Every finding on record at Trempealeau Cty HCC Imd

Based on observation, interview, and record review, the facility failed to secure controlled substances in a locked container separate from containers for any non-controlled medications, and to linit access to authorized personnel consistent with state or federal requirements and professional standards of practice for all 31 residents in the facility.Surveyor observed a medication refrigerator inside the locked medication room that did not have a lock in place securing entry to medications. Surveyor observed a box of liquid oral lorazepam and a vial for IV injection of lorazepam. Both packages were unopened.This is evidenced by:Facility policy, titled Controlled Substances, with a reviewed date of 10/29/25, states in part: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. Policy Interpretation and Implementation: 5. Controlled substances must be stored in the medication room in a locked container, separate from containers for any non-controlled medications. This container must always remain locked, except when it is accessed to obtain medications for residents.On 03/09/26 at 10:06 AM, Surveyor toured the locked medication storage room on [name of unit] with Registered Nurse (RN) H. Surveyor observed a medication refrigerator inside that did not have a lock in place securing entry to medications. Surveyor asked RN H to open the refrigerator door and observed a box of liquid oral lorazepam and a vial for IV injection of lorazepam. Both packages were unopened. Surveyor asked RN H about the lorazepam. RN H stated it was for emergency supply and not prescribed for a specific resident. Surveyor asked RN H if there was a lock for the refrigerator. RN H stated no.On 03/09/26 at 1:12 PM, Surveyor interviewed Director of Nursing (DON) B regarding observation. DON B stated not being aware of the requirement to store the controlled medication in refrigerator in a separate locked compartment. DON B stated that this would be addressed and fixed immediately.

Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (R)(R5) observed during cares.Certified Nursing Assistant (CNA) C and CNA D did not use Enhanced Barrier Precautions (EBP) when providing direct care for R5.This is evidenced by:Facility policy, titled Enhanced Barrier Precautions, with a reviewed date of 01/06/26, states in part: Enhanced barrier precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and gloves use during high contact resident care activities. 2. Initiation of Enhanced Barrier Precautions: b. An order for enhanced barrier precautions will be initiated for residents with any of the following: i. wounds (e.g., chronic wounds such as pressure ulcers.) even if the resident is not known to be infected or colonized with a MDRO. 4. High-contact resident care activities include: a. dressing, b. bathing, c. transferring, d. providing hygiene, e. changing linens, f. changing briefs or assisting with toileting, g. device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, h. wound care: any chronic skin opening requiring a dressing.R5 was admitted to the facility on [DATE] with pertinent diagnoses of pressure ulcer of sacral region stage 3 (09/25/23) and MRSA wound (03/09/25).R5's physician orders include:Dressing change order: Cleanse area with mild soap and water or wound wash, Pat Dry. Apply Vaseline to wound edges. Cut a piece of Hydrofera Blue, (Just lightly larger the wound). Moisten it with normal saline or sterile water. Squeeze out excess and place OVER wound bed. Cover with Gauze. Hold in place with tape. Change daily.- No orders for EBP noted.R5's care plan was reviewed and noted no EBP for care of R5's chronic pressure wound or during high-contact cares.On 03/10/26 at 6:56 AM, Surveyor observed R5's room door to have a sign posted stating EBP precautions. The EBP sign noted use of gown and gloves required when providing high-contact care. A large bag was hanging on R5's door filled with personal protective equipment (PPE) including disposable gloves and gowns. At 7:12 AM, Surveyor observed CNA C and CNA D providing morning cares for R5 in bed. CNA C and CNA D completed hand hygiene and donned gloves. CNA C and CNA D then removed R5's sleep clothes, washed R5's face and upper body, provided peri-care, and applied a new incontinent brief. CNA C and CNA D then transferred R5 from the bed to wheelchair. CNA C and CNA D did not use a gown at any point during R5's high-contact cares.On 03/10/26 at 7:26 AM, Surveyor interviewed CNA C and CNA D regarding observation. Both CNAs stated that they were under the impression that gown and glove use with EBP for R5 only needed to be used during wound care and not with other personal cares.On 03/10/26 at 8:35 AM, Surveyor interviewed CNA E and CNA D regarding EBP usage. Both CNAs stated that use of gowns was only needed if providing direct wound care or providing catheter care, otherwise only gloves were needed as PPE.On 03/10/26 at 8:40 AM, Surveyor interviewed Infection Preventionist (IP) G regarding observation and interviews. IP G stated that staff would be expected to use EBP when providing high-contact care for residents with wounds if they were not covered or were draining, based on CDC guidance. Surveyor then reviewed the facility's procedure/policy regarding EBP with IP G. Surveyor pointed out the facility's policy guidelines outlining that EBP was required with all high-contact care for all residents with chronic wounds and dressing changes. IP G stated having some confusion about this and stated recognition of the error in practice. IP G stated this would be addressed, and staff would be educated to use EBP in all high-contact cares with EBP residents.

Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents (R) observed for morning cares (R16 and R24). Staff did not perform hand hygiene with glove use when washing residents from a dirty location to a clean location or perform perineal care from clean to dirty for R16 and R24. Findings: Facility policy titled, Hand Hygiene revised 01/09/2024, stated in part, .5. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations: . F. Before moving from a contaminated body site to a clean body site during resident care . Example 1 R16 was admitted to the facility on [DATE] with urologist diagnosis of retention of urine. On 01/14/25 at 7:06 AM, Surveyor observed Certified Nursing Assistant (CNA) E perform morning cares with R16. CNA E performed proper hand hygiene and placed a gown and face shield per the facility's enhanced barrier precautions (EBP). CNA E took a clean wet washcloth from the basin of warm water, applied soap to washcloth then cleaned R16's groin and scrotum. CNA E then folded the washcloth using a clean area of the washcloth and began to clean the tip of the penis, the opening of the penis where the catheter comes out, without performing any glove changes and hand hygiene. CNA E then began to clean the catheter tube from the tip of the penis and away. When CNA E had finished this area CNA E noted that the resident was soiled with stool and began to clean that area. The rest of the observation was appropriate. Immediately after the observation, Surveyor asked CNA E, When you finished cleaning the arm pits, where should you start washing the perineal area and what infection control practice should be done when going from a dirty area to a clean area of the body? CNA E replied, I should have changed my gloves and washed my hands. Surveyor indicated that CNA E should start from the urethra and clean in a circular motion toward their scrotum, as the urethra is considered the cleanest part. On 01/14/24 at 12:44 PM, Surveyor interviewed the Director of Nursing (DON) B about this observation made of CNA E. DON B indicated that the staff should be cleaning the residents from cleanest areas to dirty areas of the body, and they should change gloves and perform hand hygiene when going from dirty to clean areas of the body. Example 2 R24 was admitted to the facility on [DATE] with diagnoses that include malignant neoplasm of the prostate (prostate cancer) and urine retention. On 01/14/24 at 9:38 AM, Surveyor observed morning cares provided to R24 by CNA F. CNA F put on the proper personal protective equipment (PPE) for a resident with EBP as well as performed proper hand hygiene before entering the room. CNA F placed clean washcloths in a warm basin of water and then assisted R24 in taking R24's pants down to R24's knees. CNA F then took a clean washcloth and dipped in the basin of water, applied soap to washcloth then cleaned R24's scrotum. CNA F then placed the dirty/used washcloth back into the basin with the clean washcloths and took out an unused washcloth, that was in the dirty basin of water, put soap on it and began to wash R24's tip of his penis and catheter tube. On 01/14/24 at 10:09 AM, Surveyor asked CNA F about this specific observation. CNA F indicated that she should not have put a dirty washcloth into the clean basin of water, and she should have removed her gloves and washed her hands and put new gloves on when washing the tip of the penis. On 01/14/25 at 12:44 PM, Surveyor interviewed DON B about this observation of CNA F. DON B indicated that a dirty or used washcloth should not go back into the clean water, and they should clean from clean areas of the body to dirty. The CNAs should change gloves and perform hand hygiene when going from dirty to clean areas of the body.

Based on observation, interview and record review, the facility did not provide activities of daily living (ADLs) for residents who are dependent on staff. The facility practice affected 1 of 4 residents observed for care (R23). Certified Nursing Assistants (CNA) C and D did not provide ADLs of washing, rinsing and drying R23's face, hands or body as part of R23's morning ADLs. This is evidenced by: Surveyor reviewed R23's most recent annual Minimum Data Set (MDS) dated [DATE] which notes he sometimes understands, sometimes is understood and is cognitively impaired. R23 is dependent on staff for transfers and bed mobility. R23 requires substantial assistance to wash, rinse and dry self, for hygiene. Surveyor reviewed R23's care plan and noted: Problem: This is my usual performance of my functional abilities for my ADLs. Category ADLs Functional Status/Rehabilitation Potential Start Date 10/11/2023 Last Reviewed/Revised 01/09/2025 Goal(s) I want to remain as independent as I can while performing my ADLs. Target Date: 04/22/2025 (Long Term Goal) Approach: PERSONAL HYGIENE (from the neck up and washing hands): Setup/Touch assist is my usual performance for personal hygiene. Assist of 1 BATHING (washing, rinsing and drying): Substantial is my usual performance for showering/bathing Assist of 1 Surveyor requested and received the facility policy for expected ADLs for residents who are dependent on staff for care. Surveyor was provided Standard Protocol for ADL's dated as effective July 2012 and most recently reviewed/revised on 1/2024. The protocol in part read: Encourage resident to complete hygiene, grooming and dressing tasks as independently as possible .assist as listed on plan of care. On 1/14/25 at 6:51 AM, Surveyor observed CNA C and D assist R23 with morning cares. CNA C and D rolled R23 side to side in bed to remove a soiled brief, provide peri care and donned a clean brief. CNA C and D dressed R23's lower body in bed and transferred R23 with a mechanical lift to his wheelchair. Once in wheelchair CNA D exited R23's room and CNA C wiped under R23's arms, applied deodorant, sprayed R23 with body spray and donned a clean shirt. CNA C brushed R23's dentures and placed them in his mouth, provided R23 with his glasses and baseball cap and wheeled him from his room. On 1/14/25 at 7:04 AM, Surveyor spoke with CNA C about the observation. Surveyor asked CNA C if the care provided to R23 was his morning care and what R23's morning cares consist of. CNA C indicated this was R23's morning care and she should have washed R23's hands, face and body along with his peri area when R23 was in bed. Surveyor asked CNA C why the care was not done. CNA C responded, It slipped my mind. On 1/14/25 at 7:10 AM, Surveyor spoke with CNA D about the observation and what is expected with morning ADLs. CNA D explained care expectation would be to wash arms, face, hands body and peri care in bed, as well as do teeth or dentures and comb hair. Surveyor asked CNA D why R23 was not provided the ADLs of washing face, hands and body. CNA D responded, Should have, not sure why not done, maybe nerves. On 01/14/25 at 7:18 AM, Surveyor spoke with Director of Nursing (DON) B about R23's expected morning ADLs. DON B expressed she would expect staff to wash, rinse and dry R23 top to bottom, face to bottom, clean to dirty. Surveyor asked DON B for the facility policy regarding ADL care. DON B responded expected ADLs is part of basic nurse aide training and nurse aide expectations to thoroughly wash resident top to bottom with morning cares. Face to peri care, all areas.

Based on observation, interview and record review, the facility did not ensure the resident environment remained as free of accidents as possible for 1 of 4 residents reviewed for accidents (R23). Certified Nursing Assistant (CNA) C and D did not remain at bedside when R23's bed was in a high position when providing morning care. This is evidenced by: Surveyor requested and received the facility policy titled Falls and Fall Risk Management dated as most recently reviewed 1/2024. The policy in part read: Policy Statement: Preventing falls requires a substantial interdisciplinary team effort. Such efforts should focus on minimizing fall risk and risk of fall-related injuries . ~Staff will seek to identify environmental factors .that may contribute to falling. ~Strategies for reducing the risk of falls: Risk Factor: Environment. Strategy: Beds: low position and brakes on at all times. Surveyor reviewed R23's record and noted: R23's most recent annual Minimum Data Set (MDS) dated [DATE] notes he sometimes understands, sometimes is understood and is cognitively impaired. R23 is dependent on staff for transfers and bed mobility. R23 has range of motion limitations in one lower extremity. R23 has not experienced falls. R23's most recent fall risk assessment dated [DATE] notes R23 is high risk for falls (19). Assessment notes 10 or higher represents a high risk for falls with R23 scoring a 19. Risk factors include R23's cognition, medications and osteoarthritis. R23 is unable to ambulate without assistance. At risk medications include antidepressants, antihistamines, antihypertensive, diuretics, cathartics and narcotics. R23's care plan included: Problem: I am at risk for falls r/t (related to) medications, right knee pain r/t osteoarthritis. Falls Start Date 10/25/2021 Last Reviewed/Revised 01/05/2025 Goal(s) I will remain safe from injury r/t falls. Target Date: 04/22/2025 (Long Term Goal) Approach(s) Approach: Reminder signs will also placed in room to remind to use the call light for assistance with transferring. Approach: Follow Altered Mobility/Fall Protocols. On 1/14/25 at 6:51 AM, Surveyor observed CNA C and CNA D provide peri care and dressing of R23 in bed. CNA C and D raised R23's bed to high position to provide care. CNA C went into R23's bathroom to gather supplies, and CNA D joined CNA C in the bathroom to wash his hands after going to R23's wardrobe closet to gather clothing for R23. R23 was left in bed with no staff at bedside with his bed in high position. CNA D walked across R23's room to remove his personal protective equipment and obtain a mechanical lift as CNA C went back to the bathroom to wash her hands. Again R23 was left with no staff at bedside as his bed was in high position. CNA C and D transferred R23 to his wheelchair after placing sling under R23 in bed. On 1/14/25 at 7:10 AM, Surveyor spoke with CNA D about the observation. Surveyor asked CNA D if R23 is a fall risk and if leaving R23 in bed without staff at bedside was a safe practice. CNA D respond R23 does attempt to self transfer and relies on two staff to safely transfer him. CNA D stated, Oh god no, not a good practice to leave [R23] in bed in high position without staff at bedside. On 1/14/25 at 7:04 AM, Surveyor spoke with CNA C about the observation. and R23's fall risk. CNA C expressed she was not aware of recent falls. Surveyor asked CNA C if leaving R23's bed in high position with resident in bed was a safe practice. CNA C responded, I can go and grab stuff. I think is ok to leave bed high. I think I can leave alone but not 100 percent sure. On 01/14/25 at 7:18 AM, Surveyor spoke with Director of Nursing (DON) about the observation and if R23 was at risk for falling. DON B referenced R23's electronic record and explained R23 was last assessed for fall risk 10/2025 and the assessment deemed R23 scored (19) which indicated R23 was high risk for falling. Surveyor asked DON B if R23 is care planned for low bed. DON B explained R23 was admitted with his wife and slept in a recliner. Sleeping in a bed is new for resident and he has only slept in bed for approximately 6-9 months. R23 will attempt to self transfer and is a fall risk. DON B indicated R23's care plan does not indicate he needs a low bed, and it is not ok to leave bedside when his bed is in high position as it is an unsafe practice.

Based on interview and record review, the facility did not maintain an infection prevention and control program according to professional standards of practice having the potential to affect all 34 residents residing in the facility at the time of survey. The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: Include a comprehensive assessment of the facility's water system to identify all locations where Legionella could grow and spread. Maintain acceptable ranges of control limits (temperature ranges) and corrective actions when control limits are not met. Include a process to confirm the WMP is being implemented and is effective. Findings include: The facility policy entitled, Plant Operations-Legionella control and procedure, dated 11/05/2020 documented in part, Ensuring risk assessments are carried out at least every two years or as necessary. On 11/08/23 at 10:00 AM, Surveyor interviewed Infection Preventionist (IP) I. Surveyor asked about the facility's program to prevent Legionnaire's disease. IP I stated that the facility has been working on a program but that the facility's maintenance personnel handle the majority of that program, and Surveyor should ask him about the details of the program. On 11/08/23 at 11:10 AM, Surveyor interviewed Maintenance J. Surveyor asked to see the facility assessment of the water management system. Maintenance J provided the Surveyor with a binder of water management system printouts. Within this binder it contained an assessment of the water system, which was not completed. Surveyor asked if this was the facility's assessment of the water system to identify where Legionella could grow and spread, when to apply control measures and how to monitor, and when to intervene when control limits are not met? Maintenance J answered the facility has not completed the Legionella and water system assessment. It is a work in progress; he has been working with IP I on this, but it is not completed yet. Surveyor asked and was not provided any written documentation of inspections and control measures being completed.

Based on interview and record review, the facility did not ensure the mandatory submission of staffing data based on payroll data was completed. This had the ability to affect all 34 residents residing in the facility. Payroll Based Journal (PBJ) data was not submitted by the facility since the last annual survey. Findings include: PBJ staffing data reports generated quarterly indicated the facility triggered for Failed to submit PBJ data for the fiscal year quarter 3 2023 (April 1 - June 30). Review of the past year PBJ reports show no reporting was completed by this facility. On 11/06/23 at 1:30 PM, Surveyor spoke with Nursing Home Administrator (NHA) A and Director of Finances (DF) D concerning the PBJ. NHA A and DF D said the facility had never reported PBJ data because they are an Institution for Mental Diseases (IMD) Nursing Facility. Surveyor asked NHA A and DF D who told them that they did not need to submit the PBJ data. DF D said she had the email response in her office and will provide this information. On 11/07/23 at 10:05 AM, DF D provided the email dated 05/23/16 that the facility received from CMS Nursing Home Staffing concerning PBJ data submission. CMS responded with .Only long-term care facilities that are subject to meeting the requirements for participation as specified in 42 CFR Part 483, subpart B are subject to the PBJ reporting requirements .If your facility meets the definition of an institution for mental diseases .then you would not be subject to the PBJ reporting requirements . DF D said the response from this email was why the facility was not submitting PBJ data because they are an IMD nursing facility. Surveyor reviewed the email that further read, For Medicare and Medicaid purposes (including eligibility, coverage, certification, and payment), the facility is always the entity that participates in the program, whether that entity is comprised of all of, or a distinct part of, a larger institution. For Medicare, and SNF (see section 1819(a) (1) of the Act) and for Medicaid an NF (see section 1919(a) (1) of the Act) may not be an institution for mental diseases as defined in 483.1010 of this chapter. On 11/07/23 at 12:52 PM, Surveyor interviewed NHA A and Executive Director (ED) C concerning staffing schedules. Surveyor reviewed the recent working schedules along with looking at the triggered PBJ fiscal year (FY) Quarter 3 2023 indicated at least 1 Registered Nurse (RN) on staff per day for a 12-hour shift and at least a Licensed Practical Nurse (LPN) to cover the rest of the 24-hour period. There was always an RN available in the building 24/7, not to mention the Director of Nursing (DON), NHA, and ED are all RNs and available to help. Certified Nursing Assistants (CNA) coverage was sufficient with multiple ancillary staff who are CNA certified and will assist when needed. No concerns with staffing levels. On 11/08/23 at 10:00 AM, Surveyor interviewed ED C asking if the nursing facility participates in the Medicaid program and certification and follows the 42 CFR 483, subpart b. ED C indicated the nursing facility does participate with the Medicaid program. Surveyor explained by participating with the Medicaid program and certification they would need to follow the 42 CFR 483, subpart b and this includes the PBJ reporting. ED C acknowledged understanding of the requirement and the need to complete the PBJ reporting.

Based on observation and staff interview, the facility did not follow proper food handling practice. This practice had the potential to affect all 34 residents residing in the facility. Staff did not properly seal/cover and date open food items in the cold storage. Findings include: The facility policy entitled, Storage of Food and Supplies, revised December 7, 2020, which states in part, .Cover, label and date unused portions and open packages . On 11/06/23 at 7:34 AM, Surveyor completed the initial tour of the kitchen with Cook E. Cook E took Surveyor into refrigerated storage. There was a gallon of white milk opened and over half full on the shelf in the refrigerator. Surveyor noted there was no date written on the milk container as to when it was opened. Cook E then took Surveyor into the walk-in freezer. There was a package of hotdogs on the shelf that were open to the air and no date placed on the hotdog package as to when it was opened or expires. Surveyor asked Cook E about the items not labeled. Cook E took the open package of hotdogs out of the freezer. Surveyor followed Cook E out to the main kitchen area. Cook E placed the hotdogs on the counter and said to the staff near Cook E, This needs to be thrown away. On 11/07/23 at 11:16 AM, Surveyor interviewed Registered Dietician (RD) F about the observations made regarding foods opened, and not labeled. RD F replied, When items are opened they need to be labeled and food should not be left open to the air like the hotdogs in the freezer. On 11/08/23 at 7:15 AM, Surveyor interviewed Nursing Home Administrator (NHA) A. Surveyor asked NHA A, What is your expectation for open food in the kitchen as well as frozen food left open to the air? NHA A replied, The Executive Director (ED) C and I frequently walk through the kitchen, and we look for things that might not be ok. On Mondays we know that we are getting deliveries so we will give them a couple of hours to take care of the products then we go and see if there are any items on the floor or see if there are any items not labeled or open to the air. Our staff know that we are coming, and these things are not commonly found. Surveyor asked NHA A for a copy of the policy regarding dating open food in the kitchen.

Based on record review and interview, the facility did not implement policy and procedures related to screening employees for a prior history of abuse, neglect, exploitation of residents, or misappropriation of resident property for 1 of 8 employees reviewed. The facility did not ensure their abuse policy was implemented when one employee's Criminal Background Check (CBC) was not reproducible. Findings include: The facility policy, entitled Background Screening Investigations, revised 12/22/22, states in part .Our facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on individuals making application for employment with this facility; either every two- or four-years during employment as required by CMS regulations . On 11/08/23, Surveyor reviewed 8 random staff CBCs as part of the caregiver program compliance check. On 11/08/23 at 11:00 AM, Nursing Home Administrator (NHA) A stated the CBC for Registered Nurse (RN) H was completed in 2018 and then again in December 2022. The 2022 CBC was scanned into the Vidix human resources record system, which states that it was completed, but we are unable to see the CBC results. We called Vidix and they are trying to locate this CBC. NHA A said they will have RN H complete a new CBC today. On 11/08/23 at 11:38 AM, NHA A provided RN H's new CBC completed today, 11/08/23. On 11/08/23 at 1:04 PM, Surveyor interviewed Human Resources (HR) G Assistant concerning RN H's CBC completion in December 2022. HR G said RN H turned in the Background Information Disclosure (BID) form on December 15, 2022, and I ran the CBC on that date. RN H's CBC returned with no new findings from the 2018 report. If any CBC reports return with new information, I let the NHA review the results. I then scanned RN H's CBC into our HR record system Vidix. We have called Vidix to see if they can locate this CBC for us, but they said it could take a while to find it, if at all. Surveyor asked HR G what they do with the paper copy of the BID and CBC. HR G said they shred the BID and CBC once it was scanned into the system, so there was no hard copy of these documents. Every four years a new CBC needed to be completed on each employee per the facility's policy. RN H needed a CBC completed in 2022. The facility was not able to reproduce the 2022 CBC for RN H.

Based on personnel file review and interview, the facility did not employ on a full-time, part-time or consultant basis those professionals necessary to carry out the provisions of these requirements for 1 of 1 facility staff reviewed for verification of Nurse Technician (NT) credentials. This has the potential to affect all 34 residents that reside in the facility. Professional staff must be licensed, certified, or registered in accordance with applicable state laws. NT A is not licensed or credentialed to administer medications in a licensed nursing home in Wisconsin. This is evidenced by: During this recertification survey, NT A was chosen to be reviewed for verification of eligibility to pass medications. NT A was identified as a Nurse Technician on the employee list that was provided to the surveyors upon entrance. Surveyor reviewed the Wisconsin Nurse Aide Registry for NT A and noted NT A had no medication aide class completed on the registry. Surveyor then asked to review NT A's pharmacology course completion records and licensing credentials. The facility provided Surveyor with a certificate of completion for an associate's degree in nursing, dated 12/14/16. On 05/17/17 at 11:10 a.m., Surveyor interviewed the Nursing Home Administrator (NHA) regarding NT A. The NHA indicated that NT A had not passed her nursing boards on the first try and had not retaken the exam. Surveyor asked if NT A is currently passing medications in the facility, and the NHA replied, Yes. Surveyor asked if NT A had completed the state of Wisconsin challenge exam to certify her to pass medications in a skilled nursing facility. The NHA replied, No. Surveyor asked if NT A had a graduate nurse temporary permit. The NHA indicated that NT A did not have a permit. Surveyor requested the hours that NT A had worked passing medications in the facility. The facility provided the shifts NT A has worked since 01/01/17. The schedules document 27 shifts NT A worked in the facility passing medications to all residents that reside in the facility. At 11:40 a.m., Surveyor interviewed the NHA about the concerns that NT A was not a graduate nurse with a temporary permit nor certified by the state of Wisconsin to pass medications. The NHA stated that NT A would be taken off the schedule immediately and no longer be passing medications in the facility.

Based on observation, interview, medical record review and policy review, the facility did not ensure that an infection control program was implemented regarding hand hygiene procedures for 2 of 4 residents whose personal cares were observed (R4 and R6). Staff did not perform hand hygiene at appropriate intervals while providing personal cares for R4 and R6. This is evidenced by: 1. Surveyor observed Certified Nursing Assistants (CNAs) C and D perform personal cares for R4 on 05/17/17 beginning at 6:25 a.m. After performing upper body care, CNA C performed frontal peri care, rolled R4 to his right side, and washed his buttocks and anal area. While wearing the same gloves, CNA C touched the clean disposable brief, then opened a dresser drawer and retrieved a plastic bag, and placed R4's wet brief in the bag. CNA C removed her gloves, placed them in the bag, tied the bag shut, and did not wash or sanitize her hands. CNA C then went into R4's bathroom and touched his wheelchair to bring it closer, picked up R4's gown and placed it in a plastic bag, picked up the mechanical lift sling and placed it on the bed, adjusted R4's shirt and assisted CNA D to pull up R4's shorts, turning him from side to side to adjust his clothing. CNA C then took her facility phone out of her pocket, looked at it, placed the phone back in her pocket, and then touched the mechanical lift and R4's wheelchair. CNA D put on R4's right stump sock and CNA C put the stump sock on R4's left leg. CNA C touched the lift controls, and the CNAs transferred R4 to his wheelchair. They both unhooked the sling from the lift. CNA C used a wipe to sanitize the lift, then made R4's bed. CNA C then washed her hands for the first time since performing peri care. 2. Surveyor observed CNAs C and D perform personal cares for R6 on 05/17/17 at 6:45 a.m. CNA C entered R6's room and washed her hands. CNA C then opened R6's closet door and took out clothing for R6 to wear, and placed the items on the foot of R6's bed. CNA C touched the lift controls to raise R6's bed, and then picked up R6's razor and began to shave R6, and moved his oxygen tubing away from his nose. CNA D entered the room, washed her hands, wet two washcloths, and brought them and a towel to the bedside. CNA D removed R6's oxygen from his face. After upper body cares were completed, CNA D performed frontal peri care. CNA C took her phone out of her pocket to call Registered Nurse (RN) F to come to the room to apply barrier cream to a small slit at the base of his right buttock. The CNAs then rolled R6 to his left side and CNA C washed R6's buttocks and anal area. RN F entered R6's room and dropped a disposable glove on the floor, picked it up, walked to the bathroom to dispose of it, reached into the glove box and retrieved another glove, and donned the disposable gloves. RN F picked up a jar of Lantaseptic barrier cream and applied it to R6's lower buttock. RN F took off her right glove, and placed the cover of the Lantaseptic back on the jar, and placed the jar in R6's night stand drawer. RN F washed her hands and left the room. The above observation continued, and CNA D removed her gloves but did not wash or sanitize her hands, and assisted CNA D in putting a clean disposable brief on R6. CNA D pulled down R6's blankets and both CNAs put socks on R6's feet, and put his pants on. CNA D turned off the oxygen concentrator, and they rolled R6 to place his mechanical lift sling. Both CNAs put R6's immobilizer on his right leg. CNA D picked up a dark blue rug/mat from the floor, put it near the head of the bed, and brought the mechanical lift to the bedside. R6 then stated that he wanted to sleep longer, so CNA D put the nasal cannula of his oxygen tubing back on his face, touched the bed controls to lower the bed, covered R6 with his blankets, and placed the rug back on the floor. CNA D sanitized the mechanical lift and placed the lift in the hall. She returned and washed her hands for the first time since performing peri care. Surveyor interviewed RN F on 05/17/17 at 7:25 a.m. RN F told Surveyor that she had sanitized her hands before entering R6's room. At 9:15 a.m. on 05/17/17, the Nursing Home Administrator (NHA) told Surveyor that CNA D told her, I really screwed up with hand washing this morning during R6's personnel cares. Surveyor interviewed the NHA and Executive Director (ED) E on 05/18/17 at 1:00 p.m. and shared the details of the above observations. The NHA stated that CNAs C and D had been educated, and that other CNAs would be educated as well.

Based on observations, interview, policy review and medical record review, the facility did not maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection for 5 of 5 personal cares observed. Resident #1, #2, #6, #5, and #3 had personal cares provided where the Certified Nursing Assistant did not remove her gloves or wash her hands per the facility policy to prevent infections. This is evidenced by: The facility policy titled, Handwashing, includes in part: Handwashing is regarded by this facility as the single most important means of preventing the spread of infections. Policy Interpretation 4. employees must wash their hands for at least twenty seconds .under the following conditions: s. After contact with a resident's mucous membranes and body fluids or excretions. w. After removing gloves 6. Hand hygiene is always the final step after removing and disposing of personal protective equipment. 7. The use of gloves does not replace handwashing. 1. On 04/05/16 at 8:35 a.m., Surveyor observed Certified Nursing Assistant (CNA) C and CNA D assist Resident #1 with personal cares. Both CNAs washed their hands when entering the room, for a time of five to six seconds, and donned gloves. After checking Resident #1's incontinence status, the CNAs removed their gloves and washed their hands for five seconds. 2. On 04/05/16 at 9:50 a.m., Surveyor observed CNA C assist Resident #2 with catheter cares. CNA C entered the room and washed her hands for seven seconds. CNA C then put on gloves and emptied the catheter, wiped the port with alcohol, emptied the graduate of urine into the toilet, rinsed out the graduate and removed her gloves. CNA C then washed her hands for five seconds. 3. On 04/05/16 at 9:20 a.m., Surveyor observed CNA B and CNA D assist Resident #6 to the bathroom. CNA D entered the room and washed her hands for six seconds and donned gloves. CNA D pulled down Resident #6's pants, touched the incontinent pad, removed her gloves, washed her hands seven seconds and put on new gloves. Resident #6 had a bowel movement, CNA D washed Resident #6's bottom. CNA D then removed her gloves, did not wash or sanitize her hands, and pulled up Resident #6's pants, pulled down his shirt, touched the gait belt and the wheelchair handles to get the wheelchair into position. After touching all of the other objects, CNA D washed her hands for 12 seconds. On 04/05/16 at 3:00 p.m., Surveyor shared the above observations with Registered Nurse (RN) A, who is the infection control nurse. RN A stated she would do education with the CNAs, and continue to do audits on personal cares. 4. On 04/05/16 at 8:30 a.m., Surveyor observed both CNA E and CNA F provide personal cares for Resident #5. Surveyor observed CNA E provide pericare and when finished, she removed her gloves and washed her hands for four seconds. 5. On 04/05/16 at 8:45 a.m., Surveyor observed CNA F provide personal cares for Resident #3. Resident #3 had a bowel movement on the toilet and then stood up and walked to the sink. CNA F removed several dry towelettes and put them in the bottom of the sink and turned the water on. CNA F then used the moist towelettes to provide pericare for Resident #3. When CNA F was finished with personal cares, Surveyor asked CNA F if the sink was clean or dirty. CNA F stated the sink was considered dirty and should not have placed the clean towels into the sink to get them wet. On 04/06/16 at 10:00 a.m., Surveyor interviewed RN G in regard to the above noted observations with both CNA F and CNA E. RN G stated CNA E should have washed her hands longer and CNA F should not have been using the sink to moisten the towelettes to provide cares.

Based on record review and interview, the facility did not provide a thorough comprehensive assessment related to a decline in both bowel and bladder continence for 1 of 9 residents (Resident #5) reviewed for bowel and bladder incontinence. Resident #5 had a decline in both bowel and bladder function and the facility's assessment did not include a rationale for the decline. As evidenced by: On 04/05/16 at 10:10 a.m., Surveyor reviewed the medical record for Resident #5 and noted the following: - Minimum Data Set (MDS), dated [DATE], stated Resident #5 was severely cognitively impaired and was frequently incontinent of bowel and bladder function. - MDS, dated [DATE], stated Resident #5 was severely cognitively impaired and was always incontinent of bowel and bladder function. - Comprehensive nursing care plan, received 04/06/16, states Resident #5 has functional urinary and bowel incontinence related to cognition, dementia and inability to bear weight on right side due to AKA (above knee amputation). Surveyor was unable to identify a rationale for Resident #5 to be a check and change only. On 04/06/16, Surveyor reviewed facility bowel and bladder assessments for Resident #5 and noted the following: - 05/27/15: Bladder and bowel assessment: Resident #5 is frequently incontinent of both bowel and bladder function and wears an incontinent product. - 11/25/15: Bladder and bowel assessment: Resident #5 is always incontinent of bowel and bladder function and wears incontinent products. Surveyor was unable to identify a rationale for the decline in bowel and bladder function noted on the above assessment, dated 11/25/16. On 04/06/16 at 10:00 a.m., Surveyor interviewed Registered Nurse (RN) G in regard to Resident #5's decline in bowel and bladder function, asking what interventions the facility had implemented to assist Resident #5 in restoring bowel and bladder function. RN G stated it was impossible to restore Resident #5's bowel function. RN G stated Resident #5 is a hoyer lift and this makes him very anxious. RN G indicated Resident #5 becomes aggressive and upset when a mechanical lift is used. RN G states the facility tried using a urinal but that didn't work either. RN G stated there is concern of using a bed pan because of Resident #5's fragile skin and the probability of skin breakdown. At this time, they placed him on a check and change schedule. RN G stated the facility's goal was not to place undue stress on Resident #5. Surveyor asked RN G where this rationale was on the assessment. RN G stated it wasn't in the assessment, but it should be included.

Based on observation, record review and interview, the facility did not review and revise resident care plans to reflect current status or change in condition in 2 of 10 sampled residents reviewed for care plan accuracy. This is evidenced by: 1. Resident #4's [DIAGNOSES REDACTED]. On 03/04/15, Surveyor observed staff assisting Resident #4 with the noon meal. Resident #4 was receiving thickened liquids with staff assistance. Surveyor reviewed Resident #4's Physician Orders. The Physician order [REDACTED]. Surveyor reviewed Resident #4's care plan. The care plan, entitled "Corp-Profile History Report," read in part, "...continue dietary consistency of puree solids with thin liquids." Surveyor interviewed the Director of Nursing (DON). The DON acknowledged that the care plan outlined thin liquids and did not match the Physician order [REDACTED]. The DON told Surveyor the care plan would be amended to include the correct fluid consistency. 2. Resident #1's [DIAGNOSES REDACTED]. On 03/04/15, 03/05/15 and 03/06/15, Surveyor observed Resident #1 sitting in a dining room chair for meals and entertainment. Resident #1 did not have a pillow under her right arm. Surveyor reviewed Resident #1's care plan. The care plan, entitled "Corp-Profile History Report," read in part, "...make sure right arm is supported with pillow if seated, especially in the recliner." On 03/05/15, Surveyor interviewed the DON and Registered Nurse (RN) B. RN B stated the intervention was not current and had stemmed from an injury that had since healed. RN B acknowledged the intervention should have been discontinued when the injury intervention was no longer appropriate. Surveyor reviewed a policy entitled "Care Plans-Comprehensive." The policy stated, in part, "...The Care Planning/Interdisciplinary Team is responsible for the periodic review and updating of care plans...."

Based on observation, interview, and record review, the services provided by the facility were not in accordance with the written plan of care for 1 of 10 sampled residents (Resident #2). Resident #2's plan of care states to keep either the TV or radio on so she can hear noise while in her room, and to keep bed in lowest position for safety when in bed. These things were not observed to occur during the survey. This is evidenced by: Resident #2's medical record, including the plan of care, was reviewed by Surveyor on 03/3-4/15. Resident #2's plan of care states under fall approaches: -"Keep either TV or radio on so she can hear the noise while in her room." -"Bed in lowest position with brakes locked for safety when in bed." On 03/03/15 at 1:45 p.m., Surveyor observations included the following. Certified Nursing Assistant (CNA) A entered Resident #2's bedroom. Resident #2 was lying in the low bed and the TV or radio was not on. CNA A raised the bed to hip height to empty the catheter bag. After emptying the catheter bag, CNA A walked to the resident's bathroom, out of line of sight of resident, leaving the bed in the high position with the resident in the bed. CNA A returned from the bathroom and completed the catheter care, lowered the bed and exited the room. CNA A did not turn on the radio or TV. On 03/04/15 at 10:20 a.m., Surveyor interviewed the Director of Nursing (DON). The DON indicated the plan of care is current and the radio or TV should have been on when Resident #2 is in the room and the bed should be in the lowest position whenever the resident is unattended. The DON confirmed the plan of care was not followed during the above observation.

Based on record review and interview, the facility did not provide interest bearing accounts for excess of $50.00 for 3 of 3 residents (Resident #1, 2, 10) whose accounts were reviewed. This is evidenced by: Facility Policy titled, "Resident/Client Fund," dated January 2006, stated, "Accounts with over $50 will be reviewed for savings when feasible based upon resident/client cash habits and banks availability for interest bearing accounts, with accounts of over $500 automatically considered (with resident/client's permission) for savings." 1. Resident #1: On 03/05/14 at 9:00 a.m., Surveyor # reviewed the Resident Trust Fund Statement for Resident #1, dated 12/01/13 - 03/04/14. The statement stated Resident #1 had a balance on 12/01/13 of $133.71. The ending balance on 03/04/14 was $133.71. No interest was noted on the statement. 2. Resident #2 On 03/05/14 at 9:00 a.m., Surveyor # reviewed the Resident Trust Fund Statement for Resident #2, dated 12/01/13 - 03/04/14. The statement for Resident #2 had a balance of $68.57 on 12/17/13 and an ending balance of $53.63 on 01/23/14. No interest was noted on the statement during this time frame. 3. Resident #10 On 03/05/14 at 9:00 a.m., Surveyor # reviewed the Resident Trust Fund Statement for Resident #10, dated 01/01/14 - 03/04/14. The statement stated Resident #10 had a balance of $70.41 on 01/01/14 and an ending balance of $123.34 on 02/13/14. No interest was noted on the statement during this time frame. On 03/05/14 at 9:05 a.m., Surveyor # reviewed the Facility's admission packet and the following was noted: "TCHCC (Trempealeau County HCC) must deposit any of your funds in excess of $50 in an interest bearing account which is separate from any of TCHCC's operating accounts. Any interest that is earned is credited to your account. Funds less than $50 may be kept in a non-interest bearing account or petty cash fund." On 03/05/14 at 9:15 a.m., Surveyor # interviewed the Nursing Home Administrator (NHA). This surveyor asked the NHA if resident accounts in excess of $50.00 were placed in an interest bearing account and the NHA stated, "No." The NHA stated local banks do not like to offer small accounts for less than $200.00. The NHA stated they would end up paying too much in fees if they tried to open so many small accounts and the banks only pay 1/10 of 1% of interest for a savings account. This surveyor interviewed Patient Accounts Clerk (PAC) A. PAC A stated resident accounts only get interest when it is feasible. PAC A stated, "We do have a trust fund but it is hard to split the interest." This surveyor asked the NHA if residents, who have more than $50.00 in an account, were receiving interest and the NHA stated, "No." The NHA agreed with this surveyor in that residents who have $50.00 or more in an account should be receiving interest stating, "This has been a problem for years." The NHA stated he will be putting a system together to ensure that interest be dispersed when required. No further information was provided.

Based on observation, staff interview and policy review the facility did not provide a safe and sanitary environment to help prevent the development and transmission of disease and infection during 1 of 3 resident care observations, performed by 2 of 7 Certified Nursing Assistants (CNAs) who were observed providing personal cares. Resident #6 was observed during personal cares on 02/13/13 where the CNAs did not perform proper hand hygiene in accordance with current standards of practice, the facility policy or the most recent education provided by the facility. This is evidenced by: The 09/2011 facility policy titled "Hand washing" read in part: Policy Statement Hand washing is regarded by this facility as the single most important means of preventing the spread of infections. Policy Interpretation and Implementation 2. All personnel shall follow our established hand washing procedures to prevent the spread of infection and disease to other personnel, residents and visitors. 4. Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: c. Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice); i. Before and after assisting a resident/client with personal care; o. Before and after assisting a resident with toileting; w. After removing gloves; Procedure 2. Wet hands first with water and then vigorously lather hands with soap and rub them together, creating friction to all surfaces, for at least fifteen (15) seconds under a moderate stream of running water, at a comfortable temperature... 3. Rinse hands thoroughly under running water. Hold hands lower than wrists. Do not touch fingertips to inside of sink. 4. Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel. Resident #6 was admitted to the facility on [DATE]. Resident #6 had [DIAGNOSES REDACTED]. Resident #6's 01/11/13 Minimum Data Set (MDS) assessment identified Resident #6 required extensive assistance of two staff for dressing, toileting and hygiene needs. On 02/13/13 beginning at 4:05 p.m. Surveyor observed CNA A and CNA B assist Resident #6 to the bathroom. After Resident #6 was seated on the toilet, both CNA A and CNA B removed their gloves and washed their hands. Surveyor observed from the time CNA A turned the water on until he turned the water off, the hand wash was only approximately 10 seconds total. CNA B washed her hands for only approximately six seconds for the entire procedure. Both CNA's then re-gloved and assisted Resident #6 off the toilet. While Resident #6 was standing CNA A obtained a disposable wipe and cleaned Resident #6's buttocks area with the disposable wipe. CNA A then removed his gloves and without washing or sanitizing his hands, CNA A touched the armrest of Resident #6's wheelchair, the gait belt and Resident #6's shirt. Once Resident #6 was seated in his wheelchair, CNA A washed his hands for approximately seven seconds for the entire hand washing procedure. Beginning at 4:07 p.m. on 02/18/13, the Director of Quality Improvement (DQI) F spoke with Surveyor and explained the facility had staff complete hand hygiene in-service in 01/2013 on the Silver Chair (computerized) in-service system. DQI F stated with training staff complete a pre and post test and staff were educated to wash their hands for 20-25 seconds. Surveyor pointed out the facility policy identified 15 seconds for hand washing. DQI F was asked if they had a different updated hand hygiene policy from the one Surveyor had been given. DQI F said no, they will need to update the policy to reflect the training. Surveyor asked DQI F if he could check to see if CNA A and CNA B had completed the hand hygiene in-service in 01/2013. On 02/19/13, DQI F provided Surveyor with a print out of the education provided to employees with the 01/2013 hand hygiene in-service. In the material provided, page 8 of 20 read "Lather and scrub for at least 20 to 25 seconds. Cover all surfaces, including the backs of your hands." Surveyor was also provided with verification CNA A had completed the hand hygiene education on 01/30/13 and CNA B had completed the hand hygiene education on 01/02/13.

Based on observation, interview, medical record review and policy review, the facility did not complete an interdisciplinary team assessment to ensure 1 of 1 supplemental resident reviewed for self-administration of medications was safely able to do so. Resident #11 was observed on 02/13/13 and 02/14/13 independently self-administering medication by inhalation through a mask used for an updraft/nebulizer treatment. Resident #11 had not been assessed for safe self-administration of the medications; there was no physician order or care plan for Resident #11 to self-administer his updraft medications. This is evidenced by: The 11/2011 facility policy titled "Self Administration of Medication" read in part as follows: 1. As part of their overall evaluation, the staff and practitioner will assess each resident/client's mental and physical abilities to determine whether a resident/client is capable of self-administering medications. 5. Findings of the interdisciplinary team's assessment must be documented in the resident/client's clinical record. 6. A physician's order must be obtained for self-administration of medication. 7. A plan of care will be developed for self-administration of medications. 10. The resident/client's care plan shall indicate the resident/client self-administers his/her medications. Resident #11 was admitted to the facility on [DATE]. Resident #11 had [DIAGNOSES REDACTED]. On 02/13/13 at 4:05 p.m. Surveyor entered Resident #11 and Resident #6's room to observe cares for Resident #6. Surveyor observed Resident #11 in his bed with a nebulizer mask on, receiving a nebulizer treatment. A staff person was standing near Resident #11's bed when Surveyor and other staff entered the room. The staff person standing near Resident #11 ' s bed left the room at approximately 4:07 p.m., while Resident #11's nebulizer was still going. Surveyor observed this same person return to Resident #11's room at 4:17 p.m. and shut the nebulizer machine off and remove the nebulizer mask from Resident #11's face. On 02/13/13 at approximately 4:35 p.m., Surveyor asked the staff person who had initially been in with Resident #11 and then returned to shut off the nebulizer machine and remove his mask what her name and title were. The Certified Nursing Assistant (CNA) E identified herself and verified she was a CNA. The Registered Nurse (RN) on duty, RN C was not in the room while Resident #11 was receiving his nebulizer treatment during the above observation on 02/13/13. On 02/14/13 beginning at 10:25 a.m. Surveyor observed Licensed Practical Nurse (LPN) D prepare Resident #11's [MEDICATION NAME] treatment. LPN D put the medication in the nebulizer cup and applied the nebulizer mask to Resident #11's face and turned on the nebulizer machine. LPN D then said to Resident #11, "I'm going to let it run for 10-15 minutes, then I'll be back to check your lungs." LPN D left Resident #11 in his room unattended with his nebulizer treatment going. On the afternoon of 02/14/13, Surveyor shared the above observations with the Director of Nursing (DON) and asked for a copy of Resident #11's self-administration assessment, physician order and care plan for self-administering his nebulizer unattended. On the morning of 02/18/13, Surveyor was provided with a copy of a "Self-Administration Of Medication Assessment" completed on 02/15/13 by the DON, a copy of a physician order for [REDACTED].#11's care plan that contained an approach dated 02/15/13 that identified Resident #11 could self-administer his updraft after set up. On 02/18/13 at 12:45 p.m. Surveyor met with the DON and verified Resident #11 had not had an assessment to self-administer his nebulizer, a physician order to do so or a care plan that identified he was able to self-administer his nebulizer until 02/15/13, after Surveyor had brought the concern to the DON's attention.

Based on observation and interview the facility did not post RN (Registered Nurse) and LPN (Licensed Practical Nurse) hours separately on the daily nurse staff posting. This had the potential to affect all 34 residents of the facility, as well as family and visitors interested in the staffing pattern of the facility. The facility posting listed all RN and LPN as Licensed Nursing Staff. The facility combined RN and LPN hours and listed the total number of staff for each shift. This is evidenced by: Surveyor reviewed the daily staff posting of the facility. The posting indicated the total number of licensed nursing staff and CNA's (Certified Nursing Assistants) per shift. The licensed nurses shifts did not indicate how many of the nurses were RNs or LPNs. The daily licensed nursing staff reports for dates 02/13 - 02/19/2013 were reviewed. All daily nurse staff postings reviewed listed the total number of licensed staff working on each shift. On 02/19/2013 at 11:00 a.m., Surveyor discussed with Director of Quality Improvement F that the daily nurse staff postings did not identify separately the RN and LPN hours. On 02/19/13 at 1:00 p.m., the DON provided Surveyor with a daily nurse staff posting form that was updated on 02/19/13. The daily nurse staff posting form separated the RN and LPN hours under the section, "Licensed Nursing Staff".

Based on observation, interview and record review the facility did not ensure that a resident assessment result was used to develop, review and revise the resident's comprehensive plan of care for 4 residents out of 10 reviewed Residents 5, 6, 8 and 7). Resident 5 was assessed to need alarms after receiving a fracture of her leg. Resident 5 was unhooking her alarms. Resident 5 had a fall after unhooking her alarms on 10/19/11. Resident 5's care plan was not updated and/or revised when staff was aware that she was unhooking her alarms. Resident 6's care plan was not updated to reflect his current status. Resident 8's care plan was not updated to reflect that he no longer used a TABS alarm. Resident 7's care plan was not updated or revised when the facility became aware that Resident 7 was unhooking the alarms. Findings as follows: Example 1 Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. Resident 1 was ambulating independently. On 9/21/11 Resident 5 had a fall that resulted in a broken bone in her leg. Resident 5 had surgery and was readmitted to the facilty with a no weight bearing status. Resident 5's BIMS (Brief interview of mental status) score from her 10/5/11 significant change of status MDS (minimum date set) is a 9, which indicates cognitive impairment. Resident 5's comprehensive care plan related to falls implemented on 4/24/09 reveals an approach added 10/5/11 to include utilizing a low bed with mat on floor, TABS bed and clip monitor and Home free monitor on bed to alert staff of attempted self transfers. TABS clip on wheel chair and Home free detection unit on cushion in wheelchair. (The CNA care plan also states the same interventions for Resident 5.) An approach added to Resident 5's care plan dated 10/19/11 states that Resident 5 had a fall as she unhooked the TABS alarm and self transferred. Resident 5 continues to unhook the monitors and attempt to self transfer. On 11/7/11 at 10:00 AM Surveyor entered Resident 5's room introduce self. Resident 5 stated that she needed to lay down bad and and she transferred herself from her wheel chair to her bed. No alarms were sounding at the time of observation. This was reported to facility staff. An observation at 2:30 PM of Resident 5 in her bed indicates that her TAB alarm that was pinned to her shirt was not on her person, and the TABS bed sensor was not hooked up to the sensor. A therapy person came into room and was going to ambulate her. When Resident 5 got out of the bed her Home free sensor pad alarmed. Resident 5 has a total of 3 alarms in bed and she has a history of unhooking the alarms. On 11/10/11 at 2:00 PM Surveyor requested follow up on Resident 5's 10/19/11 fall when she unhooked her alarms. DON B indicated that Resident 5's alarm does sound at times as she is not consistently taking the alarm off every time and still can alert staff of her attempting to self transfer, in addition a Home free fall detection unit was added for bed an chair. (It is important to note that the Home free alarm was added to Resident 5's bed and wheelchair on 10/5/11 according to Resident 5's care plan). It is documented in Resident 5's medical record and staff are aware that Resident 5 is taking off her alarms that are assessed by the facility to need to alert staff for attempts of self transferring. The facility is aware that this intervention is not effective and Resident 5's care plan is not updated with new interventions to prevent her from unhooking the alarms Example 2 Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/9/11 at 8:15 AM Surveyor observed cares for Resident 6. Resident 6 was lying on his bed and independently got out of bed and showed the surveyor and RN C his bottom per RN D request. Resident 6's ischium had a scar area but the pressure area was healed. RN C stated that the pressure ulcer had been healed for some time. RN C went on to state that Resident 6 was very sick when he first came and now is pretty independent. Resident 6's care plan start date 9/30/11 indicates the following interventions: *utilize a pressure reducing pad in his wheelchair * pressure reducing mattress-an air overlay mattress that will be on hourly checks for monitor that it is working properly *reposition every 2 hours from side to side avoiding his left ischium *remind/Assist to toilet upon rising after meals and prior to HS to reduce the potential for incontinence and increased moisture *encourage to lay in bed rest after each meal to limit time on buttocks *encourage to walk at least 1 time per shift using staff assist, gait belt, and walker. * administer [MEDICATION NAME] coagulant *INR (international Normalized Ratio) and follow up with MD *infection to stage 3 pressure ulcer on left ischial tuberosity and induration of left posterior medial upper thigh. Additionally the intervention lists all treatment and dressing change instructions *minimize time spent in wheelchair to promote healing to ulcer *will be going to (facility name) daily until 10-2-11 to received IV [MEDICATION NAME] therapy *Has a PICC (a type of IV) line in place that is ordered to be removed after his last dose of antibiotic on 10/2/11. Additionally the intervention lists all PICC line care orders On 11/9/11 at 10:00 AM Surveyor interviewed RN C regarding Resident 6's care plan. RN C reviewed the above interventions with Surveyor and did state the above interventions were not longer appropriate and should not be on the care plan. RN C stated that she did not get to updating his care plan yet, and she placed him on the list to be done in early December. Example 3 Resident 8 was admitted to the facility with [DIAGNOSES REDACTED]. On 11/10/11 at 8:55 AM Surveyor observed Resident 8 in his wheelchair. Surveyor observed that he had a pressure alarm in his wheelchair. Surveyor did not observe any other alarms on his wheelchair. On 11/10/11 at 9:00 AM, CNA's E, F, and G assisted Resident 8 to the toilet. Surveyor asked if Resident 8 had a tabs alarm on his wheel chair. CNA's E, F, G stated that he used to be all agreed that he has not used on for a while. Surveyor asked CNA F to see the CNA care plan (noted to be last updated 10/27/11), it states that Resident 8 was to have a tabs alarm and home free alarm (pressure alarm) while in wheel chair, bed or recliner to alert staff of attempts to transfer independently. Make sure tab clip locking mechanism is in place and working. Has history of removing his tabs off of his clothing and self transferring. Place tab clip in a position that he is not able to unhook. CNA D stated that she would check into the tab alarm. Resident 8's comprehensive care plan dated 5/1/11 indicates an intervention to utilize tabs alarm and make sure locking mechanism is on TAB clip is in place and working. Has history of unhooking his TAB alarm of his clothing and self transferring. Place TAB clip in a position that he is unable to unhook. On 11/10/11, at 9:30 AM Surveyor interviewed RN C regarding Resident 8's TAB alarm. RN C stated that Resident 8 no longer uses a TAB alarm and the care plan should have been updated. Example 4 Resident 7 was identified as being at risk for falls and a care plan was initiated on 6/22/09. Per Resident 7's plan of care a TABs alarm was to be used in bed and in the wheelchair for safety on or before 10/17/10. On 7/29/11 the care plan reflex the addition of a Home Free Falls Detection Unit placed on Resident 7's wheelchair and bed along with the TABs device. Resident 7's nursing notes indicate that on 7/23/11, Resident 7 was found sitting on the edge of the bed and the TABs alarm was unhooked. Resident 7 stated he unhooked the alarm. On 7/24/11 Resident 7 was noted to be sideways in bed and again had disconnected the TABs alarm. There is no indication the facility addressed Resident 7's ability to unhook the TABs alarm and continued to use the TABs alarm as a safety device. On 11/10/11, at 12:21 PM, Surveyor interviewed Director of Nursing (DON) B about Resident 7's TABs alarm. DON B stated Resident 7 puts himself on the floor at times thus the facility did not consider them falls and were not looking at Resident 7 with the falls program. DON B stated Resident 7 probably should not have a TABs alarm on in bed if he is taking it off and putting himself safely on the mat on the floor.