Every finding on record at Tieszen Memorial Home

Based on observation, interview, and policy review the provider failed to ensure food items did not spoil in one of one walk-in refrigerators in the main kitchen, and one of one refrigerator on the Memory Care Unit was clean. Findings include: 1. Observation and interview on 5/26/26 at 12:04 p.m. in the walk-in refrigerator in the main kitchen with dietary F revealed, two one-pound containers of strawberries left in a flat. Both containers had moldy strawberries in them. There was a five-pound box of red bell peppers with six peppers in it. All the peppers had mold growing on them. Dietary F started working at the facility in December 2025 and, was being trained to take over some of the dietary manager's duties after she retired. He had completed his ServSafe training. He confirmed there were moldy strawberries and red bell peppers in the walk-in refrigerator. He agreed they should have been removed. He took them out of the walk-in refrigerator and discarded them. 2. Interview on 5/27/26 at 11:02 a.m. with dietary manager G regarding the moldy strawberries and red bell peppers revealed that she expected them to be discarded when found. The facility was having issues with the condensation ventilation in the walk-in refrigerator, and maintenance was working on it. The dietary staff were trying to rotate produce to reduce exposure to the condensation. She agreed the moldy strawberries and red bell peppers should have been removed from the walk-in refrigerator and discarded. 3. Observation on 5/26/26 at 12:14 p.m. of the Memory Care Units refrigerator revealed that there was a dried brown substance that covered the bottom of the refrigerator. 4. Interview on 5/27/26 at 2:25 p.m. with certified nursing assistant (CNA) L revealed the refrigerator in the Memory Care unit was to be cleaned on Saturdays by the overnight CNAs. 5. Interview on 5/28/26 at 1:03 p.m. with dietary manager (DM) G revealed that it was the CNAs responsibility to clean the refrigerator in the Memory Care Unit. She was not sure who was responsible for monitoring that the cleaning of that refrigerator was completed. 6. Interview on 5/28/26 at 12:39 p.m. and 1:44 p.m. with registered nurse (RN)/Infection Control (IC) C revealed it was the overnight CNAs responsibility to clean the Memory Care Unit refrigerator, and they had it on a cleaning schedule. She thought the dietary staff was responsible for monitoring that it was cleaned. 7. Interview on 5/28/26 at 1:56 p.m. with director of nursing (DON) B revealed she expected the refrigerator in the Memory Care Unit to be cleaned by the overnight CNAs. She could not find that task on the CNAs checklist and stated she would put that task on their checklist. She stated DM G was responsible for monitoring the cleanliness of the Memory Care Units' refrigerator. 8. Review of the provider's 2013 Food Storage policy revealed, Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored in an area that is clean, dry and free from contaminants. Food is stored, prepared, and transported at appropriate temperatures and by methods designed to prevent contamination or cross contamination. 8. All stock must be rotated with each new order received. Rotating stock is essential to assure [ensure] the freshness and highest quality of all foods. 9. Review of the provider's February 2021 Facility refrigerator cleaning and monitoring policy revealed that all facility refrigerators shall be cleaned, monitored, and maintained routinely to ensure sanitary storage conditions. Each department utilizing a refrigerator is responsible for ensuring routine cleaning and monitoring is completed according to this policy. The policy listed the medication room and activity room refrigerators, and did not list the refrigerator in the Memory Care Unit.

Based on interview, record review, observation, document review, and policy review, the provider failed to ensure that food was kept and served at a safe temperature for one of one Memory Care Unit dining room, and that food was palatable, appetizing, and warm in one of one main dining room. Findings include:1. Interview on 5/26/26 at 11:27 a.m. with resident 23 in room revealed that her food was sometimes cold. 2. Review of resident 23's electronic medical record (EMR) revealed her 5/1/25 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated her cognition was intact. 3. Interview on 5/26/26 at 11:30 a.m. and 2:27 p.m. with resident 8 in her room revealed that some of the food tasted bland and was sometimes cold. There were no spices or sauces, such as ketchup, mustard, or mayo, at her table to use. She stated she had discussed this at the Resident Council meeting before. 4. Review of resident 8's EMR revealed her 3/30/26 BIMS assessment score was 15, which indicated her cognition was intact. 5. Observation and interview on 5/26/26 from 11:46 a.m. through 11:59 a.m. in the Memory Care Unit dining room revealed that a staff member brought in a food warmer with food in it. She plugged it into the wall, and the temperature indicated it was 159 degrees Fahrenheit (F). Certified nursing assistant (CNA) N checked the temperature of the food within the food warmer and stated the ribs were 118 degrees F and the corn was 132 degrees F. She removed the potato salad from the refrigerator in the kitchenette, and it was 57 degrees F. CNA N was going to serve the food to the residents. When asked what the serving temperature should be, she stated she did not know and called someone from the kitchen. The kitchen staff member informed her they had to check what the food temperatures were supposed to be and would get back to her. 6. Observation and interview on 5/26/26 at 12:03 p.m., in the Memory Care unit dining room with licensed practical nurse (LPN) O revealed she entered the dinging room, checked the temperature of the food with a different thermometer, and the ribs were 110 degrees F. She stated they should be greater than 165 degrees F. She checked the temperature of the ribs on another tray, and they were 122 degrees F. The corn was 120 degrees F. She removed the potato salad from the refrigerator, and the temperature was 56 degrees F. She said the temperature of the cold food should be less than 41 degrees F and stated she was taking the food to the kitchen. 7. Interview on 5/26/26 at 12:12 p.m. with CNA N revealed it was the CNAs responsibility in the Memory Care unit to take the temperature of the food and to serve it. She stated she was not educated on what the food temperatures were supposed to be. 8. Observation and interview on 5/26/26 from 12:28 p.m. through 12:38 p.m. in the Memory Care unit kitchenette with LPN O revealed she brought in a food warmer with food trays in it. She took the temperature of the food, and it was at a safe serving temperature. She poured a glass of milk from a gallon of milk that was in the refrigerator in the Memory Care Units' kitchenette, and it was 42 degrees. She stated she was going to get a new gallon of milk. LPN O came back with a new gallon of milk, she poured a glass of milk, and the temperature was at a safe serving temperature. She verified that the thermometer in the refrigerator read 50 degrees F. She called maintenance to come check it. She could not find the refrigerator temperature logs and said the refrigerator temperature was supposed to be checked daily. 9. Observation and interview on 5/26/26 at 12:41 p.m. in the Memory Care unit dining room with CNA P revealed she removed two bowls of potato salad from the refrigerator and was going to serve it to the residents without checking the temperature. After she was asked by the surveyor, she checked the temperature, and it was 51 degrees. She then called the kitchen for new potato salad for the residents. 10. Observation on 5/26/26 at 12:44 p.m. in the Memory Care unit kitchenette revealed LPN O instructed the staff not to use anything from the refrigerator since the food was not meeting safe temperatures and needed to be discarded in the trash can. 11. Interview on 5/27/26 at 3:00 p.m. with residents 8, 20, 53, 54, and 57 during the Resident Council meeting revealed that resident 8 reported that sometimes her food was cold and that the pork and chicken were dry and hard to swallow. Resident 20 reported that her food was often cold and thought some of the food was for the younger generation. She ate in the main dining room. Resident 53 reported that the meat was dry and hard to chew. He ate in the main dining room. Resident 54 reported that her food was sometimes cold and was sometimes too spicy. She ate in the main dining room. Resident 57 reported that his food was cold about half of the time, the roast beef was hard to chew, so he was sometimes unable to eat it. He ate in the main dining room. The residents stated they had discussed this at the Resident Council meetings before and were unsure what was being done about it. 12. Review of resident 20's EMR revealed her 5/1/26 BIMS assessment score was 15, which indicated her cognition was intact. 13. Review of resident 53's EMR revealed her 5/18/26 BIMS assessment score was 15, which indicated his cognition was intact. 14. Review of resident 54's EMR revealed her 4/22/26 BIMS assessment score was 15, which indicated her cognition was intact. 15. Review of resident 57's EMR revealed his 3/4/26 BIMS assessment score was 13, which indicated his cognition was intact. 16. Review of the March, April, and May 2026 Resident Council meeting notes revealed there were complaints about the food not tasting good, the toast being hard, the pork being hard, some of the food being hard to swallow, they requested condiments, and they were not always served what they had circled on their food menus that they wanted. The notes indicated the dietary manager (DM) was either present for the meeting or notified of the residents' concerns. It did not indicate what was done to address the complaints. 17. Interview on 5/28/26 at 1:03 p.m. with dietary staff E and F, and DM G revealed that dietary staff E and F were training to be the new DM's. They thought the food was cold because it sometimes sat in the window for too long before being served to the residents when the CNAs were short-staffed and could not serve it right away.DM G recently switched to the spring and summer menu, and the residents did not like it, so she had to make some changes. She changed what meats she was buying due to the complaints of the meat being dry. She did not document what she had done to try to resolve the issues related to the food issues brought up in the Resident Council meeting, but she tried to address the issues on the spot. DM G stated that the Memory Care Units' food was brought over in a warmer and was served last. She had noticed that the temperatures were not always recorded, and some temperatures did not meet the required serving temperature. She said the CNA working in the Memory Care unit was responsible for checking food temperatures before serving the food to the residents. She thought the CNAs completed a computer training course regarding checking food temperatures. 18. Interview on 5/28/26 at 1:25 p.m. with registered nurse (RN)/infection control (IC) C revealed that the CNAs completed a computer training course regarding checking food temperatures. The food serving temperatures were listed at the bottom of the sheet that the CNA recorded the food temperatures on. 19. Interview on 5/28/26 at 1:56 p.m. with director of nursing (DON) B revealed she expected the CNAs to take the food temperatures before serving the food to the residents on the Memory Care unit, and not to serve the food if it did not reach the serving temperature. In the main dining room, she expected the dietary staff to plate the residents food until a CNA staff member was available to serve the food. 20. Review of the Memory Care food temperature log from 3/29/26 to 5/26/26 revealed that there were 52 instances of hot foods documented as less than 135 degrees F, and there were 10 instances where the food temperatures were not documented as taken. The bottom of the food temperature logs stated that the temperature of the hot foods needed to be at least 135 degrees F and the cold foods needed to be 41 degrees F or colder. Any foods that were not meeting safe food temperatures was to be reported to their supervisor immediately. 21. Review of the May 2026 Memory Care Unit refrigerator temperature logs revealed that all temperatures were documented daily at an acceptable range. 22. Review of the provider's 2013 Food Temperature policy revealed that hot foods were to be held and served at a temperature of at least 135 degrees F. All cold food items must be maintained and served at a temperature of 41 degrees F or below. Food sent to the unit for distribution.will be transported and delivered to maintain temperatures at or below 41 degrees F for cold foods and at or above 135 degrees for hot foods. Unit refrigerators will be monitored for temperatures that maintain food at or below 41 degrees F.

Based on observation, interview, record review, and policy review, the provider failed to ensure standard infection control prevention practices were followed by one of two observed certified nursing assistants (H) who used soiled gloves to obtain Aquaphor (a skin ointment) from a jar, and did not wear gloves for high-contact care provided to one of one sampled resident (5) who required Enhanced Barrier Precautions (EBP, glove and gown use when providing contact care), and by two of two observed housekeepers (J and K) who did not change their gloves before going from a dirty to a clean task while cleaning three of three observed residents rooms (39, 57, 58, and 66). Findings include:1. Observation on 5/27/26 at 3:37 p.m. of CNAs H and I in resident 5's room revealed he was lying in bed on his back, and he had a urinary catheter (flexible tubing inserted into the bladder to drain urine) bag hanging on the side of his bed frame. There was a sign on his bathroom door from the Centers for Disease Control (CDC) that indicated he required EBP, and it included what personal protective equipment was to be worn and with what activities. CNAs H and I sanitized their hands and put on a gown and a pair of gloves. CNA H used a washcloth with a cleanser on it that she had prepped prior to the surveyor coming into the room, to clean resident 5's buttocks. With those same gloved hands, she scooped Aquaphor out of the jar with her gloved right hand, and applied it to his buttocks. CNA H removed the glove on her right hand, and adjusted resident 5's incontinence (involuntary leakage of urine or bowel leakage) brief, pulled his pants up, put a transfer sling (a specialized fabric support used with a mechanical lift) underneath him, and removed her other glove. Without washing her hands or putting on a pair of clean gloves, CNA H attached the full body lift (a mechanical lift used to lift a person's full body) to the sling, handled the urinary catheter bag and hooked it on the sling strap, which was above the level of the resident's bladder, and transferred him to his wheelchair. He had approximately 350 milliliters (mL) of urine in his urinary catheter bag. 2. Interview on 5/27/26 at 3:50 p.m. with CNA H revealed that she was to wear gloves when assisting residents who were on EBP for their personal hygiene care and transfers. She acknowledged that she used a soiled glove to obtain Aquaphor from the jar. CNA H acknowledged that she was to keep the urinary catheter bag below the level of the resident's bladder and stated that not doing so could cause backflow of urine into the resident's bladder and increase his risk for infection. 3. Review of resident 5's electronic medical record (EMR) revealed that he admitted to the facility on [DATE]. His 4/13/26 Brief Interview for Mental Status (BIMS) assessment score was 13, which indicated his cognition was intact. He had a diagnosis of neuromuscular dysfunction of the bladder. He had a 12/15/25 physician's order for an indwelling urinary catheter and 2/20/26 physician's order for Aquaphor to be applied to his buttocks with each brief change. His 4/17/26 care plan indicated he required EBP because he had a urinary catheter, and to keep the urinary catheter bag below the level of the bladder. 4. Observation on 5/27/26 at 8:25 a.m. of housekeeper J cleaning residents 57 and 58's room revealed she put on a pair of gloves, cleaned the toilet bowl with a toilet brush, and wiped the outside of the toilet using a cloth that had cleaner on it. With those same gloved hands, she obtained a new cloth, sprayed it with a cleaner, and wiped the top of the residents' dresser, end tables, and bedside tables. She removed and discarded her gloves in the trash can, and sanitized her hands. 5. Observation on 5/27/26 at 8:31 a.m. of housekeeper J cleaning resident 66's room revealed she put on a pair of gloves, sprayed the bathroom sink and toilet with a cleaner, and then wiped the sink, bathroom hand rail, and the toilet. She cleaned the toilet bowl with a brush and then changed the garbage bags. With those same gloved hands, she picked up items on the resident's bedside table to wipe the table, she wiped the top of the dresser, the end table, and the personal refrigerator.With those same gloved hands, she mopped the bathroom, turned the bathroom light switch off, and removed the mop head. She obtained a new mop head and mopped the bedroom floor. She moved resident 66's bedside table to mop under it and then moved it back. She removed the mop head, removed and discarded her gloves in the trash can, and sanitized her hands. 6. Observation on 5/27/26 at 10:53 a.m. of housekeeper K cleaning resident 39's room revealed she sanitized her hands, put on a pair of gloves, sprayed the bathroom sink and toilet with cleaner, and cleaned the toilet bowl with a brush. With those same gloved hands, she mopped the resident's room, pulled out resident 39's bedside table to mop under it, and then replaced it. She wiped down the bathroom sink and the outside of the toilet. She removed and discarded her gloves in the trash can, and sanitized her hands. 7. Interview on 5/27/2026 at 11:10 a.m. with housekeeper K revealed that hand washing or sanitizing was to be completed before entering a resident's room and when changing gloves, which were to be changed between tasks. She acknowledged that she did not change her gloves after cleaning the toilet and stated she should have. 8. Interview on 5/28/26 at 11:32 a.m. with maintenance M revealed he was the maintenance director and the supervisor for the housekeeping and laundry departments. He expected the housekeepers to change their gloves when going from a dirty task to a clean task, and sanitize their hands after glove removal. 9. Interview on 5/28/26 at 12:39 p.m. with registered nurse (RN)/Infection Control (IC) C revealed that she expected the CNAs to wear gloves when assisting residents who were on EBP with their personal hygiene care and transfers. The CNAs were to remove their soiled gloves after providing incontinent care to the resident, sanitize their hands, put on a new pair of gloves to apply Aquaphor, and to keep the resident's urinary catheter bag below the level of the resident's bladder when there was urine in the bag. She stated that not doing so would increase the resident's risk for infection and bladder spasms. 10. Interview on 5/28/26 at 1:56 p.m. with director of nursing (DON) B revealed she expected CNA H to remove her soiled gloves, sanitize her hands, and put on a new pair of gloves before taking Aquaphor from the jar. She expected the CNAs to wear gloves when assisting residents on EBP with their personal hygiene care and transfers. She expected CNA H to empty resident 5's urinary catheter bag before putting it above the level of his bladder and stated that not doing so put the resident at risk for infection. 11. Review of the CDC's EBP sign revealed that staff were to wear gloves and a gown for high-contact resident care activities, which included dressing, providing hygiene care, changing incontinence products, and transferring. 12. Review of the provider's January 2025 EBP policy revealed that the facility was to follow the CDC and the Center for Medicaid and Medicare Services (CMS) guidelines regarding EBP to prevent the spread of multidrug-resistant organisms. The staff were to use EBP for the residents who have an indwelling medical device, and to wear a gown and gloves for high-contact activities, including dressing, transferring, providing hygiene care, and changing incontinent briefs. 13. Review of the provider's March 2019 Indwelling Urinary Catheter Care and Removal policy revealed Our policy is to follow the guidelines of Lippincott Nursing Procedures Manual regarding this nursing procedure. 14. Review of the Lippincott Nursing Procedures Manual revealed that the catheter urinary bag was to be kept below the level of the bladder to decrease a patient's risk for a catheter-associated urinary tract infection (CAUTI). 15. Review of the provider's May 2018 Disinfecting and Cleaning Resident' Rooms policy revealed that gloves should be used for housekeeping tasks, removed after each room was cleaned, and hand hygiene should be performed after removing gloves. The bedside tables were to be cleaned daily.

Based on record review, interview, and policy review the provider failed to ensure the Office of State Long-Term Ombudsman (an advocate of residents' overall quality of care and rights) was notified when a resident discharged from the facility, for one of two sampled residents (6).Findings include:1. Review of resident 6's electronic medical record (EMR) revealed she was discharged on 4/21/26 to another facility. Her primary care physician (PCP) was notified of the intent to discharge on [DATE] and the facility received a physician's order on 4/21/26 for resident 6 to be discharged to the assisted living with her current orders. There was no documentation that the Office of State Long-Term Care Ombudsman was notified of resident 6's transfer to another facility.2. Interview on 5/27/26 at 4:19 p.m. with social services (SS) D revealed resident 6 transferred to the assisted living facility attached to the nursing home. She was not aware she needed to report the discharge to the ombudsman. She had reported it to Dakota at Home due to the change in pay source.She did not print the ombudsman notifications out after she submitted them and had no documentation of previously submitted notifications to prove she had submitted them. She stated the computer screen would indicate the submissions she sent to the ombudsman were accepted. 3. Interview on 5/28/26 at 11:33 a.m. with administrator A revealed resident 6's ombudsman notification was made that morning. Administrator A had also given SS D education and showed her how to download the form from the ombudsman notification submission website. SS D started a binder to keep the submissions in starting today (5/28/26).4. Review of the provider's May 2025 Discharge/Transfer/Death Notification policy revealed It is the policy of the [NAME] Memorial Home to notify the appropriate state agencies when a resident is discharging/transferring death from either the nursing home or assisted living center. If a resident is transferring or discharging from either [NAME] Memorial Home or [NAME] Assisted Living, the Social Services Coordinator or her designee will notify the appropriate agencies (ex. Ombudsman, VA) of such discharge/transfer/death. This can either be via email submission, online portal, or phone call, in a timely manner.

Based on observation, interview, and policy review the provider failed to ensure the daily posted nurse staffing information included the resident census. Findings include:1. Observation from 5/26/26 at 5:00 p.m. through 5/28/26 at 7:48 a.m. of the daily posted nurse staffing form located on the wall near the reception desk revealed it did not include the resident census as required. There was a spot for the census that was blank. 2. Interview on 5/28/26 at 11:59 a.m. with director of nursing (DON) B revealed that secretary R completed the daily posted nurse staffing form, gave it to the night nurse, and the night nurse posted it on the wall by the reception desk. 3. Interview on 5/28/26 at 12:01 p.m. with secretary R revealed she completed the daily posted nurse staffing form and gave it to the night nurses to post on the wall by the front reception desk. The nurse was to edit the form for staffing changes. Secretary R was not aware that the resident census needed to be included on the nurse staffing form. 4. Interview on 5/28/26 at 12:07 p.m. with DON B revealed that she expected the night nurse to add the current resident census to the daily nurse staffing form. 5. Review of the provider's May 2025 Staff Posting policy revealed the staffing form should include the resident census at the beginning of the shift for which the information is posted.

Based on observation, interview, record review, and policy review, the provider failed to ensure that one of one sampled resident (66), who was left unsupervised to take her medication by a licensed practical nurse (LPN) (U), was assessed for the ability to safely self-administer medications. Findings include:1. Observation on 5/27/26 at 8:31 a.m. in resident 66's room revealed she was not in her room, and there was a medication cup with a grey pill inside of it and a bottle of Refresh Eye Drops sitting on her bedside table. 2. Interview on 5/27/26 at 8:41 a.m. with nursing assistant (NA) S revealed she verified that resident 66 had a pill in a medication cup on her bedside table and a bottle of eye drops. She paged the nurse. 3. Interview on 5/27/26 at 8:50 a.m. with registered nurse (RN) T revealed she verified that there was a pill in a medication cup on resident 66's bedside table, and that the resident's family brought her the bottle of Refresh Eye Drops, but it contained baby oil. She verified that resident 66 did not have orders to self-administer her medications, and her care plan did not indicate she was able to. She verified that the pill in the medication cup was levothyroxine (thyroid medication) 75 micrograms (mcg), which was due at 7:00 a.m., and left on resident 66's bedside table by LPN U. 4. Interview on 5/27/26 at 8:55 a.m. with LPN U revealed that she left the levothyroxine on resident 66's bedside table, and she was supposed to watch her take it because she did not have a physician's order to self-administer her medication. 5. Review of resident 66's electronic medical record (EMR) revealed she admitted to the facility on [DATE]. Her 5/12/26 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated her cognition was intact. She had a diagnosis of hypothyroidism (when your thyroid gland does not produce enough essential hormones). She had a 5/5/26 physician's order for levothyroxine 75 mcg to be administered daily. There was no physician's order for her to self-administer her medication. 6. Interview on 5/27/26 at 8:58 a.m. with director of nursing (DON) B revealed that she expected LPN U to watch resident 66 take her levothyroxine because she did not have a physician's order to self-administer medications or have a self-administration safety assessment completed. She was not aware that resident 66's family brought in the Refresh Eye Drops bottle that contained baby oil when she was admitted to the facility. She expected that the bottle would be labeled to indicate who it was for and what was in the bottle, baby oil. 7. Review of the provider's August 2007 Medication-Self-Administration Policy revealed If a resident wishes to self-administer drugs, the Care Team will assess the resident's cognitive, physical, and visual ability to carry out this responsibility utilizing the medication self-administration assessment on PCC [point click care]. All self-administered medication must have a written order from a physician indicating approval. Also [,] a physician order is necessary to allow a resident to keep a specific drug in their room.

Based on observation, interview, record review, and policy review, the provider failed to complete a side rail assessment for one of seven sampled residents (1). Findings include: 1. Observation and interview on 5/26/26 at 2:32 p.m. with resident 1 in her room revealed she was sitting in her recliner. She had bilateral half siderails on her bed. She stated she did use the side rails to move around in bed.2. Interview on 5/27/26 at 3:02 p.m. with Minimum Data Set (MDS) Coordinator Q revealed that resident 1 moved to a new room on February 4th. Resident 1's bed in her previous room did not have side rails. MDS Coordinator Q did the quarterly side rail safety assessments for the residents who had side rails. Resident 1 did not use side rails, so MDS Coordinator Q did not complete a side rail safety assessment for her. She was not aware the bed in resident 1's new room had side rails. She confirmed there was no physician's order obtained, and a safety assessment was not completed for resident 1.3. Interview on 5/28/26 at 2:01 p.m. with administrator A regarding resident side rails revealed that MDS Coordinator Q completed the side rail assessments. She stated side rails required a physician's order. Quarterly side rail assessments were to be completed and reassessed to ensure they were being used for the intended purpose.4. Review of resident 1's electronic medical record (EMR) revealed she admitted to the facility on [DATE]. Her Brief Interview for Mental Status (BIMS) assessment score was 8, which indicated her cognition was moderately impaired. She needed one staff members assistance with transfers. There was no documentation of a physician's order or a side rail safety assessment in resident 1's EMR.5. Review of the provider's June 2014 Half Side Rail Assessment policy revealed, It is the policy of the [NAME] Memorial Home to perform evaluations at least quarterly to ensure that the use of half side rail is appropriate. Upon admission, if the resident's physician orders 1/2 side rails for mobility/repositioning, a Bed Rail/Assist Bar Evaluation form will be completed by a licensed nurse. The Bed Rail/Assist Bar Evaluation Form will be completed a minimum of quarterly by the Licensed Nurse completing the MDS Assessment forms to ensure the use of 1/2 side rails continues to be appropriate for the resident being evaluated.

A. Based on observation, interview, and policy review the provider failed to ensure proper infection control practices for the cleaning of shared safety slings for two of two sampled residents (4 and 19) who required the use of a sit-to-stand lift (mechanical lift used to assist to a standing position for transfers). Findings include: 1. Observation on [DATE] at 8:21 a.m. of a sit-to-stand lift parked in the hallway revealed: *The lift had a laminated sign on the side of it that read 12. *There was a medium-sized sling draped over the lift. 2. Observation on [DATE] at 8:32 a.m. with resident 4 and nursing assistant (NA) D revealed: *NA D used a sit-to-stand lift labeled 11 to transfer resident 4 from her wheelchair to her recliner and then placed that lift in the hallway outside that room. -The lift had two green safety slings stacked on top of it, one medium-sized and one large. 3. Observation and interview on [DATE] at 9:23 a.m. with NA D revealed: *NA D brought sit-to-stand lift 11 into resident 19's room with the 2 green safety slings stacked on top of it. -She used that lift to transfer resident 19 from his electric wheelchair to his recliner. *NA D used a cleaning wipe to wipe the metal parts of lift 11 but did not wipe the sling and then parked that lift in the hallway with those two safety slings stacked on top of it. *NA D called this lift the one-person EZ stand. *She confirmed that lift 11 was used to transfer residents 4 and resident 19. *There were three or four other residents who also used that lift on the second floor. *The two green safety slings were shared by all the residents depending on what size they needed. -One was a size medium, and the other was a size large. *She stated the two safety slings were washed when they were visibly soiled, and they were sanitized once a day. 4. Interview on [DATE] at 11:33 a.m. with RN/infection control nurse M regarding the lift slings revealed: *She indicated that each resident who used a full-body lift had their own sling. *She stated that sit-to-stand lift slings are shared between residents. -They were to be wiped with a disinfectant wipe between being used for assisting residents. -They were to be sent to the laundry when they were visibly soiled. Review of the provider's [DATE] EZ stand and mechanical lift policy revealed: *Each resident has a dedicated harness that will be laundered if soiled. *EZ stand is cleaned with disinfecting wipes between each use. 51472 B. Based on interview, observation, record review, and policy review the provider failed to ensure one of one sampled resident (20) with an open wound had been placed on enhanced barrier precautions (EBP). Findings include: 1.Interview on [DATE] at 11:32 a.m. with housekeeper F revealed there were no residents on second floor that had precautions in place which would require her wear a gown and gloves while cleaning the room. 2. Observation and interview on [DATE] at 11:40 a.m. with NA D in the hallways of the second floor revealed: *A metal cart at the nurse's station that had a box of disposable gloves, a box of straws, a plastic container with yellow gowns inside, and a binder with a sunflower on it. *NA D stated that the sunflower symbol was to be used to indicate a resident was on precautions that required them to wear a gown and gloves. -The sunflower would be posted on the resident's door or in their room on the dresser. *NA D stated when a resident was on COVID-19 precautions their door would be closed. *NA D stated contact precautions were used for residents that had catheters or any open wound or surgical site. *No resident doors or dressers were observed to have a sunflower symbol. -NA D stated there were no residents on the second floor who required any type of precautions. 3. Observation on [DATE] at 9:10 a.m. of resident 20 revealed: *He had aa air mattress to relieve pressure. *He had a cushion in his recliner and wheelchair. *There were multiple open areas of skin on his mid-buttocks. *No wound dressings were present. *No drainage was visualized. *The skin areas were covered with a white cream. 4. Interview on [DATE] at 9:10 a.m. with RN/skin nurse L revealed: *She did not monitor all skin issues. *She monitored all pressure ulcers. *She had been monitoring resident 20's stage II pressure ulcer (partial thickness skin loss that results from pressure). *She stated that she would have considered resident 20's wound as an open wound. *Resident 20's open areas to his buttocks were a result of pressure. *Resident 20's pressure ulcer was not present when he was admitted to the facility. *Resident 20's pressure ulcer had been improving and on [DATE] the treatment to the area had changed due to suspected yeast near the wounds. *She indicated that she would have placed a resident on Enhanced Barrier Precautions (EBP) (the use of gown and gloves with high contact resident care activities) if the wound was draining. *There were no residents with draining wounds. *She stated that she worked with the infection control nurse when deciding when to initiate precautions. 5. Interview on [DATE] at 9:50 a.m. with RN/infection control nurse M regarding EBP revealed: *A resident would be placed on EBP if there was an indwelling medical device, a major wound or open skin area, or if the resident was a carrier of a multi-drug resistant organism (MDRO). *She stated the size of the wound and the ability to cover it would determine if EBP was needed. *She would have expected a resident with a stage II pressure ulcer for an extended period would need to be on EBP. 6. Review of resident 20's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *He had a [DATE] Brief Interview of Mental Status (BIMS) assessment score of 12 which indicated he was moderately cognitively impaired. *His [DATE] care plan included: -A [DATE] initial focus area that indicated he had a pressure ulcer to his left buttock and a pressure ulcer to his right buttock r/t [related to] decreased mobility. -A [DATE] initial focus area that indicated activities of daily living performance deficit. The intervention included: --He was not able to ambulate and required assistance to wheel his wheelchair. --He used a sit-to-stand lift to assist with his transfers. --He required substantial to maximum assistance to turn in bed, as well as lay down in the bed and sit up in the bed. --He required substantial to maximum assistance with putting on and taking off his clothes. --He required substantial to maximum assistance to use the toilet and perform his hygiene. *His [DATE] care plan did not include the need for EBP. *Weekly wound documentation indicated he had a stage II pressure ulcer. Review of the provider's ,d+[DATE] Enhanced Barrier Precaution policy revealed: *Use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status. *Residents shall remain on these precautions the duration of their stay or until the indwelling medical device is removed or wound is healed. *If a resident was placed on EBP It will be communicated by an orange sunflower placed on the resident's door. C. Based on observation, interview, and policy review the provider failed to ensure the alcohol-based hand sanitizers used throughout the facility were not expired. Findings include: 1. Observation on [DATE] from 8:54 a.m. to 9:05 a.m. of the alcohol-based hand sanitizers (ABHS) hanging on the walls outside the resident rooms in the second-floor hallway revealed: *There was a dispenser hanging outside each resident room below the nameplate. -Seven outdated on ,d+[DATE]. -One outdated on ,d+[DATE]. -Three outdated on ,d+[DATE]. -Three outdated on ,d+[DATE]. -One outdated on ,d+[DATE]. 2. Continued observation on [DATE] at 9:00 a.m. of the second floor revealed: *A large pump-style bottle of ABHS on a medication cart that was labeled as outdated on ,d+[DATE]. *There was no ABHS available in the resident rooms. 3. Observation on [DATE] between 9:01 a.m. and 9:03 am with registered nurse (RN) I revealed: *RN I cleaned her hands with the ABHS located on the medication cart then entered resident room [ROOM NUMBER]. *RN I used the wall-hanging hand sanitizer located outside of room [ROOM NUMBER] to clean her hands then entered resident room [ROOM NUMBER]. 4. Observation on [DATE] at 9:08 a.m. of the first floor revealed: *The wall-hanging dispenser outside room W101 that contained ABHS that was labeled with an outdate of ,d+[DATE]. *The wall-hanging dispenser outside a public bathroom adjacent to the conference room that contained ABHS that was labeled with an outdate of ,d+[DATE]. *The pump Purell ABHS located outside the chapel was labeled as outdated on ,d+[DATE]. 5. Interview on [DATE] at 10:53 a.m. with housekeeper F regarding the wall-mounted ABHS dispensers revealed: *Housekeepers were to check those ABHS dispensers and replace the ABHS when there was very little left in them. *Wall-mounted ABHS refills were provided by the maintenance department. *She had been working there five months and had not checked the expiration dates of the ABHS refills. 6. Interview on [DATE] at 9:45 a.m. with DON B regarding outdates revealed: *She expected the person who obtained the items from the basement that were not frequently used, was responsible for checking those items' outdatse. *She stated all other supplies were used frequently enough that they did not outdate. 7. Interview on [DATE] at 11:33 a.m. with RN/infection control nurse M regarding ABHS revealed that maintenance was responsible for checking these outdates because maintenance oversaw housekeeping. 8. Interview on [DATE] at 12:21 p.m. with maintenance regarding ABHS outdates revealed: *He was responsible for checking the outdates on the ABHS. *He stated the labels on the wall-hanging ABHS dispensers may have indicated that they were outdated but he refilled the dispensers from a large bottle of ABHS. *He indicated that the large bottles of ABHS on the medication cart were the type of bottles he used when he would refill the wall ABHS dispensers. *He presented a large bottle of ABHS that was consistent in appearance with the bottle on the medication cart. *The large bottle of ABHS he presented outdated on ,d+[DATE]. *He stated that there was no way to identify if the ABHS in the wall-hanging dispensers were outdated. *He stated that the wall-hanging dispensers were emptied so frequently that they would not outdate. *He indicated that if a bottle contained green colored ABHS that would mean it was the old alcohol-based hand sanitizer. *He confirmed that a bottle of green colored ABHS was in the conference room, and it outdated on ,d+[DATE]. Review of the providers ,d+[DATE] Hand Sanitizer policy revealed: *The Maintenance Director or his designee is responsible for refilling said dispensers as needed. *When the cartridges are refilled, the maintenance director or his designee checks the bulk container that is being used to refill the cartridges to ensure it is not outdated. D. Based on observation, interview, and policy review the provider failed to ensure proper infection control practices in the shower and whirlpool rooms include: *Shampoos, lotions, creams, and deoderants were not shared between residents to prevent cross-contamination during bathing. *Items stored in the whirlpool and shower rooms were not expired. Findings include: 1. Observation on [DATE] at 8:13 a.m. of the second-floor shower room revealed: *On the counter was a white plastic basket with an unidentified thick sticky yellow and brown substance that coated the caps of three razor caps and the bottom of the basket. *The basket contained the following: -A bottle of Dermasil lotion that was not labeled. -A bottle of baby shampoo that was not labeled. -An electric razor bag. -A rusty [NAME] pin. *The following items were in a tall wooden cabinet and were not labeled: -Two bottles of [NAME] body lotions. -Dove bar soap. -Five hair products. -Five scented body sprays. -Three baby powders. -Two sticks of deodorant. -A curling iron. -An electric razor with facial hairs in the blades. -Two combs. -Three nail clippers. -A bottle of Dermasil dry skin treatment. -A partial bottle of T-Gel shampoo. -A partial bottle of anti-dandruff shampoo. -A partial bottle of chlorhexidine gluconate 4% solution (a strong antiseptic skin cleanser). -Two unwrapped toothbrushes. -Two denture cups with surface discoloration. *The same tall wooden cabinet contained the following outdated items: -A partial box of alcohol wipes (,d+[DATE]). -A disposable bathing glove (,d+[DATE]). -A bottle of roll-on antiperspirant (,d+[DATE]). -A partially used bottle of rubbing alcohol (,d+[DATE]). -A tube of [NAME] toothpaste (,d+[DATE]). -A partial tube of Aloe Vest daily moisturizer (,d+[DATE]). -A partial tube of Cavilon barrier cream ([DATE]). -A partial bottle of Tena cleansing cream (,d+[DATE]). -A container of Sani-cloth disinfectant wipes (,d+[DATE]). *The following items were under the sink. -A container of Sani-wipes. -Three spray bottles of cleansers. -Three bottles of whirlpool disinfectant. -Two bottles of Oasis 499 HBV disinfectant. -A gallon container of shampoo. -A partial bottle of white distilled vinegar was outdated as of [DATE]. 2. Observation on [DATE] at 8:39 a.m. of the supply closet located behind the second-floor nurses' desk revealed: *A tall wooden cabinet contained thee following outdated resident supplies: -An unopened tube of Cavilon barrier cream ([DATE]). -A partial bottle of hydrogen peroxide 3% solution (,d+[DATE]). -A suction canister (,d+[DATE]). *The following items were under the sink: -A spray bottle labeled water for plants. -A spray bottle labeled Virex II256 disinfectant cleaner. -A white tub that contained an unidentified black and white flakey substance and a brown-substance. -A blue pail. 3. Observation on [DATE] at 8:47 a.m. of the second-floor housekeeping closet revealed: *Purell hand sanitizer for the wall dispensers that outdated on ,d+[DATE]. *A bottle of rubbing alcohol that outdated on ,d+[DATE]. 4. Observation on [DATE] at 10:15 a.m. in the east whirlpool room revealed: *The top of the whirlpool was coated in a layer of dust. *A purple 4-drawer plastic container was coated with a layer of dust. *On the counter next to the sink there were: -An electric razor that was not labeled. -One visibly soiled elastic hair tie. -A black fan with blades and a front blade guard that was coated with a thick layer of dust. -An open COVID-19 BinaxNOW test kit that contained three unopened COVID-19 tests that had an expiration date of [DATE]. *On the whirlpool shelf there were: -Six shampoo bottles that were not labeled. -One conditioner bottle that was not labeled. -A bottle of antidandruff shampoo that was not labeled or dated. *A sign posted on the wall stated, Please perform nail care with EVERY bath. *The following items were in the tall wooden cabinet and were not labeled: -An open container of powder that was not labeled. -Five open bottles of scented lotion that were not labeled. -13 open bottles of body spray that were not labeled. -Six open containers of stick deodorant that were not labeled. -An open tube of Aquaphor that was not labeled. -Three open tubes of barrier cream that were not labeled. -A tube of denture cream with an expiration date of [DATE]. *In that cabinet there was a broken plastic bin labeled Nail Care that contained: -A black elastic hair scrunchy with long gray hair in it. -Four wrapped [NAME] candies. -Three pairs of nail clippers. -Two hair picks. -A hairbrush containing a large amount of long grey hair. -A roll of white bandage gauze. -Three rolls of partially used medical tape. -An electric razor that contained gray facial hairs. -More than five hair combs. *Under the sink, in that whirlpool room, there was: -A urinal without a lid that was not labeled. -A denture cup without a lid that was not labeled. -A box containing six pairs of new compression stockings. -A metal bottle of Goof off adhesive remover. -A visibly soiled gray and white scrub brush. -Two blue scrub pads. -A red funnel. -A dry visibly soiled towel that was discolored a brown color. -An open whirlpool soap and body wash container. -A container labeled Body Fluid Cleaner that was discolored and rusted on the bottom. -Two one-gallon jugs of Whirlbath CitrusKleen. --One was open. -A half-full jug of Barbicide *Next to the whirlpool there were two uncovered white clothes basked lined with clear trash bags one contained: -Multiple visibly used gloves. -A visibly wet pull-on incontinent undergarment. -A tan-lined absorbent wound dressing with visible tan drainage on the padding. *The second uncovered white clothes basket contained multiple used washcloths and towels. *A sign above the sink that indicated instructions for enhanced barrier precautions with three residents listed by first name and last initial [residents 1, 35, and 31]. 6. Observation and interview on [DATE] at 10:37 a.m. with CNA G revealed: *CNA G was in resident 108's room, seated on his bed, and took resident 108's blood pressure. *She exited resident 108's room with a stethoscope, a pulse oximeter, and that blood pressure cuff. *Without sanitizing those items, she placed them on a metal cart in the hallway that stored contained yellow gowns, Sani wipes, and trash bags. *She indicated the equipment on that cart was shared for use with all the residents. *She confirmed she had used the blood pressure cuff, pulse oximeter, and stethoscope with the resident in room [ROOM NUMBER]. -She stated, They will need to be cleaned before they are used again and then exited the area without cleaning them. 7. Observation and interview on [DATE] at 10:45 a.m. with CNA H revealed: *She had worked as a bath aid a couple times a week for six years. *She had received additional training to be a bath aide. -That training included additional training with another bath aide. *She had used the north whirlpool room to complete baths that day. -She preferred to use the north whirlpool room but could use either whirlpool room on the first floor or the shower room on the second floor. *She stated any resident could be bathed or showered in any tub room. *She identified three residents (5, 9, and 56) who received showers in the shower room on the second floor. *She stated the shampoos, body washes, and conditioners on the whirlpool were used for all residents if they did not have a name on them. *She confirmed that the Aquaphor on the counter was used as a barrier cream and was used for multiple residents who received baths in that whirlpool room. *She confirmed that the electric razors were shared for residents who used the tub room and were to be cleaned with an alcohol wipe between residents and that the remaining facial hairs were to be dumped in the trash. *She stated that resident skin assessments were completed by the bath aide with each resident's bath or shower. -She would report to the nurse any new open skin areas or areas of concern she discovered during a resident's bath. --Areas of concern were to be reported to the nurse right away and the nurse would come to observe them at that time. *She stated when there was a new open skin area or area of concern, she would document that in the electronic medical record system under the skin assessment at the end of the day. -If there were no new areas of concern she would not need to document. *She confirmed the only areas reported to the nurse were new areas. -Skin areas that the nurse already knew about were already being looked at by the nurse and were not assessed during the resient's bath time. -She confirmed that she did not check for expiration dates on products she used in the whirlpool room. 8. Interview on [DATE] at 11:33 a.m. with RN/infection control nurse M regarding the tub and shower rooms revealed: *She stated that there was no risk of cross contamination of the shared products once the product was dispensed from the bottle. Review of the provider's ,d+[DATE] Disinfection and Cleaning of Electric Razors policy revealed: *Electric razors must be cleaned and disinfected after use. This includes shared/community razors provided by the facility and resident's personal razors. *After each use the head is disassembled from the razor base. Excess whiskers, skin and debris are brushed away with a razor cleaning brush. *Razor heads should be rinsed with warm water and dried. *The entire razor including the razor head is wiped down with a EPA registered disinfection wipe. *Daily razor heads are disassembled, brushed off, rinsed with warm water and placed in a container of 70% isopropyl alcohol for a minimum of 10 minutes.

Based on interview, record review, and policy review, the provider failed to effectively implement and follow their policy related to grievances for three of three sampled residents (18, 19, and 24) with unresolved reported concerns. They failed to ensure: *Residents were informed and information was available on how to file a grievance. *All grievances were documented and included the date received, summary statement of resident's grievance, steps taken to investigate and keep resident informed of progress, summary of pertinent findings or conclusion, any necessary corrective action, and date the grievance was resolved. *Documentation of grievances and their resolution was maintained. *Resident council notification of group-reported grievance progress and resolution. Findings include: 1. Interview on 12/17/24 at 9:32 a.m. with resident 19 in his room revealed he: *Reported he had requested that his bed be taken out of his room because he slept in his recliner and wanted more room to use his electric wheelchair. *Stated he had asked the maintenance man and anyone who will listen about it and it still hasn't been done. *Was not sure how to file a grievance regarding his unresolved request to have his bed removed from his room. 2. Interview on 12/17/24 at 3:08 p.m. with resident 24 revealed: *She sometimes waited 30 to 45 minutes in the dining room for her meal. -The wait for supper was the worst. *It was difficult for her to wait that long because she had back pain and her legs would go numb. *She had reported her concern at the resident council meeting a couple of weeks ago. *She was told that there was new staff in the dietary department but nothing had improved. 3. Interview with the residents during a resident group meeting on 12/18/24 at 1:00 p.m. revealed: *The resident council met monthly. *Eight residents attended the group meeting who regularly attended the resident council meetings. *They reported that they did not know how to file grievances. -Each department was to address reported concerns related to that specific department. -They verbally expressed their concerns to those department staff members. -If those staff were not at the resident council meeting, activities coordinator (AC) C would pass on their concerns. *There was no follow-up with the residents when they brought their concerns to each department outside of the resident council meeting. *Concerns about the food and long wait times for meal service had been brought up at resident council meeting. -Concerns were discussed verbally, and the residents stated there was no follow-up at the next meeting regarding those concerns. --Resident 3 stated she seeks out the answers because she knew where to find the department heads. -Resident 18 stated that she felt like her table was always served last and that she had told the cook Multiple times, but she felt that there was no communication in that department. -There had been turnover in the dietary department and previous concerns were not followed up on. --One resident stated, We have to start all over. -A resident shared a concern about meals and vegetables being repeated and that they lacked variety. *Resident 17 confirmed their concerns were conveyed verbally and that there was no form they filled out when they had a complaint or concern. 4. Interview on 12/19/24 at 10:16 a.m. with AC C revealed she: *Organized the resident council meetings, took the minutes, and emailed the minutes to each department head after the meeting. *Confirmed residents often shared concerns about the long wait times and the food during resident council meetings. *Stated that most concerns were addressed by that department's staff that attended the resident council meeting. -If staff from those departments of expressed concern were not in attendance, social services coordinator (SSC) J would email those concerns to the applicable department head. *Had not included the resident concerns in the resident council minutes. *Had not assisted a resident in filing a grievance. 5. Interview and review of emails on 12/19/24 at 10:32 a.m. with SSC J revealed: *She was the grievance coordinator. *She had worked there for three years. *She was aware of one resident grievance since she had worked there and that was handled by her and administrator (ADMIN) A. *There was no specific form to fill out when a resident had a complaint, concern, or a grievance. *Resident concerns were brought to her by the resident, the families, and facility staff in person, by email, or over the phone. -Sometimes she received a note that a specific resident wanted to talk to her. -She did not have a specific documented tracking system of resident concerns. --Some were documented in her emails, or the resident's electronic medical record (EMR), but most were addressed verbally. *She would notify each department involved if a resident had a concern with that department. -This was done verbally or by email. *Only very serious concerns were brought to the administrator if they could not be resolved. *She was aware of the resident's concerns regarding the food and long wait times in the dining room. -She had emailed the dietary department about concerns related to the food and long wait times on 11/15/24. --Review of that email confirmed that she wrote, .several residents tell me the meal was not good last night and it's become a regular thing. They are also telling me they are being served later and later and later . several didn't wasn't o go because they weren't served until well after 6pm. *She was aware that resident 19 had requested to have his bed removed. -She confirmed she had documented his request in the EMR during his care conference held on 10/23/24. -She stated she had emailed maintenance about his request several times and that the last email she sent was 12/10/24. --Review of that email confirmed she wrote, .he wants the bed taken out as he refuses to sleep in it. -She was not sure if that situation had been resolved. 6. Interview on 12/19/24 at 11:20 a.m. with ADMIN A regarding resident concerns and the grievance process revealed: *She considered a grievance to be very serious in nature concerning abuse, neglect, or mistreatment. *She expected issues like missing items, food complaints, and resident concerns to be handled immediately. -That was a verbal process. --She confirmed they did not have a specific form to be filled out, but said that residents could write a note and slip it under the door if they wanted to. *Department heads would learn of resident concerns at resident council meetings, or they would be emailed concerns after the meeting. *She confirmed that SSC J was the grievance official. *She stated, Residents were told [SSC J] was their person if they had concerns or complaints. *She was not aware of the process for tracking or following up with resident concerns as this was handled by SSD J. *She stated there were no grievances available to be reviewed as there had been no grievances filed in the past three years because nothing rose to the level of a grievance. 7. Review of the provider's Resident Grievance: 2024 sheet revealed: *There were nine concerns listed between 4/4/24 and 11/1/24. -Two of those concerns had no documented follow-up provided. *There was one concern regarding the food made by resident 1 on 7/2/24. Review of the provider's Resident Council minutes from July 2024 through December 2024 revealed: *Each month's meeting minutes included: -The date and time the meeting was held. -Motions to open and close the meetings. -The number of residents in attendance. -A statement that the previous month's council notes were reviewed. -Names of staff members present. -Old Business: NONE - New Business: included: --A resident's right was reviewed each month. -Special things residents have interest in doing throughout the month of -The dessert of the month. *The September minutes revealed: Residents want more fresh fruit for meals. They would like watermelon, cantaloupe, and strawberries that are ready to eat. They also stated the scalloped potatoes have no flavor. -There was no documented follow-up of that concern for October, November, or December of 2024. Review of the provider's revised July 2003 Resident Council policy revealed: *The resident council is an open meeting opportunity for residents to let their voices be heard. *Time is spent covering areas of concern including nursing care, dietary services, activities available, general comfort, etc . *No definitions or guidance was provided regarding the difference between a concern and a grievance. Review of the provider's May 2019 Resident Grievances policy revealed: *Responsible Party: Social Services Coordinator. *It is the policy of the [NAME] Memorial Home to provide a grievance procedure for any resident who feels they have a grievance. *If a resident has a grievance, the following procedure will be used: (This is the exact language from the resident policy manual). *See the review of the provider's 6/1/21 [NAME] Memorial Home Resident Policy Manual below. Review of the provider's 6/1/21 [NAME] Memorial Home Resident Policy Manual revealed: *Grievances. If you have a grievance, please use the following procedure. Each grievance will be recognized and resolved within a time frame as indicated within the procedure. This procedure is in no way designated to discourage the registration of a grievance. A grievance may be related to treatment provided or treatment not provided, the behavior of other residents, the infringement of the residence rights, or other areas of treatment or care. *If you have a grievance, contact the Administrator or the Social Service Coordinator. The grievance can be oral or in writing. You have a right to engage and be represented by your own legal counsel. If the grievance has not been resolved with a meeting of the resident/responsible party/appointed representative within 5 days, the grievance should be given to the Administrator. At this point the grievance will need to be in writing to assure that the problem remains the same as what was presented at the on-set. The Administrator may ask that the resident or appointed representative meet with him/her to discuss the problem. If the problem is not solved within 10 days, the grievance can be registered with the governing board of the nursing home. This must be in writing. Or, you may contact the State Ombudsman, telephone # [redacted], or other client advocate. Their name and addresses can be found elsewhere in this manual. *The telephone number provided in that manual for the States Ombudsman was not the correct telephone number. Review of the provider's resident rights document A Matter of Rights, in their Admission Handbook revealed: *Grievances. You have the right to speak up about grievances and have them responded to promptly and fairly. * All residents have the right: -[T]o voice concerns and complaints, spoken, in writing, or anonymously, about the treatment and care we provide or the behavior of other residents. -[T]o information on how to file a grievance or complaint. -[T]o timely response by us in which we agree to consider the issue or issues you raise and to act upon them as may be appropriate. -[T]o be free from any pressure intended to discourage you from voicing your concerns or complaints. *Residents have the right to voice grievances without fear of discrimination or reprisal for doing so. *A grievance of a resident or someone acting on behalf of a resident should be directed to our administrator, to an appropriate department head, or to a designated grievance contact person. It will be helpful if you include: your name, the date, how to reach you, if you are not the resident, details of the situation or event. * Please be as specific as possible in describing the what, where, when, and who involved in your concern or complaint. *No definitions or guidance was provided regarding the difference between a concern and a grievance.

Based on observation, interview, record review, and policy review the provider failed to ensure the oxygen concentrator filter was clean and the nasal cannula tubing was changed weekly, for one of three sampled residents (4) who received oxygen from four oxygen concentrators that were separately located throughout the facility. Findings include: 1. Observation and interview on 12/17/24 at 8:57 a.m. with resident 4 in her room revealed: *She was able to say hello but was unable to answer questions about her oxygen. *She wore an oxygen nasal cannula (flexible tubing with prongs that deliver oxygen into the nose) connected to an oxygen concentrator beside her chair. *The nasal cannula connected to that oxygen concentrator was not labeled or dated. *The filter on the back of that oxygen concentrator had visible gray dust. 2. Observation on 12/17/24 at 11:18 am in the sunroom revealed: *An oxygen concentrator located in the back corner labeled TMH#7. *Attached to that concentrator was a plastic bag labeled with resident 4's first name and last initial, and had date issued 10/20, and O2 tube written on it. -Inside that bag was a nasal cannula with a piece of tape attached to it that was dated 10/6. 3. Observation on 12/17/24 at 12:10 p.m. of resident 4 in the dining room revealed she wore an oxygen nasal cannula connected to an oxygen concentrator labeled #8 which was located under the window behind her chair. 4. Observation on 12/17/24 at 3:03 p.m. of oxygen concentrator #8 located in the dining room revealed a plastic bag labeled with resident 4's initials and dated 12/17/24 was attached to that concentrator. -Inside that bag was a nasal cannula with a piece of tape attached to it that was dated 11/17/24. 5. Interview and review of the treatment administration record (TAR) on 12/19/24 at 9:53 a.m. with director of nursing (DON) B regarding resident 4's oxygen revealed: *She confirmed that resident 4 used oxygen continuously and there were four separate concentrators that were located in her room, the sunroom, the chapel, and the dining room for her to use. *Those concentrators were only used by resident 4 because she was the only resident who required oxygen outside of their room at that time. *Portable oxygen tanks were only used when a resident went out of the facility or if their oxygen levels dropped too quickly to be moved from one concentrator to another. -Resident 4 had not required a portable oxygen tank. *When a resident was started on oxygen an order was to be added to the TAR to change the nasal cannulas weekly. *She expected that all nasal cannulas would be changed and documented on Sunday evenings by the nurse who worked the night shift. *That nurse would know which nasal cannulas needed to be changed because it would be indicated on the residents' TAR in the electronic medical record (EMR). *Resident 4's TAR did not include to change the nasal cannulas or the location of the concentrators used by resident 4. -She stated, It looks like hers may have been missed. 6. Review of resident 4's electronic medical record revealed: *Her Brief Interview for Mental Status (BIMS) assessment score was 8, which indicated she was moderately cognitively impaired. *A 10/10/24 physician's order reflected oxygen at 1 to 5 liters per nasal cannula four times a day to keep oxygen greater than 90 percent. *A 9/27/24 physician's order to Check O2 sat [saturation] qid [four times a day], Document Oxygen if in use. *Resident 4's MAR and TAR did not include to change the nasal cannulas. -There was no indication when the nasal cannula had last been changed on any of the four concentrators used by resident 4. Review of the provider's revised May 2024 Oxygen Administration Policy revealed: *Tieszen Memorial Home's standard of practice for nursing staff for oxygen administration. *Infection Control: .Oxygen mask, nasal cannula and equipment storage bag will be changed weekly, labeled and dated.

Based on observation, record review, interview, and policy review, the provider failed to: *Adequately assess, reassess, and monitor for resident changes in cognition and safety awareness for self and others for one of eight sampled resident (19) who used a power wheelchair for mobility. *Obtain a physician's order for use with cognitive ability acknowledged for that resident. Findings include: 1. Observation on 12/17/24 at 12:18 p.m. of resident 19 while he exited the dining room while in his power wheelchair revealed he bumped into resident 210's chair, who was seated at the table. 2. Observation on 12/19/24 at 10:46 a.m. of resident 19 while in his power wheelchair revealed he hit the couch in the hallway seating area near the chapel with his power wheelchair and moved that couch by several inches. 3. Review of resident 19's paper chart and electronic medical record revealed: *He was admitted on [DATE]. *His diagnosis included *He received an occupational therapy (OT) evaluation for the initial use of the power wheelchair on 6/21/23 and was discharged from OT on 7/5/23. -That evaluation indicated: --Pt [patient] has demo [demonstrated] independent and safe operation of his power wc [wheelchair] within the SNF [skilled nursing facility] and outside the SNF/ALF [assisted living facility]. --His safety awareness was Intact. --His decision-making ability for routine activities was independent. *His 7/16/24 Brief Interview for Mental Status (BIMS) assessment score was 13, which indicated he was cognitively intact. *His 10/15/24 BIMS assessment score was 9, which indicated he was moderately cognitively impaired. *An 11/22/24 progress note (PN) indicated, . resident will make a point to follow the [floor cleaning] machine multiple times throughout the duration of cleaning. Most times, resident passes the machine extremely close where maintenance has had to move out of resident's way. Other times when resident passes the machine the motorized wheelchair with [would] get hooked on the floor machines wheel resulting in maintenance having to stop to wait until resident becomes unhooked from machine. Resident's wheelchair is swung around to the side once wheels are hooked and that is when resident is able to unhook himself after [the cleaning] machine is stopped. Per staff, this happens often when floor are being washed by motorized machine. At this point, no injuries have been conducted by staff or resident. Resident was spoken to by writer regarding safety and proper use of his electric wheelchair, resident acknowledged writer with a head nod. Will continue to monitor PRN [as needed]. Social services verbally notified. *An 11/29/24 PN indicated, Resident has been riding in electric wheelchair most of the day and getting close to other staff, residents, and visitors when passing by. Writer asked resident to be mindful of where he is driving and make sure he is not getting too close or running into people. Resident made a few remarks to rider about not looking out for others and that he drives just fine. Later resident came to writer and mentioned how many people he had ran over today with his wheelchair. Writer repeated for resident to be mindful of others and cautious about getting too close. Writer explained poor decision making could impact his ability to keep his electric wheelchair if he does not practice safe driving. Resident told writer no and drove wheelchair away. *An 11/30/24 PN indicated, Resident yelling out at staff about getting other residents, Out of his way and demanding that he gets cared for prior to other residents. *A 12/2/24 PN indicated, Resident was in electric wheelchair and got very close to one of our staff members. Staff made a comment about resident getting too close and resident laughed at staff and continued riding around in wheelchair. *A 12/13/24 PN indicated, Secretary reported that resident was driving his electric wheelchair around the entry way this morning when he ran into the face mask dispenser. Resident also continues to get very close to writer and other staff in the hallway when driving around. Rude to staff when they mention he is getting too close. *There was no physician order for resident 19's use of the power wheelchair. 4. Interview on 12/19/24 at 9:33 a.m. with physical therapy assistant P revealed: *They communicated with nursing through email. *OT evaluated residents for use of their ability to safely use their power wheelchairs. -Residents were to be reassessed for safe operation of power wheelchairs annually or if there was an incident that involved their unsafe driving of the power wheelchair. *She confirmed resident 19 was evaluated for use of his power wheelchair in June 2023. *She was not aware of resident 19's unsafe power wheelchair driving incidents. -She reviewed her emails and stated she had not received any emails regarding resident 19. *Resident 19 had not been reassessed by therapy for his ability to safely operate his power wheelchair since his June 2023 evaluation. 5. Interview 12/19/24 at 10:09 a.m. with secretary E regarding resident 19 driving his power wheelchair revealed she: *Reported a concern regarding resident 19 having been observed getting too close to other residents and staff while driving his power wheelchair. *Was aware resident 19 had recently hit the mask stand in the entryway with his power wheelchair. 6. Interview on 12/19/24 at 1:16 PM with anonymous registered nurse O regarding resident 19 driving his power wheelchair revealed she: *Had concerns about resident 19's safety while driving his power wheelchair. -Stated, He gets too close, and He tries to be funny and one of these days it's not going to be funny. *Documented those concerns in the EMR and reported them to the director of nursing. *Confirmed that residents were evaluated by OT when they had a power chair they wanted to use. -She did not know how often the resident was reassessed by OT. Review of the provider's revised June 2023 Electronic Methods of Transportation (Electric Scooters, Electric Wheelchairs, etc) Policy revealed: *Any resident using an electric transportation device must be safe in the operation of the device . *Any resident who wishes to use an electric transportation device must have a physician's order to do so. *If at any time, a resident is observed to be operating their electronic transportation device in an unsafe manner, the licensed nurse will be notified. In order for the resident to continue to operate the device, an evaluation will need to be completed by the therapy department to ensure the resident is safe to use the device.

Based on record review, interview, and policy review the provider failed to ensure two of two resident-to-resident altercations had been reported to the South Dakota Department of Health (SD DOH) in the designated time frame for one of one sampled resident (6). Findings include: 1. Review of resident 6's medical record revealed: *Diagnoses of the following: Sensorineural hearing loss, bilateral, major depressive disorder, epilepsy, and chronic pain. *Her most recent Brief Interview of Mental Status (BIMS) examination score was 14 indicating she was cognitively intact. *The care plan updated on 7/19/23 for physically aggressive behavior: -Do not argue with the resident. -Refer to Social Services for evaluation. -Reinforce unacceptability of verbal abuse. -Remove from public area when behavior was disruptive and unacceptable. -Monitor and document target behaviors. -Assist in selection of appropriate coping mechanisms. Review of resident 6's nursing progress notes on the following dates revealed: *7/9/23 6:08 p.m. resident [resident 6 name] slapped resident [resident 10 name] when resident B exited the bathroom because she was taking to long and [resident 6 name] needed to use the bathroom. *Registered Nurse (RN) C, unusual occurrence completed and social services notified. *7/10/23 9:31 a.m. unusual report due to resident hitting roommate. Communicated with resident and explained not to use violence. Talk to a nurse or myself when frustrated. social services E. *7/19/23 2:34 p.m. Resident hit another resident in the face. Witnessed by another resident's family member who told [name] Activity Assistant, what happened. Watched video on CCTV with [administrative assistant name] and [resident 6 name] did hit another resident on the face. When I asked her why, she communicated with me that she did not and it was a lie. A report was made to the charge nurse. social services E. Interview on 8/22/23 at 3:12 p.m. with certified nursing assistant (CNA) H in regards to resident to resident incidents revealed she would: *Separate the individuals. *Get another employee to supervise for the safety of the residents. *Notify the charge nurse to investigate and document the situation. Interview on 8/23/23 at 8:56 a.m. with licensed practical nurse (LPN) F in regards to resident to resident incidents revealed she would: *Separate the individual. *Assess for injuries. *Notify the director of nursing (DON) and social services. *Document in the chart and fill out an incident report. *Report it to the state. Interview on 8/23/23 at 2:01 p.m. with social services E revealed she: Was aware of the two incidents with resident 6 in July 2023. Was not aware that resident to resident altercations should have been reported to the SD DOH. Had set up a behavior counseling appointment for resident 6 after the incident occurred on 7/19/23. Interview on 8/23/23 2:46 p.m. with DON B in regard to resident to resident incident reporting revealed: *Staff completed an incident report and then it would have been forwarded to herself or social services. *Social Services usually reviewed the resident to resident and elopement incidents. *Nursing reviewed the falls and falls with injury. *Incidents were reviewed and discussed at the unusual occurrence meeting. *She was not aware the incidents for resident 6 had not been reported to SD DOH. * Her expectation was resident to resident incidents should have been reported. Review of the provider's undated policy/procedure for resident abuse and neglect revealed: *The Corporation, in accordance with the Federal Rules, will not tolerate Resident abuse or Neglect. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, or staff of other agencies serving the individual, family members or legal guardians, friends, or any other individuals. The policy is clarified as follows: . Any act that is suspicious of abuse will be reported to the South Dakota Department of health within 24 hours.

Based on observation, interview, and policy review, the provider failed to ensure proper hand hygiene and glove use for food preparation and meal service during three of three meal services by two cooks (H and I). Findings include: 1. Observation on 5/24/22 from 8:53 a.m. to 9:11 a.m. revealed cook H: *Wore the same gloves while she did the noon meal prep. *Used her gloves to pick up multiple kitchen utensils while she was preparing the roast beef for the residents with diets that called for ground meat. *Did not change her gloves or perform hand hygiene until after she had finished with the noon meal preparation. *Then took her gloves off and washed her hands. 2. Observation on 5/24/22 from 11:11 a.m. to 11:24 a.m. revealed cook I: *Did not wash his hands prior to putting his gloves on. *Used a marker to label lids and got a squirt bottle of thickener from the cupboard. *Filled cups with milk, water, supplements and thickener, stirring them with a plastic spoon. *Put lids on the cups while wearing the same gloves. *Took his gloves off and put them in the garbage, he did not wash his hands. Observation on 5/24/22 from 11:25 a.m. to 11:40 a.m. revealed: *Cook H was wearing a glove on her left hand to serve the noon meal. She: -Started serving lunch by picking up plates and dietary cards with her gloved hand. -Touched the counter and trays with her gloved hand. -Searched through the plate covers and handed one to an aide through the serving window. -Went back to serving the meal with the same glove on her left hand. -Put a piece of bread on the plate with a tongs and re-positioned the bread on the plate with her gloved hand. -Finished serving lunch with the same glove on her left hand. -Put bread and roast beef in a Styrofoam container for a room tray and again re-positioned the bread with her gloved hand. 3. Observation on 5/24/22 at 4:53 p.m. revealed: *Cook I was wearing gloves to serve the evening meal. He: -Touched his face mask. -Got tongs out of a drawer. -Grabbed a plate with his gloves on and began serving the evening meal. Interview on 5/24/22 at 4:58 p.m. with cook I revealed he: *Had been educated about hand washing and glove use. *Stated, If I leave the steam table, I take my gloves off and wash my hands before I put new gloves on to continue serving the meal. Interview on 5/25/22 at 9:49 a.m. with registered dietitian (RD) G and dietary manager F about glove use in the kitchen revealed: *They both agreed that: -Kitchen staff should not use gloves while serving meals due to the possibility of cross contamination. -Staff should use tongs and other utensils to plate the meals. -Staff should wash their hands before putting gloves on and between glove use. *RD G stated they had just talked about it at the last education session we had done for dietary staff. The glove use policy was requested and the policy that was received from Administrator A was titled, Bare Hand Contact with Food and Use of Plastic Gloves. Review of the policy, taken from the 2013 [NAME] & Associates, Inc. policy & procedure manual 4-9 revealed: 3. Gloved hands are considered a food contact surface that can get contaminated or soiled. If used, single use gloves shall be used for only one task (such as working with ready-to-eat food or with raw animal food), used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. 4. Hands are to be washed when entering the kitchen and before putting on the single-use gloves . 6. Gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed . 7. Wash hands after removing gloves.

Based on observation, interview, record review, and policy review, the provider failed to ensure the use of Tabs chair and bed alarms (position change alarms) was based on assessed assessment for use, physician acknowledgement and order, evaluation for effectiveness or least restrictive measure, and appropriately care planned for five of five sampled residents (26, 31, 33, 35, 47). Findings include: 1. Observations and interviews with resident 47 revealed: *On 5/24/22 at 11:29 a.m.: -She was seated in a lounge chair in front of the window in her shared room facing the hallway. -A Tabs alarm cord was clipped to her recliner that was by the wall on her half of the shared room. *On 5/24/22 at 4:35 p.m.: -She was in her lounge chair in her room with the overbed table angled away in front of her. -She was leaning forward to reach a pencil on the floor and replied that she could not reach it. -The alarm cord was clipped to the back of her shirt and stretched out as she reached for the pencil. -When asked what was clipped to her shirt, she explained the alarm cord was to call staff and reported the Tabs alarm was moved to her bed when she was there. *On 5/25/22 at 3:41 p.m.: -She was seated as before with the alarm cord clipped to the back of her shirt and working on a word search puzzle. -She confirmed she had a serious injury from a fall and was still sore from it. -A grabber reacher tool was not visible in her room. When asked, she reported she could use a grabber reacher tool like her roommate had for when she dropped pencils on the floor. Review of the 4/25/22 final fall investigation report submitted by the provider to the South Dakota Department of Health revealed: *The fall occurred on 4/23/22 at 4:45 p.m. in the resident's room. *The resident reported her pencil had fallen and she was attempting to pick it up. *The conclusion of the investigation stated: -She enjoys independence in the facility with regards to ambulation. -Cue cards and signs were to be provided to remind her to use her call light and walker. -A red star was posted outside her door to indicate resident had fallen--notifies staff to check on resident to ensure safety. -An action taken by facility was to review and revise the care plan. A progress note dated 4/29/22 at 3:03 a.m., 12 hours after resident 47 returned from the hospital, revealed: *She was experiencing intermittent confusion forgetfulness and has been trying to self-transfer. *An alarm was put in place to ensure resident safety and it was set off multiple times when she attempted to transfer. *In leu [sic] of this, TABS alarm will be kept on resident as necessary fall precaution. Review of the 5/5/22 significant change minimum data set (MDS) assessment for resident 47 revealed: *She had mild impairment recalling current date and needed cues. *She needed weight bearing support to transfer between surfaces and move about with a walker or wheelchair. *Her prior functioning for mobility had been independent with her walker. *Bed and chair alarm restraints were coded as used daily. *The care area assessment for falls noted: -She had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . -She was able to stabilize her balance by herself with her four-wheel walker. -She is impulsive and attmepts [sic] to self transfers so a tabs alarm was placed. The provider was requested during the survey to provide copies of the Tabs alarm assessment including the medical symptom being treated. However, only fall risk assessments were provided, which revealed: *The 5/9/22 assessment, the score was 13 compared to a score of 8 on the 4/13/22 assessment. A score above 10 represents HIGH RISK. *The parameter (factors) that caused the increased score included the recent fall, increased incontinence, and the balance problem. The active care plan with a start date of 7/2/19 for resident 47 regarding risk for falls revealed: *The risk was not revised to address the recent fall with injury but remained as related to medications with fall-related side effects and bilateral knee pain. *The only new intervention added on 4/29/22 after her recent fall was Tabs Alarm on at all times. *An intervention started on 7/2/19 to keep items she frequently uses within easy reach to avoid fall was not revised to address reaching for pencils that had fallen on the floor. *An intervention dated 1/15/20 was Falling Star Program without any further instructions. Review of the physician orders revealed no order for the use of [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on 5/25/22 at 3:42 p.m. with registered nurse (RN) E revealed she: *Confirmed the serious fall occurred but was not aware of the factors that contributed to the fall. *Did not know if a reacher tool had been offered to help resident 47 pick-up items that dropped on the floor. Interview on 5/25/22 at 3:13 p.m. with director of nursing (DON) B revealed, when asked about the Tabs alarms and assessment for the indication of use, she replied, If they're not allowed we'll take them all off, I guess. If we use them, there's no way to defend the use so I guess we'll remove all of them. 2. Observation of resident 33 on 5/24/22 at 11:53 a.m. in the Memory Care Unit dining room revealed she was seated in a wheelchair with cord attached to the back of her sweatshirt fastened to a Tabs alarm. Review of resident 33's medical record revealed: *She was admitted on [DATE]. *Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] *Her 4/12/22 quarterly MDS assessment indicated a bed alarm/chair alarm was used daily. *Her current care plan included a 7/23/21 start date for the following interventions: -Uses a Tab alarm while in the chair. -Uses a Tab alarm while in bed. *No physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] *No medical conditions were identified that warranted the use of the Tabs alarms. *No assessment for the Tabs alarms that evaluated the appropriateness of the devices and whether those devices met the definition of a physical restraint. *No assessment for the Tabs alarms that evaluated the psychosocial impact of the devices on the resident. *No ongoing re-evaluation for the need of the Tabs alarms and the effectiveness of those devices in treating the medical conditions identified. Interview on 5/26/22 at 9:14 a.m. with social services designee J revealed she: *Was not involved in the process of using Tabs alarms but was aware that the alarms were discussed with the resident's representative and though approval was obtained for their use. *Had not evaluated the impact those devices had on the resident's psychosocial well-being. Interview on 5/26/22 at 10:22 a.m. with RN C revealed: *Their policy indicated no physician order was needed. *There were no physician orders for Tabs alarms. *There were no assessments conducted on Tabs alarms. 3. Observation and interview on 5/24/22 at 8:35 a.m. with resident 35 revealed she: *Was sitting in her wheelchair with a Tabs alarm attached to her shirt. *Required help with transferring from bed to her wheelchair. *Had fallen in the past. *Said it feels like something is pulling when she was attached to the Tabs alarm. *Observation on 5/24/22 at 12:00 p.m. revealed she had been eating lunch in the dining room with a Tabs alarm attached to her and the wheelchair. *Observation on 5/25/22 at 11:00 a.m. revealed she was sitting in a wheelchair in her room with a Tabs alarm attached. Interview and record review on 5/25/22 at 2:42 p.m. with RN C regarding Tabs alarm use revealed: *She was not aware that resident 35 had a Tabs alarm, was unsure when the alarm was placed on resident 35, but confirmed that nursing staff initiated the use of alarms. *Resident 35 had been self-transferring and had fallen in the past. *She agreed that resident 35's care plan had not identified the use of a Tabs alarm for an intervention and there were no nurses' progress note found indicating when and why the Tabs alarm was initiated. *The end of shift nursing report had not provided any information about the use of the Tabs alarm. Interview on 5/25/22 at 2:45 p.m. with DON B regarding Tabs alarms revealed she had not been aware that resident 35 had a Tabs alarm. Interview on 5/25/22 at 2:52 p.m. with MDS coordinator D regarding Tabs alarms revealed: *She was not aware about the use of the Tabs alarm for resident 35 and agreed the MDS had not been appropriately coded for an alarm use. agreed that the MDS had not been coded for alarm usage for resident 35. *She had not known about a Tabs alarm used on resident 35 prior to the interview. *She usually had a list of residents identified using Tabs alarms but had no list. Review of resident 35's care plan dated 1/29/21 revealed: *She was identified as being in the Falling Star Program with a star placed outside of resident's door indicating fall risk. *There was no mention of the use of a Tabs alarm while in her wheelchair. 4. Observation and interview on 5/24/22 at 2:24 p.m. with resident 26 revealed she: *Had been laying in her bed with a Tabs alarm attached to her shirt. *Stated, I have only fallen once since I moved in. On 5/24/22 at 3:22 p.m., while at the nurse's station across the hall from resident 26's room, this surveyor heard a beeping noise come from her room. Upon entering her room, I observed her sitting on the side of her bed with the Tabs alarm sounding, and she stated, I want to move to my recliner. Interview on 5/25/22 at 3:10 p.m. with RN C revealed she: *Was not aware that resident 26 had a Tabs alarm. *Did not think there was any reason for her to have an alarm. *Was not sure who put it on her. *Had not done a safety alarm assessment. *Stated, There was no reason for her to have one, she had one fall since coming to the facility and that was shortly after her husband passed away. Observation on 5/25/22 at 4:54 p.m. revealed resident 26 was in her room sitting in her wheelchair with a Tabs alarm attached to her shirt. She was reaching for the doorknob and the alarm sounded. She asked, Is it time to go to supper? Follow-up interview on 5/26/22 at 9:27 a.m. with charge nurse C regarding resident 26 and the alarm she stated, We are leaving the Tabs alarm on her because she is a fall risk, we will do an assessment and add it to her care plan. Review of resident 26's care plan revealed there was no documentation for a Tabs alarm. 5. Observation on 5/24/22 at 9:49 a.m. of resident 31 in her room revealed: *She self-transferred from her recliner to her bed. *RN K then entered the room to assist resident 31 from her bed to her wheelchair and clipped the Tabs alarm to the back of her sweater before exiting the room. Interview on 5/24/22 at 11:15 a.m. with RN K revealed: *The Tabs alarm was placed on resident 31 for fall precautions. *Resident 31's baseline mood state was anxious. *She frequently removed the Tabs alarm from her shirt and would get up by herself without asking for assistance. Review of resident 31's record revealed: *Over the past 13 months from 4/30/21 through 5/25/22, she had 29 falls recorded on the Resident Fall Tracking Log. *[Provider's name] Fall Report from 12/20/21 indicated, Resident took TABS [Tabs alarm] off. -No Tabs alarm assessment was found anywhere in resident 31's record. -The provider's standard fall report indicated that a Tabs alarm was an acceptable immediate intervention after a resident fell . *Resident 31's care plan identified a 9/16/21 intervention for Tabs monitor on at all times. Monitor/Check every 30 minutes and record. *Section P of her 4/11/22 MDS indicated bed and chair alarms were used daily. *On 4/13/22, her Fall Risk Assessment score was 19, indicating she was at a high risk for falls. Review of the provider's fall risk assessment policy and procedures, revised 11/2007, revealed the assessment was completed with each MDS and reviewed during the resident's care conference if the resident had several falls. Review of the provider's safety alarm policy and procedures, dated 9/2015, specified: -The policy is to outline the procedure for use of alarm devices used to alert staff attention to a resident in an unsafe situation. -It is the policy of the [provider's name] to provide alternatives for monitoring residents that are a fall risk that are less restrictive than a restraint. -Resident alarm systems may be used at the discretion of the licensed nurse or upon physician orders for any resident considered unsafe to transfer independently and lacking the cognitive ability to wait for assistance. -A physician's order is not required to initiate and use alarm. -Before the alarm is installed the nursing staff will explain the alarm to the resident and also contact the resident's responsible party so they understand why they have it. -If the resident's condition changes the licensed nurse may discontinue the alarm unless ordered by physician.

Based on observation, interview, label review, and policy review, the provider failed to ensure infection control practices and techniques were maintained for: *Cleaning and disinfecting two of two glucometers by one of one registered nurse (RN) (M). *Handwashing and glove use during two of two randomly sampled residents (26 and 60) medication administration by one of one RN (M). *Handwashing and glove use by one of one RN (M) during one of one sampled resident's (16) wound care. *Handwashing and glove use for one of one sampled resident's (21) personal care by two of two nursing assistants (NA) (K and L) and one of one certified nursing assistant (CNA) (M). Findings include: 1. Observation and interview on 10/28/19 at 5:01 p.m. in resident 21's room with CNA J and NAs K and L revealed: *NA K was in his room. *CNA J: -Entered the room and without performing hand hygiene put on gloves. -Loosened the resident's brief to check for incontinence. -Walked over to his dresser and began to open the drawers and took out an incontinent brief. *NA L entered the room and washed her hands. *CNA J left the room. *Without gloves on NAs K and L placed the Hoyer lift sling under him. -NA K stated I think we need someone in here with us. -NA K left the room without performing hand hygiene. *CNA N and NA K returned to the room and did not perform hand hygiene. *NAs K and L without gloves on loosened his brief and checked for incontinence. *Without doing hand hygiene NAs K and L: -Attached the Hoyer lift sling to the Hoyer lift. -Transferred him from the bed to the wheelchair (w/c). *After he was in the w/c CNA N washed her hands and left the room. *Without performing hand hygiene: -NA K pushed him in the w/c to the dining room. -NA L carried the oxygen tubing to the dining room. 2. Observation on 10/29/19 from 10:40 a.m. through 10:55 a.m. with RN M as she was administering medications revealed: *At 10:40 a.m.: -She performed hand hygiene. -Opened up the bottom drawer of the medication cart and removed three Sani-cloth Bleach Germicidal Disposable wipes. -Went to resident 26's room. -Put on gloves. -Laid the Sani-cloth Bleach wipes on top of his dresser without creating a barrier under them. -Checked his blood sugar with the glucometer. -Picked up the supplies and returned to the medication cart. -Discarded the supplies into the garbage. -Removed her gloves and did not perform hand hygiene. -Took one Sani-cloth wipe and wiped the glucometer with it. -Had not left the Sani-cloth on the glucometer to keep it wet. -Without doing hand hygiene she put on gloves. -Drew up eleven units of [MEDICATION NAME]in the syringe. -Removed her left hand glove and without doing hand hygiene put on gloves. -Administered the insulin to resident 26. -Discarded the syringe. -Removed her gloves and did not perform hand hygiene. -Documented she had given the insulin. *At 10:48 a.m. without performing hand hygiene and after having contact with resident 26 she: -Put on gloves. -Removed a single-dose vial of Refresh eye drops from the box. -Took the glucometer supplies and the eye drops and went to resident 60's room. -Placed the supplies on top of her dresser without laying down a barrier under them. -Dropped the single-dose vial of Refresh eye drops on the floor. -Picked up the single dose vial of Refresh eye drops from the floor, removed the tip, and administered them. *With the same gloves on and doing no hand hygiene she:-Checked her blood sugar. -Returned to the medication cart and discarded the needle into the Sharps container. -Took a Sani-cloth Bleach Germicidal Disposable wipe and wiped the glucometer off with it. -Had not left the Sani-cloth on the glucometer to keep it wet. -Put it back in the container and then in the medication drawer. -Removed her gloves and without performing hand hygiene put on clean gloves. -Removed [MEDICATION NAME]and Tresiba insulin pen from the medication cart. -Drew up the [MEDICATION NAME]into the syringe. -Placed the needle on the Tresiba insulin pen and dialed it to twenty. -Administered the Tresiba and [MEDICATION NAME] insulin. -Returned to the medication cart. -Removed her gloves and did not perform hand hygiene. -Documented the medications as having been given. Interview on 10/30/19 at 9:56 a.m. with RN M regarding the above observations revealed she: *Thought it was alright to administer the eye drops after they had been dropped on the floor, because they were in an enclosed vial. *She confirmed the residents' shared the same glucometer. *The glucometer was cleaned between each resident's use. *She thought she had done hand hygiene between glove use. Interview on 10/30/19 at 10:40 a.m. with the director of nursing (DON) regarding the above observations revealed: *Her expectations would have been for the nurse to have discarded the Refresh eye drop vial and gotten a new one. *She agreed there were several missed hand hygiene opportunities. Interview on 10/30/19 at 1:15 p.m. with RN D regarding the glucometers revealed: *There was one glucometer on each of the four medication carts. *They cleaned the glucometers with the Sani-cloth bleach germicidal wipes. *They shared the glucometers with other residents. Review of the provider's (MONTH) (YEAR) Cleaning and Disinfecting Glucose Monitor policy revealed: *Standard of practice to provide guidelines for cleaning glucose monitors. -2. The surface of the monitor should be cleaned between testing residents using an EPA - registered disinfectant containing bleach. -3. Wipe off meter with an EPA- registered disinfectant wipe containing bleach to remove all visible debris and/or blood. Then use a 2nd wipe to thoroughly wet the surface enough to allow manufacturers stated contact time. Review of the Sani-cloth Bleach Germicidal Disposable wipes bottle recommendation for use label revealed: *To clean, disinfect and deodorize: -Use a wipe to remove heavy soil. -Unfold a clean wipe and thoroughly wet surface. -Treated surface must remain visibly wet for a full four (4) minutes. -Use additional wipes if needed to assure continuous 4 minute wet contact time. Review of the provider's (MONTH) (YEAR) Handwashing/Hand Hygiene policy revealed: *2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 6. Use an alcohol-based hand rub, soap and water for the following situations: -b. Before and after direct contact with residents; -c. Before preparing or handling medications; -g. Before handling clean or soiled dressings, gauze pads, etc.; -h. Before moving from a contaminated body site to a clean body site during resident care; -k. After handling used dressings, contaminated equipment, etc.; -m. After removing gloves. *7. Hand hygiene is the final step after removing and disposing of personal protective equipment. *8. The use of gloves does not replace hand washing/hand hygiene. -Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. 3. Observation on 10/29/19 at 9:40 a.m. of RN M during wound care and a dressing change for resident 16 revealed: *She had the dressing supplies placed on top of the medication cart. *She had gloves on and with those gloved hands she: -Placed the folded barrier sheet, the packaged applicator stick of [MEDICATION NAME], and a package of [MEDICATION NAME]/gauze on the resident's overbed table. -The overbed table had not been sanitized prior to setting the wound care items on it. -Opened and placed a plastic garbage bag on the floor bedside the resident's feet. -Sat on the floor in front of his feet. -Removed his left shoe and sock. -Placed the barrier on the floor under his left foot. -Removed the soiled dressing from his left great toe. -Took the supplies off the overbed table, opened the [MEDICATION NAME], and swabbed his left great toe. -Opened and placed the [MEDICATION NAME] dressing on his toe. *She then removed her gloves and without hand hygiene she: -Put her hand in her pocket and removed a black marker. -Dated and initialed the dressing and placed the marker back into her pocket. -Picked up the barrier and wound dressing packages and placed them in the garbage bag, tied the bag, took it to the medication cart in the hall by the nurses station, and placed it on the floor. -Used hand sanitizer, picked up the garbage bag, and took it into the soiled utility room. Interview on 10/30/19 at 12:45 p.m. with the infection preventionist RN revealed hand hygiene and glove use was audited at different times, places, and with different people performing the audits. A goal for 80% had been set, but it went up and down. Interview on 10/30/19 at 2:00 p.m. with RN M confirmed the above findings. She agreed she had missed opportunities to have changed her gloves and performed hand hygiene during the wound care and dressing change for resident 16. Surveyor Review of the provider's (MONTH) (YEAR) Handwashing/Hand Hygiene policy revealed: *2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 6. Use an alcohol-based hand rub, soap and water for the following situations: -b. Before and after direct contact with residents; -c. Before preparing or handling medications; -g. Before handling clean or soiled dressings, gauze pads, etc.; -h. Before moving from a contaminated body site to a clean body site during resident care; -k. After handling used dressings, contaminated equipment, etc.; -m. After removing gloves. *7. Hand hygiene is the final step after removing and disposing of personal protective equipment. *8. The use of gloves does not replace hand washing/hand hygiene. -Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.

Based on observation, interview, and policy review, the provider failed to: *Prepare medication according to product specification for Tresida Flextouch Pen for one of one randomly sampled resident (60) done by one of one registered nurse (RN) (M) during the medication pass. *Maintain infection control during administration of eye drops to one of one randomly observed resident (60) done by one of one observed RN (M). Findings include: 1. Observation and interview on 10/29/19 at 10:48 a.m. with RN M revealed: *Without performing hand hygiene she put on a pair of gloves. *She: -Took a box of Refresh eye drops from the medication cart. -Removed a single-dose vial of Refresh eye drops from the box. -Picked up the glucometer supplies and the single-dose vial of Refresh eye drops and went to resident 60's room. -Placed the supplies on top of the resident's dresser without placing a barrier under them. -Dropped the single-dose vial of Refresh eye drops on the floor. -Picked up the single-dose vial of Refresh eye drops, removed the tip, and administered the eye drops. *With those same gloves on and doing no hand hygiene she: -Checked her blood sugar. -Returned to the medication cart and discarded the finger stick sharp. -Took a Sani-cloth Bleach Germicidal Disposable wipe, wiped the glucometer off with it, and placed the glucometer back into the container. -Removed her gloves and without doing any hand hygiene put on a new pair of gloves. -Removed the [MEDICATION NAME]and Tresiba insulin pen from the medication cart. -Drew up the [MEDICATION NAME]into the syringe. -Placed a needle on the Tresiba insulin pen and dialed it to 20. -Administered the Tresiba insulin and the [MEDICATION NAME] insulin. -Returned to the medication cart and discarded the items. -Removed her gloves and did not perform hand hygiene. -Documented the medications as having been given. *She had not primed or wasted 2 units of the Tresiba insulin prior to administering it. Interview on 10/30/19 at 9:56 a.m. with RN M regarding the above medication pass for resident 60 revealed she: *Thought it was alright to administer the eye drops after they had been dropped on the floor, because they were in an enclosed vial. *Was not aware the Tresiba insulin pen had to be primed before use. Interview on 10/30/19 at 10:40 a.m. with the director of nursing regarding the above medication pass revealed: *Her expectations would have been for the nurse to have: -Followed the manufacturer's recommendations for priming the insulin pen. -Discarded the Refresh eye drop vial and gotten a new one. Review of the provider's Tresida Flextouch insulin pen manufacturer's instructions revealed: *Priming your Tresiba FlexTouch Pen: -Step 7: Turn the dose selector to select 2 units. -Step 8: Hold the Pen with the needle pointing up. Tap the top of the Pen gently a few times to let any air bubbles rise to the top. -Step 9: Hold the Pen with the needle pointing up. Press and hold in the dose button until the dose counter shows '0.' The '0' must line up with the dose pointer. -A drop of insulin should be seen at the needle lip. -Step 10: Check to make sure the dose selector is set at 0. --Turn the dose selector to select the number of units you need to inject. Review of the provider's 11/3/17 Medication Administration: Eye Medication policy revealed: 11. Perform hand hygiene and put on gloves.

Based on observation, interview, and manufacturer's Operators, Instructions review the provider failed to ensure safety practices were followed for one of two sampled residents (15) who required a mechanical device for transfers. Findings include: 1. Observation on 10/29/19 at 8:55 a.m. of resident 15 and certified nursing assistant (CNA) A revealed: *The resident was alert and had advanced dementia. *She was dependent on staff for assistance with all activities of daily living. *She was going to be taken in the bathroom of the Memory Care Unit (MCU) day room area. *An EZ stand lift was going to be used in transferring her from her wheelchair to the toilet. *CNA A: -Attached the harnesses to the resident's upper torso. -Placed her slippered feet on the platform of the EZ stand. -Stated she did not use the leg straps the because the resident would not leave her feet on the platform. -She always curled her legs when she was transferred and did not use them to support herself. -Encouraged the resident to hold onto the EZ stand handles with her hands. *As the transfer was initiated the resident: -Repeatedly curled her legs in a dangling position. -Was suspended with the full weight of the transfer on her shoulders and the upper torso harness. -Released at least one of her hands from the EZ stand handles. *During the transfer the CNA attempted to replace her feet on the platform, but the resident removed them and curled her legs in a dangling position. *When the resident was transferred back to her wheelchair she again did not use her legs to support herself on the EZ stand. Interview with CNA A following the above transfer revealed: *She never used the leg strap and did not know if other staff did, but she had not been taught to use it. *She reiterated the resident did not support her legs during transfers with the EZ stand. -She was only being supported by straps. Interview on 10/29/19 at 9:36 a.m. with registered nurse (RN) C and the director of nurses (DON) regarding resident 15 revealed: *A resident using the EZ stand should have been able to bear weight. *She was not aware that resident was lifting her legs and was not standing on the platform of the EZ stand. *The resident had recently been treated for [REDACTED]. *They thought someone had mentioned she was having problems with transfers and had done an evaluation. -They would look for it. *Further interview at 11:34 a.m. revealed they could not find that an assessment had been done on the resident. -They wondered why the CNA had not let them know, because she was working in the MCU every week. Interview on 10/29/19 at 11:51 a.m. with CNA A regarding resident 15 revealed: *The resident had been lifting her legs for quite awhile. *She worked on the MCU on her weekends to work, which was every other weekend. *She had told RN D about it the last weekend she had worked. -That was one and one half weeks ago. Interview on 10/29/19 at 3:30 p.m. with CNA B regarding resident 15 revealed: *He worked mainly in the MCU. *The resident had not stood during transfers with the EZ stand for quite awhile. -She sometimes put her knees on the rest but always curled her legs up. -She did not know how to hold the handles. *He thought the residents should have been able to stand to use the EZ stand. *She never had been able to understand that she needed to stand up. *He questioned a long time ago why they were using an EZ stand with her. Interview on 10/30/19 at 8:11 a.m. with physical therapy assistant (PTA) [NAME] regarding resident 15 revealed: *They had not seen the resident or worked with her for a long time. *She had lifted her legs for a long time, but should not have used the EZ stand if she was not using her legs. *They thought she had some sensory issues that had previously been a concern if they were using a Hoyer lift with her. *Their normal practice was to do an evaluation when nursing made a request for one. -They had not received one for that resident. Interview on 10/30/19 at 8:21 a.m. with occupational therapy assistant (OTA) H regarding resident 15 revealed: *They had received a request on 10/25/19 to do an evaluation on that resident from CNA/bath aide I. -She was having more difficulty with getting the resident to lift her arms to put her shirt on. -She was guarded with using her right arm. *Both the OTA and PTA [NAME] thought her shoulders and arms could hurt due to the pressure put on them during transfers. -Because an evaluation had not been done they did not know for sure though. -It was a possibility though. *When OT evaluated a resident they would have assessed her for pain and did an X-ray to ensure nothing was wrong. -That had not been done yet. *She confirmed the discomfort could have been related to transfers and the repeated pressure put on her shoulders. Telephone interview on 10/30/19 at 8:41 a.m. with OT G regarding resident 15 revealed: *They had worked with her a couple of months ago regarding positioning in the wheelchair. -They had assessed her for the removal of a lap buddy on her wheelchair that had been used for positioning. --That had been discontinued. *She confirmed the discomfort with her shoulder in the bath could be related to the pressure that was being put on her shoulder during the transfer. *She could not imagine that would be very comfortable to be transferred using the EZ stand with the pressure on her shoulders if she was not using her legs. Interview on 10/30/19 at 8:43 a.m. with physical therapist (F) regarding resident 15 revealed: *A resident who was transferred with an EZ stand should have been able to use her legs in the transfer. *They had not received a request to evaluate that resident related to transfers. Interview on 10/30/19 at 9:01 a.m. with RN D regarding resident 15 revealed: *She did not recall being told that resident was not using her legs during transfers. *She had not transferred her personally, but she had observed CNA B transfer her. -She was aware the resident curled her legs up, because that was what she had done when she observed her being transferred. --She did not recall specifically when that was, but it had been quite awhile ago. Review of resident 15's medical record revealed there was no documentation of when the last time the resident had been evaluated for transfers. Interview on 10/30/19 at 10:16 a.m. with bath aide/CNA I regarding resident 15 revealed: *It was difficult to work with her, because she had a hard time moving her arms. -She had contractures. *It was hard to tell if she had pain, but sometimes she would say no. *When she transferred she put her knees up. Interview on 10/30/19 at 10:20 a.m. with the DON regarding resident 15 revealed: *She did not understand why no one had communicated the resident was not using her legs for support during transfers. *They did not have a written policy regarding transfers. *The expectation was if they identified a resident who was having difficulty with transfers they would make a referral to therapy. -That had not happened, because they were not aware of it. Review of the provider's EZ Way Smart Stand Operator's Instructions revealed: *Patients (resident) should be able to bear some weight, have upper body strength and be able to follow simple commands. *If a patient does not meet each of these three criteria, an EZ Way total body lift must be used. *Safety Notes: The EZ Way Smart Stand was designed to transfer weight bearing patients to and from a chair, wheelchair, toilet, or bed and for safely ambulating patients. *Stand Support Strap: -The Support Strap is used for additional lower body support and is effective in helping patients stand in an upright position.

A. Based on observation, interview, and policy review, the provider failed to ensure one of one glucose meter had been sanitized between patient use, and glove use and hand hygiene had been correctly completed during glucometer testing by two of two licensed practical nurses (LPN) (B and G) for two of two observed residents (10 and 16). Findings include: 1. Observation on 7/25/17 at 11:00 a.m. of LPN B during a blood sugar check for resident 10 in the memory care unit (MCU) revealed he: *Got gloves, glucometer, cotton ball, alcohol packet, glucose testing strip, and a lancet from the medication cart drawers. *Placed all the above items on top of the medication cart. *Put on gloves without any hand hygiene. *Picked up the remaining items from the top of the medication cart and went to resident 10's room. *Placed all of the items on the bedding without any barrier between the items and the bedding. *Attempted to test her blood glucose, and the glucometer had an error reading. *Gathered the glucometer, used lancet, cotton ball, alcohol pad from the bed, and returned to the medication cart. *Disposed of the used items, disposed of his gloves, and without any hand hygiene used a bleach wipe to wipe down the glucometer. *Wrapped the wet wipe around the glucometer and set it on the top of the medication cart. *Then took the glucometer out of the MCU to the nurses station. He returned with a different glucometer and placed it on the medication cart. *Again retrieved from the medication cart drawers gloves, glucometer, cotton ball, alcohol packet, glucose testing strip, and a lancet. *Placed all the above items on top of the medication cart. *Put on the gloves without any hand hygiene. *Picked up the remaining items from the top of the medication cart and went to resident 10's room. *Placed all of the items on the bedding again without any barrier. *Completed the blood glucose test. *Gathered the glucometer, used lancet, cotton ball, alcohol pad from the bed, and returned to the medication cart. *Disposed of the used items and used a bleach wipe to wipe down the glucometer. *He then set that glucometer on the top of the medication cart without any barrier underneath it. *Disposed of his gloves and performed hand hygiene. Interview on 7/25/17 at 5:15 p.m. with LPN B revealed:*He was not aware he should have used a barrier when he placed the supplies on the bed. *He felt the top of the medication cart was clean. *He agreed he should have done hand hygiene after each glove use. 2. Observation on 7/26/17 at 11:00 a.m. of LPN G during a blood sugar check for resident 16 revealed she: *Retrieved gloves, glucometer, cotton ball, alcohol packet, glucose testing strip, and a lancet from the medication cart drawers . *Went to resident 16's room and placed the supplies on the overbed table. *Went into the resident's bathroom, got a clean paper towel, and placed it on the bed. *Then took the supplies from the overbed table and put them on the paper towel. *Put on gloves without any hand hygiene and tested resident 16's blood glucose. *Disposed of the used items in the garbage and sharps container in the room. *Removed her gloves and without any hand hygiene returned to the medication cart. *Took a bleach wipe, wiped the glucometer for less than one minute, and placed it on top of the medication cart. Review of the Chlorox Bleach wipes label revealed the surface should have remained wet for three minutes. Interview on 7/26/17 at 2:00 p.m. with the infection control registered nurse revealed: *LPNs B and G had not maintained proper glove use and hand hygiene practices. *Agreed the glucometer had become recontaminated by LPN B and had not been sanitized properly by LPN G. Review of the provider's February 2012 Handwashing/Hand Hygiene policy revealed: *Employees must wash their hands after the removal of gloves. *Alcohol based hand rub could also be used after the removal of gloves. Review of the provider's revised 7/26/17 Cleaning and Disinfecting of Glucose Monitors policy revealed: *Between testing residents blood glucose the surface of the monitor should have been cleaned using a Chlorox wipe. *Wipe off the glucose meter with a Chlorox wipe to remove all visible debris and/or blood. *Use a second wipe to thoroughly wet the surface enough to allow a three minute contact time. B. Based on observation, interview, manufacturer's intructions review, and policy review, the provider failed to follow product guidelines for contact time for two of two randomly observed resident bathroom cleanings by two of two housekeepers (D and F). Findings include: 1. Observation and interview on 7/25/17 at 10:30 a.m. with housekeeper D cleaning a resident's room revealed she: *Had worked as a housekeeper for seven years. *Was one of two housekeepers for the entire facility and cleaned about half of it. *Used appropriate hand hygeine then sprayed the bathroom toilet and sink surfaces with Oasis 499 disinfectant. *Waited three minutes then wiped off those surfaces with a dry cloth. *That was how she always cleaned the resident's bathrooms. *Would use bleach to clean an isolation bathroom. 2. Observation and interview on 7/26/17 at 8:00 a.m. of housekeepers D and F revealed: *They entered a resident's room to clean it. *Housekeeper D was training housekeeper F. *At 8:00 a.m. housekeeper F: -Sprayed the handsink and the toilet with Oasis Germicidal Acid Cleaner. *At 8:02 a.m. housekeeper F took a dry cloth and wiped the handsink and the toilet. *Interview at that time with housekeeper D revealed: -They left the spray on a few minutes. -They were supposed to leave it on ten minutes, but if they left it on wet that long they would never get their rooms done. 3. Interview on 7/26/17 at 2:13 p.m. with the maintenance director/housekeeping supervisor revealed: *They were to leave the disinfectant spray on for ten minutes. *They should have continued with their room cleaning process, leaving the sink and toilet to air dry. -If it dried during that time they should have re-misted it. *They had received re-training on this recently, but they had not done it correctly. -He did not state when that training occured. Review of the Oasis Germicidal Acid Cleaner's manufacturer's instruction for use revealed Apply use-solution to hard, nonporous surfaces, thoroughly wetting surfaces with a cloth, mop, sponge, sprayer or by immersion. Treated surfaces must remain wet for 10 minutes. Review of the provider's undated Cleaning and Disinfecting Resident's Room policy revealed: Manufacturer's instructions will be followed for proper use of disinfecting (or detergent) products.

Based on observation, testing, record review, interview, and policy review, the provider failed to ensure one of two dining rooms (memory care unit) food temperatures were properly monitored and maintained for two of two observed meals. Findings include: 1. Observation in the memory care unit on 7/25/17 at 11:25 a.m. of certified nursing assistant (CNA) A revealed she: *Opened the heated food cart and removed a plate of food. *Took a food thermometer and tested the temperature of the mashed potatoes on that plate. -The temperature of the mashed potatoes was 130 degrees Fahrenheit (F). *Returned the plate of food back into the heated food cart and sanitized the thermometer. *Did not test any of the other food on the plate at that time. Surveyor: Continued observation on 7/25/17 at 11:50 a.m. of CNA A revealed she: *Began passing trays to the residents seated at their tables. *Did not inquire of the residents if their food was warm enough. *Did not offer to reheat any of the food. Interview on 7/25/17 at 12:20 p.m. with CNA A revealed: *The temperature of the food had been checked while the residents were at the Sensory group. -That was prior to 11:30 a.m. *Hot food temperatures were supposed to have been 140 degrees F. *She had not reheated any of the food that had been served. -She was not sure what she was supposed to do if the food was not warm enough, but she hesitantly said, she wondered if she was supposed to reheat it. *She confirmed the food served had not been 140 egress F, but was served anyway. Review of the 7/25/17 Temperature Monitoring log with CNA A revealed the following temperatures had been recorded: *At breakfast the egg was 103 degrees F, and the cereal was 123 degrees F. *At noon the meat was 110 degrees F, potatoes were 130 degrees F, and the vegetable was 120 degrees F. 2. Interview on 7/25/17 at 6:00 p.m. with the dietary manager revealed: *Hot food temperatures were supposed to have been 140 degrees F. *If they were not that hot the staff were supposed to reheat the food to the appropriate temperature. *They had used a different food cart at the noon meal, and that might not have kept the food warm enough. -It had been hot enough when it left the kitchen. *She was unaware there had been a one-half hour delay in getting the residents served their food in addition to the food not being warm enough. *She was unsure if the CNA who had served the food at the noon meal had been trained on what to do if the food was not hot enough. Review of the provider's April 1999 Dietary Department policy revealed Minimum of 140 degrees F for hot foods and not more than 41 degrees for cold foods.

Based on observation, interview, and policy review, the provider failed to meet professional standards of administration of eye drops for one of one randomly observed resident (17) by one of one licensed practical nurse (LPN) (B). Findings include: 1. Observation on 7/25/17 at 3:40 p.m. of LPN B during the administration of [MEDICATION NAME] eye drops to resident 17 revealed the tip of the eye drop bottle applicator touched each corner of resident 17's eyes during administration. Interview on 7/25/17 at 5:15 p.m. with LPN B confirmed the above finding. He stated some of the residents would hold the lower lid of their eye for eye drop administration, but resident 17 was unable to do that. He stated that was his usual practice of administering eye drops if a resident was unable to assist. Review of the provider's revised July 1990 Eye Drops and Ointments policy included: *Evert lower lid by placing finger on cheek below eye and pulling down. *Take care not to touch medication bottle tip to eye. Review of Patricia A. Potter and Anne Griffen Perry, Fundamentals of Nursing, 9th Ed., St. Louis, Mo., 2017, p. 638, revealed: Avoid touching the eyelids or other eye structures with eyedroppers or ointment tubes. The risk of transmitting infection from one eye to the other is high.

A. Based on record review, nursing procedure review, professional standards, and interview, the provider failed to assess, monitor, and intervene in the individualized care and service to maintain the highest practical physical and psychosocial well being for one of one sampled resident (1) who had no recorded bowel movement (BM) for 13 days. Findings include: ?Review of resident 1's Medicare Assessment Form dated 12/15/10 through 1/19/11 revealed: ?Symbol key for use with documentation that included: -Check mark=assessment matched standard parameter. -H=deviation, chart findings (on this form or focus notes). -Arrow to left=deviation continues, no change since preceding H assessment. -P=pre-existing condition, describe. ?Standard parameters identified for "Gastrointestinal" that pertained to bowel elimination were: -Abdomen soft. -Nontender and nondistended. -Continent of bowels. -Passing [MEDICATION NAME]. -Bowel sounds present times 4 quadrants. -No N (nausea)/V (vomiting), diarrhea, constipation. -No tarry or bloody stools. -Stools brown, semi-soft, formed, describe if abnormal. -Supp (suppository)/enemas: type/color returned. ?12/15/10 at 9:15 p.m. There was a check mark and a note BS (bowel sounds positive X 4. There was also an asterisk with a note that read "res (resident) states BM was "last week." ?12/16/10 at 10:00 a.m. There was a check mark and an asterisk with a note that read "C/o (complains of) constipation Dr. ____ to see res. today will get order for bowels." ?12/16/10 at 8:20 p.m. There was a check mark and an asterisk with a note that read no BM. Those forms dated 12/17/10 at 9:25 a.m. through 1/19/11 at 1:30 p.m. had check marks indicating the assessment matched the standard parameters. There were no other notes on these dates related to bowel elimination. Review of resident 1's BM report roster dated 1/10/11 through 1/24/11 revealed no record of the resident having had a BM after 1/10/11 at 9:27 p.m. until 1/24/11 at 4:09 a.m. Review of resident 1's nurses' notes dated 12/15/10 through 1/24/11 revealed the following entries related to bowel elimination: ?12/16/10 at 2:30 p.m. Senakot 1-4 tabs (tablets) PO (orally) daily PRN (as needed, per request to nurse). Adjust per results. ?12//28/10 at 5:15 p.m. . . . frequently incontinent of bladder and continent of bowel. ?12/31/10 at 11:00 a.m. Weekly summary . . .Continent of bowels . . . . ?1/4/10 (incorrect year) at 2:20 p.m. . . . frequently incontinent of bowel/bladder. Wears pads at all Xs . . . . ?1/6/11 at 1:45 p.m. MDS (Minimum Data Set) 30 days Medicare assess . . . frequently incontinent of bowel/bladder . . . . ?1/21/11 at 5:30 p.m. Received the following order per T.O. (telephone order): [MEDICATION NAME] 17 gm (gram) daily. (May decrease dose if has loose stools). ?1/22/11 at 9:15 a.m. Orders from Dr. visit on 1/20/11 to increase Senna to 6 tabs PO daily, [MEDICATION NAME] 17 gm PO daily, [MEDICATION NAME] supp every 12 hours PRN. ?1/23/11 at 11:40 a.m. Dr. ____ faxed per pharmacy request to clarify Senna order. ?1/24/11 at 2:50 a.m. CNA (certified nurse assistant) reported res had a extra large loose BM and also appeared warm to touch and more lethargic than usual. T-103.3, P-124, R-24, B/P-88/44, SPO2-91% RA. LSC bilat. (bilateral). Also soft, NT with BS+ no pedal [MEDICAL CONDITION]. Tylenol given for increased temp. Fluids given. Review of resident 1's care plan revealed problem/need "Alteration in Bowel Elimination - Constipation" was 1/21/11; goal - resident will have BM every 2-3 days through 3/31/11. Approaches were [MEDICATION NAME] 17 gm daily, Senna 6 tablets daily, and [MEDICATION NAME] rectal suppository every 12 hours as needed. Review of the provider's prepared Patient Transfer Form to hospital dated 1/24/11 reflected resident had received Senna tablets and [MEDICATION NAME] for bowels with the last BM on 1/10/11. Review of 6/4/98 nursing procedure for Unusual complaints and symptoms revealed staff were to check vital signs and do assessment, chart in nurses notes, notify doctor if necessary, notify family if necessary, and put the chart on the UPPER RACK so each shift followed up. Interview on 1/31/11 at 12:00 noon with certified nurse assistant (CNA) A revealed CNAs used palm hand held or wall mounted electronic documentation devices. They were able and must record bowel elimination or BMs. The system prompted the individual to document the above. The CNA demonstrated by accessing a resident file and proceeded to the screen that read Bowel movement (BM) this shift? The CNA stated he/she was not able to print the report, but the nurses were able to access and print. The CNA believed the night nurse accessed the report and provided the information to the day nurse, so they would address. The CNA also indicated the nurse usually "does something," if there was no record of a BM after 3 days. CNA A preferred to carry the palm so "I can record things as they happen, but have to do it for sure before the end of my shift." CNA A also stated "Some of the older ones wait until the end of the shift." Interview on 1/31/11 at 12:20 p.m. with registered nurse (RN) B revealed he/she had worked on 1/20/11. Resident 1's physician discussed treatment options with him/her and his/her spouse and spoke to the resident's daughter per phone. RN 2 did not recall any discussion related to bowel elimination. Discussion was related to making decisions about hospice treatment or other interventions as RN 2 indicated resident 1 was not improving. Interview on 1/31/11 at 12:30 p.m. with RN C revealed nurses used the Medicare Assessment Form with no additional instructions other than what was on the form indicating the use of the symbol key. Interview on 1/31/11 at 12:40 p.m. with CNA D confirmed CNAs use the palm hand held or wall mounted electronic documentation devices to document bowel and bladder elimination plus "lots of other ADLs (activities of daily living)." CNA D reported the nurses were the ones who looked at how often the residents had BMs. If a resident did not have a BM after 2-3 days, the nurse usually gave a laxative or a suppository. Interview on 1/31/11 at 12:50 p.m. with RN E revealed there was no policy or procedure for the use of the Medicare Assessment form. RN E stated "It s pretty self explanatory." RN E reported a resident was given a laxative or a suppository when there was no BM after 3 days. RN E confirmed the CNAs documented BMs using the palm devices. He/she confirmed the night nurse pulled the BM reports and prepared a check list for the day nurse. The night nurse might give a suppository in the early a.m., but the night nurse provided the check list to the "cart" nurse every morning. Interview on 1/31/11 at 1:30 p.m. with the director of nurses (DON) confirmed there is no written policy or procedure for use of the Medicare Assessment Form, stating , "It is self explanatory, directions are on it." DON confirmed the CNA staff must document on bowel elimination each shift. The system prompted them and they could not leave without finishing that. DON continued confirming the night nurse checked the residents' BM reports, prepared a BM check list, and provided that list to the day nurse. When asked why there might have been no response or intervention after 2-3 days for resident who did not have a BM the DON stated, "The day nurse probably didn't share that information." The DON did not offer or provide anyone else or any other documentation when asked if there was anyone else or any other documentation he/she would like to have the surveyor review regarding resident 1. B. Based on record review, nursing procedure review, professional standards, and interview, the provider failed to prevent the development of a pressure ulcer for one of one sampled resident (1). Findings include: Provision of pressure ulcer care for resident 1 who acquired a pressure ulcer, accurate documentation of discovery and continued course of care documentation. Refer to F314.

Based on record review, nursing procedures review, professional standards and interview the provider failed to prevent the development of an additional pressure ulcer and failed to provide accurate documentation of the discovery and course of care for one of one resident (1) with an acquired pressure ulcer. Findings include: Review of resident 1's skin assessment form completed by a nurse on 12/15/10 revealed a stage I (persistent area of skin redness without a break in the skin) pressure ulcer to the coccyx and scattered bruising on both forearms. Review of resident 1's Norton Plus Pressure Ulcer form completed by a nurse on 12/22/10 revealed a score of 6. A score of 6 out of 20 indicated a higher level of risk for pressure ulcer development. The Norton Scale is a total rating scale that measures functional capabilities and other health care issues of the person that contribute to his/her risk in developing pressure ulcers. Review of resident 1's nurse notes from 12/15/10 through 1/24/11 pertaining to the skin revealed: ?12/15/10 Admit - Treatments for "discolored area on buttocks" and left (L) abd. (abdominal) fold. ?12/28/10 at 5:15 p.m. Norton pressure scale done quarterly. Stage I area to coccyx area reddened, no open areas, no dressing, no swelling noted. ?12/31/10 at 11:00 a.m. R (right) buttock scabbed area no redness or drainage noted; 1 cm diameter. ?1/4/10 (incorrect year) at 2:20 p.m. Norton pressure scale done quarterly, score 6. Currently has a stage I to coccyx being treated with [MEDICATION NAME] BID (twice daily) until healed. Has pressure relieving mattress, repositioned per turn sheet, supplements given. ?1/5/11 at 2:30 a.m. Resident has 4 cm diameter blister to heel of L foot. Dark-red in color and fluid filled. No drainage presently. ?1/6/11 at 11:50 a.m. .... (2) Protective boot/device L foot heel wound (3) clean daily-reapply dressing. ?1/6/11 at 1:45 p.m. Has unstageable (not able to determine severity) pressure area to L heel. ?1/6/11 at 3:00 p.m. Dr. ____ here to remove dead skin layer from left heel. Outer layer of dead skin removed, dressing applied, heel protector also applied. ?1/14/11 at 6:00 p.m. Weekly summary - Open wound on left heel, half-dollar sized black area, no drainage, scant red ring surrounding black area. Review of resident 1's Medicare Assessment Form from 12/15/10 through 1/24/11 revealed: ?Symbol key for use with documentation that included: -Check mark=assessment matched standard parameter. -H=deviation, chart findings (on this form or focus notes). -Arrow to left=deviation continues, no change since preceding H assessment. -P=Pre-existing condition, describe. ?Standard parameters identified for "Integumentary" that pertained to skin were: -Skin color within normal limits (WNL). -Skin warm/dry. -Turgor WNL for patient's age. -Moist mucous membranes. -Skin intact, no redness, rash, bleeding, bruising, scaling or breakdown. -No mouth sores. -No itchiness. -Bony prominences and heels W/O (without) pressure areas or breakdown. ?12/15/10 at 9:15 p.m. Asterisk not identified on symbol key, then bruising scattered to bilateral arms, stage I redness to coccyx. ?12/16/10 at 10:00 a.m. and 8:20 p.m. (arrow to right). ?12/14/10 9:25 (check mark), scattered bruising bilateral arms, see TAR (treatment administration record) for details on coccyx. ?12/17/10 at 2:30 a.m. (check mark). ?12/18/10 at 10:30 a.m. through 12/21/10 at 9:50 a.m. (check mark) then scattered bruises bil. (bilateral) arms. ?12/22/10 at 1:00 p.m. (check mark) scattered bruises to forearms bil. *Stage 1 nickel-size open area to buttocks. No drainage noted. ?12/23/10 at 9:25 a.m. (check mark) scattered bruises to bil. forearms. Stage I nickel size area on Rt buttocks, [MEDICATION NAME] covering. ?12/24/10 at 9:00 a.m. (check mark) scattered bruises to bil. forearms. Stage I on Rt buttocks-see TAR (treatment administration record). ?12/28/10 at 10:00 a.m. through 1/4/11 (check mark) See TAR for Rt buttocks documentation. ?1/5/11 at 1:00 p.m. (difficult to tell if an asterisk or a check mark that was crossed through) Pressure ulcer L heel measures 5 cm (centimeter) long X 4 cm wide purplish color with thin covering of skin - was a LARGE Fluid Filled Blister like Area. Dr. ____ to see tomorrow 1-6-11. ?1/6/11 at 10:30 (check mark) L heel purple area. ?1/7/11 at 9:35 (check mark) See TAR for L heel documentation. ?1/8/11 at 9:10 (check mark) See TAR for L heel documentation. L heel with 1 ? inch round blackened area with edges pink. No redness, drainage, or foul odor noted. Heel protector on L. ?1/9/11 and 1/10/11 (check mark) See TAR for L heel documentation. ?1/11/11 at 11:00 a.m. (check mark) See TAR for Lt heel & buttocks documentation. ?1/12/11 at 9:20 a.m. (check mark) L heel half dollar size black area - dry. No [MEDICAL CONDITION] or drainage. Surrounding edges red. Refer to TAR for tx (treatment). ?1/13/11 at 8:40 (check mark) L heel ulcer. Refer to TAR for details. ?1/14/11 at 1:20 p.m. (check mark) L heel ulcer half-dollar sized black area. No drainage, scant amount of redness surrounding black area. ?1/15/11 at 6:45 a.m. (check mark) L heel ulcer (See TAR). ?1/16/11 at 6:45 a.m. (arrow to right). ?1/17/11 at 10:20 a.m. (check mark) L heel ulcer See TAR. ?1/18/11 at 1:00 p.m. (check mark) L heel ulcer See TAR for detail. ?1/19/11 at 1:30 p.m. (No symbol) L heel ulcer left open to air with protective boot. Half dollar sized black, no drainage, dry. Review of resident 1's care plan activity of daily living (ADL) sheet and care plan with admitted [DATE] revealed: ?Resident required an assist of one person for position change in bed and turn sheet. ?Problem/need identified 12/15/10 was "Potential for skin breakdown." ?Goal was to maintain intact skin integrity over the next 90 days ?Approaches included: ?Monitor skin daily with dressing and 2 X week with bathing. ?Trim nails weekly. ?Heel boots on bilat. while in bed. ?Increase vitamin C and protein as diet allowed. ?Provide measures to decrease pressure/irritation to skin, fleece pad, heel/elbow protectors, wheel chair cushions. ?Change incontinent pad as soon as possible after voiding or bowel movement. ?Apply preventive or barrier lotion after incontinence. ?Keep bed linen clean, dry and free from wrinkles. ?Offer supplements as ordered. ?Have one or two people move resident to avoid skin friction rubs. ?Use draw sheet or lifting device to move resident. ?Reposition resident per turn sheet. ?Pressure relieving mattress to bed. ?Cleans perineal area with Promise cream and water after each incontinence. Keep resident as clean and dry as possible. ?Additional handwritten approaches added on 1/6/11 were protective boot/device to left foot and clean daily, reapply dressing left heel. ?Added on 1/7/11 was air pressure relieving mattress. Review of provider prepared Patient Transfer Form dated 1/24/11 for resident 1 documented he/she had a L heel open area blackened, (symbol for no) drainage. Interview on 1/31/11 between noon and 12:45 p.m. with two separate unidentified CNAs and CNA D revealed they did not "input identified skin problems such as skin tears or what may be pressure ulcers on the palm or wall mounted electronic documentation devices. They go right to the nurse to report." Interview on 1/31/11 at 12:30 p.m. with RN C revealed the nurses used the Medicare Assessment Form with no additional instructions other than what was on the form, indicating the use of the symbol key. Interview on 1/31/11 at 12:50 p.m. with RN E revealed the CNA staff came directly to the nurse to report any identified skin concerns or problems. Also there was no policy or procedure for the use of the Medicare Assessment Form. "It's pretty self explanatory." Interview on 1/31/11 at 1:30 p.m. with the director of nurses (DON) confirmed there was no policy or procedure for the use of the Medicare Assessment Form. "It's self explanatory, directions on it." When asked if there was anyone else or any other documentation she would like to have the surveyor review to ascertain that the surveyor had found all data related to the course of stay of resident 1 from 12/15/10 through 1/24/11, there was none offered or provided. Review of the provider's nursing procedures dated 6/4/98 "Open areas" revealed: ?When found: 1. Document in nurses notes. 2. Add to are plan. 3. Put on dressing list on MAR. 4. Notify dietary department. 5. Obtain [MEDICATION NAME] order if needed. 6. Add to communication board. 7. Charge out dressing ?Facts to be charted on when open areas existed: 1. Size and stage. 2. Location of open areas. 3. Drainage. 4. Color. 5. Odor. 6. What you did to it. 7. Swelling. (Off to side) definitions of stages on next page: ?Stages -Stage 1: A persistent area of skin redness (without a break in the skin) that did not disappear when pressure was relieved. -Stage 2: A partial thickness loss of skin layer that presented clinically as an abrasion, blister, or shallow crater. -Stage 3: A full thickness of skin was lost, exposing the subcutaneous tissue as a deep crater with or without undermining adjacent tissue. -Stage 4: A full thickness of skin and subcutaneous tissue was lost, exposing muscle and/or bone. Review of a document dated 11/07 titled " Open areas-skin tears " revealed: When found: -Document in nurses notes. ?Size of wound. ?How deep the wound is (stage). ?Drainage present. ?Location of open area. ?Color of wound and surrounding tissue. ?Treatment to be done. ?Add the open area to the resident's care plan. ?Place their name and the problem on the dressing list or have it added to the computer. ?Notify the kitchen that an open area is present. ?If [MEDICATION NAME] is needed, obtain a physician's orders [REDACTED]. ?Charge out any dressing used. ?Write a note on the communication board to notify nursing staff of any change in the resident's care. ?The open area should be charted on a minimum of twice weekly. When healed: ?Chart what the healed area looked like. ?Take the problem off the care plan. ?Take the treatment of [REDACTED]. ?Notify the kitchen that area is healed ?Notify the nursing staff of the open area being healed. Review of resident 1's electronic Treatment Administration Record received after the 1/31/11 exit interview revealed there was no documentation to reflect the origination of the acquired left foot heel ulcer noted on 1/5/11 at 2:30 a.m. Review of the provider's word document titled "Skin Issues" from 1/3/11 through 1/24/11 received after the 1/31/11 exit interview revealed resident 1 was included on 1/3/11. Documentation reflected the previously noted stage I area to right outer buttock. Documentation from 1/11/11 reflected the presence of a left heel ulcer. That area measured 3.5 cm X 2.75 cm with a dark purplish/black intact scabbed area measuring 2.5 cm X 2.5 cm in diameter adjacent to healthy tissue at the wounds medial edge. Stage II area surrounding the scabbed portions measured approximately 0.75 cm in width and extended to the wound edges on the proximal, lateral, and distal sides of the wound. That area was filling in with granulation tissue without redness or swelling. There was a small amount of dried blood noted to the old dressing. Heel lift boot was in place to the left lower extremity. Nowhere in that documentation was there an explanation on how the pressure ulcer originated, or that the physician had removed an outer layer of dead skin.