Every finding on record at Clark County Rehabilitation & Living Center

Based on interviews, observations, and record review, the facility failed to protect the resident's right to be free from physical and verbal abuse by staff for 1 of 4 residents (R) reviewed for abuse (R1). R1 voiced being physically and verbally abused by staff. R1 stated Certified Nursing Assistants (CNA) L and CNA M attempted to undress R1 while they were sitting in their wheelchair. R1 requested staff place him in bed first. The CNAs yelled at R1 to shut up and pulled and tugged on R1 to the point R1 was close to falling on the floor. R1 verbalized feeling verbally and physically abused which caused R1 to be fearful of the two staff. R1 voiced feeling humiliated. R1 was observed to be extremely emotional and teary-eyed when sharing the experience with Surveyor.The facility did not conduct an ongoing assessment and/or develop interventions for R1 following staff's verbal and physical abuse resulting in R1 becoming emotionally upset, teary-eyed and expressing fear and humiliation.This is evidenced by:The facility policy titled Abuse, Neglect, Mistreatment, and Misappropriation of Resident property Policy and Procedure states: It is the policy of [Facility Name] that each resident will be free from Abuse. Abuse can include verbal, mental. Under section F. Protection (a) states Procedures must be in place to provide the resident with a safe, protected environment during the investigation. V. Social Services or designee should keep in frequent contact with the resident. R1 was admitted to the facility on [DATE] and has a diagnosis of a traumatic brain injury. R1's Minimum Data Set (MDS) assessment, dated 07/08/26, indicated a Brief Interview for Mental Status (BIMS) score of 12/15 (mildly impaired cognition). R1 is their own legal decision maker. R1's care plan initiated on 07/20/23 with a target date of 10/11/26, states: Cognition/psychosocial well-being/mood/behavior symptoms/potential trauma. R1 is own legal decision maker. An intervention includes 1-1 visit/check with R1 to confirm satisfaction with services and/or offer opportunity for him to express self, as needed.R1's care plan initiated 01/06/23 with a target dated of 10/11/26 states: R1 has an Activities of Daily Living (ADL) self-care performance deficit r/t (related to) activity intolerance, impaired balance, and limited mobility with interventions for transfers to provide 2 person assist with a Hoyer. On 08/10/26 at approximately 11:30/11:40 AM, R1 requested to speak to Social Worker (SW) G regarding an incident that occurred on 08/07/26 at approximately 3:00 PM where CNA L and CNA M were preparing R1 for a shower. R1 was sitting in their wheelchair wearing shorts and an incontinence brief. CNA L and CNA M attempted to remove R1's shorts and incontinence brief while R1 was sitting in wheelchair. R1 began sliding forward off the seat of wheelchair. R1 was telling CNA L and CNA M to stop and requested the CNAs place him in bed to undress him. R1 told SW G, They were rough with me. They weren't doing it right and it was hurting me. R1 stated, I have back problems and they were twisting me and it hurt. R1 reported telling CNA L and CNA M to stop and one of them stated shut up, we are doing it our way. R1 reported being halfway out of his wheelchair from all of the pulling and tugging before staff finally used the Hoyer lift to assist him into bed. SW G documented R1 was visibly upset and shaken by the incident as evidenced by tone of voice (raised, upset) and voicing fear of working with either CNA again. R1 stated, Where is the respect and dignity for me in the wheelchair when they are being so rough.On 08/19/26 at 8:27 AM and 1:45 PM, surveyors interviewed R1 regarding the incident that occurred on 8/7/26. During the interview R1 stated he is scared of the 2 CNAs, you don't know what they are going to do. They roughhoused me. I had back pain for a couple days. R1 stated they do not want either CNA to enter their room or provide care. R1 stated they were unaware if CNA L and CNA M were still employed but they have not seen the CNAs on the unit since reporting the incident. R1 stated that no one has followed up with them after they reported the incident to the facility. On 8/19/26 at 8:27 AM and 1:45 PM, surveyors interviewed R1. During the interview, Surveyors observed R1 very animated and heightened while sharing the incident. R1 appeared red faced and teary eyed and stated, It was hard and I felt extremely humiliated. R1 stated they didn't know who they could talk to and stated that they felt they could talk to the Social Worker so waited until 08/10/26. R1 stated that when he talked with Social Worker (SW) G and told them they feared the CNAs because they were behind closed doors. On 08/19/26 at 2:56 PM, Surveyor interviewed SW G regarding the reported incident and R1 stating they do not want CNA L and CNA M in their room or to provide care. SW G stated they were aware of R1's concern and failed to document this in an incident report or on R1's plan or care. SW G stated CNA L and CNA M no longer work on that unit, but they are not aware if CNA L and CNA M are working in the building. On 08/19/26 at 3:10 PM, Surveyor interviewed SW G and asked if any follow up assessment or care plan interventions have been documented for R1 since the incident occurred. SW G stated they followed up with R1 later in afternoon on 08/10/26 as R1 was impacted and upset earlier when reporting the incident to SW G. SW G stated R1 seemed okay and felt better after talking with SW G. SW G stated this information was not documented and stated R1 did not want all the staff to know. SW G stated R1 is a private person. On 08/20/26 at 8:27 AM, Surveyor interviewed DON B and asked about the incident involving staff and R1. DON B stated they were unable to provide any documentation to support if R1 had any assessment or monitoring of psychosocial harm, fear, or if the facility updated care plan interventions following the reported incident. DON B stated the facility overlooked doing a 24-hour follow-up on the incident with R1. On 08/20/26 at 10:00 AM, Surveyor interviewed Director of Social Services (DSS) K regarding the incident with R1. Surveyor asked DSS K if any assessment or psychosocial evaluation was completed for R1. DSS K stated they requested SW G follow up with R1 on 08/10/26 but they did not request to conduct a psychosocial evaluation. Surveyor asked DSS K for an expectation of care after an incident of abuse and a resident states they are fearful of staff and feel extremely humiliated. DSS K stated there is no process in place. They rely on nursing to indicate changes in residents and update care plans. DSS K confirmed the Social Services department is part of the Interdisciplinary Team, and they are responsible for behavioral health needs of residents. R1 reported two staff rough housed them and told them to shut up. R1 experienced psychosocial harm as a result of the verbal and physical abuse as evidenced by observations of R1 being extremely emotional and teary-eyed and expressing fear and humiliation as a result of the incident.

Based on observation, interview, and record review, the facility did not provide medically related social services to R1 following an allegation of verbal and physical abuse. Social Services did follow-up with R1 to ensure R1 maintained their highest practicable psychosocial well-being following the incident. The facility failed to identify and seek ways to support R1's mental and psychosocial well-being needs through the assessment and care planning process. The facility policy, titled Abuse, Neglect, Mistreatment and Misappropriation of Resident property Policy and Procedure, states: it is the policy of [NAME] County Rehabilitation & Living Center that each resident will be free from Abuse. Abuse can include verbal, mental.Under section F. Protection (a) states Procedures must be in place to provide the resident with a safe, protected environment during the investigation .V. Social Services or designee should keep in frequent contact with the resident. R1 was admitted to the facility on [DATE] and has diagnoses that include a traumatic brain injury.R1's Minimum Data Set (MDS) assessment, dated 07/08/26, indicated a BIMS score of 12/15 (mildly impaired). R1 is their own legal decision maker.R1's care plan initiated on 07/20/23 with a target date of 10/11/26, states, Cognition/psychosocial well-being/mood/behavior symptoms/potential trauma., states R1 is own legal decision maker. with an intervention of 1-1 visit/check with R1 to confirm satisfaction with services and/or offer opportunity for him to express self, as needed.On 08/10/26, at approximately 11:30/11:40 AM, R1 requested to speak to Social Worker (SW) G of an incident that occurred on 08/07/26 at approximately 3:00 PM wherein Certified Nursing Assistant (CNA) L and CNA M were preparing R1 for a shower. R1 was sitting in their wheelchair wearing shorts and an incontinence brief. CNA L and CNA M attempted to remove shorts and incontinence brief while R1 was sitting in their wheelchair. R1 began sliding forward off seat of wheelchair. R1 was telling CNA L and CNA M of needing to transfer them to bed, undress, and place into shower chair as they were rough with me, they weren't doing it right and it was hurting me. I have back problems and they were twisting me and it hurt. R1 reported telling CNA L and CNA M to stop and one of them stated shut up, we are doing it our way. R1 reported being halfway out of their wheelchair from all of the pulling of the shorts before they finally Hoyer lifted them into bed to do it the right way.SW G documented R1 was visibly upset and shaken by the incident as evidenced by tone of voice (raised, upset) and voicing fear of working with either CNA again, where is the respect and dignity for me in the wheelchair when they are being so rough.On 08/19/26 at 8:27 AM and 1:45 PM (for clarification) Surveyors interviewed R1, who during telling the events that occurred on 08/07/26 stated they are scared of the 2 CNAs, you don't know what they are going to do. They roughhoused me. I had back pain for a couple days, and R1 stated does not want either CNA to enter room or provide cares. R1 stated they were unaware if CNA L and CNA M were still employed but have not seen them on the unit since reporting the incident.R1 stated that no one has followed up with him after the day of reporting the incident to facility.During interview, Surveyors observed R1 very animated and heightened while sharing the incident. R1 appeared red faced and teary eyed and stated, It was hard and I felt humiliated.On 08/19/26 at 1:36 PM, Surveyor interviewed Licensed Practical Nurse (LPN) N regarding knowledge of R1's incident of psychosocial harm. LPN N stated they were unaware of an incident involving staff and R1.On 08/19/26 at 1:37 PM, Surveyor interviewed CNA C regarding knowledge of R1's incident of psychosocial harm. CNA C stated they were unaware of an incident involving staff and R1.On 08/19/26 at 2:56 PM, Surveyor interviewed SW G regarding reported incident and R1 stating they do not want CNA L and CNA M in their room or to provide cares. SW G stated they were aware of R1's concern and failed to document in incident report or their plan or care. SW G stated CNA L and CNA M no longer work that unit but is not aware if CNA L and CNA M are working in the building.On 08/19/26 at 3:10 PM, Surveyor interviewed SW G and asked if any follow up assessment or change in plan of care intervention have been documented. SW G followed up with R1 later in afternoon of reporting incident on 08/10/26 as R1 was impacted and upset earlier when reporting incident to SW G. SW G stated R1 seemed okay and felt better after talking with SW G. SW G stated this information was not documented and stated R1 did not want all of the staff to know, [R1] is a private person.On 08/20/26 at 8:27 AM, Surveyor interviewed Director of Nursing (DON) B and asked about the incident involving staff and R1. DON B stated they were unable to provide any documentation to support if R1 had any assessment or monitoring of psychosocial harm, pain, or updated care plan interventions put into place following the reported incident. DON B stated facility overlooked doing a 24-hour oversight follow up on incident with R1.On 08/20/26 at 10:00 AM, Surveyor interviewed Director of Social Services (DSS) H regarding whether any assessment on psychosocial evaluation was completed for R1. DSS H stated they requested SW G follow up on R1 on 08/10/26 but they did not request to conduct a psychosocial evaluation. Surveyor asked DSS H their expectation of care after an incident with obvious distress. DSS H stated there is no process in place and they rely on nursing to indicate changes in residents and update care plans. DSS H confirmed they are a part of the Interdisciplinary Team and are responsible for behavioral health needs of residents.

Based on interview and record review, the facility failed to conduct a thorough investigation regarding an injury of unknown source for 1 of 4 residents reviewed (R1).The facility policy, titled Abuse, Neglect, Mistreatment and Misappropriation of Resident property Policy and Procedure states: It is the policy of [Facility Name] that each resident will be free from Abuse. Abuse can include verbal, mental. or physical abuse.Under Section E. Investigation: Abuse policy requirements: it is the policy of this facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, .are promptly and thoroughly investigated. **E(b). Investigation of injuries of unknown origin or suspicious injuries: must be immediately investigated to rule out abuse. Injuries include but are not limited to bruising of an unusual size, multiple unexplained bruises, and/or bruising in an area not typically vulnerable to trauma.R1 was admitted to the facility on [DATE] and has a diagnosis of a traumatic brain injury. R1's Minimum Data Set (MDS) assessment, dated 07/08/26, indicated a Brief Interview for Mental Status (BIMS) score of 12/15 (mildly impaired). R1 is their own legal decision maker. R1's care plan initiated on 01/06/23 with a target date of 10/11/26 states, R1 has an Activities of Daily Living (ADL) self-care performance deficit r/t (related to) activity intolerance, impaired balance and limited mobility with interventions for transfers to provide 2 person assist with Hoyer. On 08/13/26 at 7:56 AM, the facility documented a progress note: new skin issue located on the left gluteus, issue type: bruising. Wound acquired in house. It is unknown how long the wound has been present. Resident is .own legal decision maker and was made aware of the bruise. On 08/14/26 at 2:16 PM, the facility documented a progress note: Writer spoke with resident regarding bruise to left buttock. Resident is their own person. Resident stated feels bruise is may be from positioning in wheelchair. On 08/19/26 at 1:45 PM, Surveyor interviewed R1 regarding their knowledge of the bruise discovered by staff. R1 stated they were not aware how it occurred and stated it could possibly be from sliding down in their wheelchair. R1 stated they have not had a bruise from sliding down in their wheelchair previously. On 08/19/26 at 1:36 PM, Surveyor interviewed Licensed Practical Nurse (LPN) N who initially received report of the discovery of the bruise of unknown origin and reported it to the Nurse Care Consultant (NCC) O. Surveyor asked LPN N if it was determined how the bruise occurred. LPN N stated was not sure of how it occurred but stated R1 is up all day in their wheelchair, maybe from the Hoyer sling, or using a bed pan. LPN N stated they were unaware of an incident involving staff and R1. On 08/19/26 at 3:25 PM, Surveyor interviewed NCC O regarding R1's bruise of unknown origin reported to them on 08/14/26. NCC O stated they were informed of the bruise and directed LPN N to measure and take a picture of the bruise. NCC O stated recalling that they had a discussion with Director of Nursing (DON) B about potential causes of the bruise and was not aware of an investigation and/or report being completed by facility. On 08/20/26 at 8:27 AM, Surveyor interviewed DON B regarding completing an investigation into the bruise on R1's buttocks. DON B stated the facility followed the injury of unknown source flowchart P-00362 in determining not to report/investigate based on R1's statement of feels bruise is from positioning. DON B stated the facility overlooked doing a 24-hour oversight follow up on incident with R1.

Based on interview and record review, the facility did not report an injury of unknown origin to the State Agency (SA) for 1 of 4 (R1) residents reviewed. The facility policy, titled Abuse, Neglect, Mistreatment and Misappropriation of Resident property states: It is the policy of [NAME] County Rehabilitation & Living Center that each resident will be free from Abuse. Abuse can include verbal, mental. or physical abuse Under Section E. Investigation: Abuse policy requirements: It is the policy of this facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, .are promptly and thoroughly investigated. **E(b). Investigation of injuries of unknown origin or suspicious injuries: must be immediately investigated to rule out abuse. Injuries include but are not limited to bruising of an unusual size, multiple unexplained bruises, and/or bruising in an area not typically vulnerable to trauma. Under Section G. Reporting and Response states: The facility will ensure that all alleged violations involving abuse, neglect.including injuries of unknown source., are reported immediately, but not later than 2 hours after the allegations is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that causes the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials.including to the State Survey Agency. R1 was admitted to the facility on [DATE] and has diagnoses that include a traumatic brain injury. R1's Minimum Data Set (MDS) assessment, dated 07/08/26, indicated a Brief Interview for Mental Score (BIMS) score of 12/15 (mildly impaired). R1 is their own legal decision maker. R1's care plan initiated on 01/06/23 with a target date of 10/11/26 states, R1 has an Activities of Daily Living (ADL) self-care performance deficit r/t (related to) activity intolerance, impaired balance and limited mobility with interventions for transfers to provide 2 person assist with Hoyer. On 08/13/26 at 7:56 AM, the facility documented a progress note: new skin issue located on the left gluteus, issue type: bruising. Wound acquired in house. It is unknown how long the wound has been present. Resident is .own legal decision maker and was made aware of the bruise. On 08/14/26 at 2:16 PM, the facility documented a progress note: Writer spoke with resident regarding bruise to left buttock. Resident is .own person. Resident stated .feels bruise is from positioning in their wheelchair. On 08/19/26 at 1:45 PM, Surveyor interviewed R1 regarding their knowledge of the bruise discovered by staff. R1 stated they were not aware of bruise until staff informed them about it. R1 stated they were not aware how it occurred and stated it could possibly be from sliding down in their wheelchair. R1 stated they have not had a bruise from sliding down in their wheelchair previously. On 08/19/26 at 1:36 PM, Surveyor interviewed Licensed Practical Nurse (LPN) N who initially received report of the discovery of the bruise. LPN N reported the bruise to Nurse Care Consultant (NCC) O. Surveyor asked LPN N if it was determined how the bruise occurred. LPN N stated they were not sure of how it occurred but stated R1 is up all day in their wheelchair, maybe from the Hoyer sling, or using a bed pan.On 08/19/26 at 3:25 PM, Surveyor interviewed NCC O regarding R1's buttock bruise. NCC O stated they were informed of the bruise and directed LPN N to measure and take a picture of the bruise. NCC O stated recalling that they had a discussion with Director of Nursing (DON) B about the potential cause of the bruise and was not unaware of an investigation and/or reported being completed by facility relating to the bruise/injury of unknown origin. On 08/20/26 at 8:27 AM, Surveyor interviewed DON B and asked if the resident or staff were able to state what caused the bruise. DON B stated the facility followed the injury of unknown source flowchart P-00362 in determining not to report/investigate based on R1's statement of feels bruise is from positioning.

Based on record review, interviews, and review of the facility reported incidents (FRI) the facility failed to protect the resident's right to be free from physical abuse by other residents for four residents (R3, R5, R10, and R2) of eight residents reviewed for abuse out of a total sample of 23 residents. The facility's failure to protect residents from abuse placed residents at continued risk of harm. Findings include:1. Review of the facility's reported incident (FRI) revealed that on 01/21/26 R4 struck R3 on both arms after R3 attempted to intervene when R4 got upset at a certified nurse aide who was redirecting R4 after attempting to take a meal tray that was for another resident. The FRI revealed that R4 and R3 were separated and R4 went to his room. The FRI also revealed that R4 was put on a one-to-one with staff and R3 moved to a different unit. Review of R4's electronic medical record (EMR) revealed an admission record located under the Profile tab of the EMR with an admission date of 07/06/25. The quarterly minimum data set (MDS) with an Assessment Reference Date (ARD) of 01/13/26 revealed a Brief Interview for Mental Status (BIMS) of 10 out of 15 indicating moderately impaired cognition. Review of R4's care plan located under the Care Plan tab of the EMR, dated 01/21/26, revealed that R4 had an impaired cognitive deficit and impulse disorder, had a motion activated doorbell above the door and was receiving one-on-one related to impulsive behaviors. During an interview on 04/09/26 at 1:25 PM, Certified Nurse Aide (CNA) 4 stated that R3 was helping place trays on the tables when R4 attempted to remove a tray that was not his. CNA4 stated that when I attempted to redirect R4 he became agitated. CNA4 stated that when R3 saw what was happening R3 confronted R4. The CNA stated that R4 struck R3 in the upper arm at the time R3 confronted R4. CNA stated that she separated the residents and reported the incident. During a follow-up interview on 04/10/26 at 9:05 AM, R3 stated that the altercation happened because R4 tried to take a food tray that did not belong to him and CNA4 was attempting to redirect R4. R3 stated that's when R4 got mad and was yelling at the CNA. R3 stated at that point R3 said something to R4 about being mean to the CNA so R4 then hit R3 in the arm. R3 stated that he started laughing at R4 and R4 hit R3 in the other arm before the CNA4 could get to R4. R3 stated that R4 was removed from the area and they put a guy to watch R4 all the time. During an interview on 04/10/26 at 10:05 AM, the Nurse Practitioner (NP) stated that R4 received a medication review and medication changes to help with the uncontrolled impulses. The NP also stated that R4 was seen by psychiatry for behaviors. During an interview on 04/10/26 at 10:30AM the Director of Nurses (DON) stated that after the resident-to-resident altercation R3 was asked if he wanted to change rooms and he agreed. The DON stated that we had R4 seen by psychiatry and they made some medication changes to help with impulse control. The DON also stated that R4 remained on one-to-one supervision during the investigation. The DON stated that interventions were put in place to alert staff when R4 leaves his room. 2. Review of R5's admission Record in the EMR under the Census tab revealed R5 was re-admitted to the facility on [DATE] with the diagnosis of dementia. Review of R5's quarterly MDS, in the EMR under the MDS tab with ARD of 02/17/26, indicated that R5 has a BIMS four out of 15, meaning that R5 is cognitively impaired. Further review indicates that R5 has a history of wandering. During observation and attempted resident interview on 04/08/26 at 4:31 PM, R5 was sitting quietly in his wheelchair, alert yet stared when approached by others. R5 was unable to answer any questions. Review of R4's admission Record in the EMR under the Census tab revealed R4 was re-admitted to the facility on [DATE] with the diagnosis of conduct disorder. Review of R4's admission MDS, in the EMR under the MDS tab with ARD of 01/13/26, indicated that R5 has a BIMS 10 out of 15, meaning that R4 is moderately cognitively impaired. Further review indicates that R4 has a history of behavior toward others. Review of R4's Care Plan dated 10/27/25 and revised 02/17/26 revealed no concerns. During observation on 04/09/26 at 8:33 AM, R4 was in the hallway, when surveyor attempted to speak, and R4 refused to answer and kept walking. Review of facility provided, Misconduct Incident Report, (initial report), dated 02/16/26, indicated, R5 walking around unit and walked into R4's room. CNA6 could not redirect R5. R4 yelled and R5 kept entering so R4 got out of bed and punched R5 three times with a closed fist on the left upper arm. After the last punch, R5 turned around and exited the room. R5 walked down the hallway and sat down in a chair. On 04/10/26 at 1:58 PM, surveyor attempted to contact CNA6; however, CNA6 was not available. During interview on 04/10/26 at 3:20 PM, the Director of Nursing (DON) confirmed that R5 was punched three times in the arm by R4 when R5 could not be redirected out of R4's room. 3. Review of the provider's reported investigative summary titled Alleged Nursing Home Resident Mistreatment, Neglect and Abuse Report with a report submitted date of 01/22/26 provided by the Administrator revealed, On 1/16/26 [CNA5 ] heard yelling coming from [R10's] room. CNA5 immediately responded and found R9 in R10's room. R9 thought it was his room and took R10's blanket off his bed. R10 was upset and tried to get R9 out of his room and take his blanket back causing R9 to starting hitting R10 in the chest and shoulder. CNA5 redirected R9 out the R10's room. CNA5 immediately intervened and separated R9 and R10. The report states that R10 continues with his daily routine per usual. Behaviors, demeanor, appetite, and function remain unchanged, and no other residents were affected. The facility listed the following steps the entity took upon learning of the incident to protect the affect person(s) from further potential misconduct. Residents were separated. Law enforcement notified. R9 has a door alarm to alert staff when he is out of his room and will be in line of site when out of his room. Review of R9's undated Face Sheet located in the resident's EMR under the Resident tab, revealed the resident was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease and dementia in other diseases classified elsewhere, unspecified severity, with agitation. Review of R9's comprehensive assessment MDS with an ARD of 12/27/25 revealed R9 had a Brief Interview for Mental Status (BIMS) score of three out of 15, indicating severe cognitive impairment. This assessment also identified R9 as having physical, verbal and wandering behaviors occurring one to three days of the assessment period. During an observation on 04/09/26 at 10:04 AM on the 3W unit, R9 was observed sitting in a recliner in the common area of the unit in the area where the television was on. R9 acknowledged the surveyor was on the unit by waving at the surveyor. When attempting to talk with R9, he could not tell the surveyor what show was playing on the television or carry on a conversation with the surveyor. Review of R10's undated Face Sheet located in the resident's EMR under the Resident tab revealed R10 was admitted to the facility on [DATE] with diagnoses which included neurocognitive disorder with Lewy bodies, cerebrovascular disease, and during his stay was diagnosed with vascular dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of R10's 11/20/25 quarterly MDS with an ARD of 11/05/25 revealed R10 had a BIMS of two out of 15, indicating severe cognitive impairment with no behavioral symptoms during the assessment period. An interview was conducted with CNA12 on 04/09/26 at 10:00 AM on the 3W locked unit. CNA12 was asked if he knew of any situations where R9 and R10 had any altercations. CNA 12 said that they do not really like each other but confirmed he did not witness any altercations between the residents. During an interview with CNA5 on 04/09/26 at 2:10 PM she stated she usually worked this unit and stated that the residents need the consistency. CNA5 was asked if she recalled an incident between R9 and R10 when R9 went into R10's room and R9 tried to take R10's blanket. CNA5 recalled the incident stating that she heard yelling and it was coming from R10. She said that she saw R9 in R10's room and R9 was trying to take R10's blanket away. She recalled that R9 hit R10 and R10 hit R9. She stated that she placed her arm around R9 and they backed up out of R10's room. CNA5 stated there was an investigation into the incident and R9 was placed on every 15-minute checks and R10 on every 30-minute checks. When asked if there have been any other altercations between the two residents, she said it has been only verbal. An interview was attempted with R10 on 04/10/26 at 9:05 AM, R10 did not respond to the surveyor when attempting to converse with him. 4. Review of R2's undated Face Sheet located in the resident's EMR under the Resident tab revealed R2 was admitted to the facility on [DATE] with diagnoses including other specified chronic obstructive pulmonary disease and type 2 Diabetes Mellitus. Review of R2's admission MDS with an ARD of 10/28/25 revealed R2 had a BIMS of 11 out of 15 indicating moderate cognitive impairment and did not display any behavioral symptoms during the assessment period. Review of R4's undated Face Sheet located in the resident's EMR under the Resident tab revealed R4 was readmitted to the facility on [DATE] with diagnoses including unspecified symptoms and signs of cognitive functions and awareness and degenerative disease of the nervous system. Review of R4's admission MDS with an ARD of 10/13/25 revealed R4 had a BIMS of two out of 15 indicating severe cognitive impairment. The assessment indicated R4 had wandering behaviors. Review the facility's report titled, Alleged Nursing Home Resident Misconduct, Neglect and Abuse Report dated 01/08/26, revealed the facility reported to the Department of Health Services Division of Quality Assurance, State of Wisconsin an incident involving R2 and R4. The Brief Summary of Incident states, R2 was watching TV when R4 came out picked up the remote and changed the channel, then set it back down. R2 got up, grabbed the remote, changed the channel and R4 grabbed his R2's wrist and yelled at him. R2 yelled back. R4 let go and went to his room with caregiver. The incident was reported to have occurred at 5:00 PM and the report was completed by the RN on the unit. The facility's investigation stated, R2 was involved in a resident-to-resident altercation with another R4. R4 grabbed the tv remote and changed the tv channel off the program R2 was watching. When R4 put the tv remote down R2 went to grab it and that's when R4 grabbed R2's wrist and swore at R2 telling him to leave it alone. Staff immediately separated residents. Review of the facility's investigation conducted by the Assistant Director of Nursing (ADON) and attached to the facility's reported incident revealed there have been no further issues between the two residents. The action taken was to put a TV schedule into place on the unit for residents to see and the remote control for the TV in the dayroom would be placed in the cabinet. During an interview on 04/08/26 at 9:00 AM, R2 was asked if he recalled an incident he and R4 had involving a remote for the TV. R2 stated that he was watching TV and R4 got the remote and changed the channel and put the remote back down. R2 said he then picked up the remote and R4 grabbed his wrist. He said that that is what happened. R2 said he lived on another unit before and this one and that is where the incident happened. When asked what happened as a result, R2 said the facility talked to him about it. He said he was moved to the room he is currently in and at first did not like it but was okay with his room today. On 04/09/26 at 10:00 AM, an attempt to see R4 to interview him about the incident was made. R4 was in his room and was not allowing anyone to come in to speak to him. Review of the facility's undated Abuse Policy, indicated, It is the policy of [NAME] County Rehabilitation & Living Center that each resident will be free from 'Abuse'. Abuse can include verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. The facility will strive to educate staff and other applicable individuals in techniques to protect all parties.

Based on observations, record review, interviews, and policy review, the facility failed to ensure staff members involved in allegations of abuse were removed from resident care while the investigation was ongoing for three of nine abuse allegations involving Resident (R) R5, R14, and R16. In addition, the facility failed to ensure that a complete and thorough investigation was conducted for investigations of alleged abuse for two of nine investigations involving R4 and R16. Findings include:1.Review of R14's admission Record in the electronic medical record (EMR) under the Census tab revealed R14 was admitted to the facility on [DATE] with the diagnosis of schizoaffective disorder-bipolar type. Review of facility provided, Misconduct Incident Report, (initial report), dated 02/20/26, indicated, R14 making allegation of abuse towards Certified Nursing Assistant (CNA) 2 and R15. During interview on 04/10/26 at 10:50 AM, the Director of Nursing (DON) confirmed that CNA2 was not taken off the schedule during the investigation process and indicated that she should have been. During interview on 04/10/26 at 1:00 PM, CNA2 confirmed that she only took R14 into her room when R14 wanted to be taken into her room. CNA2 denied ever making R14 stay in her room. Confirmed that R15 never spoke with R14 and/or never followed her around. In addition, CNA2 stated that R14 had delusions that various staff on various shifts were giving her enemas, which was not true. Review of facility provided CNA3's Timecard, February 2026, indicated the following dates and times that CNA2 worked: 02/20/26: 2:00 PM-10:00 PM and 6:00 AM-2:00 PM; 02/21/26:2:00 PM-10:00 PM and 6:00 AM-2:00 PM; 02/22/26: 2:00 PM-10:00 PM and 6:00 AM-2:00 PM; 02/23/26: 2:00 PM-10:00 PM and 6:00 AM-2:00 PM; 02/25/26: 2:00 PM-10:00 PM, 10:00 AM-2:00 PM, and 6:00 AM-2:00 PM; 02/26/26: 2:00 PM-10:00 PM, 10:00 AM-2:00 PM, and 6:00 AM-2:00 PM; and 02/2/26: 2:00 PM-10:00 PM, and 6:00 AM-2:00 PM. 2. Review of R16's admission Record in the EMR under the Census tab revealed R16 was admitted to the facility on [DATE] with the diagnosis of paraplegia with thoracic spinal cord injury at T7-T10, and anxiety disorder. Review of facility provided Inventory of Clothing, dated 1/8/24, indicated, Red long sleeved [NAME] shirt (blue [NAME] on sleeve), 2XL. Review of facility provided, Misconduct Incident Report, (initial report), dated 2/13/26, indicated, R16 is upset and is expressing harm to CNA3 because R16 feels CNA3 stole his shirt. Nobody else was affected by this situation. The facility has no evidence of any resident interviews during investigation. ( The red [NAME] shirt.) During interview on 04/09/26 at 5:15 PM, the DON confirmed that CNA3 is a floating staff member; however, during the investigation, CNA3 was reassigned to another unit. Further interview on 04/10/26 at 11:00 AM, the DON confirmed that there were no residents interviewed during the investigation. During interview on 04/09/26 at 6:09 PM, CNA3 stated that about a month or so ago, he was contacted by Assistant Director of Nursing (ADON) and was told to stay away from R16; however, that is not easy because R16 has an electric wheelchair and he can go anywhere in the building. R16 confirmed that he was moved to another unit and was not removed from resident care during the facility's investigation. Review of facility provided CNA3's Timecard, February 2026, indicated the following dates and times that CNA3 worked: 02/13/26: 6:00 PM-10:00 PM and 10:00 PM-6:00 AM; 02/14/26: 10:00 PM-6:00 AM and 6:00 PM-10:00 PM; 02/15/26: 6:00 PM-10:00 PM, and 10:00 PM-6:00 AM; and 02/20/26: 6:00 PM-10:00 PM, and 10:00 PM-6:00 AM. 3. Review of R5's admission Record in the EMR under the Census tab revealed R5 was re-admitted to the facility on [DATE] with the diagnosis of dementia. Review of R5's quarterly Minimum Data Set (MDS), in the EMR under the MDS tab with Assessment Reference Date (ARD) of 02/17/26, indicated that R5 has a Brief Interview for Mental Status (BIMS) four out of 15, meaning that R5 is cognitively unaware. Further review indicates that R5 has a history of wandering. During observation and attempted resident interview on 04/08/26 at 4:31 PM, R5 was sitting quietly in his wheelchair, alert yet stared when approached by others. R5 was unable to answer any questions. Review of R4's admission Record in the EMR under the Census tab revealed R4 was re-admitted to the facility on [DATE] with the diagnosis of conduct disorder. Review of R4's admission MDS, in the EMR under the MDS tab with ARD of 01/13/26, indicated that R5 has a BIMS 10 out of 15, meaning that R4 is moderately cognitively aware. Further review indicates that R4 has a history of behavior toward others. During observation on 04/09/26 at 8:33 AM, R4 was in the hallway, when surveyor attempted to speak, and R4 refused to answer and kept walking. Review of facility provided, Misconduct Incident Report, (initial report), dated 2/16/26, indicated, R5 walking around unit and walked into R4's room. CNA6 could not redirect R5. R4 yelled and R5 kept entering so R4 got out of bed and punched R5 three times with a closed fist on the left upper arm. After the last punch, R5 turned around and exited the room. R5 walked down the hallway and sat down in a chair. On 04/10/26 at 1:58 PM, attempted to contact CNA6; however, CNA6 was not available. During interview on 04/10/26 at 3:20 PM, the DON confirmed that there was only one staff interview, and that staff interview was from CNA6. The DON indicated that all staff should have been interviewed during the investigation. Review of the facility's undated policy titled, Abuse, Neglect, Mistreatment & Misappropriation of Resident Policy and Procedure states, Purpose: It is the policy of [NAME] County Rehabilitation and Living Center that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion . F. Protection Abuse Policy Requirements: It is the policy of this facility that the resident(s) will be protected from the alleged offender(s). Procedure: Immediately upon receiving a report of alleged abuse, the Administrator and or designee will coordinate delivery of appropriate medical and/or psychological care and attention. Ensuring safety and well-being for the vulnerable individual are of utmost priority. Safety, security and support of the resident, their roommate, if applicable and other residents with the potential to be affected will be provided. This should include as appropriate: a. Procedures must be in place to provide the resident with a safe, protected environment during the investigation: i. The alleged perpetrator will immediately be removed and resident protected. Employees accused of alleged abuse will immediately be removed from the facility and will remain removed pending the results of a thorough investigation.

Based on observation, interview and record review, the facility did not provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections with the potential to affect all 144 residents.-Staff allowed to work 24 hours after gastrointestinal symptoms reported.-Mechanical lifts not sanitized between use by separate residents.-1 resident (R30) was not placed on Enhanced Barrier Precautions (EBP) for an indwelling catheter.-R7's catheter bag was hung on her garbage can. Findings include: Example 1 Facility policy titled, Gastroenteritis outbreak (Viral), including Norovirus last reviewed on 07/17/23, reads in part: Symptomatic staff will be required to remain off duty until they are symptom-free for at least 48 hours. On 12/16/25 at 8:30 AM, Surveyor reviewed infection line list for staff. Facility allowed 2 staff members return to work less than 48 hours after last symptoms. One staff member reported onset of vomiting and diarrhea on 10/16/25 at 15:57. Line list states that staff member was off work 10/13/25-10/15/25 and returned to work on 10/16/25. Another staff member reported onset of vomiting on 09/17/25 at 9:59 AM with a return-to-work date of 09/18/25. On 12/16/25 at 2:33 PM, Surveyor interviewed Infection Preventionist (IP) O. IP O stated if the facility is not in outbreak, staff can return to work 24 hours after gastrointestinal symptoms resolve. IP O stated the guidelines for this procedure were in place prior to IP O taking this position and was not sure what source was utilized. On 12/16/25 at 1:37 PM, Surveyor interviewed Dietary Manager (DM) M. DM M stated any dietary staff that are ill are reported to IP O. IP O informs all staff in the facility when they can return to work. Example 2 On 12/15/25, at 11:55 AM, Surveyor observed direct care staff remove Hoyer lift from resident room and did not sanitize it before taking it to another resident room. On 12/16/25 at 2:33 PM, Surveyor interviewed IP O. IP O stated the expectation is for staff to sanitize all shared medical equipment before and after use by each resident. Example 3 Findings: R30 was admitted to the facility on [DATE], with diagnoses including benign prostatic hyperplasia (BPH) and urine retention. R30's care plan included: -Foley catheter related BPH and urinary retention. Date initiated, 10/18/24. Revision on, 03/06/25. -Urinary tract infection signs/symptoms, lab results, hematuria, suprapubic pain. Date initiated, 10/19/25. Revision on, 10/19/25. -EBP to prevent multidrug-resistant organism (MDRO), due to: urinary catheter. Date initiated, 10/17/24. Revision on, 03/17/25. Interventions: EBP sign placed on resident's door. Personal protective equipment (PPE) will be hung on the inside of resident's door. PPE will be used when performing high-contact resident care activities. On 12/15/25 at 9:33 AM, Surveyor interviewed R30. R30 was sitting in his wheelchair in his room. R30 confirmed to Surveyor he had a Foley catheter. Surveyor noted R30 did not have EBP signs placed on his door and did not have PPE on the back of his door, per his care plan. On 12/16/25 at 12:33 PM, Surveyor noted R30 did not have EBP signs on his door or PPE on the back of his door, per his care plan. Surveyor interviewed Certified Nursing Assistant (CNA) D. CNA D stated R30 should be on EBP, but since he moved to a different floor on 12/12/25, staff must have forgot. CNA D confirmed licensed nursing staff are responsible for ensuring residents are placed on EBP when appropriate. CNA D reported she has worn gloves when providing catheter care to R30. On 12/16/25 at 12:37 PM, Surveyor interviewed Registered Nurse (RN) E. RN E stated she is contracted staff and has not worked R30's unit in approximately two weeks. Surveyor asked RN E to describe the process when a resident is placed on EBP. RN E stated the Nurse Care Coordinator (NCC) would know. RN E stated when a resident has something infectious, staff gown up. Surveyor asked RN E what staff do for a resident placed on EBP. RN E asked, You mean, like gowns and gloves? Surveyor asked RN E what staff do for residents with an indwelling device. RN E stated, Well, we have gowns and gloves, and stuff. On 12/17/25 at 8:25 AM, Surveyor noted R30 did not have EBP signs on his door, or PPE on the back of his door, per his care plan. Surveyor interviewed RN F. RN F reported R30 should be on EBP, and she was not sure why he was not. RN F stated R30 should have come with the PPE from his previous room when he was transferred to his new room. RN F stated she was not sure why this wasn't done and felt it, must have gotten missed. RN F confirmed licensed nursing staff or the NCC is responsible to ensure residents are placed on EBP when appropriate. On 12/17/25 at 8:50 AM, Surveyor interviewed NCC G. NCC G confirmed R30 should be on EBP. NCC G stated when a resident transfers from a different unit, the previous unit sends a transfer sheet, which would indicate if a resident required precautions. NCC G was not sure what happened. NCC G did place EBP signs on R30's door. Example 4 R7 was admitted to the facility on [DATE], with diagnoses including dementia. R7's care plan included the following: -Indwelling catheter, neurogenic bladder with urine retention. Date initiated, 07/14/25. Revision on, 08/18/25. On 12/15/25 at 9:55 AM, Surveyor observed R7 in her room sitting in her recliner. Surveyor observed R7's catheter bag hanging from the garbage can placed next to the recliner. On 12/15/25 at 10:15 AM, Surveyor interviewed CNA H. CNA H reported she was not sure why R7's catheter bag was hanging from the garbage can. CNA H confirmed staff have received training on infection control. On 12/18/25 at 11:43 AM, Surveyor interviewed NCC G. NCC G acknowledged R7's catheter bag hanging on the garbage can was not facility practice. NCC G stated staff may need re-education on this matter.

Based on observation, interview and record review, the facility did not ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety with the potential to affect all 144 residents.-Staff did not demonstrate appropriate hand hygiene while serving a meal.-Food was uncovered and exposed while transported from one unit to another via the hallway.-Towel meant to cover food was observed in the food.-Plastic pitcher observed sitting in a bowl of food.-Hot food items not kept hot.-Drinks for meals service not kept cold on cart.-Multiple beverage containers not labeled and/or covered.-Freezers on units not monitored for temperature.Findings include: Facility policy titled, Food Production and Food Safety, last revised on 11/22/2017, reads in part: Food or beverages should be labeled and dated to monitor for food safety.Foods should be stored at the appropriate temperature to maintain safety -cold foods: less than 41 degrees F. Facility policy titled, Hand Hygiene, last reviewed on 06/22/22, reads in part: Employees are required to use soap and water if hands are visibly soiled, before eating or handling food.hand hygiene using soap and water is required when handling food. According to the U.S. Food and Drug Administration (FDA). (2022). Food Code 2022. U.S. Department of Health and Human Services, Public Health Service, FDA, reads in part: The FDA Food Code requires hot foods to be held at 135 degrees F (57 degrees C) or above for serving and safety, preventing bacterial growth, with thermometers used to verify internal temperatures. On 12/15/25 at 8:45 AM, Surveyor observed a small plastic pitcher sitting in a bowl of elbow macaroni that was being used as a scoop. Elbow macaroni was also not covered. On 12/15/25 at 10:51 AM, Surveyor observed unlabeled pitcher of liquid in the med room refrigerator on 1 East Unit B. On 12/15/25 at 11:11 AM, Surveyor observed a pitcher of unknown liquid not dated or labeled in the dining area refrigerator on 2 [NAME] Unit B. On 12/15/25 at 11:15 AM, Surveyor observed the refrigerator on 2 [NAME] Unit A had two pitchers of unknown liquid not dated or labeled. Surveyor observed there was no thermometer present in the freezer on the same unit. On 12/15/25 at 11:27 AM, Surveyor observed the refrigerator on 2 East Unit B had 3 pitchers of unknown liquid not labeled or dated. Surveyor observed there was no thermometer in the freezer of the same unit. On 12/15/25 at 11:30 AM, Surveyor interviewed Certified Nursing Assistant (CNA) H. CNA H was unaware of who monitors temperatures in the refrigerators and freezers. On 12/15/25 at 12:44 PM, Surveyor observed kitchen/serving staff push a portable steam table from 3 East Unit B to 3 East Unit A during mealtime. Food items on the steam table were uncovered in the hallway. The aluminum foil previously covering the food had been torn open. On 12/15/25 at 12:48 PM, Surveyor observed Dietary Aide (DA) N. DA N adjusted eyeglasses and shirt while serving lunch and did not perform hand hygiene. DA N used the walkie talkie to contact the main kitchen staff twice while serving lunch without performing hand hygiene. DA N did not perform hand hygiene after removing a glove during meal service. On 12/16/26 at 7:30 AM, Surveyor entered 3 [NAME] Unit A. Breakfast food cart was present. Food was first distributed to residents at 7:49 AM. Pancakes appeared dry, and butter did not melt when applied. Facility schedule indicated a delivery time of 7:20 AM. On 12/16/25 at 12:45 PM, Surveyor observed DA N wheel the steam table from 3 East Unit B to 3 East Unit A. The pans of food on the steam table were covered with a towel, but the corner/side of the towel was resting inside the pan of mashed potatoes. On 12/16/25 at 12:58 PM Surveyor observed unknown liquid in a glass bottle on 2 East Unit A without labeling. Surveyor observed the water, juice, and chocolate milk for resident's meal were sitting on cart with no way to keep them cold. On 12/16/25 at 1:13 PM, Surveyor received a test tray. The temperature of the chocolate milk was 52 degrees. Hot food items were warm and ranged from 98-128 degrees. On 12/16/25 at 12:37 PM, Surveyor observed food cart being delivered to 2 East Unit A. Trays first provided to residents at 12:58 PM. Facility schedule indicates a delivery time of 12:45 PM. On 12/16/25 at 1:00 PM, Surveyor interviewed CNA J. CNA J stated CNA J was the only one working on 2 East Unit A. CNA J stated staff from Unit B were supposed to assist but that does not always happen. CNA J stated at times there will be a CNA that is on light duty floating, but they can only do so much. CNA J stated some days CNA J has no help. On 12/17/25 at 1:37 PM, Surveyor interviewed Dietary Manager (DM) M. DM M stated it is expected the staff cover foods on the portable steam table when transporting it from one unit to another. DM M confirmed the towel should not be resting in the food. DM M reported drinks should be dated when opened in original container and when placed in pitchers and should only be used for 4 days. DM M stated drinks should be placed in cold tubs or on ice to keep them cold when serving. DM M stated all refrigerators and freezers should have a thermometer in them for monitoring. DM M stated the kitchen staff monitor the kitchen freezer and refrigerator temperatures, and nursing monitors the ones on the units. On 12/15/25 at 10:04 AM, Surveyor observed on the 100 south hall the coffee bar refrigerator stored 4 carafes of juice not covered or dated. A zip lock plastic baggie of macaroni and cheese was not dated and labeled. On 12/16/25 at 11:33 AM, Surveyor observed on the 100 south hall the coffee bar refrigerator stored 4 carafes of juice not covered or dated. A zip lock plastic baggie of macaroni and cheese was not dated and labeled. On 12/17/15 at 8:30 AM, Surveyor held Resident Council discussion: R1 stated all snacks were removed from resident rooms for infection control reasons. R1 stated they must ask staff for their personal snacks and must eat them in the dining room. R1 stated they are not allowed to take snacks to their room to eat them. R45, R134 and R1 report the meals are late at times and the food is cold. On 12/18/25 at 11:00 AM, Surveyor observed on the 100 south hall the coffee bar refrigerator stored 4 carafes of juice not covered or dated. On 12/18/25 at 1:00 PM, Surveyor interviewed and reviewed observations with Director of Nursing (DON) B. DON B stated would expect food to be dated and covered when stored in the refrigerators, and served at proper temperatures.

Based on observation, interview and record review, the facility did not ensure the resident environment remained free from accidental hazards with supervision and assistance devices to prevent accidents for 1 resident (R96) of 2 residents reviewed for accidents in a sample of 29 residents.The facility did not have a position change bed alarm device placed on R96's bed, following care planning interventions to alert staff to any potential hazards of R96 attempting to get self out of bed, thus preventing an avoidable accident.Findings include:The facility policy, titled Fall Prevention, not dated, states in part: The [NAME] County Rehabilitation and Living Center strives to minimize resident falls and related injuries through a fall management program whose purpose is.to reduce the incidence of falls and minimize injury.develop effective interventions to prevent falls and minimize injury.ensure safety devices are in place.R96 was admitted to the facility on [DATE] and has diagnoses that include schizophrenia, altered mental status, weakness and repeated falls. R96 has a Brief Interview Mental Status (BIMS) score of 99, which means the resident was unable to complete the interview.R96's Minimum Data Set (MDS) states she is dependent for all mobility, including transferring of self.R96's care plan, dated 11/23/2022, with a target date of 10/26/2025, states in part: [R96] has an ADL self-care performance deficit related to limited mobility and cognitive impairment. Interventions include Safety: bolster mattress, bed alarm, floor mat.R96's care plan, revised 08/13/2025, with target date of 10/26/25, states in part: [R96] is at risk for falls related to gait imbalance problems, poor communication/comprehension, unaware of safety needs and cognitive impairment. Interventions include, Bed alarm education to staff for proper placement of pads under shoulders.On 12/17/2025 at 8:40 AM, Surveyor observed morning cares for R96 by Certified Nursing Assistants (CNA) R and CNA Q. CNA R noted the bed alarm device for R96 was not in place at head of bed, which would be alerting them to position changes by R96 when being rolled to a lateral position for peri-area cares. CNA R stated the white box was missing and no bed alarm was found to be present. CNA R stated, It was there yesterday. CNA R and CNA Q could not determine how long bed alarm device had been off or who alarm was removed by when asked by Surveyor. At 9:10 AM, Nursing Care Coordinator (NCC) C came to R96's room after CNA Q alerted her to the missing bed alarm device. NCC C stated she found the bed alarm white box at the nurse's station and changed the battery. After being reconnected, the bed alarm indicator light for alarm activation lit up indicating it was working properly. CNA Q and CNA R stated they believed the battery low light came on sometime within the last several hours and it was removed by a staff person from the bed. Bed alarm device was not replaced in the meantime.On 12/17/2025 at 9:20 AM, Surveyor interviewed CNA Q and asked if R96 had any recent falls. CNA Q stated she was not aware of R96 having any falls since CNA Q worked at the facility, which was a period of about 6 months. CNA Q stated R96 was a Hoyer lift for all transfers.On 12/18/2025, record review of R96's nursing documentation for falls/accidents within the past 7 months states as follows:On 05/19/2025, [R96] was found lying on her back on her bedroom floor close to her bed.it appears that [R96] rolled out of bed and fell on the floor.On 08/05/2025, [R96] was observed to be sitting on the floor beside her bed, leaning against the bed on her right side. [R96] stated 'I was going to walk to the closet.'On 08/13/2025, Resident fell from her bed this morning after having a large bowel movement. Resident was found kneeling on floor facing her bed.bed alarm did not sound as it was lower in the bed.On 11/08/2025, Unwitnessed fall, found on her knees next to her bed. It was documented that bed alarm was in place and staff responded to alarm sounding.

Based on observation, interview and record review, the facility did not ensure accommodation of resident toileting needs and preferences for 1 resident (R19) of 29 residents reviewed and sampled.The facility did not allow use of a bathroom in R19's room for meeting toileting needs.The facility required R19 to locate staff to unlock a bathroom down the hall from R19's room when needing to meet toileting needs.The facility did not reassess interventions in R19's care plan for meeting toileting needs safely and update care plan in a timely manner. Findings include:The facility policy, titled Incontinence: Urinary and Bowel, Prevention and Management, revised 03/21/2014, states in part: Each resident will be assessed.and interventions provided to maintain continence and normal function as is possible.Maintaining continence may include (but not limited to).keeping paths to toileting facilities free of carts or impediments to access.providing bedside commodes when needed.having access to call lights with prompt response.The facility policy, titled Care Plans, Care Plan Comprehensive Assessment, dated 05/31/2023, states in part: .Revisions to the comprehensive plan of care will occur as necessary based on ongoing assessment by the nurse or other disciplines and will be identified in the plan of care. A review of the care plan occurs as needed and with every quarterly MDS process and updates made as necessary.R19 was admitted to the facility on [DATE] and has diagnoses that include autistic disorder, schizotypal disorder, moderate intellectual disabilities. R19 has a Brief Interview for Mental Status (BIMS) score of 15/15 meaning cognitively intact. R19 does however have a legal representative for health care appointed due to diagnoses mentioned. R19's Minimum Data Set (MDS) assessment, dated 10/10/25, indicated R19 is continent of bladder and bowel.R19's care plan, initiated 04/04/2018, last revised 10/11/2023, states: [R19] is at risk for falls related to schizotypal personality disorder and history of wandering. Interventions include.review information on past falls.record possible root causes.R19's care plan, dated 09/6/2022, with target date of 10/05/2025, states in part: Behavioral symptoms/psychosocial well-being mood: Has a history of believing he is unable to care for himself because he lives in a nursing home.[R19's] personal bathroom was locked for infection control purposes after being found 'washing up' in the toilet on multiple occasions, despite being educated numerous times about the risks. No interventions are documented for meeting toileting needs under behavioral/psychosocial needs. R19's care plan does indicate intervention for toileting as stated: Supervision in the Big Bathroom - do not leave alone. Bathroom attached to bedroom is locked, in care plan under the Activities for Daily Living (ADLs) focus.On 12/15/2025 at 1:07 PM, Surveyor observed a shared toilet between R19's room (room [ROOM NUMBER]) and a female resident's room (room [ROOM NUMBER]). The doorknob on R19's bathroom door has been removed, and bathroom door is locked. On 12/15/2025 at 2:13 PM, Surveyor interviewed Certified Nursing Assistant (CNA) R on the reason there is no doorknob on R19's bathroom door. CNA R stated she was not sure why there was no doorknob in place. CNA R stated R19 goes down the hall to the bathing room to use the bathroom.On 12/15/2025 at 2:24 PM, Surveyor observed CNA R ask Nursing Care Coordinator (NCC) C about the missing doorknob on R19's door. NCC C told CNA R she was not aware there was no doorknob on R19's bathroom door.On 12/15/2025 at 2:27 PM, Surveyor observed the door to the bathing room was locked for entry. CNA R stated to Surveyor that R19 has to find and ask a staff person to unlock the door to use the toilet. Surveyor asked CNA R to unlock the door to the bathing room in order to view the space. Surveyor observed the bathing room had a toilet and sink in a corner with a call light available next to toilet. The bathing room had a large spa tub, and several pieces of transfer equipment, including a Hoyer lift, EZ stand lift, and shower chair stored near vicinity of toilet. A clear path to toilet was observed, however potential for fall/tripping hazard identified with bathing room also being utilized as a storage space.On 12/15/2025 at 2:30 PM, Surveyor observed R19 in his room lying in bed with urinal on the floor next to bed. Surveyor asked R19 where he goes to the bathroom. R19 pointed to the urinal on the floor. R19 stated he uses the bathroom down the hall if he needs to have a bowel movement. R19 confirmed to Surveyor this routine is for nighttime as well. Surveyor asked R19 how he felt about this. R19 stated, What choice do I have. R19 stated he must find a staff member to unlock the door when he needs to use the toilet in the bathing room, including at night. R19 walks around until he finds someone to unlock the door, that all staff have a key. R19 did not answer when Surveyor asked if he uses a call light to alert staff when needing to use a toilet. On 12/16/25 at 12:10 PM, a record consent was found in chart, dated 04/14/2018 and signed by R19's legal representative, allowing R19 to use a shower room that is used by both male and female residents. It is noted this consent form is a universal Bathroom/Shower Room Waiver Consent used facility wide. There is no consent found in R19's medical record, signed by a legal representative, giving permission for the door to R19's bathroom to be locked, preventing R19 to use toilet. On 12/19/25 at 8:57 AM, R19's legal representative returned a phone message left by Surveyor and confirmed he was aware bathroom door in R19's room was locked, that R19 used toilet in bathing room at times, and was not aware of any adverse events happening because of it.On 12/17/2025 at 8:32 AM, Surveyor interviewed NCC C about R19 having to use the bathing room for toileting needs. NCC C stated R19 had a long-standing history of psychotic behaviors which include hoarding and aggressiveness towards staff and other residents. NCC C stated R19 used to wash up in his bathroom toilet, and since it is a shared toilet with another resident, the bathroom door was locked for R19's safety and infection control concerns. Surveyor asked NCC C when was the last time R19 had been reevaluated for this behavior since care plan intervention was placed in 2022, and NCC C stated she was not sure. NCC C stated R19 should be reassessed for any behaviors of using the toilet in his bathroom for washing up in.On 12/17/25, a nursing note dated 09/06/2022, indicated episode of R19 using his bathroom toilet to wash up in. Intervention was then placed to lock R19's bathroom door. No further documentation of continued behavior monitoring of this kind was found in chart. No documentation of offering a trial of personal bathroom use to R19 since incidents in 2022 found in R19's medical record or care plan.On 12/17/25 at 12:58 PM, Surveyor interviewed Social Worker (SW) S, about R19's history of using his bathroom toilet to wash up in. SW S stated the behaviors happened before she worked at the facility and is unaware if R19 has been reevaluated since 2022. SW S was not made aware of any continued behaviors of R19 washing up in a toilet.

Based on interview and record review, the facility did not ensure that a resident who requires dialysis receives such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 2 of 2 sampled residents (R9 and R17) reviewed for dialysis.The facility failed to provide ongoing assessments of R9 and R17's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. This is evidenced by:R9 was admitted to the facility on [DATE]. R9's current diagnoses include in part, streptococcal sepsis, pressure ulcer of sacral region stage 3, end stage renal disease, dependence on renal dialysis, heart transplant status, paraplegia, severe protein-calorie malnutrition, long term use of antibiotics, methicillin resistant staphylococcus aureus, open wound of right buttock, epidural hemorrhage, heart valve replacement, osteoporosis, wedge compression fracture thoracic vertebra, and major depressive disorderMinimum Data Set (MDS) dated [DATE] a quarterly assessment documented R9 having a Brief Interview of Mental Status (BIMS) score of 11/15 meaning R9's cognition is moderately impaired. R9 is dependent on staff for toileting hygiene, lower body dressing, bed mobility and transfers. R9 requires moderate assistance of staff for upper body dressing. R9's care plan, [R9] receives hemodialysis r/t renal failure 3x/wk. Date Initiated: 06/07/2022 Revision on: 06/07/2022.INTERVENTIONS: Do not draw blood or take B/P in arm with graft.Date Initiated: 06/07/2022If bleeding from the fistula occurs after dialysis, apply hemostatic sponge and apply pressure to side for at least 10 min. Emergency kit in closet. Date Initiated: 06/07/2022 Revision on: 06/07/2022Monitor/document/report PRN new/worsening peripheral edema. Date Initiated: 06/07/2022 Monitor/document/report PRN any s/sx of infection to access site: Redness, Swelling, warmth or drainage. Date Initiated: 06/07/2022Monitor VITAL SIGNS per facility protocol and with acute change in condition.Review of R9's physician orders documented 10/10/25 Take Vitals M, W, F before and after dialysis. two times a day every Mon, Wed, Fri.Review of R9's medical record found the medication and treatment administration record did not document vital signs. Documentation of a comprehensive assessment of an inspection of dialysis port site before or after return from dialysis was not documented. When staff documented in the electronic medical record of R9's blood pressure (b/p) readings, Surveyor is unable to determine if the readings were immediately upon R9's return from dialysis. Review of R9's electronic medical record documented on dialysis days only one b/p reading on 11/14/25, 11/19/25, 11/24/25, 12/03/25, 12/08/25, 12/10/25, 12/12/25 and 12/17/25. The vital sign flowsheet-weight flowsheet sent to dialysis did not document on 11/19/25 on PM a temperature and weight, 11/21/25 no vitals for AM or PM, 11/26/25 no PM vitals, 11/28/25 no AM vitals, 12/01/25 no PM vitals, 12/03/25 no AM or PM vitals, 12/05/25 no AM weight and no PM vitals, 12/08/25, 12/10/25, and 12/12/25 no AM weight and no PM vitals, and 12/15/25 no weights.On 12/16/25 at 8:47 AM, Surveyor interviewed R9 asking if nurses assess resident before and after dialysis appointments. R9 stated she has dialysis Monday, Wednesday, and Friday. After dialysis, staff get R9 into bed and she has supper. Staff sometimes take blood pressure and the bandage on the port site stays on for 24 hours, and R9 doesn't think staff observe the site.Example 2R17 was admitted to the facility on [DATE]. R17's current diagnoses include in part, traumatic subarachnoid hemorrhage, traumatic subdural hemorrhage, hemorrhage of left cerebrum, fracture of orbit, maxillary fracture, end stage renal disease, dependence on renal dialysis, type 2 diabetes mellitus, congestive heart failure, atherosclerotic heart disease, retention of urine, dizziness and giddiness, and chronic kidney disease stage 4. MDS dated [DATE] a 5 day assessment documented R17 having a BIMS score of 6 meaning R17's cognition is severely impaired. R17 requires staff supervision for upper body dressing and transfers. Moderate assistance from staff for lower body dressing.R17's care plan read in part: [R17] needs dialysis (hemo) r/t renal failure Date Initiated: 01/23/2023. Intervention: Do not draw blood or take B/P in arm with graft. Date Initiated: 01/23/2023Review of R17's physician orders documented, 10/22/25 Take Vitals Tues, Thur, Sat before and after dialysis. two times a day every Tue, Thu, Sat for Dialysis 10/22/25 Bleeding fistula- Emergency kit, Apply helistat sponge to area and apply pressure for at least 10minutes. as needed Emergency kit to be in wound cart in bag. (helistat sponge, gauze and tape).Review of R17's medical record found the medication and treatment administration record did not document vital signs. Documentation of a comprehensive assessment of an inspection of dialysis port site before or after return from dialysis was not documented. When staff documented in the electronic medical record of R17's blood pressure (b/p) readings Surveyor is unable to determine if the readings were before dialysis and immediately upon R17's return from dialysis. Review of R17's electronic medical record on dialysis days documented only one set of b/p on 11/11/25, 11/20/25, 11/22/25, 11/25/25, 11/27/25, 11/29/25, 12/04/25, 12/09/25, 12/11/25, and 12/16/25. No b/p was documented on 11/18/25, 12/02/25, and 12/13/25. The vital sign flowsheet was not available for review. On 12/18/25 at 11:00 AM, Director of Nursing (DON) B stated the facility does not have a policy and procedure for assessments for dialysis.On 12/18/25 at 11:14 AM, Surveyor interviewed Nursing Care Coordinator (NCC) I asking if assessments of vitals and site inspection are to be completed pre and post dialysis. NCC I stated the assessments should be completed with vitals and weight before they go. They have a dialysis communication book with the vitals and RN stated facility staff fills out the sheets. When resident returns staff are to check vitals and check the site.

Based on observation and interview, the facility did not ensure 1 of 29 residents (R89) reviewed, reserved the right to make choices about an aspect of their life that was significant to them. The facility implemented a care plan for R89's request to go to the therapy room and complete independent exercises daily, Monday through Friday. The facility did not follow R89's care plan and did not assist R89 to therapy. The facility's policy titled, Resident Rights, read in part, Residents have a comprehensive set of rights aimed at ensuring dignity, autonomy, and quality of life. These rights include the right to be treated with respect, participate in care planning, and voice grievances without fear of retaliation. Residents have the right to be treated with consideration and respect for their individuality, including their personal preferences. Residents have the right to actively participate in the planning of their individualized care and services, including treatment options, and to make informed decisions about their care. Residents have the right to make their own decisions about their lives, including their care, finances, and personal relationships. R89 was admitted to the facility on [DATE], with diagnoses including heart failure, chronic obstructive pulmonary disease (COPD), atrial fibrillation, anxiety, history of falling, and chronic pain. R89 was admitted from the hospital following generalized weakness, COPD exacerbation, and pneumonia. Upon admission, R89's goal was to increase his strength and return home. On 11/25/25, a Minimum Data Set (MDS) assessment confirmed R89 scored 13/15 during Brief Interview for Mental Status (BIMS), indicating intact cognition. R89 was his own decision maker.R89 required assistance with the following functional abilities:-Eating, set-up-Oral hygiene, set-up-Toileting, dependent on staff-Showering, substantial assistance-Dressing upper body, partial assistance-Dressing lower body, substantial assistance-Putting on/Taking off footwear, dependent on staff-Personal hygiene, set-up-Mobility, independent with wheelchair-Transfers, staff supervision-Ambulation with walker, staff supervision R89's care plan included the following:Activities of Daily Living (ADL) self-care deficit, 08/01/25.Interventions:-Assist of one with front wheeled walker and gait belt (RESTORATIVE), revised 11/11/25.-Take R89 to the therapy room at shift report on the way out of the building M-F, date initiated 12/17/25.-Rehab/Restorative: walking program. Ambulate assist of one with gait belt and front wheeled walker to his tolerance up to 200 feet, with wheelchair to follow. No date.-Please ambulate R89 to/from meals with front wheeled walker and gait belt, revised 12/18/25. At risk for falls related to deconditioning, limited mobility, 08/04/25.Interventions:-15-minute checks to decrease impulsive transferring without assistance, revised 10/01/25. Chronic pain, revised 11/17/25Interventions:-Exercises to address stiffness, 08/04/25.-Observe and report changes in functional abilities and/or range of motion, 08/04/25. Hypertension, 08/04/25Interventions: -Educate about the importance of maintaining a normal weight for height, the value of regular exercise, 08/04/25. On 12/15/25 at 9:33 AM, Surveyor interviewed R89. R89 was in his room, self-propelling his wheelchair within his room. R89 was anxious and making statements of: will I get to talk to the head nurse today, being up here is not like downstairs, it's taking a long time to get use to this. R89 reported he was moved to his current unit on 12/11/25. R89 reported the move to his new room and unit was, chaotic. R89 stated on his previous unit he would go to the therapy room daily and complete independent exercises, even though he was no longer in therapy. R89 stated since he moved on 12/11/25, he has asked staff to take him to the therapy room, but staff have told him, 'We don't have enough staff to take you,' and 'Therapy staff will take you down to therapy.'On 12/15/25 at 9:58 AM, Surveyor observed therapy staff go into R89's room. Surveyor heard therapy staff talking with R89, and telling R89 nursing staff would bring R89 down to use the therapy room. On 12/16/25, Surveyor observed R89 on the unit, intermittently throughout the day. Surveyor did not observe staff ambulate with R89 or offer to take him to the therapy room. On 12/16/25 at 2:50 PM, Surveyor interviewed R89. R89 stated staff have not walked with him or taken him down to the therapy room. On 12/17/25 at 8:32 AM, Surveyor interviewed Certified Nursing Assistant (CNA) J. CNA J was not sure if R89 had a restorative program. CNA J looked at the Kardex she had in her pocket and verified the Kardex read, ambulate with front wheeled walker daily. Surveyor asked CNA J if staff were ambulating with R89, and CNA J stated she was not sure, as she does not usually work on the unit R89 resided on. On 12/17/25 at 8:47 AM, Surveyor interviewed R89. R89 was seated in the recliner in his room. R89 was upset when telling Surveyor, Staff are supposed to talk with me and follow with the wheelchair. They don't. It hasn't happened since I've been here. I guess it's supposed to change today at 2:00 PM, they are supposed to walk me to the nurse's station and then take me to the therapy room. We'll see, I don't know if they don't have enough people, or what. It seems like they don't give a damn. I'm sorry, I'm just getting anxious I guess, I've been sitting here since Thursday. On 12/17/25 at 8:50 AM, Surveyor interviewed Nurse Care Coordinator (NCC) G. NCC G reported R89 does have a restorative program for ambulation and staff should be walking him. NCC G stated she spoke with CNA D on 12/16/25. R89's plan was updated to include, at 2:00 PM, staff will ambulate R89 to the nurse's station and then take him to therapy, and therapy staff will bring R89 back to the unit. On 12/17/25 at 1:55 PM, Surveyor observed R89's unit. Surveyor observed R89 was seated in his recliner, in his room. Surveyor asked R89 if staff walked with him or took him to therapy on this date. R89 stated staff had not, but he was waiting as NCC G told him this would happen at 2:00 PM, at shift change. On 12/17/25 at 2:00 PM, Surveyor observed two CNAs on the unit, charting and wiping off dining tables. Surveyor interviewed CNA K about residents with restorative programs. CNA K indicated residents on the unit with a restorative program; CNA K did not indicate R89 was on a restorative program. CNA K stated she did not ambulate R89, but stated the previous unit R89 was on, he did have a walking program. CNA K did confirm with Surveyor, 2:00 PM was shift change and CNA J and CNA K would be ending, and two new CNAs would be starting. Surveyor continued to observe R89 and staff and noted the following:-At 2:01 PM, two new CNAs on the unit-At 2:14 PM, R89 told new, oncoming CNAs he was to walk to the nurse's station and then go to therapy. Surveyor observed the CNAs look at R89's Kardex and ask CNA J and CNA K about R89's request. CNA J and CNA K stated they were not sure.-At 2:16 PM, Surveyor observed staff assist a resident with a mechanical lift transfer.-At 2:23 PM, CNAs assisted another resident with a mechanical lift transfer. Surveyor observed CNA J charting on the computer and CNA K was not on the unit.-At 2:37 PM, Surveyor observed R89 ambulating with walker from his room. At 2:37 PM, Surveyor interviewed R89. R89 stated, [NCC G] told me there was an order from therapy for staff to walk me to the nurse's station and take me to therapy, but there must not be an order. [NCC G] isn't here now, and I've been waiting 45 minutes. I am just going to walk by myself dammit! Surveyor observed CNA J charting at the computer, and RN F giving report at the nurse's station. Surveyor observed R89 continue to ambulate independently with his walker in the hallway. At 2:40 PM, Surveyor observed Social Worker (SW) L come onto the unit. Surveyor observed R89 tell SW L at 2:00 PM, staff were supposed to help him walk to the nurse's station and then take him to therapy. SW L told R89 she would get staff to help him. R89 began talking louder to SW L, and continued walking. Surveyor observed R89 was notably upset. Surveyor observed SW L request CNA J assist R89. At 2:45 PM, Surveyor interviewed Registered Nurse (RN) F. RN F was giving report to another nurse at the nurse's station. RN F reported she was not aware of the plan for R89 to ambulate with staff to the nurse's station and then staff assist R89 to therapy. RN F confirmed she has witnessed staff assist R89 with ambulating on the unit as recently as 12/16/25. On 12/18/25 at 11:11 AM, Surveyor interviewed R89. R89 was seated in his recliner in his room. R89's overall demeanor was calmer on this date compared to previous interviews with R89. R89 reported staff did not take him to therapy yesterday, 12/17/25. R89 stated he thinks it is worked out now as NCC G came and talked with him this morning. On 12/18/25 at 11:18 AM, Surveyor interviewed NCC G. NCC G stated she was aware of the incident on 12/17/25, with R89 ambulating independently and R89 becoming upset. NCC G reported she did update R89's care plan from 12/17/25, please take R89 down to therapy room at shift report, to, revised 12/18/25, please take R89 down to therapy room at shift report on way out of the building. Ensuring staff leaving their shift at 2:00 PM will be responsible to assist R89 to therapy. NCC G confirmed she spoke with R89 this morning, and R89 was satisfied with this plan. Surveyor and NCC G discussed the negative impact this had on R89. NCC G stated she understood, and staff would be re-educated on resident's restorative programs.

Based on interview and record review, the facility did not ensure staff received training regarding abuse, neglect, and exploitation and what activities constitute abuse, procedures for reporting and dementia management and resident abuse prevention. This has to potential to affect all 134 residents.This is evidenced by:The facility's policy titled Abuse, Neglect, Mistreatment & Misappropriation of resident property policy & procedure, which is not dated, states in part: .Staff and volunteers will receive education about resident mistreatment, neglect, and abuse, including injuries of unknown source, exploitation and misappropriation of property upon first employment and annually after that.Surveyor reviewed Certified Nursing Assistant (CNA) G, CNA F, and Registered Nurse (RN) E's education for abuse. CNA G completed abuse education on 07/05/23, and RN E completed abuse education on 01/30/24. CNA F did not have recorded abuse education training. On 10/14/25 at 11:50 AM, Surveyor interviewed CNA G about the abuse training. CNA G stated had received abuse education when they first took the CNA class at the facility in 2022.On 10/15/25 at 10:00 AM, Surveyor interviewed Director of Nursing (DON) B asking about monitoring for completion of staff education on abuse, neglect and misappropriation at time of hire and annually. DON B stated CNA F's abuse training upon hire was not completed. DON B stated it is the expectation new hire training to be completed before working with residents. Currently working on a system to ensure all staff are assigned training in the computer and to be completed by 10/31/25. DON B stated understanding there may be staff with a lapse in annual training since trying to put this new system in place. CNA G's training was missed since CNA G was casual. RN E will be scheduled to complete trainings. No additional information was provided.

Based on interview and record review, the facility did not implement policy and procedure to protect residents following a known incident of abuse, report and investigate allegations of abuse, and complete required training of staff. This has the potential to affect all the facility's 134 residents. The facility did not implement its abuse policy and procedures by the following:Certified Nursing Assistant (CNA) G was instructed to physically restrain Resident (R) 1 while CNA F administered medication. CNA G did not immediately report to Director of Nursing (DON) or Nursing Home Administrator. Accused staff continued to work in the facility until the incident was reported a week later.The facility did not submit to the state agency a facility reported incident for 2 abuse allegations.The facility did not report the abuse of R1 to law enforcement. The facility did not notify R1's representative of the incident of abuse. The facility did not complete a full investigation of allegations of abuse for R1 and R3. The facility did not ensure staff upon hire and annually completed abuse, neglect, mistreatment and misappropriation of resident property.This is evidenced byThe facility's policy titled Abuse, Neglect, Mistreatment & Misappropriation of resident property policy & procedure, which is not dated, states in part: Each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, corporal punishment or involuntary seclusion. The resident will also be free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms.the Nursing Home Administrator or designee will report abuse to the state agency per State and Federal requirements.Staff and volunteers will receive education about resident mistreatment, neglect, and abuse, including injuries of unknown source, exploitation and misappropriation of property upon first employment and annually after that.When an incident or suspected incident of abuse is reported, the Administrator or designee will investigate the incident with the assistance of appropriate personnel.The Administrator will keep the resident or his/her resident representative informed of the progress of the investigation.All reports of suspected crime and/or alleged sexual abuse must be immediately reported to local law enforcement to be investigated. The follow-up investigative notes will be submitted via email or fax to DQA within five working days of the initial report.Employees accused of alleged abuse will be immediately removed from the facility and will remain removed pending the results of a thorough investigation.The facility will ensure that all alleged violations involving abuse, neglect exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made.Example 1R1 was admitted to the facility on [DATE] with pertinent diagnoses of anxiety disorder, depression, personality disorder with other symptoms and signs involving cognitive functions and awareness, and unspecified psychosis not due to substance or known physiological condition.R1's most recent significant change Minimum Data Set (MDS) assessment dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 00, indicating severely impaired cognition. R1 was noted to have physical, verbal, and other behavioral symptoms occurring 1-3 days, delusions present, and rejection of cares occurred 4-6 days. R1 was independent with eating, sit to lying, sit to stand, and chair/bed transfers. R1 was receiving antipsychotic and antianxiety medications.The facility's investigation dated 08/12/25 documented on 08/12/25 Registered Nurse (RN) C reported RN D received a concern from CNA G regarding inappropriate medication administration to R1 by CNA F. CNA G stated that on that day, both CNA F and RN E asked CNA G to assist in giving R1 his medication. CNA G was instructed to stand behind R1 and hold his arms to his side. CNA G observed CNA F placing her hands on both sides of R1's cheeks to open his mouth and placing medication into his mouth. RN E then handed CNA F a bottle of Gatorade, which CNA F poured into R1's mouth to assist with swallowing. RN E handed CNA F a syringe of Haldol, to administer. CNA F reported that someone would hold R1's hands while CNA F squirted the syringe of Haldol medication into the side of his cheek. CNA G acknowledge placing her hands under his chin while administering Haldol. CNA F and RN E were placed on paid administrative leave on 08/12/25. On the same day all CNA and nursing staff received re-education on identifying and reporting abuse, following court-ordered medication care plans, and the prohibition of physical holds unless properly trained. Facility's conclusion, CNA F engaged in inappropriate medication administration practices and was terminated. On 10/14/25 at 11:50 AM, Surveyor interviewed CNA G about the abuse with R1. CNA G stated between 9:00 - 9:30 PM, CNA F and RN E instructed CNA G to assist holding R1's hands to give medication. CNA G held R1's hands and CNA F placed CNA F's hand on R1's face to open mouth and gave medication. CNA G stated this also occurred the next afternoon shift around the same time. CNA F threw R1 into a recliner and stated to R1 CNA F will sit on you if you don't take your medication. CNA F squatted over R1 while CNA G held R1's hands and CNA F gave medications by holding R1's face. CNA G could not recall the dates of both incidents and believed this occurred on a Tuesday and Wednesday and reported to RN D on that Thursday or Friday. RN D did not report to administration for 3 days. CNA G stated had received abuse education when first taken the CNA class at the facility in 2022.Surveyor reviewed CNA F, CNA G, and RN E's time sheets. CNA F continued to work on 08/09/25, 08/10/25, and 08/11/25. CNA G continued to work 08/07/25, 08/08/25, and 08/10/25 through 8/19/25. RN E continued to work 08/08/25 through 08/10/25.Surveyor reviewed CNA G and RN E's education for abuse. CNA G completed abuse education on 07/05/23 and RN E completed abuse education on 01/30/24. CNA F did not have recorded abuse education training. Surveyor reviewed signed memorandums for all CNAs and nursing staff for reminders of reporting and identifying abuse, following court-ordered medication care plans, prohibition on untrained physical holds. The signed memorandums did not appear to have all facility's CNAs and nursing staff signatures. The memorandum did not include education of the entire abuse policy to include ensuring safety of residents to remove the accused staff, reporting to state agency and law enforcement. On 10/14/25 at 12:58 PM, Surveyor interviewed DON B about the abuse allegation, reporting, and education. DON B stated this was not reported to State because it was late being reported to DON and State survey agency would be giving them a cite for reporting late so decided not to report. Then completed the investigation and education. Surveyor asked what date the incident occurred on as it was not stated in the facility's investigation. DON B could not recall and thought the date was in the report. Surveyor asked why the incident on 08/06/25 was not included in the investigation when CNA F's termination letter stated for the incidents that occurred on 08/05/25 and 08/06/25. DON B could not answer to that. Surveyor asked if R1's representative was notified of the incident of abuse occurring. DON B stated R1's representative was notified. Surveyor asked for documentation of the notification. Of note, Surveyor was not provided documentation. On 10/15/25 at 10:00 AM, Surveyor interviewed DON B asking about monitoring for completion of staff education on abuse, neglect and misappropriation after the incident and annually. DON B stated the trainings were left out for a week and the Nurse Clinical Coordinators (NCC) would be checking to make sure their staff were educated. Surveyor asked if there is a system to ensure all nursing staff were educated after R1's incident. DON B stated there is no system, only the NCCs to monitor. Surveyor asked about all staff education upon hire and annually. DON B stated CNA F's abuse training upon hire was not completed. DON B stated it is the expectation new hire training to be completed before working with residents. Currently working on a system to ensure all staff are assigned training in the computer and to be completed by 10/31/25. DON B stated understanding there may be staff with a lapse in annual training since trying to put this new system in place. CNA G's training was missed since CNA G was casual. RN E will be scheduled to complete trainings. Surveyor asked if the incident with R1 was on 08/05/25 and 08/06/25 why did it take until 08/12/25 to report. Surveyor asked if there were written statements from staff or notes from interviews with staff. DON B stated on 08/12/25, RN D reported to RN C. RN D came to RN C in a panic about forgetting to report the incident with R1. RN C immediately reported to DON B. RN E and CNA F were put on administrative leave on 08/12/25. DON B stated there were no staff written statements and did not keep notes of staff interviews after typing up the timeline. Surveyor asked if DON B reported RN E and CNA F to state agency of caregiver quality. DON B stated this incident was not reported. Surveyor asked if the incident was reported to the police and DON B stated it was not reported.Example 2R3 was admitted to the facility on [DATE] with pertinent diagnoses of mild cognitive impairment of uncertain or unknown etiology, personality disorder, delusional disorders, unspecified psychosis not d/t a substance or known physiological condition, and depression.On 08/08/25 at 2:45 PM, local law enforcement was contacted by R3's sister reporting an allegation of abuse.On 08/08/25 at 3:31 PM, law enforcement arrived at facility and informed staff purpose of visit was related to allegation of abuse concerning R3. The facility did not submit a Facility Reported Incident (FRI) concerning allegation of abuse to the State Agency. On 10/14/25 at 1:10 PM, Surveyor interviewed DON B regarding incident. DON B stated that R3 and his sister have called the police and reported numerous allegations of abuse that were unfounded. DON B stated that on 08/08/25, R3 had been threatening to call 911 numerous times for being held against his will and had notified the police that R3 might call to report this. Surveyor asked why this allegation was not reported. DON B stated the facility already knew this allegation was not true due to the multiple prior reports and did not think it should be reported or investigated.

Based on record review and interview, the facility did not implement policies and procedures for ensuring the reporting of physical abuse in accordance with section 1150B of the Act when an allegation of physical abuse was not reported immediately, but no later than 2 hours to the administrator and local law enforcement in accordance with state law through established procedures for 2 of 3 residents (R) reviewed (R1 and R3).On 08/08/25, the facility was notified by local law enforcement that an allegation was reported of abuse regarding R3. The facility did not investigate or report this allegation to the State Agency (SA).On 08/12/25, the facility was made aware of an allegation of abuse regarding R1. The facility did not report this allegation to the SA.This is evidenced by:Facility policy titled, Abuse, Neglect, Mistreatment & Misappropriation of Resident Property Policy & Procedure, with no implemented or reviewed date, states in part: G. Reporting and Response: It is the policy of this facility that abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the event that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.Example 1R3 was admitted to the facility on [DATE] with pertinent diagnoses of mild cognitive impairment of uncertain or unknown etiology, personality disorder, delusional disorders, unspecified psychosis not d/t a substance or known physiological condition, and depression.On 08/08/25 at 2:45 PM, local law enforcement was contacted by R3's sister reporting an allegation of abuse.On 08/08/25 at 3:31 PM, law enforcement arrived at facility and informed staff purpose of visit was related to allegation of abuse concerning R3.The facility did not submit a Facility Reported Incident (FRI) concerning allegation of abuse to the State Agency.On 10/14/25 at 1:10 PM, Surveyor interviewed Director of Nursing (DON) B regarding incident. DON B stated that R3 and his sister have called the police and reported numerous allegations of abuse that were unfounded. DON B stated that on 08/08/25, R3 had been threatening to call 911 numerous times for being held against his will and had notified the police that R3 might call to report this. Surveyor asked why this allegation was not reported. DON B stated the facility already knew this allegation was not true due to the multiple prior reports and did not think it should be reported or investigated.Example 2R1 was admitted to the facility on [DATE] with pertinent diagnoses of anxiety disorder, depression, personality disorder with other symptoms and signs involving cognitive functions and awareness, and unspecified psychosis not due to substance or known physiological condition.On 08/12/25, DON B was notified of an allegation of abuse regarding R1 that occurred on 08/05/25 and 08/06/25 and began an investigation. On 08/05/25, between 9:00-9:30 PM, Certified Nursing Assistant (CNA) G was asked to assist CNA G and Registered Nurse (RN) E administer R1's medications. CNA G was told by CNA F and RN E to hold R1's hands/arms while CNA F held R1's chin and squirted the syringe of medication into R1's mouth. As CNA F administered R1's medications using physical restraint, RN E would supervise. CNA G did not immediately report this to a supervisor.On 08/06/25 between 9:00-9:30 PM, CNA G observed CNA F throw R1 into a recliner in the day room and told R1 that CNA F will sit on you (R1) if you don't take your meds. CNA G then observed CNA F squat over R1 to act like CNA F was going to sit on R1. CNA G heard R1 state 'no, no' during this encounter. The following day, CNA G reported concerns to the unit nurse manager, RN D. RN D stated to CNA G that this is bad and is abuse. RN D did not immediately report this to Director of Nursing (DON) B.On 08/12/25, DON B was notified and began an investigation. On 08/19/25, facility investigation determined abuse occurred and terminated CNA F. A FRI was not submitted to the State Agency to report allegation of abuse. No documentation was noted demonstrating local law enforcement was contacted to report allegation of abuse.On 10/14/25 at 1:10 PM, Surveyor interviewed DON B regarding reporting allegation of abuse. DON B stated this was not reported to State because it was late being reported to DON and State survey agency would be giving them a cite for reporting late so decided not to report.

Based on interview and record review, the facility did not ensure prescription medications were administered by qualified staff for 1 of 3 residents (R1) reviewed.R1's medications were administered by a Certified Nursing Assistant (CNA).This is evidenced by:Facility policy titled, Medication Administration & Treatment by Certified Nursing Assistants, with no date, states in part: Policy: This facility will comply with all state and federal guidelines related to medication administration in order to ensure the safety of resident. Nursing assistants may NOT administer any medications or perform any treatments with the following exception as delegated by the nurse: 1. Nursing assistants can apply prescription and nonprescription topical creams and ointments to UNBROKEN skin during daily cares. 2. Nursing assistants can provide oral care with mouthwashes.Facility policy titled, Medication Administration, with no date, states in part: Policy: Medication administration will adhere to all federal and state regulations. All medications shall be administered by a licensed nurse or nurse technician per physician order.R1 was admitted to the facility on [DATE] with pertinent diagnoses of anxiety disorder, depression, personality disorder with other symptoms and signs involving cognitive functions and awareness, and unspecified psychosis not due to substance or known physiological condition.R1's physician orders:-Haloperidol Lactate Oral Concentrate 2 MG/ML (Haloperidol Lactate) Give 2.5 ml by mouth one time a day for Behavior/agitation/mood.-Valium Oral Tablet 5 MG (Diazepam) Give 1 tablet by mouth every 8 hours as needed for anxiety.On 08/12/25, Director of Nursing (DON) B was made aware of an allegation of abuse regarding R1 and began an investigation. Interviews were completed with Certified Nursing Assistant (CNA) F, CNA G, and Registered Nurse (RN) E, who were identified in the complaint. Facility's documentation noted CNA F admitted administering R1's medications using food, ice cream, and a syringe. CNA F stated that someone would hold R1's hand while CNA F held R1's chin and squirted the syringe of medication into R1's mouth. While CNA F administered R1's medications using physical force, RN E would supervise.Surveyor reviewed CNA F's personnel file and noted no medication administration training completed.On 10/14/25 at 1:10 PM, Surveyor interviewed DON B regarding facility's investigation and the noted medication administration by CNA F. DON B stated it was common practice for the facility to allow CNAs to administer medications while under direct supervision of a nurse. Surveyor asked DON B if CNAs received additional training or competency evaluation to administer medications. DON B stated, no, that no competency would be needed if the nurse prepares the meds and directly observes the administration by the CNA. DON B further stated that as long as the nurse delegated the medication administration task to the CNA, it was completely acceptable for unlicensed staff to administer medications as long as the RN directly supervised.

Based on interview and record review, the facility did notify the resident representative of a change in condition for 1 of 3 residents (R) reviewed (R1).On 08/12/25, the facility was notified of an allegation of abuse regarding R1. R1's legal guardian was not notified of incident or subsequent investigation findings.This is evidenced by:Facility policy titled, Abuse, Neglect, Mistreatment & Misappropriation of Resident Property Policy & Procedure, with no implemented or reviewed date, states in part: G. Reporting and Response: The Administrator or designee will inform the resident or resident's representative of the report of an incident and that in investigation is being conducted. The Administrator or designee, will inform the resident and/or responsible party the results of the investigation.R1 was admitted to the facility on [DATE] with pertinent diagnoses of anxiety disorder, depression, personality disorder with other symptoms and signs involving cognitive functions and awareness, and unspecified psychosis not due to substance or known physiological condition.R1's most recent significant change Minimum Data Set (MDS) assessment dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 00, indicating severely impaired cognition. R1 was noted to have physical, verbal, and other behavioral symptoms occurring 1-3 days, delusions present, and rejection of cares occurred 4-6 days. R1 was independent with eating, sit to lying, sit to stand, and chair/bed transfers. R1 was receiving antipsychotic and antianxiety medications. No use of physical restraints.R1's care plan, with an initiated date of 01/28/25 and a target date of 08/04/25, states: Medication non-compliance r/t unspecified schizophrenia spectrum and other psychotic disorder and personality disorder with interventions of If R1 refuses to take medication attempt to determine the reason for refusal; if no response after 1 attempt do not use progressive verbal prompts as it leads to verbal aggression and physical threats, re-approach in a few minutes, notify physician and guardian of change of condition.Surveyor reviewed R1's medical record and noted:04/30/25 - documentation of court appointed permanent guardianship due to incompetency.05/01/25 - documentation of an Involuntary Order to Treat with Psychotropic Medications ordered by the court.Between 10/13/25 - 10/15/25, Surveyor investigated an anonymous complaint regarding an allegation of facility staff holding R1's arms and face while administering medications. Surveyor reviewed facility's documentation and noted that on 08/12/25, Director of Nursing (DON) B was notified of an allegation of abuse that occurred on 08/05/25 and 08/06/25. The facility completed an investigation and determined on 08/19/25 that the allegation was substantiated. The facility completed staff and resident interviews, re-education with direct care staff, and notified the provider of the incident. No documentation of informing the guardian was noted.On 10/14/25 at 9:22 AM, Surveyor interviewed R1's Guardian (G) H. Surveyor asked G H if she was aware of incident that occurred on 08/05/25 and 08/06/25. G H stated no one in the facility had informed her of this occurring and no details of an investigation or findings of abuse being confirmed were communicated. G H told Surveyor this was the first time hearing of this event.On 10/14/25 at 1:03 PM, Surveyor interviewed DON B regarding incident. DON B stated that she was pretty sure the guardian was notified but would double-check for documentation to provide the surveyor. No additional documentation was provided.

Based on interviews and record review, the facility failed to ensure each resident is free from physical restraints that are not required to treat the resident's medical symptoms for 1 of 3 resident reviewed for restraints (R1).On 08/05/25 and 08/06/25, facility staff used physical restraint to give R1 oral medications.This is evidenced by:Facility policy titled, Restraints, Use of (Physical), with a most recent revised date of 01/09/14, states in part: Policy: The use of any type of physical restraint will be based on evaluation of risk versus benefit of use following a comprehensive assessment and identification of needs and medical symptoms. A physical restraint will be used as a last resort or on a temporary trial following failure of alternative interventions. The choice of physical restrain will be identified as the least restrictive and used only when deemed necessary and appropriate as permitted by regulation. The use of a physical restraint will be an exception. The individual's legal representative will be involved in the decision-making process following education of risk versus benefit of use. Definition of Physical Restraint: Any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body (SOM, Appendix PP). Requirements for use: A physician order that identifies the medical symptom(s) supporting the use of the physical restraint. Verbal followed by a written consent for the use of the restraint by the legal representative. Completion of a pre-restraining assessment to determine possible contributing factors to the identified behavior and to identify all other alternative that have been tried and failed or may need to be tried prior to use of a physical restraint.The care plan must focus on: preventing adverse effects (i.e. ADL decline, increased patterns of incontinence, skin breakdown) of physical restraint use, identification of when the restrain is to be used and how long, a process in place for systematic and gradual restraint reduction or elimination, a tracking mechanism must be in place to identify when a restraint was applied and when it was removed.Facility policy titled, Medication Administration, with no date, states in part: 14. B. Court-Ordered Medications: If a court order for involuntary medication is in place, medications may be administered without the resident's consent.Medications may be administered in resident food or fluid without their knowledge or by means of restraint. Restraints may only be completed by individuals properly trained in restrain techniques. 15. The nurse is aware of the repercussions of misconduct or unprofessional conduct as it relates to medication administration per Rules of Conduct, Chapter N 7.04, Wisconsin Statutes and Administration Code for the Board of Nursing.R1 was admitted to the facility on [DATE] with pertinent diagnoses of anxiety disorder, depression, personality disorder with other symptoms and signs involving cognitive functions and awareness, and unspecified psychosis not due to substance or known physiological condition.R1's most recent significant change Minimum Data Set (MDS) assessment dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 00, indicating severely impaired cognition. R1 was noted to have physical, verbal, and other behavioral symptoms occurring 1-3 days, delusions present, and rejection of cares occurred 4-6 days. R1 was independent with eating, sit to lying, sit to stand, and chair/bed transfers. R1 was receiving antipsychotic and antianxiety medications.R1's care plan, with an initiated date of 01/28/25 and a target date of 08/04/25, states: Medication non-compliance r/t unspecified schizophrenia spectrum and other psychotic disorder and personality disorder with interventions of:-Document refusal,-If [R1] refuses to take medication:-Attempt to determine the reason for refusal; if no response after 1 attempt do not use progressive verbal prompts as it leads to verbal aggression and physical threats, re-approach in a few minutes,-Wait a few minutes and then offer again,-Provide education as to why the need of the medication,-If refusals continue, explore other options with primary care physician,-Questions to ask to try to determine the reason for refusal: Does [R1] experience unpleasant side effects from the medication? Does [R1] have difficulty swallowing? Is [R1] afraid for some reason?Special Instructions: *COURT ORDERED PSYCHIATRIC MEDICATIONS - Psychiatric medications should be disguised in food or drink. Court ordered psychotropic medications is in place so do not need to tell him medication is in food).-Of note: R1's care plan does not include interventions associated with the use of physical restraints to administer psychotropic medications.R1's physician orders:-Haloperidol Lactate Oral Concentrate 2 MG/ML (Haloperidol Lactate) Give 2.5 ml by mouth one time a day for Behavior/agitation/mood.-Valium Oral Tablet 5 MG (Diazepam) Give 1 tablet by mouth every 8 hours as needed for anxiety.-Of note: no physician order for use of physical restraints to administer psychotropic medications was noted.Surveyor reviewed R1's medical record and noted:05/01/25: Involuntary Order to Treat with Psychotropic Medications ordered by the court. R1's care plan and guardian were updated.Surveyor reviewed R1's Medication Administration Record (MAR) and noted all doses of psychotropic medications were administered as ordered. All other physician ordered medications had documented refusals almost daily during the month of 08/25. R1's MAR did not include reasons for refusals, alternative approaches, or interventions attempted.Between 10/13/25 - 10/15/25, Surveyor investigated an anonymous complaint regarding an allegation of facility staff holding R1's arms and face while administering medications. Surveyor reviewed facility's documentation and noted that on 08/12/25, Director of Nursing (DON) B was notified of an allegation of abuse that occurred on 08/05/25 and 08/06/25 and began an investigation. Interviews were completed with Certified Nursing Assistant (CNA) F, CNA G, and Registered Nurse (RN) E, who were identified in the complaint. Facility's documentation noted CNA F admitted administering R1's medications using food, ice cream, and a syringe. CNA F stated that someone would hold R1's hand while CNA F held R1's chin and squirted the syringe of medication into R1's mouth. While CNA F administered R1's medications using physical force, RN E would supervise. On 08/05/25, CNA F and RN E asked CNA G to assist in giving R1 medications. CNA G was told to stand behind R1 and hold R1's arms down to his sides while CNA F held R1's cheeks to administer medications into R1's mouth. CNA G stated R1 was not being physically aggressive but was trying to push the medications away. CNA G asked if there was another way to administer R1's medications. CNA F stated that R1's medications were court ordered and this was how they had to be administered and RN E did not respond. CNA G then reported his concern with using force to administer R1's medications to another nurse, RN D. RN D did not report this concern to supervisor until 08/12/25. The facility completed additional staff and resident interviews and determined on 08/19/25 that the allegation was substantiated. The facility completed re-education with direct care staff and notified the provider of the incident.On 10/14/25 at 11:50 AM, Surveyor interviewed CNA G regarding R1's care and treatments. CNA G stated being unable to remember the date when RN E and CNA F asked him to assist giving R1's Haldol and other medication. CNA G stated R1 was sleeping in chair in R1's room. When CNA G entered R1's room, CNA F and RN E got R1 up out of chair to a standing position. CNA F told CNA G to hold R1's arms up above R1's head. CNA G stated holding R1's hands above head like a police officer would ask. CNA G stated while holding R1's hands above head in this position, R1 was moving around too much and was then told to hold R1's arms at R1's side of body to keep him still. CNA F then held R1's face to have R1's mouth open and CNA F then put the medication in R1's mouth. RN E was standing in the corner of the room. CNA G then asked RN E and CNA F why they were doing this. CNA G was told R1's medications were court ordered, and this is how they had to give the medications. The next day, around 9:00-9:30 PM, CNA G was in the day room and observed CNA F throw R1 into the recliner and told R1 that CNA F will sit on you (R1) if you don't take your meds. CNA G then observed CNA F then squat over R1 to act like CNA F was going to sit on R1. CNA G heard R1 state 'no, no' during this encounter. CNA G reported concerns the next day to the unit nurse manager, RN D. RN D stated to CNA G that this is bad and is abuse. Surveyor asked CNA G if R1 would refuse medications if it was given in food or drink. CNA G stated no, that R1 did not fight if it was in food.On 10/14/25 at 1:10 PM, Surveyor interviewed DON B regarding incident. DON B stated these two incidents were not reported to a supervisor immediately and became aware of it on 08/12/25. The dates of the two noted observations were determined to be 08/05/25 and 08/06/25 during the facility's investigation. DON B acknowledged facility staff used inappropriate physical restraints during the administration of R1's medications and that CNA F was terminated due to the behavior.

Based on interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 of 3 (R3) residents reviewed.On 08/08/25, an allegation of abuse was reported to local law enforcement regarding R3. The facility did not investigate this allegation.This is evidenced by:Facility policy titled, Abuse, Neglect, Mistreatment & Misappropriation of Resident Property Policy & Procedure, with no implemented or reviewed date, states in part: E. Investigation: It is the policy of this facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriate of property) are promptly and thoroughly investigated. Procedure: The investigation is the process used to try to determine what happened. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed.R3 was admitted to the facility on [DATE] with pertinent diagnoses of mild cognitive impairment of uncertain or unknown etiology, personality disorder, delusional disorders, unspecified psychosis not d/t a substance or known physiological condition, and depression.On 08/08/25 at 2:45 PM, local law enforcement was contacted by R3's sister reporting concerns that R3 was being abused at the facility and R3 does not feel safe.On 08/08/25 at 3:31 PM, law enforcement arrived at facility and informed staff purpose of visit was related to allegation of abuse concerning R3.Surveyor reviewed R3's progress notes and noted:On 08/08/25, R3 stated desire to call 911 for being held prisoner at facility and upset about guardianship and protective placement. At 2:45 PM, facility called local police to inform them that R3 may call and was told that R3's sister had already called to report brother being abused at facility. At 3:10 PM, R1's guardian and county APS SW, DON, and supervisor notified of events and police involvement via email.No additional documentation of investigating allegation of abuse noted.On 10/14/25 at 1:10 PM, Surveyor interviewed Director of Nursing (DON) B regarding incident. DON B stated that R3 and his sister have called the police and reported numerous allegations of abuse that were unfounded. DON B stated that on 08/08/25, R3 had been threatening to call 911 numerous times for being held against his will and had notified the police that R3 might call to report this. Surveyor asked why this allegation was not reported. DON B stated the facility already knew this allegation was not true due to the multiple prior reports and did not think it should be reported or investigated.

Based on interviews, record review and policy review, the facility failed to ensure that residents were provided timely updates of concerns voiced at resident council meetings for three residents (Residents (R) 8, R9 and R10) of 13 sampled residents. Failing to update residents of measures taken to address their concerns, demonstrated their lack of knowledge of ensuring resident council was used for what it was intended, an opportunity for residents to voice their concerns and have adequate follow-up. Findings include: Review of the facility policy titled, Resident Voice/Council Policy, modified 06/11/25, revealed, It is the policy of this facility to ensure that all residents have a consistent, respectful; and structured opportunity to share feedback, voice concerns . to improve their quality of life and care within the facility . Responses and updates will be shared with residents during the next meeting. 1.Review of the admission Record under Profile tab, located in the electronic medical record (EMR), revealed R8 was admitted on [DATE] with diagnoses that included multiple sclerosis. Review of the annual Minimum Data Set (MDS), located under the MDS tab in the EMR, with an assessment reference date (ARD) date of 05/03/25 revealed R8 had a BIMS score of 15 out of 15 which revealed R8 was cognitively intact. 2. Review of the admission Record under Profile tab, in the EMR, revealed R9 admitted on [DATE] with diagnoses that included quadriplegia. Review of the quarterly MDS, located under the MDS tab in the EMR, with an ARD date of 04/26/25 revealed R9 had a BIMS score of 15 out of 15 which revealed R9 was cognitively intact. 3. Review of the admission Record under Profile tab, R10 admitted on [DATE] with diagnoses that included coronary artery disease. Review of the annual MDS, located under the MDS tab in the EMR, with an ARD date of 04/23/25 revealed R10 had a BIMS score of 15 out of 15 which revealed R10 was cognitively intact. Review of the Resident Voice Minutes provided by the facility, revealed residents stated during the meetings held on 08/01/24, 09/05/24 and 10/03/24 residents could Hear staff talk about other residents. Review of the Resident Voice Minutes provided by the facility revealed residents stated during the meetings held on 10/03/24 and 11/07/24, they need more staff. Review of the Resident Voice Minutes provided by the facility, revealed residents stated during the meetings held on 01/02/25, 02/06/25 and 04/03/25, call lights waiting too long. Review of the Resident Voice Minutes provided by the facility, revealed during the 03/06/25 meeting and the 05/01/25 meeting call light waiting times were too long were addressed at the NCC (Nurse Care Coordinator) meeting. During a group interview on 06/09/25 at 2:30 PM, R8, R9, and R10, stated they often have to wait for call lights up to thirty minutes. They stated they feel like the facility never has enough staff to help and administration never comes and talks to them about it. During an interview on 06/10/25 at 10:00 AM, R9 stated, There are never enough staff. He stated he had never seen the administrator to know what is going on. During an interview on 06/11/25 at 10:21 AM, the Director of Nursing (DON) stated that she does not attend Resident Council but did when she first started in the role as DON. She stated she was not aware when it occurred but stated, I should go. During an interview on 06/11/25 at 10:44 AM, the Activity Director (AD) stated she does not document any conversations she has had with specific residents regarding their concerns voiced in Resident Council. During an interview on 06/11/25 at 11:05 AM, R10 stated she always attends Resident Council and the concern about not enough staff is frequently mentioned. She stated the Activity Director (AD) states, We'll check it out. R10 stated it is not mentioned again. R10 stated it is important to her that they give updates in Resident Council about staffing. R10 stated the lack of staff does impact her breakfast. R10 stated that she would like coffee around seven in the morning but both yesterday (06/10/25) and this morning (06/11/25) when she went to the dining room, there was no one to get her coffee and the lights were off. R10 stated she came back to her room. R10 stated that she went back to the dining room at 7:25 AM and was able to get coffee. R10 stated breakfast should be served at 7:15 AM. During an interview on 06/11/25 at 12:24 PM, Case Manager (CM) stated the social services department is responsible for grievances and concerns. CM stated they do not have a formal process for following up with residents when a concern is voiced in resident council. The CM stated if a resident brought up staffing concerns in resident council the AD would notify nursing. CM stated social services would not be involved in anything related to staffing.

Based on interview and record review, the facility did not obtain laboratory services to meet the needs of the residents in a timely manner for 1 of 28 residents (R122) resulting in delayed results used to determine treatment for a urinary tract infection (UTI.) R122 displayed signs and symptoms of a urinary tract infection on 04/14/23. Urinalysis (UA) and urine culture and sensitivity (C&S) were ordered by the provider, but the facility staff did not enter the order for the C&S. This caused a delay in getting the lab culture performed, delaying treatment for R122. The UA results were positive for infection. R122 was hospitalized with diagnoses of acute metabolic encephalopathy, urinary tract infection, dehydration, and anemia requiring intravenous fluids (IV) and antibiotics. This is evidenced by: R122 was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, metabolic encephalopathy, adult failure to thrive, vascular dementia, UTI, anemia, dehydration, abnormal lab results, frontotemporal neurocognitive disorder, acute cystitis without hematuria, urinary incontinence, and overactive bladder. R122's care plan, dated 09/22/22, stated in part that R122 had urge bladder incontinence related to confusion due to dementia. Interventions included monitoring and document for signs and symptoms of UTI (pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns.) R122's minimum data set (MDS) assessments indicated on 03/17/23: Activities of daily living (ADLs) were extensive assist with one person, limited assist with walking with walker, eating needs supervision. Brief Interview for Mental Status (BIMS) score of 00. BIMS scores range from 00 to 15, with 00-07 indicating severe impairment. R122's orders indicated on 04/14/23 at 11:34 PM, Lab: UA and C&S. On 04/20/23 at 11:59 AM, Lab: UA and C&S. The facility's communication form indicated R122 notification to the provider, On 04/14/23 for signs and symptoms of UTI, fever, dysuria, and suprapubic pain. Obtaining UA. R122's daily fluid intakes prior to hospitalization were reviewed and met daily needs. Review of R122's Registered Nurse (RN) progress notes showed the following: On 04/14/23 at 11:09 PM, RN assessed [R122] and noted the resident to be lethargic, requiring more help with activities of daily living (ADL) and transferring, poor appetite, restless before urination, cloudy odorous urine, fatigued. When assessed resident grimaced with palpation of the suprapubic area. Rapid covid test: negative. Vitals signs (VS) were taken and were within normal limits except for blood pressure of 152/79 and temperature of 101.3 degrees. The doctor was notified and obtained an order for UA with C&S. On 04/15/23 at 3:48 AM, R122's vital signs were within normal limits except for blood pressure of 138/94 and pulse 104. UA obtained to send out. On 04/15/23 at 9:50 AM, Resident [R122] is still noted to be lethargic and doesn't seem interested in food. Vital signs stable. UA results returned negative for UTI. **The 4/15/23 nurses note states the U\A was negative in error. R122's urine results completed on 04/15/23 were positive with 1+ bacteria, 3-5 red blood cells (RBC), 11-20 squam epithelial, >100 white blood cells (WBC), and WBC clumps present. No urine C&S results were resulted from the 04/15/23 UA as staff did not enter the order correctly, so it was not ordered to be done in the lab order system. On 04/17/23 at 10:56 PM, Monitoring resident [R122] for fever, lethargy, suprapubic pain, dysuria. Urine culture indicating bacteria present. Awaiting culture and sensitivity. On 04/17/23 at 11:45 PM, VS stable 108/65 (blood pressure), 97.9 (temperature), 80 (pulse), 19 (respiratory rate). Resident [R122] is still lethargic compared to her norm. She is having more difficulty eating and transferring. 2 people needed for transferring her. Urine culture was positive for bacteria. Waiting on C&S. **The nurses note entry Urine culture was positive for bacteria refers to UA positive results on 04/15/23, not a urine culture result. On 4/17/23, R122's function of daily living shows a decline from the MDS completed in March. Now R122 is needing assistance of two people with transfers, unable to walk with a walker, and needing assistance with eating. On 04/18/23 at 4:24 AM, Afebrile. No complaints voiced this night shift. On 04/18/23 at 11:33 AM, Resident [R122] is still lethargic compared to her norm. She is having more difficulty eating and transferring. 2 people needed for transferring her. 135/74 (blood pressure), 97.9 (temperature), 74 (pulse), 18 (respiratory rate). On 04/18/23, the Nurse Practitioner (NP) signed the communication form acknowledging this information. Surveyor did not locate any progress notes or documentation that the NP had assessed R122 on 4/18/23, or that the NP had been updated with R122's ongoing symptoms. On 04/19/23 at 0:31 AM, Resident [R122] is resting quietly in bed this night shift. No issues or concerns noted. On 04/19/23 at 1:52 PM, VS 156/71 (blood pressure), 98.8 (temperature), 90 (pulse), 20 (respiratory rate). Resident [R122] continues to be a 2 assist with transfers and more lethargic. She had an intake of 820 milliliters this AM shift. On 04/19/23 at 10:37 PM, VS 146/83 (blood pressure), 99.0 (temperature), 96 (pulse), 20 (respiratory rate). Remains lethargic and needing more assistance. Needs assistance eating and 2 person transfer. There are no nursing notes on 4/20/23 documenting resident's condition. The medical record has a new order for U/A with C&S on 4/20/23. Medical record has lab results on 4/20/23: UA completed on 04/20/23 was positive with 2+ bacteria, 3-5 RBC, Gran Cast present, >100 WBC, and WBC clumps present. On 04/21/23 at 2:00 PM, Resident [R122] is still noted to be lethargic and doesn't seem interested in food. Increased thirst. Shaky. Vital signs stable. UA results awaiting C&S. On 04/21/23 at 10:38 PM, R122's vital signs were within normal limits. UA returned shows signs of prevalent UTI. R122 has been more lethargic today. R122 is now profusely sweating, last received APAP (Tylenol) at 5:45 PM. Blood pressure is lower than baseline, she is typically 130-150 / 70-80s. On 4/21/23 at 10:45 PM, On call doctor contacted regarding resident's [R122] condition. The doctor agrees to send [R122] to the emergency room (ER) for further evaluation and treatment due to prevalent UTI labs returned, profound sweating, minor twitching, and decreased responsiveness. On call doctor stated that if the guardian is in agreement to send her to the ER. Guardian contacted and agreed to send for further evaluation. R122 was admitted to the hospital from 04/22/23 through 04/25/23. Review of R122's discharge summary from the hospitalization indicated diagnoses of acute metabolic encephalopathy, urinary tract infection, dehydration, and anemia. From a Medical News Today article, .Metabolic encephalopathy occurs when toxic chemicals, or a chemical imbalance caused by an infection, affects brain function .Symptoms can include confusion, behaving out of character, feeling very tired, involuntary muscle twitching, shaking, muscle weakness, trouble swallowing . https://www.medicalnewstoday.com/articles/324008 R122's labs completed at the hospital included in part the following: Lactate 1.1, WBC 14.2 (high), C-reactive protein (CRP) 28, (high), alk phos 165, creatinine 1.06, BUN 33 (high), eGFR (kidney filtration rate) 55, blood cultures had no growth. UA results: 2+ blood, trace ketones, + protein, 3+ esterase, greater than 100 WBC, 3+ bacteria. Urine culture greater than 50,000 E.coli. Hospital information documents R122 received IV fluids and IV antibiotics while hospitalized to treat the condition. R122 returned to the facility on [DATE]. Review of R122's primary care provider nursing home readmit visit note dated 04/28/23 stated, [R122] was sent to the hospital with worsening confusion and urinary frequency and was found to have a urinary tract infection with likely urosepsis .With hydration and treatment of her urinary tract infection her mentation improved and she was thought to be stable to return to the facility .Since her return from the hospital, she has been very lethargic and has not been eating or drinking well .We will reach out to the patient's sister and power of attorney about possible referral to hospice due to dementia and failure to thrive . Staff Interviews: On 07/26/23 at 11:45 PM, Surveyor interviewed Certified Nursing Assistant (CNA) D about R122 going to the hospital in April 2023. CNA D stated R122 was unable to express things and she started to behave different. The urinalysis was sent out and we were waiting on the results of the urine culture to come back to treat. On 07/26/23 at 12:00 PM, Surveyor interviewed Registered Nurse (RN) E and asked about R122's hospitalization in April 2023. RN E stated R122's behavior was different and that alerted the staff to know something was going on with the resident and to look further into what was going on. The doctor was notified right away on 4/14/23 of R122's symptoms (lethargic, requiring more help with activities of daily living, poor appetite, restless before urination, cloudy odorous urine, fatigued, pain over suprapubic area). An order for urinalysis with C&S was ordered and sent to the lab. Labs are sent out to a lab facility. We did check R122 for Covid during this time and it was negative. Surveyor asked RN E how R122 was doing before the start of this incident. RN E stated R122 was declining before this time. R122's power of attorney (POA) wanted to keep the resident comfortable and did not want to keep sending her back and forth to the hospital. R122's fluid intake was good, and she did not trigger for dehydration monitoring. Staff make sure the residents get enough fluid intake to prevent dehydration. Surveyor asked RN E what the status of R122 was during the timeframe while waiting for the C&S results. RN E stated R122's symptoms remained the same (lethargic, requiring more help with activities of daily living, poor appetite, restless before urination, cloudy odorous urine, fatigued, pain over suprapubic area) and was stable with no reason to send the resident out to the hospital until we did on April 21, 2023, due to the change in her symptoms that included profound sweating, minor twitching, and decreased responsiveness. The doctor was updated on the change of symptoms on 4/21/23. An order was obtained to send R122 to the hospital if the resident's power of attorney agreed. Surveyor asked RN E what the notifications to the provider during this time frame were. RN E stated the provider was notified at initial onset of symptoms on 04/14/23, the Nurse Practitioner was here on 04/18/23, the provider was notified on 04/20/23 when we found out the C&S was not done and received new orders for UA with C&S, and then when R122's symptoms changed on 04/21/23, sending her to the hospital. Surveyor asked RN E what the procedure was for starting a resident on antibiotics for a UTI. RN E stated the doctor was waiting on the results of the urine C&S to come back before treating because we follow McGeer's criteria, and it is a part of our antibiotic stewardship. When we found out the urine C&S was not back for R122 on 04/20/23, the nurse contacted the lab and found out the C&S was not completed. Staff notified the provider and sent a new urine sample out as the lab did not have the original one still. It usually takes 2-3 days to get the urine C&S results back from the lab. Surveyor asked RN E what the process was they used to make sure the results of the C&S are followed up on and addressed by the provider. RN E stated the nurses will notify the oncoming nurse at shift change that they are waiting on the results and the nurse will look to see if it is back. When the results are received, the provider is updated by the nurse. On 07/26/23 at 2:05 PM, RN E stated she just reached out to the lab facility to check into R122's urinalysis and C&S order. RN E provided a copy of the lab requisition order that she obtained from the lab facility for R122's urinalysis dated 04/15/23. RN E stated the order that was entered into the lab facility's system was only for the urinalysis, not the C&S. Therefore, the first urinalysis did not have the C&S results. RN E stated the order from the provider in our electronic medical records was for both the urinalysis and C&S. Facility staff then must enter the provider's order into the lab facility's system. The lab does not automatically do a C&S if there is no order for it. Surveyor asked RN E if they did any staff education about receiving lab results because of what happened with the urine C&S for R122. RN E stated they did not do any education because they did not know there was a problem until now. RN E stated they will do staff education on this issue. On 08/01/23 at 1:20 PM, Director of Nursing (DON) B said today we did reach out to the provider for R122 who responded with this, I do remember and due to McGeers, I could not treat until we had a culture. I asked for the repeat UA and was waiting on the culture. That's all I know. The provider was aware and awaiting C&S results.

Based on interview and record review, one of six residents (Residents #9) reviewed for pressure ulcers and pressure ulcer risk did not receive necessary treatment and services to promote healing, and prevent new and reoccurring ulcers from developing. 1. Resident #19 developed reoccurring open areas, from 04/23/15 to 02/07/16, that later developed into a stage III pressure ulcer. The facility did not implement or attempt new interventions to prevent the development of the open areas and pressure ulcer. The facility did not routinely assess and monitor these open areas from August 2015 to February 2016. This is evidenced by: 1. On 02/29/16 at 1:48 p.m., Surveyor reviewed Resident #9's medical record. The resident has [DIAGNOSES REDACTED]. Resident #9's most recent Brief Interview for Mental Status (BIMS) score, dated 12/29/15, was a 09 out of 15 possible points, indicating the resident has moderately impaired cognition. The resident currently makes her own healthcare decisions. A Minimum Data Set (MDS), dated [DATE], indicates the resident is dependent on staff for bed mobility, transfers, toileting, dressing, personal hygiene and bathing. Resident #19 is occasionally incontinent of bladder function. The MDS identifies the resident has upper body and lower body range of motion limitations on both sides of the body. An MDS, dated [DATE], identifies the resident does not have any pressure ulcers. Surveyor reviewed Resident #9's nurses' notes, dated 03/07/15 to 06/29/15. The notes state the following, in part: -04/23/15: An open abrasion is identified on the resident's right inner buttocks; which measures 0.7 centimeters (cm) by 0.6 cm by 0.01 cm in depth. The intervention documented at this time is to monitor the open area until healed. -05/06/15: The open area is still present, and the note states, .Resident continues to be on bottom throughout the day while sitting in W/C (Wheelchair) and recliner. Discussed possibility of placing a pillow under resident Q (every) 2 hours. Resident stated she will try. There is no documentation in the medical record the use of a pillow was attempted as an intervention. The use of the pillow is not identified on Resident #19's care plan. -06/04/15: The abrasion is still present, but is not currently open. Surveyor reviewed Resident #9's nurses' notes, from 08/01/15 to 02/25/16. The notes state the following, in part: -08/01/15: Resident #19 has two open areas to the right buttocks, which appears to be from shearing of the skin (Tissue layers slide on each other causing blood vessels to kink or stretch, which interrupts blood flow to the skin.) There are no measurements for the open areas, and the intervention is to encourage the resident to use a cushion while sitting in the recliner. There is no documentation a cushion for the recliner was ever provided to the resident. There is no documentation if staff, or if Resident #19, ever moved the cushion from the wheelchair to the recliner, when the recliner was used. -08/13/15: The first measurements of each open area is documented. The first area is 1.4 cm by 0.6 cm; the second measures 0.2 cm by 0.2 cm. -08/26/15: The first open area is becoming larger, measuring 1.7 cm by 1.0 cm. There is no measurement of the second open area. There is no documentation in the medical record the facility implemented or attempted any interventions to promote healing or prevent further skin breakdown, once the area became larger. -09/04/15: There is a new open area to Resident #19's left buttocks, which measures 0.3 cm by 0.4 cm. The open area to the right buttock is still present. -09/23/15: The resident has two new open areas on top of the gluteal cleft (the area by the coccyx), which measure 0.2 cm by 0.3 cm and 0.2 cm by 0.2 cm. The open area to the right buttocks is smaller. There is no documentation regarding the open area to the left buttock. -10/01/15: The open area to the left buttock is now healed. There is no documentation assessing the open areas on the gluteal cleft, or if the area healed. The open area on the right buttocks continues to be open. -10/02/15: Resident #19 now has a urinary tract infection [MEDICAL CONDITION], and is more incontinent of urine. Urinary incontinence places a resident at higher risk for developing further skin breakdown and the development of open areas. This increased risk was not addressed in the resident's care plan. -10/08/15 to 10/28/15: The nurses' notes identify the resident has an open area to the buttocks, there is no documentation in the medical record of the specific location. The last documented measurement of this open area, on 10/28/15, is 0.2 cm by 0.4 cm, 20 days later. -11/11/15: The nurse's note refers to the weekly wound assessment for more details on the open areas; however, no weekly wound notes or assessments were located in Resident #19's medical record. There are no measurements for any of the resident's open areas to the buttocks, for the month of November 2015. -12/01/15: The resident has three fluid filled blisters on the left mid-buttocks. There is no documentation identifying the cause of these blisters. There is no documentation the facility implemented or attempted any interventions to promote healing or prevent further skin breakdown after the blisters developed. -12/16/15: The open area to the right inner buttock measures 0.5 cm by 0.6 cm. -12/30/15: The resident's blisters on the left mid-buttock have healed, and the open areas to the right buttock continue to be open. A new open area to the gluteal cleft is identified, which measures 0.4 cm. There is no documentation the facility implemented or attempted any interventions to promote healing or prevent further skin breakdown, after new area on the gluteal cleft opened. -01/08/16: A wound assessment indicates the resident was offered a different mattress, which the resident refused. The medical record identifies no other interventions or other mattresses were offered to the resident. -01/13/16: The resident's open area to the gluteal cleft has healed; however, the open area to the right buttock remains open. -01/23/16 to 02/04/16: The nurses' notes identify the resident has an open area to the right buttocks; there are no assessments or measurements of the open area, until 02/04/16. -02/07/16: The note identifies Resident #19's open area to the right buttock is healed. No open areas to the buttocks are documented in the medical record There is no documentation the facility implemented or attempted any interventions to promote healing or prevent further skin breakdown once the resident's wounds resolved. -02/09/16: The notes identify a stage III pressure ulcer to the resident's gluteal fold/coccyx area. The ulcer measures 2.0 cm by 0.5 cm by 0.3 cm. -02/10/16: A physician's orders [REDACTED].#19 for wheelchair fit and positioning was obtained. It is noted, there are six documented entries in the nurses' notes, from 08/01/15 to 02/25/16, in which Resident #19 refused a bath and/or did not allow staff to assess the open areas. There is one documented entry, from 09/29/15, which the resident refused to receive incontinence cares from staff. There is no documentation in which nursing staff is educating and/or reminding the resident to move the cushion from the wheelchair to the recliner, use the bathroom, reposition, or offload. There is no documentation Resident #19 has refused these interventions. Surveyor reviewed a progress notes, written by OT. The notes state the following, in part: -02/12/16: .Note: pt (patient) EDU (Educated) therapist on what is wrong with her current w/c .is hoping for a new w/c along with better cushioning. Pt shown how to weight shift with leans in order to off load pressure in coccyx area .based on pt current w/c positioning has resulted in stage 3 pressure wound at coccyx . -02/29/16: .Note: Pt to therapy with out cushion in wc (wheelchair); cushion left in recliner. Measure seat for recommendation of coccyx cushion to address wound; rertieve (sic) cushion from don (Director of Nursing). Caregiver education and collaboration with staff to put cushion in place with staff due to Pts inconsistencies and issues with compliance . Surveyor reviewed Resident #19's current comprehensive care plan. The care plan states the following, in part: Focus: PRESSURE ULCERS: At risk for impaired skin integrity R/T (Related To): Chronic shearing to buttocks due rocking back and forth during self transfers; lateral right ankle under nodule due to [MEDICAL CONDITION] . Interventions/Tasks .Assess skin weekly and PRN (as needed). Frequently refuses bath and skin checks. Reapproach to gain cooperation with skin checks. Has cushion in w/c. Apply barrier cream to buttocks prn for protection as she will allow. Encourage/remind (Resident #19's first name) to ask staff for transfer assistance to prevent sliding/rocking/shearing during transfers in/out of recliner and w/c. Gel cushion to recliner AAT (At All Times). Often falls asleep in recliner while watching movies per her choice. Pressure reduction gel cushion in w/c .panacea mattress, preferred rising time is 7 AM, preferred time is 1 AM . The resident's care plan does not identify the presence of the pressure ulcer to the coccyx area, or when the gel cushion was added to the recliner. The care plan does not identify how often the resident is to be encouraged/reminded by staff to reposition and offload the buttocks and coccyx. The care plan does not identify any education provided to the resident regarding the risk of developing and worsening pressure ulcers and repositioning. INTERVIEWS On 03/01/16 at 11:11 a.m., Surveyor interviewed Certified Nursing Assistant (CNA) E. CNA E stated staff do not encourage or remind Resident #19 to move the wheelchair cushion to the recliner, or offer toileting or repositioning. At 12:21 p.m., the DON and Nurse Care Coordinator, Registered Nurse, (RN) D, provided the manufacturer's guidelines on Resident #19's current mattress and wheelchair cushion. The DON indicated the resident's mattress is rated to prevent a stage II pressure ulcer. The DON stated the resident has had the same mattress and wheelchair cushion since 09/16/13. RN D stated staff previously offered a different wheelchair cushion to Resident #19, in December 2015, but Resident #19 refused the new cushion. RN D stated there is no documentation as to when the new cushion was offered and declined. On 03/02/16 at 9:04 a.m., Surveyor interviewed Resident #19. The resident has contractures to both hands, and a significant contracture and deformity to the right ankle and foot. The resident states she is not able to ambulate but is able to self-propel in the wheelchair with the use of her left foot. The resident stated she is able to pivot transfer on her own to the toilet, wheelchair and recliner, but knows she should wait for staff assistance. Resident #19 stated she spends the majority of the day sitting in the wheelchair, and spends most nights in the recliner. The resident further indicated she will sometimes sleep in bed after 2:00 a.m., or 4:00 a.m., until she wakes up for the day. Resident #19 stated staff do not, and have not, reminded or encouraged the resident to move the wheelchair cushion to the recliner, use the bathroom, reposition or offload from a sitting position. The resident stated she will ask for help to transfer or use the bathroom when she needs assistance. On 03/02/16 at 11:17 a.m., Surveyor interviewed RN D. RN D stated all of Resident #19's open areas to the buttocks occurred from skin shearing, as the resident scoots down in the recliner and in the wheelchair. RN D stated the stage III pressure ulcer is located in the same area as the previous open areas on the gluteal cleft, since the skin at this location is very fragile. RN D stated Resident #19 is not on any toileting or repositioning schedule. Surveyor asked how Resident #19's recurrent open areas on the buttocks, and the pressure ulcer was unavoidable. RN D replied the skin breakdown was unavoidable because of the resident's non-compliance. RN D stated the nurses re-educate Resident #19 regarding skin breakdown, but since the resident is her own person, the resident has the right to make choices. On 03/03/16 at 10:16 a.m., Surveyor interviewed RN D. Surveyor was present at this time. Surveyor discussed the above nursing documentation and wound assessments with RN D. RN D confirmed Resident #19's open areas will appear, heal and then reappear. Surveyor referred to the charting on 05/06/15, regarding the use of a pillow under the resident's bottom to prevent further skin breakdown. RN D stated she will have to check to determine if the use of the pillow was ever attempted or documented. Surveyor discussed the wound assessments and measurements not documented for the the thirteen days in August 2015, twenty days in October 2015, the month of November 2015, and the thirteen days from January 2016 to February 2016. RN D stated she would have to look at wound assessment notes from these dates. Surveyor asked if any new or different interventions were implemented, offered or attempted once the buttocks were healed on 02/07/16, or after the pressure ulcer was identified on 02/09/16. RN D stated she would have to look to see if any other interventions, besides OT, were attempted or implemented. When asked about the use of the wheelchair cushion, RN D stated staff should have been trying to encourage Resident #19 to move the cushion from the wheelchair to the recliner, when the resident transfers into the recliner. RN D confirmed the pressure ulcer is not identified on the resident's care plan. RN D stated either she, or the wound care nurse, should have added it to the comprehensive care plan. At 1:20 p.m., RN D informed Surveyor there is no documentation in Resident #19's medical record a pillow was ever tried or discontinued. RN D stated there is no documentation regarding staff encouraging/reminding or educating the resident to change the cushion, toilet, reposition or offload. RN D further stated there are no wound assessments or measurements for the missing dates in August, October and November 2015, and the thirteen days in 2016. No additional information was provided to the surveyors.

Based on interview and record review, the facility did not ensure the residents' environment remained as free of accident hazards as possible, for 4 of 19 residents (Residents #19, 3, 14, and 6) reviewed for falls. 1. Resident #19 had four falls in the facility, from 12/06/15 to 02/25/15, and sustained two pelvic fractures and a fractured collarbone during the most recent fall. The facility did not consistently identify a root cause of each fall, and did not implement new or appropriate safety interventions to prevent further falls and injury. 2. Resident #3 sustained a fall and required stitches in the hospital. The facility did not ensure appropriate interventions were put into place to prevent future falls from occurring and did not assess for root cause and analysis for how the fall occurred. 3. Resident #14 experienced seven falls between November and January. The fall reports did not thoroughly investigate the falls, did not include root cause analysis or interventions to prevent future falls. 4. No root cause analysis and no new interventions were completed for Resident #6 following a fall. This is evidenced by: Surveyor reviewed the facility Fall Prevention and Reduction policy, dated 11/19/15. The policy includes a list of possible strategies to prevent falls and a list of possible root cause/contributing factors to consider. The policy states that the nurse will make efforts to determine the root cause of the fall and revise the plan of care as necessary to prevent furture falls. It further states that when there are multiple contributing factors and/or root cause is still being determinied; the use of a bed or chair alarm may be appropriate pending other interventions. The policy states: The nurse will document the details of the fall in the medical record. Revisions to the plan of care will be made by the nurse, as appropriate, following a fall and determination of the root cause of the fall. Nurse care coordinators monitor falls to identify any trends. A fish bone diagram is completed for three or more falls in a week and for five or more falls in a month. 1. On 03/02/16 at 3:19 p.m., Surveyor reviewed Resident #19's medical record. The resident was admitted to the facility on [DATE] for a short term respite stay. The resident has [DIAGNOSES REDACTED]. The resident's Brief Interview for Mental Status (BIMS) score, dated 12/04/15, was a 14 out of 15 possible points, indicating the resident has intact cognitive function. Resident #19's Minimum Data Set (MDS), dated [DATE], indicates the resident needs assistance for ambulating, bed mobility, transfers, dressing, toileting and personal hygiene. The resident was taking the following medications, upon admission: -Carbidopa-Levodopa (used to treat Parkinson's disease) 25-100 milligrams (mg), three tablets, twice a day -Carbidopa-Levodopa 25-100 mg, two tablets, once a day -Furosemide (a diuretic) 10 mg, every morning. -Alprazolam (antianxiety medication) 0.125 mg, once a day, as needed. Start date 12/28/15. -Trazodone (an antidepressant used to promote sleep) 50 mg, at bedtime. Started on 01/08/16. A nurse's note, dated 12/02/15, states the following, in part: (Resident #19's first name) is here for respite and has left sided neglect. Tends to wander to the left and items need to be placed on this (sic) right side for better visualization .is forgetful at times . Resident #19's current comprehensive care plan states the following, in part: Focus: The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) right CVA (stroke), Parkinson's disease, Left sided weakness .Interventions/Tasks .Can be impulsive . Focus: The resident is at hx (history) of falls r/t Vision/hearing problems secondary to RCVA (right-sided stroke), impulsiveness, lack of safety awareness, and Parkinson Disease .Interventions/Tasks: Call light is within reach RIGHT side D/T (Due To) left sided weakness and encourage the resident to use it for assistance as needed. Has left sided weaknes (sic) The resident needs prompt response to all requests for assistance .Sensor pad in bed and TABS monitor in w/c (wheelchair), recliner etc. Fold blankets in half to avoid tangling around legs/feet. 15 min (minute) checks AAT (At All Times). Gripper socks on while in bed . Surveyor reviewed Resident #19's fall reports, from 12/06/15 to 02/25/16. The reports state the following, in part: -12/06/15 at 3:59 a.m. (medical record does not specify if this is the time the report was completed, or if this is the time in which the resident fell ): .Resident Description .Resident explained that he had sat up on the side of his bed, reached for the call light that was secured to the rail behind him, and slid off the bed when reaching .Resident was calling to obtain assistance to use the bathroom . The report further indicates the resident was incontinent at the time of the incident, but does not identify if the incontinence was due to bowel or bladder. The medical record does not identify the time the resident was last toileted, or which side of the bed the call light was located. According to the medical record, the facility did not investigate the root cause of the fall or implement any safety interventions after this fall, in order to prevent future falls from occurring. -12/12/15 at 4:15 a.m.: .Incident Description .Was called to Lounge at (4:15 a.m.). Resident was sitting on the floor next to recliner. Resident Description: 'I got up and fell down' Table with bell was near him but he did not use it. No injuries noted .Resident is on 15 min checks at noc (night shift). POC (Plan of Care) updated . There is no documentation in the resident's medical record indicating why Resident #19 attempted to get up without assistance. The resident's care plan identifies fifteen minute safety checks were implemented on 12/12/15 and discontinued on 12/13/15. On 12/13/15, a sensor pad alarm was placed in Resident #19's bed, and a tab alarm was placed in the wheelchair. The investigation does not identify when the resident was last toileted. The facility did not implement appropriate interventions or supervision related to the root cause of the resident's fall (Resident #19 fell out of a recliner). On 01/28/16, Resident #19 was moved to a room on the second floor. -02/14/15: Resident #19 fell on his left side, while on an outing with family. The resident sustained [REDACTED]. -02/15/15 at 5:00 a.m. (medical record does not specify if this is the time the report was completed, or if this is the time in which the resident fell ): .Incident Description .Staff went to answer (Resident #19's first name) call light and found him on the floor. His lower extremities were on the floor while the upper extremities were leaning over the side of the bed. Two blankets were wrapped around his legs. We believe he was getting up to go to the bathroom as he had BM (Bowel Movement) in his depends .Immediate Action Taken .Educated on calling for help during night .Notes .He has a silent sensor bed alarm that goes through the call light system and that is what alerted staff to his room .can be impulsive and due to his cognition decline he lacks safety awareness .reported to staff of mild discomfort to his knees .Resident is continent of both bowel and bladder and does know when he needs to use the bathroom however he does forget to wait for staff's assistance. Intervention at this time is to fold blankets in half to avoid blankets potentially tangling around his legs/feet. The facility did not identify when the resident was last toileted, or determine the resident's nighttime toileting patterns. The facility did not implement appropriate interventions related to the root cause of Resident #19's fall, as it relates to the resident being incontinent and having to use the bathroom. -02/25/16 at 12:45 a.m.: .Incident Description .Resident was FOF (Found On Floor) in peers (sic) room. He had his wheelchair and was trying to stand up. He was wearing gripper socks .Immediate Action Taken .15 minute checks on night shift .Notes: Per staff interview (Resident #19's first name) transferred self from his bed and into his w/c setting off the silent bed sensor alarm through the call light system. When staff arrived (Resident #19) was attempting to stand up from floor where he had fallen in a peers (sic) room down from his room. Per staff (Resident #19) was trying to find a bathroom .had gripper socks on his feet .Intervention appropriate to be placed on 15 min checks during the night shift and gripper socks on while in bed . The facility did not thoroughly investigate how long the resident's silent alarm was sounding, when the resident was last toileted, or in which room Resident #19 had fallen. A nurse's note, dated 02/25/16 at 8:20 a.m., states the following, in part: Assessment: Resident had fall at (12:45 a.m.) .At (6:30 a.m.) CNA (Certified Nursing Assistant) alerted nurse that resident was 'off.' Upon assessment wheezes heard throughout lungs .Resident stated shortness of breath, left shoulder and left hip pain. Respirations 32/minute and SpO2 (oxygen saturation) 78% on room air. Resident was soaked in sweat. Mental status change .O2 via nasal cannula applied at 2l/min (two liters of oxygen per minute). O2 sat at (7:00 a.m.) 84% on 2L O2. At (8:00 a.m.) O2 sat 97% on 3L. Mental status per baseline. Resident weaker than usual with transfers, typically a one assist with wheeled walker. Today transfer took 2 assist and resident had no strength during transfer. Resident was toileted and CNA alerted nurse that under wear were soaked in blood. Writer visually saw blood coming from residents (sic) penis. MD (Doctor of Medicine) alert and viewed resident. MD ordered resident to be sent to .hospital for further evaluation . The medical record identifies Resident #19 was admitted to the hospital, on 02/25/16, with a left superior (part of pubic bone located by the hip bone) and interior (thin, flat part of the pubic bone) fractures, a left clavicle (collarbone) fracture, pneumonia, anemia due to bleeding, blood in the urine, and a prevesical hematoma (an internal bruise by the pelvis), which measured 5 centimeters (cm) by 2.9 cm by 3.1 cm in depth. On 02/29/16, Resident #19 was readmitted to the facility, on an antibiotic for pneumonia. The resident is now a two-person assist for transfers, uses a bedside commode, and wears a sling on the left arm. A nurse's note, dated 03/01/16, states the following, in part, .Family requested mats at bed side related to resident trying to crawl out of bed continuously. Bed sensor also in place. Resident has history of crawling out of bed and attempting to self transfer. Resident has a history of being fast at transfer. Mats have been placed at each side of residents (sic) bed. The facility did not assess to determine if the fall mats on each side of the resident's bed is an appropriate and safe intervention. The facility did not assess the resident's toileting needs at night, implement a nightly toileting schedule or provide a bedside urinal, for the resident. On 03/03/16 at 8:41 a.m., Surveyor interviewed Resident #19. The resident stated when he falls, he just loses it, and will fall over. Resident #19 stated he has to use the bathroom, throughout the night time, and will turn the call light on for help. The resident further stated it takes staff approximately 30 minutes during the night to answer the call light, and it is difficult to wait for staff assistance. During the continued interview, the resident stated at the time of the fall, on 02/25/16, his call light went unanswered for about 30 minutes. Resident #19 stated he could not wait any longer, and got out of bed to find a bathroom. The resident stated staff did not, and do not encourage or offer to help the resident use the bathroom at night, nor does the resident have a bedside urinal to use at night. On 03/03/16 at 1:32 p.m., Surveyor interviewed the first floor Nurse Care Coordinator, Registered Nurse, (RN) AA. Surveyor was present at this time. Surveyor and RN AA reviewed Resident #19's fall, from 12/06/15. RN AA was unable to remember the time of the resident's fall, any interventions or supervision implemented by the facility after this fall. RN AA stated there is no additional documentation in the resident's medical record regarding this fall. During the continued interview, RN AA stated the sensor pad and tab alarms were added to the resident's bed and wheelchair after the resident's fall on 12/12/15. No additional supervision or interventions were added to prevent further falls. RN AA stated Resident #19 was not on any type of toileting plan during the day or at night. RN AA stated the resident was continent of both bowel and bladder and was able to inform staff of any toileting needs. RN AA stated the facility did not identify the resident's toileting needs to be a root cause of these falls. RN AA provided a copy of Resident #19's fall care plan, with original dates of when interventions were added and discontinued. The documentation states on 12/12/15, the following items were initiated: SAFETY: Sensor pad in bed and TABS monitor in w/c, recliner etc. Fold blankets in half to avoid tangling around legs/feet. 15 min checks AAT. Gripper socks on while in bed. There is no revision date pertaining to this documentation. RN AA confirmed the above safety interventions were initiated on 12/12/15. On 03/03/16 at 10:40 a.m., Surveyor interviewed the second floor Nurse Care Coordinator, RN D. Surveyor was present at this time. Surveyor reviewed Resident #19's fall, dated 02/15/16. RN D stated the intervention of folding the resident's blankets in half, while the resident is in bed at night, was the intervention implemented after this fall. Surveyor asked if any supervision or intervention, such as a toileting schedule, was put into place after the resident's fall on 02/15/16. RN D replied no other supervision was implemented, and the resident was able to inform staff of his toileting needs, therefore no toileting schedule was necessary. RN D stated she would have to check to see if the facility offered the resident a bedside urinal to use at night. During the continued interview, Surveyor reviewed Resident #19's fall, dated 02/25/16. RN D stated she did not know which room Resident #19 was found in at the time of the fall, or how long the resident's silent bed alarm/call light had been alarming. Surveyor asked if the facility interdisciplinary team reviews resident falls. RN D stated the facility reviews a resident's falls if the resident has three falls within one week, or five in one month. RN D stated the interdisciplinary team does not review each individual fall, as they occur. No other information related to the resident's falls were provided to the surveyor. 2. On 02/29/16 at 1:21 p.m., Surveyor reviewed the medical record for Resident #3 and noted the following: - MDS, dated [DATE], states Resident #3 requires extensive assistance for all transfers and was at high risk for falls. MDS states Resident #3 had had a prior fall within the facility. - CNA care plan, received 02/29/16, states Resident #3 has an unsteady gait and to remind resident to wear proper footwear (shoes or grippy socks) at all times. - Comprehensive nursing care plan, received 02/29/16, states Resident #3 is at high risk for falls due to poor communication/comprehension, vision/hearing problems, incontinence, medications, agitation, aggression, congestive heart failure (CHF), degenerative brain disorder, obesity, arthritis, post traumatic stress disorder, explosive disorder, mood disorder and seizure disorder. Care plan states staff are to remind Resident #3 to wear proper footwear (shoes or grippy socks) at all times. On 02/29/16 at approximately 2:30 p.m., Surveyor reviewed fall investigations for Resident #3 and noted the following: - FALL 11/02/15 at 11:20 p.m.: Resident #3 had self reported to staff at 11:20 p.m. he had fallen and had gotten himself up on his own. Fall report states Resident #3 had received a two bruises to his right ribcage. Predisposing situation factors were improper footwear. Intervention was for Resident #3 to wear grippy socks at night. Surveyor was unable to identify the root cause and analysis of the fall. - FALL 11/19/15 at 6:50 p.m.: Staff had brought food into Resident #3's room. Staff member left the room to go get a table to set the food on and left the food tray on the sink counter. Report states Resident #3 self transferred to the bathroom and when staff returned to the room found Resident #3 on the floor with pants down to thighs and barefoot and sitting on his buttock. Resident #3 was ambulating without a walker and was attempting to use the counter where his food tray was for support and and fell due to the tray not being stable enough to support him. No injuries noted. Intervention was that the meal tray cannot be set on his sink counter only on the tray table. Predisposing situation factors included improper footwear. - FALL 01/23/16 at 11:40 a.m.: Resident #3 attempted to self transfer to the bathroom and started urinating prior to reaching the bathroom and slipped in the urine and fell to the floor. Staff noticed a bump on the left side of the head. Intervention was for resident to have gripper socks and shoes on at all times and on 15 minute checks for the remainder of the over night shift. Predisposing situation factors included ambulating without assist and improper footwear. - FALL 02/11/16 at 1:42 p.m.: Staff found resident sitting on the floor with his pants down with an empty denture cup. Water was thrown across the resident's room and the hallway. The faucet was running in the resident's sink. Resident #3's shoes were left next to him on the floor. No injury noted. Predisposing situation factors included improper footwear. Report states, Root cause psychological impairment with poor impulse control related to peer interactions. Poor safety awareness d/t resident urinating in sink right before opening the door and throwing fluid at a peer. His pants hampered his ability to move as quick as he wanted. His shoes look a bit too big and/or old Velcro contributed to his left foot came out of the shoe. Intervention: writer called guardian for new shoes and a sign above sink to use the toilet. - FALL 02/25/16 at 11:30 p.m.: Resident #3 had fallen on 02/25/16 at 11:30 p.m. The report states staff responded to a call light and found Resident #3 on the floor. Report states, He was self transferring from walker to bed. Blood was noted on resident and on the floor. Resident stated, I was trying to sit back in bed and missed. Fall investigation description states, Pupils are round and reactive to light and accommodation. full range of motion to all extremities, resident did complain of pain to right hip, however, no changes to range of motion or weight bearing. VSS (vital signs stable) .Resident is alert and oriented. 9 cm laceration noted to right side of head with a smaller abrasion below it. Minimal bleeding noted; clotting is present; ;lacerations washed. On call contacted for order to transport to hospital for evaluation and treatment of [REDACTED]. Start neuro checks per protocol. Transfer to (Luther hospital) for evaluation and treatment following a fall. INJURY TYPE: Laceration. PREDISPOSING ENVIRONMENTAL FACTORS: None. PREDISPOSING PHYSIOLOGICAL FACTORS: Confused, gait imbalance and impaired memory. PREDISPOSING SITUATION FACTORS: During transfer, ambulating without assist, improper footwear. WITNESSES: (staff member): I went to his room to answer his light and he was sitting on floor mad at himself for falling on the floor. I went and got the nurse to assess him. (staff member) helped me get him off the floor with the lift and onto his bed. NOTES: No notes found. Surveyor was unable to identify the root cause of the fall. On 03/02/16, Surveyor reviewed the ER report for Resident #3, dated 02/26/15. The report stated the patient got out of bed and states he slipped and fell backwards hitting his head against the bed railing. Did not lose consciousness. Denies headache. Did sustain laceration to the right side of the back of head .patient is currently at his baseline neurological and functional status. CT scanning of the head would most likely not add to the evaluation, after staples were placed, patient complained of pain to the laceration site .Diagnosis: [REDACTED]. On 03/01/16 at 12:22 p.m., Surveyor received a new copy of the fall investigation, dated 02/25/16, and noted the following changes: NOTES: Writer reviewed report and finds the intervention appropriate as (Resident #3) is forgetful and needs reminders to keep his gripper socks or shoes on so he doesn't slip. Surveyor noted a caption at the top of the investigation to state, Revision date: 02/29/16. On 03/02/16 at 12:00 p.m., Surveyor interviewed RN R in regard to Resident #3's fall on 02/25/16 and the noted revision on the new fall investigation noted above. RN R stated she had entered the note into the system and closed it out and ran the report to give to this surveyor. RN R stated she is very busy and doesn't always get the chance to enter the information in. On 03/02/16 at 12:00 p.m., Surveyor interviewed the Director of Nursing (DON) in regard to the above noted falls. The DON stated that on 02/11/16, Resident #3 had fallen and the intervention was for the family to bring in new shoes due to Resident #3's shoes being too big. Surveyor asked the DON if new shoes had been provided and the DON stated, Not yet .his brother works a lot and has nine kids .we have given him extra grippy socks to make up the room in the shoes so they would fit better because he doesn't fit his shoes being they are too big for him. The DON stated she would look into the situation and if the facility had to they would try to find better fitting shoes from the laundry department. Surveyor asked the DON what the the intervention was for the fall on 02/25/16, and the DON stated the facility reviews falls during their QA meetings but it takes a while. The DON was unable to find an intervention for the fall and was unable to identify a root cause and analysis. Surveyor discussed concerns in regard to the facility knowing he had improper footwear and did not provide appropriate footwear to prevent falls with injuries from occurring. Surveyor discussed concerns in regard to RN R making revisions to the investigation during the survey process. 3.Surveyor reviewed Resident #14 medical record. Resident #14 has [DIAGNOSES REDACTED]. Resident #14's Kardex (CNA care plan) indicates the resident ambulates independently. Wears shoes during awake hours/gripper socks at night. Wears hipsters at all times. Has a history of falls. Has a silent bed sensor. He is incontinent. The interventions on the Kardex are not dated as to when they began. The comprehensive care plan identifies potential for falls related to unaware of safety needs, confusion, phychoactive drug use, hearing problems, wandering, incontinence, physical aggression and seizure disorder. The interventions include: - Anticipate and meet needs - Encourage to participate in activities that promote exercise for strenghening and improved mobility - Ensure approriate footwear. Shoes during awake hours and gripper socks during hour of sleep - Follow facility fall protocol - Hipsters at all times - Needs safe environment with: even floors free from spills and/or clutter; adequate, glare free light, working and reachable call light, bed in low position at night, silent bed alarm - Provide activities that minimize the potential for falls (several are listed) - PT eval and treat as ordered or PRN - Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes. None of the interventions are dated on the care plan as to when they began. Nurses' notes for Resident #14 falls state, See risk management for assessement. The nurses' notes do not include any notes or investigation of root cause into the falls. The nurses' notes do not describe the falls or the circumstances of the fall or who was involved/working at the time. The following fall reports were reviewed: 11/14/15 - 6:15 p.m. No injury Incident description - Unit nurse reprted a witnessed fall at 18:15 (6:15 p.m.) CNA reported to unit nurse that (Resident #14 name) wandered into a peers room while CNA was assisting peer on mat, before she could redirect (Resident #14 name) tripped on peers feet and fell to the floor on his stomach. Immediate action taken - .Intervention: LOS (line of sight) the rest of the shift. POC (plan of care) updated and reviewed with staff. Effective no further falls. Staff continues to redirect out of peers rooms. The Notes section of the report states, No notes found. The fall report does not indicate what type of footwear Resident #14 had on, if he was incontinent at the time or if his hipsters were on. There are no additions to the care plan to prevent further falls. 12/07/15 - 7:25 p.m. laceration to back of head Incident description - Staff reported that resident was moving furniture in the day room this PM. When staff tried to redirect resident away from this activity, he stumbled backward and hit the back of his head on a wooden chair. Immediate action taken - Resident stood up by himself after the fall and continued with his usual activiyt of wandering and pacing. Neuro checks implemented per protocol. Resident refused initial neuro check. He was compliant with second neuro check, which was WNL (within normal limits). Notes - 12/10/15 Interviewed CNA. She reported that she was having difficulty redirecting (Resident #14 name) from moving furniture when he tripped over his feet. Discussion regarding ways to encourage him to a different activity. Example assist him to where he wants to move the furniture in effort to keep him and others safe until he forgets what task he is attempting to complete. The fall report does not indicate what type of footwear Resident #14 had on or if his hipsters were on. There are no additions to the care plan to prevent further falls. 12/21/15 - 8:15 p.m. Abrasion top of scalp Incident description - Staff reported that resident came down hallway quickly and was shuffling his feet. He proceeded through the doorway and into another resident's room. The room was pitch black and resident ran head first into the wall. After bumping his head, he was found on his knees on the floor with a bloody nose. Immediate action taken - Resident was assisted to a chair and cleaned up. Neuro checks implemented per protocol. Resident did not want to sit still in a chair, but continued to try and get up and wander around. Unable to obtain BP (blood pressure) and pulse due to residents behavior. Resident had scheduled Tylenol 650 mg at that time. Staff stayed with resident 1 on 1 and encouraged him to stay seated. There are no notes included on this report. The fall report does not indicate what type of footwear Resident #14 had on, if he was incontinent at the time or if his hipsters were on. There are no additions to the care plan to prevent further falls. 01/18/16 - 10:45 p.m. No injury Incident description - Staff heard resident loudly say ohhh and went to investigate, and found resident sitting on the floor of peers room. Staff called RN to assess. Writer came into room and found resident sitting on the floor on his left hip with legs bent under him. He was leaning forward with his hands on the floor. Resident was sitting next to a curtain that was hanging in the room that is used for privacy and to partician off room. Resident was unable to describe how he fell . Immediate action taken - The documention includes the assessment for injury and notifications to physician and guardian. It then states, LOS for the rest of the shift while up. Notes - states the guardian was notified of the fall The fall report does not indicate what type of footwear Resident #14 had on, if he was incontinent at the time or if his hipsters were on. There is no root cause analysis or interventions to prevent future falls. 01/29/16 - 9:00 p.m. - hematoma and laceration to face Incident description - Resident had been very active and agitated early in the PM shift. He had PRN ativan 1mg at 1808 (6:08 p.m.). Staff reported that they found resident on the floor in peer #5700 room. He had a small, bleeding laceration above his left eye and a hematoma on his forehead. Prior to the incident, staff had observed resident walking briskly without regard to safety of himself or others. He was not able to be redireted and would try to push staff over when they got in his way. Resident refused to sit still Immediate action taken - Resident was assisted off of the floor and immediately wanted to get back up and going again. Steri strips were applied to laceration. Uncooperative with neuro exam. Staff provided direct supervision until calm. Notes - Interviewed RN. RN reported that (Resident #14's name) was active and difficult to redirect. Staff providing direct supervision during his hyperactivity. Staff unable to redirect. He was pushing through staff. He received a prn at 1800 (6:00p.m.) with little effect. The fall report does not indicate what type of footwear Resident #14 had on, if he was incontinent at the time or if his hipsters were on. There is no root cause analysis or interventions to prevent future falls. 01/30/16 - 1:50 p.m. - laceration Incident description - states Resident #14 was coming out of another resident's room and caught his foot on the leg of the TV stand. It states the resident was in a high state of anxiety before the fall, the CNA attempted non-pharmacological interventions and then requested a PRN. Resident #14 had received a scheduled Lorazepam at 12:30 with little effect on his anxiety. Immediate action taken - This section describes the care to the wound, neuro checks, and assessement. No interventions are listed in this section. Notes - dated 02/03/16 states, (Resident #14's name) is a [AGE] year old individual with the medical [DIAGNOSES REDACTED]. He experiences negative behaviors - anxiety, agitation/aggression, wanders, intrusiveness and sundowning. he is goal oriented and difficult to redirect. He is unaware of potential hazards. At times he appears hyperkinetic. I interviewed CNA. This event was caused by lack of safety awareness. He is followed by psychiatry. He was seen by psychiatry on January 20th, 2016. It was the recommendation to continue the medication regimen. Follow up in 3 months or sooner. The fall report does not indicate what type of footwear Resident #14 had on, if he was incontinent at the time or if his hipsters were on. Review of the fall occured three days after the fall. There is no root cause analysis or interventions to prevent future falls. 01/30/16 - 7:00 p.m. laceration to back of head, taken to hospital. Recieved stitches to two lacerations by his eyes (right eye 5 sutures, left eye 2 areas 4 sutures and 3 sutures)

Based on record review and interviews, the facility did not ensure a resident who is incontinent of bladder receives appropriate treatment and services to restore as much normal bladder function as possible for 1 of 24 (Resident #1) residents reviewed for a decline in bladder function. This is evidenced by: The facility policy titled: Incontinence: Urinary and Bowel, Prevention & Management date revised 02/27/14 reads in part: Each resident will be assessed for incontinence and interventions provided to maintain continence and normal function as is possible. Each resident will receive services to prevent urinary tract infections and restore or improve bladder function when possible. 1. Resident will be assessed for bowel and bladder incontinence at admission and significant change of condition. Bowel and bladder pattern will be tracked in the medical record (Point of Care) for three days to establish the pattern and periods of incontinence. 2. Clinical trials will be initiated for another three days following review of the data in an attempt to individualize toileting and maintain continence to the extent possible. Clinical trials will be tracked in the medical record. 4. The Register Nurse (RN) will consult with the physician to determine type of incontinence, treatment options, and if medications are warranted or may be interfering with bowel or bladder function.... 9. For those resident who are continent on admission all efforts will be directed at maintaining continence including (but not limited to): a) having access to call lights with prompt response b) keeping night lights on for access to bathrooms c) keeping paths to toileting facilities free of carts or impediments to access d) having available access to toileting facilities before or after planned outings or activities e) maintaining mobility through nursing restorative programs f) providing bedside commodes when needed g) having easy access to beside urinals h) assessment and management of pain issues that may interfere with the ability to access the toilet. 12. Changes in continence will be monitored and documentation will be provided monthly in the medical record. Based on a review of the documentation a determination will be made if a repeat clinical trial is warranted. Changes in continence will be addressed through further assessments and repeat trail to determine whether or not the incontinence can be reduced and if not, documentation will support the reason for the change in continence. Surveyor reviewed Resident #1's medical record. Resident #1 has [DIAGNOSES REDACTED]. On 01/02/13, the Urinary Continence Assessment was completed and identified Resident #1 as continent of urine. On 07/02/13, the quarterly Minimum Data Set (MDS) identified Resident #1 is occasionally incontinent of bladder, which was Resident #1's first decline of continent voiding. On 10/02/14, the quarterly MDS identifies Resident #1 is occasionally incontinent of bladder, which is less than seven episodes of incontinence. On 01/02/14, the annual MDS identifies Resident #1 as frequently incontinent of bladder; this is a further decline of continent voiding. Frequently incontinent is seven or more episodes of urinary incontinence, but at least one episode of continent voiding. The annual MDS identifies Resident #1 needs extensive assist with one person assist. No assessments or patterning were completed when Resident #1 had a decline of continent voiding. No assessments were completed to determine the type of incontinence. No toileting trials were completed. The care plan titled: Resident #1 has urinary incontinence related to (R/T) advancing dementia. The care plan was initiated on 09/19/13. Goals: Resident #1 will maintain 80% or greater continence of bowel and bladder per week. Interventions: ...Toileting : Independent to Assist of 1, wears medium pull up, many need help finding bathroom, during NOC (night time) leave light on in bathroom and door cracked. The care plan titled: Resident #1 has an Activity of Daily Living (ADL) self-care performance deficit r/t dementia. Goals: Resident #1 will maintain 80% or greater continence of bowel and bladder per week. Interventions: ...1. Prompt Resident #1 to void/defecate after breakfast and supper. Assist with wiping and changing of pull ups as needed. 2. Provide reminders throughout the day to the location of the bathroom... Surveyor reviewed nurses' notes for monthly restorative toileting program, which identified Resident #1 was meeting the goal of 80% continence. Surveyor was given the toileting documentation the Certified Nursing Assistants record voiding from 12/06/13 - 03/07/14. Review of the voiding record identifies Resident #1 as frequently incontinent as to the definition of the MDS. On 03/12/14 at 9:35 a.m., Surveyor reviewed with Registered Nurse - Nursing Care Coordinator (RN NCC) S, Resident #1's decrease of continence. RN NCC S indicated the night shift informs RN NCC S when there is change of continence with residents. If there was a change, then a trial and assessment will be done. Surveyor asked RN NCC S if the MDS section H is completed by the same person. RN NCC S indicated she is the person completing the MDS. Surveyor asked when there is a change in bladder or bowel continence on the MDS, is a trial and assessment completed to determine the voiding patterns and the type of incontinence to be able to individualize a toileting program. RN NCC S indicated she was unsure and will check. Surveyor asked RN NCC S for any further completed trials or assessment for Resident #1. On 03/13/14 at 2:55 p.m., Surveyor was informed by RN NCC S there was no assessment for bladder change for Resident #1. On 03/17/13 at 2:35 p.m., Surveyor reviewed the above findings with the Director of Nursing (DON). The DON indicated RN NCC S started a three day voiding trial on Friday. The DON indicated the night nurse is to document monthly of resident's voiding to identify a change before the quarterly MDS is completed. The DON indicated the number of incontinent episodes was not calculated as needed and will be reviewing the way this will be completed.

Based on observations, interviews, record reviews, and a review of the Facility's infection control program, the Facility did not establish an infection control program under which it investigated, controlled, and prevented infections in the facility; decide what procedures, such as isolation, should be applied to an individual resident; and maintain a record of incidents and corrective actions related to infections. The Facility's infection control program failed to prevent the spread of a gastrointestinal illness because the facility did not immediately implement appropriate precautions for prevention. An outbreak of gastrointestinal illness, confirmed to be the Norovirus infection, went through this facility beginning 1/3/11 affecting 28 Residents and approximately 44 staff members by the time it ended on 1/24/11. The facility did not implement their infection prevention and control program and did not: ~Follow their policies and did not implement their established procedure for tracking all residents with signs/symptoms of acute gastroenteritis. The Facility did not follow their policies to immediately implement appropriate precautions when multiple residents on a common unit presented with symptoms of acute onset of diarrhea and/or vomiting. ~Suspend resident gatherings for dining and activities on the unit to ensure that residents who were not ill and had no symptoms were not exposed to residents who were presenting with signs/symptoms of acute gastroenteritis and to prevent further transmission of a potentially infectious agent. ~Assure that housekeeping was using a disinfectant that killed the Norovirus. ~Limit new admissions when a confirmed and/or suspected outbreak was occurring in the Facility. In terms of ongoing infection control: ~The Facility is not conducting ongoing surveillance but rather retrospective surveillance at the end of the month. The monthly surveillance logs are incomplete. No causative organisms were identified, no indication of what precautions were used, and no resolved dates were identified on the logs for any of the entries. Lack of current surveillance means that early detection of clusters or outbreaks could be missed or not easily identified. ~ The Facility is not identifying and tracking residents who enter the facility with infections. The ADON (Assistant Director of Nursing) who is responsible for the infection control program only tracked infections for current residents, not new admissions. ~The September 2011 nosocomial infection report was not completed. This report indicates the total number of infections for respiratory tract infection, urinary tract infection, gastrointestinal infection, skin infection, eye/ear/nose/mouth infection, systemic infection and other infections. This report also includes the baseline infection rate for the abovementioned infections. ~The Facility did not have a policy and procedure which would direct staff on how to care for a Resident with[DIAGNOSES REDACTED]icile, a bowel infection. Resident #35 was diagnosed with [REDACTED]. ~ A Resident was placed on antibiotic medications for symptoms not consistent with the facility's clinical criteria for UTI (Urinary Tract Infection). The Facility's failure to have an infection control program that identified and prevented the spread of infection, created a finding of Immediate Jeopardy that began on 10/10/11. The Administrator, Director of Nursing and ADON (Assistant Director of Nursing)-K, who is responsible for the infection control program were informed of the immediate jeopardy on 10/10/11 at 12:20 p.m. by Surveyor # . The finding of Immediate Jeopardy was removed on 10/14/11 and continues at a scope and severity of an F (potential for harm that is not immediate jeopardy/widespread) as the facility continues to implement corrective action related to infection control practices. This deficient practice has the potential to affect all 157 Residents currently residing in the Facility. Findings include: MANAGEMENT OF NOROVIRUS OUTBREAK On 10/12/11 at 2:00 p.m. during the infection control interview with ADON-K, Surveyor # asked if the Facility had any outbreaks. ADON-K informed Surveyor # and # that they had a Norovirus outbreak in January 2011. ADON-K informed the Surveyors that this outbreak was isolated mainly on the East side of the building. Surveyor # inquired when the first sign and symptom of Residents becoming ill was. ADON-K indicated that it started on the two East unit on 1/3/11 with one Resident and then on 1/5/11 three more Residents became ill. Surveyor # reviewed the January 2011 monthly surveillance logs and noted the following number of Residents exhibiting signs and symptoms of the GI (Norovirus) illness: 1/3/11 One Resident on the 2 East A unit. 1/5/11 Three Residents on the 2 East A unit. 1/6/11 one Resident on the 2 East A unit 1/7/11 One Resident on the 2 East A unit 1/11/11 Three Residents on the 1 East B unit, one Resident on the 1 East A unit and three Residents on the 3 East. 1/12/11 One Resident on the 3 East unit. 1/13/11 One Resident on the 1 East B unit 1/17/11 One Resident on the 2 East B unit 1/18/11 One Resident on the 2 East A unit and one Resident on the 2 East B unit 1/19/11 Six Residents on the 2 East B unit 1/22/11 One Resident on the 2 East B unit 1/23/11 One Resident on the 2 East B unit 1/24/11 One Resident on the 2 East B unit No date for One Resident on the 2 East B unit. 1. On November 14, 2010, the Department of Health Services, Division of Quality Assurance sent out via email list serve an announcement that directed providers to the link <http://www.dhs.wisconsin.gov/rl_DSL/Publications/pdfmemos/10-033attach.pdf> to view DQA Memo 10-033/Recommendations for the Prevention and Control of Viral Gastroenteritis Outbreaks in WI Long-Term Care Facilities (LTCF). This document notes the following to include but is not limited to: Facilities are required to maintain an infection prevention and control program that includes a surveillance program for infections common to LTCFs including viral gastrointestinal disease. An outbreak of viral gastroenteritis should be suspected when two or more residents and/or staff develop new onset of vomiting and/or diarrhea within one to two days. On 12/15/10, the Wisconsin Division of Public Health (WDPH) revised the definition to state: an outbreak of viral gastroenteritis should be suspected when three or more cases of illness among residents and/or staff within a 72 hour period with vomiting and diarrhea. A new "case" definition of suspected Norovirus is "3 or more loose stools in a 24 hour period in a resident or staff member and whose symptoms have no other apparent cause." The 5/1/2009 "Recommendations for Prevention and Control of Viral Gastroenteritis Outbreaks in Wisconsin Long-Term Care Facilities" include: Management of Staff and Residents: - Immediate isolation of the resident and restricting access to affected areas is essential; - confine symptomatic residents to their rooms until 48 hours after symptoms cease. Surveyor # asked ADON-K on 10/12/11 at 2:00 p.m. when she considered that the Facility had an outbreak. ADON-K replied "on the fifth." ADON-K stated that this time they posted signs on the 2 East A unit and quarantined that unit. ADON-K informed Surveyor # & # that the Residents from the 2 East unit did not go to the large dining room but ate on their unit in the dining/lounge area. On 10/13/11 at 8:50 a.m. Surveyor # and # continued the interview regarding the Norovirus outbreak with ADON-K. ADON-K informed the Surveyors that on 1/11/11 they stopped the large dining room, residents ate on their units and they were quarantined. Surveyor # asked whether Residents ate in their rooms or in the lounge/dining area on the units. ADON-K replied they would have eaten in the central lounge because the Residents needed direct supervision from staff. ADON-K also stated that large groups with Residents from different units together were not held but there were activities on the units in the central lounge area that were held. Because the facility did not immediately implement isolation procedures, residents from the East and West units were able to eat together from January 5 to January 10, 2011. Once dining was confined to the unit, ill and non-ill residents within the unit were allowed to eat together and interact together in group activities, creating opportunity for the infection to spread within the unit. 2. The WDPH recommendations indicate facility staff should use only chlorine bleach or a U.S. Environmental Protection Agency approved disinfectant in controlling Norovirus outbreaks. On 10/13/11 at 7:23 a.m., Surveyor # interviewed HSKP (Housekeeper)-HH regarding cleaning of the facility during the Norovirus outbreak in January, 2011. HSKP-HH stated for more than the past year, they have used Virex for all their cleaning, "for everything". HSKP-HH stated they did nothing different during the outbreak; they used the Virex as they always do, nothing more, nothing different. HSKP-HH showed Surveyor # a bottle of Virex 256 from Johnson Diversey in the housekeeper's closet, and stated that is what they used during the outbreak to clean all surfaces. On 10/13/11 at 8:25 a.m. Surveyor # interviewed HS (Housekeeping Supervisor)-GG to inquire what product his staff used during the January 2011 GI outbreak. HS-GG informed Surveyor # that they used Virex 256 and that they have been using this product for years. Surveyor # asked HS-GG whether his staff did anything different in January during the outbreak. HS-GG informed Surveyor # that they wiped down the hand rails, door knobs, and side rails on a daily basis with Virex 256. HS-GG indicated that after ADON-K had informed him of the outbreak he had called the company and was informed that it killed the Norovirus. Surveyor # asked if HS-GG had received the manufacturer's information sheet on the product. HS-GG informed Surveyor # that after Surveyor # spoke with ADON-K regarding the outbreak he called the company to request the sheet be sent. HS-GG informed Surveyor # that ADON-K has the material sheet for Virex 256 and that ADON-K informed him that the product they were using does not kill the Norovirus. HS-GG informed Surveyor # that the company representative is coming in and they will be looking at another product that is supposed to kill the Norovirus. 3. The WDPH recommendations indicate facility staff should wear personal protective equipment to include gloves and gowns upon entry to the room and when in contact with the symptomatic resident, and masks/goggles if vomitus is present. The facility's Standard & Transmission-Based precautions for prevention of transmission policy and procedure revised 9/20/11 notes under Contact documents "Contact precaution will be instituted for residents diagnosed or with active signs and symptoms of influenza (fever, coughing, sneezing, runny nose) or gastroenteritis or Norovirus (vomiting, diarrhea, fever)." On 10/13/11 at 8:50 a.m. Surveyor # and # continued the interview regarding the Norovirus outbreak with ADON-K. Surveyor # inquired if the Residents with signs and symptoms of the GI (Norovirus) illness were placed on any type of isolation. ADON-K informed Surveyor # that staff just wore gloves, washed their hands, and if there was a big mess (vomit) then staff would put on a gown if they felt they needed to. ADON-K gave surveyors an e mail that had been sent to staff on all the units. Surveyor # noted this e mail was dated 1/14/11 for subject GI illness. This e mail notes, in part, "Keep doing the best you can ... If you need to use a gown to clean up large messes, please do so." 4. The WDPH recommendations indicate the facility should limit new admission until the incident of new cases has reached zero for at least 48 hours. On 10/13/11 at 2:56 p.m. Surveyor # interviewed DSS (Director Social Service)-FF, who is also responsible for admissions. Surveyor # asked DSS-FF if there were any Residents admitted from 1/5/11 through 1/24/11. DSS-FF replied "I'm sure we did." DSS-FF printed out an admission analysis report for Surveyor # which showed there were eight Residents admitted during this time period. 5. The WDPH recommendations regarding laundry care include: 1. Do not shake soiled linens and laundry. Aerosols created may pose a risk for transmission. Soiled linens should be placed directly into a bag at the point of removal. Minimize the number of staff handling this material. 2. Contaminated pillows should be laundered as infected linen unless they are covered with an impermeable cover, in which case they should be disinfected with a hypochlorite solution. 3. Ensure proper segregation of clean and soiled laundry. 4. Ensure laundry personnel are made aware of the potentially infected linen and are provided with appropriate PPE. Surveyor # asked ADON-K if anything changed with the way laundry handled the linen. ADON-K replied that they (the laundry department) were aware and that they didn't handle the linen any differently. On 10/26/11 the facility submitted additional information regarding infection control and inservicing during the gastrointestinal outbreak in January. The documentation indicates that on 1/11/11 the facility held a mandatory inservice regarding abuse/neglect/misappropriation of property and inserted into the follow up test questions was a question asking staff to answer during a gastrointestinal outbreak what type of precautions are used: a.) contact precautions b.) standard precautions c.) only hand washing and d.) wear a mask. Additionally, the submitted documentation included a message that was posted on the CareTracker screen stating ITEMS for REVIEW!!! *Gastroenteritis out break on units: 1. Units with residents having vomiting and diarrhea will be quarantined to their units 2. All meals will be served on the units 3. Use contact precautions during cares 4. Encourage fluids and monitor intakes closely 5. Large group activities will be canceled. Provide activity on the unit & in resident rooms. While this additional information shows that information was provided to staff beyond an e-mail from the ADON-K at the time of the outbreak, Surveyor # noted that the information from the CareTracker is not dated and still allows for Residents to co-mingle on the units despite the occurrence of an out break. Additionally, both the test question and the CareTracker posting talk about precautions to be used yet the proper precautions were not used during the facility outbreak because standard precautions were used. INFECTION CONTROL PROGRAM/SURVEILLANCE On 10/12/11 at 2:00 p.m. Surveyor # and # interviewed ADON-K regarding the Facility's infection control program. Surveyor # inquired how the Facility tracks infections. ADON-K explained that each unit has a monthly surveillance log and that anytime a Resident has an infection the nurse on the shift when the infection is identified would place the Resident on the log. ADON-K further explained when the month is completed she receives the monthly surveillance logs from the units. ADON-K informed Surveyor # and # after she receives the monthly surveillance logs she compares this report with the antibiotic report from the pharmacy. ADON-K indicated that sometimes she finds infections that were not on the monthly surveillance logs by reviewing the antibiotic report. After she compares the monthly surveillance log with the antibiotic report she completes the nosocomial infection report. ADON-K informed Surveyor # and # that September 2011 nosocomial infection report is not completed. Surveyor # inquired if any one is responsible for reviewing the monthly surveillance log on a daily basis. ADON-K replied that the NCC (Nurse Care Coordinators) or the nurse on the unit would look at the log. Surveyor # inquired who is responsible for the surveillance of the whole Facility and not each individual nursing unit. ADON-K replied that she reviews the monthly surveillance logs at the end of the month but the nurses know that if there are two Residents on the unit with the similar symptoms then they are suppose to notify her and also the Resident would be placed on their daily report. ADON-K informed Surveyor # that they would consider two Residents with similar symptoms as an outbreak. ADON-K informed Surveyor # with the influenza season coming up two or more Residents with the same symptoms the nurses would call her. Surveyor # inquired if ADON-K maps the infection to see if the Residents are in rooms next to each other or maybe the Residents with the infections are cared for by the same CNA (Certified Nursing Assistant) assignment. ADON-K informed Surveyor # that they do not map any infections. On 10/12/11 at 3:57 p.m. Surveyor # and # continued the infection control interview. Surveyor # asked ADON-K if ADON-K could tell Surveyor # which Residents currently have infections in the Facility. ADON-K informed Surveyor # that she would have to call the units and look at the monthly surveillance logs on each unit. Surveyor # asked ADON-K if she was tracking community acquired infections. ADON-K replied "no" and informed Surveyor # that she is not tracking them at all. August log. On 10/13/11 Surveyor # reviewed the monthly surveillance log for August 2011 and noted the following: On the 1 East unit there are ten Residents listed. There are no organisms, isolation, or resolved dates listed. On the 1 West unit there is one Resident listed. There is no organism, isolation or resolved date. On the 2 West unit there are seventeen Residents listed. There are no dates of onset, organism, isolation or resolved dates. On the 3 East unit there are three Residents listed. There are no organism, isolation or resolved dates. On the 3 East A unit there are three Residents listed. There is one Resident without a date of onset, none of the Residents have organisms, isolation, or resolved dates. On 10/13/11 Surveyor # noted the August 2011 nosocomial infection report indicates that there were 19 Residents with fungal skin infections. During review of the August monthly surveillance log Surveyor # noted there were only 2 Residents checked for skin/wound. Surveyor # asked ADON-K how she came up with 19 Residents with fungal skin infections when there were only 2 Residents listed on the log. ADON-K informed Surveyor # that she probably picked them up when she reviewed the antibiotic log. On 10/13/11 Surveyor # reviewed the monthly surveillance log for September 2011 and noted the following: On the 1 East unit there are eleven Residents listed. There are no organism, isolation or resolved dates. On the 2 East unit there are nine Residents listed. There are no organism, isolation or resolved dates. On the 2 West unit there are eleven Residents listed. Nine of the Residents there are no dates of onset. None of the Residents have organism, isolation or resolved dates. On the 3 West A unit there is one Resident listed. There is no date of onset, organism, isolation, or resolved date. On the 3 West B unit there is one Resident listed. There is no date of onset, organism, isolation, or resolved date. September log. During review of the September 2011 monthly surveillance log, Surveyor # noted that Resident #35 was listed on the 2 West log under signs/symptoms "loose stools (+) [DIAGNOSES REDACTED]. There is no date of onset listed, type of precautions implemented is not listed and date infection resolved is not listed. On 10/13/11 Surveyor # reviewed Resident #35's medical record and noted on the lab report dated 9/7/11 documents "C-Difficile-toxigenic positive." On 9/9/11 the physician ordered [MEDICATION NAME] 250 mg (milligrams) three times a day for seven days. On 10/13/11 at 9:43 a.m. Surveyor # interviewed RN (Registered Nurse)-L to inquire what type of precautions Resident #35 was on for the[DIAGNOSES REDACTED]icile. RN-L replied "standard precautions." Current standard of practice indicate that Residents with[DIAGNOSES REDACTED]icile should be placed on contact isolation. Surveyor # inquired if there was any additional testing completed for the[DIAGNOSES REDACTED]icile other than the initial lab on 9/7/11. RN-L informed Surveyor # that they did not do any additional testing. At 10:09 a.m. RN-L informed Surveyor # that they did not have a specific policy for[DIAGNOSES REDACTED]icile. October log. On 10/13/11 Surveyor # reviewed the monthly surveillance log for October 2011 and noted the following: On the 1 East unit there is one Resident listed. There is no organism identified, isolation or resolved date. The 2 East documents for month "September 2011/Oct. 2011." There are six Residents listed. Three Residents do not have date of onset; none of the Residents have organisms, isolation, and resolved date. On the 2 West unit there are seven Residents listed. There are no dates of onset, organism, isolation, or resolved dates. On the 3 East unit there are four Residents listed. There are no organism, isolation or resolved dates listed. On the 3 West unit there is one Resident listed. There is no date of onset, organism, isolation, or resolved date. On 10/26/11, in the additional information that the facility submitted for review, ADON-K indicated that the information that was provided to Surveyor # during the survey was their "QA surveillance logs" used to help gather information from their tracking and trending of organisms throughout the building. The additional information continues to indicate that when ADON-K completes her reports ADON-K gathers the information on the organisms from their online lab reports and compares these organisms from month to month with their physicians, medical director, and QA committee. On 11/1/11 at approximately 2:00 PM Surveyor # contacted ADON-K and DON-B to clarify the additional information referencing that the surveillance logs provided are the facility's logs for QA purposes. ADON-K indicated that the logs are created putting together information from multiple sources and that while the log may not indicate organism information etc. that information is available to them on other forms but that these logs are created to bring information to QA. Surveyor # asked ADON-K and DON-B if they are indicating that the logs should be privileged as part of their QA process and both indicated that they wanted to make sure that the surveyors understood the purpose for the logs. Surveyor # asked if there are any other logs that are completed for the purpose of tracking and trending that contain the necessary information to be comprehensive that are different from the provided logs and ADON-K indicated that there was not. Surveyor # noted that if the provided logs are considered privilege by the QA process and that there is not an alternative comprehensive log/listing used daily for the purposes of tracking and trending infections facility wide that the facility is deficient in their surveillance process. Surveyor # also noted that if the logs provided are not protected by the QA process, the facility is still deficient in their surveillance process in that the logs are completed retrospectively rather than daily and are not comprehensive with details. HAND HYGIENE Surveyor # reviewed Resident #8's medical record on 10/11/11 and 10/12/11. Resident #8 is incontinent of bowel and bladder. On 10/11/11 at 9:12 a.m. Surveyor # observed CNA (Certified Nursing Assistant)-EE in Resident #8's room. CNA-EE placed on gloves and informed Surveyor # that Resident #8 wants her pad changed. CNA-EE unfastened the incontinence product, which contained urine, and washed Resident #8's inner thighs and perineal area from front to back. CNA-EE positioned Resident #8 on her right side and wiped the stool from the rectal area with a disposable wash cloth. CNA-EE asked Resident #8 if she could push as there is BM (bowel movement) in there. Resident #8 was able to evacuate the stool from her rectum and CNA-EE wiped the rectal area and buttocks with a disposable wash cloth. CNA-EE removed the incontinence product and placed the product in the garbage. CNA-EE removed her gloves, informed Resident #8 that she was going to get a clean pair of gloves, went to the cabinet by the sink and removed a pair of gloves. CNA-EE placed the gloves on but did not wash her hands. CNA-EE placed a new incontinence product under Resident #8 stating "bet that feels better." CNA-EE fastened the incontinence product and pulled down the gown. CNA-EE asked Resident #8 if she needed anything else, removed her gloves and placed them in the garbage. CNA-EE tied the garbage bag, covered Resident #8 and asked Resident #8 if she was warm enough. CNA-EE then went over to the sink and washed her hands. On 10/12/11 at 9:09 a.m. Surveyor # entered Resident #8's room with RN (Registered Nurse)-DD. RN-DD informed Resident #8 that she was going to change the dressing on her foot. RN-DD placed gloves on and proceeded to cut the tape from the kling asking Resident #8 how her appointment at the wound clinic was yesterday. Resident #8 responded "painful." RN-DD unwrapped the kling and then placed a barrier under Resident #8's left foot. RN-DD then removed the dressing from the 2nd toe. RN-DD tipped a cotton applicator in normal saline and removed the packing strip. RN-DD removed her gloves, washed her hands, and placed new gloves on. RN-DD informed Surveyor # that the 2nd toe had a black tip which they must have taken off at the wound clinic yesterday. RN-DD cleansed the wound under the first metatarsal with normal saline and then cleansed the 2nd toe with normal saline. After cleansing Resident #8's wounds, RN-DD did not remove her gloves and wash her hands. RN-DD placed a piece of folded four by four gauze in between Resident #8's toes, dipped the 1/4 packing strip into normal saline and placed on the wound of Resident #8's second toe. RN-DD placed a folded four by four gauze over Resident #8's second toe. RN-DD placed 1/4 packing strips which were dipped in normal saline in the wound under the first metatarsal, covered the wound with a four by four gauze and informed Resident #8 that it should feel better. While RN-DD wrapped Resident #8's left foot with kling and taped the kling. RN-DD removed her gloves, informed Resident #8 that she was all done, cleaned her scissors with alcohol, placed the supplies in the cabinet and then washed her hands. On 10/13/11 at 9:15 a.m. Surveyor # asked ADON-K when she would expect staff to wash their hands. ADON-K informed Surveyor # that staff should wash their hands before they leave the room, after they are finished with pericare, & when they remove their gloves. Surveyor # asked ADON-K during a treatment, when should a nurse wash their hands. ADON-K replied after removing a dirty dressing, after cleaning a wound, and when they remove their gloves they should wash their hands. URINARY TRACT INFECTIONS Cross Reference F329. The American Medical Directors Association, Common Infections in the Long-Term Care Setting Clinical Practice Guideline. Columbia, MD: AMDA 2011 under "COLONIZATION OR INFECTION?" documents "The confusion of colonization (a positive bacterial culture without signs or symptoms of an inflammatory host response) with infection is a common problem in LTC (long term care) facilities that contributes to the intense use of antibiotic therapy in this setting. According to the Centers for Disease Control (CDC) 3/12/10 Multidrug-resistant Organisms in Non-hospital Health Care Settings: Colonization means that the organism is present on or in the body but is not causing illness. Studies have consistently shown that about 30% of elderly LTC patients have no symptoms of UTI (urinary tract infection) and as many as half of patients who are highly functionally impaired have a positive urine culture on routine surveillance sampling. The more debilitated the patient, the more likely that asymptomatic bacteriuria will be present. Thus, a positive urine culture in the absence of urinary symptoms (i.e., dysuria, frequency, urgency) is of limited value in identifying whether a patient's symptoms are caused by a UTI. In general, cultures should be obtained only in the presence of signs or symptoms of infection. The CDC (Center for Disease Control) Campaign to Prevent Antimicrobial Resistance in Healthcare settings; 12 Steps to Prevent Antimicrobial Resistance Among Long-term Care Residents includes under step 7 - Treat infection, not colonization or contamination ~Perform proper antisepsis with culture collection ~Reevaluate the need for continued therapy after 48-72 hours ~Do not treat asymptomatic Bacteriuria The Facility has a policy effective 4/11/07 for Management of Urinary Tract Infections and Bacteriuria which was not implemented as 1 Resident was placed on antibiotic medications for symptoms not consistent with the facility's clinical criteria for UTI (Urinary Tract Infection). The Facility's Management of Urinary Tract Infections and Bacteriuria effective 4/11/07 documents under policy "Chronic asymptomatic bacteriuria occurs frequently in the long-term care setting. Research-based literature suggests treating only symptomatic UTIs (urinary tract infections). The following criteria will be followed in the treatment of [REDACTED]. Residents without a catheter should have at least three of the following signs and symptoms: ~Fever (increase in temperature of 2 degrees F (Fahrenheit) or rectal temperature 99.5 degrees F, or a single measure of temperature 100 degrees); ~New or increased burning pain on urination, frequency or urgency; ~New flank or suprapubic pain or tenderness; ~Change in character of urine (e.g. new bloody urine, foul smell, or amount of sediment) or as reported by the laboratory (new pyuria or microscopic hematuria); and/or ~Worsening of mental or function status (e.g. confusion, decreased appetite, unexplained falls, incontinence of recent onset, lethargy, decreased activity. 1.) On 10/12/11 Surveyor # reviewed the 2E (East) monthly surveillance log for September 2011. Surveyor # noted Resident #28 is listed on the log as having a UTI with the date of onset of 9/3. Increased behaviors are documented under the section signs/symptoms. Under treatments/comments documents "keflex 500 mg (milligrams) po (by mouth) x 7 days" with date infection resolved 9/11/11. Surveyor # noted that the date of resolution is the date the antibiotic is completed. There is no organism listed on the surveillance log. Resident #28 was placed on Keflex without meeting the Facility's criteria for the treatment of [REDACTED]. On 10/12/11 during the daily exit meeting with the facility the above concern was shared. The facility's lack of real-time surveillance of the facility as a whole, which would hinder the immediate detection of a possible outbreak and implementation of effective measures to reduce the spread of infection (e.g., isolation of ill residents; contact precautions) created a finding Immediate Jeopardy. The facility removed the Immediate Jeopardy on 10/14/11 when the facility implemented the following: 1. The facility contacted the Medical Director to seek professional guidance and input regarding infection control and the citation being issued. 2. The facility reviewed infection policies and reviewed the Center for Disease Control (CDC) standards for information and to prepare for training/policy revision. 3. The facility held a department head meeting and initiated immediate changes to the infection control data collection system and established inservice training schedule for all nursing staff. 4. The facility reviewed information regarding[DIAGNOSES REDACTED]icile and initiate the development of a policy. 5. The facility established a weekly meeting schedule to review all infectious processes. 6. The facility obtained information regarding the cleaning product Virex and obtained cleaning products that will be effective against the Norovirus. The deficient prac

Based on observation, record review and staff interview, the facility did not ensure residents receive appropriate bowel management and pain management. This was observed with 3 of 3 residents with a bowel decline. Residents' #2, #4, #12 had bowel continence declines between MDS (minimum data set) reference periods and no bowel assessment. 2 of 24 sampled residents reviewed bowel movement records showed patterns of constipation without evidence of being addressed. Residents' #3 and #4 did not have appropriate bowel monitoring. 1 of 1 residents (Resident #8) observed during a treatment expressed pain that was not addressed. Resident #8 verbalize significant pain during a treatment in which it was not addressed at that time. Findings include: Bowel Continence Decline 1.) Resident #2's medical record was reviewed by Surveyor # on 10/10-10/13/11. Resident #2 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #2's most recent MDS (minimum data set) is a Significant Change in Condition MDS completed on 9/16/11. The section for bowel indicates a '2', which means frequently incontinent. Resident #2 requires total assist with transfers and hygiene, and is non-ambulatory. The previous comparison MDS is a Quarterly completed on 5/10/11. The section for bowel indicates a '1', which means occasionally incontinent. Resident #2 requires total assist with transfers and hygiene, and is non-ambulatory. This shows Resident #2 has declined in bowel function. Resident #2's medical record did not contain a comprehensive assessment that addressed bowel management. The CAA's (Care area Assessment) that correlate with the MDS completed on 9/16/11 indicates check and change for bowel movement and has occasional bowel incontinence, but also states that Resident #2 requests to have a bowel movement. There is no documentation of a comprehensive assessment that may include reason for incontinence, habits, medications or treatments used for managing bowels. There is no documentation that indicates why Resident #2's bowel function has declined. On 10/12/11 at 9:40 a.m. Surveyor # spoke with RN-C (Registered Nurse) regarding bowel assessments. RN-C indicated that Care Tracker is reviewed for patterning for the MDS reference period and the information is in the CAA's and that's the bowel assessment. On 10/12/11 at 11:55 a.m. DON-B (Director of Nurses) and ADON-K (Assistant Director of Nurses) spoke with some of the survey team regarding bowel and bladder assessments. The DON-B indicated that bladder assessments include the initial nursing assessment completed upon admission. The section for bladder and bowel, just indicates if they are incontinent or not; there is not a formal bowel assessment. The bowels are monitored by Care Tracker and if there is no bowel movement in 72 hours interventions are initiated. There is not a bowel patterning or history done to determine the individual's bowel habits. Surveyor # shared the concerns regarding Resident #2 not having a comprehensive bowel assessment. On 10/12/11 at 12:28 p.m. Surveyor # spoke with RN-C (Registered Nurse) regarding Resident #2's bowels. RN-C indicated that the bowels are monitored daily by the night nurses, and if there is no bowel movement in 3 days the night nurse notify's the day nurse for follow up treatment. There is an admission assessment that is done upon admission that indicates if the resident is incontinent or continent. There is not a bowel history, laxative use or pattern obtained on this assessment. On 10/12/11 at 3:15 p.m. at the facility exit meeting, the facility verbalized awareness of the lack of Resident #2's bowel assessments that were discussed earlier in the day. 2.) Resident #4's medical record was reviewed by Surveyor # on 10/10/11-10/13/11. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #4's most recent MDS (minimum data set) was an annual MDS completed on 6/7/11. This MDS indicates Resident #4 is non-ambulatory and requires total assist with transfers and hygiene. The bowel section indicates a '2' which means frequent incontinence. The comparison MDS is a Quarterly completed 8/29/11. This MDS indicates Resident #4 is non-ambulatory and requires total assist with transfers and hygiene. The bowel section indicates a '3' which means always incontinent. This shows a decline in bowel function. Resident #4's CAAs that correlated with the annual MDS completed on 6/7/11 was reviewed by Surveyor # . The CAA indicates that Resident #4 has bowel incontinence. There is no documented assessment that indicates what are Resident #4's bowel habits, pattern, treatments or why Resident #4 incontinence has declined since last assessment period of the Quarterly MDS completed on 8/9/11. Resident #4's bowel movement documentation was reviewed for the past few months. Resident #4 had several periods of not having a bowel movement for 4 days or more. The most recent bowel or/and bladder assessment was a annual assessment that indicates incontinence status only. This assessment form was completed 9/14/08. There is not a comprehensive bowel assessment discovered in Resident #4 medical record. On 10/12/11 at 9:40 a.m. Surveyor # spoke with RN-C (Registered Nurse) regarding bowel assessments. RN-C indicated that care tracker is reviewed for patterning for the MDS reference period and the information is in the CAA's and that's the bowel assessment. On 10/12/11 at 11:55 a.m. DON-B (Director of Nurses) and ADON-K (Assistant Director of Nurses) spoke with some of the survey team regarding bowel and bladder assessments. The section for bladder and bowel, just indicates if they are incontinent or not; there is not a formal bowel assessment. The bowels are monitored by care tracker and if there is no bowel movement in 72 hours interventions are initiated. There is not a bowel patterning or history done to determine the individual's bowel habits. The bladder assessments are done on admission or if changes. Surveyor # shared the concerns with regard to Resident #4 not having a comprehensive bowel assessment to address incontinence and bowel movement monitoring in which Resident #4 had several occasions of going more then 4 days without a bowel movement. On 10/12/11 at 12:28 p.m. Surveyor # spoke with RN-C (Registered Nurse) regarding Resident #4 bowel assessments. RN-C indicated that the bowels are monitored daily by the night nurses, and if there is no bowel movement in 3 days the night nurse notify's the day nurse for follow up treatment. There is a admission assessment that is done upon admission that indicates if the resident is incontinent or continent. There is not a bowel history, laxative use or pattern obtained on this assessment. On 10/12/11 at 3:15 p.m. at the facility exit meeting, the facility verbalized awareness of Resident #4's bowel assessments that were discussed earlier in the day. Bowel Monitoring 3.) Resident #3's medical record was reviewed by Surveyor # on 10/10/11-10/13/11. Resident #3 was admitted to the facility on [DATE] with a re-admitted [DATE] with [DIAGNOSES REDACTED]. Resident #3's most recent MDS (minimum data set) is an annual MDS completed on 8/3/11. This indicates Resident #3 is non-ambulatory and requires total assist with transfers and hygiene. The section for bowels indicate a '0' which means total control. The prior comparison MDS is a Quarterly completed on 5/4/11. This indicates Resident #3 is non-ambulatory and requires total assist with transfers and hygiene. The bowel section indicates a '0' which means total control. Resident #3's bowel monitoring record was reviewed for the past few months and shows the following: - 8/13/11 - 8/17/11 no documented bowel movement. - 8/17/11 - 8/23/11 no documented bowel movement. - 8/30/11 - 9/08/11 no documented bowel movement. - 9/9/11 - 9/13/11 no documented bowel movement. - 9/13/11 - 9/18/11 no documented bowel movement. - 9/18/11 - 9/22/11 no documented bowel movement. - 9/30/11 - 10/3/11 no documented bowel movement. - 10/6/11 - 10/11/11 no documented bowel movement. Resident #3 CAAs (Care Area Assessment) that correlated with the Annual MDS completed on 8/3/11 were reviewed by Surveyor # . The CAA's indicated that Resident #3 is usually continent of bowels. There is no documentation that indicates when Resident #3 is incontinent or patterns, habits or treatments for bowel management. Resident #3 requires staff assist with toileting needs and is non-ambulatory. Resident #3's most recent documentation of an assessment for bowel and bladder is dated 2/9/10 and just indicates bladder incontinence and bowel incontinence. No further patterning, habits, history or treatments are documented. On 10/12/11 at 9:40 a.m. Surveyor # spoke with RN-C (Registered Nurse) regarding bowel assessments. RN-C indicated that care tracker is reviewed for patterning for the MDS reference period and the information is in the CAA's and that's the bowel assessment. On 10/12/11 at 11:55 a.m. DON-B (Director of Nurses) and ADON-K (Assistant Director of Nurses) spoke with some of the survey team regarding bowel and bladder assessments. The section for bladder and bowel, just indicates if they are incontinent or not. There is not a formal bowel assessment. The bowels are monitored by care tracker and if there is no bowel movement in 72 hours interventions are initiated. There is not a bowel patterning or history done to determine the individual's bowel habits. The bladder assessments are done on admission or if changes. Surveyor # shared the concerns with regard to Resident #3's bowel movement monitoring in which Resident #3 had several occasions of going more then 4 days without a bowel movement. On 10/12/11 at 12:28 p.m. Surveyor # spoke with RN-C (Registered Nurse) regarding Resident #3 bowel and bladder assessments. RN-C indicated that the bowels are monitored daily by the night nurses, and if there is no bowel movement in 3 days the night nurse notify's the day nurse for follow up treatment. There is a admission assessment that is done upon admission that indicates if the resident is incontinent or continent. There is not a bowel history, laxative use or pattern obtained on this assessment. On 10/12/11 at 3:15 p.m. at the facility exit meeting, the facility verbalized awareness of the concerns regarding Resident #3's bowel assessments that were discussed earlier in the day. 4.) Resident #4 medical record was reviewed by Surveyor # on 10/10/11-10/13/11. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #4's most recent MDS (minimum data set) was an annual MDS completed on 6/7/11. This MDS indicates Resident #4 is non-ambulatory and requires total assist with transfers and hygiene. The bowel section indicates a '2' which means frequent incontinence. The comparison MDS is a Quarterly completed 8/29/11. This MDS indicates Resident #4 is non-ambulatory and requires total assist with transfers and hygiene. The bowel section indicates a '3' which means always incontinent. Resident #4's CAAs that correlated with the Annual MDS completed on 6/7/11 was reviewed by Surveyor # . The CAA indicates that Resident #4 has bowel incontinence. There is not a documented assessment that indicates bowel habits, patterning, treatments or why Resident #4's incontinence has declined since the last assessment period of the Quarterly MDS completed on 8/9/11. Resident #4's bowel movement documentation was reviewed for the past few months and showed the following: - 8/14/11 - 8/20/11 no documented bowel movement. - 9/11/11 - 9/16/11 no documented bowel movement. - 10/1/11 - 10/6/11 no documented bowel movement. - 10/6/11 - 10/11/11 no documented bowel movement. The most recent bowel and/or bladder assessment was an annual assessment that indicates incontinence status only. This assessment form was completed 9/14/08. There is not a comprehensive bowel or bladder assessment discovered in Resident #4's medical record. On 10/12/11 at 9:40 a.m. Surveyor # spoke with RN-C (Registered Nurse) regarding bowel assessments. RN-C indicated that care tracker is reviewed for patterning for the MDS reference period and the information is in the CAA's and that's the bowel assessment. On 10/12/11 at 11:55 a.m. DON-B (Director of Nurses) and ADON-K (Assistant Director of Nurses) spoke with some of the survey team regarding bowel and bladder assessments. The section for bladder and bowel, just indicates if they are incontinent or not; there is not a formal bowel assessment. The bowels are monitored by care tracker and if there is no bowel movement in 72 hours interventions are initiated. There is not a bowel patterning or history done to determine the individual's bowel habits. Surveyor # shared the concerns with Resident #4's bowel movement monitoring in which Resident #4 had several occasions of going more then 4 days without a bowel movement. On 10/12/11 at 12:28 p.m. Surveyor # spoke with RN-C (Registered Nurse) regarding Resident #4's bowel and bladder assessments. RN-C indicated that the bowels are monitored daily by the night nurses, and if there is no bowel movement in 3 days the night nurse notify's the day nurse for follow up treatment. There is an admission assessment that is done that indicates if the resident is incontinent or continent. There is not a bowel history, laxative use or pattern obtained on this assessment. On 10/12/11 at 3:15 p.m. at the facility exit meeting, the facility verbalized awareness of the concerns regarding Resident #4's bowel assessment that were discussed earlier in the day. Bowel Continence Decline 5.) Surveyor # reviewed Resident #12's medical record on 10/10/11 - 10/12/11. Resident #12 was originally admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #12 was readmitted to the facility 6/20/11 after hospitalization following a stroke. Surveyor # reviewed Resident #12's Significant Change in Status MDS (Minimum Data Set) dated 6/27/11 which indicates Resident #12 has short term memory problems and modified independence in cognitive skills for daily decision making. Resident #12 is also noted to need extensive assistance from 2+ persons physically assisting for bed mobility, transfers, and toilet use; and extensive assistance of one person for hygiene. Resident #12 is assessed as always continent of bowel, and frequently incontinent of urine. (ADON (Assistant Director of Nursing)-K later stated there was a coding error and bowel should have been assessed as occasionally incontinent.) Surveyor # reviewed the CAA (Care Area Assessment) dated 7/1/11 for Resident #12 for Urinary Incontinence and Indwelling Catheter. It states "...Offered use of bathroom when getting up in the AM, after meals and at HS (bedtime/ hour of sleep). Needs assist with care of incontinence garments and pericare. Cloth incontinence pad to bed. Continent of bowel but incontinent of bladder. Uses open back pants for toileting as he is continent of bowel but unable to stand with mechanical lift due [MEDICAL CONDITION](cardiovascular accident/ stroke). PT (physical therapy) assessed mobility and unable to safely stand to transfer. [MEDICAL CONDITION] (benign hypertrophy of prostate) with medication use. Monitored for signs and symptoms of constipation...." (Note: the CAA was not updated when the MDS was corrected to reflect occasional bowel incontinence instead of totally continent.) Surveyor # reviewed Resident #12's Quarterly MDS dated [DATE] which indicates Resident #12 had declined from either continent as the original MDS and CAA state or occasionally incontinent as the corrected MDS states, to frequently incontinent of bowel; and from frequently incontinent of urine to always incontinent of urine. Surveyor # reviewed Resident #12's October 2011 monthly physician orders, which include [MEDICATION NAME] (diuretic) 80 mg. (milligrams) once a day, and [MEDICATION NAME] sodium (stool softener) 100 mg.- two, twice a day. Resident #12's monthly physician visit progress note dated 9/27/11 states "DSS ([MEDICATION NAME] sodium) increased related to constipation on 9/12/11." Surveyor # did not locate any further assessment in the medical record regarding Resident #12's decline in bowel continence, including a comprehensive bowel assessment. The 1998 Management of Constipation Evidenced-Based Guideline from the University of Iowa Gerontological Nursing Interventions Research Center recommends assessing stool patterns and characteristics, types of laxatives used, physical assessment of bowel sounds and abdominal distension, psychological status, fluid and dietary status including fiber intake, level of activity, medications or disease conditions known to cause constipation. The 2002 Practice guidelines for the Management of Constipation in Adults from the Rehabilitation Nursing Foundation recommends an Assessment consisting of a description of bowel patterns, evaluation of cognitive ability, environmental factors, cultural beliefs, functional ability, diet and fluid intake, medication review, medical and surgical history, and physical exam. No assessment was seen regarding Resident #12's bowel incontinence, such as what time of day the episodes occur, how often, if he is aware of the incontinence, if he can feel the urge to defecate, if he can communicate this to staff, if he can sit on the toilet or bed pan, if his stool is loose, among other things, which would help staff identify factors contributing to his decline from previously being continent of bowel. Surveyor # reviewed a Dietary Note dated 9/27/11 stating Resident #12 was on a 2400 cc. fluid restriction, that had been discontinued but then restarted due to increased [MEDICAL CONDITION], notes [MEDICATION NAME] use, and the [MEDICATION NAME] sodium was increased on 9/16/11. Surveyor # reviewed Resident #12's Care Plan for Nutritional Status originally dated 2/15/10 and most recently updated 9/12/11 which also indicates Resident #12 receives 4 ounces of prune juice at breakfast and 1/2 cup of pureed prunes each day, but does not mention any problem with constipation or any reference to bowels at all. Resident #12's Care Plan for Incontinence/ Skin originally dated 2/12/10 with interventions most recently added 6/27/11, with a goal date of December, 2011, states: "Problem: Alteration in bladder elimination, potential for skin breakdown R/T (related to) urinary incontinence, PAD (peripheral artery disease) with history of open areas, history of calloused area to right great toe." "Goals: 1. Dignity will be maintained with episodes of incontinence being minimized through prompted voiding or scheduled toileting. 2. Will remain free from skin break down..." "Approaches" 1. (Resident #12) uses incontinence briefs and cloth incontinence pads to bed. Assist him in the use of these. 2. Provide incontinence care after each incontinent episode. Apply moisture barrier to skin. Report any redness, breakdown, discharge to nurse. 3. (Resident #12 will ask to use the bathroom. He requires assist for transfers, toileting. Ask him if he needs to use bathroom when getting him up in the AM, after meals and at HS (hour of sleep). 4. Monitor skin condition... 5. Refer to Resident Profile for more information. 6. Open back pants for toileting for BM if resident requests. There had been an intervention dated 5/12/11 stating Resident #12 may be left on the toilet as he needs to "sit awhile" at times, but to be checked on every 15 minutes until removed from toilet. This intervention was discontinued after Resident #12 had his stroke and was no longer safe to sit alone, per ADON-K. An intervention for Resident #12 to use a urinal at night was discontinued 6/27/11. The Care Plan does not address what the prompted voiding or scheduled toileting schedule is, or which intervention staff are to use since they are different. The Care Plan does not address constipation, though Resident #12 is on a stool softener, and receives prunes and prune juice. The Care Plan does not address bowel incontinence, though on the 6/27/11 MDS he is noted to be occasionally incontinent of bowel and on the 922/11 Quarterly MDS he is frequently incontinent of bowel. Surveyor # reviewed the entire care plan and did not note any reference to bowel incontinence or constipation. Surveyor # reviewed Resident #12's Profile, dated 10/10/11, which CNA's carry with them so they know what each resident's care plan is. Under "Toileting" it states "Check and Change program." There is no mention of prompted toileting, scheduled toileting, offering Resident #12 use of the bathroom in the morning, or use of open-back pants for toilet use. On 10/10/11 at 11:25 a.m., Surveyor # observed CNA-Y and CNA-PP get Resident #12 up from bed for lunch. Surveyor # asked CNA-Y how they assist Resident #12 with his toileting needs. CNA-Y stated he is a "check and change" and showed Surveyor # the Resident Profile stating that. Surveyor # asked if Resident #12 can use the toilet. CNA-Y stated he can't sit alone any more. Surveyor # asked if Resident #12 could sit on the toilet if staff stayed with him. CNA-Y did not know. The CNA's proceeded to change Resident #12's incontinence brief which was wet per CNA-Y, and provide pericare while he was in bed. The CNA's put a fresh incontinence brief on Resident #12, adjusted his slacks (not open-back), transferred him to his wheel chair and took him to the dining room for lunch. On 10/12/11 at 8:35 a.m. Surveyor # interviewed ADON-K, who stated upon admission, staff ask when the resident had their last BM (bowel movement), if known, what their usual pattern is, and if they have problems with constipation. ADON-K stated they document this information in the IDT (Interdisciplinary Team) notes, and update the information if the resident has a significant change. Surveyors met with ADON-K and DON (Director of Nursing)-B on 10/12/11 at 11:55 a.m., who stated they conduct bowel assessments on admission, re-admission, annually and with significant changes in status. CNA's (Certified Nursing Assistants) document on CareTracker when a resident voids or has a BM. An alert is sent every day identifying which residents have not had a BM in 72 hours. The report is run by night shift. Day shift may give some type of bowel prep/laxative, dietary may get involved. Some residents may have PRN's (as needed medications), or the nurses may call the physician for orders. The NCC's are the ones who bring it all together. DON-B stated they do not have any formal policy regarding bowel assessment and management. On 10/13/11 at 12:15 p.m., Surveyor # met with ADON-K and NCC-T, asking for any additional information/ documentation regarding Resident #12's decline in bowel continence. NCC-T stated she does review CareTracker, which documents when the resident voids or has a BM, and develops the care plan from that information, along with information from Dietary. No assessment of the decline in bowel continence was provided. Surveyor # noted the Care Plan in Resident #12's chart does not correspond with the Resident Profile the CNA's carry with them to reference when providing cares. The Care Plan speaks of prompted voiding or scheduled toileting, (but gives no time frames), open back pants, and offering use of the toilet upon rising, whereas the Profile simply states "check and change". ADON-K stated before Resident #12 had his stroke he would regularly sit on the toilet for a while after breakfast, around 9:30 a.m. and have a bowel movement, but he can not sit alone any more. ADON-K and NCC-T stated Resident #12 does not ask to use the toilet anymore. Surveyor # asked if Resident #12 still has bowel movements after breakfast, and if so, can he sit on the toilet with staff present or use a bed pan to improve his incontinence. ADON-K and NCC-T stated they would follow up on these issues. No further information was provided. 6.) On 10/10/11 and 10/11/11 Surveyor # reviewed Resident #5's medical record. Resident #5 was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicates that Resident #5 requires extensive assistance with 2 assist for transfers and toilet use. It also indicates Resident #5 is occasionally incontinent of bowels. The previous MDS dated [DATE] indicates Resident #5 needs extensive assistance with two assist for transfers and toile use. In this MDS Resident #5 is continent of bowel. This shows a decline in bowel continence status. Resident #5's medical record did not contain a comprehensive assessment that addressed bowel management. The CAA's (Care area Assessment) that correlate with the MDS completed on 6/22/11 does not indicate what are Resident #5's bowel habits. There is not documentation of a comprehensive assessment that may include reason for incontinence, habits, medications or treatments used for managing bowels. There is not documentation that indicates why Resident #5's bowel function has declined. On 10/12/11 at 9:00 a.m. Surveyor # spoke with NCC (Nurse Care Coordinator) L regarding bowel assessments. NCC L indicated that care tracker is reviewed for patterning for the MDS reference period and the information is in the CAA's and that's the bowel assessment. On 10/12/11 at 11:55 a.m. DON-B (Director of Nurses) and ADON-K (Assistant Director of Nurses) spoke with some of the survey team regarding bowel and bladder assessments. The DON-B indicated that bladder assessments include the initial nursing assessment completed upon admission. The section for bladder and bowel, just indicates if they are incontinent or not. There is not a formal bowel assessment. The bowels are monitored by CareTracker and if there is no bowel movement in 72 hours interventions are initiated. There is not a bowel patterning or history done to determine the individual's bowel habits. Surveyor # shared the concerns with Resident #5 not having a comprehensive bowel assessment. 7.) On 10/10/11 and 10/11/11 Surveyor # reviewed Resident #6 medical record. Resident #6 was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicates that Resident #6 is dependent with 2 assist for transfers and toilet use. It also indicates Resident #6 always incontinent of bowels. The previous MDS dated [DATE] indicates Resident #6 is dependent with two assist for transfers and toilet use. In this MDS Resident #6 is frequently incontinent of bowel. This shows a decline in bowel continence status. Resident #6's medical record did not contain a comprehensive assessment that addressed bowel management. The CAA's (Care area Assessment) that correlate with the MDS completed on 8/10/11 does not indicate what Resident #6's bowel habits are. There is not documentation of a comprehensive assessment that may include reason for incontinence, habits, medications or treatments used for managing bowels. There is not documentation that indicates why Resident #6 bowel function has declined. On 10/12/11 at 9:00 a.m. Surveyor # spoke with NCC (Nurse Care Coordinator) L regarding bowel assessments. NCC L indicated that care tracker is reviewed for patterning for the MDS reference period and the information is in the CAA's and that's the bowel assessment. On 10/12/11 at 11:55 a.m. DON-B (Director of Nurses) and ADON-K (Assistant Director of Nurses) spoke with some of the survey team regarding bowel and bladder assessments. The DON-B indicated that bladder assessments include the initial nursing assessment completed upon admission. The section for bladder and bowel, just indicates if they are incontinent or not. There is not a formal bowel assessment. The bowels are monitored by CareTracker and if there is no bowel movement in 72 hours interventions are initiated. There is not a bowel patterning or history done to determine the individual's bowel habits. Surveyor # shared the concerns with Resident #6 not having a comprehensive bowel assessment. Bowel Assessment without decline 8.) On 10/11/11 and 10/12/11 Surveyor # reviewed Resident #18's medical record. Resident #18 was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicates that Resident #18 requires extensive assist with 2 assist for transfers and toilet use. It also indicates Resident #6 is frequently incontinent of bowels. The previous MDS dated [DATE] indicates the resident remains frequently incontinent of bowels. Resident #18's medical record did not contain a comprehensive assessment that addressed bowel management. The CAA's (Care area Assessment) that correlate with the MDS completed on 2/10/11 does not indicate Resident #18 bowel habits. There is not documentation of a comprehensive assessment that may include reason for incontinence, habits, medications or treatments used for managing bowels. On 10/12/11 at 9:00 a.m. Surveyor # spoke with NCC (Nurse Care Coordinator) L regarding bowel assessments. NCC L indicated that care tracker is reviewed for patterning for the MDS reference period and the information is in the CAA's and that's the bowel assessment. On 10/12/11 at 11:55 a.m. DON-B (Director of Nurses) and ADON-K (Assistant Director of Nurses) spoke with some of the survey team regarding bowel and bladder assessments. The DON-B indicated that bladder assessments include the initial nursing assessment completed upon admission. The section for bladder and bowel, just indicates if they are incontinent or not. There is not a formal bowel assessment. The bowels are monitored by care tracker and if there is no bowel movement in 72 hours interventions are initiated. There is not a bowel patterning or history done to determine the individual's bowel habits. Surveyor # shared the concerns with Resident #18 not having a comprehensive bowel assessment. 9.) On 10/11/11 and 10/12/11 Surveyor # reviewed Resident #19's medical record. Resident #19 was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicates that Resident #19 requires extensive assistance with 2 assist for transfers and dependent with 2 assist for toilet use. It also indicates Resident #19 is always incontinent of bowels. The previous MDS dated [DATE] indicates Resident #19 needs extensive assistance with one assist for transfers and dependent with one assist for toilet use. In this MDS Resident #19 continues to be always incontinent of bowels. Resident #19's medical record did not contain a comprehensive assessment that addressed bowel management. The CAA's (Care area Assessment) that correlate with the MDS completed on 2/17/11 does not indicate Resident #19 bowel habits. There is not documentation of a comprehensive assessment that may include reason for incontinence, habits, medications or treatments used for managing bowels. On 10/12/11 at 9:00 a.m. Surveyor # spoke with NCC (Nurse Care Coordinator) L regarding bowel assessments. NCC L indicated that care tracker is reviewed for patterning for the MDS reference period and the information is in the CAA's and that's the bowel assessment. On 10/12/11 at 11:55 a.m. DON-B (Director of Nurses) and ADON-K (Assistant Director of Nurses) spoke with some of the survey team regarding bowel and bladder assessments. The DON-B indicated that bladder assessments include the initial nursing assessment completed upon admission. The section for bladder and bowel, just indicates if they are incontinent or not. There is not a formal bowel assessment. The bowels are monitored by care tracker and if there is no bowel movement in 72 hours interventions are initiated. There is not a bowel patterning or history done to determine the individual's bowel habits. Surveyor # shared the concerns with Resident #19 not having a comprehensive bowel assessment. Pain Assess

Based on observation, interview and record review, facility staff did not address a decline in bladder continence for one of one residents who had a decline in bladder continence (Resident #12); nor did staff thoroughly assess bladder incontinence for 4 other residents with incontinence (Residents # 5, 6, 3, and 4,) to identify possible reversible causes and to restore as much bladder function as possible. Resident #12 declined from frequently incontinent of bladder to always incontinent of bladder without appropriate follow up to identify possible reversible factors or interventions to improve the incontinence. Findings include: The Urinary Incontinence: Prevention & Management policy and procedure revised 8/16/11 documents "Each resident will be assessed for incontinence and interventions provided to maintain normal urinary function. Each resident will receive services to prevent urinary tract infections and restore or improve bladder function when possible. All indwelling urinary catheters will have medical justification for use and will be removed when possible to restore bladder function. Residents who are continent will be provided services to maintain continence and normal urinary function. 1. All residents will be assessed for urinary incontinency at admission and change of condition. Voiding will be tracked using Caretracker data for 3 days to establish the voiding pattern and periods of incontinence. 2. Clinical trials will be initiated for another 3 days following review of the data in an attempt to individualize toileting and maintain continence to the extent possible Voiding trials will be tracked using Caretracker data. 3. After review of the voiding trails and staff interview (resident interview if possible) the RN (Registered Nurse) will initiate a urinary incontinence plan of care and determine a toileting plan with measurable goals." 1.) Surveyor # reviewed Resident #12's medical record on 10/10/11 - 10/12/11. Resident #12 was originally admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #12 was readmitted to the facility 6/20/11 after hospitalization following a stroke. Surveyor # reviewed Resident #12's Significant Change in Status MDS (Minimum Data Set) dated 6/27/11 which indicates Resident #12 has short term memory problems and modified independence in cognitive skills for daily decision making. Resident #12 is also noted to need extensive assistance from 2+ persons physically assisting for bed mobility, transfers, and toilet use; and extensive assistance of one person for hygiene. Resident #12 is assessed as frequently incontinent of urine. Surveyor # reviewed the CAA (Care Area Assessment) dated 7/1/11 for Resident #12 for Urinary Incontinence and Indwelling Catheter. It states "...Offered use of bathroom when getting up in the AM, after meals and at HS (bedtime/ hour of sleep). Needs assist with care of incontinence garments and pericare. Cloth incontinence pad to bed. Continent of bowel but incontinent of bladder. Uses open back pants for toileting as he is continent of bowel but unable to stand with mechanical lift due [MEDICAL CONDITION](cardiovascular accident/ stroke). PT (physical therapy) assessed mobility and unable to safely stand to transfer. [MEDICAL CONDITION] (benign hypertrophy of prostate) with medication use..." Surveyor # reviewed Resident #12's Quarterly MDS dated [DATE] which indicates Resident #12 had declined from frequently incontinent of urine to always incontinent of urine. Surveyor # reviewed Resident #12's October 2011 monthly physician orders, which include [MEDICATION NAME] (diuretic) 80 mg. (milligrams) once a day. Surveyor # reviewed a Dietary Note dated 9/27/11 stating Resident #12 was on a 2400 cc. fluid restriction, that had been discontinued but then restarted due to increased [MEDICAL CONDITION], and notes [MEDICATION NAME] use. Resident #12's Care Plan for Incontinence/ Skin originally dated 2/12/10 with interventions most recently added 6/27/11, with a goal date of December, 2011, states: "Problem: Alteration in bladder elimination, potential for skin breakdown R/T (related to) urinary incontinence, PAD (peripheral artery disease) with history of open areas, history of calloused area to right great toe." "Goals: 1. Dignity will be maintained with episodes of incontinence being minimized through prompted voiding or scheduled toileting. 2. Will remain free from skin break down..." "Approaches" 1. (Resident #12) uses incontinence briefs and cloth incontinence pads to bed. Assist him in the use of these. 2. Provide incontinence care after each incontinent episode. Apply moisture barrier to skin. Report any redness, breakdown, discharge to nurse. 3. (Resident #12 will ask to use the bathroom. He requires assist for transfers, toileting. Ask him if he needs to use bathroom when getting him up in the AM, after meals and at HS (hour of sleep). 4. Monitor skin condition... 5. Refer to Resident Profile for more information. 6. Open back pants for toileting for BM if resident requests. There had been an intervention dated 5/12/11 stating Resident #12 may be left on the toilet as he needs to "sit awhile" at times, but to be checked on every 15 minutes until removed from toilet. This intervention was discontinued after Resident #12 had his stroke and was no longer safe to sit alone, per ADON-K. An intervention for Resident #12 to use a urinal at night was discontinued 6/27/11. The Care Plan does not address what the prompted voiding or scheduled toileting schedule is, or which intervention staff are to use since they are different. Surveyor # reviewed Resident #12's Profile, dated 10/10/11, which CNA's carry with them so they know what each resident's care plan is. Under "Toileting" it states "Check and Change program." There is no mention of prompted toileting, scheduled toileting, offering Resident #12 use of the bathroom in the morning, or use of open-back pants for toilet use. On 10/10/11 at 11:25 a.m., Surveyor # observed CNA-Y and CNA-PP get Resident #12 up from bed for lunch. Surveyor # asked CNA-Y how they assist Resident #12 with his toileting needs. CNA-Y stated he is a "check and change" and showed Surveyor # the Resident Profile stating that. Surveyor # asked if Resident #12 can use the toilet. CNA-Y stated he can't sit alone any more. Surveyor # asked if Resident #12 could sit on the toilet if staff stayed with him. CNA-Y did not know. The CNA's proceeded to change Resident #12's incontinence brief which was wet per CNA-Y, and provide pericare while he was in bed. The CNA's put a fresh incontinence brief on Resident #12, adjusted his slacks (not open back), transferred him to his wheel chair and took him to the dining room for lunch. Surveyors met with ADON-K and DON (Director of Nursing)-B on 10/12/11 at 11:55 a.m., who stated they conduct bowel and bladder assessments on admission, re-admission, annually and with significant changes in status. CNA's (Certified Nursing Assistants) document on CareTracker when a resident voids or has a BM. The NCC's are the ones who review the data and bring it all together to develop a plan. On 10/13/11 at 12:15 p.m., Surveyor # met with ADON-K and NCC-T, asking for any additional information/ documentation regarding Resident #12's decline in bladder continence. NCC-T stated she does review CareTracker, which documents when the resident voids, and develops the care plan from that information, along with information from Dietary. Surveyor # noted the Care Plan in Resident #12's chart does not correspond with the Resident Profile the CNA's carry with them to reference when providing cares. The Care Plan speaks of prompted voiding or scheduled toileting, (not specifying which to use or time frames), open back pants, and offering use of the toilet upon rising, whereas the Profile simply states "check and change". ADON-K stated before Resident #12 had his stroke he would regularly sit on the toilet for a while after breakfast, around 9:30 a.m., but he can not sit alone any more. ADON-K and NCC-T stated Resident #12 does not ask to use the toilet anymore. Surveyor # asked if Resident #12 can sit on the toilet with staff present or use a urinal to improve his incontinence. ADON-K and NCC-T stated they would follow up on these issues. No further information was provided. 2.) On 10/10/11 and 10/11/11 Surveyor # reviewed Resident #5's medical record. Resident #5 was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicates Resident #5 needs extensive assistance with two assist for transfers and toilet use. It also indicates Resident #5 is frequently incontinent of bladder. The previous MDS dated [DATE] also indicates Resident #5 is frequently incontinent of bladder. The CAA (Care Area Assessment) dated 6/22/11 indicates Resident #5 is "incontinent of bladder and this is felt to be r/t (related to) stress. She states she does not even feel the urge to void and then she realizes she is wet." It also indicates Resident #5 is encouraged to void upon rising and between meals and PRN (as needed). There is no assessment documentation that shows how toileting pattern was determined. Nor is the type of incontinence determined. Resident #5 does not have a bladder assessment in the medical record. On 10/12/11 at 9:00 a.m. Surveyor # spoke with NCC L regarding bladder assessments. NCC L states a bladder assessment is done on admission and with any change. The "Urinary Continence Assessment"form dated 2/11 indicates the type incontinence and the type of toileting program to conduct. NCC L states that because Resident #5 has been at the facility prior to 2/11 Resident #5 wouldn't have had this assessment completed. NCC L indicated that the staff nurse initially starts bladder assessments and looks a care tracker for a 3-day period to see bladder tracking. The bladder assessments are completed upon day of admission, re-admission and changes. This component of a bladder assessment is completed prior to a bladder history or patterning. On 10/12/11 at 11:55 a.m. DON-B (Director of Nurses) and ADON-K (Assistant Director of Nurses) spoke with some of the survey team regarding bowel and bladder assessments. The DON-B indicated that bladder assessments include the initial nursing assessment completed upon admission. The section for bladder and bowel, just indicates if they are incontinent or not. The bladder assessments are done on admission or if changes. Surveyor # shared the concerns with regard to Resident #5 not having a comprehensive bladder assessment to address incontinence. 3.) On 10/10/11 and 10/11/11 Surveyor # reviewed Resident #6's medical record. Resident #6 was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicates Resident #6 is dependent with two assist for transfers and toilet use. It also indicates Resident #6 is always incontinent of bladder. The previous MDS dated [DATE] also indicates Resident #6 is always incontinent of bladder. The CAA dated 8/17/11 indicates Resident #6 "wears incontinent briefs for dignity due to incontinence. Staff assist with incontinence" There is no assessment documentation that shows how toileting pattern was determined. Nor is the type of incontinence determined. Resident #6 does not have a bladder assessment in the medical record. On 10/12/11 at 9:00 a.m. Surveyor # spoke with NCC L regarding bladder assessments. NCC L states a bladder assessment is done on admission and with any change. The "Urinary Continence Assessment"form dated 2/11 indicates the type incontinence and the type of toileting program to conduct. NCC L states that because Resident #6 has been at the facility prior to 2/11 Resident #6 wouldn't have had this assessment completed. NCC L indicated that the staff nurse initially starts bladder assessments and looks a care tracker for a 3-day period to see bladder tracking. The bladder assessments are completed upon day of admission, re-admission and changes. This component of a bladder assessment is completed prior to a bladder history or patterning. On 10/12/11 at 11:55 a.m. DON-B (Director of Nurses) and ADON-K (Assistant Director of Nurses) spoke with some of the survey team regarding bowel and bladder assessments. The DON-B indicated that bladder assessments include the initial nursing assessment completed upon admission. The section for bladder and bowel, just indicates if they are incontinent or not. The bladder assessments are done on admission or if changes. Surveyor # shared the concerns with regard to Resident #6 not having a comprehensive bladder assessment to address incontinence. 4.) Resident #3's medical record was reviewed by Surveyor # on 10/10/11-10/13/11. Resident #3 was admitted to the facility on [DATE] with a re-admitted [DATE] with [DIAGNOSES REDACTED]. Resident #3's most recent MDS (minimum data set) is a Annual completed on 8/3/11. This indicates Resident #3 is non-ambulatory and requires total assist with transfers and hygiene. The bladder section indicates a '2' which means frequently incontinent. The prior comparison MDS is a Quarterly completed on 5/4/11. This indicates Resident #3 is non-ambulatory and requires total assist with transfers and hygiene. The bladder section indicates '3' which means always incontinent. Resident #3's CAAs(Care Area Assessments) that correlates with the Annual MDS completed on 8/3/11 was reviewed by Surveyor # . The CAA's indicate frequent bladder incontinence and to check and change every 2 to 3 hours and to also assist with toileting program. There is not assessment documentation that shows how toileting and check and change was determined. Nor is the type of incontinence determined. Resident #3's most recent documentation of an assessment for bowel and bladder is dated 2/9/10 and just indicates bladder incontinence and bowel incontinence. No further patterning, habits, history or treatments are documented. On 10/12/11 at 9:40 a.m. Surveyor # spoke with RN-C (Registered Nurse) regarding bladder assessments. RN-C indicated that the staff nurse initially starts bladder assessments and looks a care tracker for a 3-day period to see bladder tracking. The bladder assessments are completed upon day of admission, re-admission and changes. This component of a bladder assessment is completed prior to a bladder history or patterning. On 10/12/11 at 11:55 a.m. DON-B (Director of Nurses) and ADON-K (Assistant Director of Nurses) spoke with some of the survey team regarding bowel and bladder assessments. The DON-B indicated that bladder assessments include the initial nursing assessment completed upon admission. The section for bladder and bowel, just indicates if they are incontinent or not. The bladder assessments are done on admission or if changes. Surveyor # shared the concerns with Resident #3 not having a comprehensive bladder assessment to address incontinence. On 10/12/11 at 12:28 p.m. Surveyor # spoke with RN-C (Registered Nurse) regarding Resident #3 bowel and bladder assessments. There is a admission assessment that is done upon admission that indicates if the resident is incontinent or continent. There is a yellow colored form titled "Urinary Continence Assessment" that is done on admission , re-admission and change in condition. On 10/12/11 at 3:15 p.m. at the facility exit meeting, the facility verbalized awareness of the concerns regarding Resident #3's bowel and bladder assessments that were discussed earlier in the day. 5.) Resident #4's medical record was reviewed by Surveyor # on 10/12/11-10/13/11. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #4's most recent MDS (minimum data set) was an Annual MDS completed on 6/7/11. This MDS indicates Resident #4 is non-ambulatory and requires total assist with transfers and hygiene. The bladder section indicates '3' which means always incontinence. The comparison MDS is a Quarterly completed 8/29/11. This MDS indicates Resident #4 is non-ambulatory and requires total assist with transfers and hygiene. The bladder section indicates a '3' which means always incontinent. Resident #4's CAAs (Care Area Assessments) that correlated with the Annual MDS completed on 6/7/11 were reviewed by Surveyor # . The CAA indicates that Resident #4 appears to have functional incontinence, wears incontinence briefs, and toilet with max assist at mealtimes and bedtime. There is not documentation of a assessment that indicates how this information was obtained or patterning, habits or treatment. The most recent bowel and/or bladder assessment was an annual assessment that indicates incontinence status only. This assessment form was completed 9/14/08. There is not a comprehensive bowel or bladder assessment discovered in Resident #4 medical record. On 10/12/11 at 9:40 a.m. Surveyor # spoke with RN-C (Registered Nurse) regarding bladder assessments. RN-C indicated that the staff nurse initially starts bladder assessments and looks a care tracker for a 3-day period to see bladder tracking. The bladder assessments are completed upon day of admission, re-admission and changes. This component of a bladder assessment is completed prior to a bladder history or patterning. On 10/12/11 at 11:55 a.m. DON-B (Director of Nurses) and ADON-K (Assistant Director of Nurses) spoke with some of the survey team regarding bowel and bladder assessments. The DON-B indicated that bladder assessments include the initial nursing assessment completed upon admission. The section for bladder and bowel, just indicates if they are incontinent or not. The bladder assessments are done on admission or if changes. Surveyor # shared the concerns with Resident #4 not having a comprehensive bladder assessment to address incontinence. On 10/12/11 at 12:28 p.m. Surveyor # spoke with RN-C (Registered Nurse) regarding Resident #4 bowel and bladder assessments. There is a admission assessment that is done upon admission that indicates if the resident is incontinent or continent. There is a yellow colored form titled "Urinary Continence Assessment" that is done on admission , re-admission and change in condition. On 10/12/11 at 3:15 p.m. at the facility exit meeting, the facility verbalized awareness of the concerns regarding Resident #4's bowel and bladder assessments that were discussed earlier in the day.

Based upon interview, record review and observation, the facility did not ensure that 1 of 1 residents reviewed (Resident #24) with an order to use a warm pack received adequate supervision to prevent an accident. Additionally, the facility did not ensure that 1 of 3 Residents reviewed with a personal safety alarm (Resident #18) had their alarm properly attached to ensure proper function as a facility designated safety device. - Resident #24 sustained a second degree burn to their face and arm from a warm pack that was placed on the Resident and later shifted while Resident #24 was unsupervised. Facility staff did not check the warm pack for hot spots before placing the pack on the Resident. Resident #24 required total assistance from staff as she had no voluntary movement and also had sensory deficits. - Resident #18 was observed over a three day period with their facility designated personal safety alarm not being properly attached. Findings include: 1. Resident #24's medical record was reviewed as a closed record on 10/12/11 and 10/13/11. Resident #24 passed away at the facility 7/26/11 with [DIAGNOSES REDACTED]. The most recent full MDS (minimum data set) was a Significant Change in Condition MDS completed on 4/25/11. This MDS indicates Resident #24 required total assistance and had no voluntary movement of upper or lower extremities. Surveyor # reviewed Resident #24's Interdisciplinary notes and noted the following entries: -5/18/11 at 4:55 a.m. "Resident has been yelling out more at night with pain. In between scheduled pain medication staff usually provide gentle massage to the facial area or apply a warm pack to the area. A warm pack wrapped in a washcloth was applied to the area. Resident continued to yell out and when staff returned to remove the warm pack it was found on right upper arm area and unwrapped from washcloth. Right upper arm area was red and a blister was noted measuring 3.5 by 4 centimeters. A cool compress was applied followed by a OpSite. Resident denies pain in area and was not even aware of the warm pack moving and causing a blister. Resident moves head around quickly as they are yelling out and warm pack must of slipped off facial area and onto arm." -5/18/11 at 1:18 p.m. "Large blister on right upper right intact- 2 more small blisters around the large blister along with red burn line on the right ear and red area on the right cheek. These areas/blisters measure: ear- 0.6 by 0.4 centimeters; cheek 2.2 centimeters; small fluid blister right upper arm 0.6 centimeters and raised 0.2 centimeters; large fluid filled blister right upper arm 2.4 by 1.8 centimeters and raised 0.8 centimeters; small fluid filled blister right upper arm 0.6 by 0.4 centimeters and raised 0.2 centimeters. Resident has poor sensory perception to pain due to multiple sclerosis. A treatment of [REDACTED]. Per Rxlist.com: Silvadene Cream 1% (silver sulfadiazine) is a topical antimicrobial drug indicated as an adjunct for the prevention and treatment of [REDACTED]. According to webmd.com a second degree burn is one that affects the epidermis and the dermis (lower layer of skin). They (second degree burns) cause pain, redness, swelling and blistering. Resident #24's physician orders [REDACTED]. Surveyor # reviewed Resident #24's plans of care and noted that the plan of care did not include documentation regarding the use of warm packs as a intervention. Surveyor # noted that there also was no revision to Resident #24's plans of care after the 5/18/11 incident to help prevent future accidents from occurring despite the finding that Resident #24 sustained second degree burns to the face, ear and arm. On 10/13/11 at 3:10 p.m. Surveyor # spoke with ADON-K (Assistant Director of Nurses) regarding Resident #24's burn blisters. ADON-K indicated the alleged staff was talked to by the Nurse Care Coordinator of that unit (who is on vacation as of 10/13/11 but had a typed up statement) to check for hot spots before applying the warm pack. ADON-K indicated that an e-mail was sent to the Nurse Care Coordinators in the facility to remind them to check for hot spots and follow instructions on the warm pack. ADON-K indicated that the alleged staff has applied warm packs before with out problem. ADON-K indicated that she did not know how the 2nd degree burns occurred except that there must have been a hot spot. ADON-K did not know how long of a period the warm pack was used for that night. On 10/13/11 at 5:00 p.m. Surveyor # spoke with DON-B (Director of Nurses) and ADON-K about Resident #24's burn blisters. DON-B indicated as a follow up to the event the alleged staff was re-educated, e-mails went out and instructions were posted also on the microwaves. The staff are expected to follow the instructions on the package and feels this was an accident due to the warm pack having hot spots. DON-B indicated that the alleged staff did not feel the warm pack was hot before applying the pack to Resident #24. At this time Surveyor # expressed concerns that hot spots were not assessed prior to applying the warm pack with Resident #24 being unsupervised and the results were 2nd degree burns on the face and arm. On 10/18/11 at 8:30 a.m. Surveyor # received additional staff statements from DON-B and also spoke over the phone. The staff statements indicated that it was their determination that the incident was not abusive in its nature and was an accident due to hot spots in the warm pack. There is not conclusive documentation or review of the incident that indicates how Resident #24 obtained 2nd degree burns to the face and arm. 2.) Surveyor # reviewed Resident #18's medical record on 10/10/11, 10/11/11 and 10/12/11. Resident #18 was admitted on [DATE] with medical [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) dated 8/12/11 indicates Resident #18 is moderately impaired in cognitive skills for daily decision making, has physical and verbal behavioral symptoms directed towards others, refuses cares, needs extensive assistance with two staff for transfers, bed mobility and dressing. The interdisciplinary notes for September 2011 indicate Resident #18 had 5 falls without injuries. On 10/1/11 the interdisciplinary note indicates Resident #18 had an unwitnessed fall. The 10/2/11 interdisciplinary note indicates that Resident #18 was in her wheelchair "propelling self around unit and trying to take Tabs monitor off shirt throughout the day." The care plan dated 9/23/11 indicates Resident #18 has a bed sensor alarm, Tabs to wheelchair, and wheelchair by bed with brakes. On 10/10/11 at 10:53 a.m. and 11:23 a.m. Surveyor # observed Resident #18 seated in a wheelchair in the lounge area. Resident #18's Tab alarm was not clipped to the resident. On 10/10/11 at 11:35 a.m. Surveyor # observed Resident #18 seated in a wheelchair in the lounge area with Tabs alarm clipped to the sweater near the lower back area. On 10/10/11 at 3:19 p.m. Surveyor # observed Resident #18 seated in a wheelchair in her room. Surveyor # observed Resident #18's Tab alarm clipped to her sweater near her shoulder area. On 10/10/11 at 3:22 p.m. Surveyor # observed Resident #18 remove her sweater which triggered the chair alarm to sound. Staff responded to the alarm immediately. On 10/11/11 at 7:22 a.m. and 7:36 a.m. Surveyor # observed Resident #18 seated in a wheelchair by the nurse's station with Tabs alarm not attached to the resident. On 10/12/11 at 7:35 a.m. Surveyor # observed Resident #18 seated in a wheelchair in the lounge area and the Tab alarm was not attached to the resident. On 10/12/11 during the daily exit meeting with the facility Surveyor # shared the above observations. On 10/13/11 at 8:20 a.m. NCC (Nurse Care Coordinator) L spoke with Surveyor # regarding the above observations. NCC L stated that Resident #18 tends to remove the Tab alarm and staff has to clip it lower on the Resident's #18 back so resident can't easily remove it.