**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 4 residents (R5) reviewed for equipment. R5 requested a referral for a new wheelchair for use out of the building. The facility did not follow up with the outside vendor in a timely manner. Evidenced by: The facility's Social Worker Job Description, undated, states, in part: .The Social Worker will also assist residents and their representatives in locating and accessing financial, legal, and other community resources. Accurately and completely document social service actions and interactions in each resident's medical record . Surveyor requested facility policy for requisition of wheelchairs. No policy provided. R5 admitted to the facility on [DATE] and has diagnoses that include, in part: Parkinsonism (a group of movement disorders characterized by symptoms including tremor, rigidity, slow movements, and postural instability/inability to maintain body balance), abnormalities of gait and mobility, low back pain, weakness, and depression (a mental health condition characterized by persistent feelings of sadness, loss of interest, and low energy levels). R5's MDS (Minimum Data Set), with target date of 3/7/25, indicates a BIMS (Brief Interview of Mental Status) score of 15, indicating that R5 is cognitively intact. It also indicates that R5 uses a wheelchair for mobility. R5's Social Service Note, dated 1/23/25, states: WVOS H (Wheelchair Vendor Operations Supervisor) called. Vendor received the order from doctor's office, but also stated that she has the original order that I sent in November. She stated that vendor did not open the order in November because they were not able to fill the order. This is because R5 resides in a skilled level of care facility and already has a wheelchair, so it is not a necessity that they could bill Medicare for. On 4/1/25 at 1:07 PM, Surveyor interviewed R5 and asked about R5's wheelchair. R5 stated the wheelchair doesn't fold so it can't be taken anywhere. R5 stated that when going out of the facility, R5 uses a borrowed poor one. R5 clarified by stating that R5 is crammed into the chair; the seat is too small and the foot pedals are too close. R5 stated there has been work on getting a new chair since August 2024, but no new chair is yet in place. R5 stated there was approval from Occupational Therapy, but apparently that is not enough, as R5 is still waiting. R5 stated it is frustrating. On 4/1/25 at 1:29 PM, Surveyor interviewed OT D (Occupational Therapist) and DOR E (Director of Rehab) and asked about process for getting a new wheelchair. OT D stated a letter of recommendation is written with justification for the chair along with measurements. The recommendation is sent from DOR E to SSD F (Social Services Director) for processing. Generally, chairs are ordered a few days before a resident discharges from the facility and arrive prior to the discharge. Surveyor asked if R5 was looking for a new chair. DOR E stated yes, RR G (Resident Representative) was asking about a new chair and trying to assist R5 with the process, but was running into road blocks. DOR E stated there was some lack of communication between RR G and SSD F. Surveyor asked if a letter of recommendation was written for a new chair. OT D stated yes, two or three letters had been written and forwarded to SSD E. Surveyor asked if there was follow up communication after the letters of recommendation had been submitted. OT D stated that OT D had spoken with SSD F on a couple occasions and was told that SSD F had spoken to the vendor, but was waiting for further information. DOR E stated that the status of the chair would be talked about at Medicare meetings and SSD F would state that SSD F was still waiting on response from the vendor. On 4/1/25 at 2:27 PM, Surveyor interviewed WV C (Wheelchair Vendor) and asked about a referral for R5. WV C stated there was a referral on 1/23/25. Surveyor asked if there had been any referrals prior to 1/23/25. WV C stated no. Surveyor asked if a referral was made into another office of their company, would WV C be aware. WC V stated yes, all referrals are documented in the same system, no matter which office. On 4/2/25 at 9:03 AM, Surveyor interviewed SSD F and asked about the process for getting a new wheelchair. SSD F stated a referral letter from therapy is written, an order is obtained, and the paperwork is submitted to a DME (Durable Medical Equipment) vendor. Surveyor asked how soon after the referral is the paperwork sent to the vendor. SSD F stated right away. Surveyor asked if residents living in a SNF (skilled nursing facility) qualify for a new chair. SSD F stated it depends; if the resident has their own, functional equipment, they may not qualify, but sometimes they will. Surveyor asked if R5 was looking for a new chair. SSD F stated yes, the chair that he has doesn't fold properly to fit into RR G's car; RR G saw a chair on the internet and asked us to send in a referral. The referral was sent to a local vendor and was denied due to not being in network. SSD F stated that SSD F then contacted R5's managed care organization for assistance and was advised to send a referral to another vendor. SSD F shared a fax cover letter to the new vendor with a fax date of 11/8/24 and refax of 11/9/24. Surveyor asked why the cover letter stated it had been refaxed. SSD F stated the vendor had not received it. SSD F stated that SSD F spoke with WVOS H on 1/23/25 and WVOS H had indicated that an order had come from a physician's office and would not be filled due to resident living in SNF. Surveyor asked if there was any correspondence with vendor between 11/9/24 and 1/23/25. SSD F stated I believe I may have left messages. Surveyor asked for any documentation of communication attempts with vendor. SSD F stated there was no documentation. Surveyor asked if R5 or RR G were updated on the status of the chair. SSD F stated that SSD F told R5 in passing. Surveyor asked if there was documentation of R5 being updated. SSD F stated no. On 4/2/25 at 10:04 AM, Surveyor interviewed WVOS H and asked about a referral for a wheelchair for R5. WVOS H stated that a referral was made on 1/23/25. Surveyor asked if there had been a referral prior to 1/23/25. WVOS H stated that sometimes referrals are received, and the vendor is not able to fill the order, so the referral is not opened in the vendor's system. If the order is not opened in the system, the SNF would be notified that the order could not be filled. WVOS H stated that all received faxes are kept for a year whether they are opened or not and that all received faxes from October 2024 through December 2024 had been reviewed and that no referral for R5 was found. On 4/2/25 at 1:21 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked if a resident/resident representative asked for a wheelchair referral to be sent to a vendor, should it be sent. NHA A stated yes. Surveyor asked how soon a referral written by therapy should be sent to the vendor. NHA A stated right away. Surveyor asked if a referral is sent and there is no response from vendor, would the facility be expected to follow up with vendor about the status. NHA A stated yes, that would be reasonable. Surveyor asked if a fax letter was dated 11/9/24, would follow up be expected prior to 1/23/25. NHA A stated yes. Surveyor asked if there should be documentation of the referral and follow up. NHA A stated yes. R5 requested a referral for a new wheelchair for use out of the building. The facility did not follow up with the outside vendor in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure that residents with pressure injuries receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new injuries from developing for 2 of 3 residents (R34 and R51) reviewed for pressure injuries. R34 did not have wound care treatments documented as completed in October and December. R51's pressure injury was left open to air for approximately 2 hours. This is evidenced by: The facility policy and procedure entitled Documentation of Wound Treatments dated 9/19/24, documents the following in part: .3. Wound treatments are documented at the time of each treatment. If no treatment is due, an indication on the status of the dressing shall be documented each shift (i.e., clean, dry, intact) . Example 1 R34 is a long-term resident of the facility who is receiving Hospice services. R34's goal for her pressure injury is to be as comfortable as possible and be free from infection. R34 has the following diagnoses: myotonic muscular dystrophy (genetic disorder that causes progressive muscle weakness), protein-calorie malnutrition, palliative care (end of life care), neoplasm of endocrine glands (tumor), neoplasm of spinal cord, weakness, benign neoplasm of spinal meninges, underweight, and cord compression. R34's October Physician Orders include: -Wound care to ischial tuberosity: - cleanse SNS (sterile normal saline), - skin prep to peri wound, - Apply Manuka honey/Alginate to wound bed (cut to size), - cover with foam dressing daily and PRN (as needed) until healed then DC (discontinue) every day shift for wound care. Start date 8/30/24. End date 10/4/24. -Wound care to ischial tuberosity: - cleanse SNS (sterile normal saline), - skin prep to peri wound, - Apply Medi-honey GEL to wound bed, - cover with bordered foam dressing daily and PRN until healed then DC every day shift for wound care. Start date 10/4/24. End date 11/8/24. R34's October TAR (Treatment Administration Record): Ischial tuberosity had a blank box in TAR on 10/4/24, 10/11/24, 10/19/24, 10/24/24, and 10/28/24. R34's December Physician Orders include: -Cleanse wound with cleanser, protect periwound with Skin Prep, Apply Manuka honey/Alginate to wound bed, Cover wound with Foam, change daily, Change PRN for soiling and/or saturation, every day shift for wound care. Start date 11/8/24. R34's December TAR: Blank box in TAR on 12/6/24 and 12/27/24. It is important to note that despite the TAR not being signed out for the above dates, R34's wounds did not cause more pain or become infected. On 1/9/25 at 1:34 PM, Surveyor interviewed LPN C (Licensed Practical Nurse). Surveyor asked LPN C if there is a blank in the TAR what does that indicate, LPN C said someone didn't click it off, if they would have clicked it and put refused or whatever it would show their initials and a number code, if blank someone probably didn't do it. Surveyor asked LPN C should treatments be signed out and completed as ordered, LPN C stated yes, the order should be done, if not signed out it wouldn't have been done, physician orders should be carried out as ordered and signed off. On 1/9/25 at 3:28 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if there is a blank in the TAR what does that indicate, DON B said they forgot to sign it out. Surveyor asked DON B if the blank could indicate that the treatment was not completed, DON B stated it could. Surveyor asked DON B if she expects all treatments to be done as ordered, DON B stated yes. Example 2 R51 admitted to the facility on [DATE]. R51's physician orders for January 2025 include left inner gluteal cleft: cleanse with wound cleanser, pat dry, apply Santyl to wound bed, zinc to peri-wound, cover with foam dressing change daily and as needed. On 1/7/25 at 10:53 AM, Surveyor observed R51 in bed with no dressing on her gluteal pressure injury. Surveyor interviewed RN F (Registered Nurse) regarding R51's pressure injury being open to air with no dressing in place. RN F indicated R51 had a shower earlier and the dressing had not replaced after R51's shower. RN F indicated a wound should not remain uncovered for more than 30 minutes. RN F indicated prolonged exposure to air can hinder wound healing. On 1/7/25 at 11:30 AM, Surveyor interviewed CNA H (Certified Nursing Assistant) regarding R51's shower. CNA H indicated R51's shower was done before 9:00 AM. On 1/9/25 at 9:05 AM, Surveyor interviewed DON B (Director of Nursing) regarding wound care. DON B indicated a wound should not be left uncovered and the dressing should have been applied after R51's shower without delay.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure they provided adequate supervision and assistance to prevent accidents for 1 (R11) of 4 residents reviewed for accidents and supervision. R11's care plan indicates R11 needs supervision for all meals. Surveyor observed R11 eating meal in his room alone. R11 indicated it was difficult to eat the meal. Evidence by The facility policy, Activities of Daily Living, dated 8/24, states, in part; .2. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . R11 was admitted to the facility on [DATE] with a diagnoses including parkinsonism (collection of movement symptoms- slow movements, stiffness, walking/balance issues, and/or tremors), dysphagia (difficulty swallowing), osteoporosis (bones become weak and brittle), tremor, and mild cognitive impairment. R11's most recent MDS (Minimum Data Set) dated 12/20/24, states that R11 has a BIMS (Brief Interview of Mental Status) of 15 indicating R11 is cognitively intact. R11 is own person. R11's care plan states, in part; .At nutrition risk r/t (related to) Parkinson's, mild cognitive impairment, weakness, tremors I would prefer finger foods as they are easiest for me to eat .I do not want items I have trouble eating such as spaghetti .date initiated 4/20/23 .revision 12/19/24 .The resident has a swallowing problem r/t coughing or choking during meals .Resident to eat only with supervision .initiated: 9/30/24 . On 1/7/25 at 12:10PM, Surveyor observed R11 eating in his room alone. R11 was eating spaghetti and having difficulty scooping up the noodles. Surveyor asked R11 how lunch was going. R11 stated difficult, and that R11's food was delivered cold. On 1/8/25 at 10:41AM, RN I (Registered Nurse) indicated R11 needs supervision for all meals. On 1/8/25 at 11:03AM, ST J (Speech Therapist) indicated R11 should have supervision for meals. ST J indicated it is her expectation if a resident care plan states they should have supervision for meals the facility must follow care plan. On 1/9/25 at 9:14AM, NHA A (Nursing Home Administrator) and DON B (Director of Nursing) indicated they would expect staff to follow resident care plan for supervision and preferred food items. NHA A and DON B indicated understanding with concern for R11. The facility failed to ensure they provided adequate supervision and supports per resident care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure that pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, this affected 2 of 2 residents reviewed for med errors, 1 sampled resident (R38) and 1 supplemental resident (R50). R38 had the wrong pain medication administered on 8/15/24 and 8/16/24. R38's narcotic count was not accurate on 9/26/24. RN G (Registered Nurse) used a contaminated pill cutter to cut an unscored tablet for R50. This is evidenced by: The Facilities Policy and Procedure entitled Medication Administration dated 10/2024 documents in part: .9. Ensure that the six rights of medication administration are followed: a. Right resident, b. Right drug, c. Right dosage, d. Right route, e. Right time, f. Right documentation .16. Administer medication as ordered in accordance with manufacturer specifications .c. Crush medications as ordered. Do not crush medications with do not crush instructions . The Facilities Policy and Procedure entitled Medication Errors dated 2/22/24 documents in part: .Medication error means the observed or identified preparation of administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturer's specification (not recommendations) regarding the preparation and administration of the medication or biological; or accepted professional standards and principles which apply to professionals providing services .Policy Explanation and Compliance Guidelines: 1. The facility shall ensure medications will be administered as follows: a. According to physician's orders. b. Per manufacturer's specifications regarding the preparation, and administration of the drug or biological. c. In accordance with accepted standards and principles which apply to professionals providing services .4. The facility will consider factors indicating errors in medication administration, including, but not limited to, the following: a. Medication administered not in accordance with the prescriber's order. Examples include, but not limited to: i. Incorrect dose, route of administration, dosage form, time of administration .b. Medication administered not in accordance with the manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological. Examples include, but not limited to: .ii. Crushing do not crush medications .7. To prevent medication errors and ensure safe medication administration, nurses should verify the following information: a. Right medication, dose, route, and time of administration b. Right resident and right documentation . R38 is a long-term resident of the facility. R38 has the following diagnoses: polyosteoarthritis (arthritis that affects 5 or more joints), pain in right shoulder, pain in right elbow, osteoarthritis (chronic disease that causes breakdown of cartilage and other tissues in the joints), gout (form of arthritis), and low back pain. RN G (Registered Nurse) used a contaminated pill cutter to cut an unscored tablet for R50. Example 1 R38's August Physician Orders document: -Hydrocodone-Acetaminophen Oral Tablet 5-325 mg (milligrams) Give 1 tablet by mouth four times a day for pain R38's Telephone Orders for 8/14/24 document: 1) Oxycontin ER 10 mg tablet po (by mouth) BID (twice per day) Dx (diagnosis): pain 2) Oxycodone 5 mg every 6 hours PRN (as needed) Dx: pain 3) D/C (discontinue) Hydrocodone 4) Monitor every shift for increased sedation r/t (related to) Oxycontin, update R38's MAR (Medication Administration Record) documents: -Oxycodone HCl Tablet 10 mg Give 1 tablet by mouth two times a day for pain. Start date 8/14/24. End date 8/16/24. This medication is signed out twice (AM and PM) on 8/15/24 and once (AM) on 8/16/24. -Oxycontin Oral Tablet ER 12 Hour -Abuse-Deterrent 10 mg (Oxycodone HCl) Give 10 mg by mouth two times a day for pain. Start date 8/16/24. -Oxycodone HCl Oral Tablet 5 mg (Oxycodone HCl) Give 1 tablet by mouth every 6 hours as needed for pain. Start date 8/14/24. R38's Controlled Drug Record Count Sheet documents: -Oxycodone HCl (IR) 5mg tablet issued 8/14/24, 10 tablets dispensed -8/16/24 at 0830 (8:30 AM) 2 tablets were signed out The medication errors on 8/15/24 and 8/16/24 were due to the incorrect order being transcribed twice a day for scheduled pain medication. R38's September Physician Orders document: -Oxycontin ER 12 Hour Abuse-Deterrent 10 mg Give 10 mg by mouth two times a day for pain -Oxycodone HCl Oral Tablet 5 mg Give 1 tablet by mouth every 6 hours as needed for pain R38's Controlled Drug Record Count Sheet documents: -Oxycodone HCl (IR) 5mg tablet issued 8/23/24, 8 tablets dispensed -9/26/24 count on this form goes from 5 tablets to 3 tablets The facility identified that the count on R38's controlled drug record was wrong and identified that someone had taken 2 tablets from R38's card instead of another residents' card. Therefore, R38's care was inaccurate with 2 few tablets and the other resident's card was also inaccurate with 2 many tablets. On 1/9/25 at 10:06 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if R38 had any medication errors August 2024-present, DON B stated there are no medication errors for R38. On 1/9/25 at 3:29 PM, Surveyor interviewed DON B. Surveyor asked DON B if on 8/15-8/16/24 if the medications Oxycodone and Oxycontin could have been inverted (used in place of the other), DON B replied yes. Surveyor asked DON B if she could explain how the error occurred on 9/26/24, DON B explained that the wrong card of medication was taken for another resident and that is why R38's count was incorrect. Surveyor asked DON B if there should be medication error reports for these issues, DON B said yes. Example 2 R50 admitted to the facility on [DATE]. R50's physician orders dated 1/9/25 include Vitamin D3 oral capsule 25 mcg, give 1 capsule by mouth in the morning. On 1/8/25 at 8:06 AM, Surveyor observed RN G (Registered Nurse) prepare R50's medications. During this observation, RN G removed a Vitamin D 50 mcg tablet from the medication bottle. Surveyor observed the Vitamin D 50 mcg tablet was not a scored tablet. RN G opened the pill cutter to cut the Vitamin D 50 mcg tablet in half. Surveyor observed the pill cutter contained white chunks and powder from previously cut medications. Surveyor also observed the cutting blade contained white powder. RN G placed the Vitamin D 50 mcg tablet into the pill cutter and cut the pill in half. RN G placed the cut Vitamin D into a medication cup to administer to R50. Surveyor stopped RN G and interviewed RN G regarding the preparation of R50's medications. RN G indicated the pill cutter was contaminated with unknown medication residue and she should have cleaned the pill cutter prior to cutting R50's Vitamin D. Surveyor interviewed RN G regarding which medications are allowed to be cut in half. RN G indicated only medications that are scored should be cut in half. RN G indicated she should not cut the Vitamin D tablet in half since it was not a scored tablet. On 1/9/25 at 9:07 AM, Surveyor interviewed DON B (Director of Nursing) regarding medication administration. DON B indicated the pill cutter should be clean prior to cutting a medication. DON B also indicated an unscored tablet should not be cut.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections RN F touched items within resident room with dirty gloves. R319 was admitted with a pressure injury (PI) and previous wound infection. During observation of wound care, the facility failed to utilize standard infection control practices. This is evidenced by: The facility policy Clean Dressing Change dated 10/2024, states, in part: .17. Discard disposable items and gloves into appropriate trash receptacle and wash hands. 18. Return resident to a comfortable position . Example 1 On 1/7/25 at 10:53 AM, Surveyor observed RN F (Registered Nurse) perform wound care for R51. Surveyor observed RN F complete R51's dressing change. RN F removed the old dressing and RN F proceeded to discard the used wound care supplies and with same gloves, RN F touched the bed side table and bed controller. RN F then stated she should take the gloves off. RN F removed gloves and then performed hand hygiene. Surveyor observed RN F complete wound care. Surveyor observed RN F, with gloved hands, apply R51's dressing. Surveyor interviewed RN F regarding touching the bed side table and bed controller with dirty gloves. RN F indicated she should have removed her gloves and performed hand hygiene prior to touching anything. On 1/9/25 at 9:05 AM, Surveyor interviewed DON B (Director of Nursing) regarding wound care. DON B indicated RN F should have performed hand hygiene before touching the bed side table and bed controller. Example 2 R319 was admitted to the facility on [DATE] with diagnoses that include pressure ulcer of sacral region, stage 4, type 2 diabetes mellitus without complications, need for assistance with personal care, cognitive communication deficit, unspecified abnormalities of gait and mobility, and depression unspecified. R319's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/24/24, documented R319 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. Section M of the MDS indicates that R319 had a Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle, slough or eschar may be visible on some parts of the wound bed, may include undermining or tunneling) PI on admission. R319's discharge paperwork from the hospital dated 12/10/24 indicates in part: (R319) who is being admitted today with sacral wound infection . she developed a sacral wound and has been following at wound care clinic . today she was at the wound care clinic and there was suspicion for abscess so she was sent back to ED (Emergency Department) . CT (computed tomograghy) showed abscess and General Surgery debrided it at the bedside . previous culture shows MRSA (methicillin-resistant Staphylococcus aureus, a bacterial infection that does not get better with usual antibiotics) and Morganella (an opportunistic pathogen that mainly causes post-operative wound infections) with some resistance . Patient Active Problem List includes pressure injury of buttock, unstageable and Skin ulcer of sacrum, unspecified ulcer stage. R319's admission Weekly Skin Charting on 10/20/24 indicates that R319 had a pre-existing open area to left buttock. R319's admission Skin Assessment on 12/20/24 indicates a wound Stage 4 to left gluteus with measurements of 1.96 cm (centimeters) by 1.44 cm. R319's physician orders include an order to treat the left gluteus wound: Cleanse wound with saline, protect periwound with skin prep, apply Hydrofera Blue or Derma Blue (cut to size) to wound bed, cover wound with Bordered Gauze, change daily, change PRN (as needed) for soiling and/or saturation, as needed. R319's Care Plan includes in part: . Focus: (R319) has actual impairment to skin integrity of the left gluteus , stage 4 at risk for further skin breakdown . Intervention: pressure reducing cushions, to protect the skin while up IN CHAIR. pressure reducing mattress to protect the skin while IN BED . Intervention: Assist me with my general hygiene and comfort measures . Intervention: Consult Dietary for my nutritional needs, Encourage good nutrition and hydration in order to promote healthier skin . Intervention: Encourage/assist me to elevate heels, Encourage/assist me with reposition as needed . Intervention: Follow facility protocols for treatment of injury . Intervention: My skin will be assessed on a weekly basis on my scheduled bath day and document findings on a weekly skin assessment, Report any skin redness/impaired integrity areas to my nurse . Intervention: Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations . Intervention: Use barrier cream to prevent skin impairment issues, as needed, Wound doctor to follow wound progression . On 1/7/25 at 10:15 AM, Surveyor observed wound care for R319. RN F (Registered Nurse) gathered the supplies to perform wound care, entered R319's room and performed hand hygiene. RN F donned appropriate PPE (personal protective equipment) including gown and gloves. RN F placed an unused garbage bag at the end of R319's bedside table. RN F stated she planned to tape the garbage bag to the end of the bedside table but forgot the tape. RN F assisted R319 to bed and completed the wound care according to physician orders, performing hand hygiene and glove changes as appropriate. RN F then began to clean up, but the loose garbage bag fell on the floor with the old, soiled dressing falling out onto the floor, as well as used gloves and paper towels. RN F picked up the trash and placed it back in the garbage bag. As RN F was walking toward R319's door, the soiled trash fell onto the floor again. RN F picked up the trash and placed it back in the garbage bag a second time. RN F placed trash bag into a larger trash receptacle inside R319's door. RN F then stated that she had forgotten to give R319 back her call light. Surveyor observed RN F go back to R319's bedside and gave her the call light and put bedside table back near R319's bed, still wearing the soiled gloves she had used to pick up the trash off the floor. RN F then removed soiled gloves and washed hands before leaving R319's room. Surveyor asked RN F when it was appropriate to change gloves during wound care. RN F answered any time touching a dirty area and going to a clean area. Surveyor asked RN F if she had changed gloves after picking up the trash and soiled dressing and before she touched the resident's belongings such as call light and bedside table. RN F stated she couldn't remember but that she probably forgot because she had been so nervous. Surveyor asked RN F if touching dirty paper towels, dirty gloves, and soiled bandage would be a potential for infection. RN F stated yes, that would be possible. On 1/9/25 at 7:32 AM, Surveyor interviewed DON B (Director of Nursing) about infection control practices. Surveyor asked DON B when it is appropriate to change gloves and perform hand hygiene during wound care. DON B stated gloves should be changed and hand hygiene should be performed anytime the nurse goes from dirty to clean and hand hygiene should be performed before putting on gloves and after removing them. Surveyor asked DON B if the nurse should remove soiled gloves and perform hand hygiene after picking up soiled bandages, paper towels, and gloves and before touching the resident's belongings. DON B stated yes, the soiled gloves should be removed and hand hygiene performed before touching resident's belongings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 5: On 1/6/25 at 11:02 AM, Surveyor interviewed R58. Surveyor asked R58 how the food is at the facility, R58 said not good. Surveyor asked R58 if his hot foods are hot and cold foods are cold. R58 stated hot foods are lukewarm and cold foods are warm. Surveyor asked R58 if there was anything else about the food he wanted to share. R58 replied all the meat is mysterious. Example 6: On 1/6/25 at 2:50 PM, Surveyor interviewed R31. Surveyor asked R31 how the food is at the facility, R31 said it's ok. Surveyor asked R31 what would make it better? R31 said if the vegetables weren't cold. Based on observation, interview, and record review, the facility did not ensure that each resident receives food and drink that is palatable and at a safe and appetizing temperature. This has the potential to affect all 65 residents residing at the facility. Residents (R) voiced concern with hot foods being served cold and cold foods being served warm. (R46, R11, R5, R31, R4, R58, and R55) 2 of 2 test trays were observed to not be served at desirable temperatures. Evidenced by: The facility policy Food Temperatures, dated 2023, states in part: .1. All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 F . Example 1: R46 was admitted to the facility on [DATE]. On 1/7/25 at 9:58AM, R46 indicated hot food is often served cold in the dining room. R46 indicated they discuss food concerns at the monthly resident council meeting. Example 2: R11 was admitted to the facility on [DATE]. On 1/6/25 at 3:17PM, R11 indicated the food was supposed to get better under new management in the kitchen. R11 indicated R11 still has concerns with the meals. R11 indicated he eats in his room and that food is not always palatable, hot foods are served cold, and the portions are small. Example 3: On 1/7/25 at 8:28AM, Surveyor received the last tray that was being served in dining room on the first floor. Scrambled eggs temped at 98.9 F, bacon 85.4 F, oatmeal 105.8 F, and the toast was hard. All food tasted cold and was not palatable. Example 4: On 1/7/25 at 11:59AM, Surveyor received the last room tray that was being served on the third floor. Spaghetti with meat temped at 125 F, garlic bread 108 F, and mixed vegetables 109 F. The milk temped at 45.5 F and juice 42.8. The hot food was cold and the milk and juice warm and not palatable. On 1/8/25 at 3:11PM, Food and Service Director D and District Manager E Indicated they would expect hot foods to be served hot and cold foods to be served cold. Both indicated understanding with the concerns voiced by residents and test tray temperatures. The facility failed to ensure that each resident receives food and drink that is palatable and at a safe and appetizing temperature. Example 7: R5 admitted to the facility on [DATE] with diagnoses including rheumatoid arthritis in left and right hand (a chronic inflammatory disorder usually affecting small joints in the hands) and acquired absence of right and left leg above knee (amputation of both legs above the knee). On 1/7/25 at 9:58 AM, Surveyor interviewed R5 regarding food temperatures at mealtimes. R5 indicated he eats his meals in the dining room and the resident lounge. R5 states the hot foods are served cold. R5 states there is a small microwave in the other room (not in the dining room) the facility can use to warm up the food, but it takes forever for the staff to warm up the food. Example 8: R55 was admitted to the facility on [DATE]. Her most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/11/24, indicates her cognition is intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15. On 1/6/25 at 10:14 AM, Surveyor interviewed R55 who indicated that most of the time the food that is served is not hot. R55 stated especially the french fries are always cold, and that every day the food that is served is lukewarm at best. On 1/6/25 at 12:04 PM, Surveyor observed dining service on the 300 unit, and noted that french fries were being served for lunch. Surveyor approached R55 and asked her about the french fries on her plate. R55 indicated they were not warm at all and that they looked undercooked. R55 then held up a french fry from her plate and stated, See they are soft and limp. They should not really even call them french fries because they are not. Example 9: R4 admitted to the facility on [DATE]. His most recent MDS with an ARD of 11/5/24 indicates his cognition is intact with a BIMS score of 15 out of 15. On 1/6/25 at 11:59 AM, Surveyor observed dining service on the 300 unit and noted that R4 declined what was being served for lunch and requested soup. Staff brought R4 a bowl of soup at 12:04 PM. Surveyor heard R4 comment to his tablemates that the soup was a little bit warm. On 1/6/25 at 2:52 PM, Surveyor interviewed R4 who stated that breakfast is okay but after that the food is downhill. R4 stated that the meals were not very good and that the food is never hot. R4 indicated that breakfast is sometimes lukewarm. R4 stated that all the staff know that the food is cold and sometimes they have to heat it up in the microwave, but usually he tries to eat it as fast as he can and go back to his room.

Based on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 65 residents who reside in the facility. FSD D (Food Service Director) was taking temperatures of lunch on 1/6/25. Surveyor observed FSD D wearing gloves touching items in FSD D pocket, thermometer, alcohol wipes, hot pad, lids on pans, and then directly touch chicken with same pair of gloves. Surveyor observed FSD D then go to dishwashing room and touch items, use cell phone, and touch steam table with same pair of gloves on. Surveyor observed no changing of gloves or hand washing. Evidenced by The facility policy, General Food Preparation and Handling, dated 2023, states, in part; .Food items will be prepared to conserve maximum nutritive value, develop, and enhance flavor and keep free of harmful organisms and substances .h. Bare hands should never touch ready to eat raw food directly. Disposable gloves are a single use item and should be discarded after each use. Employees should wash their hands prior to putting gloves on and after removing gloves . On 1/6/25 at 10:18AM, Surveyor observed FSD D (Food Service Director) temping food that was being served for lunch. Surveyor observed FSD D wearing gloves. FSD D was observed touching items in FSD D's pocket, including a thermometer, alcohol wipes, a hot pad, 2 lids on pans, and then directly touch chicken multiple times with the same pair of gloves on. Surveyor observed FSD D then go to dishwashing room and touch items, use cell phone, and touch steam table with the same pair of gloves on. Surveyor observed no changing of gloves or hand washing. On 1/8/25 at 3:11PM, Food and Service Director D and District Manager E indicated they would expect staff to change gloves and wash hands before and after directly touching food items. The facility failed to maintain a safe and sanitary environment in which food is prepared, stored, and distributed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure that self-administering of medications was determined to be clinically appropriate for 1 of 1 resident (R128) reviewed for self-administration of medications out of a total sample 71. R128 was observed with medication sitting on the bedside table. R128 does not have an order to self-administer medications. This is evidenced by: The facility policy titled, Medication Administration, reviewed/revised date, 10/23, indicates, in part: Policy: Medications are administrated by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice . The facility policy titled, Resident Self-Administration of Medication, reviewed/revised date 10/23, indicates, in part: Policy: .A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. Policy Explanation and Compliance Guidelines: .4. The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment Form, which is placed in the resident's medical record. R128 was admitted to the facility on [DATE]. On 11/27/23 at 11:23 AM, during the initial screening process, Surveyors interviewed R128 and noted two (2) medication cups on the bedside table that both contained pills. R128 stated that she likes to take them slow, so she doesn't get so full. On 11/27/23 at 1:52PM Surveyor interviewed LPN C (Licensed Practical Nurse) and asked what the process is for self-administration of medications. LPN C indicated typically the resident would need to be their own person and cognitively aware, they have to be able to identify the medications, know side effects and risks, an assessment must be completed, and a physician order is needed that says the patient may self-administer. Surveyor asked LPN C where this information would be documented. LPN C indicated it would be in the electronic record under notes and that there is an assessment tab for the actual assessment. Surveyor asked LPN C if she had given R128 her medications this am. LPN C indicated that she had. Surveyor asked LPN C if R128 has an assessment to self-administer medications. LPN C indicated R128 did not. Surveyor asked LPN C if her medications should be left at the bedside if she does not have an assessment. LPN C indicated, no. On 11/28/23 at 3:05 PM, Surveyor interviewed DON B (Director of Nursing) and asked what the process is for self-administration of medication. DON B indicated we get a doctor's order, we do an assessment on the patient, and further processes depend on if it's a set up or if they keep them in their room or not. Surveyor asked DON B if medications should be left at the bedside if an assessment has not been completed? DON B indicated, no.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 2 R56 was admitted to the facility on [DATE] with diagnoses of unspecified dementia and repeated falls. R56's record review of a fall report on 8/19/23 documents, in part, . unwitnessed fall on 8/19/23 He attempted to transfer himself onto the toilet resulting in a fall . He would benefit from a reminder sign in the bathroom to use call light for assist. The care plan has been updated and nursing will continue to monitor and implement the intervention and evaluate the effectiveness. R56's Care plan initiated on 7/7/23, states in part, . Focus . at risk for falls r/t (related to) frequency of falls . I am impulsive and don't call for help with ambulation . Interventions . Visual reminder sign in bathroom to use call light for assist. Date initiated 8/19/23 . On 11/30/28 at 10:43 AM, Surveyor observed no reminder sign in R56's bathroom to use the call light for assist. On 11/30/28 at 10:46 AM, Surveyor interviewed RN G (Registered Nurse). Surveyor asked RN G to describe the fall on 8/19/23, she indicated that she came and assessed the resident that had fallen in the bathroom while transferring himself and had a laceration on his head. RN G further indicated that R56 is impulsive and transfers himself without help. Surveyor asked RN G if R56 care plan states to have a sign in the bathroom should there be a sign in the bathroom RN G stated yes. On 11/30/28 at 10:52 AM, Surveyor interviewed CNA H (Certified Nursing Assistant) in R56's room. Surveyor asked CNA H if R56 has a reminder sign to call for assist in the bathroom, she indicated she does not see a sign posted. Based on observation, interview, and record review, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 5 residents (R19 & R56) reviewed for falls out of a sample of 25 for supervision and accidents. R19 is a fall risk and has had multiple falls. R19's care planned fall interventions that were not in place. Root causes were not identified for one of R19's falls on 7/16/23. The facility did not follow a care plan intervention after a fall for R56. Evidenced by: The facility policy, entitled Clinical Protocol: Falls, dated 10/2023, states, in part: . Cause Identification: 1. For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall . 2. If the cause of a fall is unclear ., or if the individual continues to fall despite attempted interventions, a physician will review the situation and help further identify causes and contributing factors . 3. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable. Treatment/Management: 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling . Monitoring and Follow-Up: . 2. The staff and physician will monitor and document the individual's response to interventions . The facility policy, entitled Comprehensive Care Plans, dated 10/2023, states, in part: . Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident . Policy Explanation and Compliance Guidelines: . 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions . Example 1 R19 was admitted to the facility on [DATE], and has diagnoses that include: Unspecified Dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Age-Related Osteoporosis (a condition in which bones become weak and brittle) without current pathological fractures, and Unspecified Osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down). R19's Minimum Data Set (MDS) Quarterly Assessment, dated 10/5/23, shows R19 has a Brief Interview of Mental Status (BIMS) score of 15 indicating R19 is cognitively intact. R19's Care Plan, dated 5/16/23, with a target date of 1/27/23, states, in part: . Focus: resident is risk for falls r/t (related to) Gait/balance problems, Incontinence, dementia with impaired thought process, osteoporosis Date Initiated: 5/16/23 Revision on: 10/18/23. Goal: Resident will not sustain serious fall related injury through the next review date. Date Initiated: 7/3/23 Revision on: 10/30/23 Target Date: 1/27/24. Interventions: *Anti rollbacks to wheelchair Date Initiated: 6/30/23 Revision on: 7/17/23 . *Dycem in wheelchair Date Initiated: 6/30/23 *Follow facility fall protocol. Date Initiated: 5/16/23 . R19's Fall Report dated 7/16/23 at 9:04 AM, states, in part: . Incident Location: Resident's Room . Incident Description: Resident was noted on the floor by CNA (Certified Nursing Assistant) this am at 7:55, resident was lying on floor parallel to windows in her room, resident states she did hit her head and neuros intact, states her tailbone hurts, prom (passive range of motion) of all extremities. The call light was not on. There was nothing on the floor which aided in this fall. Resident has been reminded to call for help with transfers. Not clear what resident was attempting at the time of the fall. RN (Registered Nurse) assessed resident and was cleared to be moved from floor. DON (Director of Nursing), POA (Power of Attorney), Administrator notified. Resident Description: Resident reported she fell off her WC (wheelchair) Immediate Action Taken: Assessed for injuries and none were noted. Resident was able to move all extremities per base line. Resident's daughter was updated and requested resident be sent to the ER (emergency room) for eval due to being on blood thinners. Resident transported to hospital via 911. All notifications were made. Resident Taken to Hospital: Y Injuries Observed at Time of Incident: Injury Type: No injuries observed at time of incident. Level of Pain: Level of Consciousness: Alert Mobility: Wheelchair bound. Mental Status: Oriented to Person Oriented to Place . Notes: Resident is A/O (alert/oriented) x 2 with confused at most times . Predisposing Environmental Factors: . Other Predisposing Physiological Factors: Confused .Impaired Memory .Other . Predisposing Situation Factors: . Ambulating without assist . R19's progress note, dated 7/16/23 at 9:30 AM, states, Resident was found on floor by CNA this am, at 7:55, resident was lying on floor parallel to windows in her room, resident states she did hit her head and neuros intact, states her tailbone hurts, prom of all extremities. DON, Administer, Physician and POA notified. R19's Interdisciplinary Team (IDT) note, dated 7/17/23, at 9:39 AM, states, IDT met to review fall from 7/16 at approximately 9:00 AM. Fall was unwitnessed. Resident was in her room at time of fall, sitting on floor in front of WC at the time of incident. Resident unable to state what she was doing or if she hit head. On-call notified, sent to ED (emergency department) for evaluation. POA updated, RN updated. Resident returned to facility with no new orders or concerns. Resident is currently working with therapy and recently upgraded to an EZ stand. Staff routinely remind her to use her call light signs are in her room. New intervention includes offering and encouraging resident to sit in the common area and read before breakfast after ADLs (activities of daily living) are completed. R19's Post Fall Assessment, dated 7/16/23, states, in part: . Post Fall Data Collection: 1. Date and Time fall occurred: 7/16/23 7:55 AM 2. Location where fall occurred: Resident's room 3. What was resident doing prior to the fall, if known? Sitting in WC 4. Did the resident sustain an injury? . No injuries sustained from fall. 5. Date and Time family notified: 7/16/23 8:08 AM 6. Date and Time physician notified: 7/16/23 8:10AM 7. Fall interventions currently in use (prior to fall): reminder signs, frequent checks in room, call light within reach, posters on wall as a reminder to not walk alone and not to self-transfer A. Fall History 1. Choose one of the following: 2. 1-3 Falls in 3 months B. Underlying Diseases or Conditions: . 11. Describe any other diagnoses that may apply: Dementia C. Medications: . 9. Diuretics . 11. Has the resident recently started a new medication/change in medications? No . F. Environmental Status/Equipment Factors 1. Are there any environmental factors that may have contributed to the fall? No G. Review of Post Fall Findings 1. Summarize the post-fall Findings: Resident was found on fall parallel to window. RN assessed resident and was cleared to be moved from fall no injury noted. VS (vital signs) and neuros (neurological assessment - Checks neurological responses rule out injury to brain) done. POA, DON, Administrator and PA (Physician's Assistant) notified. Resident was sent to the hospital due to facility protocols she is on blood thinners. 2. Describe new fall interventions to be implemented as a result of the assessment: New Fall intervention will be after all ADLs are completed in the AMs to not leave resident alone in bedroom. She can be in the dining room for breakfast or close to nurses' station. During the day resident will be put to bed and place call light within reach. 3. List suggestions of referrals to be made as a result of the fall: IDT to meet . On 11/30/23, at 10:01 AM, Surveyor and LPN K (Licensed Practical Nurse) observed R19 in wheelchair in activities without dycem in her wheelchair and no anti-roll backs on her wheelchair. Surveyor asked LPN K if R19 is a fall risk and LPN K indicated yes. Surveyor asked LPN K if R19 is care planned for the dycem and anti-roll backs, would you expect to see them in place. LPN K indicated yes. Surveyor asked LPN K if she knows why R19 does not have these interventions in place and LPN K indicated no, but she will check R19's orders. On 11/30/23, at 10:34 AM, Surveyor interviewed DON B and asked what the root cause was for R19's fall on 7/16/23. DON B indicated after looking over the fall report, the root cause was not identified. DON B indicated she does not know what R19 was trying to do. Surveyor asked DON B if she would expect root cause to be identified with each fall and DON B indicated yes. Surveyor asked DON B if she expects care plans to be followed and DON B indicated yes. Surveyor informed DON B of R19 in her wheelchair without dycem and anti-roll backs on her wheelchair. Surveyor asked DON B with R19 being care planned for the dycem and anti-roll backs on her wheelchair as interventions for fall preventions should R19 have them in place and DON B indicated yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure medication error rates are not 5% or greater during medication administration, this affected 1 of 3 Residents (R12) observed for medication pass. The facility medication error rate was 10.71%, for 3 errors out of 28 opportunities. The facility did not follow a physician order to administer medication before breakfast and was administered after breakfast. The facility did not administer two (2) medications as ordered and documented as administered. This evidenced by: Example 1 The facility's policy titled Medication Administration, dated 10/2023, states in part: . 11. Compare medication source (bubble pack, vial, etc.) with MAR (Medication Administration Record) to verify resident name, mediation name, form, dose, route, and time . b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician . R12 was admitted to the facility on [DATE] with diagnoses that include gastro-esophageal reflux disease and weakness. R12's Physician Orders, provided to the Surveyor on 11/29/23, states in part, . Omeprazole oral capsule delayed release 20mg (milligrams) (omeprazole) Give 1 capsule by mouth in the morning for GERD (gastro-esophageal reflux disease) Take before breakfast, start date 04/20/23 . R12's MAR indicates the administration times are AM (morning). R12's record review of his MAR documents that Omeprazole medication was administered on 11/27/23 at 9:15 AM. On 11/27/23 at 9:06 AM, Surveyor observed LPN C (Licensed Practical Nurse) prepare R12's morning medication for administration. During this observation, LPN C prepared R12's Omeprazole capsule delayed release 20mg that is scheduled for AM. Surveyor observed LPN C administer the prepared morning medication to R12 at 9:06 AM. On 11/29/23 at 9:38 AM, Surveyor interviewed LPN C. Surveyor asked LPN C the time a medication should be administered if it is ordered before breakfast, she indicated ideally 30 minutes before breakfast. Surveyor asked LPN C when omeprazole was administered to R12, she indicated it was after breakfast and it should have been administered before breakfast. On 11/29/23 at 11:06 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor reviewed R12's medication orders with DON B. Surveyor asked DON B when a medication should be administered if it has been ordered before breakfast, she indicated the medication should have been administered before breakfast and expects staff to follow the physician orders. R12's Physician Orders, provided to the Surveyor on 11/29/23, states in part, . Vitamin D3 oral tablet 25 mcg (micrograms) (Cholecalciferol) Give 1 tablet by mouth in the morning for supplement . Senna S oral tablet 8.6-50mg (sennosides-docusate sodium) give 1 tablet by mouth in the morning for constipation . R12's MAR indicates the administration times are AM. R12's record review of his MAR documents that Vitamin D3 and Senna S medications were both administered on 11/27/23 at 9:16 AM. On 11/27/23 at 9:06 AM, Surveyor observed LPN C (Licensed Practical Nurse) prepare R12's morning medication for administration. During this observation, LPN C did not prepare R12's Vitamin D3 or Senna S medications that are scheduled for AM. Surveyor observed LPN C document Vitamin D3 and Senna S medications as administered on 11/27/23 at 9:16 AM. On 11/29/23 at 9:38 AM, Surveyor interviewed LPN C. Surveyor reviewed R12's medication administration findings of Vitamin D3 and Senna S with LPN C. Surveyor asked LPN C if the medications Vitamin D3 and Senna S were administered, she indicated she must have omitted them as they were on the last page of the MAR and should have been administered. Surveyor asked LPN C if medications should be signed out as administered when the medications were not administered, she indicated no. On 11/29/23 at 11:06 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B the time frame for AM medication administration, she indicated between 7:00 AM-10:30AM. Surveyor reviewed R12's medication administration observation from 11/27/23 with DON B. Surveyor asked DON B if staff is expected to go through all the pages of the MAR when administering medications, she indicated yes and to sign those medications that have been administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility must develop policies and procedures to ensure that residents and/or resident responsible party receives education regarding the benefits and potential side effects of the immunization prior to offering the immunization and documentation is noted in the medical record on whether the resident received or declined the immunization. This affected 1 of 5 residents (R39) reviewed for pneumococcal immunizations. R39 had an incomplete pneumococcal vaccine consent form and no evidence the vaccine was administered. This evidenced by: The facility policy, titled, Pneumococcal Vaccine (Series), with a reviewed/revised date of 10/23, indicates, in part: Policy: It is our policy to offer our residents and staff immunization against pneumococcal disease in accordance with current CDC (Centers for Disease Control) guidelines and recommendations. Policy Explanation and Compliance Guidelines: 1. Each resident will be assessed for pneumococcal immunization upon admission .2. Each resident will be offered a pneumococcal immunization unless it is medically contraindicated, or the resident has already been immunized. Following assessment for any medical contraindications, the immunization may be administered in accordance with the physician-approved standing orders. [sic] 3. Prior to offering the pneumococcal immunization, each resident or the resident's representative will receive education regarding the benefits and potential side effects of the immunization . 5. A consent form shall be signed prior to the administration of the vaccine and filed in the individual's medical record . R39 was admitted to the facility on [DATE]. On 11/29/23 Surveyors reviewed the immunization history in R39's electronic medical record as part of the infection control task. R39's immunization history did not show evidence of pneumococcal vaccinations. A Pneumococcal Vaccine Consent Form in R39's record, dated 12/8/22, Section 3: Consent, includes an area to indicate I, resident or representative name, Give Consent for or Do Not Give Consent for. Neither of these options are completed. The form is signed by R39's representative with a signature date of 12/8/22. On the afternoon of 11/29/23, Surveyor requested documentation from the facility for all pneumococcal vaccinations or declinations for R39. On 11/29/23 at 2:20 PM, Surveyor interviewed DON B (Director of Nursing). DON B and Surveyor reviewed the consent that was signed on 12/8/22 in the electronic health record. Surveyor confirmed with DON B that at this time there is a pneumococcal consent signed by the Power of Attorney (POA) on 12/8/22; however, I consent, or I do not consent, is not filled in and there is no documentation that it was administered and no true declination. Surveyor asked DON B if the form should have been filled out completely and R39 should have either been given the appropriate pneumococcal vaccines or a complete declination should have been in place. DON B indicated this was correct.

Based on observation and interview, the facility did not ensure residents received food that is palatable and at a safe and appetizing temperature for 1 of 1 resident's (R12) and 1 of 1 test tray affecting 24 residents out of a total census of 71. Surveyor received a food test tray, and the food was cool. Surveyors viewed grievance log to find grievance of food being cold when trays are delivered. R12 informed surveyor during initial screening that hot food is served cold. Evidenced by: The Wisconsin Food Code reads that hot food foods should be served at 135* degrees Fahrenheit (F) or above. Guidance 483.60(i);(1) -(2) in the State Operations Manual states the following: Tray line and Alternative Meal Preparation and Service Area- A resident's meal tray may consist of a combination of foods that require different temperatures. Food preparation or service area problems/risks to avoid include, but are not limited to: Holding foods in the danger zone temperatures which are between 41 degrees F and 135 degrees F. Example 1 On 11/29/23, 8:20 AM, Surveyor had the following observation of the last breakfast tray (test tray) served on the third floor. Breakfast test tray: Scrambled eggs 95.5 (F) Bacon 89.7 (F) Oatmeal 111.0 (F) Coffee 114.0 (F) Cranberry Juice 57.0 (F) Toast slightly soggy and cool to touch The facility Monthly Grievance-Report Log for July 2023 indicated a resident complained of the food being cold when trays are delivered, dated 7/26/23. Resolution: Education provided to kitchen and nursing staff to deliver trays in timely manner. On 11/29/23, at 8:44 AM, Surveyor interviewed DCS J (Director of Culinary Services) and informed him of concerns from resident about food being cold on third floor. Surveyor informed DCS J of results of test tray: Scrambled eggs 95.5 (F), Bacon 89.7 (F), Oatmeal 111.0 (F), Coffee 114.0 (F), Cranberry Juice 57.0 (F), and Toast slightly soggy and cool to touch. Surveyor asked DCS J if these temperatures were acceptable and DCS J indicated no. Surveyor asked DCS J what temperatures should be when served to residents and DCS J indicated meat 135 (F) or over and all other food 135 (F). DCS J indicated cold juices/food should be under 40 (F). Example 2 On 11/28/23 at approximately 10:00AM Surveyor interviewed R12 and asked if he had any concerns regarding food at the facility. R12 indicated that the food is cold. On 11/30/23 at 1:36PM Surveyor interviewed R12 and asked how often his hot food is cold. R12 indicated a couple times per week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has a potential to affect all 71 (R) residents who reside in the facility. During kitchen walk through, Surveyor observed the following: * 1 gallon of [NAME] Real Mayo with no receive date or expiration date in the dry storage area. * 1 gallon of Dusseldorf Mustard with no receive date or expiration date in the dry storage area. * Container of prepared Gluten Free Chicken [NAME] with a prepared date of 11/26/23 and no use by date in the refrigerator * An opened 1-gallon French Dressing with a receive date of 4/20/23 with no use by or open date in the refrigerator. * An opened 1-gallon Buttermilk Ranch Dressing with a receive date of 4/22/23 with no use by or open date in the refrigerator. * An opened 1-gallon [NAME] Original Barbeque Sauce with an expiration date of 3/17/23 in the refrigerator. * An opened 1-gallon Dusseldorf Mustard with a receive date of 4/10/23 with no use by or open date. * An opened 1-gallon Italian Dressing with a receive date of 5/11/23 with no use by or open date. * An opened 80-ounce bottle of Sweet Baby Rays Barbeque Sauce with no open date or use by date in the refrigerator. * 6 pints of fresh blueberries with receive a date of 11/13/23 with no use by date in the refrigerator. * A bucket of Golden Medal Vanilla Creme Icing with an open date of 10/28/23 with no use by date in the refrigerator. * 2 pans of cooked pork tenderloins with no prepared dates or use by dates in the refrigerator. * A container of prepared egg salad dated 11/19/23 and no use by date in the refrigerator. * A broken egg on the floor of the refrigerator. * 3 ground beef patties in plastic wrap with no open date or use by date in the freezer. * An opened box of French toast in an opened plastic bag with a receive date of 11/6/23 and no use by date in the freezer. * Ceiling of the freezer had ice crystals on and the floor beneath the ceiling ice crystals had ice on the floor. * In the main kitchen area there was a half-pound peanut butter container opened with no open date or use by date. * In the main kitchen area two utensil drawers had tiny particles and a seed was observed laying on bottom of the drawers. * In the main kitchen area, the stove burners were dirty with food particles and uncooked macaroni. * In the main kitchen area, the sugar was uncovered with the lid lying next to the container which was in a bigger metal roll cart. * A plastic container of barley with no use by or open date. * [NAME] was washing dishes in the three compartments sink and the water had not been tested. * The ice machine had lime going down the right side. * During dish washing observation, wet stacking was observed. * Surveyor observed CNA D touch ready to serve food with bare hands. The facility policy, entitled Food Storage, dated 1/2/23, states, in part: . Policy: Food items will be stored, thawed, and prepared in accordance with good sanitary practice . Procedure: All products shall be dated upon receipt or when they are prepared. Use Date shall be marked on all food containers . Leftovers shall be dated according to the Leftovers policy . Frozen Meat/Poultry and Foods: . *Storage: . Foods shall be stored in their original containers if designed for freezing. Foods to be frozen shall be stored in airtight containers or wrapped in heavy-duty aluminum foil or special laminated papers. Label and date all food items . Fresh Fruits: . *Most fruits shall be used within 3 to 5 days . Dry Storage: . *Label and date all storage containers as follows: 1. The received date should already be on it. 2. Date opened. 3. Date the item expires . The facility policy, entitled Sanitation of Equipment, dated 5/1/19, states, in part: . Procedure: Sanitation of Equipment Frequency: Daily *Wipe up spills on shelves, sides, and floor of refrigerator. *Use clean sanitizing solution and clean cloth . The facility policy, entitled Labeling Food Product, with a revision date of 1/3/23, states, in part: . Policy: All prepared foods, leftovers and opened products stored for later use will be labeled according to food safety standards along with local and state regulations. Procedures: . 2.All food service workers within the unit will be trained on proper labeling of prepared foods and products stored for later use. 3. All labels will contain: a. The complete name of the product. b. The date the product was prepared or opened. c. The date the product must be utilized by . Example 1 On 11/27/23, at 7:46 AM, Surveyor conducted the initial walk through in the kitchen with KS I (Kitchen Supervisor) and DCS J (Director of Culinary Services) finding the following: *Surveyor observed a 1-gallon container of [NAME] Real Mayo and 1-gallon container of Dusseldorf Mustard in the dry storage area with no receive date or expiration date. Surveyor asked KS I if the containers should have a receive date and expiration date and KS I indicated yes. *Surveyor observed in the first refrigerator a container of prepared gluten free chicken alfredo with a prepared date of 11/26/23 and no use by date. Surveyor asked KS I if she would expect to see a use by date on the container and KS I indicated yes. Surveyor observed an opened 1-gallon container of French Dressing with a receive date of 4/20/23 with no use by or expiration date and an opened 1-gallon container of Buttermilk Ranch Dressing with a receive date of 4/22/23 with no use by or expiration date. Surveyor asked KS I how a person would know how long these are good for and KS I indicated if the containers are opened, they go 2 months out from received date. KS I indicated both are expired. Surveyor asked if a use by date should be labeled on both containers, and KS I indicated yes. Surveyor observed an opened 1-gallon container of [NAME] Original Barbeque Sauce with an expiration date of 3/17/23. Surveyor asked KS I if it is expired and KS I indicated yes. Surveyor asked if the [NAME] Original Barbeque Sauce should be on the shelf to be used and KS I indicated no. Surveyor observed an opened 1-gallon container of Dusseldorfs Mustard with a receive date of 4/10/23 and no use by or expiration date. KS I indicated there should be use by dates on opened items but if not, they go by expiration dates and if no expiration dates, they use the item up by 7 days. Surveyor observed an opened 1-gallon container of Italian Dressing with a receive date of 5/11/23 and no use by date or expiration date. KS I indicated the Italian Dressing should not be on shelf for use without use by or expiration date. DCS J took the [NAME] Original Barbeque Sauce, the French Dressing, Italian Dressing, Buttermilk Ranch Dressing, Dusseldorf Mustard, and the [NAME] Real Mayo out of refrigerator and indicated they are to be thrown out due to no open dates. DCS J removed 80-ounce bottle of Sweet Baby Rays Barbeque Sauce out with no use by date and indicated it should not be on shelf for use either with no open date. Surveyor observed an opened 1-gallon container of [NAME] Real Mayo with no receive date or use by date and 6 pints of fresh blueberries with a receive date of 11/13/23. DCS J indicated he believes fresh fruit there is a two-week window to use. Surveyor observed a container of Golden Medal Vanilla Crème Icing with an open date of 10/28/23 and no use by date and two pans of cooked pork tenderloin with no prepared dates or use by dates on. DCS J indicated they were prepared the evening prior and were to be used for dinner today. DCS J indicated they should be labeled with prepared date and use by date. DCS J indicated anything opened should have an open date. Surveyor observed prepared egg salad in the second refrigerator with a prepared date of 11/19/23 and no use by date. DCS J indicated yes it should have a use by date and needs to be thrown out. Surveyor and DCS J observed a broken egg on the floor of the refrigerator. DCS J indicated he would have expected this to be cleaned up when it occurred. Surveyor observed three frozen ground beef patties in the freezer in just the plastic bag out of the box with no open date or receive date. DCS J indicated there should be use by date and open date on them. Surveyor observed a box of French toast on the freezer shelf with the box opened and the plastic bag the French toast was in open. DCS J indicated the plastic bag should be tied shut. Surveyor and DCS J observed water crystals on the ceiling of the freezer and an ice patch below the water crystals on the freezer floor. DCS J indicated it was a safety concern. DCS J indicated it happens when the freezer auto defrosts. DCS J indicated the old maintenance guy was aware but recently the facility has a new maintenance guy, and he is not aware. DCS J indicated he will notify the maintenance guy today. Surveyor observed in the main kitchen area a half-pound peanut butter container opened with no use by date or open date. DCS J indicated it should have an open date and pulled from the shelf. Surveyor observed two utensil drawers with little particles and a seed on the bottom of the drawers. DCS J indicated he would expect the drawers to be clean. Surveyor observed food particles and uncooked macaroni on the stove burners. DCS J indicated he would expect the burners to be clean and free of particles. Surveyor observed a plastic container of sugar uncovered with the lid lying next to the container. The sugar container was placed in a metal roll cart. DCS J indicated the sugar lid should be on, so it does not become contaminated when one opens the metal lid of cart to get to the sugar. Surveyor observed a plastic container of barley with no use by, open date or expiration date on it. DCS J indicated there should be use by and open date on and it should not be on shelf for use. DCS J removed off shelf. Surveyor observed lime down the right side of the ice machine. DCS J indicated it was rental equipment and the company is responsible for cleaning. DCS J indicated he will notify the maintenance guy to call the company to get it properly cleaned. On 11/28/23 at 12:26 PM, Surveyor observed dishwashing and observed the plate warmer being wet stacked. Surveyor showed DCS J, and he removed numerous plate warmers with water still on them from the rim. DCS J indicated it was not acceptable for wet stacking. Example 2 On 11/27/23 at 12:00 PM, in the 3rd floor dining room, Surveyors observed CNA D (Certified Nursing Assistant) place a resident tray from the tray cart onto a table next to the cart, use hand sanitizer, and began setting up the tray. During this set up CNA D pulled out a roll from a baggie that was on the tray with an ungloved hand and placed it on the plate. CNA D then delivered the tray to R46. CNA D then pulled another resident tray from the cart and placed it on the table, used hand sanitizer, and began setting up. CNA D pulled out a roll from a baggie that was on the tray with an ungloved hand and placed it on the plate. CNA D then delivered the tray to R12. CNA D began to remove a brownie from a baggie while only touching the outside of the baggie. However, when the brownie was partially out of the baggie, she used her ungloved left hand to pull the brownie the rest of the way out of the baggie. On 11/27/23 at approximately 12:15 PM, Surveyor interviewed CNA D and asked what the process is when directly touching resident food. CNA D indicated to use hand sanitizer before touching food. Surveyor asked CNA D if she has been trained to use gloves when directly touching resident food. CNA D indicated she had not. On 11/29/23 at 8:44 AM, Surveyor interviewed DCS J (Director of Culinary Services) and asked if staff should be handling food with bare hands. DCS J indicated, absolutely not.

Based on observation, interview, and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect all 71 residents (R) in the facility. The facility's infection control line lists for staff are incomplete. The facility's monthly infection control rates were not calculated according to current standards of practice. This is evidenced by: The facility policy titled, Infection Prevention and Control Program, with a reviewed/revised date of 10/23, includes, in part: Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines: .3. Surveillance: a. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards. b. The Infection Preventionist serves as a leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee . The facility policy titled, Infection Surveillance, with a reviewed/revised date of 10/23, includes, in part: Policy: A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infection. Policy Explanation and Compliance Guidelines: 1. The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee, and public health authorities when required .4. The CDC's National Healthcare Safety Network Long Term Care Criteria .or other nationally recognized surveillance criteria will be used to define infections. 5. Surveillance activities will be monitored facility-wide . 6. The facility will collect data to properly identify possible communicable diseases or infections among residents and staff before they spread . 7. The facility will communicate .to staff and/or prescribing practitioners information related to infection rates and outcomes in order to revise interventions/approaches and/or re-evaluate medical interventions as indicated .10. Employee, volunteer, and contract employee infections will be tracked .14. Formulas used in calculating infection rates will remain constant for a minimum of one calendar year, and will require discussion in QAA meetings before changes in the formulas are made . Example 1: On 11/28/23 and 11/29/23, Surveyor reviewed infection control documentation provided by the facility. September Staff Line List: -No symptom onset dates and there is no column listed for this documentation. -The column for last day of symptoms is blank for all 17 entries for the month. -2 staff members with symptoms consistent with covid and no testing information. -1 staff member with symptoms consistent with covid that indicates neg under covid test, but no date is provided. October Staff Line List: -No symptom onset dates and there is no column listed for this documentation. -The column for last day of symptoms is blank for 11 of 13 entries for the month. -2 staff with symptoms consistent with covid and no testing information. November Staff Line List: -No symptom onset dates and there is no column listed for this documentation. -7 staff members with symptoms consistent with covid and no testing information. It is important to note that without symptom onset dates there is no way to know if the facility would be in an outbreak. It is also important to note that without documentation of last day of symptoms there is no way to discern if the return-to-work dates are accurate. On 11/29/23 at 4:01 PM, Surveyor interviewed Scheduler F and asked to explain the process for when someone calls off. Scheduler F indicated she fills out the line list form. Depending on what it's for, so, if they call off for cold symptoms, I let them know that they can't come back until 48 hours after last symptoms and ask if they did a COVID test; if not I ask them to test and then they will call me back and tell me they tested and then I will write the neg on the form. Surveyor asked Scheduler F if she knew what dates any of the negatives are on the forms as there is only one with a date listed. Scheduler F indicated usually it's the same day because they usually test right away. Surveyor asked Scheduler F if she contacts the DON (Director of Nursing) for call offs that could involve infectious issues. Scheduler F indicated she does. Surveyor asked Scheduler F if she does that right away. Scheduler F indicated usually. Scheduler F added the DON will give her instructions or the DON will talk to them herself. She will tell me that they can't come back until a certain date so that I don't put them on the schedule before they can come back. Surveyor asked Scheduler F what the checkmarks under other mean for two staff members on the November 2023 staff line list. Scheduler F indicated she must have made a mistake because she normally writes in a symptom like the other staff have, like backache. Surveyor asked if this should have been filled in with the specific symptoms. Scheduler F indicated it should. On 11/29/23 at 2:52 PM, Surveyor interviewed DON B who indicated she is also the Infection Preventionist for the facility since starting there in October. Surveyor asked DON B how daily surveillance for staff is completed. DON B indicated when staff call off it goes on the line list. The scheduler will contact her and tell her who called in. DON B will then ask when symptoms started and what the symptoms are. DON B tells the scheduler that staff can't come back until this time and then the scheduler calls the staff member. Surveyor asked DON B who is completing the staff line list. DON B indicated the scheduler. Surveyor asked DON B if she reviews the staff line list. DON B indicated she had not done that yet. Surveyor confirmed with DON B that there are no dates for symptom onset for the staff line lists for September, October, and November of this year. DON B indicated this was correct and that she has amended the form and sent it to the scheduler, and it will be used in stand up starting tomorrow. Surveyor asked DON B how she would know if the facility were in an outbreak if there are no symptom onset dates. DON B indicated they wouldn't. Surveyor reviewed line lists with DON B where symptoms consistent with COVID were marked and there is no documentation under testing. Surveyor asked DON B if she knew if any of these people were tested. DON B indicated not without calling them. DON B indicated agreement with staff line lists being incomplete. Example 2: On 11/28/23 and 11/29/23 Surveyor reviewed infection control documentation provided by the facility. Surveyor was provided the following monthly Infection Control (IC) rates for 2023: January: 741.9355%; February: 678.5714%; March: 1161.2903%; April: 166.6667%; May: 225.8065%; June: 266.6667%; September: 366.667%; October: Two documents provided. One indicates a rate of 290.3226% and one a rate of 322.5806% Of note, the facility monthly documents note calculations are based on Infection Rate per 1,000 patient days . On 11/29/23 at 2:52 PM, Surveyor interviewed DON B (Director of Nursing) who is also the Infection Preventionist for the facility since October. Surveyor reviewed monthly infection rates with DON B and asked if they were calculated correctly. DON B indicated the number of patient days are incorrect on the form and so the calculation for the rates is incorrect. The calculation is completed with a formula in Excel. Surveyor asked DON B how they were reviewed in QAPI (Quality Assurance and Performance Improvement) if they are not calculated correctly. DON B indicated, I guess we didn't catch it, but we went over the number of infections. Surveyor asked DON B if the calculations should be correct. DON B indicated they should.

Based on observation, interview, and facility policy review, the facility did not provide care and services in a manner to prevent the development and transmission of infections for 1 of 5 residents observed during personal care (R2). CNA K (Certified Nursing Assistant) placed clean washcloths in a dirty sink, turned the faucet on to wet them, wrung out the washcloths and was going to use the dirty washcloths to provide pericare to R2. This is evidenced by: The facility policy, Perineal Care, dated 3/16/22, states, as follows: Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Preparation: 2. Assemble the equipment and supplies as needed. Equipment and Supplies: The following equipment and supplies will be necessary when performing the procedure: 1. Wash basin; 2. Towels; 3. Washcloth; 4. Soap On 7/10/23 at 6:51 AM, Surveyor observed CNA K enter R2's room to get him out of bed and perform morning cares. CNA K voiced that there are no wipes in the room so she will use washcloths. Surveyors observed CNA K take two (2) clean washcloths and drop them in the sink in R2's bathroom. CNA K then turned the water on for a few minutes and let it run over the washcloths. CNA K washed hands in the second sink in the room, applied gloves, and wrung out the washcloths. On 7/10/23 at 6:53 AM, Surveyor observed CNA J enter R2's room with the lift. Surveyor asked CNA K if she is ready to perform pericare for R2. CNA K stated, Yes. Surveyor intervened to stop CNA K from using the dirty washcloths to provide pericare to R2. CNA K is a new CNA and voiced concern that CNA I trained her to put the washcloths in the sink to wet them. CNA K stated, she thought this was how she was supposed to do it. CNA I stated, we can't blame the CNAs that taught us as they were also trained incorrectly. On 7/10/23 at 10:23 AM, Surveyor spoke with CNA I via telephone and asked if she has ever put washclothes in the sink basin to wet for pericare. CNA I indicated that you should hold them and not put them in the sink but I'm sure things happen and I probably have. On 7/10/23 at 5:00 PM, Surveyor spoke with NHA A (Nursing Home Administrator). Surveyor asked NHA A, is it acceptable for CNAs to put clean washcloths in a dirty sink and then use them to perform pericare on a resident. NHA A stated, No, they should not put it in the sink.

Based on interview and record review the facility did not ensure all alleged violations involving mistreatment, neglect, or abuse were reported to other officials in accordance with State law through established procedures for 5 of 17 residents (R5, R7, R13, R15, and R16) reviewed for neglect. Multiple staff members at the facility were aware of concerns with residents being found with more than one brief in place, pads in briefs, and saturated briefs and/or bedding and this was not reported to the administrator. This is evidenced by: The Facility Policy, titled, Abuse, Neglect and Exploitation, with a reviewed/revised date of 10/22, includes, in part: Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. Definitions: .Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property . Policy Explanation and Compliance Guidelines: .VII. Reporting/Response A. 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: a. Immediately, but no 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 b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury . On 7/6/23 at 8:04 AM, Surveyor interviewed CNA F (Certified Nursing Assistant) regarding residents being found with more than one brief on, pads in their brief, or saturated. CNA F indicated she has found residents saturated in the morning and that it occurs once every couple week. On 7/10/23 at 4:50 PM, Surveyor contacted CNA F via telephone and asked if she reported her observations of residents being saturated. CNA F indicated she reported R13 being saturated on 7/6/23 to LPN H. Surveyor asked CNA F if she had ever reported any issues related to this previously. CNA indicated yes, to DON B (Director of Nursing). Surveyor asked CNA F when this was reported. CNA F indicated she could not give an exact date but thought it was over a month ago. Surveyor asked if she reported it directly to DON B. CNA indicated, yes, I went to his office. Surveyor asked CNA F what she reported. CNA F indicated I told him I wasn't happy when I came in that morning, and he said he would take care of the problem. Surveyor asked if her discussion was related to residents' incontinence and being found saturated. CNA F indicated, yes. On 7/6/23 at 8:23 AM, Surveyor interviewed CNA G regarding finding residents who were saturated or had multiple briefs or pads in their briefs. Surveyor asked CNA G if she has reported this before today. CNA G indicated, yes, every time I have this happen, I report it. Surveyor asked CNA G how many times she has reported this in the past month. CNA G indicated every time CNA N works nights. I came in and saw 3 briefs on R5 probably a week and a half ago. CNA G indicated she reported it to a nurse but could not recall the name. CNA G indicated R16 was saturated including the pad two weeks ago, and R15's soaker pad and brief were saturated last week. Surveyor asked CNA G how many times in the last month she has reported to LPN H about residents being saturated. CNA G indicated, probably thirteen times. CNA G indicated she reported to RN L (Registered Nurse) the other day that R7 was soaked and that she feels like people are tired of telling them and nothing changing. On 7/5/23 at 10:25 AM, Surveyor interviewed LPN H and asked if any CNA's have ever reported to her that residents are being found saturated. LPN H indicated the last time it happened was about one and a half months ago and staff were wondering if the night staff was rounding. Surveyor asked LPN H if she had reported this to anyone. LPN H indicated she either reported it to ADON E (Assistant Director of Nursing) or the previous DON but could not recall which one for sure. On 7/5/23 at 10:10 AM, During an interview CNA I indicated to Surveyor that residents were being found in the morning soaked through their briefs and at times needing a complete bed change. CNA I also indicated residents were being found with more than one brief applied. Surveyor asked CNA I if she reported this. CNA I indicated she reported it to LPN H. Surveyor asked CNA I what LPN H said when she reported this. CNA I indicated, OK. Surveyor asked if she went above LPN H. CNA I indicated she had not. Surveyor asked CNA I if there was a reason she did not take this to the administrator. CNA I indicated she feels like management doesn't listen. Surveyor asked CNA I when the last time was, she reported these issues to LPN H. CNA I indicated last week. Surveyor asked CNA I when the last time was, she reported these issues to anyone. CNA I indicated 7/3/23 to MT/CNA O (Medication Technician/Certified Nursing Assistant). (Of note, CNA I indicated she thought MT/CNA O was a nurse.) On 7/10/23 at 5:35 AM, Surveyor interviewed CNA M regarding finding residents who had multiple briefs or pads in their briefs. CNA M indicated she has not seen this for a while, probably a couple months back was the last time. Surveyor asked CNA M if she reported this. CNA M indicated she had reported it to the nurse and left a note in the CNA book on the 3rd floor but is unsure if it is still in there. (Of note, Surveyor reviewed the CNA book on third floor and could not locate a note from CNA M.) On 7/10/23 at 12:42 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked when she first became aware of the issues with double briefing, pads being placed in briefs, and residents being found saturated and at times needing complete bed changes. NHA A indicated the bed saturation was Thursday morning, 7/6/23. The double briefing and pads were found when we were doing our wound PIP (Process Improvement Project) and staff brought it up to us. Surveyor asked NHA A if a CNA reports to a nurse or management that residents are being found with more than one brief, a pad in their brief, or saturated and at times needing a complete bed change, could this be an allegation of neglect. NHA A indicated, yes. Surveyor asked NHA A if a nurse that received a concern about this should report this up the chain of command. NHA A indicated yes, they could go to the ADON (Assistant Director of Nursing) or myself. Surveyor asked NHA A if anyone had come to her before this. NHA A indicated, no.

Based on interview and record review, the facility failed to investigate allegations of neglect and take steps to prevent further neglect for 5 of 17 residents (R5, R7, R13, R15, and R16) reviewed for neglect. Approximately one and a half months ago, the facility became aware of an allegation of neglect involving multiple residents and this was not reported to the Nursing Home Administrator (NHA) so that an investigation could be completed. This is evidenced by: The Facility Policy, titled, Abuse, Neglect and Exploitation, with a reviewed/revised date of 10/22, includes, in part: Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. Definitions: .Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property . Policy Explanation and Compliance Guidelines: .V. Investigation of Alleged Abuse, Neglect, and Exploitation. A. An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur .VI. Protection of Resident. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation; Examine the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; .D. Rooming or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; . On 7/10/23 at 4:50 PM, During an interview with CNA F (Certified Nursing Assistant), via telephone, CNA F indicated she had reported to LPN H that on the morning of 7/6/23 R13 was found saturated. CNA F also indicated over a month ago she had reported concerns with finding residents saturated in the morning to DON B. (Of note, there is no evidence this was reported to NHA A or that a grievance or investigation was opened prior to 7/6/23.) On 7/6/23 at 8:23 AM, During an interview CNA G indicated she reported concerns with residents being found saturated and or with multiple briefs or pads in briefs for R5 around a week and a half ago; R16 two weeks ago; and R15 last week. CNA G indicated she has reported concerns to LPN H probably thirteen times in the last month and reported to RN L regarding R7 the other day. (Of note, there is no evidence this was reported to the NHA A prior to 7/6/23 thus an investigation into this allegation of abuse did not occur.) On 7/5/23 at 10:25AM Surveyor interviewed LPN H and asked if any CNA's have ever reported to her that residents are being found saturated. LPN H indicated the last time it happened was about one and a half months ago and that she either reported it to the ADON E (Assistant Director of Nursing) or the previous DON but could not recall which one for sure. (Of note, there is no evidence this allegation was reported to the NHA A prior to 7/6/23.) On 7/5/23 at 10:10 AM, during an interview CNA I indicated she reported concerns with residents being found saturated and or with multiple briefs or pads in briefs for multiple residents. CNA I indicated the last time she reported it to LPN H was last week and the last time she reported to anyone was 7/3/23 to MT/CNA O. (Of note, CNA I indicated she thought MT/CNA O was a nurse). CNA I indicated she did not report this to the NHA A. On 7/10/23 at 5:35 AM, during an interview CNA M indicated she reported concerns to a nurse probably a month ago regarding finding residents who had multiple briefs or pads in their briefs. (Of note, there is no evidence this was reported to the NHA A prior to 7/6/23.) On 7/10/23 at 12:42 PM, Surveyor interviewed NHA A and asked when she first became aware of the issues with double briefing, pads being placed in briefs, and residents being found saturated and at times needing complete bed changes. NHA A indicated the bed saturation was Thursday morning, 7/6/23. The double briefing and pads were found when we were doing our wound PIP (Process Improvement Project) (Of note, this began on 6/9/23) and staff brought it up to us. Surveyor asked NHA A if a CNA (Certified Nursing Assistant) reports to a nurse or management that residents are being found with more than one brief, a pad in their brief, or saturated and at times needing a complete bed change, should an investigation be started NHA A indicated, yes. Surveyor asked NHA A if a nurse that received a concern about this should report this up the chain of command. NHA A indicated yes, they could go to the ADON (Assistant Director of Nursing) or myself. Surveyor asked NHA A if anyone had come to her before this. NHA A indicated, no. The facility became aware of multiple allegations of residents being found saturated and at times needing complete bed changes approximately a month and a half ago, with continued allegations after this time. Staff had reported these concerns; however, there is no evidence staff reported directly to NHA A prior to 7/6/23 thus an investigation into this allegation did not occur until 7/6/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure that residents who are unable to carry out Activities of Daily Living (ADLs) received the necessary services for assistance with incontinent cares for 15 of 17 residents (R1, R2, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, and R17) reviewed for ADLs. R1, R2, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, and R17 are frequently found with either pads in briefs, more than one brief on, and/or saturated briefs and bedding. R12 was observed to have a pad inside her brief; the pad, brief, and soaker pad under R12 were saturated in urine. R14's brief was observed by Surveyor to be saturated with a strong odor while observing staff's assisting R14 with morning cares. This is evidenced by: The facility policy titled, Pressure Injury Prevention Guidelines, with a reviewed/revised date of 3/2023, indicates, in part: Preventive Skin Care: .4. Keep the skin clean and dry. a. Manage incontinence with absorptive products. Check every 2 hours, and provide perineal care as needed after incontinent episodes. b. Protect skin from exposure to excessive moisture with barrier products . Example 1: On 7/6/23 at 8:10 AM, Surveyor observed CNA F (Certified Nursing Assistant) assist R14 with morning cares. CNA F assisted R14 to walk to the bathroom. CNA F removed R14's brief and a strong odor was noted. CNA F put the brief in the garbage in the bathroom and a thump was heard. Surveyor asked CNA F if she would consider the brief saturated. CNA F picked up the brief with gloved hands and showed the Surveyor and stated yes. Surveyor asked CNA F if she noted the strong odor. CNA F indicated yes. CNA F added that R14 is normally pretty continent. Surveyor asked CNA F how often she is finding this in the morning? CNA F indicated once every couple weeks, it depends on who you come in after. Surveyor asked CNA F if there are other residents found saturated in the morning? CNA F indicated R13 had a saturated brief today, while last week she got her up and she was dry. R14 was admitted to the facility on [DATE] with diagnoses to include in part: Nondisplaced fracture of left humerus (upper arm bone); Difficulty walking; Unspecified Dementia; Limitation of Activity due to Disability; and Personal History of Other Malignant Neoplasm of Bronchus and Lung . R14's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/24/23 indicates a Brief Interview of Mental Status (BIMS) score of 7 indicating R14 has a severe cognitive impairment. Section G Activities of Daily Living (ADL) documents in part: toilet support - Extensive assistance, Two+ person physical assist. Section H Bladder and Bowel documents in part: Urinary Continence - always continent; Bowel Continence - always continent. R14's ADL care plan dated 6/22/23 states in part: self-care performance deficit related to left humerus fracture, memory impairment. History of right knee replacement. Goal will improve current level of function with ability to transfer self with assistive device by next review date. Intervention Toilet Use X2A (Times 2 Assist) - dependent/max hygiene. Of note, the Resident Roster provided to Surveyors by the facility indicated R14 was non-interviewable. Example 2: On 7/6/23 at 8:04 AM, Surveyor interviewed CNA F and asked if there were any residents that she assisted in getting up this AM that had on more than one brief or had pads in their brief? CNA F indicated that R13 was saturated, but she did not see double briefing or a pad in the brief. CNA F indicated that Surveyor should talk to CNA I about R2 as she had already started helping him before CNA F got to the room and so is unsure if he had more than one brief or pad. R13 was admitted to the facility on [DATE] with diagnoses to include in part: Displaced fracture of .femur (thigh bone); Alzheimer's; Contracture, Left Hand, unspecified urinary incontinence, and full incontinence of feces . R13's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/25/23 indicates R13's Brief Interview of Mental Status (BIMS) was not completed as R13 is rarely/never understood. Section G Activities of Daily Living (ADL) documents in part: toilet support - total dependence, One-person physical assist. Section H Bladder and Bowel documents in part: Urinary Continence - always incontinent; Bowel Continence - always incontinent. R13's ADL care plan, revision date 3/10/23, states in part: physical functioning/ADL deficit related to advanced dementia. New right hip fracture. Goal will maintain current ROM (Range of Motion) to upper extremities thru next review date. Intervention Incontinent of B & B (Bowel and Bladder) toilet schedule: Incontinent care upon awakening for the day, before and after meals and at with [sic] bedtime cares. Incontinent checks/cares approximately every two hours at night. Toileting Assistance two. Of note, the Resident Roster provided to Surveyors by the facility indicated R13 was non-interviewable Example 3: On 7/6/23 at 8:23AM, Surveyor interviewed CNA G and asked which resident she assisted to get up this AM and if she noted residents who were saturated or had multiple briefs or pads in their briefs? CNA G reported the following to Surveyor: R7: Required a full bed change, gown, pad, blankets, everything today. I reported to LPN H (Licensed Practical Nurse,) and she told NHA A (Nursing Home Administrator) as well today. I come in often and she is soaked. Surveyor asked how often she is finding R7 soaked? CNA G indicated probably at least three times a week. R7 can walk to the bathroom. R7 is a heavy wetter so I've asked for them to get her up to the bathroom in the night, they agree, but nothing changes. I've come in where there is urine on her, and it is like a puddle and it's odorous. R7 was admitted to the facility on [DATE] with diagnoses to include, in part: Anoxic Brain Damage; Type II Diabetes; Schizoaffective Disorder, Bipolar Type; and Weakness . R7's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/16/23 indicates a Brief Interview of Mental Status (BIMS) score of 5 indicating R7 has a severe cognitive impairment. Section G Activities of Daily Living (ADL) documents in part: toilet support - Extensive assistance, Two+ person physical assist. Section H Bladder and Bowel documents in part: Urinary Continence - Frequently incontinent. Bowel Continence - Always Continent. R7's ADL care plan, revision date 5/3/22 states in part: ADL self-care performance deficit related to confusion incontinence and cognitive impairment secondary to anoxic brain injury, at times refuses meds, labs, and cares. Interventions assist to toilet during routine rounds and prn (as needed) as tolerated. If R7 refuses to go to the bathroom check and change during routine rounds and prn (as needed.) Do not leave in the bathroom alone. Check and change during routine rounds and prn at night. (Intervention revision 5/23/23) Of note, the Resident Roster provided to Surveyors by the facility indicated R7 was non-interviewable Example 4: R9: CNA I said that R9 was soaked and R9 can tell you if she has to go to the bathroom. (See interview with CNA I) Example 5: R16: R16 will put her light on, and she'll be soaked, she was ok today. Surveyor asked CNA G when the last time she felt R16 wasn't checked and changed and was saturated? CNA G indicated, two weeks ago she was saturated, the pad was wet and R16 can tell staff when she has to go. R16 was admitted to the facility on [DATE] with diagnoses to include in part: Parkinson's Disease; Type II Diabetes; and Dementia . R16's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/1/22 indicates a Brief Interview of Mental Status (BIMS) score of 12 indicating R16 has a moderate cognitive impairment. Section G Activities of Daily Living (ADL) documents in part: toilet support - Extensive assistance, One-person physical assist. Section H Bladder and Bowel documents in part: Urinary Continence - Always Incontinent. Bowel Continence - Always Incontinent. R16's ADL care plan, revision date 8/10/22 states in part: Focus: Alteration in elimination of bowel and bladder related to progressive Parkinson's, dementia. Intervention: Use of brief/pads for incontinence protection. Sometimes I will ask for the bedpan, I usually request in the morning, assist of (2) to apply/remove. Of note, the Resident Roster provided to Surveyors by the facility indicated R16 was non-interviewable Example 6: R5: I came in and saw 3 briefs on R5 probably a week and a half ago. R5 was admitted to the facility on [DATE] with diagnoses to include in part: Cerebral Infarction; Hemiplegia and Hemiparesis affecting right dominant side; and Chronic Pain Syndrome . R5's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/7/23 indicates a Brief Interview of Mental Status (BIMS) score was not completed as R5 is rarely/never understood. Section G Activities of Daily Living (ADL) documents in part: toilet support - Extensive assistance, Two+ person physical assist. Section H Bladder and Bowel documents in part: Urinary Continence - Always Incontinent. Bowel Continence - Always Incontinent. R5's ADL care plan, revision date 9/1/21 states in part: Focus: ADL self-care performance deficit related to effects from stroke with spastic right sided hemiparesis, unable to express herself due to aphasia. Intervention: Toilet use: does not sit on a commode, routine check and change approximately every 2 hours and as needed, staff to provide brief changes and incontinence cares. (Intervention Revision Date 8/29/22) Of note, the Resident Roster provided to Surveyors by the facility indicated R5 was non-interviewable Example 7: R15: Last week on shower day, she was soaked through before breakfast. The soaker pad and brief were saturated. R15 is transferred to the bathroom with an EZ stand (Electric Lift) and the brief sagged and dripped as we took her to the bathroom. We have to use zinc or paste on her because she gets redness. Surveyor asked CNA G how many times she finds R15 saturated. CNA G indicated probably three times a week. CNA G indicated, I feel like people are tired of telling them and nothing changing. R15 was admitted to the facility on [DATE] with diagnoses to include in part: Dementia; Functional Urinary Incontinence; and Atrial Fibrillation (Irregular Heartbeat) . R15's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/3/23 indicates a Brief Interview of Mental Status (BIMS) score of 5 indicating R5 has a severe cognitive impairment. Section G Activities of Daily Living (ADL) documents in part: toilet support - Extensive assistance, One-person physical assist. Section H Bladder and Bowel documents in part: Urinary Continence - Always incontinent. Bowel Continence - Frequently Incontinent. R15's ADL care plan, revision date 1/19/21 states in part: ADL self-care performance deficit related to osteoarthritis, dementia. Intervention: Toilet Use 1 assist wit [sic] SUL (Stand Up Lift) for transfers, assist to toilet before and after meals and check and change on night shift for incontinence (revised 4/15/22). Goal Intervention Of note, the Resident Roster provided to Surveyors by the facility indicated R15 was non-interviewable Surveyor asked CNA G if she reported this? CNA G indicated she reported this to LPN H (Licensed Practical Nurse) and the NHA A today. Surveyor asked CNA G if she has reported this before today? CNA G indicated yes, every time I have this happen, I report it. Surveyor asked CNA G how many times she has reported concerns with finding residents this way in the past month? CNA G indicated every time CNA N works nights, I have reported this to LPN H probably thirteen times in the last month and to RN L the other day. On 7/5/23 at 10:10 AM, Surveyor interviewed CNA I and asked how the bowel and bladder training process works in the facility? CNA I indicated they wait for two hours to toilet. Surveyor asked what happens if the resident wants to use the restroom prior to the two hours? CNA I indicated, management tells us to wait or change them in bed. Surveyor asked, so residents are being allowed to go in a brief in between the two hours instead of getting them up? CNA I indicated yes. Surveyor asked CNA I who is telling them to let the residents wait? CNA I indicated Management but did not provide a name when asked. CNA I added, usually we have enough staff to get it done, we are supposed to have 3 CNAs and we sometimes only have 2 and there are a lot of 2 assist people. If we don't have enough staff, they have to go in their brief. Surveyor asked CNA I, how long people have to wait for call lights to be answered? CNA I indicated, when I'm here, 10-15 minutes. I've come in on days and people have had 3 briefs shoved under them and they will be saturated and falling apart. Literally it turns to gel, it's disgusting. Surveyor asked CNA I how many times they have to let residents go in their briefs because of staffing? CNA I indicated, I've come in, I think Monday, I had to do 7 bed changes because the residents soaked through the brief, the pad, the Chux, and the depends. Surveyor asked how often this happens? CNA I indicated at least 3 of my 5 days a week. Example 8: On 7/6/23 at 9:45 AM, Surveyor interviewed CNA I and informed her that CNA G had told us to talk to her about getting R9 up this AM. CNA I indicated that R9 was soaked. The bed and brief were soaked. There was one pad in her brief. A complete bed change was needed. CNA I indicated this was unusual for R9 because she can tell you when she needs to go. R9 was admitted to the facility on [DATE] with diagnoses to include in part: Alzheimer's Disease; Emphysema; Heart Failure; and Chronic Obstructive Pulmonary Disease . R9's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/25/23 indicates a Brief Interview of Mental Status (BIMS) score of 4 indicating R9 has a severe cognitive impairment. Section G Activities of Daily Living (ADL) documents in part: toilet support - Extensive assistance, One-person physical assist. Section H Bladder and Bowel documents in part: Urinary Continence - Occasionally Incontinent. Bowel Continence - Always continent. R9's ADL care plan, revision date 5/2/23 states in part: Focus: I have a physical functioning deficit related to history of right hip fracture, memory impairment due to dementia. Intervention: Toileting assistance: assist of (1) and 2WW (wheeled walker) with contact guard assist from bed or wheelchair to toilet. Focus: Alteration in elimination of bowel and bladder, unable to reach toilet independently due to factors of general weakness, dementia, arthritis. Intervention: use of briefs/pads for incontinence protection. (Intervention initiated 11/2/22). Of note, the Resident Roster provided to Surveyors by the facility indicated R9 was non-interviewable Example 10: On 7/6/23 at 2:00 PM, Surveyor interviewed CNA I and asked if she ever cared for R1? CNA I indicated she had. Surveyor asked CNA I if she ever observed pads inside of his brief, double briefing, or saturated briefs? CNA I indicated yes and that R1 had 2 pads overlapping in his brief. CNA I put her two hands together to show how the pads were in the brief, showing the pads would have been put together to make one long pad. CNA I indicated when she would come on the AM shift, he would be saturated. Surveyor asked what time CNA I comes in for the AM shift? CNA I indicated 6AM - 2PM. Surveyor asked how often she would find R1 saturated? CNA I indicated pretty much every time I came in. Full bed changes were needed a few times a week and he would never want to get out of bed, so we had to roll him to do it. R1 was admitted to the facility on [DATE] with diagnoses to include in part: Failure to thrive, Diabetes Mellitus Type II, Abnormalities of gait and mobility, and history of malignant neoplasm of large intestine. R1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/1/23 indicates a Brief Interview of Mental Status (BIMS) score of 8 indicating R8 has a moderate cognitive impairment. Section G Activities of Daily Living (ADL) documents in part: toilet support - Total Dependence, One-person physical assist. Section H Bladder and Bowel documents in part: Urinary Continence - Occasional Incontinence. Bowel Continence - Occasional Incontinence. R1's ADL care plan, revision date 3/30/23 states in part: Focus The resident has an ADL self-care performance deficit related to hospitalization, diagnosis failure to thrive, Parkinson like rigidity. Goal will improve current level of function in ADLs through the review date (Revision 4/5/23.) Intervention Toilet Use x1A (dependent) (Times 1 assist) Example 11: On 7/10/23 at 6:06 AM, Surveyor interviewed CNA J and asked CNA J if she has ever seen pads in briefs or double briefing when caring for residents? CNA J indicated she has seen pads in briefs and the only resident she has seen double briefed was R2. CNA J indicated she did not remember when for sure, but that it was when she was training with CNA I, so it was at least two weeks ago, probably on the 26th before leaving on vacation. Surveyor asked CNA J if she was trained to put pads in briefs when she started working at the facility? CNA J indicated she was and that the other CNAs acted like that was what you were supposed to do. CNA J indicated, I think they thought that was correct because they were probably trained that way. On 7/10/23 at 4:46PM, Surveyor spoke to CNA J via telephone and reviewed interview from earlier this morning regarding R2. Surveyor asked CNA J if she had ever observed R2 saturated? CNA J indicated when she would get R2 up his bed would be soaked about 2 times a week. Surveyor asked CNA J if she could recall when this happened? CNA J indicated it was mostly in June as she has only worked two shifts in July. R2 was admitted to the facility on [DATE] with diagnoses to include in part: Encephalopathy (damage or disease that affects the brain); hemiplegia (one-sided muscle paralysis or weakness); and Epilepsy . R2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/19/23 indicates a Brief Interview of Mental Status (BIMS) score of 8 indicating R2 has a moderate cognitive impairment. Section G Activities of Daily Living (ADL) documents in part: toilet support - Total Dependence, One-person physical assist. Section H Bladder and Bowel documents in part: Urinary Continence - Always Incontinent. Bowel Continence - Always incontinent. R2's ADL care plan, revision date 6/27/23 states in part: ADL self-care performance deficit related to encephalopathy, traumatic brain injury, right sided hemiparesis (contracted right shoulder), cognitive impairment. Goal: will improve current level of function in ADLs through the review date (Goal Revision 7/4/23). Intervention: Toilet Use: Dependent (Intervention Revision 6/15/23). Example 11: On 7/10/23 at 6:06AM, Surveyor interviewed CNA K and asked if she has ever found pads in briefs or double briefing when changing residents? CNA K indicated yes. Surveyor asked CNA K how often she is finding this? CNA K indicated every day. Surveyor asked CNA K how many residents she recalls finding this way? CNA K indicated around five have had the control pad in the brief; I've never seen double briefing before. Surveyor asked CNA K if she could recall which residents she found with the control pad in their brief? CNA K indicated she could recall R6, R13, R17, R11, and R2. CNA K added, I was trained to put a pad in the brief. Surveyor asked CNA K when was the last time she saw pads in the briefs? CNA K indicated there were none on Friday, early Monday, or Tuesday of last week. Surveyor clarified with CNA K that she was referencing the 3rd and 4th of July. CNA K indicated the dates were correct. R6 was admitted to the facility on [DATE] with diagnoses to include in part: Developmental Disorder of Speech and Language; Type II Diabetes; and Other Seizures . R6's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/21/23 indicates a Brief Interview of Mental Status (BIMS) score of 9 indicating R6 has a moderate cognitive impairment. Section G Activities of Daily Living (ADL) documents in part: toilet support - Extensive assistance, One-person physical assist. Section H Bladder and Bowel documents in part: Urinary Continence - Occasional Incontinence. Bowel Continence - Frequently Incontinence. R6's ADL care plan, revision date 7/3/23 states in part: Alteration in elimination of bowel and bladder. Refuses to be toileted at times or to allow staff to provide incontinent cares at times. At times will spend the day at family home and will return with increased redness to buttock due to incontinence. Intervention: Coordinate with resident, front desk, unit staff to return resident to unit for toileting management between 11:00 - 11:30 and 2:00 - 2:30 and as needed (Date initiated 8/16/19) .Provide routine check and change (Date initiated 8/10/22) .Use brief/pads for incontinence protection (Date initiated 8/10/22). Wears incontinent briefs (Date initiated 8/10/22) . Of note, the Resident Roster provided to Surveyors by the facility indicated R6 was non-interviewable Example 12: R17 was admitted to the facility on [DATE] with diagnoses to include in part: Cerebral Infarction (Stroke); Displaced fracture of left radial styloid process (fracture of forearm bone near wrist); and Alzheimer's Disease . R17's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/31/23 indicates R17's Brief Interview of Mental Status (BIMS) was not completed as R17 is rarely/never understood. Section G Activities of Daily Living (ADL) documents in part: toilet support - Total Dependence, One-person physical assist. Section H Bladder and Bowel documents in part: Urinary Continence - Always incontinent. Bowel Continence - Frequently Incontinent. R17's ADL care plan, revision date 3/21/23 states in part: physical functioning deficit related to: CVA (Stroke); Dementia ., and a recent diagnosis of osteopenia with subsequent fracture involving the left radial styloid process with mild displacement .Goal: .I will improve my current level of physical functioning (Revision Date 4/16/23). Intervention: Toileting assistance x 2 Hoyer (Revision date 3/2/23). Of note, the Resident Roster provided to Surveyors by the facility indicated R17 was non-interviewable Example 13: R11 was admitted to the facility on [DATE] with diagnoses to include in part: Dementia; Type II Diabetes; and Difficulty in walking . R11's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/12/23 indicates R11's Brief Interview of Mental Status (BIMS) was not completed as R11 is rarely/never understood. Section G Activities of Daily Living (ADL) documents in part: toilet support - Total Dependence, One-person physical assist. Section H Bladder and Bowel documents in part: Urinary Continence - Always incontinent. Bowel Continence - Always incontinent. R11's ADL care plan, revision date 6/26/23 states in part: Focus bladder incontinence. Intervention I wear incontinent briefs, assist with peri-care during routine rounds and as needed (Date Initiated 6/26/23). Focus I have a physical functioning deficit related to: dementia causing long term placement at Skilled Nursing Facility (Revision 6/20/23). Intervention .Toileting assistance of 1-2 (Revision 9/22/22). Of note, the Resident Roster provided to Surveyors by the facility indicated R11 was non-interviewable On 7/5/23 at 10:25AM, Surveyor interviewed LPN H and asked if any CNAs have ever reported to her that residents are being found saturated? LPN H indicated the last time it happened was about one and a half months ago and staff were wondering if the night staff were rounding. We have newer CNAs working on nights so not sure if they need more training. On 7/10/23 at 5:35AM, Surveyor interviewed CNA M and asked if she has seen any residents who have pads in their brief or who have more than one brief on? CNA M indicated she has not seen this for a while, probably a couple months back was the last time. Surveyor asked CNA M if she has noticed a pattern of who is working or when she works as to when she noted the pads or double briefing? CNA M indicated she has not noticed a pattern, but we have a lot of new CNAs, so we have to remind them. Surveyor asked CNA M what they are reminding the new CNAs of? CNA M indicated, only one brief, only Chux on air mattress and soaker pads on the regular mattresses. Surveyor asked CNA M when the last time was that she gave reminders and to whom? CNA M indicated it was probably a month ago on 3rd floor with a lot of new staff but did not recall exactly who. On 7/6/23 at 10:10AM, Surveyor interviewed CNA N and asked what the process for toileting and providing check and changes to residents is? CNA N indicated every two hours check and changes are done. If a resident can use the restroom most will hit the button to call for help. Surveyor asked CNA N what the process is for check and changes? CNA N indicated when she comes in at 10:00 PM she completes rounds and at that point usually no one is too bad, if they are wet, she will change them, and this takes about an hour. The next rounds are at 1:00 AM and take until about 2:00 AM, then round again at 4:00 AM and she leaves at 6:00 AM. CNA N added that this morning she told the girls before she left the last couple of hours of her shift were hectic and so there may be a few people who need attention right away. Surveyor asked CNA N what products are used during check and changes? CNA N indicated a pack of wipes in each room and that there are a lot of people that soak through, I don't double brief anyone. Surveyor asked CNA N if she ever puts pads inside briefs. CNA N indicated not on nights. Surveyor asked if she does this on other shifts. CNA N indicated the only time she does this is if the person is independent and prefers it. CNA N added that she has put a pad inside a pull-up for dinner periods. Surveyor asked CNA N if she is supposed to do this? CNA N stated Nope. Surveyor asked CNA N who assists the night CNA on the memory care unit with check and changes? CNA N indicated either the float staff or the nurse. Surveyor asked CNA N if she has ever put a brief under someone who already has one on? CNA N stated, No ma'am. Surveyor asked CNA N if she had been provided education recently regarding brief changes, double briefing, and pads in briefs? CNA N indicated she had not and that she is aware that double briefing is a problem but did not know that putting a pad in a pull-up for a resident who was more independent while awake was a problem. Of note, CNA N's name and signature were not found on the In-service training record provided to the surveyors for the education completed on 6/9/23. Also of note, CNA N is listed as the night nurse for second floor (memory care unit) for night shift on 7/5/23. On 7/6/23 at 10:57 AM, Surveyor interviewed CNA G and asked who she followed from the night shift and if she received report? CNA G indicated she followed CNA N; she did not receive report and her shift started at 6:00 AM. On 7/6/23 at 11:20AM, Surveyor asked CNA F if she received report from CNA N this AM. CNA F indicated yes and that her shift started at 5:30 AM today. Surveyor asked CNA F what CNA N told her when she reported off to her? CNA F indicated CNA N told her that she had spilled some water, didn't clarify if she cleaned it up, she hadn't, and so CNA F cleaned it up. She said that she didn't make it to a couple people but that she did not recall who. On 7/6/23 at 2:58 PM, Surveyor interviewed RN P (Registered Nurse) via telephone and asked if she worked last night on second floor? RN P indicated she did, but that she was being oriented to the facility by RN Q for the first two hours as it was her first night in the facility. Surveyor asked if RN P if she assisted with any check and changes of residents? RN P indicated she assisted with a resident on the first floor and did not assist with any others. Surveyor asked RN P if she was aware of any CNAs coming to assist on the second floor that night? RN P indicated yes. Surveyor read from the schedule the other names of CNAs and RN P indicated CNA R sounded correct. Of note, CNA R is on the July 5th schedule under first floor night shift till 2. Of note, Surveyor attempted to contact RN Q for interview without success. On 7/6/23 at 3:17 PM, Surveyor interviewed CNA R and asked if she recalled seeing double briefing or pads in briefs on second floor? CNA R indicated that she has not seen this on nights. CNA R included that she normally only works until 2:00 AM and rarely goes to second floor. On 7/6/23, the facility provided Surveyor with a grievance form with date and time submitted noted as 7/6/23 at 7:05AM. The grievance contained the following information, in part: A list of the 11 residents referenced in the staff statements: R5, R6, R7, R8, R9, R10, R2, R11, R12, R13, and R14. Grievance Information: CNA I stated residents were wet when she arrived. She cleaned residents and informed LPN on shift. Administrator and Regional RN are marked as notified . Three Staff Statements: CNA F - I CNA F am writing this on 7/6/23. I was given a broad report this morning then the NOC (night) CNA left instead of waiting for the other AM aides to give them report as well. I was told one patient was on the toilet, a couple were missed, and water was spilled, but it was not clear or clarified if the water was cleaned up. When I got to resident (room number) water was across the floor, so before I collected supplies first thing, I did was clean up the water. Everything I found out was unethical care this am, I reported to the nurse, and Admin I informed state that it depends on who you come in after as to weather [sic] or not people are properly cared for or drenched. I also told state it is one other person I am aware of besides who I came in after today. The statement is signed by CNA F. CNA G - Noc CNA N continuously leaves residents soaked for day shift. Numerous of times this issue has been reported to the nurse on duty (LPN H) She reports that she'd been telling management about it but almost every shift I have worked I have more than 2 of my own bed changes. 7/6/23 the 2nd floor together had 11 bed changes. She has stated to us as well people she washes up for day shift or had just been done and they had been very wet in result [sic] to a new outfit for the day and being washed again. Also having residents changed but bed sheet soaked with them left on top of it. The statement is signed by CNA G. CNA I - 11 residents were soaked through depends, pads, linens and needed complete bed changes today. This is a common issue when certain CNAs are scheduled Nocs. Numerous residents were double padded/double briefed. Issues have been reported to the nurse scheduled (LPN H.) Unsure of who is told afterwards. The statements are signed by CNA I. On 7/10/23 at 11:55AM, Surveyor interviewed DON B (Director of Nursing) and asked what the expectation is for toileting and check and changes for residents? DON B indicated upon request and about every 2 hours check that they are clean and dry, if soiled, clean them. Surveyor asked DON B if residents should have more than one brief applied at a time or have a pad in their brief? DON B indicated no, and that they do not do double briefing and there should not be a pad in the brief either. There should only be a single product on. Surveyor asked DON B if he was aware of staff bringing concerns about double briefing, using pads in briefs, and briefs and beds being soaked? DON B stated, Not to my knowledge. The idea had come up about if it's appropriate and we have said [TRUNCATED]

Based on interview and record review, the facility did not ensure that an alleged violation was thoroughly investigated for 1 of 1 Facility Reported Incident (FRI) reviewed. Licensed Practical Nurse (LPN) F was alleged to have been a part of misappropration of a resident's narcotic medication. The facility did not complete a thorough investigation to determine what happened to the narcotic. Findings include: On 03/06/23, Surveyors were reviewing a FRI about allegations of misappropriation of medications. Surveyor asked the facility to review the alleged LPN's personnel file. Upon review of the personnel file Surveyor found a hand written document dated 12/13/22 with LPN F's name across the top. The bottom of the paper reads in part CNA - drug bust with CNA E. This statement was not a part of the facility's investigation packet they gave the Surveyor to review regarding the misappropriation of narcotic medication. On 03/07/23 at 12:24 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and showed her the piece of paper and asked what the piece of paper was from. NHA A indicated it was a phone interview with LPN F, human resources and herself. Surveyor read the above to NHA A and asked if they had a CNA by that name. NHA A indicated yes. Surveyor asked if it meant that LPN F was indicating they destroyed a medication with CNA E. NHA A indicated yes. Surveyor asked NHA A if she interviewed CNA E. NHA A indicated she could not recall. Surveyor was not able to locate a statement in the FRI packet from CNA E. The facility did not complete a thorough investigation interviewing all staff to rule out misappropiation of controlled substances.

Based on record review and interview, the facility did not ensure the proper disposition of a controlled medication. Licensed Practical Nurse (LPN) F destroyed a controlled substance with a Certified Nursing Assistant (CNA) E Findings include: On 03/06/23, Surveyors were reviewing Facility Reported Incident (FRI) about allegations of misappropriation of medications. Surveyor asked the facility to review the alleged LPN F's personnel file. Upon review of the personnel file Surveyor found a hand written document dated 12/13/22 with LPN F's name across the top and 858AM. The bottom of the paper reads in part CNA - drug bust with CNA E. On 03/07/23 at 12:24 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and showed them the piece of paper and asked what the piece of paper was from. NHA A indicated it was a phone interview with LPN F, human resources and herself. Surveyor read the above to NHA A and asked if they had a CNA by that name. NHA A indicated yes. Surveyor asked if it meant that LPN F was indicating they destroyed a medication with CNA E. NHA A indicated yes. Surveyor asked NHA A if she interviewed CNA E. NHA A indicated she could not recall. Surveyor asked NHA A if the facility practice was for a licensed nurse to destroy a controlled medication with a CNA. NHA A indicated the facility policy is to destroy narcotic medications with two nurses, not a CNA.

Based on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 70 residents who reside in the facility. Cook R was observed adjusting his mask and picking wrappers up off of the floor and continuing to plate up resident food, without performing hand hygiene. The ceiling in facility's freezer had dripped and frozen into some of the facility's food boxes that were no longer sealed by the manufacturer. Surveyor and Dietary Staff observed hairlike dust in facility's stove hood directly above open food. Surveyor and RD P (Registered Dietician) observed [NAME] R temping food and then cleaning thermometer with alcohol wipes. [NAME] R did not allow the thermometer to air dry in between foods. Surveyor observed staff wet-stacking clean dishes as they came out of the dishwasher. Evidenced by: Example 1 Facility policy, entitled Food Preparation and Service, updated 7/6/22, includes, in part: . Food and nutrition services staff, including nursing staff, wash their hands before serving food to residents. Employees also wash their hands after collecting soiled plates and food waste prior to handling food trays. On 9/08/22 at 11:08 AM Surveyor and RD P (Registered Dietician) observed [NAME] R plating resident food. [NAME] R touched his face mask several time and picked up wrappers off of the floor and continue to plate resident food. RD P indicated [NAME] R should have washed his hands after touching his face or picking garbage off of the floor. Example 2 Facility policy, entitled Food Safety Requirements, 11/22/17, includes in part: . Physical contaminants are foreign objects that may advertently enter the food . On 9/7/22 at 9:17 AM during initial tour of the facility's kitchen RD P and Surveyor observed frozen drips hanging from the facility freezer. Under the dripping were unsealed boxes that also had been dripped on and in. These boxes contained bacon, chicken nuggets, and chicken breasts. RD P indicated he sees the ice on and inside of the boxes and is unsure if the food inside these boxes was contaminated. Example 3 Facility policy, entitled Food Safety Requirements, 11/22/17, includes in part: . Physical contaminants are foreign objects that may advertently enter the food . On 9/7/22 at 9:17 AM during initial tour of the facility's kitchen RD P, [NAME] R, and Surveyor observed hairlike dust in the facility's stove hood. [NAME] R was preparing a red sauce directly under the dust. RD P and [NAME] R indicated there is potential for the dust to fall into the uncovered food. Example 4 Facility policy, entitled Food Preparation and Service, updated 7/6/22, includes, in part: . Food thermometers used to check food temperatures are clean, sanitized, and calibrated for accuracy . On 9/8/22 at 11:08 AM RD P and Surveyor observed [NAME] R temping food in the tray line. [NAME] R used alcohol wiped to clean the thermometer in between foods, but did not give the thermometer time to air dry before dipping in the next food. RD P indicated [NAME] R should allow the thermometer to dry completely before using it in the next food. [NAME] R indicated he should allow thermometer to air dry after cleaning it with alcohol wipes. Example 5 On 9/13/22 at 9:10 AM Surveyor observed DA Q (Dietary Aide) stacking wet dishes. Surveyor asked DA Q to pick up some of the bowls and when DA Q did, water dripped from them. DA Q indicated the dishware should be dried completely before stacking due to the risk of bacteria growth. On 9/13/22 at 9:13 AM NHA A (Nursing Home Administrator) indicated staff are to wash hands after touching facemask, after picking wrappers up off of the floor, and before handling food. NHA A indicated she expects staff to allow thermometer to air dry after cleaning it with alcohol wipes and before using it to temp food. NHA A indicated visibly soiled and unsealed boxes could have contaminated food in them as seen under dripping in the freezer and should be thrown out. NHA A indicated there is potential for dust to dislodge and fall into open food cooking directly under the stove hood and the facility staff already cleaned this since it was identified. NHA A indicated dishware should be allowed to air dry completely before staff stack them.