Every finding on record at Alden Meadow Park HCC

Based on interview and record review the facility failed to ensure a system for preventing, 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 the facility assessment conducted and following accepted national standards this has the potential to affect the census (58). From Feb-April 2026 there were 33 staff call ins from work without giving their symptoms to the facility (i.e. sick) and/or had a symptom that could have been a respiratory virus symptom (i.e. cough/cold/headache/sore throat) and should have been tested prior to coming back to work. This is evidenced by: The Facilities Policy and Procedure entitled Staff Management and Exclusion dated 9/25, documents in part: The facility will manage situations involving staff with acute respiratory illness (ARI) or exposure in accordance with existing guidance from the CDC (Centers for Disease Control and Prevention), state, and local health departments. Guidance 1. Staff with mild to moderate ARI, regardless of whether testing is performed, and who are not moderately to severely immunocompromised can return to work after the following criteria have been met: a. At least 3 days have passed since symptom onset, and b. At least 24 hours have passed since the last fever without the use of fever-reducing medications, and c. Symptoms (e.g., cough, shortness of breath) have improved, and d. They feel well enough to return to work . Document entitled Employee Illness Log dated 2020 documents the following pertinent column headings and information below table: Report Date, Employee, Vomiting, Fever, Diarrhea .A respiratory cough, sore throat, runny nose, Comments or other symptoms, Date returned to work .Employees with diarrhea or vomiting must be excluded from work for at LEAST 24 hours after symptoms are gone. Food service Workers with diarrhea or vomiting must be excluded from work for at LEAST 48 hours after symptoms are gone. February staff call ins documents the following: -Sore throat x1 -Headache x 5 -Sick x 5 -Stomach issues/Stomach/Food Poisoning x 2 March staff call ins documents the following: -Headache x 2 -Sick x 9 -Stomach Issues/Food Poisoning/Stomachache x 4 -Cough/cold x 1 April staff call ins documents the following: -Headache x 1 -Sick x 2 -Stomach Issues x 1 The staff line list Feb-April 2026 only documents one specific symptom which is fever. There is no consistent time off for staff, it varies from 1-7 days from date of call in to return to work. On 4/23/26 at 11:19 AM, Surveyor interviewed ADON/IP C (Assistant Director of Nursing/Infection Preventionist). Surveyor asked AODN/IP C when the staff line list documents sick what symptoms does that include, ADON/IP C replied when not respiratory, headache as example, mild symptoms probably. Surveyor asked ADON/IP C how long should staff be off work if they call in sick, ADON/IP C said the one thing we ask is if they have a fever then we follow ARI (Acute Respiratory Illness) protocol. Surveyor asked ADON/IP C if any staff have COVID testing completed prior to returning to work, ADON/IP C indicated that some staff have tested. ADON/IP C further explained she's trying to screen and get better with the line listing and checking for more than one symptom. On 4/23/26 at 11:40 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B would you expect staff to have symptoms listed for call ins so that the IP is able to determine how long they need to be off work, DON B stated yes. Surveyor asked DON B would you expect staff that have COVID symptoms present to have a COVID test completed prior to returning to work, DON B replied yes.

Based on interview and record review the facility failed to implement written policies and procedures for screening employees to prevent abuse, this affected 3 of 8 background checks reviewed.PT J (Physical Therapist) lived outside of Wisconsin (WI) in Illinois (IL) and did not have an IL or national background check completed.SSD K (Social Service Director) and Receptionist L did not have WI Caregiver Background check completed and as a result they did not have the Government Findings Report resulted.This is evidenced by:The Facilities Policy and Procedure entitled Abuse Prevention and Reporting dated 11/25 documents, in part: .III. Prevention the facility is committed to preventing abuse, neglect, misappropriation, and exploitation by fostering a culture of safety, respect, and accountability. Prevention efforts include careful employee screening .1. Pre-Employment Screening The facility maintains a safe environment by ensuring that all employees and contracted personnel meet strict background and credentialing requirements prior to hire. The facility will not employ or contract with any individual who: Has been convicted of abuse, neglect, or misappropriation of resident property. Is listed on the Wisconsin Caregiver Misconduct Registry of the Office of Inspector General (OIG) Exclusion List. Has any disciplinary action on a professional license related to abuse, neglect, exploitation, or misappropriation. Required Checks Prior to Hire: Before an employee begins work, the following verifications must be completed and documented .Conduct a Wisconsin Department of Justice (DOJ) Background Check in accordance with DHS 13 (Department of Health Services). If the applicant currently resides in Illinois or has lived outside of Wisconsin within the past three (3) years, complete the appropriate State Police Healthcare Worker Background Check (Illinois or other applicable state) .The Facilities Policy and Procedure entitled Criminal Background Investigations Wisconsin Facilities dated 1/25, documents in part: .The facility is committed to ensuring the safety and well-being of all residents by conducting thorough background checks on all employees, contractors, and volunteers in accordance with Wisconsin Department of Health Services (DHS) and Division of Quality Assurance (DQA) requirements. No individual shall be permitted to work in a capacity that provides care or services to residents without appropriate background screening and clearance. This policy applies to: All prospective and current employees and volunteers and students with resident contact .Example 1PT J (Physical Therapist) was hired on 6/7/25 as a contracted therapy employee. PT J indicated on her Background Information Disclosure (BID) that she does or did live outside of WI in the last 3 years. PT J did not have an IL (Illinois) or national background check completed. Example 2SSD K (Social Service Director) was hired on 1/3/26 and did not have the Wisconsin Caregiver Background Check completed, because of that, she does not have the Government Findings Report results. Example 3 Receptionist L was hired on 2/26/26 and did not have the Wisconsin Caregiver Background Check completed, because of that, she does not have the Government Findings Report results.On 4/22/26 at 1:32 PM, Surveyor interviewed BOM M (Business Office Manager). Surveyor asked BOM M how SSD K and Receptionist L did not have the Government Findings Report, BOM M stated they aren't clinical staff. Surveyor asked BOM M if she could help me understand what that means in relation to completion of their pre-employment background check, BOM M explained that she runs the Caregiver Background Check for clinical staff and the general for non-clinical staff. Surveyor asked BOM M if these staff, On 4/22/26 at 3:28 PM, Surveyor interviewed BOM M. Surveyor asked BOM M if PT J's contracted company had an IL or national background check for her, BOM M replied that PT J is not working in an IL facility, so they didn't do one.On 4/23/26 at 9:31 AM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A would you expect all staff to have the caregiver background check completed, NHA A said yes, in IL all staff are fingerprinted, so that is how this was overlooked. Surveyor asked NHA A would you expect any staff that has resided outside of WI to have that state specific or a national background check completed, NHA A replied yes.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the appropriate agencies for 1 of 1 abuse allegations of Residents (R7). R7 reported an abuse allegation involving CNA D (Certified Nursing Assistant). This incident was reported to NHA A (Nursing Home Administrator), DON B (Director of Nursing), and CNA F (Certified Nursing Assistant), but was not reported to the state agency.Evidenced by: Facility policy titled Abuse Prevention and Reporting Policy, undated, states, in part: . III. Prevention. Orientation and Annual Training Topics include: . Identification, prevention, and reporting of abuse under both federal and Wisconsin law. Mandatory reporting laws, including who must report, how to report, and applicable timeframes . IV. Identification and Reporting: 1. All employees, contractors, and volunteers must immediately report any allegation or reasonable suspicion of abuse, neglect, misappropriation, or exploitation to their supervisor and the Administrator or designee. 8. Reporting to Other Agencies: Wisconsin Division of Quality Assurance (DQA): Must receive the initial allegation report immediately and a five-day final investigation report including findings and corrective actions. R7 was admitted to the facility on [DATE]. Her most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/11/26, indicates R7 has a Brief Interview of Mental Status (BIMS) of 15 out of 15, indicating R7 is cognitively intact. Section GG of R7's MDS indicates that she requires partial/moderate assistance for rolling left to right. On 4/20/26 at 2:36 PM, during an interview, R7 indicated that she no longer allows CNA D (Certified Nursing Assistant) to care for her. R7 stated that, approximately two weeks prior, CNA D hurt her while rolling her in bed. R7 stated that normally the aides use the draw sheet under her to assist with rolling her in bed, but that CNA D just used his hands, and it felt like fists were pushing into her hips. R7 stated that it hurt so bad that she almost started crying. R7 indicated that she told CNA I about it, who was also working that night, and asked that CNA D not provide cares for her anymore. Surveyor reviewed the facility grievance forms, which included a grievance dated 4/6/26, stating: Concern: Requests CNA D not to do her cares anymore. This was documented by AD G (Activities Director) who forwarded the concern to NHA A (Nursing Home Administrator). NHA A documented, Follow-up action taken: CNA D no longer doing cares for her talked with R7 and her preference is CNA D not provide cares. CNA D and R7 both aware. On 4/22/26 at 10:34 AM, Surveyor interviewed R7 about the incident between her and CNA D. R7 stated again that when CNA D was putting her on the side, he hurt her. R7 stated it was like he used his fists putting her on the hip, although it was probably just his palms. R7 stated that she has arthritis in both hips, and that when the other aides roll her over, that they use the draw sheet so as not to cause pain. R7 indicated that CNA F was also aware of the situation, as she told her that she doesn't allow CNA D to care for her anymore because he hurt her. On 4/22/26 3:04 PM, Surveyor interviewed CNA F about the incident between R7 and CNA D. CNA F stated that when she works the night shift, she has to provide cares for R7, even if she is not working that hall, because R7 does not want CNA D working with her anymore. CNA F stated that R7 told her it was because CNA D was rough with her one night about two to three weeks ago. Surveyor asked CNA F if she had reported this to anyone. CNA F indicated that all the staff knew about it, and that there had been other female residents that thought CNA D was aggressive while doing cares. CNA F stated that she would consider being rough or aggressive as abuse. On 4/22/26 at 3:32 PM, Surveyor interviewed AD G (Activities Director) who stated that she documented what R7 said on the grievance form but did not have any additional information about it. AD G stated that she turned the form over to NHA A on the same day she received the concern from R7. 4/22/26 at 3:40 PM, Surveyor interviewed CNA D about the incident with R7. CNA D confirmed that he works primarily the night shift and that he often works the hall that R7 resides on. CNA D stated that R7 refuses his service and that she said he hurt her when turning her. CNA D stated that he told his colleagues that he would not be able to take care of her. CNA D stated he told NHA A and SC E (Scheduling Coordinator), to ensure that there was always another CNA working that could assist R7. On 4/22/26 at 3:46 PM, Surveyor interviewed SC E (Scheduling Coordinator) about the incident between R7 and CNA D. SC E stated that CNA D reported to her that R7 no longer wanted him to care for her. SC E stated it was reported to her that R7 just did not want any male caregivers, so she makes sure to always schedule two people on that hallway so that someone else can go in and take care of R7. Surveyor pointed out to SC E multiple observations of other male caregivers providing cares for R7. SC E stated that she thought R7 might not want CNA D caring for her because they were close in age. SC E indicated that she had never heard that CNA D was rough or aggressive in providing cares for R7, and if she had she would report it right away to DON B and NHA A. SC E stated that DON B might have more information on CNA D being rough with R7. On 4/23/26 at 9:21 AM, Surveyor interviewed NHA A (Nursing Home Administrator) about the incident between R7 and CNA D. NHA A stated that R7 is very particular and told her that she didn't want CNA D to provide cares for her anymore. NHA A indicated that when she asked R7 for more details, that she didn't really give a specific reason. NHA A stated that no one had reported to her that CNA D was rough with or hurt R7, and if they did, she would have reported it right away. NHA A stated that it was her expectation that staff would report any and all allegations of abuse to her promptly so that she could report it to the state agency. On 4/23/26 at 9:37 AM, Surveyor interviewed DON B (Director of Nursing) about the incident between R7 and CNA D. DON B stated that R7 told her that CNA D was a little rough with her when he put her on her side. DON B indicated that she asked R7 to provide further explanation, and that R7 stated that CNA D goes too quickly and kind of tosses her this way and that way. DON B stated that she didn't feel like R7's concern rose to the level of anything major, and that if they thought CNA D's conduct was abuse in any way, of course they would have reported it. Of note: The facility provided Surveyor with documentation of staff education that occurred on 4/8/26 and included a Knowledge Check form stating, A Resident tells the nurse that the night shift CNA was. rough with her while providing. care. Answer: Report this to the DNS (Director of Nursing Services. This education was presented at an Inservice/Meeting which was attended by 31 staff members. The facility staff list provided to the survey team documented 84 active staff members, which indicates approximately 36% of the staff were educated on abuse. On 4/23/26 at 9:47 AM, Surveyor called and left a message with CNA I for information about the incident between R7 and CNA D but did not receive a call back. The Facility considered this a grievance instead of an abuse allegation, despite multiple staff members knowing that R7 considered CNA D to be rough with her; therefore, they did not follow their policy and did not report this accusation of abuse to the state reporting agencies. Cross Reference F610.

Based on interview and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment, all alleged violations were thoroughly investigated for 1 of 1 resident (R7) reviewed for abuse. On 4/6/26, the facility became aware of an allegation of abuse by a Certified Nursing Assistant (CNA) to a resident and did not conduct a thorough investigation. Evidenced by: Facility policy titled Abuse Prevention and Reporting Policy, undated, states, in part: . III. Prevention: The facility is committed to preventing abuse, neglect, misappropriation, and exploitation by fostering a culture of safety, respect, and accountability. 3. Resident and family engagement: All residents and families are informed of the facility's grievance and concern procedures. Resident and family concerns are documented, investigated, and reviewed. 4. Documentation and Oversight: . The Administrator and/or Director of Nursing will review protective actions daily until the investigation is complete to ensure continued safety and compliance. Vi. Final Reporting and Follow-Up: 1. Investigator shall obtain and review documentation, interview witnesses, and maintain confidentiality until investigation conclusion. R7 was admitted to the facility on [DATE]. Her most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/11/26, indicates R7 has a Brief Interview of Mental Status (BIMS) of 15 out of 15, indicating R7 is cognitively intact. Section GG of R7's MDS indicates that she requires partial/moderate assistance for rolling left to right. On 4/6/26, the facility became aware of an allegation of abuse between CNA D (Certified Nursing Assistant) and R7. A grievance/concern form completed by AD G (Activities Director) documented: Concern: Requests CNA D not to do her cares anymore. This was documented by AD G (Activities Director) who forwarded the concern to NHA A (Nursing Home Administrator). NHA A documented, Follow-up action taken: CNA D no longer doing cares for her talked with R7 and her preference is CNA D not provide cares. CNA D and R7 both aware. On 4/22/26 at 10:34 AM, Surveyor interviewed R7 about the incident between her and CNA D. R7 stated again that when CNA D was putting her on the side he hurt her. R7 stated it was like he used his fists putting her on the hip, although it was probably just his palms. R7 stated that she has arthritis in both hips, and that when the other aides roll her over, that they use the draw sheet so as not to cause pain. R7 indicated that CNA F was also aware of the situation, as she told her that she doesn't allow CNA D to care for her anymore because he hurt her. On 4/22/26 3:04 PM, Surveyor interviewed CNA F about the incident between R7 and CNA D. CNA F stated that when she works the night shift she has to provide cares for R7, even if she is not working that hall, because R7 does not want CNA D working with her anymore. CNA F stated that R7 told her it was because CNA D was rough with her one night about two to three weeks ago. Surveyor asked CNA F if she had reported this to anyone. CNA F indicated that all the staff knew about it, and that there had been other female residents that thought CNA D was aggressive while doing cares. CNA F stated that she would consider being rough or aggressive as abuse. On 4/22/26 at 3:32 PM, Surveyor interviewed AD G (Activities Director) who stated that she documented what R7 said on the grievance form, but did not have any additional information about it. AD G stated that she turned the form over to NHA A on the same day she received the concern from R7. 4/22/26 at 3:40 PM, Surveyor interviewed CNA D about the incident with R7. CNA D confirmed that he works primarily the night shift and that he often works the hall that R7 resides on. CNA D stated that R7 refuses his service and that she said he hurt her when turning her. CNA D stated that he told his colleagues that he would not be able to take care of her. CNA D stated he told NHA A and SC E (Scheduling Coordinator), to ensure that there was always another CNA working that could assist R7. On 4/22/26 at 3:46 PM, Surveyor interviewed SC E (Scheduling Coordinator) about the incident between R7 and CNA D. SC E stated that CNA D reported to her that R7 no longer wanted him to care for her. SC E stated it was reported to her that R7 just did not want any male caregivers, so she makes sure to always schedule two people on that hallway so that someone else can go in and take care of R7. Surveyor pointed out to SC E multiple observations of other male caregivers providing cares for R7. SC E stated that she thought R7 might not want CNA D caring for her because they were close in age. SC E indicated that she had never heard that CNA D was rough or aggressive in providing cares for R7, and if she had she would report it right away to DON B and NHA A. SC E stated that DON B might have more information on CNA D being rough with R7. On 4/23/26 at 9:21 AM, Surveyor interviewed NHA A (Nursing Home Administrator) about the incident between R7 and CNA D. NHA A stated that R7 is very particular and told her that she didn't want CNA D to provide cares for her anymore. NHA A indicated that when she asked R7 for more details, that she didn't really give a specific reason. Surveyor asked NHA A if she had any documentation of this interviewed with R7. NHA A stated that she talks to residents all day so it's not possible to document every conversation she has with them. NHA A stated that no one had reported to her that CNA D was rough with or hurt R7, and if they did, she would have reported it right away. NHA A stated that it was her expectation that staff would report any and all allegations of abuse, and that she would do a full investigation, but that she could only go off what was reported to her. On 4/23/26 at 9:37 AM, Surveyor interviewed DON B (Director of Nursing) about the incident between R7 and CNA D. DON B stated that R7 told her that CNA D was a little rough with her when he put her on her side. DON B indicated that she asked R7 to provide further explanation, and that R7 stated that CNA D goes too quickly and kind of tosses her this way and that way. DON B stated that she didn't feel like R7's concern rose to the level of anything major, and that if they thought CNA D's conduct was abuse in any way, of course they would have reported it. The facility did not follow their policy to complete a thorough investigation, as no other residents or staff were interviewed to identify if any further abuse by CNA D had occurred. Cross Reference F609.

Based on interview and record review, the facility did not provide care and treatment in accordance with professional standards of practice (Wisconsin Nurse Practice Act, N6) related to assessment and monitoring of a resident's change in condition. This had the potential to affect 1 of 3 sampled residents (R1).R1 reported to staff that an event occurred at her time away from the facility that caused an increase in pain to her leg/foot. The facility did not complete a Registered Nurse (RN) Assessment timely. Staff observed R1 to have swelling and bruising after the change in condition was noted, staff failed to continuously assess, record, and monitor R1's change in condition for new or worsening symptoms. R1's x ray results showed a questionable non-displaced fracture of the tibia metaphsis (neck portion of a long bone). Evidenced by:Facility policy, titled Change of Condition, dated 9/2020, includes: To ensure that the resident's physician/physician on call/Nurse Practitioner and responsible party is kept informed regarding the resident's change of condition. The attending physician or physician on call/Nurse Practitioner and responsible party will be notified with changes in a residence condition. Document time of call, physician or nurse practitioner or other person spoken to, reason for call, and results or orders received.Interact Change In Condition: When to Report, Version 4.0 Tool, copyright 2011 Florida Atlantic University, includes: Immediate Notification - any symptoms, signs, or apparent discomfort that is: acute or sudden in onset and a marked change in relation to usual symptoms and signs or unrelieved by measures already prescribed. Non-immediate Notification- New or worsening symptoms that do not meet above criteria. Discoloration of skin- immediate- any new discoloration accompanied by significant pain. non-immediate-any new discoloration without any other symptoms. Pain-immediate- new severe pain, or marked increase in chronic pain. non-immediate-increase in frequency or severity of pain.According to the Wisconsin Nurse Practice Act, N6.03(1), An R.N. (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s (Licensed Practical Nurse) or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis.According to N6.04(1), In the performance of acts in basic patient situations, the L.P.N. shall, under the general supervision of an R.N. or the direction of a provider . (b) Provide basic nursing care. (c) Record nursing care given and report to the appropriate person changes in the condition of a patient .(e) Perform the following other acts when applicable: 1. Assist with the collection of data. 2. Assist with the development and revision of a nursing care plan. 3. Reinforce the teaching provided by an R.N. provider and provide basic health care instruction. 4. Participate with other health team members in meeting basic patient needs .R1 admitted to the facility on [DATE] and had the following diagnoses: Type 2 Diabetes Mellitus with diabetic neurological complications, neuralgia (severe nerve pain that occurs due to irritation or damage to the nerves) and neuritis (inflammation of the nerves), chronic kidney disease stage 3, fibromyalgia (disorder that causes widespread pain throughout the body), epilepsy (Seizure disorder), history of falling, morbid obesity, age related osteoporosis (disease that weakens bones or makes them thinner and less dense), and Parkinson's disease (condition that affects movement and mood when nerve cells in the brain fail to produce enough dopamine.).R1's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 9/5/25 indicates R1's cognition is moderately impaired with a BIMS (Brief Interview for Mental Status) score of 12 out of 15.R1's Comprehensive Care Plan, initiated 11/22/22, includes: Transfer with 2 assist and hoyer lift (full body lift) . Provide broda chair when up out of bed.(It is important to note the facility did not provide hospice nurse progress notes, as they could not locate them during survey. Surveyor requested them from the hospice agency to obtain copies.)R1's Hospice Progress Note, dated 11/4/25 6:45 AM -8:05 AM, includes: dressing completed, shower completed, linen change completed, no skin changes., no pain during visit. (of note: R1 had no skin changes noted on 11/4/25)R1's Hospice Progress Note, dated 11/5/25 2:02 PM - 3:09 PM, includes: gave patient massage therapy, Reiki, lymph drainage for lower extremities, and sound therapy in her broda chair. she was bothered by the swelling of her right foot/leg. She has been struggling with finding the right words for awhile, but she was able to get her point across. It was obvious she was in some distress. I was able to reduce slightly some of the swelling in her foot, but keeping her feet up is causing her stomach to hurt more. I used the weighted, booted, tuning fork with vibration over the area and the pain calmed down, but was still present. She was less agitated and more calm when I finished.(Of note: R1 had swelling of her right foot on this day. R1's left leg was not indicated.) R1's Hospice Progress Notes, dated 11/6/25 1:45 PM - 2:59 PM, includes: Chaplain visit with patient in her room. She was irritable because she was in pain and discomfort. She said that she was experiencing generalized body pain and needed some medications for it. I contacted the staff on hand to advise her that R1 was hurting. Otherwise the patient was content with watching television and getting her mind off of the pain .R1's Hospice Progress Notes, dated 11/6/25 3:46 PM - 4:17 PM, includes: . No pain noted during visit. No skin changed noted during visit.R1's Nurse Practitioner Note, dated 11/7/25 at 8:45 AM, includes: is seen resting in her room in no apparent distress, seen in follow-up on chronic medical conditions; no concerns reported by patient or nursing staff.R1's Interdisciplinary Note, dated 11/7/25 at 2:47 PM, includes: Patient was assessed by DDS (Doctor of Dentist) today. No pain or discomfort reported during assessment. Health Drive x-ray report was faxed, no new orders were given at this time, dentist recommended no further action unless tooth bothers patient. POA (Power of Attorney) was informed and is in agreement with no further dental work at this time.(It is important to note R1's medical record did not contain clinical notes by this provider.)R1's Hospice Progress Note, dated 11/7/25 3:37 PM - 4:07 PM and resumed 4:33 PM - 5:31 PM, includes: Pain: . yes. numerical scale: 9 out of 10. Did patient report pain since last visit: yes. Frequency: all of the time. Location: Abdomen, calves, feet, knees. Description of abdominal pain: aching. Duration: occasional. rate the worst your abdominal pain gets: 3 out of 10. Specify location of calf pain: right. Description of pain: aching and sharp. Duration: Intermittent. rate the worst your calf pain gets: 9 out of 10. rate least calf pain: 3. factors that exacerbate the pain: movement. Specify location of foot pain: bilateral. description of foot pain: aching and sharp. duration: intermittent. How would your [sic] rate the worst your foot pain gets: 9 out of 10. How would you rate the least foot pain: 3 out of 10. Specify location of knee pain: bilateral. Indicate description of knee pain: intermittent. worst knee pain gets : 9 out of 10. least knee pain gets: 3 out of 10. factors that exacerbate pain: movement. How would you rate your pain in the last 24 hours: 9 out of 10. Abnormal cardiovascular findings: edema. Location and scale of edema: lower right extremity/ankle 3 + and lower left extremity/ankle 2+. Abnormal gastrointestinal finding: abdominal pain, tenderness, and bowel incontinence. Abnormal musculoskeletal findings: pain/stiffness, decreased strength, limited range of motion, swelling. Is cause of pain known: yes, chronic.R1's Hospice Progress Note, dated 11/7/25 5:30 PM, includes: . Patient verbalized pain to right lower extremity. Writer asked what happened. Patient replied, I was out for a walk today and twisted my knee on the uneven sidewalk. Patient is non-ambulatory, hoyer lift for transfers, and broda chair for positioning and comfort. Staff arrived with as needed morphine and administered during visit. Edema noted to bilateral lower extremities 3+ to right lower extremity and 2+ to left lower extremity. No issues reported by staff.R1's Hospice Progress Note, dated 11/7/25 9:52 PM, includes: on call triage note: 9:51 PM central time, LPN I, from facility called to pass on that patient was at dentist today and they bumped her leg on the doorway. She is complaining of pain, . has bruising. No deformity. Offered nurse visit, but patient is currently sleeping and staff report that only time she complains of pain is with touching her leg with the bruising and pain medication as needed is helping. LPN I will return call if they would prefer a visit or with any changes.(It is important to note the facility did not provide evidence of continued/close monitoring of R1 after noting her bruising. No documentation of an RN assessment by facility staff, no documentation of R1 bumping her leg at the dentist, no documentation that LPN I or an RN checked R1's range of motion or updated a provider regarding R1's change)R1's MAR/TAR (Medication Administration Record/Treatment Administration Record) for 11/7/25, includes:Pain Evaluation Every Shift: Day- 0 out of 10, Evening-0 out of 10, Evening- 0 out of 10, Night- 0 out of 10. (It is important to note the facility's pain ratings of 0 while hospice notes R1's pain to be 9 out of 10.)Morphine Sulfate Solution 20 mg/ml (milligrams/milliliter). Give 0.5ml by mouth every 4 hours as needed for moderate pain/shortness of breath. Administered at 3:28 PM (It is important to note the facility recorded R1's pain as 0 out of 10 and then administered her as needed pain medication.)R1's skin sheet, undated, indicates R1 has shearing in the buttock area and a faint bruise on the anterior left lower extremity. On 12/16/25 at 5:05 PM, NHA A (Nursing Home Administrator) indicated the form should have been dated, but she knows it was completed on 11/8/25 during a house wide skin sweep.(It is important to note this form was not included in R1's medical record.)R1's MAR/TAR, for 11/8/25, includes:Pain Evaluation Every Shift: Day- 2 out of 10, Evening-0 out of 10, Evening- blank, Night- 0 out of 10.Morphine Sulfate Solution 20 mg/ml. Give 0.5ml by mouth every 4 hours as needed for moderate pain/shortness of breath. Administered at 10:09 PM (It is important to note the facility recorded R1's pain as 0 out of 10 and then administered her as needed pain medication.)Of note: there is no facility documentation of continued monitoring of R1's edema, range of motion, or bruising to R1's left leg on 11/8/25.R1's Hospice Progress Note, dated 11/9/25 9:30 AM - 11:00 AM, includes: . as needed visit for left lower leg pain. Assessment of left lower leg demonstrates localized edema and bruising to the lateral aspect. Patient does not tolerate movement and cries out with even the slightest movement. Patient, facility, and POA requesting an x ray. pain: yes. pain score: 7 out of 10. goal pain: 4 out of 10. worst pain in the last 24 hours: 10 out of 10. frequency of pain: all of the time. Abnormal musculoskeletal findings: pain/stiffness in left lower extremity. Indicate reason for pain: Patient bumped her leg and has edema and bruising. What discipline did you communicate with: Registered Nurse/Supervisor. On call visit due to unexpected status change involving an adverse event. Indicate other unexpected status change: Patient's left lower extremity was bumped during transport on 11/7/25 resulting in increased pain with movement, bruising, and edema.(of note: there is no documentation of an incident report indicating R1 bumped her leg during transport on 11/7/25 and the Dental office denied any incident occurred.)R1's Hospice Progress Note, dated 11/9/25 at 10:52 AM, includes: as needed visit for left lower leg pain. Plan of care discussed with RN [Name], facility. Per report patient was transported to an appointment on 11/7/25. During transport patient's left lower extremity was bumped and patient experienced severe pain and discomfort. Assessment of left lower extremity demonstrates localized edema and bruising to the lateral aspect. Patient does not tolerate movement and cries out with even the slightest movement. Patient, facility, and POA are requesting an x ray. Medical Doctor contacted for x ray to be completed. Vitals signs obtained and within normal limits. Patient has a persistent cough. Lungs clear to auscultation and no shortness of breath noted. Patient answers questions but conversation is confused and she is not oriented to time or situation. Advised staff that order has been placed and x ray company contacted.R1's Nurse Note, dated 11/9/25 at 2:34 PM, includes: Hospice called to be informed that patient continues to have increased pain and requesting to be sent out. Patient was evaluated and X ray was ordered by hospice. Patient and POA (power of attorney) informed.Of note: there is no facility documentation of continued monitoring of R1's edema, range of motion, or bruising to R1's left leg on 11/9/25.R1's X ray results, dated 11/9/25, include: Tibia and fibula left 2 views: Normal mineralization. Status post total knee arthroplasty. Questionable non-displaced fracture of the proximal tibial metaphysis. Normal alignment. Diffuse soft tissue phleboliths. Osteoporosis and ankle/foot osteoarthritis noted. Conclusion: questionable non-displaced fracture of the tibia metaphsis (neck portion of a long bone); correlate for site of injury/pain. Dedicated knee radiographs may be useful. Status post knee arthroplasty.R1's MAR/TAR, for 11/9/25, includes:Pain Evaluation Every Shift- Day- 0 out of 10, Evening- 0 out of 10, Evening- blank, Night-0 out of 10. (It is important to note the facility's pain ratings of 0 out of 10, while the hospice ratings are 10 out of 10, 4 out of 10, and 7 out of 10.)Morphine Sulfate Solution 20 mg/ml. Give 0.5ml by mouth every 4 hours as needed for moderate pain/shortness of breath. Administered at 11:15 AM. (It is important to note the facility recorded R1's pain as 0 out of 10 and then administered her as needed pain medication.)R1's Hospice Progress Note, dated 11/10/25 11:04 AM - 11:44 AM Writer collaborated with hospice staff and facility staff including DON B (Director of Nursing) for today's visit. Patient denied shortness of breath. Per patient decreased appetite due to pain. Pain rated 7 out of 10 to left lower extremity. Left lower extremity noted with bruising, light yellow/green in color. Edema noted to lateral aspect of shin/bruised area. +1 to left foot/ankle region, elevated on pillow. Writer asked patient what happened and she replied, I caught my toe on the cement. Per patient, has been using as needed morphine for pain management. +2 to +3 pitting edema noted to right lower extremity. Hoyer lift for transfers. Broda chair for positioning and comfort. Educated staff on when to contact hospice. POA updated on visit.R1's Nurse Practitioner (NP) Note, dated 11/10/25 at 1:30 PM, includes: . seen In follow up on chronic medical conditions. No concerns reported by patient or nursing staff. She has a possible spontaneous fracture, with past medical history including osteoporosis.On 12/16/25 at 3:11 PM, NP J stated that she was told that they didn't believe there was any fall or incident, so she had said it sounded like it was a spontaneous fracture based on her osteoporosis and her other co-morbidities. NP J stated, I used the information I had at the time to diagnose. NP J indicated that she had not been informed of any injury and x-ray said possible fracture, so there wasn't anything real definitive. NP J stated if there was some kind of incident it is possible that it could have contributed to R1's death.R1's MAR/TAR, for 11/10/25, includes:Pain Evaluation Every Shift- Day- 0 out of 10, Evening- 0 out of 10, Evening- 0 out of 10, Night-0 out of 10. (It is important to note the pain rating by facility of 0 out of 10 while hospice rating is 7 out of 10.)Morphine Sulfate Solution 20 mg/ml. Give 0.5ml by mouth every 4 hours as needed for moderate pain/shortness of breath. Administered at 12:03 PM. (It is important to note the facility recorded R1's pain as 0 out of 10 and then administered her as needed pain medication.)R1's Nurse Notes, dated 11/11/25 at 2:42 PM, include: Hospice called to inform them of patient noted extremely tired the last couple of days. Recent vital signs relayed. Patient is awake and alert during conversation but falls asleep while in her room. Patient is also requiring assistance with meals. Hospice states they will have a nurse come see her tomorrow morning.R1's MAR/TAR, for 11/11/25, includes:Pain Evaluation Every Shift- Day- 1 out of 10, Evening- 0 out of 10, Evening- blank, Night-0 out of 10.Morphine Sulfate Solution 20 mg/ml. Give 0.5ml by mouth every 4 hours as needed for moderate pain/shortness of breath. Administered at 8:46 AM. (It is important to note the facility recorded R1's pain as 1 out of 10 and then administered her as needed pain medication.)R1's Hospice Progress Notes, dated 11/12/25 11:54 AM -12:40 PM, includes: .She was calm and comfortable, sleepy, her feet were elevated in bed and since she injured her left leg recently, and she was so tired, I focused on comfort care .R1's Nurse Notes, dated 11/14/25 at 9:26 PM, include: hospice aware, resident has no output. Will be coming back tomorrow to assess further.R1's Hospice Progress Notes, dated 11/14/25 6:45 PM -7:52 PM, included: Patient is on hospice services. Upon arrival collaborated with facility nurse (named in document).Vital signs obtained hypotensive and tachycardic. Patient does not have any indications of urinary retention with assessment. Lungs have crackles and rhonchi in all fields. Heart rate regular, . Has 2 + pitting edema to bilateral lower extremities. Patient is somewhat responsive and attempts to answer questions but appears to be lethargic. She has a history of renal disease. Denies pain or discomfort. Suspect patient may have renal failure due to disease progression.R1's Hospice Progress Note, dated 11/15/25 5:07 PM - 6:08 PM, includes: per facility caregiver patient had an emisis [sic] earlier today. No antimetics [sic] were needed. Patient continues to be fatigued and drowsy throughout the day. No food intake and minimal fluid intake throughout the last 24 hours. She is able to verbalize answers to questions when awake but quickly falls asleep after. She has received as needed lorazepam throughout the day. Encouraged facility caregiver to administer as needed morphine as patient shows labored breathing with accessory muscle use. Denies pain at this time. Due to sudden change in status after left lower calf injury suspect patient may have passed an embolism. She does have urinary output, no other minimal [sic] and concentrated. Lungs continue to have crackles throughout. Call placed to POA with update. She plans to be back in town early tomorrow and will be visiting patient as soon as possible. She is in agreement with caregivers providing comfort focused care only.R1's Nurse Notes, dated 11/15/25 at 11:36 PM, include: Resident with labored respirations- as needed medications given. Hospice notified that oxygen applied at this time.R1's Nurse Note, dated 11/16/25 at 12:36 AM, includes: Resident with no vital signs at this time. Hospice notified.(It is important to note R1's medical record did not contain hospice nurse progress notes or assessments. The facility documentation lacked ongoing assessments when R1 was noted to have a change in condition, all assessments were completed by hospice nurses and not the facility nurses for ongoing monitoring.)R1's Certificate of Death, file date of 11/25/25, includes: . Immediate cause of death: Complications of blunt force trauma of left lower extremity with tibia fracture. Interval between onset and death: 9 days. Date of injury: 11/7/25. Place of injury: Dental office. Manner of death: accident. If injury stated anywhere in cause of death, describe how it occurred: struck leg on door while ambulating.(of note: R1 does not ambulate and requires a full body lift for transfers). On 12/16/25 at 10:24 AM, Surveyor interviewed RR C (Resident Representative) for R1. RR C stated that on 11/7/25, R1 had a dentist appointment but that the facility forgot to call transport so they asked her if they could push R1 to the dentist in her wheelchair. RR C indicated that the dentist's office was only a few blocks away from the facility, and it was a nice day out, so she agreed. RR C stated that R1 uses a Broda chair (a specialized positioning wheelchair for comfort, support, and positioning for individuals with complex medical needs). RR C stated that she thought that they tried to push R1 to the dentist in her Broda chair and not a regular wheelchair, and that they couldn't get the Broda chair through the door to the exam room, so the dentist examined her in the lobby. RR C stated that R1 had a hematoma on her left leg after the dentist appointment on 11/7/25, and that she expected that they would have kept an eye on that. RR C stated and that R1 also complained about a lot of pain in her legs after 11/7/25, but it was mostly ignored by the facility. RR C indicated that R1 was on hospice, and she wanted them to keep her comfortable, but that she never thought the severity of her injury would result in R1's death.On 12/16/25 at 11:04 AM, Surveyor interviewed DON B (Director of Nursing), who stated that the dentist's office was less than a block away from the facility, so that R1 got a ride there and then staff walked her back to the facility because it was a nice day out. DON B indicated that the walk would have taken less than 5 minutes, and that she didn't think R1 was taken in her Broda chair. (Please Note: This would have left R1 unattended by anyone from the facility for a period of time.) On 12/16/25 at 11:09 AM, Surveyor interviewed DR D (Doctor of Dentistry), who stated that the facility brought R1 in with a wheelchair that would not go through the door to his exam room, so he told them they would have to bring her back in a chair that would fit. DR D stated that he was unable to examine her, but that he did talk to her in the waiting room, and did not see that she had bumped her leg. DR D indicated that R1 told him that she walked by herself, but that was obviously not the case, and that R1 had two female staff members with her. DR D asked his assistant, who was there at the time, who also stated that she did not recall R1 bumping her leg, just that she was in a really wide chair. DR D measured both his interior and exterior doors and told Surveyor that the width of his outside door is 5 or 6 inches wider than the width of his interior door so there would have been no problem getting R1 into the building, but there was a problem getting R1 into the exam room. DR D stated that at no time did R1 complain of any pain or say anything about bumping her leg, and that there was no sign of injury while she was in his waiting room.(It is important to note the facility provided no evidence of a safety assessment or positioning assessment being completed for R1 prior to transporting R1 in a wheelchair.)On 12/16/25 at 11:48 AM, Surveyor interviewed ME E (Medical Examiner) for [Name of county], who stated that the information provided to his investigator on 11/16/25 was that when R1 was taken to a dental office in [Town name], that she struck her left leg on the front door. ME E stated that this information was given by the hospice nurse that pronounced the death. ME E stated that his office was notified that the date of injury was 9 days prior, and that she must have hit her leg pretty hard, sustaining pain, bruising, and swelling. ME E indicated that the mobile x-ray showed a non-displaced fracture of the tibia, and that afterwards R1 started to quickly decline with less activity and food intake. ME E stated that prior to 11/7/25, R1 had been more alert and active, and there were no other falls or injuries noted. ME E stated that the conclusion that we draw for the death certificate is based on medical records and not just hearsay of the reporting nurse.On 12/16/25 at 11:59 AM, Surveyor interviewed SSD F (Social Service Director) and BOM G (Business Office Manager), who stated that they went and got R1 from the dentist on 11/7/25. SSD F and BOM G indicated that the dentist was not able to really examine R1 or do any x-rays of her mouth, the dentist just did a verbal visit and recommended that they monitor R1 and treat her for any dental pain. BOM G stated they had no trouble getting R1 in the front door of the dental office and into the lobby BOM G stated that she walked R1 down to the dentist, and then SSD F gave her a ride back to pick R1 up, at which time she walked R1 back to the facility. SSD F indicated that R1 was not in her Broda chair but was in one of the facility's standard transport wheelchairs with foot pedals. BOM G clarified that the wheelchair used to transport R1 was not the standard wheelchair that fits in the van, but one that was a little wider than the standard transport wheelchair. BOM G stated that R1 did not complain of any pain either to or from the walk to the dentist's office. On 12/16/25 at 12:04 PM, Surveyor interviewed DON B and asked about the results of R1's x-ray, which indicated a questionable non-displaced fracture of the proximal tibial metaphysis. DON B stated that she talked to RR C about the x-ray, and that RR C said as long as hospice was keeping R1 comfortable, she did not want to do anything more at that time. DON B indicated that it was a questionable fracture because R1 had osteoporosis and was very immobile. On 12/16/25 at 1:00 PM, Surveyor interviewed hospice RNCM H (Registered Nurse Case Manager), who indicated that LPN I (Licensed Practical Nurse) from the facility called the triage nurse on 11/7/25 at 9:52 PM and reported that R1 had a dentist appointment earlier in the day, had bumped her leg on the doorway, and that there was some bruising but no deformity. RNCM H stated that if something is found before the next hospice visit, if it goes to the on-call nurse and they would go in the next day to assess. RNCM H stated that she did see R1 on 11/8/25, and that she did have some pain in her lower extremities. RNCM H stated that R1 told her that she was out walking and twisted her knee on the sidewalk, but that R1 is non ambulatory. RNCM H stated that R1 was becoming more and more confused over time with her disease process. RNCM H stated that it was her understanding that R1 had gone out to a dentist appointment on 11/7/25, and the next day when she visited R1, R1 said she was having pain in her right extremity. RNCM H indicated that DON B and ADON L (Assistant Director of Nursing) had reported to her that R1 had bruising on her left extremity, not her right extremity. RNCM H stated that she remembered that DON B asked if they knew anything about this bruise because there was no documentation on their end and no knowledge of what happened either, so RNCM H stated that she sent the DON the triage call note and the documentation from their triage nurse via email on 11/10/25. RNCM H stated that it was hospice who ordered the x-ray on 11/9/25, and that note indicated that the patient (R1) was transported and that her left lower leg was bumped and she was experiencing great pain and discomfort, and that there was localized edema and bruising to the lateral aspect of the lower extremity. RNCM H indicated that the results of the x-ray were a suspected fracture. RNCM H stated that she would have expected that the staff at the facility would have assessed R1's leg as well and pass that information on to the hospice nurse. On 12/16/25 at 1:25 PM, Surveyor interviewed DON B. DON B indicated that she was told that R1 had bruising to her leg but no discoloration. DON B stated that the x-ray was ordered because R1 was experiencing increased pain. DON B indicated that R1 always had pain all over, so it was difficult to determine when she was having increased pain. Surveyor asked DON B what she would expect staff to do if a resident endorsed having increased pain. DON B stated that she would want to know where the pain is, what it looks like, if there is redness or warmth. Surveyor asked DON B if she would expect staff to assess for ROM (Range of Motion). DON B stated yes, they should check for movement, but that R1 had no ability to lift her leg. DON B stated that staff should offer pain medication and see if it was effective. Surveyor pointed out to DON B that none of that information was anywhere in R1's medical record. DON B stated that they should have it. Surveyor asked DON B if she had the email correspondence from hospice about their visits to R1 regarding the increased pain to the leg. DON B stated that she usually tries to talk to hospice and not put any of the resident's names in an email. Surveyor asked if the facility should keep hospice notes as part of the medical record. DON B indicated that yes, they should have those. On 12/16/25 at 2:24 PM, Surveyor interviewed LPN I (Licensed Practical Nurse). LPN I stated that on 11/7/25 she started her shift at 6:00 PM, and that it was reported to her that R1 went out to the dentist and when she came back she had complaints of pain in her left leg. LPN I stated that she wasn't sure at that point because R1 had chronic pain, so she was unaware if it was new or a chronic issue. LPN I stated that when she went to see R1 in her room, she was in bed and seemed fine. LPN I indicated that R1 did have pain with movement when the staff would change and turn her that night. LPN I stated that R1 maybe had a little redness to her left lower leg so she called hospice. LPN I indicated that hospice asked her if it was uncontrolled pain, and she said no, that R1 was fine, nothing that was not her normal, and that she slept for me all night. LPN I stated that she gave R1 her PRN tramadol that she took every single night and she felt fine and slept all night. LPN I stated that it was LPN K who reported to her at the start of her shift that R1 had went out to the dentist and came back, and that the aides told her R1 was having some pain. LPN I indicated that LPN K had said that possibly R1 bumped her leg on the doorway because R1 is a bigger woman and her wheelchair was wider than the normal wheelchair. LPN I stated she did not know if that was true or not, that it was more of a hearsay thing that R1 had bumped her leg at the dentist's office. Surveyor asked LPN I to describe the bruise she noted on R1's leg, and LPN I stated that what she saw was some redness, like maybe a bruise was starting, and maybe some mild swelling, but that she never saw it again after that night. LPN I indicated that usually they would do an incident report for bruising of unknown origin but that she was not positive if an incident report was done in this situation, and that she herself had not completed one. Surveyor indicated that there was no

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, and including injuries of unknown source, are reported immediately for 1 of 3 residents (R) reviewed for abuse (R1).R1 had an injury of unknown source on 11/7/25 and 11/9/25 that the facility was aware of and did not report the injuries of unknown source to the State Agency. This is evidenced by: The facility's policy Abuse Prevention and Reporting Policy, dated 11/25, includes: I. Purpose To ensure all residents are free from abuse, neglect. This policy establishes clear expectations for the prevention, identification, investigation, and reporting of all allegations or reasonable suspicions of mistreatment. IV. Identification and Reporting 3. Nursing staff must report bruising of unknown origin or other abnormalities. 4. The nursing supervisor is responsible for assessing and reporting such occurrences. 8. Reporting to Other Agencies Wisconsin Division of Quality Assurance (DQA): Must receive the initial allegation report immediately and a five-day final investigation report including findings and corrective actions. R1 admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a progressive brain disorder affecting movement), neuralgia (intense nerve pain), dementia (a cognitive decline affecting memory, thinking, language, and daily function), fibromyalgia (a chronic condition causing widespread body pain, fatigue, sleep issues, and cognitive difficulties), and history of falling. R1's 11/7/25 2:47 PM nurse progress note states, Patient was assessed by DR D (DDS) (Dentist) today. No pain or discomfort reported during assessment. [Company Name] x-ray report was faxed, no new orders were given at this time, dentist recommended no further action unless tooth bother patient. POA [Name] was informed and is in agreement with no further dental work at this time. On 12/16/25 at 11:59 AM, Surveyors interviewed BOM G (Business Office Manager). BOM G indicated on 11/7/25, she used a transport wheelchair and wheeled R1 to the dentist for an appointment. BOM G indicated the dental office was only a couple of blocks from the facility. BOM G indicated R1's wheelchair was too wide to fit through the exam room door, so the dentist provided information to R1 and BOM G in the lobby. BOM G indicated she wheeled R1 back to the facility. BOM G indicated there was no incident that occurred during the transportation to, at, or from the dental office. On 12/16/25 at 11:09 AM, Surveyors interviewed DR D (Dentist) regarding R1's 11/7/25 visit. DR D indicated 2 staff members walked R1 to his office and he spoke with them at length about what he would need to be able to see R1, including a smaller wheelchair. DR D indicated R1's wheelchair was too wide to fit through the exam room door. DR D indicated he spoke with R1 in the lobby. DR D measured both the main door and the exam room door. DR D indicated the main door is 5 or 6 inches wider than the exam door so there should have been no difficulties getting the wider wheelchair into the main door. DR D and his staff do not recall an incident or R1 stating she bumped her leg. DR D indicated R1 had no sign of injury while R1 was waiting in his lobby. R1's hospice note, written by HRN M (Hospice Registered Nurse) dated 11/7/25 at 5:30 PM, includes: Patient verbalized pain to RLE (Right Lower Extremity). Writer asked patient what happened, replied I was out for a walk today and twisted my knee on the uneven sidewalk. Patient is non-ambulatory, hoyer lift (Full body mechanical lift) for transfers and broda chair (a specialized wheelchair designed for comfort, support, and safety) for positioning and comfort. Edema noted to BLE (Bilateral Lower Extremity), 3+ to RLE, 2+ to LLE (Left Lower Extremity). no issues reported by staff. R1's hospice triage note, written by HRN N (Hospice Registered Nurse) dated 11/7/25 at 9:52 PM, includes: LPN I (Licensed Practical Nurse), facility, called to pass on that patient was at dentist today and they bumped her leg on the doorway. She is complaining of pain, but has bruising, No deformity. Offered nurse visit, but patient is currently sleeping and staff report that only time she complains of pain is with touching her leg with the bruising and pain medication as needed is helping.On 12/16/25 at 2:24 PM, Surveyors interviewed LPN I (Licensed Practical Nurse) regarding R1 on 11/7/25. LNP I indicated, LPN K stated in report that R1 had bumped her leg at the dentist and when R1 returned she had complained of pain to her leg. LPN I stated when she went to R1's room, R1 was fine. LPN I indicated R1 had pain with movement when the CNAs would change or turn R1. LPN I indicated R1 had redness to her leg like it was starting to bruise and there was some mild swelling. LPN I indicated staff usually complete and incident report for bruising of unknown origin. LPN I indicated she was unsure if an incident report was completed. LPN I indicated if she charted on this, it would be under R1's progress notes. Of note, R1 does not have a nurse progress note from LPN I regarding this on 11/7/25.On 12/16/25 at 3:35 PM, Surveyors interviewed LPN K regarding R1. LPN K indicated later in the shift on 11/7/25, after R1 had returned from the dentist, LPN K went into R1's room. LPN K stated a hospice nurse was in with R1. LPN K indicated R1 complained of leg pain and LPN K looked at R1's leg. LPN K stated the leg was swollen and there was some discoloration. LPN K indicated she gave R1 pain medication as R1 requested. LPN K indicated she did not know what caused the swelling, discoloration, and pain but that R1 stated the ride to the dentist was rough. LPN K stated from what R1 had said LPN K assumed R1 had bumped into something but R1 wasn't specific so LPN K did not get exactly what had happened. LPN K stated BOM G (Business office Manager) transported R1 and did not mention anything about R1 bumping her leg. LPN K indicated the hospice nurse was in the room and aware of the situation and LPN K did inform DON L (Assistant Director of Nursing). LPN K indicated she did not document a note because she thought DON L would since LPN K believed DON L assessed R1.Of note, R1 does not have a nurse progress note regarding bumped her leg at the dentist from LPN K on 11/7/25. There is no incident report indicating R1 had an incident occur. On 12/16/25 at 3:55 PM, Surveyors interviewed DON L (Assistant Director of Nursing) regarding R1. DON L indicated LPN K informed DON L that R1 was having new pain to her foot. DON L indicated LPN K stated R1 told LPN K that R1 was walking and got hurt. DON L stated since R1 was not ambulatory, it was a flag to go see what happened. DON L indicated she went to R1's room and the hospice nurse was in there. DON L indicated the hospice nurse had already done an assessment and reported her assessment to DON L. DON L indicated she uncovered R1's legs and positioned R1's legs onto pillows. DON L indicated R1 did not complain of pain and DON L did not recall seeing any swelling. DON L indicated she does not recall if she completed an assessment for R1. R1's skin sweep sheet, undated, includes shear (BL) (Bilateral) buttock, LLE (Left Lower Extremity) anterior - faint bruise. No new skin condition. NHA A (Nursing Home Administrator) indicated the skin sweep was conducted on 11/8/25. R1's 11/9/25 2:34 PM nurse progress notes state, Hospice called to be informed that patient continues to have increased pain and requesting to be sent out. Patient was evaluated and X ray was ordered by [Name] hospice. Patient and POA informed. R1's 11/9/25 4:51 PM R1's X-ray results include, Conclusion: 1. Questionable non-displaced fracture of the proximal tibial metaphysis; correlate for sit of injury/pain. Dedicated knee radiographs may be useful.On 12/16/25 at 3:55 PM, Surveyors interviewed DON B (Director of Nursing). DON B indicated there was nothing showing R1 bumped her leg and staff did not know what happened. DON B indicated there was no event that the facility is aware of that would have caused the bruise or possible fracture. DON B indicated the bruise and possible fracture are injuries of unknown source. DON B indicated this was not reported as an injury of unknown source. On 12/16/25 at 5:05 PM, Surveyors interviewed NHA A (Nursing Home Administrator) regarding R1's injuries. NHA A indicated R1's injuries were injuries of unknown source and should have been reported. NHA A indicated this was not reported.R1 had an injury of unknown source on 11/7/25 and 11/9/25 that the facility was aware of and did not report the injuries of unknown source to the State Agency.

Based on interview and record review, the facility did not ensure that in response to injuries of unknown source, that all alleged violations are thoroughly investigated to rule out the potential for abuse for 1 or 3 residents reviewed (R1).R1 had an injury of unknown source on 11/7/25 and 11/9/25 that the facility was aware of and did not complete a thorough investigation of these injuries. This is evidenced by: The facility's policy Abuse Prevention and Reporting Policy, dated 11/25, includes: I. Purpose To ensure all residents are free from abuse, neglect. This policy establishes clear expectations for the prevention, identification, investigation, and reporting of all allegations or reasonable suspicions of mistreatment. IV. Identification and Reporting 3. Nursing staff must report bruising of unknown origin or other abnormalities. 4. The nursing supervisor is responsible for assessing and reporting such occurrences. V. Protection of Residents Pending Investigation The facility will take immediate and effective measures to protect all residents from potential abuse, neglect. while any allegation or investigation is in process. Protection begins the moment an allegation is made or a suspicion is reported and continues until the investigation is fully resolved. All staff must cooperate fully with internal and external investigative authorities. The facility will immediately evaluate the emotional and physical well-being of the alleged victim(s) and provide support through Social Services, counseling, or other appropriate interventions. All protective measure taken shall be documented in detail in the incident report, including the time, date, and name of the staff member implementing the intervention. The Administrator and/or Director of Nursing will reviewed protective actions daily until the investigation is complete to ensure continued safety and compliance. VI. Final Reporting and Follow-Up 1. Investigator shall obtain and review documentation, interview witnesses, and maintain confidentiality until investigation conclusion. R1 admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a progressive brain disorder affecting movement), neuralgia (intense nerve pain), dementia (a cognitive decline affecting memory, thinking, language, and daily function), fibromyalgia (a chronic condition causing widespread body pain, fatigue, sleep issues, and cognitive difficulties), and history of falling. R1's 11/7/25 2:47 PM nurse progress note states, Patient was assessed by DR D DDS (Dentist) today. No pain or discomfort reported during assessment. [Company Name] x-ray report was faxed, no new orders were given at this time, dentist recommended no further action unless tooth bother patient. POA [Name] was informed and is in agreement with no further dental work at this time. On 12/16/25 at 11:59 AM, Surveyors interviewed BOM G (Business Office Manager). BOM G indicated on 11/7/25, she used a transport wheelchair and wheeled R1 to the dentist for an appointment. BOM G indicated the dental office was only a couple of blocks from the facility. BOM G indicated R1's wheelchair was too wide to fit through the exam room door, so the dentist provided information to R1 and BOM G in the lobby. BOM G indicated she wheeled R1 back to the facility. BOM G indicated there was no incident that occurred during the transportation to, at, or from the dental office. On 12/16/25 at 11:09 AM, Surveyors interviewed DR D (Dentist) regarding R1's 11/7/25 visit. DR D indicated 2 staff members walked R1 to his office and he spoke with them at length about what he would need to be able to see R1, including a smaller wheelchair. DR D indicated R1's wheelchair was too wide to fit through the exam room door. DR D indicated he spoke with R1 in the lobby. DR D measured both the main door and the exam room door. DR D indicated the main door is 5 or 6 inches wider than the exam door so there should have been no difficulties getting the wider wheelchair into the main door. DR D and his staff do not recall an incident or R1 stating she bumped her leg. DR D indicated R1 had no sign of injury while R1 was waiting in his lobby. R1's hospice note, written by HRN M (Hospice Registered Nurse) dated 11/7/25 5:30 PM, includes: Patient verbalized pain to RLE (Right Lower Extremity). Writer asked patient what happened, replied I was out for a walk today and twisted my knee on the uneven sidewalk. Patient is non-ambulatory, hoyer lift (Full body mechanical lift) for transfers and broda chair (a specialized wheelchair designed for comfort, support, and safety) for positioning and comfort. Edema noted to BLE (Bilateral Lower Extremity), 3+ to RLE, 2+ to LLE (Left Lower Extremity). no issues reported by staff. R1's hospice triage note, written by HRN N (Hospice Registered Nurse) dated 11/7/25 9:52 PM, includes: LPN I (Licensed Practical Nurse), facility, called to pass on that patient was at dentist today and they bumped her leg on the doorway. She is complaining of pain, but has bruising, No deformity. Offered nurse visit, but patient is currently sleeping and staff report that only time she complains of pain is with touching her leg with the bruising and pain medication as needed is helping.On 12/16/25 at 2:24 PM, Surveyors interviewed LPN I (Licensed Practical Nurse) regarding R1 on 11/7/25. LNP I indicated, LPN K stated in report that R1 had bumped her leg at the dentist and when R1 returned she had complained of pain to her leg. LPN I stated when she went to R1's room, R1 was fine. LPN I indicated R1 had pain with movement when the CNAs would change or turn R1. LPN I indicated R1 had redness to her leg like it was starting to bruise and there was some mild swelling. LPN I indicated staff usually complete and incident report for bruising of unknown origin. LPN I indicated she was unsure if an incident report was completed. LPN I indicated if she charted on this, it would be under R1's progress notes. Of note, R1 does not have a nurse progress note from LPN I on 11/7/25. On 12/16/25 at 3:35 PM, Surveyors interviewed LPN K regarding R1. LPN K indicated later in the shift on 11/7/25, after R1 had returned from the dentist, LPN K went into R1's room. LPN K stated a hospice nurse was in with R1. LPN K indicated R1 complained of leg pain and LPN K looked at R1's leg. LPN K stated the leg was swollen and there was some discoloration. LPN K indicated she gave R1 pain medication as R1 requested. LPN K indicated she did not know what caused the swelling, discoloration, and pain but that R1 stated the ride to the dentist was rough. LPN K stated from what R1 had said LPN K assumed R1 had bumped into something but R1 wasn't specific so LPN K did not get exactly what had happened. LPN K stated BOM G transported R1 and did not mention anything about R1 bumping her leg. LPN K indicated the hospice nurse was in the room and aware of the situation and LPN K did inform DON L (Assistant Director of Nursing). LPN K indicated she did not document a note because she thought DON L would since LPN K believed DON L assessed R1. On 12/16/25 at 3:55 PM, Surveyors interviewed DON L (Assistant Director of Nursing) regarding R1. DON L indicated LPN K informed DON L that R1 was having new pain to her foot. DON L indicated LPN K stated R1 told LPN K that R1 was walking and got hurt. DON L stated since R1 was not ambulatory, it was a flag to go see what happened. DON L indicated she went to R1's room and the hospice nurse was in there. DON L indicated the hospice nurse had already done an assessment and reported her assessment to DON L. DON L indicated she uncovered R1's legs and positioned R1's legs onto pillows. DON L indicated R1 did not complain of pain and DON L did not recall seeing any swelling. DON L indicated she does not recall if she completed an assessment for R1. R1's skin sweep sheet, undated, includes shear (BL) (Bilateral) buttock, LLE (Left Lower Extremity) anterior - faint bruise. No new skin condition. NHA A (Nursing Home Administrator) indicated the skin sweep was conducted on 11/8/25. R1's 11/9/25 2:34 PM nurse progress notes state, Hospice called to be informed that patient continues to have increased pain and requesting to be sent out. Patient was evaluated and X ray was ordered by [Name] hospice. Patient and POA informed. R1's 11/9/25 4:51 PM X-ray results include, Conclusion: 1. Questionable non-displaced fracture of the proximal tibial metaphysis; correlate for sit of injury/pain. Dedicated knee radiographs may be useful.On 12/16/25 at 3:55 PM, Surveyors interviewed DON B (Director of Nursing). DON B indicated there was nothing showing R1 bumped her leg and staff did not know what happened. DON B indicated there was no event that the facility is aware of that would have caused the bruise or possible fracture. DON B indicated the bruise and possible fracture are injuries of unknown source. DON B indicated she did not feel this was abuse. DON B indicated this was not investigated as an injury of unknown source. On 12/16/25 at 5:05 PM, Surveyors interviewed NHA A (Nursing Home Administrator) regarding R1's injuries. NHA A indicated R1's injuries were injuries of unknown source and should have been investigated. NHA A indicated these injuries of unknown source were not investigated.

Based on interview and record review the facility did not maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for 1 of 3 sampled residents (R1) for change of condition.During interviews staff indicated R1 had experienced an increase in pain, a bruise, and swelling to her lower left extremity on 11/7/25. Hospice Nurse Notes reflect R1 was experiencing pain 9 out of 10, 10 out of 10, and 7 out of 10. R1's medical record does not accurately reflect her pain.R1 reported an event happened while she was off premises at an appointment with one or two staff members. R1 reported the event with inconsistent details to facility staff and to hospice staff. Staff failed to capture R1's allegation/details of the event in her medical record.R1 had a dental appointment on 11/7/25 and R1's medical record contained no documentation from this provider.R1's medical record did not contain hospice nurse progress notes.Evidenced by:The facility did not provide a policy related to charting, documentation, or medical record filing.R1 admitted to the facility on [DATE] and had the following diagnoses: Type 2 Diabetes Mellitus with diabetic neurological complications, neuralgia and neuritis, chronic kidney disease stage 3, fibromyalgia, epilepsy, history of falling, morbid obesity, age related osteoporosis, and Parkinson's disease. R1 passed away on 11/16/25 at 12:45 AM.R1's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 9/5/25 indicates R1's cognition is moderately impaired with a BIMS (Brief Interview for Mental Status) score of 12 out of 15.R1's Hospice Progress Note, dated 11/7/25 9:52 PM, includes: on call triage note: 9:51 PM central time, LPN I, from facility called to pass on that patient was at dentist today and they bumped her leg on the doorway. She is complaining of pain, . has bruising. No deformity. Offered nurse visit, but patient is currently sleeping and staff report that only time she complains of pain is with touching her leg with the bruising and pain medication as needed is helping. LPN I will return call if they would prefer a visit or with any changes.(It is important to note R1's medical record did not have documentation about this event, did not contain a description of R1's bruise, did not have accurate pain assessments, did not have an indication for use of R1's as needed pain medications, did not have a Registered Nurse Assessment, did not contain continued monitoring after change in condition was identified, and did not contain Hospice Nurse Notes or Hospice Nurse Assessments at the time of survey.)R1's Hospice Progress Note, dated 11/9/25 9:30 AM - 11:00 AM, includes:. as needed visit for left lower leg pain. Assessment of left lower leg demonstrates localized edema and bruising to the lateral aspect. Patient does not tolerate movement and cries out with even the slightest movement. Patient, facility, and POA requesting an x ray. pain: yes. pain score: 7 out of 10. goal pain: 4 out of 10. worst pain in the last 24 hours: 10 out of 10. frequency of pain: all of the time. Abnormal musculoskeletal findings: pain/stiffness in left lower extremity. Indicate reason for pain: Patient bumped her leg and has edema and bruising. What discipline did you communicate with: Registered Nurse/Supervisor. On call visit due to unexpected status change involving an adverse event. Indicate other unexpected status change: Patient's left lower extremity was bumped during transport on 11/7/25 resulting in increased pain with movement, bruising, and edema.(It is important to note R1's medical record does not reflect R1's pain.)R1's Nurse Note, dated 11/9/25 at 2:34 PM, includes: Hospice called to be informed that patient continues to have increased pain and requesting to be sent out. Patient was evaluated and X ray was ordered by hospice. Patient and POA informed.(It is important to note R1's medical record does not reflect the increase in pain.)R1's MAR/TAR, for 11/9/25, includes:Pain Evaluation Every Shift- Day- 0 out of 10, Evening- 0 out of 10, Evening- blank, Night-0 out of 10. (It is important to note R1's medical record does not accurately reflect her pain ratings as the facility's pain ratings are 0 out of 10, while the hospice ratings are 10 out of 10, 4 out of 10, and 7 out of 10.)Morphine Sulfate Solution 20 mg/ml. Give 0.5ml by mouth every 4 hours as needed for moderate pain/shortness of breath. Administered at 11:15 AM. (It is important to note the facility recorded R1's pain as 0 out of 10 and then administered her as needed pain medication.)R1's Hospice Progress Note, dated 11/10/25 11:04 AM - 11:44 AM Writer collaborated with hospice staff and facility staff including DON B (Director of Nursing) for today's visit. Writer entered patient's room. Patient sleeping. Writer introduced self and reason for visit. Patient agreeable to visit. Lethargic for remainder of visit. Patient denied shortness of breath. Per patient decreased appetite due to pain. Pain rated 7 out of 10 to left lower extremity. Left lower extremity noted with bruising, light yellow/green in color. Edema noted to lateral aspect of shin/bruised area. +1 to left foot/ankle region, elevated on pillow. Writer asked patient what happened and she replied, I caught my toe on the cement. Per patient, has been using as needed morphine for pain management. +2 to +3 pitting edema noted to right lower extremity. Hoyer lift for transfers. Broda chair for positioning and comfort. Educated staff on when to contact hospice. POA updated on visit.R1's MAR/TAR, for 11/10/25, includes:Pain Evaluation Every Shift- Day- 0 out of 10, Evening- 0 out of 10, Evening- 0 out of 10, Night-0 out of 10. (It is important to note the pain rating by facility of 0 out of 10 while hospice rating is 7 out of 10.)Morphine Sulfate Solution 20 mg/ml. Give 0.5ml by mouth every 4 hours as needed for moderate pain/shortness of breath. Administered at 12:03 PM. (It is important R1's medical record did not capture R1's pain as they rated it as 0 out of 10 and then administered her as needed pain medication.)On 12/16/25 at 3:55 PM ADON L (Assistant Director of Nursing) stated that the reason that she didn't document an assessment on R1 was that she was not in charge of fully documenting all the assessments, and she went in and talked to R1 about her pain, but that she didn't go in and do a full assessment. Surveyor asked ADON L if she should have documented what was discussed with R1 and what she did and what she was going to do somewhere in R1's medical record. ADON L stated that change of condition in her mind because she didn't physically see anything wrong with R1's leg. ADON L indicated R1's medical record should accurately reflect her pain, should contain hospice nurse notes, should contain Medical Doctor after visit summaries, and should include descriptions of injuries, and descriptions of possible events that are reported, especially if they lead to an increase in pain or a bruise/other injury.On 12/16/25 at 2:24 PM, Surveyor interviewed LPN I (Licensed Practical Nurse). LPN I stated that on 11/7/25 she started her shift at 6:00 PM, and that it was reported to her that R1 went out to the dentist and when she came back she had complaints of pain in her left leg. LPN I stated that she wasn't sure at that point because R1 had chronic pain, so she was unaware if it was new or a chronic issue. LPN I stated that when she went to see R1 in her room, she was in bed and seemed fine. LPN I indicated that R1 did have pain with movement when the staff would change and turn her that night. LPN I stated that R1 maybe had a little redness to her left lower leg so she called hospice. LPN I indicated that hospice asked her if it was uncontrolled pain, and she said no, that R1 was fine, nothing that was not her normal, and that she slept for me all night. LPN I stated that she gave R1 her PRN tramadol that she took every single night and she felt fine and slept all night. LPN I stated that it was LPN K who reported to her at the start of her shift that R1 had went out to the dentist and came back, and that the aides told her R1 was having some pain. LPN I indicated that LPN K had said that possibly R1 bumped her leg on the doorway because R1 is a bigger woman and her wheelchair was wider than the normal wheelchair. LPN I stated she did not know if that was true or not, that it was more of a hearsay thing that R1 had bumped her leg at the dentist's office. Surveyor asked LPN I to describe the bruise she noted on R1's leg, and LPN I stated that what she saw was some redness, like maybe a bruise was starting, and maybe some mild swelling, but that she never saw it again after that night. LPN I indicated that usually they would do an incident report for bruising of unknown origin but that she was not positive if an incident report was done in this situation, and that she herself had not completed one. Surveyor indicated that there was no RN working the night shift on 11/7/25, and she was unaware if an RN had done an assessment on 11/7/25. LPN I stated that there was an RN working the day shift on 11/8/25 who may have done an assessment, but she was not positive. LPN I stated that she did not do any Range of Motion (ROM) or passive ROM with R1, because she couldn't really move her legs. LPN I stated that the length of R1's legs looked normal to me. Surveyor asked LPN I if she had documented any of this in R1's medical record, and LPN I stated that she thought she had put in a progress note. (of note: evidence of documentation of an assessment was not provided)On 12/16/25 at 1:25 PM, Surveyor interviewed DON B (Director of Nursing) . DON B indicated that she was told that R1 had bruising to her leg but no discoloration. DON B stated that the x-ray was ordered because R1 was experiencing increased pain. DON B indicated R1's medical record should accurately reflect R1's pain. DON B indicated staff are to document no findings if they do not have finding on an assessment. Surveyor asked if the facility should keep hospice notes as part of the medical record. DON B indicated that yes, they should have those. Surveyor asked DON B if she expected the staff to document in the medical record when they call hospice or a medical doctor. DON B stated yes, that was her expectation. Surveyor asked DON B if a resident has an appointment and is leaving the facility with staff, should that be documented in the medical record. DON B stated that they have a transport log excel spreadsheet for that, but that yes, it probably should be documented in the resident's chart. Surveyor asked DON B if the hospice notes should be part of the resident's medical record. DON B stated yes, and that she could see that some were missing in R1's chart. Surveyor asked DON B if R1 ever had zero pain, and DON B indicated that with R1's history of fibromyalgia and osteoporosis, she would not have a zero-pain rating.On 12/16/25 at 5:05 PM NHA A (Nursing Home Administrator) indicated R1's medical record is not complete. Surveyor asked NHA A if she would expect the staff to chart an assessment even if there were no findings, and NHA A stated yes, that was her expectation. Surveyor asked NHA A what she would expect the staff to do with increased monitoring of R1's leg. NHA A stated that she would expect that the staff check on R1's leg every two hours when they reposition her and yes, she would expect them to document that. Surveyor asked NHA A if she would expect resident pain ratings to be documented accurately. NHA A stated yes, that was her expectation. Surveyor asked if a resident states a pain rating of zero, should they be given PRN morphine. NHA A indicated no, that would not be appropriate. NHA A stated that it was her expectation if a staff is giving morphine, that they would evaluate the pain and give the medication based on the pain scale and also later follow up to see if the medication was effective. Surveyor asked NHA A if a pain rating of zero would be accurate for R1. NHA A stated that R1 was very up and down on pain, and that some days she would complain of pain and other days she would be fine. However, NHA A stated that she did not think a pain rating of zero would be accurate for R1, as she was never without pain. NHA A stated that she 100% agreed that the documentation was lacking in this instance. On 12/17/25 at 8:30 AM NHA A indicated she is still trying to coordinate with hospice to get R1's nurse progress notes and assessments to add to R1's medical record. NHA A indicated these documents should have been in R1's medical record.(It is important to note Surveyor filled out a release form on 12/16/25 and obtained a copy of R1's hospice records from the hospice agency on 12/17/25.)Cross Reference F684

Based on interview and record review, the facility did not ensure accurate reporting of the mandatory submission of staffing information based on payroll data to the Centers for Medicare & Medicaid Services (CMS.) This has the potential to affect all 65 residents residing within the facility. The facility failed to enter accurate data in their Payroll Based Journal (PBJ) reporting and triggered for four fiscal year quarters for excessively low weekend staffing, triggered one fiscal year quarter for failure to have licensed nursing coverage 24 hours a day, and triggered for one fiscal year quarter for failure to have RN (registered nurse) hours each day Evidenced by: According to https://www.cms.gov/medicare/quality/nursing-home-improvement/staffing-data-submissionExample the Centers for Medicare & Medicaid Services (CMS) has long identified staffing as one of the vital components of a nursing home's ability to provide quality care. CMS has utilized staffing data for a myriad of purposes in an effort to more accurately and effectively gauge its impact on quality of care in nursing homes . Therefore, CMS has developed a system for facilities to submit staffing information - Payroll Based Journal (PBJ). This system allows staffing information to be collected on a regular and more frequent basis than previously collected. It is auditable to ensure accuracy . The first mandatory reporting period began July 1,2016 . The deadlines for each reporting period are as follows: Fiscal Quarter 1-October 1- December 31 due February 14, Fiscal Quarter 2- January 1- March 31 due May 15, Fiscal Quarter 3- April 1 - June 30 due August 14, Fiscal Quarter 4- July- September 30 due November 14 . November 1, 2017, CMS began posting a public use file containing PBJ staffing data submitted by long term care facilities. The file includes the hours nursing staff are paid to work each day, for each facility. The categories of nursing staff include director of nursing, registered nurses with administrative duties, registered nurses, licensed practical nurses with administrative duties, licensed practical nurses, certified nurse aides, medication aides, and nurse aides in training. The file also includes a facility's census for each day within the quarter as calculated using the minimum data set (MDS) submission. Example 1: CMS's PBJ Staffing Data Report, for fiscal year quarter 1 2024 (October 1 - December 31), includes: This Staffing Report identifies areas of concern that will be triggered . requires follow-up during survey . Excessively Low Weekend Staffing: Triggered - Submitted Weekend Staffing data is excessively low . Possible reasons for suppressed metrics: Invalid data, Facility is too new to rate, Special Focus Facility . Facility failed to provide Surveyor a copy of CASPER Report 1702D, Individual Daily Staffing Report from 10/1/2024-12/31/24. (It is important to note this report would have showed the hours that were reported to CMS.) Example 2: CMS's PBJ Staffing Data Report, for fiscal year quarter 3 2024 (April 1 - June 30), includes: This Staffing Report identifies areas of concern that will be triggered . requires follow-up during survey . One Star Staffing Rating: Triggered-Star Staffing Rating Equals 1 . Excessively Low Weekend Staffing: Triggered - Submitted Weekend Staffing data is excessively low . Possible reasons for suppressed metrics: Invalid data, Facility is too new to rate, Special Focus Facility . Facility failed to provide Surveyor a copy of CASPER Report 1702D, Individual Daily Staffing Report from 4/1/24-6/30/24. (It is important to note this report would have showed the hours that were reported to CMS.) Example 3: CMS's PBJ Staffing Data Report, for fiscal year quarter 2 2024 (January 1 - March 31), includes: This Staffing Report identifies areas of concern that will be triggered . requires follow-up during survey . Excessively Low Weekend Staffing: Triggered - Submitted Weekend Staffing data is excessively low . Possible reasons for suppressed metrics: Invalid data, Facility is too new to rate, Special Focus Facility . Facility failed to provide Surveyor a copy of CASPER Report 1702D, Individual Daily Staffing Report from 1/1/24-3/31/24. (It is important to note this report would have showed the hours that were reported to CMS.) Example 4: CMS's PBJ Staffing Data Report, for fiscal year quarter 4 2024 (July 1 - September 30), includes: This Staffing Report identifies areas of concern that will be triggered . requires follow-up during survey . One Star Staffing Rating: Triggered-Star Staffing Rating Equals 1 . Excessively Low Weekend Staffing: Triggered-Submitted Weekend Staffing data is excessively low . Failed to have Licensed Nursing Coverage 24 Hours/Day: Triggered-Four or More Days Within the Quarter with less than 24 Hours/Day Licensed Nursing Coverage. See Infraction Dates . Possible reasons for suppressed metrics: Invalid data, Facility is too new to rate, Special Focus Facility . Infraction Dates: No RN (Registered Nurse) Hours: 07/01 (MO); 07/02 (TU); 07/03 (WE); 07/04 (TH); 07/05 (FR); 07/06 (SA); 07/07 (SU); 07/08 (MO); 07/09 (TU); 07/10 (WE); 07/11 (TH); 07/12 (FR); 07/13 (SA); 07/14 (SU); 07/15 (MO); 07/16 (TU); 07/17 (WE); 07/18 (TH); 07/19 (FR); 07/20 (SA); 07/21 (SU); 07/22 (MO); 07/23 (TU); 07/24 (WE); 07/25 (TH); 07/26 (FR); 07/27 (SA); 07/28 (SU); 07/29 (MO); 07/30 (TU); 07/31 (WE) 08/01 (TH); 08/02 (FR); 08/03 (SA); 08/04 (SU); 08/05 (MO); 08/06 (TU); 08/07 (WE); 08/08 (TH); 08/09 (FR); 08/10 (SA); 08/11 (SU); 08/12 (MO); 08/13 (TU); 08/14 (WE); 08/15 (TH); 08/16 (FR); 08/17 (SA); 08/18 (SU); 08/19 (MO); 08/20 (TU); 08/21 (WE); 08/22 (TH); 08/23 (FR); 08/24 (SA); 08/25 (SU); 08/26 (MO); 08/27 (TU); 08/28 (WE); 08/29 (TH); 08/30 (FR); 08/31 (SA) 09/01 (SU); 09/02 (MO); 09/03 (TU); 09/04 (WE); 09/05 (TH); 09/06 (FR); 09/07 (SA); 09/08 (SU); 09/09 (MO); 09/10 (TU); 09/11 (WE); 09/12 (TH); 09/13 (FR); 09/14 (SA); 09/15 (SU); 09/16 (MO); 09/17 (TU); 09/18 (WE); 09/19 (TH); 09/20 (FR); 09/21 (SA); 09/22 (SU); 09/23 (MO); 09/24 (TU); 09/25 (WE); 09/26 (TH); 09/27 (FR); 09/28 (SA); 09/29 (SU); 09/30 (MO) Failed to have Licensed Nursing Coverage 24 Hours/Day: 07/01 (MO); 07/02 (TU); 07/03 (WE); 07/04 (TH); 07/05 (FR); 07/06 (SA); 07/07 (SU); 07/08 (MO); 07/09 (TU); 07/10 (WE); 07/11 (TH); 07/12 (FR); 07/13 (SA); 07/14 (SU); 07/15 (MO); 07/16 (TU); 07/17 (WE); 07/18 (TH); 07/19 (FR); 07/20 (SA); 07/21 (SU); 07/22 (MO); 07/23 (TU); 07/24 (WE); 07/25 (TH); 07/26 (FR); 07/27 (SA); 07/28 (SU); 07/29 (MO); 07/30 (TU); 07/31 (WE) 08/01 (TH); 08/02 (FR); 08/03 (SA); 08/04 (SU); 08/05 (MO); 08/06 (TU); 08/07 (WE); 08/08 (TH); 08/09 (FR); 08/10 (SA); 08/11 (SU); 08/12 (MO); 08/13 (TU); 08/14 (WE); 08/15 (TH); 08/16 (FR); 08/17 (SA); 08/18 (SU); 08/19 (MO); 08/20 (TU); 08/21 (WE); 08/22 (TH); 08/23 (FR); 08/24 (SA); 08/25 (SU); 08/26 (MO); 08/27 (TU); 08/28 (WE); 08/29 (TH); 08/30 (FR); 08/31 (SA) 09/01 (SU); 09/02 (MO); 09/03 (TU); 09/04 (WE); 09/05 (TH); 09/06 (FR); 09/07 (SA); 09/08 (SU); 09/09 (MO); 09/10 (TU); 09/11 (WE); 09/12 (TH); 09/13 (FR); 09/14 (SA); 09/15 (SU); 09/16 (MO); 09/17 (TU); 09/18 (WE); 09/19 (TH); 09/20 (FR); 09/21 (SA); 09/22 (SU); 09/23 (MO); 09/24 (TU); 09/25 (WE); 09/26 (TH); 09/27 (FR); 09/28 (SA); 09/29 (SU); 09/30 (MO) Facility failed to provide Surveyor a copy of CASPER Report 1702D, Individual Daily Staffing Report from 1/1/24-3/31/24. (It is important to note this report would have showed the hours that were reported to CMS.) On 1/28/25 at 11:00 AM, NHA A (Nursing Home Administrator) indicated the Corporate Office staff submit the PBJ data to CMS. NHA A indicated the data was submitted inaccurately and because of this the facility's star rating dropped to a 1 out of 5. NHA A indicated the facility used a computer system to store PBJ data and the company went under. Then the Corporate Office staff had to manually enter the data into the CMS website. NHA A explained the Corporate Office staff entered page one data and clicked to page two. She did not press the save button. Then page two data was entered, and the Corporate Office Staff clicked to page 3 without pressing save. After page three data was entered the Corporate Office staff pressed submit thinking all three pages would be submitted, but only page three was submitted. NHA A indicated page one and page two populated with all zeroes while page three data read correctly. NHA A indicated after submitting the data the page locks and there is no way to correct or add an addendum. NHA A indicated she understands the requirements set by CMS and the information was not reported accurately.

Based on observation, interview, and record review, the facility failed to ensure that the current copy of a resident's advance directive was reflected accurately in the resident's medical record, for 1 of 17 sampled residents (R312) reviewed for advance directives. The facility had an incorrect advanced directive order in R312's medical record. Evidenced by: The facility policy, entitled Advance Directives, dated ,d+[DATE], states, in part: . A. Policy: The Social Service Director and/or designee will assess, care plan and implement Advance Directives. B. Procedure: . 7. All advanced directive preferences will be documented in the resident's care plan and updated quarterly, annually and upon any significant changes in cognition. 8. If the resident or resident representative chooses to initiate/change any advance directives, the Social Service Director/designee will document changes and update the plan of care. 9. The resident will have a code status order entered in their physician orders in accordance with advance directives on file . R312 was admitted to the facility on [DATE], with diagnoses that include Chronic Kidney Disease (a long term condition where the kidneys gradually lose their ability to filter waste products from the blood), Type 2 Diabetes Mellitus (a long term condition where the body does not produce enough insulin or does not use insulin effectively), and Congestive Heart Failure (a condition where the heart muscle is weakened and cannot pump blood effectively). R312's Admission Minimum Data Set (MDS) Assessment, with Assessment Reference Date (ARD) of [DATE], shows R312 had a Brief Interview of Mental Status (BIMS) score of 12 indicating R312 has moderate cognitive impairment. On [DATE], an order was entered into R312's Electronic Health Record (EHR) indicating: YES CPR: Attempt Cardiopulmonary Resuscitation (CPR) Utilize all indicated modalities per standard medical protocol . Of note, Full Code is a medical term used to indicate a patient's preference for receiving all possible life-saving measures in the event of a cardiac or respiratory arrest. Specifically, full code means that healthcare providers will: Perform Cardiopulmonary Resuscitation (CPR), use a defibrillator, Intubate the patient (insert a breathing tube), and administer medications and other treatments necessary to maintain life. On [DATE], a Do Not Resuscitate (DNR) order was signed by R312 and the Attending Health Care Professional. The DNR form was scanned into R312's EHR. Of note, a DNR indicates the person has chosen not to receive CPR in an emergency. The DNR order informs healthcare providers not to perform CPR if a person's heart stops beating or their breathing stops. On [DATE], surveyor observed the banner listed at the top of R312's EHR banner states Code Status: Attempt Resuscitation/CPR (Full Code). On [DATE] at 11:40 AM, Surveyor interviewed LPN C (Licensed Practical Nurse) and asked what she would do if she found a resident to be pulseless and non-breathing. LPN C stated she would check for pulse, respirations and code status. Surveyor asked LPN C where she would find a resident's code status. LPN C stated she would look on the resident's banner in the EHR, and that if the banner stated DNR, she would check the paperwork on file to prove it was a signed DNR. Together Surveyor and LPN C reviewed R312's banner in the EHR, which stated Full Code. On [DATE] at 11:43 AM, Surveyor interviewed RN D (Registered Nurse) and asked what she would do if she found a resident to be pulseless and non-breathing. RN D stated she would initiate CPR and call for a rapid response. Surveyor asked RN D where she would find a resident's code status. RN D replied that she would look on the resident's banner in the EHR. Together Surveyor and RN D reviewed R312's banner in the EHR, which stated Full Code. On [DATE] at 11:48 AM, Surveyor interviewed RN E and asked what she would do if she found a resident to be pulseless and non-breathing. RN E stated she would check the resident's breathing and start CPR. Surveyor asked RN E where she would find a resident's code status. RN E replied that she would look in the resident's chart in the EHR or at the nurse's desk. Together Surveyor and RN E reviewed R312's banner in the EHR, which stated Full Code. Surveyor asked RN E if she found R312 to be pulseless and non-breathing, would she provide CPR. RN E stated yes, she would provide R312 with CPR. On [DATE] at 12:01 PM, Surveyor interviewed DON B (Director of Nursing) and asked her if she expected the nursing staff to check a resident's code status before starting CPR. DON B replied yes, that was her expectation. Surveyor asked DON B if R312 was CPR or DNR. DON B reviewed the EHR and stated R312 was a Full Code and would receive CPR in the event of an emergency. Surveyor reviewed with DON B the copy of the DNR form signed by R312 on [DATE] that had been scanned into his EHR. DON B stated that R312 would be a DNR as of today. On [DATE] at 12:12 PM, Surveyor interviewed DSS F (Director of Social Services) and asked her if R312 was a Full Code or a DNR. DSS checked in R312's EHR and stated he was a Full Code. Surveyor asked DSS F if the EHR banner, physician orders, signed DNR form, and EHR code status should all match. DSS F stated they should all be the same. Surveyor asked DSS F if all of them should accurately reflect the resident's advance directive wishes. DSS F stated yes, everything in the resident's EHR should be accurate. Surveyor reviewed R312's DNR form signed on [DATE] by R312 and scanned into the resident's EHR, as well as the banner that indicated Full Code. DSS F indicated she would change that immediately. On [DATE] at 1:49 PM, NHA A (Nursing Home Administrator) supplied a copy of R312's revised order, which states in part: .NO CPR: Do Not Attempt Resuscitation (DNAR) . as well as a screen shot of R312's banner in the EHR, which now indicated: (Advance Directives): NO CPR. Do Not Attempt Resuscitation (DNAR). The electronic health record (EHR) did not accurately reflect R312's wishes to be a DNR.

Based on observation, interview, and record review, the facility did not ensure that each resident has a safe, clean, comfortable, and homelike environment, including, but not limited to receiving treatment and supports for daily living for 1 (R33) of 17 resident rooms observed. R33's room had both breakfast and lunch trays containing food and dirty dishes for hours after the meals had been served. This is evidenced by: The State of Operations Manual Appendix PP states in part: . Environment refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas. A homelike environment is one that de-emphasizes the institutional character of the setting, to the extent possible, and allows the resident to use those personal belongings that support a homelike environment. A determination of homelike should include the resident's opinion of the living environment. Orderly is defined as an uncluttered physical environment that is neat and well-kept. Sanitary includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes, but is not limited to, equipment used in the completion of the activities of daily living . R33 was admitted to the facility on [DATE] with diagnoses that include need for assistance with personal cares, unspecified abnormalities of gait and mobility, generalized muscle weakness, and repeated falls. R33's most recent Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 1/16/25 documented that R33 had a Brief Interview for Mental Status (BIMS) score of 14, indicating R33 is cognitively intact. Section GG0130 indicates that R33 needs setup and cleanup assistance with eating, but that resident is able to feed herself independently. On 1/29/25 at 1:41 PM, Surveyor observed R33 sitting in her wheelchair in her room, asleep, with her untouched lunch tray sitting before and her half-eaten breakfast tray sitting on the chair next to her. On 1/29/25 at 1:54 PM, Surveyor interviewed CNA G (Certified Nursing Assistant) and asked her if she had been in R33's room and noticed her breakfast and lunch trays still sitting in her room. CNA G stated she had not been in R33's room since this morning. Surveyor asked CNA G if she would consider it a homelike environment for R33 if her breakfast and lunch trays with dirty dishes and old food were still sitting in her room. CNA G replied no, she did not consider that a homelike environment. On 1/29/25 at 1:56 PM, Surveyor interviewed LPN C (Licensed Practical Nurse) and asked her if she had been in R33's room and noticed her breakfast and lunch trays still sitting in her room. LPN C stated that she had been in R33's room to administer medications but had not noticed her trays. Surveyor asked LPN C if she would consider it a homelike environment for R33 if her breakfast and lunch trays with dirty dishes and old food were still sitting in her room. LPN C replied no, she did not consider that a homelike environment. On 1/29/25 at 1:59 PM, Surveyor interviewed CNA H and asked her if she would consider it a homelike environment if a resident had breakfast and lunch trays still sitting in their room with dirty dishes and food on them. CNA H stated no, she did consider it homelike, and she didn't let dirty dishes sit around in her own home. CNA H stated she had been in R33's room but had not noticed the trays sitting there. On 1/29/25 at 2:09 PM, Surveyor observed LPN C remove R33's breakfast tray and CNA H remove R33's lunch tray. On 1/29/25 at 3:00 PM, Surveyor interviewed R33 and asked her if she considered it a homelike environment to have her breakfast and lunch trays sitting in her room with dirty dishes and food on them. R33 indicated that she did not think that was a homelike environment and stated that it upsets her when they do that. R33 stated she would be embarrassed if visitors came to see her and there was nowhere to sit because the chair had a tray with dirty dishes on it. On 1/30/25 at 3:19 PM, Surveyor interviewed ADON I (Assistant Director of Nursing) and asked what her expectations would be for removing trays from resident rooms after meals. ADON I replied that R33 takes a long time to eat, and requests that her meal trays be kept in her room for longer. Surveyor asked ADON I if she would expect a breakfast tray to still be in the room after 2:00 PM. ADON I replied no, that was too long for the breakfast tray to still be in her room. Surveyor asked ADON I if she expected the residents to have a homelike environment, including free of clutter and dirty dishes. ADON I indicated yes, that was her expectation.

Based on observation, interview, and record review, the facility did not provide repositioning for dependent residents for 1 of 1 residents (R) reviewed for Activities of Daily Living (ADLs) assistance (R33). Staff did not assist R33 with repositioning in her wheelchair per her plan of care. Evidenced by: Facility policy, entitled Activities of Daily Living, dated 3/10/22, states in part: .assist resident to perform ADL's (grooming, dressing, oral hygiene, transfer, ambulation, toileting, etc.) and encourage resident to participate as much as the resident is able . R33 was admitted to the facility on [DATE] with diagnoses that include need for assistance with personal cares, transient ischemic deafness, unspecified abnormalities of gait and mobility, generalized muscle weakness, repeated falls, rheumatoid arthritis (a chronic autoimmune disease that primarily affects the joints causing inflammation, pain, stiffness, and damage to the joints), bilateral primary osteoarthritis of the knee (a common type of joint disease that causes pain, stiffness, and swelling in the joints that occurs when the cartilage that cushions the ends of bones in the joints wears down over time), primary generalized osteoarthritis, and ankylosing spondylitis of the spine (a chronic inflammatory disease that primarily affects the spine. It causes inflammation of the joints between the vertebrae, leading to pain, stiffness, and fusion of the spine over time). R33's most recent Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 1/16/25 documented that R33 had a Brief Interview for Mental Status (BIMS) score of 14, indicating R33 is cognitively intact. Section GG0130 indicates that R33 needs assistance or setup with bed and chair mobility and turning. R33's Care Plan, initiated on 7/7/22, includes, in part: Focus: [Resident Name] has an ADL self-care performance deficit related to having weakness and inability to care for self. Intervention: Encourage use of positioning device for bed mobility as needed. Date Initiated 7/20/22 . Focus: Potential for alteration in skin integrity related to having weakness which may impact ability to always offload enough to avoid friction or shearing . Intervention: Position body with pillows/support devices. Date initiated 7/20/22 . Focus: Potential for pain related to diagnosis of Rheumatoid Arthritis, Bilateral Arthritis to knees . Intervention: Position resident for comfort. Date initiated 7/22/22 . Reposition resident as necessary. Date initiated 7/20/22 . January, 2025 Certified Nursing Assistant (CNA) Point of Care (POC) charting indicates in part: Turned and Repositioned at no greater than every 2 hours based on resident need . Repositioning was documented as follows: -One time per shift on 4 days -Twice per shift on 12 days -Three times per shift on 13 days Of note: no days in January were documented as repositioning every 2 hours. On 1/28/25 at 9:06 AM, Surveyor interviewed R33 who was sitting in her room in her wheelchair. R33 indicated that she is in pain when she sits for a long period of time due to her arthritis in her knees. R33 stated she feels like the staff are ignoring her. On 1/30/25 at 8:34 AM, Surveyor observed R33 in her wheelchair in her room, with her head forward on her chest. R33 appeared to be sleeping. On 1/30/25 at 9:42 AM, Surveyor observed R33 in her wheelchair in her room, with her head forward on her chest. R33 appeared to be sleeping. On 1/30/25 at 10:05 AM, Surveyor observed R33 in her wheelchair in her room, with her head forward on her chest. R33 appeared to be sleeping. On 1/30/25 at 11:02 AM, Surveyor observed R33 in her wheelchair in her room, with her head forward on her chest. R33 appeared to be sleeping. On 1/30/25 at 12:00 PM, Surveyor observed R33 in her wheelchair in her room, with her head forward on her chest. R33 appeared to be sleeping. On 1/30/25 at 12:53 PM, Surveyor observed R33 in her wheelchair in her room, with her head forward on her chest. R33 appeared to be sleeping. On 1/30/25 at 12:57 PM, Surveyor interviewed CNA J (Certified Nursing Assistant) and asked if R33 was able to reposition herself in her wheelchair. CNA J stated that sometimes R33 can reposition herself and if she needs help, she will ask. On 1/30/25 at 2:50 PM, Surveyor observed R33 in her wheelchair in her room, with her head forward on her chest. R33 appeared to be sleeping. Of note, at no time throughout the day did R33 appear to have been moved or repositioned in her wheelchair. Surveyor did not observe staff interacting with R33, nor were there any pillows or repositioning devices used to assist R33 with offloading. On 1/30/25 at 2:56 PM, Surveyor interviewed RN K (Registered Nurse) and asked if R33 was able to reposition herself in her wheelchair. RN K stated that at times R33 needs help and that the aides help her. On 1/30/25 at 3:09 PM, Surveyor interviewed CNA L and asked if R33 was able to reposition herself in her wheelchair. CNA L stated no, R33 could not reposition herself and that she needs help because of her bad knees. On 1/30/25 at 3:19 PM, Surveyor interviewed ADON I (Assistant Director of Nursing) and asked what her expectation was for staff for repositioning with R33. ADON I indicated she expected the staff to help turn R33 and help her get off her bottom by putting pillows under her and making sure she is comfortable. Surveyor asked ADON I how often the staff should be assisting R33 with repositioning. ADON I stated she expected the staff would do rounds every 2 hours, that included checking on R33 and all the residents and making sure their needs were met. Surveyor asked ADON I if it was acceptable for R33 to be sitting in the same position in her wheelchair for 6 hours. ADON I indicated no, that would not be acceptable. Cross Reference: F688, F697

Based on interview and record review, the facility did not ensure that a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for 1 of 1 residents reviewed for mobility (R33). The facility was not walking R33 in accordance with her plan of care. This is evidenced by: Facility policy titled Restorative Nursing Program, dated 3/10/22 states, in part: Policy: It is the policy of this facility that a resident is given the appropriate treatment and services to enable residents to maintain or improve his or her abilities and to promote the resident's ability to adapt and adjust to living as independently and safely as possible . 1. The purpose of the Restorative Nursing Program is to: a. Restore to original status or improve level of independence after a decline in Activities of Daily Living (ADLs), and/or . d. Maintain or improve functional abilities in ADLs, and/or . e. Promote ability and wellness and where possible, prevent decline or loss of independence, and/or . f. Enable residents to attain or maintain their highest practicable level of functioning . 2. A Restorative Nursing Program may be established: . b. When restorative needs arise during the course of a longer-term stay . 3. Activities provided by restorative nursing staff include: c. Bed mobility . e. Walking . Facility policy titled Walking/Ambulation, dated 3/10/22 states, in part: Definition: Ambulation refers to activities provided to improve or maintain the resident's self-performance in walking, with or without assistive devices. RNP (Restorative Nursing Program) walking programs are individualized to the resident's needs, planned, monitored, evaluated, and documented in the resident's medical record . Considerations: 1. The purpose of RNP walking programs is to: a. Promote increased independence . b. Promote circulation, stimulation, and muscle strengthening . c. Reduce potential for falls . d. Increase self-esteem . R33 was admitted to the facility on [DATE] with diagnoses that include need for assistance with personal cares, transient ischemic deafness, unspecified abnormalities of gait and mobility, generalized muscle weakness, repeated falls, rheumatoid arthritis (a chronic autoimmune disease that primarily affects the joints causing inflammation, pain, stiffness, and damage to the joints), bilateral primary osteoarthritis of the knee (a common type of joint disease that causes pain, stiffness, and swelling in the joints that occurs when the cartilage that cushions the ends of bones in the joints wears down over time), primary generalized osteoarthritis, and ankylosing spondylitis of the spine (a chronic inflammatory disease that primarily affects the spine. It causes inflammation of the joints between the vertebrae, leading to pain, stiffness, and fusion of the spine over time). R33's most recent Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 1/16/25 documented that R33 had a Brief Interview for Mental Status (BIMS) score of 14, indicating R33 is cognitively intact. Section GG0120 indicates that R33 uses a walker and a wheelchair as assistive devices for ambulation. Section GG0170 indicates that R33 requires supervision and/or touch assistance for sitting to lying and lying to sitting in the bed, for moving from sitting to standing, for all transfers and for walking. R33's Care Plan, initiated on 7/7/22, includes, in part: Focus: [Resident Name] has an ADL (Activities of Daily Living) self-care performance deficit related to having weakness and inability to care for self . Intervention: Provide walker as needed for ambulation. Date initiated 7/20/22 . Intervention: Provide wheelchair as needed for mobility. Date initiated 7/20/22 . Intervention: Transfer with assist of 1 with gait belt and walker. Date initiated 7/20/22 . Focus: Potential for alteration in skin integrity related to having weakness which may impact ability to always offload enough to avoid friction or shearing . Intervention: Encourage mobility and/or ambulation. Date initiated 7/20/22 . Focus: [Resident Name] requires assistance with ambulation. Resident requires task segmented directions to participate in ambulation activities with staff. Decreased ability to walk, Risk for falls, Weakness . Goal: [Resident Name] will ambulate with gait belt and walker and 1 person assist from her room to the nurse's station daily as tolerated . Intervention: Provide 1 assist with gait belt and walker to ambulate from bed to bathroom daily as tolerated. Date initiated 7/20/22 . Intervention: Set up assistive device to aid in assisting resident to a standing position. Date initiated 7/20/22 . Intervention: Stand along side of resident to provide verbal cues/guidance/assist while ambulating. Date initiated 7/20/22 . R33's Physician Orders state, in part: Ambulate with staff using walker and gait belt 1x daily every evening shift for restorative care ambulate with patient with appropriate DME (Durable Medical Equipment) . Order Date: 1/22/25. Start Date: 1/23/25. R33's Documentation Survey Report states, in part: A Nursing Rehab: Walking [Resident Name] will ambulate with gait belt and 4-wheeled walker from her room to the nurse's station . Frequency Q-shift (once per shift) . R33's Restorative Nursing Assessment, dated 1/16/25, states, in part: Based on the assessment the Residents priority programs will be: . c. Bed Mobility/Walking . Goal: Walking [Resident Name] will ambulate with gait belt and 4-wheeled walker from her room to the nurse's station . In November, 2024, the Documentation Survey report indicates: -27 shifts left blank for walking R33, and -27 shifts documented N/A (Not Applicable) In December, 2024, the Documentation Survey report indicates: -20 shifts left blank for walking R33, and -41 shifts documented N/A In January, 2025, the Point of Care (POC) charting by the CNAs (Certified Nursing Assistants) indicates: -21 shifts left blank for walking R33 On 1/28/25 3:42 PM, Surveyor interviewed R33 who stated that she has arthritis in her legs, and that the pain at times is a 10 out of 10. Surveyor asked R33 if staff knew she was in so much pain. R33 states yes, staff knew about her pain. R33 indicated that walking would help with her pain, but that it wasn't happening because there wasn't enough staff. R33 stated that the pain was so bad that at times she wanted to sit and cry. On 1/28/25 at 3:57 PM, Surveyor interviewed CNA/Med Tech M (Certified Nursing Assistant/Medication Technician) who stated that R33 does have pain in her knees before she gets the cortisone shots. Surveyor asked CNA M if the staff were assisting R33 with walking. CNA M stated they will walk her back and forth to the bathroom once per shift. Surveyor notified CNA/Med Tech M that R33 was endorsing 10 out of 10 pain. CNA M stated she would look into it. On 1/28/25 at 4:00 PM, Surveyor interviewed CNA H who stated that R33 does have ongoing pain. Surveyor asked CNA H if the staff were assisting R33 with walking. CNA H replied that they have not been walking R33 in the hall lately, but at bedtime they walk her from the bathroom to bed. On 1/28/25 at 4:04 PM, Surveyor interviewed PTA O (Physical Therapy Assistant) who stated that R33 does have a restorative program and that she loves to walk. PTA O indicated that ADON I (Assistant Director of Nursing) was in charge of the restorative program. On 1/29/25 at 8:36 AM, Surveyor interviewed LPN C (Licensed Practical Nurse) who stated that she didn't know about the aides walking with R33 in the hall but that she has seen her walk with physical therapy. On 1/29/25 at 3:00 PM, Surveyor interviewed R33 and asked if any of the staff had assisted her with walking in the hallway today. R33 replied no. Surveyor asked R33 if she ever refused to walk due to pain. R33 replied no, that she never refuses. R33 again stated that therapy wants her to walk. R33 said she felt like the staff did not want to walk with her because they didn't have time. On 1/29/25 at 3:28 PM, Surveyor interviewed CNA H and asked her what N/A in the charting meant. CNA H replied that it was not a refusal, as that would be marked as R. Surveyor asked specifically about walking with R33. CNA H stated that for this resident N/A meant they didn't have enough time or an opportunity to get her out of her room to walk. On 1/30/25 at 12:57 PM, Surveyor interviewed CNA J about walking with R33. CNA J stated that she walks R33 to the bathroom and back once per shift, but that if she is sitting in her wheelchair, she will just wheel her to the bathroom. CNA J stated that R33 will walk in the hallway with therapy, but that it doesn't happen very frequently. Surveyor asked CNA J what N/A on the chart meant. CNA J replied that if N/A was documented, that meant they couldn't get to walking her. Surveyor asked CNA J what a blank meant in the documentation. CNA J stated it either wasn't done or staff forgot to document it. On 1/30/25 at 3:19 PM, Surveyor interviewed ADON I (Assistant Director of Nursing) about R33's restorative walking program. Surveyor asked ADON I what her expectation was for someone on the walking program. ADON I indicated it was her expectation for staff to walk with them to meet their goal, and for the aides to walk them at least once a day if the resident wants to. Surveyor asked ADON I if someone was requesting to walk, would she expect staff to meet that need. ADON I replied yes, depending on the staffing situation. Surveyor asked ADON I what N/A meant in the CNA charting. ADON I stated that the restorative program was new to the facility and she planned to educate staff on how to chart appropriately. Surveyor asked ADON I what a blank meant in the documentation. ADON I indicated that a blank could mean staff forgot to go back and chart something. Surveyor asked ADON I if she would expect the care plan interventions and physician orders to be followed in walking R33. ADON I replied yes, she would expect the care plan and physician orders to walk with R33 to be followed. Cross Reference F677 and F697

Based on observation, interview, and record review, facility staff did not adequately assess and treat pain and provide necessary care and services to attain or maintain the highest practicable physical well-being for 1 of 2 Residents (R) reviewed for pain (R33). The facility failed to adequately assess R33's pain or provide non-pharmacologic interventions to treat her pain. This is evidenced by: The facility policy titled, Pain Management, dated 4/19/12 states, in part: Policy: Our mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. Procedure: 1. Residents shall be assessed for pain and his or her manner of expressing pain upon admission, re-admission, and annually . 3. Residents will be assessed for chronic pain or persistent pain (a pain state that continues for a prolonged period of time or recurs more than intermittently for months) when the symptoms present themselves . Plan of Care: For any resident with orders for scheduled pain management, staff will initiate an interdisciplinary plan of care based on the initial assessment and the development of pain relieving strategies. The plan will include both pharmacological and complementary interventions. Documentation: Document interventions and responses to pain management in the medical record as appropriate (i.e. medication administration record, treatment record, nursing progress notes, etc.) . R33 was admitted to the facility on [DATE] with diagnoses that include need for assistance with personal cares, transient ischemic deafness, unspecified abnormalities of gait and mobility, generalized muscle weakness, repeated falls, rheumatoid arthritis (a chronic autoimmune disease that primarily affects the joints causing inflammation, pain, stiffness, and damage to the joints), bilateral primary osteoarthritis of the knee (a common type of joint disease that causes pain, stiffness, and swelling in the joints that occurs when the cartilage that cushions the ends of bones in the joints wears down over time), primary generalized osteoarthritis, and ankylosing spondylitis of the spine (a chronic inflammatory disease that primarily affects the spine. It causes inflammation of the joints between the vertebrae, leading to pain, stiffness, and fusion of the spine over time). R33's most recent Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 1/16/25 documented that R33 had a Brief Interview for Mental Status (BIMS) score of 14, indicating R33 is cognitively intact. Section J: Health Conditions indicates that R33 is on a pain medication regimen and received non-pharmacological interventions for pain. Section J0300 indicates pain is present. Section J0410 indicates pain is rarely or not at all present. Section J0600 indicates mild pain, with a numeric rating of 3. R33's Care Plan, initiated on 7/7/22, includes, in part: Focus: [Resident Name] has an ADL (Activities of Daily Living) self-care performance deficit related to having weakness and inability to care for self . Intervention: Monitor for any signs and symptoms of pain/discomfort during ADLs. Date Initiated 7/20/22 . Intervention: Offer PRN (as needed) analgesics (pain relieving medication) prior to ADL activities and/or rehab if indicated. Date initiated 7/20/22. Focus: Potential for pain related to diagnosis of Rheumatoid Arthritis, Bilateral Arthritis to knees . Intervention: Administer pain strategies according to MAR (Medication Administration Record)/TAR (Treatment Administration Record). Date initiated 7/7/22 . Intervention: Assess pain every shift. Date initiated 7/20/22 . Intervention: Complete pain assessment. Date initiated 7/20/22 . Intervention: Monitor for non-verbal indicators of pain daily with care tasks and activities. Date initiated: 7/20/22 . Intervention: Observe resident for effectiveness of pain relief. Date initiated 7/20/22 . Intervention: Offer PRN analgesics prior to ADL activities and/or rehab if indicated. Date initiated 7/20/22 . Position resident for comfort. Date initiated 7/20/22 . Reposition resident as necessary. Date initiated 7/20/22 . R33's Physician Orders Include: Pain eval (evaluation) Q-shift (every shift). Start date: 6/30/22. No end date. Acetaminophen 500 mg (milligram) tablet. Give 2 tablets by mouth every 6 hours as needed for fever/pain management. Start date: 12/15/22. No end date. Acetaminophen 500 mg tablet. Give 2 tablets by mouth two times a day for pain management. Start date: 12/15/22. No end date. Voltaren Gel 1% (Diclofenac Sodium). Apply 2 gram transdermally every 6 hours as needed for pain management. Apply to bilateral hands. Start date: 8/14/24. No end date. Voltaren Gel 1% (Diclofenac Sodium). Apply 2 gram transdermally every 6 hours as needed for pain management. Apply to bilateral knees. Start date: 8/14/24. No end date. Lidocaine External Patch 4% (Lidocaine). Apply to lower back topically as needed for pain management. Apply one patch on 12 hours daily. Start date: 12/30/24. No end date. Gabapentin 100 mg capsule. Give 1 capsule by mouth at bedtime for neuropathic pain. Start Date: 1/15/25. No end date. R33's Medical Record includes, in part: On 10/21/24 a Pain Management Evaluation states in part: . Pain Level: 0. Diagnosis: Does the resident have any diagnosis which would give you reason to believe he/she would be in pain? Yes. If yes, list: Rheumatoid Arthritis, Spondylitis of spine, Osteoarthritis of knee. What is your acceptable level of pain: 0 . On 10/28/24, a MD (Medical Director) Progress Note states in part: . Patient admitted to the SNF (Skilled Nursing Facility) on 7/7/22 for skilled nursing and rehab. Patient asked to be seen by therapy to optimize therapy, pain control . Assessment/Plan: Previously noted to likely be someone who would need every 3 months of knee injection for pain management. Received injections 10/9/24 and 7/9/24. Previous to that was March 2024. She reports effectiveness and success with pain control post injections . Pain, unspecified. Patient is high risk for functional impairment without therapy and adequate pain control .No apparent distress . No new concerns . Of note, MD Progress Notes dated 10/31/24, 11/8/24, 11/12/24, 11/21/24 state word for word the same as MD Progress Note on 10/28/24. No personalized or new interventions to address resident's pain. On 1/9/25, a Nurse Progress Note states in part: . Resident has rheumatoid arthritis and spine is kyphotic (excessive outward curvature of the spine); gets knee injections regularly per Dr. Lynch for this; that is effective for functional decline. Resident has chronic joint pain and takes scheduled Tylenol for this which has been effective . On 1/11/25, a Nurse Progress Note states in part: . Resident . has osteo and rheumatoid arthritis that primarily affect her knees and at times needs more assistance with ADLs. Sees Dr. Lynch regularly for knee injections that greatly improved her function . On 1/16/25, a Pain Management Evaluation states in part: . Pain Level: 0. Diagnosis: Does the resident have any diagnosis which would give you reason to believe he/she would be in pain? No . On 1/28/25 at 3:42 PM, Surveyor interviewed R33 in her room. R33 indicated that she has sharp pains in her feet and toes, and that she has told the nurses, but they don't believe her. R33 stated that she tells the nurse that she wants to see the nurse about her pain, but that the nurses never come in and ask her about her pain. R33 stated that this pain has been going on for over a month, and she feels ignored by staff. R33 stated that she also has arthritis in her legs, and that the pain at times is a 10 out of 10. R33 indicated that walking would help with her pain, but that it wasn't happening because there wasn't enough staff. R33 stated that the pain was so bad that at times she wanted to sit and cry. On 1/28/25 at 3:57 PM, Surveyor interviewed CNA/Med Tech M (Certified Nursing Assistant/Medication Technician) who stated that R33 does have pain in her knees before she gets the cortisone shots. Surveyor notified CNA/Med Tech M that R33 was endorsing 10 out of 10 pain. CNA M stated she would look into it. On 1/28/25 at 4:00 PM, Surveyor interviewed CNA H who stated that R33 does have ongoing pain. CNA H stated that R33's pain has been so bad in her knees lately that the staff have not been walking with her much. On 1/28/25 at 4:04 PM, Surveyor interviewed PTA O (Physical Therapy Assistant) who stated that R33 does have knee pain and gets cortisone shots that does help with the pain and her mobility. On 1/29/25 at 8:36 AM, Surveyor observed LPN C (Licensed Practical Nurse) administering morning medications to R33. LPN C went into R33's room and gave her a medication cup with her medications, then waited at the doorway to R33's room while she waited for R33 to take them. Surveyor asked LPN C if she had assessed R33 for pain before giving her medications. LPN C stated that she had not completed a pain assessment yet. Surveyor asked LPN C if she had marked anything in R33's EHR (Electronic Health Record) for pain. LPN C stated she had marked a zero for pain. Surveyor observed LPN C then go into R33's room and utilize the whiteboard to communicate with R33. (R33 is deaf and reads lips or reads the white board for communication). LPN C returned from R33's room and said that R33 had indicated that her legs hurt bad today and she had rated her pain 9 out of 10. LPN C stated she had just given R33 her scheduled acetaminophen for pain. Surveyor asked LPN C if R33 had any PRN (as needed) medications for breakthrough pain. LPN C stated R33 only had acetaminophen ordered, as R33's pain comes and goes. LPN C stated that R33 does get injections in her knees that help with her pain, mobility, and transfers, but then it wears off and R33 experiences more pain again. Surveyor asked LPN C if there were any non-pharmacological interventions for R33's pain, such as walking. LPN C stated she was unsure but had seen R33 walking with physical therapy. At 1/29/25 at 9:09 AM, Surveyor interviewed DON B (Director of Nursing) about R33's pain. DON B indicated that R33 had had previous orders for stronger narcotic medications for pain, but that R33 had refused to take them. Surveyor reviewed the NP (Nurse Practitioner) progress notes in R33's EHR (Electronic Health Record) with DON B. DON B stated that the NP tends to just copy and paste without reading the resident's chart, and that is a process they need to work on. Surveyor asked DON B what her expectation was for assessing resident's pain. DON B stated that she would expect the nurses to assess pain prior to giving medications. Surveyor shared with DON B her observation of LPN C not assessing R33's pain, and entering a zero for pain before assessing her, only to realize she had 9 out of 10 pain. DON B replied that sometimes R33 will tell you she has 10 out of 10 pain, but when the nurses do a pain assessment she will tell them 0 out of 10. 01/29/25 at 11:06 AM, Surveyor interviewed CNA O. Surveyor asked CNA O if R33 had ever complained of pain. CNA O replied yes, that R33 has pain when they get her up in the morning. Surveyor asked CNA O if R33 rated her pain when they were getting her up. CNA O stated no, but that she will scrunch up her face in pain and ask them to move slow because of her pain. Surveyor asked CNA O if she ever notifies the nurse of R33's pain. CNA O stated no, they just move slower and give R33 time to rest. Surveyor asked CNA O if she should stop and tell the nurse if R33 is exhibiting pain. CNA O stated yes, she should probably get the nurse. On 1/29/25 at 1:16 PM, Surveyor interviewed FM Q (Family Member) of R33. FM Q indicated that R33 has rheumatoid arthritis that is bone on bone, and very painful. FM Q stated that the steroid shots help but when they wear off the pain is really bad. FM Q said that facility staff tell her that R33 is getting old and imagining things but that R33's mind is actually very sharp. FM Q stated that she feels that the facility looks at R33 and her age and that she is deaf and they don't treat her like she knows what she is talking about. FM Q indicated that she thinks the facility could be doing more to address R33's pain. On 1/29/25 at 3:00 PM, Surveyor interviewed R33 and asked her if anyone had come in and assessed her pain today. R33 replied, no, that is part of the problem. Surveyor asked R33 if she had walked in the hall today with staff. R33 replied no, that no one had offered to walk with her. Surveyor asked R33 if she ever refused to walk due to pain. R33 replied no, that she never refuses. R33 again stated that therapy wants her to walk and that it helps with the pain in her legs. R33 said she felt like the staff did not want to walk with her because they didn't have time. On 1/30/25 at 2:56 PM, Surveyor interviewed RN K. Surveyor asked RN K how she assesses R33's pain. RN K replied she usually asks her, and that R33 can read her lips. Surveyor asked RN K if R33 ever endorsed pain greater than a 1. RN K said no, not to her. Of note, R33's documented pain ratings in the EHR have consistently been documented as 1's and 0's. In December 2024, R33's MAR (Medication Administration Record) indicates six pain evaluations documented as 1 and the rest are documented as 0. In January 2025, R33's MAR indicates ten pain evaluations documented as 1 and the rest are documented as 0. On 1/30/25 at 3:19 PM, Surveyor interviewed ADON I (Assistant Director of Nursing) about R33's pain. Surveyor asked ADON I what her expectation was for assessing a resident's pain. ADON I stated she would expect the staff to complete a pain assessment when the resident has signs or symptoms of pain or is reporting any pain or if they are asking for a pain medication. Surveyor asked ADON I if R33 had concerns with pain. ADON I stated no, she had never heard that R33 complained of pain. Surveyor reviewed R33's pain assessment with ADON I and asked if the information in it was correct. ADON I replied no, that R33 does have a diagnosis that would indicate pain ADON I reviewed R33's EHR and confirmed that R33 has rheumatoid arthritis which would indicate pain. The facility failed to recognize and evaluate R33's ongoing pain, and failed to treat her pain with appropriate pain management interventions and strategies. R33's has diagnoses that indicate pain. Staff are aware that R33 has unrelieved pain, and that walking can help the pain, however documentation shows that staff are often not walking with her. R33 indicates that she has pain daily and that staff are not assessing or treating her pain. Cross Reference F677 and F688

Based on interview, record review, and facility policy review, the facility failed to ensure an allegation of abuse was submitted to the State Survey Agency within two hours after the allegation was made and failed to submit the results of the investigation to the State Survey Agency within five working days of the incident for 2 (Resident #1 and Resident #2) of 4 residents reviewed for resident-to-resident abuse. Findings included: A facility policy titled, Abuse Policy, dated 09/2020, revealed, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility will report reasonable suspicion of a crime. This facility therefore prohibits mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. The policy revealed, Initial Reporting of Allegations are reported immediately. CMS [Centers for Medicare and Medicaid Services] defines 'immediately' as not later than 2 hours after forming the suspicion of abuse which results in serious body injury or not later than 24 hours if no bodily injury. The policy revealed, c. Five Day Final Investigation Report. Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation will be sent to the Wisconsin Division of Quality Assurance. An Admission Record indicated the facility admitted Resident #1 on 07/16/2021 and most recently admitted the resident on 10/22/2024. According to the Admission Record, the resident had a medical history that included diagnoses of depression and adjustment disorder with mixed anxiety and depressed mood. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/29/2024, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident did not exhibit physical, verbal, or other behavioral symptoms directed toward others during that assessment period. Resident #1's care plan included a focus area initiated 12/03/2024, that indicated Resident #1 was at risk for abuse related to a history of repetitive verbalizations/yelling out and a history of socially inappropriate behavior. Interventions directed staff to redirect the resident calmly and firmly to more socially acceptable behaviors; respond with reassurance; not to argue with the resident; and to remind others to ignore or move away from repetitive noises or comments. An Admission Record indicated the facility admitted Resident #2 on 06/22/2022. According to the Admission Record, the resident had a medical history that included diagnoses of senile degeneration of the brain, dementia, mild cognitive impairment, hemiplegia, anxiety disorder, and major depressive disorder. A quarterly MDS, with an ARD of 09/20/2024, revealed Resident #2 had a BIMS (Brief Interview of Mental Status) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident had verbal behaviors directed toward others for one to three days during the assessment period. Resident #2's care plan included a focus area initiated 08/26/2024, that indicated Resident #2 was at risk for abuse related to a diagnosis of dementia. Interventions directed staff to redirect the resident calmly and firmly to more socially acceptable behaviors; respond with reassurance and not argue; and to monitor and report signs and symptoms of abuse. A Concern Form, dated 11/14/2024, revealed that Resident #1 stated that they were walking down the hall when Resident #2 stuck their foot out as they were passing Resident #2 and caught the back of their leg. The section of the form labeled Time, date and person notified of outcome of concern: revealed 11/14/2024 4:45 PM. An Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report, dated 11/14/2024, revealed that Resident #1 stated that Resident #2 attempted to trip them when they walked by. The report revealed Resident #1 used explicit language when confronting Resident #2. The report revealed the Maintenance Director redirected Resident #1 and the residents were separated. Further review revealed that the report was submitted to the State Survey Agency on 11/14/2024 at 8:00 PM, which was not compliant with the required timeframe. A Misconduct Incident Report, dated 11/21/2024, revealed the incident between Resident #1 and Resident #2 occurred on 11/14/2024 at 2:00 PM. According to the Summary of Incident, section of the Misconduct Report, Resident #2 was sitting in their wheelchair in the hallway when Resident #1 was walking down the hallway. The summary revealed Resident #2 moved toward Resident #1 and Resident #1 yelled out that Resident #2 was trying to trip them. The summary revealed, Resident #1 then started being verbally aggressive towards Resident #2. The summary revealed the Maintenance Director witnessed the incident, intervened, and did not observe contact between the residents. Further review revealed that the report was submitted to the State Survey Agency on 11/22/2024 at 9:19 PM, which was not compliant with the required timeframe. During an interview on 12/07/2024 at 7:48 AM, the Administrator stated she did not know why the report was not submitted on time. She stated she signed the report on 11/21/2024, but it was not submitted until 11/22/2024.

Based on observation, interview, record review, and facility clinical guideline review, the facility failed to ensure staff used proper hand hygiene during wound care, which affected 1 (Resident #6) of 2 residents observed for wound care. Findings included: The facility's Clinical Practice Guidelines included a guideline titled, Non-Sterile Dressing Change, dated 03/2021, that revealed, 6. Perform hand hygiene and apply gloves. 7. Prepare/open dressing items on the work area. If dressings need to be cut to size, use clean or sterile scissors. Open packages and cut the tape. 8. Reposition resident to expose area to be dressed. 9. May place the linen saver or towel under the resident. 10. Remove soiled dressing and place in a trash bag after observing soiled dressing and peri-wound for any drainage, checking for amount, color, consistency and odor. Document all observations on Skin Progress Notes (S.P.N.) in E.H.R. (Electronic Health Record) or Treatment Administration Records (T.A.R.) when using paper documentation. 11. Remove gloves, perform hand hygiene, and apply new gloves. The guideline revealed, 15. Upon completion remove gloves, perform hand hygiene and apply new gloves. 16. Apply liquid barrier film or moisture barrier to periwound (if applicable). 17. Apply prescribed topical agent to the wound bed. 18. Apply wound dressing. The guideline revealed, 21. Discard gloves and all supplies in trash bag and remove equipment. 22. Perform hand hygiene. An Admission Record indicated the facility admitted Resident #6 on 11/22/2024. According to the Admission Record, the resident had a medical history that included diagnoses of type 2 diabetes, congestive heart failure, chronic kidney disease, and anemia. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/29/2024, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident had diabetic foot ulcers and surgical wounds. Per the MDS, the resident received treatment that included application of nonsurgical dressings and dressings to their feet. Resident #6's care plan included a focus area initiated 11/22/2024, that indicated the resident had amputated toes to their right foot, surgical/arterial wound to their right foot, abrasion to the right knee, and scattered areas to the right lower leg with drainage secondary to edema. Interventions directed staff to use enhanced barrier precautions during high contact resident care activities for chronic wounds (initiated 11/22/2024), and to provide Treatment as ordered (initiated 11/22/2024). Resident #6's Order Summary Report, dated 12/06/2024, revealed an order dated 12/06/2024 for povidone-iodine swab 10% to be applied to the right great toe each day shift, with directions to cleanse the area with normal saline, Paint the wound, and then wrap the lower leg and foot with Kerlix (gauze) and cover with Tubigrip (support bandage). The Order Summary Report also revealed an order dated 12/05/2024 for Optifoam Gentle Ex 4x4 External (foam dressing), to be applied to the right knee topically each day shift, with directions to cleanse the knee with normal saline, pat dry, then apply the dressing. The Order Summary Report revealed an order dated 12/06/2024 for Xeroform (medicated dressing) to the right leg, with directions to cleanse the area with normal saline, apply and cover with abdominal Kerlix and Tubigrip or ACE wrap (compression wrap). During an observation of Resident #6's wound care on 12/06/2024 at 10:44 AM, Registered Nurse J (RN) performed hand hygiene and applied new gloves, a gown, and a mask. She cleaned and used a barrier on the bedside table for wound dressing supplies. She placed a barrier under Resident #6's feet and removed the resident's right stocking. RN J removed the Kerlix wrap from Resident #6's leg and foot and the soiled dressings from the resident's right leg and right knee, performed hand hygiene, and applied clean gloves. RN J held gauze under Resident #6's open knee wound and dripped normal saline on the wound, and patted the knee dry with the gauze. At 10:49 AM, RN J dripped normal saline on the scattered open areas on Resident #6's right leg and patted the areas dry. RN J proceeded to clean the resident's right third toe with normal saline and patted it dry. RN J cleaned the resident's wound areas without performing hand hygiene or applying new gloves between the wounds. RN J applied clean gloves without performing hand hygiene and placed a clean barrier under Resident #6's leg. She opened and applied the povidone-iodine swab, did not clean her hands or change gloves, and applied an Optifoam dressing to Resident #6's right knee. RN J applied new gloves but did not perform hand hygiene and dressed Resident #6's right mid-leg wound with Xeroform dressings, applied abdominal pads, and wrapped the resident's leg and foot with Kerlix wrap. During an interview on 12/06/2024 at 11:12 AM, RN J stated she had been trained on infection control related to wound care. She stated she was supposed to perform hand hygiene after every change of gloves. She stated for wound care with more than one wound, she should have changed gloves between cleaning the wounds and dressing the wounds. She stated she was trained to clean and dress one wound at a time to prevent cross contamination between wounds. She stated that she did not realize she had not done that. During an interview on 12/06/2024 at 11:26 AM, the Director of Nursing (DON) stated that after removing the soiled dressings, the nurse should have removed her gloves, changed the barrier, performed hand hygiene, and put on clean gloves. The DON stated the nurse should have performed hand hygiene and changed gloves between wounds and should have cleaned and dressed each wound separately to prevent cross contamination of the wounds. She stated that there was a risk that an infection could be transferred from one wound to the next. The DON stated the nurse should start and finish one wound at a time. She stated that hand hygiene should be performed between each time the nurse's gloves were taken off. During an interview on 12/07/2024 at 9:37 AM, the Administrator stated she expected staff to follow the policy for hand hygiene and to complete a clean procedure.

Based on interview and record review, the facility did not permit a resident to remain in the facility and not discharge the resident from the facility when R1 was pending Medicaid eligibility. On 8/7/24, R1 was given a Discharge Notice indicating R1 was going to be discharged on [DATE] to a hotel or apartment due to nonpayment. R1 was actively applying for Medicaid and a decision was pending. The facility discharged R1 despite pending Medicaid eligibility. Evidenced by: The facility's Discharge Planning policy, dated 11/17, includes, in part, the following: A. Policy: The resident's potential to discharge will be assessed with the resident/their representative initially, quarterly, annually and with significant changes. Once the Interdisciplinary Team (IDT) determines the resident is a candidate for discharge or the resident/resident representative expresses a desire to discharge that is feasible, under the supervision of the Social Service Director of designee, active discharge planning will ensure. B. Procedure: 2. The Social Services Director or designee will formulate a plan of care addressing the potentiality for discharge, resident's/representative's discharge goals and any discharge needs and preferences based on the assessment completed with the resident/representative and IDT. 3. Discharge to the community is determined to not be feasible, it should be documented in an assessment, plan of care, and/or progress note. 4. Upon the knowledge of a discharge date , the IDT shall develop a plan and coordinate services needed. 5. The Social Services Director or designee will be responsible for making referrals to a home health agency, durable medical equipment company, and other care agencies (i.e. Local Contact Agency) of the resident's choosing, as appropriate. 6. The Nursing Department will obtain a discharge order including orders for referrals to home health, and for durable medical equipment, as appropriate, from the resident's physician. 7. The Social Service Director or designee will be responsible for coordinating care with other agencies as appropriate. 10. The IDT shall complete the Discharge Summary Transition and Recapitulation Form for residents who are candidates for discharge. 11. The Discharge Summary Transition and Recapitulation Form will include input (i.e. preferences and needs) from the resident and/or resident's representative, and the resident and/or representative will be informed about the final plan. The document will be signed and dated by the nurse, resident, and/or resident's representative. Supporting documentation will be provided. 12. After the resident or resident's representative has signed the form indicating understanding of the discharge plan, the original will be provided to the resident/resident representative and a copy remains in the resident's medical record. The facility Notice Before Discharge policy, undated, includes, in part, the following: The written notice must state the location to which the resident is to be discharged . The resident may not be involuntarily discharged unless an alternate living arrangement has accepted the resident, and the alternate placement is arranged. A facility to which the resident is to be discharged must have accepted the resident for and in advance of the transfer, except in a medical emergency. R1 was admitted on [DATE]. R1's diagnosis include lung cancer, congestive heart failure, acute kidney failure, alcoholic cirrhosis of liver with ascites, depression, and anemia. R1's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/26/24 includes, in part, the following: R1 is understood and understands and R1 is cognitively intact. R1 has no behaviors and is independent with his own cares and toileting. R1 is currently receiving chemotherapy. R1's Care Plan Focus, Resident's discharge plans are undecided currently. Date Initiated: 10/5/23. Interventions include, in part, the following: Complete the Discharge Summary, Transfer and Recapitulation form as before discharge. Involve the resident/family in the discharge process. Will reassess discharge plans quarterly and/or as needed. R1's Care Plan Focus, (R1) is at risk for falls related to history of muscle weakness, abnormal gait, history of falls prior to admit. Use of antidepressant medication with potential side effects that may impact balance or coordination. Currently undergoing chemo therapy dx (diagnosis) of Lung cancer. Takes diuretic daily, independent with toileting. Date Initiated: 7/16/21. Interventions: Encourage and offer rest periods when walking long distances. Encourage resident to call, don't fall. Encourage resident to keep room free of obstacles. Monitor for changes in ability to navigate the environment. Monitor for changes in gait or ability to ambulate. Provide an environment clear of clutter. Provide proper, well-maintained footwear. R1's Care Plan Focus, Potential for alteration in skin integrity, admitted with vascular wounds to bilateral lower front ext. (extremity) (have healed. Alert and oriented times three. At risk for skin breakdown related to diagnosis of venous insuff (insufficiency), and weakness which may impair his ability to always offload enough to avoid friction or shearing. DX of Kidney and Liver disease. Power Port Clearvue implantable port (chemo access) implant site - RT (right) IJ (intrajugular) cath length 24 cm (centimeter). (Oncology physician name and phone number) (ref # (reference number) lot number (number) located to right chest. Power Port Clearvue implantable port. Check power port right IJ site every shift. Date Initiated: 8/7/24. Interventions include in part, the following: Absorbent to wick up moisture. Bathe with mild soap. Check power port right IJ site every shift. Engage resident and/or family in risk reduction interventions. Monitor for s/s (signs and symptoms) of infection. Monitor labs, weight, and/or intake. Monitor nutritional status. Pressure reduction foam mattress or pressure redistribution support (low air or alternation air) in bed. Pressure reduction support on wheelchair. Treatment as ordered. Venous insufficiency interventions: Compression therapy, leg elevation, lubricate dry skin and ambulate as tolerated, if able. R1's Care Plan Focus: Potential for pain related to Dx of Stage 1 Bronchogenic Carcinoma Alert and oriented times three and able to utilize verbal pain scale indicator. Currently undergoing chemotherapy. Date Initiated: 7/16/21. Interventions include, in part, the following: Administer pain strategies according to MAR/TAR (Medication Administration Record/Treatment Administration Record). Allow for rest periods. Assess pain every shift. Monitor for nonverbal indicators of pain daily with care tasks and activities. Observe resident for effectiveness of pain relief. Offer PRN (as needed) analgesics prior to ADL (Activity of Daily Living) activities and/or rehab if indicated. Provide support and reassurance. R1's Care Plan Focus Receiving mirtazapine psychotropic medication. To manage behavior or mood issues of low appetite. Related to diagnosis of Appetite Stimulant. Date Initiated: 4/28/24. Interventions include, in part, the following: Assess nutritional and sleep patterns for disturbances and address accordingly. The facility's Discharge Notice, dated 8/7/24, includes, in part, the following: Dear (R1), This letter serves as a letter of discharge from (facility name). The reason for your being discharged is that: You've failed to pay, after having been given a reasonable notice and opportunity to pay, for your care at this facility. The anticipated date of your discharge is 9/7/24. The location to which you'll be moving is Hotel or apartment in Beloit, WI. You have a right to relocation assistance and to be prepared for and oriented to being discharged . A separate notice will be provided inviting you and others to a discharge planning conference. You have the right to contact an advocate to discuss this notice and seek assistance. You may call or write an Ombudsman (for persons over age 60) or a representative from Disability Rights Wisconsin (for persons under age 60). This notice is signed by R1 and NHA A (Nursing Home Administrator) and dated 8/7/24. R1's Discharge Summary, Transition and Recapitulation Form 10.2023 -V2, includes, in part, the following: Effective Date 9/11/2024, 14:07 (2:07 PM), 2. Transition Information. a. Transition Time and Date: 9/12/24, 03:00 (PM). b. Transition to 5. Other. C. LTC (Long Term Care) or other: Motel 6. Transition with d. Alone. Transition Via: h. Car. l. Reason for Discharge: 2. Financial Reasons/Insurance Non-Coverage. m. Discharge Initiated by 2. Facility. Pharmacy: a. Name, contact person and phone number: (Name of Pharmacy, Town Pharmacy is in) 2 months prescriptions sent. Signed by: RN C (Registered Nurse). Signed Date: 09/27/2024. R1's Progress Notes include, in part, the following: 8/7/2024 11:49 (AM) Type: Interdisciplinary Team Note: Note Text: Admissions Director and SSD (Social Services Director) had a conversation with resident regarding non-payment and involuntary discharge. Social Services presented notice of involuntary transfer and indicated that resident had failed, after reasonable and appropriate notice, to pay for his stay at the facility. Explained to resident that IVD (Involuntary Discharge) process can be stopped by agreeing to payment plan, applying for public aid, and/or bringing their account current. Offered to make referrals to alternate facilities of choice. If no alternate site is identified/secured, informed resident that he would be discharged to a local Hotel on September 6, 2024, as he stated that he cannot go live with family. SSD provided resident with list of alternative placement options and will assist with and supervise transfer. Admissions and SSD explained resident's right to appeal the involuntary transfer and provided resident with a stamped, addressed envelope along with the request for hearing. Resident stated he understood what Social Services had explained and stated he had no questions. Admissions placed a copy of the notice of involuntary transfer in resident's chart. Author: SSD D. 9/10/2024 12:36 (PM) Type: Interdisciplinary Team Note: Note Text: Spoke with (R1) regarding his discharge and that would take place on Thursday. He stated that he called his Medicare insurance, and they suggest appealing his discharge. It was explained to him that an appeal cannot be done as he has not had a Medicare stay to appeal. Writer called the appeal company and left a message for a return call to discuss the appeal that was filed. (R1) also is not willing to turn over his income to help pay for his stay here at the facility. Author: SSD D. 9/12/2024 17:16 (5:16 PM) Type: Orders Note for eMAR (electronic Medication Administration Record) Note Text: . Resident discharged from facility. Author: RN E (Registered Nurse) 9/23/2024 15:57 (3:57 PM) Type: Social Services Note Text: Writer received a call from Human Services regarding (R1) and if he could return to the facility as his Medicaid had now been approved and should show up in the portal in the next couple days. Writer explained to him that he was issued an IVD for non-payment to the facility and that we tried to work with (R1) on several accounts to make payment arrangements with him and he refused to turn over his income as his part of the Medicaid requirements. Also explained to him that we had been trying to work with him since February to do his Medicaid renewal and he wanted no help from the facility that he would take care of it and tried to help him with apartment hunting, and he denied help with that as well. Writer also got the administrator on the phone call, and she told him the same things. Human Services understood once we explained everything as (R1) is not telling whole story to them. We also let him know that (R1) has not reached out to us at the facility to see if a return is possible. Author: SSD D. 9/24/2024 12:08 (PM) Type: Interdisciplinary Team Note Note Text: This writer received a call from (AMS F) (Anthem Medicare Staff) to talk about (R1's) stay and the possibility of returning. This writer let her know that the facility had multiple times since March tried to work with (R1) both on Medicaid and setting up a payment plan for the amount owed due to resident liability. (R1) refused each time and refused to pay his part of the liability refused to pay his part of the liability going forward as he needed the money for an apartment. (AMS F) asked about medications, as (R1) stated that he had none. This writer let her know that all information was sent with (R1), including 2 months of medications to be picked up at Walmart. (AMS F) looked at (R1) insurance program and asked why he had not picked them up as he is on a low-income program, so all meds have no copay. This writer stated she was not sure, as all medications were sent to the Walmart across the street from his hotel for easy access. (AMS F) stated it seemed like he was purposely being difficult as he had yelled at her because the Medicare would not pay for his stay of the amount owed. (AMS F) stated she tried to explain, but he refused to listen. This writer let (AMS F) know that (R1) had told us that he could stay with his son or friends and that he would have enough money to get an apartment. This writer explained that (R1) refused to assist us with further discharge planning, but we are willing to help with what he may need. (AMS F) mentioned she was hoping Elcho [sic] (ECHO is an emergency service for low-income families) would call back so they could help set him up. This writer let (AMS F) know to call back if needed and that at this time (R1) had not contacted the facility. Author: NHA A (Nursing Home Administrator) 9/24/2024 14:32 (2:32 PM) Type: Social Services Note Text: Writer received a call from APS (Adult Protective Services) regarding (R1). (APS G) stated that she received a referral on R1 that he is unable to care for himself and that we only gave him 1 night at a hotel he made it seem that he was just discharged within the last day. Explained to her that he was discharged on [DATE] with 2 weeks of a hotel stay paid for by the facility and that he is fully independent with all cares and all we did for him was give him his medications and deliver his food and that he refused for us to do any cares on him, clean the room or help with anything and that he walked inside and outside independently. Writer let her know that he was served an IVD due to nonpayment of approximately $50 K ($50,000) and that (R1) has not been cooperating since February to renew his Medicaid and refused to turn over his income according to Medicaid requirement and would not tell us his income either. (APS G) stated that (R1) is telling a different story but the information I was providing made more sense. (APS G) was appreciative of the information. Author: SSD D NHA A provided Surveyor with a timeline as follows: 8/7/2024 - IVD served, explained to both (R1) and his son including payment plans and appeal rights. 8/12/2024 - Social Services and Administrator offered payment plan to (R1), (R1) denied stating that he needs his money. 8/20/2024 - Social Services and Administrator asked (R1) about his discharge plans, offered a discharge planning conference and brought up payment plan again. (R1) walked away stating that he did not need help. 8/30/2024 - Social Services and Administrator tried to speak with (R1). (R1) walked away without saying a word. 9/3/2024 - Social Services and Administrator spoke to (R1) about his discharge plans, where he would like to go, appeal rights, payment plans, etc. (R1) stated that he would go with his son but was avoidant with other questions. Administrator asked (R1) if he would like a hotel in Beloit or Janesville, (R1) stated he would take care of himself. 9/6/2024 - Social Services and Administrator attempted to speak with (R1) about the above stating that his discharge date would be 9/12/2024. (R1) refused further conversation, just said ok. Administrator let (R1) know she would get him a hotel in Janesville to be close to appointments and Walmart. 9/10/2024 - Reinterated (sic) conversation on 9/6/2024, offered payment plan again. (R1) stated he needed his money and could not turn over income. (R1) stated he was working on Medicaid. Administrator let (R1) know, that is a great start, but we would still need his patient liability. 9/12/2024 - Hotel information given to (R1), appointments, transportation information all given to (R1). Offered to help pack, (R1) denied, but got him boxes. Offered transportation to the hotel, (R1) stated that his son would take him. Spoke again of payment plan and staying, (R1) stated he would be fine and stay with his son. Administrator let (R1) know hotel was paid for so he had the option to use that as well. 2 months of medications was called into the Walmart across the street from his hotel as well. (R1) said OK. Signed by NHA A and SSD D. On 9/24/24 at 10:50 AM, Surveyor interviewed R1 via telephone. R1 stated he was discharged from the facility and the facility had paid for a 10-day stay at Motel 6 from 9/12/24 through 9/22/24. R1 stated he was told he had to leave due to no payment source. R1 stated he had applied for Medicaid and was awaiting approval. R1 stated he has nowhere to go; R1 stated he could not live with his son. R1 stated he was discharged with no medications and no food. R1 stated someone had delivered food to the motel for him - it was spoiled, and the front desk staff threw it away. R1 did not know where it came from. R1 stated the motel front desk staff had given him some food. R1 stated he was informed his medications could be picked up at Walmart, but he could not find a ride to get to Walmart. R1 stated he has an appointment on 9/26/24 to have a chemotherapy treatment for lung cancer but was unsure if he would be able to find a ride to the clinic, which was downtown and not within walking distance. On 9/27/24 at 11:55 AM, Surveyor interviewed R1 via telephone. R1 stated he needed to have blood work done prior to his chemotherapy treatment. R1 stated he called the physician's office and was told to go to the hospital for the blood work. R1 called 911 to go to the hospital and was discharged back to the motel. R1 stated he had missed his chemotherapy treatment on 9/26/24 due to not having a ride. Surveyor asked if R1 had picked up his medications at Walmart. R1 stated he could not find a ride and did not feel safe walking to Walmart as he needed to cross a six-lane highway and it was a longer distance than he could walk. R1 stated he had an appointment on 9/30/24 with ECHO to receive assistance to get into a men's homeless shelter. R1 stated he had called the ADRC, APS, and Ombudsman for assistance and was assisted with staying at the hotel until 10/1/24. On 9/30/24 at 9:35 AM, Surveyor interviewed SSD D. Surveyor asked about R1. SSD D stated R1 was a very private man and would not cooperate with filling out his Medicaid renewal and refused to turn over his income/liability to the facility. R1 had Medicaid since his initial admission in 2021, his Medicaid was up for renewal in March 2024. SSD D stated she offered to assist R1 with filling out his Medicaid application and he refused, stating he wanted to do it himself. SSD D stated that R1 did not cooperate and R1's Medicaid was no longer effective in March. Surveyor asked SSD D how and when did R1 receive his Involuntary Discharge Notice. SSD D stated R1 was given an involuntary discharge due to non-payment of his liability. SSD D stated she read the entire notice to R1. SSD D stated she felt R1 understood the notice, including how to appeal. SSD D stated she did not send any referrals to other facilities, nursing homes, or assisted livings since R1 did not have a payor source. SSD D stated R1 did file an appeal through Lavanta, but that was denied since he did not have a Medicare stay. R1 had no private funds, he would not disclose his income. Surveyor asked SSD D where R1 was discharged to. SSD D stated the facility paid for two weeks at a motel for R1. R1's medications were called into Walmart. SSD D stated she was unsure if R1 picked up his medications and was unsure if R1 could sustain paying for the motel since he refused to disclose his income to the facility. SSD D stated she thought R1 could take public transport to and from any doctor appointments, SSD D was unsure of how close public transport was to the motel R1 was discharged to. On 9/30/24 at 9:45 AM, Surveyor interviewed AD H (Admissions Director). Surveyor asked AD H if she delivered R1's monthly statements from the facility. AD H stated R1 owed between $40,000 - $50,000 and would not talk about his finances. AD H stated she personally handed R1 his monthly statements and felt that R1 understood he owed the facility money. AD H stated she offered to assist R1 in filling out his Medicaid application. R1 refused assistance from AD H. On 9/30/24 at 9:53 AM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A to explain R1's discharge. NHA A stated R1 refused to talk to NHA A about his discharge. NHA A stated she asked R1 about whether he wanted to live in an apartment or if he would like referrals made to other nursing homes or assisted livings, R1 refused to talk about anything. NHA A stated R1 told her that he could live with his son when he was not living with his mother. NHA A stated that R1 finally filled out the Medicaid application after he was given his bill at the end of June. NHA A stated she was aware that R1 now has Medicaid, however he would not tell the facility about his finances or liability. NHA A stated she thought R1 received about $2000 a month from Social Security. NHA A stated R1 had offered to pay $200 a month and refused to talk about anything else. NHA A stated R1's son gave R1 a ride to the motel. R1 had not been in contact with the facility since he left. NHA A stated she was contacted by staff from both ADRC (Aging and Disability Resource Center) and APS (Adult Protective Services). On 9/30/24 at 11:55 AM, Surveyor interviewed R1. R1 stated he still did not have any ride services set up for his physician's appointments or chemotherapy treatment, which was rescheduled for later in the week. R1 stated he needs to take a steroid medication the day before his chemotherapy treatment, or the treatment will be canceled. Surveyor asked R1 about the day he discharged , 9/12/24. R1 stated he returned from a physician's appointment and was told he had to leave. R1 stated no one offered to assist R1 with transportation to the motel. R1 said he called FM I to help him. FM I came to the facility after he was done with work, assisted R1 to pack and drove R1 to the motel. R1 stated on 9/14/24, FM I gave R1 a ride back to the facility to pick up the rest of his belongings. R1 stated he asked staff if he could have his medications as he was unable to pick them up from Walmart. Staff stated no, they were unable to give him his medications. Surveyor asked R1 if the facility allowed him to return would he return to the facility. R1 stated yes, he would return as he had lived there for three years. On 9/30/24 at 1:20 PM, Surveyor asked NHA A if she had informed the Ombudsman prior to R1's discharge. NHA A stated she had spoken with Ombudsman J on the phone and Ombudsman J was in the facility after R1 discharged . Surveyor asked NHA A if she would allow R1 to return to the facility. NHA A stated she would allow R1 back if financial payment would be prearranged. On 9/30/24 at 2:14 PM, Surveyor interviewed FM I via telephone. FM I stated he was made aware of R1's discharge when R1 called him on 9/12/24 to arrange for a ride to the motel. FM I stated he assisted R1 with packing his belongings and drove R1 to the motel. R1 had no money and the voucher for the room was for 10 days. FM I stated he bought some food for R1 to get through a couple of days as he had no food and no medications. FM I stated he had no idea how R1 got any more food as there was nothing close to the motel to buy food and R1 did not have any money. Surveyor asked FM I if he thought R1 could walk to Walmart. FM I stated no, R1 could walk but not that far due to his lung cancer. Surveyor asked FM I if R1 could live with him. FM I stated no. Surveyor asked FM I if he knew where R1 would go after his motel stay. FM I stated the only place he knew of was a men's homeless shelter. FM I stated he thought R1 would return to the facility if they allowed him to. On 10/1/24 at 10:30 AM, Surveyor interviewed Ombudsman J. Surveyor asked Ombudsman J when she was made aware of R1's discharge from the facility. Ombudsman J stated she was not notified of R1's involuntary discharge from the facility until 2 days after his discharge when R1 called her. Ombudsman J stated on 9/16/24 she emailed NHA A regarding not being notified of the involuntary discharge. Ombudsman J received an email from NHA A on 9/18/24 stating that a care conference was offered to R1 to work through options, but he refused. NHA A stated she did not know she had to contact the Ombudsman when giving an involuntary discharge notice. On 10/4/24 at 9:45 AM, Surveyor interviewed APS K (Adult Protective Services). Surveyor asked APS K if she had made contact with R1. APS K stated she had made contact with R1, R1 was working on getting into the men's homeless shelter, he had an interview to see if he was an appropriate candidate. On 8/7/24, the facility gave R1 an Involuntary Discharge Notice. R1 had filled out a Medicaid application, which the facility was aware of, and awaiting approval. On 9/12/24, R1 was discharged to a motel in which the facility paid for a 10-night stay for R1. R1 had no transportation to Walmart, which was 0.6 mile from the motel, across a 6-lane highway, to be able to pick up his medications. R1 missed a chemotherapy treatment due to no transportation to the clinic. R1 was not provided a safe and sustainable discharge from the facility.

Based on observation, interview and record review the facility did not ensure that 1 of 16 residents reviewed for ADL care (Activities of Daily Living) received the necessary services to maintain good nutrition grooming, personal and oral hygiene. R18 voiced concern of not receiving oral care. This is evidenced by: The facility policy, entitled Morning Care, General Guideline, dated 9/20, states in part: .5. Encourage resident to perform ADL's (grooming, dressing, oral hygiene, transfer, ambulation, toileting, etc.) or to participate as much as the resident is able . R18 was admitted on [DATE] with diagnoses which include assistance with personal care, unspecified lack of coordination, cerebellar ataxia in diseases classified elsewhere (damage to the part of the brain that control muscle coordination). R18's Care Plan, initiated: 12/3/22, states, .Focus: .has an ADL Self Care Performance Deficit related to having weakness and need for assist with personal cares . Assist resident with oral care daily as needed. (Natural teeth) .Provide needed level of assistance and support to complete Activities of Daily Living . On 12/13/23 at 11:19 AM, Nurse notes documents, The resident did get out of bed. No undesired behavior this shift. On 12/12/23 at 11:09 AM, Surveyor interviewed R18 during initial screening. R18 indicated his teeth have not been brushed since he has been here, stating my teeth feel nasty. R18 further indicated that he should not have to ask to have his teeth brushed and it is a part of washing up every day. R18 stated to the Surveyor, They don't even offer to brush my teeth. Surveyor observed R18's teeth and noted the teeth surfaces are rough with thick white material noted along the gum lines. On 12/13/23 at 9:12 AM, Surveyor interviewed R18 and indicated his teeth had not been brushed and no morning cares yet. Surveyor observed R18's teeth without changes from yesterday's observation of white substances along the gum lines. Surveyor asked staff to observe cares for R18. On 12/13/23 at 10:10 AM, Surveyor was advised by staff that they were finished with R18's care and that he has an appointment to go to at 10:30 AM. On 10/12/23 at 10:12 AM, Surveyor interviewed R18. R18 was in his wheelchair in his room. R18 indicated he did not get his teeth brushed and showed the Surveyor his teeth. Surveyor observed R18's teeth with white thick material noted along the gum lines. On 12/13/23 at 1:29 PM, Surveyor interviewed CNA E (Certified Nursing Assistant). CNA E indicated that his morning cares consisting of oral care that was completed and that his teeth were brushed. On 12/13/23 at 1:42 PM, Surveyor interviewed CNA F. CNA F indicated she performed cares with CNA E and did not observe R18's oral care. CNA F indicated that she did leave the room to get the hoyer lift for R18. Surveyor asked CNA F if R18 refused any care this morning, she indicated no. On 12/13/23 at 1:51 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor explained R18's concern of teeth not being brushed and the observations. DON B indicated that a resident's teeth should be brushed daily. Surveyor and DON B went together to R18's room and observed R18's teeth. DON B asked R18 if his teeth were brushed today, he stated, No, how can I? DON B asked R18 if he was offered to have his teeth brushed, he indicated no. Surveyor and DON B left R18's room together. Surveyor asked DON B the appearance of R18's teeth, she stated, They need to be brushed and indicated that his teeth should have been brushed.

Based on observation, interview and record review the facility did not ensure that a resident who is fed by enteral means receives the appropriate treatment and services 1 resident (R32) of 1 of 2 sampled residents reviewed for G/T (gastrostomy tube) care. Facility staff did not check placement of R32's G/T by residual prior to medication administration. This is evidenced by: The facility policy entitled, Enteral Nutritional Feeding dated 9/20, states in part: .Procedure: .8. Check position of tube for proper placement .a. Check residual by placing barrel of syringe into tube and pulling back on syringe. If contents less than 100 ml (milliliters), return aspirate contents to the resident. Proceed with feeding. If content is greater than 100 ml, replace contents, turn off feeding and call MD (medical doctor)/NP (nurse practitioner) . R32 was admitted to the facility on [DATE] and has the following diagnoses of dysphagia (difficulty swallowing) following cerebral infarction, intestinal bypass and anastomosis (a surgical connection between parts of the intestine) status and acquired absence of other specified parts of digestive tract. Physician's order states: Enteral Feed Order every shift for G tube protocol, check enteral tube placement prior to administering feeding, medications, and flushes. Start date, 10/3/2019. On 12/13/23 at 11:28 AM, Surveyor observed RN C (Registered Nurse) administer medication to R32 by G/T route. RN C unclamped the G/T, attached the barrel of the syringe, poured approximately 50cc of water into the barrel of the syringe, the water did not flow into the stomach by gravity, applied the plunger into the syringe and pushed the water and air into the tube, and continued with medication administration. RN C did not check placement by residual prior to administering medications. On 12/13/23 at 2:51 PM, Surveyor interviewed LPN D (Licensed Practical Nurse). Surveyor asked LPN D the process for administering medication through a G/T, she indicated she would check placement by checking residual prior to administration of medication. On 12/13/23 at 2:54 PM, Surveyor interviewed RN C. Surveyor asked RN C if she checked R32's G/T placement prior to administering medication, she indicated she did not and should have checked before pouring water into the barrel of the syringe. Surveyor asked RN C how she would have checked for placement, she indicated they do not check placement and they check by x-ray. Surveyor asked RN C if there was another method she would use to check placement, she indicated she would listen for auscultation with her stethoscope on the abdomen. On 12/13/23 at 3:38 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B the process for administering medication by G/T, she indicated that she would check the site, unclamp the G/T, apply a piston syringe, pull back on the syringe for residual and if there was more than 100 ml to contact the physician. Surveyor explained the process of R32's medication administration observation to DON B and she indicated that the residual should have been checked prior to medication administration.

Based on observation, interview, and record review, the facility did not ensure effective pest control for 3 of 3 wings. This has the potential to affect all 66 residents residing in the facility. Residents voiced concerns of being bitten and awakened by pests and having pests, including flies and beetles, crawling on them. Residents indicated they have had to purchase and use pest control supplies including Raid (pesticide) for pest relief. Surveyor observed a variety of pest species including flies, wasps, and moths, as well as spider webs throughout the building. Residents on all three wings (east, west, and south) of the facility voiced concerns of pest issues at the facility. This is evidenced by: The facility policy entitled Pest Control, dated 1/25, states: All employees will maintain the pest control program by communicating and documenting pest sightings, maintaining a clean environment, and eliminating conditions conductive to pest harborage . Employees will not apply any pesticides. Pesticides will not be stored in the facility. Example 1: R5 was admitted to the facility on [DATE]. R5's Minimum Data Set (MDS) assessment dated [DATE] shows that R5's Brief Interview for Mental Status (BIMS) score is 13, indicating that R5 is cognitively intact. On 7/27/23 at 9:45 AM, during an interview with R5, Surveyor observed a fly swatter laying on R5's bed, within R5's reach. R5 indicated that he had provided the fly swatter for pest relief. R5 indicated that the flies at the facility were bothering him. R5 indicated that multiple flies crawl on him throughout the day and wake him up at night. R5 stated, They (flies) land on my face and on my straw. At 9:50 AM, Surveyor observed a fly flying around R5's room. R5 indicated that facility staff had sprayed for the flies, but they continue to be a bother. Example 2: R7 was admitted to the facility on [DATE] and has diagnoses that include hemiparesis (weakness or the inability to move on one side of the body) following cerebral infraction (stroke) affecting left non-dominant side. R7's MDS assessment dated [DATE] shows that R7's BIMS score is 11, indicating that R7 has moderate cognitive impairment. On 7/27/23 at 10:05 AM, Surveyor observed a fly crawling on R7's clothing. R7 stated, Too many of them (flies) around here, they bother me, they are all over me, they are waking me up every night. At 10:18 AM, Surveyor observed a fly land on R7's right arm. R7 indicated that he can't move to swat the fly away and they are a nuisance. Example 3: R8 was admitted to the facility on [DATE]. R8's MDS assessment dated [DATE] shows that R8's BIMS score is 15, indicating that R8 is cognitively intact. On 7/27/23 at 10:50 AM, Surveyor interviewed R8 who indicated there was a bug problem at the facility. R8 stated, I just killed a moth in the window. Surveyor observed the smell of mothballs in R8's room. R8 indicated that he has mothballs in his room and he does not like the smell of mothballs. R8 stated, You got to do what you got to do. Surveyor observed two fly swatters hanging from above R8's bed. R8 indicated that he purchased the two fly swatters along with an electric fly swatter and a can of Raid that R8 used for pest control. R8 indicated that he is probably not supposed to have Raid (pesticide) at the facility. Surveyor observed the can of Raid and the electric fly swatter in R8's room. R8 stated, The bugs keep me awake at night. Example 4: R10 was admitted to the facility on [DATE]. R10's MDS assessment dated [DATE] shows that R10's BIMS score is 14, indicating that R10 is cognitively intact. On 7/27/23 at 11:05 AM, Surveyor interviewed R10 who indicated that she has seen flies, spiders, lots of spiders, and earwigs in her room. R10 indicated that she has told staff that she is getting bitten by bugs. R10 indicated that maintenance staff sprayed for bugs a couple of days ago and earlier in the season. At 11:20 AM, Surveyor observed a fly on the wall, and a spider web with a bug in it between the doorway and the wardrobe in R10's room. R10 indicated that she is getting bitten at night by bugs and the bugs are making it hard for her to sleep. Example 5: R4 was admitted to the facility on [DATE] and has diagnoses to include: posterior subcapsular polar age-related cataract (fast-growing opacity in the rear of the natural lens) right eye, unspecified visual loss, and palmar fascial fibromatosis dupuytren (disorder characterized by decreased hand function.) R4 has not had a MDS submitted during this stay. During a previous stay, R4's MDS assessment dated [DATE] showed that R4's BIMS score was 15, indicating that R4 is cognitively intact. On 7/27/23 at 11:50 AM, Surveyor interviewed R4 who indicated that flies/bugs crawling on her woke her up at 5:00 AM. Later in the morning, she thought she felt something crawling on her, and a CNA (Certified Nursing Assistant) told her there was a beetle crawling on her. R4 indicated that the CNA killed the beetle. R4 stated that the beetle crawling on her was creepy. (It is important to note that due to R4's diagnoses, R4 is unable to see and swat away flies and/or other bugs that are crawling on her.) On 7/27/23, Surveyor completed rounds of the facility. Surveyor saw an unusually large numbers of flies in the facility on all wings, throughout the building, and in resident rooms. Numerous residents complained of flying insects and concerns regarding the nuisance of flies within the facility. On 7/27/23 at 11:08 AM, Surveyor observed a moth in resident room (305). On 7/27/23 at 10:29 AM, Surveyor observed a fly flying above the three compartment sink in the facility kitchen. On 7/27/23 at 11:44 AM, Surveyor observed a wasp in resident room (107). On 7/27/23 at 5:39 PM, Surveyor interviewed DOM D (Director of Maintenance) who indicated that currently the facility is preventing and treating for the following pests: mice, rats, spiders, and ants. DOM D indicated that he has not seen any pests inside the facility, but the residents have reported seeing earwigs and ants. DOM D indicated that he has sprayed Raid inside residents' room as needed. DOM D indicated that he was unaware of flies in the facility. Surveyor asked DOM D if residents should have their own pesticides/Raid stored in their rooms? DOM D stated, They generally do not. DOM D indicated that a pest control contractor comes to the facility on ce a month and for pest issues as needed. On 7/27/23, Surveyor requested all pest exterminator contractor documentation from the facility for the last year. Pest control contractor treated the outside perimeter of the facility for the prevention of spiders and boxelder bugs on 8/30/22. Pest control contractor treated outside perimeter for prevention of rodents on 11/12/22, 12/20/22, and 1/11/23. Pest control contractor treated rooms 202, 207, 215, 217, and neighboring rooms for prevention of ants on 2/11/23. Pest control contractor treated all residents' rooms for the prevention of spiders and ants on 2/23/23. Pest control contractor treated all residents' rooms for the prevention of ants on 3/8/23. Pest control contractor treated room [ROOM NUMBER] and neighboring rooms for the prevention of ants on 4/7/23. Pest control contractor treated the outside perimeter of the facility for the prevention of ants, spiders, and boxelder bugs on 6/27/23 and 7/27/23. It is important to note that despite pest control coming to the facility, the facility had an unusually large number of flies in the facility. Multiple residents complained of the number of flies in the facility. On 7/27/23 at 6:25 PM, Surveyor interviewed NHA A (Nursing Home Administrator) who indicated that depending on the type of bug the facility staff will spray for pests or call a pest control contractor to spray. NHA A stated residents should not have pesticides at the bedside. NHA A stated she was not aware residents had concerns of pests in the home.

Based on record review and interview the facility did not ensure 1 (R1) of 6 Residents who required their blood levels to be monitored received the necessary care and treatment. R1 was admitted to the facility on [DATE] with discharge orders from the hospital for [MEDICATION(S)] levels to be drawn twice weekly on Monday & Thursday. An [MEDICATION(S)] level was drawn on Monday 5/17/21. There is no evidence in R1's medical record R1's physician or nurse practitioner was notified of the [MEDICATION(S)] level of 122 on 5/17/21 which was high. NP (Nurse Practitioner)-C informed Surveyor she couldn't say whether the facility had notified her of this lab value. There is no evidence an [MEDICATION(S)] level was drawn on Thursday 5/20/21 or that the facility notified the NP of this. On 5/22/21, R1's [MEDICATION(S)] was 95, which continued to be high. The facility attempted to contact the NP on 5/22/21 and faxed the results on 5/23/21 to the office. NP-C informed Surveyor there is no one at the office to receive faxes during the weekend. A change in treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was discharged to the hospital on 5/24/21 due to confusion and lethargy that had developed over the weekend. Findings include: R1 was admitted to the facility on [DATE] and discharged to the hospital on 5/24/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital physician discharge summary dated 5/14/21 under patient course documents; [R1] is .seen in ED (emergency department) for a chief complaint of generalized weakness and acute on chronic hepatic [CONDITION(S)] He has a history of alcoholic [CONDITION(S)], recurrent hospitalization s for the [CONDITION(S)], weakness, pancytopenia, cognitive impairment, placement issues. He was admitted on the 5th of May and discharged on the 14th of May. Patient was admitted on the medical floor and received high dose [MEDICATION(S)], [MEDICATION(S)], lasixs, and [MEDICATION(S)] .Throughout his 9 day hospital stay he slowly improved from a mentation standpoint. [MEDICATION(S)] levels were closely monitored as well. PT did conclude that he would require short term rehab and patient would be best served at a short term care facility. Today the patient is doing well. His chronic conditions remain stable. He will be discharged to Meadow Park. MSW (masters social work) has successfully arranged placement today. The hospital after visit summary under discharge orders for labs documents, Twice weekly [MEDICATION(S)] levels (Monday and Thursday). The nurses note dated 5/17/21 documents, Resident is alert oriented-able to make needs known et (and) to use call light effectively. up in w/c (wheelchair) propel self around facility. Newly admitted to facility-inct (incontinent) of bowel et bladder with peri cares done per staff. Able to feed self with no problems with chewing or swallowing. Takes medication whole et is insulin dependent. Need numerous verbal cues to wear mask when out of room. The nurses note dated 5/17/21 documents, NP (Nurse Practitioner)-C in to visit resident. New orders provided to draw labs on Wednesday. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . NP-C's progress note dated 5/17/21 under history of present illness documents, .was discharged from the he (sic) hospital on 4/29/21 after a 9 day hospitalization . He was brought to the hospital for weakness and falls. On discharge from the hospital [MEDICATION(S)] level was 77 on admission on this occasion it was noted to be 148. Patient was restarted on his [MEDICATION(S)] and [MEDICATION(S)] with improvement in his mentation. Patient's overall condition improved. He is now at [name of facility] for medical management and sub acute rehab. Under assessment includes documentation, 1. AMS (altered mental status) secondary to hepatic [CONDITION(S)] - continue xifaxin and [MEDICATION(S)]. Patient was non-compliant in the home setting. Will continue to monitor closely. Patient continues to be at his baseline. 2. Alcoholic [CONDITION(S)] - continue [MEDICATION(S)], xifaxin and [MEDICATION(S)]. As stated above patient was not compliant with medications. Monitor. Under plan documents, Laboratory orders: CBC (complete blood count), CMP (comprehensive metabolic panel) Lab Comments: 5/19/21 Referrals: PT/OT (physical therapy/occupational therapy) Education: Alternative treatments, Symptom management, written instructions for tapering/titrating medications, Discussed risk of future events, Patient was reassured, Discussed POC (plan of care) with facility and/or nursing. The laboratory report with a collection and reported date of 5/17/21 for [MEDICATION(S)] has a result of 122 umol/L (micromole per liter). The reference range is 16-53. This [MEDICATION(S)] result is high. Surveyor noted there is no documentation of R1's high [MEDICATION(S)] level on 5/17/21. NP-C progress note dated 5/19/21 under review of systems documents, Update - patient states that he is doing well today. Denies complaints of CP (chest pain), SOB, diarrhea or constipation. States that his therapy is going well. Denies complaints of pain at this time. Under assessment for active problems addressed during today's visit documents, 1. AMS secondary to hepatic [CONDITION(S)] - continue xifaxin and [MEDICATION(S)]. Patient was non-compliant in the home setting. Will continue to monitor closely. Patient appears to be at his baseline. 2. Alcoholic [CONDITION(S)] - continue [MEDICATION(S)], xifaxin and [MEDICATION(S)]. As stated above patient was not compliant with medications. Monitor. Under plan documents, Laboratory Orders: CBC, CMP Lab Comments: 5/19/21; pending Referrals: PT/OT Education: Alternative treatments, Symptom management, Written instructions for tapering/titrating medications, Discussed risk of future events, Patient was reassured, Discussed POC with facility and/or nursing Eligible clinician attests that medications were reviewed and/or updated. Surveyor noted there is no documentation of R1's high [MEDICATION(S)] level on 5/17/21. Surveyor reviewed the laboratory report collected and reported on 5/19/21 and noted [MEDICATION(S)] is not included in this lab report. An [MEDICATION(S)] level was not drawn on Thursday 5/20/21 contrary to discharge orders. NP-C progress note dated 5/21/21 under review of systems documents, Update - patient seen while up and about in the facility self propelling in his wheelchair. Patient states that he is doing well today. Denies complaints of CP, SOB, diarrhea or constipation. States that his therapy is going well. Denies complaints of pain at this time. Under assessment for active problems addressed during today's visit documents, 1. AMS secondary to hepatic [CONDITION(S)] - continue xifaxin and [MEDICATION(S)]. Patient was non-compliant in the home setting. Will continue to monitor closely. Patient appears to be at his baseline. 2. Alcoholic [CONDITION(S)] - continue [MEDICATION(S)], xifaxin and [MEDICATION(S)]. As stated above patient was not compliant with medications. Monitor. Under plan documents, Laboratory Orders: CBC, CMP Lab Comments: 5/19/21; discussed with nursing. Referrals: PT/OT Education: Alternative treatments, Symptom management, Written instructions for tapering/titrating medications, Discussed risk of future events, Patient was reassured, Discussed POC with facility and/or nursing Eligible clinician attests that medications were reviewed and/or updated. The nurses note dated 5/21/21 at 9:03 p.m. documents, [Name of Managed Care Organization] visited resident in facility this afternoon. She stated resident is more confused than his norm and requested for resident to be transported to the ER (emergency room ). Resident was admitted on ,d+[DATE] and status has remained the same since discharge from hospital. He is AxO (alert times orientated) to self and place. Incontinent of B & B (bowel and bladder). Utilizes w/c (wheelchair) to mobilize. wander up and down the halls. Feeds self with no issues. Writer assessed residents vitals and wnl (within normal limit) as charted. Lungs clear, denies coughing or SOB (shortness of breath). Denies of pain or discomfort at this time. On call NP (Nurse Practitioner)-D notified. Orders to draw labs and continue to monitor. Labs called in to [name of lab]. The laboratory report for collection & reported date of 5/22/21 (Saturday) for [MEDICATION(S)] documents, 95 umol/L. The reference range is 19-53. This [MEDICATION(S)] result, while going down, is still high. The nurses note dated 5/22/21 at 8:15 p.m. documents, Lab results received and [name of medical group] called x (times) 2 to report results and awaiting response. The nurses note dated 5/23/21 at 8:46 p.m. documents, Labs faxed to NP and left for NP at facility. The nurses note dated 5/24/21 at 12:23 p.m. documents, Received call from NP-C regarding lab results received order to increase [MEDICATION(S)] to 30ML (milliliter) 4x/day (four times per day). The nurses note dated 5/24/21 at 12:58 p.m. documents, Spoke to RN (Registered Nurse)-E from [name of managed care organization] regarding patient [MEDICATION(S)] lab results on 5/22 vitals signs WNL (within normal limits) at 0900 (9:00 a.m.) and new order received. NP-C [name of medical group] faxed at 1250 regarding RN-E request to be evaluated by NP (Nurse Practitioner) or ED (emergency department) today faxed NP-C regarding patient assessment done on 5/24 and request for NP assessment per [name of managed care organization]. NP-C's progress note dated 5/24/21 under review of systems documents, Update - noted by staff that patient noted to have a change of condition over the weekend. [Name of Managed Care Organization] Case Worker wanted him sent out 911. Apparently over the weekend patient with increased confusion and lethargy. Patient was seen today sitting up in his wheelchair. Smiling and grinning. His speech is still slurred, he answers questions minimally. Per staff patient had to be fed today. He is taking his medications. Updated Case discussed adjustments to medications and monitoring. Do not believe that patient requires transfer to the ER at this time, especially 911 as patient's VS (vital signs) are stable and his [MEDICATION(S)] level has a noted downward trend. All questions were answered. ADON (Assistant Director of Nursing) and Administrator were updated on plan of care. Under assessment for active problems addressed during today's visit documents, 1. AMS secondary to hepatic [CONDITION(S)] - continue xifaxin and [MEDICATION(S)]. Patient was non-compliant in the home setting. [MEDICATION(S)] levels 122 (5/17/21) -> 95 (5/24/21). Will increase [MEDICATION(S)] and continue to monitor closely. 2. Alcoholic [CONDITION(S)] - continues [MEDICATION(S)], xifaxin and [MEDICATION(S)]. As stated above patient was not compliant with medications. Monitor. Under plan documents, Laboratory Orders: CMP, [MEDICATION(S)] level Lab Comments: 5/26/21 Referrals: PT/OT Education: Alternative treatments, Symptom management, written instructions for tapering/titrating medications, Discussed risk of future events, Patient was reassured, Discussed POC with facility and/or nursing. The nurses note dated 5/24/21 at 11:36 p.m. documents, Paratech here at 2030 (8:30 p.m.) for transport to [name of hospital] per case manager arrangements earlier today; resident was noted to look more yellow today, skin clammy and cold, fatigued and refused to eat today or take meds (medication). The hospital history and physical dated 5/25/21 at 12:01 a.m. under history of present illness documents, .known to me from admission 1 month ago for hepatic [CONDITION(S)] and known medication noncompliance in the setting of known hepatic insufficiency, alcoholism, [CONDITION(S)] C. He presented to ED at 2100 (9:00 p.m.) hrs (hours) this evening for worsening confusion and generalized weakness at [name of facility]. I asked emergency department to place NG (nasogastric) tube and give first dose of [MEDICATION(S)]. Patient has had prior medication noncompliance. Last month's hospitalization ran 9 days. He was sent to short-term rehab. Patient's BUN (blood urea nitrogen) elevation tonight is new. Bilirubin 3.4 somewhat elevated from recent 2.2-3 range, though he was this high earlier in April. Patient's pancytopenia stable. Normal saline 1 L bolus given the emergent department. 30 g (grams) [MEDICATION(S)] per NG tube given in emergency department. On limited interview, pt (patient) denies h/o (history of) SOB (shortness of breath)/CP (chest pain)/Fever/Chills/Vomiting/Diarrhea/Abd (abdominal) Pain/change in bladder habit/focal neuro changes. Under problems/impressions includes, Reurrent (recurrent) hepatic [CONDITION(S)]. Altered mental status. [MEDICATION(S)] 108. On 6/9/21 at 1:45 p.m. Surveyor asked DON (Director of Nursing)-B when a nurse receives a faxed lab what is the process for labs. DON-B informed Surveyor the nurse will review the lab and if the lab is not abnormal the nurse practitioner will look at the lab when they come into the facility. If the lab is abnormal and the NP is not in the building they will call the on call NP and update the regular NP. DON-B informed Surveyor the regular NP comes to the facility on Monday, Wednesday, & Friday between 2 and 5 pm. Surveyor asked how long should the nurse wait for the NP to get back to them. DON-B informed Surveyor if the NP hasn't gotten back to them in an hour then they should call the in home medical group as they are on call. DON-B also informed Surveyor if the lab result is critical the Resident would be sent to the emergency room . Surveyor informed DON-B Surveyor was unable to locate when R1's Physician or NP was notified of the [MEDICATION(S)] level on 5/17/19 and another [MEDICATION(S)] level was received on 5/22/21 but the NP did not get back to the facility until 5/24/21 two days later at which time the treatment was changed. Surveyor asked DON-B to get back to Surveyor with any additional information. On 6/9/21 at 2:40 p.m. Surveyor informed ADON (Assistant Director of Nursing)-M the hospital after-summary visit discharge instructions includes twice weekly [MEDICATION(S)] levels on Monday and Thursdays. Surveyor asked when the lab comes into the facility. ADON-M informed Surveyor on Monday, Wednesday, and Fridays but the labs can be drawn other days. On 6/9/21 at 3:00 p.m. Surveyor spoke with NP-C regarding R1. Surveyor informed NP-C Surveyor had reviewed her 5/17/21 progress note and didn't note any documentation regarding R1's [MEDICATION(S)] level dated 5/17/21. Surveyor asked if facility staff had informed her of R1's [MEDICATION(S)] level of 122. NP-C informed Surveyor 5/17/21 was the first time she had seen R1. Surveyor asked NP-C if she would have written a note regarding the [MEDICATION(S)] level. NP-C informed Surveyor she doesn't always write a note but signs off on all labs that they give her. NP-C informed Surveyor she doesn't know if the facility called the on call NP regarding the [MEDICATION(S)] level and can't answer Surveyor's question. Surveyor informed NP-C the hospital discharge instructions indicated [MEDICATION(S)] level should be drawn twice weekly on Monday and Thursday. NP-C informed Surveyor she didn't see this on the discharge summary. Surveyor informed NP-C the discharge instructions were on the after visit summary. NP-C informed Surveyor she looked at the discharge summary and did not look at the after visit summary. Surveyor informed NP-C facility staff called twice on 5/22/21 which was a Saturday and faxed on 5/23/21, Sunday, R1's abnormal [MEDICATION(S)] lab but there was no response until 5/24/21. NP-C informed Surveyor she was not on call over the weekend and during the weekend there is no one in the office to receive a fax. Surveyor informed NP-C Surveyor noted on 5/24/21 she increased R1's [MEDICATION(S)] from three times a day to four times a day. On 6/9/21 at 4:10 p.m. Administrator-A, DON-B and ADON-M were informed of the above. On 6/10/21 at 10:16 a.m. Surveyor received via email from Administrator-A with a statement attached from Medical Director-F which is not dated and documents, Regarding review of [R1's] records this is a .patient with a long-standing history of alcoholic [CONDITION(S)], [CONDITION(S)], weakness, pancytopenia, cognitive impairment, hypertension, diabetes and chronic depression. He was admitted to the hospital for generalized weakness and acute on chronic hepatic [CONDITION(S)]. Upon admission to the hospital [R1] had an [MEDICATION(S)] level of 148. Adjustments were made to medication and he began to work with physical therapists. [R1] was transferred to [NAME] Meadow Park on 5/14. On 5/17 [MEDICATION(S)] level noted 122 and on 5/22 [MEDICATION(S)] level was 95, a continued improvement. [R1's] mentation has remained stable with expected characteristics of personality changes, intellectual impairment, and a depressed level of consciousness. treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Thank you for the opportunity to review this case. This statement does not change the deficient practice as the facility did not follow hospital lab discharge orders which documented an [MEDICATION(S)] level should have been drawn Monday & Thursdays. An [MEDICATION(S)] level was drawn on 5/17 but not on 5/20. There is no evidence in R1's medical record R1's physician or nurse practitioner was notified of the [MEDICATION(S)] level reported on 5/17/21 of 122 which was high. During interview with NP-C, NP-C informed Surveyor she couldn't say whether the Facility had notified of her of this lab value. Another [MEDICATION(S)] level was reported on 5/22/21 of 95, continued to be high. The Facility attempted to contact the NP on 5/22 and faxed the results on 5/23. Interview with NP-C revealed there is no one at the office to receive faxes during the weekend. A change in treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was transferred to the hospital on 5/24/21 and as of the date of the survey had not returned to the Facility.

The facility did not ensure that residents were free from abuse, neglect, misappropriation of resident property, and exploitation for 2 of 3 sampled residents (R1 and R2.) R1 verbalized concerns to a CNA (Certified Nursing Assistant) with interactions with CNA C that she felt were inappropriate. R2 verbalized inappropriate care provided / interactions with CNA C to DON B, NHA A, and LPN F. This is evidenced by: The facility's Policy and Procedure entitled Abuse dated 6/19 documents in part; This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion .6. Implementing systems to investigate all reports and allegations of mistreatment promptly and aggressively, and making the necessary changes to prevent future occurrences . Example 1 R1 was a short term rehab resident of the facility from June to August of this year. Her most recent MDS (Minimum Data Set) dated 8/12/2020 documents a score of 15 on her BIMS (Brief Interview of Mental Status,) which indicates that she is cognitively intact. R1 had the following Diagnoses: [REDACTED].) R1's ADL (Activities of Daily Living) care plan dated 6/9/20 includes the following intervention dated 7/23/20, .R1 prefers female caregivers . R1 has a care plan dated 7/23/20 that documents the following; Focus: R1 has expressed feeling uncomfortable with male care givers (assisting with adl cares) history of sexual abuse. R1 prefers female caregivers as her abuser was a male. Goal: R1's ADL cares will be met per her preference of female staff. Interventions/Tasks: Avoid male staff performing personal cares with R1 . It is important to note that on 7/23/20 the facility made a care plan for R1 to not have male caregivers, yet there is no other information regarding this. On 9/17/20 at 9:50 AM, Surveyor asked NHA A (Nursing Home Administrator) if they had any self-reports or other internal investigations from June through August. NHA A brought self-reports that he had; none were related to this. On 9/17/20 at 10:18 AM, Surveyor interviewed R1. Surveyor asked R1 if she had any concerns regarding any of the staff at the facility. R1 stated that the first night she was there, CNA C told her, You're really pretty while you sleep. She went on to explain that she had requested to use the bathroom and CNA C placed one hand on either side of her on the bed and began pushing on it so it was moving up and down, his face was directly in front of her, and then CNA C said I can't help you until you say my name. R1 stated she was in pain and really needed to use the bathroom but she couldn't recall his name; R1 said that CNA C then said, Piss yourself and we will change your diaper. R1 said I had urinate so bad, so I did, my anxiety was sky high! R1 went on to explain that she was a CNA and that this was not appropriate treatment so she started asking about CNA C and she found out that he was not actually a CNA. Surveyor asked R1 if that was the only incident. R1 said no, when she moved rooms from the quarantine unit to a regular one, she had been trying to position herself and got stuck so she put her call light on and CNA C came. R1 explained that she requested to be pulled up in bed. R1 explained that CNA C pulled the bed out from the wall and climbed up onto the mattress. R1 said CNA C's knees were by her butt, he then put his arms under R1's arms and pulled her backward onto him in the bed. R1 said she told CNA C, Get off of me. Surveyor asked R1 if these were the only occurrences. R1 said no, multiple times, I would wake up and CNA C would be sitting in my wheelchair rolling back and forth. R1 then stated, This was the last straw, when I finally decided I needed to speak up because if this was happening to me, what else was happening to people that can't speak up? Surveyor asked R1 to explain, R1 stated I was asleep and I heard someone say, You need a drink and I felt something on my lips, this startled me and I woke up. CNA C was standing there. R1 said she stated to CNA C, The only reason I need a drink is if you're going to put your dick in my mouth! Surveyor asked R1 what happened then. R1 stated he left the room and a female CNA came into the room. Surveyor asked R1 if she recalled who she talked to about CNA C. R1 said she wasn't real good with names but it was a female CNA. Surveyor asked R1 if anyone else talked to her about CNA C, R1 said yes, the Nurse that is in charge of the CNAs, DON B (Director of Nursing) and called her by name and NHA A (Nursing Home Administrator) and called him by name. R1 stated, Once I talked to NHA A (using his name) then CNA C left me alone, he took care of it. R1 stated he gave me the creeps and he shouldn't be in this line of work when other people can't fend for themselves, who knows what he's doing. Surveyor asked R1 if she was aware of any other inappropriate conduct by CNA C. R1 said yes, my neighbor (referring to R2) had complaints about him too. It is important to note that CNA C was hired at the facility as a hospitality aide but the facility utilized their waiver to train him to be a CNA. Surveyor received additional information from NHA A on 9/21/20. This included a statement from another CNA that documents the following in part; .CNA C remembers that one night after he had been in R1's room he came out and he was visibly upset. He said She is upset because I woke her up to drink something and she told me that she could do this herself and did not need anyone to do this for her. She is mad. CNA D went into the room directly after this to see if she could get more information about this. The resident was spoken to by CNA D and she said that he (CNA C) came in here and woke me up and asked me to drink water. I do not need anyone in here waking me up. I can do this stuff on my own . This statement was provided to Surveyors after leaving the facility. He in this statement refers to CNA C. Example 2 R2 verbalized concerns to DON B, NHA A, and LPN F regarding interactions with CNA C that she felt were inappropriate. R2 was admitted on [DATE] for short term rehab. Her most recent MDS dated [DATE] documents a score of 15 on her BIMS, which indicates that she is cognitively intact. R2 had the following Diagnoses: [REDACTED]. R2's care plan dated 7/27/20 states .due to issues of abuse from her past she would prefer female caregivers. The goal was then updated on 8/17/20 with an intervention stating R2 is ok with male caregiver as long as female is with him. On 9/17/20 at 10:09 AM Surveyor interviewed R2. Surveyor asked R2 if there has been any staff members that have made inappropriate comments to her and R2 stated that there was one staff member that has crossed some boundaries. R2 continued to say that CNA C had tried to give her a hug and that she had to tell him that was inappropriate. R2 also reported that CNA C had stood at the end of her bed and said, It looks like you have lost some weight since you have been here. In another instance, R2 reported that CNA C was standing behind her while she was rolled over in bed because she needed to be cleaned up and CNA C never performed the cares. R2 stated that the next night she refused to have CNA C care for her and she told the staff that she did not want him caring for her and that he still attempted to come in her room with a co-worker and R2 told them that he is not allowed. R2 stated that she spoke with DON B, NHA A, and LPN F (Licensed Practical Nurse) and expressed her concerns. Surveyor asked if she had a care conference to discuss her concerns with CNA C and she stated that she had a care conference with SW E (Social Worker), DON B, and LPN F. R2 stated that during the meeting the staff members told her that CNA C's behavior was because he was new and could be because he's a different culture. R2 told Surveyor that she has a history of verbal and physical abuse and that it is not ok for someone to grab you to hug you when you don't know them. Surveyor asked R2 if she felt safe with CNA C providing cares for her and she stated that she was uncomfortable with his comments and did not feel as if he was cleaning her up. On 9/17/20 at 11:47 AM Surveyor interviewed SW E. Surveyor asked SW E if she could recall a care conference with R2 regarding her preference for caregivers, SW E stated that they had a meeting with R2 and that she said that she prefers female caregivers over male caregivers due to them talking too much and that R2 thought there was a cultural thing, but did not give specific details. Surveyor asked SW E if there was any follow up with the employee or R2 after the care conference and SW E stated that she did not follow up with the employee and that she followed up with R2 to see how she was doing but most of their conversations have been related to discharge. On 9/17/20 at 12:01 PM Surveyor interviewed LPN F. Surveyor asked LPN F if she could explain the care conference held with R2. LPN F stated that she, DON B, and SW E met with R2 who had expressed some concern and expressed her preference for female versus male caregivers and that R2 stated that it was her preference due to her history. Surveyor asked LPN F if there were any other residents with the same concern regarding male staff members, LPN F stated that she could not recall. On 9/17/20 at 12:59 PM Surveyor interviewed NHA A. Surveyor asked NHA A if he had a conversation with R2 about CNA C. NHA A stated that he did have a conversation with R2 and she told him that there seemed to be a cultural difference because he likes to sit down and talk. NHA A stated that he called CNA C and told him that he was not allowed to take care of R2. Surveyor asked NHA A that once a care plan is updated to reflect R2's preferences, would you expect that staff follow the care plan. NHA A stated that he made it very clear that CNA C is not to go in R2's room. Surveyor asked NHA A if he had received any other concerns from residents regarding CNA C; he stated no. On 9/17/20 at 1:51 PM Surveyor interviewed DON B. Surveyor asked DON B if she recalled the care conference with R2 regarding CNA C. DON B stated that R2 told her that she preferred not to have males, but it was ok if a female was with the male. Surveyor asked if R2 gave any specific reason for her preference. DON B stated that R2 thought that CNA C might be more comfortable doing peri-care if a female was with. Surveyor asked DON B what her expectations are once R2's preferences were on the care plan. DON B stated that if she prefers females only then it should be just females. DON B stated that she assigned the male CNAs to another hall. Surveyor asked DON B if she recalled any other residents having the same concerns about CNA C, she stated no.

Based on observation, interview, record review, the facility did not ensure that a resident, who displays or is diagnosed with [REDACTED]. This affected 1 of 3 sampled residents (R1). R1 is diagnosed with [REDACTED]. The facility did not notify the physician or change treatments and services when a quarterly assessment showed her mood score had decreased and showed moderate depression. R1 attempted suicide on 3/19/18 by wrapping the call cord around her neck. The facility did not secure the resident's call cord until after she made a third suicide attempt by wrapping it around her neck. The facility did not increase supervision of the resident when she had increased agitation and depression. (R1 stated her intent to commit suicide waxes and wanes depending on her mood.) These failures created a finding of Immediate Jeopardy (IJ) that began on 6/28/18 when R1 made her second suicide attempt. Surveyor notified NHA A (Nursing Home Administrator) of the IJ on 7/13/18 at 11:15 AM. The IJ was removed on 7/12/18, however, the deficient practice continues at a scope/severity of D as the facility continues to implement its action plan. According to www.healthyplace.com, the American Psychiatric Association (the accepted authority on mental illness and personality disorders) explains in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders Fifth Edition) book that someone with a [MEDICAL CONDITION] disorder meets the primary criteria for [MEDICAL CONDITION], which includes two or more of the following: -Delusions -Hallucinations -Disorganized speech (speech that is easily derailed or is incoherent) -Grossly disorganized or catatonic behavior -Negative symptoms (flat expressions, loss of pleasure/anhedonia, lack of motivation / avolition, and other experiences that are taken away from the person) [MEDICAL CONDITION] disorder includes at least two of the above symptoms related to [MEDICAL CONDITION] and these DSM-5 criteria: -A major mood episode (either [MEDICAL CONDITION] or mania) that lasts for an uninterrupted period of time. -Delusions or hallucinations for two or more consecutive weeks without mood symptoms sometime during the life of the illness. -Mood symptoms are present for the majority of the illness. -The symptoms aren't caused by substance abuse. When someone is experiencing both psychotic and mood symptoms, it can be difficult to determine what he or she is truly experiencing. [MEDICAL CONDITIONS] disorder, and [MEDICAL CONDITION] disorder all can involve: -Feelings of elation for an extended period -Rapid speech -Racing thoughts -Bizarre behavior -Risk-taking behaviors -Agitation -Grandiose delusions -Hallucinations Example 1 R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/1/17, R1's care plan was put in place for receiving an anti-depressant [MEDICAL CONDITION] medication (Duloxetine and [MEDICATION NAME]) to manage symptoms related to a [DIAGNOSES REDACTED]. Interventions put in place were to assess nutritional and sleep patterns for disturbances and address accordingly; and document mood and behaviors as needed as they occur. R1 had a MDS (Minimum Data Set) Admission Comprehensive Assessment completed on 12/7/18. R1 scored a 3 for her mood, indicating she had minimal depression, and a 13 on her BIMS (Brief Interview for Mental Status), indicating she was cognitively intact. It specifically indicates she felt tired, had little energy several days a week, and had trouble concentrating on things such as reading the newspaper or watching TV for more than half of the days of the assessment. She was admitted with Physician order [REDACTED]. R1's Admission MDS Care Area Assessment (CAA) included [MEDICAL CONDITION] drug use, stating she had received an antianxiety and antidepressant. It had marked that she has anxiety, lethargy, and depression. It had marked to address this on her care plan with the statement, Care plan will reflect the use of [MEDICAL CONDITION] drugs and related symptoms. The facility completed the only sleep assessment for R1, starting 12/7/17 to 12/9/17, showing she slept a straight 8 hours, then 10 hours, and 5 hours with getting up to toilet during the night on the last night. There was no summary or conclusion from this sleep study. On 1/10/18, R1's care plan for receiving anti-depressants was updated to include: If (R1) is observed to have trouble adjusting to placement as evidenced by negative comments related to her desire to go home check these areas for improvements: remind that she can smoke weather permitting, encourage 1:1 (one to one) with her husband, encourage to call family for re-assurance, offer to talk to staff 1:1 to provide re-assurance. If (R1) presents as tearful with negative comments related to not being able to smoke check these areas for improvements: remind of upcoming smoke time, encourage to call family to come in to take her out to smoke, offer to spend time with husband to calm her down, offer to talk to staff 1:1. On 1/11/18, R1 had her [MEDICATION NAME] reduced from 1 mg to .5 mg every evening. There was no documentation regarding the reason or if R1's mood and behaviors were discussed. On 1/17/18, R1 was readmitted to the facility from a hospital stay for a medical concern with the following medication changes: Discontinued [MEDICATION NAME] for [MEDICAL CONDITION], [MEDICATION NAME] PRN (as needed) .5 mg. On 2/16/18, the facility completed R1's Quarterly MDS, which she had a score of 15 for her BIMS, indicating she is cognitively intact and a 12 for her mood, indicating she had moderate depression. It specifically indicates she was feeling down, depressed, hopeless, had trouble falling/staying asleep, nearly daily, felt tired or had little energy, and nearly daily felt bad about herself or that you are a failure or have let yourself or your family down. (It is important to note that her mood on 12/7/18 had been a score of 3 and that her current score reflected a negative change in mood.) It should be noted there is no indication that R1's physician was updated regarding R1's increased depression and feelings of hopelessness. Lack of physician notification prevented R1 from receiving the necessary assessment and potential treatment changes related to R1's increased depression. The facility completed the Comprehensive Social Services Assessment on 2/16/18 stating R1 was feeling bad about herself, depression, poor appetite, sleep cycle issues. The Progress Note includes that R1 has the potential to present with symptoms related to a [DIAGNOSES REDACTED]. The facility provided no evidence they identified her increase in mood or of any new interventions they took regarding her increase in symptoms. The facility Nursing Home to Hospital Transfer Form, dated 3/19/18, includes that R1 had call light cord wrapped around neck, Resident stated, 'the only way I can get out of here is feet first.' Would not release the cord when writer. (sic) The form stated under additional relevant information, (R1) noted to have altered mental status and decreased O2 (oxygen) sat. 83% room air; 87% with O2/21 (oxygen at 2 liters/minute). Noted to be mumbling incoherently to self, but can understand speech when talking to her directly. It is important to note that Surveyor had requested any further investigation on this event and the facility did not have any further documentation or investigation. Her Progress Notes only include that she was sent to the emergency room , but do not include why she was sent. R1 did not sustain any injury from this suicide attempt. The facility Progress Note, 3/20/18, stated they started 15 minute checks on R1 when she returned from the hospital. They provided evidence of 15 minute checks for R1 on 3/20/18 and 30 minute checks on the 21st, 22nd, and 23rd of (MONTH) (YEAR). There is no evidence the 30 minute checks continued after (MONTH) 23, (YEAR). The Progress Note written by DON B (Director of Nursing), dated 7/12/18, is a late entry for 3/20/18, states: Additional notes to suicidal assessment. This writer completed Suicidal Ideation Assessment and Head-to-Toe Assessment after this writer was notified by staff that resident (R1) had attempted to wrap a call light cord around her neck, resident was alert and oriented at that time, but was visibly upset and stated, 'I don't know why I did that and will never harm myself.', writer assessed her room, surroundings to make sure resident was safe and would not carry through her intention of trying to harm self. All sharp objects removed, TV cords were secured. This writer physically assessed the call light cord and noted the cord was not flexible enough for the resident to tie the cord around her neck due to physical impairments associated with functional deficits related to history [MEDICAL CONDITION] with left [MEDICAL CONDITION] with no functional use to LUE (left upper extremity) and is confined to w/c (wheelchair), RUE (right upper extremity) 3/5 in strength, right hand grip was moderately weak, needed two assist in doing ADLs (Activities of Daily Living). Writer notified PT (physical therapy) to validate assessment. (It is important to note that this progress note was written during the complaint survey). On 3/27/18, the following medications were changed at the hospital for R1 and she was admitted with [MEDICATION NAME] discontinued, Duloxetine increased from 30 mg to 60 mg, added PRN [MEDICATION NAME] and continued PRN [MEDICATION NAME] .5 mg. The facility continued to have the PRN [MEDICATION NAME] reordered by the physician. The Occupational Therapy Assessment, completed on 3/28/18, includes that R1 presented with decreased activity tolerance, increased c/o (complaint of) pain in left wrist and left leg and decreased strength RUE affecting participation in self-care tasks and requiring more assistance with transfers . no functional use of LUE and is w/c confined. The facility NP did see R1 regularly on the following dates: 3/20, 3/22, 3/29, 4/3, 4/5, 4/10, 4/19, 4/26, 5/23, and 6/5. NP note, dated 7/11/18, states, It was not determined that patient presented as threat to self. When asked, patient did not verbalize a plan or intent for self-harm. Charting is by exception. (Please note that this entry was added during the complaint survey). The facility Weekly Nursing Summary, dated 3/20/18, under behavior, states, Resident (R1) is pleasant and response (sic) very well to verbal commands, denies being depressed today, stated 'I don't know what prompted me to be depressed the other day, but am better today and life is worth living' I am so glad my family came to visit. 3/21/18, R1's Care Plan for Suicide Ideation was initiated. It included the interventions: After assessing lethality of previous/current suicidal attempt, analyze proper placement for (R1) to ensure proper safety and security of (R1). Arrange for initial psychiatric evaluation, as well as on-going psychiatric appointments for proper medication management. Consult with psychiatrist upon increased suicidal ideation with intent/plan. Arrange for psychiatric hospitalization as ordered by psychiatrist/psychologist to ensure the safety of the resident. The facility provided a list of interventions they completed after this suicide attempt: Suicide Assessments completed on (MONTH) 20, 21, 22, and 23 after her attempt, she was seen by a psychiatrist in the hospital who had no changes to her medication or care, removed potentially harmful objects from resident room, but left the call light (cord), because when she pulls it from the wall it turns on and alerts staff, therapeutic home passes arranged, had a care plan meeting, her daughter increased her visits, which increased her ability to smoke more often, made sure she was eating in the dining room among peers with increased supervision, and R1 only has use of her one arm. The facility wrote, (Call light) Cord is not a true risk, and can be a vital means for calling for help. 4/4/18 Progress Notes at 12:26 AM stated R1 was given her PRN [MEDICATION NAME] .5 mg for anxiety, documented effective at 1:29 AM with note at 5:19 AM that resident was a little anxious tonight, but calmed down after medication given for anxiety. 4/5/18 Progress Note at 9:26 PM stated resident (R1) was upset and tearful, 1:1 with staff provided and was effective. 4/6/18 Progress Notes at 8:35 AM stated resident (R1) reports moderate anxiety. Requested PRN. At 12:17 PM - It states she denied anxiety or agitation and the PRN was effective. Later that day at 11:07 PM R1 was given her PRN [MEDICATION NAME] for anxiety and later documented effective. 4/9/18 Progress Notes at 1:29 AM, R1 was given 25 mg [MEDICATION NAME] PRN for [MEDICAL CONDITION] later documented effective. 4/10/18 Progress Notes state R1 was not interested in a potential Assisted Living Facility because they did not allow smoking. 4/10/18 Progress Notes at 8:24 PM state R1 wanted to go home to be with her husband. R1's daughter was called and R1 stated she felt better after talking with her daughter. 4/11/18 Progress Notes at 14:16 PM state, Before lunch resident (R1) was very sad and stated, 'I'm tired of being sick she denied any pain/discomfort. Social worker was notified and talked to her (R1), after having lunch and going out to smoke resident stated she felt a lot better and didn't exhibit any other behaviors during shift. 4/12/18 Progress Notes at 7:17 AM, PRN [MEDICATION NAME] discontinued. At 11:06 PM - No behaviors this shift. Still stating she wants to go home. The facility arranged for R1 to see a psychologist. The sessions took place on the following dates: 4/20/18, 5/7/18, 5/21/18, 6/4/18, 6/18/18, and 7/2/18. Surveyor asked NHA A when the notes from the session were acquired by the facility and she stated that they were acquired after Surveyor requested them on 7/11/18. The note, dated 6/18/18, states: Patient was seen for session, chart reviewed, and status discussed with staff. She was alert and oriented to self, time and place. She reported having problems with stomach upset and requested [MEDICATION NAME]. Did report this to the nurse following visit. Otherwise no complaints or concerns at this time. Given her history of tendencies toward recurrent depression and adjustment issues, will follow-up with her on an every 1-2 week basis. The facility provided a signed medication review on 4/30/18 by her physician with no medication changes. There was no evidence that any symptoms of her mental illness were discussed and the facility stated the physician has access to R1's electronic medical record. 5/4/18 Progress Note at 2:02 PM CNA (Certified Nursing Assistant) - (R1) was crying during lunch and did not want to be bothered, she was asked if she wanted to go to her room and have some privacy. R1 was also asked what the problem was, but resident said she was fine and that she did not want to go to her room. CNA later explained that resident got upset and started crying because she asked to go to bed and CNA explained that it was lunch time it would be better to stay up and go to bed after lunch. Checked on resident after lunch and she was fine, and wasn't crying anymore. Also stated, at 4:22 PM today, resident had an episode where she wouldn't stop crying, but did not want to share any information of what was going on, resident was given some space to calm and after a while she stopped crying and was fine. Per interview with NHA A and DON B and timeline review, R1 moved from the 200 Wing to a room on the 300 Wing on 5/7/18. From the interview on 7/12/18 this was at R1's request to decrease noise and to be with a more alert roommate. The facility Weekly Nursing Summary, dated 5/14/18, under behavior, has checked cooperative, anxious, restless, pleasant and calm. It states under describe, Resident (R1) becomes restless and anxious at times. The facility had completed the Comprehensive Social Services Assessment on 5/15/18 stating R1s depressive symptoms were feeling bad about herself, depression, poor appetite, sleep cycle issues. It states under Current Psycho-Social Factors, Any suicide attempts since last evaluation? This is marked no. Under changes in Psych [DIAGNOSES REDACTED]. The Discharge Potential Assessment states her discharge is anticipated, feasible, R1 in conjunction with her husband, family care and daughter believe that she requires 24 hour supervision and care. The Progress Note includes, . She has the potential to present with symptoms related to a [DIAGNOSES REDACTED]. She had family involvement in her care. Since last review (R1) had a come to Jesus as her dtr (daughter) described it. R1's dtr explained to (R1) that accusations of not wanting to live can put her in a place with more restrictions and different conditions than she is currently dealing with. (R1) is no longer interested in discharge and is content having a window bed and the ability to go out on pass with family. Staff will monitor for any changes through next review. The facility Weekly Nursing Summary, dated 5/21/18, under behavior has checked cooperative, anxious, restless, pleasant and calm. It states under describe, Resident (R1) becomes restless and anxious at times. Per interview with NHA A and DON B and timeline review R1 moved from the 300 Wing to a room on the 100 Wing on 5/31/18. From the interview on 7/12/18 this was at R1's request because the new room was bigger and less noisy. The facility Weekly Nursing Summary, dated 6/12/18, under behavior has checked cooperative, anxious, restless, pleasant and calm. It states under describe, Resident (R1) becomes restless and anxious at times. The facility Weekly Nursing Summary, dated 6/19/18, under behavior has checked disruptive, restless, and socially inappropriate. It states under describe, (R1) has behavioral outbursts when demands not met immediately. 6/20/18 Progress Notes at 12:52 PM state R1 complained of severe anxiety. R1 was observed visibly trembling and appeared alarmed while speaking. The nurse notified the physician and relayed the observations. R1 received a one-time dose of [MEDICATION NAME] .25 mg and reordered PRN [MEDICATION NAME] .5 mg as needed for anxiety/restlessness. The facility provided a signed medication review on 6/22/18 by her physician with no medication changes. There was no evidence that any symptoms of her mental illness were discussed and the facility stated the physician has access to R1's electronic medical record. 6/23/18 Progress Notes at 5:08 AM, R1 was given earlier in the shift for complaint of anxiety and at this time stated it was effective. The facility Weekly Nursing Summary, dated 6/27/18, under behavior has checked cooperative, anxious, restless, and pleasant. It states under describe, Resident (R1) becomes restless and anxious at times. The facility Progress Note, on 6/28/18 at 1:18 PM, states, CNA altered nurse about resident being found in room with the cord of the call light wrapped around her neck and holding onto it and refusing to let go. Resident (R1) stated, I'm not letting it go. I want to kill myself. Nurse asked staff to stay with resident while DON, Administrator and Social Services were notified. Administrator and DON advised nurse to have resident transported to ER (emergency room ) for treatment and evaluation . R1 returned from the ER at 4:11 PM. The note at 4:11 PM states that counseling services will be arranged if R1 and her family agree to participate. There was no injury resulting from this suicide attempt. Of note, this was R1's second attempt to utilize the call cord to attempt suicide. R1 utilized the call cord twice as a device to attempt to commit suicide. The facility failed to recognize the call light cord as a potential hazard and failed to secure the call light in a fashion to prevent it from being utilized as a hanging device. The SSD C waited with R1 for transport to the ER. SSD C wrote, .conducted suicide assessment twice . upon entering room (R1) was lying in bed crying. Writer asked (R1) what happened, what triggered her to do this? (R1) replied, 'I just want to be dead. I can't do anything.' .Writer asked (R1) if pain is the cause for her suicidal thoughts. (R1) stated, 'It is not just one thing, but a combination; nothing else will do' . (R1) began talking about increased depression and believes she could benefit from an increased dose. (R1) stated, 'I don't want to be depressed all the time, but my mind won't let me be happy. I cry when I get mad and need to calm down then; I can discuss things or need a [MEDICATION NAME]. I just need something stronger for my depression.' Writer advised (R1) to come to writer, nurse, administrator, or any staff member when she is experiencing suicidal ideation or intent. (R1) stated, 'my brain isn't thinking right, right now.' Writer reminded (R1) of previous times she presented writer with ideas or questions that she wanted carried out or answered; and writer helped her resolve those areas. Such as (R1)'s desire to have therapy again. Ironically, a member from therapy entered room and asked (R1) if she would like to go to therapy today? (R1) replied yes and informed that she would be going to the hospital. Writer encouraged (R1) that when she came back she can continue therapy as scheduled. Writer asked (R1) if she felt emotionally better and if she felt suicidal in the present moment. (R1) replied, 'I'm ok, my nerves calmed down or I cried it all out. I don't feel suicidal.' Writer offered to call or text dtr (daughter). (R1) insisted that '(daughter) was sleeping and should not be disturbed at this time.' Writer offered to call (daughter) in the afternoon to inform her. (R1) offered acceptance, writer stayed with (R1) until transport arrived. Writer reminded (R1) that she can always come to writer or any other staff member if she feels suicidal, as well as discusses her thoughts about her [MEDICAL CONDITION] medication with staff at the hospital. The County Human Services Department Progress Note, dated 6/28/18, states: They received a call from the hospital reporting R1 came in for voluntary inpatient after attempting to strangle herself three times at the facility. When the County Worker met with R1 she no longer wanted to go inpatient but stated she wanted out of the facility. Risk Factors: (R1) reported thinking about death all the time. She has struggled with depression throughout her life. (R1) attempted to overdose a couple of times prior to having a stroke. Her depression worsened after her stroke 5 years ago. As a result of the stroke, (R1) is paralyzed in her left arm and leg. Additionally, she is legally blind in 1 eye. (R1) reported she used to have a strong faith, however, no longer does due to her health problems. (R1) said that she does not blame God for her stroke because she smoked for [AGE] years and this is what caused the stroke. (R1) used to work as a caregiver . and struggles to be the one who now needs care. (R1) stated that her father completed suicide when she was [AGE] years old. She reported that she understands the impact a suicide would have on her family. Warning Signs: (R1) placed the call light around her neck in an attempt to end her life. Other Clinical Data: (R1) thinks that her medication is no longer working. She stated that she has been on the same meds (medication) for [AGE] years . (NHA A) reported that everyone receives monthly [MEDICAL CONDITION] medication reviews. Plan: (R1) is able to guarantee her safety and wishes to return to the nursing home. She is agreeable to a potential med change and counseling . (NHA A) agreed that she would talk to the facility MD (Medical Doctor) about a potential med change . will (also) get outpatient counseling services set up . talked with (R1) about coping skills as she appears to be impulsive in response to stressors. (R1) agreed to talk to staff is she is feeling depressed or suicidal. She said that they do not always respond to the call light right away, the County Worker encouraged her to use it repeatedly if she thought that she might harm herself. (R1) said she would scream and holler if she does not get an answer. (R1) also listed calling her husband as a way to cope. The facility completed a Suicidal Assessment, on 6/28/18, with the following items marked yes: Recurrent thought and wishes for death; feelings of hopelessness; history of suicide attempts; daily variation of mood: symptoms worse in morning; multiple awakening during sleep thinking about death; and poor self-esteem: self-blame, self-depreciation, feelings of failure. Summary/Conclusion: (R1) reported being on the same anti-depressant for a long period of time and feels like she is immune to it. (R1) believes she is experiencing increased symptoms of her [MEDICAL CONDITION] [DIAGNOSES REDACTED]. The facility updated R1's care plan with new interventions to: Encourage (R1) to talk about feelings, fears, problems, especially during periods of increased stress/depression/anxiety. Increase supervision/monitoring of (R1) during period of increased depression/suicidal ideation. Maintain calm, soothing approach/environment with resident. Assess for suicidality (ideation, intent, plan) when needed. Intervene as appropriate including psych consult, increase safety observation checks, and utilize 1:1 session. The facility started, on 6/28/18, monitoring the symptom of (R1) presents extremely tearful or reports ideas about suicide. It includes the interventions: Stay with (R1) and put call light on to alert staff or bring (R1) to nurse and inform nurse, offer to talk 1:1 about feelings, encourage to participate in activities of interest (mentally stimulating, trivia like activities), offer/encourage to sit in common area with peers, encourage to call family, and offer to take (R1) out for a walk. This was also added to her care plan. The facility provided documentation of 15 minute checks on 6/28/18 and 6/29/18. Then they provided 30 minute checks on 6/30/18 to 7/5/18 when she was found wrapping the call cord around her neck. They provided a list that indicated they sent a referral out for counseling, the psychologist saw her in the facility on 7/2/18, she had an alert and oriented roommate, they encouraged her to eat and smoke in highly supervised areas, the pharmacist did a medication review with no changes, and they continued home visits with her family. On 7/2/18, Progress Notes stated that the psychologist was updated about R1's increased depression, and that he met with R1 on this date. A message was left with the counseling center by the facility for R1's evaluation and treatment. The Occupational Therapy Assessment, completed on 7/2/18, states that R1's RUE strength was 5/5 Part moves through full range against max resistance and gravity - muscle hold test position against strong pressure. Her LUE strength was 0/5 no tension/contraction is palpated in muscle or tendon. The facility Weekly Nursing Summary, dated 7/4/18, under behavior has checked cooperative, anxious, pleasant and calm. It states under describe, (R1) Gets very anxious and has depressive episodes at times. 7/5/18 at 3:14 AM Progress Notes stated that R1 had a brief meltdown at 0100 (1:00 AM) due to expiration of [MEDICATION NAME]. Advised would have provider contacted in the morning. Resident weepy and swearing and stating 'I'm going home, this is ridiculous, you know I take that every night! Why can't I ever have anything I need?' Calmed after much reassurance but did ask for it ([MEDICATION NAME]) again at 0200 (2:00 AM) and was again discussed as above. (sic) (Of note the facility was aware of R1's increased agitation and previous suicide attempts when agitated or depressed. The facility made no attempt to increase supervision on 7/5/18 or to call the on-call physician to report R1's increased agitation or obtain an order for [REDACTED].>7/5/18 at 6:26 AM Progress Notes stated R1 noted to have self-transferred from bed to w/c a total of 3 times this shift, noted call light off and within reach. Resident stated she is doing it on purpose. Advise of fall risk and safety concerns she stated 'I don't care. Has been awake all night focused on the [MEDICATION NAME]. Was at desk at 0430 (4:30 AM) stating she woke up soaked. Noted was dry at 0130 (1:30 AM). Did not ring for toileting. Bed strip done and shower given. Is at desk asking to go out and smoke. Belligerent when advised smoking times. (sic) 7/5/18 at 9:03 AM Progress Notes stated Patient continues to be angry about last night and does not seem to recall her behavior of multiple self-transfers and refusal to use the call light. She does not believe that anyone was in to check on her all night long despite her being on 30 minute checks and multiple staff checking on her and counseling her on behaviors through the night. Her [MEDICATION NAME] was ordered PRN for anxiety. Discussion with provider to schedule the [MEDICATION NAME] will occur today. Resident id (is) demonstrating a need for a more consistent dosing of [MEDICATION NAME]. (sic) 7/5/18 at 2:26 PM Progress Notes stated, Nurse entered room and observed resident actively wrapping call light cord around throat. When nurse intervened, resident struck out at nurse and said 'Leave me alone! Just walk out of the room and close the door and I won't be here to worry about.' When nurse asked resident what she meant while unwrapping the cord from around resident's throat, resident responded, 'I mean I want to die. Just let me kill myself with this cord.' Nurse successfully disengaged cord from around resident's throat, resident reached behind herself to grab another portion of the cord saying, 'Get out of my room! I'm going to kill myself today. Right now.' Nurse and CNA stay in room with resident. Nurse notified (DON B) and (NHA A), who advised to have resident transported to ER for psych evaluation and treat. The facility's failure to recognize the call cord as a potential hazard and to secure the call cord created an opportunity for R1 to utilize the call cord as a hanging device and to make a third attempt to commit suicide. R1 used the call cord as a hanging device in all three attempts. The Facility Investigation Report also includes that the nurse had the CNA stay in the room with R1 and that R1 had no observed injuries. It includes that throughout the shift R1 had been belligerent, manipulative with staff, argumentative with staff, crying several times, refused activities involvement and the nurse listened to her concerns about food issues and dislike of the facility. As the shift progressed the resident was less and less approachable and standoffish. (Of note the facility failed to identify R1's increased behaviors as triggers and failed to provide the appropriate support and supervision R1 required to remain safe). The statements from the staff interviewed about R1 included staff consistently report that residents call light was on and this is what alerted them to enter her room. Upon entering her room the call light cord was pulled out of the wall and R1 was wrapping it around her neck. The facility's failure to recognize the call cord as a potential hazard and to secure the call cord created an opportunity for R1 to

Based on observation, interview, and record review, the facility did not ensure each resident receives adequate supervision and assistive devices to prevent accidents. R1 was noted to have upper body tremors. R1 was prescribed muscle relaxants for these noted tremors. R1 was assessed by a RD (Registered Dietitian) to need assistance with meals, although assist was not defined. R1 was not assessed to determine if she is safe to drink hot beverages independently, without the need for adaptive equipment, so to maintain her safety in light of her tremors. On 11/27/17, R1 spilled hot coffee on her shoulder / chest region resulting in second degree burns. This is evidenced by the following: R1 was admitted to the facility on [DATE]. R1's [DIAGNOSES REDACTED]. On 12/21/17 at 9:00 AM, Surveyor observed R1 seated in a Broda chair, in the dining room, at the table. R1 had empty plates in front of her. R1 was able to reach and pick up from the table, a tall Styrofoam cup covered with a lid and straw. R1 took a drink from the cup, and placed the cup on the chair seat just to the left of her left thigh. R1 had another Styrofoam cup with a lid and straw on her chair seat as well. R1 appeared to have frequent small to moderate movements of her upper torso and upper and lower extremities. On 12/21/17, the facility staff provided Surveyors with a temperature log. This log includes the following recorded temperatures: 11/28/17: Breakfast 174 degrees (Fahrenheit), Lunch 176 degrees, Dinner 176 11/29/17: Breakfast 180 degrees, Lunch 181 degrees, Dinner 180 degrees. 11/30/17: Breakfast 181 degrees, Lunch 178 degrees, Dinner 176 degrees (Note: At 155 degrees, hot water can cause a third-degree burn within 1 second of skin contact.) R1's most current MDS, with an observation end date of 11/24/17, documents that R1 has a BIMS of 11 out of 15 indicating moderate cognitive impairment, has limited ROM to one side on both upper and lower extremities, and needs limited assistance with eating, with Staff guiding or maneuvering limbs or other non-weight bearing assist. R1's care plan that was in place at the time of her coffee spill (11/27/17) was an Interim Care Plan. This care plan does not address ADL Assistance in that ADL Assistance was not checked as a Focus area, and no goals and interventions were checked. R1's record contains the following entries: *11/17/17 Initial Nursing Assessment: . Upper extremity weakness . right weak . *11/20/17 Nurses Progress Notes 10:50 AM: Residents (sic) alert with confusion, forgetful . spasms in her arms . *11/21/17 NP O Note: .Objective: General Comments: 11/21/17 . Primary reason for visit is to establish care .Extremities: increased weakness on right, pt has involuntary movements of arms . Reduced ROM. *11/21/17 Nutritional Assessment / Reassessment: Initial . 2. Chewing / Swallowing Problems: dysphagia. 3. Meal Assistance Provided: assist . 7. Assessment. Initial: pt admitted on general diet with aspiration precautions. She is on Hospice care now . eats in dining room, needs assist . On 12/21/17 at 1:00 PM, Surveyor spoke with RD G regarding R1 and her Initial Nutritional Assessment completed on 11/21/17 as noted above. Surveyor asked RD G what is meant when she identifies a resident is in need of assist with meals. RD G stated there are different levels of assist. RD G stated R1 needed someone to make sure she was set up with her tray, and come back and check on her, but did not need someone next to her the whole meal. Surveyor asked how one would know this if the assessment simply said assist. RD G stated if R1 needed to be 1:1 with her meals it would have said 1:1. RD G stated the DM (Dietary Manager) will alert her to any resident that she (RD G) may want to focus on. RD G stated she is only in the building once a week and she was not aware R1 had a problem with tremors, stating she had not been informed of this. RD G stated Now I see it, but again states she did not know prior to the coffee spill on 11/27/17. RD G stated had she known R1 had tremors she would have looked into this. *11/22/17 Nurses Progress Notes 1:15 PM: Received new orders for [MEDICATION NAME] 5 mg BID, for muscle spasms, and Methocaranol (sic) 750 mg TID prn . *11/27/17 Nurses Progress Notes 9:52 AM: (R1) reported to staff that during breakfast she spilled her coffee on her right chest area. Visual inspection of the area revealed all skin intact with area of discoloration. (R1) reports minor discomfort. Call made to Hospice, new orders received. (Please know Surveyor questioned ADON C (Assistant Director of Nursing) and RNC D regarding any orders related to this incident. Surveyor was not provided with new orders received on 11/27/17 regarding R1's burn.) *11/27/17 Occurrence Report: . 11/27/17 9:00 AM: Nurse's Note of what happened written by (RN F), entered by (RN F) on 11/27/17 15:09 (3:09 PM). R1 has tremors at times. R1 reported to staff that during breakfast she spilled her coffee on her right chest area. Visual inspection of the area revealed all skin intact with area of discoloration. R1 reports minor discomfort. Call made to Hospice. New orders received. In addition, this Occurrence Report states that immediate actions taken include Medicated ointment applied. Please note that there is no evidence of any medication ointment used for R1 in her medical record on the date of occurrence. On 12/21/17 at 1:45 PM, Surveyor spoke with RN F (Registered Nurse) regarding R1 and her coffee burn from 11/27/17. RN F was working on 11/27/17 and completed the incident report noted above. RN F stated R1 approached her at the medication cart and told her (RN F) that she (R1) had spilled her coffee, and requested someone take her to her room. RN F stated she helped R1 to her room and assisted her to change her top. RN F stated she observed the area and there was nothing there, and the skin was intact. RN F stated she placed a cool cloth on the area and notified Hospice who said to continue to monitor the area. RN F stated she let administration know so to prevent this from occurring again. RN F stated R1 had tremors to her upper body since she got here. On 12/22/17 at 10:15 AM, Surveyor spoke with RN F via telephone. Surveyor asked RN F what type of medicated ointment she had applied as an immediate action taken to R1's burn as noted in the Occurrence Report. RN F stated she did not apply any medicated ointment to R1 right after she became aware of the burn on 11/27/17. *11/27/17 Nurses Progress Note 3:15 PM: . red discolored area to right upper chest and right clavicle region. *11/28/17 Nurses Progress Notes 1:34 PM: .Swelling . raised area to right chest as well as area to right clavicle region purple raised. * 11/28/17 NP O Progress Note. (This note was not provided to Surveyor on 12/21/17.) This note states in part: Pt is being seen today in follow up visit . Reported that pt spilled coffee on front during lunch yesterday. Pt denies pain. Staff assessment that pt has red area with no blistering present. Today staff reports that pt has a couple small blisters on left chest area .Skin appears slightly red and shiny with a few small blistered areas over left breast. (Please know Nurses Notes document R1 spilled coffee on her right shoulder / chest area.) . Plan: can cover with non - adhesive dressing, monitor for changes . *11/28/17 Nurses Progress Note 9:16 PM: Skin Progress Note . right shoulder . pink . 2.9 x 1.8 x 0.1. wound bed (% of Epithelization) . 100 . as a result of yesterday's incident involving hot coffee during breakfast another area that was not previously present. *11/29/17 Nurses Progress Notes 3:10 AM: . C/O (complaints of pain) . coffee burn to right chest / shoulder area from tremor at breakfast 11/27. (Please know this note was written by RN F, the RN present on the day of the burn incident, stating the burn was from tremor.) *11/29/17 Nurses Progress Note 4:00 PM: Writer met with resident and family . to discuss residents (sic) risk for falls and risk associated with resident smoking and drinking coffee Writer discussed that resident and staff had discussed in the morning and previous day that it would reduce risk [MEDICAL CONDITION] enable resident to continue to drink her coffee as she prefers if she would consider drinking iced coffee, and that the resident was agreeable to this with flavored creamer provided to her for flavoring . *11/29/17 Nurses Progress Notes 9:48 PM: . Right chest discoloration - right shoulder blister - dressing intact . *11/30/17 Nurses Progress Notes 2:53 AM: . red discoloration right chest blistered area to right shoulder treatment in place . *11/30/17 Nurses Progress Notes 11:51 AM: . red discoloration right chest blistered area to right shoulder treatment in place . *11/30/17 Nurses Progress Note 7:00 PM: Late entry. Resident noted to have s/s of tremors / shakiness. (Name) NP, in to visit and assess. Talked to family and explained it could be a side effect of past medical issues. Hospice aware. Resident A & O. *11/30/17 NP Note: Pt is being seen today for follow up visit . Reported that pt spilled coffee on chest. Small red area. On left upper chest. (Please know Nurses Notes document the burn to be to R1's right shoulder / chest area.) No blisters on initial assessment. Small blisters later appeared. Spoke with Wound Nurse. Family concerned about tremors and spasms. Pt is reported to have spasms. Not sure if it is [MEDICAL CONDITION] or spasm. Pt reported by SO to have them at home Plan: Spoke with family and pt at length about tremors / spasms. Does not appear to be [MEDICAL CONDITION] as pt is alert before during and after. I witnessed several such events while speaking to pt and family. Suspected it is due to [MEDICAL CONDITION]. Conservative management . burn area reported to be healing. [MEDICATION NAME] to area daily with dressing change and PRN. 11/30/17 Physician order [REDACTED]. Apply to chest / shoulder open areas topically every day and evening shift for skin alteration to medial and lateral chest cleanse area with normal saline, pat dry, apply cream, apply bordered gauze dressing. 12/2017 TAR: Silver [MEDICATION NAME] Cream 1%. Apply to chest / shoulder open areas topically every day and evening shift for skin alteration to medial and lateral chest cleanse area with normal saline, pat dry, apply cream, apply bordered gauze dressing. (Although this order was received on 11/30/17, the first treatment is noted to be given on 12/1/17 on the day shift. This is 3 days after .Swelling . raised area to right chest as well as area to right clavicle region purple raised was noted on 11/28/17, and 2 days after Right chest discoloration - right shoulder blister - dressing intact . was noted on 11/29/17.) On 12/21/17 at 12:10 PM, Surveyor was provided with requested information to review regarding R1's burn from 11/27/17. RD E (Regional Director) provided Surveyor with an Accident / Incident Management Meeting form which documents the root cause of this incident to be: Coffee too hot for this lady to handle herself. New interventions include: Evaluate coffee maker and get covered coffee mug or see if resident wants iced coffee instead. Follow up needs include, but not limited to: Find out if anyone else is having issues. RD E stated no one saw the incident happen and that initially the area to R1's shoulder / chest region was red. RD E stated R1 was not getting 1:1 assistance with her meals at the time of the incident and had no complaints of pain to the area initially. RD E stated it was a few days later that R1 developed blisters to the area. RD E stated R1 was a new admission so the Initial Care Plan was in place at the time of the incident. On 12/21/17 at 1:22 PM, Surveyor spoke with CNA H (Certified Nursing Assistant) regarding R1 and her tremors. CNA H stated she did not notice the tremors when R1 first came in and understands this is something new. CNA H states she does see the tremors now. On 12/21/17 at 1:40 PM, Surveyor spoke with DM J (Dietary Manager) regarding R1 and her dining experiences. DM J stated prior to R1's coffee spill on 11/27/17 R1 was using regular coffee cups for her coffee. She stated R1 was placed at the assist table as she was aware she (R1) needed assist, but stated it is up to the CNAs to determine what type of assist a resident needs. DM J states now, since R1's coffee spill, her card has been updated that she needs to be monitored with any and all hot liquids. On 12/21/17 at 2:15 PM, Surveyor spoke with OT L (Occupational Therapist). OT L stated she did not work with R1, but would think OT would get a referral for an assessment if a resident is known to have tremors. On 12/21/17 at 3:50 PM, Surveyor spoke with CNA / Med (Medication) Tech (Technician) M and asked what is meant by assist for meals. CNA / Med Tech M stated this could mean anything from set up, to verbal cueing, to total assist. CNA / Med Tech M stated the Kardex or care plan would give specifics. On 12/21/17 at 4:05 PM, Surveyor spoke with CNA N. Surveyor asked CNA N what assist meant in regards to feeding. CNA N stated it could mean you may have to feed them or hold their drink, or may just need supervision. CNA N stated specific instructions would be on the care plan, or we just ask. On 12/22/17, Surveyor received a fax from NHA A (Nursing Home Administrator). NHA A was not present at the facility on 12/21/17. This fax states R1 is independent in her eating skills with only occasional needs for assistance. NHA A included an Eating Self Performance check list (not provided to Surveyor on 12/21/17), which documents the assistance R1 needed at meals: 11/23/17 12:08 PM - Supervision (Oversight, encouragement, cueing) 1:56 Limited Assistance (Resident highly involved; staff provide guided maneuvering of limbs or other non - weight bearing assistance) 7: 06 PM - Limited Assistance 11/24/17 9:02 AM - Independent 6:00 PM - Extensive Assistance (Resident involved in activity; staff provide weight bearing assistance) 11/25/17 8:53 AM - Independent 11/26/17 8:46 AM - Independent 11/27/17 9:20 AM - Independent (Date of coffee spill) 3:46 PM - Independent On 12/21/17, at approximately 2:30 PM, Surveyor spoke with DON B who had done R1's dressing change on this day. R1 declined to allow Surveyor to observe a dressing change and treatment. DON B stated the burn area is to R1's right shoulder / chest area. DON B states the area is raised, dry and without infection. DON B states there are 3 areas: #1 approximately 3 x 2 cm (centimeters), at the top, #2 Below the top area and slightly connected to it which is approximately 2 x 2 cm, and #3 at the bottom approximately 1.5 x 1 cm. DON B stated the skin is intact and R1 had not complained of pain. DON B stated this area is being treated with [MEDICATION NAME] and a foam dressing was applied. DON B stated she would describe the burn to be a healing second degree burn. On 12/21/17 at 4:00 PM, Surveyors spoke with R1. R1 stated the coffee that had burnt her shoulder was super-hot and she yelled when it happened and told them about it. R1 states the burn area is painful in the middle area and it itches. In addition, R1 told Surveyors that she does not like iced coffee. The facility staff (Nursing Staff, as well as NP) were aware R1 was experiencing weakness, spasms, involuntary movements and tremors to her upper extremities. This information was not shared with the RD who did not do an assessment to determine R1's safety with hot beverages.

Based on observation, interview, and record review, the facility did not ensure that a resident who enters the facility without a pressure injury (PI) does not develop an avoidable PI for 1of 2 residents (R7) reviewed for pressure injuries. R7 (Resident) was admitted to the facility without a PI on his left heel and was identified to be at risk for PI development. R7 developed an avoidable, unstageable PI to his left heel as preventative measures were not in place. This is evidenced by the following: The Quick Reference Guide entitled Pressure Ulcer Prevention published by the National Pressure Ulcer Advisory Panel (NPUAP), in 2009, indicated to prevent pressure ulcers in individuals considered to be at risk for the development of pressure ulcers, ensure the heels are free of the surface of the bed. Heel protection devices should elevate the heels completely (offload them) in such a way as to distribute the weight of the leg along the calf without putting pressure on the Achilles tendon. Ensure the heels are free of the surface of the bed. Using a pillow under the calves, so the heels are elevated (i.e., floating), will accomplish reduction of pressure on heels. The facility's policy Prevention and treatment of [REDACTED]. The facility will implement preventative measures and provide appropriate treatment modalities for skin impairments according to industry standards of care. R7 was admitted to the facility, on 3/20/17, with a readmission date of [DATE]. [DIAGNOSES REDACTED]. R7's Braden (skin assessment), dated 3/20/17, scored a 14, indicating R7 is at moderate risk for skin breakdown. R7's Braden, dated 5/10/17, scored a 15, indicating R7 is at mild risk for skin breakdown. R7's admission Minimum Data Set (MDS), dated [DATE], indicates A Brief Interview for Mental Status (BIMS) scored a 14, which indicates R7 is cognitively intact. Section M0150 of the MDS indicates R7 is at risk for developing a PI. Section M0300 Unhealed Pressure Ulcers Section indicates R7 does not have a PI. G0110, Activities of Daily Living (ADL's), indicates R7 requires extensive assistance with 1 person physical assist for bed mobility and extensive assistance with one person to transfer. A PI Care Area Assessment (CAA) worksheet, dated 3/27/17, includes in part: Triggers: bed mobility self - performance problem is indicated - extensive assistance is required. Extrinsic risk factors: needs special mattress or seat cushion to reduce or relieve pressure. [MEDICATION NAME] Factors: immobility, incontinence, altered mental state, cognitive loss, and antidepressants. Considerations: Yes, CAA triggered due to R7 needing assistance with bed mobility and skin care plan in place, with focus to heal existing impairment and prevention of further impairment. R7's comprehensive care plan, Actual alteration in skin integrity related to surgical site to right [MEDICAL CONDITION]. Skin tears to left hand, ulcer to left heel. Hx (history) of gangrene right foot leading to amputation. DX (diagnosis) of [MEDICAL CONDITION], DM, new fistula left arm, dated 3/22/17. (Of note: R7 did not have a PI on his original or readmission to the facility). Goal - Site will show sign of healing through next review date of 9/8/17. Interventions include: inspect skin daily with cares, prevent trauma, proper fitting footwear, pressure relief to heels, optimize blood flow to extremities, keep legs in neutral position, pressure reduction in chair, wheelchair and bed, turn and reposition every 2 hours and as needed, treatment as ordered. CNA (Certified Nursing Assistant) kardex, dated 4/21/17, Section for Skin Ulcer Treatment includes in part: pressure reducing device for chair, pressure reducing device for bed, nutrition or hydration intervention, ulcer care, surgical wound care, non - surgical dressings, ointments/ mediations, dressings to feet. (Of note: float heels is not included on the CNA care plan kardex). On 7/5/17, at 1:50 PM, Surveyor interviewed R7 regarding floating heels. R7 indicated the facility did not get his heel off the mattress. R7 indicated they put the black boot on my left foot last Friday (6/30/17) while at an appointment. Surveyor asked R7 if he has pain in his left heel. R7 indicated that his left heel hurts at night. Surveyor observed a black tennis shoe in R7's w/c (wheelchair). RN C (Registered Nurse) was in R7's room and indicated R7 will wear the black shoe when he is out of bed. On 7/5/17, at 2:00 PM, Surveyor observed R7's left heel with RN C. RN C removed the black brace/boot from R7's left heel, then removed R7's white ankle sock. Surveyor observed the PI on R7's left lateral heel. Surveyor asked RN C to describe the PI. RN C stated, The PI was stable hard eschar. Surveyor asked RN C if she was wound care certified. RN C indicated that she took the class but has not tested out yet. RN C indicated that she does wound rounds with NP D (Nurse Practitioner). Surveyor asked RN C what standard of practice the facility follows for PI. RN C indicated she would get back to the surveyor. Surveyor noted R7's mattress was a Q-Star 111. Surveyor asked for the manufactures recommendation for the mattress. On 7/5/17, at 2:15 PM, DON B (Director of Nursing) indicated to the surveyor the facility follows the NPUAP guidelines for PI's. DON B indicated that she is wound care certified. On 7/5/17, at 5:00 PM, NHA A (Nursing Home Administrator) indicated she could not get the recommendations for the Q-Star 111 mattress, but did give surveyor a copy of the mattress tag which includes in part: Pressure reduction, reduces PI, reduce skin shear, fluid proof, antimicrobial, multi layered, high resiliency, die cut foam, firm boarders for support, inverted side seam closure, 5 year full warranty. R7 was placed on this mattress upon admission and continues to use this mattress even though he developed an unstageable PI to his left heel. Hospital Progress Notes, dated 5/1/17, includes in part: R7 has abnormal ankle - brachial indices from February 28, 2017. As a result of a non-healing ulcer (diabetic) affecting the fifth digit of R7's left foot, he went under peripheral [MEDICATION NAME] (x- ray of the blood vessels) on 3/16/17 indicating, 100% occlusion (blockage) of the left femoral artery which was reduced to minimal obstruction after angioplasty (unblocking of an artery). Review of R7's Nursing Progress Notes, dated 5/16/17, includes in part: wound observed left lower extremity (LLE). Clear filled blister. 0.9 cm x 0.7 cm. Review of R7's Nursing Progress Notes, dated 5/19/17, includes in part: heel dry left foot. Blood noted on the dressing. Review of R7's Nursing Progress Notes, dated 5/22/17, includes in part: in bed all day. Heel wound looks good. Review of R7's Nursing WASA Weekly Assessment of Skin Alteration form, dated 5/16/17, includes in part: Wound: PI Location: Left heel Stage: unstageable Length: 3.5 centimeters (cm) Width: 3.2 cm Comments: Blood fluid filled blister to left heel. DON spoke with R7 and his wife asked her (DON to contact the MD (Medical Doctor) who performed the previous surgery). Arrangements to be made for R7 to see the surgeon by DON. Treatment order for skin prep and cover with [MEDICATION NAME] adhesive dressing, change daily and prn (as needed.) Review of R7's Nursing WASA form, dated 5/24/17, includes in part: Wound: PI Location: Left heel Stage: unstageable Length: 3.5 cm Width: 4.2 cm Comments: Wound appears in evolution from what was initially a blister and now is appearing to be an unstageable heel ulcer. MD and family are aware. No s/sx (signs / symptoms) of infection. Review of R7's Nursing WASA form, dated 5/31/17, includes in part: Wound: PI Location: Left heel Stage: unstageable Length: 3.5 centimeters cm Width: 4.2 cm Comments: Wound shows no s/sx of infection. R7 denies pain or discomfort during wound assessment and treatment application. Interventions remain in place to promote wound healing, such as pressure reducing mattress, heel lift boots, pressure relieving w/c cushion, R7 has been educated to frequently shift positions independently to off load pressure. (Of note: R7 requires extensive assistance for bed mobility). Review of R7's Nursing WASA form, dated 6/7/17, includes in part: Wound: PI Location: Left heel Stage: unstageable Length: 3.2 cm Width: 4.5 cm Wound bed: 100% eschar. Comments: No s/sx of infection. No pain or discomfort noted. MD and family aware of wound status and POC (plan of care). R7 to wear heel lift boot while in bed. Interventions remain in place to promote wound healing such as pressure reducing mattress, heel lift boots, pressure relieving w/c cushion, R7 has been educated to frequently shift positions independently to off load pressure. Review of R7's Nursing WASA form, dated 6/14/17, includes in part: Wound: PI Location: Left heel Stage: unstageable Length: 3.6 cm Width: 4.7 cm Wound bed: 100% eschar. Comments: Wound shows no s/sx of infection. R7 denies pain or discomfort during wound assessment and treatment application. R7 to wear heel lift boot while in bed. Interventions remain in place to promote wound healing such as air mattress, heel lift boots, pressure relieving w/c cushion, R7 has been educated to frequently shift positions independently to off load pressure frequently. (Of note: R7 does not have an air mattress nor can he reposition independently). Review of R7's Nursing WASA form, dated 6/21/17, includes in part: Wound: PI Location: Left heel Stage: unstageable Length: 2.9 cm Width: 4.5 cm Wound bed: 100% eschar. Comments: Wound shows no s/sx of infection. R7 denies pain or discomfort during wound assessment and treatment application. R7 to wear heel lift boot while in bed. Interventions remain in place to promote wound healing such as air mattress, heel lift boots, pressure relieving w/c cushion, R7 has been educated to frequently shift positions independently to off load pressure frequently. Review of R7's Nursing WASA form, dated 6/28/17, includes in part: Wound: PI Location: Left heel Stage: unstageable Length: 1.7 cm Width: 3.0 cm Wound bed: 100% eschar. Comments: Wound shows no s/sx of infection. R7 denies pain or discomfort during wound assessment and treatment application. R7 to wear heel lift boot while in bed. Interventions remain in place to promote wound healing such as air mattress, heel lift boots, pressure relieving w/c cushion, R7 has been educated to frequently shift positions independently to off load pressure frequently. (Of note: R7 does not have an air mattress nor can he reposition independently. The interventions continue to be the same even though R7 cannot reposition independently. R7 was not provided with an air mattress as it states in the wound measurements comments). Review of R7's NP D (Nurse Practitioner) notes, dated 6/14/17, includes in part: Wound consult: pressure ulcer left heel unstageable; vascular ulcer to left fifth toe. Both are unstageable as there is eschar covering both. Left heel PI measures 3.6 cm x 4.7 cm with firm eschar in place. Continue to paint with [MEDICATION NAME] daily, float heels, and encourage R7 to turn in bed to relieve pressure. Review of R7's NP D notes, dated 6/21/17, includes in part: Wound follow up: pressure ulcer left heel unstageable; vascular ulcer to left fifth toe. Both are unstageable as there is eschar covering both. Left heel PI measures 2.9 cm x 4.5 cm with firm eschar in place. Continue to paint with [MEDICATION NAME] daily, float heels, and encourage R7 to turn in bed to relieve pressure. Review of R7's NP D notes, dated 6/28/17, includes in part: Wound follow up: pressure ulcer left heel, unstageable. Both are unstageable as there is eschar covering both. Left heel PI measures 1.7 cm x 3.0 cm with firm eschar in place. Continue to paint with [MEDICATION NAME] daily, float heels, and encourage R7 to turn in bed to relieve pressure. R7 was seen by Podiatry and the left foot 5th digit wound was a corn and removed per Podiatry. Review of R7's progress note, by OS E (Orthotic Specialist), dated 6/30/17, includes in part: R7 seen at the request of Podiatry. R7 has a significant ulcer due to pressure on the posterior / lateral side of left heel. R7's spouse reports noting this about a month ago. R7 has seen Podiatry and was fitted with an AFO (ankle foot orthosis) and fit with a PRAFO (pressure relieving ankle foot orthosis) boot. R7's shin is red and mottled. OS E recommends R7 see his MD about this soon. Spouse feels the color is redder than usual. Review of R7's NP D notes, dated 7/5/17, includes in part: Wound follow up: pressure ulcer left heel, unstageable. Eschar is covering the wound. Left heel PI measures 1.7 cm x 2.9 cm with firm eschar in place. Continue to paint with [MEDICATION NAME] daily, float heels, and encourage R7 to turn in bed to relieve pressure. R7 was seen by Podiatry last week and the left foot 5th digit wound was a corn and removed per Podiatry. Podiatry ordered to be worn when in bed or recliner. Review of R7's Treatment Administration Record (TAR), dated 5/1/17, includes in part: [MEDICATION NAME] swab to left lateral 5th toe daily. (Of note: this was not signed out on 5/5/17and 5/20/17). Review of R7's TAR, dated 5/17/17, includes in part: Foam boarder 4x4 apply to left heel every shift for skin condition. Cleanse area with water/ normal saline. Apply skin prep and cover with dressing. (Of note: 5/18/17, 5/20/17, and 5/25/17 is not signed out). Review of R7's TAR, dated 6/1/17, includes in part: [MEDICATION NAME] swab to left lateral 5th toe every shift. (Of note: this was not signed out for 13 shifts in June). Review of R7's TAR, dated 6/1/17, includes in part: Foam boarder 4x4 apply to left heel every shift for skin condition. Cleanse area with water/ normal saline. Apply skin prep and cover with dressing. New order for [MEDICATION NAME] to left heel, leave open to air everyday starting 6/2/17. (Of note: this order was only signed out on 6/2/17 and 6/3/17). Review of R7's TAR, dated 7/1/17, includes in part: [MEDICATION NAME] swab to left lateral 5th toe and left heel. Leave open to air every shift. (Of note: this order was not signed out on the night shift of 7/2/17 and 7/3/17). On 7/5/17, at 5:30 PM, Surveyor asked DON B for documentation indicating diabetic foot checks are being completed. DON B indicated that the facility is not documenting diabetic foot checks for R7, as he has a treatment to his left foot every shift and DON B indicated the nurses are looking at R7's foot. On 7/5/17, at 6:00 PM, Surveyor asked DON B for R7's shower sheet documentation. DON B indicated that the PI was not found during a shower and a nurse noticed it when doing a foot treatment. On 7/5/17, at 6:30 PM, Surveyor asked DON B for documentation on any staff education that was provided once the PI was identified of R7's left heel. DON B did not provide any documentation of education regarding PI's. R7 developed an avoidable PI to his left heel and was identified to be at risk for PI development upon admit. However, the facility failed to implement current standards of practice such as floating heels, and create / update the comprehensive care plan with new interventions once R7's PI was identified.

Based on review of a facility investigation and self-report, record review, and interviews, the facility did not promptly consult with the physician when there was a significant change of condition and a need to significantly alter treatment for 1(Resident 1) of 11 sampled residents. Resident 1 had a change in condition that resulted in hospitalization . Resident 1's physician and family were not consulted when Resident 1's food and fluid intake significantly declined, when she developed a fever and her overall condition declined, and when the antibiotic she was on was shown to be resistant to the underlying organism. Notes from the emergency roiagnom on [DATE] indicate Resident 1's mucous membranes are extremely dry , that she appeared in extreme distress, and that she had MRSA e-coli .(which) was resistant to [MEDICATION NAME] (the antibiotic the resident had been receiving since [DATE]). Resident 1 died at the hospital on [DATE]. The failure to notify the physician promptly with significant changes in condition for Resident 1 and the failure to promptly notify the physician when culture results showed that the resident was resistant to the antibiotic that had been prescribed created a finding of Immediate Jeopardy that began on [DATE]. The NHA was notified on [DATE] that immediate jeopardy existed. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope/severity of D (potential for harm that is not immediate jeopardy/isolated) as all portions of the corrective actions have not been fully implemented. This is evidenced by: Facility policy titled, change of condition (Resident), dated ,[DATE], Purpose: To ensure that the resident's physician/physician on call and responsible party is kept informed regarding the resident's change in condition. Policy: The attending physician or physician on call/Nurse Practitioner (NP) and responsible party will be notified with changes in a resident's condition. Procedure: 1. Attending physician or physician on call/NP and responsible party will be notified of all changes in condition. 2. Follow framework for reporting changes in vital signs or laboratory values bases on American Medical Directors Association (AMDA) guidelines. 3. Follow suggested guidelines for reporting clinical problems based on AMDA guidelines. 4. Document time of call, physician or NP or other person spoken to; reason for call or orders received. 5. Place call to responsible party to notify them of resident's change in condition. Resident 1 is an [AGE] year old female with the following Diagnoses: [REDACTED]. Resident 1's current active care plan, Undated, Focus: Scores at risk for dehydration due to having loose stools. Resident 1 is alert and oriented times 3 able to express thirst and able to drink independently. Goal: Resident 1 will not exhibit signs of dehydration. Interventions: Monitor fluid intakes. Monitor decreased ability to drink and eat without assist. Monitor for signs and symptoms of dehydration. report acute changes in level of consciousness (LOC) to medical doctor (MD). Laboratory (labs) per MD order. Report abnormal labs to MD. Resident 1's Physician order, dated [DATE], [MEDICATION NAME] 500 mg every 12 hours for UTI for 10 days. Significant change in food and fluid intake Resident 1's nutritional assess, dated [DATE], Weight 118 #. GI symptoms: Diarrhea and constipation. Fluid estimated needs 1375 - 1650. (Calculated by 30 cc = 1600 ml per day) Wt maintenance is good intake 50% or greater of meals. Resident stated she drinks well. Diet: Lactose free, pureed vegetables and fruits Food intake records for Resident 1 from ,[DATE] to ,[DATE] show the following: [DATE] - Breakfast 51% to 75% Lunch 26% -50%.and Dinner (No % listed) [DATE] - Breakfast 51% to 75% Lunch 0% to25% - Dinner 25% to 50% [DATE] - Breakfast 51% to 75% Lunch 51% to 75% Dinner 51% to 75% [DATE] - Breakfast 51% to 75% Lunch 51% to 75% Dinner 51% to 75% [DATE] - No % listed for all 3 meals [DATE] - Breakfast 51% to 75% Lunch 25% to 50% Dinner 0%- 25% [DATE] - Breakfast 51% to 75% Lunch 25% to 50% Dinner (no % listed) [DATE] - No % listed all 3 meals. [DATE] - No % listed all 3 meals ( date fall occurred) [DATE] - Breakfast 51% to 75%, Lunch & Dinner (no % listed) The following documentation for food intake was written on the March intake record: [DATE] - Breakfast 0% to 25 %, Lunch and Dinner (No % listed) [DATE] - Breakfast 0% to 25%, lunch 0% to 25% - Dinner (no 0% listed) [DATE] - Breakfast 0% to 25%, Lunch 0% to 25%, Dinner 0% to 25%. [DATE] - Breakfast 0% to 25%, Lunch 0% to 25%, Dinner 26% -50%. [DATE] - Breakfast 0% to 25 %, Lunch 0%, Dinner 0% A review of the dietary records for [DATE] through [DATE] revealed Resident 1's meal intake significantly declined and Resident 1 was eating 25% or less of her meals. The facility did not promptly consult with Resident 1' Physician of Resident 1's decline in food intake. Fluid intake from [DATE] to [DATE] was documented as follows in Resident 1 ' s medical record (ml - milliliters). [DATE] 1st shift 1600 ml, 2nd shift 840 ml, night shift 120 ml = 2,560 ml [DATE] 1st shift 1,900 ml, 2nd shift 760 ml, night shift 90 ml = 2,750 ml [DATE] 1st shift 1,920 ml, 2nd shift 910 ml, night shift 120 ml = 2,950 ml [DATE] 1st shift 1,670 ml, 2nd shift 1,020 ml, night shift 90 ml = 2,560 ml [DATE] 1st shift 1,680 ml, 2nd shift 1,140 ml, Night shift 90 ml. = 2,910 ml Fluid intake was documented as follows for the first eight days of March. (Please note that the surveyor calculated total intake for each day. Resident 1's fluid sheet did not have the daily total calculated upon review of the intake form.) Estimated fluid need was 1375 - 1650 ml. [DATE] 1st shift 280 ml, 2nd shift 270 ml, Night shift (0) total intake = 550 ml. [DATE] 1st shift 360 ml, 2nd shift 210 ml, night shift 90 ml = 630 ml [DATE] 1st shift 440 ml, 2nd shift 330 ml, night shift 60 ml = 830 ml [DATE] 1st shift 340 ml, 2nd shift 150 ml, night shift 120 ml = 610 ml [DATE] 1st shift 360 ml, 2nd shift 240 ml, night shift 120 ml = 720 ml [DATE] 1st shift 280 ml, 2nd shift 210 ml, night shift 90 = 580 ml [DATE] 1st shift 390 ml, 2nd shift 310 ml, night shift 60 ml = 760 ml [DATE] No documentation provided. The facility did not promptly consult with Resident 1's Physician when Resident 1 continued not to meet her daily fluid intake needs. Resident 1's temperature Summary: [DATE] - Temperature 100.1 at 5:32 PM [DATE] - Temperature 99.2 at 8:28 PM [DATE] - Temperature 100.4 at 1:58 AM [DATE] - Temperature 99.3 at 6:00 AM [DATE] - Temperature 99.5 at 6:34 PM [DATE] - Temperature 99.5 at 1:27 AM [DATE] - Temperature 101.1 at 1:37 AM [DATE] - Temperature 99.5 at 1:09 PM [DATE] - Temperature 103.6 at 1:30 AM Fever increases the need for fluids. On [DATE] at 2:00 PM, Surveyor spoke with Medical Doctor (MD) F regarding Resident 1's condition, fluid intakes and appetites. MD F stated she was notified on [DATE] of Resident 1's fever and change in mental status. MD F stated she was not consulted about Resident 1's decrease in fluids or appetite on [DATE]. MD F stated she was not consulted from [DATE] through [DATE] when she saw a note indicating Resident 1 had been sent to the ER by the on call MD. MD F stated she should have been notified of Resident 1's decline in eating on [DATE]. MD F stated on [DATE] she should also have been contacted when Resident 1 was only taking sips of fluid and refusing meals. MD F continued to state on [DATE] Resident 1's temperature was 101 she would have expected a call. MD F stated if she would have been notified of decreased fluid intake and decreased appetite on [DATE] MD F would have requested Resident 1 to be sent to ER for an evaluation. MD F stated I know Resident 1's history and would have been much more aggressive with Intravenous fluids for Resident 1. MD F stated by [DATE] with the continual decline she would expect to be consulted with the poor fluids intake and the unresponsiveness of Resident 1. MD F stated by [DATE] she would have admitted Resident 1 to the hospital for aggressive intravenous fluids to ensure her hydration status especially with Resident 1 length of decline and poor intakes. MD F stated she is reviewing the faxes and any notes from any MD at the clinic from [DATE] through [DATE]. MD F stated there has been no notification to the clinic regarding Resident 1 since she was notified on [DATE]. Significant change in overall condition A review of Resident 1's nursing notes shows a significant change in Resident 1's overall condition. [DATE] at 1:08 PM Resident return from the emergency room (ER) after a fall. New order to start [MEDICATION NAME] 500 mg every 12 hours times 10 days for UTI. [DATE] at 8:34 PM Resident temperature was 100.1 has a poor appetite, no speaking tonight, mumbled and groaned, given [MEDICATION NAME] which was effective. MD notified. (It does not indicate which MD was notified, how the MD was notified or if new orders were given.) Urine is clear amber fluids are encouraged, but not taking fluids well. [DATE] at 10:53 AM, Continues to run a low grade temperature 100.4 Tylenol was provided. Urine is light tea colored with minimal sediment which is her norm. Lungs have scattered crackles with loose productive cough. Resident 1's Physician was called and new orders received for complete blood count (CBC), Blood cultures times 2, Urinalysis and chest X-ray. Daughter has been updated. (Medical Doctor (MD) F stated she was only notified of the fever and cough, was not notified of poor appetite or not taking fluids.) [DATE] at 2:26 PM, Social Services note, Daughter notified Hospice will be in building on Friday and she is welcome to come and discuss options. She is going to try to stop in. (It is important to note Resident 1's Daughter did not agree to Hospice and there is not a Physician order [REDACTED].>[DATE] at 6:02 PM, Occasional moist loose cough, is scattered crackles, urine dark amber, fluids encouraged only takes a sip or two at a time, no speaking. [DATE] at 1:46 PM, Resident remains in bed throughout the shift. Oral consumption is poor, staff has assisted with meals less than 25% is being consumed her family is aware in addition to her MD. Family is coming to facility to discuss hospice. (It is important to note Resident 1's Family was not aware of the decline or decreased appetite) (Resident 1's Physician was not updated or aware of appetite or fluids per Medical Doctor (MD) F interview. Facility did not have evidence MD was consulted of Resident 1's declining condition since [DATE].) [DATE] at 11:32 PM, Resident very drowsy though wakes up easily and takes sips of fluids, Refuses to eat supper, scheduled [MEDICATION NAME] crushed and given. [DATE] at 1:52 PM. Signs and symptoms of infection are present. Resident 1 has been running a low grade temperatures. Foley catheter draining tea colored urine. [DATE] at 8:48 AM. Temperature 101.1. No signs and symptoms of infection. Had a fever of 101 but goes down with Tylenol (It is important to note Resident 1's orders do not include Tylenol for fever and Resident 1 Physician was not consulted prior to giving the Tylenol.), needs her meds crushed to swallow. Takes water per straw but just a few swallows, does not speak. Foley is draining amber urine. [DATE] at 8:35 AM, Condition has not changed still nonverbal but has her eyes open. No cyanosis. Oxygen saturation 89% has head of bed up. [DATE] at 1:07 PM Day 13 of antibiotic therapy. Resident 1 is resting quietly, medicated with Tylenol for temperature (Resident 1's Orders do not include Tylenol for fever). Skin warm and dry. Temperature 99.6 [DATE] at 6:32 PM, Resident 1 has remained in bed throughout this shift, has poor oral intake will take a few sips, mouth swabbed for comfort, does open eyes in response to name, refused medications, continues not to speak to staff and will not answer yes or no questions. [DATE] at 1:48 AM, Temperature 103.6 pulse rapid, Skin hot to touch. Cool bath given. Tylenol Suppository given. MD called to report elevated Temperature. Resident sent to ER for evaluation. (It is important to note Resident 1's orders do not include Tylenol Suppository or to give Tylenol for fever. Resident 1 was given the Tylenol suppository without a physician order [REDACTED].) SBAR dated [DATE] at 1:45 AM, Change in condition: Temp 103.6 declining condition. This started on [DATE] and it has gotten worse. Decreased consciousness (sleepy lethargic). Decreased urine output. What do you think is going on with resident? dehydration ?sepsis ER Note [DATE], Temp 103.6 at NH. Oxygen sat 89%. Physical exam: Severe distress, ill appearing. Mouth Mucous membranes are extremely dry and does appear to have oral thrush. Foley catheter appears infected, but nodes have [MEDICATION NAME] cells, it turns out she was [MEDICAL CONDITION] E-coli and organism was resistant to Cipro. It is not appear that she was adequately treated and that is the most likely cause of her hesitation. Patient is very ill may not have a good prognosis. She will likely become more ill and could die from this infection. On [DATE] at 11:53 AM, Surveyor spoke with Family Member (FM) H, regarding Resident 1's change of condition from [DATE] through [DATE]. FM H stated she was not notified or aware of Resident 1's decline in condition until [DATE] when Resident 1 was transferred to the hospital. FM H stated she was informed Resident 1 was going to have test and chest X-ray completed on [DATE]. FM H stated the nurse did not inform FM H of Resident 1 ' s decline in eating or drinking. FM H also stated she was not asked about intravenous fluids or to send Resident 1 to the hospital when she declined in eating, speaking or drinking. FM H stated she would have agreed to have Resident 1 have Intravenous fluids at the nursing home or hospital sooner had she known Resident 1 had declined in condition. FM H stated she is not clinical so she leaves those decisions up to the nurses to tell her what Resident 1 would need. FM H stated she never agreed to Hospice while Resident 1 was at the Nursing Home. FM H stated someone talked to her about talking to them but a decision was never made. FM H stated she was not aware of how bad Resident 1's condition was on [DATE]. Had she been told, she would have wanted Resident 1 sent to the emergency room for an evaluation and to receive Intravenous fluids. On [DATE] at 2:40 PM, Surveyor spoke with Director of Nursing (DON) B regarding Resident 1's change in condition from [DATE] through [DATE]. Surveyor reviewed Resident 1's nursing notes and Temperature elevations to include a fever of 101.1 on [DATE]. DON B stated she would expect the nurses to keep the physician aware of Resident 1's declining condition. DON B stated the physician should have been aware of fluid intake less than required amounts. DON B stated Resident 1's Physician should have been notified of decreased in alertness and poor appetite prior to [DATE]. DON B also stated Resident 1's family should have been notified of fevers and decline in fluid intakes especially on [DATE] when the mouth was swabbed for comfort. Need to alter treatment significantly On [DATE] at 9:00 AM, Surveyor requested Resident 1's urine culture report from [DATE] from Director of Nursing (DON) B. DON B stated she had just received the culture report from the hospital on [DATE]. DON B stated she had not attempted to get the culture report prior to [DATE]. DON B also stated Resident 1's primary physician was not notified of the culture results by the facility. Urine culture results, dated [DATE] (from urinalysis [DATE]), Organism 1. greater than (>)100,000 Escherichia coli isolated. Susceptibility results: Resistant to the following: [MEDICATION NAME], Pipercillin, [MEDICATION NAME] and [MEDICATION NAME]/Sulfa,. Susceptible to all other antibiotics. Organism 2. > 100, [MEDICATION NAME] faecalis. Susceptibility results: Resistant to the following: [MEDICATION NAME]. Susceptible to all other antibiotics listed. (Emphasis added.) On [DATE] at 2:00 PM Surveyor spoke with Medical Doctor (MD) F regarding Resident 1's urine culture for Urinalysis on [DATE]. MD F stated she was unaware the culture results were resistant to [MEDICATION NAME]. MD F also stated she was unaware of the culture results when she ordered the [MEDICATION NAME] again for a possible UTI on [DATE]. MD F stated she should have been notified of the results and should have expected the facility to know of urine culture results on all residents they are treating with antibiotics. MD F stated she would have considered a different antibiotic for Resident 1 had she been aware of the resistance. MD F stated Resident 1 has received Intravenous antibiotic in the past due to her allergies and this may have been considered. On [DATE] at 2:40 PM, Surveyor spoke with Director of Nursing (DON) B regarding Resident 1's urine culture from her Urinalysis on [DATE]. DON B stated the nurses should have followed up on the culture report to validate the antibiotic was the right one. DON B stated Resident 1's Physician should have been called on [DATE] with the culture result due to the medication Resident 1 was receiving was resistant to the organism cultured. DON B stated she was unaware of the culture results until [DATE]. DON B stated Resident 1 should have been monitored every shift while Resident 1 was on the antibiotic to monitor for side effects and for effectiveness. DON B stated Resident 1's physician and the on call Physician were not aware of the culture results from [DATE] when the same antibiotic was ordered on [DATE]. Resident 1 died at the hospital on [DATE]. According to the hospital discharge summary dated [DATE], Resident 1's final [DIAGNOSES REDACTED]. 2. E coli UTI (urinary tract infection). 3. Dementia with oblundation. 4. Possible aspiration. Systemically, the facility's failure to promptly consult with the physician for Resident 1 created an immediate jeopardy situation which began [DATE]. The facility removed the immediate jeopardy on [DATE] by taking the following actions: *House audit to be completed [DATE] to ensure there are no change in conditions to be communicated to the residents' physician and family. *If changes are identified, resident will be reassessed immediately and family and Physician will be immediately notified. *An in-service had been initiated on [DATE] on changes of condition including notification of family and physician. *Quality assurance tool will be implemented on [DATE] to: Conduct daily reviews to ensure physicians and families are aware of changes in condition. Cross Reference F 327

Based on interviews and record reviews, the facility did not ensure that 1 (Resident 1) of 11 residents reviewed for hydration was provided with sufficient fluids to meet assessed needs. Resident 1 experienced a decrease in fluid intake from [DATE] through [DATE] Resident 1 took less than ,[DATE]% of her assessed fluid needs of 1375 to 1650 milliliters each day. The intakes were not totaled from [DATE] through [DATE]. Resident 1 lost 8 lbs (7%) in 3 days from [DATE] to [DATE]. There is no evidence that staff analyzed the daily fluid intakes, alerted the Registered Dietician (RD) or the physician to the low intakes and/or implemented approaches to assist Resident 1 in meeting her daily fluid needs. On [DATE], Resident 1 was transferred to the hospital due to decline in health status. The admitting [DIAGNOSES REDACTED]. She died at the hospital on [DATE]. The facility's failure to ensure that Resident 1 received sufficient fluids to ensure proper hydration - which subsequently led to increased confusion and the need for hospitalization - created a finding of immediate jeopardy. Immediate jeopardy began on [DATE], the date that Resident 1 was noted to have a decline in oral intake. The NHA was notified on [DATE] that immediate jeopardy existed. The immediate jeopardy had been removed on [DATE]. The deficient practice continues at a scope/severity of D (potential for harm that is not immediate jeopardy/isolated) as all portions of the corrective actions have not been fully implemented. This is evidenced by: The University of Iowa, College of Nursing ,[DATE] provides Standards of Practice based on evidence in research findings. Under Ongoing Management of Oral Intake it lists 5 components of hydration management. #1 is to calculate a daily fluid goal. All residents need to have an individualized fluid goal determined by a documented standard for daily fluid intake. All residents need to have an individualized fluid goal determined by a documented standard for daily fluid intake. Other standards include: 30 ml/kg body weight with 1500 ml/day minimum. #4. Plan for at risk individuals for residents who are at risk of under hydration because of poor intake. #5 Documentation should include at least one accurate intake and output recording and should include the amount of fluid consumed, intake pattern, difficulties with consumption, and a urine specific gravity and color. Facility policy titled, Hydration assessment, dated ,[DATE], Policy: To be completed for all residents to assess potential for dehydration. Procedure: 1. Complete hydration assessment on admission, re-admission, quarterly and significant change in status. 2. Interpret scores to determine level of risk. 3. Regardless of the resident's total risk score, each resident's needs will be evaluated on an individual basis. 4. Care plan will be developed utilizing identified risk factors; needs will be evaluated on an individual basis. 5. Effectiveness of hydration plan of care will be monitored through clinical observation and lab monitoring. Resident 1 is an [AGE] year old female with the following Diagnoses: [REDACTED]. Resident 1's annual minimum data set (MDS), dated [DATE], Resident 1 brief interview for mental status scored a 13 meaning Resident 1 is cognitively alert. Resident 1 needs set up assist to eat. Resident 1's current active care plan, Undated, Focus: Scores at risk for dehydration due to having loose stools. Resident 1 is alert and oriented times 3 able to express thirst and able to drink independently. Goal: Resident 1 will not exhibit signs of dehydration. Interventions: Monitor fluid intakes. Monitor decreased ability to drink and eat without assist. Monitor for signs and symptoms of dehydration report acute changes in level of consciousness (LOC) to medical doctor (MD). Laboratory (labs) per MD order. Report abnormal labs to MD. Resident 1's care plan in part, undated, Resident 1 has a history of diarrhea. Goal: Resident 1 will show no complications related to bowel incontinence. Interventions: Encourage to remain well hydrated to assist with bowel elimination. Monitor for changes in stool. Monitor for excoriation near peri area, Apply barrier cream as ordered, Provide pericare with each episode of incontinence. Resident 1's nutritional assess, dated [DATE], Weight 118 #. GI symptoms: Diarrhea and constipation. Fluid estimated needs 1375 - 1650. (Calculated by 30 cc = 1600 ml per day) Wt maintenance is good intake 50% or greater of meals. Resident stated she drinks well. Diet: Lactose free, pureed vegetables and fruits Resident 1's hydration assessment, dated [DATE], score 3 not at risk. Resident condition is marked yes for Abnormal lab values and currently taking a diuretic or laxative. Resident 1 is marked no for Dry mucous membranes, constipation, Diarrhea in past 7 days, [DIAGNOSES REDACTED]. The facility documented Resident 1 ' s fluid intake for the last days of February 2015 as follows in the medical record (ml = milliliters). Please note that Resident 1's fluid sheet did not have the daily total calculated upon review of the intake form and that daily totals were calculated by the surveyor. [DATE] 1st shift 1600 ml, 2nd shift 840 ml, night shift 120 ml = 2,560 ml [DATE] 1st shift 1,900 ml, 2nd shift 760 ml, night shift 90 ml = 2,750 ml [DATE] 1st shift 1,920 ml, 2nd shift 910 ml, night shift 120 ml = 2,950 ml [DATE] 1st shift 1,670 ml, 2nd shift 1,020 ml, night shift 90 ml = 2,560 ml [DATE] 1st shift 1,680 ml, 2nd shift 1,140 ml, Night shift 90 ml. = 2,910 ml Fluid documentation for [DATE] reveals the following. [DATE] 1st shift 280 ml, 2nd shift 270 ml, Night shift (0) total intake = 550 ml. [DATE] 1st shift 360 ml, 2nd shift 210 ml, night shift 90 ml = 630 ml [DATE] 1st shift 440 ml, 2nd shift 330 ml, night shift 60 ml = 830 ml [DATE] 1st shift 340 ml, 2nd shift 150 ml, night shift 120 ml = 610 ml [DATE] 1st shift 360 ml, 2nd shift 240 ml, night shift 120 ml = 720 ml [DATE] 1st shift 280 ml, 2nd shift 210 ml, night shift 90 = 580 ml [DATE] 1st shift 390 ml, 2nd shift 310 ml, night shift 60 ml = 760 ml [DATE] No documentation provided. Based on the [DATE] assessment, Resident 1's fluid intake was ,[DATE]% less than his assessed need during the first 7 days in [DATE]. During this same period of time, Resident 1 also had poor food intake, which is significant in that persons consuming less than 50% of meals are at high risk for dehydration. [DATE] - Breakfast 51% to 75%, Lunch 51% to 75%, Dinner 26% to 50% [DATE] - Breakfast 0% to 25%, Lunch 26% to 50%, Dinner 51% to 75% [DATE] - Breakfast 0% to 25 %, Lunch and Dinner (No % listed) [DATE] - Breakfast 0% to 25%, Lunch 0% to 25%, Dinner (no 0% listed) [DATE] - Breakfast 0% to 25%, Lunch 0% to 25%, Dinner 0% to 25%. [DATE] - Breakfast 0% to 25%, Lunch 0% to 25%, Dinner 26% -50%. [DATE] - Breakfast 0% to 25 %, Lunch 0%, Dinner 0% A Review of Resident 1's weight summary revealed: *[DATE] weight 115.2 pounds (lbs) *[DATE], weight 113 lbs *[DATE], weight 104.95 lbs (47.7 kg) (Hospital admission weight) Resident 1 lost 8 lbs or 7% of his weight in 3 days from [DATE] through [DATE]. Despite a dramatic change in Resident 1's food and fluid intake, the facility made no changes to the resident ' s care plan to push fluids. The facility did not inform the physician of the resident ' s poor fluid intake, and did not consult with the family about intravenous intake. During this same time period, charting indicates that Resident 1 had a fever, as was documented below. Fever increases fluid needs, thus Resident 1 ' s assessed fluid needs might have been greater than that calculated in [DATE]. [DATE] - Temperature 100.1 at 5:32 PM [DATE] - Temperature 99.2 at 8:28 PM [DATE] - Temperature 100.4 at 1:58 AM [DATE] - Temperature 99.3 at 6:00 AM [DATE] - Temperature 99.5 at 6:34 PM [DATE] - Temperature 99.5 at 1:27 AM [DATE] - Temperature 101.1 at 1:37 AM [DATE] - Temperature 99.5 at 1:09 PM [DATE] - Temperature 103.6 at 1:30 AM A review of Resident 1's nursing notes regarding appetite and fluid intake from [DATE] (the day Resident 1 experienced on set of an infection) through [DATE] described Resident 1's ongoing fever (which increases the need for fluids) and decline in appetite and mental status. Excerpts from these notes include: [DATE] at 1:08 PM Resident return from the emergency room (ER) after a fall. New order to start [MEDICATION NAME] 500 mg every 12 hours times 10 days for UTI. [DATE] at 6:59 PM , Resident consumed less than 25% of all meals today liquid nourishment was excepted and did have approximately 20% of meal alternatives. [DATE] at 6:27 PM, Consumed less than 25% of dinner other meal 50%. [DATE] at 8:34 PM Resident temperature was 100.1 has a poor appetite, no speaking tonight, mumbled and groaned, given [MEDICATION NAME] which was effective. MD notified. (It does not indicate which MD was notified, how the MD was notified or if new orders were given.) Urine is clear amber fluids are encouraged, but not taking fluids well. [DATE] at 10:53 AM, Continues to run a low grade temperature 100.4 Tylenol (Resident 1 did not have an order for [REDACTED]. Lungs have scattered crackles with loose productive cough. Resident 1's Physician was called and new orders received for complete blood count (CBC), Blood cultures times 2, Urinalysis and chest X-ray. Daughter has been updated. (Important to note Medical Doctor (MD) F stated she was only notified of the fever and cough, was not notified of poor appetite or not taking fluids.) [DATE] at 2:26 PM, Social Services note, Daughter notified Hospice will be in building on Friday and she is welcome to come and discuss options. She is going to try to stop in. (It is important to note Resident 1's Daughter did not agree to Hospice and there is not a Physician order [REDACTED].>[DATE] at 6:02 PM, Occasional moist loose cough, is scattered crackles, urine dark amber, fluids encouraged only takes a sip or two at a time, no speaking. [DATE] at 1:46 PM, Resident remains in bed throughout the shift. Oral consumption is poor, staff has assisted with meals less than 25% is being consumed her family is aware in addition to her MD. Family is coming to facility to discuss hospice. (It is important to note Resident 1's Family was not aware of the decline or decreased appetite) (Resident 1's Physician was not updated or aware of appetite or fluids per Medical Doctor (MD) F interview. Facility did not have evidence MD was consulted of Resident 1's declining condition since [DATE].) [DATE] at 11:32 PM, Resident very drowsy though wakes up easily and takes sips of fluids, Refuses to eat supper, scheduled [MEDICATION NAME] crushed and given. [DATE] at 1:52 PM, Signs and symptoms of infection are present. Resident 1 has been running a low grade temperatures. Foley catheter draining tea colored urine. [DATE] at 8:48 AM, Temperature 101.1. No signs and symptoms of infection. Had a fever of 101 but goes down with Tylenol, needs her meds crushed to swallow. Takes water per straw but just a few swallows, does not speak. Foley is draining amber urine. [DATE] at 8:35 AM, Condition has not changed still nonverbal but has her eyes open. No cyanosis. Oxygen saturation 89% has head of bed up. [DATE] at 1:07. Resident 1 is resting quietly, medicated with Tylenol for temperature. (Resident 1 continues not to have an order to give Tylenol for fever.) Skin warm and dry. Temperature 99.6. [DATE] at 6:32 PM, Resident 1 has remained in bed throughout this shift, has poor oral intake will take a few sips, mouth swabbed for comfort, does open eyes in response to name, refused medications, continues not to speak to staff and will not answer yes or no questions. [DATE] at 1:48 AM, Temperature 103.6 pulse rapid, Skin hot to touch. Cool bath given. Tylenol Suppository given. MD called to report elevated Temperature. Resident sent to ER for evaluation. Resident 1's nurses notes indicate Resident 1 has a decrease in appetite, a decrease ability to feed self and a change in mental status, which are all signs of dehydration. It is important to note a dehydration assessment was not completed as Resident 1's condition declined. The facility made no revisions to the care plan with interventions for pushing fluids. Resident 1's Physician was not consulted to give alternative treatment to Resident 1 as her condition continued to decline. Situation Background Assessment Recommendation (SBAR) dated [DATE] at 1:45 AM, Change in condition: Temp 103.6 declining condition. This started on [DATE] and it has gotten worse. Decreased consciousness (sleepy lethargic). Decreased urine output. What do you think is going on with resident? dehydration ?sepsis Resident 1's Emergency Medical System (EMS) transportation note, dated [DATE] at 3:15 AM, Summary of events: Resident 1 was laying in bed and was breathing rapid and shallow. Nursing staff stated they noticed patient was having difficulty 15 minutes prior to calling (EMS). EMS took vitals and placed Resident 1 on 5 liters of oxygen. Resident 1's respiration 30 and labored, Oxygen saturation 88%, pulse rate of 100. Chief complaint difficulty breathing. emergency room (ER) Note [DATE], Resident 1 was seen in theER on [DATE] after sustaining a fall. At that time, she was found to have an UTI and was started on [MEDICATION NAME]. Family stated Resident 1 was her usual self [DATE] when she started to have a change in mental status. Today she had a fever of 103.6. Oxygen saturation sat 89% requiring increases and supplemental oxygen. Physical exam: Severe distress, ill appearing. Mouth Mucous membranes are extremely dry and does appear to have oral thrush. Foley catheter appears infected, but does have [MEDICATION NAME] cells, it turns out she was [MEDICAL CONDITION] E-coli and specifically the organism was resistant to [MEDICATION NAME]. It is not appear that she was adequately treated and that is the most likely cause of her hesitation. Patient is very ill may not have a good prognosis. She will likely become more ill and could die from this infection. Laboratories: Blood urea Nitrogen (BUN) 51 (Normal ,[DATE]), Creatinine (CRT) 1.43 (Normal 0XXX,[DATE].60), Glomerular Filtration rate (GFR) 35 (Resident normal 60), Sodium (Na) 152 (Normal ,[DATE]), Potassium (K) 3.5 (Normal 3XXX,[DATE].1). Associated risk factors: [MEDICAL CONDITION], shock, [MEDICAL CONDITION], dehydration and acidosis History and Physical: [DATE] admitted with progressive weakness and lethargy for about 2 weeks prior to this admission. Was seen inER on [DATE] for UTI. After a prolonged course of [MEDICATION NAME] she continues to deteriorate. Past few days she became less alert and completely unresponsive to any commands. Upon arrival she was Hypoxic and was placed on Oxygen. Resident 1 is nonverbal. GI: appetite poor. Vital signs: Temperature 100.9 Blood Pressure ,[DATE]. Pulse 110 Respirations 24 with oxygen. Looks very pale and cachectic. Staring ahead blankly no verbal response. Ears nose mouth and throat Dry. Oral Mucous Dry. Resident has a large decubitus ulcer over sacral with necrotic base and foul smelling secretions. BUN 51, Crt 1.43, GFR 35 (her normal GFR was 60) NA 152, K 3.5. Urine looked like pus. Sepsis likely from UTI and sacral decubitus ulcer. Resident looks extremely sick. Her prognosis remains rather poor. [MEDICAL CONDITION] consistent with hypovolemia and dehydration. Started on intravenous hydration 0.45 Normal saline. Resident 1 died at the hospital on [DATE]. Discharge Summary, dated [DATE], 1. Severe dehydration with [MEDICAL CONDITION], 2. E coli UTI, 3. Dementia with oblundation, 4. Possible aspiration. Progressive weakness and lethargy over a 2 week period of time. Patient was admitted with marked Oblundation (decreased alertness) associated with [MEDICAL CONDITION] and free water deficit. She appears very clinically dehydration. She was given D5 half normal saline for resuscitation and correction of her clinical dehydration and her [MEDICAL CONDITION]. Resident received [MEDICATION NAME] and Aztreonam on admission both for coverage of health care associated pneumonia and for her UTI, failing outpatient Cipro, and this combination also provided coverage for her decubitus ulcer. Urine culture from admission E coli [MEDICAL CONDITION]. On [DATE] at 11:53 AM, Surveyor spoke with Family Member (FM) H regarding Resident 1's change of condition from [DATE] through [DATE]. FM H stated she was not notified or aware of Resident 1's decline in condition until [DATE] when Resident 1 was transferred to the hospital. FM H stated she was informed Resident 1 was going to have test and chest X-ray completed on [DATE]. FM H stated the nurse did not inform FM H of Resident 1 decline in eating or drinking. FM H also stated she was not asked about intravenous fluids or to send Resident 1 to the hospital when she declined in eating, speaking or drinking. FM H stated she would have agreed to have Resident 1 have Intravenous fluids at the nursing home or hospital sooner had she known Resident 1 had declined in condition. FM H stated she is not clinical so she leaves those decision up to the nurses to tell her what Resident 1 would need. FM H stated she never agreed to Hospice while Resident 1 was at the Nursing Home. FM H stated someone talked to her about talking to them but a decision was never made. FM H stated she was not aware of how bad Resident 1 condition was on [DATE], she would have wanted Resident 1 sent to the emergency room for an evaluation and to receive Intravenous fluids. On [DATE] at 2:00 PM, Surveyor spoke with Medical Doctor (MD) F regarding Resident 1's condition, fluid intakes and appetites. MD F stated she was notified on [DATE] of Resident 1's fever and change in mental status. MD F stated she was not consulted about Resident 1's decrease in fluids or appetite on [DATE]. MD F stated she was not consulted from [DATE] through [DATE] when she seen the note indicating Resident 1 was sent to the ER by the on call MD. MD F stated she should have been notified of Resident 1's decline in eating on [DATE]. MD F stated on [DATE] she should also have been contacted when Resident 1 was only taking sips of fluid and refusing meals. MD F continued to state on [DATE] Resident 1's temperature was 101 she would have expected a call. MD F stated if she would have been notified of decreased fluid intake and decreased appetite on [DATE] MD F would have requested Resident 1 to be sent to ER for an evaluation. MD F stated I know Resident 1's history and would have been much more aggressive with Intravenous fluids for Resident 1 at a sooner date than [DATE]. MD F stated by [DATE] with the continual decline she would expect to be consulted with the poor fluids intake and the unresponsiveness of Resident 1. MD F stated by [DATE] she would have admitted Resident 1 to the hospital for aggressive intravenous fluids to ensure her hydration status especially with Resident 1 length of decline and poor intakes. MD F stated she is reviewing the faxes and any notes from any MD at the clinic from [DATE] through [DATE]. MD F stated there has been no notification of Resident 1 decline to the clinic since she was notified on [DATE]. According to a study published by the National Institute of Health (<http://www.ncbi.nlm.nih.gov/pubmed/ 084>), an overall mortality rate of 29.8% was found in elderly persons who were hospitalized with dehydration. This increased to 33.3% for those whose sodium levels were ,[DATE] and to 71.4% whose sodium level exceeded 154. According to Medscape (www.medscape.com/view article/ 8) Dehydration in Geriatrics from Geriatrics and Aging 2007:10(9) ,[DATE]: Dehydration is a common and serious condition in older adults. Mortality of patients with dehydration is high if not treated adequately. In the older adult dehydration often causes atypical symptoms such as confusion, constipation, or falls. Body weight proved to be the most responsive to changes in hydration. Patients consuming less than 50% of meals are at high risk for dehydration. Caregivers should be aware of and anticipate this hazard. Diagnosing dehydration and monitoring fluid balance requires repeated measurement of weight, Creatinine, and physical signs such as tongue hydration. The facility's failure to assess, evaluate and attempt aggressive nutritional and fluid interventions for Resident 1 created an immediate jeopardy situation which began [DATE]. The facility removed the immediate jeopardy on [DATE] by taking the following actions: All residents were assessed for dehydration risk [DATE] by DON or designee. 1. Any resident who scores at High risk for dehydration: *Hydration status assessed, if signs or symptoms present Family/Physician notified. *Input sheet put in place. * Care Plan reviewed and revised as needed. *Intake sheets will be monitored daily by DON or designee for resident meeting fluid intake needs based on dietician recommendations. 2. If Resident's not meeting fluid needs: a. Assess hydration. b. Call family/Physician notified. c. Refer to dietician, if appropriate. d. Update care plan as necessary. 3. An in-service was initiated on [DATE] for all nurses on above process and hydration policy and procedure. 4. Quality Assurance tools were implemented for the following: a. Conducting random audit of hydration assessments. b. Conducting daily review on intake for residents at risk for hydration. Cross reference F157

Based on interview and record review, in 1 of 11 total residents reviewed (Resident 1) the facility did not ensure each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Resident 1 was prescribed an antibiotic without meeting the criteria of a urinary tract infection. Three days later, when the culture results were returned, the isolated bacteria were found to be resistant to the antibiotic. The facility did not consult with Resident 1's physician concerning the resistant culture or question the indications for its use. Resident 1 continued to receive the antibiotic for the entire ten days. On [DATE], when the resident now met the criteria for a urinary tract infection, the physician re-ordered the antibiotic without having been told that the antibiotic was not effective against the underlying infection. Without effective treatment, Resident 1 began a more rapid decline in overall condition and functioning, during which time the facility continued to give Resident 1 [MEDICATION NAME], the resistant antibiotic. Resident 1 subsequently was admitted to the emergency room (ER) where ER notes indicate it does not appear that she was adequately treated and that is the most likely cause of her hesitation. Patient is very ill may not have a good prognosis. She will likely become more ill and could die from this infection. Resident 1 died in the hospital four days later. The failure to ensure that Resident 1's drug regimen was free from a drug without adequate indications for its use (did not meet criteria for use; organism was resistant to the drug) and in the presence of adverse consequences (resident's condition worsened) created a finding of immediate jeopardy. Immediate jeopardy began on [DATE], the date that Resident 1 met the criteria for a urinary tract infection and was re-ordered an antibiotic that was resistant to the underlying infection. The NHA was notified on [DATE] that immediate jeopardy existed. The immediate jeopardy had been removed on [DATE]. The deficient practice continues at a scope/severity of D (potential for harm that is not immediate jeopardy/isolated) as all portions of the corrective actions have not been fully implemented. This is evidenced by: The CDC's (Centers for Disease Control and Prevention) website states, People infected with antimicrobial-resistant organisms are more likely to have longer, more expensive hospital stays, and may be more likely to die as a result of the infection. The Chicago Journals / SHEA (The Society for Healthcare Epidemiology of America) Surveillance Definitions of Infections in Long Term Care Facilities: Revisiting the McGeer Criteria ,[DATE] states: Residents with an indwelling catheter (both criteria 1 and 2 must be present) 1. At least 1 of the following sign and symptoms subcriteria a. Fever, rigors, or new onset [MEDICAL CONDITION], with no alternate site of infection. b. Either acute changes in mental status or acute functional decline, with no alternate [DIAGNOSES REDACTED]. c. New-Onset suprapubic pain or costovertebral angle pain or tenderness. d. Purulent discharge from around the catheter or acute pain, swelling, or tenderness of the testes, epididymis or prostate. 2. Urinary catheter specimen culture with at least 100,000 of any organism. A positive urine culture is necessary for [DIAGNOSES REDACTED]. Urinary catheter specimens for culture should be collected following replacement of the catheter (If current catheter has been in place for greater than 14 days.) Resident 1 is an [AGE] year old female with the following Diagnoses: [REDACTED]. She has a chronic indwelling Foley catheter. Urine culture results, dated [DATE], 30,000 Escherichia coli isolated, 60,000 [DIAGNOSES REDACTED] oxytoca isolated. Susceptibility results: [MEDICATION NAME] resistant only. Susceptible to all other antibiotics to include [MEDICATION NAME]. Resident 1 was treated with [MEDICATION NAME] 500 mg twice a day for 7 days. Resident 1 was placed [MEDICATION NAME] though she met none of the criteria in the SHEA guidelines: Revisiting the McGeer Criteria. Resident 1's care plan in part, dated [DATE], Focus: Antibiotic therapy related to Urinary Tract infection [MEDICAL CONDITION]. Goal: Resident 1 will be free from signs or symptoms of UTI. Resident will tolerate antibiotic therapy. Interventions: Document signs and symptoms related to use of the antibiotic medication and indicate effectiveness, Monitor side effects from antibiotic, Monitor for signs and symptoms of infection to evaluate effectiveness of medication, Monitor vital signs as ordered while on antibiotic therapy, Notify medical doctor (MD) for any acute changes, Notify MD of any signs of UTI, Obtain Urinalysis as ordered, provide catheter care. Resident 1 subsequently developed a resistance to Cipro, as shown by culture results on [DATE]. Resident 1's Physician order, dated [DATE], [MEDICATION NAME] 500 mg every 12 hours for UTI for 10 days. Urine culture results, dated [DATE] (from urinalysis [DATE]), Organism 1. greater than (>)100,000 Escherichia coli isolated. Susceptibility results: Resistant to the following: [MEDICATION NAME], Pipercillin, [MEDICATION NAME] and [MEDICATION NAME]/Sulfa,. Susceptible to all other antibiotics. Organism 2. > 100,[MEDICATION NAME] faecalis. Susceptibility results: Resistant to the following: [MEDICATION NAME]. Susceptible to all other antibiotics listed. (Emphasis added.) On [DATE] at 2:40 PM Surveyor spoke with Director of Nursing (DON) B regarding the culture results for [DATE] urinalysis. DON B stated she received the results from the culture results on [DATE]. DON B stated she was not aware of the [MEDICATION NAME] resistance until [DATE]. DON B stated Resident 1 was not placed on the infection control log for the month of February or March so she did not track Resident 1's culture. DON B also stated the facility should have followed up on the culture for Resident 1 after her emergency room visit on [DATE]. DON B stated she uses the McGeer Criteria for treatment of [REDACTED]. On the same date, [DATE], that the culture results showed that the underlying organism was resistant to Cipro, an emergency room (ER) progress note, written by a physician's assistant noted: Reviewed this patient's chart. She was seen with an initial fall and evaluation of those injuries. She had no urinary complaint. Since reviewing the culture, antibiotics that would cover her infections she is allergic to. She was not febrile at her visit and because she had no urinary complaints felt no treatment is necessary at this time. Resident 1's Physician visit, dated [DATE], Resident 1 had a fall and hit her head (on [DATE]). Resident 1 was presented to the emergency room (ER). She was placed on [MEDICATION NAME] for a UTI. She continues to have peri rectal pain due to her chronic loose stools from her [MEDICAL CONDITION]. Assessment: Urinary Tract Infection continue [MEDICATION NAME]. (It is important to note the facility had not asked for Resident 1's urine culture results prior to this Physician visit.) Resident 1 continued [MEDICATION NAME] ten days (,[DATE] - [DATE]), even though the culture report showed that the underlying organism was resistant [MEDICATION NAME] even though the hospital now questioned whether she needed to be on an antibiotic. During the time period of [DATE] to [DATE], Resident 1's condition declined. She ate less and took in less fluids than assessed as needing. She became more lethargic and developed a fever. Details of the declines in the resident's condition are documented in F157 and F327. (Cross reference F157 and F327). On [DATE], when nursing notes now indicate that Resident 1 has a low-grade fever of 100.4 degrees, Resident 1's Physician re-ordered [MEDICATION NAME] 500 mg every 12 hours for UTI for 10 days. DON B stated on [DATE] at 9 AM that the facility had not notified Resident 1's physician and the on call physician of the resistance of the [MEDICATION NAME] prior to the continuation of the resistant medication. Urine culture, dated [DATE], again shows that Resident 1 is resistant to Cipro. These results indicate Organism 1. > 100,00 Escherichia coli Susceptibility results: Resistant to the following: [MEDICATION NAME]. Susceptible to all other antibiotics listed. Organism 2. > 100,000 [MEDICAL CONDITION] resistant to [MEDICATION NAME], [MEDICATION NAME], Oxacilliin, [MEDICATION NAME]. Susceptible to all other antibiotics listed. (Emphasis added.) Urine culture result, dated [DATE], Indicates Organism 1. > 100,00 Escherichia coli Resistant to [MEDICATION NAME], Organism 2. 60,000 [MEDICAL CONDITION] resistant to [MEDICATION NAME], Organism 3. 100,000 [MEDICATION NAME] faecalis Resistant to [MEDICATION NAME]. (Emphasis added.) Given the culture results and the fact that Resident 1 had a fever on [DATE] and [DATE], she met the criteria for having a urinary tract infection. She continued, however, on an antibiotic that was resistant to the underlying infection. A review of Resident 1's February and March Medication Administration Record [REDACTED]. Resident 1's last dose of [MEDICATION NAME] was given on [DATE] at 8:00 PM. On [DATE] at 2:00 PM Surveyor spoke with Medical Doctor (MD) F regarding Resident 1's urine culture for Urinalysis on [DATE]. MD F stated she was unaware the culture results were resistant to [MEDICATION NAME]. MD F also stated she was unaware of the culture results when she ordered the [MEDICATION NAME] again for a possible UTI on [DATE]. MD F stated she should have been notified of the results and should have expected the facility to know of urine culture results on all residents they are treating with antibiotics. MD F stated she would have considered a different antibiotic for Resident 1 had she been aware of the resistance. MD F stated Resident 1 has received Intravenous antibiotic in the past due to her allergies and this may have been considered. On [DATE] at 2:40 PM, Surveyor spoke with Director of Nursing (DON) B regarding Resident 1's urine culture from her Urinalysis on [DATE]. DON B stated the nurses should have followed up on the culture report to validated the antibiotic was the right one. DON B stated Resident 1's Physician should have been called on [DATE] with the culture result due to the medication Resident 1 was receiving was resistant to the organism cultured. DON B stated she was unaware of the culture results until [DATE]. DON B stated Resident 1 should have been monitored every shift while Resident 1 was on the antibiotic to monitor for side effects and for effectiveness. DON B stated Resident 1's physician and the on call Physician were not aware of the culture results from [DATE] when the same antibiotic was ordered on [DATE]. Resident 1's condition continued to decline following the re-order [MEDICATION NAME] [DATE], as evidenced below. [DATE] at 10:53 AM, Continues to run a low grade temperature 100.4 Tylenol was provided. Urine is light tea colored with minimal sediment which is her norm. Lungs have scattered crackles with loose productive cough. Resident 1's Physician was called and new orders received for complete blood count (CBC), Blood cultures times 2, Urinalysis and chest X-ray. Daughter has been updated. [DATE] at 6:02 PM, Occasional moist loose cough, is scattered crackles, urine dark amber, fluids encouraged only takes a sip or two at a time, no speaking. [DATE] at 1:46 PM, Resident remains in bed throughout the shift. Oral consumption is poor, staff has assisted with meals less than 25% is being consumed . [DATE] at 11:32 PM, Resident very drowsy though wakes up easily and takes sips of fluids, Refuses to eat supper, scheduled [MEDICATION NAME] crushed and given. [DATE] at 1:52 PM, Day 11 of antibiotic therapy. Signs and symptoms of infection are present. Resident 1 has been running a low grade temperatures. Foley catheter draining tea colored urine. [DATE] at 8:48 AM, Day 12 of antibiotic therapy. Temperature 101.1. No signs and symptoms of infection. Had a fever of 101 but goes down with Tylenol, needs her meds crushed to swallow. Takes water per straw but just a few swallows, does not speak. Foley is draining amber urine. [DATE] at 8:35 AM, Condition has not changed still nonverbal but has her eyes open. No cyanosis. Oxygen saturation 89% has head of bed up. [DATE] at 1:07 PM Day 13 of antibiotic therapy. Resident 1 is resting quietly, medicated with Tylenol for temperature. Skin warm and dry. Temperature 99.6 [DATE] at 6:32 PM, Resident 1 has remained in bed throughout this shift, has poor oral intake will take a few sips, mouth swabbed for comfort, does open eyes in response to name, refused medications, continues not to speak to staff and will not answer yes or no questions. [DATE] at 1:48 AM, Temperature 103.6 pulse rapid, Skin hot to touch. Cool bath given. Tylenol Suppository given. MD called to report elevated Temperature. Resident sent to ER for evaluation. SBAR dated [DATE] at 1:45 AM, Change in condition: Temp 103.6 declining condition. This started on [DATE] and it has gotten worse. Decreased consciousness (sleepy lethargic). Decreased urine output. What do you think is going on with resident? dehydration ?sepsis ER Note [DATE], Temp 103.6 at NH. Oxygen sat 89%. Physical exam: Severe distress, ill appearing. Mouth Mucous membranes are extremely dry and does appear to have oral thrush. Foley catheter appears infected, but nodes have [MEDICATION NAME] cells, it turns out she was [MEDICAL CONDITION] E-coli and organism was resistant to Cipro. It is not appear that she was adequately treated and that is the most likely cause of her hesitation. Patient is very ill may not have a good prognosis. She will likely become more ill and could die from this infection. Resident 1 died at the hospital on [DATE]. Discharge Summary, dated [DATE], 1. Severe dehydration with [MEDICAL CONDITION], 2. E coli UTI, 3. Dementia with oblundation, 4. Possible aspiration. Progressive weakness and lethargy over a 2 week period of time. Patient was admitted with marked Oblundation (decreased alertness) associated with [MEDICAL CONDITION] and free water deficit. She appears very clinically dehydration. She was given D5 half normal saline for resuscitation and correction of her clinical dehydration and her [MEDICAL CONDITION]. Resident received [MEDICATION NAME] and Aztreonam on admission both for coverage of health care associated pneumonia and for her UTI, failing outpatient Cipro, and this combination also provided coverage for her decubitus ulcer. Urine culture from admission E coli [MEDICAL CONDITION]. The facility's failure to ensure that an antibiotic was not used without adequate indications for its use or in the presence of adverse consequences created an immediate jeopardy situation which began [DATE]. The facility removed the immediate jeopardy on [DATE] by taking the following actions: 1. On [DATE] all residents being treated with antibiotics were reviewed to ensure that this is an appropriate treatment based on culture and sensitivity results, if completed. 2. DON or designee will monitor all resident's with an infection to ascertain the individual; response to treatment and care, including progress or lack of progress toward a therapeutic goal on a daily basis. 3. Medical Doctor (MD) and family will be notified if resident not responding to antibiotic therapy. 4. On [DATE] DON in-service on completing antibiotic therapy tracking and following up as necessary to ensure culture and sensitivity results to MD and monitoring resident's response to antibiotic therapy. 5. Quality Assurance tools will be completed by DON or Designee on an on-going basis on the following. a. Culture and sensitivity results are reported to MD. b. Resident's antibiotic treatment is appropriate based on culture and sensitivity if appropriate.

Based on interviews and record reviews, the facility did not ensure that 2 (Residents 1 and 4) of 6 residents reviewed for hydration were provided with sufficient fluids to meet assessed needs. Resident 1 experienced a decrease in fluid and food intake from 3/1/14 through 3/10/14 Resident 1 consistently took less than his assessed fluid needs of 1925 to 2310 milliliter each day. The intakes were not totaled from 3/1/14 through 3/10/14. Resident 1 lost 33.4 lbs (14.5%) in 30 days from 2/6/14 to 3/5/14. The facility does not have a hydration policy to ensure residents whose intake does not meet the daily estimated needs and are at risk for dehydration are monitored for and provided with adequate hydration. There is no evidence that staff analyzed the daily fluid intakes, alerted the Registered Dietician (RD) to the low intakes and/or implemented approaches to assist Resident 1 in meeting his daily fluid needs. On 3/10/14, Resident 1 was transferred to the hospital due to decline in health status. The admitting [DIAGNOSES REDACTED]. The facility's failure to ensure that Resident 1 received sufficient fluids to ensure proper hydration - which subsequently led to increased confusion and the need for hospitalization - created a finding of immediate jeopardy. Immediate jeopardy began on 3/5/14, the date that Resident 1 was noted to have a 30 pound weight loss with decline in oral intake. The NHA was notified on 3/18/14 that immediate jeopardy existed. The immediate jeopardy was removed on 3/18/14. The deficient practice continues at a scope/severity of D (potential for harm that is not immediate jeopardy/isolated) as all portions of the corrective actions have not been fully implemented and as evidenced by the example below. Resident 4 was did not take in her estimated fluid needs during a period when she was experiencing increased diarrhea. The facility did not calculate total fluid intakes to ensure that Resident 4 remained hydrated. The facility did not assess Resident 4 for dehydration. This evidence by: According to a study published by the National Institute of Health (<http://www.ncbi.nlm.nih.gov/pubmed/ 084>), an overall mortality rate of 29.8% was found in elderly persons who were hospitalized with dehydration. This increased to 33.3% for those whose sodium levels were 151-153 and to 71.4% whose sodium level exceeded 154. According to Medscape (www.medscape.com/view article/ 8)Dehydration in Geriatrics from Geriatrics and Aging 2007:10(9) 590-596: Dehydration is a common and serious condition in older adults. Mortality of patients with dehydration is high if not treated adequately... In the older adult dehydration often causes atypical symptoms such as confusion, constipation, or falls.... Body weight proved to be the most responsive to changes in hydration.... Patients consuming less than 50% of meals are at high risk for dehydration. Caregivers should be aware of and anticipate this hazard. Diagnosing dehydration and monitoring fluid balance requires repeated measurement of weight, Creatinine, and physical signs such as tongue hydration. The University of Iowa, College of Nursing 2/2004 provides Standards of Practice based on evidence in research findings. Under Ongoing Management of Oral Intake it lists 5 components of hydration management. #1 is to calculate a daily fluid goal. "All residents need to have an individualized fluid goal determined by a documented standard for daily fluid intake. All residents need to have an individualized fluid goal determined by a documented standard for daily fluid intake. Other standards include: 30 ml/kg body weight with 1500 ml/day minimum. 4. Plan for at risk individuals for residents who are at risk of under hydration because of poor intake. #5 indicated documentation should include at least one accurate intake and output recording and should include the amount of fluid consumed, intake pattern, difficulties with consumption, and a urine specific gravity and color. On 3/18/14 at approximately 10:30 AM Surveyor requested the hydration policy the facility uses to ensure that residents in the facility are receiving adequate fluids to prevent dehydration. DON B stated they do not have a hydration or a dehydration policy. DON B presented Surveyor with an intake and output policy and a Hydration Assessment policy. Intake and output policy, dated 5/10, Policy: Intake and output will be recorded for all residents on intravenous fluids, [MEDICAL TREATMENT] (if ordered), restricted intake and for others as ordered by physician or assessed as needed by a Registered Nurse (RN) Licensed Practical Nurse (LPN). Only output will be recorded for residents with a Foley or any other catheter that collects urine... Hydration Assessment policy, dated 5/10, states Policy: To be completed for all residents to assess potential for dehydration. Procedure: 1. Complete hydration assessment on admission, quarterly, and with any significant change of condition. 2. Interpret scores to determine level of risk...4. A care plan will be developed utilizing identified risk factors...5. Effectiveness of the hydration plan of care will be monitored through clinical observation and lab monitoring. Example 1 Resident 1 is a [AGE] year old male with the medical [DIAGNOSES REDACTED]. Resident 1's Activation of Durable power of Attorney for Health Care, activation date of 6/19/12... Resident 1's care plan titled, Receiving Antibiotic therapy, undated, Goal: Resident will tolerate antibiotic therapy. Intervention: 1. Document sign and symptoms related to antibiotic use. 2. Encourage fluids unless contraindicated. 3. Monitor side effects. 4. Monitor for Signs and Symptoms of effectiveness. 4. Monitor Vital signs...5 Notify Medical Doctor for any acute changes. Resident 1's Nutritional care plan, undated, Problem: Resident 1 is on a no added salt, no concentrated sweets diet. He likes most foods will eat most anything. He prefers to eat in his room.... No significant weight changes. Goal: Resident 1 will follow diet... weight will remain plus or minus 3% of usual body weight (UBW) with no significant weight changes. Interventions: 1. Honor food preferences... 2. Monitor weight per Medical Doctor (MD) order... 3. Monitor and document intakes of meals. 4. Provide...diet as ordered. Encourage diet compliance. 5. Set up Resident 1's room tray and provide assist as needed. (It is important to note Resident 1 care plan was not updated of changed to direct the care of Resident 1's weight loss on 3/6/14 or his inability to feed himself.) A Review of Resident 1's weight summary revealed: *12/5/13, weight 234.2 *1/5/14, weight 230 lbs *2/6/14, weight 230.8 lbs *3/5/14, weight 197.4 Pounds (lbs) Resident 1 lost 33.4 lbs or 14.5% of his weight in 30 days from 2/6/14 to 3/5/14. Despite a dramatic change in Resident 1's condition, poor appetite, change in mental status, 33.4 lbs weight loss, a dehydration care plan was not initiated. Resident 1's Quarterly Minimum Data Set (MDS), completion date of 2/27/14, Resident's cognitive score is 7; indicating Resident 1 is severely cognitively impaired. Resident needs supervision with 1 person assist with meals. Resident 1's weight is 231 lbs and receives a therapeutic diet. Resident 1's Physician order, dated 2/8/14, [MEDICATION NAME] 500 mg tablet times 10 days for Pneumonia. Resident 1's chest X-ray, dated 2/8/14, Right lower lobe pneumonia with effusion. Resident 1's Physician order, dated 2/12/14, increase [MEDICATION NAME] to 75 milligrams (mg) BID (twice a day), increase insulin to 20 units BID. Resident 1's Physician order, dated 2/25/14, [MEDICATION NAME] 1 gram (gm) intramuscular daily times 5 days, for ongoing fever of unknown cause... Resident 1's Quarterly Nutrition assessment, dated 2/13/14, completed during the MDS process, Resident 1's current weight 230.8 lbs. Clinical observations: Usually eats well small decline times 2 days with acute illness. Resident stated appetite is good and has been eating well. Noticed decrease in intake times 2 days, resident currently on antibiotic... Intake likely to pick backup... weight has essentially been stable for past 6 months... Recommendations: None given... Resident 1's estimated fluid needs are 1700 to 1925. (It important Resident 1's fluids needs were decreased from the assessment on 11/27/14, during the time Resident 1 was having an acute illness. also Resident 1's AHCPOA was not involved in the recommendation or the assessment portion of Resident 1's nutritional status.) Resident 1 Hydration assessment, dated 2/18/14, done in correlation of the quarterly minimum data set (MDS). 1. Dry mucous membranes... 2. History of constipation... 3. Fever or Vomiting in last 7 days (It is important to note Resident 1 was diagnosed with [REDACTED].) 4. [DIAGNOSES REDACTED]. 5. Abnormal labs - BUN, Creatinine, hematocrit is marked "Yes." 6. Unable to reach fluids independently. (It important to note resident has a [DIAGNOSES REDACTED].) 7. Repeated refusal of fluids (It is important to note Resident 1 appetite intake was 0 to 25% during this assessment period.). 8. [MEDICAL CONDITION]. Questions 6 through 8 were all marked with "No." 9. Currently taking diuretic or laxative is marked "Yes." 10. Fluid restriction. 11. Difficulty swallowing... 12. Dementia which resident forgets to drink or how to drink. 13. Coma. Questions 10 through 13 were all answered "No." Resident 1's weekly summary, dated 3/1/14, Weight: 230.8 lbs on 2/6/14... Oral; Lips moist, Mucous membranes pink and moist, mouth clean. Nutrition: General diet. (It is important Resident 1's diet order read No added salt, No concentrated sweets.) Eating: fed by staff. Infection: Not applicable. (It is important to note Resident 1 was receiving day 4 of [MEDICATION NAME] IM during this assessment.). Antibiotic therapy; (blank). Additional Comments; (blank). Resident 1's weekly summary does not identify Resident 1's decrease in appetite or Resident 1's use of antibiotic therapy.) Resident 1's Nutritional assessment, dated 3/6/14, Weight loss: Weight 197.4. Assessment: Significant weight loss during the past 30 days due to decrease in oral intake. Resident normally eats well under his own control at meals and snacks freely on food provided by family, but has recently had a medical decline which is affecting his appetite. Resident now needs to be fed and has poor intake during meals. "Attempted to discuss current situation with resident but he provided no logical answers." Observed Resident 1 at lunch with a "poor intake"... Certified Nursing Assistant stated he is eating a little bit better now that his antibiotic is completed, but still remains poor. "Discussed supplemental options with resident but he did not positively respond to any options." " He (Resident 1) stated he was thirsty" so liquids option may be good choice until appetite improves. Goal: Improve PO (oral) intake, no further weight changes. Plan: Weekly weight times four and to receive 90 milliliters med pass (nutritional supplement drink) twice a day. (It is important to note Resident 1's POA is activated and the dietary assessment did not include Resident 1's AHCPOA for input to Resident 1's significant weight loss.) Resident 1's current Nutritional assessment does not calculate Resident 1 current fluid needs. (It is important to note Resident 1 did not receive the 90 ml Med Pass per the RD's recommendation on 3/6/14.) Resident 1's Medication Administration Record [REDACTED]. According to the MAR indicated [REDACTED]. A review of the MAR indicated [REDACTED]. Resident 1's Braden scale assessment, dated 3/7/14,.. Nutrition: Usual food intake pattern: Probably inadequate: Rarely eats a complete meal and generally eats only 1/2 of food offered... On 3/18/14 Surveyor received a copy of Resident 1's dietary intake records for the months of February and March 2014. A review of the dietary records for 2/11/14 through 3/10/14, revealed Resident 1' meal intake had significantly declined and Resident 1 was eating less than 50% of his meals. The following documentation for food intake was written on the March intake record. 3/1/14 - Breakfast 0 % to 25 % , Lunch 0% to 25% , Dinner 76% to 100%. 3/2/14 - Breakfast 0 % to 25 %, Lunch 26% to 51%, Dinner 26% to 50%, 3/3/14 - Breakfast 0% to 25%, Lunch 26% to 50%, Dinner 76% to 100% 3/4/14 - Breakfast Refused, Lunch 26% to 50%, Dinner 26% to 50%, 3/5/14 - Breakfast 26 % to 50 %, Lunch 26 to 50% Dinner 0% to 25% 3/6/14 - Breakfast 26 % to 50 % Lunch 0% to 25% Dinner 26 to 50% 3/7/14 - Breakfast 26 % to 50 %, Lunch 0% to 25% , Dinner 0% to 25% . 3/8/14 - Breakfast 26 % to 50 %, Lunch 0% to 25% Dinner 0% to 25% 3/9/14 -Breakfast 76 % to 100 % Lunch 0% to 25%, Dinner 0% to 25% 3/10/14 - Breakfast 0 % to 25 % of breakfast. Fluid intake documented, daily documentation of resident intake record for March 2014 reveals: Resident 1's fluid sheet did not have the daily total calculated upon review of the intake form. 3/1/14 Breakfast 100, Lunch 240, Dinner 480 = 820 ml 3/2/14 Breakfast 480, Lunch 360, Dinner 360 = 1,200 ml 3/3/14 Breakfast 480, Lunch 240, Dinner 180 = 900 ml 3/4/14 Breakfast 360, Lunch 360, Dinner 240 = 960 ml 3/5/14 Breakfast 360, Lunch 240, Dinner 440 = 1,040 ml 3/6/14 Breakfast 240, Lunch 240, Dinner 600 = 1,080 ml 3/7/14 Breakfast 540, Lunch 520, Dinner 300 = 1,360 ml 3/8/14 Breakfast 240, Lunch 240, Dinner 280 = 760 ml 3/9/14 Breakfast 360, Lunch 240, Dinner 280 = 880 ml 3/10/14 no record received for 3/10/14. According to Resident 1's Nutritional assessment dated [DATE], Resident 1's fluids needs had been assessed at 1700 to 1925 ml according to his adjusted body weight. Resident 1 ' s fluid intake was 25-60% less than his assessed need during the first nine days in March 2014. A review of Resident 1's nursing notes regarding appetite and fluid intake from 2/8/14 (the day Resident 1 experienced on set of an infection) through 3/10/14 described Resident 1's ongoing fever (which increases the need for fluids) and decline in appetite and mental status. Excerpts from these notes include: *2/8/14, Temperature 101.2 degrees Fahrenheit. Called NP and stated to give Tylenol. Resident 1 started on [MEDICATION NAME] 500 mg times 10 days. AHCPOA was notified... *2/12/14, Day 5 of antibiotic use.,in part, Resident 1 exhibiting behaviors: Verbally abusive, Socially inappropriate, Screaming, Profanity... At 2:00 PM Resident 1 refused his nebulizer treatment and has scattered lower lobe crackles... *2/13/14, Day 6 of antibiotic, at 6:42 AM, in part, Temperature 99.2, urinates in large amounts and is incontinent... *2/15/14, Day 8 of antibiotic. at 12:07 AM temperature 101.3... Fever moist cough, chest congestion..NP called regarding elevated temperature. Resident refusal of Tylenol (resident has spit out medication times 3.) No new orders continue to encourage taking Tylenol... At 1:54 AM, Removing nasal cannula for oxygen, swearing at staff...at 8:52 PM, fluids encouraged... **2/17/14, Day 10 of antibiotic. At 3:35 AM, Temperature 100.6, did take Tylenol for fever. Resident has strong odor to urine which could mean concentrated. Temperature is 100.6 and is last day of antibiotic... AHCPOA notified and informed Nurse Resident 1 has noted to have some more confusion at times. NP to see Resident 1 for evaluated his mental condition and changes, does not talk as much anymore, falls asleep when doing something, and is not interested in his environment as he use to be... *2/18/14, day 10 of antibiotic. At 3:02 AM... Fluids encouraged. At 1:12 PM, Resident 1 often refuses nebulizer treatment... Loose moist lower lobe crackles. *2/22/14, at 7:38 AM, Temperature 100.2 At 2:48 PM, Temperature 100.2... *2/23/14,Temperature 99.8 during the night. *2/24/14, At 2:24 PM, Resident fed by staff and ate very poor, very aggressive during activities of daily living (ADLs) cares. *2/25/14, at 3:32 AM, Temperature 99.4 during the night...At 2:24 PM, Resident refused to get up for breakfast. Out of bed for lunch resident ate poorly. Staff assisted with meal ate 25%. *2/26/14, at 1:38 PM, NP seen on 2/25/14 with new orders to begin [MEDICATION NAME] IM times 5 days for ongoing fever... At 4:08 AM , Behaviors: Verbally abusive, Physically aggressive episode, Socially inappropriate, Screaming, Profanity, During care resident searing at CNAs, hitting them... At 1:11 PM, Seen by MD (see MD progress note). Assisted with both meals appetitive poor, accepted fluids with encouragement... *2/28/14, Day 3 of antibiotic charting, at 7:15 PM, Summary resident seems to react less to environment, had to be fed on PM shift. Has a poor appetite. He is less boisterous yelling at staff... *3/2/14, Day 5 of Antibiotic: At 7:53 AM, Summary: Last day of antibiotic.... Resident "has to be fed most of his meals, does not even chew tobacco as he used to. does not get up at noc (night) seems to have given up." At 1:38 PM, No S/S of infection, fluids encouraged. *3/7/14, At 1:38 PM, Continued to remove oxygen... "writter (sic) fed his breakfast as he had been refusing to eat." *3/8/14, at 10:20 AM, Note: continues to remove oxygen. *3/10/14, At 9:57 AM, Resident unable to swallow morning medications, fluids or food. seen by MD this morning. Referred to Hospice. "family wanted resident sent out, MD agreed."... At 2:39 PM. Called placed to hospital emergency room . resident admitted [DIAGNOSES REDACTED]. Resident 1's nurses notes indicates Resident 1 has a decrease in appetite, a decreased ability to fed himself and a change in mental status, which are all signs of dehydration. Resident 1's emergency room Physical findings, dated 3/10/14, Skin warm and dry... Mouth Dry mucous membranes... Medical decision making: Patient is severe [MEDICAL CONDITIONS]. Intravenous hydration. Resident 1's Blood Urea BUN 76 Creatinine 3.42 and serum sodium was 173, (which is an indicator of severe dehydration.) Resident 1's primary [DIAGNOSES REDACTED]. Resident 1's Hospital History and Physical, dated 3/10/14, Resident 1 presents dehydrated and inability to swallow. Res 1 does not verbalize and completely aphasic. Resident 1 has been declining over the past couple of weeks... Laboratory: Blood Urea Nit (BUN) 88, Creatinine 4.27. Sodium is elevated at 174. Liver panel is significant for mild elevated transaminases... Urinalysis is negative for a urinary tract infection. Chest X-ray showed no acute [MEDICAL CONDITION] disease... Assessment and Plan: Dehydration: 1. Resident 1 received 2 liters of fluid in the emergency department... 2. Resident 1 with acute [MEDICAL CONDITION] most likely pre-renal secondary to dehydration. ... On 2/18/14, Surveyor spoke with Director of Nursing (DON) B, regarding Resident 1's intake sheet. DON B stated the nurses look them over and if the nurses notice a decrease from day to day, they are to encourage the CNAs to push fluids. DON B stated the fluid intakes are not totaled daily. DON B stated the nurses do not know how much fluids are needed by a resident every day and does not check the fluid intake sheet to the estimated fluids to ensure the residents are getting the proper fluids to prevent dehydration. DON B continued to state she would expect the nurse to start intake and output for residents who have a decrease in fluids or appetite and do an assessment for dehydration to include skin turgor and a full nursing assessment. DON B she would expect the care plan to be updated with change in appetite and weight loss. DON B stated the facility does not have policy regarding Resident not meeting fluid needs and calculating total fluids daily. DON B stated there is a hydration assessment used every quarter to evaluate for risk of dehydration. DON B also stated resident at risk are not placed on intake and their fluids are not calculated to ensure they do not become dehydrated. DON B stated the estimated fluid needs are placed on the Nutrition assessment and the nursing staff does not have knowledge of how many fluids each resident would need. DON B stated the Dietary Manger receives the fluid sheet and food intakes daily to look at resident for decline. On 3/18/14, at 1:12 PM Surveyor spoke with Dietary Manager (DM) D regarding monitoring residents' food and fluid intake. DM D stated she does not receive or review resident daily fluid intake. DM D stated she does review the food intake 2 to 3 times per week to see if there were any declines in appetite. DM D stated she does not actually review how many mls of fluid are given she only reviews the meal percentages placed in the computer. DM D stated she utilizes the information when she does the MDS. DM D stated she looks to see if the resident eats less than 75 % of their meals and for how long. DM D stated fluids are offered on the diet card. The dietary staff follows the dietary cards and places the fluids on the trays according to the dietary card. DM D stated there is a standard in the kitchen for each meal what should be placed on each tray each meal. The dietary cards follow the standard. DM D stated the daily intake sheets are completed, but she has never received the sheet. On 3/18/14, at 1:30 PM Surveyor spoke with Activated Health Care Power of Attorney (AHCPOA) F regarding Resident 1's weight loss. AHCPOA F stated she had not been to visit Resident 1 in about 2 weeks because the hallway was under quarantine for an illness outbreak. AHCPOA F stated she did meet for a care conference at the end of February, and was not informed of any weight loss at that time. AHCPOA F stated the meeting was our every 3 month meeting. AHCPOA F stated she had not seen Resident 1 to see how sick he really was until 3/3/14. AHCPOA F stated she went to the facility on [DATE] and visited with Resident 1. She stated she asked the nurse at that time if Resident 1 had a stroke because he was not himself. Resident 1 was more tired and not able to feed himself and did not make any sense when he talked. The nurse informed AHCPOA F that Resident 1 was ill from the pneumonia and they were monitoring him. AHCPOA F stated she returned to the facility a few days later and was informed by the nurse on the floor that Resident 1 had lost 30 lbs. AHCPOA F stated she asked the nurse how did (Resident 1) lose 30 lbs in 2 weeks. AHCPOA F stated the nurse stated he was ill with the pneumonia and they were monitoring him. She again asked the nurse are you sure he did not have a stroke. AHCPOA F stated the nurse stated he is weak from being sick and we are monitoring him. AHCPOA F sated she was coming every morning or other family members would come to fee Resident 1 breakfast. She stated he would eat most of his breakfast but it took a long time with him to get him to eat. AHCPOA F stated they said he was not eating much, but when I fed him he ate a lot; doesn't believe they took time to assist him. Surveyor asked AHCPOA F if she seen Resident 1 being assisted with meals by the staff. AHCPOA F stated she did not. She would come into his room and his tray breakfast tray would be set up in front of him with the lid off most days, and no one was in the room. AHCPOA F stated we always tried to come in and feed him every day since 3/3/14. AHCPOA F stated on 3/10/14, she came to see Resident 1 and he was not eating and unable to swallow. She said she went to talk to the nurse and again asked if he had a stroke. The nurse informed her Resident 1's Physician was in the building and she would see if he could see Resident 1. AHCPOA F stated the Physician agreed to see Resident 1, but they had to put him in a wheel chair and take him down to an office to be seen. AHCPOA stated the Physician looked over Resident 1 and offered Hospice care for Resident 1. AHCPOA F stated she was never asked about Resident 1 having an IV or about Resident 1 receiving a tube feeding for nutrition. AHCPOA F stated she was not aware Resident 1 ever refused IV fluids or IV fluids were ever an option for Resident 1 while he was in the nursing home. AHCPOA F stated she wanted Resident 1 to be seen at the Hospital. Resident was transferred to the hospital. AHCPOA stated she would have wanted more done for Resident 1 prior to his admission to the hospital. AHCPOA stated she would have wanted an IV or tube feeding if it would have been recommended by the facility. AHCPOA F stated Resident 1 is having a tube feeding placed on 3/19/14. On 3/18/14, at 1:50 PM Surveyor spoke with Resident 1's Medical Doctor (MD) regarding Resident 1's decline in condition and weight loss of 30 lbs. MD G stated he was aware of Resident 1's poor appetite and 30 lbs weight loss on 3/10/14. MD G stated Resident 1 would not let anyone evaluate him. MD G stated he would expect the staff to try to encourage Resident 1 to eat and drink, but you cannot force someone to eat or drink. Surveyor asked MD G if he was aware of Resident 1's resuscitation status.MD G stated he did not know Resident 1's resuscitation status. Surveyor asked MD G if he was aware Resident 1 was a full code and wanted resuscitation and Resident 1's advanced directives also stated he wanted the use of a Tube feeding if he was unable to take in nutrition. MD G stated he would not have considered a Tube feeding to be given to Resident 1 and did not talk with the AHCPOA regarding a tube feeding for Resident 1. MD G stated Resident 1 had plenty of weight to loose, with all else he did for resident he did not address the weight loss. MD G stated he advised the family to Hospice and later the AHCPOA came back and wanted Resident 1 sent to the hospital. On 3/18/14, Surveyor , asked MD G what he would have expected the facility to monitor when Resident 1 was not eating or drinking, after a weight loss of 30 lbs. MD G stated he was not going to comment on that. No further information provided to Surveyor . On 3/28/14, at 1:36 PM, Surveyor spoke with Registered Dietician (RD) E regarding Resident 1's fluid needs and significant weight loss. RD E stated she calculated Resident 1's fluid needs by using Resident 1's adjusted weight. RD E stated her calculation are not completed using Resident 1's actual weight of 230.8 lbs to equal 2,622 estimated fluids needs using 25 ml/kg . RD E continued to explain she used Resident 1's adjusted weight of 168.5 lbs to calculate the fluid needs of 1925 ml per day by using the calculation of 25 ml/kg. RD E stated yes as of 2/13/14 Resident 1's fluids needs should have been 1925 according to her calculation. Surveyor asked RD E how does she expect the estimated fluid needs calculated are given to the resident? RD E stated they are given by the drinks placed on the resident's trays and water pass during the day. Surveyor clarified with RD E the fluids are provided in fluid form of the drinks given during each meal and then on the unit during water pass. RD E stated yes. The dietary department provides so many glasses of fluids on a tray, such as milk coffee and juices and that is the amount calculated for the estimated fluid needs. RD E then stated other fluids are given by the staff on the floor for example during water pass. On 3/18/14, at 1:36 PM Surveyor spoke with RD E regarding Resident 1's weight loss. RD F stated she was not informed prior to 3/6/14, when she identified the weight loss from 3/5/14, that Resident 1 had a decrease in appetite. RD E stated she spoke to the CNAs and they stated he was not eating, but they could get him to drink. RD E stated so she went with the Med pass as a supplement because the CNA stated he was still drinking. RD E stated she did not have conversation with the AHCPOA regarding Resident 1's weight loss. RD E stated she has never had a conversation with the AHCPOA to discuss what measures Resident 1 or the AHCPOA wanted when Resident 1 was losing weight or could no longer eat or drink. RD E stated she comes to the facility on ce a week to do nutrition evaluations, RD E stated no one called her or updated her that Resident 1's intake had decreased. RD E stated she was aware Resident 1 had pneumonia in the past due to the assessment completed in February. RD E stated she would expect the DM or RD to be notified when a resident has had a significant decline in appetite so changes could be made. The facility had not assessed and care planned for potential. The facility knew the resident had pneumonia and was declining in his intakes and did not initiate a more rigorous assessment/care plan to prevent further decline and did not discuss treatment options with the Activated Health Care Power of Attorney. Systemically, the facility's failure to assess, evaluate and attempt aggressive nutritional and fluid interventions for Resident 1 created an immediate jeopardy situation which began 3/6/14. The facility removed the immediate jeopardy on 3/18/14 by taking the following actions: *Discussed with Nurses who they felt would be at risk for Dehydration. *Assesses all residents who would be at risk for dehydration. *Any resident who scores at risk for dehydration input sheet in place. *Family and Physician notified. *Check daily fluid intake sheet and compare against dietary fluid recommendation by dietician. To add up fluid intake sheets daily. Water consumed in room. Any fluid in activities. Med pass given. * Call Family and Physician if fluid intake not met for any other suggestions. *Refer to dietician. *Care Plan put in place. *In-service nurses on above process immediately and before they start shift. *Quality assurance done by Director of Nursing or designee. *Develop guidelines on monitoring residents at risk for dehydration. Cross reference F 325 The deficient practice continues at a scope/severity level of D (potential for harm that is not immediate jeopardy/isolated) as evidenced by: Example 2 According to "Appendix 3. Sample Case Log (Line List) of Residents During outbreaks of Gastrointestinal Illness", the facility experienced an outbreak of gastrointestinal illness from 2/20/14 to 2/27/14. Resident 4 experienced the symptom of diarrhea on 2/20/14 and was well on 2/22/14. Resident 4's "Medical Diagnosis" dated 6/1/12 indicate [DIAGNOSES REDACTED]. The facility completed a "Hydration Assessment" dated 2/11/14. This assessment notes that Resident 4 is at risk for dehydration as evidenced by a score of nine points. Resident 4's "Care Plan Detail" (undated) states, "(Resident 4) has potential for dehydration related to history of UTI (urinary tract infection). (Resident 4) is alert and oriented times three with a history of confusion. She is able to express thirst, has no swallowing difficulties ...Interventions: Encourage fluids unless contraindicated. Labs per MD order as indicated. Monitor for decreased ability to drink and eat without assistant from staff. Monitor for signs and symptoms of dehydration (dizziness on sitting/standing, change in mental status, decreased urine output, concentrated urine, poor skin turgor, dry/cracked lips, sunken eyes, constipation, fever, infection, electrolyte imbalance ...Resident is noted to have diarrhea...Interventions: Encourage increased fluids unless contraindicated, monitor for signs and symptoms of dehydration, monitor vital signs..." The facility completed a "Nutritional Assessment" dated 2/3/14. This assessment notes that Resident 4's nutritional needs include 1474 to 1775 milliliters of fluid per 24 hours. This assessments states, "Observed resident at lunch today. Resident was encouraged and redirected throughout meal. (she was sleeping on a

Based on facility and hospital record review and interviews, the facility did not ensure that residents maintained acceptable parameters of nutritional status unless the resident's clinical condition demonstrated that this was not possible, for 3 (Residents 1, 4 and 5) of 6 residents reviewed for weight loss. Resident 1 experienced a significant weight loss of 33.4 pounds, occurring between a February weight of 230.8 pounds on 2/6/14 and a facility monthly weight in the first week of March (3/5/14) of 197 pounds. This is a 33.4 pounds (14.5%) weight loss. The Dietary Intake Record for reveals a dramatic decrease in food intake starting on 2/11/14. Despite this dramatic decrease in intake, the Dietary Manager and Registered Dietician (RD) were not notified of the decreased intake until 3/6/14, when the RD reviewed Resident 1 for a significant weight loss. There was no evidence that the facility considered changing Resident 1's diet or adding nutritional supplements when Resident 1 stopped eating or explored any other means of encouraging intake for Resident 1. The dietitian was unaware of the extent of Resident 1's decreased intake until she reviewed the Dietary Intake Record on 3/6/14. The RD ordered Med Pass 90 ml on 3/6/14. Resident 1 did not receive the nutritional supplement from 3/6/14 through 3/10/14, when Resident 1 was discharged to the hospital. Additional examples not at the actual harm level include: It was recommended that Resident 4 receive a Bene Protein supplement to aide in nutrition and wound healing. The facility did not follow up on the recommendation and Resident 4 did not receive the supplement. It was recommended that Resident 5 receive a Bene Protein supplement to aide in nutrition and wound healing. The facility did not follow up on the recommendation and Resident 5 did not receive the supplement. This is evidence by: Nutrition assessment policy dated 6/97 and revised 2/12, Policy: A Nutrition assessment will be completed for each resident admitted in to the building. Purpose: to reduce the risk of malnutrition. Procedure: 1. the Licensed Dietician is responsible for developing a nutritional assessment for each resident admitted to the facility. 2. The nutrition assessment must be developed within fourteen days of admission... 3. Comprehensive assessments must be completed prior to developing the resident in-depth assessment and care plan. 4. Nutrition care must be reviewed quarterly and revised as necessary. 5. Care plans are developed to identify nutrition problems/strengths, goals, and approaches. Meal monitoring policy dated 2/12, Policy: Resident oral intake will be monitored and recorded after meals. Purpose: To reduce the risk of altered nutritional status of the resident. Procedure: 1. Upon completion of the resident meal the Certified Nursing Assistant (CNAs) or Dietary Aide (DA)... will evaluate and document the resident intake... 2. Oral intake will be documented as good, fair, poor, refused. 3. The CNAs will advise the nurse of refuse or poor intake for 2-3 consecutive meals as recorded in the Food Intake Record... The nurse will advise the dietary manager when the resident has a pattern of poor or refuse. 4. The licensed Dietitian will screen the resident for altered nutrition status and proceed as needed. Example 1 Resident 1's [DIAGNOSES REDACTED]. Resident 1's Activation of Durable power of Attorney for Health Care, activation date of 6/19/12... Resident 1's Quarterly Nutrition Assessment, dated 11/27/13, notes that Resident 1's weight was 233.4 pounds (lb). Resident 1's usual weight was in the 220's, weight trend has some gain. Clinical observation: Resident 1 eating 75 to 100% most breakfast and lunch and 50 to 75% dinner. Meal assistance provided; None. Nutritional needs: Total energy in kilocalories (Kcal) 1925 to 2310 kcal per day, fluids in milliliters (ml) 1925 to 2310 based on 25 to 30 ml per kilograms (kg). Assessment: ... Resident 1's weight has slowly trended up over the past year which is most likely related to snacking between meals and sedentary lifestyle... Writer has no recommendations for further interventions at this time... Review of Resident 1's weight summary revealed: *12/5/13, weight 234.2 *1/5/14, weight 230 lbs *2/6/14, weight 230.8 lbs *3/5/14, weight 197.4 Pounds (lbs) Resident 1 lost 33.4 lbs (14.5%) in 30 days from 2/6/14 to 3/5/14. Resident 1's Quarterly Minimum Data Set (MDS), completion date of 2/27/14, Resident's cognitive score is 7, indicating Resident 1 is severely cognitively impaired. Resident Needs supervision with 1 person assist with meals... Resident 1's weight is 231 lbs and receives a therapeutic diet... Resident 1's care plan titled, Receiving Antibiotic therapy, undated, Goal: Resident will tolerate antibiotic therapy. Intervention: 1. Document sign and symptoms related to antibiotic use... 2. Encourage fluids unless contraindicated. 3. Monitor side effects. 4. Monitor for Signs and Symptoms of effectiveness.. 4. Monitor Vital signs...5 Notify Medical Doctor for any acute changes... Resident 1's Nutritional care plan, undated, Problem: Resident 1 is on a no added salt, no concentrated sweets diet. He likes most foods will eat most anything. He prefers to eat in his room.... No significant weight changes. Goal: Resident 1 will follow diet... weight will remain plus or minus 3% of usual body weight (UBW) with no significant weight changes. Interventions: 1. Honor food preferences... 2. Monitor weight per Medical Doctor (MD) order... 3. Monitor and document intakes of meals. 4. Provide...diet as ordered. Encourage diet compliance. 5. Set up Resident 1's room tray and provide assist as needed. (It is important to note Resident 1's care plan was not updated or changed to direct the care for Resident 1's weight loss on 3/6/14 or his inability to feed himself.) On 2/18/14 Surveyor received a copy of Resident 1's dietary intake records for the months of February and March 2014. A review of the dietary records for 2/11/14 through 3/10/14 revealed Resident 1's meal intake had significantly declined and Resident 1 was eating less than 50% of his meals. The following documentation for food intake was written on the February intake record from 2/8/14 through 2/28/14. (Resident 1 was diagnosed with [REDACTED]. 2/8/14 -Breakfast 76 % to 100 % , Lunch 26% to 50%, Dinner 26% to 50%, 2/9/14 - Breakfast 76 % to 100 % Lunch 76 % to 100 %, Dinner 76 % to 100 % . 2/10/14 - Breakfast 76 % to 100 % Lunch 51% to 75% Dinner 76% to 100% . 2/11/14 -Breakfast ate 26 % to 50 % Lunch 51% to 100% Dinner 0% to 25%. 2/12/14 -Breakfast 26 % to 50 %, Lunch 0% to 25%, Dinner 76% to 100% 2/13/14 - Breakfast refused, Lunch 51% to 76% and Dinner 76% to 100% 2/14/14 -Breakfast 76 % to 100 %, Lunch 51% to 75%, Dinner 0% to 25% 2/15/14 - Breakfast 0 % to 25 % Lunch, 25% to 50%, Dinner 0% to 25%. 2/16/14 - Breakfast 25% to 50 % of breakfast, Refused lunch and Dinner 0% to 25%. 2/17/14 - Breakfast 0% to 25%, Lunch 0% to 25 %, Dinner 26% to 50%. 2/18/14 - Breakfast refused of breakfast, Lunch 75% to 100%, Dinner 75% to 100% . 2/19/14 - Breakfast 0 % to 25 %, Lunch 26% to 50%, Dinner 0% to 25%. 2/20/14 - Breakfast 26 % to 50 %, Lunch 0% to 25%, Dinner (blank) 2/21/14 - Breakfast 0 % to 25 %, lunch 0 % to 25 %, Dinner 0 % to 25 % . 2/22/14 - Breakfast 0 % to 25 %, Lunch 0 % to 25 %, and Dinner (blank) 2/23/14 - Breakfast 0% to 25 %, Lunch 0% to 25 %, and Dinner 51% to 75%. 2/24/14 - Breakfast 0 % to 25 %, Lunch 0 % to 25 %, Dinner 26% to 50%. 2/25/14 - Breakfast refused, Lunch 51% to 75%, Dinner 26 to 50% 2/26/14 - Breakfast 0% to 25% Lunch 0% to 25%, Dinner 0% to 25% . 2/27/14 - Breakfast 26 % to 50 %, Lunch 26 % to 50 %, Dinner 0% to 25%. 2/28/14 - Breakfast 0% to 25%, Lunch 0% to 25%, Dinner 26% to 50% The following documentation for food intake was written on the March intake record. 3/1/14 - Breakfast 0 % to 25 %, Lunch 0% to 25%, Dinner 76% to 100%. 3/2/14 - Breakfast 0 % to 25 %, Lunch 26% to 51%, Dinner. 26% to 50%, 3/3/14 - Breakfast 0% to 25%, Lunch 26% to 50% ,Dinner 76% to 100% 3/4/14 - Breakfast Refused, Lunch 26% to 50%, Dinner 26% to 50%, 3/5/14 - Breakfast 26 % to 50 %, Lunch 26 to 50%, Dinner 0% to 25% 3/6/14 - Breakfast 26 % to 50 % Lunch 0% to 25%, Dinner 26 to 50% 3/7/14 - Breakfast 26 % to 50 %, Lunch 0% to 25%, Dinner 0% to 25% . 3/8/14 - Breakfast 26 % to 50 % , Lunch 0% to 25%, Dinner 0% to 25% 3/9/14 -Breakfast 76 % to 100 %, Lunch 0% to 25%, Dinner 0% to 25% 3/10/14 - Breakfast 0 % to 25 % of breakfast. Resident 1 was admitted to the hospital on [DATE]. Resident 1's appetite began to decline on 2/11/14. There is no evidence the Registered Dietician was notified of Resident 1's decline prior to 3/6/14, when a weight loss of 14.5% was identified. A review of Resident 1's nursing notes regarding appetite and fluid intake from 2/8/14 (The day Resident 1 experienced onset of an infection) through 3/10/14 described Resident 1's ongoing fever and decline in appetite and mental status. Nursing notes beginning 2/24/14 note that Resident 1 now needs to be fed by staff, but still ate poorly: *2/24/14, At 2:24 PM, Resident fed by staff and ate very poor, very aggressive during activities of daily living (ADLs) cares. *2/25/14, at 3:32 AM, Temperature 99.4 during the night...At 2:24 PM, Resident refused to get up for breakfast. Out of bed for lunch resident ate poorly. Staff assisted with meal ate 25%. *2/26/14, at 1:11 PM, Seen by MD (see MD progress note). Assisted with both meals appetitive poor, accepted fluids with encouragement... *2/27/14, Day 2 of Antibiotic: At 12:12 PM,... With a lot of encouragement resident will get up with staff and participate in cares and eating meals... Resident was fed this morning and did well... *2/28/14, Day 3 of antibiotic charting, at 7:15 PM, Summary resident seems to react less to environment, had to be fed on PM shift. Has a poor appetite. He is less boisterous yelling at staff... *3/2/14, Day 5 of Antibiotic: At 7:53 AM, Summary: Last day of antibiotic.... Resident "has to be fed most of his meals, does not even chew tobacco as he used to. does not get up at noc (night) seems to have given up." At 1:38 PM, No S/S of infection, fluids encouraged. *3/7/14, At 1:38 PM, Continued to remove oxygen... "writter (sic) fed his breakfast as he had been refusing to eat." *3/10/14, At 9:57 AM, Resident unable to swallow morning medications, fluids or food. seen by MD this morning. Referred to Hospice. "family wanted resident sent out, MD agreed."... At 2:39 PM. Called placed to hospital emergency room . Resident admitted [DIAGNOSES REDACTED]. physician progress notes [REDACTED]. History and Physical. Resident 1 was recently treated for [REDACTED]. He no longer has symptoms of pneumonia... His Activated Power Attorney for Health Care. (AHCPOA) thinks that he is more confused at times lately. Staff has not noticed that he is confused... Primary physician (Physician Name) recently increased his beta blocker and insulin due to worsening of his blood pressure and elevated bloods sugars... Continues low grade fever. "Apetite (sic) good" (It is important to note Resident 1's appetite has shown a decline since 2/11/14.)... Vitals... Weight 230.8 pounds (lb)... physician progress notes [REDACTED]. History and Physical: Resident 1 seen last week for fever... Resident 1 refused labs to be drawn... He is lethargic today and states that he will not have his blood drawn... Resident 1 does not have a cough or evidence of a urinary tract infection except he continues to have intermittent low grade fever. He requires nursing to feed him today and is usually independent. He states he will not go to the hospital... He is not taking his meds well today. Contacted AHCPOA regarding treatment. "Request treat here for today and address whether to (be) sent to ER (emergency room ) tomorrow if continued decline." Resident 1 continues low grade fever. Appetite poor today, needs fed. (It is important to note Resident 1's appetite has declined since 2/8/14. Resident 1's progress note does not indicate appetite decline over the past several weeks was discussed with Physician or the AHCPOA.) Vitals: weight 230.8 lb. General: Awake but lethargic. Lethargic. Assessment /Plan: Altered mental status: New, Fever ongoing...weakness not able to eat or transfer. [MEDICATION NAME] 1 gram intramuscular daily times five days, fever unknown cause. Refuses workups. Refuses to have Intravenous started. No ER at this time per AHCPOA and Resident 1 refuses. Progress note signed by the Nurse Practitioner (NP). physician progress notes [REDACTED]. History and Physical: ... Staff wanted MD to see Resident 1 today as they don't know what to do for him. He is not eating, not cooperating with cares... Resident 1 refuses to go to the hospital. NP started him on [MEDICATION NAME] but we don't have a focus on infection. There is no obvious source... Resident 1 only says he doesn't feel well. He is less ornery today than most days, per staff... "He would not talk to me today. History is obtained from the staff only." "His daughter is POA (AHCPOA). (NP name) did talk to her yesterday and she wants us to keep him here for now." (It is important to note NP note from 2/25/14 indicated AHCPOA wanted Resident 1 treated at facility on 2/25/14 and to discuss ER if Resident 1 condition declined.) Resident has no fever /chills. "Apetite (sic) good". Vitals: weight 230.8 lbs. Physical: Overall: awake, alert... Not interacting with MD, not answering questions except he'll say "what" when MD ask him something, but then does not answer...Plan: ... Director of Nursing (DON) organize family conference. Continue on antibiotic for now. Laboratory test if he ever consents. Will RX (prescribe) [MEDICATION NAME] to see if this will improve his cooperation. Consider Hospice if he continues to decline. (It is important to note Resident 1 has requested to be a full code upon admission to the nursing home and full code status remains current.) Resident 1 is stable but has multiple morbidities and condition could change quickly... Resident 1's Activated Power of Attorney was not contacted by the physician to discuss Resident 1' plan of care. Minimum Data Set (MDS) progress note, dated 2/27/14, Interdisciplinary team (IDT) met and discuss plan of care with family. Resident 1 declined invitation to attend. Family discussed current health status and changes they have noted such as sleepy during conversations. Nursing noted current Medical Doctor (MD) orders and recent treatment. Dietary noted weight and appetite. Resident 1's weekly summary, dated 3/1/14, ... Weight: 230.8 lbs on 2/6/14... Oral; Lips moist, Mucous membranes pink and moist, mouth clean... Nutrition: General diet. (It is important Resident 1's diet order read No added salt, No concentrated sweets.) Eating: fed by staff. Infection: Not applicable. (It is important to note Resident 1 was receiving day 4 of [MEDICATION NAME] IM during this assessment.). Antibiotic therapy; (blank)...Additional Comments; (blank). (Resident 1's weekly summary does not identify Resident 1's decrease in appetite or Resident 1's use of antibiotic therapy.) Resident 1's Nutritional assessment dated [DATE], Weight (Wt) Loss; Wt: 197.4 pounds (#) in March 2013. 230.8 # in February 2013. 234.2 # in December 2013. 231# in September. 225 # in April 2013. Diet: No Concentrated sweets/ No added salt. Medications [MEDICATION NAME], Aspirin, [MEDICATION NAME] and [MEDICATION NAME]. Assessment: Significant weight loss during the past 30 days due to decrease in oral (po) intake. Resident normally eats well under his own control at meals and snacks freely on food provided by family but has recently had a medical decline which is affecting his appetite. Resident now needs to be fed and has poor oral intake during meals. Attempted to discuss current situation with Resident 1 but he provides not logical answer. (It is important to note Resident 1 is cognitively impaired and has an activated Power of Attorney for Health Care.) Observe him at lunch with poor intake, offered resident another bite of chicken, but he pushed away. Certified Nursing Assistant (CNA) stated he is eating a little bit better now that his antibiotic (ABT) is completed but still remains poor. Discussed supplemental options with resident but the resident did not positively respond to any options. he did state he was thirsty so liquids options may be good choice until appetite improves. Goal: Improve PO intake, no further weight changes. Plan: weekly weights times 4 weeks. 90 Milliliters med pass (nutritional supplement) twice a day. (It is important to note Resident 1 did not receive the nutritional supplement from 3/6/14 the day of the recommendation through 3/10/14 the day Resident 1 was admitted to the hospital.) Resident 1's Braden scale assessment, dated 3/7/14, Nutrition: Usual food intake pattern: Probably inadequate: Rarely eats a complete meal and generally eats only 1/2 of food offered... physician progress notes [REDACTED]. History and Physical: Resident 1's AHCPOA wanted MD to see him this morning as he is not eating or drinking much anymore. In fact he is spitting out food and pills. AHCPOA wondered if Resident 1 had a stroke. Staff says he is still not eating... Resident 1 only says again he does not feel well. His Blood pressure is high... Today he feels more short of breath than usual... No recent fevers or chills. "Apetite (sic) not good" Vitals: Weight 197.4 lbs. Physical exam; Resident 1 is sitting in his wheel chair, occasionally interacts with MD... Blood pressure (BP) high, high normal improved... Long discussion with AHCPOA if resident 1 did have Stroke ([MEDICAL CONDITION]) he is already on aspirin and has decent BP control at this time. Will refer to hospice...Otherwise no change to medication or plan.... There was no evidence Resident 1 had been physically assessed for weight loss or condition which could result from an extreme weight loss, such as dehydration.. Resident 1's emergency room Physical findings, dated 3/10/14, Skin warm and dry... Mouth Dry mucous membranes... Medical decision making: Patient is severe hyprenatremia, [MEDICAL CONDITION]. Intravenous hydration. Resident 1's Blood Urea BUN 76 Creatinine 3.42 and serum sodium was 173, (which is an indicator of severe dehydration.) Resident 1's primary [DIAGNOSES REDACTED]. Resident 1's Hospital History and Physical, dated 3/10/14, Resident 1 presents dehydrated and inability to swallow. Res 1 does not verbalize and completely aphasic. Resident 1 has been declining over the past couple of weeks... Laboratory: Blood Urea Nit (BUN) 88, Creatinine 4.27. Sodium is elevated at 174. Liver panel is significant for mild elevated transaminases... Urinalysis is negative for a urinary tract infection. Chest X-ray showed no acute [MEDICAL CONDITION] disease... Vital sign: Blood Pressure 97/45... Assessment and Plan: Dehydration: 1. Resident 1 received 2 liters of fluid (Intravenous IV fluids) in the emergency department. Resident 1 will continue on [MEDICATION NAME] 5% IV solution... 2. Resident 1 with acute [MEDICAL CONDITION] most likely pre-renal secondary to dehydration. ... [MEDICATION NAME] consult, dated 3/17/14, Chief complaint: Percutaneous Endoscopic Gastrostomy (PEG) placement. History and Physical: ... While hospitalized , speech pathology swallow study was performed showing neuromuscular Dysphagia. Despite dietary changes in his food to allow safer swallowing his oral intake has been poor and not sufficient to maintain adequate nutrition. As such, PEG tube was requested... On 3/18/14, at 1:12 PM Surveyor spoke with Dietary Manager (DM) D regarding monitoring resident's food and fluid intake. DM D stated she does not receive or review resident daily fluid intake. DM D stated she does review the food intake 2 to 3 times per week to see if there were any declines in appetite. DM D stated she does not actually review how many mls of fluid are given she only reviews the meal percentages placed in the computer. DM D stated she utilizes the information when she does the MDS. DM D stated she looks to see if the resident eats less than 75 % of their meals and for how long. On 3/18/14, at 1:30 PM Surveyor spoke with Activated Health Care Power of Attorney (AHCPOA) F regarding Resident 1's weight loss. AHCPOA F stated she had not been to visit Resident 1 in about 2 weeks because the hallway was under quarantine for an illness outbreak. AHCPOA F stated she did meet for a care conference at the end of February, and was not informed of any weight loss at that time. AHCPOA F stated the meeting was our every 3 month meeting. Resident 1's nutrition and health status other than he was ill from the pneumonia. AHCPOA F stated she had not seen Resident 1 to see how sick he really was until 3/3/14. AHCPOA F stated she went to the facility on [DATE] and visited with Resident 1. She stated she asked the nurse at that time if Resident 1 had a stroke because he was not himself. Resident 1 was more tired and not able to feed himself and did not make any sense when he talked. The nurse informed AHCPOA F that Resident 1 was ill from the pneumonia and they were monitoring him. AHCPOA F stated she returned to the facility a few days later and was informed by the nurse on the floor that Resident 1 had lost 30 lbs. AHCPOA F stated she asked the nurse how Resident 1 lost 30 lbs in 2 weeks. AHCPOA F stated the nurse stated he was ill with the pneumonia and they were monitoring him. She again asked the nurse are you sure he did not have a stroke. AHCPOA F stated the nurse stated he is weak from being sick and we are monitoring him. AHCPOA F sated she was coming every morning or other family members would come to fee Resident 1 breakfast. She stated he would eat most of his breakfast but it took a long time with him to get him to eat. AHCPOA F stated they said he was not eating much, but when I fed him he ate a lot; don't believe they took time to assist him. Surveyor also asked AHCPOA F if she seen Resident 1 being assisted with meals by the staff. AHCPOA F stated she did not. She would come into his room and his tray breakfast tray would be set up in front of him with the lid off most days, and no one was in the room. AHCPOA F stated we always tried to come in and feed him every day since 3/3/14 . AHCPOA F continued to state on 3/10/14, she came to see Resident 1 and he was not eating and was unable to swallow. She said she went to talk to the nurse and again asked if he had a stroke. The nurse informed her Resident 1's Physician was in the building and she would see if he could see Resident 1. AHCPOA F stated the Physician agreed to see Resident 1, but they had to put him in a wheel chair and take him down to an office to be seen. AHCPOA stated the Physician looked over Resident 1 and offered Hospice care for Resident 1. AHCPOA F stated she was never asked about Resident 1 having an IV or about Resident 1 receiving a tube feeding for nutrition. AHCPOA F stated she was not aware Resident 1 ever refused IV fluids or IV fluids were ever an option for Resident 1 while he was in the nursing home. AHCPOA F stated she wanted Resident 1 to be seen at the Hospital. Resident was transferred to the hospital. AHCPOA F stated she was never offered the option of IV's or tube feeding for Resident while at the facility. AHCPOA stated Resident 1 was having a tube feeding placed on 3/19/14. On 3/18/14, at 1:50 PM Surveyor spoke with Resident 1's Medical Doctor (MD) regarding Resident 1's decline in condition and weight loss of 30 lbs. MD G stated he was aware of Resident 1's poor appetite and 30 lbs weight loss on 3/10/14. MD G stated Resident 1 would not let anyone evaluate him. MD G stated he would expect the staff to try to encourage Resident 1 to eat and drink, but you cannot force someone to eat or drink. Surveyor asked MD G if he was aware of Resident 1's resuscitation status. MD G stated he did not know Resident 1 resuscitation status. Surveyor asked MD G if he was aware Resident 1 was a full code and wanted resuscitation and Resident 1's advanced directives also stated he wanted the use of a Tube feeding if he was unable to take in nutrition. MD G stated he would not have considered a Tube feeding to be given to Resident 1 and did not talk with the AHCPOA regarding a tube feeding for Resident 1. MD G stated Resident 1 had plenty of weigh to loose and with all else he did for resident he did not address the weight loss. MD G stated he advised the family to Hospice and later the AHCPOA came back and wanted Resident 1 sent to the hospital . On 3/18/14, Surveyor 2094, asked MD G what he would have expected the staff to monitor when Resident 1 was not eating or drinking, after a weight loss of 30 lbs. MD G stated he was not going to comment on that. No further information provided to Surveyor . On 3/28/14, at 1:36 PM, Surveyor spoke with Registered Dietician (RD) E regarding Resident 1's fluid needs and significant weight loss. On 3/18/14, at 1:36 PM Surveyor spoke with RD E regarding Resident 1's weight loss. RD F stated she was not informed prior to 3/6/14, when she identified the weight loss from 3/5/14, that Resident 1 had a decrease in appetite. RD E stated she spoke to the CNAs and they stated he was not eating, but they could get him to drink. RD E stated the facility did not believe the facility calculates the total fluid intakes so she went with the Med pass as a supplement because the CNA stated he was still drinking. RD E stated she did not have conversation with the AHCPOA regarding Resident 1's weight loss. RD E stated she has never had a conversation with the AHCPOA to discuss what measures Resident 1 or the AHCPOA wanted when Resident 1 was losing weight or could no longer eat or drink. RD E stated she comes to the facility on ce a week to do nutrition evaluations, RD E stated no one called her or updated her that Resident 1's intake had decreased. RD E stated she was aware Resident 1 had pneumonia in the past due to the assessment completed in February. RD E stated she would expect the DM or RD to be notified when a resident has had s significant decline in appetite. The facility had not assessed and care planned for potential dehydration that the dehydration was avoidable. The facility knew the resident had pneumonia and was declining in his intakes and did not initiate a more rigorous assessment/care plan to prevent further decline and did not discuss treatment options with the Activated Health Care Power of Attorney. Cross reference F 327 Example 2 Resident 4's "Medical Diagnosis" dated 6/1/12 indicate [DIAGNOSES REDACTED]. The facility completed a "Nutritional Assessment" dated 2/3/14. This assessment notes that Resident 4's most recent weight was 195.6 pounds on 1/5/14. This assessments states, "Observed resident at lunch today. Resident was encouraged and redirected throughout meal. (She was sleeping on and off through meal). Resident will usually strike out at staff if they attempt to help with meals. Resident had fed herself a few bites. CNA (Certified Nursing Assistant) stated (Resident 4's) intake has decreased but she has been stable X 30 days. Wt (weight) continues to slowly trend downward ..." Resident 4's current "Care Plan Detail" (undated) states, "Resident is involved in restorative eating program secondary to requiring assistance to eat meals, difficulty focusing on task ...Interventions: Offer resident opportunity to transfer from wheelchair to dining room chair per resident preference, position resident at the dining room table ...prompt and cue resident to remain seated throughout the meal. Prompt and encourage resident to maintain intake. Routine tray set up per facility guidelines ...(Resident 4) is on a NCS(no concentrated sweets)/NAS (no added salt) diet. Currently receives a pureed diet d/t behavioral condition. (Resident 4) does not talk much and eats at assist table in DR (dining room). She is a good eater at mealtimes leaving just a little of the food on her plate. (Resident 4) self feeds and is encouraged to do so. Gradual weight lost desired r/t high BMI ...Interventions: Honor food preferences. Offer alternative food choices if needed. Monitor weight as ordered by MD. Provide NCS/NAS, mechanically altered diet as ordered. Set up resident's tray and provide assist or cueing for meals as needed." Resident 4's weights are recorded as follows in "Weight Summary": 1/5/14: 195.6 pounds 2/7/14: 176.0 pounds 2/10/14: 178.2 pounds 2/19/14: 177.2 pounds 3/5/14: 176.3 pounds Resident 4's "Progress Notes" state the following: "2/17/14: Needing to be fed at supper this evening, making no attempt to pick up fork or spoon to feed self. Drank milk independently when handed the class (SIC). Needed numerous reminders to swallow what was in her mouth as tended to pocket food. Needing assistance numerous times with repositioning win wheelchair due to leaning and sliding forward in seat." "2/27/14 Nutritional Assessment: new pr/u (pressure ulcer); Diet: NCS/NAS. Pureed 2% milk, Meds Pass 90 mL (milliliters) TID (three times per day). A. (assessment): Resident has a new stage 2 pr/u to left buttock. This wound is within excoriation to same area. Resident has poor po (by mouth) intake for most meals. Resident needs to be fed but does not let staff help her; she only eats well for certain people. Nurse stated she is taking Med Pass well. Suggest supplementing Med Pass with Bene Protien to assist with healing. Wt (weight) has been stable X (for) 3 weeks. Goal: Improve skin integrity. Plan: 1 scoop bene protein ? mix with med pass." There is no evidence that the recommendation was communicated with Resident 4's physician. An order was not received and Resident 4 did not receive the supplement. Progress Notes state: "3/6/14: Nutritional Assessment: Monthly weight change and pr/u ...A: Sig (significant) wt loss X 90 days d/t (due to) poor po intake. Wt has been stable X 30 days. Resident needs more and more assistance at meals; however, she does not let all staff members feed her. She will refuse to allow certain staff help her and will refuse meals ...Resident may benefit from supplement during meals. Diet is currently supplemented with Med Pass (540 Kcals (kilocalories)/day) which nursing reports she takes well. Resident is in need of additional calories and PRO (protein) at this time d/t stage II to buttock and excoriation to same area. Wound is slowly healing. Plan: Health shake Q (each) meal. Goal: No sig wt loss X 30 days." The facility did provide Resident 4 with the Health Shake at mealtime. Surveyor spoke with Resident Care Coordinator (RCC) C on 3/18/14 at 2:15 PM. RCC C stated that the dietary department will give their recommendations to nursing and nursing faxes this to the physician. RCC C stated that then the facility will wait to hear back from the physician. Surveyor requested follow-up regarding Resident 4's recommendation for the Bene Protein supplement. RCC C stated that she did not see this on the MAR (medication administration record) and that she would keep looking for the follow-up. RCC C later stated that no follow-up was located for (Resident 4's) Bene Protein supplement. Example 3: Resident 5 has [DIAGNOSES REDACTED]. The facility obtained the following weights for Resident 5 according to "Weight Summary": 1/5/14: 148.0 pounds 1/15/14: 148.4 pounds 1/29/14: 147.2 pounds 2/10/13: 143.0 pounds 2/19/14: 139.0 pounds 3/5/14: 131.0 pounds The facility

Based on observation, interview and record review the facility did not ensure that a resident who enters the facility without a pressure ulcer does not develop a pressure ulcer unless the individual's clinical condition demonstrates that they were unavoidable and a resident having a pressure ulcer receives necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing for 1 of 7 residents (Resident 5). Resident 5 is known to have a history of difficulty with wound healing. Resident 5 was noted to have an open area on her buttock and the facility did not properly identify the pressure ulcer, complete weekly assessments according to current standards of practice including staging and characteristics of both the wound and the peri-wound, involve the dietician timely, update the care plan or consult timely with the physician. The wound ultimately deteriorated to an infected stage 4. The immediate jeopardy began on 9/18/13 when the length and width of the pressure ulcer had each septupled in size from the week before despite the use of a Foley catheter to reduce moisture. The Director of Nursing was notified of the immediate jeopardy on 11/7/13 at 5:00 PM. The immediate jeopardy was removed on 11/7/13 and continues at a severity/scope level of D (potential for harm that is not immediate jeopardy/isolated) as the facility needs to fully implement its removal plan. This is evidenced by the following: The "Skin and Wound Management Course Seminar Work Book," by the Wound Care Education Institute, copyright 2011, indicates: 4. Types of skin breakdown related to moisture-not to be confused as a pressure ulcer a. Incontinence associated [MEDICAL CONDITION] (IAD) 1) other names: Perineal [MEDICAL CONDITION] and diaper rash when noted in children...3) d) "A full-thickness wound (tissue destruction into the subcutaneous tissue or deeper), with or without necrosis (slough or eschar), reflects ischemic tissue damage and would be classified as a pressure ulcer not as perineal [MEDICAL CONDITION]." The facility's policy "Prevention and treatment of [REDACTED]. -It is the policy to properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity and pressure ulcers; to implement preventative measures and to provide appropriate treatment modalities for ulcers according to industry standards of care. a. Identify Clinical Conditions which indicate Risk for Pressure Ulcer and Skin Breakdown i. Identification of potential risk factors using Braden Scale, contributing [DIAGNOSES REDACTED]. ii. Identify clinical conditions that are risk factors, implement prevention protocols and develop care plan. Potential risk conditions include: Decreased mobility, [MEDICAL CONDITION]/hydration deficits, moisture/incontinence, fractures... 2. Prevention of Skin Breakdown a. Daily Skin Hygiene and Inspection iii. Keep local areas of skin clean, dry and free of body wastes, perspiration and wound drainage. vi. Complete Shower Day Worksheet and document findings per facility policy. b. Activity, Mobility and Positioning ii. Establish an individualized turning and repositioning schedule if the resident is immobile. While in bed not to exceed 2 hours and while in a sitting position not to exceed 1 hour. iii. Frequency of position changes is titrated for the individual resident. ix. Elevate heels off bed. c. Skin Protection v. Assess and treat incontinence. Apply protective ointments/products to the skin to counteract effects of excessive moisture on the skin. vi. Select incontinent products that are absorbent to wick incontinence moisture away from the skin verses trapping the moisture against the skin, which causes maceration. d. Nutrition i. Observe for clinical signs of [MEDICAL CONDITION], significant unintentional weight loss and hydration deficits. If inadequate, assess labs and obtain dietary consult. ii. Notify dietician of residents who have pressure ulcers. iii. Obtain order for nutritional supplements and use of protein supplements as indicated. v. Tight glucose control for diabetic residents. l. Pressure Ulcer Treatment i. Initiate Wound Care Protocols ii. Implement Care Plan with appropriate interventions. Procedure for Pressure, diabetic, venous and arterial wounds, initiation of Weekly Assessment of Skin Alteration Form (WASA) which will include: type of ulcer, location, date, stage (if applicable), length, width and depth, wound bed description, wound edge description and if present, exudates, undermining, tunneling and pain. iii...other skin alterations will be assessed and documented on the front of the Treatment Administration Record (TAR) weekly, under each treatment order. Resident 5's [DIAGNOSES REDACTED]. Resident 5 was admitted to the facility on [DATE]. Resident 5's Minimum Data Set (MDS) on admission, reference date 12/26/12, indicates Resident 5 required limited assistance with 1 person for bed mobility, transfers and ambulation. On 5/20/13, Resident 5 had a fall and sustained a right tibia/fibula fracture. Resident 5's MDS, reference date 8/27/13, indicates Resident 5 now requires extensive assistance with 2 or more people for physical assistance for bed mobility, transfers and walking in her room and extensive assistance with 1 person physical assistance for mobility on and off the unit. The MDS also indicates Resident 5 is at risk for developing a pressure ulcer and has a pressure reducing cushion in the chair and on her bed. Resident 5 developed a surgical wound and has been seen in the wound clinic three times a week due to the surgical wound on her leg not healing properly since that time. This should have put the facility on notice that Resident 5 was a poor wound healer and that aggressive interventions might be needed to prevent new skin problems from deteriorating. Resident 5's most recent nutritional assessment was completed on 8/22/13 and indicates the following: Resident 5 with trending weight loss likely from diuretic and variable/poor intakes at meals. Resident 5 is now seated at an assisted table for meals. She will however, resist assistance and then feed herself at times. Observed resident today with poor intake. Resident 5 may benefit from supplement to prevent rapid weight loss. Recommend Med Pass 60 ml three times a day. (Note Resident 5 did not receive Med Pass.) Resident 5's nursing notes: -8/25/13, written by Registered Nurse (RN) NN- CNA (Certified Nursing Assistant) reported finding small open area on resident's left lower buttock just above the gluteal fold 0.7 cm (centimeter) x 0.7 cm area with dark base noted surrounded by area 3 cm x 4 cm of peeling skin. Area covered with border gauze for protection. -8/26/13, New orders noted for treatment to buttock. Per Resident 5's TAR (Treatment Administration Record), the treatment ordered was barrier cream and cover with gauze daily. On 8/27/13 the order was changed to A&D ointment to left lower buttock daily until healed. Resident 5's care plan on 8/26/13 included the following interventions related to skin and incontinence: Position body with pillows/supportive devices, protect bony prominences, Turn and reposition every 2 hours and as needed, Encourage mobility and ambulation, Pressure reduction support surface in bed, Pressure reduction sitting/wheelchair surface, Lift do not slide resident, use assistive device to decrease friction, Inspect skin with cares daily, Weekly completion of shower worksheet, Weekly wound progress assessment by nurse, Teach resident to shift weight in the wheelchair side to side, offer toileting assist every 1-2 hours while awake, Voiding pattern quarterly, and Update resident voiding schedule as needed. Resident 5's care plan was updated on 8/27/13 to indicate an alteration in skin integrity related to Stage 2 to left lower buttock and surgical wound to right lower leg. Resident 5's care plan problems were again revised on 8/29/13 and changed from a stage 2 to excoriation to left lower buttock. No additional interventions were added. The facility was unable to locate the bi-weekly "Shower Day Worksheet" for this time frame. 9/3/13-Resident 5's "Shower Day Worksheet" has the buttock area circled and excoriated wound is written and the right leg surgical wound is noted. 9/8/13 nothing is marked including the surgical leg wound. 9/10/13 the buttock area is again circled with no writing. 9/9/13-Resident 5's Braden score was 15 indicating a mild risk for skin breakdown. Resident 5's nursing notes do not refer to the buttock area noted on 8/25/13 again until 9/11/13 which LPN (Licensed Practical Nurse) T states-unable to keep dressing to area on related to incontinence and moisture, increased maceration to left lower buttock, wound worsening call placed to physician and request to place a Foley catheter. RN O documents-Resident 5 has a 0.5 cm x 0.5 cm abrasion to under left buttock/upper leg crease peri abrasion had initially had 3 x 4 (no unit of measure noted) area of white tissue. Resident 5 is frequently incontinent of bowel and bladder causing her skin to be moist most of the time the area has become macerated and opening up. A request was made to place a Foley catheter related to the inability to keep dressing in place. Will request [MEDICATION NAME] adhesive to clean daily with wound cleanser. Note: There is no indication that other interventions i.e. more frequent repositioning or toileting were initiated. 9/11/13-fax order was received for a catheter for abrasion to left lower buttock worsening continuing to have moisture from incontinence and dribbling. 9/12/13-Resident 5's care plan was updated for the use of a catheter due to inability to keep dressing in place due to moisture. Resident 5's TAR indicated the order to cleanse the left lower buttock wound with normal saline and cover with [MEDICATION NAME] daily was received on 9/12/13 and the A&D ointment was last completed on 9/11/13. There is no indication of a treatment being completed on 9/12-9/13/13 or reason why it was not done. 9/18/13-nursing note by LPN T-Resident 5's left lower buttock area is 4.9 cm x 3.2 cm with drainage. Maceration decreased. (There is no description of the wound, peri-wound, type of drainage or if odor was present.) On 11/6/13, RN O documents a late entry for 9/18/13-"this writer agrees with below documentation of wound." 9/23/13-Resident 5 seen at wound clinic for leg wound. 9/25/13-nursing notes, by RN O-Resident 5 has excoriation to buttock/near peri area. She has fluctuating blood sugars and is incontinent of bowel and bladder. Her skin appears scaly and eroded. A Foley catheter was placed to help keep area clean and dry to promote healing of area. An order was received for [MEDICATION NAME] ointment to small open area cover with non adherent dressing change daily. Area 3 x 3.5 (no units given) will continue to monitor for progression of healing. 10/1/13-nursing note, low air loss mattress delivered and applied to Resident 5's bed. 10/1/13, Resident 5's care plan was updated to include: Resident 5 to be side to side in bed when not in meals or activities. This was not added to the Resident care sheets the CNAs refer to nor was the air mattress added to either care plan. No other interventions were added to the care plan. 10/2/13-nursing note by RN O-Resident 5's excoriated area has declined despite treatments and interventions. Area is becoming white in color and soft upon palpitation, she continues to be up for meals only and positioned off effected area. Her brief is left off to allow air and to help prevent fecal contamination as she in incontinent of bowel frequently. Physician and family have been updated on status of wound and current treatment. (Resident 5's care plan was not updated to indicate to leave brief off.) 10/2/13-Resident 5's TAR indicates treatment orders were changed to clean right (SIC) buttock wound with wound cleanser and apply silvadine cream sparingly to wound bed. Protect peri wound with skin prep cover with [MEDICATION NAME] and change daily. 10/11/13, nursing note by LPN T- on 10/9/13 measurement for left buttock is 3.9 cm x 3.9 cm. LPN T later documented the treatments were changed to twice daily. 10/11/13, TAR indicates the treatment was changed to change the dressing twice a day. 10/11/13, nursing note by LPN OO, Resident 5 seen by Physician LL, labs to be drawn. 10/11/13, physician visit. No notation related to the buttock wound. On 11/14/13, at 9:39 AM, Surveyor interviewed Physician LL. Physician LL stated on 10/11/13 he saw Resident 5 at the facility for a regular monthly visit. Physician LL stated the nurses did not report any concerns so he did not do a complete exam on Resident 5. Physician LL stated he did not see Resident 5's wound on her buttock on that day and has never seen the wound. Surveyor asked Physician LL to clarify the last line of his note from 10/11/13 and Physician LL stated is says P (plan) "orders reviewed." Physician LL also confirmed he ordered the wound culture based on a CBC (complete blood count) that showed elevated white blood count and he wondered if the wound was the cause. 10/15/13-nursing note by RN O, Resident 5 continues with daily dressing changes to her left buttock leg fold excoriated area. Due to the non healing of this wound a Foley catheter was inserted. Her wound continues to deteriorate despite the different treatments that have been made. She is a very brittle diabetic with sporadic blood glucose readings. Physician is aware of contributing factors. Resident 5 is turned side to side and is layed down in bed after meals. Resident 5 has a history of non healing surgical incision and was referred to the wound clinic. The wound clinic provided treatments three times a week dressing to be kept in place between treatments. This was effective in the healing process. (Regarding leg wound) A request has been placed to physician for a wound clinic assessment of area. 10/15/13-Per phone interview by Surveyor on 11/7/13 at 2:11 PM with Clinic RN Q: a call was placed to Resident 5's physician's office on 10/15/13 from RN O. RN Q stated the message was "decubitus ulcer left buttock, large and open not healing." RN Q stated RN O requested an order for [REDACTED]. 10/16/13-nursing note late entry by RN O, Resident 5's left buttock/leg fold wound 4 x 3 (no unit) with 100 percent slough now present. There is moderate amount of tan serous drainage. No odor noted at this time dressing continue to be changed daily. Will follow up with Physician LL for further recommendations on wound treatment and referrals. Resident 5 has a history of difficulty with wound healing. 10/16/13-Nutrition note-Resident 5 has a slow healing excoriation to buttock. Preventative measures are in place to help with further breakdown. Intake is variable per CNA intake is 25-50% at best. CNA states Resident 5 drinks well and will take yogurt when offered. Resident 5 is a brittle diabetic with history of slow healing skin conditions. Resident 5 may benefit from PRO (protein) supplement to help protect against further breakdown and aid in healing. Plan 1 scoop bene protein twice a day in yogurt. (Giving Resident 5 yogurt was not added to the plan of care or diet card). 10/17/13-Fax sent to Physician LL by RN O, Resident 5 "now has on area of excoriation. This area is now 4 x 3 (no units) 100% slough- it's visible once slough is out will be large open area..." requesting wound clinic referrals have tried several unsuccessful treatments. The order was received for the wound clinic. Nursing notes indicate an appointment was made with the wound clinic on 10/22/13. 10/21/13-Fax from Resident 5's physician with order for wound culture to be done in the wound clinic on 10/24/13 due to elevated white blood count and then start [MEDICATION NAME] (antibiotic). On 11/14/13, at 9:39 AM, Surveyor interviewed Physician LL. Physician LL confirmed he ordered the wound culture based on a CBC (complete blood count) that showed elevated white blood count and he wondered if the wound was the cause. 10/22/13-nursing note by RN O, Resident 5 out of facility for evaluation of left buttock/leg fold wound. Area started as an excoriation has continued to deteriorate despite having Foley inserted for wound healing and all treatments attempted "this wound has progressed to an open crater." Physician ordered wound clinic consult as she has a history of inability to heal wounds. Resident 5's blood glucose continues to be sporadic with extreme highs and lows. Her appetite fluctuates and she prefers sweets verse nutritional foods to promote healing, bene protein has been added to her diet. Resident 5 is up for meals then has been in bed positioned off area with her brief off and is repositioned every hour. (note: this is not indicated on the care plan). Resident 5 returned from the wound clinic consult, orders received to follow up with general surgeon to deride necrotic issue. Physician is aware of wound care plan. Dressing was applied at the wound clinic orders received to leave dressing in place until her next visit. May replace meplex if soiled however the [MEDICATION NAME] AG is not to be removed wound clinic will provide all dressing changes and will provide weekly measurements and status of wound. 10/23/13-nursing note, treatment to be done here at facility until surgery for [REDACTED]. 10/23/13-nursing note by LPN T, left buttock measures 3.2 cm x 3 cm x 2.2 in (SIC) depth. 10/24/13, nursing note by RN O, agree with wound assessment area does have moderate amount of purulent drainage. Wound clinic will manage till further orders, clinic is updated that weekly measurements are to be completed on Wednesday. 10/24/13, nursing note, out to appointment with surgeon. Returned with new treatment order. Order for wound culture then start antibiotic related to CBC (Complete Blood Count) results. Surveyor interviewed CNA R on 11/7/13 at 8:33 AM regarding the appointment on 10/24/13. CNA R stated she is the one who went with Resident 5 to the wound clinic on 10/24/13. CNA R stated Physician MM stated he had to deride the pressure ulcer. CNA R stated she explained to Physician MM how the wound started and what it originally looked like and Physician MM said it was a pressure ulcer. CNA R stated when she returned with Resident 5 to the facility she reported this to the nurse, could not remember for sure who, and gave her the gauze and directions sent with CNA R. CNA R stated she had seen the area when it was first noticed and it was dry, red and flaky. CNA R stated when she saw it at the wound clinic it was "gross with black stuff around it." 10/24/13, wound clinic note (not received by facility until Surveyor requested it on 11/6/13). Diagnoses: [REDACTED]. Chief complaint: "left gluteal decubitus ulcer.....NECROTIC!!!!" Plan: sharp surgical debridement. Pack with wet to dry with Dakins for 1 week. Change three times a day. Return in 1 week. Indications for operation (Resident 5) brought to the office because of a foul-smelling decubitus ulcer left gluteal region. The ulcer measures 4 cm x 5 cm x 4 cm. It was sharply debrided with sharp scissors and debrided down through skin, subcutaneous fascial and subcutaneous fat. 10/24/13, nutrition note, nursing reports Resident 5 having difficulty with mechanical soft diet. She may benefit from pureed textures. Suggest downgrade. Resident 5 has lost weight with variable intake. 10/25/13, infection note, started on antibiotic, [MEDICATION NAME], for wound infection. 10/25/13, Comprehensive Pressure Ulcer Assessment was completed by RN O. The summary includes: Resident 5 has excoriation to left buttock. Area continues to decline and has now opened up. Physician was updated and a Foley catheter was inserted related to her incontinence. Resident 5 prefers to lay on her side, staff does however continue with current toileting schedule. Wound clinic will be contacted for recommendation as Resident 5 has history of non healing wounds. Her blood sugars are very sporadic. A low air loss mattress to be in place. Treatment orders will be followed through wound clinic. The remainder of Resident 5's skin is in good condition all intact, not further excoriations or skin concerns... 10/28/13, nursing note by RN NN, antibiotic changed to [MEDICATION NAME]. Wound continues to have serosanguinous drainage. 10/29/13, infection note by LPN T, some serosanguinous drainage, scant odor. 10/29/13, nursing note by RN NN, taking [MEDICATION NAME] today for wound infection. Wound continues to have serosanguineouse drainage. Up and out to dining room for supper; appetite poor. 10/30/13, nursing note by LPN T, left buttock wound with serosanguinous drainage, slight odor measures 4 cm x 3.4 cm by 2.5 cm in depth. 10/31/13, nursing note RN PP, Resident 5 returned from appointment with Physician MM. Wound clinic provides measurements length 3.2 width 3 depth 2.2 (no units). Continue wet to dry dressing changes decreased to twice a day. 10/31/13, wound clinic note (not received by facility until Surveyor requested it on 11/6/13). Complaint: Left gluteal decubitus ulcer stage 4. 4 x 4 x 3 cm necrotic gluteal decubitus ulcer that requires more sharp surgical debridement. Diagnosis: [REDACTED]. 11/1/13, nursing note by RN O, 3:56 AM Resident 5's wound bed is 75% granulation and 25% slough there is slight foul odor noted to her wound. Will follow up with wound physician on 11/7/13. 6:28 PM, wound has no odor, no peri wound redness, no purulent drainage. 11/4/13, nursing note, Glucerna 1 can two times per day sugar free, on order. On 11/5/13, at 12:02 PM, Surveyor observed Resident 5 in bed and her heels were not floated off the mattress. At 1:04 PM, Resident 5 received her meal in the main dining room. Surveyor observed Resident 5 during this time and Resident 5 only ate 1 bite of pureed cake and a yogurt and drink tea, water and lemonade. Resident 5's intakes for the meal were recorded at 26%-50%. 11/6/13, nursing note by LPN T, received Glucerna sugar free. Wound measurement 3.5 cm x 4 cm x 4.8 cm in depth. 11/6/13, nursing note by RN O, writer agrees with below wound documentation. On 11/6/13, at 9:02 AM, Surveyor had observed Resident 5 in the dining room. Resident 5 drank the Glucerna and tea. Resident 5 did not eat any of her meal. Resident 5's intake for the meal was recorded as 26%-50%. On 11/6/13, at 9:55 AM, Surveyor observed LPN T and RN O do the wound treatment for [REDACTED]. Surveyor noted the wound to have 25% slough surrounded by beefy red tissue and a small amount of maceration on the outside edge. On 11/6/13, at 5:08 PM, Surveyor interviewed DON (Director of Nursing) B and MDS Nurse C. DON B stated the facility does not have a wound nurse but RN O is usually at the facility to assess the wounds. DON B also stated they have a Nurse Consultant that is wound certified. DON B stated shower sheets are done twice a week and if the CNAs notice anything the nurse will come in and do the assessment. DON B stated the LPN can go in and measure and describe the area but the RN goes in behind and does the assessment. DON B stated if a wound is considered a pressure ulcer, vascular ulcer or diabetic ulcer the facility uses the WASA forms otherwise any other skin issues are documented in the nursing notes. DON B stated Resident 5's buttock started out as maceration and Resident 5 is very compromised, has problems with her blood sugars and had to be seen by the wound clinic after a surgery. DON B stated they were watching her and on the 3rd week it had decreased but they got an order for [REDACTED]. DON B stated the last line says plan "assess wound." MDS Nurse C stated Resident 5 is repositioned only on her sides and is only up in her wheelchair for meals. DON B stated when Resident 5 came back from the wound clinic the facility only got a hand written note with the treatment orders. DON B confirmed she had not seen the dictated notes from 10/24/13 and 10/31/13 until today and so now they will call it a pressure ulcer. DON B stated CNA R reported when she went with Resident 5 to the wound clinic CNA R tried to explain to Physician MM that it started as an excoriation and Physician MM stated no it's a stage 4 pressure ulcer. On 11/7/13, at 9:00 AM, Surveyor interviewed Physician MM via phone regarding Resident 5. Physician MM stated when he first saw Resident 5 the wound was necrotic and he debrided it until there was bleeding tissue. Physician MM stated after the debridement it looked like a stage 3 pressure ulcer. On 11/7/13, at 9:25 AM, Surveyor interviewed LPN T. LPN T stated she was in and out during the time of concern but remembered when she first noted changes in Resident 5's buttock it was a red, dry and flaky patch of skin and they started using barrier cream. LPN T stated the patch of skin looked different and more like a dry callous and they were then using a foam dressing. LPN T stated when she came back from vacation there was some drainage. LPN T stated the wound changed the fastest she has ever seen. LPN T also stated Resident 5 is not a good eater but will drink whatever she is given. LPN T also said Resident 5 will eat yogurt and apples and Resident 5 does need encouragement to eat. On 11/7/13, at 9:36 AM, Surveyor interviewed CNA S. CNA S stated she refers the care plan book and kiosk for instructions on how to care for the residents. CNA S stated the guideline for repositioning residents is every 2 hours but with Resident 5 CNA S checks on her about every 30 minutes to an hour because Resident 5 moves around so much in bed. CNA S said they are trying to keep Resident 5 off her bottom. Surveyor asked how intakes are recorded. CNA S stated she was taught it is based on the resident's personal preferences not by what was on the plate. CNA S stated for Resident 5 eating a yogurt would be considered 50% of her meal based on her normal eating pattern as Resident 5 does not eat much. On 11/7/13, at 10:24 AM, Surveyor interviewed RN O. RN O stated the following: When she needs to do a wound assessment she goes in with the LPN and the LPN will do the treatment and she measures the area and puts the information in the computer. When the LPN documents on the wound and she writes agree she is indicating that she saw the area and agrees with what the LPN is saying in the note. Resident 5's buttock area started as flaky skin from incontinence of urine and stool. The area was excoriated from moisture. Resident 5 previously had an incision on her shin that when the staples were removed it opened up and Resident 5 had to go to the wound clinic for the treatments. When Resident 5's buttock became excoriated they started using a barrier cream. The area looked like a diaper rash. They changed the treatment to [MEDICATION NAME] for about a week and then it was changed on 10/11/13 to Silvadine after it started to open up superficially. When Resident 5 went to the wound clinic for the buttock the facility received a treatment order but did not receive any additional information. RN O then stated that Resident 5 did have one little black spot a while ago but when she went to the wound clinic they had to dig around to find the necrotic area. Surveyor asked if the surface was necrotic and RN O stated no. RN O stated Nurse Consultant HH came in and looked at Resident 5's wound and gave them treatment advice. Physician MM did not send anything but orders back with Resident 5. RN O stated she was shocked when she saw the notes from Physician MM calling it a stage 4 ulcer. On 11/7/13, at 11:42 AM, Surveyor interviewed DON B and MDS Nurse C again. DON B stated the facility uses guidelines from Metastar to identify and treat wounds. MDS Nurse C stated that per their guidelines Resident 5's buttock was excoriated which can include open skin. MDS Nursing C stated Resident 5's Braden scale identified her as a moderate risk for skin breakdown but that was completed before Resident 5 sustained the fracture when she was more mobile. DON B confirmed Nurse Consultant HH did not write a note when she saw Resident 5 but that Nurse Consultant HH is the one that suggested changing the treatment to [MEDICATION NAME] and then Silvadine. DON B stated on 10/16/13 when the wound changed drastically is when they requested Resident 5 be seen at the wound clinic. DON B stated they did not mention the buttock wound to the wound clinic during Resident 5's visits for her leg because it was an excoriation and it was getting better. Surveyor asked what was done when the wound was noted to have slough. DON B stated there was not any pressure on the area so they did not know what the area was. DON B stated they contacted the physician and had Resident 5 seen in the wound clinic. DON B stated she did not find out until yesterday that the wound clinic called it a pressure ulcer. On 11/7/13 at 11:42 AM, Surveyor then asked DON B about recording resident intakes. DON B stated the CNAs record the intake and if it is less than 75% of the plate they should report it to the nurse who documents it and tries to figure out why they did not eat. DON B continued that they should offer additional items and that should be documented. DON B stated Resident 5 sits at a table where CNAs are so they can encourage her intake. If Resident 5 does not eat with encouragement staff should be assisting her in eating. DON B stated intakes are based on what was served not what the resident typically eats. Note: there is no documentation that Resident 5 was offered additional items after the meal. On 11/7/13, at 3:36 PM, Surveyor interviewed Nurse Consultant HH. Nurse Consultant HH stated the following: She has looked at Resident 5's skin on multiple occasions but she does not document in the resident's medical record. When she first saw Resident 5's buttock she felt it looked like a fungus and was very irritated from incontinence. There were some open areas from chaffing but it was not pressure related. There was one open area that was eroded and macerated. She stated when she visited she would discuss with the facility the need to change treatments and other things like positioning. Resident 5's meal consumption was reviewed along with weight and staff were encouraging Resident 5 with intakes. Nurse Consultant HH stated she knew Resident 5 went to the wound clinic for the buttock but had not been at the facility since then to review the wound clinic notes. Surveyor read the documentation from Physician MM calling it a stage 4. Nurse Consultant HH stated she did not know Physician MM had staged it and he may not have known the etiology of the wound. Nurse Consultant HH stated that is what he sees without him knowing the history of fungal infection and erosion. The facility removed the immediacy on 11/7/13 when it began the following: a house wide sweep of all wounds including a registered nurse assessment of the wounds, education of nurses related to wounds, education of dietary to watch intake sheets and their involvement in wound healing, establishment of a skin team to review wounds weekly and a Quality Assurance audit was developed.