Every finding on record at St Croix Health Center

Based on observation, interview and record review, the facility did not distribute and serve food in accordance with professional standards for food service safety which had the potential to affect all 38 residents.Food Server (FS) H did not cover facial hair while temping and serving food.Findings include:Facility policy titled Dress Policy from New Horizon's Food Handbook dated December 2021, reads in part. Hair restraints while handling food including facial hair covers in accordance with state and health department regulations.On 12/01/2025 at 12:07 PM, Surveyor observed FS H temping and serving food with a hat on, beard net on, and full mustache uncovered and exposed.On 12/02/2025 at 8:15 AM, Surveyor observed FS H serving breakfast with mustache exposed and uncovered. On 12/02/2025 at 10:02 AM, Surveyor interviewed [NAME] J in the main kitchen. [NAME] J stated that as long as hair is up and covered, kitchen staff can wear a hat or hairnet. [NAME] J also stated facial hair must be covered. On 12/03/2025 at 7:48 AM, Surveyor interviewed Dietary Manager (DM) I. DM I stated kitchen staff must wear either a hair net or hat depending on length of hair. DM I stated facial hair must be covered. DM I stated the beard restraint should also cover a mustache. DM I acknowledged the improper use of hair restraints and plans to reeducate all kitchen staff.

Based on interview and record review the facility did not ensure the Quality Assessment and Assurance (QAA) committee required the Medical Director (MD) to attend the Quality Assurance Process Improvement meetings each quarter. This has the potential to affect all 38 residents. This is evidenced by:On 12/03/25 at 2:36 PM, Surveyor interviewed Director of Nursing (DON) B about Quality Assurance Process Improvement (QAPI) meetings and who should be in attendance at these meetings. DON B stated the Medical Director (MD) has not attended the last two meetings on 11/20/25 and 08/21/25. The meeting information is sent to MD to review and if additional information is to be added. Nursing Home Administrator A (NHA) is in contact with the clinic for a new MD and physician. The current physician is leaving, and MD is retiring and NHA A is hoping the new physician will also be the MD. On 12/03/25 at 3:05 PM, Surveyor interviewed NHA A asking if MD attended QAPI meetings and if formal negotiations have occurred to contract a new Medical Director. NHA A stated MD did not attend the meetings. NHA A stated the clinic is reorganizing and waiting to hear the clinic's decision for physician and MD. The facility does not have evidence of the medical director being simultaneously involved in the QAPI meeting nor has there been an acceptable alternative in attendance at the QAPI meetings.

Based on interview and record review, the facility did not ensure 2 of 6 residents reviewed were free from unnecessary medications in relation to excessive duration.R2 was prescribed Lorazepam 2MG/ML Concentrate (0.25 ml / 0.5mg) by mouth every 2 hours as needed without a required end date.R27 was prescribed Lorazepam 0.5mg by mouth every 6 hours as needed for anxiety without a required end date. Findings include: Example 1 R2 was admitted to the facility on [DATE]. Pertinent diagnoses include bipolar disorder, unspecified, and unspecified dementia, unspecified severity, with other behavioral disturbance. R2 is on Hospice Pertinent medication order includes: Lorazepam 2MG/ML Concentrate Dose: (0.25 ml / 0.5mg) by mouth every 2 hours as needed For: Anxiety, Restlessness, Insomnia (Trouble Sleeping) Administration Instructions: no stop date, indefinitely Surveyor noted the facility did not have a policy or procedure for as-needed psychotropic medications. On 12/03/25 at 7:43 AM, Surveyor interviewed Licensed Practical Nurse (LPN) F. LPN F stated when getting orders from Hospice, typically the charge nurse or unit coordinator will enter them. If not available, the floor nurse enters in the orders. LPN F stated as needed psychotropics are only good for 14 days unless the provider orders it for longer. LPN F stated orders could be marked indefinite if that is how the provider ordered it. LPN F stated LPN F was not told any different. On 12/03/25 at 7:51 AM, Surveyor interviewed Charge Nurse (CN). CN G stated if staff receive an as-needed order for a psychotropic that does not specify an end date, it would be good for 14 days. CN G stated the order would then be reviewed and renewed as necessary. CN G said providers may order it for longer such as 30, 60, or 90 days, and sometimes longer. CN G stated providers have ordered as-needed psychotropic medications indefinitely instead of having an actual end date. CN G stated she believed that to be appropriate and was never told otherwise. On 12/03/25 at 8:47 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and Director of Nursing (DON) B. NHA A and DON B both stated PRN psychotropics should have an end date of 14 days and then it should be reviewed. DON B stated she understood why a provider would order a Hospice patient Lorazepam with indefinite in place of end date, but the order should have an actual end date, and that an indefinite time was not appropriate. Example 2 R27 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease and other specified anxiety disorders. On 05/16/25, R27 was prescribed Lorazepam 0.5mg by mouth every 6 hours as needed for anxiety without a required end date. On 12/03/2025 at 7:57 AM, Surveyor reviewed record which indicated R27 had received as needed Lorazepam: May 2025 6x June 2025 7x July 2025 10x August 2025 8x September 2025 4x October 2025 1x November 2025 = 0 December 2x on 12/02/25

Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to prevent the development and transmission of communicable diseases and infections for 2 of 13 residents (R) (R7, R24)Staff did not change gloves or perform hand hygiene during observation of incontinence cares for R7 and R24.Staff utilized contaminated high touch environmental surfaces to conduct resident cares for R7 and R24. Findings: The facility policy titled Hand Hygiene updated on 05/20/25 states: Purpose: Appropriate hand hygiene is essential in preventing transmission of infectious agent. To cleanse hands to prevent the spread of potentially deadly infections, to provide a clean and healthy environment for residents, staff, and visitors. To reduce the risk to the healthcare provider of colonization or infections acquired from a resident. Hand hygiene continues to be the primary means of preventing the transmission of infection. Hand hygiene (e.g. hand washing and/or Alcohol Based Hand Rub (ABHR) consistent with accepted standards of practice such as the use of ABHR instead of soap and water in all clinical situations except: in part: A. Hands are visibly soiled (e.g. blood, body fluids). Example 1 R24 was admitted to the facility on [DATE] and has diagnoses that include Parkinson's and dementia. On 12/02/2025 at 6:50 AM, Surveyor observed Certified Nursing Assistant (CNA) C conduct morning cares on R24 while sitting on toilet. R24 had been incontinent of urine prior to sitting on toilet and had small bowel movement while sitting on toilet. CNA C, with gloved hands, cleansed R24's rectal area with wet wipes and utilizing wet washcloths that were placed in and utilized from bottom of R24's bathroom sink and body soap cleansed front and back peri areas. CNA C then proceeded, without removing contaminated gloves and conducting hand hygiene, to pull up R24's clean pants, hooked up R24 into mechanical lift and worked controls and lift to position R24 into wheelchair before removing gloves and conducting hand hygiene. On 12/02/25 at 8:07 AM, Surveyor interviewed CNA C regarding expectation of changing gloves and conducting hand hygiene. CNA C stated the expectation would be to change gloves and conduct hand hygiene when going from dirty to clean areas. Example 2 On 12/02/2025 at 7:24 AM, Surveyor observed CNA D and CNA E assist R7 with personal cares. CNA B sanitized hands and applied gloves. CNA D placed a clean washcloth in bottom of sink. CNA D removed R7's blankets, raised bed, gathered clothes, and removed R7's socks. CNA D removed gloves, applied soap to hands, wrung out washcloth and set the washcloth to the side. CNA D washed hands for less than 20 seconds and turned faucet off with clean hands, dried hands, and applied gloves. CNA D wet a clean washcloth and applied hand soap to the washcloth. CNA D removed R7's brief and cleaned buttocks with the soaped washcloth. CNA D dried R7's buttocks and placed a clean brief. CNA D went to bathroom and took the wet washcloth that was set aside from being in the bathroom sink and is contaminated. CNA D wet the washcloth and applied hand soap to the washcloth. CNA D used the contaminated washcloth to wash R7's groin and penis. CNA D did not use another washcloth to rinse the washed areas. CNA D removed gloves and washed hands for less than 20 seconds, turned faucet off with clean hands and applied gloves. CNA D wet a clean washcloth and applied hand soap to the washcloth. CNA E entered room, sanitized hands and applied gloves. CNA E applied R7's socks and pants. CNA E removed gloves and applied clean gloves without hand hygiene. CNA D assisted R7 to sit at side of bed and removed t-shirt. Washed R7's underarms with the soaped washcloth and dried, applied clean t-shirt and shirt. CNA D applied gait belt to R7. CNA D and CNA E assisted R7 to stand and pivot to wheelchair. R7 then was transferred to toilet. CNA E removed gloves and applied clean gloves with no hand hygiene. CNA E brought linen bag and garbage to utility room and returned to R7's room and sanitized hands and applied gloves. CNA D and CNA E assisted R7 to stand from the toilet. CNA E used a wet wipe and cleansed penis. CNA E used a clean wipe to cleanse stool from R7's buttocks. CNA E removed gloves. CNA D and CNA E assisted to pull up R7's brief and pants and transferred R7 to wheelchair. CNA D removed gloves and washed hands for less than 20 seconds, turned faucet off with clean hands, and dried hands. CNA E without completing hand hygiene after providing peri care started to fold and hang up R7's clean clothes. On 12/03/25 at 10:13 AM, Surveyor interviewed CNA D about proper hand hygiene. CNA D stated they get training yearly on infection control and hand washing. CNA D stated proper hand washing should be about 20 seconds and use a paper towel to turn faucet off and then dry hands. CNA D stated had washed hands more than needed and probably did not wash as long. Surveyor asked when removing gloves should hand hygiene of hand sanitizer or washing of hands be completed before applying clean gloves. CNA D stated it depends on what was touched prior. CNA D stated the facility does have peri wash but usually uses the hand soap in the resident's bathroom to wash the resident and will fold the washcloth to rinse the soap from the resident. CNA D stated CNA D did put the washcloth in the sink and probably should not put the washcloth directly in the sink for infection control. On 12/03/25 at 10:54 AM, Surveyor interviewed DON B about observation of cares and expectations. DON B stated the hand soap should not be used for cares and would expect the areas be rinsed. Facility does have peri wash products to use or resident's own soap. The facility does not use a no rinse soap. The washcloth should not be placed in the sink for infection control purpose. Hand hygiene should be completed with every glove change and proper technique. DON B stated staff were recently educated and audited for proper hand hygiene.

Based on observation, record review and interview, the facility did not serve foods in a sanitary manner which has the potential to affect all 42 residents. Nutritional Aide (NA) F touched her reading glasses several times when preparing and serving lunch without performing hand hygiene and continuing to serve foods. While checking the lunch foods temperatures NA F did not allow the thermometer probe to air dry after sanitizing with alcohol and before inserting into foods. Staff did not wear hair restraint when preparing food and when in the kitchenette where food was being served. This is evidenced by: Surveyor requested and received facility policies as follows: ~Handwashing dated 2010 notes: Policy: Staff will wash hands frequently as needed throughout the day following proper hand washing procedure. Procedure: During food preparation as often as necessary to remove soil and contamination and to prevent cross contamination . ~Taking Accurate Temperatures dated 2010 notes: To take temperatures a clean, rinsed, sanitized and air-dried thermometer .is needed. Example 1 On 9/16/24 at 12:25 PM, Surveyor observed NA F preparing for lunch service in the 300 wing kitchenette. NA F went to the sink, washed her hands and removed food items from a cart that was placed on burners on the counter. NA F used an alcohol preparation pad to wipe the thermometer probe and immediately inserted the thermometer into the pork chops being served for lunch. NA F did not air dry the thermometer probe prior to inserting the probe into the pork chops. NA F wiped the thermometer again with a clean alcohol prep pad and inserted the probe into sweet potatoes. NA F repeated this process for all foods being served, wiping the thermometer probe with an alcohol prep pad and immediately inserting the probe into the foods. Example 2 NA F removed her glasses from the top of her head and placed them on her face to record each food's temperature. NA F replaced her glasses to the top of her head after recording each food's temperature without washing her hands after touching her glasses (presumably dirty) and before proceeding to take additional food's temperature. NA F placed her glasses back to the top of head and donned gloves with no hand hygiene completed NA F removed bread from bag to make a grilled cheese sandwich at the stove. NA F began plating foods. NA F put her glasses back on to read the resident lunch slips as she served. NA F placed her glasses back to top of her head and did not perform hand hygiene before gathering scoops for serving. NA F went back and forth to the stove to make grilled cheese sandwiches. As she walked to the stove, she removed her glasses and placed them to the top of her head. When she returned to reading lunch slips to plate resident foods she placed her glasses back on. NA F did not wash her hands after touching her glasses and proceeding to reach inside the bread bag and obtain bread, and touch the surface of plates where she then placed the food items when serving lunch. On 9/17/24 at 6:42 AM, Surveyor interviewed NA F about the observation. NA F expressed she had been on staff since January 2024 and has never been given instruction about allowing the thermometer probe to air dry after wiping with alcohol prep pad and she was not aware of a wait time to allow the probe to air dry after wiping with the alcohol prep pad. NA F expressed, Makes sense to air dry the alcohol before inserting into foods. NA F also explained she doesn't even think about touching her glasses. She understands the glasses are not clean and hand hygiene should be done after touching her glasses. On 9/17/24 at 8:02 AM, Surveyor interviewed Dietary Manager (DM) G who has been on staff about one month through a contracted service about the observation. DM G expressed she is a certified dietary manager with many years of experience. DM G indicated she would expect staff to be aware of what they are doing with their hands. Staff should leave glasses on and don't touch them. If glasses are touched, she would expect staff to wash their hands after touching them. DM G expressed she would expect staff to allow the thermometer probe to air dry after wiping with alcohol prep pad before inserting into foods. DM G further expressed she talked with the server and instructed her to count to 10 after wiping the thermometer with alcohol pad and before inserting into foods to prevent contamination of foods. 46693 Example 3 The facility policy titled, Employee Sanitary Practices, states, in part, .All employees shall: 1. Wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food . On 09/18/24 at 8:23 AM, Surveyor observed Certified Nursing Assistant (CNA) H enter the Bluebird dining hall and grab a bowl and a can of chicken noodle soup, opened the can of soup, and poured it into a bowl. CNA H then placed it into microwave and heated it. Breakfast was being served in the same area at this time. CNA H was not wearing a hair restraint. Surveyor asked CNA H if she was ever told to wear a hair restraint when preparing food and/or in the kitchenette where food is being served. CNA H said no one has told her that. CNA H then asked the Dietary Aide (DA) J if there was a hair net in the kitchenette and DA J said no. CNA H then left the food service area. On 09/18/24 at 8:41 AM, Surveyor interviewed DM G and asked what the expectation is regarding hair restraints. DM G stated that all staff should be wearing them anywhere food is being prepared. Surveyor informed DM G about the above observation and DM G replied that this needs collaboration with the Director of Nursing to address the hair restraint expectations with the CNAs.

Based on interview and record review, the facility failed to follow procedures that prohibit and prevent abuse, neglect, and exploitation of residents. The facility did not perform a Minnesota background check in the last 4 years for a staff member that has direct contact with residents. This was found for 1 of 8 staff members investigated for background check compliance. Findings include: The facility policy entitled, Abuse Policy, dated 04/24/24 states: Screening: Potential employees of St. Croix Health Center are screened for any history of abuse, neglect, or mistreatment of residents. A criminal background check and a call to the Caregiver Background Registry is performed by Human Resources upon hire. (Note: Policy does not mention follow up background checks.) On 09/17/24 at 10:00 AM, Surveyor performed record review of eight employees' background checks and found that one employee, Certified Nursing Assistant (CNA) I, did not have a Minnesota background check. CNA I's only background information in the file was for the state of Wisconsin. Surveyor reviewed the personnel file for CNA I that noted a hire date of 06/25/01. The background information disclosure (BID) form, dated 09/24/21, noted, .Have you resided outside the state of Wisconsin in the last 3 years. The box was marked yes and stated in Minnesota. It is also noted that CNA I has a MN address. No Minnesota background check was provided at that time. On 09/17/24 at 12:20 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked how often the criminal background checks (CBC) are completed for staff which NHA A stated, Every 4 years. Surveyor asked if staff resided out of state in the last 3 years, do you complete CBCs for those states as well. NHA A replied that they do. Surveyor asked where CNA I's background check was for the state of Minnesota. NHA A stated they hire a company to do the CBCs and NHA A will check with them. NHA A left the room, then came back at 1:45 PM and provided a background check on CNA I dated 09/12/17. NHA A stated they do not have one completed in the last 4 years, but they are doing one now. Surveyor asked NHA A what the expectation is for background checks. NHA A said they would expect that the proper background checks including Minnesota be completed to ensure resident safety.

Based on observation, record review and interview, the facility did not provide necessary services to maintain good personal hygiene for 1 of 3 residents (R) observed for care (R2). This is evidenced by: Surveyor reviewed R2's most recent quarterly Minimum Data Set (MDS), completed on 8/06/24. The MDS notes R2 is understood, usually understands and has severely impaired cognition. R2 is dependent on staff for bed mobility, transfer and hygiene. R2 is always incontinent of bowel and bladder. R2's diagnoses include heart failure, renal insufficiency and non-Alzheimer's dementia. Surveyor reviewed R2's care plan and noted: Need: I have the potential to have skin injury Goal: keep my skin healthy and intact Date: 08/09/24 three months Approach: Check and change me upon arising, before/after meals at bedtime and on night rounds. Surveyor reviewed R2's Kardex guidelines for daily care and noted: Check and change as needed upon arising, before/after meals, hs (hour of sleep) and night rounds Surveyor requested the facility policy regarding Activities of Daily Living (ADL) for dependent residents. Nursing Home Administrator (NHA) A informed Surveyor the facility did not have a policy; it is an expectation staff provide the needed care for dependent residents. On 9/17/24 at 7:05 AM, Surveyor observed Certified Nursing Assistant (CNA) C provide R2 morning care. CNA C checked R2's brief and informed Surveyor R2 was not incontinent and peri care was not completed. During the observation Surveyor asked CNA C about R2's usual routine. CNA C expressed she is an agency CNA and is not familiar with R2. CNA C further expressed she is taking direction from CNA D who is familiar with R2. At 7:26 AM, Surveyor observed CNA C and D transfer R2 to her wheelchair and take her to the lounge next to the dining room. R2 remained in the lounge until taken to the dining room for breakfast. R2 remained in the dining room until 9:27 AM when staff wheeled her back to the lounge and placed her in front of the fireplace. R2 remained in the lounge until 10:24 AM when she was wheeled to an activity room for church. At 11:06 AM, R2 was taken back to her unit and again placed in front of fireplace in lounge where she previously was seated. R2 remained in the lounge until Surveyor concluded the observation at 11:26 AM. R2 remained up in her wheelchair for 4 hours without receiving incontinence care. On 9/17/24 at 7:37 AM, Surveyor interviewed CNA D about R2's normal routine. CNA D explained R2 gets up early, usually around 5:30 AM as she goes to bed early. CNA D explained she works night shift and day shift and provides care to R2 routinely. When working night shift, she gets R2 up around 5:30 am. If she is working day shift, R2 is the first to get up in morning just after 6:00 AM. R2 lays down after lunch around 12:45. Incontinence care is done when laid down. CNA D further explained R2 sleeps in her chair mostly during the day. On 9/17/24 at 12:19 PM, Surveyor interviewed Nurse Supervisor/RN (NS) E about the observation and the expectation for providing R2 incontinence care. NS E indicated R2 is at risk for the development of pressure injuries; she is immobile and incontinent. NS E expressed she would expect staff to provide incontinent care as written in R2's plan of care, upon arising and before and after meals. NS E stated that R2 is incontinent; staff did not check and change her as expected which is not acceptable. Staff need to follow resident care plan not their own routine.

Based on observation, record review and interview, the facility did not provide the necessary care and treatment to prevent the development of pressure injuries for 1 of 3 residents (R) reviewed for pressure injuries (R2). This is evidenced by: Surveyor requested and reviewed the facility policy titled Prevention and Treatment of Skin Breakdown dated as most recently updated on 5/2024. The policy in part read: Purpose: To properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity and pressure ulcers; to implement preventative measures . Procedure: ~Prevention of Pressure Ulcers: Braden Scale will be done: Upon admission Review quarterly Annually. Surveyor reviewed R2's most recent Minimum Data Set (MDS) which was a quarterly assessment completed on 8/06/24. The MDS notes R2 is understood, usually understands and has severely impaired cognition. R2 is dependent on staff for bed mobility, transfer and hygiene. R2 is at risk for pressure injury. R2 uses a wheelchair. R2's diagnoses include heart failure, renal insufficiency and non-Alzheimer's dementia. Surveyor reviewed R2's care plan and noted: Need: I have the potential to have skin injury Goal: keep my skin healthy and intact Date: 08/09/24 three months Approach: Check and change me upon arising, before/after meals at bedtime and on night rounds. Surveyor reviewed R2's Kardex guidelines for daily care and noted: Check and change as needed upon arising, before/after meals, hs (hour of sleep) and night rounds Surveyor requested R2's most recent Braden Scale for Predicting Pressure Sore Risk assessment. Surveyor was provided the assessment dated [DATE] (the day requested). The assessment noted the following: Mobility: Completely immobile, does not even make slight changes in body/extremity position without assistance. Friction/Shear: Potential problem-moves with minimal assist. Some sliding with repositioning. Occ. slides down in chair or w/c. Activity: Chairfast: ability to walk severely limited/none. Can't bear weight and/or assisted to chair or w/c. Moisture: occasionally moist-skin is occasionally moist; requiring an extra linen change approx. once a day. Nutrition: Probably inadequate: rarely eats full meal; usually eats 1/2 food offered. Eats 3 protein/day. Occ. supplement. Total score: 13=moderate risk On 9/17/24 at 7:05 AM, Surveyor observed Certified Nursing Assistant (CNA) C provide R2 morning care. During the observation, Surveyor asked CNA C about R2's usual routine. CNA C expressed she is an agency CNA and is not familiar with R2. CNA C further expressed she is taking direction from CNA D who is familiar with R2. At 7:26 AM, Surveyor observed CNA C and D transfer R2 to her wheelchair and take her to the lounge next to the dining room. R2 remained in the lounge until taken to the dining room for breakfast. R2 remained in the dining room until 9:27 AM when staff wheeled her back to the lounge and placed her in front of the fireplace. R2 remained in the lounge until 10:24 AM when she was wheeled to an activity room for church. At 11:06 AM, R2 was taken back to her unit and again placed in front of fireplace in lounge where she previously was seated. R2 remained in the lounge until Surveyor concluded the observation at 11:26 AM. R2 remained up in her wheelchair for 4 hours without repositioning. On 9/17/24 at 7:37 AM, Surveyor interviewed CNA D about R2's normal routine. CNA D explained R2 gets up early, usually around 5:30 AM as she goes to bed early. CNA D explained she works night shift and day shift and provides care to R2 routinely. When working night shift, she gets R2 up around 5:30 AM. If she is working day shift, R2 is the first to get up in morning just after 6:00 AM. R2 lays down after lunch around 12:45 PM. CNA D further explained R2 sleeps in her chair mostly during the day. On 9/17/24 at 12:19 PM, Surveyor interviewed Nurse Supervisor/RN (NS) E about the observation, asking about R2's risk for the development of pressure injuries and the expectation for repositioning R2. NS E indicated R2 is at risk for the development of pressure injuries; she is immobile and incontinent. NS E expressed she would expect staff to provide repositioning as written in R2's plan of care. Staff should reposition R2 when taken back to bed, change her pad and get resident back up in her chair. R2 is at risk for the development of pressure injury; staff did not reposition her as expected which is not acceptable. Staff need to follow resident care plan not their own routine.

Based on observation, record review and interview, the facility did not provide the necessary services in attempt to prevent any further decrease in range of motion for 1 of 3 residents (R) reviewed (R2). This is evidenced by: Surveyor requested the facility policy regarding Restorative/Range of Motion (ROM) programs. Nursing Home Administrator (NHA) informed Surveyor the facility does not have a policy regarding ROM programs; it is an expectation Certified Nursing Assistants perform ROM. Surveyor reviewed R2's most recent quarterly Minimum Data Set (MDS), completed on 8/06/24. The MDS notes R2 is understood, usually understands and has severely impaired cognition. R2 is dependent on staff for bed mobility and transfer. R2 has range of motion impairment on one upper extremity. R2 uses a wheelchair. R2's diagnoses include heart failure, renal insufficiency and non-Alzheimer's dementia. Surveyor reviewed R2's care plan and noted: I need help with all may cares, have dementia and not able to sequence tasks, I also have muscle weakness and decreased mobility, I have contractures of my left wrist and hand. Goal: Nursing staff will anticipate my needs and provide needed cares . Goal time: 8/09/24 x three months Approach: Assist me with PROM to my legs every morning. Kardex, Guidelines for daily care indicated: Restorative: Perform passive range of motion with legs every morning. On 9/17/24 at 7:05 AM, Surveyor observed Certified Nursing Assistant (CNA) C provide morning care for R2. R2's legs were suspended on a pillow. CNA C donned R2's socks and pants to her ankles with her legs suspended. CNA C rolled R2 side to side in bed to pull R2's pants up to her waist. CNA C did not provide any range of motion (ROM) to R2's lower extremities. Surveyor observed R2's ankles to be turned inward with contracture. Following the observation, Surveyor asked CNA C if R2 has any range of motion programs that are completed by CNA staff. CNA C expressed she is not aware of any ROM programs for R2. CNA C referenced R2's kardex guidelines for daily care which read perform passive ROM w/legs Q (every) morning 1 x a day (AM). CNA C expressed she thought therapy does the ROM. R2's therapy communication (physical) read: Please perform passive range of motion with pts (patients) legs every morning (as shown in the following program) to help maintain ROM. Attached were instructions for hip and knee range of motion and ankle and foot exercises. Surveyor reviewed R2's documentation for completion of her ROM for the past 3 months (6/17/24-9/17/24). The documentation showed ROM occurred on 7 occasions in three months. On 09/17/24 at 12:19 PM, Surveyor interviewed Nurse Supervisor (NS)/RN E about R2's ROM. NS E expressed R2 has a passive ROM program for her legs which is done every morning with her cares. The expectation is for CNAs to perform for each joint of both R2's legs. The program is important to prevent further contractures of R2's legs.

Based on observation, interview and record review, the facility did not ensure resident safety through assessment and that the environment remains free of accident hazards as is possible for 2 of 4 residents (R) R31 and R2 reviewed. Facility did not complete a smoking risk assessment or implement care plan interventions for smoking safety for R31. R2 was evaluated by the facility to be a fall risk. R2 was observed sitting unsupervised on edge of bed in high position and fall mat not in place. Findings include: Facility policy entitled, Non-smoking Campus, last updated 04/24/24, stated in part, .we are a NON-SMOKING campus and there is NO smoking on our grounds. R31 was admitted to the facility on [DATE] with pertinent diagnoses of parkinsonism, polyneuropathy, muscle weakness, nicotine dependence, hemiplegia right side, corticobasal degeneration, and emphysema. R31's most recent admission Minimum Data Set (MDS), dated [DATE], had a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition is intact. R31 had impairment on both lower extremities and used a motorized wheelchair. Review of R31's personalized care plan did not include safety assessment or interventions for smoking. Review of R31's record did not include a smoking safety/risk assessment of R31's ability to safely light, handle and put out cigarette safely. No documentation noted of where smoking materials are kept. On 09/16/24 at 10:30 AM, Surveyor asked Nursing Home Administrator (NHA) A during entrance conference if there were any residents who smoked in the facility. NHA A stated that the facility is non-smoking, but there is one resident R31 that does sneak out to smoke. Surveyor asked for the facility's policy for smoking. NHA A stated the facility did not have a policy as it is a non-smoking campus. Surveyor asked for the facility's policy/procedure for assessing residents that smoke. NHA A stated the facility did not have a policy for assessment because they do not allow smoking on facility grounds. On 09/17/24 at 10:34 AM, Surveyor interviewed R31 regarding smoking. R31 became angry and stated being aware of the no smoking rule and has been talked to numerous times about it. R31 stated he does not smoke on the property. R31 stated being his own person and will smoke if and when he chooses. On 09/18/24 at 6:12 AM, Surveyor observed R31 exit the facility's main doors on motorized wheelchair. R31 was wearing shorts and a t-shirt. R31 did not have shoes or socks on. R31 drove wheelchair through parking lot to the roadway. Surveyor observed R31 position wheelchair between the road and parking lot entrance and light cigarette. No concerns with R31 safely maneuvering self in wheelchair observed. No other individuals observed with R31. Surveyor entered facility and observed that the reception desk window was closed, and no staff was monitoring the entrance doors for residents entering/exiting facility. On 09/18/24 at 10:39 AM, Surveyor interviewed Nurse Supervisor (NS) E about R31 smoking. NS E stated that staff are aware R31 goes outside to smoke. Surveyor asked if a safety/risk assessment for smoking had been completed on R31. NS E stated no. Surveyor asked if any safety interventions had been care planned regarding smoking for R31. NS E stated no. NS E stated recognizing the safety risk knowing R31 continues to disregard the facility policy of not smoking. NS E stated that facility staff had completed education with R31 multiple times regarding the no-smoking policy and safety risk, educated family about the policy and not to bring in smoking materials, but R31 is their own person, and they can't restrict his movements. Surveyor asked NS E if there were other interventions that could have been implemented to ensure R31's safety. NS E stated that yes, they could have implemented other interventions such as a pass to indicate when R31 was going to be exiting the facility so that staff could be aware when R31 was outside of building. NS E stated recognition that the failure to assess safety/risk for smoking and implement care plan interventions for knowing R31's non-compliance of facility's non-smoking policy had the potential for harm. 30570 Surveyor requested and reviewed the facility policy titled Accident/Incident reporting updated most recently on 4/24/24. The policy in part read: Purpose: To provide documentation of accident/incidents and improve resident safety. Procedure: Each accident/Incident is reviewed and investigated as deemed as necessary. The residents care plans will be revised and updated as needed. Surveyor reviewed R2's most recent quarterly Minimum Data Set (MDS), completed on 8/06/24. The MDS notes R2 is understood, usually understands and has severely impaired cognition. R2 is dependent on staff for bed mobility and transfer. R2 has range of motion impairment on one upper extremity. R2 uses a wheelchair. R2's diagnoses include heart failure, renal insufficiency and non-Alzheimer's dementia. R2 had not experienced falls. Surveyor requested R2's most recent fall risk assessment. Surveyor was provided with R2's fall risk assessment dated [DATE] which was not completed. Surveyor reviewed R2's care plan and noted: Need/Preference: 8/09/24 I am unaware of safety risks have dementia/Alzheimer's disease: I also have decreased mobility and need assistance for all moving. Goal: avoid injury Goal time: date: 8/09/24-three months Approach: I need my aides to make sure my bed is in low position and the mat is on the floor next to my bed when I am in bed. Kardex: guidelines for daily care: Special equipment/needs: low bed, bedside mat On 9/17/24 at 7:05 AM, Surveyor observed Certified Nursing Assistant (CNA) C provide morning care to R2. Upon entering R2's room, Surveyor noted R2's bed to be in low position, with the bed against the wall on one side and a mat on the floor in front of the bed. CNA C raised R2's bed height and removed the floor mat and proceeded to the bathroom to fill a basin. Surveyor asked CNA C if she was familiar with R2's care needs. CNA C expressed she is a little familiar with the residents; she takes direction from CNA D and there are care sheets to direct staff with resident needs. During R2's care, CNA C walked from bedside to the bathroom and closet with R2's mat not in place and her bed remaining in high position. After care was completed, CNA C exited R2's room to retrieve a Hoyer lift. CNA C did not put the mat down or lower R2's bed when she exited the room. On 9/17/24 at 7:37 AM, Surveyor interviewed CNA D about R2's fall risk and interventions used in attempt to prevent a future fall and keep R2 free of injury if she falls from bed. CNA D expressed she works with R2 routinely and is familiar with her needs. R2 should have a low bed with mat in front of her bad whenever she is in bed. Further expressing R2 has rolled from bed or tried to get up from bed in the past. CNA D stated, If she is in bed the bed should always be in low position with mat on the floor. CNA D explained the Kardex should be used to direct staff in these approaches. On 9/17/24 at 7:52 AM, Surveyor interviewed CNA C about R2's low bed and mat related to fall risk. CNA C showed Surveyor R2's kardex at nurses station which does not direct staff in R2's low bed or bedside mat. CNA C expressed she has been a CNA for about 6 months and has worked at the facility a few times through her agency. CNA C explained she saw the mat on the floor and R2's bed in low position when entering R2's room, she did not think about lowering the bed and placing the mat down when walking away from R2's bed. CNA C further expressed she should have gathered her supplies first, brought everything to R2's bedside and stayed with R2 if her bed is in high position. Record shows R2 experienced a fall on 11/05/23 at 5:01 AM observed on floor Injury type: no apparent injury, resident found laying on the mat on the floor next to bed Root cause: slid from bed onto floor mat at bedside 11/06/23: IDT met to review fall from 11/05/23. POC reviewed. Current interventions in place were successful (low bed/bedside mat) On 09/17/24 at 12:11 PM, Surveyor spoke with Nurse Supervisor (NS)/RN E about the observation, R2's fall risk and interventions used in attempt to keep R2 free of injury should she fall from bed. NS E expressed the care observation is concerning. R2 is not a not a huge risk for falling but will randomly throw her legs over the side of her bed or attempt to rise. R2 experienced a previous fall from bed and continues to have the potential risk for falls. The fall risk assessment should have been done most recently when R2 fell on [DATE] and it was not. NS E expressed she would expect staff to follow R2's care plan due to resident risk for falling.

Based on observation and interview, the facility did not ensure food was distributed, and served in accordance with professional standards for food service. This affected 4 of 33 residents (R). Surveyors observed staff touching ready to eat foods with bare hands during food service and set up for 4 residents. (R79, R14, R18, and R3) Findings include: On 08/28/23 at 12:20 PM, Surveyor observed Certified Nursing Assistant (CNA) H pick up the top bun from R79's plate with bare hands to place it on the burger. CNA H then held the bun with bare hands when cutting it in quarters for R79 to eat. On 08/28/23 at 12:28 PM, Surveyor observed CNA D remove the top bun from R14's burger with bare hands to put ketchup on the burger. CNA D then placed the bun back on the burger with bare hands. On 08/30/23 at 9:15 AM, Surveyor explained to Director of Nursing (DON) B the observations of staff touching resident ready to eat foods with bare hands during meal set up. Surveyor asked DON B what the facility expectation was when staff assist residents with ready to eat foods. DON B stated staff should use a glove or utensil when serving or setting up ready to eat foods and should not touch ready to eat foods with bare hands. 48793 On 08/29/23 at 8:26 AM, Surveyor observed CNA D drop menu on floor, picked it off the floor and placed it back on the serving counter. CNA D then delivered R18's tray to the table and prepped the piece of toast with a knife and applied peanut butter while using her bare left fingers to hold the toast in place. Surveyor did not observe CNA D use hand hygiene or apply gloves before or after prepping R18's toast. On 08/29/23 at 11:20 AM, Surveyor interviewed CNA D and asked what the process is for hand hygiene in the dining room when touching foods. CNA D indicated that CNA D should have worn gloves when touching the toast before applying peanut butter. CNA D stated that washing hands and applying gloves is normally what would be performed before touching foods. 47284 On 08/28/23 at 12:12 PM, Surveyor observed CNA K assist R3 with lunch. CNA K with bare hands picked up R3's hamburger bun to place condiments on the hamburger. CNA K placed the hamburger bun back on the hamburger and then pressed down on the bun.

Based on observation, interview and record review, the facility did not ensure 1 of 6 residents reviewed during medication administration task (R21) was free of significant medication errors. The facility did not ensure R21 was administered crushed oral medication inappropriately based on the observation of Licensed Practical Nurse (LPN) I crushing Metoprolol Succinate Extended Release (ER). ER tablets are not to be crushed or chewed. Doing so can result in too much of the medication given at once and not spread out over time as intended, along with increasing the risk of lowering the blood pressure or heart rate to critical low levels. This is evidenced by: The facility policy, entitled Oral Medication Administration, dated 05/18, states: .Refer to crushing guidelines (See Appendix 6: Medication Crushing Guidelines) prior to crushing any medication for assurance that it can be pulverized .Appendix 6: Medication Crushing Guidelines states .Medications that should not be crushed or chewed: When a resident's condition prohibits the administration of solid dosage forms (tablets, capsules, etc.), the nurse administering the medication should check to see that there is no contraindication to crushing the medications in question. If crushing is contraindicated, the nurse should consult the pharmacist for assistance in obtaining the medication in liquid form, if possible, and obtain a physician's order to change dosage forms and directions. The rational for not crushing some medications includes: .Time release tablets are designed to release medication over a sustained period, usually 8 to 24 hours. These formulations are utilized to reduce stomach irritation in some cases and to achieve prolonged medication action in other cases. In either case these tablets should not be crushed . R21 has diagnoses that include in part ischemic stroke, high blood pressure, diabetes, and gastroesophageal reflux disease. R21's physician orders state Aspirin Enteric Coated (EC)81mg 1 tab daily, Metoprolol Succinate ER 50mg 1 tab daily, Metformin ER 500mg 2 tabs daily, and Omeprazole 40mg Delayed Release (DR) 1 cap daily. On 08/29/23 at 7:45 AM, Surveyor observed LPN I crush Metoprolol Succinate Extended Release 50mg 1 tab and administer to R21. This medication is not to be crushed and could cause a significant impact on R21's blood pressure and heart rate. On 08/29/23 at 10:25 AM, Surveyor asked the charge nurse Registered Nurse (RN) J if medications that were ER can be crushed. RN J said they need an order for that from the provider as the provider needs to decide if a medication can be crushed. RN J said if the medication was ER, then it cannot be crushed. Surveyor asked RN J if R21 had an order to have medications crushed. RN J said she will look into it. On 08/29/23 at 10:36 AM, Surveyor spoke with Director of Nursing (DON) B about crushed ER medications. DON B said there was a standing order for crushing medications. If the medication was ER, then we can have the medication changed to a crushable one if okay with the provider or talk with the pharmacy to see if it was ok to crush. Surveyor asked DON B for the policy on crushed medicine and if R21's ER medication had been approved by the provider to be crushed. DON B indicated they would contact the provider and get new orders for crushable medications.

Based on observation, interview and record review, the facility did not provide the services necessary to maintain Range of Motion (ROM) for 1 of 1 resident reviewed. (R3) R3's care plan indicated R3 should wear a palm protector on left hand due to contractures. Throughout the survey on 08/28/23 and 08/29/23, Surveyor observed R3 wearing a palm protector on her right hand, providing no measures for R3's left hand contracture. This is evidenced by: R3 was admitted to the facility in 2018 with diagnoses including contracture of left hand, dementia, depression, and anxiety. The Minimum Data Set (MDS) dated [DATE] indicated R3 has limited ROM to upper extremity on one side, requires one person assistance with eating, dressing, toileting and completing personal hygiene. R3's most recent occupational therapy (OT) services were in December 2022. R3 scored 11/15 during Brief Interview for Mental Status (BIMS) indicating moderately impaired cognition. R3 has an activated power of attorney (POA). R3's care plan included the following: -07/10/23, I have the potential to have a skin injury. I need my aides to . Palm protector with finger separators in left hand every morning, wear during the day as tolerated. -07/10/23, I have contractures of my left wrist and hand. I need my aides to . Encourage me to complete self-feeding as much as I can. Palm protector with finger separators in left hand every morning, wear during the day as tolerated. R3's Kardex (a summary) included . Palm protector with finger separator in left hand every morning, wear during day as tol. R3's physician order included orders for: -12/01/22, lorazepam 2 mg for anxiety related to nail care. Give 1 hour prior to nail care. -12/21/22, Left Hand: Intradry in palm, change daily (works best to floss it in). Daily AM. -06/28/23, oxycodone 5 mg for pain. Give 1 hour prior to nail care. On 08/28/23 at 11:36 AM, Surveyor observed R3 sleeping in a reclined wheelchair. Surveyor observed a palm protector on R3's right hand. R3's left hand was contracted and curled into a fist, resting on her abdomen. R3 was not wearing a palm protector or any other device on her left hand. On 08/28/23 at 12:13 PM, Surveyor observed Certified Nursing Assistant (CNA) K feeding R3 lunch. On 08/29/23 at 1:47 PM, Surveyor observed R3 in her bed. R3's palm protector was on her right hand. There was no device on R3's left hand. On 08/29/23 at 1:56 PM, Surveyor interviewed CNA L. CNA L reported R3's palm protector is applied to her right hand. CNA L and Surveyor observed R3 was wearing palm protector to right hand and no device to left hand. During observation, a carrot (therapy device, shaped like a carrot) was found lying on R3's right chest/shoulder area. Surveyor asked CNA L what the carrot was for, and CNA L replied she didn't know. CNA L and Surveyor reviewed R3's kardex and care plan to confirm the palm protector was to be applied to R3's left hand. There was no mention to use a carrot in either care plan or kardex. Surveyor then interviewed Registered Nurse (RN) N. RN N reported he was not sure which hand R3's palm protector was to be in, but he thought the palm protector was used to prevent R3's fingernails from cutting into her palm. RN N stated he would have to ask another nurse. Surveyor and CNA L were reviewing R3's shower logs and skin assessments and CNA M was present. CNA M reported palm protector is placed in R3's right hand as she refuses to wear it in her left hand. There were no concerns regarding R3's skin. During this time, Surveyor observed RN N exiting R3's room. RN N stated, I missed placing intradry in left palm this morning, I just completed it now. RN N reported he spoke with another staff nurse regarding R3's palm protector and it is not placed in left hand because it is too difficult to get into R3's left palm due to her contractures. Surveyor observed intradry to R3's left palm, observed that intradry was laced through R3's fingers on her left hand. Palm protector was still on R3's right hand. On 08/29/23 at 3:15 PM, Surveyor interviewed Certified Occupational Therapy Assistant (COTA) O. COTA O is also the Director of Rehab services. COTA O and Surveyor went to R3's room, where she was lying in bed. COTA observed R3's hands and completed a small assessment by maneuvering his finger between R3's clenched left fist. COTA O reported R3's palm was, Pretty moist. COTA O confirmed that intradry placed between R3's fingers was not effective. COTA O asked R3 to open her right hand, R3 did this and was able to open her right hand and extend her fingers. COTA O stated the palm protector was not effective on R3's right hand and should be placed on her left hand, as that is the hand affected. COTA O confirmed R3's left hand contracture could improve with therapy services. On 08/30/23 at 9:09 AM, Surveyor observed that R3 did not have palm protector on either hand. Surveyor interviewed CNA K. CNA K stated she is an agency nurse. CNA K was unsure which hand R3's palm protector was to be in. When Surveyor showed CNA K R3's Kardex indicating it should be in the left hand, CNA K agreed, stating, Because she squeezes that hand. CNA K and Surveyor observed R3's left hand and noted her middle fingernail was pressed into her palm; however, the skin underneath was still intact. CNA K confirmed R3 has no skin concerns. CNA K attempted to put palm protector on R3's left hand, R3 pulled her hand away and scowled at CNA K. CNA K did not attempt further. CNA K stated if R3 refuses, CNAs are to update the nurse. CNA K reported if the palm protector was placed on the wrong hand, the nurses should make sure it is placed on the correct hand. CNA K confirmed licensed nurses complete R3's nail care due to difficulty. Surveyor reviewed R3's record for refusal to wear palm protector, no documentation to support R3 refuses to wear palm protector on left hand. R3's progress notes indicated on 12/01/22, staff attempted nail care on R3. R3 would not open her left hand. Assessment reported R3's nails were long and there was a cheesy odor with rust colored discharge from R3's left hand. Staff updated R3's Nurse Practitioner, and an order for lorazepam prior to nail care was received. Staff requested an OT evaluation for hand contractures. Surveyor reviewed OT care plan from 12/01/22-12/29/22, with goals to decrease pain in left hand in order to perform contracture management with splinting and tolerate hand splints to prevent skin breakdown. R3's progress notes indicate the following regarding R3's nail care: -02/08/23, update to POA, considering having R3's nail care completed outside of facility due to difficulty. -02/23/23, nail care completed and partially successful. -05/23/23, nail care partially successful. -06/28/23, NP order for oxycodone 1 hour prior to nail care. Medication Administration Record (MAR) indicated R3 received lorazepam and oxycodone on 07/18/23 and 08/15/23. Surveyor was not able to find documentation to confirm nail care had been completed or effective on these dates. On 08/30/23 at 9:35 AM, Surveyor interviewed COTA O. COTA O stated therapy can complete a screen or evaluation when a resident has a change in condition. COTA O confirmed R3's refusals to wear palm protector and difficulty with nail care would be considered a change in condition, and the expectation would be to complete a therapy screen or evaluation. On 08/30/23 at 9:44 AM, Surveyor interviewed Director of Nursing (DON) B. DON B reported R3 admitted with hand contractures and had received OT services related to contractures. DON B confirmed palm protector to left hand was a referral from therapy from September 2019. DON B was unsure why palm protector was not in R3's treatment administration record (TAR), as nurses should confirm placement and sign off daily. DON B stated she would have expected nursing staff to request an OT screen or evaluation when R3 started refusing to wear palm protector.

Based on observation, record review and interview, the facility did not ensure a medication error rate of 5% or less. During medication administration task, Surveyor observed 5 errors out of 30 medication opportunities, resulting in an error rate of 16.67%. This affected residents (R79, R83, and R21) 3 of 6 residents in the medication administration sample. R79 and R83 were administered insulin inappropriately based on technique errors while using insulin pens. The pen was not primed before administration, and the pen was not held to ensure the full dose was administered, resulting in two errors. R21 was administered 3 crushed oral medications that were extended release (ER)/enteric coated (EC). Doing so can result in too much of the medication given at once and not spread out over time as intended, resulting in three errors. This is evidenced by: The manufacturer's instructions for the Insulin Lispro injection KwikPen states: .Priming your pen: Prime before each injection. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin . The instructions continue with how to prime the pen.Injecting the Lispro dose .Insert the needle into the skin. Push the dose knob all the way in. Continue to hold the dose knob in and slowly count to 5 before removing the needle . The manufacturer's instructions for the Insulin Lantus injection prefilled pen states: .Do a safety test. Always do a safety test before each injection to check your pen and the needle to make sure they are working properly and make sure that you get the correct Lantus dose . The instructions continue with how to do a safety test.Injecting the Lantus dose .Keep the injection button held in and when you see 0 in the dose window, slowly count to 10. This will make sure you get the full dose . The facility policy, entitled Oral Medication Administration, dated 05/18, states: .Refer to crushing guidelines (See Appendix 6: Medication Crushing Guidelines) prior to crushing any medication for assurance that it can be pulverized .Appendix 6: Medication Crushing Guidelines states .Medications that should not be crushed or chewed: When a resident's condition prohibits the administration of solid dosage forms (tablets, capsules, etc.), the nurse administering the medication should check to see that there is no contraindication to crushing the medications in question. If crushing is contraindicated, the nurse should consult the pharmacist for assistance in obtaining the medication in liquid form, if possible, and obtain a physician's order to change dosage forms and directions. The rational for not crushing some medications includes: .Time release tablets are designed to release medication over a sustained period, usually 8 to 24 hours. These formulations are utilized to reduce stomach irritation in some cases and to achieve prolonged medication action in other cases. In either case these tablets should not be crushed . R79 Order for Lantus Insulin 10 units subcutaneous for diagnosis of diabetes. R83 Order for Lispro Insulin for diagnosis of diabetes. Insulin Lispro subcutaneous three times per day at 8am, 12pm, 5pm sliding scale insulin directions: 150-200 = 1 u, 201-250 = 2u, 251-300 = 3 u, 301-350 = 4u, 351-400 = 5 u, >401 call provider. For blood sugars <70 treat with oral glucose replacement then recheck after treatment, then 30 min after treatment, then 60 min after treatment and notify provider. R21 Order for: Aspirin EC 81mg 1 tab daily for ischemic stroke. Metoprolol Succinate ER 50mg 1 tab daily for high blood pressure. Metformin ER 500mg 2 tabs daily for diabetes. Omeprazole 40mg Delayed Release (DR) 1 cap daily for gastroesophageal reflux disease. On 08/29/23 at 7:22 AM, Surveyor observed Licensed Practical Nurse (LPN) I administer Lispro insulin 3 units via insulin pen to R83. LPN I did not prime the insulin pen prior to administration and only held the needle in the SQ tissue for 2 seconds. This is an error in technique which could result in the wrong dose being given. On 08/29/23 at 7:30 AM, Surveyor observed LPN I administer Lantus insulin 10 units via insulin pen to R79. LPN I did not prime the insulin pen prior to administration and only held the needle in the SQ tissue for 2 seconds. This is an error in technique which could result in the wrong dose being given. On 08/29/23 at 7:45 AM, Surveyor observed LPN I crush the following medications and administer to R21: Omeprazole Delayed Release 40mg 1 cap, Metformin Extended Release 500mg 2 tabs, Aspirin Enteric Coated 81mg 1 tab, and Metoprolol Succinate Extended Release 50mg 1 tab. This is an error in technique and could result in changes in the rate at which the medication is absorbed and processed within the body. On 08/29/23 at 8:01 AM, Surveyor asked LPN I if she primes the insulin pens before use. LPN I said no she had never primed the insulin pens and was never taught that. Surveyor asked LPN I how long she holds the insulin needle in the SQ tissue upon injection and she said only a few seconds. On 08/29/23 at 10:25 AM, Surveyor spoke with the charge nurse Registered Nurse (RN) J about priming and holding in place insulin pens. RN J said the pens need to be primed with 2 units before administration and hold the needle in the SQ for 6-10 seconds. Surveyor asked RN J if medications that were ER or EC can be crushed. RN J said they need an order for that from the provider as the provider needs to decide if a medication can be crushed. RN J said if the medication was ER or EC, then it cannot be crushed. Surveyor asked RN J if R21 had an order to have medications crushed. RN J said she will look into it. On 08/29/23 at 10:36 AM, Surveyor interviewed Director of Nursing (DON) B about priming insulin pens. DON B said it depends on the pen. Surveyor asked for the manufacturer's instructions for Lispro and Lantus insulin pens. Surveyor then asked DON B about crushed ER or EC medications. DON B said there was a standing order for crushing medications. If the medication was ER or EC, then we can have the medication changed to a crushable one if okay with the provider or talk with the pharmacy to see if it was ok to crush. DON B stated they would get new orders today for the medications that were crushed and start education for use of insulin pens.

Based on observation, record review and interviews, the facility did not ensure that 1 of 12 sampled residents (R) who are unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene. (R280) R280 was not offered and did not receive toileting every hour as care plan stated. Findings include: R280 was admitted on [DATE]. R280 had the following diagnoses, in part, infantile cerebral palsy, right hemiparesis, intractable epilepsy, schizophrenia, and mood disorder with a Brief Interview of Mental Status (BIMS) score of 8 indicating moderately impaired cognition. R280's most recent Minimum Data Set (MDS) assessment dated [DATE] identified R280 required extensive assist of 2 person for transfers and toileting. R280's nursing care plan, stated in part, for toileting plan: .due to decreased awareness offer toileting approximately hourly with safety checks while awake, turn and reposition approximately every two hours . Intervention under mobility care plan stated in part: .assist of two/walker, offer toileting approximately hourly with safety checks while awake . Intervention under risk/alteration in skin integrity care plan to prevent skin breakdown stated in part: .offer toileting hourly, turn and reposition in chair every hour and every two hours when in bed . On 08/29/23 at 7:45 AM, Surveyor observed R280 up in wheelchair in the lobby. On 08/29/23 at 8:00 AM, Surveyor observed Certified Nurse Aide (CNA) D bring R280 in dining room for breakfast from lobby. CNA D did not ask if R280 had to use the bathroom before breakfast. On 08/29/23 at 9:08 AM, Surveyor observed R280 finish breakfast. CNA D wheeled R280 to the lobby area to watch TV. Surveyor did not observe CNA D offer or inquire about toileting to R280. On 08/29/23 at 9:25 AM, Surveyor observed Activity Aide (AA) F take R280 to activities. Surveyor did not observe AA F offer or inquire about toileting to R280. On 08/29/23 at 9:50 AM, Surveyor observed AA F bring R280 back to lobby from activities. Surveyor did not observe AA F offer or inquire about toileting to R280. On 08/29/23 at 9:53 AM, Surveyor observed CNA G push R280 over to an activity table to work crossword puzzles. Surveyor did not observe CNA G offer or inquire about toileting to R280. On 08/29/23 at 9:58 AM, Surveyor observed CNA G take R280 to physical therapy. Surveyor did not observe CNA G offer or inquire about toileting to R280 prior to physical therapy. On 08/29/23 at 10:40 AM, Surveyor observed Physical Therapist Assistant (PTA) E take R280 to activities room for church services. Surveyor did not observe PTA E offer or inquire about toileting to R280 prior to church services. On 08/29/23 at 11:00 AM, Surveyor observed AA F bring R280 back to lobby to watch TV from activities. Surveyor did not observe AA F offer or inquire about toileting to R280. On 08/29/23 at 11:55 AM, Surveyor observed CNA D take R280 from lobby to dining room for lunch. Surveyor did not observe CNA D offer or inquire toileting to R280. On 08/29/23 at 11:15 AM, Surveyor interviewed PTA E and asked if R280 was toileted during physical therapy. PTA E stated that R280 never asked or inquired about using the restroom and PTA E did not offer or toilet R280. On 08/29/23 at 11:30AM, Surveyor interviewed CNA G and asked what the process is for toileting R280 and how they follow all care plans for residents. CNA G indicated that they are to follow the care plans for what's expected such as toileting R280 which is to offer or toilet every hour while awake. CNA G indicated that maybe PTA E had toileted R280, but that CNA G nor CNA D has toileted R280 because it is a two-assist transfer to toilet. Surveyor noted R280 had been sitting up in wheelchair and had not been offered or assisted to the bathroom for almost 4 hours. On 08/29/23 at 11:40 AM, Surveyor interviewed Nurse Supervisor (NS) C and asked what the expectations and process is for implementing care plans for residents. NS C indicated that care plans are made with the interdisciplinary team (IDT) and that all other team members such as CNAs are expected to follow individualized care plans for each resident. CNAs are to be following R280's care plan for offering or toileting every hour. On 08/29/23 at 11:55 AM, Surveyor interviewed Director of Nursing (DON) B and asked what the expectations and process is for implementing specific care plans for residents. DON B indicated that all CNAs should be following care plans as indicated on the individualized care plans. DON B stated that all CNAs should be offering toileting to R280 as care planned.

Based on observation, interview, and record review, the facility did not assess resident risk for entrapment or attempt alternative methods prior to installing bedrails for 6 of 6 Residents (R) reviewed (R87, R3, R23, R185, R10, R85.) R87, R3, R23, R185, R10, and R85 had grab bars on their beds without an assessment completed to determine their risk for entrapment and without first attempting alternate methods prior to installing the rails on their beds. This is evidenced by: Example 1: On 07/25/22 at 11:45 a.m., Surveyor observed R87's bed having bilateral grab bars. Review of R87's medical record documented current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident was a recent admission to the facility and the Minimum Data Set (MDS) was not completed. Review of the base line care plans documented grab bars as equipment being used. Review of Certified Nursing Assistant (CNA) documentation identified R87 is independent with bed mobility. Review of the medical record documented a consent signed by R87 on 07/22/22 with list of risks example death, bruising, asphyxiation, and strangulation. Review of the facility's Physical Device Assessment with no date, for the use of bilateral grab bars. The assessment question number 2, What alternatives (least restrictive) have been utilized (i.e., verbal instructions, diversional activities, positioning devices) and what was the outcome of the other alternatives/devices trialed? was not filled out. This assessment did not assess the risk for entrapment with the use of grab bars. Observations of R87 on 07/25/22 showed R87 being independent with bed mobility and transfers. Interview with R87 asking if able to use the grab bars. R87 indicated able to use grab bars for getting out of bed. On 07/27/22 12:52 p.m., Surveyor interviewed Director of Nursing (DON) B asking about the bedrail assessments for alternatives trialed before placement and if the resident is assessed for entrapment. DON B indicated when a resident is admitted to the facility, the grab bars are already on the bed. If the assessment did not have alternatives trialed, then it was not completed. DON B understood the assessments did not have risk for entrapment. Example 2: R3 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment, dated 07/12/22, identified R3 had a Brief Interview for Mental Status (BIMS) score of 12. This score indicated R3 had moderate cognitive impairment. The MDS assessment also identified R3 required limited assist of one for bed mobility, and extensive assist of one for transfers. On 07/25/22, at 10:54 AM, Surveyor observed two grab bars on the upper half of R3's bed. Surveyor noted R3 also had an alternating pressure air mattress on the bed. R3 stated he used the grab bars for repositioning in bed. Surveyor reviewed R3's paper and electronic medical record. A physical device assessment form was located on the paper chart dated 03/22/22. There was no documentation of assessment for risk of entrapment on the form. The second page of the document was a consent form with risks of bedrail use. The consent was signed on 03/22/22. There was no documentation of alternatives tried before implementing the grab bars. Example 3: R23 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment, dated 06/20/22, identified R23 had a BIMS score of 1. This score indicated R23 had severe cognitive impairment. The MDS assessment also identified R23 required extensive assist of two for bed mobility, and was totally dependent on two for transfers. On 07/25/22, at 2:52 PM, Surveyor observed two grab bars on the upper half of R23's bed. Surveyor reviewed R3's paper and electronic medical record. A physical device assessment form was located on the paper chart dated 03/09/22. There was no documentation of assessment for risk of entrapment on the form. The second page of the document was a consent form with risks of bedrail use. The consent was signed on 03/09/22. There was no documentation of alternatives tried before implementing the grab bars. The medical record also identified R23 had two falls in April. The fall note dated 04/29/22 stated in part, R23 was seen lying next to his bed, facing bed on his left side. R23's right arm and leg are strong and he most likely grabbed the grab bar and flipped himself out of the bed. On 07/26/22, at 12:47 PM, Surveyor interviewed Certified Nursing Assistant (CNA) K, who reported the grab bars were just always on all of the beds. CNA K stated that R23 did not use the grab bars on the bed for turning or transfers. CNA K stated R23 was totally dependent for bed mobility and transfers. Example 4: R185 was admitted to the facility on [DATE] from an acute care hospital after a fall with right hip fracture and surgical repair. R185 had an additional diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R185's initial BIMS score was 12 on 07/25/22. This score indicated R185 had moderate cognitive impairment. R185's baseline care plan indicated R185 required assist of one for bed mobility, and mechanical sit-to-stand lift assist of two for transfers. On 07/25/22 02:04 PM, Surveyor observed two grab bars on the upper half of R185's bed. Surveyor reviewed R185's paper and electronic medical record. A physical device assessment form was located on the paper chart dated 07/22/22. There was no documentation of assessment for risk of entrapment on the form. The second page of the document was a consent form with risks of bedrail use. The consent was signed on 07/22/22. There was no documentation of alternatives tried before implementing the grab bars. Example 5: On 07/26/22 7:24 a.m., Surveyor observed R10's bed having bilateral grab bars. Review of R10's medical record documented current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident was a recent admission to the facility and the Minimum Data Set (MDS) was not completed. Review of the base line care plans documented grab bars as equipment being used. Review of CNA documentation identified R10 is extensive assist of one staff with bed mobility and extensive assist of two staff for transfers. Review of the medical record documented a consent signed by R10 on 07/19/22 with list of risks example death, bruising, asphyxiation, and strangulation. Review of the facility's Physical Device Assessment with no date, for the use of bilateral grab bars. The assessment question number 2, What alternatives (least restrictive) have been utilized (i.e., verbal instructions, diversional activities, positioning devices) and what was the outcome of the other alternatives/devices trialed? was not filled out. This assessment did not assess the risk for entrapment with the use of grab bars. On 07/26/22 at 8:30 a.m., Surveyor interviewed R10 asking about the use of the grab bars. R10 stated that she uses the grab bars to promote her independence because her goal is to return home. Example 6: On 07/26/22 7:24 a.m., Surveyor observed R85's bed having bilateral grab bars. Review of R85's medical record documented current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident was a recent admission to the facility and the Minimum Data Set (MDS) was not completed. Review of the base line care plans documented grab bars as equipment being used. Review of CNA documentation identified R85 is limited assist of one staff with bed mobility and transfers. Review of the medical record documented a consent signed by R85's Power of Attorney on 07/11/22 with list of risks example death, bruising, asphyxiation, and strangulation. Review of the facility's Physical Device Assessment with no date, for the use of bilateral grab bars. The assessment question number 2, What alternatives (least restrictive) have been utilized (i.e., verbal instructions, diversional activities, positioning devices) and what was the outcome of the other alternatives/devices trialed? was not filled out. This assessment did not assess the risk for entrapment with the use of grab bars.

Based on observation and interview, the facility did not ensure all drugs and biologicals were stored in locked compartments, and did not ensure controlled drugs were stored in separately locked, permanently affixed compartments. Multiple observations were made of medication carts left unlocked when unattended and out of view of staff. Observations were made of controlled medications left open on top of medication cart when cart was unattended and out of view of staff. Two of two medication carts were observed stored in the resident hallways when not in use. Findings include: On 07/26/22, at 06:58 AM, Surveyor observed a medication cart in the hallway outside a room on the 400 hall. The door to the resident room was closed. One of the medication drawers was partially opened and the cart was not locked. No staff was present in the area. At 7:00 AM Surveyor observed Licensed Practical Nurse (LPN) C exit the room and go to the medication cart. On 07/26/22, at 07:09 AM, Surveyor observed LPN C place a bottle of liquid [MEDICATION(S)] and a bottle of liquid [MEDICATION(S)] on the top of the medication cart in the hallway outside of resident room [ROOM NUMBER]. LPN C filled a syringe with [MEDICATION(S)] and a syringe with [MEDICATION(S)]. LPN C left the cart and entered a resident room and closed the door. Surveyor observed both the [MEDICATION(S)] and [MEDICATION(S)] bottles unattended on top of the medication cart with the caps not on the bottles. The medication cart was not locked. At 07:11 AM, Surveyor observed LPN C exit the resident room and return to the medication cart. On 07/27/22, at 09:00 AM, Surveyor interviewed Director of Nursing (DON) B and explained the above observations. DON B stated the medication cart should always be locked when not attended, and the controlled substances should not have been left open and unattended on the medication cart when the nurse left the cart. On 07/26/22 10:40 a.m., Surveyor observed on Bluebird wing, the medication cart at the end of the hallway near the nurse's desk was unattended and unlocked. There was not a nurse or other staff at the nurse's desk. This medication cart is approximately 25 feet from the door to the outside of the building. This cart is not affixed to a permanent fixture in the facility. At 10:52 a.m., Licensed Practical Nurse (LPN) C returned to cart and then left the medication cart unlocked at the end of the hallway. Surveyor observed this medication cart continued to be unlocked and unattended at the end of the hallway from 10:59 a.m. until 11:53 a.m. Surveyor observed medication administration at 12: 41 p.m. for R14. LPN C prepared [MEDICATION(S)] into a syringe. LPN C placed the bottle of [MEDICATION(S)] into the [MEDICATION(S)] box and left it on the medication cart and went into R14's room to administer the medication. At 12:44 p.m., Surveyor interviewed LPN C asking if it is appropriate to leave the [MEDICATION(S)] in the box on the medication cart unattended. LPN C indicated the medication should be locked in the medication cart. Surveyor asked if the medication cart is to be locked when unattended. LPN C indicated the medication cart is to be locked. Surveyor reviewed observations of LPN C leaving the medication cart unlocked and unattended. On 07/27/22 at 7:20 a.m., Surveyor interviewed Registered Nurse (RN) D asking if the medication cart was at the end of the hallway near the nurse's station upon the beginning of her shift. RN D indicated the medication cart was in the same spot in the hall when she came in at 6:00 a.m. The medication cart when not in use, stays at the end of the hall; before they tried to store it next to the nurse's desk but it got in the way of the scale. Surveyor asked if they ever keep the medication cart in the medication room. RN D indicated the medication room is small and the medication cart would hit against the wall. On 07/27/22 at 12:26 p.m., Surveyor interviewed LPN E asking where the medication carts are stored when not in use for medication pass. LPN E is working on Juniper wing. LPN E indicated the medication carts are left locked by the nurse's desk on the Juniper wing at the end of the hall. Surveyor asked if the nurse's desk always have staff at the desk. LPN E indicated staff are not always at the desk. On 07/27/22 at 1:15 p.m., Surveyor interviewed Director of Nursing (DON) B about the medication carts left unlocked and unattended at the end of the hallway. DON B indicated she does not have a policy for storage of the medication carts when not in use. DON B indicated the medication carts are to be stored in the medication room when not in use. DON B indicated the medication carts are to be locked when the nurse is not at the cart or in a resident's room. Surveyor reviewed the observations of medication carts not being used and stored at the end of the hallways near the exit door and the medication carts being unlocked and narcotic medication on top of the cart left unattended. DON B indicated a message education was sent out to all nurses to have the medication carts locked in the medication room when not in use. On 07/28/22 at about 9:25 am, Surveyor was on Wildflower Hallway and noticed a medication cart in the hallway; no staff were around the cart, the medication cart was unlocked and out of sight of nursing staff. After about 5 minutes Registered Nurse (RN) F opened the door of a resident's room and went to the medication cart. Surveyor interviewed RN F and asked about the medication cart being unlocked. RN F indicated she did not think she would be that long but the resident kept asking questions.

Based on observation, interview, and record review, the facility did not ensure that they conducted regular inspections and routine maintenance of bed systems when bedrails are used for 6 of 6 sampled Residents (R) using bedrails (R23, R10, R85, R185, R87, and R3). Regularly scheduled maintenance and inspections of beds with bedrails to prevent potential entrapment for R87, R3, R23, R185, R10, and R85 were not conducted as part of a regular maintenance program. This is evidenced by: Example 1: On 07/25/22 at 11:45 a.m., Surveyor observed R87's bed having bilateral grab bars. Review of R87's medical record documented current diagnosis of nondisplaced fracture 2nd metatarsal bone left foot. Resident was a recent admission to the facility and the Minimum Data Set (MDS) was not completed. Review of the base line care plans documented grab bars as equipment being used. Review of Certified Nursing Assistant (CNA) documentation identified R87 is independent with bed mobility. Review of the medical record documented a consent signed by R87 on 07/22/22 with list of risks example death, bruising, asphyxiation, and strangulation. Surveyor was unable to identify documentation that routine maintenance inspections of the grab bars were completed. On 07/27/22 at 12:52 p.m., Surveyor asked DON B if maintenance has documentation of inspection of the beds with the bedrails and for risk of entrapment and if the beds are functioning properly. DON B indicated not sure if maintenance does inspections of the beds or bedrails. 07/27/22 at 3:15 p.m., Surveyor interviewed Nursing Home Administrator (NHA) A asking about maintenance's routine inspection of the bed and use of grab bars and risk of entrapment. NHA A indicated the maintenance director has not been doing the inspections and mattress measurements. Surveyor asked if assessments have been completed when a new mattress or air mattress that is not the manufacturer's mattress is used. NHA A indicated no assessments were completed and they will be starting the assessments immediately. Example 2: R3 was admitted to the facility on [DATE], with diagnoses including in part, [CONDITION(S)] ([CONDITION(S)]), [CONDITION(S)], and respiratory failure. The Minimum Data Set (MDS) assessment, dated 07/12/22, identified R3 had a Brief Interview for Mental Status (BIMS) score of 12. This score indicated R3 had moderate cognitive impairment. The MDS assessment also identified R3 required limited assist of one for bed mobility, and extensive assist of one for transfers. On 07/25/22, at 10:54 AM, Surveyor observed two grab bars on the upper half of R3's bed. Surveyor noted R3 also had an alternating pressure air mattress on the bed. R3 stated he used the grab bars for repositioning in bed. Surveyor was unable to identify documentation that routine maintenance inspections of the grab bars were completed. Example 3: R23 was admitted to the facility on [DATE], with diagnoses including in part, cerebral infarction (stroke), [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting left non-dominant side, and unspecified dementia with behavioral disturbances. The Minimum Data Set (MDS) assessment, dated 06/20/22, identified R23 had a BIMS score of 1. This score indicated R23 had severe cognitive impairment. The MDS assessment also identified R23 required extensive assist of two for bed mobility, and was totally dependent on two for transfers. On 07/25/22, at 2:52 PM, Surveyor observed two grab bars on the upper half of R23's bed. Surveyor was unable to identify documentation that routine maintenance inspections of the grab bars were completed. Example 4: R185 was admitted to the facility on [DATE] from an acute care hospital after a fall with right hip fracture and surgical repair. R185 had an additional diagnosis of dementia. R185's initial BIMS score was 12 on 07/25/22. This score indicated R185 had moderate cognitive impairment. R185's baseline care plan indicated R185 required assist of one for bed mobility, and mechanical sit-to-stand lift assist of two for transfers. On 07/25/22 02:04 PM, Surveyor observed two grab bars on the upper half of R185's bed. Surveyor was unable to identify documentation that routine maintenance inspections of the grab bars were completed. Example 5: On 07/26/22 7:24 a.m., Surveyor observed R10's bed having bilateral grab bars. Review of R10's medical record documented current diagnoses of tibia and fibula fracture, muscle weakness, [CONDITION(S)], [CONDITION(S)], and DM type 2 controlled. Resident was a recent admission to the facility and the Minimum Data Set (MDS) was not completed. Review of the base line care plans documented grab bars as equipment being used. Review of CNA documentation identified R10 is extensive assist of one staff with bed mobility and extensive assist of two staff for transfers. Review of the medical record documented a consent signed by R10 on 07/19/22 with list of risks example death, bruising, asphyxiation, and strangulation. Surveyor was unable to identify documentation that routine maintenance inspections of the grab bars were completed. Example 6: On 07/26/22 7:24 a.m., Surveyor observed R85's bed having bilateral grab bars. Review of R85's medical record documented current diagnoses of respiratory failure with [CONDITION(S)], dysphagia, dementia, pneumonitis d/t inhale of food and vomit, and type 2 DM with [CONDITION(S)]. Resident was a recent admission to the facility and the Minimum Data Set (MDS) was not completed. Review of the base line care plans documented grab bars as equipment being used. Review of CNA documentation identified R85 is limited assist of one staff with bed mobility and transfers. Review of the medical record documented a consent signed by R85's Power of Attorney on 07/11/22 with list of risks example death, bruising, asphyxiation, and strangulation. Surveyor was unable to identify documentation that routine maintenance inspections of the grab bars were completed. On 07/26/22 at 1:35 p.m., Surveyor interviewed Maintenance Staff (MS) I asking about bed inspections. MS I indicated the facility follows manufacturer guidelines for installing grab bars and rails. They check rails or bars only in the event of a request from staff to have them added, removed, or fixed.

Based on observations, interviews, and record review, the facility did not implement the plan of care for 1 of 12 sampled residents (R18). The facility did not follow the care plan to include using baby wash and [MEDICATION(S)] mouthwash. Findings include: R18 was admitted to the facility on [DATE], and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R18's Minimum Data Set (MDS) on admission was a score of 00, which indicates that R18 has severe impairment. R18's Care Plan dated 06/13/22 states in part wash my eyes and entire face with baby wash/soap . perform oral cares use [MEDICATION(S)] mouthwash. On 07/23/22 at about 7:40 AM, Surveyor observed Certified Nursing Assistant (CNA) G wash R18's eyes and face with a washcloth. CNA G then dried R18's eyes and face with a dry cloth. On 07/23/22 at about 7:45 AM, Surveyor interviewed CNA G and asked what she used to wipe R18's face with; CNA G indicated, just warm water. CNA G then brushed R18's teeth with toothpaste, gave R18 some water to rinse her mouth and told R18 to spit it in the basin. CNA G did not use the [MEDICATION(S)] mouthwash as instructed on the care plan. On 07/23/22 at about 9:00 AM, Surveyor interviewed CNA G and asked her how she knew what cares each resident needed. CNA G pulled out a piece of paper from her pocket and showed Surveyor a kardex with a list of residents and the guidelines for their daily cares. R18 also has a 2 page kardex that is kept at the nurses' station in a binder.

Based on observation and interview, the facility did not ensure that resident identifiable information was kept confidential. During the four day survey, Surveyors had two observations of computer screens left open and unattended on medication carts with resident (R) identifiable information visible (R85, R29.) Findings include: Facility policy entitled, St. Croix County HIPPA Security Policies and Procedures, last updated August 2020, states in part, .Health Information Physical Security .Computer monitors should, when possible, be situated so that unauthorized people cannot view the information on the screen . On 07/26/22, at 6:58 AM, Surveyor observed a medication cart in the hallway outside R85's room. The door to the resident room was closed. The computer screen was up with R85's resident information visible. No staff was present in the area. At 7:00 AM, Surveyor observed Licensed Practical Nurse (LPN) C exit R85's room and go to the medication cart. On 07/27/22, at 9:00 AM, Surveyor interviewed Director of Nursing (DON) B and explained the above observation. DON B stated the computer screen should always be closed or made not visible when the nurse leaves the medication cart to enter a resident room to administer medications. On 07/28/22 at about 9:25 AM, Surveyor observed a medication cart in the Wildflower hallway unattended; computer screen was open, identifiable resident information for R29 was visible on the screen by anyone who walked by. After about 5 minutes, Registered Nurse (RN) F opened the door of a resident's room and went to the medication cart. Surveyor interviewed RN F and asked about the computer screen having resident information up and available for others to see. RN F indicated she did not think she would be that long but the resident kept asking questions.

Based on observation, interview, record review and policy review, the facility did not ensure the resident's environment remained as free of accident hazards as possible, for one of six residents reviewed for falls. 1. Resident #12 had falls in her room on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Resident #12 fractured her hip on [DATE] and was hospitalized . After returning from the hospital to the facility, Resident #12 had significant pain related to the hip fracture, and had a significant decline in her physical condition which required the continuous use of oxygen as well as a catheter. The facility did not place new interventions or supervision in order to prevent further falls and injury. The facility did not investigate and identify the root cause of each fall, and no fall assessments for Resident #12 were completed, contrary to facility policy. 2. The facility did not ensure the resident's environment remained as free of accident hazards as possible, for two of four tub room doors during the environmental tour, which had the potential to affect all residents on the unit. This is evidenced by: 1. On [DATE], Surveyor reviewed the facility "Fall Risk Assessment and Protocol" policy, which is dated [DATE] and last reviewed on [DATE]. The policy states, in part: "POLICY: 1. All residents who are assessed as being at high risk for falls will be identified with individualized fall precautions and interventions. 2. Preventative measures shall be taken to decrease the number of falls whenever possible. PURPOSE: 1. To consistently identify and evaluate residents who fall and to treat or refer for treatment appropriately. 2. To achieve each resident's maximum potential of physical functioning. 3. To prevent/reduce injuries related to fall. 4. To enhance resident dignity and self-worth. 5. To rehabilitate residents to their fullest potential of function. PROCEDURE: 1. A Fall Risk Assessment will be completed at the following times: Upon admission/readmission. Quarterly. With a significant change of status. 2. If the assessment finds the resident at risk, implement appropriate interventions/precautions. 3. Initiate, review and revise the fall risk care plan as appropriate after each fall, with new interventions etc. 4. Any changes in interventions will be noted on the resident's care plan, nursing assistant assignment sheets and, if appropriate, in the nurses' notes. 5. The Interdisciplinary team will meet at least weekly to review incident reports and determine if investigation of incident is needed and will assist with assessing for further intervention(s). 6. The Interdisciplinary Team will evaluate the resident's fall risk in conjunction with the care plan to develop, review and revise at a minimum quarterly with increased frequency as needed to reduce resident falls. 7. The physician/GNP, family/resident representative will be notified of the resident's fall risk as appropriate and will be requested to participate in the planning for reduction of falls as able. 8. For the use of fall prevention alarms: ...Frequency and use of device will be part of medical care and will be identified on resident care plan." Resident #12 has [DIAGNOSES REDACTED]. Resident #12 has a history of falls occuring between 2008 and 2012, while a resident at the facility. Surveyor reviewed Resident #12's medical record on [DATE] at approximately 2:00 p.m. It was noted Resident #12 had eight falls between [DATE] and [DATE]. On [DATE], Surveyor reviewed the documentation in Resident #12's nurses' notes, and noted the following: -[DATE] 02:56 a.m. EMOTIONAL STATE: ...impatient at times; may not wait for staff assistance. PSYCHOLOGICAL: staff assist is needed to encourage, to supervise, to monitor activity, restless per Dr. Simon's note of [DATE]. -[DATE] 06:49 p.m. COMMENTS: Resident has made multiple attempts to self transfer so far on this shift. Resident seems restless, but is cooperative and pleasant with staff. Surveyor reviewed Resident #12's Incident Report from [DATE], which states, in part, "Date of Incident: [DATE]. Time of Incident: 05:45AM shift change NOC (night shift). Possible cause: without assist device, without staff assist. Stated 'well my feet gave out.' Non skid matt (sic - mat) on floor at bed side. Alarm sounding and CNA went to answer call light/alarm and heard resident say 'oh[***]' Resident found sitting on floor at bedside along side nitestand (sic - nightstand) and bed. Injury: abrasion left, mid back, skin tear right arm(s) elbow area ...INJURY SIZE: 6 cm by 7 cm, 1cm diameter. Location: resident's room. Preventative Action: Continue to place walker near resident when in bed. Continue with non skid mat on floor at bedside as well as bed alarms and commode at bedside." No new interventions or a root cause (i.e. needing to use the restroom, restlessness, pain, etc) were investigated, nor were any new interventions put into place after Resident #12's fall, in order to prevent further falls. Surveyor noted Resident #12's nurses' notes continue to document the following: -[DATE] 01:49 a.m. SAFETY MEASURES: call light kept in reach, bed and chair alarm to alert staff to attempts with self transferring. ENDURANCE: tires easily. SUPPORTIVE DEVICE: bed alarm, chair alarm, non skid floor mat, grab bars for positioning for safety. PLAN: Appropriate. -[DATE] 07:12 a.m. SLEEP PATTERN: Frequent voiding up to commode 8 x's (times) and voiding (urinating) in about 100cc (cubic centimeters) amts (amounts). -[DATE] 01:35 a.m. COGNITIVE STATE: staff assist needed to give reminders, alert short term memory (impaired) long term memory (impaired) uncooperative at times in re: (regarding) waiting for assistance irritable at times DECISION MAKING SKILLS: makes decisions which are poor, requires cues and supervision when making decisions, poa (Power of Attorney for Healthcare) is activated. -[DATE] 05:42 p.m. ACUTE CONDITION: started on antibiotic for UTI. The facility sent a fax notification to Resident #12's physician. The fax, which was sent on [DATE] at 02:40 p.m., states, in part, "PROBLEM: ...Also, res (resident) experiencing (increase in) loose stools-has used prn (as needed) immodium x20 (20-times) in the past week. Does have hx (history): colitis. Please Advise." Receiving the Immodium medication up to 20-times in a week, may indicate Resident #12 was having to get up and use the bathroom, which would put her at an increased risk for falling. This concern was not addressed on her fall prevention care plan. Surveyor reviewed the following Incident Report, dated [DATE], which reads, "Date of Incident: [DATE]. Time of Incident: 04:00 PM. Possible Cause: self-inflicted. Activity at the Time: other: Resident was standing trying to turn off the alarm and leaned over to (too) far and went down ending up on her bottom on the floor. CNA was in room but unable to get to resident in time. Equipment Involved: none, she did not have her walker with her. Injury: c/o (complained of) pain on her right knee stated this has been stiff for several days. Location: resident's room. Preventative Action: adjust equipment, keep alarms out of residents reach. Staff Involved: none." Surveyor reviewed the following Incident Report, which states, in part, "Date of Incident: [DATE]. Time of Incident: 11:30 AM day shift. Possible Cause: without staff assist, resident did not use her call light, did turn off her chair alarm, had taken self to the bathroom. Equipment Involved: walker. Injury: no apparent injury. INJURY LOCATION: left hip(s) area as this is how we found her. Preventative Action: we had resident sit in her w/c (wheelchair) and come out to the lounge so that we can watch her continuously for the next hour or so, as it is close to the noon hour and she will be in the dining room with staff. We will also change out the chair alarm so that she is not able to turn it off." Surveyor found no documentation, nor was provided any documentation, which supported Resident #12's chair alarm was changed to ensure Resident #12 could no longer turn off the alarm. Nurses' notes continued to read on [DATE], in part, "01:31 p.m. TRANSFER: (Resident #12) continues on a Restorative Nursing Program for transferring that was originally started with directives from therapies. The overall goal of the program is for res (resident) to maintain her mobility and strength by continuing to transfer with assist of one, her WW (wheeled walker) and cues. Upon review of CNA (Certified Nursing Assistant) charting and observation, is noted that this goal is being met-she has maintained her strength and mobility ... 11:22 p.m. COMMENTS: continue with 30" (30-minute) checks on the ,[DATE] hour. Alarm sounding at 1120pm attempting self transfer to commode at bedside ...Poor stance and movement of right leg with transferring." The next incident report read: "Date of Incident: [DATE]. Time of Incident: 01:16AM, night shift. Possible Cause: without staff assist. Does have bed alarms as will self transfer on/off bed and does not wait for help. Resident is on 30 minute checks and last check was at 1245AM with assist on/off commode at bedside ...Resident sitting on floor with back against bedside stand, still holding onto walker ....Did acknowledge hitting head and brought hand up to right side/back. Injury: bruising linear noted left lower clavicle area ...left breast(s) above breast and below left clavicle area. INJURY SIZE: 7 cm long and 1 cm wide bruise. Location: resident's room. Preventative Action: Continue with 30 minute checks, Continue with bed and chair alarm and non skid mat on floor at bedside. Therapy referral will address falls with therapy." The facility did not identify or investigate a root cause for this fall, nor did the facility increase the frequency of safety checks or use any other interventions to prevent further falls until therapy services could evaluate Resident #12. On [DATE], Surveyor reviewed the Physical Therapy Plan of Care for Resident #12. The therapy Plan of Care reads, in part, "ONSET DATE: [DATE]. TREATMENT Diagnosis: [REDACTED]. ...Precautions: Fall risk." There is no mention of Resident #12's falls from [DATE], [DATE] or [DATE], or having a high risk for falls, in the Physical Therapy Plan of Care. Surveyor continued to review Resident #12's nurses' notes, which indicate, "[DATE] 01:08 a.m. NERV (nervous) SYST (system) CONDITION: ...Continue with 30" (minute) checks on the ,[DATE] hour. Set off alarm at 1240 am after had just checked and appeared resting. Attempting to transfer self onto commode. Unable to pull down briefs per self and still trying but sitting on the bed ...Grippy socks on, non skid matt (sic -mat) on floor at bedside with bedside commode and walker within reach. Bed alarm in place and functional ... 03:17 a.m. COMMENTS: Continue with 30" checks on the ,[DATE] hour. Alarm sounding at 02:55am and attempting to toilet self on commode at bedside ...Unsteady with transfers ..." Surveyor reviewed an Incident Report for Resident #12, which reads, in part, "Date of Incident: [DATE]. Time of Incident: 02:40PM. Possible Cause: Resident stated she got up from her chair and was walking across her room when she fell on her bottom. She did say she hit left side of head, but not hard. Is on chair alarms. Chair alarm was going off ... Equipment Involved: walker. Resident was walking with walker when she fell . Injury: no apparent injury. Action: checked ROM (Range of Motion), is already on Neuro checks from last incident. Preventative Action: other, place resident on 30-minute checks for the rest of shift. Bring resident out to nurses' lounge to join activities as well as closer observation. Is on 30 min (minute) checks indefinitely." The facility did not investigate nor identify a root cause as to why Resident #12 had self-transferred and walked across her room. The facility does not indicate how long Resident #12 will be observed by the nurses for safety and also did not document if Resident #12 participated in any activities after the fall, and for how long. Resident #12 was previously on 30-minute safety checks and continued to have falls. A nurses' note dated [DATE] 03:24 a.m. read: ACUTE CONDITION: remains on antibiotic for UTI ...Up x3 thus far this shift to void ...Hx (history) FALLS: Has fallen in the past 30 days. Continues with 30" checks and continues to attempt transfers on commode per self. Bed alarm working and alerts staff with any attempts between checks. -[DATE] 3:08 p.m. PHYSICIAN VISIT: Attending physician...saw resident extra today due to residents change over the past couple of weeks. Explained to him that she did have a UTI and was treated for [REDACTED]., speech was clear, he did check her arms, hand grasps, legs etc. for strength, stated that he does not think she had a stroke or a TIA ...Stated that he thinks it was the urinary tract infection. -[DATE] 11:44 a.m. FAX RETURNED: by physician on call Dr. (name), new orders, to start Cipro 500mg (milligrams) BID (two times per day) x (times) 3 days for UTI. -[DATE] 06:15 a.m. COMMENTS: Up to commode x6 ... Surveyor reviewed Resident #12's Incident Report from [DATE], which states, "Date of Incident: [DATE]. Time of Incident: 08:05AM. Possible Cause: self-inflicted-self transferred without staff assist. CNA was in adjacent room toileting/transferring other res when she heard this res (Resident #12) in bathroom-as soon as other res was safely transferred to her w/c, aide hurried into BR (bathroom)-res had already walked back into her room. Was found on floor laying on left side near her arm chair, chair alarm had been turned off. Denies hitting her head, aide stated head was not on floor. Injury: no apparent injury. Location: resident's room. Preventative Action: others, Caregiver Key function activated on chair alarm. Vitals: blood pressure ,[DATE], pulse 99." On [DATE] at approximately 1:15 p.m., Surveyor interviewed the Director of Nursing (DON) regarding the Caregiver Key alarm function on Resident #12's chair alarm. The DON stated the Caregiver Key function requires staff to use a key to turn off the alarm, so the resident would not be able to do this on her own. On [DATE], Surveyor reviewed the Social Services notes. A Social Services staffing note from [DATE] states, in part, " STAFFING NOTE FIRST FLOOR re: (regarding) Care Conference today. Medically she (Resident #12) was seen in January, anemia was chronic w/ (with) no issues. She does have a bed alarm, chair alarm, grab bars, she is a class C w/ no CPR (Cardiopulmonary Resuscitation), she did have a UTI this month and has had several in the past quarter, and again, the main goal here is to keep her as comfortable as possible." (Surveyor noted there was no documentation of Resident #12's re-current falls, nor was it documented what other interventions could be used in order to prevent future falls, per facility policy, to include the family or resident representative in the discussion of potential fall interventions or care plan updates.) Surveyor continued to review Resident #12's nurses' notes which read, in part, "[DATE] 12:43 p.m. COGNITIVE STATE: oriented to person not oriented to time not oriented to place forgetful uncooperative at times, irritable occasionally with staff and is impulsive with transferring she does not remember to put on the call light, she transfers with out staff. MEMORY: short term memory long term memory (impaired) DECISION MAKING: makes decisions which are poor; requires cues and supervision when making decisions ... -[DATE] 05:05 a.m. SLEEP PATTERN: Up to commode at least x6 ... -[DATE] 10:29 p.m. COMMENTS: ...Resident up to commode approx. (approximately) 12 times since getting into bed at HS (hour of sleep). -[DATE] 05:37 a.m. SLEEP PATTERN: Up x10 this noc (night shift) to use the commode ..." An Incident Report from Resident #12's fall on [DATE], states, "Date of Incident: [DATE]. Time of Incident: 09:30PM. Possible Cause: self inflicted without staff assist.-res. Up to bedside commode without staff assist. Found down in sitting position next to bed with back against nightstand. States she was attempting to get back into bed. Equipment Involved: commode-walker near resident. Injury: no apparent injury. ACTION: checked ROM ...speech per usual, answers questions appropriately ... Preventative Action: adjust equipment walker placed closer to bedside as res. Gets up by self always. Will not wait for staff assist, does not put on call light-remains on hourly checks. Non-skid mat. Vitals: temperature 100.8 T." There was no documentation in Residents #12's medical record as to when 30-minute checks were discontinued and hourly safety checks were implemented. The facility also did not implement any new interventions after this fall, as the intervention of the walker placement at Resident #12's bedside had already been tried after her fall on [DATE]. The nurses' notes continue to read, in part: "[DATE] 02:26 p.m. PHYSICIAN VISIT: ...reviewed chart, meds, VS (vital signs), labs, res being on floor yesterday, res up ,[DATE] times at night to use commode ...MD (Doctor of Medicine) plan is to have urine cultured ... -[DATE] 08:00 p.m. SKIN CONDITION: ...Resident continues to itch and has been getting up out of bed out of restlessness approximately every 15 minutes." No other interventions were put into place by the facility after Resident #12 was attempting to get up every 15-minutes. Surveyor reviewed Resident #12's Incident Report, dated [DATE], which states, "Date of Incident: [DATE]. Time of Incident: 10:40AM day shift. Possible Cause: self inflicted. Equipment Involved: none. Injury: Right hip is pink she is favoring the right hip, leg. Resident's bed alarm was sounding staff was walking by and heard it and as they entered they seen her walking across the room and fall down onto her left side, she did not hit her head. Staff stepped back into the hallways to alert the nurse and when she returned resident had rolled onto her right side in a fetal position. She was calling out for help. She had her shoes on, grippy mat on the floor next to her bed. Her walker was on the other side of the room. She was c/o (complaining of) her right leg and grabbing at her right hip area ...'don't touch me.' ACTION: checked ROM, ice applied, charge nurse updated. Was sent to ER (emergency room ). Preventative Action: keep walker next to resident, staff teaching." The facility did not investigate and identify the root cause of why Resident #12 was walking across her room, nor were any new interventions put into place after this fall. Surveyor was not provided any information related to staff education or which staff was educated, after this incident. On [DATE], Surveyor reviewed Resident #12's comprehensive care plan entitled, "Potential for Trauma-Falls." The care plan does not address the eight falls Resident #12 had from [DATE] until [DATE], or that she is a high fall risk. The care plan does not address the preventative measures which were listed on Resident #12's Incident Reports, potential safety interventions used to prevent falls, nor does it mention the CNA safety checks Resident #12 had, which started in February 2013. It does not address Resident #12's [DIAGNOSES REDACTED]. The care plan does not address Resident #12 had used any assistive devices for safety; which included a walker, bed grab bars, a non-skid mat on the floor at bedside, or bed and chair alarms. The care plan does not address Resident #12's multiple attempts of self-transferring in her room, which contributed to her multiple falls. On [DATE] at 11:10 a.m., Surveyor interviewed the DON and Registered Nurse (RN) A regarding Resident #12's falls and incident reports. Surveyor was also present for the interview. Surveyor asked if the facility tracked and trended Resident #12's falls, which the DON replied, "I believe I did in February. It looks like the falls (for Resident #12) in February were related to the UTIs. I looked at all the falls, the date and time, the people involved, what were they doing, and how can we prevent the next one (fall)." Surveyor asked if other interventions were considered, such as providing one-to-one supervision by staff. The DON indicated one-to-one supervision was not used for Resident #12, in order to ensure Resident #12's independence. The DON indicated one-to-one supervision is provided, at times, to residents when they are anxious. During the continued interview, The DON stated the staff look for immediate interventions after each resident's falls, and the Interdisciplinary Team (IDT) puts the final intervention in the Kardex (Certified Nursing Assistant care plan). Surveyor requested to see Resident #12's old Kardexes to see what previous interventions were put into place by the IDT. The DON indicated the facility was unable to print Resident #12's Kardex due to the computer software as being an "old system." The DON also stated resident falls are discussed every morning during the IDT meeting. Surveyor asked the DON if any documentation could be provided to determine if Resident #12 was discussed after each fall, as well as what possible interventions were discussed at these IDT meetings. The DON stated she started working at the facility in [DATE], and she did not know if the previous DON kept any documentation from the IDT meetings prior to [DATE]. The DON provided Surveyor with a document entitled, "Daily Meeting," dated [DATE]. No time was indicated on the document. This document reads, under Resident #12's name, "Up ,[DATE] x ' s/Shift, Screen for Alarm (decrease) Therapy." The DON informed Surveyor and Surveyor she was concerned about Resident #12 so the DON discussed Resident #12 at the morning meeting of [DATE]. The DON requested to have Physical Therapy screen Resident #12 for the use of alarms, and to see if the alarms were causing Resident #12's falls. Surveyor noted no other interventions or possible causes for Resident #12's multiple falls were documented during this meeting. During the above interview, Surveyor asked the DON and RN A if Fall Assessments were ever completed for Resident #12, per facility policy. The DON stated the facility considered factors (for falls) but they do not use any forms to assess resident's falls. RN A further stated the physical Fall Assessment "form" consists of the resident's care plan, which includes potential goals, interventions and "walks you through what you can do." Surveyor noted there were no updates to Resident #12's care plan after each fall until [DATE] under "Approach." During the above interview, the DON and RN A were asked by Surveyor why the term "self-inflicted" was sometimes used on the incident reports as a possible cause, which may infer the resident was held responsible for the fall. The DON stated "self-inflicted" was a button-word in the computer system which has to be used whenever staff types up an Incident Report. She further stated the facility was in the process of having this button-word removed from the computer system, so this term could no longer be used. During the above interview with the DON and RN A, Surveyor discussed the comprehensive care plan which did not list Resident #12's multiple attempts to self-transfer, her mobility, and multiple falls from [DATE] to [DATE]. The DON replied it states on the comprehensive care plan "See CNA Kardex" for transfer and ambulation status, and further stated the facility was unable to "pull" the CNA Kardex care plan from the computer for Surveyor to review. Surveyor asked which staff members use the CNA Kardex for direction on Resident #12's daily care, which the DON stated the CNAs only use the CNA care plan Kardex for direction. When Surveyor asked the DON which facility staff use Resident #12's comprehensive care plan, the DON replied, the nurses and the interdisciplinary team would use the comprehensive care plan for direction of the resident's care. Environment: On [DATE] at 10:40 a.m. during the environmental tour Surveyor noted on 2 of 4 doors identified as bath or tub rooms a plastic protruding door guard that had a hole in the corners approximately 2 inches in diameter that were chipped and broken with ragged edges. FD (Facilities Director) O, who accompanied Surveyor on tour, verified the area had potential to cause harm to a resident.