Every finding on record at Water's Edge

The facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. This has the potential to affect 21 residents (R4, R10, R11, R12, R13, R14, R15, R16, R18, R19, R26, R27, R29, R6, R31, R32, R35, R36, R39, R40, and R41) of 39 residents on the Sunrise Bay Unit of the facility. Staff did not wear hair restraints properly while preparing food in the kitchenette.Staff did not perform hand hygiene with glove use.Staff did not consistently date or label food items when opened.Staff observed touching ready to eat food with contaminated gloves.Findings:Example 1The 2022 FDA Food Code documents at 2-402 Hair Restraints2-402.11 Effectiveness.(A) Except as provided in (B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single use articles.Facility policy titled, Food Service Infection Control/Personal Hygiene (no revision date noted) Date of origin: 1987, stated in part: 6. Hair must be worn back from the face and off the collar. Hair should be kept clean, groomed, hair sprayed and /or [NAME] pinned. All hair must be contained/covered by hair net or cap and worn at all times in designated areas.On 06/29/2026 at 10:13 AM, Surveyor observed in Sunrise Bay kitchenette Certified Nursing Assistant (CNA) M put hair net on and did not pull up and cover the ponytail portion of her hair which hung down to the midback area.On 06/29/2026 at 10:18 AM, Surveyor asked CNA M if the ponytail portion of her hair sticking out of the back of the hair net was acceptable while working in the kitchen and serving food to the residents. CNA M shook her head in a No direction.Example 2Facility policy titled, Hand Hygiene, revised 2/19/26, stated in part: .INDICATIONS FOR HANDWASHING AND HAND ANTISPESIS per WHO .3. Clean hands before donning gloves and after removal of gloves . 7. Clean hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of patient .8. Before eating or preparing food and after using a restroom, wash hands with soap and water.On 06/29/2026 at 10:13 AM, Surveyor continued observation of CNA M in the kitchenette. CNA M washed hands in the sink, put on single use gloves, took a plate out of the refrigerator and placed it in the microwave. CNA M left the kitchenette to ask a kitchen staff person for a food thermometer. CNA M found the thermometer and took the temperatures of the food items on the plate with the gloved hands. CNA M removed the gloves and did not perform any hand hygiene. CNA M put on new gloves, took three juice glasses, and filled one with ice and water from the tap. CNA M took milk and juice out of the refrigerator, poured into the glasses and served residents in the dining room. On 06/30/2026 at 11:16 AM, Surveyor informed Director of Nursing (DON) B of the glove use without hand hygiene. DON B informed Surveyor hand hygiene is expected before putting on gloves and after removing gloves.Example 3The 2022 FDS Food Code documents at 3-501.18Ready-to-Eat, Time/Temperature Control for Safety Food: Disposition .A date marking system may be used which places information on the food, such as on an overwrap or on the food container, which identifies the first day of preparation, or alternatively, may identify the last day that the food may be sold or consumed on the premises. A date marking system may use calendar dates, days of the week, color coded marks, or other effective means, provided the system is disclosed to the Regulatory Authority upon request, during inspections.Facility policy titled, Nutrition Services, Label, Dating, Stocking of Food, Beverage and Supplies. For Care Center and Hospital stated in part: Policy Food, beverage, and supplies will be stocked in such a way as to maintain a standard par level of stock in each kitchen on units. As well as proper label and dating.Procedure1.Nursing will send requests to Nutrition Services when supplies are needed. Three times per week, the Nutrition Services staff or volunteers will check the amount of food and supplies needed in each hospital kitchenette. Nourishments include, but are not limited to, bread, margarine, peanut butter, jelly, ice cream, juices, milk, and instant breakfast drinks. Kitchenettes will be stocked as needed. All outdated items will be disposed of.2. Daily, the CNAs will check for items needed, checking for and disposing of outdated items.On 06/29/2026 at 10:13 AM, Surveyor observed CNA M pouring milk and juice into three different glasses. Surveyor noticed the top of the juice pitcher had a small 1/2 inch diameter sticker with a date on it. Surveyor asked CNA M if there was a date anywhere on the open and used gallon of milk. (The gallon of milk was about 2/3 full at this time). CNA M confirmed there was no date on the milk container. CNA M then served the milk to R6 sitting in the dining room.On 06/29/2026 at 8:37 AM, Surveyor asked Dietary Aide (DA) P if they could look at the milk jug in the refrigerator. DA P said, Sure, and pulled out the milk jug. No opened date noted on the used gallon of milk. Surveyor asked DA P, Do you typically mark the milk jug when you open it? DA P replied, No, we usually use it up that same day. Surveyor asked, What if something gets pushed in front of it like a gallon pail of something? DA P replied, No, we use it up right away. Surveyor asked, So, it is not a common practice to mark a gallon of milk with the date opened? DA P replied, No. Surveyor noted there were other staff in the kitchenette listening and did not say anything.On 06/30/2026 at 9:09 AM, Surveyor asked Dietary Manager (DM) Q, Is it a common practice to label a gallon of milk with the date that it is opened? DM Q replied, No, because we go through it right away. Well except one time there was a gallon of whole milk that was not being used right away.Example 4The 2022 FDA Food Code documents 3-304.15 Gloves Use Limitation: (A) 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.On 06/29/2026 at 12:55 PM, Surveyor observed DA N serving hot food in the Sunrise Bay unit wearing blue single use gloves. DA N was touching multiple potentially contaminated surfaces with gloved hands. Surveyor observed DA N touching lids that covered the hot food items, ladles, the steam table edging directly in front of her, plates, and multiple bun bags. Surveyor then noted that DA N picked up a bun with the contaminated gloves, put it on a plate, then put a cheeseburger on the bun using tongs, and then placed the top of the bun on the cheeseburger. Surveyor observed DA N pick up half of a cheeseburger (that was cut previously) and place it on a plate with the same contaminated gloves and then served it to the resident in the dining room.On 06/29/2026 at 9:11 AM, Surveyor informed DM Q of this observation. DM Q replied, No, this is not our practice.

Based on observation, interview and record review, the facility did not ensure residents were free of significant medication errors for 1 of 5 residents (R7) reviewed from a sample of 13 residents.R7's sliding scale insulin and as needed (PRN) furosemide were not administered per physician orders having the potential to cause harm.This is evidenced by:Facility policy titled, 'Medication Administration,' with a reviewed date of 12/03/25, states: All medications will be.administered according to physician order and documentation of administration recorded appropriately in the resident's medical record.R7 was admitted to the facility on [DATE] with type 2 diabetes mellitus and edema.R7's physician orders:-insulin lispro 100 unit/ml sub Q per sliding scale four times a day:<70 = initiate hypoglycemic protocol150-199 = 1 units200-249 = 2 units250-299 = 3 units300-349 = 4 units>349 = 5 units call MD-furosemide 20 mg tab give 0.5 tab (10 mg) PO daily PRN for wt gain of 3 pounds overnight.Surveyor reviewed R7's medication administration record (MAR):03/06/26, R7's weight was 283.6 lb.03/07/26, R7's weight was 292 lb., an increase of 8.4 lb. PRN furosemide was not administered per physician orders.04/02/26, R7's weight was 281.6 lb.04/03/26, R7's weight was 284.8 lb., an increase of 3.2 lb. PRN furosemide was not administered per physician orders.04/17/26, R7's weight was 282.8 lb.04/18/26, R7's weight was 285.8 lb., an increase of 3 lb. PRN furosemide was not administered per physician orders.04/30/26, R7's AM blood glucose was 404 and 4 units of insulin lispro were administered. Physician orders were not followed; 5 units of insulin should have been administered.05/19/26, R7's weight was 290.4 lb.05/20/26, R7's weight was 298 lb., an increase of 7.6 lb. PRN furosemide was not administered per physician orders.05/28/26, R7's weight was 290.4 lb.05/29/26, R7's weight was 293.6 lb., an increase of 3.2 lb. PRN furosemide was not administered per physician orders.06/23/26, R7's weight was 300.2 lb.06/24/26, R7's weight was 303.4 lb., an increase of 3.2 lb. PRN furosemide was not administered per physician orders.On 06/30/26 at 2:51 PM, Surveyor interviewed Registered Nurse (RN) L regarding R7's PRN furosemide. Surveyor asked RN L to review R7's MAR to verify if PRN furosemide had been administered. RN L reviewed R7's MAR and stated no PRN furosemide had been administered on the dates when R7's weight had increased 3 lb. Surveyor asked RN L if R7 should have received the PRN furosemide. RN L stated yes.On 06/30/26 at 3:27 PM, Surveyor interviewed Director of Nursing (DON) B regarding R7's medications. Surveyor explained to DON B the findings on R7's MAR of administering only 4 units of insulin when the provider's orders noted that 5 units should have been administered on 04/30/26. DON B nodded head in recognition. Surveyor also told DON B finding of numerous dates when R7's weight increased by 3 lb. and R7's PRN furosemide had not been administered. Surveyor asked DON B what the expectation was for nursing staff when R7's weight increased by 3 lbs. DON B stated that nursing would be expected to follow the provider's orders and administer the PRN furosemide.

Based on observation, interview and record review, the facility did not allow the right to exercise autonomy when choosing a mealtime preference for 1 resident (R10) of 13 residents reviewed for self-determination in a sample of 13 residents.The facility did not allow R10 to have a bowl of soup when requested because it was not during a facility scheduled mealtime. This resulted in R10 being denied the right to make choices about aspects of life that are significant to R10 that could lead to psychosocial harm.Findings:The facility policy titled Water's Edge Care Center Rights of Residents, last revised 04/03/2026, states, The resident has a right to choose activities, schedules.the resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident.R10 was admitted to the facility on [DATE]. R10 has a Brief Interview for Mental Status (BIMS) score of 11/15, which indicates moderate cognitive impairment. R10 makes own healthcare decisions.R10's care plan, dated 11/20/2025, states, I need some assistance because I have mild cognitive impairment.I need my aides to: Is willing to have the lunch meal small portions. Please bring the lunch meal to her and then if she chooses not to eat it, offer soup and sandwich.On 06/29/2026 at 11:00 AM, Surveyor observed R10 asking certified nursing assistant (CNA) M for a bowl of tomato soup to be delivered to room. Surveyor observed CNA M inform R10 that lunch would be served in 1.5 hours and R10 could have tomato soup then. R10 told CNA M because R10 did not eat much for breakfast, and was now hungry, R10 would like to have a bowl of soup earlier than the scheduled mealtime. CNA M informed R10 they had another resident to attend to first, then CNA M would bring R10 a bowl of tomato soup in about 30 minutes time. R10 was agreeable to this plan. On 06/29/2026 at 12:08 PM, Surveyor observed a bowl of tomato soup had not been delivered to R10. On 06/29/2026 at 1:04 PM, Surveyor observed R10 ambulating into hallway outside of room. CNA O asked R10 where she was going and R10 told CNA O, I was wondering where my food is, I have been waiting and waiting. On 06/29/2026 at 1:05 PM, Surveyor observed CNA O deliver a tray of tomato soup and ice cream to R10's room. Surveyor asked R10 how the lunch was that was served to her and R10 stated, I am glad it finally got here. R10 informed Surveyor they had requested it earlier and had to wait until lunch time to get it. R10 stated they did not eat much for breakfast as they did not feel well earlier that morning. On 06/30/2026 at 1:30 PM, Surveyor interviewed Director of Nurses (DON) B what the facility's expectations are of staff when a resident asks to be served food outside of a scheduled lunch mealtime. DON B stated, Inform them lunch is an hour away. DON B stated the facility has pre-made sandwiches and salads supplied in the kitchen for residents who want something to eat in between meals. Surveyor asked DON B what staff do when a resident requests a food item that is not a salad or sandwich, such as soup. DON B stated the soup can be offered at lunch time. Surveyor asked DON B if cans of condensed soup are available for staff to heat up between meals or after kitchen hours. DON B confirmed there are condensed cans of soup for residents upon request. Surveyor asked DON B if residents have the right to request food/snacks during all hours of the day and DON B stated, Yes.

Based on observation, interview and record review, the facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 of 6 residents (R20) reviewed from a sample of 13 residents.R20's pharmacy labels for toresemide, spironolactone, and gabapentin did not match the physician order.This is evidenced by:Facility policy titled, 'Medication Administration,' with a reviewed date of 12/03/25, states: All medications will be.administered according to physician order and documentation of administration recorded appropriately in the resident's medical record. General: 6. Medication directions on the pharmacy label should correlate with the medication directions on the MAR.On 07/01/26 at 7:35 AM, Surveyor observed Medication Aide (MA) J prepare and administer medications during medication administration task. Surveyor observed MA J remove R20's medication bin from the cabinet and prepare R20's medications. MA J opened one of the bottles, removed 1 tab and handed the bottle to the Surveyor. Surveyor observed the pharmacy label stated torsemide 20 mg with printed instructions to give 1 tab in AM and 1 tab in PM. The number 1 was crossed off with a black marker and handwritten a number 2. Surveyor asked MA J what this handwritten number on the label meant. MA J stated that the order must have changed and someone changed it on the label. Surveyor looked at R20's physician order on the medication administration record (MAR) and noted: torsemide 40 mg 1 tab twice daily. Surveyor asked MA J to look at the prescription bottle and order again. MA J looked and stated that it was right because the order in the MAR said 1 tab. Surveyor again asked MA J to re-check. MA J looked again and stated, Oh, it should be 2 tabs because the order in the MAR says 40 mg. I got confused because the MAR said 1 tab. MA J continued preparing R20's medications and Surveyor observed 2 more prescription bottles have the handwritten changes in marker on the prescription bottle pharmacy label:-2 tabs spironolactone 25 mg daily had the 2 crossed off and a 1 written on top.-2 tabs gabapentin 300 mg three times a day had the 2 crossed off and a 3 written on top.Surveyor reviewed R20's physician orders:03/25/26 torsemide 40 mg PO take 1 tab daily.-Pharmacy label on bottle stated torsemide 20 mg take 1 tab in AM and 1 tab in PM. Both number 1's crossed off and changed to 2 in marker.03/25/26 spironolactone 50 mg take 1 tab PO daily.-Order updated 06/08/26: 25 mg take 1 tab PO daily.03/25/26 gabapentin 300 mg take 2 caps PO three times daily.-Order updated 06/16/26: 300 mg take 3 caps PO three times daily.On 07/01/26 at 7:54 AM, Surveyor interviewed Licensed Practical Nurse (LPN) K regarding process for medication changes and pharmacy labels. Surveyor asked LPN K what nursing staff does when a provider changes a medication order and the pharmacy label does not match. LPN K stated that the nurse verifies the order, has a new label for the bottle made, and updates the order in the MAR to match. LPN K stated that the order should always match the prescription bottle.On 07/01/26 at 8:06 AM, Surveyor interviewed Director of Nursing (DON) B regarding observation during medication pass. Surveyor asked DON B what the expectation is for nursing staff when a medication order is changed and no longer matches the pharmacy label on the bottle. DON B stated that the expectation is for nursing to ensure that the order in the MAR matches the label and this should have been changed.

Based on observation, interview and record review, the facility did not ensure residents received adequate assistance devices and supervision to prevent accidents for 2 residents (R6, R21) of 7 residents reviewed for accidents/hazards in a sample of 13 residents. -R6 was assisted from sitting to standing position by Certified Nursing Assistant (CNA) staff without the use of a gait belt device. -R6 was transferred from toilet to wheelchair with a nonmechanical lift assist device by one CNA staff person when R6's care plan directs 2 persons assist when using lift device.-R6 was left unattended on the toilet by staff when R6's care plan indicated to not leave R6 unattended during toileting. -R21 was assisted from a sitting to standing position by CNA staff without the proper use of a gait belt. The facility staff's lack of proper use of assisted devices during transferring of residents and leaving residents unattended during toileting could result in physical harm to R6 and R21. Findings include: The facility policy, titled Safe Resident and Tenant handling, last revised 12/02/2025, states, Avoid hazardous resident/tenant handling and movement tasks whenever possible.use resident/tenant handling equipment and other approved resident/tenant handling aids for high-risk resident/tenant handling and movement tasks. Example 1 R6 was admitted to the facility on [DATE] with diagnoses including history of falling, bilateral cataracts, metabolic encephalopathy and diabetes. R6 has a Brief Interview for Mental Status (BIMS) score of 15/15, which indicates R6 is cognitively intact. R6's Minimum Data Set (MDS) assessment, dated 05/22/2026, indicated R6 is dependent on staff with toileting to chair and bed to chair transfers. R6's care plan, last revised on 06/03/2026, with a target date of 09/03/2026, states: I can't complete cares on my own because I have weakness, fatigue.impaired mobility.I transfer with 2 helpers providing less than half the effort to more than half the effort with EZ Way and use of gait belt for sit to stand, chair/bed to chair transfer.DO NOT LEAVE UNATTENDED IN THE BATHROOM – HIGH FALL RISK. On 06/30/2026 at 7:55 AM, Surveyor observed CNA M leave R6's room after assisting him to the bathroom. R6 was left unattended on the toilet with EZ Way device (a non-mechanical transfer assist) in front of him. CNA M returned to R6's room to finish assisting with toileting needs at 8:03 AM. On 06/30/2026 at 8:03 AM, Surveyor observed certified nursing assistant (CNA) M assisting R6 during toileting. CNA M attempted to place gait belt around R6's waist when R6 commented, You have never done that before, no one uses that. CNA M informed R6 he had the right to refuse the use of the gait belt stating, We ask you, but you refuse to wear it. R6 responded to CNA M with, I have never had anyone ask me before. CNA M proceeded to assist R6 to a standing position without the use of the gait belt. CNA M informed Surveyor, if R6 refuses gait belt, they do not use it. Using the EZ Way device, CNA M transferred R6 from the bathroom to the wheelchair, which was placed outside of the bathroom and across the room next to R6's bed. CNA M did not call for another staff person to assist during the transfer. CNA M lowered R6 into his wheelchair without the use of a gait belt. On 06/30/2026 at 8:15 AM, Surveyor asked R6 if staff normally use the gait belt during transfers and R6 stated, I don't know that I should say anything. On 06/30/2026 at 10:30 AM, Surveyor asked CNA M how staff know transferring status on residents. CNA M stated they follow a resident's care plan. CNA M stated care plans are available to view on the resident's electronic medical record. On 06/30/2026 at 1:30 PM, Surveyor interviewed director of nurses (DON) B what the facility's expectations are of CNA staff to safely transfer residents using the EZ Way. DON B stated a gait belt is always used during any type of transfer. DON B stated one person can transfer a resident with the EZ Way, however agreed that if a resident's care plan indicates using 2 persons during transfers of any kind, then CNA staff need to follow care plan directions for a resident's safety. DON B stated a resident's wheelchair should be placed as close as possible to lessen the distance a resident has to be transferred using the EZ way. DON B confirmed pushing a resident in an EZ Way from the bathroom across the room with only one person assisting, was not optimal for resident safety. Example 2 R21 was readmitted to the facility on [DATE] with diagnoses including fracture of the left humerus, sick sinus syndrome, anemia, hyperlipidemia, seizure disorder, anxiety, and depression. R21's Minimum Data Set (MDS) assessment, dated 05/27/26, identified R21 scored 5/15 during a Brief Interview for Mental Status (BIMS), indicating impaired cognition. R1 had no impairment to upper or lower extremities. R1 was dependent on toileting, upper/lower body dressing, and personal hygiene. R21 is a fall risk. Surveyor reviewed R21's Activities of Daily Living (ADL) care plan, -Toilet Transfer: With two helpers providing more than half the effort using pivot transfer and gait belt. On 06/30/26 at 7:52 AM, Surveyor observed Certified Nurse Assistant (CNA) C enter R21's room to get up for the morning. CNA C walked over to R21 and placed gait belt on R21's upper chest under arm pits. CNA D entered to assist CNA C with transferring to toilet. Surveyor observed CNA D grab underneath R21's gait belt from behind and instructed R21 to stand on the count of 3. CNA C grabbed under R21's armpits to lift from the front. CNA C lifted R21 by armpits while CNA D lifted R21 from behind with gait belt. CNA C transferred R21 to wheelchair. CNA C wheeled R21 into bathroom and CNA D assisted. Surveyor observed CNA C instruct R21 to stand as CNA C and CNA D lifted R21 to the toilet. Surveyor observed CNA C grabbing under R21's left arm to assist picking up R21 to transfer to the toilet. R21 sat on the toilet. CNA D prompted R21 to stand. CNA D asked R21 to stand up and assisted by grabbing the gait belt to lift R21 off toilet. Surveyor observed CNA C grab under R21's right armpit again until R21 could grab the toilet assist bar. CNA C then pulled R21's pants up and assisted R21 to the wheelchair by grabbing under R21's armpit. Surveyor observed R21 transferred to wheelchair and wheeled out of room down to the dining room. On 06/30/26 at 8:15 AM, Surveyor interviewed CNA C and asked if it was normal process to grab R21 under armpits to transfer from recliner to wheelchair, and from wheelchair to the toilet. CNA C reported to Surveyor CNA C sometimes grabs one side of the gait belt and then the other side under R21's armpit depending on how R21 stands for CNA C. On 06/30/26 at 1:29 PM, Surveyor interviewed Director of Nursing (DON) B and reported Surveyor's observation of CNA C providing cares to R21 for toileting and during transfer CNA C applied gait belt to upper chest area on R21 above breasts but lifted R21 under R21's arm pits and under arms. Surveyor asked DON B's expectations for CNA C transferring with gait belt. DON B reported CNA C is supposed to apply the gait belt at the lower half of waist then CNA C is to grab the gait belt on each side on R21 and not under R21's armpits.

Based on observation, interview, and record review, the facility did not use the least restrictive device and document on-going re-evaluation of the need for the restraint for 1 (R34) of 13 sampled residents reviewed for restraints. R34 was placed in a recliner chair with the footrest elevated and recliner unplugged from the wall, which R34 could not independently release the footrest to have unrestricted movement. Findings include: Surveyor reviewed facility policy titled, Rights of Residents, dated last revised 04/03/26, states: .(e) Respect and dignity. The resident has a right to be treated with respect and dignity, including: The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with S483.12(a) . Surveyor reviewed facility policy titled, Physical Restraints and Resident Rights, dated last revised 12/04/25, which states: .A physical restraint is a prescription device that is defined as: 1) any article, device, or garment that is used primarily to modify a resident's behavior by interfering with the free movement of the resident, and which the resident is unable to remove easily. R34 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, spinal stenosis, atrial fibrillation, and chronic kidney disease. R34's Minimum Data Set (MDS) assessment, dated 05/13/26, identified R34 scored 3/15 during a Brief Interview for Mental Status (BIMS), indicating impaired cognition. R34 had no impairment to upper or lower extremities. R1 was dependent on toileting, transfer with non-mechanical lift and assist of one, upper/lower body dressing, and personal hygiene. Surveyor reviewed R34's Activities of Daily Living (ADL) care plan:-On 05/05/26, Power recliner not to be plugged in. Cannot be used to elevate legs (example plug in elevate legs then unplug) as this would be a restraint. OT will provide a footstool for her to elevate feet. Surveyor reviewed Occupational Therapy (OT) notes, in part, .-On 05/07/26 at 6:54 AM, Use of chair control poor. [R34] raised versus lowering seat surface when asked to extend leg rests. OT unplugged power from wall for patient safety.-On 05/15/26 at 11:06 AM, [R34] seated in recliner chair, unplugged from wall. On 06/29/26 at 10:32 AM, Surveyor entered R34's room. Surveyor observed R34 sleeping in recliner with footrest in the up position. Upon entrance to R34's room, Surveyor observed recliner electrical cord unplugged from the wall lying on the floor next to recliner. On R34's wall to the right of the recliner a wall sign stated, Keep recliner unplugged. Surveyor observed R34's recliner unplugged from the wall. On 06/30/26 at 11:37 AM, Surveyor observed R34 sitting in recliner with R34's feet in the up position on the footrest. R34 was yelling out for assistance. Surveyor entered R34's room and asked if R34 is ok. Upon entrance into R34's room, Surveyor observed recliner electrical cord unplugged from the wall lying on the floor next to recliner. R34 reported to Surveyor they want to get out of their chair as it's uncomfortable, and R34 wanted to go eat lunch. Surveyor observed R34 slightly agitated as R34 wanted to get out of recliner. Surveyor let R34 know Surveyor would go get assistance for R34. Surveyor exited R34's room. On 06/30/26 at 11:47 AM, Surveyor approached Certified Nurse Assistant (CNA) D and reported R34 wanted to get out of recliner. Surveyor observed CNA D enter R34's room and Surveyor followed. CNA D walked straight over to R34's recliner cord lying on the floor and plugged R34's recliner cord into the electrical outlet on the wall. On 06/30/26 at 11:55 AM, Surveyor interviewed CNA D and asked why R34's recliner was unplugged. CNA D reported to Surveyor R34's recliner stays unplugged while R34 is in recliner for safety concerns. Surveyor reported to CNA D Surveyor's observation of R34 having a sensor pad under R34 in recliner and would CNA D think the sensor pad was enough safety to let staff know R34 was trying to get out of the recliner. CNA D reported R34's recliner is unplugged and R34's feet are up because R34 likes to shimmy downwards to end of footrest and get out of recliner. Surveyor asked CNA D if it is normal to have recliner unplugged and R34's feet elevated with footrest up. CNA D reported to Surveyor that CNA D did not want to tell Surveyor wrong information so CNA D would ask someone. On 06/30/26 at 12:14 PM, Surveyor interviewed CNA D and asked if CNA D asked for clarification on R34's recliner being unplugged with R34's footrest up. CNA D reported to Surveyor CNA D spoke with Registered Nurse (RN) F, and RN F reported the recliner being unplugged is for R34's safety. On 06/30/26 at 12:23 PM, Surveyor interviewed Physical Therapy (PT) H and Occupational Therapy (OT) I and asked how assessments are conducted for residents to safely use recliner. OT I reported to Surveyor once a resident receives a recliner, OT I and PT H will assess residents for recliner safety and then report the assessment findings and recommendations to the Interdisciplinary Team (IDT). PT H reported to Surveyor assessment of safety for recliner use is a group effort and is communicated with the entire team. Once determination of safety, nursing staff is made aware, and nursing staff implements interventions. Surveyor asked PT H's expectation how residents are to use recliners once deemed not safe to utilize. PT H reported nursing staff is made aware of the safety concern, nursing types a paper that states, Unplug recliner from wall, and then places in resident's room. PT H reported to Surveyor residents can be placed in recliner, but staff need to ensure feet are in the down position when sitting residents in an unplugged recliner. Surveyor asked OT I's expectation for R34 in recliner when in room. OT I reported R34 should have recliner unplugged from the wall but be placed in a sitting position in recliner, always. On 06/30/26 at 12:48 PM, Surveyor interviewed Registered Nurse (RN) F and asked RN F's expectation for recliner use for R34. RN F reported R34 has been deemed to be unsafe with recliner remote use, so staff are to unplug recliner from wall with resident in recliner in sitting position. Surveyor reported to RN F Surveyor observed CNA D transferring R34 out of recliner but upon entering the room, R34 has had her legs up on the footrest in the recliner with the recliner unplugged. RN F reported to Surveyor aides should not be placing any residents in recliners with feet up with the recliner unplugged. On 06/30/26 at 1:29 PM, Surveyor interviewed Director of Nursing (DON) B and reported to DON B Surveyor observed R34 on 06/29/26 most of day sitting in recliner with feet up on footrest with recliner unplugged. Surveyor also informed DON B of Surveyor's observation of R34 sitting in recliner on 06/30/26 yelling for assistance while sitting in recliner that is unplugged with feet up on footrest. Surveyor asked DON B's expectation for how staff are to place R34 in R34's unplugged recliner. DON B reported to Surveyor CNA D should have had R34's feet down in a sitting position. DON B reported for any residents who are unsafe to use recliner remote they should be left in recliner in a sitting position and never with feet up if unplugged from the wall.

Based on observation, interview and record review, the facility did not ensure 1 (R21) of 13 sampled residents was provided privacy during personal cares. *Certified Nurse Assistant (CNA) C did not provide R21 privacy to use the toilet as requested from R21.Findings include: Surveyor reviewed facility policy titled, Rights of Residents, dated last revised 04/03/26, states: .(e) Respect and dignity. The resident has a right to be treated with respect and dignity, including: The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would danger the health or safety of the resident or other residents. (h) Privacy and confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. (1) Personal privacy includes accommodations, medical treatment, written and telephone communications, and personal care . R21 was readmitted to the facility on [DATE] with diagnoses including sick sinus syndrome, anemia, hyperlipidemia, seizure disorder, anxiety, and depression. R21's Minimum Data Set (MDS) assessment, dated 05/27/26, identified R21 scored 5/15, during a Brief Interview for Mental Status (BIMS), indicating impaired cognition. R1 had no impairment to upper or lower extremities. R1 was dependent on toileting, upper/lower body dressing, and personal hygiene. Surveyor reviewed R21's Activities of Daily Living (ADL) care plan,Toilet Transfer: With two helpers providing more than half the effort using pivot transfer and gait belt. -Toilet hygiene with 1 helper providing usually more than half the effort. -R21 wears incontinent briefs and needs help adjusting clothes.-Please follow my bowel and bladder program to promote continence, decrease the risk for falls and decrease risk for skin injuries: 7-7:30 AM, 11:30-12 PM, 1:30 PM-2 PM, 4:30-5 PM, 6:30 PM-7 PM upon arising before and after meals and prior to going to bed for the night. On 06/30/26 at 7:52 AM, Surveyor observed CNA C enter R21's room to assist with R21's ADLs for the morning. Surveyor observed CNA C walk over to R21 and began setting up washcloths for washing R21. CNA C placed gait belt on R21. CNA D entered to assist CNA C with transferring R21 to the toilet. CNA C wheeled R21 into bathroom and CNA D assisted. Surveyor observed CNA C and CNA D transfer R21 to the toilet. R21 sat on toilet and stated, I think I have to go to the bathroom. CNA C reported to R21 once CNA C was done getting R21 dressed for the day, CNA C would step out to give privacy. Surveyor observed CNA C gather washcloths, clothes, and shoes to dress R21. Surveyor observed CNA D assist CNA C with dressing R21. CNA C stated to Surveyor, [R21] is very private and has a bashful bladder, so we will step out soon for [R21]. R21 responded, Yes, I have a bashful bladder. Surveyor observed CNA C continue to dress R21. CNA C asked R21 to stand as it was time to get off the toilet and transfer to wheelchair. R21 stated, I don't think I peed yet, at least I can't remember if I did. CNA D reported to R21, CNA D did not hear or observe R21 urinate, but R21 could try to use bathroom after breakfast. Surveyor observed R21 sit in silence and then stand when CNA D and CNA C prompted R21 to stand. Surveyor observed R21's transfer to wheelchair, and R21 was wheeled out of room down to the dining room. On 06/30/26 at 8:58 AM, Surveyor observed CNA C approach R21 in dining room and ask if R21 was done eating breakfast so that CNA C could take R21 back to R21's room. R21 reported to CNA C that R21 was ready to go back. CNA C wheeled R21 to R21's room and parked R21 in room. Surveyor asked CNA C if they were going to be taking R21 to the bathroom since R21 did not use the toilet prior to breakfast. CNA C reported to Surveyor they will go grab another aide to help sit R21 on the toilet since R21 did not go prior to breakfast. CNA C exited R21's room to grab CNA E. On 06/30/26 at 9:03 AM, Surveyor observed CNA C and CNA E enter R21's room and took R21 into the bathroom. As CNA C and CNA E were lifting R21 to the toilet, R21 stated, Oh no, I am peeing right now. CNA C and CNA E lowered R21 to the toilet, and R21 continued to urinate in the toilet. Surveyor observed CNA C grab R21's insert pad from inside R21's underwear which appeared sopping wet, and CNA C threw it in the trash and replaced with a dry pad. R21 stated, I am sorry, I have a bashful bladder. CNA C instructed R21 that staff would step out so that R21 had more privacy while R21 continued to pee. On 06/30/26 at 9:08 AM, Surveyor asked CNA C if R21's pad inside was wet. CNA C reported to Surveyor that R21's pad was in fact wet. Surveyor asked CNA C if R21 had urinated prior to breakfast. CNA C reported to Surveyor that R21 did not prior to breakfast and CNA C probably should have stepped out while CNA C was getting R21 ready for the day while in the bathroom. CNA C reported to Surveyor, R21 probably would have urinated if CNA C had left the bathroom and given them time. On 06/30/26 at 11:39 AM, Surveyor interviewed R21's Family Member (FM) G and asked if there are particular needs R21 requires while using the restroom. FM G reported to Surveyor, R21 is very private when it comes to the bathroom so R21 likes to have privacy while on the toilet. FM G reported they will step out of bathroom and leave door cracked to provide privacy but still keep R21 safe while in bathroom. On 06/30/26 at 1:29 PM, Surveyor interviewed Director of Nursing (DON) B and reported Surveyor's observation of CNA C providing cares to R21 for toileting. R21 requested privacy to use the bathroom, CNA C did not provide privacy to R21 and then R21 was not able to urinate as R21 requested. Surveyor asked DON B's expectation for CNA C to provide privacy for R21 as requested. DON B reported to Surveyor the expectation would be CNA C should have stepped out of the bathroom so that R21 could use the bathroom in private.

Based on interview and record review, the facility did not notify the provider of changes for 1 of 13 residents (R7) reviewed out of 13 sampled residents.R7's weight increased and the provider was not notified per provider's order.This is evidenced by:Facility policy titled, 'Change of Condition,' with no date, states: Immediate notification any symptom, sign, behavior or complaint this is: acute or sudden in onset and a marked change in relation to usual symptoms and signs or unrelieved by measures already prescribed.R7 was admitted to the facility on [DATE] with edema.Surveyor reviewed R7's medication administration record (MAR):On 03/06/26, R7's weight was 283.6 lb.On 03/07/26, R7's weight was 292 lb. Provider was notified and new order entered: Weight gain greater than 3 lb. give 10 mg furosemide and notify primary care provider.On 04/03/26, R7's weight increased by 3.2 lb. overnight.-No notification to provider documented.On 04/18/26, R7's weight increased by 3 lb. overnight.-No notification to provider documented.On 05/12/26, R7's weight increased by 7.6 lb. overnight.-No notification to provider documented.On 05/29/26, R7's weight increased by 3.2 lb. overnight.-No notification to provider documented.On 06/24/26, R7's weight increased by 3.2 lb. overnight.-No notification to provider documented.On 06/30/26 at 2:51 PM, Surveyor interviewed Registered Nurse (RN) L regarding provider notification. Surveyor asked RN L when nursing would be expected to notify the provider of changes. Surveyor asked RN L if nursing would be expected to document in resident's chart when contacting the provider. RN L stated yes.On 06/30/26 at 3:14 PM, Surveyor interviewed Director of Nursing (DON) B regarding notifying the provider of R7's weight increases. Surveyor informed DON B of findings of R7's weight increase and no documentation of notifying provider. Surveyor asked DON B what the expectation for nursing staff would be. DON B stated that nursing is expected to follow the provider's orders to notify of changes and to document the communication in the resident's chart. DON B stated this should have been done for R7's weight increases.

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 when staff did not perform hand hygiene after removing soiled gloves during care observations. This affected 1 of 6 residents (R) observed for cares. (R21) Certified Nursing Assistant (CNA) C did not perform hand hygiene when changing gloves while performing peri care for R21.Findings include: On 06/30/26 at 7:52 AM, Surveyor observed CNA C enter R21's room to get R21 up for the morning. CNA C walked over to R21 and transferred R21 to wheelchair. CNA C wheeled R21 into bathroom and CNA D assisted. Surveyor observed CNA C apply gloves and gather washcloths, clothes, and shoes to dress R21. Surveyor did not observe CNA C perform hand hygiene prior to donning gloves. Surveyor observed CNA D assist CNA C with dressing R21's lower body with R21's shoes, underwear, and pants. Surveyor observed CNA C remove gloves and then apply another pair of gloves. CNA C asked R21 to stand as it was time to get up off the toilet and transfer to wheelchair. Surveyor observed CNA C stand R21. Surveyor observed CNA C don gloves. CNA C washed R21's peri care area with washcloth and soap, then dried with towel. Surveyor observed CNA C pause for a second, looked around the bathroom at the glove box, and then proceeded to pull R21's underwear and pants up with contaminated gloves. Surveyor did not observe CNA C doff contaminated gloves. CNA C pulled R21's pants up and assisted R21 to the wheelchair by touching under R21's armpit with contaminated gloves. Surveyor observed CNA C touch R21's wheelchair brakes and handles with contaminated gloves. Surveyor observed CNA C continues to grab R21's trash and clothing items out of bathroom with contaminated gloves and then doffed contaminated gloves and walked out of R21's room. Surveyor observed that CNA C did not sanitize hands prior to donning gloves, or removing gloves. On 06/30/26 at 8:15 AM, Surveyor interviewed CNA C and asked about performing hand hygiene in between glove changes and changing gloves from cleaning peri care area to pulling R21's clean pants up. CNA C stated, Yea, I forgot. On 06/30/26 at 1:29 PM, Surveyor interviewed Director of Nursing (DON) B and reported to DON B, CNA C provided cares to R21 for toileting and did not sanitize hands prior to donning gloves and in between glove changes. Surveyor asked for DON B's expectation for hand hygiene. DON B reported CNA C should have sanitized hands prior to applying gloves and in between.

Based on record review, observation, and interview, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 3 residents (R) (R1 and R2) reviewed.The facility did not ensure R2's bed alarm was functioning to alert staff of self-transfer resulting in R2 falling and sustaining an acute fracture involving the left orbital roof, opacified left frontal sinus consistent with fracture involving its lateral wall, and a left nasal fracture. This example is being cited at actual harm.The facility did not ensure that R1 was transferred with assist of 2 and correct sling causing R1 to fall to the floor. Findings:The facility policy titled Plan for the Provision of Nursing Care, undated, states in part under the section Staffing: .E. Nursing assistance provide assistance and care to residents according to the plan of care. The facility policy titled Falls Management Program: Accident Prevention & Investigation, undated, states: It is the mission of the Water's Edge Care Center to prevent falls, prevent accident, and reduce the risk of injuries. Our goal is to ensure the environment remains safe and [NAME] from potential hazards that may lead to an accident, to ensure adequate supervision and ultimately improve the quality of life of our residents. Under the section titled Definition, the policy continues to state: Our facility has adopted the Health Care Association of New Jersey (HCANJ) Best practice evident based Fall Management Guidelines which includes assessments, analysis of risk level, treatment plan, evaluation, education and quality improvement tools.The facility policy states in part: they have specific interventions not included in HCANJ Fall Management Guidelines include but are not limited to: .Risk rounds done before/after shifts assuring obstacles are clear, personal items are within reach, and bed exits are on.We attempt to provide an alarm free facility, we do provide silent bed exits to pager alarms for some residents in an attempt to assist them when they have exited the bed (note this is not to prevent a fall as it has been proven that alarms do not work to prevent a fall, only alert staff that someone has risen). Ours are silent to resident but alert staff via pager.Example 1R2 was admitted to the facility on [DATE] with diagnoses that include cerebral infarction, unspecified symptoms and sign involving cognitive functions following cerebral infarction.R2's quarterly MDS, dated [DATE], indicates a BIMS score of 12/15 indicating mildly impaired cognition and documents R2 requires supervision for transfers.R2's care plan needs, dated 10/23/24, states: I have the potential to fall down and hurt myself, because I am weak, take some medications that can make me dizzy, tired, confused or weak. Approaches include I need my nurses to know that coumadin has a black box warning of Bleeding Risk and can cause major or fatal bleeding.R2's care plan needs, dated 05/07/25, state in part: I can't complete my cares on my own . because I have left facial droop and left sided weakness with a care plan approach dated 01/02/25 that states: I can't transfer safely without help, so I use a bed alarm, page recliner, pager alarm. Check that alarm(s) are applied correctly and turned on.R2‘s nurses notes indicated R2 sustained a major injury on 07/03/25 wherein R2 was found on the floor at 8:00 PM, with head surrounded by a pool of blood and sustained bruising and hematoma over left front skull 3 cm x 4cm, left eye bruised and swollen shut. Alarm not functioning due to the alarm not being plugged in. When staff plugged alarm in, it was noted to be defective and was replaced.R2's physician was contacted and R2 was sent out to emergency room. R2 returned to facility on 07/04/25 at 12:00 AM with diagnoses of left orbital fracture and left nasal fracture.On 08/08/25, Surveyor reviewed emergency room record dated 07/03/25, which stated a CT of Maxillofacial without contrast was completed and impressions of: 1. Moderate left-sided facial soft tissue swelling with moderate left frontotemporal scalp soft tissue swelling. 2. Acute fracture involving the left orbital roof. Opacified left frontal sinus consistent with fracture involving its lateral wall. 3. Left nasal fracture.On 08/08/25 at 11:03 AM, Surveyor interviewed Certified Nursing Assistant (CNA) C regarding expectations of following plans of care and how CNAs are made aware of care plan interventions and changes. CNA C stated care plans are in the computer and are expected to be followed. If there are changes made we receive information during morning rounds, and they are to look up in electronic record. There is a button where staff can view changes using separate buttons for a 1, 3, or 7 day look back period for any changes made based on the last time they worked. CNA C confirmed recently receiving education regarding ensuring following care plans and to ensure correct lifts and 2-person assist is utilized for residents per individual care plans.On 08/08/25 at 11:15 AM, Surveyor interviewed CNA D who confirmed electronic records buttons are to be utilized at the beginning of each shift and CNA D recently received education on following plans of care.On 08/08/25 at 12:30 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and Director of Nursing (DON) B regarding their expectations of following plans of care both related to recent falls of R1 and R2. NHA A and DON B confirmed expectation that staff follow the plans of care.Surveyor asked NHA A and DON B about their expectation of ensuring alarms were applied correctly and functional. DON B stated that CNAs are responsible for applying and ensuring alarms are working. The alarms chirp when the battery is low and facility has been conducting weekly audits on all residents who utilize alarms to ensure alarms are plugged in and if chirping indicating the battery is low, batteries are replaced. Surveyor asked when audits of alarms were started. DON B stated they were in the 4th week of audits. Surveyor asked what prompted the audits; DON B stated as a result of a fall wherein an alarm did not work properly. Surveyor asked DON B if this was due to the fall of R2 on 07/03/25 and DON B stated Yes. Surveyor asked what was the root cause of the alarm not working properly? DON B stated that one alarm box is used per resident and with R2 it is used between the bed and recliner. The alarm box was not changed from the bed to the recliner when R2 was placed in recliner. DON B stated the expectation would be for the CNA to transfer the box to the sensor pad cord in use and ensure the alarm is plugged in.Surveyor asked DON B and NHA A if an investigation was conducted and reported for R2's fall. NHA A stated a Root Cause Analysis (RCA) is being completed through the facility quality department and this usually takes months. Surveyor requested information of audits conducted on alarms. DON B stated she does not have documentation for proof of audits or documentation to support education was provided to staff for the process of checking alarm function. DON B stated the expectation was for them to check during shift to shift rounding. Surveyor asked if this was a process that started following the 07/03/25 fall, DON B stated, No. The expectation was in place prior to R2's fall but was not completed.Example 2R1 was admitted to the facility on [DATE] and has diagnoses that include malignant neuroendocrine tumors and mild cognitive impairment of uncertain or unknown etiology.R1's most recent Minimum Data Set (MDS), was a significant change MDS, with target date of 06/02/25. R1 has a Brief Interview for Mental Status (BIMS) score of 10/15 indicating mildly impaired cognition and is dependent with toileting needs, dressing, and transfers. R1 has an Activated Power of Attorney (POA) as of 07/05/24.R1's care plan needs, dated 05/28/25, state, I can't complete cares on my own. Care plan approaches per facility indicated at time of fall R1 should have been transferred using an Arjo lift (full body lift) and assist of 2 helpers.On 06/26/25, the facility submitted a Misconduct Incident Report wherein R1 sustained minor injuries from a fall that occurred on 06/26/25 as a result of a Certified Nursing Assistant (CNA) failing to follow the plan of care for R1. The CNA transferred R1 with an incorrect mechanical lift and without the assist of another helper. The facility completed an investigation upon reporting the incident and educated all staff regarding following the plan of care to prevent falls/safety. Current non-compliance was discovered during this survey with F689.

Based on 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. The facility did not describe the building water systems using text and flow diagrams. This has the potential to affect all 37 residents in the facility. Findings include: Surveyor's record review of the facility's water management plan revealed a description of some areas where water was stagnated, and a record of weekly flushing of facility's stagnate water, but no text and flow diagrams were found with hotspots indicating potential hazards on the diagram. On 05/14/25 at 9:09 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and Chief Operating Officer (COO) E regarding the lack of a text and flow diagram. NHA A and COO E stated they would attempt to locate the text and flow diagram, as their head of maintenance was unavailable. A flow chart was located with points of concerns noted, but there was not any identification of areas of concern and the flow chart did not show all areas on concerns noted in the water management plan for the nursing home.

Based on record review and interview, the facility did not ensure 1 of 1 resident ((R)8) who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident. R8 expressed he had lost his son in a tragic car accident which at certain times of the year it is very difficult. The facility did not assess R8 for trauma informed care. R8's care plan did not identify potential triggers in attempts to mitigate re-traumatization. Findings Include: On [DATE] at 1:21 PM, Surveyor requested and received the facility policy titled Trauma-Informed Care dated [DATE]. The policy in part read: Purpose: The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Policy: Staff review each residents record for, but not limited to recent or past traumatic events . Social Services gathers each resident's social history. If traumatic events are identified these events are care planned . Care planned approaches will be culturally competent and account for experiences and preferences and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Surveyor reviewed R8's record and noted the following: R8's most recent Minimum Data Set (MDS) dated [DATE] notes R8 understands, is understood, and R8 has moderate cognitive impairment. R8 had depressive mood symptoms of feeling down, depressed, or hopeless nearly every day. R8's diagnosis included depression. R8's record did not include a social history from admission on [DATE]. R8's record did not include a trauma-informed assessment. R8's care plan includes: [DATE]: Need/Preference: I have the potential to feel sad, depressed because I have a diagnosed mood disorder-major depressive disorder, traumatic event=[AGE] year old son passed away as a result of car accident. When I feel this way I: feel down or depressed. My goal is to feel safe and secure. Goal Time: [DATE] Approach: ~Ask me how I am feeling ~Evaluate for environmental triggers: e.g.: room temperature, positioning, noise level. If demonstrating signs of sadness or depression complete ortho bp (blood pressure) checks as ordered and as needed . Provided clear explanations, assess understanding, offer me distractions, treat for pain and evaluate effectiveness . ~Know that I have potential to demonstrate side effects of zoloft . ~Monitor for signs and symptoms of Serotonin Syndrome . ~Refer to activity care plan my simple pleasure. ~Ask me if I am having pain and report to nurse if I am, remind me of my favorite activities, help me call my family as needed, present tasks one at a time, follow my toileting plan, let my nurse know if my appetite changes, reassure me, offer me choices, ask me how I'm feeling today, encourage me to participate in activities, ask me what activities I would like to attend, invite me to attend activities, spend time with me one on one. At night quiet down my area, such as turn down the lights, be aware of my stressors . ~Complete PHQ-9 mood interviews with me. ~Speak with me and make eye contact, give me choices, let my nurse know if I am having pain, say something positive to me. R8's care plan documents the traumatic event of losing his son. It does not address R8's preferences and does not address R8's needs related to trauma or identify triggers to prevent re-traumatization. On [DATE] at 12:35 PM, Surveyor interviewed R8 who stated R8 sometimes feels down and sad over the loss of his son who died in a tragic car accident when he was [AGE] years old. R8 expressed sometimes the loss affects R8 more around certain times of the year. On [DATE] at 10:47 AM, Surveyor interviewed Certified Nursing Assistant (CNA) C, who has been on staff almost 5 years and often cares for R8. CNA C expressed she had never heard of R8's son's passing. R8 has not talked about it with CNA C. CNA C stated CNA C is not aware of any approaches specific to R8's trauma stating, I would redirect or distract resident if he would bring it up. On [DATE] at 10:52 AM, Surveyor interviewed Social Services Director (SSD) D regarding R8's trauma and trauma informed care. SSD D provided Surveyor with R8's social history, dated [DATE], from a prior admission, which notes the following: My Adult Life: .We also had a son .he passed away in car accident at age [AGE]. Traumatic Events: See above regarding son .will complete mental well-being care plan. SSD D expressed facility uses a social history to develop a care plan for emotional well-being. The facility did not complete a social history when R8 was admitted on [DATE] as R8 was a prior resident. Surveyor asked SSD D if the facility completes a trauma-informed assessment looking at R8's preferences, needs, and potential triggers when trauma is identified. SSD D expressed the facility does not currently do trauma-informed-assessments or gather information which addresses specific triggers regarding traumatic events to develop a care plan. SSD D further expressed SSD D sees why the information would be needed.

Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect all 40 residents (R). The facility did not complete surveillance for the time of onset of symptoms for COVID-19 symptomatic staff. Findings include: Surveyor requested and reviewed the facility procedure titled House Supervisor and Leader Guidance for Ill Employee Calls dated 02/19/24. The procedure in part reads: .What should House Supervisors initially do when a phone call from an ill employee calls? Questions to ask include, but are not limited to: -When did employee symptoms start? What symptoms is the employee having? - Has the employee had any exposure to anyone else that is ill? -Has the employee had a known COVID-19 exposure? Surveyor reviewed Infection Control (IC) surveillance logs and found the facility identified the facility had an outbreak of COVID-19 starting on 02/08/24 and ending on 03/05/24, which affected 12 of 40 residents. Surveillance logs identified 7 out of 14 employees who had symptoms of COVID 19, that did not have the date and time of onset of symptoms on the surveillance log. COVID-19 logs read: -Certified Nursing Assistant (CNA) C had onset of symptoms (runny nose) on 01/09/24. CNA C last worked on 01/09/24 from 5:50 AM to 6:56 AM. The surveillance does not identify the time of onset of symptoms to determine if the employee should have been in work status. - CNA D had onset of symptoms on 02/08/24. The surveillance does not indicate the time of onset of signs and symptoms. -Registered Nurse (RN) E had onset of symptoms (fatigue, hoarse throat, and high blood sugars) on 02/07/24. The surveillance does not indicate the time of the onset of signs and symptoms, or if RN E completed a Covid test on 2/07/24 and what the results were. -Nursing Home Administrator (NHA) A had onset of symptoms on 02/07/24, worked on 02/08/24 in building and then tested COVID-19 positive on 02/09/24. The surveillance does not indicate a time of the onset of signs and symptoms, or if a Covid test was completed on 2/7/24. Without knowing the test results the facility was unable to determine if NHA A should have been in work status on 02/08/24. -Kitchen Aide (KA) F had onset of symptoms (Sore throat, headache, and exposure to two COVID-19 roommates) on 02/12/24. KA F last worked on 02/12/24. The surveillance does not indicate the time of onset of symptoms to determine if KA F worked with symptoms on 2/12/24. -Rehab G had onset of symptoms on 02/26/24. Rehab G last worked on 02/26/24. Rehab G tested COVID-19 positive on 02/27/24. The surveillance does not document time of onset of symptoms or if a Covid test was done on 2/26/24 to determine if Rehab G was working with symptoms on 2/26/24. -Patient Access (PA) H had onset of symptoms on 02/23/24. PA H last worked on 02/23/24. The time of onset of symptoms is not documented to determine if PA H worked with symptoms. On 04/24/24 at 7:42 AM, Surveyor interviewed Infection Preventionist (IP) I and asked what the process is and expectations for sick employees. IP I indicated the expectation is for staff to stay home and call Employee Health J if symptomatic. IP I indicated the facility supplies at-home kits for testing and goes off an honor system to establish if staff are positive or not. IP I indicated that staff are to not come to work sick. Surveyor asked IP I about the process for tracking surveillance of staff sicknesses. IP I indicated that IP I tracks the date of onset of symptoms, testing parameters, and then once established if positive or negative quarantine status is based on the CDC recommendations for returning to work. Surveyor asked IP I what the times were for onset of symptoms and type of symptoms for CNA C, CNA D, RN E, NHA A, KA F, Rehab G, and PA H on the day their symptoms started. IP I indicated IP I does not keep track of times of the onset of symptoms and sometimes the symptoms are not specified on the log sheet and that Surveyor would need to talk with Employee Health (EH) J. On 04/24/24 at 8:10 AM, Surveyor interviewed EH J and asked about the process for surveillance of staff infection. EH J indicated that EH J keeps track of employees' sickness the best EH J can. EH J indicated that sick employees submit an event in the Healthcare Safety Zone application electronically. Sick employees call EH J during business hours or call in and inform a leader who will submit this ticket after hours. EH J indicated the ticket populates in EH J's mailbox and EH J follows up on the submitted sick employee ticket. Surveyor asked EH J if the ticket has the time of onset of symptoms. EH J indicated the Healthcare Safety Zone application does not keep track of the time of the onset of symptoms. EH J indicated that EH J does not keep track of the time of the onset of symptoms. Surveyor asked EH J what the times were for onset of symptoms and type of symptoms for CNA C, CNA D, RN E, NHA A, KA F, Rehab G, and PA H on the day their symptoms started. EH J indicated that EH J cannot tell Surveyor any time frames on the days of onset of symptoms for the above staff as EH J does not keep track of times of the onset of symptoms and sometimes the symptoms are not specified on the log sheet if EH J did not submit the ticket. EH J indicated that EH J cannot tell Surveyor any time frames on the days of onset of symptoms for the 7 sick employees: CNA C, CNA D, RN E, NHA A, KA F, Rehab G, and PA H to determine if they were in work status with symptoms.

Based on observation, record review and interview, the facility did not provide adequate supervision to prevent accidents for 1 of 4 residents reviewed for falls (R27). Certified Nursing Assistant (CNA) C and D left R27 unattended in bed with her bed in a high position and no mat on the floor during cares, when R27's care plan directs a low bed and mat on the floor. This is evidenced by: Surveyor reviewed R27's most recent Minimum Data Assessment (MDS) which was a quarterly dated 3/07/23. The MDS notes R27 is rarely understood, sometimes understands and is severely cognitively impaired. R27 has other behaviors of hitting or scratching self. R27 requires extensive assistance of one staff for bed mobility, dressing, eating and bathing. She is dependent on staff for transfer. R27 is always incontinent of bladder and bowel. R27's diagnoses included renal insufficiency, Alzheimer's disease and depression. R27 did not experience falls during this assessment review period. R27 takes an antipsychotic and antidepressant medication. Surveyor requested and reviewed R27's fall investigations since the facility's last survey and noted: ~3/17/22: 1:30 PM Stood up and fell down, unattended for short time in dining room. All staff reinserviced: do not leave unattended ~3/15/22: 210:40 PM: resident room, left side of bed, appeared to be crawling out of bed, bed alarm functioning, placed self to floor, history of falls. Current preventative measures: low bed, raised edge mattress, bed alarm, toileting schedule, call light in reach. Was incontinent of stool at the time. Placed on 15 minute checks between 2200 and 2300, take to bathroom if awake. No injury. Surveyor reviewed R27's most recent fall risk assessment dated [DATE] which notes the following risk factors: ~Mental status: poor recall, judgement and safety awareness, ~Impaired mobility ~1-2 predisposing disease/conditions Total score: 12 (10 or above indicates high risk for falling) R27's care plan notes: Need/Preference: 4/07/2021: I have the potential to fall down and hurt myself. Because I have dementia/Alzheimer's disease, decreased safety awareness. I show this by: I have fallen not being able to move around like I use to, have a history of getting anxious or agitated. I need everyone to: place the mat beside my bed when I am lying in bed. Bed to be in low position when I am in bed. On 4/04/23 at 7:47 AM, Surveyor observed CNA C and D assist R27 with morning care. CNA C and D prepared R27's care supplies and placed the supplies at bedside. CNA C removed R27's bedside mat and raised the height of her bed to a high position. CNA C and D performed incontinence care and washed and dressed R27 in bed. CNA D exited the room after assisting CNA C with rolling R27 in bed for care. CNA C stepped away from R27's bed 3 times to gather additional supplies and tidy R27's room. On one occasion CNA C went into R27's bathroom, emptied R27's basin, washed the basin, washed her hands and brushed R27's dentures. Surveyor observed R27's bed remained in the high position with R27 in bed tapping repeatedly at her chest and stomach with no staff at bedside. CNA C was in the bathroom with her back to R27 while she was in bed with the bed in high position and no mat on the floor at bedside. Surveyor asked CNA C if she was familiar with R27. CNA C indicated she has worked at the facility since October and works with R27 on a regular basis. Surveyor asked CNA C if R27 is at risk of falling or rolling out of bed. CNA C indicated R27 is at risk for rolling/falling from bed and staff need to keep an eye on her when her bed is up. R27's bed is in low position and she has a floor mat when staff are not in the room. On 4/04/2022 at 8:15 AM, Surveyor spoke with Registered Nurse (RN) E about the observation. RN E indicated she has worked at the facility 6 years and is familiar with R27. RN E expressed R27 is at risk for falls from bed. Her bed should be low and a mat should be on floor next to her bed due to her risk for falling. R27 should not left be left unattended at any point when her bed is raised. One staff person should stay at bedside or the bed should be lowered. R27 is more mobile at times and could easily roll from bed, Not safe. On 04/04/23 at 8:29 AM, Surveyor spoke with Director of Nursing (DON) B regarding the observation. DON B indicated staff should not leave anyone unsupervised in a raised bed, especially those residents at risk for falling, such as R27. Further indicating she would expect one staff to stay at bedside with resident or the bed to be lowered and bedside mat to be placed to keep resident safe if staff need to step away from the bed.

Based on interviews and record review, the facility did not store foods in a manner that prevents foodborne illness. The correct cooling process was not being used for leftovers. This has the potential to affect all 41residents. ~The facility did not cool leftover foods using the correct process. This is evidenced by: On 2/28/2022 at approximately 10:30AM, Surveyor did initial tour of the kitchen with the Kitchen Manager (KM) C. Surveyor interviewed KM C regarding the cooling process they were doing for the foods they were using as leftovers. KM C stated they do serve leftovers. The process they use is that the staff working the afternoon shift take the food temperatures prior to putting the food in the cooler. This temperature is written on the log. There is no further temperature taken until the morning when the day shift comes in. When asked how they ensured that the temperature of the food had gone down to 70 degrees within 2 hours, as stated on the bottom of the temperature log, KM C responded they could not as there were no staff present in the kitchen to take the temperatures of the food at the 2 hour mark. On 3/1/2022 at approximately 3:00PM, Surveyor interviewed Dietary Aide (DA)-D regarding the cooling process used for leftovers. DA-D stated they did assist with cooking and that they sometimes worked the PM shift. When asked what the process was for cooling leftovers, DA-D stated they take the temperatures on the food prior to putting it into containers and then into the coolers. When asked when the next temperature was taken DA-D replied that it was taken the next day as no staff were in the kitchen to take any more temps. On 3/1/2022, Surveyor reviewed the temperature logs from the month of February 2022 that the facility supplied. It is noted the temperature was taken on foods prior to entering the cooler. The space on the log designated for the temperature 2 hours after entering the cooler is blank for all days. The area on the form for the temperatures 6 hours after entering the cooler is filled in; however, these are temps that were taken in the AM of the next day, not temperatures taken 6 hours after being placed in the cooler, per the Kitchen Manager. On 3/1/2022, Surveyor reviewed the policy titled Infection Control-Food Preparation, Storage and Serving. This is the facility policy. It states under number 13 that proper cooling of food: food must be cooled from 135 degrees to 70 degrees within 2 hours and cooled to 41 degrees or lower within a total of 6 hours. Record the temps on the food cooling log. On 3/2/2022, Surveyor reviewed the Wisconsin Food Code. It states that the process for cooling food is to cool hot foods from 135 degrees F to 70 degrees F within 2 hours and within a total of 6 hours from 135 degrees F to 41 degrees F or less. The facility's process for cooling foods being used for leftovers was not done in a manner that protected the residents from foodborne illness.

Based on observation, interview and record review, the facility did not ensure that 1 of 12 sampled residents (R31) received appropriate care as it relates to fluid restrictions. R31 has a physician ordered fluid restriction of 1200 ml (milliliters) per day. R31 exceeded his fluid restriction on 21 of the last 35 days. There was no evidence staff were monitoring and assessing R31's fluid intakes. This is evidenced by: R31 has [DIAGNOSES REDACTED]. He is dependent on staff to get him fluids as his in a wheelchair and has physical deficits from his brain hemorrhage however he is able to drink by himself. Review of his plan of care make no mention to his fluid intake with the exception of encourage me to drink frequently . provide ordered diet (registered dietician) consult . ensure adequate hydration . Keep fluids at bedside. There is nothing in his plan of care regarding his understanding of his fluid restriction and if education to him or his spouse had been provided about going over his limit. Surveyor reviewed R31's fluid intakes since 12/1/17. The recorded 24 hour intakes are as follows (the total being the previous 24 hours): 12/2/17 - 895 plus out for part of the day *12/3/17 - 1220 ml *12/4/17 - 1700 ml 12/5/17 - 1090 ml 12/6/17 - 1080 ml 12/7/17 - 865 plus day shift amount *12/8/17 - 1330 ml 12/9/17 - 700 ml *12/10/17 - 1890 ml *12/11/17 - 1400 ml 12/12/17 - 640 ml *12/13/17 - 1570 ml 12/14/17 - 725 plus out for part of the day 12/15/17 - 1020 ml 12/16/17 - 1180 ml *12/17/17 - 1570 ml *12/18/17 - 1570 ml 12/19/17 - 600 ml 12/20/17 - 555 ml *12/21/17 - 1810 ml *12/22/17 - 1610 ml *12/23/17 - 1350 ml *12/24/17 - 2590 ml *12/25/17 - 1570 ml 12/26/17 - 980 ml *12/27/17 - 1810 ml 12/28/17 - 750 ml *12/29/17 - 1640 ml *12/30/17 - 930 ml *12/31/17 - 1900 ml *1/1/18 - 2180 ml 1/2/18 - 1180 ml *1/3/18 - 1290 ml *1/4/18 - 1480 ml *1/5/18 - 1387 ml Review was made of the Diet List used by the kitchen and nursing assistant staff. On 1/5/18 at 8:08 a.m. and 8:17 a.m. CNA-D (Certified Nursing Assistant) told the surveyor this information tells the CNAs and the kitchen staff how much R31 should be served at each meal. CNA-D stated R31's fluid intakes are put into the computer and the nurses look at the totals. The list includes the 780 cc of supplements R31 is to have every day. The list does not include any other information about other fluid amounts of times, does not include fluids consumed with medications, or fluids between meals. It does not address fluids consumed when he is out of the facility. Review of the nursing notes and intakes of R31 found no notations or assessments regarding his total intakes per day or the fact that he was frequently going over this limit. There was no assessment of the signs and symptoms of fluid overload. In addition, there was no indication in the information sent over to the [MEDICAL TREATMENT] clinic that his fluid restriction was not being adhered to. Review of the IDT (Interdisciplinary Team) notes of 12/19/17 and 1/4/18 regarding nutrition found that the 1200 ml fluid restriction was noted however there are no notations regarding the fact that he was consistently taking in more that the physician prescribed limit. On 1/5/18 at 11:21 a.m. Surveyor interviewed FM-E (Family Member) about R31's care. FM-E stated the vascular wound on the back of his foot over his Achilles tendon had gotten worse as of late as he was having so much pain sitting for the length of time he needed for his [MEDICAL TREATMENT]. FM-E stated she was told that the wound got worse again because R31 could not tolerate the length of time the [MEDICAL TREATMENT] needed to take enough fluid out of his system. However, R31's physician had recently changed his pain pills and he was much more comfortable and could tolerate a full session of [MEDICAL TREATMENT]. On 01/05/18 at 12:34 p.m. Surveyor interviewed the DON (Director of Nursing) about the facility's policy involving fluid restrictions and in particular R31's fluid restriction. The DON stated the night nurse should be looking at the daily totals and if over or under, they should notify the supervising nurse and the MDS coordinator. In addition the nurse should start focus charting for fluid overload (i.e. lung sounds and a weight). If under, assess for dehydration and [MEDICAL CONDITION]. The DON stated these assessments were not outlined in the facility's policies to do so. In addition, the DON indicated that residents who received [MEDICAL TREATMENT] should have this information passed on to the [MEDICAL TREATMENT] clinic as the dry weight of the resident, (the weight taken after the [MEDICAL TREATMENT] treatment has pulled out fluids) is the only number dietary is looking at as a treatment goal.

Based on observation, record review and interview the facility did not ensure a Medication Pass error rate of 5 % (percent) or less. The error rate was 8% as calculated by 2 errors out of 25 opportunities for error. LPN-A (Licensed Practical Nurse) made 2 errors when giving medication to R45 (Resident). The first error was improper technique when giving eye drops to ensure the full dose and minimize adverse side effects. The second error was the omission of a drug. This is evidenced by: On 1/5/18 at 7:19 a.m. Surveyor observed LPN-A give R45 her morning medications and eye drop. Example 1: The first error discovered was the technique LPN-A used to give R45 her eye drops. LPN-A did not apply pressure to R45's nose to occlude the tear duct of R45's right eye in order to ensure the full dosage stayed in her eye and to prohibit the systemic absorption of the active ingredients by letting the medication run into her nasal cavity and be absorb into her body. R45 received one drop of the drug, Simbrinza, (A combination of brinzolamide 1% and [MEDICATION NAME] 2%) in her right eye. LPN-A did not press on the side of R45's nose in order to stop the medication from leaving her eye via her tear duct. At this time LPN-A was interviewed about key points to remember when giving eye drops. The LPN-A recited her technique but did not tell the surveyor about this crucial step. When asked by the surveyor if she was aware of this step when giving an eye drop, LPN-A stated she was and she should have done so. Example 2: The second error was LPN-A not giving R45 her morning dose of the drug [MEDICATION NAME] 10 mg (milligrams). This omission was not discovered by LPN-A during her checks and signing out of the medications she gave. When asked about the omission at 1:28 p.m. LPN-A stated she thought she had given the dose but would not be able to verify she gave the medication as the packaging had already been shredded. LPN-A stated the night shift nurse is responsible to get the medications ready for the day shift. A call to the pharmacy confirmed the medication had not been given that morning. PA-D (Pharmacy Technician) was able to confirm that the [MEDICATION NAME] dose had not been taking out of the Allixa dispensing machine at the facility. PA-D stated this error should be caught by the nurse during her checks. At approximately 2:15 p.m. LPN-A told the survey team she had called R45's physician and received orders to give the medication late and assess R45's vitals. LPN-A had begun the paper work to report this medication error to the DON (Director of Nursing).

Based on observation. record review, and interview the facility did not ensure infection control practices were followed specific to the removal of contaminated PPE (personal protective equipment) for 1 of 12 residents (R4). RN-B (Registered Nurse) was observed leaving the room of R4 (Resident) with her gown, mask and gloves on and taking them off in the medication room. This is evidenced by: On 01/04/18 at 6:59 a.m., Surveyor observed RN-B leaving R4's wearing a gown and mask. RN-B took the PPE off as she walked down the hall. RN-B then opened the med room door with her now contaminate hands and put these presumedly contaminate items in the med room garbage. RN-B stated R4, as well as 3 other residents, have colds. On 01/05/18 at 8:10 a.m. Surveyor met with the facility's Infection Control Preventionist (ICP) regarding infection control practices. The surveyor asked the ICP about staff expectations related to PPE. The ICP explained PPE carts are set outside resident rooms with the required PPE. A sign on the resident's door alerts staff and visitors to see the nurse prior to entering the room. Staff and visitors are required to don a mask when entering the room. Additionally if staff or visitors are going to be up close (within 3-6 feet of the resident), and the resident is unable to cover their cough or sneeze; a gown is required. The ICP further explained staff/visitors are expected to remove all PPE in resident rooms and perform hand hygiene prior to exiting the resident room to prevent the spread of the infection. On 1/5/18 at 11:28 a.m. Surveyor interviewed the DON (Director of Nursing) about the observation. The DON stated this practice was unacceptable. The DON indicated R4 had been put on precautions as R4 was now the fourth resident with respiratory illness symptoms on the unit. The DON stated putting R4 on isolation precautions was done as a precaution even though his symptoms might not be infective.

Based on observation, interview, and record review the facility did not ensure 1 of 12 sampled residents received care in a manner which promoted the highest level of functioning and well-being. Resident #6 was admitted to the facility with intact skin. Over the course of approximately 2 months, Resident #6 developed wounds on both great toes. The wounds on both toes deteriorated and Resident #6 was subsequently diagnosed with [REDACTED]. ~ Implement timely interventions to off-load pressure from Resident #6's toes; ~ Change measures to off-load Resident #6's toes when it was evident the toes were deteriorating; ~ Document at least weekly the characteristics of Resident #6's wounds; ~ Ensure Resident #6's care plan for off-loading Resident #6's toes was followed. Resident #6 also had a double lumen [MEDICATION NAME] catheter utilized for [MEDICAL TREATMENT]. There was no clamp readily available to clamp the the catheter should it be needed emergently. This has not been met as evidenced by the following. Resident #6 had current [DIAGNOSES REDACTED]. On [DATE], the Nurse Practitioner included a [DIAGNOSES REDACTED]. Resident #6's most current MDS (Minimum Data Set) was dated [DATE]. The MDS indicated Resident #6, ~ Had a BIMS (Brief Interview for Mental Status Score) of 7 indicating a severe cognitive impairment; ~ Required extensive to total assistance of 1 to 2 staff person for all aspects of care except eating; ~ Did not walk; ~ Had range of motion limitations on one side of both the upper and lower extremity; and ~ Had no skin problems. Example #1: Resident #6's skin care plan dated [DATE] had the following approaches. ~[DATE], Pressure relieving device for bed .Develop and monitor turning schedule .Foot cradle . The purge record indicates these interventions were in place on [DATE]. ~[DATE], .Elevate heels off bed . Surveyor # completed a review of Resident #6's nursing notes and noted the following. ~ [DATE]. .Resident placed on pressure reduction mattress .Resident placed on a turning schedule . ~ [DATE], .Right great toe has small amount of serosanginous (sic) drainage around base of toenail. Toe is swollen .and dark pinkish red . ~ [DATE], .Small amount of yellowish brown drainage noted along side the nail. Toe is swollen .Keep shoe off right foot . ~ [DATE], .R (right) great toe has small round open spot mid left side of nail. Also small openings on top left side of nail and bottom left side of nil (sic) .Nail loose . ~ [DATE], .Right great toe red and swollen .send to clinic and wound clinic . On [DATE] Resident #6 was seen in the clinic. A clinic note dated [DATE] indicated Resident #6 had [MEDICAL CONDITION] of the right great toe. Resident #6 was placed on an antibiotic. On [DATE] Resident #6 was seen by the wound clinic. A wound clinic note dated [DATE] indicated, .Infected right great toe and loose toenail .*careful not to bump toes! . A physical therapy note dated [DATE] indicated, .Infected right great toe with loose nail .No c/o (complaint of) pain .Likely lacks sensation in this area .Right great toe is very red and warm .Toenail was very loose, easily debrided (removed) .Dark skin color on end of toe. After nail removal, wound bed measured 1.6 cm x 2 cm x 0.2 cm (1.6 centimeters by 2.0 centimeters by 0.2 centimeters) .Undermining around nail bed . Resident #6's feet and toes were significantly compromised. Resident #6 had [MEDICAL CONDITION], end stage [MEDICAL CONDITION], and now an infected right great toe with discolored dark skin. Dark skin color on the end of Resident #6's toe was indicative of tissue death. There were no new interventions placed on Resident #6's care plan to ensure there was no pressure on Resident #6's toes. A physical therapy note dated [DATE] indicated, .Nursing concerned that the black color on the tip of the toe was increasing .inspected toe and clearly the blackened area has increased now into a portion of the nailbed and along the sides of the toes. This is a change from Wednesday when only the tip of the toe was darkened. The skin besides being more black is also dry today . On [DATE] Resident #6 was sent to the emergency room for an evaluation of the right great toe and subsequently admitted . An inpatient podiatry progress note dated [DATE] indicated, .being seen for evaluation of right great toe. Worsening [MEDICAL CONDITION] and necrosis (tissue death) for past several days. Oral course of [MEDICATION NAME] (and antibiotic) did not improve [MEDICAL CONDITION] .admitted and intravenous [MEDICATION NAME] given . There were no nursing notes describing the changes to Resident #6 right great toe from [DATE] through [DATE] when Resident #6 was admitted to the hospital. There were no new approaches added to Resident #6's plan of care which included total pressure relief to Resident #6's toes. Resident #6 returned to the facility on [DATE]. Nursing notes continue. ~ [DATE], .blackened areas of right great toe nail bed. no drainage .dry . ~ [DATE], .Right great toe blackened area remain same as yesterday .posterior toe has purplish area with intact skin .Right foot toes are warm, pedal pulses are diminished .Foot cradle placed on bed . A foot cradle is a device designed to totally off-load linens from feet and toes. Resident #6 had significant and deteriorating vascular changes to the right great toe. Despite that the facility did not implement change in Resident #6's care plan to prevent pressure on Resident #6's toes until [DATE]. This was 19 days since the facility identified the changes. Since the time the blackened eschar had been identified on Resident #6's right great toe, there had never been any measurements completed aside from the ones completed by physical therapy on [DATE]. Resident #6 was again hospitalized on [DATE] due to pneumonia. Resident #6 returned to the facility on [DATE]. Nursing notes continue. ~ [DATE], .Partial-thickness venous stasis ulcer left great toe black/brown skin below medial upper toe nail area is 1cm c 0.5 cm (1.0 cm x 0.5 cm) . Resident #6 now developed an area of necrosis to the left great toe. Of notation. Surveyor # questions the classification as a venous ulcer. Venous ulcers do not develop on toes. There were no changes made to Resident #6's plan of care. From [DATE] through [DATE] while the facility charted dry black eschar (necrosis) to both Resident #6's right and left great toes, there were no wound characteristic documented including measurements. It is critical to at least weekly describe wound characteristic including the size of any wound including eschar. This is necessary in order to determine if the areas are changing in size. Nursing notes continue. ~ [DATE], .right great toe blackened/dry, 2nd toe right foot with small area discoloration purplish by nail bed closest to great toe .left great toe blackened/dry . Resident #6 now developed a third area of compromised skin indicative of tissue death on the right second toe. There were no changes made to Resident #6's plan of care until [DATE]. On [DATE] the facility placed heel lift boots and included the approach on the care plan. The boots extended beyond the tips of Resident #6's toes. This would off-load pressure including that from linens and blankets from Resident #6's toes. It had been 39 days since the facility attempted a different modality to off-load pressure from Resident #6's toes. During this time, Resident #6 developed eschar to the left great toe and right second toe. From [DATE] through [DATE] there were no nursing notes describing the wound characteristics of Resident #6's toes. However, changes were made to the care plan to include: ~ [DATE], .Repositioning Schedule: every 1 - 2 hours . This approach dated back to [DATE]. ~ [DATE], .heel hover boots in bed, keep covers off feet by keeping blankets over end of bed .: ~ [DATE], .Float heels in bed . This approach dated back to [DATE]. Nursing notes continue. ~ [DATE], .eschar remains on right great toe nail bed 2 cm x 2 cm (2.0 cm x 2.0 cm), blackened and dry, skin around eschar is non-reddened, pale /pink .Left great toe nail discolored brownish end-tip of left great toe has dry, brown scab 1 cm x 1 cm (1.0 cm x 1.0 cm). No drainage, no increased warmth. Pedal pulses are diminished .denies discomfort .has decreased sensation . From [DATE] through [DATE] there were no nursing notes describing the wound characteristics of Resident #6's toes. On [DATE] at 1:15 p.m. Surveyor # spoke with RN-E about Resident #6's foot cradle. RN-E indicated Resident #6's foot cradle was discontinued when the facility applied the hover boots. The foot cradle is still listed on Resident #6's current care plan. On [DATE] at 7:20 a.m. Surveyor # spoke with Resident #6. Surveyor # noted Resident #6 had a blue heel boot on the left foot which extended beyond Resident #6's toes. There was however no boot on the right foot. On [DATE] at 1:30 p.m. Surveyor # spoke with LPN-F. LPN-F indicated she was the full time nurse on the unit in which Resident #6 resided. Surveyor # asked LPN-F about Resident #6's hover boots. LPN-F indicated Resident #6 had hover boots that he wore in bed. LPN-F indicated she didn't think he wore them when up in the wheel chair. LPN-F thought Resident #6 had hover boots for both feet but wasn't sure. Surveyor # asked LPN-F how Resident #6 developed the wounds on both great toes. On [DATE] at 3:35 p.m. Surveyor # observed Resident #6 in bed. There were no hover boots on either foot. Resident #6's bedding was resting directly on Resident #6's toes. On [DATE] at 9:31 a.m. Surveyor # and LPN-F (Licnesed Practical Nurse) observed Resident #6's toes. Surveyor # noted dry firmly adhered necrotic tissue on Resident #6's left great toe nail bed measuring approximately 1.0 cm x 1.0 cm. Resident #6's right great toe nail bed had dry firmly adherent necrotic tissue measuring approximately 2.0 cm x 2.0 cm. The skin surrounding both the left and right great toe wounds had no redness or drainage. LPN-F indicated to Surveyor # they had tried a foot cradle in the past but Resident #6 did not like it. LPN-F indicated Resident #6 kept bumping his feet on it. Surveyor # asked Resident #6 about the foot cradle. Resident #6 indicated he did not like it because he kept hitting his toes on it. On [DATE] at 12:45 p.m. Surveyor # spoke with RN-E. RN-E indicated she was the RN supervisor on the unit where Resident #6 resided. RN-E indicated the facility did not have a wound team. RN-E indicated the DON (Director of Nursing) was wound care certified and if there was any concerns about any wounds they would talk with the DON. RN-E indicated the floor nurses were to measure and chart on wounds weekly. On [DATE] at 1:00 p.m. Surveyor # spoke with the DON. The DON indicated she had identified weaknesses within the facility's wound management program. The DON stated she had already begun measures to correct it. The DON also indicated Resident #6 had dry gangrene (dead tissue). Example #2: Surveyor # completed a review of Resident #6's clinical record and noted the following. Resident #6 has had [MEDICAL TREATMENT] catheter for [MEDICAL TREATMENT] since admission. The catheter was placed into Resident #6's left [MEDICATION NAME] vein, a large vein in the neck. Special precautions are required should there be an emergency including a clamp to control bleeding. Surveyor # completed a review of Resident #6's care plan. The care plan did not include emergency management of Resident #6's [MEDICAL TREATMENT] catheter. Resident #6's care plan indicated Resident #6 was to shower weekly. A tub bath and not a shower is required to ensure Resident #6's catheter site and catheter dressing did not get wet. On [DATE] at 8:20 a.m. Surveyor # observed Resident #6's room. There was no clamp visible. On [DATE] at 8:25 a.m. Surveyor # spoke with RN-E about the clamp for Resident #6. RN-E indicated she thought it was located in the med room and not in Resident #6's room. RN-E indicated LPN-F could show Surveyor # where the clamp was located. On [DATE] at 8:30 a.m. Surveyor # and LPN-F observed both medications rooms on the unit in which Resident #6 resided. LPN-F could not find a clamp. On [DATE] at 8:33 a.m. Surveyor # spoke with RN-E again about the clamp for Resident #6. RN-E indicated she wasn't sure if Resident #6 ever had a clamp. Surveyor # asked RN-E what their practice was for managing [MEDICATION NAME] [MEDICAL TREATMENT] catheters. RN-E indicated she wasn't sure but stated she would call and get the information from the [MEDICAL TREATMENT] center. On [DATE] at 8:35 a.m. LPN-F approached Surveyor # . LPN-F indicated she found the clamp hanging on the bulletin board in one of the medication rooms. It was critical for the clamp for Resident #6's [MEDICATION NAME] catheter be readily accessible. Should the catheter malfunction, Resident #6 could bleed out in a matter of minutes.

Based on observation interview and record review the facility did not ensure 1 of 1 sample residents with a pressure ulcer received the necessary care and treatment to promote healing. Resident #6 returned from the hospital with a DTI (Deep Tissue Injury) on the right heel. Despite that there were no interventions immediately put into place to totally off-load Resident #6's right heel. There was no weekly documentation including wound characteristics of Resident #6's DTI. Additionally, care planned interventions were not consistently in place. This is evidenced by: Surveyor # completed a review of Resident #6's clinical record and noted the following. Resident #6 had current [DIAGNOSES REDACTED]. Resident #6's most current MDS (Minimum Data Set) was dated 2/9/16. The MDS indicated Resident #6, ~ Had a BIMS (Brief Interview for Mental Status Score) of 7 indicating a severe cognitive impairment; ~ Required extensive to total assistance of 1 to 2 staff person for all aspects of care except eating; ~ Did not walk; ~ Had range of motion limitations on one side of both the upper and lower extremity; and ~ Had no skin problems. Resident #6's skin care plan dated 12/18/15 had the following approaches. ~ 10/14/15, Pressure relieving device for bed .Develop and monitor turning schedule . ~ 5/13/15, .Elevate heels off bed . Resident #6's care plan problem titled Self Care Deficit had the following approaches. ~ 11/22/15, .Heel Lift Boots On When In Bed And Up In W/C (wheel chair) . ~ 12/2/15, .Repositioning Schedule: every 1 - 2 hours . This approach dated back to 5/13/15. ~ 12/2/15, .heel hover boots in bed, keep covers off feet by keeping blankets over end of bed . Resident #6's most current skin risk assessment was dated 3/8/16. The skin risk assessment had a cumulative score of 18. According to the facility's scoring system a cumulative score of 16 or less indicated a risk for the development of a pressure ulcer. A cumulative score of 12 or less indicated high risk. Surveyor # questioned the accuracy of the skin risk assessment given Resident #6's co-morbidities and historical skin issues. Surveyor # completed a review of Resident #6's nursing notes and noted the following. On 10/28/15, Resident #6 returned to the facility after being hospitalized . A nursing note dated 10/28/15 indicated, .Has dark black area appears as DTI on right heel 2cm x 3cm (2.0 cm by 3.0 cm) .Right foot and heel elevated off bed with pillow . A DTI is a pressure ulcer which develops due to prolonged pressure causing damage to underlying tissue. A DTI requires the area have total pressure relief or off-loading. A pillow does not provide for total off-loading. According to Resident #6's record the facility did not apply a heel lift boot until 11/22/15. This was 25 days after Resident #6 was readmitted . There was no further documentation including wound characteristics and measurements of the DTI on Resident #6's right heel until 2/17/16. A nursing note dated 2/17/16 indicated, .Right heel 0.5 cm x 0.4 cm no open area noted . There were no further nursing notes describing the DTI on Resident #6's right heel. On 3/9/16 at 9:40 a.m. Surveyor # and LPN-F (Licensed Practical Nurse) observed Resident #6's right heel. Surveyor # noted an area of Resident #6's right heel which measured approximately 1.5 cm x 0.5 cm. 75% of the wound was covered with leathery light brown tissue. The edges of the brown tissue were dry and beginning to peel away. 25% of the wound had pinkish red colored tissue indicative of healing. There was no redness surrounding the wound. There was no drainage. Because 75% of the wound was covered with brown leathery tissue and the base of the wound was not visible Resident #6's pressure was classified as an unstageable pressure ulcer. On 3/8/16 at 7:20 a.m. Surveyor # spoke with Resident #6. Surveyor # noted Resident #6 had a blue heel boot on the left foot which extended beyond Resident #6's toes. There was however no boot on the right foot. On 3/8/16 at 3:35 p.m. Surveyor # observed Resident #6 in bed. There were no hover boots on either foot. On 3/8/16 at 1:30 p.m. Surveyor # spoke with LPN-F (Licensed Practical Nurse). LPN-F indicated she was the full time nurse on the unit in which Resident #6 resided. Surveyor # asked LPN-F about Resident #6's hover boots. LPN-F indicated Resident #6 had hover boots that he wore when Resident #6 was in bed. LPN-F indicated she didn't think he wore them when Resident #6 was up in the wheel chair. LPN-F thought Resident #6 had hover boots for both feet but wasn't sure. On 3/8/16 at 12:45 p.m. Surveyor # spoke with RN-E. RN-E indicated she was the RN supervisor on the unit in which Resident #6 resided. RN-E indicated the facility did not have a wound team. RN-E indicated the DON (Director of Nursing) was wound care certified and if there was any concerns about any wounds they would talk with the DON. RN-E indicated the floor nurses were to measure and chart on wounds weekly. On 3/8/16 at 1:00 p.m. Surveyor # spoke with the DON. The DON indicated she had identified weaknesses within the facility's wound management program. The DON stated she had already begun measures to correct it.

Based on observation, interview, and record review, the facility did not ensure that each resident was given adequate supervision and sufficiently evaluated for assistive devices to prevent accidents. This was not done for 1 of 12 sampled residents. Resident #2 is dependent on staff for consuming foods and fluids related to affects of a stroke on one side and contractures on the other. On 11/22/10, CNA-D (Certified Nursing Assistant) independently rigged up a straw device to allow Resident #2 to independently drink hot liquids. The adaptation was not comprehensively assessed by nursing or therapy professionals for safety, and no supervision was provided during its use. The adaptation caused hot fluid to expel onto Resident #2's hand, chest, and side causing 2nd degree burns to 4% of his body. Second-degree burns involve the first two layers of skin. These may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin. The lack of appropriate devices and supervision to ensure Resident #2's safety while consuming hot fluids resulted in a finding of Immediate Jeopardy, which began on 11/22/10. the facility was notified of this finding on 12/8/10. The Immediate Jeopardy was removed on 11/26/10; however the deficient practice continues at a scope and severity level of E (potential for more than minimal harm that is not immediate jeopardy/pattern). The facility still needs to address the issue of appropriate assessment for use of assistive devices for residents who require staff assistance. This is evidenced by: Resident #2 is [AGE] years old first admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. According to his MDS (Minimum Data Set) assessments, he is totally dependent on 1 or 2 staff for all of his activities of daily living. Resident #2 has contractures of both of his hands and is dependent on the staff or his wife to feed him liquids and solids. Resident #2's care plan with original date of 9/23/10, indicates that Resident #2 is his own decision maker and wishes to be as independent as possible. On 12/8/10 at 2:31 p.m., Surveyor # spoke with CNA-V. CNA-V stated Resident #2 is dependent on staff to drink and that staff are to hold the straw up to his mouth. On 12/8/10 at 2:35 p.m. CNA-U stated to Surveyor # that staff need to hold onto Resident #2's glass and straw for him to drink. On 12/6/10, during the initial tour, RN-T (Registered Nurse) informed Surveyor # that Resident #2 had burns caused by hot tea. A review of the nurse's notes, hospital admission notes found, and the facility's internal investigation by Surveyor # , found that on 11/22/10 at 8:00 p.m. CNA-D gave Resident #2 a covered cup of hot tea. Into the cup, at the request of the resident, CNA-D inserted 1 straw into another straw and placed the second straw into the covered plastic cup. This created a long straw that would reach to the resident's mouth. The cup was placed on his bedside table close to his chest. CNA-D offered to place ice in the cup but Resident #2 refused several times. The resident was informed that the tea was hot and the resident stated he would wait to drink it. CNA-D then left Resident #2 with the hot tea. The above information was corroborated in several interviews of the CNA and Resident #2 by the DON (Director of Nursing). The information was also corroborated in an interview of Resident #2 by Surveyor # . Documentation indicates that the resident had placed his call light on and called out for help. This was heard by RN-B. RN-B stated she pulled off the sheet and applied cold water to the burn areas. The facility's MD (Medical Director) was in house at the time. The MD assessed the areas and his preliminary thought was that Resident #3 received second degree burns with a possibility of third degree burns. He ordered Silvadene Ointment, a narcotic analgesic, and to have the hospital wound certified nurse see Resident #2 in the morning. Of note is that this was done and the recommendation was for hospitalization for fluid, electrolyte, and blood sugar monitoring. This information was confirmed in an interview between Surveyor # and RN-B on 12/7/10 at 4:30 p.m. RN-B stated that no CNA had come to her and she was completely unaware of the straw adaptation. The facility investigation also found that this rigging of the straws was Resident #2's idea and that he requested CNA-C make the adaptation earlier on 11/22/10. The investigation also found that this rigging had been used two more times that day without incident. Entries in the nurse's notes indicate Resident #2 was hospitalized for [REDACTED]. On 12/7/10 at 2:22 p.m., Surveyor # interviewed CNA-C. CNA-C stated that she was the first to set up this adaptation for Resident #2. She stated she did it at his suggestion. CNA-C stated she put ice in the tea and stayed with Resident #2, who drank the tea without any problem. When asked if she had any input from nursing or therapies, she stated she did not as the resident had asked her to do it and was already using a hydration system to drink. The hydration system CNA-C referred to is a water pouch with an attached tube to suck the water through. Surveyor # confirmed with therapy and nursing staff that this pouch is only to be used with cold fluids and that Resident #2 had not received hot liquids in this manner. Surveyor # interviewed the NHA on 12/8/10 at 12:00 p.m. about this. The NHA indicated she was aware of the dual straw system, but she really had no idea what was in the cup but felt it was safe from tipping over. The NHA did not question why there was no input from professional nursing or therapies as she was aware of the hydration system. The facility's investigation also discovered that another staff (CNA-E) had given Resident #2 this setup at least two more times. The CNA did not recall if she had put ice in the beverage and the investigation did not identify if the CNA-E had stayed in the room. The investigation was able to determine that test cups of hot water directly from the coffee maker on 11/23/10, ranged between 160 degrees F (Fahrenheit) to 200 degrees F. It was at this time that instruction was received from the coffee maker's supplier to turn down the temperature to be no more that 174 degrees F. Of note is that water temperatures as low as 155 degrees F can cause a third degree burn in one second. Third degree burns penetrate the entire thickness of the skin and permanently destroy tissue. Resident #2's plan of care was updated on 11/26/10 when he returned from the hospital. "No hot drink without staff or wife present." On 12/7/10 at 10:04 a.m., Surveyor # observed RN-S complete the dressing change of Resident #2's burns. Surveyor # observed that the scalded area on Resident #2's chest covered the right side of his chest from the top of his sternum to his xiphoid process (mid bottom of his rib cage) and over to his side. The area was bright red with approximately 50% covered in yellow slough. According to RN-S, the red areas below the right nipple were initially covered with blisters that have since resolved. Resident #2's left palm was bright red, his index finger was puffy and mottled red/white with a red outline to the burn. Resident #2's thumb was puffy and covered with thick white opaque skin and the thumb nail was loose and bleeding. RN-S stated that Resident #2 was to see the plastic surgeon on 12/8/10 for evaluation of healing and possible reconstructive surgery. On 12/7/10 at 3:20 p.m., Surveyor # spoke with RN-B. RN-B stated that she was not aware of any other residents getting burned from hot liquids. On 12/7/10 at 3:25 a.m., Surveyor # spoke with CNA-P. CNA-P indicated that she was not aware of any other residents getting burned from hot liquids. On 12/7/10 at 3:34 p.m., Surveyor # spoke with CNA-Q. CNA-Q indicated that she was not aware of any other residents getting burned from hot liquids. On 12/7/10 at 3:35 p.m., Surveyor # spoke with RN-O. RN-O indicated that she was not aware of any other residents getting burned from hot liquids. The facility's failure to provide Resident #2 with appropriate supervision and assistive devices created a situation of immediate jeopardy. The facility removed the immediate jeopardy on 11/26/10 when: 1. The facility trained nursing staff that any resident who can not drink independently cannot be left alone with hot drinks. Staff need to keep hot drinks out of the residents' reach unless staff are there to assist. 2. Staff were educated to only serve hot beverages out of the carafes and not the coffee/hot water machine. 3. Nursing orientation and competency checklists were updated to include this information. 4. Food service department was educated on policy changes that fluids cannot be served at a temperature above 170 degrees Fahrenheit. 5. The facility turned the holding temperature of the coffee/hot water machine down.