (ER) and admitted to the hospital for an upper gastrointestinal (GI) bleed. On 8/29/24 at 11:35 AM, Surveyor interviewed CNA-E regarding R1's change in condition on 8/9/24. CNA-D stated CNA-D went to see R1 before breakfast because R1 was a new resident. CNA-D assisted R1 with toileting and R1 had a bowel movement. CNA-E noted R1 was pale, checked R1's blood pressure which was in the 80's over 60's, and notified LPN-C. CNA-D stated R1 ate approximately 50% of breakfast and lunch and had another episode of low blood pressure before lunch. CNA-D verified the episodes of low blood pressure were not documented in R1's medical record. On 8/29/24 at 1:51 PM, Surveyor interviewed LPN-C regarding R1's change in condition. LPN-C stated LPN-C was not told in report that R1 had diarrhea/dark stools and did not recall being told of any concerns by CNA-D during the AM shift. LPN-C documented a Daily Skilled note at approximately 2:00 PM on 8/9/24 that indicated R1's vital signs were within normal limits. LPN-C stated LPN-C gave R1 Miralax at approximately 2:00 PM because R1 requested it. LPN-C did not check R1's bowel charting prior to administering the Miralax and stated LPN-C was under the impression from R1 and R1's family that R1 did not have a bowel movement since 8/1/24. On 8/29/24 at 2:16 PM, Surveyor interviewed Registered Nurse (RN)-E regarding R1's change in condition. RN-E stated during shift change on 8/9/24 at approximately 2:30 PM, R1's family member approached the nurses' station and reported concerns with R1's stool. RN-E assessed R1 and noted R1's brief contained a large amount of dark/foul smelling stool. RN-E asked a CNA to obtain a set of vital signs and noted R1's blood pressure was 80/65 mm Hg (millimeters of mercury). RN-E updated Nurse Practitioner (NP)-F and got an order to send R1 to the ER. On 8/29/24 at 2:35 PM, Surveyor interviewed Director of Nursing (DON)-B regarding R1's change in condition. DON-B verified R1's low blood pressures and dark/tarry/bloody stools required an immediate update to the Medical Doctor (MD) and should have been documented in R1's medical record. DON-B stated if a resident had diarrhea/loose stools, DON-B expected staff to hold bowel medications such as Miralax. On 8/29/24 at 2:49 PM, Surveyor interviewed R1 who stated R1 did not request Miralax on 8/9/24 because R1 did not need it. R1 verified R1 had dark/loose stools at the hospital and stated the dark/loose stools got worse when R1 was admitted to the facility. On 8/29/24 at 4:05 PM, Surveyor interviewed NP-F regarding R1's change in condition. NP-F stated NP-F was first notified of R1's low blood pressures and dark/loose stools just before 4:00 PM on 8/9/24. NP-F stated if NP-F had been notified earlier in the day (at approximately 8:00 AM), NP-F would have ordered lab work to be done at the facility. NP-F agreed that R1 may have been sent to the ER earlier, but indicated R1's outcome would have been the same. NP-F confirmed laxative medications should not be given if a resident is having loose stools due to the risk of worsening diarrhea and/or dehydration.

Based on staff interview and record review, the facility did not ensure 1 Resident (R) (R3) of 2 residents who had a Guardian received services to ensure court-ordered protective placement was obtained. R3 did not have court-ordered protective placement in the facility since admission. Findings include: On 12/18/23, Surveyor reviewed R3's medical record. R3 resided in the facility for multiple years with diagnoses including traumatic subdural hemorrhage, right sided hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) of right dominant side, and mixed receptive-expressive language disorder. R3's most recent Minimum Data Set (MDS) assessment contained a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R3 had severe cognitive impairment. R3's medical record included a court order appointing guardianship of R3 from 2007. R3's medical record did not include a court order for protective placement in the facility. On 12/19/23 at 8:16 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified R3 had a Guardian, but did not have protective placement in the facility. On 12/19/23 at 10:11 AM, Surveyor interviewed Social Services Designee (SSD)-D who verified R3 did not have protective placement and stated SSD-D's understanding was that if guardianship was established prior to admission, a resident did not have to have protective placement in the facility.

Based on staff interview and record review, the facility did not ensure a physician was notified of a change in condition for 1 Resident (R) (R93) of 5 sampled residents. R93 had an order to notify the physician if R93's blood sugar level was less than 70 mg/dL (milligrams per deciliter) or greater than 400 mg/dL. The physician was not notified on 12/19/23 when R93's blood sugar level was 479 mg/dL. Findings include: The facility's Diabetes-Clinical Protocol Policy indicates: 3. The physician will order desired parameters for monitoring and reporting information related to diabetes or blood sugar management .A. The staff will incorporate such parameters into the Medication Administration Record and care plan .4. The staff will identify and report complications such as .hyper/hypoglycemia. On 12/20/23, Surveyor reviewed R93's medical record. R93 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus type 2 with hyperglycemia (high blood sugar), peripheral vascular disease (PVD), and right below-knee amputation. R93's Minimum Data Set (MDS) assessment, dated 12/18/23, contained a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated R93 had moderate cognitive impairment. R93's medical record contained the following order, dated 12/18/23: ~Insulin Glargine Subcutaneous Solution Pen-Injector 100 UNIT/ML (milliliter) Inject 20 units subcutaneously at bedtime for diabetes mellitus type 2 and blood glucose monitoring at bedtime as well as - Call MD if blood sugar is less than 70 (mg/dL) or greater than 400 (mg/dL). Surveyor noted R93's blood sugar level was 479 mg/dL on 12/19/23 at 7:32 PM. R93's medical record did not indicate the physician was notified. On 12/20/23 at 2:32 PM, Surveyor interviewed Director of Nursing (DON)-B who verified R93's medical record did not indicate the physician was notified when R93's blood sugar level was greater than 400 mg/dL. DON-B verified the physician should have been notified.

Based on staff interview and record review, the facility did not ensure a complete baseline care plan was developed or provided within 48 hours of admission for 2 Residents (R) (R20 and R93) of 2 sampled residents. R20's baseline care plan was not complete or provided to R20 within 48 hours of admission. R93's baseline care plan was not complete or provided to R93 within 48 hours of admission. Findings include: 1. On 12/20/23, Surveyor reviewed R20's medical record. R20 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, retention of urine, sensorineural hearing loss bilateral, type 2 diabetes mellitus with other diabetic kidney complication, unspecified severe protein-calorie malnutrition, moderate persistent asthma uncomplicated, pain in right knee, anxiety disorder, obstructive sleep apnea, nonrheumatic pulmonary valve disorder, essential hypertension, gastro-esophogeal reflux disease (GERD), other abnormalities of gait and mobility, and cognitive communication deficit. R20's most recent Minimum Data Set (MDS) assessment contained a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R20 had moderately impaired cognition. R20 had an activated Power of Attorney for Healthcare (POAHC). R20's medical record contained a Baseline Care Plan Summary, dated 11/20/23. The document included the following information: ~This is a written summary of your admission baseline care plan developed on 11/20/23. This temporary care plan is based on your needs, preferences, goals, physician orders and services/treatments as deemed appropriate. It will be used until your overall assessment is completed and a comprehensive care plan is developed. This facility will notify you in writing of any changes to this baseline care plan. Your Initial Goals: (Increase) independence level Your Initial Discharge Plan: TBD (to be determined) - (named facility) if possible Your Code Status: DNR (do not resuscitate) Diet Order: Reg(ular)/thin Current Medications: See attached (medication list attached) Therapy: Physical Therapy, Occupational Therapy, Speech Therapy 5 times per week provided by therapy and restorative program daily by nursing. Personal Care: Bath/shower, skin care, brushing teeth/dentures, shaving, hair care, dressing/undressing, walking, bathroom needs, eating, exercise, moving in chair/bed all daily provided by nursing. Acknowledgement of Receipt: I acknowledge that I have received this summary of my baseline care plan and my care plan has been explained to me. I understand that I may ask question at any time and request changes as I feel are necessary. Resident Representative spoke via phone and signed by facility representative on 11/20/23 at 3:00 PM, signed by Resident Representative on 11/27/23 at 1:42 PM. On 12/20/23 at 3:23 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-C who stated the admitting nurse conducts the newly admitted resident's initial assessment, enters orders, and has access to all records and verbal reports from the discharging facility so the overall medical record is accessible to staff needed to provide care to the resident. On 12/20/23 at 3:28 PM, Surveyor interviewed Director of Nursing (DON)-B who stated the document titled Baseline Care Plan Summary is not used as the baseline care plan because the facility uses all other aspects of the resident's medical record, including daily skilled assessments, the discharge summary, the resident's history and physical, nurse-to-nurse report to inform staff of a resident's immediate care needs upon admission to the facility, and nurse shift-to-shift reports to care for residents within the first forty-eight hours. DON-B stated the nurses do not refer to the Baseline Care Plan Summary. 45943 2. On 12/20/23, Surveyor reviewed R93's medical record. R93 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus type 2 with hyperglycemia (high blood sugar), peripheral vascular disease (PVD), and right below-knee amputation. R93's MDS assessment, dated 12/18/23, contained a BIMS score of 8 out of 15 which indicated R93 had moderate cognitive impairment. R93 made R93's own healthcare decisions. R93's medical record contained a Baseline Care Plan Summary, dated 12/18/23, which indicated: ~This is a written summary of your admission baseline care plan developed on 12/18/23. This temporary care plan is based on your needs, preferences, goals, physician orders and services/treatments as deemed appropriate. It will be used until your overall assessment is completed and a comprehensive care plan is developed. The facility will notify you in writing of any changes to this baseline care plan. The document also included R93's initial goals, initial discharge plan, code status, diet order, current medications, therapy, and personal care. The baseline care plan was signed by R93 and the facility's representative on 12/18/23 at 1:30 PM. On 12/20/23 at 3:10 PM, Surveyor interviewed DON-B who indicated Social Services Designee (SSD)-D completes the 72-hour meeting and baseline care plan in collaboration with therapy and nursing staff. SSD-D indicated the baseline care plan is completed ahead of time and signed by the resident in 72 hours. On 12/20/23 at 3:16 PM, Surveyor interviewed SSD-D who verified R93's baseline care plan was completed on 12/18/23 (Monday). SSD-D indicated since R93 was admitted to the facility on [DATE] (Friday), the order summary and therapy evaluations would not have been completed that day. SSD-D indicated it is difficult to complete the baseline care plan within 48 hours if a resident is admitted on Friday or over the weekend.

Based on observation, staff interview, and record review, the facility did not establish and maintain an infection control program designed to prevent the development and transmission of disease and infection for 2 Residents (R) (R15 and R25) of 3 residents observed receiving medication. Staff did not appropriately cleanse hands before preparing and administering medication to R15 and R25. Findings include: The facility's Hand Hygiene policy, dated 11/2/22, indicates: 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. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached Hand Hygiene Table. The Hand Hygiene Table states: Before preparing or handling medications. On 12/19/23 at 8:45 AM, Surveyor observed Registered Nurse (RN)-E prepare medication for R15. Surveyor did not observe RN-E perform hand hygiene prior to preparing or administering R15's medication. When RN-E returned to the medication cart, RN-E applied hand sanitizer, then was called to the desk for a phone call. When RN-E returned to the medication cart, RN-E did not perform hand hygiene before preparing and administering R25's medication. Immediately following the observation, Surveyor interviewed RN-E who stated the facility's hand hygiene policy is to perform hand hygiene before and after each resident's medication. When asked if RN-E performed hand hygiene prior to preparing and after administering R15 and R25's medication, RN-E replied, I thought I did, but if you say I didn't, I probably didn't. On 12/20/23 at 1:05 PM, Surveyor interviewed Director of Nursing (DON)-B who verified RN -E should have performed hand hygiene prior to preparing medication.

Based on observation and interview, the facility did not ensure resident food items were stored in a safe and sanitary manner. This had the potential to affect 6 residents (R30, R19, R21, R4, R44, R143). 19 Resident items located in the dining room refrigerator were not labeled properly (with a date and name), covered or sealed, and/or were expired. Findings: Facility Policy titled, Food Brought by Family / Visitors indicates the following: 6. Perishable foods will be stored in re-sealable containers with tightly fitting lids in the refrigerator. Containers will be labeled with the resident's name, the item, and the use by date. 7. The nursing staff is responsible for discarding perishable foods on or before the use by date. 8. The nursing staff and/or food service staff must discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates.). On [DATE] at 8:48 AM as part of the initial kitchen tour, Surveyor reviewed the resident refrigerator in the back of the dining room. This refrigerator was noted to be locked and nursing staff had the keys to unlock. Account Manager (AM-C) indicated the refrigerator is handled by nursing staff and items in the refrigerator would need to be labeled, covered, and tossed after 3 days. On [DATE] at 8:45 AM, when Surveyor began inspecting the items located inside of the refrigerator, the following items were noted to be out of compliance with facility policy and what AM-C: ~1 container of grapes was uncovered and did not contain a name or date. ~1 snack size Ziploc bag of sliced sausage sliced was unsealed and did not contain a name or date. ~1 resealable container of red sauce did not contain a date but was labeled with R30's name. ~,d+[DATE] of a sandwich in a zip loc bag did not contain a date but was labeled with R143's name. ~1 - 15.9 oz carrot cake dated 9.11.21 with R30's name. ~1 container of Heinz Real Mayonnaise that did not contain mayonnaise. The container had a Red Sauce that was not dated and labeled with R19's name. ~1 piece of pie in a resealable container dated [DATE] with R21's name. ~Watermelon slices in a small resealable container dated ,d+[DATE] and did not contain a name. ~1 resealable container of fruit cocktail with no name or date. ~1 opened bag of [NAME] Perfect by Nature Cherries dated ,d+[DATE] with R4's name on them. ~1 - 22 ounce container of Kozyshack Tapioca Pudding that had been opened and contained no name or date. ~1 - resealable container of mandarin oranges that contained no name or date. ~1 - 8 fluid ounce bottle of Simply Orange Orange Juice that was ,d+[DATE] full and did not contain a name or date. ~1 container of Oikos Strawberry Yogurt with an expiration date of [DATE] ~1 resealable container of chicken noodle soup dated [DATE] with no name or date. ~1 - 20 ounce bottle of Diet Pepsi that was ,d+[DATE] gone with no date and R44's name. ~2 brown bananas in a bag with date of ,d+[DATE] and no name. ~1 - 14 ounce container of Santa [NAME] Bay Crab Salad that had been opened with no name or date. After Surveyor had inspected the refrigerator, AM-C took the items not in compliance and disposed them in the trash.

Based on interview and record review, the facility failed to ensure guardianship paperwork was updated for 1 (R13) of 2 residents reviewed for guardianship. R13 had not had the required annual review for R13's guardianship since 12/28/2017. Findings: On 9/20/21 at 1:56 PM, Surveyor reviewed R13's guardianship paperwork and noted the paperwork on file in R13's electronic health record (EHR) was dated 10/7/09. On 9/20/21 at 2:56 PM, Social Worker (SW-D) indicated in interview that the annual review for R13 was an issue at the last survey (February 2020) and at that time the facility had found that R13's named tribal court (TC-E) had not been conducting the annual reviews and were far behind. SW-D indicated SW-D was told TC-E just does not do them. On 9/21/21 at 10:10 AM, Surveyor contacted TC-E who indicated the last updated annual review paperwork on file is dated 12/28/2017 and indicated that named County (County-F) had initiated the paperwork. On 9/21/21 at 11:12 AM, Surveyor contacted County-F who indicated County-F had no record of R13 in their system though they generally contract with County-G to conduct annual guardianship reviews and provided Surveyor with the contact number for County-G. On 9/21/21 at 11:14 AM, Surveyor contacted County-G who indicated County-G did not have a record of R13 either and Surveyor was told to re-contact County-F. On 9/21/21 at 11:17 AM, Surveyor again contacted County-F who indicated that most of the guardianships for tribal members are completed in the tribal court and to re-contact TC-E. On 9/21/21 at 11:22 AM, Surveyor again contacted TC-E who indicated Surveyor could initiate a Watts review. TC-E asked where resident was residing and indicated to contact a named County-F health and human services worker. On 9/22/21 at 12:30 PM, Surveyor reviewed previous notes from the facilities Recertification Survey conducted in February 2020 related to R13's guardianship and found that at that time SW-D had contacted the same named County-F Health and Human Services individual who indicated at that time that TC-E was far behind in conducting the annual reviews. On 9/22/21 at 9:35 AM, Surveyor interviewed SW-D who indicated last time the ombudsman was involved and helped to get R13's annual guardianship review completed and that was years ago. SW-D indicated that at the last survey staff contacted TC-E who indicated TC-E does not do guardianship reviews. When asked if any contact had been made or documented since that time, SW-D indicated no contact had been made. On 9/22/21 at 9:40 AM Social Services Progress Note indicated the following: Note Text: SSD (Social Services Director) left message for [named] County APS worker requesting a copy of the most recent Watts review paperwork. Awaiting response.

Based on record review and staff and resident interview, the facility did not ensure the resident environment remained as free of accident hazards as possible for 1 Resident (R) (R1) of 3 residents. R1 was admitted to the facility with metabolic [MEDICAL CONDITION] (a disturbance in brain function caused by a chemical imbalance in the blood) and increased confusion following a [DIAGNOSES REDACTED]. R1 was transported to a medical appointment three days after admission via a local cab service, but was not accompanied by facility staff. CD (Cab Driver)-G assisted R1 into the hospital's registration entrance; however, the registration department closed approximately one hour earlier. R1 was left alone in the clinic entrance when CD-G left the building and attempted to locate staff at the hospital registration entrance which was also closed. Findings include: The Surveyor reviewed R1's medical record. R1 was admitted to the facility with [DIAGNOSES REDACTED]. R1's Admission MDS (Minimum Data Set), dated 3/09/21, indicated R1 was moderately cognitively impaired and required the assistance of staff for transfers and most ADLs (activities of daily living). R1 was admitted to the facility following a hospitalization for increased confusion and hallucinations and was prescribed IV (intravenous) antibiotics for Lyme disease. Progress notes, dated 3/05/21, 3/06/21 and 3/07/21, stated, (R1) is very confused and conversations do not make sense. A progress note, dated 3/08/21, stated the facility received a call from (named hospital) and were notified R1's midline (a catheter inserted into a vein by the bend in one's elbow/upper arm and used for medications or fluids that do not irritate veins) was pulled prior to discharge despite the fact there was no order to do so. The note also stated IV (intravenous) antibiotics for R1 were not included with the hospital's discharge instructions. The note stated (named hospital) would make arrangements to have R1's midline replaced and fax orders for IV treatment. A social services admission note, dated 3/09/21, stated R1 was alert and oriented to self and year, but needed reminders for month, place and situation. On 3/11/21 at 11:40 AM, the Surveyor interviewed POA (Power of Attorney)-C via telephone. POA-C stated R1 was sent to the hospital in a cab unaccompanied by staff and had to knock on the hospital door to get inside. POA-C stated the hospital erred in pulling R1's midline prior to discharge. When the error was discovered, R1 was sent to (second named hospital) on 3/08/21 for reinsertion of the midline. POA-C stated POA-C was notified of the appointment and informed R1 would be transferred via cab; however, POA-C was not aware a staff member would not accompany R1 to the appointment. POA-C stated when POA-C received a message from R1's spouse at 7:00 PM on 3/08/21 that R1 was still at the hospital, POA-C phoned the hospital. POA-C stated hospital staff reported R1 arrived at the hospital at 6:00 PM via taxi and had to, knock on the hospital door to get it to open. POA-C stated, I assumed someone would accompany (R1). They didn't say (R1) wouldn't be accompanied. (R1) went with someone who didn't have access to (R1's) medical records or know (R1) was confused. On 3/11/21 at 10:55 AM, the Surveyor interviewed DON (Director of Nursing)-B regarding R1's appointment. DON-B stated R1 went the appointment via (named cab service) and was unaccompanied by staff. DON-B indicated there was a staff in the hospital's entrance area who accepted patients and, got them where they needed to go. DON-B stated DON-B was aware of POA-C's concern with the transfer and indicated POA-C stated R1 should not have been transferred alone. DON-B stated R1 should have been accompanied by staff and was not sure why that did not occur. DON-B stated residents can be sent to appointments unaccompanied if they are oriented to self and situation. On 3/11/21 at 11:20 AM, the Surveyor interviewed RN (Registered Nurse)-D regarding R1's appointment. RN-D stated R1 was sent to (second named hospital) via cab on 3/08/21 for insertion of a midline. RN-D stated since (second named hospital) was in close proximity to the facility, R1 was sent unaccompanied by staff. RN-D stated RN-D informed POA-C that R1 would be sent via cab and met by a nurse at the entrance to the hospital. RN-D stated, I told (POA-C) I was going to send (R1) across the street and a nurse could meet (R1). RN-D stated R1 knew R1's name, date of birth, the nature of R1's appointment and why R1 needed a midline and IV antibiotics. On 3/11/21 at 1:00 PM, the Surveyor interviewed NHA (Nursing Home Administrator)-A regarding transportation to appointments. NHA-A stated it was a judgement call as to whether or not staff accompanied residents to appointments. NHA-A stated NHA-A was not aware POA-C reported R1 had to knock on the door of the hospital. On 3/11/21 at 1:34 PM, the Surveyor interviewed HS (Hospital Staff)-E regarding appointments. When asked if there was someone available to assist patients who arrived via cab, HS-E stated it depended on the time of day. HS-E stated the hospital and clinic doors locked at 5:00 PM. HS-E stated for a midline, R1 would most likely have done the hospital registration. HS-E stated if a patient arrived after 5:00 PM and attempted to enter via the hospital registration entrance, the doors would be locked. HS-E stated the hospital had an ED (Emergency Department) entrance with sliding glass doors that were open at that time and would not require a patient to knock. On 3/11/21 at 2:03 PM, the Surveyor interviewed CS (Cab Scheduler)-F regarding R1's transport on 3/08/21. CS-F indicated (named cab company) provided curb to curb service and stated, We expect our drivers to get out of the car, open the door for the customer and see that they get into the building safely. CS-F stated the drivers don't enter buildings. CS-F stated cab company received instruction from the facility to transport R1 to the clinic entrance. CS-F stated the transport log indicated R1 was picked up at the facility at 5:21 PM and dropped off at (second named hospital). On 3/11/21 at 2:49 PM, the Surveyor interviewed CD-G regarding R1's transport. CD-G stated CD-G transported R1 to (second named hospital) Door 3 (clinic entrance) on 3/08/21. CD-G stated CD-G wheeled R1 into the building, but nobody was waiting for or came to greet R1. CD-G stated CD-G wheeled R1 toward a long hallway, but decided it was too far to transport R1. CD-G stated CD-G left R1 in the building and drove to the hospital registration entrance to let them know R1 was in the clinic entrance. CD-G stated CD-G was unable to locate anyone in the registration area either. CD-G stated CD-G had other pick ups and felt safe leaving the hospital grounds because R1 was inside the building. CD-G stated CD-G thought R1 should have been accompanied by a staff during the transport due to R1's confusion. On 3/11/21 at 3:07 PM, the Surveyor interviewed R1 regarding R1's appointment. R1 stated, I had to holler my way into the hospital .into the registration area .They were starting to close down. R1 stated R1 found an anesthesiologist after R1, hollered around the corner and said, 'You can't let me sit here .This isn't going to work.'

Based on observation, interview and record review, the facility did not ensure implementation of an infection control policy designed to prevent the development and transmission of disease and infection such as COVID-19, which had the potential to affect 2 residents (R) (R9 and R10) of 10 sampled and supplemental sampled residents. Licensed Practical Nurse (LPN)-D did not change surgical mask or disinfect face shield after caring for a resident on droplet/contact precautions for Covid-19 (a mild to severe respiratory illness that is caused by a coronavirus and at the time of this situation considered pandemic, meaning worldwide spread) and before administering medications to R9. Certified Nursing Assistant (CNA)-E did not change surgical mask or disinfect face shield after caring for a resident on droplet/contact precautions for Covid-19 and before caring for R10. Findings include: Facility provided policy titled Strategies for Optimizing PPE (Personal Protective Equipment) During a Covid-19 Outbreak with effective date of 3/23/20 stated, . 2. Strategies to Optimize Face Masks a. Conventional Capacity Strategies i. Use facemasks according to manufacturer recommendations and local, state, and federal requirements . 4. Strategies to Optimize Eye Protection a. Conventional Capacity Strategies i. Use eye protection according to manufacturer recommendations and local, state, and federal requirements . On 1/5/21, Surveyor reviewed R9's medical record. R9 was admitted to facility on 7/8/20 with [DIAGNOSES REDACTED]. on health), Dysphagia (difficulty or discomfort in swallowing), Hypertension (high blood pressure), Anxiety Disorder (exaggerated tension, worrying, and nervousness about daily life events) and Major [MEDICAL CONDITION] (a mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life). On 1/5/21, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. irregular and often rapid heart rate) and Major [MEDICAL CONDITION] (a mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life). On 1/5/21 at 6:57PM, Surveyor observed LPN-D enter the room of a resident on droplet/contact precautions for Covid-19 to answer the call light. Surveyor observed LPN-D had on a surgical mask and a face shield plus put on a clean gown and clean gloves prior to entering the room. On 1/5/21 at 7:05PM, Surveyor observed LPN-D exit the room entered at 6:57PM as stated above. Surveyor observed LPN-D had removed gown and gloves prior to exiting room. Surveyor observed LPN-D was wearing a surgical mask and a face shield. Surveyor interviewed LPN-D who indicated staff had no trouble obtaining PPE to perform duties. LPN-D indicated the resident just attended to by LPN-D was on droplet/contact precautions due to having been out of facility on Christmas Day and was having symptoms which included a lower O2 sat (oxygen saturation level: refers to the extent to which hemoglobin in blood is saturated with oxygen) and stated, A test for Covid-19 is pending. On 1/5/21 at 7:07PM, Surveyor observed LPN-D walk to medication cart to prepare medications. On 1/5/21 at 7:09PM, Surveyor observed LPN-D enter R9's room to administer medications to R9. Surveyor observed that LPN-D did not change surgical mask or sanitize face shield after leaving the room with precautions and entering R9's room. On 1/5/21 at 7:21PM, Surveyor interviewed LPN-D who verified when LPN-D exited the room with droplet/contact precautions, LPN-D did not change surgical mask or sanitize face shield prior to entering R9's room. LPN-D verified LPN-D should have changed mask and sanitized face shield upon exiting the room with droplet/contact precautions. LPN-D indicated sanitation supplies were kept in facility's utility room, medication cart and at the nurse station. On 1/5/21 at 7:15PM, Surveyor observed CNA-E enter the same room referenced above where resident is room is on droplet/contact precautions for suspected Covid-19. Surveyor observed CNA-E had on a surgical mask and a face shield plus put on a clean gown and clean gloves prior to entering the room. On 1/5/21 at 7:17PM, Surveyor observed CNA-E exit the room entered at 7:15PM as stated above. Surveyor observed CNA-E had removed gown and gloves prior to exiting room. Surveyor observed CNA-E was wearing a surgical mask and a face shield. On 1/5/21 at 7:18PM, Surveyor observed CNA-E enter R10's room. Surveyor observed that CNA-E did not change surgical mask or sanitize face shield after leaving the room with precautions and entering R10's room. On 1/5/21 at 6:52PM, Surveyor interviewed CNA-E who indicated CNA-E had no trouble obtaining PPE to perform CNA-E's duties. On 1/5/21 at 7:36PM, Surveyor interviewed CNA-E who verified when CNA-E exited the room with droplet/contact precautions, CNA-E did not change surgical mask or sanitize face shield prior to entering R10's room. CNA-E verified CNA-E should have changed mask and sanitized face shield upon exiting the room with droplet/contact precautions. CNA-E indicated sanitation supplies were kept in facility's eye wash stations and utility rooms. On 1/5/21 at 9:35PM, Surveyor interviewed Infection Preventionist (IP)-C who verified the resident referenced in the above scenarios was on droplet/contact precautions and stated, (that resident) went out with family on Christmas (12/25/20) and it is facility policy to place in quarantine upon return, we don't know what they were exposed to. IP-C verified quarantine is to last a minimum of 14 days. IP-C indicated that resident did have decreased oxygen saturation level and a fever and stated, (that resident's) Covid-19 test came back today as negative. IP-C indicated facility expectations of staff exiting room of residents in droplet/contact precautions was for staff to remove gloves and gown, change to new surgical mask and sanitize face shield prior to caring for the next resident. IP-C verified LPN-D should have changed LPN-D's surgical mask and sanitize LPN-D's face shield prior to administering medications to R9. IP-C verified CNA-E should have changed CNA-E's surgical mask and sanitize CNA-E's face shield prior to caring for R10. IP-C verified facility had no concerns obtaining enough PPE for staff use.

Based on staff interview and record review, the facility did not ensure that 1 Resident (R) (R1) of 3 residents reviewed had adequate supervision to prevent accidents. On [DATE], R1 fell to the floor from a Tempo full mechanical lift sling during a transfer from the bed to the wheelchair. R1 sustained multiple rib fractures and a hemothorax (collection of blood in the space between the chest wall and the lung) from the fall. R1 was transferred to the hospital and expired two days later on [DATE]. The facility's failure to ensure R1 received adequate supervision to prevent accidents created a finding of Immediate Jeopardy that began on [DATE] when R1 fell to the floor from a lift sling during a transfer and sustained multiple injuries. NHA (Nursing Home Administrator)-A was formally notified on [DATE] at 4;30 PM that an Immediate Jeopardy situation existed. The Immediate Jeopardy was removed and corrected on [DATE]. The deficient practice is being cited as past noncompliance. This is evidenced by the following: The facility's policy, not dated, and titled Mechanical Lift, indicated staff were to check the manufacturer's specifications before attempting transfers for information related to emergency procedures, battery charging, etc. The manufacturer's recommendations for the model of lift used to transfer R1 stated: Position sling with the head section of the sling under the patient's neck, base of the spine covered and leg sections fit under thigh to the inside of the leg. Pull sling under patient. Verify the patient is positioned in the center of the sling. Connect sling straps attachment clips to attachment points on the spreader bar. Verify all clips and straps are secure. 1. Per the closed medical record, R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE], R1 had a BIMS (Brief Interview for Mental Status) completed. The medical record documented R1 scored 8 out of 15, which indicated R1's cognition was moderately impaired. R1's quarterly MDS (Minimum Data Set) dated [DATE] documented R1 was totally dependent on staff for transfer requiring two plus person physical assist. Additionally, the MDS documented R1 did not ambulate and had no falls since admission to the facility. R1's current plan of care with a revision date of [DATE], indicated R1 had an ADL (activities of daily living) self-care deficit as evidenced by uncoordinated movements related to [MEDICAL CONDITION] and weakness. One intervention dated [DATE], indicated R1 was to transfer with two assist Easy Stand (sit to stand) lift. R1's current CNA plan of care with a printed date of [DATE], indicated R1 transferred with two assist Easy Stand lift. On [DATE] at 10:30 AM, R1 had a witnessed fall to floor from Tempo sling during a transfer in R1's room. CNA-B, CNA-C and CNA-D were assisting with transferring R1 from the bed to the wheelchair with a Tempo mechanical lift manufactured by Arjo. After cares were completed, CNA-B, CNA-C and CNA-D placed the appropriate size sling under R1. CNA-B secured the two tabs on R1's right side and CNA-C secured the two tabs on R1's left side. The CNAs indicated they heard all four tabs click into place and pushed on the tabs as they always do for a double check. CNA-B started to raise R1 with the Tempo. R1 went into the sitting position and CNA-C began to guide R1's legs off the bed towards the center of the room. When R1 was off the bed and being moved toward the wheelchair, a clip came undone and R1 fell to the floor on R1's back and struck head on the floor. The hospital ED (Emergency Department) provider notes dated [DATE] with critical ordered at 2:33 PM, indicated R1 was being transferred at the facility with a lift and fell . The notes stated R1 complains of headache, neck, rib, and back pain. A contusion and abrasion to left shoulder were noted. R1 had multiple comminuted fractures (Break or splinter of bone into more than two fragments; many pieces. Considerable force and energy is required to fragment bone. Fractures of this kind occur after high-impact trauma.) of the right ribs posterior laterally (back, farther from the midline) 5, 6, 7, 8, and ninth with anterolateral 5, 6, and seventh ribs with intervening free-floating segments. R1 was noted to have nondisplaced fractures to the right lateral third and eighth ribs. R1 also had bilateral lower lobe [MEDICAL CONDITION] contusions with small right hemothorax. A progress note from the APNP (Advance Practice Nurse Practitioner) at the hospital dated [DATE] at 11:52 AM, indicated R1's status was discussed with POA (power of attorney). The APNP was recommending acute inpatient hospice as R1's respiratory status had become tenuous (weak) even on slow flow and that R1's overall prognosis was poor. On [DATE] at 11:20 AM, MD (Maintenance Director)-E inspected the Tempo lift and sling. All plastic tabs were found to be in good physical and working condition. All the straps that connect to the main body of the sling were in good condition with no weak points, missing threads or tears. The Tempo lift was tested and was functioning properly. All the attachment points were noted to be solid and 100 percent functional. The last inspection of the Tempo lift had been completed on (MONTH) 29, 2019. On [DATE] at 11:00 AM, AT (Arjo Technician)-H started an inspection of the Tempo lift and sling that were used to transfer R1 when R1 fell out of the sling. The sling was inspected by AT-H and was found to be in good usable condition. No tearing was found on the sling and sling latches were noted to be in good condition. The Tempo lift was inspected by AT-H and was found to be in good operational condition in accordance with sp122 Tempo service procedure iss02. No mechanical or accessory fault was found with the Tempo lift and the lift and associated accessories were found safe to operate by AT-H. On [DATE] at 11:30 AM, NHA-A completed a re-enactment of the transfer with CNA-B, CNA-C and CNA-D (NHA-A was transferred in the re-enactment.) The top of the mattress on the bed measured 24 inches from the floor. The bed had not been raised or lowered from time of incident until re-enactment. CNA-B, CNA-C and CNA-D placed the sling underneath body. The sling was placed in the correct position. CNA-B fastened the two sling clips to the Tempo lift on the right side and CNA-C fastened the two sling clips to the left side. CNA-B and CNA-C both stated they heard the click into place, but did not visualize that they were locked on. CNA-C was maneuvering the tube feeding pole for safety during transfer. Tempo lift maneuvered by CNA-B. R1's body was slightly lifted off the bed (approximately ,[DATE] inch clearance) and placed in sitting position. CNA-C then guided legs toward center of room off bed (buttocks still on bed). It is possible that at this time that the clip became disengaged, as there wasn't full weight on the sling clips by the body to keep them secured if not fully fastened. The CNAs did not check at this time if all clips were fully engaged and the resident (R1) gave no indication that anything was wrong. CNA-D guided the wheelchair towards R1. When the Tempo lift was backed up from the bed and R1 came off the bed, full weight was applied to the sling, and this was when R1 fell to the floor. The CNAs stated they, did not hear the sling clip disengage, but they saw the left leg strap was disconnected from the Tempo lift after the incident. On [DATE] at 8:25 AM, the Surveyor interviewed NHA-A regarding R1's fall from the sling. NHA-A indicated R1's weight wasn't stabilized. Additionally, NHA-A verified the CNAs heard the four clicks, but didn't physically observe the clips to verify the clips were attached prior to lifting R1. On [DATE] at 9:51 AM, the Surveyor interviewed CNA-B regarding R1's fall from the sling. CNA-B confirmed the individual step of visualizing the clip was not taken to ensure the clips were engaged prior to lifting. On [DATE] at 1:08 PM, the Surveyor interviewed CNA-D regarding the steps taken to be sure clips are engaged prior to lifting a resident with a Tempo lift. CNA-D confirmed the first step is to attach the clip and then pull down on the clip to hear the clip snap. When you hear the clip snap, you know you are connected. CNA-D stated staff do not need to visualize the clips and straps of the Tempo lift prior to lifting. When you hear the snap, it is your cue that you are good to lift. On [DATE] at 11:30 AM, the Surveyor interviewed ATSS (Arjo Technical Support Specialist)-L via telephone regarding steps to ensure the clips are engaged on the Tempo lift sling. ATSS-L verified when the clips are attached correctly, it is difficult to fall out of the sling, unless the clips were not engaged properly. On [DATE] at 11:39 AM, the Surveyor interviewed CNA-J regarding R1. CNA-J indicated staff were to visualize the straps before lifting one more time and keep an eye on the straps while lifting a resident. It has always been this way, even for the old lift (Tempo lift that was taken out of service following R1's fall from the sling). On [DATE] at 12:32 PM, the Surveyor interviewed LPN (Licensed Practical Nurse)-I regarding the steps taken to be sure clips are engaged prior to lifting a resident with a Tempo lift. LPN-I confirmed after hooking up a resident to the Tempo lift, staff need to pull, push down, listen for a click, visualize clip is in place, and watch the strap as resident is being lifted up. On [DATE] at 4:07 PM, the Surveyor interviewed NHA-A regarding R1's fall from the sling. NHA-A stated, thinking (the clip was) not engaged to start with. Human error. On [DATE] at 12:02 PM, the Surveyor received an email from AQE (Arjo Quality Engineer)-K regarding steps to take to ensure clips are engaged. AQE-K indicated steps to be followed to ensure a safe lift include placing the clip on the spreader bar lug, pull the strap down, make sure the lug is locked at the top end of the clip, make sure the strap is not squeezed in between the clip and the spreader bar, and make sure the straps are not twisted. If the resident is in bed, staff are to slightly lift the resident to create tension in the sling, make sure clips are securely attached, all straps are straight (not twisted), and that the resident lays comfortable in the sling. There are also several warning notices listed within the sling instructions for use regarding the sling attachments. One warning indicated it was important to always check that all sling attachment clips are fully in position before and during the lifting cycle, and in tension as the residents weight is gradually taken up. Additionally, AQE-K indicated the only information provided to the Arjo Technician while onsite to evaluate the device and conduct staff interviews was that R1 was being transferred from bed to wheelchair with an Arjo Tempo patient lift. During transfer a clip came undone and R1 fell out, landing on the floor (fall of 24 inches.) There was no statement about whether staff required R1 to be lowered after being initially raised, nor confirmation that staff visually checked the sling clip pre/post weight loading onto the sling. R1 expired in the hospital on [DATE], two days after sustaining the fall with injuries to include multiple rib fractures. According to Traumatic Rib Injury: Patterns, Imaging Pitfalls, Complications, and Treatment published at https://www.ncbi.nlm.nih.gov/pubmed/ 860, rib fractures are associated with significant morbidity and mortality, both of which increase as the number of fractured ribs increases. Key complications associated with rib fracture include pain, hemothorax, pneumothorax, extrapleural hematoma, [MEDICAL CONDITION] contusion, [MEDICAL CONDITION] laceration, acute vascular injury, and abdominal solid-organ injury. The facility's failure to ensure R1 received adequate supervision to prevent accidents resulted in R1 sustaining a fall with serious injuries and created a finding of Immediate Jeopardy. The Immediate Jeopardy was removed and corrected on [DATE] after the facility removed the lift from service (this is the only lift in the facility that uses the type of clips involved in the incident) and conducted training and audits on appropriate lift safety procedures for all facility staff involved in resident transfers. The deficient practice is being cited as past noncompliance based on the severity of resident outcome related to the deficient practice at the time.

Based on staff interview and record review, the facility did not provide necessary medically-related social services to 4 of 15 sampled Residents (R) (R18, R207, R206 and R45) to attain or maintain the highest practicable physical, mental and psychosocial well-being for each resident. R18 was determined to required long term care at the facility by the (Interdisciplinary Team) IDT. But R18's activated Power of Attorney for Healthcare (POAHC) documents that R18's agent may not admit R18 to a nursing home for a purpose other than recuperative care or respite care. The facility did not make the appropriate referrals to maintain placement or seek alternative placement that can meet R18's medical and psychosocial needs. R207 was admitted to the facility on [DATE]. Facility did not ensure documentation of advanced care planning was on file at the facility. R206 was admitted to the facility on [DATE]. Facility did not assist R206 with completion of advanced care planning. R45 was admitted to the facility on [DATE]. Facility did not ensure documentation of advanced care planning was on file at the facility. Findings include: 1. R18 was originally admitted to the facility by activated POAHC on 11/18/14 for recuperative care. At some point, R18's IDT team determined R18 was in need of long term placement. R18's [DIAGNOSES REDACTED]. R18's POAHC document completed 05/20/03 was activated 11/2012. The POAHC documented R18 checked that health care agent may only admit to a nursing home or a community-based residential facility for short-term stays for recuperative or respite care. R18's most recent quarterly MDS (Minimum Data Set) dated 1/21/19 documented a BIMS (Brief Interview for Mental Status) score of 6/15. The higher the BIMS score the more cognitively intact the resident. R18's MDS dated [DATE] documented a BIMS score of 15/15, but following a hospitalization a significant change of condition MDS dated [DATE] documented a decline in R18's BIMS score to 6/15. On 04/04/19 at 10:30 AM, the Surveyor interviewed R18. R18 verified knowing POAHC had been activated. R18 indicated liking current health care agent and that the agent had been doing a good job. R18 also verified the health care agent had not done anything wrong. R18 indicated R18 wanted to make own decisions, but it was okay if the agent helped with complicated medical decisions. R18 also indicated R18 doesn't like being at the nursing home. R18 indicated this was not a bad nursing home, but would like to be assessed to determine if a four bed adult family home discussed with R18's PF (personal friend)-E. R18 indicated would like to be assessed to determine if the Adult Family Home could meet medical needs and if R18 would qualify for financial assistance to pay for the Adult Family Home. On 04/04/19 at 1:50 PM, the Surveyor interviewed NHA (Nursing Home Administrator)-A and SW (Social Worker)-C. The surveyor reviewed the interviews with R18 and PF-E. SW-C indicated staff have discussed deactivating R18's POAHC and alternate placement in the past, but R18's physician had some real concerns about R18's tube feeding, risks for aspiration pneumonia and R18's issues with stomach pain and throwing up. R18's physician indicated he wanted R18 to have a nurse available at all times. In addition, R18's physician will not deactivate R18's activated POAHC related to R18's communication deficits related to the [MEDICAL CONDITION] especially for medical decisions. Both NHA-A and SW-C agreed that R18 was capable of making many decisions, and that R18 had not been happy about being placed in a nursing home long term. On 04/08/19 at 10:37 AM, the Surveyor reviewed R18's activated POAHC document and noted R18 checked that the health care agent may not admit R18 to a nursing home for anything other than short term placement. The Surveyor showed this to SW-C at 10:38 AM. SW-C indicated that she had not been aware R18 checked No to admission to a nursing home. SW-C indicated she would call Medical Records to see if there was another POAHC document. SW-C verified no referrals had been made regarding protective placement related to R18's desire to not be at a nursing home. On 04/08/19 at 11:17 AM, the Surveyor interviewed NHA-A, who verified they had talked to R18's health care agent and learned that R18 had only one POAHC document. NHA-A indicated she had not been aware of R18's POAHC document which indicated R18 had not given the health care agent the authority to admit R18 to a nursing home for anything other than short term placement for recuperative or respite care. NHA-A indicated when R18 was initially admitted to the facility in 2014 it was for short term placement, but at some point it was decided R18 needed long term placement based on R18's care needs. NHA-A agreed that staff missed this and referrals should have been made based on R18's POAHC document and desire to not be at a nursing home. SW-C indicated the BIMS completed on R18 that day was 8/15, but this still indicated R18 had some cognitive deficits. On 04/08/19 at 03:40 PM, SW-C indicated to the Surveyor she felt protective placement was the most appropriate referral because if R18's physician assessed R18 and agreed R18 could complete a new POAHC document R18 would just check no again to nursing home placement and they'd have to petition for protective placement anyway. SW-C and NHA-A both indicated they would have the Adult Family Home assess R18 for potential placement and look into financial assistance for payment of the Adult Family Home per R18's request. In addition, R18 and health care agent, R18's physician and care team including Family Care caseworkers would also be involved the decision as to assessing the best options for R18's care. On 04/03/19 at 07:52 AM, Surveyor reviewed the medical record of R206. R206's medical record contained documentation dated 3/20/19 at 08:40 AM as follows: Social Services Note Text: Admission Note/72 hour CC (Care Conference) held. No POA on file. In addition, R206's medical record contained a Social Service Assessment and History dated 3/20/19 which included the following questions and answers: 1. Does the patient make his/her own decisions? 'Yes;' 2. Does the patient/patient's decision maker report that advanced care planning has been completed? 'No;' 3. Has a State Specific choice form been completed? 'No;' 4. Does the patient/patient's decision maker want information on advanced care planning? 'No.' On 04/03/19 at 07:57 AM, Surveyor reviewed the medical record of R207. R207's medical record contained documentation dated 3/15/19 at 07:56 AM as follows: Social Services Note Text: Admission Note/72 hour CC held. No POA on file. In addition, R207's medical record contained a Social Service Assessment and History dated 3/15/19 which included the following questions and answers: 1. Does the patient make his/her own decisions? 'Yes;' 2. Does the patient/patient's decision maker report that advanced care planning has been completed? 'No;' 3. Has a State Specific choice form been completed? 'No;' 4. Does the patient/patient's decision maker want information on advanced care planning? 'No.' On 04/03/19 at 08:27 AM, Surveyor reviewed the medical record of R45. R45's medical record contained documentation dated 6/4/18 at 08:51 AM as follows: Social Services Note Text: Admission Note/72 hour care conference held. No POA on file and not activated. R45's medical record also contained documentation dated 2/25/19 at 11:24 AM as follows: Social Services Note Text: Quarterly Note. No POA on file and not activated. In addition, R45's medical record contained a Social Service Assessment and History dated 6/14/18 which included the following questions and answers: 1. Does the patient make his/her own decisions? 'Yes;' 2. Does the patient/patient's decision maker report that advanced care planning has been completed? 'Yes;' 3. Has a State Specific choice form been completed? 'Yes;' 4. Does the patient/patient's decision maker want information on advanced care planning? 'No.' Surveyor observed there to be no advanced directives in R45's medical record. On 04/03/19 at 02:20 PM, Surveyor interviewed R207. When questioned by Surveyor if R207 had been asked by facility about completing advanced directives, R207 stated, We have that with the will in the safe at home. R207 did not recall that anyone from the facility asked R207 about advanced directive documentation. R207's spouse was present during interview. R207's spouse verified the above information and indicated the document could be brought to the facility. On 04/03/19 at 02:26 PM, Surveyor interviewed R45. When questioned by Surveyor if R45 had been asked by facility about completing advanced directives, R45 stated, I don't remember completing one or having anyone ask me about it. R45 further stated, I would be willing to think about completing one. On 04/03/19 at 02:40 PM, NHA (Nursing Home Administrator)-A provided Surveyor with a copy of the facility's policy on Advanced Directives. The policy provided included: 1. Residents will be given the option of completing a Living Will or Advance Directive if they have not already done so. This option will be presented to a resident on admission to the facility . The Living Will or Advance Directive will then be noted on the resident's medical record . 4. A thorough explanation of the Living Will or Advance Directive will be given to the resident and his/her family or responsible person along with a pamphlet describing its purpose, procedure, and use . 9. In the event a resident is transferred to a hospital, a copy of the Living Will, Advance Directives and/or Life-Sustaining Treatment Orders will be sent with the resident for EMS (Emergency Medical Services)/ambulance and hospital personnel use. On 04/03/19 at 03:04 PM, Surveyor interviewed R206. When questioned by Surveyor if R206 had been asked by facility about completing advanced directives, R206 stated, Someone has talked to me about it but not here, it was at the hospital but I never followed through. R206 further stated, I would consider doing one, my kids tell me I should do it. On 04/03/19 at 03:07 PM, Surveyor interviewed SS (Social Services)-C. SS-C stated, Usually with admissions we ask if a POA (Power of Attorney) or Living Will was created. If not, we talk upon admission if they would like one, that they are free and that they are an option we can help them with. SS-C indicated this would be documented in an admission note if they do or don't have one in progress and that there is a spot on the Social History in the assessment tab of (electronic medical record) to check yes or no if they want help. On 04/04/19 at 11:42 AM, Surveyor interviewed SS-C. SS-C indicated that if a resident did not have advanced directives and was not interested in completing one on admission, the topic would be revisited at each care conference which would be quarterly, annually and with any changes of condition. On 04/08/19 at 09:10 AM, Surveyor interviewed NHA-A and SS-C. NHA-A and SS-C agreed that if the facility did not have advanced directives for a resident on file, the information could not be shared with emergency medical personnel for continuity of care if the resident would need to be transferred to the hospital for an emergent health need.

Based on staff interview and record review, the facility did not ensure 5 Residents (R) (R18, R24, R28, R31, and R10) of 5 sampled residents reviewed for hospitalization s received the proper notice including reason for transfer specific to situation and contact information to exercise appeal rights. R18 was transferred to the hospital on [DATE] and was given a written transfer notice which did not contain all required information. R24 was transferred to the hospital on [DATE] and 02/15/19 and was given a written transfer notice which did not contain all required information. R28 was transferred to the hospital on [DATE] and was given a written transfer notice which did not contain all required information. R31 was transferred to the hospital on [DATE], 12/10/18, 03/04/19 and 03/17/19. R31 was given written transfer notices at each transfer which did not contain all required information. R10 was transferred to the hospital on [DATE] and was given a written transfer notice which did not contain all required information. Findings include: 1. On 04/04/19 the Surveyor reviewed R18's medical record that included documentation R18 was transferred to the hospital on [DATE]. The medical record did include documentation that R18 and R18's activated Power of Attorney (POAHC) were provided with a transfer notice at the time of the transfer which contained bullet points indicating listed regulatory reasons why any resident might be transferred but no indication as to which reason applied to R18's situations. The transfer notices were also missing name, address (mailing and email), and telephone number of the entity which receives appeal requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. On 04/08/19 at 10:41 AM, the Surveyor interviewed LPN (Licensed Practical Nurse)-D. LPN-D indicated the nurse would give the resident the transfer notice, and another copy would be kept at the facility for the resident's representative to pick up at a later time. If the resident's representative could not pick up the transfer notice the nurse would have the notice mailed or faxed to the resident's representative. LPN-D indicated the nurse would verbally explain the reason for the resident's transfer at the time of the transfer to both the resident and resident's representative. 2. On 04/04/19 the Surveyor reviewed R24's medical record that included documentation that R24 was transferred to the hospital on [DATE] and 02/15/19. The medical record did not include documentation that R24 and R24's (POAHC) were provided with a transfer notices at the time of each transfer. On 04/08/19 the facility provided the Surveyor with copies of R24's written transfer notice provided to R24 and R24's activated POAHC on 01/19/19 and 02/15/19. R24's transfer notice contained bullet points indicating regulatory reasons why any resident might be transferred but no indication as to which reason applied to R24's situation. The transfer notices were also missing name, address (mailing and email), and telephone number of the entity which receives appeal requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. 3. On 04/04/19 at 07:38 AM, Surveyor reviewed R28's medical record that included documentation R28 was transferred to the hospital on [DATE]. R28's medical record did include documentation that the facility provided R28 with a transfer notice which contained bullet points indicating listed regulatory reasons why any resident might be transferred but no indication as to which reason applied to R28's situation. The transfer notice was also missing name, address (mailing and email), and telephone number of the entity which receives appeal requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. 4. On 04/04/19 at 07:56 AM, Surveyor reviewed R31's medical record that included documentation R31 was transferred to the hospital on [DATE], 12/10/18, 03/04/19 and 03/17/19. R31's medical record did include documentation that the facility provided R31 with transfer notices at the time of each transfer which contained bullet points indicating listed regulatory reasons why any resident might be transferred but no indication as to which reason applied to R31's situations. The transfer notices were also missing name, address (mailing and email), and telephone number of the entity which receives appeal requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. On 04/04/19 at 08:37 AM, Surveyor interviewed LPN (Licensed Practical Nurse)-B. LPN-B indicated the nurse on duty at the time of a resident's transfer to the hospital would fill out the form and explain to the resident that they are being transferred out for evaluation. LPN-B stated, A verbal explanation is given of the resident's change of condition. On 04/04/19 at 09:12 AM, Surveyor interviewed SS (Social Services)-C. SS-C indicated that Social Services has the responsibility to provide transfer notices if the discharge was planned. SS-C stated, If transfer is unplanned then the nurses give the transfer notice. 5. On 04/08/19 at 08:19 AM, Surveyor reviewed R10's medical record that included documentation R10 was transferred to the hospital on [DATE]. R10's medical record did include documentation that the facility provided R10 with a transfer notice which contained bullet points indicating listed regulatory reasons why any resident might be transferred but no indication as to which reason applied to R10's situation. The transfer notice was also missing name, address (mailing and email), and telephone number of the entity which receives appeal requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. On 04/08/19 at 12:28 PM, Surveyor interviewed NHA (Nursing Home Administrator)-A. NHA-A indicated the facility's process was to discuss specific reason for transfer verbally. NHA-A indicated NHA-A was not aware of the need for the missing components of the facility's transfer notice.

Based on record and facility policy review and staff interviews the facility did not follow nursing professional standards of quality by reviewing resident allergies [REDACTED].#5). Resident #5 was reported to have a allergy to the medication [MEDICATION NAME]. On 03/03/16, Resident #5's primary physician ordered [MEDICATION NAME] for Neuropathic Pain. Nursing staff did not check Resident #5's medication allergy list and inform the physician of this. Resident #5 was still receiving [MEDICATION NAME] on 10/24/16 and 10/25/16. This is evidenced by: Surveyor # review of Resident #5's current signed physician's orders [REDACTED]. This same order sheet lists [MEDICATION NAME] as an allergy. On 10/25/16 at 9:33 a.m., Surveyor # spoke with LPN-E (Licensed Practical Nurse). LPN-E reviewed Resident #5 current physician's orders [REDACTED]. On 10/25/16 at 3:55 p.m., Surveyor # spoke with the Director of Nursing (DON). The DON indicated that she did not know where Resident #5's allergy to [MEDICATION NAME] came from and that she had a call out to Resident #5's primary physician regarding this. On 10/26/16 at 7:00 a.m., Surveyor # spoke a second time to the DON. The DON said that the expectation is that the nurse that takes the medication order from the physician checks to make sure the resident does not have any allergy to the medication. The DON said that Resident #5's [MEDICATION NAME] was started on 03/03/16. The DON said that Resident #5's physician had checked the Epic medical records system and could not find anything related to Resident #5's allergy to [MEDICATION NAME]. The DON also said that they had contacted Resident #5's son and he didn't know anything about any allergies [REDACTED].#5's allergy list. On 10/26/16 the DON gave Surveyor # a copy of the facility policy and procedure 2.1 Non-Controlled Medication Orders. Procedure #2 says the following: Any dose or order that appears inappropriate, considering the resident's age, condition, allergies [REDACTED]. On 10/26/16 at 8:35 a.m., Surveyor # spoke with LPN-B. LPN-B said that she had reviewed Resident #5's physician's orders [REDACTED].#5 had [MEDICATION NAME] listed on her allergy list. LPN-B said that she always looks for possible allergies [REDACTED].

Based on observation, resident and staff interviews and record review, the facility did not ensure 2 (residents #1 and #2) of 11 sampled residents received adequate supervision and assistant devices to prevent accidents. Resident #1 was at risk for falls and required limited to extensive assistance with transfers. On 10/10/10 during a transfer to the toilet, CNA (Certified Nursing Assistant)-D did not utilize a gait belt during an assisted transfer. Resident #1 lost her balance and fell to the floor. Resident #1 sustained a fractured right humerus and a laceration to her ear as a result of the fall. Resident #2 was at risk for falls. Resident #2's plan of care directed staff to utilize a gait belt, walker and assist of one person for transfers. On 10/21/10, CNA-G assisted resident #2 with transfers on and off of the toilet without the use of a gait belt or walker. Findings include: 1. On 10/20/10 surveyor # completed a record review for resident #1. According to the admitting record, dated 3/22/10, resident #1 was admitted to the facility on [DATE]. The hospital discharge summary dated 3/19/10 documented resident #1 had [DIAGNOSES REDACTED]. The facility completed a quarterly MDS (Minimum Data Set) with a reference date of 8/20/10. The MDS documented resident #1 did not have any long or short-term memory deficits and did not have impaired cognitive skills for decision making. According to the MDS, resident #1 required extensive staff assistance with transfers, ambulation and toileting. The facility completed a fall assessment dated [DATE]. The assessment documented resident #1 was at risk for falls related to an unsteady gait and right sided weakness. The assessment further documented a loss of movement of the arm or leg, history of a CVA and indicated fall risk would be addressed in the plan of care. The plan of care for "at risk for falls" dated 3/20/10 documented resident #1 was at risk for falls due to an unsteady gait and right sided weakness. An intervention dated 6/7/10 directed staff to toilet transfer in the bathroom with rail and shower chair. The ADL (Activities of Daily Living) plan of care dated 3/22/10 directed staff to ambulate the resident with a front wheeled walker and right leg brace to and from the bathroom with one person physical assistance and noted if staff felt uncomfortable, they should see Physical Therapy for teaching (that intervention was effective 8/26/10). The "Therapy Follow Up Communication" dated 8/27/10 documented resident #1 required one person physical assistance with walking from bed to bathroom, and one person physical assistance with transfers. On 10/20/10 at 1:07 p.m. surveyor # interviewed PT (Physical Therapist)-C. PT-C was the physical therapist who worked with resident #1 prior to the resident's discharge from PT services in August 2010. PT-C stated resident #1 required contact guard to minimal assistance with transfers at the time of therapy discontinuation. PT-C stated resident #1's level would vary day-to-day. PT-C stated therapy staff did not indicate if a gait belt should be used when staff were assisting with transfers. PT-C stated it was a standard of practice for a gait belt to be utilized on any resident who required assistance with transfers for safety reasons; therefore, therapy staff would not specifically indicate the gait belt should be used, as it is a "given" that staff should be utilizing one. PT-C stated therapy staff did not write on the care plan to utilize a gait belt, as that was a basic safety measure that should be utilized whenever providing assistance with transfers. PT-C further stated she believed a gait belt should have been utilized whenever assisting resident #1 with transfers as a safety precaution due to resident #1's right sided weakness/impairments secondary to a stroke. The nurses' notes dated 9/23/10 documented resident #1 required extensive assistance with toileting. The nurses' notes on 10/10/10 at 8:00 p.m. documented, "Res. (resident) was amb. (ambulating) with cane + CNA to bathroom. Res. was getting ready to sit on toilet reached for her cane + lost balance hitting her right ear on garbage can. Writer observed res. lying on stomach, right side of face on garbage can...Ambulance here at 2020 (8:20 p.m.)...". The Emergency Department documentation dated 10/10/10 documented resident #1 sustained a fracture of the surgical neck of the right proximal humerus, and a laceration to the ear. Resident #1 was treated at the emergency room and returned to the facility at 1:00 a.m. with physician orders [REDACTED]. On 10/20/10 surveyor # reviewed the facility investigation regarding the fall resident #1 sustained on 10/10/10. The investigation included a statement from CNA-D, which indicated on 10/10/10 resident #1 requested to walk to the bathroom. CNA-D ensured resident #1's leg brace was on and handed the resident the cane. CNA-D assisted resident #1 to ambulate into the bathroom. As resident #1 was stooping to sit on the toilet, she tipped to her right side away from CNA-D. CNA-D indicated she attempted to assist resident #1 but was unable to do so. Resident #1 fell and hit her ear on the garbage can. The "findings" of the investigation indicated the therapy team discharged resident #1 on 8/27/10, and the CNA did follow resident #1's plan of care. The care plan team addressed the fall and implemented a plan of action to ensure patients/residents who were at risk for falls were transferred safely. Following the fall, resident #1's plan of care was revised on 10/11/10 to include two staff assistance with a gait belt for all transfers. On 10/20/10 at 11:22 a.m. surveyor # interviewed LPN (Licensed Practical Nurse)-E regarding resident #1. LPN-E verified resident #1 required limited to extensive staff assistance with transfers, and the resident's ability would vary day-to-day. On 10/20/10 at 11:27 a.m. surveyor # interviewed resident #1. Resident #1 was alert and oriented and recalled the events of 10/10/10. Resident #1 stated she asked CNA-D to assist her to the bathroom. Resident #1 stated CNA-D did not apply a gait belt, as she felt the CNA-D should have. Resident #1 stated staff were to utilize a gait belt, but they often forgot. Resident #1 stated she usually reminded staff, but on that evening she forgot to remind CNA-D. Resident #1 stated CNA-D assisted her to position her wheel chair by the bed, outside of the bathroom, and handed her the cane. Resident #1 ambulated into the bathroom, held onto the grab bar in front of the toilet, and CNA-D pulled the resident's pants down. Resident #1 stated as she was attempting to sit on the toilet, she lost her balance and fell to the floor on her right side. Resident #1 stated CNA-D was on her left side at the time, and did try to grab her shirt as she was falling; but it did not help. Resident #1 commented that CNA-D had "...nothing to hold on to." Resident #1 stated after the fall, she immediately had pain in her right ear and right arm. Resident #1 verified she was treated at the emergency room for the laceration and fracture and returned to the facility after treatment. On 10/20/10 at 12:55 p.m. surveyor # interviewed DON (Director of Nursing)-A. DON-A stated she would expect staff to utilize a gait belt for safety whenever transferring a resident who required any level of physical assistance. DON-A stated after resident #1's fall occurred, the facility reviewed the plan of care; and the plan of care did not directly indicate a gait belt should be utilized. DON-A stated that was the reason CNA-D did not utilize the gait belt. DON-A stated the facility policy directed staff to utilize a gait belt "if necessary", and stated therapy staff were to determine whether or not a resident required the use of a gait belt. DON-A stated if the therapist determined a gait belt was "necessary", that would have been included in the plan of care. DON-A stated following the event, all nursing and therapy staff were directed they needed to utilize a gait belt whenever transferring any resident who required any type of assistance; and only independent residents would not need to utilize a gait belt for transfers/ambulation. On 10/20/10 surveyor # reviewed the facility policy/procedure for "Transfer Bed-Chair/Wheelchair" dated 3/16/01. The procedure directed staff to "...apply gait belt to resident, if necessary." On 10/20/10 at 1:00 p.m. surveyor # interviewed NHA (Nursing Home Administrator)-B. NHA-B verified that, prior to the incident with resident #1 on 10/10/10, the facility policy was to utilize a gait belt "if necessary". NHA-B stated "if necessary" would be determined by therapy staff and documented on the plan of care. NHA-B verified that, following the 10/10/10 event, all nursing and therapy staff had been re-educated on the need to utilize a gait belt for all residents requiring assistance for transfers. On 10/20/10 at 1:20 p.m. surveyor # interviewed CNA-D regarding the fall resident #1 sustained on 10/10/10. CNA-D verified the information as documented in the facility investigation/statement and verified she did not utilize a gait belt. CNA-D stated the care plan did not specifically indicate a gait belt should be utilized; therefore, she did not use one. CNA-D stated she assisted resident #1 to ambulate from the wheel chair, which was positioned at the end of resident #1's bed, into the bathroom. Resident #1 held onto the grab bar in front of the toilet, and CNA-D assisted with pulling the resident's pants down. As resident #1 was taking a few steps backward to sit onto the toilet, the resident lost her balance and fell to the floor, landing on her right side. CNA-D commented she did attempt to grab resident #1's shirt to prevent the fall, but could not, as it happened too fast. On 10/20/10 at 1:57 p.m. surveyor # interviewed LPN-F. LPN-F indicated CNAs were provided education in their basic training, which directed them to utilize a gait belt whenever assisting a resident with transfers or ambulation. LPN-F indicated it was a standard of practice for safety and should not have to be specifically outlined on the plan of care, as staff should know the standard. LPN-F stated she would have expected staff to utilize a gait belt whenever transferring resident #1 without the use of a mechanical lift, currently and prior to the 10/10/10 fall. 2. On 10/21/10 surveyor # completed a record review for resident #2. According to the admitting record dated 9/27/10 resident #2 was admitted to the facility on [DATE]. The hospital discharge summary dated 9/18/10 documented [DIAGNOSES REDACTED]. The facility completed a nursing admission assessment dated [DATE]. The assessment documented resident #2 was at risk for falls related to an unsteady gait, muscle weakness/numbness/tightening, used diuretic, psychotropic and cardiovascular medications. The facility completed an admission MDS with a reference date of 9/30/10. The MDS documented resident #2 required extensive staff assistance with transfers and toilet use and had impaired standing balance. The triggered fall RAP (Resident Assessment Protocol) dated 10/7/10 documented, "Resident was admitted on an antidepressant which puts resident at risk for falls. Res. has a history of CVA which also puts resident at risk for falls. Resident is transferred with stand up lift and two assist. Res. is being seen by PT to increase mobility and strength. Will proceed to care plan." The plan of care included the following intervention dated 10/15/10, "One assist with gait belt and walker for all transfers." On 10/21/10 at 8:25 a.m. surveyor # observed CNA-G assist resident #2 to a standing position from her wheel chair in the bathroom. Resident #2 held onto the grab bar in front of the toilet. CNA-G assisted resident #2 with pulling down her pants and placed the wheeled toilet/shower chair behind resident #2. After the resident was seated, CNA-G moved the toilet/shower chair over the toilet to allow resident #1 to utilize the toilet. After resident #2 was finished, CNA-G moved the wheeled toilet/shower chair in front of the grab bar. Resident #2 held onto the grab bar and stood up. CNA-G provided perineal care and assisted resident #2 to pull up the resident's pants. CNA-G then assisted resident #2 to a seated position in her wheel chair. No gait belt or walker was utilized during the observation. On 10/21/10 at 8:32 a.m. surveyor # interviewed CNA-G regarding the above observation. CNA-G verified she did not utilize a gait belt while assisting resident #2 with the transfers, and utilized the grab bar instead of the walker. Surveyor # reviewed the CNA worksheet with CNA-G, which directed staff to utilize one person assistance with a gait belt and walker for transfers. CNA-G stated she felt as though resident #2 had improved and no longer needed the use of the gait belt. CNA-G stated she believed the CNA worksheet was inaccurate. CNA-G stated she had not received any recent training regarding the use of gait belts for any resident who required assistance with transfers. CNA-G verified resident #2 did require limited staff assistance with transfers. On 10/21/10 at 8:35 a.m. surveyor # interviewed LPN-H regarding the above observation. LPN-H verified, according to resident #2's plan of care, the resident should be transferred utilizing one assist and a gait belt. LPN-H stated staff should utilize a gait belt for all residents who required assistance unless the resident was independent. On 10/21/10 surveyor # reviewed the facility education initiated on 10/11/10. The training documented, "Any time pt. (patient) requires assist with standing/transfers/amb. (ambulation), must wear gait belt." CNA-G signed the program attendance record indicating the training had been completed. At 8:55 a.m. surveyor # reviewed the document with CNA-G. CNA-G verified she read and signed the education, but thought it meant that just residents requiring "extensive assist" needed to have a gait belt utilized. CNA-G stated she did not feel the gait belt needed to be utilized for resident #2, as the resident only required limited assistance. On 10/21/10 at 9:02 a.m. surveyor # interviewed DON-A regarding the above observation. DON-A verified resident #2 was at risk for falls due to an unsteady gait and weakness; therefore, a care plan for at fall risk was developed. DON-A reviewed the plan of care with surveyor # , and verified the care plan directed staff to utilize a gait belt and a walker for all transfers.