Every finding on record at Shell Lake Health Care Center

Based on interview and record review, the facility did not ensure each resident's drug regimen is free from unnecessary drugs for 1 of 5 residents reviewed for unnecessary medications (R2) out of a sample of 16 residents.-The facility nurse transcribed R2's order as Diazepam 2mg tablet. Take 0.5 tablet twice a day, instead of take 0.5mg tablet twice a day as needed (PRN). R2 received a total of 9 doses of Diazepam.Findings include:The facility policy with a subject titled, Transcription of Physician Orders, last revised 06/2018, includes: Nurse will initiate a transcription check list for all new orders. Nurse taking order will follow and complete areas on the transcription check list.Nurse will make a copy of the order and staple to the transcription check list. The order is then transcribed accurately into [Point Click Care]. Nurse transcribing order will check the electronic medication administration record (MAR) and/or treatment administration record (TAR) to verify the order is on the MAR/TAR and is correct. Nurse transcribing will give the order to other nurse who will check the electronic physician order and the MAR/TAR for accuracy.R2 was admitted to the facility on [DATE], with diagnoses including post-traumatic stress disorder (PTSD), major depressive disorder, paranoid schizophrenia, schizophrenia, and anxiety disorder.R2's most recent Minimum Data Set (MDS) assessment showed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating no cognitive impairment.R2's medications include diazepam, Seroquel, and duloxetine.R2's progress note, dated 08/14/26, stated facility received an E-script from Nurse Practitioner with orders for Diazepam 2 mg take O.5 tablet by mouth two times a day as needed for Anxiety or other (intrusive thoughts).On 08/14/26, an order was entered by Registered Nurse (RN) I, that stated diazepam oral tablet 2 MG (Diazepam) Controlled Drug Give 0.5 tablet by mouth two times a day related to anxiety disorder.R2's MAR for August 2026 indicated R2 received scheduled diazepam 1mg twice on 08/14/26, 08/15/26, 08/16/26, 08/17/26, and once on 08/18/26 for a total of 9 doses.R2's original physician order from 08/14/26, stated the diazepam 1mg should be given twice daily as needed for anxiety or other intrusive thoughts.On 08/18/26 at 7:53 AM, Surveyor interviewed Licensed Practical Nurse (LPN) C about physician orders. LPN C stated they were unsure of the process and just followed what was in the MAR.On 08/18/26 at 7:57 AM, Surveyor interviewed LPN H about physician orders. LPN H stated the nurses put the new orders in, and they are always checked by a second nurse. LPN H stated then they follow what is in the MAR.On 08/18/26 at 8:00 AM, Surveyor interviewed Director of Nursing (DON) B about physician orders. DON B stated any of the nurses can enter new orders. They are checked again by another nurse, and there is a checklist they follow. Surveyor informed DON B of the discrepancy noted for R2's diazepam order from 08/14/26. DON B stated the checklist for the second check was no longer available for review. DON B stated they would investigate the order in question.RN I was unavailable for interview and the nurse who performed the second check was unknown due to no available checklist.On 08/18/26 at 8:30 AM, the order was verified and entered correctly into R2's MAR which states diazepam 2mg tablet give 0.5 tablet every 12 hours as needed for restlessness related to anxiety disorder. DON B acknowledged the previous discrepancy.On 08/19/26 at 10:03 AM, Surveyor interviewed Certified Nursing Assistant (CNA) G about R2's recent demeanor and activity. CNA G stated R2 did not seem to be acting any different than normal and did not appear to be more fatigued or tired.On 08/19/26 at 10:17 AM, Surveyor interviewed R2 about fatigue and feelings. R2 stated they had no concerns and felt fine. R2 stated they did not feel more tired or different than any other day. Surveyor observed R2 did not appear in any distress in relation to receiving excess doses of diazepam.

Based on observation, interview, and record review, 1 of 1 medication rooms failed to store and double lock schedule II medications in 1 of 1 medication rooms. One medication room had lorazepam which was stored in an unlocked refrigerator.Findings:Facility policy titled, Storing and Labeling Medications, reviewed 08/2021 stated,.3. Controlled substances: Schedule II medications shall be stored in a separated locked cabinet in the medications room.5. Refrigeration: Medications requiring refrigeration shall be kept in the locked refrigerator in the medication room. On 08/17/2026 at 3:06 PM, Surveyor noted the refrigerator was not locked as Licensed Practical Nurse (LPN) D was showing Surveyor the medication room. LPN D indicated because there is lorazepam in the refrigerator it has to be locked. LPN D then locked it. On 08/18/2026 at 8:43 AM, Surveyor informed Director of Nursing (DON) B of the observation made of the refrigerator door not locked in the medication room that holds the lorazepam. DON B informed Surveyor that is the second lock for a controlled substance and the refrigerator must remain locked.

Based on observation, interview and record review, the facility did not ensure staff performed hand hygiene per standards of practice for 2 of 12 hand observation opportunities affecting 1 of 1 supplemental resident (R21) and 1 of 16 sampled residents (R2). Licensed Practical Nurse (LPN) C did not perform hand hygiene according to professional standards of practice for R21 and R2.Findings:Facility policy titled, Glove Use, reviewed 04/2019, stated, Gloves are to be worn prior to contact with residents and potentially contaminated surfaces. Gloves should always be changed between residents.Gloves do not preclude the need for hand hygiene after removing gloves.Examples of Indications for Glove Use;*The potential for touching blood, body fluids, secretions, excretionsR21 was admitted to the facility on [DATE] with a Brief Interview of Mental Status (BIMS) score of 10/15, which indicated R21 had moderate cognitive impairment. R21's physician order states:Artificial Tear Solution. Instill 1 drop in both eyes every 4 hours for dryness- while awake.R2 was admitted to the facility on [DATE] with a BIMS of 15/15, which indicated R2 was cognitively intact.R2's physician order states:Artificial Tear Solution Instill 1 drop in both eyes two times a day for dry eyes. Instill 1 drop in both eyes every 4 hours as needed for dryness.On 08/18/2026 at 6:50 AM, Surveyor observed LPN C administer medications to R21. Surveyor observed LPN C log into the computer to review the doctor's order. LPN C then took out the prescribed medications for R21. R21 required back up stock medications to be removed from the lowest drawer on the medication cart. Surveyor observed LPN C take a pair of single use gloves from the medication cart and put them into LPN C's pocket. LPN C then took R21's medications into R21's room. LPN C did not perform any hand hygiene when entering R21's room. LPN C raised R21's bed, moved bedside table and walker to get closer to their bed. LPN C administered R21's oral medications. Surveyor then observed LPN C reach into LPN C's pocket for the gloves and put them on without performing hand hygiene. LPN C administered the eye drops to R21. LPN C removed the gloves and performed hand hygiene at the medication cart after leaving R21's room.On 08/18/2026 at 7:06 AM, Surveyor continued observation of medication administration for R2. LPN C logged into the computer and took out medications and placed them into a medication cup. LPN C needed to get stock medications and narcotic medications for R2. LNP C took out the narcotic sign-out binder and documented medications removed, took a pair of single use gloves from the medication cart and put them into her pocket and entered R2's room. No hand hygiene was observed. LPN C administered R2's oral medications, then put on the gloves from her pocket without performing hand hygiene and administered R2's eye drops. On 08/18/2026 at 7:21 AM, Surveyor informed LPN C of the observation of no hand hygiene before glove use with both R21 and R2's eye drop administration. LPN C replied, Oh shoot, I knew that too.On 08/18/2026 at 8:49 AM, Surveyor informed Director of Nursing (DON) B of the observation made of LPN C administering eye drops to R21 and R2 without performing hand hygiene. DON B stated to Surveyor LPN C should have performed hand hygiene before putting on the gloves.

Based on record review and interview, the facility failed to ensure that professional standards of practice were met for 1 of 3 sampled residents (R) reviewed for non-pressure skin injuries (R3). R3 is at risk for skin impairment and the facility failed to comprehensively assess, monitor, and document weekly measurements for R3's bilateral toe wounds. Findings include:The facility policy titled, Pressure Ulcer and Wound Care Protocol, includes: Every resident will have a weekly skin assessment completed. If a wound is identified, the nurse will determine the stage of the wound.following assessment, the nurse will contact the attending physician to determine the appropriate treatment option for the resident. A Braden assessment will be completed on admission, re-admission, quarterly, and with any new skin impairments. Residents with impaired skin will have a Braden assessment completed weekly. Wound Registered Nurse (RN) will assess all new skin impairments for appropriate identification of skin impairment and document in [Point Click Care]. R3 was admitted to the facility on [DATE]. R3's most recent Minimum Data Set (MDS) assessment showed a Brief Interview for Mental Status (BIMS) score of 3/15 indicating severe cognitive impairment.R3 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, kidney disease, type 2 diabetes, morbid obesity, major depressive disorder, and anxiety disorder.R3's care plan indicates R3 has impaired mobility and requires assist of 2 with repositioning.R3's skin care plan includes interventions of air mattress overlay on bed for skin (07/25/23), blue boots at all times. Broda chair with built in pressure reduction (05/05/26), intervention from incident 9/16/23.Due to inability for R3 to manage R3's feet, R3 is to have feet padded (may pad with socks) with all transfers (05/13/24), linen cradle to bed (01/24/25), observe skin daily with cares and weekly with bath (05/09/23), and skin inspection weekly with bath and as needed (05/18/23).R3's diabetic care plan includes intervention of check all of body for breaks in skin and treat promptly as ordered by doctor.R3's risk for pressure injury care plan includes interventions of follow facility policies/protocols for the prevention/treatment of skin breakdown (04/18/23), complete skin check every shift with cares and report any changes or concerns to nurse (01/07/26), monitor/document/report as needed any changes in skin status: appearance, color, wound healing, signs/symptoms of infection, wound size (length X width X depth), stage (04/18/23).On 07/24/26, R3's bath skin audit indicated R3 had abrasions to right second and third toes.On 07/29/26, R3's bath skin audit indicated R3 had abrasions to right second and third toes.On 07/29/26, R3's wound evaluation assessment indicated wound 1 was an abrasion to the left second toe, wound 2 was an abrasion to the left third toe, wound 3 was an abrasion to the right third toe, and wound 4 was an abrasion to the right second toe. All four abrasions were marked as facility acquired and no measurements were present.On 08/18/26 at 2:29 PM, Surveyor requested the investigation information regarding R3's bilateral toe wounds from Director of Nursing (DON) B. DON B stated it was part of the facility's Quality Assurance (QA) and could not provide the documentation. DON B stated R3's toes had gotten scraped on the Hoyer lift during a transfer due to the open toes on R3's foam boots. DON B stated DON B would look for any available information and speak with the Wound Registered Nurse (RN).On 07/31/26, R3's bath skin audit indicated R3 had abrasions to right great, second and third toes and an abrasion to left second toe.On 08/05/26, R3's wound evaluation assessment indicated wounds 1-4 to bilateral toes were unchanged. No measurements present.On 08/14/26, R3's bath skin audit indicated R3's abrasions to right toes continue healing and there was no documentation noted for left toes.On 08/18/26 at 3:20 PM, Survey interviewed DON B about R3's wound measurements. DON B stated RN F (Registered Nurse)was working on the day the incident happened and had forgotten to complete the documentation. DON B stated RN F would be documenting a late entry. DON B stated Wound RN E would be entering measurement documentation. DON B provided Surveyor with the initial incident report regarding R3's wounds during the interview R3's initial incident report (dated as a late entry for 07/24/26) indicated R3 received a shower and was in the Hoyer lift when R3's toes scraped against the middle of the lift. R3 did not have shoes or socks on at the time. RN F observed superficial abrasions to R3's right second toe, which measured 1cm x 1cm, the right third toe measured 0.5cm x 0.5cm, left foot had superficial abrasions to second and third toes measuring 0.5cm x 0.5cm, and areas were bleeding and superficial layer of skin peeled up.CNA J was unavailable for interview.On 08/19/26 at 10:00 AM, Surveyor interviewed RN F regarding R3's toe abrasions. RN F stated they were notified by Certified Nursing Assistant (CNA) J that R3 had abrasions to bilateral toes after scraping them on the Hoyer lift during a transfer. RN F stated they completed an assessment, cleaned and treated the wounds, and updated appropriate parties. RN F stated R3's feet were bare at the time of the transfer, and documentation had not been completed at the time of the incident, but the late entry had now been completed. The intervention listed at the time of injury was for R3 to have slippers on for all transfers for protection and once R3 was transferred, blue boots are to be put on both feet.On 08/18/26 at 3:25 PM, Surveyor interviewed Wound RN E about R3's wound measurements. Wound RN E stated they were in the process of entering the measurements for R3's wounds but no longer had the information to enter measurements for 07/31/26 and 08/05/26. Wound RN E stated wound measurements are usually entered the same day as the assessment.On 08/19/26 at 6:50 AM, Surveyor observed Wound RN E provide wound care to R3's toes. Surveyor observed more than four toes with wounds. Wound RN E stated they were unaware of the new injuries. Wound RN E completed treatment and measurements to all areas.On 08/19/26 at 7:15 AM, Surveyor interviewed CNA G about R3's toe wounds. CNA G stated they did not know the cause of the wounds, but R3 does bump their toes often. CNA G stated R3 gets a shower 3 times per week and the treatment does not always get completed when CNA G is present. CNA G was not sure how often the wounds get measured.R3's wound 1-the left second toe measured 0.2cm x 0.3cm, wound 2- the left third toe measured 0.2cm x 0.2cm, and wound 3-the right third toe measured 0.2cm x 0.2cm which had all improved. Wound 4- the right second toe measured 0.3cm x 0.3cm and was unchanged. New wound 5-the top of the right great toe, documented as a venous ulcer, measured 1.2cm x 1.5cm, new wound 6-the outer right great toe, documented as a venous ulcer measured 0.1cm x 0.1cm, and new wound 7-the right second toe near the knuckle, documented as a venous ulcer, measured 0.2cm, x 0.5cm.On 08/19/26 at 8:02 AM, Surveyor interviewed DON B regarding wound care expectations. DON B stated skin should be monitored daily by all nursing staff with observations and during weekly bath assessments. If new skin injuries are noted, they should be documented in a progress note. DON B stated wounds should be assessed weekly by Wound RN E with measurements. DON B stated new protective boots have been ordered as an intervention due to the new skin injuries observed as they now believe them to be venous ulcers. DON B stated R3 should have had protection on their feet during the transfer causing the initial injuries and wound measurements should have been obtained and documented weekly for monitoring.

Based on record review, facility document, policy review and interviews, the facility failed to ensure allegations of physical abuse by a staff member against two of five residents (Resident (R)1 and R2) reviewed for abuse were reported immediately for timely follow up and prevention of further potential abuse and failed to submit the five-day follow up investigation report to the State Agency in a timely manner. These failures had the potential to lead to further physical abuse of residents.Findings include:1. Review of R1's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] with a diagnosis of dementia.Review of R1's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/19/25 and located under the MDS tab of the EMR, revealed she had a Brief Interview for Mental Status (BIMS) score of four out of 15, indicating severely impaired cognition. She did not exhibit mood or behavioral symptoms.Review of R1's Care Plan, dated 04/24/24 and located under the Care Plan tab of the EMR, revealed, I am a vulnerable adult r/t [related to] compromised medical health as evidenced by need for care in SNF [skilled nursing facility]. I have difficulty with decision-making. The approaches included: Any situation identified as abuse/potential abuse/neglect/misappropriation/exploitation will be reported per facility protocol . Staff are aware of my vulnerability (including, but not limited to physical, verbal, financial, sexual, emotional abuse/neglect).2. Review of R2's admission Record, located under the Profile tab of the EMR, revealed she was admitted to the facility on [DATE] with a diagnosis of subarachnoid hemorrhage.Review of R2's quarterly MDS, with an ARD of 12/02/25 and located under the MDS tab of the EMR, revealed she had a BIMS score of eight out of 15, indicating moderately impaired cognition. She did not exhibit mood or behavioral symptoms.Review of R2's Care Plan, dated 06/17/25 and located under the Care Plan tab of the EMR, revealed, I am a vulnerable adult r/t compromised medical health as evidenced by need for care in SNF. The approaches included: Any situation identified as abuse/potential abuse/neglect/misappropriation/exploitation will be reported per facility protocol . Staff are aware of my vulnerability (including, but not limited to physical, verbal, financial, sexual, emotional abuse/neglect).Review of the facility's Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report, (the facility's initial report to the State Agency), dated 08/26/25 and provided on paper by the Social Services Director (SSD), revealed nursing staff reported to the Director of Nursing (DON) at 10:45 PM on 08/25/25 that Certified Nurse Aide (CNA) 1 had concerns that CNA2 had physically abused R1 and R2 on 08/23/25 based on noises she heard from R1's room behind the door. The report documented, [CNA1] alleged that 'when she was going down south hall to assist [CNA2] she heard a thud and R1 was yelling. Also, she said that [CNA2] was rough with R2 and something about her arm'. The facility suspended CNA2 pending investigation.Review of the facility's Misconduct Incident Report, (the facility's follow-up investigation report to the State Agency), dated 09/08/25 and provided on paper by the SSD, revealed the facility reported the allegations to the police and residents' physicians and representatives. The facility initiated body checks on all residents with no unexplained injuries found. Resident and staff interviews revealed no concerns with abuse or rough treatment. The facility's investigation did not substantiate that abuse occurred. CNA1 terminated her employment shortly after this incident and CNA2 was reinstated.Review of CNA2's Time Card, provided on paper by the DON, revealed CNA2 worked in the facility on 08/23/25 from 9:53 PM to 2:43 AM, on 08/24/25 from 3:18 AM to 6:47 AM and from 9:53 PM to 12:49 AM, and on 08/25/25 from 9:54 PM to 11:03 PM, at which time she was suspended pending the investigation. During an interview on 12/22/25 at 2:49 PM, the DON stated the allegations of abuse by CNA2 against R1 and R2 were not substantiated. The DON stated education was done with all staff to report any potential allegation immediately. The DON stated CNA1 received this education but terminated her employment before working again. The DON stated she expected staff to report any allegation immediately to their supervisor or to administration to ensure the alleged perpetrator was removed from the floor right away in order to prevent further potential abuse.During a telephone interview on 12/22/25 at 3:03 PM, CNA1 stated on 08/23/25, she heard R1 shouting from behind a closed door and heard a thud in the room while CNA2 was providing care. She also stated she overheard R2 saying, quit being so rough to CNA2 while CNA2 was assisting her with dressing. CNA1 stated she did not report her concerns until she came back to work on her next shift, which was 08/25/25. CNA2 stated since there was nobody around at the time to report to at the end of her shift on 08/23/25, she could not report her concerns that night.During a telephone interview on 12/22/25 at 3:24 PM, the Administrator stated CNA1 had been educated on the facility's abuse policy upon hire and reeducation was provided to all staff after this incident. The Administrator stated CNA1 was not exactly sure if what she witnessed constituted potential abuse and therefore she did not report right away; it was only after discussion with a coworker she was urged to report. The Administrator stated, [CNA1] failed to think it through and report as she should have . This is not a failure for the facility, but more a failure for her . I can't force people to think . We can offer training, educate, and give tools but can't make them think. During an interview on 12/23/25 at 10:02 AM, the DON stated she had submitted the follow-up investigation report to the State Agency, and this was the first one she had done on a new system. The DON stated she understood the report was due within five days of the initial report and she thought she had submitted it on time, but when she accessed the system again on 09/08/25, she noticed the report did not get submitted. The DON stated this may have been a glitch in the new system or user error.Review of the facility's policy titled, Abuse Prevention and Vulnerable Adult Report Plan, dated December 2023, revealed, All persons either employed or working in any capacity . are obligated under law to make a report if they have reason to believe that abuse, exploitation, and neglect has occurred . All alleged violation of abuse, neglect, mistreatment, or misappropriation of property must be reported immediately to the Administrator, Social Worker, Director of Nursing, and the appropriate state agencies . In accordance with state and federal law, the internal investigation must be completed in five working days.

Based on observation, interview and record review, the facility did not maintain a safe and sanitary environment in which food is prepared and distributed. This had the potential to affect all 35 of the 37 residents who consume food or beverages from the facility's kitchen. Facility staff did not wear a hair net in the kitchen.Dietary staff did not check food temperatures on cold beverages before serving to residents.The facility's policy and procedures titled, Standards for Dress and Cleanliness, reads in part, .Hair nets, covering all hair, will be worn by all Food Service employees at all times.The facility's policy titled, Food Temperature Maintenance, dated 1/2007, states in part, .Cold Food Items. Cold liquids should be served at 41 degrees or cooler The Food and Drug Code requires cold food at 41 degrees or below . A calibrated food thermometer must be used to measure the internal temperature of the food. Documentation may involve reviewing logs to see how often and at what temperatures staff monitor food, as it is the only way to properly check internal food temperature is with a calibrated thermometer.This is evidenced by:Example 1On 9/09/25 at 12:23 PM, during follow up kitchen inspection, Environmental Services (EVS) I came into kitchen without wearing a hairnet, walked through the kitchen preparation and clean dishes areas to a door on opposite side, and then came back through. Surveyor interviewed EVS I who stated she is aware that hair nets are required in the kitchen area. EVS I stated she should be wearing a hair net when in the kitchen.Shortly after this, Surveyor interviewed [NAME] J, as Dietary Manager was unavailable. [NAME] J stated everyone who enters the kitchen is required to wear a hair net and that most staff usually knock at the door. Surveyor noted sign on kitchen door reads, This kitchen is a restricted area for dietary personnel - Only authorized personnel allowed.Example 2On 9/09/25 at 12:27 PM, Surveyor noted staff loading trays on to cart for residents eating in dining room upstairs. These trays were filled with cups of milk and juice which had been sitting on a cart outside of the cooler.On 9/09/25 at approximately 12:45 PM, during distribution of food and drinks to residents on the 2nd floor, Surveyor interviewed Dietary Aide (DA) K, who reported she was responsible for checking the temperatures of the beverages before being served and she had taken the temperatures of the cold liquids before bringing them up to floor. DA K reported she remembers all liquids were 38 degrees and will document this later. DA K stated she just forgot to write them down on the temperature log.On 9/09/25 at approximately 1:00 PM, Surveyor requested food/beverage temperature logs for the past week and noted no documentation of milk/supplement temperatures recorded for lunch on 9/5/25 and 9/7/25 and there was no record of beverage temperatures for supper on any of the logs requested.Surveyor interviewed [NAME] J, as Dietary Manager was unavailable. [NAME] J stated the expectation is that beverages like milk and juice, which are pre-poured into cups and covered the morning before lunch is served, would be checked with thermometer at every meal and be recorded by the DA on duty in the food log. [NAME] J stated after review of the logs, beverage temperatures were not recorded on the dates noted by Surveyor for lunch or any for supper.On 9/10/2025 at approximately 3:00 PM, Surveyor interviewed Nursing Home Administrator (NHA) A, who stated everyone that goes into the kitchen is required to wear a hair net. NHA A agreed that food temperatures need to be recorded.

Based on observation, interview and record review, the facility did not ensure the resident environment remains free of accident hazards as possible and each resident receives adequate supervision and assistive devices to prevent accidents for 2 of 3 residents (R), R7 and R11, reviewed.R7 had multiple falls; the facility did not initiate immediate intervention to prevent future falls, investigate the root cause of the fall and review and revise care plan fall interventions. R11 fell on 5/25/25. New intervention to encourage resident to sleep in R11's own bed was documented to be implemented. New intervention not in care plan or on Certified Nursing Assistant (CNA) plan of care/kardex. This is evidenced by: Example 1 Facility policy titled, Falls-Incident Reports-Fall Prevention, with a revised date of 12/2018, states in part: POLICY: .When an accident or incident involving a resident occurs, any witnessing staff will offer immediate assistance. Any occurrence that, without immediate staff intervention would have proceeded in a fall, will be documented and treated as such. An Incident Report and the appropriate documentation will be completed in [name of electronic record system]. PURPOSE: To assure appropriate follow through on all accidents and incidents. To study the cause of accidents and incidents and to give guidance for corrective/preventative action. PROCEDURE: 11. Chart an objective account of the incident in the Nurses' Notes in the resident's electronic medical record, include: g. Complete the Post Fall Evaluation including: preventative interventions implemented, document preventative measures, and put on the care plan. H. Communication preventative measures and interventions per verbal and written report to direct care staff. i. Update Care Plan. j. Update the CNA Cardex. 14. The IDT [Interdisciplinary Team] will review the Incident Report. The IDT will review documentation, evaluate the possible cause and create or change interventions as needed on the resident Care Plan. The team will communicate with nursing staff. INCIDENT/ACCIDENT REPORT: Completion of the Form: 4. With all resident incidents the nurse will state what happened and how to prevent a recurrence. The care plan will be updated. The CNA plan of care will also be corrected in the same manner by adding interventions. R7 was admitted to the facility on [DATE], with pertinent diagnoses of vascular dementia with unspecified severity, localization-related (focal)(partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, and anxiety disorder. R7's most recent quarterly Minimum Data Set (MDS) assessment, dated 07/07/25, noted a Brief Interview for Mental Status (BIMS) score of 06/15, indicating severe cognitive impairment. R7 required partial/moderate assist with chair to bed transfers. R7 required substantial/maximum assist with upper/lower dressing, personal hygiene, rolling left to right, sit to lying, sit to standing, and toilet transfer. R7 had one fall without injury since admission or prior assessment. R7's care plan, dated 06/06/23, with a target date of 10/22/25, states: [R7] is a moderate risk for falls and will be free of falls through review date with interventions of anti-rollbacks on wheelchair, anticipate and meet my needs, be sure call light is within reach and encourage me to use it for assistance as needed, prompt response to all requests for assistance, ensure that I am wearing appropriate footwear when ambulating or mobilizing in w/c, leave w/c outside of room when resident in bed (02/28/24), offer to assist resident to bed after lunch (04/12/24), wear gripper socks with shoes and sign placed to mark resident's room (05/29/24), Dycem in wheelchair (06/11/24), bed alarm (06/05/23), gripper socks while in bed (06/08/24), mat on floor next to bed (06/08/23), follow facility fall protocol, sensor chair alarm on wheelchair to alert staff of the need to transfer, I need activities that minimize the potential for falls while providing diversion and distraction, wheelchair cushion that straps around back (06/10/23), no crocs or slippers, PT evaluate and treat as ordered or PRN, review information on past falls and attempt to determine causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes. R7's Falls Data Collection Assessments: 01/06/25 score 21; high-risk 04/08/25 score 21; high-risk 07/07/25 score 21; high-risk On 01/09/25 at 10:28 AM, facility's fall incident documented, [R7] had an unwitnessed fall in room next to bed and wheelchair. [R7] was found sitting up on the floor at 0948 after heard yelling for help. [R7] was attempting to self-transfer and lost her balance. Root cause of fall is believed to be d/t dementia affecting judgement. Surveyor noted the fall incident documentation did not include immediate interventions to prevent falls. On 03/03/25 at 8:39 PM, facility's fall incident documented, [R7] observed walking from dining room table without assist or wheelchair. [R7] lost her balance before anyone could help and fell hitting back of head on serving table. Ice pack applied to hematoma on back of head for first aid. Surveyor noted the fall incident documentation did not include the root cause of the fall or immediate interventions to prevent falls. On 07/21/25 at 1:43 PM, facility's fall incident documented, [R7] witnessed controlled lowering to the floor. [R7] in the shower room, resident attempted to sit down while CNA standing her up to pull up pants. Was lowered to the floor to prevent injuries. Surveyor noted fall incident documentation did not include root cause of the fall or immediate interventions to prevent falls. On 09/10/25 at 2:00 PM, Surveyor requested from Director of Nursing (DON) B the IDT investigation notes for R7's fall, including the root cause and interventions to prevent future falls. Surveyor's review of the care plans did not identify an update for fall interventions. On 09/10/25 at 4:02 PM, DON B stated being unable to provide any additional IDT investigation fall notes or updated care plans for R7's falls. Example 2 R11 was admitted to the facility on [DATE], with diagnoses including type 2 diabetes mellitus with hyperglycemia (low blood sugars), gastro-esophageal reflux disease without esophagitis, chronic kidney disease, Alzheimer's disease, dementia, and hypothyroidism. R11's Minimal Data Set (MDS) assessment, dated 6/27/25, indicated that R11 is severely cognitively impaired. R11 has clear speech and can make self-understood and understands what is said to R11. R11's depression screening was scored 00, meaning R11 or Resident Representative (RR) G reported no or minimal symptoms of depression over the last two weeks prior to assessment. R11 does not exhibit signs of aggressing, isolation, or rejecting cares. R11 requires partial assistance to complete hygiene activities and dress. R11 needs supervision for eating, mobility, and position changes, but R11 is ambulatory and likes to walk around the facility. R11's care plan, dated 7/11/25, with a target date of 10/15/2025, states: FALLS: I am at risk for fall r/t confusion, gait/balance problems, incontinence, Hx. (history) of 2 falls at home during the past year, cognitive deficit I will be free of falls through the review date Anticipate and meet my needs. Be sure my call light is within reach and encourage me to use it for assistance as needed. I need prompt response to all requests for assistance. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Encourage me to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Ensure that I am wearing appropriate footwear when ambulating or mobilizing in w/c. Follow facility fall protocol. I need a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach) I need activities that minimize the potential for falls while providing diversion and distraction Review of R11's kardex identified no direction for Certified Nursing Assistant (CNA)s to encourage R11 to sleep in R11's own bed. On 5/26/25 at 2:38 AM, facility documented R11 had an unwitnessed fall on the floor sitting directly next to spouse's bed with blood coming out of mouth. Spouse and R11 both state R11 was not fully awake when attempting self-transfer out of spouse's bed and was positioned too close to the edge of the bed, when R11 rolled out onto the floor. R11's spouse and R11 state R11 did hit head but at no time did R11 lose consciousness. No immediate intervention to prevent falls included in documentation. On 9/10/25 at 4:02 PM, Surveyor received from DON B one single piece of paper with the header #2080 Un-witnessed Fall Date 5/25/25 at 2:30 AM. Under the header was R11's name, the incident location: R11's room on west 209-2 and the name of the person preparing the report. This is followed by a second header – Notes: Underneath that is documentation 5/25/2025 Encourage resident [R11] to sleep in her own bed. On 9/10/25 at 4:03 PM, Surveyor interviewed DON B and told DON B that Surveyor did not see the interventions in the care plan or kardex for R11. DON B stated we missed that too.

Based on record review and staff interview, the facility did not ensure the accuracy of the Minimum Data Set (MDS) assessment for 1 of 12 residents (R) (R11) reviewed.R11's nutrition assessments required for quarterly Minimum Data Set (MDS) assessment were not completed.Findings include:The facility policy, titled Minimum Data Set/CAA's, last revised 6/2018, states: Purpose: To ensure that each resident receives the necessary medical, psychosocial and nutritional service to attain and maintain the highest possible mental and physical functionals status.Procedure.Sections will be completed by the staff with relevant professional backgrounds. The Policy and Procedure titled CDM and RD Role in Maintaining or Improving the Nutritional status of Residents, dated 9/10/25, emailed to Nursing Home Administrator (NHA) and Director of Nursing (DON) and shared with Surveyor, states: RD [Registered Dietician] completes comprehensive nutrition risk assessments for residents on admission, for significant changes and annually.The CDM [Certified Dietary Manager] .completes a quarterly nutrition summary documentation which include weigh, weight history within past 30/90/180 days, diet, meal intakes, nutritional supplements, nutritional supplement acceptance, chewing/swallowing abilities, skin impairments, hydration acceptance and eating ability.The Centers for Medicare and Medicaid Services Manual, titled Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2023, states: The Minimum Data Set (MDS) Assessment is a core set of screening, clinical and function status data elements which form the foundation of a comprehensive assessment for all residents. While its (MDS) primary purpose. is to identify resident care problems to address in an individual care plan.Section K related to Nutrition is required on the quarterly MDS assessment. R11 was admitted to the facility on [DATE] and has diagnoses that include type 2 diabetes mellitus with hyperglycemia (low blood sugars), gastro-esophageal reflux disease without esophagitis, chronic kidney disease, Alzheimer's disease, dementia, and hypothyroidism. R11's MDS assessment, dated 6/27/25, indicated that R11 is severely cognitively impaired. R11 has clear speech and can make self-understood and understands what is said to R11. R11's depression screening was scored 00, meaning R11 or Resident Representative (RR) G reported no or minimal symptoms of depression over the last two weeks prior to assessment. R11 does not exhibit signs of aggressing, isolation, or reject cares. R11 requires partial assistance to complete hygiene activities and dress. R11 needs supervision for eating, mobility and position changes, but R11 is ambulatory and likes to walk around the facility. R11's care plan, dated 7/11/25, with a target date of 10/15/2025, states: I am at risk for alteration in body mass and nutrition d/t therapeutic diet, . Alzheimer's, dementia, diabetes, .Goal: I will maintain adequate nutritional status as evidence by maintaining weight within 3-5 lb. range, no s/sx (signs or symptoms) of dehydration, no unacceptable nutrition labs and no skin break down through review date. Initiated 7/15/25, target date 10/15/25. Interventions include but are not limited to:CDM to monitor weekly weights and update RD and MD [Medical Doctor] with weight change of greater than 5# or significant wt (weight) gain or loss. - initiated 6/12/23CDM to notify RD with nutritional concerns regarding skin integrity or nutritional concern- initiated 6/12/23RD to assess diet, medications and nutrition on admit, readmit, significant change and prn (as needed) w/ (with) nutrition concerns. - initiated 6/12/23R11's quarterly nutrition assessments required for quarterly completion of the MDS were not consistently completed. Surveyor reviewed in computer and asked DM G and medical records for printed copies of dietary notes and assessments. R11 was readmitted in the 2nd quarter of 2024. Reviewing for this survey period, dietary failed to complete the quarterly assessment for the 3rd and 4th quarter of 2024, 2nd quarter of 2025 and 3rd quarter is pending. The last nutrition assessment dated [DATE] scored an 8 which indicated that R11 was at risk for malnutrition.Record review of dietary progress notes identified inconsistent completion of dietary assessment notes. Starting with June of 2024, the CDM completed nutrition risk assessment 6/29/24 only, missing the note for the 3rd and 4th quarters. The RD completed the annual assessment and note on 7/27/24. In 2025 there is no RD completed annual assessment. On 08/07/2025 at 11:33 AM, Surveyor interviewed R11's representative, RR G, who stated R11 has been losing weight over the last year. RR G stated RR G thinks it was the diabetic medicine R11 was on. RR G stated RR G got a call the other day that R11 has gained weight. RR G stated again, it might be because of the medication R11 is on, or possibly R11's Alzheimer's. RR G stated RR G is not worried about R11's weight loss.On 9/9/25 at 11:39 AM, Surveyor interviewed CDM E who stated, We missed the assessment in June. I don't know how. There are notes that we followed her but no assessment. CDM E stated we should be doing nutrition assessments quarterly. The RD is supposed to do an assessment annually. CDM E again stated DM does not know how they missed June. On 9/10/25 at 3:25 PM, MDS Coordinator H stated nutrition assessments are part of the quarterly MDS assessment.

Based on interview and record review, the facility failed to adequately assess and provide necessary care and services to attain or maintain the highest practicable physical wellbeing for 1 of 4 residents (R)(R27) reviewed for pain management.R27's care plan did not include resident's desired/tolerable pain level and pain assessments did not include characteristics, location, and duration to determine effectiveness of intervention or worsening of pain.This is evidenced by:Facility policy titled, Pain Management and Assessment, with a revised date of 06/2018, states in part: PURPOSE: To promote and prioritize the recognition, assessment, treatment and monitoring of pain. POLICY: To promote a systematic interdisciplinary and individualized approach to pain management. Pain will be reviewed by Nursing with the following: weekly summary charting review of PRN [As Needed] pain meds used, assess for pain every shift and documented on the electronic TAR [Treatment Administration Record], before and after administration of an as needed analgesic medication.R27 was admitted to the facility on [DATE], with pertinent diagnoses of encephalopathy, rhabdomyolysis, chronic pain, depression, and anxiety disorder.R27's admission Minimum Data Set (MDS) assessment, dated 06/23/25, noted a Brief Interview for Mental Status (BIMS) score of 08/14, indicating moderate cognitive impairment. R27 received scheduled and PRN pain medications. No non-medication interventions for pain noted. R27 has pain present frequently, occasionally affects sleep, and frequently interferes with therapy activities and day-to-day activities. R27's worst pain is noted 7/10.R27's care plan, dated 06/17/25, with a target date of 10/08/25, states: I have chronic pain and will state minimal to no pain when asked through review date with interventions of administer pain medication as ordered/requested, document effectiveness, assess location, frequency, duration and intensity of pain. Document assessment. Report increased pain trend to physician. Attempt non-pharmacological pain relief measures such as repositioning, back rubs, heat or cold, etc and document effectiveness. Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Monitor/record pain characteristics every shift and PRN. Quality (e.g., sharp, burning); Severity (1 to 10 scale); Anatomical location; Onset; Duration (e.g., continuous, intermittent); Aggravating factors; Relieving factors.R27's physician orders:6/17/25 Pain Scale every shift6/17/25 Acetaminophen Oral Tablet 500 MG (Acetaminophen)6/19/25 fentaNYL Transdermal Patch 72 Hour 25 MCG/HR (Fentanyl)7/4/25 HYDROmorphone HCl Oral Tablet 2 MG (Hydromorphone HCl) 7/24/25 Diclofenac Sodium External Gel 1 % (Diclofenac Sodium (Topical)8/1/25 Lidocaine External Patch 4 % (Lidocaine) R27's pain assessments noted pain present everyday since admission with a severity score of 1 or higher out of 10. No documentation to include quality, duration, location, or onset was noted. Non-pharmacological interventions were not noted.R27's medication administration record noted pain medications were administered per order with a follow-up evaluation of 'effective.' Pain assessments attached with medication administration note a severity score of 1-10. No documentation of quality, duration, location, or onset was noted.On 09/08/25 at 10:30 AM, Surveyor observed R27 lying in bed in room. Surveyor asked R27 about satisfaction of cares received at facility. R27 began to cry and stated it was ok. Surveyor asked if R27 was having pain. R27 stated all the time. Surveyor asked if the facility was addressing her pain concerns. R27 began to cry more and stated not really. Surveyor asked R27 what the facility was doing to help with pain. R27 stated she did not want to talk about it anymore.On 09/10/25 at 9:57 AM, Surveyor interviewed Licensed Practical Nurse (LPN) C regarding pain assessments. LPN C stated that residents are assessed for pain every shift and assessment should include a severity score of 1-10, if resident is verbal, and document the location, characteristics, quality, etc. Surveyor asked how efficacy is assessed and documented. LPN C stated by asking the resident. Surveyor asked if this is documented. LPN C stated this is usually only documented if a PRN med is administered, but not typically with scheduled pain meds. Surveyor asked if non-pharmacological interventions are used and documented. LPN C stated that it should be.On 09/10/25 at 1:49 PM, Surveyor interviewed Director of Nursing (DON) B regarding pain assessments. DON B stated that pain assessments should include severity score, characteristics, duration, quality, etc. and should be documented. Residents with chronic pain are more difficult to assess since pain is always there, so frequency, location, quality, duration is not typically documented with every pain assessment. Surveyor asked DON B how changes in pain would be assessed in chronic pain. DON B stated that the nursing staff know the residents well and would know if there was a change. Surveyor asked DON B if residents are included in care planning of chronic pain management to indicate a tolerable level of pain or interventions to help alleviate pain. DON B stated they do include the resident and/or family, but don't ask about a tolerable level to determine baseline. DON B stated that a weekly assessment of patient satisfaction with pain management is completed, but that it is not documented.

Based on interview and record review, the facility did not ensure each resident's drug regimen was free from unnecessary medications for 1 of 6 residents (R) (R4) reviewed.R4 was prescribed an antidepressant without adequate indication for use. This is evidenced by:Facility policy titled, Psychotropic Medications, with an effective date of 08/2021, states in part: POLICY: To review psychotropic medications for correlating diagnosis, appropriateness and reduction. To ensure that each residents medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing. 5. The resident Plan of Care shall address specific behaviors and interventions. 6. The attending physician will document their review, the continued need for, and the effectiveness of the antipsychotic medication in their progress note at the time of their visit.R4 was admitted to the facility on [DATE], with pertinent diagnoses of cerebral infarction, developmental disorder of speech and language, and mild cognitive impairment.R4's admission Minimum Data Set (MDS) assessment, dated 08/18/25, noted a Brief Interview for Mental Status (BIMS) was not completed as resident is rarely/never understood. R4's PHQ9 OV score was 02, indicating minimal depression symptoms.R4's care plan, initiated on 09/10/25, with a target date of 12/03/25, states: I exhibit mood symptoms r/t adjustment disorder with depressed mood and will have improved mood state happier with interventions of administer medications as ordered. Monitor/document for side effects and effectiveness. Monitor/record mood to determine if problems seem to be related to external causes, i.e. medications, treatments, concern over diagnosis. Monitor/record/report to MD prn mood patterns s/sx of depression, anxiety, sad mood as per facility behaviour monitoring protocols. Monitor for flat affect, turning face away from people with interactions as mood symptoms.-Of note: mood/behavior monitoring for depressive symptoms was initiated 10 days after the start of the antidepressant medication.R4's physician orders:8/31/25 Celexa oral tablet 10 mg (Citalopram Hydrobromide) Give 1 tablet by mouth in the morning related to adjustment disorder with depressed mood-Of note: this diagnosis was added to R4's electronic medical record on 08/30/25.Surveyor reviewed R4's behavior monitoring and did not note any behavior or mood symptoms related to depression documented. Surveyor reviewed communication to provider, dated 08/28/25, that stated: Caregiver/guardian feels that [R4] is depressed - they note [R4] was usually very happy - smiling but since being in hospital and nursing home she is flat and rarely smiles. They report that prior to CVA [Cerebrovascular Accident], she would turn her head away from them when she is upset and they are noting she does this frequently with their visits. They would like her to have an antidepressant. Can you order an antidepressant for situational depression?Provider responded on 08/29/25: Celexa 10 mg PO [by mouth] every day-Of note: no provider assessment documented noted reviewing behavior/mood monitoring prior to ordering antidepressant.On 09/10/25 at 2:19 PM, Surveyor interviewed Director of Nursing (DON) B regarding initiating of R4's antidepressant. DON B stated the facility frequently uses input from family and caregivers regarding mood and behaviors to determine use of antidepressants since they know the resident best. Surveyor asked if R4 was assessed for depressive mood or behaviors prior to the use of antidepressant. DON B stated no, because they were not familiar with what behaviors R4 demonstrates when depressed as this was later learned from R4's caregivers. Surveyor asked DON B if R4 was assessed for alternative causes of behavior or mood changes such as pain. DON B stated no.

Based on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This affected 2 of 2 residents (R) reviewed for infection control (R2, R9) Certified Nursing Assistant (CNA) F did not practice proper hand hygiene during cares for R2. Environmental Manager (EM) D was in a R9's room and did not cover nose or mouth while sneezing and did not wipe down the surface prior to leaving the room.Findings include:The facility policy, titled [Name of Facility] Subject: Handwashing, dated 1/2017, states: 5. Except for a true emergency, personal should always wash their hands:a. Before and after their tour of duty.c. Before and after physical contact with each residentd. After handling a source that is likely to be contaminated, such as equipment, dressings, and secretions and excretions form residents.g. After using the bathroom, blowing your nose or covering a sneeze or cough. Attached to the policy is a document that says CDC [Center for Disease Control] . Recommendations. to clean your hands, Immediately before touching a patient Before moving from work on a soiled body site to a clan body site on the same patient. After touching a patient or patient's surrounds After contact with blood, body fluids, or contaminated surfaces Immediately after glove removal.When to use alcohol-based hand sanitizer.When to wash with soap and water.Example 1:R2 was admitted to the facility on [DATE], with diagnoses that include dementia, major depressive disorder, cardiomegaly, chronic obstructive pulmonary disease, osteoarthritis, and retention of urine.R2's Minimum Data Set (MDS) assessment dated [DATE], indicates that R2 is severely cognitively disable but does not exbibit any delirium or behaviors. R2 needs substantial assistance with hygiene, dressing, and position changes. On 9/9/25 at 6:52 AM, Surveyor observed morning cares on R2. CNA F and CNA L transferred R2 to the bathroom via EZ stand lift. CNA F performed hand hygiene and put on glove and then removed R2's soiled brief. CNA F continued to perform R2's personal cares with contaminated gloves. CNA F then took off gloves, washed hands and put on new gloves, helped R2 to stand, performed pericare, and then placed R2 in a sitting position. CNA F, who was still wearing the contaminated gloves after performing pericare, proceeded to change the pad and top sheet on R2's bed. CNA F then took off gloves, sanitized hands and put on new gloves. LPN M came into R2's room to change a dressing. At this time, CNA F applied barrier cream to R2, took off gloved, did not perform hand hygiene, and applied new gloves.On 9/10/25 at 9:02 AM, Surveyor interviewed CNA F regarding hand hygiene and when this should be done. CNA F stated when hand hygiene should be completed. Surveyor asked when it would be appropriate to use soap and water versus hand sanitizer. CNA F stated at the very beginning and very end, and in between if you are doing peri care. Surveyor shared observations with CNA F of pulling a brief and getting new clothes, making a bed with same gloves, and taking gloves off, touching radio. CNA F stated I should have washed my hands. It's considered going dirty to clean.On 9/10/25 at 12:44 PM, Surveyor interviewed DON B, who stated DON B expects all staff to wash their hands before they enter a room, after they have been in a room, if they touch a surface in a resident's room, if they are doing cares, before they put on the gloves, and when they take them off. Example 2On 09/09/2025 at 11:11 AM, Surveyor observed EM D in room [ROOM NUMBER] helping with R9's TV and holding R9's TV remote. EM D was facing TV when EM D sneezed. EM D did not cover his sneeze. EM D did bend over at the waist when EM D sneezed, stood up, and continued with the task. EM D left the room. EM D did not wipe any surfaces, wash ED M's hands, or use hand sanitizer before leaving R9's room. EM D did not use the hand sanitizer on the hall wall. EM D left the floor, touching the doorknob to the vestibule leading to the elevator.On 09/09/2025 at 3:00 PM, Surveyor interviewed DON B, who stated that all staff, including environmental/maintenance, are provided annual training on infection control and hand washing.

Based on observation, interview and record review, the facility did not provide pharmaceutical services, including procedures that ensured the accurate acquiring, dispensing, administering, storage, and disposal of all drugs and biologicals. Licensed Practical Nurse (LPN) C administered an insulin dose without prior priming of the insulin pen for 1 out of 2 residents (R34) observed for insulin administration.Findings include:Facility's administration procedures states in part, Giving the injection. Prime the pen. The pen must be primed before the resident dose is set and insulin is injected. This will be done by giving an air shot. This removes the air bubbles and ensures the pen and the needle are working properly.R34 was admitted to the facility on [DATE], with diagnoses including epilepsy, hemiplegia following cerebral infarction, and type 2 diabetes mellitus.R34's physicians orders include, Lantus Solution (Insulin Glargine) inject 50 units subcutaneously in the morning related to type 2 diabetes.On 9/10/2025 at 7:18 AM, Surveyor observed LPN C place a new, disposable insulin needle on R34's Lantus pen and dial the pen to 50 units. LPN C then administered the insulin into R34's abdomen and returned to medication cart. Upon returning to medication cart, Surveyor interviewed LPN C about priming the insulin pen. LPN C stated she has never been instructed to prime the insulin pen, and she has never primed insulin pens in the past.On 9/10/2025 at 7:32 AM, Surveyor interviewed Director of Nursing (DON) B, who stated the expectation would be the insulin pens are primed with 2 units prior to dosing with prescribed dose. During the interview with DON B, LPN C asked DON B how to prime the insulin pen and DON B instructed her how to prime an insulin pen.

Based on observation, interview and record review, the facility did not provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections. The facility did not ensure proper infection control practices were followed during and after resident care. This occurred for 1 of 1 resident (R)1. Findings include: R1 was admitted to the facility on [DATE] with diagnoses that include dementia, cerebral palsy, stroke, type 2 diabetes, epilepsy, and left sided paralysis. R1's Minimum Data Set (MDS), dated [DATE], indicates R1 had a Brief Interview for Mental Status (BIMS) score of 5 indicating severe cognitive impairment. R1's care plan identifies that R1 is unable to walk and requires 2 assist for bed mobility, transfers, and toileting. R1 uses a broda chair and a hoyer lift. On 06/19/24 at 7:36 AM, Surveyor observed Certified Nursing Assistant (CNA) C and CNA D provide pericare for R1. CNA D provided the peri care, doffed gloves and did not sanitize hands and proceeded to grab hoyer sling, placed under R1, pushed curtain back, grabbed hoyer, attached sling, raised R1 up, placed R1 in a broda chair, donned gloves again, then grabbed R1's dentures. Surveyor stopped CNA D due to failure to sanitize hands after removing gloves following pericare. Surveyor asked CNA D if she forgot anything. CNA D stated she was not sure. Surveyor stated that CNA D should have sanitized her hands after doffing gloves from doing pericare and applying new gloves to then provide R1 denture care. CNA C discarded the soiled water from the wash basin in the sink with R1's denture cup present. Surveyor asked CNA C if it is common practice to discard the soiled water in the sink. CNA C stated she did not know that was a rule and apologized. On 06/19/24 at 8:50 AM, Surveyor interviewed DON B and was asked what the expectation would be for hand hygiene following doffing gloves and where dirty wash basin water should be discarded after use. DON B replied that hand hygiene should be completed every time after doffing gloves and basins should be emptied in the toilet.

Based on interview and record review, the facility failed to implement written policies and procedures when staff did not report an incident of caregiver neglect to the administrator immediately for 1 of 3 residents (R) reviewed for abuse and neglect. (R20) Findings include: R20 was admitted to the facility on [DATE] with diagnoses including, in part, cerebral palsy, unsteadiness on feet, absence epileptic syndrome, and lichen simplex chronicus. R20's Minimum Data Set (MDS) assessment, dated 01/03/24, identified that R20 had a Brief Interview for Mental Status (BIMS) score of 00. This indicated R20 had significant cognitive impairment and was unable to perform an accurate BIMS. The MDS assessment also identified R20 required extensive assistance of two people for bed mobility and toileting and was dependent on two people for transfers. R20's care plan included: -Mobility plan: I transfer with the assistance of two and Hoyer lift, 03/12/24. On 06/19/24 at 10:34 AM, Surveyor interviewed Certified Nurse Assistant (CNA) G who indicated that CNA M had transferred R20 by CNA M's self in February and dropped R20 on the floor. CNA G indicated that CNA M had tripped over R20's non-functional leg and dropped R20 on the floor. CNA G indicated that R20 suffered a swollen hip due to the fall but that no one reported the fall to the appropriate personnel. Surveyor asked CNA G if CNA G reported this incident to the administration, and CNA G indicated that CNA G did let DON B know about CNA M dropping R20 on the floor. CNA G indicated that CNA M keeps transferring residents alone who are ordered to be assisted by 2 or mechanical Hoyer lifts instead of receiving assistance with resident transfers. On 06/20/24 at 7:41 AM, Surveyor interviewed CNA M with another Surveyor present and asked to explain the process with R20 and the fall that occurred in February. CNA M indicated that CNA M did drop R20 during a stand pivot transfer in February. CNA M indicated CNA M does not remember the exact day in February that R20 fell but that it was on the day shift. CNA M indicated that CNA M was transferring R20 with a walker and gait belt. R20's foot went dead, CNA tripped on leg and then CNA M and R20 both fell to the ground. CNA M indicated that CNA M reported this to Registered Nurse (RN) L right away. CNA M indicated that RN L came in and assessed R20. CNA M indicated that R20 did not receive any injuries that CNA M was aware of and then therapy came and assessed R20. CNA M indicated that therapy deemed R20 to be a transfer with a Hoyer lift only. On 06/20/24 at 7:52 AM, Surveyor interviewed RN L and asked if RN L was aware of R20's fall in February. RN L indicated that RN L was aware of R20's fall. Surveyor asked RN L if RN L remembers what RN L's process was for post-fall assessment and reporting the fall. RN L indicated that RN L received notice from CNA M that R20 had fallen in R20's room during CNA M transferring R20. RN L was unaware of who helped CNA M transfer R20 as R20 was assist of 2 transfers at that time. On 06/20/24 at 10:01 AM, Surveyor interviewed Physical Therapy Assistant (PTA) N and asked what R20's transfer status was in February 2024. PTA N indicated that R20 has always been an assist of 2 pivot transfer when feeling strong or assist of 2 with mechanical Hoyer lift. On 06/20/24 at 10:53 AM, Surveyor interviewed DON B and asked if staff had reported CNA M transferred R20 alone when R20 needed assist of 2 for R20's fall in February. DON B indicated that DON B was not aware of R20 falling due to improper transfer technique. The only incident that was known was CNA M indicated that CNA M injured CNA M's foot by tripping over the wheelchair pedal in R20's room in February. DON B indicated that if a resident has fallen, staff need to report the fall right away to the charge nurse, charge nurse assesses the resident, provides proper interventions and investigate the root cause. This would determine if caregiver neglect occurred with the transfer. DON B indicated there was no documentation of R20 falling in February, the CNA misconduct was not reported to administration.

Based on observation, staff and resident interview, and record review, the facility did not have sufficient nursing staff to ensure the highest practicable physical, mental, and psychosocial well-being. This occurred for 3 of 12 residents reviewed (R4, R9, R2) This is evidenced by: The Facility Assessment staffing plan updated on 01/2023, indicated licensed nurses providing direct care; 5 (average 40-50 hours), and nurse aides: 12 (average 90-96 hours). Review of facility schedules and daily postings confirmed staff hours aligned with Facility Assessment. Surveyor observations of call light times, mechanical lift transfers, toileting, and hygiene assistance indicated the facility was not adequately staffed to meet resident needs. The facility provided additional information related to resident needs during the survey period from 06/18/24-06/20/24, confirming 33 residents are dependent on staff for needs related to activities of daily living, 15 residents are dependent on staff for mechanical lift transfers. Staff interviews confirmed the facility required two trained staff to assist with mechanical lift transfers. The facility policy titled General Care of Residents, revised on 06/2018, stated in part . 9. Call Lights a. Staff will respond to call lights timely. b. If responding to a call light and you are assisting another resident, inform the resident you are assisting another resident and will return shortly and turn off call light. c. If other departmental staff answers call lights, let the resident know that you will tell the nursing staff and turn off the call light. Example 1 R4 was admitted to the facility on [DATE]. Diagnoses included heart failure, cellulitis of upper limb, chronic kidney disease, chronic obstructive pulmonary disease, and shoulder pain. R4 was admitted with a stage 1 pressure injury to right buttock. Minimum Data Set (MDS) assessment, dated 06/06/24, confirmed R4 scored 10/15 during Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. R4's MDS assessment reported R4 is frequently incontinent of urine and always incontinent of bowel. R4 required substantial assistance with toileting, showering, and dressing, and was dependent on staff for transfers with mechanical hoyer lift. R4's care plan included: -Toileting plan: I am on a toileting schedule. Take me upon rising, before meals, after meals, bedtime, and as needed during the night, 05/31/24. The following occurred on 06/19/24 during a continuous observation from 10:22 AM-11:41 AM, for 79 minutes. Surveyor observed nine facility staff members (Director of Nursing, Assistant Director of Nursing, Physical Therapist, two licensed nursing staff, and four Certified Nursing Assistants), walk past R4's room while his call light was on, or turn off R4's call light without ensuring R4 received assistance. -10:22 AM, Surveyor observed R4 in his room, sitting in a Broda chair. Surveyor observed R4's call light was on and R4 was calling out stating he needed to use the bathroom. -10:54 AM, Surveyor interviewed CNA G. CNA G reported she was not assigned to R4's hall. CNA G stated she is working on the other hallway training CNA J. CNA G stated she assists on R4's hallway as she can as it is a heavy hall, but not all staff assist with answering resident call lights in unassigned areas. CNA G stated, With charting, no, I am not able to complete all of my workload. Surveyor observed CNA G and CNA J walk towards R4's room, where R4's call light was on. Surveyor observed CNA G and CNA J exit the hallway through a door immediately adjacent to R4's room. CNA G stated, We are finally going on break. Surveyor observed R4's call light continued to be on. -11:05 AM, Surveyor observed LPN I entered R4's room. R4 stated he needed to use the bathroom. LPN I turned off R4's call light and stated to R4 she would tell the staff. -11:17 AM, Surveyor observed R4's call light was off. Surveyor interviewed R4, R4 stated he needed to use the bathroom, and no one had helped him. Surveyor encouraged R4 to use his call light to request staff assistance. R4 did engage his call light and stated, It doesn't do any good anyway. -11:41 AM, Surveyor observed CNA D and CNA G assist R4 with mechanical lift transfer to his bed. Surveyor observed CNA D and CNA G assist R4 with incontinence care of both bowel and bladder. On 06/20/24 at 1:42 PM, Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A reported the facility considers resident acuity when developing staffing patterns. NHA A reported staffing is discussed each morning during the facility's morning meeting, and stated, We move things around based on what is discussed in morning meeting, admissions, discharges, change in condition. Surveyor reported to NHA A the observation of R4 requesting to use the bathroom and not receiving assistance for 79 minutes. NHA A did not make any statements related to the incident. 17661 Example 2 R9 has an active pressure related deep tissue injury to the right heel. R9 remains a high risk for the development of additional PIs related to comorbidities as well as immobility and bowel and bladder incontinence. On 6/19/24, a continuous observation of 4 hours 41 minutes was conducted (7:18 AM - 11:59 AM) in which toileting and repositioning was not offered. Once staff did assist R9 onto the bed for incontinence care, R9's buttocks was red and wrinkled from no pressure redistribution and the incontinence of urine and feces. Interviews were conducted with staff in which they indicated staffing was insufficient on that day, with three new and one seasoned Certified Nursing Assistant working the two halls in which residents reside. Please refer to F677 and F686 for details. 48793 Example 3 R2 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, dementia, heart failure, anemia, and hypertension. Minimum Data Set (MDS) assessment dated [DATE] confirmed R2 scored 03/15 during Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. R2's MDS assessment reported R2 is frequently incontinent of urine and always incontinent of bowel. R2 required substantial assistance with toileting, showering, and dressing, and was dependent on staff for transfers. The follow occurred on 06/19/24 during a continuous observation from 1:05 PM-2:14 PM, for 1 hour and 9 minutes. Surveyor observed four facility staff members (Director of Nursing, two licensed nursing staff, and Activities Director) walk by R2's call light. On 06/19/24 at 1:05 PM, Surveyor observed R2's call light on when ambulating down the hallway. Surveyor observed CNA G walk past R2's call light and enter another resident room. On 06/19/24 at 1:06 PM, Surveyor entered into R2's room and asked how R2 was. R2 indicated that R2 had to use the bathroom badly and wanted to get into bed as R2 was tired. On 06/19/24 at 1:25 PM, Surveyor observed R2's call light still on. Surveyor observed CNA J walk by R2's room. On 06/19/24 at 1:41 PM, Surveyor observed R2's call light still on. Surveyor observed Activities Director E walk by R2's room. On 06/19/24 at 1:59 PM, Surveyor observed R2's call light still on. Surveyor observed DON B enter R2's room and ask R2 what R2's needs were. R2 indicated that R2 had to use the bathroom and get into bed. DON B turned the call light off and indicated that DON B would let a staff member know that R2 needed assistance in R2's room. Surveyor observed DON B exit R2's room and walk down the hallway. On 06/19/24 at 2:02 PM, Surveyor observed R2's call light go on again. On 06/19/24 at 2:14 PM, Surveyor observed CNA G entering R2's room. Surveyor interviewed CNA G and asked if DON B had informed CNA G that R2 needed assistance. CNA G indicated no DON B did not let CNA G know of R2's need. CNA G indicated that CNA G now had time to answer R2's call light.

Based on observation, interview and record review, the facility did not ensure each resident receives necessary respiratory care and services that is in accordance with professional standards of practice for 1 of 1 resident (R) reviewed for respiratory care. (R6) The facility did not clean oxygen filter, change nasal cannula tubing, and ensure R6 received oxygen at the ordered rate according to physician orders. This is evidenced by: R6 was admitted to the facility on [DATE] and has diagnoses that include acute and chronic COPD, congestive heart failure, stroke, stage 5 kidney disease, and is receiving hospice services. On 06/18/24 and 06/19/24, Surveyor observed R6 using oxygen via nasal cannula continuously via a black oxygen concentrator set at 2 liters per minute. Surveyor interviewed R6 on 06/18/24 at 10:17 AM. At that time, R6 stated he had trouble breathing and has been on oxygen continuous for years but does take it off when smoking. R6's medical record reveals physician orders as follows: -Start date: 04/12/24 Oxygen at 3 liters per minute via nasal cannula as needed for shortness of breath -Start date: 12/20/23 Change and label oxygen tubing as needed when Oxygen is in use -Start date: 12/20/23 TAN MACHINE-Clean O2 filter with warm water, dry with towel, and replace BLUE MACHINE-Clean the air intake vents on the back of the machine as needed when oxygen is in use. (R6 is currently using a black oxygen concentrator. Facility did not provide the manufacturer instructions or policy and procedure for oxygen/respiratory care as requested.) On 06/19/24, Surveyor was unable to locate any information within R6's medical record as to when R6's nasal cannula was changed and oxygen concentrator filter was washed. On 06/19/24 at 1:42 PM, Surveyor interviewed Licensed Practical Nurse (LPN) H about the amount of oxygen R6 is to be receiving. LPN H stated, I think R6 is on 2 liters per minute, then looked up the order that read Oxygen at 3l/min via NC as needed. LPN H clarified that R6 has been using oxygen continuously. Surveyor asked if LPN H could tell when R6's tubing was changed and oxygen filters were washed. LPN H reviewed the medical record and stated, No one is signing it out, so I am not sure, I can do this after I finish passing medications. Surveyor saw Director of Nursing (DON) B in hallway and asked DON B to come to R6's room. DON B confirmed R6's oxygen flow rate was at 2 liter per minute instead of the correct order for 3 liters per minute. Surveyor asked how often the tubing is changed and filters are rinsed. DON B stated they are done weekly on the night shift and could not find a date on the nasal canula tubing. Surveyor then removed the filter on the back of the oxygen concentrator and there was visible dust, light beige in color, on the black filter. DON B stated the concentrator is from hospice and R6 only had it about 2 weeks. DON B stated she will address these issues.

Based on observation, interview and record review, 2 of 3 residents (R20 and R27) at risk for falls did not receive adequate supervision and assistance devices to prevent accidents. R20 required the assistance of 2 staff for transfers. CNA M transferred R20 with one person and R20 fell . R27 was at risk for falls. R27's fall interventions included wearing a knee immobilizer to the right knee during all transfers for stability. CNA G was observed transferring R27 from the wheelchair to the bed without using R27's knee immobilizer. Findings include: Example 1: R20 was admitted to the facility on [DATE] with diagnoses including, in part, cerebral palsy, unsteadiness on feet, absence epileptic syndrome, and lichen simplex chronicus. R20's Minimum Data Set (MDS) assessment, dated 01/03/24, identified that R20 had a Brief Interview for Mental Status (BIMS) score of 00. This indicated R20 had significant cognitive impairment and was unable to perform an accurate BIMS. The MDS assessment also identified R20 required extensive assistance of two people for bed mobility and toileting and was dependent on two people for transfers. R20's care plan included: -Mobility plan: I transfer with the assistance of two and Hoyer lift, 03/12/24. On 06/19/24 at 10:34 AM, Surveyor interviewed Certified Nurse Assistant (CNA) G who indicated that CNA M had transferred R20 by CNA M's self in February and dropped R20 on the floor. CNA G indicated that CNA M had tripped over R20's non-functional leg and dropped R20 on the floor. CNA G indicated that R20 suffered a swollen hip due to the fall but that no one reported the fall to the appropriate personnel. Surveyor asked CNA G if CNA G reported this incident to the administration, and CNA G indicated that CNA G did let Director of Nursing (DON) B know about CNA M dropping R20 on the floor. CNA G indicated that CNA M keeps transferring residents alone who are ordered to be assisted by 2 or mechanical Hoyer lifts instead of receiving assistance with resident transfers. On 06/20/24 at 7:41 AM, Surveyor interviewed CNA M with another Surveyor present and asked to explain the process with R20 and the fall that occurred in February. CNA M indicated that CNA M did drop R20 during a stand pivot transfer in February. CNA M indicated CNA M does not remember the exact day in February that R20 fell but that it was on the day shift. CNA M indicated that CNA M was transferring R20 with a walker and gait belt. R20's foot went dead, CNA tripped on leg and then CNA M and R20 both fell to the ground. CNA M indicated that CNA M reported this to Registered Nurse (RN) L right away. CNA M indicated that RN L came in and assessed R20. CNA M indicated that R20 did not receive any injuries that CNA M was aware of and then therapy came and assessed R20. CNA M indicated that therapy deemed R20 to be a transfer with a Hoyer lift only. On 06/20/24 at 7:52 AM, Surveyor interviewed RN L and asked if RN L was aware of R20's fall in February. RN L indicated that RN L was aware of R20's fall. Surveyor asked RN L if RN L remembers what RN L's process was for post-fall assessment and reporting the fall. RN L indicated that RN L received notice from CNA M that R20 had fallen in R20's room during CNA M transferring R20. RN L was unaware of who helped CNA M transfer R20 as R20 was assist of 2 transfers at that time. RN L assessed R20 from head to toe and gathered vitals every 15 minutes for the first half hour, then vitals every 30 minutes for the next 4 hours, and then an hour for the next 24 hours. RN L indicated that all vitals and neuros post-fall are documented on a paper flowsheet located in R20's hard chart. RN L indicated that physician notification was completed and should be in R20's Electronic Health Record (EHR). Surveyor asked RN L to show Surveyor documentation in R20's EHR about the fall incident in February, vitals, neuros, and contact of the physician notification. RN L indicated that RN L could not find any of the documentation in R20's EHR. RN L indicated that RN L thinks RN L had documented it but maybe RN L did not after all. On 06/20/24 at 10:01 AM, Surveyor interviewed Physical Therapy Assistant (PTA) N and asked what R20's transfer status was in February 2024. PTA N indicated that R20 has always been an assist of 2 pivot transfer when feeling strong or assist of 2 with mechanical Hoyer lift. PTA N indicated that R20 has never been an assist of 1 due to the instability of R20's non-functional leg. Surveyor asked if PTA N remembers R20 falling in February and PTA N indicated that PTA N is unaware of a fall in February. On 06/20/24 at 10:53 AM, Surveyor interviewed DON B and asked about any knowledge of R20's fall in February. DON B indicated there was no fall. Surveyor explained to DON B that through several interviews R20 had suffered a fall with minor injury to the right hip. DON B indicated that DON B was not aware of R20 falling and the only incident that was known was CNA M indicated that CNA M injured CNA M's foot by tripping over the wheelchair pedal in R20's room in February. DON B indicated that if a resident has fallen, staff need to report the fall right away to the charge nurse, charge nurse assesses the resident, provides proper interventions to keep the resident safe, documents the fall as an incident, and reports the incident to DON B and the physician. Surveyor asked DON B to find any documentation in R20's EHR about the fall in February. DON B indicated there was no documentation of R20 falling in February. Example 2: R27 was admitted to the facility on [DATE] with diagnoses including, in part, infection and inflammatory reaction due to unspecified internal joint prosthesis, urinary tract infection, obstructive and reflux uropathy, type 2 diabetes, unspecified dementia, and pyogenic arthritis. R27's Minimum Data Set (MDS) assessment, dated 03/27/24, identified that R27 had a Brief Interview for Mental Status (BIMS) score of 09. This indicated that R27 had significant cognitive impairment. The MDS assessment also identified R27 required extensive assistance of one to two people for bed mobility, and toileting and was dependent on one person for stand pivot transfers. R27's care plan included: -Mobility plan: Assist of 1 person pivot transfer with a two-wheeled walker or the transfer pole, use a gait belt, and hold onto it for safety. Needs locking knee brace on right leg for transfers, 04/15/24. -ADL plan: Please put a locking knee brace on the right knee when getting up in the morning, 04/15/24. -Before getting out of bed, don podus boot and knee brace to right lower extremity, 02/16/24. -When in bed resident to use blue puffy boots to right lower extremity, 02/16/24. -Potential for pressure ulcer development plan: Immobilizer to right leg when up, remove every shift to check skin, 04/30/24. -The resident requires air/float mattress to bed, pressure reduction cushion to wheel chair. Podus boot to right foot at all times, 02/05/24. On 06/19/24 at 2:07 PM, Surveyor observed CNA G transfer R27 from the wheelchair to bed without an immobilizer brace on the right leg. On 06/19/24 at 2:14 PM, Surveyor interviewed CNA G and asked if R27 was supposed to have an immobilizer brace on the right leg when transferring to and from bed or wheelchair. CNA G indicated that R27 should have an immobilizer brace on the right leg any time R27 is transferring and ambulating. CNA G indicated CNA G did not place the brace on as CNA G usually puts it on in the a.m. when R27 gets up, but he was sent to the hospital overnight and didn't get back till mid-morning. On 06/19/24 at 2:45 PM, Surveyor interviewed Licensed Practical Nurse (LPN) I and reviewed R27's medical record for transfer status. LPN I indicated that R27 should have an immobilizer brace on the right leg when up and ambulating. On 06/20/24 at 10:01 AM, Surveyor interviewed PTA N and asked what R27's transfer status was. PTA N indicated that R27 is an assist of 1 pivot transfer. PTA N indicated that R27 is to wear an immobilizer brace to the right leg with any transfers and when up for the day for stability post knee surgery to prevent injury. On 06/20/24 at 1:02 PM, Surveyor interviewed DON B and asked the expectation of R27 to wear R27's immobilizer brace to the right knee. DON B indicated that R27 is to always wear the brace once out of bed and transfer to a wheelchair or bathroom. Surveyor indicated observations of CNA G transferring R27 from a wheelchair to a bed without an immobilizer. DON B indicated that CNA G should have transferred R27 with the right immobilizer brace for stability.

Based on observations, interviews and record reviews, the facility failed to ensure 3 of 3 residents reviewed for high risk of pressure injury (PI) development (R9, R5 and R27), received the necessary treatment and services to promote healing of existing skin impairments or prevent new pressure injuries from developing. - R9 has an active pressure related deep tissue injury to the right heel. R9 remains a high risk for the development of additional PIs related to immobility and bowel and bladder incontinence. An observation of 4 hours 41 minutes was conducted in which repositioning was not offered. Once staff did assist R9 onto the bed for incontinence care, R9's buttocks was red and wrinkled from no pressure redistribution and the incontinence of urine and feces. - R5 is a high risk for PI and has a current PI on the scapula. R5 was not offered or attempts made to reposition R5 off the scapula for over 4 hours. - R27 is a high risk for the development of PIs and has a current PI on the right heel, in which the resident was to wear a Podus boot at all times while in bed. Observations were made in which the Podus boot was not applied to R27. This is evidenced by: Facility policies and procedures for Skin Integrity, Pressure Ulcer Staging and Wound Care Protocol and General Care For All Residents were reviewed. Neither policy gives clear direction to staff on repositioning guidelines for residents either at high risk for the development of PIs or for those with current PIs. There was a section in the Pressure Ulcer Staging and Wound Care Protocol for all wounds that the care plan will be initiated. Also, for any deep tissue injuries to the heel, staff are to place pressure relief boots on at all times. According to the National Pressure Injury Advisory Panel (NPIAP) 2019, page 115, . Repositioning and mobilizing individuals is an important component in the prevention of pressure injuries. The underlying cause and formation of pressure injuries is multifaceted; however, by definition, pressure injuries cannot form without loading, or pressure, on tissue. Extended periods of lying or sitting on a particular part of the body and failure to redistribute the pressure on the body surface can result in sustained deformation of soft tissues and, ultimately, in tissue damage . According to Wound Care Education Institute (2018), for immobile or bed bound individuals, a full change in position should be conducted a minimum of every two hours. Some individuals require more frequent repositioning due to their high risk status. According to RESNA (Rehabilitation Engineering & Assistive Technology Society of North America) 2015, Position on the Application of Tilt, Recline, and Elevating Leg Rests for Wheel chairs, a lift from a seated position requires at least 2 minutes in order for tissue to return to off-loading levels. (If not, it is only a microshift). RESNA continues to recommend the following for tilt, recline and elevating chairs, such as the Broda: - Tilt, when used alone, must be greater than about 25 to achieve pressure relief and/or tissue perfusion at the ischial tuberosities. - Recline, when used alone, can increase shear but may provide reduction in pressure at the ischial tuberosities at angles greater than 90-100 . - The greatest reductions in pressure are seen when tilt and recline are used together, either at tilt of 35 with recline 100 or tilt of 15-25 with recline of 120 . Example 1 R9 has medical diagnoses that include but are not limited to, diabetes mellitus type 2, a recent cerebral infarction (3/6/24), heart failure, arteriosclerotic heart disease of the native coronary artery, paroxysmal atrial fibrillation, unspecified depression and dementia. According to the most recent MDSA (Minimum Data Set Assessment), which was a Significant Change in Status Assessment with an Assessment Reference Date of 3/18/24, R9 has impaired short-term and long-term memory and severely impaired daily decision making abilities. R9 has no behavioral or mood indices Also according to this assessment, R9 required partial to moderate assistance of staff for moving from sitting to lying and lying to sitting positions to the side of the bed and is dependent on staff for toileting hygiene, upper and lower body dressing, mobility and personal hygiene. R9 is transferred with the use of a full body mechanical lift with the assistance of two staff and is frequently incontinent of bladder function and always incontinent of bowel function. Surveyor reviewed the Comprehensive Care Plan (CCP) completed for R9 and noted the following: 1. Activities of Daily Living (initiated 4/17/23 and last revised 4/30/24): Interventions included: - I need staff assist of 1 with dressing. (4/17/23) - I need the assist of two with the Hoyer (3/12/24) - I need partial assist from staff with grooming. (4/17/23) 2. I am both continent and incontinent of bowel and bladder (initiated 4/25/23 and last revised 4/30/24) Interventions for this problem included: - Scheduled toileting: every 2 hours and PRN (as needed) - Staff assist of 2 with hoyer to assist me with transferring on and off toilet/commode. 3. I have impaired mobility . (initiated 4/25/23 and last revised 6/3/24): Interventions for this problem included: - Anticipate needs, such as toileting. - I need assist of 1 with turning and repositioning in bed. - I use a Broda chair to get to destinations. I am dependent on staff with chair mobility 4. has potential for pressure ulcer development r/t (related to) Immobility, bowel incontinence, bladder incontinence, has SDTI (Suspected deep tissue injury) to right heel. (start 4/25/23; revised 6/3/24) Interventions for this problem include: - Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. - Follow facility policies/protocols for the prevention/treatment of skin breakdown. - Heel lift boots on at all times - Teach resident/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes. - The resident needs assistance of 1 staff to turn/reposition at least every 2 hours, more often as needed or requested. - The resident requires alternating air mattress overlay to bed, Broda chair for pressure reduction when up. Surveyor then reviewed the Braden Scale For Predicting Pressure Sore Risk assessments completed for R9 and noted R9 was scored the following: - 5/5/2024-14 - 6/2/2024-14 - 6/6/2024 -13 - 6/13/2024-13 Note: Scoring for Braden assessments are as follows: - 15-18 indicates individual is at risk for the development of a PI; - scores of 13-14 indicates a moderate risk; - scores of 10-12 indicates a high risk; and - scores of 9 or less indicates a very high risk. Further review of R9's medical record was completed and noted R9 developed an unstageable PI to the right heel on 6/2/24. Interventions were put into place to apply Podus boots at all times and to reposition at least every two hours. Prosource supplements were added as a dietary intervention to promote healing. On 6/19/24, Surveyor made the following observation of R9: - At 7:18 AM, R9 was up in the Broda chair in her room. R9 was seated at 90 degrees from hips to legs and at a straight 90 degrees from hips to back. R9's legs were also at a straight 90 degrees from knees to ankles. R9 was sitting on the mechanical lift sling and a small blanket covered R9's lap. - At 7:58 AM, R9 was taken to the Main Dining Room (MDR) and placed at a table in preparation for the morning meal. R9 was served her meal at 8:02 AM by nursing student (NS) K, who sat beside R9 and fed her the meal. - At 9:10 AM, R9 completed the meal and was propelled to a small television/bird aviary room by NS K. - At 9:59 AM, Certified Nursing Assistant (CNA) G approached R9 and moved the Broda chair closer to the television. CNA G then slightly reclined R9's back in the chair, approximately 25-30 degrees. Note: According to RESNA guidelines, this was a microshift as tilting of the seat was not completed to redistribute pressure, only a slight reclining of the back of the chair. R9 remained here until 10:38 AM, at which time Activity Director (AD) E approached and offered an activity of exercise. R9 affirmed a desire to attend and AD E propelled R9 to the MDR for a small group activity. AD E straightened R9's back in the chair to a 90 degree angle from the hips. Again, no tilting of the seat was completed and no pressure redistribution. Surveyor remained throughout this activity to observe R9's participation level and the assistance provided by activity staff. R9 remained in the MDR activity until 11:03 AM. There were no offers yet attempted by staff to assist R9 for repositioning or offloading. - At 11:03 AM, AD E propelled R9 to the small activity room for nail care. R9 remained in this activity until 11:40 AM. - At 11:40 AM, Licensed Practical Nurse (LPN) H propelled R9 to her room in order to screen the resident's blood sugar. No attempts to toilet or reposition R9 were offered. At 11:43 AM, Surveyor approached CNA C and interviewed regarding R9's needs with toileting and repositioning. CNA C was one of two staff responsible for R9's care on this day. CNA C stated that R9 was incontinent of bowel and bladder and required total care. CNA C stated R9 is unable to do any activities of daily living on her own and is dependent on staff and required repositioning and toileting every two hours. Surveyor then asked CNA C why R9 was not offered, or attempts were made to assist R9 to the toilet or to reposition yet on this morning. CNA C stated, I am trying, things have been happening down here, extra alarms are going off, I'm just busy. All I can say is that I am trying. CNA C mentioned to the Surveyor that she informed her nurse (LPN H) that they were behind in cares and needed help. Surveyor then approached LPN H at 11:48 AM and asked who was responsible to ensure resident's care was being provided according to the written care plan. LPN H stated, It's us, the nurses. I'm sorry. I have been trying to get them to not schedule two new ones (aides) together, but it happens. Surveyor asked LPN H if the CNAs have mentioned anything to her that staff were falling behind in providing cares. LPN H stated that she has been informed and was trying to assist the CNAs but, . when I go in to help, the other CNA comes in. No toileting or repositioning was yet completed for R9, even with Surveyor's questioning. - At 11:57 AM, CNA C and CNA D entered R9's room to assist the resident onto the bed with the use of the full body mechanical lift. The resident was assisted onto the bed at 11:59 AM, at which time, staff removed the incontinent brief. The brief was wet with urine and soiled with feces. This was 4 hours 41 minutes in which R9 was not offered or assisted with repositioning. R9's buttocks was red and wrinkled from the combination of pressure, wetness of the urine and soilage of the feces. Surveyor then asked CNA C and CNA D what the normal staffing was for this hall, in which R9 resides. Both staff indicated there is normally two on this hall and two on the adjacent hall with one additional staff assigned to float between the two halls. Surveyor then asked DON B what the repositioning needs for R9 were to prevent pressure injuries. DON B stated that R9 was to be repositioned every two hours. 48793 Example 2 R5 was admitted to the facility on [DATE] with diagnoses including, in part, scoliosis, spastic quadriplegic cerebral palsy, pressure ulcer of the right upper back, dysphagia, and fistula of the intestine. R5's Minimum Data Set (MDS) assessment, dated 06/05/24, identified that R5 had a Brief Interview for Mental Status (BIMS) score of 00. This indicated R5 had significant cognitive impairment and was unable to perform an accurate BIMS. The MDS assessment also identified R5 required extensive assistance of two people for bed mobility, and toileting and was dependent on two people for transfers. R5's care plan included: -Mobility plan: I need the assistance of one or two to turn, reposition, and boost in bed, 01/08/24. -Pressure area to Right shoulder plan: Up in chair at 10 am for 1 hour. The following occurred on 06/19/24 during a continuous observation from 9:01 AM-1:05 PM, for 4 hours and 4 minutes. -On 06/19/24 at 9:01 AM, Surveyor observed CNA G enter R5's room. Surveyor observed podus foot protectors on, but the knee pad was located down at the end of R5's bed near R5's feet. CNA G rolled R5 to the right side and washed the peri area. CNA G rolled new chuck and brief under R5. CNA G rolled R5 back to the left side. CNA G cleaned peri area thoroughly and dried it, then applied powder to the area. CNA G attached brief and then boosted R5 up in bed. CNA G turned R5 onto R5's back and placed a pillow semi-under R5's left shoulder. Surveyor observed R5 supine on the back with pressure to the right scapula. CNA G applied covers to R5 and raised the head of the bed. -On 06/19/24 at 11:24 AM, Surveyor observed R5 in a supine position with the right scapula pressing into the bed. On 06/19/24 at 1:05 PM, Surveyor observed Registered Nurse (RN) F and CNA G enter R5's room. Surveyor observed podus foot protectors on, but the knee pad was still down at the end of the bed near R5's feet. CNA G changed R5 and rolled from side to side to change. Surveyor interviewed CNA G on why knee pad was down at the end of R5's feet. CNA G indicated that someone did not place the knee pads between the knees and left the knee pad at the bottom of R5's feet. CNA G then grabbed knee pad and placed in between R5's knees. CNA G placed R5 on the back and placed a pillow semi-under R5's left shoulder. Surveyor observed R5 placed on a supine position on back with pressure to the right scapula. -On 06/19/24 at 1:12 PM, Surveyor interviewed CNA G and asked if CNA G had been in R5's room to reposition or perform incontinent care since the morning at 9:01 AM. CNA G indicated that CNA G has not been in there since CNA G and Surveyor were in R5's room at 9:01 AM on 06/19/24 and then when CNA G went in with RN F to complete wound dressing change. CNA G indicated that CNA G is doing CNA G's best and trying to perform tasks that are needed. CNA G indicated that it is hard when I am alone on a heavy hall and have an orientee who is not fully trained to know what to do with all the residents. On 06/20/24 at 12:52 PM, Surveyor interviewed RN F and asked about the repositioning and roho cushion on R5's bed. RN F indicated that R5 should still be repositioned every two hours as the roho cushion is just an additive measure to help further decrease pressure injury. On 06/20/24 at 1:02 PM, Surveyor interviewed DON B and asked about the expectation of repositioning R5. DON B indicated that staff should reposition R5 at least every two hours. DON B indicated that R5 should be repositioned and off-loaded for at least a couple minutes at a time every 2 hours. DON B indicated that CNA G should have repositioned and performed incontinent care to R5 at least every two hours. Example 3 R27 was admitted to the facility on [DATE] with diagnoses including, in part, infection and inflammatory reaction due to unspecified internal joint prosthesis, urinary tract infection, obstructive and reflux uropathy, type 2 diabetes, unspecified dementia, and pyogenic arthritis. R27's MDS assessment, dated 03/27/24, identified that R27 had a BIMS score of 09. This indicated that R27 had significant cognitive impairment. The MDS assessment also identified R27 required extensive assistance of one to two people for bed mobility, and toileting and was dependent on one person for stand pivot transfers. R27's care plan included: -Mobility plan: I need the assistance of 1 to turn, reposition and boost in bed, 04/30/24. -ADL plan: Before getting out of bed, don podus boot and knee brace to right lower extremity, 02/16/24. -When in bed resident to use blue puffy boots to right lower extremity, 02/16/24. -Potential for pressure ulcer development plan: Immobilizer to the right leg when up, remove every shift to check skin, 04/30/24. -The resident requires an air/float mattress to the bed and, a pressure reduction cushion to a wheel chair. Podus boot to right foot at all times, 02/05/24. R27's physician orders include: - Inspect right heel daily for any breakdown and monitor. - Right heel- Clean with NS, apply Mepilex for prevention of recurrence of pressure ulcer. Monitor heel for any sx recurrence every day shift. On 06/18/24 at 9:55 AM, Surveyor observed R27 lying in bed on R27's back with bilateral heels lying directly on the bed. Surveyor did not observe Podus boot on the right foot. R27's Podus boots were lying in the chair across the room. On 06/18/24 at 12:25 PM, Surveyor observed R27 lying in bed on R27's back with bilateral heels lying directly on the bed. Surveyor did not observe podus boot on the right foot. R27's Podus boots were lying in the chair across the room. On 06/19/24 at 11:01 AM, Surveyor observed R27 sitting in R27's wheelchair with R27's right foot on the pedal of R27's wheelchair. R27's right foot had a gripper sock on, but Surveyor did not observe Podus boot on the right foot. On 06/19/24 at 11:24 AM, Surveyor interviewed Licensed Practical Nurse (LPN) I and asked if R27 is supposed to have Podus boot on R27's right foot. LPN I reviewed physician orders and indicated that R27 is to have Podus boot on at all times. On 06/19/24 at 12:57 PM, Surveyor observed R27's feet bilateral lying flat on the floor while R27 was sleeping in R27's wheelchair. Surveyor did not observe Podus boot on the right foot. Podus boots were across the room lying on a chair. On 06/19/24 at 1:51 PM, Surveyor observed R27 lying in bed with bilateral heels flat on the bed without Podus boots on. Surveyor observed Podus boots in the chair across the room. On 06/19/24 at 1:55 PM, Surveyor interviewed CNA G and asked if R27 was supposed to have Podus boots on while R27 was in bed to protect the heels. CNA G indicated that R27 is supposed to have Podus boots on while in bed and R27 does not at this time. Surveyor observed CNA G enter R27's room and place Podus boots on R27 while in bed. On 06/20/24 at 12:01 PM, DON B handed Surveyor progress notes for skin assessments. Surveyor reviewed that R27's right heel wound healed back in March and then reopened 05/30/24. On 06/20/24 at 1:02 PM, Surveyor interviewed DON B and asked the expectations of R27 wearing Podus boots for heal protection to the right foot. DON B indicated that R27 should have Podus boots in place but sometimes R27 refuses. DON B asked Surveyor if R27 refused Podus boots during Surveyor's observations. Surveyor indicated that Podus boots were not offered to R27 during Surveyor's observations of R27's care. Surveyor indicated to DON B that the Podus boots were located across the room in a chair the whole day. DON B indicated that CNA G should have placed Podus boots on R27 while R27 was in bed.

Based on observations, interviews and record reviews, the facility failed to provide the necessary services for 2 of 6 sampled and supplemental sampled residents (R9, R4) to maintain good grooming, toileting and personal hygiene. This is evidenced by: The facility policy and procedure titled General Care For All Residents includes the following directives to staff: - The resident shall be kept clean and dry - Staff will respond to call lights timely Example 1 R9 has medical diagnoses that include but are not limited to, diabetes mellitus type 2, a recent cerebral infarction (3/6/24), unspecified depression and dementia. According to the most recent MDSA (Minimum Data Set Assessment), which was a Significant Change in Status Assessment with an Assessment Reference Date of 3/18/24, R9 has impaired short-term and long-term memory and severely impaired daily decision making abilities. R9 has no behavioral or mood indices. Also according to this assessment, R9 required partial to moderate assistance of staff for moving from sitting to lying and lying to sitting positions to the side of the bed and is dependent on staff for toileting hygiene, upper and lower body dressing and personal hygiene. R9 is transferred with the use of a full body mechanical lift with the assistance of two staff and is frequently incontinent of bladder function and always incontinent of bowel function. Surveyor reviewed the Comprehensive Care Plan (CCP) completed for R9 and noted the following: 1. Activities of Daily Living (initiated 4/17/23 and last revised 4/30/24): Interventions included: - I need staff assist of 1 with dressing. (4/17/23) - I need the assist of two with the Hoyer (3/12/24) - I need partial assist from staff with grooming. (4/17/23) 2. I am both continent and incontinent of bowel and bladder (initiated 4/25/23 and last revised 4/30/24) Interventions for this problem included: - Scheduled toileting: every 2 hours and PRN (as needed) - Staff assist of 2 with hoyer to assist me with transferring on and off toilet/commode. Also noted, staff no longer place R9 on a toilet to allow for normal evacuation of the bladder and bowel. Instead, observations have shown that R9 is a check and change, in which R9 is placed onto the bed and the soiled incontinent brief is changed and perineal cleansing is completed. This was not updated on the CCP. 3. I have impaired mobility . (initiated 4/25/23 and last revised 6/3/24): Interventions for this problem included: - Anticipate needs, such as toileting. - I need assist of 1 with turning and repositioning in bed. - I use a Broda chair to get to destinations. I am dependent on staff with chair mobility 4. I am at risk for falls . (initiated 4/25/23 and last revised 4/30/24): Interventions included: - Anticipate and meet my needs (4/25/23) - Be sure my call light is within reach and encourage me to use it for assistance as needed. I need prompt response to all requests for assistance (4/25/23) - Assist to eh bathroom every two hours and as needed (6/16/23) 5. The resident had a cerebral vascular accident (3/12/24) Interventions include: - Monitor and document bowel and bladder function. If incontinent, monitor and document for appropriate bowel and bladder training program and implement. A bowel and bladder training program has not yet been attempted for R9. On 6/19/24, Surveyor made the following observation of R9: - At 7:18 AM, R9 was up in the Broda chair in her room. R9 was sitting on the mechanical lift sling and a small blanket covered R9's lap. R9 was positioned at 90 degree angles from back to hips, from hips to legs and from knees to ankles. - At 7:58 AM, R9 was taken to the Main Dining Room (MDR) and placed at a table in preparation for the morning meal. R9 was served her meal at 8:02 AM by Nursing Student (NS) K, who sat beside R9 and fed her the meal. - At 9:10 AM, R9 completed the meal and was propelled to a small television/bird aviary room by NS K. R9 remained here until 10:38 AM, at which time Activity Director (AD) E approached and offered an activity of exercise. R9 affirmed a desire to attend and AD E propelled R9 to the MDR for a small group activity. Surveyor remained throughout this activity to observe R9's participation level and the assistance provided by activity staff. R9 remained in the MDR activity until 11:03 AM. There were no offers yet attempted by staff to assist R9 to the toilet or change the incontinent brief. - At 11:03 AM, AD E propelled R9 to the small activity room for nail care. R9 remained in this activity until 11:40 AM. - At 11:40 AM, Licensed Practical Nurse (LPN) H propelled R9 to her room in order to screen the resident's blood sugar. No attempts to toilet R9 were offered. At 11:43 AM, Surveyor interviewed Certified Nursing Assistant (CNA) C regarding R9's needs with toileting and repositioning. CNA C was one of two staff responsible for R9's care on this day. CNA C stated that R9 was incontinent of bowel and bladder and required total care. CNA C stated R9 is unable to do any activities of daily living on her own and is dependent on staff and required repositioning and toileting every two hours. Surveyor then asked CNA C why R9 was not offered or attempts were made to assist R9 to the toilet yet on this morning. CNA C stated, I am trying, things have been happening down here, extra alarms are going off, I'm just busy. All I can say is that I am trying. CNA C mentioned to the Surveyor that she informed her nurse (LPN H) that they were behind in cares and needed help. Surveyor then interviewed LPN H at 11:48 AM and asked who was responsible to ensure resident's care was being provided according to the written care plan. LPN H stated, It's us, the nurses. I'm sorry. I have been trying to get them to not schedule two new ones (aides) together, but it happens. Surveyor asked LPN H if the CNAs have mentioned anything to her that staff were falling behind in providing cares. LPN H stated that she has been trying to assist the CNAs but, . when I go in to help, the other CNA comes in. No toileting or repositioning was yet completed for R9, even with Surveyor's questioning. - At 11:57 AM, CNA C and CNA D entered R9's room to assist the resident onto the bed with the use of the full body mechanical lift. The resident was assisted onto the bed at 11:59 AM, at which time, staff removed the incontinent brief. The brief was wet with urine and feces. This was 4 hours 41 minutes in which R9 was not offered or assisted with toileting. R9's buttocks was red and wrinkled from the wetness of the urine and feces. Surveyor then asked CNA C and CNA D what the normal staffing was for this hall, in which R9 resides. Both staff indicated there is normally two on this hall and two on the adjacent hall with one additional staff assigned to float between the two halls. Surveyor asked what was different today, in which they could not complete cares as assigned. Both staff indicated they have been on staff for only one month. The two staff also stated there was a call in today and a new staff (CNA J) assigned on the adjacent hall, which was only her third day working. Surveyor then asked who is responsible for staffing the floors to ensure residents are receiving the care they need. Both indicated that Director of Nursing (DON) B completed the staffing schedules. At 12:15 PM, Surveyor interviewed DON B and asked how she decided on the staffing for this date, with three new CNAs and only one seasoned CNA working. DON B stated that CNA C has over [AGE] years experience as a CNA and she assigned CNA D to work with CNA C, as she needed a strong CNA to guide CNA D, who did not have any experience as a caregiver and required much direction. DON B further stated there are two CNAs assigned to each hall with one additional CNA as a float between the two halls. DON B assigned CNA J to work with CNA G on a less difficult hall, as CNA J is an orientee for the third day. DON B indicated the staffing on this day is normal. DON B further stated that it was the responsibility of the nurses on the hall to ensure residents are receiving care according to their written care plans. DON B also stated that no staff approached her to inform her that the CNAs were behind on cares. Surveyor then asked DON B what the repositioning and toileting needs for R9 were. DON B stated that R9 was to be toileted every two hours. 44863 The facility policy titled General Care of Residents, revised on 06/2018, stated in part . 9. Call Lights a. Staff will respond to call lights timely. b. If responding to a call light and you are assisting another resident, inform the resident you are assisting another resident and will return shortly and turn off call light. c. If other departmental staff answers call lights, let the resident know that you will tell the nursing staff and turn off the call light. R4 was admitted to the facility on [DATE]. Diagnoses included heart failure, cellulitis of upper limb, chronic kidney disease, chronic obstructive pulmonary disease, and shoulder pain. R4 was admitted with a stage 1 pressure injury to right buttock. Minimum Data Set (MDS) assessment, dated 06/06/24, confirmed R4 scored 10/15 during Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. R4's MDS assessment reported R4 is frequently incontinent of urine and always incontinent of bowel. R4 required substantial assistance with toileting, showering, and dressing, and was dependent on staff for transfers with mechanical hoyer lift. R4's care plan included: -Toileting plan: I am on a toileting schedule. Take me upon rising, before meals, after meals, bedtime, and as needed during the night, 05/31/24. The following occurred on 06/19/24 during a continuous observation from 10:22 AM-11:41 AM, for 79 minutes: -10:22 AM, Surveyor observed R4 in his room, sitting in a Broda chair. Surveyor observed R4's call light was on and R4 was calling out stating he needed to use the bathroom. -Between 10:22 AM and 10:35 AM, Surveyor observed physical therapy staff walk past R4's room twice. Surveyor observed Director of Nursing (DON) B walk past R4's room twice. Surveyor observed Certified Nursing Assistant (CNA) G walk past R4's room twice. -10:41 AM, Surveyor observed Licensed Practical Nurse (LPN) I walk past R4's room. -10:44 AM, Surveyor observed LPN H walk past R4's room. -10:46 AM, Surveyor observed CNA J enter R4's room. R4 stated to CNA J he needed to use the bathroom. CNA J told R4 she would let someone know and she would be back. CNA J left R4's call light on. Surveyor observed CNA J tell CNA G R4 needed to use the bathroom. -10:47 AM, Surveyor observed ADON F walk past R4's room. -10:50 AM, Surveyor observed CNA C and CNA D walk past R4's room. -10:52 AM, Surveyor observed CNA G and CNA J walk past R4's room. -10:54 AM, Surveyor interviewed CNA G. CNA G reported she was not assigned to R4's hall. CNA G stated she is working on the other hallway training CNA J. CNA G stated she assists on R4's hallway as she can as it is a heavy hall, but not all staff assist with answering resident call lights in unassigned areas. CNA G stated, With charting, no, I am not able to complete all of my workload. Surveyor observed CNA G and CNA J walk towards R4's room, where R4's call light was on. Surveyor observed CNA G and CNA J exit the hallway through a door immediately adjacent to R4's room. CNA G stated, We are finally going on break. Surveyor observed R4's call light continued to be on. -10:58 AM, Surveyor observed ADON F walk past R4's room. -11:03 AM, Surveyor observed DON B walk past R4's room. -11:05 AM, Surveyor observed LPN I entered R4's room. R4 stated he needed to use the bathroom. LPN I turned off R4's call light and stated to R4 she would tell the staff. -11:17 AM, Surveyor observed R4's call light was off. Surveyor interviewed R4, R4 stated he needed to use the bathroom, and no one had helped him. Surveyor encouraged R4 to use his call light to request staff assistance. R4 did engage his call light and stated, It doesn't do any good anyway. -11:21 AM, Surveyor observed DON B enter R4's room. R4 stated he needed to use the bathroom. DON B turned off R4's call light and told R4 she would let staff know. Surveyor observed DON B tell CNA C and CNA D R4 needed to use the bathroom. -11:27 AM, Surveyor interviewed LPN I. LPN I stated she told CNA C R4 needed to use the bathroom, after she answered R4's call light at 11:05 AM. -11:34 AM, Surveyor observed R4 was calling out from his room. Surveyor interviewed R4, R4 stated he still needed to use the bathroom. Surveyor encouraged R4 to use his call light to ask for assistance. R4 engaged his call light. -11:35 AM, Surveyor observed DON B enter R4's room. R4 stated he needed to use the bathroom. DON B left R4's call light on, exited his room, and updated CNA C and CNA D R4 needed to use the bathroom. -11:41 AM, Surveyor observed CNA D and CNA G assist R4 with mechanical lift transfer to his bed. Surveyor observed CNA D and CNA G assist R4 with incontinence care of both bowel and bladder. On 06/20/24 at 1:42 PM, Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A reported the facility considers resident acuity when developing staffing patterns. NHA A reported staffing is discussed each morning during the facility's morning meeting, and stated, We move things around based on what is discussed in morning meeting, admissions, discharges, change in condition. Surveyor reported to NHA A the observation of R4 requesting to use the bathroom and not receiving assistance for 79 minutes. NHA A did not make any statements related to the incident.

Based on observation, interview and record review, the facility did not ensure that the food was stored, distributed, and served in accordance with professional standards for food service for all 42 residents. Dishwasher temperature logs were not complete. Staff touching ready to eat foods with contaminated gloves. Findings include: On 06/26/23 at 9:30 AM, during initial tour of the kitchen with Dietary Manager (DM) G, Surveyor noted the dishwasher temperature log was missing temperature recordings on June 17, 20, 24, 25 and 26th. Surveyor asked for temperature logs for both April and May. DM G led surveyor to the office. DM G found the temperature logs for April and May, and they were also missing temperatures (April 2nd, April 10 through April 21, 25, 29 and 30th and May 5, 9, 13, 14, 19, 23, and 27 through 29th). Surveyor asked DM G for a copy of these logs and a policy on dishwasher temperatures. On 06/27/23 at 10:35 AM, DM G provided Surveyor with policy Dish Machine Temperature and Maintenance Log revised date on 06/26/23 that states in part .5. To verify the sanitizing rinse cycle temperature, a high temperature lipmus paper test must be completed per package instruction. Lipmus paper testing must be completed just once daily or in addition to verify any inaccuracies. 6. Once information has been gathered, it must be transferred to the Dishwasher Temperature Audit provided on the wall next to the dish machine . DM G handed surveyor a copy of the audit that has been started along with education dietary staff must complete. On 06/27/23 at 12:07 PM, Surveyor observed Dietary Staff (DS) F using the same gloves that she plated food for a food cart, pick up a piece of bread and place it in the toaster. DS F then went back to touching scoops in the hot foods, grabbing plates and plating food for the residents in the dining area. Then with the same gloved hands she took the toast out of the toaster and began to butter the toast touching the knife that was in the butter bin. DS F then began plating food touching plates, scoops, and tongs for noodles with the same gloved hands. Surveyor then observed DS F rest her gloved hands on the counter in front of her. DS F then grabbed another piece of bread from the bread bag with the contaminated hands and put it in the toaster and went back to plating food. DS F then grabbed the toast out of the toaster and butter the toast with the same gloved hands. On 06/27/23 at 12:24 PM, Surveyor informed DS F of the observations of touching ready to eat foods with contaminated gloves. Surveyor asked DS F what the process is for touching ready to eat foods. DS F replied I should have used tongs to touch the bread and toast. On 06/27/23 at 12:30 PM, Surveyor informed DM G of the observations of touching ready to eat foods with contaminated gloves. Surveyor asked DM G what the process is for touching ready to eat foods. DM G replied DS F should have used tongs. Surveyor asked for a policy on glove use in the kitchen. On 06/27/23 at 2:26 PM, DM G provided Surveyor with a policy Glove Use dated 10/2008 that states in part .3. Gloves are for single tasks only to avoid cross contamination .7. Employees may use utensils such as deli tissue, spatulas, tongs, or dispensing equipment as an alternative to glove use .