Every finding on record at Wausau Manor Health Services

Based on observation, interview, and record review the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials in accordance with State law through established procedures. The facility did not report a potential incident of neglect to the State Agency (SA) for 1 of 1 resident (R47) reviewed for reporting requirements.R47 requires 2 staff assistance with bed mobility and transfers. Staff did not follow R47's plan of care for bed mobility. R47 fell which result in R47 sustaining significant bruising to their face. The facility did not report this incident of potential neglect to the state agency.The facility's policy titled Abuse, Neglect and Exploitation read in part, Neglect means the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, mental anguish, or emotional distress.Possible indicators of abuse include.8. Failure to provide care needs such as feeding, bathing, dressing, turning & positioning.The facility will have written procedures that include 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes. R47 was admitted to the facility on [DATE], and diagnoses included mild intellectual disability. On 07/17/26, R47 scored 12/15 during Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. R47's care plan included: -At risk for falls due to history of falls. Intervention, provide assistance to transfer and ambulate as needed, initiated 09/04/26. -ADL self-care deficit. Interventions, bed mobility assist of 2, revised 10/10/24. Transfer with EZ stand assist of 2, revised 11/22/24. On 07/20/26 at 12:43 PM, Surveyor observed R47 in the dining room with significant bruising to their face, forehead, around both eyes, and down into both cheeks. Bruising was both dark and light shades of blue, with green and yellow coloring on the outside of the bruise. Surveyor asked R47 if they experienced pain from the bruising, and R47 stated yes. On 07/20/26, Surveyor reviewed R47's fall investigation that occurred on 07/08/26, which included the following: Description: Called into resident's room. It was observed that resident was lying on the floor on left side. CNA x 2 witnessed fall and resident hit left side of head hard on the floor. Instant large hematoma 5.6 cm by 8 cm. Ice applies to hematoma. Area not open. Resident is on Eliquis 50 mg (milligrams) twice daily. Skin shearing to left knee 1.7 cm by 3.2 cm. Skin tear to right index finger 1.7 cm by 0.1 cm. Area cleansed and band aid applied. Resident description: Resident unable to give description. Immediate Action: Resident was taken to ER for eval (evaluation) and dx (diagnosis). Notes: 07/13/26, IDT (Interdisciplinary Team) reviewed fall. Due to the impact of the resident's head and current anticoagulation therapy, 911 was called and resident was transported to the ER. All scans were within normal limits. The resident returned to the facility with no new orders. On 07/21/26 at 6:55 AM, Surveyor interviewed Certified Nursing Assistant (CNA) D. CNA D confirmed he was present when R47 fell from their bed. CNA D stated R47 is a sit to stand transfer, and all mechanical transfers require two staff. CNA D reported another CNA was present in the room and assisting R47's roommate. CNA D stated he assisted R47 to sit on edge of bed and added R47 can sit on the edge of the bed. CNA D stated he turned to grab the sling for the mechanical lift, and as he turned around R47 was already falling to the floor. CNA D confirmed Director of Nursing (DON) B interviewed him yesterday. On 07/21/26 at 8:42 AM, Surveyor interviewed DON B. DON B stated an investigation of R47's fall was completed, but maybe it was not very thorough. DON B confirmed she did not interview CNA D until 07/20/26. DON B did not indicate why. Surveyor asked DON B if this incident should have been reported to the SA (State Agency) for potential neglect, and DON B nodded her head yes. On 07/21/26 at 12:26 PM, Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A expressed confusion about R47's fall meeting the requirements for a reportable incident. Surveyor asked NHA A to provide any additional documentation to support the facility's claim R47's fall was not reportable. Surveyor did not receive any additional information. On 07/21/26 at 1:24 PM, survey team was exiting with facility leadership staff. A regional corporate staff person was present during exit but was not introduced to the survey team. During the exit conference, the regional corporate staff asked Surveyor why R47's fall should have been reported. Surveyor replied R47's care plan indicated R47 required two staff to assist with bed mobility and transfers, and CNA D's failure to do this resulted in R47's fall causing an injury. Surveyor determined that CNA D did not provide needed services to R47 per R47's plan of care resulting in R47 falling and sustaining an injury. The facility failed to report this incident to the SA.

Based on interview and record review, the facility did not ensure a thorough investigation was conducted for a potential incident of caregiver misconduct for 1 of 1 resident (R47) reviewed for investigating an alleged violation. The facility did not conduct a thorough investigation following R47's fall with injury. CNA D did not follow R47's plan of care, R47 fell and sustained an injury. The facility did not complete a thorough investigation into the incident and did not protect residents during the investigation. Findings include:The facility's policy titled Abuse, Neglect and Exploitation read in part, Neglect means the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, mental anguish, or emotional distress.Possible indicators of abuse include.8. Failure to provide care needs such as feeding, bathing, dressing, turning & positioning. An immediate investigation is warranted when allegations or suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.Identifying and interviewing all involved persons, including alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation(s).Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; andProviding complete and thorough documentation of the investigation.The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during the investigation. Examples include but are not limited to: D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator. R47 was admitted to the facility on [DATE], and diagnoses included mild intellectual disability. On 07/17/26, R47 scored 12/15 during Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. R47's care plan included: -At risk for falls due to history of falls. Intervention, provide assistance to transfer and ambulate as needed, initiated 09/04/26. -ADL (Activities of Daily Living) self-care deficit. Interventions, bed mobility assist of 2, revised 10/10/24. Transfer with EZ stand assist of 2, revised 11/22/24. On 07/20/26 at 12:43 PM, Surveyor observed R47 in the dining room with significant bruising to their face, forehead, around both eyes, and down into both cheeks. Bruising was both dark and light shades of blue, with green and yellow coloring on the outside of the bruise. Surveyor asked R47 if they experienced pain from the bruising, and R47 stated yes. On 07/20/26, Surveyor reviewed R47's fall investigation that occurred on 07/08/26, which included the following: Description: Called into resident's room. It was observed that resident was lying on the floor on left side. CNA x 2 witnessed fall and resident hit left side of head hard on the floor. Instant large hematoma 5.6 cm by 8 cm. Ice applies to hematoma. Area not open. Resident is on Eliquis 50 mg (milligrams) twice daily. Skin shearing to left knee 1.7 cm by 3.2 cm. Skin tear to right index finger 1.7 cm by 0.1 cm. Area cleansed and band aid applied. Resident description: Resident unable to give description. Immediate Action: Resident was taken to ER for eval (evaluation) and dx (diagnosis). Notes: 07/13/26, IDT (Intradisciplinary Team) reviewed fall. Due to the impact to the resident's head and current anticoagulation therapy, 911 was called and resident was transported to the ER. All scans were within normal limits. The resident returned to the facility with no new orders. On 07/21/26 at 6:55 AM, Surveyor interviewed Certified Nursing Assistant (CNA) D. CNA D confirmed he was present when R47 fell from their bed. CNA D stated R47 is a sit to stand transfer, and all mechanical transfers require two staff. CNA D reported another CNA was present in the room and assisting R47's roommate. CNA D stated he assisted R47 to sit on edge of bed and added R47 can sit on the edge of the bed. CNA D stated he turned to grab the sling for the mechanical lift, and as he turned around R47 was already falling to the floor. CNA D confirmed Director of Nursing (DON) B interviewed him yesterday. On 07/21/26 at 8:42 AM, Surveyor interviewed DON B. DON B stated an investigation of R47's fall was completed, but maybe it was not very thorough. DON B reported a thorough investigation would include talking to staff, talking with the person who reported the incident, and trying to find out what happened. Talk with staff, provide staff with training. Talk with residents and provide resident education if appropriate. DON B confirmed she did not interview CNA D until 07/20/26, DON B did not indicate why. Surveyor asked DON B if this incident should have been reported to the SA for potential caregiver misconduct, and DON B nodded her head yes. On 07/21/26 at 12:26 PM, Surveyor interviewed Nursing Home Administrator (NHA) A. Surveyor explained the facility's investigation was not thorough, as interviews were not conducted, specifically CNA D was not interviewed until 07/20/26. NHA A did not comment. CNA D did not follow R47's plan of care. CNA D continued working at the facility and did not receive training until seven days after the incident. CNA D was not interviewed until 07/20/26, 12 days after the incident. The facility did not complete a thorough investigation into the incident have evidence of the investigation and prevent further potential neglect during the investigation.

Based on record review and interview, the facility did not accurately code the Minimum Data Set (MDS) assessments for 1 of 6 residents (R) reviewed. (R2)R2 had a Preadmission Screening and Resident Review (PASARR) 1 and 2 completed, which the MDS assessment did not reflect. This is evidenced by: R2 was admitted to the facility on [DATE]. R2's current diagnoses include dementia, post-traumatic stress disorder, anxiety disorder, and major depressive disorder. Review of R2's medical record found a PASARR level 2 screen was completed, dated 10/22/25.R2's annual MDS (Minimum Data Set) assessment, dated 11/10/25, documented Section A1500: Preadmission screening and resident review (PASRR) question Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? The response selected was No.R2's significant change MDS assessment, dated 04/16/26, documented Section A1500 Preadmission screening and resident review (PASRR) question Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? The response selected was No.On 07/20/26 at 3:19 PM, Surveyor interviewed Registered Nurse (RN) C the Minimum Data Set Coordinator about the 11/10/25 and 04/16/26 MDS section 1500 of the PASRR being coded as no mental illness. RN C stated they were in training in November. There would have been MDS floats doing the MDS at that time. RN C stated they would have to look to see why section 1500 was coded as no. Surveyor asked if the system would auto fill sections from the previous MDS. RN C stated that the system will auto fill certain sections and don't know which sections. RN C would compare MDS's to catch and verify the correct information. On 07/20/26 at 3:43 PM, Surveyor interviewed RN C asking if R2's MDS was coded correctly. RN C stated they talked with their regional manager and identified RN C had coded the 04/16/26 MDS incorrectly. RN C stated they can't speak to why the other MDS was incorrectly coded. RN C stated they put in a correction for the MDS. On 07/20/26 at 4:04 PM, Surveyor interviewed Nursing Home Administrator (NHA) A about MDS for R2 incorrectly coded for PASSR. NHA A stated understanding, and a correction was made to the MDS.

Based on interview and record review, the facility did not provide adequate supervision to prevent accidents for 1 of 3 residents (R47) reviewed for accidents.R47 requires assistance from two staff with bed mobility and transfers, per the plan of care. One certified nursing assistant (CNA) sat R47 on the edge of the bed and turned to retrieve the mechanical lift sling; during this time R47 fell from the bed landing on their face. R47 sustained significant bruising to their face.Findings include: The facility's policy titled Abuse Neglect and Exploitation states in part, Neglect means the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, mental anguish, or emotional distress.Possible indicators of abuse include.8. Failure to provide care needs such as feeding, bathing, dressing, turning & positioning. The facility's policy titled Fall Prevention and Management Guidelines read in part, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized plan of care to minimize the likelihood of falls or reduce the possibility/severity of injury. R47 was admitted to the facility on [DATE], and diagnoses included mild intellectual disability. On 07/17/26, R47 scored 12/15 during Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. R47's care plan included: -At risk for falls due to history of falls. Intervention, provide assistance to transfer and ambulate as needed, initiated 09/04/26. -ADL (Activities of Daily Living) self-care deficit. Interventions, bed mobility assist of 2, revised 10/10/24. Transfer with EZ stand assist of 2, revised 11/22/24. On 07/20/26 at 12:43 PM, Surveyor observed R47 in the dining room with significant bruising to their face, forehead, around both eyes, and down into both cheeks. Bruising was both dark and light shades of blue, with green and yellow coloring on the outside of the bruise. Surveyor asked R47 if they experienced pain from the bruising, and R47 stated yes. On 07/20/26, Surveyor reviewed R47's fall investigation that occurred on 07/08/26, which included the following: Description: Called into resident's room. It was observed that resident was lying on the floor on left side. CNA x 2 witnessed fall and resident hit left side of head hard on the floor. Instant large hematoma 5.6 cm by 8 cm. Ice applies to hematoma. Area not open. Resident is on Eliquis 50 mg (milligrams) twice daily. Skin shearing to left knee 1.7 cm by 3.2 cm. Skin tear to right index finger 1.7 cm by 0.1 cm. Area cleansed and band aid applied. Resident description: Resident unable to give description. Immediate Action: Resident was taken to ER for eval (evaluation) and dx (diagnosis). Notes: 07/13/26, IDT (Interdisciplinary Team) reviewed fall. Due to the impact to the resident's head and current anticoagulation therapy, 911 was called and resident was transported to the ER. All scans were within normal limits. The resident returned to the facility with no new orders. On 07/21/26 at 6:55 AM, Surveyor interviewed Certified Nursing Assistant (CNA) D. CNA D confirmed he was present when R47 fell from their bed. CNA D stated R47 is a sit to stand transfer, and all mechanical transfers require two staff. CNA D reported another CNA was present in the room and assisting R47's roommate. CNA D stated he assisted R47 to sit on edge of bed and added R47 can sit on the edge of the bed. CNA D stated he turned to grab the sling for the mechanical lift, and as he turned around R47 was already falling to the floor. On 07/21/26 at 8:42 AM, Surveyor interviewed DON B. DON B stated the root cause of R47's fall would have been staff not having items ready prior to sitting R47 on the edge of the bed. Surveyor asked DON B if the fall occurred because CNA D did not provide R47 with adequate supervision, and DON B stated yes. DON B reported staff received training on 07/15/26, which included resident transfers. Upon review of the training sign in document, Surveyor noted CNA D's name was not included. R47 required two staff for bed mobility and transfers. CNA D did not follow R47's plan of care which resulted in R47 falling and sustaining an injury.

Based on interview and record review, the facility did not ensure that a resident who requires dialysis receives such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences for 1 of 1 sampled resident (R6) reviewed for dialysis.The facility failed to provide ongoing assessment of R6's condition and monitoring for complications before and after dialysis treatments.The facility did not have a system in place for accurate and ongoing communication with dialysis facility. The facility's policy titled Hemodialysis read in part, The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include:-The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility.-Ongoing assessment and oversight of the resident before and after dialysis treatments, monitoring for complications, implementation of appropriate interventions, and using appropriate infections control practices: and-Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services.4. The licensed nurse will communicate to the dialysis facility by utilizing the Pre-dialysis Communication UDA.7. The nurse will monitor and document the status of the resident's access site upon return from the dialysis treatment to observe for bleeding or other complications using the Post-dialysis UDA.12. The facility will ensure that the plan of care for dialysis includes:a. The type of access for dialysis (e.g., arteriovenous shunt, external dialysis catheter) and location:b. The dialysis schedule;c. The dialysis facility name and phone number;d. Transportation arrangements to and from the dialysis facility;e. Any medication administration or withholding of specific medications prior to dialysis treatments;f. Any fluid restriction if ordered by the physician.13. The nurse will ensure that the dialysis access site is checked before and after dialysis treatments and every shift for patency by auscultating for a bruit and palpating for a thrill.R6 admitted to the facility on [DATE], and diagnoses included dependence on renal dialysis. R6's primary language is not English. R6 scored 00/15 during Brief Interview for Mental Status (BIMS).R6's care plan included: -Difficulty communicating as evidenced by trouble being understood even by interpreter. Resident is usually understood but only understands some of the time. R6 rarely/never has the ability to express wants and needs. Revised 05/14/26.-Renal insufficiency related to end stage renal disease, dependence on renal dialysis. Interventions: Check access site for lack of bruit/thrill, evidence of infection, swelling, or excessive bleeding. Initiated 01/16/26.-Record dry weights and report significant changes as ordered. Initiated 02/05/26.Note, according to the National Institute of Health (NIH) dry weight in dialysis is the target post-dialysis weight after all excess fluid is removed.Note, email communication on 06/17/26 from the dialysis facility's Registered Dietician confirmed R6's estimated dry weight to be #135.R6's orders included:-Weight monitoring prior to dialysis, in the morning every Monday, Wednesday, and Friday related to end stage renal disease, start date 05/04/26.-Fluid restriction: 2000mL. Dietary: 1440mL. Nursing 560mL, AM 240, PM 240, NOC 80, every shift for fluid restriction, start date 03/09/26.On 07/21/26 at 7:01 AM, Survey requested R6's dialysis communication book. Licensed Practical Nurse (LPN) E went to the nurses' station to find this and stated it was not at the nurses' station. LPN E and Surveyor went to R6's room, and Surveyor observed LPN E looking for R6's dialysis communication book. LPN E stated she was unable to find the communication book and did not know where it was. Surveyor asked LPN E how the facility communicates with dialysis facility, and LPN E stated usually via phone.Surveyor asked LPN E to describe how staff monitor R6 for dialysis complications. LPN E stated staff obtain R6's weight and vital signs before and after dialysis treatments, and upon R6's return from dialysis, staff check R6's access site for bleeding and infection.On 07/21/26 at 8:36 AM, LPN E brought Surveyor R6's dialysis communication book, stating it was in R6's wheelchair. Surveyor reviewed the book and noted it contained pre and post-dialysis communication forms from 07/20/26, and there was no other communication contained in the book. Surveyor asked LPN E how facility staff know if dialysis facility changes or adds orders for R6. LPN E stated the dialysis facility will either call or send a paper copy. LPN E stated the dialysis center does not send communication for every session R6 attends.Surveyor reviewed R6's pre and post dialysis communication forms in the electronic record for previous four months, under assessments tab. This included the following information not consistent with the facility's policy and standards of practice, (note, the information documented is the most recent, however inconsistencies existed over the four months reviewed):-07/20/26, Post-dialysis communication-vital signs and weights not checked and documented from the pre-dialysis communication.-07/17/26, Pre-dialysis communication-weight obtained on 07/13/26.Post-dialysis communication-weight not obtained and documented from pre-dialysis communication.-07/15/26, Pre-dialysis communication-bruit/thrill present? No. Vital signs and weight obtained on 07/13/26.Post-dialysis communication-weight not obtained and documented from pre-dialysis communication.07/13/26, Pre-dialysis communication-weight obtained on 07/10/26.Post-dialysis communication-vital signs not checked and documented from pre-dialysis communication. Weight not obtained and documented from pre-dialysis communication.07/10/26, Post-dialysis communication-weight not obtained and documented from pre-dialysis communication.-07/08/26, Pre-dialysis communication-vital signs and weight obtained on 07/06/26. Post-dialysis communication-weight not obtained and documented from pre-dialysis communication.-07/06/26, Post-dialysis communication-weight not obtained and documented from pre-dialysis communication.-07/03/26, Post-dialysis communication-weight and vital signs not obtained and documented from pre-dialysis communication.-07/01/26, Pre-dialysis communication-Vital signs obtained on 06/29/26.Post-dialysis communication-weight not obtained and taken from pre-dialysis communication.On 07/21/26 at 8:42 AM, Surveyor interviewed Director of Nursing (DON) B. Surveyor asked DON B how the facility and the dialysis facility communicate, and how nursing staff know about changes, vital signs, and weights assessed by the dialysis facility. DON B stated she would need to look into this.DON B provided Surveyor with progress notes and stated this was the communication between the facility and the dialysis facility. The progress notes included the following:-05/06/26, Resident has an appointment for left fistulogram.-05/11/26, Registered Dietician nutritional note.-05/13/25, Email communication with dialysis facility Registered Dietician.

Based on observation, interview and record review, the facility did not maintain a safe and sanitary environment in which food is prepared and distributed. This has the potential to affect all 56 residents who reside in the facility.Facility staff did not conduct appropriate hand hygiene during food preparation and were observed touching ready to eat foods with contaminated gloved hands.This is evidenced by:The facility policy, titled Food Preparation, revised last 9/2017, states: All Foods are prepared in accordance with the FDA Food Code.1. All staff will practice proper hand washing techniques and glove use.The facility policy, titled Hand Washing- Food and Nutrition Services, revised last 8/16/22, states: Employees will wash hands as frequently as needed throughout the day using proper hand washing procedures1. When to wash:a. When entering the kitchen.g. During food preparation, as often as necessary to remove soil or contamination and to prevent cross contamination when changing task.i. Before donning disposable gloves for working with food and after gloves are removed.On 9/30/25 at 11:21 AM, Surveyor started the observation of the kitchen preparing and serving foods. Surveyor observed [NAME] (CK) I miss opportunities for washing hands. At 11:25 AM, CK I took off CK I's gloves after serving food to be taken to unit; CK I did not wash CK I's hands after taking off gloves and left the kitchen. At 11:32 AM, CK I came back into kitchen, did not wash CK I's hands, put on gloves and adjusted food pans in warming table with contaminated hands and prepared to serve food. At 11:38 AM, CK I took the bread bag, jelly, and peanut butter out, with contaminated hands. CK I made a sandwich. CK I took off gloves and left the kitchen, no hand washing or hygiene. At 11:53 AM, CK I came back into the kitchen with lunch tickets. CK I did not wash CK I's hands after entering the kitchen. With contaminated hands adjusted position of plate warming cart, removed tinfoil off food items in steamer table and served food onto plates. At 11:55 AM, CK I washed her hands, but using bare fingertips, opened the lid of garbage can at corner and threw paper towel away. CK I then put on gloves on her contaminated hands and went back to serving food. At 12:33 PM, CK I turned heat on steamer table off, took off CK I's gloves, washed CK I's hands but using CK I's bare fingertips to open garbage lid to throw away. Other staff observed using the foot pedal on garbage; foot pedal was in working order. At 12:35PM, CK I put new gloves on CK I's contaminated hands and made a second peanut butter sandwich. On 9/30/25 at 11:21 AM, Surveyor was stationed in a position to observe both CK I and Dietary Aide (DA) J. Surveyor observed DA J miss opportunities for hand washing. At 11:26 AM, Surveyor observed DA J make chef salads. DA J finished putting lettuce in bowls with gloved hands, took off gloves, without washing her hands, started spooning tomatoes on salad. Once done putting tomatoes on salad, DA J put new gloves on her contaminated hands and put cheese with her hands on the salads. At 11:34 AM, DA J took off gloves, without washing her hands, put on new gloves, got a new sheet pan, bowls, and brought over to the salad making station. DA J with same contaminated gloves, reached into lettuce bag and started filling the bowls on the pan. DA J took off DA J's gloves and did not wash DA J's hands. DA J retrieved a cutting board and knife, put gloves on DA J's contaminated hands and started cutting more tomatoes. At 11:51 AM, DA J put gloves on still unwashed hands and started adding tomatoes to salads with spoon. DA J took gloves off, put new gloves on contaminated hands, and again used contaminated hands to put cheese on salads. No hand washing between gloves. On 9/30/25 at 3:03 PM, Surveyor interviewed Dietary Manager (DM) K who stated, you should never use hands to touch food. DM K expects dietary staff to wash hands before coming into the kitchen or before leaving the kitchen. DM K stated staff wear gloves when dealing with raw meat and ready to eat foods. Staff should change gloves after touching meat or when they are soiled. DM K expects dietary staff to wash hands in between using gloves. DM K stated hands should be washed when taking gloves off your hands, before putting them on, all the time. DM K stated gloves never replace the need of washing hands.On 10/1/25 at 11:21 AM, Surveyor interviewed DA J who stated you wash your hands when you come in, leave the kitchen and if you start a new task. DA J stated DA J should wash hands between gloves.On 10/1/25 at 12:18 PM, Surveyor interviewed CK I who stated CKI washes CK I's hands when CK I enters the kitchen. CK I stated wash hands whenever they are dirty. Surveyor asked when gloves are worn in the kitchen. CK I stated when working with food; never touch ready to eat foods with bare hands. CK I stated you should change your gloves between tasks and if they get dirty. Surveyor asked do you have to wash hands if you wear gloves. CK I stated yes you should wash hands before you put on gloves and when you take them off.

Based on observation and interview, the facility did not ensure garbage and refuse were properly disposed in the outside garbage storage receptacles. This has the potential to affect all 33 residents residing in the facility.This is evidenced by:The facility policy titled, Environment, last revised 9/2017, states: .All trash will be contained in covered, leak-proof containers that prevent cross contamination.According to State Operations Manual, Appendix PP: Guidance to Surveyors for Long Term Care Facilities, revised last 4-25-25, garbage receptacles should be covered to prevent the harborage and feeding of pests.On 9/29/25 at 11:30 AM, Surveyor observed garbage dumpster uncovered, right side lid was open. On 9/29/25 at 2:30 PM, Surveyor observed garbage dumpster uncovered, right side lid was open. Surveyor observed for 15 minutes to make sure it wasn't being used.On 09/30/25 at 9:30 AM, Surveyor interviewed the Environment Services Manager (ESM) O who stated, Waste Management come early on Monday, Wednesday, and Friday to take garbage.On 9/30/25 at 2:54 PM, Surveyor and Dietary Manager (DM) K observed garbage dumpster uncovered, right side lid open.On 9/30/25 at 2:54 PM, DM K stated that should be closed; they should never be left open.

Based on observation, interview and record review, the facility did not maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections.Staff did not perform hand hygiene when changing gloves during resident cares and procedures for 4 of 12 residents (R). R31, R9, R5, R56Staff did not clean the mechanical lift in between patient use.Findings include:Facility policy and procedure titled, Hand Hygiene, dated 11/02/22, states in part: Hand Hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of antiseptic hand rub, also known as alcohol-based hand rub (ABHR).2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table.6. a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .The attached Hand Hygiene Table, dated 11/2/2022, states in part: Alcohol Based Hand Rub or Soap and waterBetween resident contacts Before applying and after removing personal protective equipment, including gloves During resident care, moving from a contaminated body site to a clean body site After assistance wither personal body functions On 9/29/25 at 10:34 AM, Surveyor observed Certified Nursing Assistant (CNA) L approached R31's room and put on gloves, gown and mask without hand hygiene first. CNA L went into the room of R31 and applied the mechanical lift sling to R31. CNA H came into room to help, all PPE in place. CNA L and CNA H moved R31 to the bathroom, assisted R31 by pulling down the soiled brief and clothing, lift sling also removed while R31 was on toilet. With same contaminated gloves, CNA L assisted with clean brief and pants, while CNA H assisted with clean shirt for R31. Both CNAs stepped out of bathroom to allow privacy, took off gown and gloves and left room. CNA L walked down to R9's room. CNA H went back into R31's room and grabbed the mechanical stander. CNA H did not wipe down the mechanical lift prior to taking it out of the room and down the hall to R9's room. CNA H left the lift outside of R9's room and walked away. CNA H did not complete hand hygiene after leaving room and pushing lift down hall or walking away to the next task. On 9/29/25 at 10:52 AM, Surveyor observed CNA L push dirty mechanical lift into R9's room. Surveyor continuously observed the lift; it was not wiped down. CNA L did not complete hand hygiene before entering R9's room with contaminated lift. CNA L put mechanical lift sling on R9 and put on gloves on unwashed hands while waiting for assistance. With the assistance of CNA H, R9 was maneuvered to bathroom and lowered to toilet using the contaminated lift. CNA H left the room once R9 was on the toilet; no concerns with hygiene. CNA L stayed with R9 and burped R9's colostomy. CNA L removed CNA L's soiled gloves, and put on new gloves, with no hand hygiene. CNA L assisted R9 into wheelchair and touched clean items in R9's room with contaminated gloved hands. CNA L did not wash hands, complete hand hygiene, or change gloves until CNA L left the room at end of cares. CNA H came into R9's room to assist CNA L finish R9's cares. CNA H entered R9's bathroom and put on gloves. CNA H provided peri-care, pulled up R9's brief. With same contaminated gloves, CNA H pulled up R9's pants. Using the contaminated lift, CNA L and CNA H assisted R9 into R9's wheelchair. CNA L took lift out of room and pushed it back down to R31's room. CNA H took off CNA H gloves; no hand hygiene was conducted. CNA H started picking up R9's room and putting things in place, placing dirty into a garbage bag and took out of room. Surveyor followed CNA H to dirty utility; CNA H did not complete hand hygiene after R9's care, or when leaving R9's room and walking through facility to dirty utility. On 9/29/25 at 11:09 AM, Surveyor observed CNA L push mechanical lift to R31's room. CNA L maneuvered lift into bathroom, applied same sling from earlier, and with assist from CNA H, stood R31 up. CNA L completed peri-care, took off CNA L's right glove, put a new glove on CNA L's right hand, did not conduct hand hygiene and left glove remained in place. CNA L pulled up R31's brief and pants. With contaminated gloved hands, CNA L assisted with getting R31 into R31's wheelchair, removed lift sling from R31, positioned R31's glasses on R31's face, took R31's glasses off and cleaned them with a tissue, put R31's glasses back on and made sure R31 did not need anything else. CNA L disposed gloves and left room, took dirty and garbage with him. CNA L opened dirty utility door, tossed away garbage, and came right back out. Observation was continuous; door did not get a chance to close. No hand hygiene observed between taking off gloves in R31's room, discarding things in dirty utility and going to the computer to chart. Example 2On 9/30/25 at 7:55 AM, Surveyor observed CNA M and Assistant Director of Nursing (ADON) G provide cares to R5. CNA M told ADON G that R5's groin was pink, and he needed to get a new draw sheet under R5. Both caregivers completed hand hygiene and put on appropriate PPE before entering R5's room. Both CNA and ADON G opened the brief on their respective sides. Both CNA M and ADON G gently touched and pulled apart R5's thighs so ADON G could assess redness. After, CNA M pulled tube from stand and applied cream to groin. ADON G reminded CNA M to put on fresh gloves. CNA M took off CNA M's gloves and put on new gloves, with no hand hygiene. CNA M asked if ADON G needed new gloves. ADON G stated ADON G did not need new gloves. Surveyor observed ADON G touch R5's brief and upper thigh to assess reported redness in the groin. With contaminated gloved hands, both reattached R5's used brief, rolled resident to get draw sheet under R5, straightened R5's gown, rolled R5 to R5's right and put a sheep skin roll under her right shoulder. Sheep skin roll was placed on other side of R5, but R5 remained basically on her back and on bony prominences of her buttocks. On 10/1/25 at 11:21 AM, Surveyor observed CNA M complete hand hygiene and put on gloves and gowns and enter R5's room. CNA M uncovered R5 and removed sheep skin pillows from right shoulder and touched R5's legs and brief. CNA M realized there were no wipes and took off CNA M's gloves and gown and left room. CNA M came back with wipes and put on new gown and gloves; no hand hygiene prior. CNA M provided peri care R5, applied barrier cream applied to bottom, took off dirty gloves, no hand hygiene before putting on clean gloves. CNA M, with contaminated gloved hand, secured brief tabs, straightened R5's clothing and bedding, put pillows on right side again, left sheep skin on foot of bed, and left the room. Example 3On 9/30/25 at 9:15 AM, Surveyor observed CNA M and assistant approach R56's room. No concerns with assistant. CNA M put on gloves and gowns, no hand hygiene first. CNA M, with contaminated gloved hands, checked R56's brief with a quick look, and stated R56 was fine. Both CNAs repositioned R56 and put bed in low position. With same contaminated gloved hands, CNA M adjusted R56's head to a more comfortable position and covered R56 up. CNA M removed gloves and left room. Hand hygiene was completed in hallway before entering next room.On 0929/25 at 11:14 AM, Surveyor interviewed CNA H who stated I don't remember if I wiped off the lift before it was taken to R9's room. It should have been. The slings are left in the resident's room.On 9/30/25 at 4:05 PM, Surveyor interviewed CNA H who stated hand hygiene is done before you go into a room to deal with patients, whenever your hands are dirty. CNA H stated it's a lot. When Surveyor asked about glove use, CNA H stated yes, hand hygiene should happen between gloves. CNA H stated, Oh, I missed that (hand hygiene between gloves). I should have done that.On 9/30/25, at 7:55 AM, Surveyor interviewed ADON G and CNA M. ADON G stated she had not touched the groin; she did not need to change her gloves. Surveyor asked ADON G and CNA M if the groin is a clean area. ADON G walked out. CNA M stated yes and walked out. CNA M came back when Surveyor was standing outside room. CNA M stated I meant, CNA M cleaned R5's groin before asking someone to help get the draw sheet under R5. CNA M stated no, the groin is never considered a clean area. Once a brief is on it is considered dirty.On 10/1/2025 at 11:37 AM, Surveyor interviewed CNA M who stated hand hygiene should be done whenever you are going in a resident's room, before putting stuff on, you should sanitize between cares. CNA stated if you get BM on your hands you should wash them. CNA M stated CNA M should have changed gloves and did hand hygiene every time CNA M changed them (gloves).On 10/2/25 at 9:20 AM. Surveyor interviewed ADON G who stated hand hygiene should happen before all contact with residents and food, in between glove changes, after restroom use. ADON G stated ADON G tells staff you really can't go overboard. Hand hygiene should certainly be before a resident's room or touching their belongings, after resident care and food, and in between glove changes. ADON G stated the facility does ongoing hand washing audits, also there is a checklist with new hires. ADON G stated audits are definitely ongoing routinely, even the best forgets.

Based on interview and record review, the facility did not develop a comprehensive person-centered care plan for the diagnosis of Congestive Heart Failure (CHF) with the use of a diuretic for 1 of 16 residents (R) R9 reviewed for care plans.This is evidenced by: The facility's policy, Comprehensive Care Plan read in part, The comprehensive care plan will describe, at a minimum, the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. R9 was admitted to the facility on [DATE], with diagnoses including chronic diastolic congestive heart failure, hypertensive heart disease, and edema. R9's Minimum Data Set (MDS) assessment, confirmed a Brief Interview for Mental Status (BIMS) could not be completed. Staff assessment of R9's cognition showed R9 to have moderately impaired cognition. Review of R9's medical record identified orders for the following diagnosis of CHF:-Metolazone 5 mg tablet, give one tablet by mouth every other day for possible heart failure exacerbation.-Lasix 40 mg tablet, give one tablet daily for diuresis. Review of R9's care plan identified no problems or interventions related to R9's diagnosis of CHF and use of diuretics. On 10/01/25 at 1:48 PM, Surveyor interviewed Licensed Practical Nurse (LPN) C. Surveyor asked LPN C when assessments are completed on residents with a diagnosis of CHF. LPN C reported assessments for increased weight, increased edema, and lung sounds would be completed when a resident has symptoms related to fluid overload. On 10/02/25 at 8:49 AM, Surveyor interviewed Director of Nursing (DON) B. DON B stated a resident with a diagnosis of CHF should have an individualized care plan. DON B stated R9 did have a CHF care plan, but it was resolved. DON B stated she 'unresolved' the CHF care plan and it was present in R9's record at this time. Surveyor reviewed R9's care plan and noted the CHF care plan was resolved 03/2025, and unresolved 10/02/25.

Based on record review and interview, the facility did not include the participation of a resident or family representative at care planning conferences. This occurred for 3 of 4 residents, (R) R2, R9, and R48, reviewed for care conferences. The facility did not conduct and document care planning conferences for R2, R9, and R48. Findings: The facility policy, Comprehensive Care Plan read in part, The comprehensive care plan will be reviewed and revised as appropriate by the interdisciplinary team after each comprehensive and quarterly MDS assessment, and as needed with changes in condition. The physician, other practitioner, or nurse designee will inform the resident and/or resident representative of the risks and benefits of proposed care, of treatment, and treatment alternatives/options. On 09/29/25 at 1:17 PM, Surveyor interviewed R9's activated Power of Attorney (POA). During the interview R9's POA reported concerns about R9 discharging to a different facility. R9's POA reported being unsure of what was going on or if R9 would be able to remain at the facility. On 09/30/25, Surveyor reviewed R9's record and was unable to find documented evidence of quarterly care conferences. Surveyor reviewed sampled residents R2, R6, and R48 for evidence of quarterly care conferences, and was unable to find related documentation. Surveyor requested documentation from facility. On 10/01/25, Surveyor was given the following: R2: -10/10/24, care conference summary. -03/14/25, a progress note indicating a care conference letter was sent to POA. -08/13/25, a document titled Care Plan Areas with no evidence of a care conference being held with R2 or R2's representative. R6: No concerns. R9:-03/25/24, care conference summary. -07/23/24, a progress note indicating a care conference letter was sent to POA. -10/29/24, a progress note stating a meeting was held to discuss neurology appointment and other placement, without evidence this was a care conference. -10/31/24, a progress note indicating a care conference letter was sent to POA. -03/13/25, a progress not indicating a care conference letter was sent to POA. -04/18/25, a progress note stating a care conference was discussed with POA, she will call next week to set up a meeting. -04/24/25, a progress note stating a care conference would be scheduled for 05/03/25. Note, there was no evidence of a care conference on 05/03/25. -07/07/25, a progress note stating a meeting was held to discuss placement options, with no evidence of a care conference being held with R9 or POA. -07/23/25, a document titled Care Plan Areas with no evidence of a care conference being held with R9 or his POA. -09/30/25, a progress note indicating a care conference letter was sent to POA. R48:-04/24/24, Care conference summary. -11/14/24, progress note indicating a care conference letter was sent to POA. -04/21/25, progress note indicating a care conference letter was sent to POA. -07/23/24, progress note indicting a care conference letter was sent to POA. -08/27/25, a document titled Care Plan Areas, with no evidence of a care conference being held with R48 or her POA. On 10/01/25 at 9:33 AM, Surveyor interviewed Social Services Director (SSD) E. SSD E stated care conferences are held within 48-72 hours of a resident's admission and then offered every three months or with quarterly Minimum Data Set (MDS) assessments. SSD E stated the facility has not been tracking care conferences. SSD E stated the document titled Care Plan Areas was being used by nursing staff for MDS reviews, and recently SSD E has been using the document. SSD E stated residents and/or representatives should have been offered quarterly care conferences. On 10/01/25 at 1:48 PM, Surveyor interviewed Licensed Practical Nurse (LPN) C and Certified Nursing Assistant (CNA) D. LPN C and CNA D stated they are not invited to care conferences, and sometimes supervisory staff will ask about a resident prior to a care conference being held, but not very often. On 10/01/25 at 3:50 PM, Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A reported she spoke with SSD E and was aware care conferences were not consistently being held with the resident or representative, or documentation did not support the requirements of a care conference.

Based on record review, observations and interview, the facility did not ensure a resident who was dependent for repositioning, personal cares, and hydration receive timely assistance for 1 out of 4 residents (R) (R5) reviewed for Activities of Daily Living. R5 who is dependent for hydration was not offered hydration during cares. R5 who is dependent for repositioning and turning was not repositioned for over 3 hours.This is evidenced by:The facility policy, titled Hydration, last revised 9/19/2024, states: The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. The facility policy, titled Turning and Repositioning, last revised 12/6/22, states: It is our policy to implement turning and repositioning as part of our systematic approach to pressure injury prevention and management. This policy establishes responsibilities and protocols for turning and repositioning. 2. Turning and repositioning is a primary responsibility of nursing assistants. However, facility nursing staff are expected to assist with turning and repositioning. 3. The frequency of turning and repositioning will be documented in the resident's care plan of care and will be determined by the resident's assessments including but not limited to:a. Level of activity, moisture, and mobility/Braden Scale. R5 was admitted to the facility on [DATE], with the diagnoses of malignant neoplasm of brain, partial removal of right skull, left side paralysis, difficulty swallowing, and severe protein calorie malnutrition.R5's Minimum Data Set (MDS) assessment, dated 9/2/2025, indicates that R5 is severely cognitively impaired and dependent for all hygiene, dressing, eating, movement and positioning. R5 has difficulty swallowing and a tube feeding. R5 is also always incontinent of bowel and bladder and needs assistance with peri-care and skin maintenance.R5's care plan states ADL selfcare deficit. Up in Wheelchair no longer than 2 hours at a time then in bed 1-2 hours and then may get up again. Bowel and Bladder incontinence. check and change every 2-3 hours and as needed. Completed Gentle Range of Motion (ROM) to bilateral lower legs . Daily Complete Passive (with assistance) ROM to left arm daily and active ROM to Right arm Daily. The resident has risk for impaired skin integrity related to history of Left ischium pressure injury and left buttock pressure injury (stage 3) Turn and reposition every 2-3 hours and as needed.Record review indicates R5 has a continuous Tube Feeding at 50ml/hr/24hrs. Dietician reviewed resident's labs and weight 9/15/25. Resident is to have 1200 ml of formula via tube feeding, 967ml free water and 360ml flush volume in 24 hours for an additional 1327ml. Resident has had significant weight loss and change in condition noted 9/15/25. Tube feeding was increased to 55ml/hr/24hr or 1320ml/24 hrs. R5 should be getting 967ml free water above and beyond what is provided in the tube feeding.On 9/30/25 at 7:51 AM, Surveyor observed R5 lying in bed. R5 opened her eyes and whispered hello when Surveyor entered room. R5 was weak and provided head shakes and quiet no's and yes to questions. Surveyor observed R5's lips were chapped and dry. R5 was licking her lips. There was a full water pitcher and full glass of what appeared to be apple juice on her tray table. Tray table was pushed away from bed slightly. Surveyor asked R5 if she could reach her water. R5 stated yes, but then turned her head towards tray table, stretched her neck and opened her mouth. Surveyor asked R5 if she could hold her glass. R5 said no.On 9/30/25 at 7:55 AM, Surveyor observed Certified Nursing Assistant (CNA) M and Assistant Director of Nursing (ADON) G reposition R5. R5's brief was opened. ADON G observed red area, CNA M applied barrier cream, and brief was reattached. Brief was not changed. ADON G and CNA M left the room without offering R5 a drink and R5's tray table was not moved closer to R5. Tray table remained where it had been pushed further away from R5's bed against the curtain dividing the room during cares. On 9/30/25 at 9:15 AM, Surveyor had been standing observing R5's hallway and door continuously since 7:55 AM. No one had entered R5's room.On 9/30/25 at 11:08 AM, Surveyor observed R5's room continuously for approximately 3 hours and 15 minutes. Tray table remained against the curtain dividing the room out of reach from the bed, with a water pitcher and the glass or possible juice. Levels were the same. No one had entered R5's room.On 9/30/25 at 3:55 PM, Surveyor observed R5 appearing in the same position. Tray table remained pushed off to the side with water pitcher and juice glass at the same level.On 9/30/25 at 4:30 PM, Surveyor stopped in R5's room and observed that she was holding a plastic green cup with straw. R5 attempted to lift it and bring to mouth but was unable. R5 tried to bend down and bring mouth closer but still was unable to get straw to mouth. Surveyor asked if she could lift her cup and R5 whispered no. On 10/1/25 at 7:28 AM, Surveyor observed R5 lying in bed on her back with a full water pitcher, glass of what appeared to be juice and the green cup on her tray table pushed up against curtain dividing room, out of reach from the bed. LPN C was followed into room. Surveyor observed LPN C's interaction with R5. When LPN C was done, she left room, and no drink was offered to R5. Tray table remained out of reach of the bed. On 10/1/25 at 10:00 AM, Surveyor had consistently observed R5's room. No one had entered R5's room since LPN C did this morning at 7:28 AM.On 10/1/25 at 11:21 AM, Surveyor observed CNA M provide cares to R5. CNA M uncovered R5 and removed the sheep skin pillow under R5's left side back and the pillow between R5's legs. CNA M removed brief, provided peri care to R5, applied barrier cream to bottom, reattached new brief, adjusted resident and made comfortable. R5 was not offered a drink, tray table remained pushed against curtain, and out of reach from the bed. Interviews:On 9/30/25 at 8:05 AM, Surveyor interviewed ADON G who stated R5 was repositioned when rolled to provide cares. ADON G stated the goal is to get R5 off R5's hip bones, and moved sheet to show hip was off the bed. When asked what about the bony prominences of the butt, ADON G stated the air mattress takes care of that. On 10/1/2025 at 9:03 AM, Surveyor interviewed LPN C who stated that R5 is dependent for cares. R5 has declined in the last month due to her brain tumor. R5 was admitted to hospice last week (9/24/25). R5 is repositioned every 2 hours and encouraged to take a drink when staff are in there. R5 does not eat much but is encouraged to eat and drink still; staff must stay with her.On 10/1/25 at 11:37 AM, Surveyor interviewed CNA M who stated he is a caregiver. CNA M stated CNA M tries to get dependent residents up every 2 hours but sometimes that is hard. CNA M stated this wing has a lot more residents needing Hoyer lifts (mechanical lift) so sometimes CNA M needs to wait for help. CNA M stated CNA M tries to do cares and repositioning both at once. CNA M stated we continue to provide cares to residents on hospice. CNA M stated we still help with positioning, swabbing the mouth, stuff like that. CNA M stated CNAs are on the comfort side; if residents need to be rotated, we do that. CNA M stated R5 has a plan to be repositioned. When asked directly, CNA M said most residents are independent except for R5. CNA M stated he tries to provide fluids when he is in with R5. Surveyor asked if he did that just now. CNA M stated, No I did not. Yes, I should have, and I'll go give it to her now.On 10/1/2025 at 12:50 PM, Surveyor interviewed Director of Nursing (DON) B, who stated DON B's expectation is that staff follow the care plan for repositioning. DON B stated that care plans are often every 2-3 hours. This gives staff 2 hours to get back in there; if they can't be back in time in 2 hours it gives staff leeway to position and change at same time. Surveyor told DON B about observation of R5 receiving cares at 7:58 AM and no one going into her room again until 11:21 AM. DON B stated, No that is not ok. They should have been in there between 9-10. DON B stated her expectation is that everyone is encouraged to drink every time staff are in resident's room. DON B stated R5 needs assistance with feeding self, difficulty with swallowing and is weak. R5 needs help to drink, help holding glass.

Based on interview, observation and record review, facility did not implement professional standards of practice to ensure that a resident does not develop pressure injuries (PIs), receives necessary treatment and services to promote healing and prevent new PIs from developing for 1 of 2 residents (R) reviewed. (R21) This is evidenced by:National Pressure Injury Advisory Panel (NPIAP) guidance recommends repositioning all individuals with or at risk of pressure injuries on an individualized schedule, unless contraindicated. Determine repositioning frequency with consideration to the individual's level of activity and ability to independently reposition. Reposition the individual in such a way that optimal offloading of all bony prominences and maximum redistribution of pressure is achieved.R21 was admitted to the facility on [DATE]. Current diagnoses include hypertensive heart and chronic kidney disease, weakness, cognitive communication deficit, type 1 diabetes mellitus, asthma, heart failure, chronic kidney disease stage 3, and fibromyalgia.Minimum Data Set (MDS), dated [DATE], an admission/5 day assessment documented R21 having a Brief Interview for Mental Status (BIMS) score of 14, meaning no cognitive impairment. R21 needs maximum assistance from staff for dressing and personal hygiene. R21 needs moderate assistance from staff for toileting, transfers, and bed mobility. R21 is at risk for PI and had 1 stage 2 PI that was present on admission. R21's physician orders include:09/17/25 Border foam dressing to left elbow. every day shift every 3 day(s) for Left elbow open area AND as needed.R21's care plan, dated 09/17/25, .Actual Stage 2 pressure injury to left elbow R/T (related to) resident using elbows to keep self propped up, as this is a preference for her while resting in bed. Interventions dated 09/22/25 Elbow protectors to be worn daily, check skin for redness on elbows.Braden scoring assessments for risk of skin breakdown:09/12/25 score 18 risk breakdown mild risk 15-18.On 09/17/25, a skin assessment of left elbow documented site remains and measures at 2 cm X 1.2 cm X 0.1 cm, has defined edges with a wound bed that is comprised of approximately 100% moist, light red tissue. Moderate amounts of serous drainage present. Scant amounts of sang., drainage present from site. No s/s of infection noted.On 09/29/25 at 11:30 AM, Surveyor interviewed R21 about open areas to skin. R21 stated having chronic areas on legs. Surveyor observed R21 resting in bed with head of bed elevated with elbows resting on bed. No elbow protectors noted. R21 had an alternating air mattress. On 09/30/25 at 10:48 AM, Surveyor interviewed Certified Nursing Assistant (CNA) H about R21 having worn any elbow protectors. CNA H stated not sure R21 usually has a sweatshirt on and not sure if there is anything under. Surveyor asked how would you know what is needed and is there a care plan to follow. CNA H stated there is a care plan in the closet. On 09/30/25 at 10:48 AM, Surveyor observed CNA H assist R21 to the bathroom. Surveyor observed R21 to not be wearing elbow protectors and did not observe elbow protectors in room. Surveyor observed R21's care plan posted in closet door documenting elbow protectors to be worn. CNA H did not check or place elbow protectors on R21.On 09/30/25 at 11:24 AM, Surveyor interviewed Registered Nurse (RN) F about R21 wearing elbow protectors. RN F stated the border foam is the protectors, and R21 will take off the dressing. RN F went to check on R21 and reposition R21 off coccyx. RN F stated R21 does have the dressing on elbow. R21 is able to reposition self in bed and will position self back onto her back after staff reposition. On 09/30/25 at 12:43 PM, Surveyor interviewed Director of Nursing (DON) B about R21's elbow protectors. DON B stated the elbow protectors are a foam that goes over the elbow to protect from pressure. Surveyor asked if the border foam dressing a pressure relieving elbow protector. DON B state the elbow protector is more than the dressing. The elbow protector is to prevent pressure on the elbow and cradles the elbow. Surveyor reviewed with DON B the interviews with staff and Surveyor's observation. DON B stated will check to see if the elbow protectors are in R21's room. DON B returned, stating the elbow protectors were not on R21 and are now, and staff had been educated.

Based on interview and record review, the facility did not ensure pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident, for 1 of 1 resident (R9). R9 had an order to check systolic blood pressure prior to administering medication, with parameters to hold the medication if systolic blood pressure was less that 110. The facility did not complete blood pressure checks as ordered. Findings include: The facility policy titled Medication Errors, read in part. Staff will follow best practices to prevent medication errors: a. Clarify an order that is incomplete. b. Ensure that orders are fully understood before administering medications.On 10/01/25, Surveyor reviewed R9's record and noted an order for: 01/02/25, metolazone 5 mg tablet every other day for possible heart failure exacerbation, hold for systolic blood pressure (SBP) <110. Surveyor was unable to find evidence of BPs prior to medication administration. Surveyor requested this from Director of Nursing (DON) B. On 10/01/25 at 9:21 AM, Surveyor interviewed Licensed Practical Nurse (LPN) C. LPN C was not aware of checking R9's BP prior to receiving metolazone. LPN C stated, The med techs might do that. I am not sure. If we are supposed to, I don't think it has been done. On 10/01/25 at 1:26 PM, DON B reported R9's BPs were not being completed prior to receiving metolazone, as ordered. DON B stated she would correct this in the medication record.

Based on observations, record review, and interviews, the facility failed to provide privacy during wound care for one of three residents (R) 3, reviewed for wound care out of a total sample of 6 residents. This failure had the potential for R3 to experience embarrassment or feeling exposed during treatment. Findings include: Review of R3's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R3 was admitted to the facility on [DATE]. Review of R3's admission Evaluation - V3, located under the Assessments tab in the EMR and dated 08/14/25 at 6:44 PM, indicated R3 was alert and oriented to person, place, time, and situation. Review of R3's Physician Orders, located under the Orders tab in the EMR, indicated an order dated 08/19/25 for Left Buttock wound, Sacral redness, and Bilateral Buttock redness: Cleanse with NS [Normal Saline], pat dry, and apply Periguard Ointment every day and evening shift for wound healing and as needed for wound healing. During the wound care observation on 08/21/25 at 11:22 AM, R3 stood using a walker for wound care to be provided to R3's buttocks and sacral area. R3 unbuttoned his pants and underwear and lowered both articles of clothing to mid-thigh level. R3's blinds, covering the window, were left open while the wound care was being performed by Registered Nurse (RN) 1. RN1 did not ask R3 if he wanted the blinds to be shut prior to the start of the wound care. Anyone that would walk by the window would be able to see that R3 was having wound care performed to his buttocks. During an interview on 08/21/25 at 11:35 AM, RN1 confirmed she should have closed the blinds before performing wound care to R3's sacral area. During an interview on 08/21/25 at 11:37 AM, R3 was asked about the window blinds that were left open during wound care. R3 stated, Sure, it would bother me if someone saw me. I would prefer them [staff] to close the blinds. During an interview on 08/21/25 at 2:00 PM, the Interim Director of Nursing (IDON) stated, I expect the nurses to provide dignity and respect when performing wound care to a resident by closing the blinds prior to wound care.

Based on observations, record review, interviews, and Centers for Disease Control and Prevention (CDC) guidance, the facility failed to follow infection control guidelines during a wound care observation for two of two residents resident (R), R2 and R3, observed for wound care and failed to follow Enhanced Barrier Precautions during a dressing change for R3. This failure had the potential for R2 and R3 to be exposed to infections. Findings include:Review of the CDC webpage titled, Clinical Safety: Hand Hygiene for Healthcare Workers, updated 02/27/24, revealed to change gloves and clean hands when moving from work on a soiled body site to a clean body site. Review of the CDC webpage titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), updated 04/02/24 revealed EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities and apply to residents with wounds.1. Review of R2's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R2 was admitted to the facility on [DATE] with the diagnosis of peripheral vascular disease and type two diabetes mellitus. Review of R2's admission Minimum Data Set (MDS), located under the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 06/29/25 indicated R2 had been coded as having a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R2 was cognitively intact. Review of R2's Care Plan, located under the Care Plan tab in the EMR and dated 08/13/25, had a Focus which indicated, Actual ABRASION TO RIGHT KNEE, RIGHT LOWER LATERAL CALF PROXIMAL TO ANKLE, AND TIGHT ANTERIOR SHIN [sic]. Interventions indicated, Administer treatment per MD [Medical Doctor] orders, Report evidence of infection such as purulent drainage, swelling, localized heat, increased pain, etc. Notify MD [Medical Doctor] PRN [as needed]. Review of R2's Physician's Orders located under the Orders tab in the EMR indicated an order dated 08/20/25 Right lower calf/proximal to ankle, right knee and right anterior shin: Cleanse sites with NS [normal saline], pat dry. Apply skin prep peri wound cut Dermaginate AG [silver] to size and apply. Cover with bordered foam dressing. During a wound care observation on 08/21/25 at 10:20 AM, Licensed Practical Nurse (LPN) 1 placed a towel down on the top of the bed, and then proceeded to place clean dressing supplies on the towel. LPN1 removed the old dressing to the right knee and cleaned the wound bed with normal saline. Then LPN1 using the same gloves that the old dressing was removed with, applied skin prep to the peri wound and then discarded the gloves, sanitized her hands, and then donned a new pair of gloves on. LPN1 proceeded to perform the dressing change as documented above for each of the other wounds. LPN1 finished the wound care and stepped outside the resident's door in the hallway and removed her personal protective equipment (PPE) which consisted of a gown and gloves. During an interview on 08/21/25 at 11:40 AM, LPN1 stated, I thought placing skin prep around the wound was part of the cleaning the wound. That was why I did not change my gloves. LPN1 was asked about the towel placed on the bed that the clean supplies we placed on. LPN1 stated, I put a barrier down, so I feel it was okay to do. LPN1 stated she should have removed the gown prior to exiting the room and placed it in the bin in the room. 2. Review of R3's undated Face Sheet located under the Profile tab in the EMR indicated R3 was admitted to the facility on [DATE] with a diagnosis of type two diabetes mellitus. Review of R3's admission Evaluation - V3, located under the Assessments tab in the EMR and dated 08/14/25 at 6:44 PM, indicated R3 was alert and oriented to person, place, time, and situation. Review of R3's Physician Orders, located under the Orders tab in the EMR, indicated an order dated 08/19/25 for Left Buttock wound, Sacral redness, and Bilateral Buttock redness: Cleanse with NS [Normal Saline], pat dry, and apply Periguard Ointment every day and evening shift for wound healing and as needed for wound healing. During the wound care observation on 08/21/25 at 11:22 AM, Registered Nurse (RN) 1 placed a barrier on the overbed table without cleaning it first. RN1 then proceeded to clean the left buttock wound, bilateral buttocks, and sacral areas with NS. RN1 patted these areas dry with a 4x4. RN1 applied Periguard Ointment to these areas using a tongue blade. RN1 wore gloves but did not wear a gown while performing this wound care. During an interview on 08/21/25 at 1:35 PM, RN1 stated, I didn't wear a gown because [R3] wasn't in Enhanced Barrier Precautions. When asked if R3 should be in EBP, RN1 stated, Yes, because [R3] has an open wound. When asked if a tongue blade should have used to apply the ointment to R3's buttocks RN1 stated, That's what I was told to apply it with. During an interview on 08/21/25 at 11:50 AM, the Infection Preventionist (IP) stated, I expect them [nurses] to clean off the bedside table and then place a barrier down to place the clean supplies on. The nurse should change her gloves after cleaning the wound, sanitize or wash her hands then place a clean pair of gloves on before applying skin prep around the wound. A tongue blade should not be used to apply ointment to a resident. When asked if R3 should be in Enhanced Barrier Precautions [EBP], the IP stated, According to the new guidance, a wound that will take more than a few days to heal, that resident should be placed in EBP and the nurse [should] apply the appropriate PPE when caring for the resident. Notified IP that R3 was not in EBP at this time. During an interview on 08/21/25 at 2:00 PM, the Interim Director of Nursing (IDON) stated, . The nurse should establish a clean barrier and clean it with a sanitizing wipe before placing a barrier down and then the clean supplies. Applying the skin prep is not part of the cleaning process but rather a part of dressing a cleaned wound. The nurse should clean the wound as ordered by the physician, then remove the dirty gloves, wash or sanitize her hands and then apply a clean pair of gloves before applying the skin prep around the wound. Asked how a nurse should apply ointment to the buttocks of a resident and the IDON stated, They should use a clean applicator such as a Q tip. Asked if a tongue blade could be used to apply the ointment and the IDON stated, No, it shouldn't. That could have sharp edges or splintering from the wood used and cut the wound more and that is not what you want to do, You want to protect the skin that you are applying the ointment to. Asked if a nurse was dressing a wound such as for R3, the resident should be in Enhanced Barrier Precautions. The IDON stated, Yes, they should be in EBP [Enhanced Barrier Precautions]. Notified the IDON that R3 was not in Enhanced barrier Precautions and the nurse performing wound care only wore gloves. The IDON confirmed the nurse should have also worn a gown.

Based on observation, interview and record review, the facility did not ensure activities of daily living and activities for dependent residents were completed per standards of practice and resident care plans for 2 out of 3 sampled residents (R) (R1 and R2). -R1 did not receive weekly showers. -R2 did not receive restorative care or weekly showers per standards of practice and the resident's care plan. This is evidenced by: Example 1 R1 was admitted on [DATE] with diagnoses that include post shoulder surgery, weakness, fragile X, fibromyalgia, morbid obesity, hemiplegia, and asthma. R1's brief interview of mental status (BIMS) score was 13/15 indicating intact cognition. Minimum Data Set (MDS) dated [DATE] indicates R1 is understood and understands. R1 is dependent on staff for showering, and received max assist with transfers, toileting, and bed mobility. On 07/07/25, Surveyor reviewed R1's record. In review of Certified Nursing Assistant (CNA) documentation for weekly showers, 2 out of 6 showers were not given. On 5/14/25, documentation indicates the resident refused. On 05/28/25, the documentation was left blank. This was the date R1 was scheduled to receive a shower. There was no documentation of further attempts, the reason for R1 not receiving a shower, or that it was reported to supervising nurse. Example 2 R2 was admitted on [DATE] with diagnoses that include cerebral palsy, cognitive communication deficit and developmental disability. MDS, dated [DATE], notes that R2 sometimes understands and is sometimes understood and has no speech. R2 requires max assist with dressing, toileting, and transfers and moderate assist with bed mobility. R2 was up in wheelchair in hallway, noted to have clean hair/body and dressed. R2's shower review for April, May and June showed R2 is to have showers on Saturday AM shift. On 05/10/25 NA was documented. When asked CNA C what that meant, CNA C replied that is how it is documented if it was not their shower day. This was a shower day for R2. On 05/31/25, which is another Saturday AM, the area was blank. On 6/21/25, NA was recorded, and it was a Saturday AM. Surveyor reviewed restorative care documentation for R2. R2 is dependent for all cares and requires moderate assistance with bed mobility and maximum assistance with transfers and self-care. Surveyor noted on 04/09/25, 05/09/25, and 06/06/25 there was no documentation indicating assistance with bed mobility. On 04/09/25, 05/08/25, and 06/07/25 there was no documentation indicating assistance with ambulation. On 05/31/25, there was no documentation that R2 received scheduled shower, why it was not given, interventions, or that it was reported. R2 had scheduled shower days on 05/10/25 and 06/21/25. Documentation on those days indicated only N/A. Further investigation revealed no documentation of showers given for R2 in the weeks indicating N/A. On 07/07/25 at 3:00 PM, Surveyor interviewed Director of Nursing (DON) B and Nursing Home Administrator (NHA) A regarding cares not being provided to R1 and R2. Administration could not provide further documentation of cares not provided, not reported, or not followed up on.

Based on observation and interview, the facility failed to dispose of garbage properly on 3 of 3 days of survey. Garbage was observed setting on the ground outside of the dumpsters and dumpster lids were observed to be open on 3 of 3 days of survey. This is evidenced by: Facility policy and procedure entitled Environment, last revised 9/2017, states in part: All trash will be contained in covered, leak-proof containers that prevent cross contamination. All trash will be properly disposed of in external receptacles (dumpsters) and the surrounding area will be free of debris. On 08/13/24 at 9:15 AM, Surveyor observed the 2 dumpsters; the lids were wide open and 2 bags of garbage were observed on the ground beside the dumpsters. On 08/14/24 at 8:22 AM, Surveyor observed a man inside the dumpster rearranging garbage bags. The man picked up 2 bags of garbage off the ground and placed them into the recyclable dumpster. He appeared to be attempting to rearrange the bags, so the lids could possibly close. On 08/14/24 at 4:00 PM, Surveyor observed the garbage dumpster's lids on both dumpsters were observed to be open. On 08/15/24 at 8:21 AM, Surveyor observed the garbage dumpster's lids wide open; a garbage bag was observed on the ground near the dumpsters. On 08/15/24 at 9:01 AM, Surveyor interviewed Director of Nursing (DON) B and requested information in relation to the garbage as to why the dumpsters were not emptied. DON B indicated the facility had contacted Waste Management (their garbage company) as the garbage hadn't been picked up, and they noticed it was overflowing. On 08/15/24 at 9:19 AM, DON B provided a copy of e-mails, dated 08/14/24, which state in part: I just called Waste Management because our garbage hasn't been picked up all week. Per the automated answering service, our services were ended due to unpaid invoices, again. The past due amount .has to be paid in full and services will start 24 hours after. On 08/15/24 at 10:18 AM, Surveyor interviewed Dietary Manager (DM) C who has been with the facility for about a year. Surveyor asked if there have been difficulties getting the facility dumpsters emptied. DM C replied this has happened 3-4 times within the past year.

Based on observation, interview and record review, the facility did not prepare, store and distribute foods in a safe and sanitary manner. The facility practices had the potential to affect all 48 residents. Initial tour of the facility kitchen found the floors in the kitchen, storage areas and dish room with food particles and built-up dirt present on the floors, the steamer and ovens with built up dried matter on the sides and bottom and on the industrial can opener mounted to the food preparation counter. Food temperatures were not taken at point of service in the rehabilitation kitchenette to ensure proper holding temperatures prior to serving food to residents. The food temperature logs were not complete. Dietary Aide (DA) D explained improper sanitization of thermometer procedures when temperatures are taken. This is evidenced by: Example 1 On 8/15/23 at 8:40 AM, Surveyor conducted an initial tour of the facility kitchen with Account Manager (AM) F who manages the dietary operations and has been on staff a few weeks. Surveyor noted the dry storage area floor, the kitchen floor and the dish room floor had visible dirt and food particles present. Surveyor asked Cook E about the dirty floors and Cook E responded the floors Should be cleaned x2 a day but she was not sure when they were last done as there is no cleaning schedule in place. Cook E further expressed there has not been a cleaning schedule in place for several months. Surveyor noted the lower counter where food is prepared with dried food and dirt. The can opener that is mounted on food preparation counter had dirt and grime present. Surveyor spoke with Cook E about the counter and can opener. Cook E responded, They should be cleaned daily. Cook E was not sure when they were last cleaned, possibly last week sometime. Surveyor noted the steamer with dried matter in it and the top and bottom ovens with a build-up of dried on foods on bottom and sides of the oven. Cook E again expressed the ovens should be wiped out daily and deep cleaned monthly, but was not sure when last cleaned. On 8/16/23 at 9:10 AM, Surveyor spoke with Cook E. Cook E showed Surveyor the can opener which is now clean and ovens which are now clean. Cook E expressed yesterday ovens, floors and can opener were not cleaned to her expectations and should be cleaned more often. A cleaning list is being developed to ensure more routine cleaning and holding people accountable to clean. AM F was present and also expressed the kitchen was not clean to her expectation and had an overtime build-up of food in the oven. AM F expressed she is developing a cleaning list to hold staff accountable for regular cleaning. Surveyor requested and reviewed the facility policy titled Equipment which is dated as revised on 9/2017. The policy in part reads: Policy Statement: All food service equipment will be clean, sanitary and in proper working order. Procedures: ~All food food-contact will be cleaned and sanitized after every use. ~All non-food contact equipment will be clean and free of debris. Surveyor requested and reviewed the facility policy titled Environment which is dated as revised on 9/2017. The policy in part reads: Policy Statement: All food preparation areas, food service areas and dining rooms will be maintained in a clean and sanitary condition. Procedures: ~The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting and ventilation. ~The Dining Services Director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas and surfaces. Example 2 On 8/16/23 at 7:27 AM, Surveyor observed Dietary Aide (DA) D serving breakfast from the kitchenette on the rehabilitation wing. DA D indicated she has been on staff 2 years and serving foods is part of her responsibilities. Surveyor observed DA D serving pancakes, eggs, oatmeal and, sausage from the steam table. At no point did the Surveyor observe DA D take temperatures of foods on the steam table. Surveyor also observed cold beverages on ice in bin on a cart including milk. Surveyor did not observe DA D take temperatures of the beverages. Surveyor asked DA D about the facility's practice of taking food temperatures at point of service. DA D explained the temperatures should be taken prior to serving residents and logged in the book the kitchen has. DA D stated, Supposed to take before serving and did not, important to ensure foods are at proper temperature, both hot and cold. Surveyor requested and reviewed the food temperature logs. The log for breakfast was void of any temperatures. Surveyor also noted several meals void of temperatures and days that were missing. Surveyor asked DA D how she cleans the thermometer when taking temperatures of foods and fluids. DA D indicated DA D removes a paper towel from the dispenser and wipes the thermometer before inserting into foods, in between foods and after DA D is finished taking temperatures. The thermometer is placed back in the holder when she is done. Surveyor asked DA D if wiping the thermometer probe with paper towel is sanitizing the probe. DA D responded, Probably not sanitizing. DA D further expressed DA D has never used anything but paper towel. On 8/16/23 at 9:10 AM, Surveyor spoke with AM F about the facility expectation for taking food temperatures at point of service. AM F indicated expectations are for staff to take food temperatures at point of service to ensure food temperatures are safe for serving. The temperatures are logged when taken. Surveyor asked AM F about sanitizing of the thermometer used to take food temperatures. AM F expressed the expectation is for staff to sanitize the thermometer with alcohol pad, air dry the thermometer and take food temperatures. The probe should be sanitized between foods and when done using. Surveyor requested the temperature logs and the facility policy that addresses taking of food temperatures. AM F provided the logs to the Surveyor. Surveyor reviewed the logs that dated back to 6/10/23 and noted the following: June 2023: 6/10/23-6/29/23 logs were completed for all three meals. There was no log for 6/30/23. July 2023: No logs were present from 7/01/23 through 7/12/23 or 7/25/23, 7/26/23 or 7/29/23. There was no food or beverage temperatures recorded for dinner on 7/17/23 or 7/28/23. There were no temperatures recorded for lunch or dinner on 7/24/23, 7/27/23. August 2023 to date (8/16/23). There were no logs present for 8/06/23, 8/07/23, 8/08/23, 8/10/23 or 8/14/23. No temperatures were recorded for lunch or dinner on 8/01/23, 8/02/23, 8/03/23, 8/05/23 or 8/12/23. Surveyor reviewed the facility policy titled Taking Food and Liquid Temperatures dated 9/20/2022. The policy in part reads: General Procedure: ~Open an alcohol wipe and wipe the thermometer probe clean. Dispose of the wrapper .Allow the probe to air dry a minimum of 10 seconds before you insert the thermometer into any food item. This allows the thermometer to dry and not contaminate the food .You need to take the temperature of every food item separately . ~Follow the hot holding temperature guide on your temperature log to assure all foods are kept out of the danger zone.

Based on observation, interview and record review, staff did not perform hand hygiene to prevent the spread of infection when warranted while providing care to 1 of 4 residents (R) R28 observed for cares. Certified Nursing Assistant (CNA) C did not perform hand hygiene when warranted when providing incontinence care for R28. This is evidenced by: Example 1 Surveyor requested and reviewed the facility policy titled Hand Hygiene which is dated 11/02/22. The policy in part reads: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. This applies to all staff working within the facility. Hand Hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. ~After handling contaminated objects ~Before applying and after removing personal protective equipment, including gloves ~After handling items potentially contaminated with .body fluids On 8/16/23 at 10:43 AM, Surveyor observed CNA C assist R28 with care in the resdident's room. CNA C knocked on R28's door, performed hand hygiene and donned gloves. CNA C lowered R28's pants and removed them along with a pillow that was under R28's legs. CNA C removed R28's incontinence brief and performed incontinence care. R28's brief was soiled with bowel movement and urine. CNA C did not remove her gloves and perform hand hygiene. CNA C obtained a clean brief and placed it on R28. CNA C removed gloves but did not perform hand hygiene. CNA C proceeded to placed a pillow under R28's legs and position R28 in bed. CNA C covered R28 with bedding and provided a call light. CNA C raised R28's head of bed and positioned R28's head on a pillow. CNA C offered R28 a fresh glass of water and took R28's water pitcher from her room. CNA C did not perform hand hygiene until she exited R28's room. On 8/16/23 at 11:07 AM, following the observation, Surveyor spoke with CNA C. CNA C indicated she should have removed gloves and performed hand hygiene after removing R28's dirty brief and washing R28. CNA C further expressed it is important to do hand hygiene for infection control. On 8/16/23 at 1:32 PM, Surveyor spoke with Director of Nursing (DON) B, who is the facility Infection Control Preventionist. DON B expressed the expectation is for staff to perform hand hygiene upon entering the resident room and don gloves. Staff should remove the dirty brief and perform care. Staff should then remove their gloves and perform hand hygiene before proceeding to touching items in resident environment.

Based on record review, interview and observation, the facility did not ensure a qualified activity professional was hired to direct the activities program. This had the potential to affect a large portion of the facility's residents. The facility did not have an activity program directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who is licensed or registered. Evidenced by: Review of the Life Enrichment Specialist job description stated, in part: . Required Education and Experience: Must be a qualified therapeutic recreation specialist or an activities professional who is currently licensed or registered, as required, by the State and is eligible for certification as a therapeutic recreation specialist or as an activity's professional by a recognized accrediting body. Two (2) years experience in a social or Life Enrichment program within the last five (5) years, one (1) of which was full-time in a patient activities program in a healthcare setting. Completed a training course as approved by the State. Requested and reviewed staff list with titles, noted that staff list included two Life Enrichment Coordinators but did not include a Life Enrichment Specialist. 01/24/2023 at 9:20 AM, interview with Nursing Home Administrator (NHA). NHA A confirmed facility has not had a Life Enrichment Specialist since November 2022, and NHA A has been fulfilling the Life Enrichment Specialist role. NHA A confirmed that she does not meet the requirements of an activities professional. Facility is actively recruiting for a qualified candidate. Reviewed records for five sampled residents and noted that activity assessments, comprehensive care plan goals and approaches were individualized to the skills, abilities, and preferences of each resident for activities. Observed January activities calendar, noted that activities for this day were, Nails at 10:00 AM, Bingo at 1:30 PM, and Catholic Mass at 3:00 PM. Requested and reviewed activities calendar for November and December, noted that activities calendars included multiple activities on each day. Surveyors noted the following during the Survey: -9:51 AM, observed residents in Activity Department participating in Nails activity. -9:53 AM, interview with resident in hallway, stated that she was going to get her nails done. -10:38 AM, observed Life Enrichment Coordinator walking throughout facility asking residents if they would like to get their nails done. -2:02 PM, observed residents participating in Bingo activity. -2:45 PM, interview with resident in hallway, stated that she was going to church. The facility did provide each resident with activities and preferences to support the physical, mental, and psychosocial well-being of each resident, therefore the deficient practice of not employing a qualified activities professional has the potential for causing no more than minimal harm.

Based on observations, staff interviews and record review the facility did not provide the necessary care to prevent worsening of gangrenous vascular toe ulcers for 1 of 15 sampled residents. (R10). R10 developed a vascular ulcer on her bunion of her right great toe on 05/28/17. R10 was on a repositioning program and was to have her heels elevated off the bed. However, after development of the first vascular ulcer, the facility did not implement individualized interventions to aleviate pressure to the entire foot. The vascular ulcer continued to worsen. By 06/16/17, R10 developed 3 additional vascular ulcers on her right foot. On 6/20/17, R10 was diagnosed with [REDACTED]. Observations on 06/21/17 and 06/22/17 reveal that when in bed, R10 had a sheet and comforter applying pressure to the feet and vascular ulcers. This is evidenced by: Surveyor review of R10's medical record reveals that R10 has [DIAGNOSES REDACTED]. Surveyor review of R10's most recent Minimum Data Set (MDS) assessment dated [DATE] reveals that R10 requires extensive staff assistance for bed mobility. Review of R10's Nursing Progress Notes reveal that on 05/27/17 R10 had redness and [MEDICAL CONDITION] to her right foot. On 5/28/17 the area was documented as unstageable. On 5/30/17, the facility developed a care plan related to the arterial insufficiency wound on the right foot. Interventions, dated 5/30/17, included assessing/monitoring; completion of a Braden Scale; inform resident/family/caregivers of any new areas; maintain good hydration; treat wound per facility protocol; and, follow facility policies/protocols for the prevention/treatment of [REDACTED]. On 6/2/17, the facility added interventions of encourage family to bring in bigger shoes, and to encourage resident to remove shoes when in recliner. R10 also has a care plan for potential for a pressure injury initiated 8/5/16. Interventions inlcude to keep heels off the bed with pillows. Undated interventions on the CNA (Certified Nursing Assistant) Care Card indicated R10 was to only wear gripper socks and was to be repositioned every 2 hours. It is unclear when these interventions were implemented. There were no individialized interventions implemented to assist with alleviating pressure from the feet. R10's Wound Summary for the vascular ulcer on the right great toe area indicates: ~5/28/17, ulcer measure 1.0 cm x 1.0 cm (centimeter) with 10% necrotic tissue ~6/2/17, ulcer measures 1.5 cm x 1.2 cm with no necrotic tissue ~6/9/17, ulcer measures 2.0 cm x 2.0 cm with 75% necrotic tissue ~6/16/17, ulcer measures 2.4 cm x 2.0 cm with 100% necrotic tissue The above documentation shows continued deterioration in the vascular ulcer without any interventions to alleviate pressure from R10's foot. R10's wound summaries continued: ~6/16/17, vascular ulcer to right foot, 2nd toe, distal measuring 0.4 cm x 0.4 cm, 100% necrotic. ~6/16/17, vascular ulcer right foot, 2nd toe, proximal measuring 0.6 cm x 0.6 cm, 100% necrotic. ~6/16/17, vascular ulcer right foot, 4th toe measuring 0.7 cm x 0.6 cm, 100% necrotic. On 06/20/17, R10 was seen at the wound clinic. The assessment/plan indicates the following: PAD (peripheral artery disease) (primary encounter diagnosis), Arterial insufficiency with ischemic ulcer and dry gangrene. The patient has significant [MEDICAL CONDITION] with an obvious ischemic right foot and subsequent ischemic ulcers and dry gangrene. She has classic ischemic appearance with ischemic changes to the web spaces of the toes and forefoot with skin atrophy . Nursing wound care instructions given: activity: . Protect right foot from trauma as much as able There were no new interventions developed to protect R10's foot from trauma or to alleviate pressure from the foot. On 6/21/17 at 10:11 a.m. Surveyors with the assistance of CNA-J observed R12's feet. Surveyor noted dry blackened tissue approximately quarter size on R12's right great toe bunion. The dry blackened tissue was surrounded by approximately 2.0 cm (centimeters) of redness. R12's right second toe was crossed over R12's right great toe. On the top of R12's right second toe were 2 pea sized areas of blackened tissue one close to the nail bed, and the other on a metatatarsal (toe knuckle). On R12's 4th toe around the inner toe nail was an area of blackened tissue measuring approximately 0.5 cm by 0.1 cm. On 06/21/17 at 3:00 p.m., the surveyor observed R10 sleeping in bed on her back. R10 had a sheet and a comforter covering her feet, touching her toes. R10 had socks on her feet. On 06/22/17 at 7:05 a.m., the surveyor observed R10 sleeping in bed on her back. R10 had a comforter covering her feet. On 06/22/17 at 7:55 a.m., the surveyor spoke with RN-B (Registered Nurse). RN-B said that R10's foot wounds are caused by arterial insufficiency. The surveyor asked RN-B about the blankets laying on R10's toes. RN-B said that they had never thought about using a foot cradle to keep the blankets off R10's toes.

Based on interview, record review, and observation, the facility did not promptly consult with a resident's physician when a significant change in condition occurred resulting in potential long-term vision loss to 1 of 3 sampled residents. Resident #1 was admitted to the facility for rehabilitation on 5/30/13. On admission Resident #1 had complaints of blurred vision and double vision. Interviews and facility records however, indicated Resident #1 had adequate vision. On 6/7/13, a CNA (Certified Nursing Assistant) noted Resident #1's decrease in vision and reported it to the licensed nurse. On 6/10/13, both PT (Physical Therapy) and OT (Occupation Therapy) notes indicated Resident #1 had complete vision loss. Both PT and OT notes indicated the nursing department had been notified of the significant change in Resident #1's vision. Sudden vision loss is an emergent condition and requires immediate medical attention. The facility did not notify Resident #1's physician of the vision loss and opted instead to schedule an eye appointment for three days later. On 6/13/13, Resident #1 was seen by an ophthalmologist, diagnosed with [REDACTED]. According to "Medscape Reference," [DIAGNOSES REDACTED] is an inflammation of the lining of the arteries typically affecting the temporal arteries. [DIAGNOSES REDACTED], "...is considered one of the most important ophthalmic emergencies as bilateral [MEDICAL CONDITION] can occur...prompt treatment are critical to prevent permanent ischemic damage to the retina and optic nerve..." To date, Resident #1 has remained blind. The immediate jeopardy began on 6/10/13 when Resident #1 reported complete loss of sight. The NHA (Nursing Home Administrator) was notified of the jeopardy on 6/21/13 at 3:26 p.m. The immediate jeopardy was removed on 6/21/13, but noncompliance continues at the lower scope and severity level of D (potential for more than minimal harm that is not immediate jeopardy/isolated) because the facility has yet to completely implement its plan of correction. This is evidenced by: According to the AMDA (American Medical Directors Association) "Protocols for Physician Notification," when a condition of partial or complete vision loss occurs, the practitioner should assess vital signs, as well as complete a neurological and vision exam. The "Protocols for Physician Notification" also indicate when there was an abrupt partial or complete loss of vision, the physician should be notified immediately. Resident #1 was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. During a hospital stay from 5/25/13 to 5/30/13, Resident #1 was treated for [REDACTED]. Resident #1 was also found to be in 3rd degree heart block and a pacemaker was subsequently placed. Resident #1's admission MDS (Minimum Data Set) dated 6/10/13, indicated Resident #1: ~ Was cognitively intact with a BIMS (Brief Interview for Mental Status) of 15 out of 15; ~ Was able to see fine detail, including regular print in newspaper and books; and ~ Required assistance of 1 to 2 staff persons for bathing, dressing, grooming, and going to the bathroom. Resident #1's care plan problem titled "Sensory/Communication: Plan of Care" dated 5/30/13, indicated Resident #1 had: "...Visual Disturbance..." not defined as [MEDICATION NAME] degeneration or [MEDICAL CONDITION]. The care plan directed staff to monitor for and report changes in Resident #1's vision. Resident #1's "Nursing Comprehensive Admission Data Collection and Assessment" dated 5/30/13, indicated Resident #1's vision was adequate and Resident #1 wore glasses. It also indicated Resident #1 had complaints of some visual changes. Surveyor # completed a review of Resident #1's nursing notes and noted the following: ~5/30/13, "...verbalized that her vision was blurry...Stated that this began at the hospital when she was getting ready to leave...sx (symptoms) did resolve as evening/shift progressed..." Resident #1's "Physical Therapy Plan of Care" dated 5/31/13 indicated, "...Resides at ALF (Assisted Living Facility)...Indep amb (independent ambulation)...Discharge Plans: DC (discharge) to ALF...Reports L (left) eye blurriness and at time reports of 'not seeing anything' to L eye, RN (Registered Nurse) staff informed...Rehab Potential: Good due to: Independent in prior level of function..." On 5/31/13, 1 day after admission, Resident #1 was complaining of no vision to her left eye. The physician was not contacted. A "Physical Therapy Plan of Care" dated 6/4/13 indicated, "...Reports decreased vision to L eye..." A nursing note on 6/4/13 stated, "...squints her left eye she stated that she 'sees double' sometimes..." There were no further nursing notes regarding Resident #1's vision. There are no nursing notes that Resident #1, to this point, ever had periods where she could not see at all. Resident #1's "PT Daily Treatment Note" dated 6/6/13 states, "...Pt (patient) complains of not being able to see out of her left eye at all, nursing informed..." Surveyor # interviewed CNA-O on 6/25/13 at 2:42 p.m. about Resident #1's eyesight. According to the schedule, CNA-O worked with Resident #1 on 6/6/13 and 6/7/13. CNA-O stated Resident #1 told him her eyesight "was getting worse" and "getting darker." CNA-O stated, "I even noticed it seemed to be getting worse. She was starting to grab, to feel where things were. She did not know where her wheelchair was." As CNA-O described Resident #1's actions, he demonstrated by repeatedly grasping and waving his hands into the air. CNA-O stated he had told the nurse but did not recall which nurse. He recalled this because when he came back the following week, he found out Resident #1 had to see the eye doctor that week. Surveyor # spoke with Resident #1 on 6/19/13 at 4:00 p.m. Resident #1 stated on Saturday (6/8/13), "Everything went black." Resident #1 stated, "I told them and told them but they didn't take care of it right away and let it go too long." There are no nursing notes describing Resident #1's vision on 6/8 or 6/9/13. The next note is found in Resident #1's "PT Daily Treatment Note," which stated: ~ 6/10/13, "...Pt c/o (complained of) not being able to see. Nursing notified and eye appointment was scheduled...requires verbal and tactile cues for hand placement...required tactile cue due to c/o poor vision/unable to see anything..." ~ 6/11/13, "...states several times that her vision is gone and she can see nothing today. Nursing staff informed..." Resident #1's "OT - Assistant Progress Update" indicated the following: ~6/10/13, "...Pt reports 'everything is black'...pt reports not being able to 'see' its 'all black' reported to nursing..." ~6/11/13, "...Pt reported yesterday that she could not see out of both eyes. 'All is black'..." ~6/12/13, "...reports 'all still black'..." On 6/10/13, both PT and OT informed the nursing department Resident #1 had total vision loss. There was no evidence that Resident #1's physician was immediately consulted regarding the vision loss. On 6/19/13 at 4:15 p.m., Surveyor # spoke with OT-A (Occupational Therapist). OT-A indicated she evaluated Resident #1 when initially admitted and Resident #1 had not mentioned any visual problems to her. OT-A indicated COTA-B (Certified Occupational Therapy Assistant) saw her on a day-to-day basis. OT-A reviewed COTA-B's notes with Surveyor # . OT-A indicated, according to COTA-B's notes, Resident #1's vision loss appeared to have occurred somewhere between the time they treated her on 6/7/13 and when they saw her again on 6/10/13. On 6/20/13 at 8:00 a.m., Surveyor # spoke with COTA-B and the Rehab Coordinator. COTA-B indicated on 6/10/13, Resident #1 complained to her that all she saw was "blackness." COTA-B indicated when returning Resident #1 back to her room, Resident #1 was still stating she could only see black. COTA-B stated she notified the nurses, who were sitting at the nursing station, of Resident #1's complaints. COTA-B stated she could not recall which nurse she had spoken to. On 6/20/13 at 9:20 a.m., Surveyor # spoke with PTA-D (Physical Therapy Assistant) and the Rehab Coordinator. PTA-D indicated on Monday 6/10/13, Resident #1 was complaining of seeing only black. PTA-D indicated she put her hand up to Resident #1's face in an attempt to check Resident #1's vision and Resident #1 had no response as she did not see her hand. PTA-D indicated she reported this to nursing right away. PTA-D indicated she could not recall which nurse she spoke to. Surveyor # spoke with RN-K on 6/21/13 at 11:45 a.m. RN-K indicated she worked on the unit where Resident #1 resided. RN-K indicated any change in condition of any resident would be noted on the 24-hour report, and in the nursing notes. RN-K indicated physician and family would also be notified. RN-K indicated she completed Resident #1's admission into the facility. RN-K stated on admission, Resident #1 was complaining of visual changes including blurry vision. RN-K stated hospital staff also reported this to her. RN-K indicated Resident #1's visual issues never went away which was why an appointment was made at the ophthalmology clinic. RN-K indicated she did not recall if therapy staff had reported to nursing a complete loss of vision. RN-K indicated she did recall at one point that she was told Resident #1's vision had gotten worse, however could not recall when this was. RN-K indicated Resident #1 had never complained of vision changes to her and if Resident #1 had, she would have completed an assessment of Resident #1's vision. RN-K then indicated she wasn't there when Resident #1's vision got worse and Resident #1 couldn't see at all. RN-K stated she could not recall when this occurred. Surveyor # asked RN-K why Resident #1's vision changes were not noted in the nursing notes. RN-K indicated she did not know why. On 6/21/13 at 12:15 p.m., Surveyor # spoke with RN-I. RN-I indicated she worked on the unit where Resident #1 resided. RN-I indicated an assessment should be completed anytime there was a change in a resident's condition. RN-I indicated the physician should also be contacted. RN-I indicated she was off when Resident #1 was initially admitted to the facility but had heard Resident #1 had visual problems of double vision. RN-I indicated she had not gotten a report from any staff about any change in Resident #1's vision. RN-I stated she was well versed in eye problems as she had worked in ophthalmology and if a change was noted, she would have assessed Resident #1 immediately. RN-I indicated she was the nurse approached by COTA-B on 6/10/13. RN-I stated COTA-B told her Resident #1 was still having issues with vision. RN-I stated they in turn scheduled an eye appointment. Surveyor # asked RN-I why an assessment was not done and then documented. RN-I stated she did not do an assessment because Resident #1 had no vision changes. RN-I stated because there was no change in Resident #1's vision, there would also be no documentation. Note: A nurse could not conclude that no change had occurred without first following up on what is reported and doing an assessment. On 6/21/13 at 1:08 p.m., Surveyor # spoke again with COTA-B. Surveyor # asked COTA-B what she had told RN-I about Resident #1's vision. COTA-B stated she told RN-I Resident #1 was seeing blackness with vision. On 6/21/13 at 1:30 p.m., Surveyor # spoke with CNA-M. CNA-M indicated she had assisted Resident #1 on only a couple of occasions. CNA-M indicated a volunteer told her last Monday Resident #1's eye sight was getting worse. CNA-M indicated she did not tell anyone of this as she was not told by the nurses to monitor Resident #1's vision. On 6/20/13 at 9:35 a.m., Surveyor # spoke with PSR-E (Patient Services Representative) from the ophthalmology clinic. Surveyor # asked PSR-E when the facility made an appointment for Resident #1 and what the facility indicated the reason for the appointment was. PSR-E indicated the facility made the appointment on Monday 6/10/13 at 9:20 a.m. due to a decrease in vision since Resident #1 had a pacemaker placed. Surveyor # asked PSR-E if the clinic was made aware Resident #1 had complete vision loss. PSR-E stated if they had been told Resident #1 had complete vision loss, Resident #1 would have been seen immediately by the ophthalmologist. PSR-E indicated complete vision loss is an emergent condition. On 6/20/13 at 10:15 a.m., Surveyor # spoke with COA/LPN-F (Certified Ophthalmology Assistant/Licensed Practical Nurse) from the ophthalmology clinic. COA/LPN-F indicated Resident #1 was initially diagnosed with [REDACTED]. COA/LPN-F stated Resident #1 went directly from the clinic appointment to the hospital for the diagnostic studies. Surveyor # asked COA/LPN-F about sudden vision loss. COA/LPN-F indicated sudden vision loss was a medical emergency. COA/LPN-F stated it was imperative to start treatment immediately in attempt to prevent permanent vision loss. On 6/20/13 at 12:35 p.m., Surveyor # spoke with MD-H (Medical Doctor). MD-H indicated she was Resident #1's primary physician. MD-H also indicated she had followed Resident #1 prior to Resident #1's admission to the facility. MD-H indicated she saw Resident #1 in the clinic on 6/13/13. MD-H stated when she walked into the exam room it was clearly evident that Resident #1 could not see. MD-H stated she was unaware of Resident #1's acute vision loss. MD-H indicated Resident #1 expressed to her that she was seeing black. MD-H also stated Resident #1 wondered why she had not seen her sooner. MD-H indicated acute vision loss is a medical emergency. MD-H also stated she should have been called right away when staff noted Resident #1 could not see. MD-H stated the delay in Resident #1's treatment could have an impact on the recovery of Resident #1's eye sight. On 6/20/13 at 10:30 a.m., Surveyor # spoke with the DON (Director of Nursing) and ADON (Assistant Director of Nursing). The DON indicated when Resident #1 was admitted to the facility, Resident #1 had visual changes including squinting her eyes. The DON indicated Resident #1's vision never got any better nor any worse. The DON indicated she was the person who called on 6/10/13 to make Resident #1's eye appointment due to Resident #1's continued visual problems. The DON indicated RN-I had asked her to make the appointment. The DON contends at no point was the facility made aware that Resident #1 could not see at all. When interviewed by Surveyor # on 6/19/13 at 4:00 p.m., Resident #1 stated, " Can't see nothing...I don't like it." On 6/19/13 at 5:00 p.m., Surveyor # observed CNA-C (Certified Nursing Assistant) assist Resident #1 to the bathroom. CNA-C assisted Resident #1 with all aspects of care including bed mobility, transfers, and peri care. CNA-C cued verbally or with hand over hand cueing for placement of Resident #1's hands, feet, and body. CNA-C indicated to Surveyor # that Resident #1 could not see. Surveyor # noted Resident #1 stared forward while feeling with her hands on her bed and bedside table to find items. The immediate jeopardy that began on 6/10/13 was removed on 6/21/13 when the facility: 1. Educated all CNAs and all ancillary staff on the expectation that any noted change in condition will be reported to licensed nurses immediately. 2. Nursing staff were inserviced on immediate assessment, appropriate actions, and physician consultation.

Based on interview and record review, the facility did not ensure that 1 of 4 residents reviewed for falls received adequate supervision and assistance devices to prevent accidents. Resident #1 has a history of 2 craniotomies (brain surgery) as a result of a brain aneurysm prior to admission to the facility. On 10/28/10, Resident #1 fell from a lounge chair in his room. Resident #1 was subsequently transported to the hospital because of mental status changes and diagnosed with [REDACTED]. This required another surgery to remove the hematoma. Since returning to the facility on [DATE], Resident #1 had another 6 falls. After each fall, the facility did not complete a thorough investigation to determine what the root cause was, did not identify and care plan new interventions as to keep Resident #1 as free from falls as possible including adequate supervision, did not re-evaluate current interventions when proven ineffective, and did not ensure that care planned approaches were consistently implemented. This is evidenced by: Resident #1 was admitted to the facility on [DATE]. Resident #1's current [DIAGNOSES REDACTED]. Resident #1 was admitted from the hospital following a ruptured aneurysm which resulted in intracerebral bleeding (stroke) and left sided hemiparesis (weakness), dysphagia (difficulty swallowing), and aphasia (difficulty speaking and/or understanding). The MDS (Minimum Data Set) assessment dated [DATE] indicates Resident #1: ~Has a severe cognitive impairment; ~Requires extensive assistance of 2 staff persons for bathing, dressing, grooming, and toileting, bed mobility, and transfers; ~Does not walk; ~Has poor balance; and, ~Is frequently incontinent of bowel and bladder. On admission, the facility identified Resident #1 to be at risk for falls and implemented a low bed and a floor mat next to his bed. The facility did not utilize a specific fall risk, document to determine fall risk including a cumulative risk score. The fall risk assessment was incorporated into the facility's care planning process. Resident #1's care plan titled, "Fall/Injury Assessment: Prevention and Management Plan of Care" dated 10/13/10, includes interventions of a low bed, mat on floor next to bed, and high back wheelchair with cushion. Surveyor # completed a review of Resident #1's CNA (Certified Nursing Assistant) care plan dated 2/9/11. The approaches are noted as follows: "...Toileting Scheduled: Upon rising before and after meals @ (at) hs (hour of sleep) and noc (night) rounds...Floor mat...Bed Alarm...Chair alarm...30 min (minute) checks...Floor mats most (sic) be around him at all times when in room bed, w/c (wheelchair), recliner..." Surveyor # completed a review of Resident #1's nursing notes and noted the following: ~10/20/10, "...Aid walked into room to find patient on the floor, face down next to his bed...Skin tear to right side of neck due to hitting it on IV (intravenous) pole...IDT (interdisciplinary team) met...Resident had recent fall from bed. Mat placed and bed rearranged..." Surveyor # completed a review of the facility's document titled "Accident/Incident Report." This form reiterated the documentation in the nursing notes. It also indicates that the fall was not witnessed and that Resident #1 rolled out of bed. The information under the heading "Section A - Investigation" was incomplete and did not include when Resident #1 had last been toileted. Under the heading, "Section B - Final Disposition" it states, "...Resident is becoming stronger and more mobile...unaware of what he was doing at the time of the fall. Will be rearranging room and ensuring environment is appropriate, mat on floor as well..." According to Resident #1's care plan, the mat on the floor was to be initiated on admission. According to the documentation, it was not in place at the time of the fall. This was verified during an interview with RN-A (Registered Nurse) on 02/09/11 at 12:30 p.m. The facility did rearrange Resident #1's room and placed Resident #1's bed against the wall. Nursing notes continue: ~10/22/10, "...Each day seems to be better, knowing who people are, things he has done in life..." ~10/24/10, "...A/O (Alert and oriented) to self and family. Each days seems to be better..." ~10/25/10, "...confusion at times. Doesn't uses (sic) call light appropriately..." ~10/26/10, "...Leans sl (slightly) toward right while in WC (wheelchair)...confusion at times..." The facility identified that Resident #1 had a marked improvement since admission. The facility also identified that Resident #1 had periods of confusion as well as leaning while sitting. There is no evidence that his fall risk was reassessed with [REDACTED]. A 10/28/10 nurse's note states, "...1630 (5:30 p.m.)...called to resident's room...found laying on floor in front of easy chair...laying on left side with left arm tucked under him and right hand under head...1800 (6:00 p.m.)...went to resident's room...CNA (Certified Nursing Assistant) stated resident stopped excepting (sic) food/fluid, placed his hand on left side of head...did not respond to verbal command, hand grasp was very weak...called ambulance, resident transported..." Even though Resident #1 was determined to be at risk for falls, the facility did not address Resident #1's safety needs while seated in a chair. Surveyor # completed a review of the "Accident/Incident Report" dated 10/28/10. The report indicates that Resident #1 had attempted to get out of the chair independently and fell . In response, the facility instituted a bed and wheelchair alarm. The information under the heading "Section A -Investigation" is incomplete and does not include when Resident #1 was last toileted. Under the heading "Section B - Final Disposition" it indicates, "...CNA passed room and found resident lying on his L (left) side on the floor in front of his easy chair...said he was 'trying to get up'...Reminded to use call light. Incontinent of urine when found. Bed and chair alarm obtained..." Resident #1 had been incontinent of urine. There is no evidence that the facility assessed Resident #1's bladder function to determine if the current plan of care is appropriate. On 10/28/10, Resident #1 was transported to the emergency room and diagnosed with [REDACTED]. According to the Discharge Summary on 10/29/10, Resident #1 required emergent surgery to remove the hematoma. Resident #1 returned to the facility on [DATE]. Nursing notes continue: ~11/4/10, "...admitted ...alert and oriented to self and place...peripheral vision is poor...Incontinent of bowel and bladder...Requires 2 assist for all transfers R/T (related to) left sided hemiparesis, more predominant in UE (Upper Extremities) than LE (Lower Extremities). Able to stand and bear weight momentarily for transfer...Large incision present on head extending from left frontal area in circular C shaped area to posterior head and right side of head above ear..." ~11/5/10, "...called to room at 0800 (8:00 a.m.). Resident found laying in front of w/c laying on his right side...Noted to have a small hematoma to left side of forehead just under incision...did c/o (complain of) headache...orders received ...resident transported to ...ER (emergency room )...IDT met regarding fall on 11-5. Resident had fall from reclined wheel chair...Current interventions in place are, bed and chair alarms, 15mn (minute) checks, low bed, mats on floor when in bed and when in recliner...Res (Resident) admitted for observation..." Surveyor # completed a review of the "Accident/Incident Report" dated 11/5/10. This report indicates that Resident #1 was found laying on the floor in front of his wheelchair. It also indicates that Resident #1 had increased lethargy after the fall. The information gathered under the heading "Section A - Investigation" was incomplete and did not include when the last time Resident #1 was toileted. The investigation did indicate that Resident #1's alarm was sounding at the time of the fall. Under the heading "Section B - Final Disposition" it indicates, "...resident is extremely impulsive d/t (due to) CVA (stroke), was sent to ER..." Resident #1 was readmitted to the hospital of 11/5/10. Resident #1 returned to the facility on [DATE]. Surveyor # completed a review of the hospital records, which indicates Resident #1 had no acute findings following the fall. There is a physician order [REDACTED]. Nursing notes continue: ~ 11/6/10, "...admitted ...Incontinent of bladder and bowel...total assist with all needs...able to reposition himself in bed...bed in low position with mats on the floor as he is at high fall risk due to impaired mobility, strength, CVA..." On 2/9/11 at 11:00 a.m., Surveyor # spoke with RN-A. RN-A indicated that after Resident #1's fall of 11/5/10, Resident #1's family began to sit with Resident #1 during his waking hours. RN-A indicated that the family opted for this as they were told the facility could not provide a one-on-one supervision for Resident #1. There is no evidence that the facility implemented any new approaches to address Resident #1's falls. On 2/8/10 at 3:55 p.m., Surveyor # spoke with Family-B. Family-B indicated that after Resident #1's fall on 11/5/10, the family decided to provide a sitter. Family-B indicated that the sitter usually came between 8:00 a.m. and 9:30 a.m. and stayed until Resident #1 went to bed at night. Family-B indicated the facility does not have enough staff for someone to be with Resident #1 all the time. Family-B indicated Resident #1 has short-term memory problems and doesn't comprehend or remember that he needs assistance to stand and walk. Family Member-B also stated that Resident #1 is to wear a helmet, but he refuses to wear it. Family Member-B stated Resident #1 will also remove his alarms. Nursing notes continue: ~12/7/10, "...increasing restlessness at night..." ~12/10/10, "...restless the first few hours of night shift..." ~12/24/10, "...Resident observed crawling out of his bed...at 0210 (2:10 a.m.)...stated that he was getting a pillow...did go to his knees on the floor mat...No apparent injury..." Surveyor # completed a review of the facility's "Accident/Incident Report" dated 12/24/10. The report indicates Resident #1 has had a witnessed fall from bed when reaching for pillows. The report also indicates that Resident #1's alarm had sounded. The report under the heading "Section B - Final Disposition" indicates, "...Res is alert and verbalized exactly what he was attempting. He did not fall. Reminded to use call light. Interventions remain in place to prevent injuries..." There are no new interventions put into place to ensure Resident #1's safety, even though the facility knew that Resident #1 was reaching for his pillow. Additionally, despite Resident #1's known cognitive deficit, Resident #1 is reminded to use his call light. On 2/9/11 at 11:00 a.m., Surveyor # spoke with RN-A. RN-A indicated that the facility did not implement any new interventions as they felt Resident #1 is going to continue to fall because of his brain injury and the goal is to keep him as free from injury as possible. According to the facility's "Fall/Injury Assessment: Prevention And Management Plan Of Care," there are a multitude of other interventions that could have been attempted, including increased supervision, a change in the type of alarm used, bed bolsters, winged mattress, visual cues, night light and signs. None of these approaches were implemented/attempted. Nursing notes continue: ~1/14/11, "...Discovered with legs over the side of bed. Repositioned..." ~1/24/11, "...Found on floor in bathroom this am (morning) at 0715 (7:15 a.m.). Was found by other floor nurse. Was still in wheelchair. Wheelchair was tipped over with him. Resident stated that he had hit his head...No new injuries..." Surveyor # completed a review of the facility's "Accident/Incident Report" dated 1/24/11. According to the report, Resident #1 was found on the floor in the bathroom with the wheelchair tipped on its side. The report indicates that Resident #1 stated he was trying to stand up and lost his balance. The report also indicates that Resident #1 hit his head. The report also indicates that Resident #1 often attempts to transfer himself. The information gathered under the heading "Section A - Investigation" was incomplete and did not include the last time that Resident #1 was toileted nor when Resident #1 had his last meal. Under the heading titled, "Section B - Final Disposition" it indicates, "...Res was at the bathroom sink washing. Did attempt to stand - alarm sounded...stated 'I tripped.' No injury noted...Res reminded to sit if he hears his alarm...to stay with res in BR (bathroom)..." The facility updated Resident #1's care plan to include one-to-one supervision when Resident #1 is in the bathroom. Resident #1's CNA care plan, however, was not updated. Nursing notes continue: ~1/26/11 at 2:00 a.m. states, "...found kneeling on mat next to bed...denies injury. Placed in bed and encouraged to utilize call light..." Surveyor # completed a review of the facility's "Accident/Incident Report" dated 1/25/11. The report indicates that Resident #1 was found kneeling on the floor mat next to Resident #1's bed at 21:55 (9:55 p.m.). Resident #1 indicated that he was trying to go to the bathroom. The information gathered under the section titled "Section A - Investigation" was incomplete and did not include the last time that Resident #1 was toileted. The report also indicates that the alarm was not sounding when Resident #1 was discovered. Under the section titled "Section B - Final disposition" indicates, "...no injury, found kneeling @ (at) edge of bed, stated he needed to use bathroom, B&B (Bowel and Bladder) reassessed for patterns." On 2/9/11 at 11:00 a.m., Surveyor # spoke with RN-A regarding the bladder assessment completed for Resident #1. RN-A stated they did not reassess Resident #1's voiding pattern. RN-A indicated that Resident #1's current toileting schedule was before breakfast, before and after meals, and when going to bed at night. RN-A indicated that because of the odd time of the fall, there wasn't the need to reassess his voiding pattern. Surveyor # completed a review of Resident #1's most current bladder assessment dated [DATE]. The assessment indicates that it had also been reviewed on 1/25/11. The bladder assessment indicates that Resident #1 has functional incontinence. The assessment also indicates that Resident #1 is not appropriate for a toileting program and is to have "Scheduled Check and Change" because of Resident #1's cognitive impairment and inability to sit on the toilet. There are no changes to Resident #1's plan of care. Current approaches (alarms) were not in place/functioning at the time of Resident #1's fall. Nursing notes continue: ~2/3/11, "...15:45 (3:45 p.m.) resident's alarm sounded...entered room resident was just sliding off the side of his bed landing on his knees on the floor mat...Stated, 'I have to leave'...glasses found on the floor mat bent and a lens was out...16:25 (4:25 p.m.) resident's alarm sounded. Resident found kneeling on the floor mat...no injuries...reminded of the importance of asking staff to assist him..." Surveyor # completed a review of the facility's "Accident/Incident Report" dated 2/3/11. The report indicates that Resident #1 is impulsive because of his brain injury and reiterated Resident #1's current approaches of bed and wheelchair alarms, and low bed with a mat on the floor next to Resident #1's bed. There are no changes to Resident #1's plan of care. Surveyor # completed a review of the facilities "Accident/Incident Report also dated 2/3/11. The "Section A - Investigation" had not been completed. The report again indicates that Resident #1 is impulsive because of his brain injury. The report also reiterated Resident #1's current care plan interventions. There are no changes to Resident #1's plan of care. Nursing notes continue: ~2/4/11, "...IDT met to review status and plan of care. Resident had two witness incidents of crawling out of bed yesterday afternoon...continues to be quite restless...does not have the insight to recognize his limitations..." ~2/5/11, "...Attempted to exit bed 3 times during the night...Encourage to use call light and to wait for assistance...0700 (7:00 a.m.) resident was found kneeling on floor mat next to his bed...Stated 'i (sic) wanted to shut the alarm off'...No injuries..." Surveyor # completed a review of the facility's "Accident/Incident Report" dated 2/5/11. The report indicates that Resident #1 is found kneeling next to his bed on the floor mat. The report indicates that all safety measures are in place and the goal is to prevent Resident #1 from injury. There are no changes to Resident #1's plan of care. Nursing notes continue: ~2/8/11, "...2125 (9:25 p.m.) resident noted to have slid out of bed and onto mat on floor next to bed...offered no c/o (complaint of) pain...approximately 5 minutes later, resident noted to have crawled out of bed again...placed into w/c and brought out by nurse's desk for supervision..." Surveyor # completed a review of the facility's "Accident/Incident Report" dated 2/8/11. The report indicates that Resident #1 is found out of bed 2 times. The information gathered under the heading "Section A-Investigation" is incomplete and does not include the last time when Resident #1 had been toileted. "Section B - Final Disposition" indicates, "...Resident continues to exhibit classic symptoms of TBI (Traumatic Brain Injury)...Very impulsive and restless @ times. Has shown more difficulty in following direction and had been noted to be increasingly difficult to redirect...will be placed with increased supervision @ nsg (nursing) station or with staff in view...goal remains to prevent injury..." The approaches to place Resident #1 at the nursing station and in view of staff, were not added to Resident #1's plan of care nor the CNA care plan. Surveyor # completed a review of the facility's document titled, "24 Hour Resident Flow Record." The document was utilized to check Resident #1's where-abouts at given intervals. The document indicates that Resident #1 is being checked every 30 minutes. This is in direct conflict with Resident #1's care plan which indicates Resident #1 is to be checked every 15 minutes. Surveyor # completed a review of the "24 Hour Resident Flow Record" for Resident #1. Surveyor # noted that of the 85 days reviewed, 33 days had incomplete documentation. On 2/9/11 at 12:30 p.m., Surveyor # spoke with RN-A (Registered Nurse). RN-A indicated that she was the clinical manager for the rehab unit where Resident #1 resides. Surveyor # asked RN-A what the facility's process for falls included. RN-A indicated the nurse working on the floor is the person who completes the accident report. RN-A stated that it is also the responsibility of the nurse to initiate an investigation into the cause of the fall as well as initiate immediate interventions to keep residents safe. RN-A stated it is also the responsibility of the nurse working the floor, to update the care plan. RN-A indicated the accident report is then reviewed during the facility's morning meeting with the management team. RN-A stated that this is also the time when they "brain storm" to determine new fall interventions to keep residents safe. Surveyor # asked RN-A about Resident #1's falls. RN-A indicated that Resident #1 was challenging related to his diagnoses. RN-A indicated that she felt the facility had done all they could to prevent Resident #1 from falling. RN-A indicated that the current goal is no longer to prevent falls but to prevent injury when Resident #1 does fall.