Every finding on record at St Camillus Health Center

Based on observation, record review, and interview, the facility did not ensure food was prepared, distributed, and served in accordance with professional standards for food service safety.*Supervisor Food Service - N was observed to not have facial hair covered while preparing resident food.*Manager Food Service- L was observed placing ready-to-eat bread products on residents plates with the single-use gloves after touching non-sanitized food surfaces with the same gloves. This deficient practice has the potential to affect all 41 residents who receive food from the main kitchen.Findings include: The facility policy Dress Code Policy dated 1/14/2023, documents: All hair needs to be restrained with a hair net upon entering the kitchen.The facility policy Maintain a Sanitary Tray Line documents: Use utensils such as tongs, serving spoons, etc. to handle food as much as possible. Wear gloved when handling food items, particularly when direct contact between the hands and food occurs or when handling ready-to-eat foods such as salads, fruits, sandwiches, breads, etc Change gloves when activities are changed, or when the type of food being handled is changed.On 7/20/2026, at 11:36 AM, Surveyor observed meal tray assembly in the satellite kitchen with Supervisor Food Service- N and Manager Food Service- L. Supervisor Food Service- N was observed to not have a beard restraint on while assembling meal trays from which residents eat from.Surveyor then observed Manager Food Service- L wearing single use gloves to handle ready-to-eat bread. Manager Food Service-L was observed handling multiple utensils and plates with gloves on both hands and then use the same single use gloves to handle ready-to-eat bread. Surveyor noted that Manager Food Service-L did not wash their hands or replaced their gloves after touching non sanitized food surfaces and or before handling ready to eat food. Surveyor observed Manager Food Service -L handle five ready-to-eat bread buns with the same gloved hands after touching multiple utensils, plates and non-sanitized food surfaces.On 7/21/2026, at 10:58AM, Surveyor interviewed Dietary Aid- P regarding the use of hair restraints. Dietary Aid- P stated all hair needs to be covered in any kitchen area. Surveyor asked Dietary Aid- P if only certain activities require hair restraints, even when food is not being handled. Dietary Aid- P stated hair restraints must be worn at all times regardless of activity being performed in any kitchen area.On 7/21/2026, at 11:45 AM, Surveyor interviewed Preparation [NAME] (Prep. Cook) - J regarding utensil use when plating food. Prep. Cook-J stated when plating food, everything needs a utensil to transport food onto a plate, and each type of food gets its own utensil and there cannot be cross contamination. Surveyor asked Prep. Cook-J how to handle finger foods or ready-to-eat foods. Prep. Cook-J stated utensils need to be used, and tongs are the easiest to use and showed surveyor a plate of cookies with tongs.Surveyor asked Prep. Cook-J if gloves can be used to handle ready-to-eat foods and if the same gloved can be used to handle utensils during meal assembly. Prep. Cook-J stated no, gloves are single use for one activity and need to be changed between each meal activity. Prep. Cook-J stated they personally do not like to handle any ready to eat food with gloves and prefers using tongs or other utensils to handle ready to eat food. On 7/21/2026, at 4:00 PM, Surveyor asked Assistant Culinary Director (ACD)-M regarding the expectations of hair restraints and proper food handling. ACD-M stated hair restraints are to be worn at all times when inside of kitchen areas, including beard restraints. ACD-M stated when transferring food to a plate a utensil must be used and food is to not be handled with gloved hands, including ready-to-eat foods and bread.On 7/22/2026, 12:36 PM, Surveyor informed Nursing Home Administrator- A that Supervisor Food Service- N did not have a beard restraint while assembling trays, and observations of Manager Food Service- L used single use gloves to handle ready-to-eat food with the same gloved hands after touching multiple utensils, plates and non-sanitized food surfaces.

Based on observation, interview and record review the facility did not ensure that residents who are unable to carry out activities of daily living receive the necessary services to maintain good nutrition and grooming for 1 (R11)of 1 residents reviewed for meal assistance.* R11's meal tray was not set up and R11 was not positioned upright to eat.Findings include:R11 was admitted to the facility on [DATE] with diagnoses that included Acute on chronic congestive heart failure, chronic kidney disease stage 3B, atherosclerotic heart disease and cerebral infarction.R11's Annual Minimum Data Set (MDS) dated [DATE] documents that R11 was assessed as follows: Eating - The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident - set up or clean up assistance. R11's Care Plan (revised 5/19/26) documents: Nutritional problem or potential nutritional problem r/t (related to) therapeutic diet, congestive heart failure, chronic kidney disease, depression, diuretic use, history of weight fluctuations.Interventions included monitor/document/report PRN (as needed) any s/sx (signs or symptoms) of dysphagia: Pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals - initiated 1/20/26. ; Provide, serve diet as ordered. Monitor intake and record every meal - initiated 1/20/26. R11's resident daily care (Certified Nursing Assistant care card) dated 7/21/26 documents: Diet - NAS (no added salt), regular texture, thin liquids. Set up assist. Give magic cup if meal refusal. On 7/20/26 at 8:30 AM, Surveyor observed R11 laying in bed on her back with the head of bed elevated less than 30 degrees. R11's breakfast tray was on the tray table in front of R11 which consisted of scrambled eggs, toast, bacon, pancake, orange juice, syrup and a banana. Surveyor noted R11 was not positioned upright to eat and R11's tray had not been set up for her to eat. There was a cover on the orange juice, the pancake was not cut up, the syrup was not opened, and the banana was not peeled. Surveyor asked R11 if R11 was hungry and going to eat, and R11 stated yes. Surveyor asked R11 if R11 could reach her tray to eat, R11 replied not really.On 7/20/26 at 9:15 AM, Surveyor observed R11 in the same position in bed, not positioned upright to eat, with R11's eyes closed. The tray remained the same, untouched and was not set up for her to eat.On 7/20/26 at 9:30 AM, Surveyor observed Certified Nursing Assistant (CNA)-F in R11's room looking in the closet. Surveyor asked CNA-F if R11 needs assistance with her meal. CNA-F stated, No, she pretty much does it herself, she's really slow. Surveyor asked CNA-F if R11 needs assistance with setting up her tray, pointing out the syrup was not open, pancake was not cut up, banana not peeled, and the cover was on the orange juice. CNA-F stated, No she can pretty much do it herself and left the room. Surveyor asked R11 if she was hungry and wanted to eat, to which R11 replied yes. Surveyor asked if R11 could reach the food on her tray. R11 attempted to reach the food but was unable. On 7/20/26 at 9:45 AM, Surveyor observed CNA-F in R11's room with the curtain closed. Surveyor asked CNA-F if R11 ate her breakfast, she stated, I don't know, the tray was gone when I came in. On 7/21/26 at 8:16 AM, Surveyor observed R11 laying in bed awake with the breakfast tray on the table in front of her consisting of scrambled eggs, toast, bacon, donut, cup of fruit, coffee, banana and dry cereal. Surveyor noted the tray was not set up for her to eat. The banana was not peeled, jelly was not opened or put on toast, creamer was not opened or put in coffee. Surveyor noted the head of bed was elevated 30 degrees, however R11 was not positioned upright to eat, she was positioned further down in the bed so that her head was barely parallel to table. Surveyor asked if R11 was hungry, R11 replied yes. Surveyor asked if R11 could reach her tray. R11 stated, I'll try, but I'm down to far, I need to go up higher.On 7/21/26 at 8:27 AM, Surveyor asked Licensed Practical Nurse (LPN)-G to accompany Surveyor to R11's room. Surveyor asked if R11 needed assistance with her meal. LPN-G stated, No, she doesn't need to be fed, she's just a set up. Surveyor asked what set up meant. LPN-G stated, Setting up her tray, opening things, cutting up food if needed. Surveyor pointed out that the banana wasn't peeled and the creamer and jelly were not opened. Surveyor pointed out that R11 had dry cereal with no milk provided. LPN-G said, Maybe they went to get some. Surveyor asked if set up would include positioning the resident upright to eat. LPN-G stated, yes. Surveyor asked LPN-G if she thought R11 could eat the way she is currently positioned. LPN-G stated, I hear what you're saying, she needs to be boosted. On 7/21/26 at 8:42 AM, Surveyor observed a staff member enter R11's room and heard them say, I have some milk for your cereal, do you want your banana to be peeled? to which (R11 replied no). Surveyor entered R11's room and observed that R11 had been boosted up slightly, however was still not positioned upright to eat.Surveyor asked R11 if she could reach the food on her tray, R11 attempted with her hand, stating not really. Surveyor noted the way R11 was positioned in bed, R11 would be unable to drink liquids (including coffee) without spilling them. Surveyor asked the night shift supervisor (NOC)-T to accompany Surveyor to R11's room. Surveyor asked if she thought R11 was positioned upright to eat, to which NOC-T replied not really. Surveyor asked R11 if R11 could reach the tray, R11 attempted to reach food and could pick up a piece of bacon, but that was all. NOC-T stated, She usually does pretty good eating herself.Surveyor asked if NOC-T thought R11 could eat and drink in the position she was in. NOC-T stated, Maybe, but yeah - it would be difficult. At this time LPN-G entered the room and told Surveyor they gave R11 milk for R11's cereal. Surveyor advised LPN-G that R11 was still not positioned upright to be able to eat independently, as R11 was unable to reach the silverware or food except for bacon, and there was concern if R11 tried to drink coffee in current position, R11 would spill onto self. LPN-G stated, Yeah, OK - I'll get someone to boost her up more. On 7/21/26 at 12:20 PM, Surveyor informed Nursing Home Administrator (NHA)-A of observations and concern that R11 was not set up for meals and not positioned upright to eat. NHA-A told Surveyor that CNA-E came to her yesterday and said a Surveyor was asking questions about R11's meal tray, and that CNA-E provided R11 with a food tray and R11 refused. Surveyor told NHA-A that Surveyor did not speak with CNA-E and there was no mention of refusal, R11's tray was observed not set up and R11 was observed to be not positioned upright to eat. On 7/21/26 at 12:28 PM, Surveyor confirmed with NHA-A that the CNA Surveyor spoke to was CNA-F and not CNA-E. NHA-A apologized that NHA-A was confused, and she spoke with CNA-E who confirmed CNA-E did not speak with Surveyor and did not report anything to NHA-A on 7/20/26. On 7/21/26 at 1:35 PM, Surveyor spoke with Occupational Therapist (OTR)-D who reported R11 was last seen in May 2023. R11's OT assessment indicated R11 needs set up for eating and that has not changed, that is R11's current level and that R11 can feed self. The last quarterly therapy screen dated 2/5/26 documents no functional changes, no therapy indicated. Surveyor asked what is meant by set up for meal. OTR-D stated, Making sure food is cut up if needed, usually meat, opening items as needed and of course making sure she is positioned so that she can reach her tray to feed herself. Surveyor reviewed R11's Point Click Care (PCC) tasks documentation from 6/23/26 - 7/22/26. Self-care eating - the ability to use suitable utensils to bring food to the mouth and swallow food once the meal is presented on a table/tray, including modified food consistency. Surveyor noted documentation entered indicated R11 was dependent 3 times, needed partial/moderate assist 5 times, substantial/maximal assist 7 times, supervision/touching assist/verbal cues 32 times and set up/clean up assist 33 times. On 7/22/26 at 1:46 PM, Surveyor asked Director of Nursing (DON)-B for the facility policy regarding Activity of Daily Living and/or meal assistance needed or provided and was told the facility does not have a policy. NHA-A and DON-B were informed of the above findings.

Based on interview and record review, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1(R1) of 12 residents reviewed. * Staff did not place Tubi grips on R1's bilateral lower extremities on 7/20/26 & 7/21/26.Findings include:R1's diagnoses include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominate side and congestive heart failure.R1's physician order dated 1/28/24 documents: Tubi grips to BLE (bilateral lower extremities) on in AM (morning), off HS (hour sleep) one time a day and remove per schedule.On 7/20/26 from 9:03 a.m. to 9:25 a.m., Surveyor observed incontinence cares and coccyx wound treatment for R1 with Certified Nursing Assistant (CNA)-O and Licensed Practical Nurse (LPN)-G. During this observation Surveyor observed that neither CNA-O or LPN-G placed Tubi grips on R1 bilateral lower extremities according to R1's physician orders.On 7/20/26, at 1:45 p.m., Surveyor observed R1 in bed with the head of the bed elevated. Surveyor observed R1 wearing pressure-relieving boots but is not wearing Tubi grips per physician order.On 7/21/26, at 10:54 a.m., Surveyor observed R1 in bed with the head of the bed elevated. Surveyor observed R1 wearing pressure-relieving boots but is not wearing Tubi grips per physician order.On 7/21/26, at 1:06 p.m., Surveyor observed CNA-O in R1's room with R1. R1 was sitting in a Broda chair with gripper socks on R1's feet. Surveyor observed that R1 is not wearing Tubi grips according to physician orders.On 7/21/26, at 3:38 p.m., Surveyor observed R1 in bed with a family friend sitting next to R1's bed who informed Surveyor they just put R1 to bed. Surveyor inquired if R1 was wearing pressure relieving boots. R1's family friend stated to Surveyor you can see and lifted up R1's bedding. Surveyor observed a pillow under R1's lower legs. Surveyor also observed R1 is not wearing Tubi grips according to physician orders.On 7/22/26 at 8:31 a.m., Surveyor asked Nurse Manager/Infection Preventionist (NM/IP)-C if MD (medical doctor) orders should be followed. NM/IP-C replied absolutely. Surveyor asked NM/IP-C how a Certified Nursing Assistant (CNA) knows a resident should be wearing Tubi grips according to physician orders. NM/IP-C informed surveyor the expectation is the nurse puts the Tubi grips on or delegates it to the CNA. Surveyor informed NM/IP-C of the observations of R1 not wearing Tubi grips according to physician orders on 7/20/26 & 7/21/26.

Based on observation, interviews and record review, the facility did not ensure that residents receive care, consistent with professional standards of practice, to prevent pressure ulcers and that residents without pressure ulcers do not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for 2 of 4 (R11 and R35) residents reviewed at risk for pressure injuries. * R11 was observed not wearing Prevalon boots on and heels were not offloaded, per R11's plan of care. * R35 was observed not wearing Prevalon boots per physician's order. Findings include: The facility policy titled Prevention of Pressure Ulcers and Injuries dated 8/1/18 documents: It is the policy of (facility) to provide information as a guideline to nursing staff regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors, and information regarding clinical identification of pressure ulcers/injuries and associated risk factors. Prevention: Mobility/Repositioning: 5. Teach residents who can change positions independently the importance of repositioning. Provide support devices and assistance as needed. Support surfaces and pressure redistribution: Select appropriate support surfaces based on the resident's mobility, continence, skin moisture and perfusion, body size, weight and overall risk factors. Monitoring: 2. Review the interventions and strategies for effectiveness on an ongoing basis. 1.) R11 was admitted to the facility on [DATE] with diagnoses that include Acute on chronic congestive heart failure, chronic kidney disease stage 3B, atherosclerotic heart disease and cerebral infarction. R11's Annual Minimum Data Set (MDS) dated [DATE] documents: Mobility - Roll left and right: The ability to roll from lying on back to left and right side and return to lying on back on the bed - dependent. R11's Skin Integrity Care Plan dated 7/26/22 documents: Potential alteration in skin integrity r/t (related to) decreased mobility, hypertension, atrial fibrillation, congestive heart failure, right shoulder pain. Interventions include: Avoid scratching and keep hands and body parts from excessive moisture, keep fingernails short, encourage good nutrition and hydration in order to promote healthier skin, keep skin clean and dry, use lotion on dry skin, use a draw sheet or lifting device to move resident, use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. R11's Braden Scale For Predicting Pressure Sore Risk assessment dated [DATE] documents a score of 14, indicating R11 is at moderate risk for pressure injuries. On 7/20/26 at 7:00 AM, Surveyor observed R11 laying in bed on her back with her eyes closed, asleep. Surveyor observed R11's heels not offloaded and laying directly on the air mattress. On 7/20/26 at 8:30 AM, Surveyor observed R11 laying in bed on her back with the head of bed elevated less than 30 degrees. Surveyor observed R11's heels not offloaded and laying directly on the air mattress. On 7/20/26 at 9:15 AM and 9:30 AM, Surveyor observed R11 to be in the same position, laying in bed on her back with the head of bed elevated less than 30 degrees. Surveyor observed R11's heels not offloaded and laying directly on the air mattress. On 7/21/26 at 7:30 AM, Surveyor observed R11 lying in bed on her back, asleep. R11 was observed to not wearing socks or boots on R11's feet, and R11's heels were resting directly on the mattress and not offloaded. On 7/21/26 at 10:22 AM, Surveyor asked a Certified Nursing Assistant (CNA) on R11's unit how she would know how to care for a resident. Surveyor was told the CNA's use a care card and provided Surveyor a sheet titled Residents daily care dated 7/21/26. Surveyor was told the night shift supervisor prints a new one every day. R11's care card documents: Heel boots and air mattress. Surveyor noted multiple observations of R11 not wearing heel boots and R11's heels not offloaded per R11's plan of care. On 7/22/26 at 11:03 AM, Surveyor observed R11's heels with assistance of the CNA. Surveyor noted no open skin or signs/symptoms of skin breakdown. On 7/22/26 at 1:43 PM, Surveyor informed Director of Nursing (DON)-B of R11's heel boots not in place, R11's heels not being offloaded and R11's heels resting directly on the mattress. On 7/23/26 at 7:35 AM, Nursing Home Administrator (NHA)-A told Surveyor that R11 does not have an order for Prevalon boots and they're not on R11's care plan. She located a boot in her room but is not sure when or why it was implemented. NHA-A added, But she doesn't have an order, so I don't think they're using it, and she has a heel up pad that we use to elevate her heels. Surveyor informed NHA-A that R11's CNA care card, which is part of the care plan, includes an intervention for heel boots. NHA-A agreed. Surveyor told NHA-A that the heel up pad is not on the care plan or the CNA care card, and Surveyor had multiple observations of R11's heels not offloaded, lying directly on the mattress and no heel up pad or Prevalon boots in place. 2.) R35 was admitted to the facility on [DATE] with diagnoses that included systemic lupus, morbid obesity, Alzheimer's disease, and dementia. R35's Quarterly Minimum Data Set assessment, dated 5/14/26, documented a Brief Interview for Mental Status score of 0, which indicated severe cognitive deficits for R35. The MDS also documented that R35 was assessed to be dependent on mobility and transfer assistance and that R35 was always incontinent of urine and frequently incontinent of bowel. The MDS also documented R35 was at risk for the development of pressure ulcers/injuries. R35's Pressure Ulcer/Injury Care Area Assessment (CAA) dated 2/11/26 documented: R35 was at risk for skin breakdown as evidence by being dependent for bed mobility rolling from left to right, sitting to lying and lying to sitting side of bed and always incontinent of bowel and bladder. Staff will apply barrier cream to buttocks and peri area with care to prevent skin breakdown. Goal is to be free from skin breakdown. Care plans will address to avoid complications and minimize risk and improve skin integrity. Staff will continue to assess skin condition with activities of daily living (ADL) cares and daily and report any abnormalities. Staff will continue to encourage and assist in turning repositioning regularly. R35's Braden Scale dated 6/7/26,documented R35 was high risk with a score of 11 for developing a pressure ulcer/injury. R35's physician orders dated 2/7/26 documented that R35 was to have Prevalon boot to both feet. On 7/20/26, R35's physician orders were changed and documented Prevalon boots to both feet when in bed every shift. R35's skin integrity comprehensive care plan initiated 2/7/26 and revised 2/23/26 documented: The resident (R35) has actual impairment to skin integrity of due to fragile skin, skin irritation, incontinence. Interventions included: Gel cushion to recliner, date initiated: 01/29/2026; Place a folded towel/blanket over recliner armrest when resident is seated to reduce friction and protect skin, date initiated: 02/25/2026, revision on: 04/22/2026. R35's Certified Nursing Assistant (CNA) care card instructing CNAs in the care of R35 documented R35 was on an air mattress, ensure gel cushion was placed in recliner when resident transferred, and Prevalon boots to both feet. On 7/20/2026, at 6:28 AM, Surveyor observed R35 sleeping in bed. R35 was observed to not be wearing Prevalon boots and R35's heels were observed to not be offloaded with any device. On 7/20/2026, at 8:16 AM, Surveyor observed R35 sleeping in bed.R35 was observed to not be wearing Prevalon boots and R35's heels were observed to not be offloaded with any device. On 7/20/2026, at 10:02 AM, R35 remained sleeping in bed. Surveyor observed no Prevalon boots on R35. Surveyor observed no Prevalon boots in R35's room. On 7/20/2026, at 1:41 PM, Surveyor observed R35 up in R35's Broda chair with a gel cushion in place. R35 is wearing white socks with heels directly on the foot pedal. R35 was not wearing Prevalon boots on either foot. On 7/21/2026, at 7:18 AM, Surveyor observed R35 sleeping in bed. R35 was observed to not be wearing Prevalon boots and R35's heels were observed to not be offloaded with any device. On 7/21/2026, at 9:27 AM, R35 remained in bed. R35 was observed to not be wearing Prevalon boots and R35's heels were observed to not be offloaded with any device. On 7/22/2026, at 7:00 AM, Surveyor observed that R35 did not have Prevalon boots on while in bed. R35 was observed to not be wearing Prevalon boots and R35's heels were observed to not be offloaded with any device. On 7/22/2026, at 7:04 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-K. CNA-K stated that the shift starts at 6:30 AM and the expectation was to make rounds right away to make sure everything is okay with the residents on the assignment. Surveyor asked CNA-K to accompany Surveyor to R35's room to determine if R35 was wearing R35's Prevalon boots while R35 was in the bed. Surveyor and CNA-K got to R35's doorway and CNA-K immediately stated that CNA-K could tell from the doorway that R35 did not have Prevalon boots on both feet. CNA-K lifted up the sheet and both Surveyor and CNA-K observed that R35 did not have the Prevalon boots on and was wearing white socks with R35's heels resting directly on the mattress. CNA-K then informed Surveyor CNA-K did not see the Prevalon boots anywhere in the room. CNA-K then opened R35's closet and found 2 Prevalon boots. Surveyor asked CNA-K if R35 should be wearing the Prevelon boots when in bed, and CNA-K stated, I believe so. Surveyor asked CNA-K if CNA-K had their resident CNA care card on CNA-K and CNA-K stated no. CNA-K stated sometimes R35 fights. Surveyor asked CNA-K if R35 was resistant to putting on the Prevalon boots what CNA-K would do. CNA-K stated CNA-K would step out and give R35 time to calm down and then re-approach. Surveyor then observed CNA-K put the Prevalon boots on and R35 did not resist during the process. On 7/22/2026, at 1:29 PM, Surveyor interviewed Nurse Manager (NM)-C regarding R35 wearing Prevalon boots. NM-C stated if there was a physician order for Prevalon Boots, then Prevalon boots should be on R35 as ordered. Surveyor informed NM-C that R35 was observed to not be wearing Prevalon boots and CNA-K observed R35's Prevalon boots not on when in bed. On 7/22/2026, at 3:09 PM, Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that R35 was at high risk for developing a pressure injuries and was observed not wearing Prevalon boots per physician order. On 7/23/2026, at 7:13 AM, Surveyor observed R35 in bed. R35's left Prevalon boot was on, with the right off. Surveyor observed R35's right heel resting directly on the mattress. No additional information was provided.

Based on observation, interview, and record review, the facility did not ensure residents received adequate supervision to prevent accidents for 2 (R6 & R39) of 5 residents reviewed. *R6 was observed sitting on the edge of the bed without a Certified Nursing Assistant (CNA) present, Dycem was not observed under R6's cushion and R6 was observed in bed with the bed in a high position with the floor mat removed and no staff present in R6's room. *R39's call light was observed not within reach per R39's falls plan of care. Findings include: The facility's policy titled, Fall Risk Assessment Policy and dated 6/10/13 documents: It is the policy of [Facility's name] to routinely assess and intervene for risk factors that my increase resident risk of falling, while honoring resident's rights. Under procedure #3 it documents: Fall risk factors identified will be noted on the plan of care and addressed with interventions to mitigate these risks. 1.) R6's diagnoses includes Alzheimer's Disease and dementia. R6's high risk for falls care plan initiated & revised 4/9/24 documents the following interventions: Anticipate and meet the resident's needs, initiated 4/9/24; Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, initiated 4/9/24; Floor mat next to bed, low bed, gripper socks, initiated 8/9/24 & revised 2/14/25; Dycem in wheelchair, initiated 2/1/26 and revised 2/5/26; Ensure resident is centered in middle of bed, initiated 3/23/26. R6's Falls CAA (care area assessment) dated 4/14/26 documents: [R6's first name] triggered CAA due to risk for falls related to impaired balance and psychotropic med use. Staff to assist with mobility as indicated. Staff observes for adverse reactions to medications. Observe for changes. Proceed to care plan. Under the care plan considerations section it documents: [R6's first name] triggered CAA due to risk for falls related to impaired balance and psychotropic med use. Staff to assist with mobility as indicated. Staff observed for adverse reactions to medications. Observe for changes. Proceed to care plan. R6's Quarterly MDS (minimum data set) with an assessment reference date of 7/8/25 documents a BIMS (brief interview mental status) score of 2, which indicates severe cognitive impairment for R6. R6 is assessed as not having any behavior. R6 is assessed as being dependent for eating, toileting hygiene, roll left and right, sitting to lying, lying to sitting on edge of the bed, chair/bed to chair transfer and toilet transfer. The MDS documents that R6 is frequently incontinent of urine and bowel and that R6 is assessed as having fallen since prior assessment period with one fall with no injury. R6's fall risk assessment dated [DATE] has a score of 9. A score of 10 or higher indicates resident is at high risk for falls. On 7/21/26, at 7:02 a.m., Surveyor observed R6 sleeping in bed. Surveyor observed R6's bed is in a low position and there is a mat on the left side of R6's bed. Surveyor checked R6's Broda chair and no dycem was observed under R6's cushion. On 7/21/26, at 8:23 a.m., Surveyor observed Certified Nursing Assistant (CNA)-I in R6's room. Surveyor asked CNA-I what she was going to do. CNA-I informed surveyor she's going to do cares & get R6 up. CNA-I informed surveyor she needs to get a sling and left R6's room. On 7/21/26, at 8:25 a.m., Surveyor checked R6's Broda chair. Surveyor observed there is not dycem under the cushion in R6's Broda chair. On 7/21/26, at 8:27 a.m., CNA-I entered R6's room with a sling, filled a wash basin and placed gloves on. CNA-I removed the bedding off R6 stating, okay girl friend we're going to get dressed, raised the height of R6's bed and removed the floor mat. CNA-I placed new gripper socks and pants on R6, lowered the height of the bed down stating I'm going to sit you up and wash your face. CNA-I swung R6's legs, sat R6 at the edge of the bed, removed R6's gown stating I have a nice shirt for you. CNA-I washed R6's face, under R6's under arms and applied deodorant. At 8:36 a.m., CNA-I placed a sling around R6, stating going to get a brief, let me borrow one from [R6's room mates first name], and went over to the roommate's side of the room returning with an incontinent product. Surveyor observed CNA-I did not lay R6 back down in bed and left R6 sitting on the edge of the bed. Surveyor noted R6 has had two falls from the bed. CNA-I placed the incontinence product on R6's bed, wheeled the sit to stand lift over in front of R6, attached the sling to the lift, had R6 hold onto the bars and raised R6 off the bed. R6 removed the soiled incontinence product and provided incontinence care. CNA-I placed a new incontinence product on R6, pulled up R6's pants, wheeled the sit to stand lift over to R6's Broda chair and lowered R6 down. At 8:43 a.m. CNA-I wheeled R6 out of the room and into the dining room. On 7/21/26, at 9:42 a.m., Surveyor observed R6 sitting in a Broda chair at a table in the dining room. On 7/21/26, at 12:44 p.m., Surveyor observed R6 sitting in a Broda chair at a table in the dining room. On 7/21/26, at 3:34 p.m., Surveyor observed R6 sitting in a Broda chair at a table in the dining room. On 7/22/26, at 8:05 a.m., Surveyor checked R6's Broda chair. Surveyor did not observe dycem under R6's cushion. On 7/22/26, at 8:17 a.m., Surveyor asked Nurse Manager/Infection Preventionist (NM/IP)-C when R6 went from being in a wheelchair to the Broda chair. NM/IP-C informed surveyor she believes when R6 went onto hospice. Surveyor asked NM/IP-C if the intervention of dycem under R6's cushion should be also in the Broda chair or was it just in the wheelchair. NM/IP-C informed Surveyor she would look into this and let Surveyor know. Surveyor asked NM/IP-C if the expectation is that CNAs gather all their supplies and then start cares. NM/IP-C replied yes, I would think they would collect all their supplies before they start. Surveyor asked NM/IP-C if a CNA should leave R6 sitting on the edge of the bed by themselves and be left alone while the CNA goes to the roommate's side to get an incontinence product. NM/IP-C replied forgive me on this, you think its a simple yes or no. R6's a fall risk. Surveyor then asked NM/IP-C if R6 should have been laid back down in bed. NM/IP-C informed Surveyor that it would have been better that CNAs should have laid R6 back. Surveyor informed NM/IP-C of the observation of R6 being left sitting up on the edge of the bed while the CNA went to the roommate's side to get an incontinence product. On 7/22/26, at 9:06 a.m., Surveyor informed Director of Nursing (DON)-B of R6 having two falls from bed and R6 being left alone sitting on the edge of the bed while the CNA went to the roommate's side to get an incontinence product. DON-B informed Surveyor that CNAs are to make sure they have everything they need. On 7/23/26, at 7:51 a.m., Surveyor observed R6 sleeping in bed on the right side. Surveyor checked R6's Broda chair and observed there is green dycem under the cushion. On 7/23/26, at 8:32 a.m., Surveyor asked NM/IP-C if dycem under R6's cushion in the Broda chair is a current intervention. NM/IP-C replied yes. Surveyor informed NM/IP-C surveyor did not observe dycem under R6's cushion until today. On 7/23/26, at 9:43 a.m., Surveyor observed R6 in bed on the right side. Surveyor observed the floor mat on the left side has been removed and there is a breakfast tray on the over bed table across R6's bed. Surveyor observed that R6's bed is in a high position, not in a low position. Surveyor noted that per R6's plan of care, R6's bed is to be in the low position. Surveyor noted that there were no staff in R6's room. On 7/23/26, at 10:18 a.m., Surveyor observed R6 is awake in bed rubbing R6's forehead. Surveyor observed that the floor mat was still not on the floor by R6's bed, R6's breakfast tray is on the over bed table across R6 and R6's bed remained in the high position. Surveyor observed there was no staff in R6's room. On 7/23/26, at 10:32 a.m., Surveyor observed NM/IP-C sitting next to R6's bed feeding R6. On 7/23/26, at 10:46 a.m., Surveyor asked NM/IP-C if staff should have left R6's breakfast tray with the bed up high and fall mat removed. NM/IP-C replied no. NM/IP-C informed Surveyor she spoke with CNA-U about this. 2.) R39 was admitted to the facility on [DATE] with diagnoses that included other abnormalities of gait and mobility, muscle weakness, and weakness. R39's hospital discharge summary signed 6/19/26 documented R39 was admitted to the hospital on [DATE] due to R39 having 2 falls in the past week with increasing weakness and fatigue at home. R39's hospital physical and occupational therapy notes documented R39 had been on fall precautions. R39 discharge diagnoses included weakness and falls. R39's baseline care plan completed 6/19/26 documented: R39 required one-person physical assistance for walking in room. R39 was a safety risk due to R39 having a history of falls. On 6/19/26, R39's Fall Risk Evaluation documented a score of 13, which stated R39 is at high risk for potential falls. Prevention protocol should be initiated immediately and documented on the care plan. On 6/22/26, Advanced Practice Nurse Prescriber (APNP)-R documented R39 was admitted to the facility for complex medical management and functional deficits in mobility, safety and activities of daily living (ADLs). APNP-R documented R39 had a diagnosis of generalized weakness and recurrent falls. R30 was to receive physical and occupational therapy (PT and OT) to eval and treat and assist with ADLs as needed. R39's admission Minimum Data Set assessment, dated 6/22/26, documented that R39's Brief Interview for Mental Status score was 13, which indicated R39 was cognitively intact for daily decision-making skills. R39's MDS also documented R39 required supervision for mobility and transfers. R39's MDS documented R39 had a fall prior to admission and had 1 fall since admission to the facility. R39's Falls Care Area Assessment (CAA) signed 7/1/26 documented: R39 is at risk for falls as evidence by history of fall prior to admission to facility and last fall since admission was 6/19/26 without injury. R39 is on physical therapy (PT) caseload for strengthening and endurance. The goal is to be free from major injury if a fall occurs. Care plan will address to minimize risk and maintain current level of functioning. Staff will continue to assist resident with transfer as needed. On 6/24/26, Doctor of Medicine (MD)-S documented R39's chief complaint was falls, progressive cognitive and functional decline at home, failure to thrive. MD-S documented R39 had recurrent falls and required fall precaution, therapy efforts, and ADL support. R39's Certified Nursing Assistant (CNA) care card documented R39 was a fall risk, would self-transfer, and was unsteady to walk. R39 required minimal assistance with 1 and gait belt and walked with a walker. R39's fall comprehensive care plan initiated 6/20/26 and revised 6/21/26 documented: At risk for falls due to confusion, deconditioning, incontinence, psychoactive drug use, unaware of safety needs, impulsivity with history of falls. Interventions included: Be sure the resident's (R39) call light is within reach and encourage the resident (R39) to use it for assistance as needed. The resident (R39) needs prompt response to all requests for assistance, date Initiated: 6/20/2026; Ensure that the resident (R39) is wearing appropriate footwear shoes, slippers, non-skid socks when ambulating or mobilizing in wheelchair. Date Revised: 6/20/2026; Ensure the walker is positioned directly in front of & within reach of the resident (R39) before standing, date Initiated: 7/15/2026; Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident (R39)/family/caregivers/interdisciplinary team (IDT) as to causes, date Initiated: 6/20/2026. Surveyor noted that R39 had 2 falls since admission to the facility. On 6/12/26, at 6:15 PM, R39 was found sitting on the floor in front of R39's television. CNA stated R39's walker was not by him (R39), at the time of the fall R39 told CNA R39 did not use R39's walker. R39 stated R39 was trying to go to the bathroom. R39's fall investigation did not document if R39 had been in bed or sitting in the armchair by the window prior to the fall. The fall investigation did not document if R39's call light had been within reach. On 6/22/26, the IDT progress note documented R39 was alert but forgetful, confused, impulsive, and unsteady with ambulation, with frequent attempts to self-transfer and walk without assistance. Root cause determined to be impaired safety awareness and impulsivity related to dementia, compounded with unfamiliarity with the new environment. On 7/12/26, at 7:00 PM, R39 had been sitting out on the balcony for few minutes because R39 wanted to go and sit out in the warm weather for few minutes. Nurse went to get R39 and R39 was observed on the floor, sitting position, walker was nearby R39. On 7/20/2026, at 6:46 AM, Surveyor observed R39 in bed with both legs dangling off the bed. Call light was not within reach. Gripper socks were on the floor. [NAME] is away from the bed with clothes hanging on the walker. On 7/20/2026, at 8:21 AM, Surveyor interviewed R39. R39 informed Surveyor R39 was able to use the call light and would use the call light. On 7/21/2026, at 7:21 AM, Surveyor observed R39 sleeping in bed. Surveyor observed R39's call light draped over the bedside table, which was away from the bed. R39's call light button is facing the window, away from the bed. The call light was not within reach of R39. On 7/21/2026, at 9:30 AM, Surveyor observed R39 was in bed, R39's left leg was propped up on the walker and R39's call light was not within reach. Call light remained draped over the bedside table with the call light button facing the window. On 7/21/2026, at 11:14 AM, Surveyor interviewed Occupational Therapist (OTR)-D regarding R39. OTR-D stated R39 required standby assist for transfers and toileting. OTR-D explained R39 had no safety awareness and when OTR-D would go to grab the walker, R39 would already be getting up. OTR-D stated the best strategy for R39's impulsivity would be to have supervision. On 7/21/2026, at 11:30 AM, Surveyor again interviewed OTR-D who informed Surveyor that R39 required supervision with transfers and R39 required being checked on more frequently, and that intervention was in place prior to 2 falls in the facility and would not change that intervention after the 2 falls. OTR-D also stated that R39 knows how to use the call light and had used the call light. On 7/21/2026, at 12:01 PM, Surveyor interviewed Speech Therapist (ST)-H who had worked with R39. ST-H confirmed R39 was very capable of using the call light and ST-H had been working on the use of the call light and had been doing a lot of safety work. ST-H stated cuing was important for R39. On 7/21/2026, at 12:41 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-I regarding R39. CNA-I stated R39 can use the call light and had used it. On 7/22/2026, at 7:02 AM, Surveyor observed R39 in bed. Surveyor observed R39's call light, which was draped over the bedside table, in the same position with the call light button facing the window, and not within reach of R39. On 7/22/2026, at 12:54 P, CNA-K informed Surveyor that R39 was fully capable of using the call light and had used the call light. On 7/22/26, at 1:17 PM, Surveyor interviewed Nurse Manager (NM)-C. NM-C confirmed that R39 had the ability to use the call light. NM-C also stated that when R39 was in bed, the call light should always be within reach. Surveyor shared the observations of R39 being in bed and the call light was not within reach of R39. On 7/22/2026, at 3:09 PM, Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that R39 was observed to not have the fall care plan intervention of call light within reach. Surveyor shared the observations of R39's call light being draped over the bedside table with the call light button facing away from R39. Surveyor shared that R39's call light was not within reach. On 7/23/2026, at 7:27 AM, NHA-A informed Surveyor that R39 had been interviewed and R39 preferred call light draped over the bedside table effective 7/22/26.

Based on record review and interview, the facility did not ensure that pharmacist recommendations made during the monthly medication review were reported to the attending physician and acted upon for 3 of 5 (R5, R6 and R11) residents reviewed for unnecessary medications. R5's March, April and June 2026 pharmacy recommendations were not addressed by the physician. R6's June 2026 pharmacy recommendations were not addressed by the physician. R11's January, March and April 2026 pharmacy recommendations were not addressed by the physician. Findings include: The facility policy titled Medication Monitoring Medication Regimen Review dated 06/15 documents: The consultant pharmacist performs a comprehensive review of each resident's medication regimen at least monthly. The medication regimen review (MRR) includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and preventing or minimizing adverse consequences related to medication therapy. Findings and recommendations are reported to the director of nursing and the attending physician, and if appropriate, the medical director and/or the administrator. (3) The findings are phoned, faxed or e-mailed within (24 hours) to the Director of Nursing or designee and are documented and stored with the other consultant pharmacist recommendations in the resident's active record. (4) The prescriber and/or medical director is notified if needed. F. Resident-specific irregularities and/or clinically significant risks resulting from or associated with medications are documented in the resident's active record and reported to the Director of Nursing and/or prescriber as appropriate. (3) If a continuing irregularity is deemed to be clinically insignificant, or evidence of a valid clinical reason for rejecting the recommendation is provided, the consultant pharmacist will reconsider whether to report the irregularity again or make a new recommendation on an annual basis. G. Recommendations are acted upon and documented by the facility staff and/or the prescriber. (1). Prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreeing. 1.) Surveyor review of R5's medical record revealed the following pharmacy notes: 3/25/26 at 11:29 PM - Monthly Medication Regimen Review completed, see pharmacist report for further details. 4/20/26 at 11:41 AM - Monthly Medication Regimen Review completed, see pharmacist report for further details. 6/17/26 at 10:15 PM - Monthly Medication Regimen Review completed, see pharmacist report for further details. R5's Consult Pharmacist Recommendation to Physician document: 3/26/26: Resident currently has an order for Ferrous Sulfate taken every day. Iron absorption is reduced by hepcidin and serum hepcidin peaks around 8 hours, remains elevated at 24 hours but is not elevated at 48 hours. A double-blind placebo-controlled study (n=150) was published in the Lancet in 2023 demonstrating that alternate day dosing of FeSO4 (Ferrous Sulfate) reduced iron deficiency at 6 months and led to fewer GI side effects. Please consider changing the ferrous sulfate to every other day dosing. Surveyor noted there was no documented Physician/prescriber response. 4/23/26: Surveyor noted the same pharmacist recommendations as 3/26/26 and there was no documented Physician/prescriber response. 6/26/26: Surveyor noted the same pharmacist recommendations as 4/23/26 and there was no documented Physician/prescriber response. Surveyor review of R5's July 2026 Medication Administration Record includes an order for [NAME] Sul Oral Tablet 325 MG (Ferrous Sulfate) Give 1 tablet by mouth in the morning for iron supplement ordered 8/6/25. On 7/22/26 at 8:57 AM, Surveyor asked Nursing Home Administrator (NHA)-A who is responsible for following up on pharmacy recommendations. NHA-A told Surveyor the recommendations are sent to the Nurse Practitioner box for review. NHA-A stated, The other Surveyor brought this to our attention, and we realized they were not getting scanned into PCC (point click care) to alert us to follow up. We're putting a plan in place to fix that. Surveyor informed NHA-A that there is no evidence the facility followed up with the physician regarding R5's pharmacy recommendations. 2.) R6's diagnosis includes hypothyroidism. On 7/20/26, at 2:23 p.m., surveyor reviewed R6's medications and noted a physician order dated 4/8/24 that documents: Levothyroxine Sodium Oral Tablet 50 MCG (micrograms) (Levothyroxine Sodium) Give 1 tablet by mouth in the morning for hypothyroidism before breakfast. R6's progress note dated 6/17/26 at 2147 (9:47 p.m.) written by Pharmacist-Q documents Monthly Medication Regimen Review completed, see pharmacist report for further details. On 7/21/26, Surveyor reviewed R6's medical record and was unable to locate Pharmacist-Q's report dated 6/17/26. On 7/21/26, at 9:25 a.m., Surveyor asked Nursing Home Administrator (NHA)-A to explain the process when the pharmacist makes a recommendation. NHA-A informed Surveyor the DON (Director of Nursing) prints them, and they are placed in a box to be completed by the nurse practitioner & orders are put in. Surveyor asked for R6's pharmacy report dated 6/17/26. On 7/21/26, at 3:17 p.m., during the end of the day meeting with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B, Surveyor requested Pharmacist-Q's monthly medication regimen review dated 6/1726. On 7/22/26 at 7:12 a.m., NHA-A provided surveyor was provided with R6' consultant pharmacist recommendation to physician order printed 6/26/26. Surveyor noted Pharmacist-Q's report documents: Resident is currently taking levothyroxine 50 mcg (micrograms) daily. To decrease pill burden as well as the need for lab draws, please consider discontinuing levothyroxine. Surveyor noted the physician/prescribe response section which includes an area to agree, disagree or other along with signature and date have not been completed. On 7/22/26 at 8:28 a.m., Surveyor asked Nurse Manager/Infection Preventionist (NM/IP)-C to explain the process when Pharmacist-Q makes a recommendation during the monthly drug regimen review. NM/IP-Q explained the recommendations are sometimes in the progress notes which DON-B reviews notes every day. The pharmacist also sends his recommendations via email which we all get. DON-B explained DON-B, nurse manager, and administration all get this email. Surveyor asked who ensures the resident physician receives the recommendations in order for this recommendation to be addressed. NM/IP-Q informed Surveyor the DON or Administrator should address this, stating I look at them but I'm not the DON anymore. On 7/22/26, at 8:55 a.m., Surveyor asked DON-B when the pharmacist makes a recommendation what is the process to ensure the physician addresses the recommendation. DON-B explained she gets an email and then goes into it but the one part that she hasn't been trained on is how to pull the recommendations. Surveyor asked DON-B if she hasn't been trained who would be responsible. DON-B informed Surveyor NHA-A has pulled those. R6's consultant pharmacist recommendation to physician report dated 6/17/26 & printed on 6/26/26 was not addressed by R6's physician/prescriber. 3.) On 7/21/2026, at 3:08 PM, Surveyor reviewed R11's pharmacy recommendations from January 2026 to July 2026. On 1/27/2026, the pharmacist reviewed R11's medications and recommended R11 take potassium at meal time with 4-8 ounces of water. On 4/16/2026 and 3/25/2026, the pharmacist reviewed R11's medications and recommended the facility verify if R11's order for Guaifenesin 5 mL every 6 hours as needed is still required as the medication had no documented use in 90 days. Surveyor reviewed R11's electronic health record and was unable to locate any documentation that the physician reviewed the recommendations and what actions were taken for the pharmacy recommendations in January, March, and April of 2026. On 7/22/2026, at 12:38 PM, Surveyor asked Nursing Home Administrator (NHA)-A regarding R11's pharmacy recommendations and the actions taken. NHA-A stated they were unable to find actions taken for R11's pharmacy recommendations for January, March, and April. NHA-A stated the facility is currently working on a new system to track and document when pharmacy recommendations are made, the physician review, and action taken. NHA-A stated the expectation is that the physician reviews the pharmacy recommendations and there is documentation to reflect what action was taken.

Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 2 (R1 & R6) of 2 Residents observed during incontinence cares and for a pattern of residents the facility's policies and procedures may affect.*Infection control policies were not reviewed on an annual basis.* Appropriate hand hygiene was not observed during incontinence cares for R1.* Appropriate hand hygiene was not observed during incontinence cares for R6 and the soiled incontinent product was on the floor.Findings include:1.) On 7/22/26, Surveyor reviewed infection control policies provided by Nurse Manager/Infection Preventionist (NM/IP)-C. The policies included Legionella water management program dated 7/2018; Legionella Surveillance & Detection dated 8/1/202; Infection Prevention and Control Program dated 8/1/2018; Pneumococcal, Influenza, Covid 19, RSV Immunization policy dated 10/22/24; Reporting Communicable Disease policy dated 8/18; Enhanced Barrier Precautions dated 4/9/25; Infection Control Guidelines for all Nursing Procedures dated 4/18; Healthcare associated Infections dated 8/18; Equipment and Supplies During Isolation dated 4/18; Outbreak Respiratory Pandemic dated 3/9/20; admission of Residents with Communicable Diseases updated 8/2018; Isolation Categories of Transmission Based Precautions dated 8/18; Surveillance for Infections dated 8/8/18, Antibiotic Stewardship policy dated 9/1/18; Infections Clinical Protocol dated 8/1/18 and Handwashing/Hand Hygiene dated 8/2018.On 7/22/16, at 11:14 a.m. Surveyor met with NM/IP-C and Nursing Home Administrator (NHA)-A to discuss infection control. Surveyor informed NM/IP-C and NHA-A infection control polices should be reviewed on an annual basis and asked where Surveyor could find when these policies were last reviewed. NHA-A informed Surveyor she would get back to surveyor.On 7/23/26, at 10:35 a.m., NHA-A informed Surveyor that NHA-A isn't able to provide proof the facility reviewed their infection control policies.2.) The facility's policy titled, Handwashing/Hand Hygiene reviewed/updated 8/2018 under policy statement documents [Facility's name] follows CDC (Centers for Disease Control and Prevention) guidelines for hand hygiene and promotes hand hygiene as the primary means to prevent the spread of infections. #5 Wash hands with soap and water for the following situations includes f. Before donning and after removing sterile or non-sterile gloves. h. Before moving from a contaminated body site to a clean body site during resident care. j. After contact with blood or bodily fluids.R1's diagnosis include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominate side.R1's Significant Change MDS (minimum data set) with an assessment reference date of 6/30/26 documents a BIMS (brief interview mental status) score of 6, which indicates severe cognitive impairment. R1 is assessed as being dependent for toileting hygiene, roll left and right and chair/bed to chair transfers. R1 is assessed as always being incontinent of urine and bowel.On 7/20/26, at 9:03 a.m., Surveyor observed Certified Nursing Assistant (CNA)-O donned PPE (personal protective equipment) and informed R1 CNA-O was going to get R1 cleaned up. At 9:05 a.m. Licensed Practical Nurse (LPN)-G entered R1's room asking CNA-O if CNA-O needs any help. LPN-G donned PPE on. CNA-O removed the bedding from R1, asked R1 to check the temperature of the water in the basin and unfastened R1's incontinence product. CNA-O washed R1's frontal perineal area, informed R1 she was going to turn R1 a little and LPN-G assisted R1 with positioning on the left side. CNA-O washed R1 rectal area and buttock with a disposable wipe to remove fecal matter multiple times. CNA-O did not remove her gloves and did not perform any hand hygiene after removing fecal matter.CNA-O placed an incontinence product under R1, R1 was positioned on R1's back and LPN-G indicated LPN-G needed to do a treatment. CNA-O wiped R1's frontal perineal area again. At 9:12 a.m., CNA-O and LPN-G switched the sides of the bed, R1 was positioned on the left side with CNA-O holding R1 on the side. From 9:11 a.m. to 9:16 a.m. LPN-G completed R1's coccyx pressure injury treatment according to MD (medical doctor) orders and performed appropriate hand hygiene. At 9:19 a.m. R1 was positioned on R1's back, CNA-O pulled the incontinence product up between R1's legs and fastened the incontinence product. CNA-O and LPN-G repositioned R1 up in bed. LPN-G removed her PPE and washed her hands. CNA-O lowered R1's bed down to the lowest position, raised the head of the bed, placed a pillow around R1's left arm, covered R1 with bedding and placed the call light within reach. CNA-O then emptied the basin, removed her PPE and washed her hands.On 7/22/26, at 12:12 p.m., Surveyor asked Nurse Manager/Infection Preventionist (NM/IP)-C, along with Nursing Home Administrator (NHA)-A what is the expectation for hand hygiene. NM/IP-C informed Surveyor definitely before starting cares on any patient, and in between, if doing peri care. NHA-A informed Surveyor that staff should wash their hands when moving from dirty to clean. Surveyor asked after a CNA completes peri care and before going to the next step, which is clean, what should they do. NM/IC-C informed Surveyor that staff should remove their gloves and perform hand hygiene. Surveyor asked after they remove a resident's incontinence product what should they do with the product. NM/IC-C informed Surveyor staff should put it in the garbage and once they leave the room, place it in the big hamper. Surveyor informed NM/IP-C and NHA-A of the observations regarding hand hygiene during R1's incontinence cares.3.) R6's diagnoses include Alzheimer's Disease and dementia.R6's quarterly MDS (minimum data set) with an assessment reference date of 7/8/25 documents a BIMS (brief interview mental status) score of 2, which indicates severe cognitive impairment. R6 is assessed as not having any behaviors. R6 is assessed as being dependent for eating, toileting hygiene, roll left and right, sitting to lying, lying to sitting on edge of the bed, chair/bed to chair transfer and toilet transfer. R6 is documented as being frequently incontinent of urine and bowel. On 7/21/26, at 8:27 a.m., CNA-I entered R6's room with a sling, filled a wash basin and placed gloves on. CNA-I removed the bedding off R6 stating okay girlfriend we're going to get dressed, raised the height of R6's bed and removed the floor mat. CNA-I placed new gripper socks and pants on R6, lowered the height of the bed down stating I'm going to sit you up and wash your face. CNA-I swung R6's legs, sat R6 at the edge of the bed, removed R6's gown stating I have a nice shirt for you. CNA-I washed R6's face, under R6's under arms and applied deodorant. At 8:36 a.m., CNA-I placed a sling around R6, stating that CNA-I is going to get a brief, let me borrow one from [R6's roommates' first name], and went over to the roommate's side of the room returning with an incontinent product. CNA-I placed the incontinence product on R6's bed, wheeled the sit to stand lift over in front of R6, attached the sling to the lift, had R6 hold onto the bars and raised R6 off the bed. R6 removed the soiled incontinence product and threw the incontinence product onto the floor. While R6 was standing in the sit to stand lift, CNA-I washed R6's frontal area and buttocks, placed an incontinence product on and pulled R6's pants up. CNA-I wheeled the sit to stand over to R6' Broda chair and lowered R6 down. CNA-I did not remove her gloves and perform hand hygiene after providing continence care to R6 or lowering R6 into the Broda chair. CNA-I unhooked the sling from the lift, moved the lift away from R6 and removed the sling from behind R6. CNA-I combed R6's hair, placed glasses on top of R6's head and a blanket on R6's lap. At 8:43 a.m., CNA-I removed her gloves, placed her gloves on the over bed table, and wheeled R6 out of the room placing R6 at the end of the table in the dining room. Surveyor did not observe CNA-I perform any hand hygiene during this observation.On 7/22/26, at 12:12 p.m., Surveyor asked Nurse Manager/Infection Preventionist (NM/IP)-C, along with Nursing Home Administrator (NHA)-A what is the expectation for hand hygiene. NM/IP-C informed Surveyor definitely before starting cares on any patient, and in between, if doing peri care. NHA-A informed Surveyor that staff should wash their hands when moving from dirty to clean. Surveyor asked after a CNA completes peri care and before going to the next step, which is clean, what should they do. NM/IC-C informed Surveyor that staff should remove their gloves and perform hand hygiene. Surveyor informed NM/IP-C and NHA-A of the observations regarding hand hygiene during R6's incontinence cares and the incontinence product being thrown on the floor.

Based on interview and record review, the facility did not ensure 2 (R1 and R2) of 2 residents with allegations of abuse and injuries of unknown origin were reported to the state agency and one or more law enforcement entities.* On 6/13/25, R1's daughter Companion-K allegedly overheard Certified Nursing Assistant (CNA)-I verbally abusing R1 when providing cares to R1. The facility did not report this allegation of abuse to law enforcement.* On 6/13/25, the facility was informed by R2's wife of bruising and swelling of unknown origin with R2's right foot. R2 had an X-RAY of R2's foot on 6/14/25, which showed a fracture of the 5th metatarsal in R2's right foot. The Registered Nurse (RN) Supervisor did not notify the Nursing Home Administrator (NHA)-A of the injury with fracture until 6/16/25. The facility did not report this significant injury of unknown origin within 24 hours to the State Agency as required.Findings include:The facility's policy titled, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, dated 7/26/18, and last updated 4/29/21, documents:*Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation of an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Abuse includes verbal abuse, sexual abuse, physical abuse and mental abuse, including abuse facilitated or enabled through the use of technology.*Injuries of unknown origin: any injuries should be classified as an injury of unknown source when both of the following conditions are met:The source of the injury was not observed by any person or the source of the injury could not be explained by the resident;The injury is suspicious because of the extent of the injury for the location of the injury (example, the injury is located in an area not vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time.*Immediately: means as soon as possible, but ought not to exceed 24 hours after discovery of the incident. Federal requirements under 42 CFR state that if the events that caused the allegation involve abuse or result in serious bodily injury, nursing homes must report the violation to the administrator of the facility and Wisconsin Division of Quality Assurance (DQA) no later than two hours after the allegation is made.*All other allegations that do not involve abuse and do not result in serious bodily injury must be reported no later than 24 hours after the allegation is made. In addition, nursing homes must report to DQA and law enforcement any reasonable suspicion of a crime against any individual who is the resident of, or is receiving care from, the facility. Immediately for the purposes of reporting a crime resulting in serious bodily injury means covered individual shall report immediately, but not more than two hours after forming the suspicion.*Internal reporting:Employees must always report any allegations of or witnessed abuse or suspicion of abuse immediately to the administrator.*Law enforcement:All reports of suspected crime and/or alleged sexual abuse must be immediately reported to local law enforcement to be investigated. R1 was admitted to the facility on [DATE] with diagnoses that include cerebral infarction (a condition where blood flow to part of the brain is blocked, causing brain tissue to die due to lack of oxygen and nutrients), muscle weakness, cognitive deficit (a condition where there are difficulties with thinking abilities, including memory, learning, problem solving, and decision making), aphasia (a disorder that affects the ability to communicate), Transient Ischemic Attack (TIA) (a temporary blockage of blood flow to the brain often referred to as a stroke), and falls. R1's admission Minimum Data Set (MDS) completed on 6/15/25, documents that R1 has impairment to both upper extremities and requires partial/moderate assistance with bathing and rolling left to right. R1 is dependent on staff for toileting, dressing, and transfers. R1 is frequently incontinent of bowel and bladder. R1 was documented as having a Brief Interview for Mental Status (BIMS) score of 5, indicating that R1has severe cognitive impairment.On 7/7/25, at 10:11 AM, Surveyor reviewed the facility self-report which documents the following:*On the afternoon of Friday, 6/13/25, Companion-K reported to R1's daughter, Companion-K was walking down the hall to see R1, when Companion-K observed CNA-I close R1's door to provide cares. Companion-K waited in the hallway to give CNA-I time to complete cares. Companion-K could hear through the door, CNA-I with a stern and demanding voice when talking to R1 during cares. Companion-K heard CNA-I tell R1 to stop crying, calm down, and R1 was getting up and to stay focused and pay attention. After listening for several minutes outside the door to the struggle and to the point of R1 going into hysterics, Companion-K knocked on the door. Companion-K walked into R1's room and observed CNA-I yanking R1's shirt off. R1 was tearful, upset, and anxious.*R1's daughter notified Director of Nursing (DON)-B of the allegation of abuse on 6/13/25. DON-B started an investigation immediately.*Initial self-report was submitted to the state agency on 6/13/25, at 2:50 PM. *A 5-day self-report was submitted to the state agency on 6/20/25, at 2:27 PM.*Resident interviews were obtained and reviewed.*Staff interviews were obtained and reviewed.*Resident (R1) interview/statement was obtained and reviewed.*DON-B interviewed R1's roommate, who did not recall the incident on 6/13/25.*R1's Electronic Medical Record (EMR) documents skin and pain assessments were completed on 6/13/25.Surveyor notes the facility did not contact law enforcement.On 7/8/25, at 8:54 AM, Surveyor attempted to contact Companion-K.On 7/7/25, at 12:16 PM, Surveyor interviewed Physical Therapy Assistant (PTA)-J who stated R1 has cognitive changes, confusion, and has a hard time remembering things at times. PTA-J states she entered R1's room on 6/13/25, about 20-30 minutes after the alleged abuse on 6/13/25, with CNA-I, and observed R1 visibly upset and crying. PTA-J states Companion-K notified PTA-J that CNA-I was verbally abusive with R1 and made R1 cry. Companion-K notified PTA-J that she requested to speak with a supervisor regarding the incident with CNA-I. PTA-J states nobody should treat people like that and didn't think CNA-I was very kind when talking with R1. PTA-J states R1 and Companion-K we're both visibly upset about what happened, with Companion-K stating she couldn't believe CNA-I could act like that with someone.On 7/7/25, at 2:40 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and DON-B who stated Companion-K is not an employee with the facility and is a friend/companion to R1. DON-B states Companion-K asked facility staff to speak with a supervisor at the time of the incident on 6/13/25, but never clarified with facility staff what she wanted to speak with the supervisor about. DON-B indicated that Companion-K contacted R1's daughter regarding the alleged abuse on 6/13/25, and R1's daughter contacted DON-B with allegations of abuse witnessed by Companion-K on 6/13/25. DON-B states she immediately started the investigation. NHA-A states R1 was monitored for possible negative side effects and/or psychiatric concerns related to the allegations of abuse on 6/13/25. Surveyor asked NHA-A if the facility had contacted law enforcement with the allegations of abuse on 6/13/25. NHA-A replied no, the facility did not contact law enforcement due to the facility had not substantiated the allegations at that time and the facility was still investigating. NHA-A then stated R1 had no visible injuries and no adverse effects when DON-B interviewed R1. NHA-A stated we didn't feel it was deliberate by CNA-I. Surveyor notified NHA-A and DON-B of concerns with the facility not contacting law enforcement with allegations of abuse that occurred with R1 on 6/13/25. NHA-A and DON-B acknowledged the concern. Surveyor requested additional information if available. No additional information was provided. 2.) R2 was admitted to the facility on [DATE] with diagnosis that included, Traumatic Subdural Hemorrhage without loss of consciousness (brain bleed), Cognitive Communication Deficit, and Dementia.R2's MDS (Minimum Data Set) assessment with an assessment reference date of 6/8/25 documents that R2 has short and long term memory problems. R2's Nursing Note dated 6/13/25, at 7:30 PM, documents: Wife reported that she took off his socks and saw Lg (large) bruising on Rt foot, measures 10 x 12 cm. Foot also has some swelling. And the Resident does c/o pain but not able to rate pain. The wife said that she sees staff & also his personal caregiver that was here today not using foot pedals when pushing him in wc. Said she thinks that is the reason he has the bruise. This Res is also very demented, agitated daily, extremely uncooperative and difficult to redirect as he doesn't seem to understand anymore. He is a high fall risk & requires close supervision, but frequently after staff helps him to bed, he will be up walking around in his room. Sometimes staff will find him walking in hallway or into other Resident rooms.R2's Nursing Note dated, 6/13/25, at 7:54 PM, documents: Found bruises on his right foot, slightly swollen and tender to touch and says ouch. he had falls couple times and self-transferring and propels in w/c. spouse is aware and NP (nurse practitioner) is updated and NOR x-ray to right foot x 2 view d/t bruising/swelling and pain. Call placed to (name x-ray company) and scheduled for tomorrow. Icing as needed and elevate the legs.R2's Nursing Note dated, 6/14/25, at 3:23 PM, documents:{name} imaging at facility for XRAY. Resident tolerated well. Awaiting results.R2's Physician's Note. dated, 6/14/25, at 11:42 PM, documents: Date of Service: 06/14/2025 11:14 PM CT. Details: Nurse Name: Registered Nurse (RN)-E. Patient Name: R2. Primary Chief Complaint: Radiology review: abnormal results and/or requiring provider assessment. History Present Illness: x-ray right foot showed acute fracture of the 5th metatarsal Review of Systems: ROS as per HPI, all other systems reviewed and are negative MH and SH : Reviewed PMH, SH and Medications Source of verification for all history : Per nurse and/or patient: Vital Signs : T: 97.1 (°F). HR: 60 (bpm). BP Sys: 123 (mm/Hg). /Dia: 68 (mm/Hg). RR: 1 (rpm) SpO2: 94 (%) Sp02 Levels: Room Air. Physical Exam: Exam findings per nurse and video observation Physical Exam - Notes: not in distress. Diagnosis, Assessment/Plan: M79671 - Pain in right foot (Primary) acute fracture of the 5th metatarsal. Condition is stable. Orders: obtain Orthopedic consult. Notify a clinician of any change in condition. Disposition: Stay at Facility. Technology Used: Audio and video with patient and nurse present. Statement of Medical Necessity: Yes. Consent for telemedicine/virtual visit obtained from patient/POA: YesOn 7/7/25, at 12:52 PM, Surveyor interviewed NHA-A and Director of Nursing (DON)-B. Surveyor asked how NHA-A knows when and where to report a significant Injury of unknown origin or abuse allegations to the state agency and police. NHA-A informed Surveyor that NHA-A had a flow chart that informed NHA-A what to report and when to report significant injuries of unknown origin and to whom. NHA-A informed Surveyor if there is a severe or significant injury of unknown origin NHA-A will report that to the state agency right away. Surveyor asked NHA-A why the delay in reporting R2's injury to the state agency from 6/14/25 when the fracture was confirmed until 6/16/25. NHA-A informed Surveyor that the night shift supervisor RN-E did not inform NHA-A of the fracture until 6/16/25. NHA-A informed Surveyor the wife reported the incident on 6/13/25 and the x-ray results came back 6/14/25 on Saturday evening at 11:17 PM which likely caused the delay in reporting to NHA-A. NHA-A acknowledged it was an error not reporting the fracture until Monday 6/16/25 by RN-E to the NHA-A. NHA-A believed the delay was because of the late X-Ray results on 6/14/25. NHA-A informed Surveyor that NHA-A did a plan of correction and educated RN-E on 6/16/25 the need to immediately report significant injuries of unknown origins to administration. NHA-A informed Surveyor that NHA-A started to educate the rest of the staff on 6/16/25 on reporting significant injuries of unknown origin to NHA-A immediately. NHA-A provided surveyors with the completed education provided to staff on reporting injuries of unknown origin. On 7/7/25, at 03:41 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-D. Surveyor asked LPN-D to describe what LPN-D observed on 6/13/25 when R2's injury of unknown origin was discovered on R2's right foot. LPN-D informed Surveyor that LPN-D had entered R2's room and R2's spouse was holding onto R2's socks. LPN-D informed Surveyor that LPN-D assessed R2's bruised and swollen foot. LPN-D informed Surveyor that after speaking with R2's wife, LPN-D or R2's wife didn't know how the injury to R2's right foot occurred. Surveyor asked LPN-D if LPN-D reported the injury. LPN-D informed Surveyor that LPN-D reported the injury to Registered Nurse (RN)-C.On 7/7/25, at 03:41 PM, NHA-A came in to speak to Surveyors. NHA-A informed Surveyors that NHA-A admitted that the algorithm that NHA-A uses does lead NHA-A to call the police for Abuse and Significant injuries or unknown origin. NHA-A informed Surveyors that NHA-A will notify police moving forward.On 7/8//25, at 09:34 AM, Surveyor interviewed RN-C on the phone. Surveyor asked RN-C about R2's right foot injury on 6/13/25. RN-C informed Surveyor that RN-C assessed R2's bruised and swollen foot and had discovered no information on how the injury happened. RN-C informed Surveyor that RN-C informed the on-call doctor service and received orders for an x-ray of R2's right foot. RN-C informed Surveyor the x-ray was scheduled for 6/14/25 and that RN-C updated administration. RN-C informed Surveyor that RN-C believed on call administration was NHA-A at the time and that RN-C always informed administration of injuries. Surveyor asked when administration was informed of R2's right foot fracture. RN-C informed Surveyor that RN-C was off work on 6/14/25 and 6/15/25 and was not aware of the fracture until RN-C came back for a work shift on 6/16/25.On 7/8/25, at 09:42 AM and 10:10 AM, Surveyor attempted to call RN-E. RN-E has no voice mail. RN-E's phone plays a message to call back later.On 7/8/25, at 09:46 AM, Surveyor interviewed RN-G on the phone. Surveyor asked RN-G about R2's right foot fracture injury. RN-G was aware of the right foot injury and had assessed R2's right foot and updated R2's family, the family declined an orthopedic consult. RN-G informed Surveyor that RN-G had no x-ray results for R2's right foot as of the end of RN-G's shift. RN-G informed Surveyor that RN-G had no new information on R2's right foot injury at that time to provide administration.On 7/8/25, at 11:41 AM, NHA-A came in to discuss with Surveyors reporting abuse allegations and injuries of unknown origin to police. Surveyor expressed concern to NHA-A that the significant injury to R2's right foot had not been reported to the state agency or police when the fracture was verified on 6/14/25 until 6/16/25 at 09:26 AM. No additional information was provided by the facility.

Based on observation, interview, and record review, the facility did not ensure residents received adequate supervision and assistive devices to prevent accidents for 2 of 6 residents (R291 and R24) reviewed for accidents. The deficient practice has the likelihood of affecting a pattern of residents at the facility has 14 residents who utilize lifts for transfers. * R291 had a care planned approach to use a Hoyer lift (a full body transfer lift that uses a sling to fully support the resident during the transfer) for transfers. R291's family brought in a sling they had purchased from an outside vendor. The facility did not ensure the sling was appropriate for R291's size/weight and also did not ensure the sling was appropriate to use with the Hoyer lift used in the facility. On 2/8/25, staff were transferring R291 with the Hoyer lift and the sling purchased by the family. R291 slid out of the sling and fell to the floor sustaining a subdural hematoma and laceration to the back of the head. R291 ultimately, was transported to the hospital and received 10 staples to the back of their head. R291 returned to the facility but was sent back to the hospital for additional care for their injuries. The facility did not have a system where residents were assessed to determine the correct size sling to safely transfer each resident. There was also no system in place to ensure slings were compatible with the lift(s) used in the facility. During the survey, staff were observed using random slings not assigned to the resident regardless of lift used or size of the individual resident to ensure safety. During interviews, facility staff were unaware of manufacturer's recommendations for specific use of slings and whether the sling being utilized for a transfer was safe for the resident to use. The facility's failure to assess each resident's individual needs and to provide appropriate slings for transfers created a finding of immediate jeopardy that began on 2/8/25. Surveyor notified Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the immediate jeopardy on 4/3/25 at 12:35 PM. The immediate jeopardy was removed on 4/4/25, however, the deficient practice continues at a scope and severity of a G (actual harm/isolated) based upon the additional example regarding R24. * Since R24's admission in May of 2024 R24 has had 11 falls in the facility. On 10/4/24 R24 fell when left unattended during personal hygiene in the bathroom when staff did not anticipated R24's needs when providing cares. R24 sustained multiple fractures of her ribs at this time. Prior to 10/4/24 R24 had an injury of unknown origin this involved a fracture of one rib that was discovered 3 days after an attempt to self transfer. The facility did not collect or analyze the details regarding each of R24's falls or attempts to self transfer to develop an individualized, comprehensive plan of care to prevent future falls. R24 was known to be incontinent upon admission and was known to be impulsive. The facility did not complete a voiding pattern to establish an incontinence plan to meet R24's individual needs. The facility did not review a plan to increase supervision of R24 despite staff input post fall sharing R24 needed increased supervision to prevent falls. Findings include: 1.) The facility policy titled Safe Resident Handling/Transfers with no implementation or revision date documents: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Compliance Guidelines: 1. The interdisciplinary team (IDT) or designee will evaluate and assess each resident's individual mobility needs, taking into account other factors as well, such as weight and cognitive status. 6. The staff will inspect the equipment prior to use to ensure functionality and will alert maintenance or other designee if not functioning properly. 7. Damaged, broken, or improperly functioning lift equipment will not be used and tagged out according to facility policy. 8. The facility will ensure that there are appropriate amounts of varying sizes of slings to accommodate residents as per the manufacturer's instructions on proper sling sizing. 9. Ensure that the sling designed for the lift is utilized with that specific lift. Surveyor noted that each wing has two Hoyer style mechanical lifts: 1. EZ way smart lift which has a sling harness color coding system identifier on the lift that is indicates sling color by the resident's weight. 2. Direct Supply Atlas floor lift. Surveyor reviewed the manufacturer's/owner's manual for both brands of lifts and documented the following: 1. Per the EZ way smart lift operators' instruction: Safety notes: - Do not modify the sling design in any way. Please make sure the accessories used with each lift are appropriate for both the patient and the transferring situation. - EZ way slings are made specifically for EZ way smart lifts. For the safety of the patient and caregiver, only EZ way slings should be used with EZ way lifts. 2. Per Direct Supply Atlas Floor lift owner's manual: Operating guidelines: Warning-only slings and accessories specifically designed for use with direct supply resident lifts should be used. Use of other manufacturers components or accessories may compromise the operation of this resident's lift. 1.) R291 was admitted to the facility on [DATE] and had diagnoses that include diastolic congestive heart failure, chronic kidney disease stage 3, chronic venous insufficiency, chronic pain syndrome, transient ischemic attacks and cerebral infarctions, and chronic obstructive pulmonary disease. R291's quarterly minimum data set (MDS) dated [DATE] indicated R291 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 14 and the facility assessed R291 as needing maximal assist with 1 staff member for dressing, repositioning, and personal/toileting hygiene and dependent on 2 staff for transfers. R291 used continuous oxygen at 2 Liters via nasal cannula for shortness of breath and had a Do Not Resuscitate (DNR) order and an activated Power of Attorney. R291's self-care deficit care plan had the following intervention initiated on 3/4/24: -Transfer: EZ stand lift (a lift to help raise the resident to a standing position). On 2/4/25, R291 transitioned to Hospice care with diagnosis of: Chronic diastolic heart failure. R291's Risk for falls care plan was revised on 2/4/25 with the following intervention: -Change to Hoyer Transfer for change in condition. On 2/4/25, at 14:51 (2:51 PM) in the progress notes, nursing documented: Toileting Hoyer sling (typically a mesh sling with an opening to allow toileting without removing the sling) requested from hospice. On 2/5/25, Hospice brought in a toileting sling for the Hoyer lift to use for R291 per request when toileting because R291 did not want to use a bed pan. Surveyor noted that there is no indication of an assessment or revision to R291's care plan regarding what type/size of Hoyer lift sling R291 requires for transfers or that R291 has a different Hoyer lift sling to use for toileting that Hospice provided on 2/5/25. On 4/2/25 at 11:01 AM, Surveyor interviewed CNA-I who stated R291's family brought in a sling on 2/8/25 and asked CNA-I to use it for R291. CNA-I stated that CNA-A, CNA-C, and a nurse put the sling on R291. CNA-I stated that CNA-I was familiar with the sling having used it in other facilities. CNA-I stated the sling that was put on R291 had flaps that went around the legs so R291 could go into a sitting position. CNA-I stated that there was no teaching on how to use it, R291's family asked that CNA-I use it, so CNA-I did. CNA-I does not recall if CNA-I told oncoming shift about the sling or reported that R291's family had brought it in. CNA-I stated that normally they are not sure what kind of sling is needed and would normally grab the sling that was in the resident's room to use. On 2/8/2025 at 1630 (4:30 PM) in the progress notes RN-E documented at approximately 1500 (3:00PM) RN-E was called into (R291's) room due to a fall. Per staff, was a witnessed fall and (R291) slid off Hoyer sling during transfer and hit head at base of Hoyer lift legs. Moderate amount of blood noted at back of (R291's) head . hematoma noted at base of back of head and approximately a 1 cm laceration. Suggested (R291) go to the emergency room for evaluation, but resident and family/power of attorney (POA) declined, family at bedside. Medical doctor (MD) made aware and continue to monitor with neurological checks. It was documented that vital signs are at (R291's) baseline, noted that the bleeding had stopped, and (R291) did not lose consciousness and denied pain. Surveyor noted that R291 was prescribed Eliquis (an anticoagulant medication) 2.5 mg two times a day (BID) for atrial fibrillation at the time of the fall and had received the AM dose on 2/8/2025. R291 did not get the PM dose of Eliquis 2.5 mg. On 2/9/25 at 7:58 AM in the progress notes, nursing documented (R291) found lying in bed in large pool of blood originating from laceration to occipital area of head from fall on 2/8/25. Dressing reinforced, (R291) denied pain or discomfort. Nursing spoke with (R291's power of attorney) and agreed to send (R291) to the emergency room for further evaluation. It was documented that (R291) was alert and responding appropriately, vital signs documented: (Blood pressure-105/70, pulse-91, respirations-18, oxygenation at 95% with 2 L (liters)/oxygen, and (R291) denied headache, dizziness, or nausea. On 2/9/25 at 1800 (6:00PM), in the progress notes, nursing documented (R291) returned from emergency room . order to discontinue Eliquis . staples to be removed in 7-10 days. Surveyor reviewed R291's emergency room discharge summary dated 2/9/25 and noted the following: - Emergency medical specialists (EMS) arrived at the facility and obtained vitals; it was noted R291's Blood pressure had dropped to 88/58. - Upon arrival to the hospital, R291's blood pressure went up to 98/48, and the bleeding to the laceration had stopped. - CT (computed tomography) head results document left subdural hemorrhage measuring 5 mm (millimeter). - 3 cm (centimeter) laceration was repaired with 10 staples. - Kcentra (prothrombin complex concentrate) was given for reversal of R291's anticoagulant (Eliquis). - R291 and Family/POA did not want further interventions after closing laceration. - R291 returned back to facility with Hospice for comfort measures, and order to discontinue Eliquis. Surveyor notes that the AM Eliquis 2.5 mg dose was not documented as being given to R291 on 2/9/25. On 2/10/25 at 11:49 AM, in the progress notes is a Late Entry health status note: Created on 4/1/25 at 16:51 (4:51) by DON-B that documents: emergency room consult from 2/10/2025. -Facility staff noted (R291) had oozing from (R291's) posterior scalp . on EMS arrival to facility, (R291) was found to be hypoxic at 70% on 4L oxygen via nasal cannula. (R291) was placed on 15L oxygen via nonrebreather mask. Surveyor reviewed R291's emergency room discharge summary dated 2/10/25 and noted the following: - R291's vital signs in the emergency roiagnom on arrival were documented: blood pressure 167/127, pulse 116, respirations 25, oxygenation at 93% on 15L oxygen with nonrebreather mask. - R291 was noted to be in atrial fibrillation with rapid ventricular rate (irregular heart rhythm) - An additional staple was placed to R291's laceration for bleeding and bleeding stopped. - R291's lab work documented an elevated creatinine and potassium which was associated to the increased Lasix R291 was receiving. - Treatment was discussed with R291 and family/POA and wanted to return to facility on Hospice with comfort measures. emergency room physician discussed with R291 and family/ POA and understood that with increased oxygen demand and increase of Lasix may worsen R291's renal function and blood pressures. R291 and family/POA were agreeable and understood. - Order for Lasix increased to 60mg BID (twice daily) . - Discharge diagnoses: acute on chronic hypoxic respiratory failure, acute kidney injury, hypervolemia, and shortness of breath. On 2/13/25 at 00:39 (12:39 AM), in the progress notes nursing documented (R291) alert, slow to respond, but responds appropriately . oxygenation at 80% on 6L oxygen via nasal cannula, face mask applied, and oxygen increased to 6.5 L and oxygenation at 95% with no concerns of shortness of breath or dyspnea, occasional tracheal rattle . Head of bed elevated, lung sounds clear but diminished in the bases. (R291) denies discomfort or pain . Chronic bilateral lower extremity edema remains with feet elevated, continue to monitor. On 2/13/25 at 1400 (2:00 PM), in the progress notes, nursing documented (R291) change of condition (COC)/actively dying. morphine and Ativan started this morning and given throughout the day, (R291) yelling out help me and asking to help breathe.(R291) was lethargic most of day, 2 scopolamine patches put on and atropine drops for increased secretions . On 2/13/25 at 1720 (5:20 PM), in the progress notes, nursing documented (R291) had no vital signs detected. Family/POA at bedside. Surveyor reviewed the facility self-report that was submitted to the state agency on 2/10/25. The facility obtained family statements, and it was documented that R291's family brought a sling to the facility for staff to use for R291 when toileting. The sling was purchased through [name of company] online and was intended to have (R291) in a sitting position to assist in having a bowel movement. There is no indication this sling was assessed prior to use to ensure the safety of R291. On 4/1/25 at 9:40 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-D who stated CNA-D was not assigned to R291's unit on 2/8/25 but assisted CNA-C with the Hoyer transfer that resulted in R291's fall from the sling on 2/8/25. CNA-D stated that R291 was sitting in the recliner chair and wanted to be changed in bed and then put into electric wheelchair to go out of room. CNA-D stated the sling got hooked up to the Hoyer lift, the straps were crossed under R291's legs and when CNA-C started to raise R291 in the sling to move to R291's bed, CNA-D bent down to move a cord and at that time R291 was falling out and R291 fell on to the ground. CNA-C went to get help and CNA-D stayed with R291. CNA-D stated they were not sure how R291 fell out of the sling because the sling was still connected to the lift. Surveyor asked CNA-D how staff know what sling to use for a resident. CNA-D stated that R291 was already on a sling and was not on CNA-D's assignment 2/8/25 so assumed R291 was in the correct sling. CNA-D stated that CNA-D had not seen that kind of sling before, but figured it was R291's to use. CNA-D stated that they felt sling was put on correctly but was following CNA-C's guidance. On 4/1/25 at 1:15 PM, Surveyor interviewed CNA-C who stated they were called to the room by R291's family and asked if R291 could be changed and put into the electric wheelchair. CNA-C stated they got help from CNA-D and hooked R291's sling up to the lift. CNA-D got R291 off the recliner and started to move over to the bed when CNA-C noted R291 was sliding out of the sling. CNA-C stated they went to grab R291 but were too late and R291 fell on to the ground. Surveyor asked what sling CNA-C used for the transfer. CNA-C stated that R291 was already on a sling, so they used that one. CNA-C stated they had not seen the sling before, so CNA-D and CNA-C figured out how to hook it up to the lift. CNA-C stated that the sling had two straps and CNA-D, and CNA-C crisscrossed the straps under R291's legs and hooked them up to the lift. CNA-C stated CNA-D and CNA-C did not ask for help because R291 was already in the sling so figured it was R291's sling. On 4/1/25 at 2:29 PM, Surveyor interviewed RN Supervisor-E who stated they were called into R291's room because of a fall. RN Supervisor-E noted R291 on the floor and there was blood behind R291's head. R291 and the family did not want R291 to go to the hospital so after doing assessments and making appropriate phone calls, R291 was put back into R291's bed. RN Supervisor-E stated the sling that was under R291 was a sling RN Supervisor-E had not seen before, so staff got R291 a full body sling that was in R291's chair and lifted R291 off the floor with the lift. Surveyor asked where the sling R291 had in place came from. RN Supervisor-E did not know where the sling had come from, never saw the sling in the facility before, and did not get told in report that R291 had a different sling. On 4/1/25 at 3:36 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-F who stated LPN-F had just started shift when CNA-C came out of R291's room asking for assistance. LPN-F stated R291 was on the ground and noted bleeding on the head during RN Supervisor-E's assessment. LPN-F stated the sling that was under R291 was one LPN-F had never seen before. Staff removed the sling and put a full body sling under R291 before using the lift to transfer R291 into the bed. LPN-F stated that the sling R291 was using had a lot of flaps to it. LPN-F stated they were not sure when R291 received the sling or who provided it, but it was one LPN-F had never seen or used before. On 4/2/25 at 1:42 PM, Surveyor shared concerns with Nursing Home Administrator (NHA)-A and DON-B regarding staff using a sling on a mechanical lift that staff were not trained how to use or approved to use for R291 resulting in R291 falling out of the sling during a transfer and sustaining a laceration requiring 10 staples and a subdural hemorrhage. Surveyor shared that several staff members used the sling even though the staff had not seen it before and were not fully aware of the correct way to apply it to safely transfer R291 with the lift. OBSERVATIONS/CONCERNS REGARDING LIFTS/SLINGS DURING SURVEY Surveyor reviewed the Resident Care Cards for the East, North, and [NAME] wings. Each care card was labeled with columns that referenced resident needs that the staff could look at quickly for details regarding resident care. The columns were titled: - Room number and shower day. - Residents name. - Glasses or dentures. - Activities of daily living (ADLs) - Toileting. - Transfers/ambulation. - Comments. - Precautions. - Diet. Surveyor reviewed the Transfer/ambulation column for residents. Hoyer with assist of 2 was documented for some residents and other residents it was simply documented Hoyer with no level of staff assistance needed. Surveyor noted that there is no indication of what sling size, type of sling, or named lift (EZ way smart lift or a Direct Supply Atlas floor lift) that a resident should use or is assessed for. Surveyor noted that there are currently 14 out of 36 residents that have a transfer status indicating a Hoyer lift and would be at risk for staff not using an appropriate sling during transfers with a mechanical lift. On 4/1/25 at 9:40 AM, Surveyor interviewed CNA-D who stated all residents have their own slings in their room. CNA-D stated that if a sling is not in the room, then staff go to the supervisor and get a new sling. Surveyor asked CNA-D how staff know if the sling in the resident's room is the accurate sling for them or if they are already on a sling, how do staff confirm they are on the accurate sling. CNA-D stated that it is just assumed that it is the accurate sling because it was on the resident's side and the resident is already in a sling. Surveyor asked if the type of Hoyer sling (correct size, correct model) to be used for each individual resident is listed anywhere that staff could look at to confirm the accurate sling is used. CNA-D was not sure and stated they would go to the supervisor. On 4/1/25 at 1:15 PM, Surveyor interviewed CNA-C who stated all residents have their own sling in their room for the lift. Surveyor asked CNA-C how it is determined that a sling is appropriate for a resident. CNA-C stated that the resident's sling is usually located in their chair and if there is not a sling present then CNA-C would go to the supervisor and get a sling. Surveyor asked if the type of sling to be used for each individual resident is located anywhere that the staff could look. CNA-C stated that the resident Kardex states the type of transfer a resident is and if the resident provided their own sling, then it is documented on the Kardex, otherwise it just lists the type of transfer. Surveyor asked how staff assess if the sling in the resident's room is the appropriate sling for the resident. CNA-C stated because the sling is in the resident's room, usually in their chair, would just assume it was the resident's sling. CNA-C stated that some slings will have resident's name on them, but not all of the slings are labeled. On 4/1/25 at 1:50 PM, Surveyor interviewed Director of Therapy (DOT)-G who stated therapy does not assess a resident for sling size. Therapy assesses the resident for the appropriate transfer and the sling size is determined by nursing following the manufacturer's sling recommendations. DOT-G stated R291 was not receiving therapy services during the time of the fall or when R291 was admitted on to Hospice but was aware R291's transfer status changed to a (Hoyer-mechanical lift) transfer. On 4/1/25 at 2:29 PM, Surveyor interviewed RN Supervisor-E who stated that each resident should have their own sling in their room and the sling should have the resident's name on the sling. Surveyor asked if a resident did not have a sling in their room, where do staff find an appropriate sling. RN Supervisor-E pointed to a shelf that had several slings on it and stated they would give the staff one of those. RN Supervisor-E stated that staff would take the sling that matches what the resident usually uses. Surveyor asked if there was anything documented regarding the type and size of sling a resident should use or how it is determined what size sling a resident should use. RN Supervisor-E stated they were not sure. On 4/1/25 at 3:36 PM, Surveyor interviewed LPN-F who stated that usually the resident is already on a Hoyer sling when they help with transfers, so never really look at the slings. LPN-F stated the residents' slings are usually in the residents' chair. LPN-F said staff use common sense as well, if a resident is large, staff are not going to use a small sling, staff would use a larger sling. On 4/2/25 at 7:54 AM, Surveyor observed R21 sleeping in bed. Surveyor noted a blue mesh sling on R21's Broda chair, Surveyor did not locate R21's name on the sling. The sling was labeled with (brand name) patch on the back of the mesh sling. Surveyor noted another sling on a walker that was blue mesh with a green striping around the edges of the sling. Surveyor did not locate R21's name on the sling but noted size large was marked on the (brand name) patch and labeled with Integra H. Surveyor noted the brand of the two slings were not the same. On 4/2/25 at 8:28 AM, Surveyor observed CNA-K in R21's room assisting R21 with breakfast. Surveyor asked CNA-K what sling is used for R21. CNA-K stated that R21's name will be on the sling. Surveyor and CNA-K looked at the sling located on R21's Broda chair. CNA-K noted that R21's name was not on the sling. Surveyor asked CNA-K what Integra H meant; CNA-K was not sure. Surveyor asked if CNA-K could locate a size on the sling. CNA-K could not locate a size on the sling. Surveyor and CNA-K looked at the sling that was on R21's walker. CNA-K could not locate R21's name on the sling. Surveyor asked CNA-K what sling CNA-K will use on R21. CNA-K stated that R21's slings must be in laundry getting washed, so staff put the two slings in R21's room. CNA-K stated that the sling on the Broda chair does not look like R21's typical sling, but the sling on R21's walker does. Surveyor asked CNA-K how it is verified that the slings are appropriate for R21. CNA-K stated that they are in R21's room so would assume they are the correct slings. On 4/2/25 at 10:47 AM, Surveyor observed CNA-K, CNA-J, and CNA-H transfer R21 from the bed to R21's Broda chair using a Hoyer lift. Surveyor observed a blue mesh sling underneath R21. Surveyor asked what sling was used to transfer R21. CNA-K stated the sling that was on R21's Broda chair. Surveyor asked CNA-K if it was the same blue mesh sling that was noted in R21's chair in the morning. CNA-K stated yes it was the same sling. Surveyor noted the blue mesh sling with green trim was still on R21's walker. Surveyor asked whether CNA-K confirmed that was the correct sling to use. CNA-K stated the sling was in R21's Broda chair indicating it was R21's sling to use. On 4/2/2025 at 8:03 AM, Surveyor interviewed CNA-J who stated residents usually have blue Hoyer slings, some have holes all over it (mesh) and others are just plain fabric, some of the legs straps cross, others do not. Surveyor asked what happens if a resident does not have a Hoyer sling in their room. CNA-J stated that staff would get one from the laundry room or nurse's station. CNA-J stated they would grab a sling that looked like the one the resident usually uses. Surveyor asked how it would be verified that a sling would be appropriate to use for the resident. CNA-J stated that by working a lot you get to know what sling to use for a resident. Surveyor asked if there was anything to indicate what size or type of sling a resident should have that staff could look at. CNA-J replied they were not sure. On 4/2/25 at 9:47 AM, A Surveyor observed CNA-J assisting R23 and interviewed CNA-J who stated every resident has a blue or black Hoyer sling, if the sling is a different color, it would not be used. CNA-J stated therapy assesses what size Hoyer sling residents need and then lets staff know what sling to use. Surveyor asked what sling R23 would need. CNA-J stated based on R23's size, R23 would need a small. Surveyor and CNA-J looked at the sling in R23's room which was a blue mesh sling and saw a L written on the tag and (brand name) patch on back of the sling. CNA-J stated that maybe R23's sling is large. At that time CNA-K entered R23's room and stated that the sling in R23's room is small because the cotton sling is bigger than that one. CNA-K stated that resident's do not have names on the slings, staff just say what size is needed. Surveyor reviewed the Resident care card and noted that R23's Transfer column documented: -Hoyer (use personal grey Hoyer sling) Surveyor noted that there was not a grey sling located in R23's room and staff used a blue mesh sling to transfer R23 with the lift. On 4/2/2025 at 9:59 AM, Surveyor interviewed Laundry Service Specialist (LSS)-O who stated that slings are received in soiled bags and washed individually. LSS-O stated the social worker will get slings and put a name on it if it is the resident's personal sling. Otherwise, the slings are put into rooms and are shared. LSS-O stated most of the slings do not have labels on them and are community slings that can be used for everyone. On 4/2/25 at 9:58 AM, Surveyor interviewed EZ way employee-L who stated the company only recommends their brand of sling be used with the EZ way lift Hoyer and stated all Hoyer slings are made in house at the company. EZ way employee-L stated that the Hoyer slings are color coded according to weight and indicate what size the resident would need when using a sling for Hoyer transfers. Surveyor asked if EZ way employee-L has heard of the 2 brand slings Surveyors observed in resident rooms. EZ way employee-L stated they have not heard of those brands and recommends only using the EZ way slings for EZ way Hoyer lifts. On 4/2/25 at 11:13 AM, Surveyor interviewed Direct Supply Account Manager (DS AM)-M who stated direct supply Hoyer slings typically do not have logos on them and would recommend using only direct supply slings with direct supply lifts. DS AM-M stated that there is a compatibility list located on the website to determine if the slings are appropriate to use with a direct supply lift. Surveyor asked DS AM-M if the two brands of slings Surveyor observed in resident rooms are compatible with Direct Supply lifts. DS AM-M stated DS AM-M did not see the two brands on the compatibility list to use with a Direct Supply lift. On 4/2/25 at 1:42 PM, Surveyor interviewed NHA-A and DON-B who stated that the slings in the facility for resident use were purchased from Direct Supply. Surveyor asked how it is determined what sling can be used with the lifts. NHA-A stated that all slings are compatible with both Hoyer lifts. Surveyor shared with NHA-A and DON-B that the EZ way company recommended only EZ way slings be used with the EZ way Hoyer lift and did not recommend other slings be used with it. Surveyor also shared that the two brands of slings observed in resident's rooms were not familiar to EZ way or Direct Supply company representatives. NHA-A stated that Hospice provides their own slings through Invacare and believes they write on the sling and use the two brands observed in residents' rooms. Surveyor asked how it is determined that the brand of slings Hospice provides are compatible with the facility lifts. NHA-A stated they would get back to Surveyor. Surveyor shared that R23 had on the care card to use personal grey sling, and a blue mesh sling was noted in R23's room. Surveyor also shared that the mesh sling in R23's room was a brand that is provided by Hospice, however R23 is not on Hospice. DON-B stated that the care card should be revised and that R23 no longer uses the grey slings. DON-B stated they would go see what sling R23 has in R23's room. Surveyor asked how staff determine what sling is appropriate for the residents. NHA-A stated that slings are based on weight. NHA-A stated that when a resident is admitted or transfer status changes to a Hoyer lift, resident's weight is obtained and a sling is labeled with the resident's name; if a resident is on Hospice, Hospice will order two slings for the resident and label them with integra. NHA-A stated that the sling stays on the resident's side of the room and if there was not a sling, then staff would verify the resident's weight and get the appropriate sling if the resident's sling was not available. Surveyor shared that the slings observed in residents' rooms during survey were not labeled with the resident's name and some slings did not indicate what size the sling was. Surveyor shared that staff statements did not indicate looking at the residents' weight and getting the appropriate size sling but grabbing a sling that looked like the sling the resident had used before. Surveyor shared concerns that the resident care cards did not indicate what size sling or type of sling the staff should use for each resident. Surveyor shared significant concern that there is not a process in place for staff to make sure residents have the appropriate sling to use when doing a Hoyer transfer that could lead to a significant incident if the appropriate sling is not used for the resident. The facility's failure to have a system in place to ensure residents were individually assessed for the level of assistance needed for a mechanical lift transfer, the type and size of sling and lift to use, individualized plans of care were in place regarding lift status, and a system to ensure equipment brought in by families is assessed for appropriateness and safety prior to use created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The facility removed the immediate jeopardy on 4/4/25, however, the deficient practice continues at a scope/severity level of E (potential for harm/pattern) as the facility continues to implement the following action plan: Nursing, therapy, recreational therapy, skilled nursing leadership, and hospice departments to be educated on how to determine appropriate Hoyer sling use per resident needs. Date initiated 4/4/25. 40%

Based on observations, interviews, 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. * The facility does not have a current comprehensive water management plan that includes Water Management team members, flow charts specific to the facility to determine areas of concern or interventions implemented to prevent the spread of opportunistic pathogens (Legionella) in the facility's water systems. *3 observations of staff providing cares and administering medications without proper Personal Protective Equipment (PPE) for R23. *Observations of improper hand hygiene during wound cares for R23. *Observations of no Enhanced Barrier Precautions (EBP) in place for R392. Findings include: Water Management Program The Facility policy, titled Legionella Water Management Program, with an effective date of 07/2018, documents the following, . Procedure: 1. As part of the infection prevention and control program, our facility has a water management program, which is overseen by the Environmental Services Team. 2. The water management program team will consist of at least the following personnel: a. The infection preventionist; b. The administrator; c. The medical director (or designee); d. The director of maintenance; e. The director of environmental services; and f. The director of clinical services. 3. The purpose of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. 4. The water management program used by our facility is based on the Center for Disease Control and Prevention and ASHRAE recommendations for developing a Legionella water management program. 5. The water management program includes the following elements: a. An interdisciplinary water management team; b. A detailed description and diagram of the water system in the facility, including the following: (1) Receiving; (2) Cold water distribution; (3) Heating; (4) Hot water distribution; and (5) Waste. C. The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including: (1) Storage tanks; (2) Water heaters; (3) Filters; (4) Aerators; (5) Showerheads and hoses; (6) Misters, atomizers, air washers and humidifiers; (7) Hot tubs; (8) Fountains; (9) Medical devices such as CPAP machines, hydrotherapy equipment; etc d. The identification of situations that can lead to Legionella growth, such as: (1) Construction; (2) Water main breaks; (3) Changes in municipal water quality; (4) The presence of biofilm, scale or sediment; (5) Water temperature fluctuations; (6) Water pressure changes; (7) Water stagnation and; (8) Inadequate disinfection. e. Specific measures used to control the introduction and/or spread of legionella (e.g., temperature, disinfectants); f. The control limits or parameters that are acceptable and that are monitored; g. A diagram of where control measures are applied; h. A system to monitor control limits and the effectiveness of control measures; i. A plan for when control measures are not met and/or control measures are not effective; and j. Documentation of the program. The Facility's document, titled Facility Assessment, with a last completed date of 01/28/2025, documents in part, . Infection Control The facility has conducted an infection control risk assessment which evaluated and determined the risk or potential vulnerabilities within the resident population and the surrounding community. We have evaluated our building for potential for legionella and we have no fountains, window AC units or other standing water that puts us at risk. 1.) The 6/24/21 CDC Toolkit titled, Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings identifies the key elements of a water management program for healthcare facilities to include: 1. Establish a water management program team 2. Describe the building water systems using text and flow diagrams 3. Identify areas where Legionella could grow and spread 4. Decide where control measures should be applied and how to monitor them 5. Establish ways to intervene when control limits are not met 6. Make sure the program is running as designed and is effective 7. Document and communicate all the activities The 6/24/21 CDC Toolkit documents, program team members should possess certain skills that are needed to develop and implement your water management program. The team should also include: -Someone who understands accreditation standards and licensing requirements -Someone with expertise in infection prevention -A clinician with expertise in infectious diseases -Risk and quality management staff The CDC toolkit identifies locations in a buildings water system where Legionella can grow and spread to include but not limited to: ~Hot and cold-water storage tanks ~Water heaters ~Water Filters ~Electronic and manual faucets ~Aerators ~Shower heads and hoses ~Pipes, valves, and fittings ~Infrequently used equipment including eye wash stations. ~Ice machines ~Hot tubs Control Measures: Determine Locations Where control measures must be applied and maintained to stay in established control limits. The CDC toolkit identifies factors internal to buildings that can lead to Legionella growth to include: ~Water temperature fluctuations: Provides conditions where Legionella grows best (77 -108 Fahrenheit (F)) ~Water pressure changes ~PH (measurement of acidity or alkalinity of a solution on a scale 0 to 14) ~Inadequate disinfectant: Does not kill or inactivate Legionella ~Water stagnation: Encourages biofilm growth and reduces temperature and levels of disinfectant. Common issues that contribute to water stagnation include renovations that lead to 'dead legs' and reduced building occupancy. The Wisconsin State Plumbing Code, Chapter SPS 382.50(3)(b)6, requires a nursing homes hot water system to be installed and maintained to provide bacterial control by one of the following methods: ~Water stored and circulation initiated at a minimum of 140 F and with a return of a minimum of 124 F. This standard is best practice even considering the facility was built prior to May 2003 and grandfathered to meet requirement. ~ 5mg/L residual chlorine. ~Another disinfection system approved by the department. Surveyor requested the Facility's Water Management Program (WMP) information from Nursing Home Administrator (NHA)-A, who is also the Facility's current Infection Preventionist. NHA-A provided Surveyor with the Facility's WMP policy and a map. On 04/02/2025, at 11:39 AM, Surveyor interviewed Environmental Services Director (ESD)-AA. ESD-AA informed Surveyor that the map provided does not reflect the water flow and does not indicate risk areas. ESD-AA indicated that water temperature in resident rooms are checked on a daily basis, and indicated logs are kept. ESD-AA informed Surveyor that ESD-AA does not do anything with humidifiers or medical devices. ESD-AA indicated the Facility has no dead legs, water system is a centralized loop and indicated the Facility has portable eye washing station in the kitchen. ESD-AA indicated ESD-AA would have to look into getting further information on the Facility's comprehensive WMP. Surveyor asked ESD-AA who is part of the WMP, ESD-AA was unsure of who all is on the WMP team. On 04/02/2025, at 03:21 PM, Surveyor informed NHA-A that Surveyor needs to see the Facility's comprehensive WMP that includes description of the Facility's building water systems using text and flow diagrams, Identified areas where Legionella could grow and spread, where control measures should be applied and how to monitor them, ways to intervene when control limits are not met and documentation and communicate of all the activities. NHA-A indicated NHA-A would look into it. 04/03/2025, at 09:49 AM, NHA-A informed Surveyor that ESD-AA would be bringing in information soon regarding the WMP. On 04/03/2025, at 09:55 AM, ESD-AA provided Surveyor with a plumbing plan map for first, second floors and basement. Surveyor asked ESD-AA to show Surveyor where on the map are the identified risk areas. ESD-AA informed Surveyor those areas are not listed on the map. ESD-AA was able to provide logs for daily hot ESD-AA water temperatures from resident rooms from 01/2024 to current. ESD-AA indicated ESD-AA started in his current role about 2 months ago and will have to look into the WMP more and indicated there may be something from the previous Environmental Services Director. On 04/03/2025, at 11:06, Surveyor was informed by NHA-A that there was a big focus on WMP during a previous call with Division of Quality Assurance (DQA) on 09/15/2023. NHA-A indicated NHA-A, ESD-AA and former [NAME] President of Plant Services were among those who attended the call. NHA-A indicated NHA-A will look into what can be found regarding the Facility's WMP. On 4/10/25 NHA-A sent an email to the region sharing the state regional infection prevention nurse and state plumber are coming onsite for a campus walk though to help develop proof of a program/ indicating the facility has a policy and procedure which were reviewed and approved. No additional information was submitted by the facility following this email. 38829 2.) The facility's Enhanced Barrier Precautions policy effective 7/15/22 documents: . Purpose of Enhanced Barrier Precautions(EBP) EBP are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. EBP involve gown and glove use during high-contact Resident care activities for Residents known to be colonized or infected with a MDRO as well as those at increased risk of catching a MDRO (e.g. Residents with wounds or indwelling medical devices) Enhanced Barrier Precautions require: -The use of gown and gloves only for high-contact Resident care activities (unless otherwise indicated as part of Standard Precautions). Because EBP do not impose the same activity and room placement restrictions as Contact Precautions, they are intended to be in place for the duration of a Resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk R23 was admitted to the facility on [DATE] with diagnoses that include encounter for attention to gastrostomy. R23's Quarterly Minimum Data Set(MDS) completed 3/13/25 documents R23 currently receives 51% proportion of calories received through gastrostomy tube (g-tube). R23's care plan for Enhance Barrier Precautions (EBP) due to g-tube includes the following interventions initiated 1/22/24. -Good hand washing technique -Inform all departments isolation is in place; to include but limited to dietary, housekeeping, nursing, therapies -Instruct nursing staff on isolation technique and see that all personnel follow through -Place isolation sign outside door On 3/31/25, at 12:56 PM, Surveyor observed a cart containing personal protective equipment (PPE) outside of R23's room and a sign on R23's door indicating R23 required EBP. The EBP sign indicates that everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and a gown for the following high-contact resident care activities: -Dressing -Bathing/showering -Transferring -Changing linens -Providing Hygiene -Changing briefs or assisting with toileting -Device care or use-central line, urinary catheter, feeding tube, tracheostomy -Wound care: any skin opening requiring a dressing On 4/1/25, at 7:07 AM, Surveyor passed R23's room and observed Registered Nurse (RN)-Z administering medications into R23's g-tube. RN-Z was not wearing gloves or a gown. On 4/1/25, at 7:22 AM, Surveyor observed RN-Z at the medication cart outside of R23's room. Surveyor observed RN-Z obtain gloves out of a drawer of the medication cart. RN-Z carried the gloves in their left hand and carried medications with right hand into R23's room and placed the medications on the overbed table. RN-Z came back out to the medication cart and obtained more medications. RN-Z was observed still carrying the gloves in left hand. RN-Z moved the medication cart while carrying the gloves. RN-Z then placed second set of medications the overbed table. RN-Z then put the gloves on. Surveyor did not observe RN-Z perform hand hygiene before putting the gloves on. RN-Z then came back out of R23's room without the gloves on and obtained a towel. Surveyor observed RN-Z put the same gloves on. Surveyor again did not observe RN-Z to perform hand hygiene. Surveyor then observed RN-Z administer each medication into R23's g-tube. RN-Z was not wearing a gown during the administering of medications. Surveyor did observed RN-Z perform hand hygiene before exiting R23's room. On 4/1/25, at 8:53 AM, Surveyor observed Certified Nursing Assistant (CNA)-K exiting R23's room. Surveyor asked CNA-K what CNA-K had completed for R23. CNA-K stated that CNA-K had just finished feeding R23, repositioned her, and checked for incontinence. Surveyor observed that CNA-K had gloves on but was not wearing a gown. Surveyor did observed CNA-K perform hand hygiene before exiting R23's room. On 4/2/25, at 7:20 AM, Surveyor observed Licensed Practical Nurse (LPN)-Y go into R23's room and place medications on the overbed table. LPN-Y obtained water from the bathroom sink. LPN-Y then went and obtained gloves. Surveyor observed LPN-Y perform hand hygiene and put gloves on. LPN-Y then stated to Surveyor I should do vitals first. LPN-Y took gloves off and put the gloves on the overbed table. LPN-Y took vitals. LPN-Y then put the same gloves on that were on the overbed table. LPN-Y then administered all medications into R23's g-tube. LPN-Y was not wearing a gown during the administration of medications. Surveyor observed LPN-Y discard the gloves and performed no hand hygiene before exiting R23's room On 4/2/25, at 8:32 AM, Surveyor observed LPN-Y take a gown out of the cart, part of the gown was observed to touch the floor upon removal. LPN-Y went into R23's room and put the gown on. LPN-Y put gloves on and did not perform hand hygiene prior to putting the gloves on. LPN-Y pushed the overbed table away from R23's bed with the gloves on and administered R23's antibiotic through R23's g-tube. LPN-Y took the gloves off, then the gown and performed hand hygiene. Surveyor asked LPN-Y if there was a reason why LPN-Y did not wear a gown the first time LPN-Y administered medications to R23. LPN-Y stated, I forgot. I was supposed to. I was just flying to get things done. On 4/2/25, at 3:07 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that Surveyor observed RN-Z, CNA-K, and LPN-Y not following EBP by not donning a gown and at times not performing hand hygiene when administering medication through R23's g-tube and when performing cares for R23. No further information was provided by the facility at this time. 51016 3.) Policy document titled: Hand Washing Hand hygiene, Updated 8/2018. Policy statement: {facility} follow CDC guidelines for hand hygiene and promotes hand hygiene as the primary means to prevent the spread of infections. 1, All personnel should be trained and in serviced as needed on the importance of hand hygiene and preventing the transmission of health care associated infections. 2. All personnel shall follow the hand washing hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. 3. Hand hygiene products and supplies, (sinks soap, towels, alcohol-based hand rub, etcetera) shall be readily accessible and convenient for staff to encourage compliance with hand washing policies. 4. Residents, family members and or visitors will be encouraged to practice hand hygiene through the use of fact sheets, pamphlets and or other written materials provided at the time of admission and or posted throughout the facility. Wash hands with soap and water for the following situations. A. Before and after coming on duty. B. Before and after direct contact with residents. C. Before preparing or handling medications. D. Before performing. Any non-surgical invasive procedures? E. Before and after handling an invasive device. (Example urinary catheters. IV Access sites). F. Before donning and after removing sterile or non-sterile gloves. G. Before handling clean or soiled dressings, gauze pads, etcetera H. Before moving from a contaminated body site to a clean body site during resident care. I. After contact with a residence, intact skin J. After contact with bloody or bodily fluids, K. After handling used dressings, contaminated equipment, etcetera. L. After contact with objects (example medical equipment) in the immediate vicinity of the resident. M. After removing gloves. N. Before and after entering isolation precautions settings. O. Before and after eating or handling food. P. Before and after assisting a resident with meals and, Q. After personal use of the toilet or conducting your personal hygiene. 6. Hand hygiene is the final step after removing and disposing of personal protective equipment. 7. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare associated infections On 03/31/25, at 09:02 AM, Surveyor interviewed R392. R392 informed Surveyor that R392 was a retired Registered Nurse. R392 informed Surveyor that R392 was admitted to the facility with a right heel stage 2 pressure wound. Surveyor observed that R392 was not on enhanced barrier precautions (EBP). On 04/01/25, at 08:38 AM, Surveyor interviewed DON-B. DON-B informed Surveyor that R392 had blister on the right heel on R392's 1/17/25 admission to the facility. Surveyor asked DON-B if R392's stage 2 pressure injury was an open wound. DON-B informed Surveyor that R392's wound is open, but it has decreased in size. On 04/02/25, at 07:34 AM, Surveyor observed Certified Nursing Assistant (CNA)-H went into R392's room with a [NAME] stand without donning Personal Protective Equipment (PPE). Surveyor knocked on door to ask CNA-H if R392 was getting up for the day. CNA-H informed the Surveyor that R392 was being taken to the bathroom. Surveyor observed that CNA-H had no PPE on, and that R392 had already been transferred to the bathroom toilet. On 04/02/25, at 08:18 AM, Surveyor observed R392's wound treatment with Director of Nursing (DON)-B and Registered Nurse Manager (RN)-W. Surveyor observed RN-W remove R392's dressing and assist DON-B with wound care. Surveyor witnessed RN-W remove RN-W's gloves. Surveyor observed RN-W prior to performing hand hygiene pick up and place the soiled un-sanitized scissors along with the clean Normal Saline spray bottle in the clean transport bin. Surveyor observed RN-W take the bin to the clean wound cart in the hallway before washing RN-W's hands. Surveyor observed R392 has a wound on the right heel and the wound is not closed and that R392 is not on the required EBP for open pressure wounds. Surveyor observed that DON-B and RN-W donned only gloves for the wound treatment and used no other personal protective equipment as required for EBP when treating an open pressure wound. On 04/02/25, at 03:24 PM, Surveyor informed NHA-A and Director of Nursing (DON)-B about Surveyor's hand hygiene concerns during R392's wound treatment and the concern that R392 was not in enhanced barrier precautions for the open pressure ulcer on R392's right heel. NHA-A informed the Surveyor that NHA-A thought that pressure injuries did not require EBP. Surveyor reviewed the Centers for Medicare & Medicaid Services, Center for Clinical Standards and Quality/Quality, Safety & Oversight Group memo Ref: QSO-24-08-NH on Enhanced Barrier Precautions dated March 20, 2024, with NHA-A and DON-B. NHA-A informed Surveyor they would place R392 immediately into EBP. 4.) On 04/02/25, at 07:40 AM, Surveyor observed R23's wound treatment with Director of Nursing (DON)-B and Registered Nurse Manager (RN)-W. Surveyor noted R23 had pressure reliving boots on in bed, bolster under left arm and R23's left hand splint was in place. Surveyor observed RN-W assist DON-B with wound care and cleaning up stool on R23. Surveyor witnessed RN-W remove RN-W's gloves. Surveyor observed RN-W, prior to performing hand hygiene, pick up and place the soiled un-sanitized scissors along with the clean Normal Saline spray bottle in the clean transport bin. Surveyor observed RN-W take the bin to the clean wound cart in the hallway before washing RN-W's hands. On 04/02/25, at 03:24 PM, Surveyor informed NHA-A and Director of Nursing (DON)-B about the hand hygiene concerns during R23's wound treatment.

Based on observation and interview, the Facility does not conduct regular inspection of all bed rails as part of a regular maintenance program to identify areas of possible entrapment for 4 (R1, R24, R28 and R392), of 4 Residents observed with bilateral enabler bars on the beds during the survey process. Findings Include: The facility's Proper Use of Bed Rails effective 7/18/24 documents: .Policy: It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails. Installation and Maintenance of Bed Rails 12. The facility will assure the correct installation and maintenance of bed rails, prior to use. This includes: iii. Inspecting and regularly checking the mattress and bed rails for areas of possible entrapment v. Checking the bed rails regularly to make sure they are still installed correctly, and have not shifted or loosened over time. c. Observing ongoing precautions such as following manufacturer's equipment alerts and recalls and increasing Resident supervision, especially with the use of air-filled mattresses or or therapeutic air-filled beds that may present a different entrapment risk than rail entrapment. d. Conducting routine preventative maintenance of beds and bed rails to ensure they meet current safety standards and are not in need of repair. Ongoing Monitoring and Supervision 15. The facility will continue to provide necessary treatment and care to the Resident who has bed rails in accordance with professional standards of practice and the Resident's choices. d. The maintenance director, or designee, is responsible for adhering to a routine maintenance and inspection schedule for all bed frames, mattresses, and bed rails. On 4/2/25, at 11:45 AM, Surveyor interviewed Environmental Services Director (ESD)-AA regarding conducting regular inspection of all bed frames, mattresses, and bed rails to identify areas of possible entrapment. ESD-AA is responsible for checking bed rails but only when ESD-AA gets a work order to install or on an as needed basis. ESD-AA does regularly inspect and maintain the bed rails as part of ESD-AA's regular maintenance program to check for safety. 1.) R1 was admitted to the facility on [DATE]. R1 currently has an activated Health Care Power of Attorney(HCPOA). R1's current physician orders documents assist rails to both sides of bed every shift for skin integrity with a start date of 1/31/23. R1's care card documents R1 is high fall risk and has assist rails to both sides of bed. R1's care plan contains an intervention initiated on 1/31/23 for self-care deficit: -adaptive device on both sides of bed to assist for bed mobility and repositioning 2) R24 was admitted to the facility on [DATE]. R24 currently has an activated HCPOA. R24 does not have a current physician order for the repositioning bars. R24's side rail evaluation documents the need for repositioning bars to assist with bed mobility completed 5/26/24 with no re-evaluation completed. A verbal consent for the repositioning bars was obtained from the activated HCPOA on 5/26/24. During the survey process, Surveyor observed bilateral repositioning bars on both R1 and R24's beds. Both beds were observed to pushed next to the wall. On 4/2/25, at 3:07 PM, Surveyor shared the concern that R1 and R24's repositioning bars have not been regularly inspected for areas of possible entrapment and safety with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B. No further information was provided by the facility at this time. 51016 3) R28 was admitted to the facility on [DATE]. R28's admission MDS (minimum data set) with an assessment date of 03/13/25 documents a BIMS (brief interview mental status) score of 6 indicating severe impairment of R28's cognition. Section GG mobility documents R28 as requiring supervision or touching assistance to roll side to side in bed. Section P physical restraints documents bed rails as not used for R28. R28's Activity of Daily Living (ADL) dated 3/12/25, revision on 3/12/25, documents, self-care performance deficit r/t (related to) Activity Intolerance, Confusion, Dementia, Fatigue, Impaired balance, Limited Mobility. R28's intervention section includes the following: Adaptive device on both sides of bed to assist for bed mobility and repositioning. On 03/31/25 at 09:13 AM, Surveyor observed R28 in bed with a quarter side rail on both sides of R28's bed. On 04/02/25, at 03:24 PM, Surveyor informed NHA-A and Director of Nursing (DON)-B about the Surveyor's concern the side rails are not being checked by maintenance on R-28's bed as required for entrapment and safety concerns. 4) R392 was admitted to the facility on [DATE]. R392's Significant change in status MDS (minimum data set) with an assessment date of 02/04/25 documents a BIMS (brief interview mental status) score of 13 indicating intact cognition for R392. Section GG mobility documents R392 as requiring partial to moderate assist to roll side to side in bed. Section P physical restraints documents bed rails as not used for R392. R392's Activity of Daily Living (ADL) dated 2/1/25, documents, self-care deficit r/t (related to) periprosthetic fracture around internal prosthetic right knee joint. R392's intervention section includes the following: Adaptive device on both sides of bed to assist for bed mobility and repositioning. On 03/31/25. at 09:02 AM, Surveyor observed R392 in bed with a quarter side rail on both sides of R392's bed. On 04/01/25, at 08:27 AM, Surveyor observed R392 in bed with a quarter side rail on both sides of R392's bed. On 04/02/25, at 03:24 PM, Surveyor informed NHA-A and Director of Nursing (DON)-B about the Surveyor's concerns that the side rails are not being checked by maintenance on R392's bed as required for entrapment and safety concerns.

Based on record review and staff interview, the facility did not ensure all allegations involving potential abuse (R1) were thoroughly investigated for 1 of 4 reviewed facility reported incidents. *On 6/13/24, 2/21/25, and 3/5/25, the facility submitted facility reported incidents (FRI) involving R1 and allegations of R1 and sexual misconduct. All three FRIs were not thoroughly investigated by the facility. Findings Include: The facility's Abuse, Neglect, Mistreatment and Misappropriation of Resident Property updated 4/29/21 documents: .E. Investigation It is the policy of this facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. Procedure: The investigation is the process used to try and determine what happened. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed. The information gathered is given to administration. a. Investigation of abuse: When an incident, allegation, or suspected incident of abuse is reported, the Administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include: i. Who was involved ii. Residents' statements a. For non-verbal Residents. cognitively impaired Residents or Residents who refuse to be interviewed, attempt to interview Resident first. If unable, observe Resident, complete an evaluation of Resident behavior, affect, and response to interaction, and document findings. iii. Resident's roommate statements if applicable iv. Involved staff and witness statements of events v. A description of the Resident's behavior and environment at the time of the incident vii. Observation of Resident and staff behaviors during the investigation viii. Environmental considerations if pertinent b. Investigation of injuries of unknown origin or suspicious injuries: must be immediately investigate to rule our abuse R1 was admitted to the facility on [DATE] with diagnoses of Unspecified Dementia (loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life), Unspecified Severity, With Other Behavioral Disturbance, Other Alzheimer's Disease(progressive disease that destroys memory and other important mental functions), Impulsiveness, Major Depressive Disorder(persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities), Chronic Obstructive Pulmonary Disease(lung disease that block airflow and make it difficult to breathe), and Primary Generalized Osteoarthritis (breakdown of cartilage). R1 currently has an activated Health Care Power of Attorney (HCPOA). R1's Quarterly Minimum Data Set (MDS) completed 3/6/25 documents R1's Brief Interview for Mental Status(BIMS) score to be 7, indicating R1 is severely impaired for daily decision making. R1 has range of motion impairment on 1 side of lower extremity. R1 is dependent for dressing, mobility, and transfers. The facility submitted 3 facility reported incidents involving R1 and allegations of sexual misconduct directed at R1. Surveyor reviewed the documentation of the investigations. On 4/1/25, at 8:08 AM, Surveyor reviewed the 3 FRIs. On 6/13/24, reported at 12:48 AM, R1 stated that R1 was raped by 3 men on the way home from work. R1 described the 3 men having shaggy shoulder length hair and were wearing green scrubs. Surveyor notes that the facility did not obtain R1's roommate's statement (R24). 5 Resident statements were obtained with the same 3 questions asked: 1. Have you ever been treated roughly by a staff member? 2. Do you feel rushed by staff? 3. Has any staff member seemed frustrated with your or raised their voice at you? Surveyor notes the above 3 questions do not relate to the allegation of sexual abuse. On 2/21/25, reported at 3:17 AM, R1 reported an aide put a finger in R1's vagina causing pain. 8 Residents were interviewed with the same questions: 1. Have you ever been treated roughly by a staff member? 2. Do you feel rushed by staff? 3. Has any staff member seemed frustrated with your or raised their voice at you? R1's roommate (R24) was interviewed with the above questions but not specifically if R24 had heard or seen anything out of the ordinary in the room at the time of the allegation. On 3/5/25, reported at 12:59 AM, R1 reported a man came into R1's room, held R1 down by R1's shoulders, told R1 to lay still and quiet, and raped R1. Surveyor notes that the facility did not obtain R1's roommate's statement.(R24) 5 Residents interviewed with the same questions 1. Have you ever been treated roughly by a staff member? 2. Do you feel rushed by staff? 3. Has any staff member seemed frustrated with your or raised their voice at you? Surveyor notes the above 3 questions do not relate to the allegation of sexual abuse. The facility provided no documentation in the facility investigation of any men in the building before or during the time of the allegation. Surveyor requested the schedule from the facility for 3/5/25 and notes Registered Nurse (RN)-E was working and there is no statement from RN-E. Surveyor notes the facility reported the 3 allegations of sexual misconduct with in the regulatory reporting time-frame(within 2 hours) and on required reporting forms. Law enforcement was notified and responded. On 4/2/25, at 12:18 PM, Surveyor interviewed Director of Social Services (DSS)-P. Surveyor asked DSS-P what role DSS-P has when there is an abuse/neglect/or misappropriation allegation. DSS-P stated that DSS-P interviews 5 Residents. Surveyor asked why only 5 Residents? DSS-P stated DSS-P was told 5 is the sample. Surveyor asked if there is a roommate would DSS-P make it a point to interview the roommate. DSS-P stated that interviewing the roommate is not necessarily part of the process. DSS-P explained that it is 5 Residents, 1 from each unit to get a sample. That is part of the facility process. On 4/3/25, at 10:07 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON-B) in regards to the investigation of the 3 allegations of sexual misconduct involving R1. NHA-A stated that there is no defined process of who to talk to for the day as part of the investigation. NHA-A explained that a sample of staff from different departments statements are obtained with each investigation. NHA-A stated that there was nothing from all the departments that would initiate NHA-A to expand to other staff for more interviews. Surveyor asked why R1's roommate (R24) was not interviewed with the 6/13/24 and the 3/5/25 investigation. NHA-A stated that Resident statements are based on 25% of the census. Surveyor asked why RN-E's statement was not obtained for the 3/5/25 investigation where R1 reported an allegation of a male raping R1. NHA-A stated, Don't know why there is no interview. He is our only male and is sensitive to this. We would have talked to him. Surveyor shared that DSS-P informed Surveyor that DSS-P only obtains a sample of 5 Residents, 1 from each unit. NHA-A stated, That is correct. NHA-A would follow-up if there is a roommate to interview with an allegation of abuse or neglect to determine if the roommate saw or heard anything. Surveyor shared that R1's roommate (R24) was not interviewed for the 6/13/24 and the 3/5/25 investigation. NHA-A explained that it is a case by case investigation. Surveyor shared the concern that RN-E's statement as the only male for the 3/5/25 allegation was not obtained with the investigations and the Resident interviews is only 5 Residents, 1 from each unit with the same 3 questions that are not pertaining to R1's allegation of sexual abuse. Surveyor explained that it is a concern that a thorough investigation was not completed by the facility in regards to R1's 3 allegations of sexual abuse.

Based on observation, interview and record review, the facility did not assess the risk for possible entrapment and review the risks & benefits and obtain consent on a quarterly basis for 2 (R1 and R24) of 4 Residents observed having side/bed rails. Findings Include: The facility's Proper Use of Bed Rails effective 7/18/24 documents: .Policy: It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails. Examples of bed rails include, but are not limited to side rails, bed side rails, safety rails, grab bars and assist bars. Policy Explanation and Compliance Guidelines: Resident Assessment 1. As part of the Resident's comprehensive assessment, the following components will be considered when determining the Resident's needs, and whether or not the use of bed rails meets those needs: a. Medical diagnosis b. Size and weight c. Sleep habits d. Medication(s) e. Acute medical or surgical interventions f. Underlying medical conditions g. Existence of delirium h. Ability to toilet self safely i. Cognition j. Communication k. Mobility(in and out of bed) l. Risk of falling 2. The Resident must also assess the Resident's risk from using bed rails. a. Accident hazards(falls, entrapment, and other injuries sustained from attempts to climb over, around, between, or through the rails, or over the footboard) b. Barrier to Residents from safely getting out of bed c. Physical restraint(hinders Residents from independently getting out of bed or performing routine activities) d. Decline in Resident function e. Skin integrity issues f. Decline in other areas of activities of daily living such as using the bathroom, continence, eating, hydration, walking and mobility g. Other potential negative psychosocial outcomes such as an undignified self-image, altered self-esteem, feelings of isolation, or agitation/anxiety 4. The Resident assessment should assess the Resident's risk of entrapment between the mattress and bed rail or in the bed rail itself. 5. The facility will assess to determine if the bed rail meets the definition of a restraint. Informed Consent 6. Informed consent from the Resident or Resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bed rails. This information should be presented in an understandable manner, and consent given voluntarily, free from coercion. 7. The information that the facility should provide to the Resident, or Resident representative includes, but not to: a. What assessed medical needs would be addressed by the use of bed rails b. The Resident's benefits from the use of bed rails and the likelihood of these benefits c. The Resident's risks from the use of bed rails and how these risks will be mitigated d. Alternatives attempted that failed to meet the Resident's needs and alternatives considered but not attempted because they were considered to be inappropriate 8. Upon receiving informed consent, the facility will obtain a physician's order for the use of the specified bed rail and medical diagnosis, condition, symptom, or functional reason for the use of the bed rail. Ongoing Monitoring and Supervision 15. The facility will continue to provide necessary treatment and care to the Resident who has bed rails in accordance with professional standards of practice and the Resident's choices. This should be evidenced in the Resident's records, including their care plan, including, but not limited to, the following information: a. The type of specific direct monitoring and supervision provided during the use of bed rails, including documentation of the monitoring c. Ongoing assessment to assure that the bed rail is used to meet the Resident's needs d. Ongoing evaluation of risks e. The identification of who may determine when the bed rail will be discontinued f. The identification and interventions to address any residual effects of the bed rail 16. Responsibilities of ongoing monitoring and supervision are specified as follows: b. A nurse assigned to the Resident will complete reassessments in accordance with the facility's assessment schedule, but not less than quarterly, upon a significant change in status, or a change in type of bed/mattress/rail . 1.) R1 was admitted to the facility on [DATE]. R1 currently has an activated Health Care Power of Attorney (HCPOA). R1's Quarterly Minimum Data Set (MDS) completed 3/6/25 documents R1's Brief Interview for Mental Status (BIMS) score to be 7, indicating R1 is severely impaired for daily decision making. R1 has range of motion impairment on 1 side of lower extremity. R1 is dependent for dressing, mobility, and transfers. Use of a siderail is not documented on R1's MDS. R1's current physician orders documents assist rails to both sides of bed every shift for skin integrity with a start date of 1/31/23. Surveyor reviewed R1's Treatment Administration Record (TARS) which reads assist rails to both sides of bed every shift for skin integrity for the following months: October 2024-3 shifts not completed November 2024-4 shifts not completed December 2024-8 shifts not completed January 2025-5 shifts not completed February 2025-6 shifts not completed March 2025-7 shifts not completed R1's care card documents R1 is high fall risk and has assist rails to both sides of bed. R1's care plan contains an intervention initiated on 1/31/23 for self-care deficit: -adaptive device on both sides of bed to assist for bed mobility and repositioning R1's Care Area Assessment (CAA) for self-care deficit completed 9/12/24 documents R1 needs substantial assistance for bed mobility, roll left to right, sitting to lying and lying to sitting on the side of the bed. R1's fall risk evaluation completed 9/3/24 documents R1 is at risk for falls R1's potential for injury related to falling due to impulsiveness and history of falling care plan was initiated 4/7/20 R1's Care Area Assessment (CAA) for at risk for falls completed 9/12/24 documents R1 has a history of falls since admission to the facility. The goal is to be free from major injury if a fall will occur. Surveyor notes that an actual care plan addressing the need for repositioning bars has not been implemented for R1. R1's side rail evaluation completed 3/4/24 with a re-evaluation dated 3/4/25 documents the need for the repositioning bars to assist with bed mobility and transfers. A verbal consent for the repositioning bars was obtained from the activated HCPOA on 3/4/24 with no informed consent obtained with the re-evaluation on 3/4/25. 2.) R24 was admitted to the facility on [DATE]. R24 currently has an activated HCPOA. R24's Quarterly Minimum Data Set(MDS) completed 3/3/25 documents short and long term memory impairment and R24 is severely impaired for daily decision making. R24 has range of motion impairment on 1 side of lower extremity. R24 requires substantial/maximum assistance for mobility and partial/moderate assistance for transfers. Use of a siderail is not documented on R24's MDS. R24 does not have a current physician order for the repositioning bars. R24's care card documents R24 is a fall risk and impulsive and will attempt to self transfer R24 most recent fall risk evaluation completed 3/16/25 documents a score of 18 meaning R24 is high risk for falls. R24's high risk for falls due to confusion, gait/balance problems, incontinence, poor communication/comprehension, unaware of safety needs, and impulsive care plan was initiated on 5/26/24. R24's Care Area Assessment (CAA) for at risk for falls completed 9/26/24 documents R24 is at risk for falls as evidenced by history of fall prior to admission. A significant change MDS was completed due to right rib fracture with increase pain and need for more assistance with upper extremity activities of daily living. The goal is to be free from major injury if a fall will occur. R24's side rail evaluation documents the need for repositioning bars to assist with bed mobility completed 5/26/24 with no re-evaluation completed. A verbal consent for the repositioning bars was obtained from the activated HCPOA on 5/26/24. During the survey process, Surveyor observed bilateral repositioning bars on both R1 and R24's beds. Both beds were observed to pushed next to the wall. On 4/1/25, at 3:26 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A and Director of Nursing (DON-B) that R1 did not have consent obtained when R1's repositioning bars were re-evaluated for the need on 3/4/25. Surveyor shared that both R1 and R24 did not have a re-positioning bar evaluation completed on a quarterly basis and no actual care plan for the need for the re-positioning bars. On 4/2/25, at 9:47 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-J in regards to R1 and R24's repositioning bars. CNA-J confirmed CNA-J takes care of both R1 and R24 on a regular basis. CNA-J has never observed R1 and R24 use the repositioning bars on their own and only sometimes uses the repositioning bars when transferring. On 4/2/25, at 12:08 PM, DON-B confirmed there should be an order for re-positioning bars and the facility tries to have consents signed for the re-positioning bars on a yearly basis. DON-B also confirmed that re-positioning bars should be done quarterly per facility policy. On 4/3/25, at 8:16 AM, DON-B gave Surveyor documentation that on 4/2/25, at 5:54 PM, DON-B completed a new side rail use evaluation, obtained consent from the activated HCPOA and obtained a physician order.

Based on staff interview and record review, the facility did not ensure interventions were implemented to protect 2 Residents (R) (R4 and R9) of 2 residents from abuse. R4 and R9 resided in the same room. On 3 occasions, R4 was observed to be aggressive and grabbed, pulled, squeezed, and punched R9. R9 required medical attention at the emergency room (ER) following one of the incidents. Following the observations, the facility either did not implement measures to ensure R9 was protected from further potential aggression or did not follow through on recommendations for treatment. In addition to the observed incidents, R9 had numerous injuries of unknown origin which were not investigated to determine the cause or to put measures in place to prevent further injuries from occurring. The facility's failure to keep residents free from abuse and initiate safety measure to prevent further abuse created a finding of immediate jeopardy that began on 1/28/23. The State Agency (SA) notified Nursing Home Administrator (NHA)-A of the immediate jeopardy on 1/25/24 at 9:16 AM. The immediate jeopardy was removed on 1/25/24, however, the deficient practice continues at a severity/scope level D as the facility continues to implement its action plan. Findings include: The facility's Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy, with a revision date of 4/21/21, indicates: It is the policy of the facility that each resident will be free from abuse and that residents will be protected from abuse, neglect, and harm while they are residing in the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. On 1/24/24, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] and received Hospice services. R9 had diagnoses including hemiplegia (weakness on one side of the body) and hemiparesis (paralysis on one side of the body) with frontal lobe and executive function deficit following cerebrovascular disease affecting the right dominant side, anxiety disorder, psychotic disorder with delusions due to known physiological condition, mild cognitive impairment of uncertain or unknown etiology, and vascular dementia. R9's Minimum Data Set (MDS) assessment, dated 1/10/24, contained a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R9 had severely impaired cognition. On 1/24/24, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and received Hospice services. R4 had diagnoses including cerebral atherosclerosis, unspecified dementia, unspecified severity, with other behavioral disturbance, anxiety, and depression. R4's MDS assessment, dated 1/10/24, contained a BIMS score of 1 out of 15 which indicated R4 had severely impaired cognition. A care plan, initiated on 1/16/23, indicated R4 had a history of physically aggressive behavior, including hitting staff, and grabbing at staff and R9 related to dementia and poor impulse control. An intervention, dated 1/16/23, indicated staff should intervene before R4's agitation escalates. An intervention, dated 1/5/23, indicated staff should monitor for target behavior of pulling on R9's arm when staff provide care for R9. A late entry progress note in R9's medical record, dated 1/25/23 at 9:30 AM, indicated Registered Nurse (RN)-C entered the shared room of R4 and R9 and observed R4 and R9 in beds that were pushed together. RN-C witnessed R4 grabbing and undressing R9. When additional staff entered the room to separate and assist both residents, staff noted redness and bruising on R9's right eyelid and multiple bruises and redness in various stages of healing on R9's arms and hands. R9 was confused and alert to self, but did not remember what occurred or if R4 harmed R9. R4 could not be interviewed due to advanced dementia. The progress note indicated the redness on R9's eye was not present earlier in the shift. On 1/24/24, Surveyor reviewed an incident report, dated 1/25/23, that indicated the incident occurred on 1/24/23 at approximately 4:15 AM. A statement from RN-C indicated the redness on R9's right eyelid was not present at 12:00 AM or 2:00 AM when RN-C assisted R9 with cares. RN-C's statement also indicated R4 and R9 were aggressive with each other and should not sleep together. Surveyor reviewed an additional staff statement that indicated R4 and R9 should be separated because R4 was often aggressive with R9. The report indicated R4 and R9's beds were separated, a floor mat was placed between the beds, and frequent checks were initiated. On 1/24/24 at 11:19 AM, Surveyor interviewed NHA-A who indicated frequent checks/72-hour monitoring were initiated for safety. NHA-A also indicated R9 showed no signs of distress and the redness on R9's eyelid went away. The 1/24/23 incident report did not indicate the redness or bruising on R9's right eye went away and the facility did not provide evidence that frequent checks/72-hour monitoring were completed. Surveyor reviewed R9's care plan and noted there were no revisions or interventions added after the incident. Surveyor reviewed a second incident report, dated 1/28/23 at 11:00 PM. The report indicated RN-C entered the shared room of R4 and R9 and observed R9 laying on a floor mat between R4 and R9's beds. R4 was pulling at R9's arms. RN-C observed a bleeding skin tear on R9's right arm and indicated R4 displayed aggressive behavior when RN-C attempted to move R9 onto R9's back. R4 continued pulling and grabbing at R9's right arm and was yelling out, aggressive and agitated. Staff were unable to separate R4 and R9 or remove R9 from R4's grasp. R4 continued hitting, grabbing, and holding onto R9's arms and grabbing at R9's skin tear. Documentation indicated that in order to separate R4 and R9, RN-C pulled the bed and floor mat (with R9 laying on it) away from R4. Staff then removed R4 from the room. R9 had a 16 cm (centimeter) x 6 cm bleeding skin tear on the right arm with a half dollar size hematoma at the distal end of the wound. Staff called 911 and R9 was sent to the ER. The wound was treated and R9 returned to the facility. The incident report indicated interventions for a sleep assessment and psychiatric consult were added for R4 and R9. Witness statements included staff comments that R4 and R9 should have separate rooms, or one-to-one supervision. A note written by Nurse Practitioner (NP)-D, dated 1/30/23, indicated R9 complained of severe pain and screamed in pain with any movement of the right arm. R9 was prescribed morphine and Norco (a combination of hydrocodone and acetaminophen) for pain. On 1/24/24 at 3:35 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed sleep assessments for R4 and R9 were not completed following the 1/28/23 incident. DON-B was unsure why the sleep assessments were not completed, but verified they should have been. Surveyor reviewed R4 and R9's care plans and noted there were no monitoring or safety interventions added following the 1/28/23 incident. On 1/24/24 at 11:19 AM, Surveyor interviewed NHA-A who indicated NHA-A could not confirm R4 acted willfully and the facility did not believe R4 intended to harm R9. The Centers for Medicare and Medicaid Services (CMS) defines willful as the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Surveyor reviewed R4's progress notes and noted the following: -A note, dated 2/2/23 at 2:00 PM, indicated R4 continued to pull on R9's (right) arm. -A note, dated 2/4/23 at 9:51 AM, indicated R4 hit staff and R9. -A note, dated 2/4/23 at 2:29 PM, indicated R4 grabbed and pulled on R9's arm. -A note, dated 2/8/23 at 12:48 PM, indicated R4 was agitated and pulled on R9's (right) arm. -A note, dated 2/14/23 at 2:21 PM, indicated R4 had behaviors all day and pulled on R9's (right) arm. -A note, dated 2/16/23 at 10:37 AM, indicated R4 was agitated, tried to push R9, and grabbed R9's (right) arm. -A note, dated 2/16/23 at 2:08 PM, indicated R4 pulled on R9's (right) arm. -A note, dated 2/18/23 at 2:00 PM, indicated R4 grabbed and squeezed staff and R9's arms. -A note, dated 2/21/23 at 2:04 PM, indicated R4 pulled at R9. -Notes, dated 2/22/23 at 11:41 AM and 12:26 PM, indicated R4 was agitated and hit at R9. -A note, dated 3/6/23 at 10:23 PM, indicated R4 squeezed R9's arm, was combative, and tried to hit staff. -A note, dated 3/19/23 at 9:17 PM, indicated R4 was aggressive, confused, anxious, and grabbed and strongly squeezed R9's arms and hand. -A note, dated 3/20/23 at 10:20 PM, indicated R4 was anxious, confused, combative, aggressive, pushed a table, and grabbed, pulled, and squeezed R9's arm. -A note, dated 3/22/23 at 2:12 PM, indicated R4 struck out and pulled on R9's arm. Surveyor reviewed a third incident report, dated 5/28/23 at 6:00 PM. The report indicated R4 and R9 were sitting in the hallway and staff witnessed R4 punch R9 on the right side of the face. Witness statements indicated R9 shouted at R4 which made R4 angry and aggressive. A skin assessment was completed for R9 and no bruising or injuries were noted. Surveyor reviewed R4 and R9's care plans and noted there were no safety or monitoring interventions added to prevent further incidents from occurring. On 1/24/24 at 11:19 AM, Surveyor interviewed NHA-A who indicated the facility could not determine if R4 acted willfully and R9 did not sustain physical injury. Surveyor reviewed additional documentation related to the following injuries of unknown origin for R9: -On 3/21/23 at approximately 6:45 AM, RN-C noted a bruise on R9's left eye, multiple purple bruises on R9's left arm and lower extremities, a 12 cm x 7 cm maroon bruise on R9's upper right posterior bicep with a light yellow halo, and scratches on R9's right back. The injuries were unwitnessed and R9 could not state how the injuries occurred. -On 6/5/23 at 11:40 PM, RN-C assessed R9's left hand and noted purple bruising on the right middle and pinky fingers. The injuries were unwitnessed and R9 could not state how the injuries occurred. -On 6/6/23 at 3:30 AM, staff noted a 1 cm x 1 cm circular maroon bruise on R9's left bicep and a 7 cm x 3 cm bruise on R9's right calf. The injuries were unwitnessed and R9 could not state how the injuries occurred. A staff statement, dated 6/6/23, indicated R4 and R9 were combative with each other at times. -On 12/17/23 at 6:30 PM, staff noted a 3 cm x 3.5 cm bruise on R9's right lateral eye area. The injury was unwitnessed and R9 could not state how the injury occurred. A progress note, dated 12/18/23, indicated R9 was known to rest R9's head on the handle of the lift used to transfer R9 to the bathroom. A note instructed staff to cue R9 to sit upright while on the toilet. Surveyor noted R9's care plan was not updated with the intervention. -On 12/22/23 at 6:45 PM, staff reported a 12 cm x 6 cm dark blue bruise on R9's right wrist. The injury was unwitnessed and R9 could not state how the injury occurred. An incident report indicated R4 had a history of grabbing and squeezing R9's arms and staff had to move R4 further away from R9. When interviewed, 2 staff referenced past events in which R4 grabbed R9. A pillow was placed in R9's wheelchair to straighten R9 while sitting and keep R9's arm from being pinched in the wheelchair. Surveyor noted R9's care plan was not updated with the intervention. On 1/22/24 at 1:27 PM, Surveyor interviewed R9 who was sitting across from R4 at a table in the lounge area. R9 indicated R9 liked living at the facility with R4. R9 referred to R4 when asked additional questions. On 1/22/24 at 1:27 PM, Surveyor attempted to interview R4 who did not respond to questions. During the interview, R4 was pounding on the table and pointing toward R9. On 1/25/24 at 7:25 AM, Surveyor interview RN-C who indicated R4 can be aggressive when gripping or pulling at others; however, RN-C did not believe R4 understood the possibility of inflicting harm on others due to R4's cognitive deficits. The failure to keep residents free from abuse and initiate safety measures to prevent further abuse created a reasonable likelihood for serious harm which created a finding of immediate jeopardy. The facility removed the jeopardy on 1/25/24 when it completed the following: 1. Placed R9 on 1:1 supervision. 2. Moved R4's bed across the room from R9's bed. 2. Made the appropriate notifications, including Hospice, and the residents' provider and power of attorney (POA). 3. Educated staff. 4. Initiated resident-to-resident altercation audits to ensure safety components are in place.

Pot for all FACILITY Kitchen Initial Kitchen Tour: 01/22/24 9:49 AM Interview with DM (Assistance Dietary Manager) completed: 01/22/24 9:49 AM Assist DM Name: [NAME] Credentials: Service Aid Manager and in school with Univ. South Dakota for Food Director Certification. 4 dietary manager in the building and all work somewhat with the SNF. 1/23/24 10:00 AM interview with DM [NAME] - has associate degree in food service. RD present daily, full time on site. Experience: [AGE] years Food Code Used: State food code Clinical Dietitian Name: [NAME] Time In Facility: Full time on site. Who completes resident assessments: RD Who meets with new residents regarding preferences: RD Vender: Sysco, Rynhardt Delivery Days: Tuesday and Friday. When do they begin temperature checking and serving? Cooking temps are done in the main kitchen. Holding temps done in kitchen in SNF at approximately 11:30 AM When do they begin dishwashing?1:00 - 1:15 PM Dry Storage Dating System (first in/first out): First in/First Out Cleanliness: No concerns Food Storage: - 6 inches off ground: Y - Open foods are stored in closed labeled containers: Y - handles and not touching food items: Y Dented Can Policy: Y - reject or place in office to send back. Refrigerator/Cooler Storage Temperature log (temps are at or below 41 F): Y Thermometers are inside coolers: Y Cleanliness: No concerns Food items labeled: Y Food items stored to prevent cross contamination: Y Facility is using pasteurized eggs: Y Freezer Storage: Temperature logs (maintaining a level to keep frozen food solid): Yes Thermometers: Y Cleanliness: No concerns Food items labeled: Y Holding Temperatures (Hot foods 165 F; Cold foods 41 F) 1. Meat - 179 2. Onion Rings - 168 3. Puree Veg - 176 4. Gravy - 165 5. Mech Soft Meat - 161 6. Soup - 170 7. Mash - 159 8. Veggies Mech - 163 9. 1/22/24 - COLD salad - 45; 1/23/24 - Jell-O w/whipped cream topping - 52 Reheating to 165 F: Y Cooling Methodology: see interview and observation below Dishwashing What type of dishwasher do they use: Hot Water Temperature logs: Reviewed - concerns with temps over 190 for rinse, and one temp under 180. Hot Water Sanitization: Wash Temp: 150 Rinse Temp: 180+ - 1/21/24 AM temp check states 173; PM is 179 Process for monitoring internal temperature of 160 F (not greater than 190 F) - Log has initials under internal temps Dishwashing Process (including 3 compartment sink if applicable): Good Cleaning and Sanitizing Cleaning Schedule: Provided Sanitizer solution test kit/ and logs: Yes Equipment Slicer: Good Microwave: Good Mixer: Good Can Opener: Observed red food debris on device and on blade. ADM states it is rotated out by and external company weekly, and cleaned in-between rotation. Range/Oven: Hood is inspected by outside company, last inspection 10/9/23, looks good. Oven observed to have dried grainy substance on internal window/glass, ADM assumes it's hard water stain, put uncertain. States it's cleaned every night. Requested cleaning schedule and logs, Does not have Observations of Infection Prevention Hand Hygiene: Main kitchen Good Hairnets / Facial Hairnets: Good Handwashing Sink/Temperature/Garbage for hand towel: Observed staff member use paper towel to open lid and dispose of towel. Garbage/Dumpster Observed trash compactor with closed lid/door. Concerns/Questions: Interview with ADM 01/23/24 02:27 PM Dishwasher Temps: - How do you measure/document internal temperature? - strip: used for internal temp - 160 today observed. staff knows what to do, call management. 190 rinse concern. ADM was unaware of 190 guideline and why it should not rise above 190. 14/63 instances plus initiatial obs of kitchen tour 3-Compartment Sink: - What chemical sanitizer do you use? - sanitizer sol - Hydrion - Ecolab QT-40. - Where do you document water temp? - do not test temp water prior to test. Observe Handwashing Sink: Observed staff use paper towel to lift lid. Discussed, DM placed new garbage can by handwashing sink to be dedicated only for disposal of the paper towels. Cold Holding Temps: - Expectation v. Food Code - cold temp - chef salad left kitchen at 40 - temp at 45 - acknowledged by ADM that is should be 41 or below, and that salad was temp at 45 and jello was at 52. What cooling method do you use: cooling in freezer, or put it in a certain place - by time leftover comes down its at temp. ADM acknowledged no cooling process in place. Observed items in cooler and observed egg salad 1/20/24 - In cooler and was cooked prior to being placed in the cooler. Do you have a cleaning schedule/log: Yes - Can opener - still food debris on. Observed first during initial kitchen tour 1/22/24, and again on revisit to the kitchen on 1/23/24. 1/23/24 observed DM scrubbing and cleaning can opener after discussed.

Based on observation, staff interview, and record review, the facility did not ensure safe food handling practices were implemented. This had the potential to affect 43 of 43 residents residing in the facility. Staff did not cool foods with an approved cooling method. Staff were unaware of temperature requirements when testing parts per million (PPM) of the sanitizing solution. Staff did not ensure a can opener was clean. Findings include: On 1/22/24, at 9:49 AM, Surveyor conducted an initial tour of the kitchen with Assistant Dietary Manager (ADM)-E who stated the facility follows the Wisconsin Food Code. Food Cooling Temperatures: The Wisconsin Food Code 2022 documents at section 3-501.14 Cooling. (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 57 Celsius (C) (135 Fahrenheit (F)) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less. (B) Time/temperature control for safety food shall be cooled within 4 hours to 5 C (41 F) or less. The Wisconsin Food Code 2022 documents at section 3-501.15 Cooling Methods. (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3-501.14 by using one or more of the following methods based on the type of food being cooled: (1) Placing the food in shallow pans; (2) Separating the food into smaller or thinner portions; (3) Using rapid cooling equipment; (4) Stirring the food in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods On 1/23/24 at 2:27 PM, Surveyor completed a follow up tour of the kitchen. Surveyor and ADM-E observed a container of egg salad, dated 1/20/24 and sealed with plastic wrap, in the cooler. ADM-E confirmed the item was cooked prior to cooling and meant for resident consumption. ADM-E also confirmed the facility did not have a process for monitoring the temperature of foods made ahead of time for meal service and did not use an approved cooling method or have cooling temperature logs. Sanitizing Solution: The Wisconsin Food Code 2022 documents at section 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration. Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. On 1/23/24 at 2:27 PM, Surveyor interviewed ADM-E who verified the facility uses Ecolab Quaternary sanitizer for the three-compartment sink. ADM-E verified staff use Hydrion Quaternary test strips to test the sanitizing solution. Surveyor and ADM-E verified the Hydrion Quaternary test strip instructions indicate the sanitizing solution should be between 65-75 degrees F when mixed with water and tested for PPM. ADM-E stated staff do not test the water temperature prior to testing the sanitizing solution. Cleanliness: The Wisconsin Food Code 2022 documents at section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. During an initial tour of the kitchen on 1/22/24 at 9:49 AM, Surveyor observed dried, crusted, red food debris on a can opener. ADM-E stated the can opener is cleaned nightly by staff and replaced weekly a by third-party vendor. During a follow up visit to the kitchen on 1/23/24 at 2:27 PM, Surveyor noted the can opener was in the same unclean condition. Surveyor reviewed the kitchen's weekly cleaning checklist which did not include the can opener. During Surveyor's follow up visit to the kitchen on 1/23/24, ADM-E verified the can opener contained food debris.

Based on staff interview and record review, the facility did not ensure all allegations of abuse and injuries of unknown origin were reported to the State Agency (SA) for 2 Residents (R) (R4 and R9) of 2 sampled residents. On 5/28/23 at approximately 6:00 PM, staff witnessed R4 punch R9 on the right side of the face. The facility did not report the allegation of abuse to the SA. On 1/28/23 at approximately 11:00 PM, Registered Nurse (RN)-C entered the shared room of R4 and R9 and observed R9 laying on a floor mat next to R4's bed. R4 was pulling at R9's arms. Despite redirection, R4 continued to pull and grab at R9's right arm which contained a bleeding skin tear. The facility did not report the allegation of abuse to the SA. On 1/24/23 at approximately 4:15 AM, RN-C entered the shared room of R4 and R9 and observed R4 grabbing and undressing R9. Staff noted redness and bruising on R9's right eyelid and multiple bruises in various stages of healing on R9's arms and hands. The injuries were unwitnessed and R9 could not state how the injuries occurred. The facility did not report the injuries of unknown origin to the SA. On 12/17/23 at 6:30 PM, staff noted a 3 cm (centimeter) x 3.5 cm bruise on R9's right lateral eye area. The injury was unwitnessed and R9 could not state how the injury occurred. The facility did not report the injury of unknown origin to the SA. On 12/22/23 at 6:45 PM, staff noted a 12 cm x 6 cm bruise on R9's right wrist. The injury was unwitnessed and R9 could not state how injury occurred. The facility did not report the injury of unknown origin to the SA. On 3/21/23 at 5:30 AM, RN-C noted multiple purple bruises on R9's left arm, bilateral lower extremities, and upper right posterior bicep, and scratches on R9's right back. The injuries were unwitnessed and R9 could not state how the injuries occurred. The facility did not report the injuries of unknown origin to the SA. On 6/5/23 at 11:40 AM, RN-C noted bruising on R9's right middle and pinky fingers. The injuries were unwitnessed and R9 could not state how the injuries occurred. The facility did not report the injuries of unknown origin to the SA. On 6/6/23 at 3:30 AM, RN-C noted a 1 cm x 1 cm circular maroon bruise on R9's left bicep and a 7 cm x 3 cm bruise on R9's right calf. The injuries were unwitnessed and R9 could not state how the injuries occurred. The facility did not report the injuries of unknown origin to the SA. Findings include: The facility's Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy, with a revision date of 4/21/21, indicates: It is the policy of the facility that all abuse, including injuries of unknown source, are reported to the SA or local law enforcement per federal and state law .An injury should be considered an injury of unknown source when the injury was not observed by any person, or the injury cannot be explained by the resident; and the injury is suspicious because of extent, location, or number of injuries observed at one time or over a period of time. On 1/24/24, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] and received Hospice services. R9 had diagnoses including hemiplegia (weakness on one side of the body) and hemiparesis (paralysis on one side of the body) with frontal lobe and executive function deficit following cerebrovascular disease affecting the right dominant side, anxiety disorder, psychotic disorder with delusions due to known physiological condition, mild cognitive impairment of uncertain or unknown etiology, and vascular dementia. R9's Minimum Data Set (MDS) assessment, dated 1/10/24, contained a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R9 had severely impaired cognition. On 1/24/24, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and received Hospice services. R4 had diagnoses including cerebral atherosclerosis, unspecified dementia, unspecified severity, with other behavioral disturbance, anxiety, and depression. R4's MDS assessment, dated, 1/10/24, contained a BIMS score of 1 out of 15 which indicated R4 had severely impaired cognition. Surveyor noted R4's care plan, dated 1/16/23, indicated R4 had the potential to be physically aggressive with staff and R9 related to a diagnosis of dementia and poor impulse control. R4's target behavior, dated 1/5/23, stated R4 had a history of pulling R9's arm when staff provided care for R9. 1. On 1/24/24, Surveyor review an incident that occurred on 5/28/23 at approximately 6:00 PM. The incident report indicated R4 and R9 were sitting in the hallway and staff witnessed R4 punch R9 on the right side of the face. Witness statements indicated R9 was shouting at R4 which made R4 angry and aggressive. Nursing staff completed a skin assessment for R9 and noted no bruising or injuries. On 1/24/24 at 11:19 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed NHA-A did not report the 5/28/23 incident to the SA. NHA-A referred to Department of Health Services (DHS) Form P-00361 and stated the facility could not determine if R4 acted willfully and R9 did not sustain physical injury. 2. On 1/24/24, Surveyor completed reviewed an incident that occurred on 1/28/23 at approximately 11:00 PM. The incident report indicated RN-C entered R4 and R9's shared room and observed R9 laying on a floor mat next to R4's bed. R4 was pulling at R9's arms. RN-C attempted to move R9 onto R9's back and noted a bleeding skin tear on R9's right arm. R4 continued to pull and grab R9's right arm and was aggressive and agitated. Staff were unable to separate R4 and R9 or remove R9 from R4's grasp as R4 continued to hit, grab, and hold onto R9's arms. In order to separate R4 and R9, RN-C pulled the bed and floor mat (with R9 laying on it) away from R4 and removed R4 from the room. RN-C noted a 16 cm x 6 cm bleeding skin tear on R9's right arm with a half dollar size hematoma at the distal end of the wound. Staff called 911 and R9 was sent to the emergency room (ER). The wound was treated and R9 returned to the facility. A note written by Nurse Practitioner (NP)-D, dated 1/30/23, indicated R9 complained of severe pain and screamed in pain with any movement of the right arm. On 1/24/24 at 11:19 AM, Surveyor interview NHA-A who confirmed the 1/28/23 incident was not reported to the SA. NHA-A referred to DHS Form P-00361 and stated NHA-A did not report the incident because the facility could not confirm that R4 acted willfully and the facility did not believe R4 intended to harm R9. 3. On 1/24/24, Surveyor reviewed an incident that occurred on 1/24/23 at approximately 4:15 AM. The incident report stated RN-C entered R4 and R9's shared room and observed R4 and R9 in beds that were pushed together. RN-C witnessed R4 grabbing and undressing R9. Additional staff entered the room to separate and assist R4 and R9. Staff noted redness and a bruise on R9's right eyelid and multiple bruises and redness in various stages of healing on R9's arms and hands. R9 was confused and alert to self, but did not remember what occurred or if R4 harmed R9. R4 was unable to provide a statement due to advanced dementia. RN-C's statement indicated the redness on R9's right eyelid was not present at 12:00 AM or 2:00 AM when RN-C assisted R9 with care. RN-C's statement also indicated R4 and R9 were aggressive with each other and should not sleep together. Surveyor reviewed an additional staff statement that indicated R4 and R9 should be separated because R4 was often aggressive with R9. On 1/24/24 at 11:19 AM, Surveyor interviewed NHA-A who confirmed the incident was not reported to the SA and indicated prior to reporting, NHA-A refers to the State of Wisconsin DHS Division of Quality Assurance (DQA) Resident-to-Resident Altercation Flowchart. NHA-A stated since R9 showed no signs of distress and the redness faded, the incident was not reportable. 4. On 1/24/24, Surveyor reviewed an injury of unknown origin that was discovered on 12/17/23 at 6:30 PM. The incident report indicated staff reported a 3 cm x 3.5 cm bruise on R9's right lateral eye area. The injury was unwitnessed and R9 could not state how the injury occurred. 5. On 1/24/24, Surveyor reviewed an injury of unknown origin that was discovered on 12/22/23 at 6:45 PM. The incident report indicated staff noted a 12 cm x 6 cm bruise on R9's right wrist. Staff interviews indicated R4 had a history of grabbing and squeezing R9's arms and staff had to place R4 further away from R9. The injury was unwitnessed and R9 could not state how the injury occurred. 6. On 1/24/24, Surveyor reviewed an incident that occurred on 3/21/23 at 5:30 AM. The incident report indicated staff heard yelling, entered R9's room, and observed R9 hit R9's self in the face while attempting to wake up R4. Staff noted bruising on R9's left eye and notified RN-C who noted multiple purple bruises on R9's left arm and bilateral lower extremities, a 12 cm x 7 cm bruise on R9's upper right posterior bicep, and scratches on R9's right back. The injuries were unwitnessed and R9 could not state how the injuries occurred. 7. On 1/24/24, Surveyor reviewed an injury of unknown origin that was discovered on 6/5/23 at 11:40 AM. The incident report indicated RN-C provided treatment for R9 and noted bruising on R9's right middle and pinky fingers. The injuries were unwitnessed and R9 could not state how the injuries occurred. 8. On 1/24/24, Surveyor review an injury of unknown origin that was discovered on 6/6/23 at 3:30 AM. RN-C provided care for R9 and noted a 1 cm x 1 cm circular maroon bruise on R9's left bicep and a 7 cm x 3 cm bruise on R9's right calf. The injuries were unwitnessed and R9 could not state how the injuries occurred. On 1/24/24 at 11:19 AM, Surveyor interviewed NHA-A who confirmed NHA-A did not report the injuries of unknown origin discovered on 12/17/23, 12/22/23, 3/21/23, 6/5/23, and 6/6/23 to the SA and was unaware the injuries should be reported.

Based on staff interview and record review, the facility did not ensure allegations of abuse and injuries of unknown origin were thoroughly investigated for 2 Residents (R) (R4 and R9) of 2 sampled residents. On 1/24/23 at approximately 4:15 AM, Registered Nurse (RN)-C entered the shared room of R4 and R9 and witnessed R4 grabbing and undressing R9. Staff noted bruising on R9's right eye and multiple bruises in various stages of healing on R9's arms and hands. The injuries were unwitnessed and and R9 could not state how the injuries occurred. The facility did not complete a thorough investigation for the injuries of unknown origin. On 3/21/23 at 5:30 AM, RN-C noted multiple purple bruises on R9's left arm and lower extremities. RN-C also noted bruising on R9's upper right posterior bicep and scratches on R9's right back. The injuries were not witnessed and R9 could not state how the injuries occurred. The facility did not complete a thorough investigation for the injuries of unknown origin. On 6/5/23 at 11:40 AM, RN-C noted bruising on R9's right middle and pinky fingers. The injuries were not witnessed and R9 could not state how the injuries occurred. The facility did not complete a thorough investigation for the injuries of unknown origin. On 6/6/23 at 3:30 AM, RN-C noted a 1 cm (centimeter) x 1 cm circular maroon bruise on R9's left bicep and a 7 cm x 3 cm bruise on R9's right calf. The injuries were not witnessed and R9 could not state how the injuries occurred. The facility did not complete a thorough investigation for the injuries of unknown origin. Findings include: The facility's Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy, with a revision date of 4/21/21, indicates: It is the policy of the facility that reports of abuse will be immediately investigated and injuries of unknown origin will be thoroughly investigated to rule out abuse. During the investigation, the facility will take measures to ensure the safety of resident(s), by assessing and interviewing the resident and other residents who could be potentially affected. An injury should be considered an injury of unknown source when the injury was not observed by any person, or the injury cannot be explained by the resident; and the injury is suspicious because of extent, location, or number of injuries observed at one time or over a period of time. On 1/24/24, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] and received Hospice services. R9 had diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) with frontal lobe and executive function deficit following cerebrovascular disease affecting the right dominant side, anxiety disorder, psychotic disorder with delusions due to known physiological condition, mild cognitive impairment of uncertain or unknown etiology, and vascular dementia. R9's Minimum Data Set (MDS) assessment, dated 1/10/24, contained a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R9 had severely impaired cognition. R9's impaired skin integrity care plan, last revised on 1/9/24, indicated R9 had a history of combativeness, frail and thin skin, leaned to the right, and received Plavix daily which placed R9 at risk for easy bruising. Interventions included: skin inspection weekly, staff to make sure each bed is on opposite wall, and pillow to right side when in wheelchair. R9's risk for falls care plan, last revised on 12/29/23, indicated R9 was at high risk for falls due to poor safety awareness and use of psychotropic medication. A target behavior, initiated on 1/11/23 and revised on 1/9/24, indicated R9 had behaviors of disrobing and violence/aggression toward staff and others. The care plan did not include interventions or preventative measures to ensure safety between R9 and R4 or to protect R9 from self-harm. On 1/24/24, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and received Hospice services. R4 had diagnoses including cerebral atherosclerosis, unspecified dementia, unspecified severity, with other behavioral disturbance, anxiety, and depression. R4's MDS assessment, dated, 1/10/24, contained a BIMS score of 1 out of 15 which indicated R4 had severely impaired cognition. Surveyor noted R4's care plan, dated 1/16/23, indicated R4 had the potential to be physically aggressive with staff and R9 related to a diagnosis of dementia and poor impulse control. R4's target behavior, dated 1/5/23, stated R4 had a history of pulling R9's arm when staff provided care for R9. 1. On 1/24/24, Surveyor reviewed an investigation for the incident that occurred on 1/24/23 at approximately 4:15 AM. The incident report indicated RN-C entered R4 and R9's shared room and observed R4 and R9 in beds that were pushed together. R4 was grabbing and undressing R9. When staff entered the room to separate and assist R4 and R9, staff noted redness and bruising on R9's right eyelid and multiple bruises and redness in various stages of healing on R9's arms and hands. R9 was confused and alert to self, but did not remember what occurred or if R4 harmed R9. R4 was could not be interviewed due to advanced dementia. RN-C's statement indicated the redness on R9's right eyelid was not present at 12:00 AM or 2:00 AM when RN-C assisted R9 with care. RN-C indicated R4 and R9 were aggressive with each other and should not sleep together. Surveyor reviewed a second staff statement that indicated R4 and R9 should be separated because R4 was often aggressive with R9. The facility implemented interventions to separate R4 and R9's beds with a floor mat in between and complete frequent checks. The investigation included a skin injury report and 2 staff statements. The investigation did not include interviews with additional staff or other residents to rule out abuse. The investigation also did not include documentation of frequent checks to ensure safety. 2. On 1/24/24, Surveyor reviewed an investigation for the incident that occurred on 3/21/23 at 5:30 AM. An incident report indicated staff heard yelling, entered R9's room, and observed R9 hitting R9's self in the face while attempting to wake up R4. Staff noted bruising on R9's left eye and notified RN-C who observed additional injuries, including multiple purple bruises on R9's left arm and lower extremities, a 12 cm x 7 cm bruise on R9's upper right posterior bicep, and scratches on R9's right back. The injuries were unwitnessed and R9 could not state how the injuries occurred. The investigation included a skin injury report and 2 staff statements. The investigation did not include interviews with additional staff or other residents or a root cause analysis to rule out abuse. 3. On 1/24/24, Surveyor reviewed an investigation for R9's injuries of unknown origin that were discovered on 6/5/23 at 11:40 AM. An incident report indicated RN-C noted bruising on R9's middle and pinky fingers during the provision of care. The injuries were unwitnessed and R9 could not state how the injuries occurred. The investigation included a skin injury report and 1 staff statement. The investigation did not include interviews with additional staff or other residents or a root cause analysis to rule out abuse. 4. On 1/24/24, Surveyor reviewed an investigation for R9's injuries of unknown origin that were discovered on 6/6/23 at 3:30 AM. During the provision of care, RN-C noted a 1 cm x 1 cm circular maroon bruise on R9's left bicep and a 7 cm x 3 cm bruise on R9's right calf. The injuries were unwitnessed and R9 could not state how the injuries occurred. A staff statement, dated 6/8/23, indicated R4 and R9 were combative with each other at times. The investigation included a skin injury report and staff interviews. The investigation did not include interviews with other residents or a root cause analysis to rule out abuse. On 1/24/24 at 11:19 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated the cause of R9's injuries of unknown origin was R9's history of resisting cares, combativeness, and inflicting injury on self.

Based on observation, staff interview, and record review, the facility did not ensure the accurate and safe administration of medication for 1 Resident (R) (R139) of 14 sampled residents. On 1/22/23, Surveyor observed medications left at R139's bedside. R139 did not have a self-administration of medication assessment or a physician's order to self-administer medication. Findings include: The facility's Medication Administration policy indicates: Medications are administered only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to administer medications .Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. On 1/22/24, Surveyor reviewed R139's medical record. R139 was admitted to the facility on [DATE] with diagnoses including urinary tract infection (UTI). R139's medical record contained a Power of Attorney for Healthcare (POAHC) document that indicated R139's POAHC was responsible for R139's healthcare decisions. On 1/22/24 at 9:43 AM, Surveyor interviewed R139 and R139's family member. Surveyor observed one white medication capsule and two small circular peach-colored medication tablets on R139's bedside table. R139's family member indicated they asked the nurse to leave the medication on R139's bedside table and the family member would ensure R139 took the medication. On 1/23/24, Surveyor reviewed R139's medical record which did not contain a physician's order to self-administer medication or self-administration of medication assessment. On 1/23/24 at 2:22 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-F who indicated LPN-F left medication with R139 and R139's family member because R139 lashed out at LPN-F and wouldn't take the medication. LPN-F verified the medication should not have been left at R139's bedside. LPN-F agreed the best practice is to supervise residents until all medications are administered. On 1/23/24 at 2:58 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated medication should not be left at the bedside unless a resident has a self-administration assessment and an order to self-administer medication. Per DON-B, nurses are expected to observe residents take their medication. On 1/23/24 at 3:34 PM, DON-B confirmed R139 did not have a self-administration of medication assessment or an order to self-administer medication.

Based on staff interview and record review, the facility did not monitor for adverse reactions of a high risk medication for 1 Resident (R) (R16) of 5 residents reviewed for unnecessary medications. R16 had an order for morphine sulfate (concentrate) solution (an opioid medication) 20 mg/ml (milligrams per milliliter) as needed (PRN) for pain at a level 4-6 or shortness of breath (SOB). The facility did not monitor for adverse side effects or the effectiveness of the medication. Findings include: The facility's Medication Management policy, dated 6/2015, indicates: To optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility staff, the attending physician/prescriber, and the consultant pharmacist perform ongoing monitoring for appropriate, effective, and safe medication use. When selecting medications and non-pharmacological interventions, members of the interdisciplinary team participate in the care process to identify, assess, address, advocate for, monitor and communicate the resident's needs and changes in condition .as needed (PRN) orders include .the resident is monitored for the effectiveness of the medication or possible adverse consequences. Results are documented in the resident's active record .The medication regimen is re-evaluated (periodically) to determine whether prolonged or indefinite use of a medication is indicated. On 1/23/24, Surveyor reviewed R16's medical record. R16 was admitted to the facility on [DATE] with diagnoses including type 1 diabetes mellitus, atrial fibrillation, and congestive heart failure. R16's Minimum Data Set (MDS) assessment, dated 11/23/23, contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R16 had intact cognition. R16 received Hospice services and made R16's own healthcare decisions. R16 had an order for morphine sulfate (concentrate) solution 20 mg/ml PRN for pain at a level 4-6 or SOB, give 0.25 ml by mouth every 1 hour as needed .Give 0.5 ml by mouth every 1 hour as needed for pain at a level 7-10 or SOB . On 1/24/24 Surveyor reviewed R16's medical record which did not contain monitoring for adverse reactions or the effectiveness of morphine sulfate. On 1/24/24 at 1:11 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B regarding monitoring for adverse reactions and the effectiveness of high-risk medications. DON-B indicated if a resident is prescribed opioid pain medication, monitoring for adverse reactions and the effectiveness of the medication is included in the resident's care plan. NHA-A indicated a black box warning is listed on the resident's medication administration record (MAR) and confirmed monitoring for adverse effects and the effectiveness of the high-risk medication should be included in the resident's care plan.

Based on observation, interview, and record review, the facility did not ensure each resident is offered sufficient fluids to maintain proper hydration and health in 3 of 10 residents reviewed for hydration (R1, R10, and R11). R1 was identified to be at risk for dehydration. R1's physician instructed staff three times, within 11 days, to increase R1's fluid intake. Per intake records, R1's documented total fluid intake did not consistently meet R1's calculated daily fluid needs. R1 was subsequently hospitalized with [DIAGNOSES REDACTED]. R10 did not consistently meet her calculated fluid needs. R11 did not consistently meet his calculated fluid needs. This is evidenced by the following: The facility's policy entitled Resident Hydration and Prevention of Dehydration, with a revised date of 10/2011, states, in part: The facility will endeavor to provide adequate hydration and prevent and treat dehydration 2. Minimum fluid needs will be calculated and documented on initial, annual, and significant change assessments, using current Standards of Practice . 7. Nurses' Aides will provide and encourage intake of bedside snack and meal fluids on a daily and routine basis as part of daily care. Intake will be documented in the medical records. Aides will report intake of less than 1200 ml (milliliters) / day to nursing. 8. If potential inadequate intake and/or signs and symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into the care plan. ADL (Activity of Daily Living) status, diagnosis, individual preferences, habits and cognitive and medical status will be considered in all interventions. Physician will be informed. 9. Orders may be written for extra fluids to be encouraged between meals and/or with medication passes. A specific minimum amount should be included in the order (e.g. 240 ml fluids BID (twice a day) with medication (med) pass). Force fluids is not an appropriate order. Encourage fluids is not an adequate order . 12. If laboratory results are consistent with actual dehydration, the physician may initiate IV (intravenous) hydration. hospitalization will be recommended as necessary. 13. Nursing will monitor and document fluid intake and the dietitian will be kept informed of status. Interdisciplinary Team will update care plan and document resident response to interventions until team agrees that fluid intake and relating factors are resolved. Example 1 R1's [DIAGNOSES REDACTED]. On 11/6/17 at 12:14 PM, Surveyor observed facility staff assisting R1 with her noon meal. R1's liquids were thickened. R1 needed staff assistance to take fluids. R1 took in 100% of her noon meal including her liquids. R1's Dehydration Risk Data Collection Tool, dated 6/24/17 at the time of R1's admission, and most current at the time of her hospital admission on 8/4/17, gives R1 a score of 12 which indicates a risk for dehydration. Greater than 10 are at risk. (Please note that on 11/17/17, via telephone, NHA A (Nursing Home Administrator) informed Surveyor that R1's score of 12 on R1's Dehydration Risk Data Collection Tool, obtained on 6/24/17, was incorrect. NHA A stated the score should have been noted as an 8 indicating no risk as R1 did not have a UTI (Urinary Tract Infection) at the time of admission.) R1's Dehydration Assessment, also dated 6/24/17, at the time of R1's admission, and most current prior to her hospital admission on 8/4/17, states that R1's daily fluid needs are 2217 ml with a minimum of 1500 ml/day. This assessment identifies R1 to be at risk for dehydration due to [MEDICAL CONDITION] and Dementia and facility should proceed to care plan and monitor R1's fluid intake. R1's Comprehensive Care Plan, in place at the time of R1's hospitalization of 8/4/17, has a care planned category of Nutrition - Potential for Alteration in Nutrition less than requirements R/T (related to) therapeutic diet, dx (diagnoses) DM (Diabetes Mellitus), [MEDICAL CONDITION], Dementia . This care plan category has a goal dated 6/26/17, which states: Resident will exhibit no s/s (signs and symptoms) of dehydration with the intervention of Monitor and report s/s of dehydration. (This care plan does not indicate R1's daily fluid goals, does not indicate what s/s to look for, which would be indicative of dehydration, and does not show any updates during the time prior to R1's hospitalization on [DATE], when facility staff were to be closely monitoring R1's fluid intake. R1's record contains the following documentation: 7/19/17 and 8/2/17 - MD (Medical Doctor) Progress Notes: . Nursing Home Staff have been educated on preventing . Hydration, Preventing Urinary Tract Infections . Educated on being proactive in recognizing signs and symptoms [MEDICAL CONDITION], . Educated on Preventing hospitalization and re - hospitalization s . 7/20/17 - ID (Interdisciplinary Notes) - Nursing 5:56 PM: NOR (new orders received) for nectar thick fluids, bil (bilateral) heel boots while in bed and UA (urinalysis) . 7/21/17 - 24 Hour Nursing Shift Report: Monitor fluid intake. (Please note that there is no documentation of the daily totals of fluids to assess if R1 is meeting her daily fluid goals.) 7/22/17 - Preliminary Urine Culture Report from UA, collected 7/20/17, Multiple pathogens isolated. Complete identification and antibiotic susceptibility testing not performed due to the doubtful value of such information for direction of therapy. Hand written on this lab (laboratory) report it states: Push fluids. It is unclear if this was a Physician / Practitioner Order, or a Nursing Order. (No order to push fluids is noted on R1's Physician order [REDACTED].) 7/22/17 - ID Notes - Nursing 4:11 PM: (Physician) notified of urine culture results. No new orders. 7/22/17 - 24 Hour Nursing Shift Report: Monitor fluid intake. 7/23/17 - Final Urine Culture Report from UA, collected 7/20/17, Multiple pathogens isolated. Complete identification and antibiotic susceptibility testing not performed due to the doubtful value of such information for direction of therapy. Hand written on this lab report it states: Push fluids per MD. (This order was never transcribed onto a physician's orders [REDACTED]. (Please recall, as noted above, the facility policy entitled Resident Hydration and Prevention of Dehydration states: Orders may be written for extra fluids to be encouraged between meals and/or with medication passes. A specific minimum amount should be included in the order (e.g. 240 ml fluids BID (twice a day) with med pass). Force fluids is not an appropriate order. Encourage fluids is not an adequate order . ) 7/23/17 - ID Notes - Nursing 5:26 AM: . fluids offered q (every) 2 hours and resident takes sips . 7/23/17 - 24 Hour Nursing Shift Report: Monitor fluid intake. Push Fluids. 7/24/17 - 24 Hour Nursing Shift Report: Monitor fluid intake. Push Fluids. 7/25/17 - 24 Hour Nursing Shift Report: Monitor intake. Push Fluids. 7/26/17 - 24 Hour Nursing Shift Report: Monitor intake. Push Fluids. (Please note that there is no documentation of R1's totals of fluids to make sure she was receiving her daily fluid goals. In addition, there is no documentation of a hydration assessment completed for R1 to determine if there is s/s of dehydration. A hydration assessment per Nursing 2009: April 2009-Volume 30 Issue 4 indicates a nursing assessment would include thirst, weight loss, dry mucous membranes, sunken eyes, decreased skin turgor, assessment of oral mucus membranes and [MEDICAL CONDITION].) 7/26/17 - Chemistry - Blood: Sodium 151 (Reference range 136 - 145). Physician F has hand written on this lab report (arrow going up meaning 'increase') hydration H2O (water) . (This order was never transcribed onto a physician's orders [REDACTED]. 7/27/17 - 24 Hour Nursing Shift Report: Monitor intake. Push Fluids. 7/28/17 - 24 Hour Nursing Shift Report: Monitor intake. Push Fluids. 7/29/17 - 24 Hour Nursing Shift Report: Monitor intake. Push Fluids. 7/30/17 - 24 Hour Nursing Shift Report: Monitor intake. Push Fluids. 7/31/17 - 24 Hour Nursing Shift Report: Monitor intake. Push Fluids. 8/1/17 - 24 Hour Nursing Shift Report: Monitor intake. Push Fluids. 8/2/17 - CBC (Complete Blood Count) and Differential: WBC (white blood count) 13.6 (Reference range 3.9 - 11.2). The physician has written on this lab report:[MEDICATION NAME]([MEDICATION NAME]) 500 mg (milligrams) po (oral) BID x 5 days. CBC on Friday (8/4/17). (Arrow going up meaning 'increase') hydration. (Increase hydration was not transcribed onto the Physician order [REDACTED].) 8/2/17 - MD (Physician F) Progress Note: . Decreased po (oral) intake . Risk of dehydration discussed with (RN Manager C) the nursing manager on the floor -monitor if continues - start IV (intravenous) fluids . 8/2/17 - 24 Hour Nursing Shift Report: Monitor intake. Push Fluids. 8/3/17 - 24 Hour Nursing Shift Report: Monitor intake. Push Fluids. 8/4/17 - Chemistry - Blood: Sodium 162 . This critical value reported to (Nurse Manager C). 8/4/17 - Interdisciplinary Notes - Nursing 12:49 PM: MD and family updated on resident's WBC, BMP (Basic Metabolic Panel), weight loss, resident had finished Bactrim PO for UTI, however, remained febrile with elevated WBC. MD [MEDICATION NAME] mg po, after 48 hours on Cipro, labs were rechecked and remain elevated including critical NA (Sodium) and elevated K (Potassium), Family and MD agrees that evaluation in ER (emergency room ) appropriate for this full code resident . 8/4/17 - 24 Hour Nursing Shift Report: Monitor intake. Push Fluids. On 8/4/17, R1 was sent to the ER and was subsequently admitted to the intensive care unit (ICU). R1's Hospital ICU Admission Note states, in part: (R1) . with a history of [MEDICAL CONDITION] s/p (status [REDACTED]. and recurrent UTIs, who presented to the ED (Emergency Department) from her nursing facility with dehydration and metabolic derangements. She was found to have significant [MEDICAL CONDITION], AKI (Acute Kidney Injury), lactic acidosis and dirty UA. She was admitted to MICU (Medical Intensive Care Unit) for closer monitoring and management [MEDICAL CONDITION]: Likely representative of volume depletion. Has now received 4L (liters) IVF (Intravenous Fluids). Will continue to monitor BMP . Patient critically ill with severe metabolic derangement(s) and overwhelming infection and requires high complexity decision making for assessment and support including volume resuscitation, assessment and treatment of [REDACTED]. On 11/7/17, Surveyor requested R1's Daily Fluid Intakes. Surveyor was provided with a computer generated Daily Fluid Intake per meal and additional fluid intake per shift documentation. These totals were not added up to provide a daily total fluid amount. On 11/7/17 at 2:10 PM, Surveyor spoke with DON B (Director of Nursing) and RN Manager C regarding R1 and R1's fluid intakes. RN Manager C stated during the time, prior to R1's hospitalization on [DATE], R1 was discussed during the daily stand up meetings, but that no one was adding up her daily fluid intakes for review. RN Manager C stated staff was aware of how sick R1 was and her name was noted throughout the 24 hour shift report sheets indicating staff was to increase R1's fluid intake. Surveyor asked if fluid amounts noted in the Nurses Notes were included in the amounts provided to Surveyor. DON B stated there is no way to know if the amounts in the Nurses Notes were already noted as additional fluid on the computerized intake sheets provided to Surveyor. On 11/7/17 at 3:10 PM, RN Manager C provided Surveyor with a computer document that included R1's calculated total daily fluid intakes. Surveyor noted there to be inconsistent increase in fluids during the 14 day period of time when R1's fluids were to be increased. RN Manager C told Surveyor: She (R1) was already taking in as much as possible. We didn't know what was going on with her. We didn't know why her sodium was elevated. We couldn't figure it out. R1's Resident I/O (Intake / Output) by day chart documented as follows: 7/13/17 - 1560 ml 7/14/17 - 2100 ml 7/15/17 - 1590 ml 7/16/17 - 1560 ml 7/17/17 - 1560 ml 7/18/17 - 1740 ml 7/19/17 - 1320 ml 7/20/17 - 1410 ml - UA obtained 7/21/17 - 1800 ml 7/22/17 - 1680 ml - Push fluids written on lab report. 7/23/17 - 1420 ml - Push fluids per MD written on lab report. 7/24/17 - 1630 ml 7/25/17 - 1020 ml 7/26/17 - 1260 ml - Increase hydration written on lab report per MD. 7/27/17 - 1800 ml 7/28/17 - 1710 ml 7/29/17 - 850 ml 7/30/17 - 1400 ml 7/31/17 - 1440 ml 8/1/17 - 1260 ml 8/2/17 - 1590 ml - Increase hydration written on lab report per MD. At risk for dehydration, if continues start IV fluids written in MD Progress Notes. 8/3/17 - 841 ml (As noted above, R1's calculated daily fluid intake needs were 2217 ml and her minimum daily fluid needs were 1500 ml. From 7/20/17 - 8/3/17, R1 did not meet her calculated daily fluid needs at all, and did not meet her minimum daily fluid needs 62.5 % of the time.) On 11/9/17, the day after the completion of the survey, the facility emailed Surveyor new daily fluid totals for R1 stating the ones Surveyor received during survey were incorrect. Per a telephone call on 11/9/17 at 10:30 AM, which included NHA A, COO R (Chief Operations Officer), Physician F, and DON B, the fluid amounts in the Nurses Notes were not included in the calculated totals given to Surveyor and did not include supplements from med pass. Surveyor received the following new intake totals hand written onto the intake sheet on 11/9/17 via email: 7/13/17 - 1830 ml 7/14/17 - 2370 ml 7/15/17 - 1860 ml 7/16/17 - 1830 ml 7/17/17 - 1830 ml 7/18/17 - 2010 ml 7/19/17 - 1710 ml 7/20/17 - 1680 ml 7/21/17 - 3150 ml 7/22/17 - 2930 ml - Push fluids written on lab report 7/23/17 - 2410 ml - Push fluids per MD written on lab report 7/24/17 - 2450 ml 7/25/17 - 1290 ml 7/26/17 - 1830 ml - Increase hydration written on lab report per MD. 7/27/17 - 2070 ml 7/28/17 - 2105 ml 7/29/17 - 1120 ml 7/30/17 - 1670 ml 7/31/17 - 1710 ml 8/1/17 - 2190 ml 8/2/17 - 1860 ml - Increase hydration written on lab report per MD. At risk for dehydration, if continues start IV fluids written in MD Progress Notes. 8/3/17 - 1111 ml (Please note there are 8 entries between 7/13/17 and 8/2/17 in which R1's Nurses Notes document R1's % of a meal intake consumed, along with R1's fluids (in cc) consumed (e.g. 50% of breakfast and 360cc of nectar thick cranberry juice). As noted above, during a telephone conversation with Surveyor on 11/9/17 at 10:30 AM, the day after the survey, the facility now identifies these fluids noted in the Nurses Notes (e.g. 360 cc) as extra fluids not included in the fluid intake per meal or the total daily fluid intakes provided to Surveyor during the survey. The facility has added these extra fluids found in R1's Nurses Notes to their new recalculated totals provided to Surveyor on 11/9/17 via email.) As noted above, R1's calculated daily fluid intake needs were 2217 ml and her minimum daily fluid needs were 1500. From 7/20/17 - 8/3/17, R1 did not meet her calculated daily fluid needs 73% of the time. On 11/8/17 at 9:05 AM, Surveyor spoke with RD D (Registered Dietitian) regarding hydration assessments, R1's hydration status, and R1's hospitalization on [DATE]. Surveyor asked RD D if R1's daily fluid intake goal should be 2217 ml / day, as calculated per RD or 1500 ml / day which is R1's minimum requirement. RD D stated R1's goal would be the number she had calculated (2217 ml / day). Surveyor asked RD D how often she does hydration assessments to determine if residents are indeed meeting their fluid needs. RD D stated she does assessments quarterly as well as when the residents are not eating well. RD D stated the computer system will flag if a resident is not taking in more than 1000 ml / 24 hours. Surveyor asked RD D if nursing would notify her if a resident was not meeting their fluid needs. RD D stated: I don't think they would because they are not tracking that. On 11/8/17 at 9:35 AM, Surveyor again spoke with RN Manager C regarding R1 and her fluid needs. RN Manager C stated that during the time, just prior to R1's hospitalization on [DATE], staff were making sure R1 was taking adequate fluid by watching her closely and seeing her drink. Surveyor asked RN Manager C if staff informed the MD how much R1 was taking in since he instructed staff 3 times to increase her fluids. RN Manager C stated R1's physician was told R1 was taking in all she could. Surveyor asked if this conversation was documented. RN Manager C stated that the charting indicates the physician was updated but confirmed that it does not state specifically what the MD was told. Surveyor asked RN Manager C if there was ever discussion about starting IV fluids as indicated in R1's MD Progress Note of 8/2/17. RN Manager C stated that R1's family member was spoken to and it was decided to wait and see how R1 did on the antibiotics since she was still taking in oral fluid. RN Manager C stated the family wanted to wait. RN Manager C stated, We would have given (R1) IVs if (Family Member) did not want to wait to see how [MEDICATION NAME]. Surveyor asked if this discussion was documented. RN Manager C was unable to find documentation of this conversation. RN Manager C stated the computer system will alert staff if any resident is down in fluid intake for the day. RN Manager C stated staff will review this information about once a shift. Surveyor asked if she was aware R1's calculated daily fluid intake need was 2217 ml per R1's Hydration assessment. RN Manager C stated, I don't think that was ever communicated to me. We go by 1500 cc (minimal amount to get in over 24 hours). Surveyor asked RN Manager C about R1's MD physician progress notes [REDACTED]. Nursing Home Staff have been educated on preventing . Hydration, Preventing Urinary Tract Infections . Educated on being proactive in recognizing signs and symptoms [MEDICAL CONDITION], . Education on Preventing hospitalization and re - hospitalization s . RN Manager C stated this education is not done formally and there is no documentation of this education. RN Manager C stated R1's physician will chat with the nurses when they call with updates and this is what is meant by the education. On 11/8/17, Surveyor spoke with LPN Q (Licensed Practical Nurse) regarding R1 and her hydration status prior to her hospitalization of 8/4/17. LPN Q stated she did work with R1 just prior to the hospital stay. LPN Q stated she did give R1 more fluids and that it would be added as extra fluids. LPN Q stated she did not remember ever speaking with the physician about R1's fluid intake and does not recall discussing the possible need for IV fluids. On 11/8/17, at approximately 10:45 AM, Surveyor spoke with Physician F via telephone regarding R1 and her hydration status. Physician F stated R1 was at risk for dehydration. Physician F stated, Absolutely we talked about IVs. I'm not sure how the family conversation went. Surveyor asked Physician F if he was aware of R1's intake totals not meeting her calculated daily requirements. Physician F stated, Honestly, I know their (Facility Staff's) interventions were all very good I know they tried everything and it got to the point we just had to send her out. On 11/8/17 at 12:00 PM, Surveyor spoke with FM E (Family Member) regarding R1 and her hospitalization on [DATE]. Surveyor asked FM E if there was ever any discussion of R1 receiving IV fluids prior to her hospitalization of 8/4/17. FM E stated, Nothing was said about IV fluids. FM E stated, If it would have helped her (R1) she (FM E) would have been agreeable to the IV fluids. FM E stated R1 needed so much water that R1 couldn't drink as much as they needed to give her. FM E stated the facility waited too long before they sent her to the hospital. On 11/9/17, the day after the end of the survey, the facility emailed Surveyor additional information regarding R1 and her condition just prior to her hospitalization on [DATE]. Included in this information was an email from Physician F to COO R. This email states in part: She (R1) was severely septic and also she is very high risk [MEDICAL CONDITION], she can go into septic shock anytime. Which is a Catabolic (sic) state and the body is breaking down with many metabolic and electrolyte derangements with Hypovolemic shock and fast, calling just dehydration is not enough, saving time and getting to the Hospital was important. As you know in Shock, time is the essence and sending her to the Hospital when family was not ready for Hospice was the best for her. In the context of Septic Shock and treating her and resuscitating (sic) her in a hospital was important. We have prevented death by sending her to the Hospital and having treatment for [REDACTED]. With Vasodilatation in Shock it is harder to get IV line, but hospital can.[MEDICAL CONDITION] and septic Shock was and still is a big concern for her and as long as she is able to take oral fluids dehydration may not be a big concern but Septic Shock is . Example 2 R11's [DIAGNOSES REDACTED]. On 11/8/17 at 8:35 AM, Surveyor spoke with R11 who was seated in his room. R11 stated he feels he gets more than enough to eat and drink. R11 Dehydration Risk Data Collection Tool, dated 10/3/17, documents R11's score as 4 indicating no dehydration risk. This Tool goes on to document that facility staff will proceed to care plan. R11's Nutrition Assess. (Assessment) for short - term stay, dated 10/6/17, documents R11's calculated daily fluid needs to be 2795 ml per day, with a minimum requirement of 1500 ml / day. This assessment documents R11 is at risk for dehydration, due to his use of a diuretic and thickened fluids. This assessment states R11 has a goal to monitor oral intake of food and fluid. R11's current Comprehensive Care Plan has a concern area which states: Potential for Alteration in Nutrition, less than requirements R/T mech (mechanically) altered diet and dx left cerebral infarction with dysphagia, tooth abscess. A goal for this concern area includes: Resident will exhibit no s/s of dehydration. An intervention to this care plan concern includes Monitor and report s/s of dehydration. This care plan does not indicate R11's daily fluid goal and does not indicate what s/s to look for which would be indicative of dehydration. On 11/8/17 at 9:05 AM, Surveyor spoke with RD D regarding hydration assessments. Surveyor asked RD D how often she does hydration assessments to determine if residents are indeed meeting their fluid needs. RD D stated she does assessments quarterly as well as when the residents are not eating well. RD D stated the computer system will flag if a resident is not taking in more than 1000 ml / 24 hours. Surveyor asked RD D if nursing would notify her if a resident was not meeting their fluid needs. RD D stated, I don't think they would because they are not tracking that. A review of R11's Resident I/O by Day Chart documents the following total fluid intakes for R11 from 10/7/17 - 11/7/17: 10/7/17 - 1320 ml 10/8/17 - 2160 ml 10/9/17 - 1320 ml 10/10/17 - 960 ml 10/11/17 - 1920 ml 10/12/17 - 1200 ml 10/13/17 - 744 ml 10/14/17 - 1320 ml 10/15/17 - 1200 ml 10/16/17 - 1540 ml 10/17/17 - 1680 ml 10/18/17 - 1320 ml 10/19/17 - 1320 ml 10/20/17 - 1440 ml 10/21/17 - 120 ml 10/22/17 - 720 ml 10/23/17 - 1440 ml 10/24/17 - 1260 ml 10/25/17 - 1260 ml 10/26/17 - 1680 ml 10/27/17 - 580 ml 10/28/17 - 1440 ml 10/29/17 - 1300 ml 10/30/17 - not recorded 10/31/17 - not recorded 11/1/17 - 1320 ml 11/2/17 - 1900 ml 11/3/17 - 1780 ml 11/4/17 - 1806 ml 11/5/17 - 1800 ml 11/6/17 - 2040 ml 11/7/17 - 720 ml R11 never met his calculated daily fluid needs requirement of 2795 ml / day, and did not meet his minimum daily fluid needs requirement of 1500 ml / day 70% of the time recorded, from 10/5/17 through 11/7/17. There is no documented evidence the facility noted this occurrence, or evidence R11's plan of care was adjusted or updated to ensure he meets his daily fluid needs. Example 3 R10's [DIAGNOSES REDACTED]. R10's Dehydration Risk Data Collection Tool, dated 10/11/17, gives R10 a total score of 8 indicating R10 is not at risk for dehydration. This Tool goes on to document that facility staff will proceed to care plan. R10's Nutrition Assessment, dated 10/11/17, shows that R10's daily fluid needs have not been calculated. R10's current plan of care documents a goal that R10 will exhibit no s/s of dehydration, and staff will monitor and report any such symptoms. This care plan does not indicate R10's daily fluid goal and does not indicate what signs and symptoms to look for which would be indicative of dehydration. On 11/8/17 at 9:05 AM, Surveyor spoke with RD D regarding hydration assessments. Surveyor asked RD D how often she does hydration assessments to determine if residents are meeting their fluid needs. RD D stated she does assessments quarterly as well as when the residents are not eating well. Surveyor asked RD D what R10's daily fluid needs would be as this is not calculated on R10's initial assessment. RD D looked at R10's assessment in the computer and stated: Oh, I didn't (calculate R10's daily fluid requirements.) RD D then calculated R10's daily fluid needs to be 1500 ml / day. RD D stated the computer system will flag if a resident is not taking in more than 1000 ml / 24 hours. Surveyor asked RD D if nursing would notify her if a resident was not meeting their fluid needs. RD D stated: I don't think they would because they are not tracking that. A review of R10's Resident I/O by Day Chart documents the following total fluid intakes for R10 from 10/15/17 - 11/7/17: 10/15/17 - 1280 10/16/17 - 1680 10/17/17 - 1500 10/18/17 - 2180 10/19/17 - 1440 10/20/17 - 1680 10/21/17 - 1200 10/22/17 - 1680 10/23/17 - 540 10/24/17 - 1080 10/25/17 - 1440 10/26/17 - 1380 10/27/17 - 1873 10/28/17 - 540 10/29/17 - 640 10/30/17 - 1920 10/31/17 - 1140 11/1/17 - 1320 11/2/17 - 1440 11/3/17 - 1500 11/4/17 - 1320 11/5/17 - 1920 11/6/17 - 1210 11/7/17 - 1170 R10 did not meet her calculated daily fluid needs requirement of 1500 ml / day 64.5% of the time, from 10/15/17 through 11/7/17. There is no documented evidence the facility noted this occurrence, or evidence R10's plan of care was adjusted to ensure she met her daily fluid needs.

Based on interview and record review, the facility did not ensure each resident received and the facility provided care and services to help attain or maintain each resident's highest practicable level of well-being for 1 (Resident #1) of 11 sampled Residents. When RN-B understood that Resident #1 became pulseless and non-breathing, she did not immediately provide CPR (cardiopulmonary resuscitation) for Resident #1, who had expressed a wish to be a "full code" and thus receive CPR services. On [DATE], nursing assistant (CNA)-D heard grunting noises from the hallway outside this resident's room. She stepped into the room, saw that the resident was pale and having difficulty breathing, and notified the nurse supervisor, registered nurse (RN)-B. RN-B checked the resident, verified that the resident was having difficulty breathing, and went to get the machine for checking the resident's vital signs. When she returned, she saw that the resident's condition had deteriorated and that her color had changed. RN-B gave directions to Licensed Practical Nurse (LPN)-C to apply oxygen to Resident #1. Instead of taking vital signs, RN-B went to check the resident's advance directives and to call 911. The 911 operating center received this call at 3:37 AM. While RN-B was on the phone with the 911 operator (having told the operator that they had a resident in respiratory distress), RN-B saw LPN-C gesturing to her from down the hallway. RN-B interpreted this to mean that the resident had died and told the operator that the resident had passed. When the operator asked and was told that the resident was full code, the operator said she would still send the paramedics. RN-B did not go to the Resident's room to assess the resident, to take vital signs, to ensure that oxygen had been applied to Resident #1 or to begin cardiopulmonary resuscitation (CPR). Instead, RN-B contacted the Resident's family and physician to notify them that the Resident had expired. Upon the arrival of the paramedics to the facility, they noted and documented that Resident#1 was pulseless and non-breathing and that no CPR was in progress by the facility staff. The paramedics initiated CPR and revived this resident and left the facility. Resident #1 subsequently died at the hospital. The facility's failure to ensure that the facility nursing staff provided care based upon the Resident's expressed wishes and expected standards of nursing care when a Resident experiences a clinical change in condition created a situation of Immediate Jeopardy. The facility Nursing Home Administrator (NHA)-A was notified of this finding on [DATE] at approximately 2:30 pm. The Immediate Jeopardy began on [DATE] and was removed on [DATE]. The deficient practice continues at a scope and severity of an E (potential for harm/pattern) as the facility addresses the advanced directive status for the 9 Residents identified as not having code status documentation that reflects the facility's current policies and procedures (Cross-reference F155) and the facility continues to implement their action plan related to nursing services in response to a change in condition. Findings include: Resident #1 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The resident's clinical record contains a document entitled Advanced Directive Information dated [DATE]; this document, initialed by facility staff on the same date, indicates Resident #1's desire to be provided with CPR. The document goes on to state the resident has been informed of her right to formulate advanced directives, to refuse or accept medical or surgical care; the facility does not require each resident to formulate advanced directives in order to receive medical care; the facility will follow the advanced directives that are formulated by the resident, in accordance with the law and that it is the policy of the facility to initiate CPR only when a [MEDICAL CONDITION] is witnessed. (Cross-reference F155.) The resident's clinical record contains a notation in the nurses' notes dated [DATE] at 4:39 AM. Although RN-B later wrote a different summary of the events three days later, the most contemporaneous nursing note at 4:30 AM on [DATE] states: "CNA (CNA-D) heard a grunting/blowing sound in resident's room (at) around 0340; called this writer (RN-B) to check on resident. Resident was unresponsive noted pale and progresses to become cyanotic (blue color to the skin due to low blood oxygen levels) fast. (RN-B) then called 911 and while talking to the operator the nurse (LPN-C) whom I told to start (oxygen) went in the room and motioned to (RN-B) that resident is gone. No pulse, no respirations. 911 operator then made aware of no respirations, no pulse. . . . Paramedics/911 came performed CPR and resuscitated the resident and pulse was detected (at) around 0354." The above notation also states Resident #1's physician and family were also notified of the resident's change in condition, immediately after the emergency medical services (EMS) were called. Resident #1's clinical record contains a late entry or amended notation by RN-B on [DATE] at 1:43 PM. This entry states: "This writer was in the charting room when CNA called to assess a resident. I followed her to the resident's room where she heard a sound. When this writer went into the room, this writer saw the resident unresponsive and pale. (Head of bed) was elevated, assessment done. I stepped out of the room to get the (vital signs) machine to take the vital signs of the resident, but when writer went back into the room, VS were not obtained as resident's condition declined rapidly. This writer opted to check the chart for code status, resident is a full code. This writer then called 911 right away. (Resident's physician) and family made aware. This writer went back into the room to further assess the resident. Resident is breathing. Radial pulse is present when palpated but resident remains unresponsive. This writer then left the room to meet the Paramedics who are in the building." Surveyor # noted that these two entries are the only entries in Resident #1's clinical record for the change of condition that occurred on [DATE]. The more contemporaneous note indicates that the resident was pulseless and non-breathing, which is consistent with what the resident ' s daughter was told. Surveyor # conducted an initial interview via telephone with RN-B on [DATE] at 9:40 AM. RN-B was asked about Resident #1's condition upon the initial encounter, and why she placed the call to EMS. RN-B indicated upon her entering the resident's room, she observed the resident to be unresponsive. RN-B then indicated she stepped out of the resident's room to obtain the equipment to obtain the resident's vital signs (VS) - pulse, blood pressure, temperature, blood oxygen etc. RN-B then stated she opted to return to the nurses' desk to check the resident's code status, as she was declining. RN-B indicated after checking the resident's code status, and noting Resident #1 to be a "full code", she called 911/EMS, and then called the resident's physician and family to notify both parties of the resident's condition. Surveyor # then asked RN-B what the resident's condition was the last time she observed the resident; RN-B indicated she went back to the resident's room after making the phone calls, and at that time she found the resident to be unresponsive but with a pulse and to be breathing. Surveyor # interviewed LPN-C on [DATE] at 6:44 AM. LPN-C was asked what her role was when Resident #1 was found in respiratory distress on the morning of [DATE]. LPN-C indicated both she and RN-B entered Resident #1's room after being told by CNA-D that the resident was experiencing respiratory distress. LPN-C indicated she remained in the resident's room while RN-B stepped out of the room to check the resident's "code" status, and make the subsequent phone calls. LPN-C indicated the resident was unresponsive, but breathing. LPN-C indicated the resident also continued to have a pulse, even though LPN-C admitted she did not check for a pulse. LPN-C indicated she remained in the resident's room approximately five minutes until the paramedics arrived. LPN-C was asked if she was CPR certified. LPN-C indicated she was current with her certification. Surveyor # also interviewed CNA-D on [DATE] at 6:32 AM. CNA-D indicated around "three something" while in the hall outside of Resident #1's room, she heard a coughing noise coming from the room. CNA-D indicated she stepped into the resident's room and found the resident "coughing and changing colors." CNA-D indicated she went immediately to get the nursing supervisor, RN-B. CNA-D indicated LPN-C was in the room when they got there. Surveyor # asked CNA-D if she or the licensed nurses initiated CPR. CNA-D indicated she was not CPR certified, but neither RN-B nor LPN-C conducted CPR. Surveyor # conducted a second telephone interview with RN-B on [DATE] at 10:45 AM to ask why she wrote the addendum to the original notation of [DATE], the night of the incident, and why there are discrepancies in the documentation. RN-B indicated in this interview, she followed up with the second notation, because she wanted to clarify what she was told by LPN-C. RN-B indicated while she was talking to the 911 operator, LPN-C indicated the resident was unresponsive and was not breathing and had no pulse. RN-B indicated she misinterpreted LPN-C's gestures as Resident #1 was "gone", but that after she had finished the telephone calls to EMS, the resident's physician and family, RN-B indicated she went back to the resident's room, and found the resident to have a pulse and breathing. Surveyor # also asked RN-B if she was CPR certified; RN-B indicated she was current with her certification. A copy of the local fire department's report, who responded to the 911 call on [DATE] was obtained by Resident #1's family and sent to the state agency - Division of Quality Assurance (DQA). The 911 report notes upon arrival in the facility at 3:43 AM Resident #1 was found unresponsive by the nursing staff, the paramedics upon arrival to the facility found the resident in bed, no CPR in progress. The resident was pulseless and not breathing and ashen gray. The paramedics moved the resident to the floor and initiated CPR, which progressed to further advanced life support i.e., placement of a breathing tube, heart defibrillation, medications etc. The fire department received the telephone call at 3:37 AM. The report further notes the resident was initially resuscitated, regained pulses, but quickly lost them. An additional two rounds of rescue treatment was provided, before Resident #1 was transported to an area hospital. Surveyor # obtained copies of Resident #1's hospital clinical record. The hospital record documents Resident expired on [DATE] from [MEDICAL CONDITIONS] secondary to [MEDICAL CONDITION]. Surveyor # interviewed Paramedic-E via telephone on [DATE] at 12:24 PM. Paramedic-E initially indicated due to the length of time that had transpired since the incident, but on further reflection, Paramedic-E indicated he recalled the incident. Paramedic-E indicated upon arrival to the resident's bed side, the resident was assessed to be unresponsive and with no pulse and not breathing, and CPR was not initiated until his team arrived on the scene. Paramedic-E stated he stands by his documentation of the incident in the official report. On [DATE], DQA obtained a recording of the 911 call from the facility to the fire department from the morning of [DATE]. On the recording RN-B was heard telling the 911 operator that she had an emergency regarding respiratory distress. RN-B answered the operator's questions regarding the location of the facility and the resident room number. RN-B was asked about the nature of the call. RN-B stated that the nature of the call is that she (Resident #1) is "just moaning and that RN-B could see that she was getting pale and cyanotic so we are starting O2 (oxygen) right now." The operator was heard stating, "Okay, we will be on our way, thank you and to watch for the please." There is a brief pause where you can hear RN-B interacting with someone in the background stating "huh?" and then RN-B returns to the operator to state, "Oh you know what?" with a response from the operator of "What?" RN-B states, "She's gone, I've heard." The operator then states, "She's gone? What do you mean she's gone?" RN-B states, "She just passed away." "Okay," stated the operator. RN-B then states, "That I just got out of the room to call you guys." The operator states, "Okay so we still have to respond unless you know that the person is a DNR (do not resuscitate)? Do you have paperwork for that? Or No?" RN-B states "No, full code." The operator then states "All right, we will be on our way okay?" RN-B states, "Okay, thank you, okay, bye-bye." At this time the call concludes. On [DATE] Surveyor # and # met with NHA-A regarding Resident #1. At this time NHA-A provided the surveyors with a copy of the facility investigation regarding the [DATE] incident dated [DATE] and [DATE]. NHA-A indicated that the facility initiated an investigation after receiving questions from the Resident's family on [DATE]. Review of the investigation indicates that interviews/statements from RN-B were not collected until [DATE]; this coincides with RN-B's change in documentation regarding the Resident #1; [DATE] is also 3 days after the change in condition occurred and 2 days after the Resident's family expressed concerns about how the change in condition was handled. Review of the investigation indicates that an interview/statement from LPN-C was not collected until [DATE], again multiple days after the event occurred. Review of the individual statements indicates inconsistencies regarding just exactly who was doing what and when; both nurses indicate that they were running to obtain documents needed that night. Both of the statements from the nurses indicate the resident at no time became pulseless and non-breathing, even though the 911 operator was told the resident was "gone." The investigation also indicates Resident #1 did not receive oxygen, even though she experienced significant respiratory distress, nor was CPR initiated by either RN-B or LPN-C. On [DATE] at approximately 10:30 AM surveyor # interviewed Family Member-F regarding Resident #1. Family Member-F indicated that they never really understood what happened on [DATE]th because they received a call stating that (Resident #1) had passed away. Family Member-F indicated that they were processing what they were just told that (Resident #1) had just died when the phone rang and now they were told that she (Resident #1) was being taken to the hospital in an ambulance. Surveyor # asked Family Member-F if she recalled whether any explanation was offered to explain why she was told that the Resident had died and then she later was alive. Family Member-F indicated that no explanation was given other than the paramedics were able to revive her. Family Member-F stated that they always wondered what happened because the staff at the hospital told her that (the Resident) had died at the facility and no one there did CPR and then she really did die at the hospital and the nurses said it was from not getting enough oxygen to her brain. According to the Long Term Care Nursing Desk Reference by Barbara Acello dated 2005 "The standards of care hold nurses accountable for maintaining competence needed to perform procedures that are part of their job responsibilities. Cardiopulmonary resuscitation (CPR) is a procedure that occasionally is needed in the care of residents ..." Brain death begins within four minutes of the time of cardiac or respiratory arrest or occlusion of the airway. Because of the narrow time frame, nurses must begin emergency resuscitation procedures while awaiting the arrival of an ambulance. Nurses are expected to maintain proficiency in skills needed to manage the resident pending ambulance arrival and for complete and accurate documentation of the event." The facility failed to provide care to Resident #1 on [DATE] based upon the Resident's desired wishes, needs and nursing standards. RN-B did not document vital signs, did ensure that oxygen had been initiated, and did not immediately begin CPR when she understood that the resident had passed. Instead she called the family and the physician to inform them of the resident's death. This created a situation of Immediate Jeopardy on [DATE] that was removed on [DATE] when the facility implemented the following: 1. The facility established a system to retrain all of their licensed nursing staff on the facility's change in condition policy and procedure, CPR policy and procedure and conducting appropriate assessments with corresponding documentation. 2. The Resident admission packet was reviewed to ensure that it contains and reflects the facility's current CPR policy. 3. The facility established a system to monitor for Resident changes in condition, cardiac events and hospitalization s to ensure that the plan of care, expectations for assessment and implementation of care are met. 4. The facility will utilize their daily stand up meeting to review Resident changes in condition 5. The Director of Nursing/designee will review all new admission and readmissions to ensure adherence to CPR protocols.