Every finding on record at Columbia Health Care Center

Based on interview and record review the facility did not ensure that a resident who enters the facility with an indwelling catheter receives appropriate treatment and services 1 of 1 residents (R32) reviewed for indwelling catheters. R32 has an indwelling catheter, and a provider was not notified timely when the resident presented with urethral bleeding around the catheter tubing following catheter insertion. R32's catheter was advanced into the bladder and not changed with a new sterile catheter when R32 had no urine output noted 2 hours after insertion. This is evidenced by: Facility policy entitled, Catheter Care, Urinary, dated 9/2014, states, in part: Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections . Changing Catheters 1. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised . Complications 1. Observe the resident for complications associated with urinary catheters . c. Notify the physician or supervisor in the event of bleeding, or if the catheter is accidentally removed . Facility policy entitled, Catheterization, Intermittent, Male Resident, dated 10/2010, states, in part: Purpose: The purpose of this procedure is to provide guidelines for the aseptic insertion of an intermittent catheter . Steps in the Procedure . 21. Insert the catheter gently into the meatus (approximately 5-7 inches) until urine begins to flow from the bladder. When urine begins to flow advance the catheter another 2 inches. 22. If slight resistance is met, instruct the resident to take a slow deep breath to relax the perineal muscles and overcome resistance to entry. If resistance continues, do not force the entry. Stop the procedure and notify your supervisor . Reporting . 2. Notify the physician of any abnormalities (i.e. urine output of 800 mL (milliliters), obstruction, etc.) . (Of note: Facility did not provide Surveyor with a Foley or chronic catheter policy.) Facility policy entitled, Acute Condition Changes - Clinical Protocol, dated 3/2018, states, in part: . 8. The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less). 9. The attending physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status . Facility policy entitled, Medical Change of Condition and hospitalization of Resident, dated 4/11/11, states, in part: .D. If the condition is not life threatening: 1. The primary physician or his designated on-call physician will be contact and informed of the medical condition and the licensed nurse's observations and assessments . According to the CDC, with a revision date of 10/24/16 includes, in part: Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. R32 was admitted to the facility on [DATE] with diagnosis that include, in part: type 2 diabetes, chronic kidney disease, stage 3, NSTEMI (heart attack), other idiopathic peripheral autonomic neuropathy (nervous system disorder causing involuntarily bodily functions), congestive heart failure (heart fails to properly provide oxygen to the body's tissues), and a personal history of malignant neoplasm of bladder (bladder cancer). R32's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/2/25, indicates that R32 has a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating that he is cognitively intact. Section H indicates that R2 is currently utilizing an indwelling catheter. R32's Comprehensive Care Plan states, in part: I need to have a catheter because I have urinary retention related to DM (diabetes mellitus), neuropathy and spinal stenosis. I have dx (diagnoses) kidney cyst and hx (history) of malignant bladder neoplasm and UTI (urinary tract infection). I need my nurses to . care for my catheter, facilitate a urology consult as appropriate, contact MD (medical doctor) as needed. I need my aides to . take care of my catheter equipment and skin and keep track of my urine output .let my nurse know if my urine looks different than usual, sometimes I can get hematuria (blood in urine) in my tubing or my foley bag. If that happened please monitor me closely for a UTI. Usually the hematuria is from the tubing getting pulled and not something more significant. R32's Physician Orders indicate, in part: Change indwelling foley catheter. Reason for indwelling foley: Urinary retention related to DM, neuropathy and spinal stenosis. Size: 16 French 10 ML balloon. As needed. Occlusion or dislodgement. First date: 12/19/24. Change foley bag as needed. First date: 12/19/24. Nursing order. Catheter irrigation with 60 ml normal saline as needed. Occlusion. First date: 12/19/24 FYI Resident is taking anticoagulant = monitor for any unusual bruising or bleeding AM (day shift) PM (evening shift) NOC (night shift) Nursing Order: Change foley catheter every 4-6 weeks 1x (one time) month 3rd Tuesday PM. First date: 1/21/25. [APNP (advanced practice Nurse Practitioner) Name] Dx Urinary retention related to DM, neuropathy, spinal stenosis. Discontinued 1/23/25. Apixaban (blood thinner) 2.5 MG (milligram) tablet dose ordered: (1 tablet/2.5 mg) by mouth twice a day AM HS (at bedtime) first date: 3/5/24. (Of note: All orders were active in January 2025) R32's Medication Administration Record (MAR) indicates R32 received Apixaban: 1/21/25: AM and HS 1/22/25: HS 1/25/25: AM (Of note: This medication was held 1/22/25 AM, 1/23/25 AM and HS, 1/24 AM and HS, and 1/25/25 HS.) R32's Treatment Administration Record (TAR) indicates that no abnormal bruising or bleeding was observed on 1/21/25. On 1/22/25 and 1/23/25 this section is marked See NN (nurses notes). On 1/21/25 on the PM shift, the TAR indicates R32 had his foley catheter changed. On 1/21/25 at 7:28 PM, a Nurses Note is written that states, Scheduled foley catheter change done using sterile technique 16fr with 10ml balloon as per order. Foley placed without resistance, resident did say it was sensitive. Small amount of bright red blood in return. Catheter flushed with 60 ml of normal saline. Resident is on blood thinners. On call [Doctors Name] updated and instructed to just watch to make sure it clears up. Resident later . he felt mild discomfort. (Surveyor notes that several provider notes indicate the difficulty in assessing the patient due to his diagnosed neuropathy and is important to note that R32 is feeling discomfort following catheter placement) On 1/22/25 at 12:35 AM, a Nurses Note is written that states, Superficial open area to mid anterior scrotum, no bleeding at this time. No signs of infection. Area washed, dried and Desitin (skin moisturizer) applied. On 1/22/25 at 1:58 AM, a Nurses Note is written that states, Resident had catheter change after supper on PM shift. RN (Registered Nurse) reported no urinary output since catheter changed and blood filled the tube at 22:30 (10:30 PM). This RN deflated the balloon and advanced the catheter tubing. Red/urine began to flow slightly more into the tubing. Resident had no pain or discomfort during intervention. No discomfort when RN palpated lower abdomen/bladder region. CNA (Certified Nursing Assistant) called RN into room at 0145 (1:45 AM). At that time resident had large clot of blood in catheter bag tubing which seemed to impede the further drainage of urine. Bag changed, catheter irrigated and there was an immediate return of normal saline and pale yellow urine with no hematuria present. Resident continues to have no pain or discomfort and indwelling catheter is draining to gravity. (Of note: The nurse advanced the catheter tubing after being placed for several hours. Foley catheter insertion is a sterile procedure utilizing sterile equipment. There is no way to sterilize the catheter tubing after being in place outside of the urinary tract for several hours.) On 1/22/25 at 5:21 AM, a Nurses Note is written that states, Follow up Hematuria following a scheduled catheter change. Resident's urine clear at end of shift with no hematuria present. Resident had a total of 825mL of urine out this shift. On 1/22/25 at 11:58 AM, a Nurses Note is written that states, in part: . When CNA assisted this resident to the toilet for a bowel movement at 0800 (8:00 AM) there was a significant amount of bright red blood on the brief therefore this writer was called. Upon examination there was found to be clotting of blood around the urethra. The catheter was patent but the urine was blush color with hematuria and a few almond size blood clots were in the catheter tubing. When resident was off the toilet there was a moderate amount of fresh blood in the bowl. Resident was cleansed and the bleeding ceased . Vitals were checked . GU (Genitourinary) discomfort was denied . RN has scheduled monitoring of this condition and this writer added TID (Three times a day) monitoring of vitals. Apixaban scheduled with AM medication held and MD update was to occur but prior to this action resident would be checked to reassess the bleeding. Resident returned to his room at 1130 (11:30 AM) following activities. Upon checking this resident has a light bloody 50 cent size stain in his brief. Upon standing resident to change his undergarment a steady stream[sic] of [NAME] red blood began to flow from the urethra around the catheter. The urine in the catheter was cranberry color. Since the bleeding was uncontrolled resident was assisted into bed and his LE (lower extremities) were elevated. RN was contacted to assess the situation and concurred [Resident's Name] should be evaluated in the ER (emergency room ). NP (Nurse Practitioner) was contacted and EMS (Emergency Medical Services) was called. Plan is to recheck vitals prior to this transfer. On 1/22/25, with no time provided, a Progress Note was written by NP C that states: 1/22/25 [Nurse Name], facility nurse, calling reporting patient is having significant bleeding around Foley catheter. Pouring out when he is in a sitting position. Last night, his Foley catheter was changed. No output until nurse re-advanced the catheter then had immediate return of 800 ml. He then had light pink urine with almond sized blood clots. Since this morning, bleeding oozing around Foley catheter through meatus. Eliquis was held. When staff got patient up for lunch, significant bleeding started. Please send to ER for immediate evaluation. Concerning for urethra or prostate issue given amount of bleeding. On 1/22/25 at 11:11 PM, a Nurses Note is written that states: follow-up: [Hospital Name] transfer: resident returned at 1855 (6:55 PM). Traumatic foley insertion with no new orders. VSS (vital signs stable) as entered in TAR. On 1/22/25 at 1:40 PM, a Nursing Emergency Department Note is written by RN D, that states, in part: . presents to ED from [Facility Name] for evaluation of Catheter. Placement of foley 2 days ago, no drainage. Replaced with immediate output of 800 ml of blood urine. Arrives with clear urine draining. Position change causes blood in urine .Denies pain . On 1/22/25 at 1:50 PM, a Physician Emergency Department Note is written that states, in part: . Chief Compliant: Bleeding around Foley History of Present Illness: . presents via ambulance for a Foley concern. He had his 30 day Foley exchanged yesterday. This morning there is no drainage, so they repositioned it and his bladder drained. Since then he has had blood leaking from his penis. He denies significant pain . Physical Exam . GU: Blue Foley catheter tubing in place and patient's urethra, no phimosis/paraphimosis (inability to retract foreskin). Small amount of blood oozing from around the Foley. Good drainage into the Foley bag, no frank blood . Patient appears to have bleeding from a traumatic Foley catheter insertion/adjustment. He does not appear to have any blood in the bag itself, no pain in the penis or lower abdomen, no lightheadedness, minimal blood loss overall. Bladder scan the patient with 0 mL no urinary retention and Foley appears to be in the proper location. Inflated fully an additional 5 cc (cubic centimeters) and pulled[sic] gently towards urethra to assist with tamponade of the likely site of the bleed. Very small amount of bleeding continues, however risks of replacement further traumatize an area outweigh the benefits attempting to replace the Foley. No suspicion for cystitis at this time . On 1/23/25 at 11:00 PM, a Physician's Telephone Order is written providing orders for desitin twice daily for R32's scrotal abrasion and change R32's hemoglobin lab from 1/24/25 to 1/23/25 due to the patient's hematuria. On 1/23/25 at 11:29 PM a note was started by NP C that was not signed until 2/19/25 at 12:23 PM that states, in part: . Gross hematuria: [Hospital Name] ER yesterday for gross hematuria. No labs completed. No imaging completed. Returned from ER without any new orders. Eliquis was given last night as ordered. Today, patient has significant bleeding from meatus again. Clots and dripping visualized by writer today. Foley draining clear yellow urine with occasional sporadic pink tinge urine. Patient denies pain. No fever or chills. Reports no suprapubic tenderness . (Of note: NP copies the Physician Emergency Department Note described previously into her note then continues.).Physical Exam . GU: Gross hematuria from meatus outside of foley catheter tubing. Large clots. Per nursing staff, this has improved since this morning. Assessment/Plan: 1. Acute prostatitis 2. Gross hematuria. Comment: Active, significant bleeding around catheter tubing out meatus which is very possibly related to prostatitis . Has had recurrent hematuria historically and is at further risk of bleeding due to chronic anticoagulation with Eliquis .Complete assessment is impaired due to patient's neuropathic ability . On 1/23/25 at 2:43 PM, a Nurses Note is written that states, in part: Gross hematuria and bleeding from the urethra evaluated at theER on [DATE] follow up: This morning the foley catheter was patent and the urine was pale yellow/clear. At 1030 (10:30 AM) when resident used the toilet for a bowel movement resident began bleeding from the urethra. When resident stood in the EZ stand for hygiene blood began to stream from the urethra. Resident had no complaints of pain, feeling dizzy, lightheaded, or faint. Vitals were WNL (within normal limits) for [Resident's Name]. RN and NP were called to visualize the amount of bleeding. Resident was assisted into his bed and once laying in bed hygiene was performed. Following the change in position the bleeding slowly subsided to a trickle but the urine was now a light cranberry color .NP visualized the urethral bleeding, some mild scrotal enlargement, and the open skin on the scrotum. New orders were received and transcribed . (Of note: The new orders placed were for Ciprofloxacin, an antibiotic, with an indication of prostatitis (inflammation of the prostate)) On 1/23/25 at 7:37 PM, a Nurses Note is written that states, in part: .Recent Hematuria/Abx for Prostatitis/Recent ER visit. Resident had two times of blood flow come from the catheter . On 1/24/25 at 1:46 PM, a Nurses Note is written that states: follow-up: Follow up for traumatic bleeding in urinary tract. This morning after breakfast res (resident) had a small amount of blood in his brief (about the size of a baseball) and some hematuria. It is a lot less than what res was having. Blood thinner was held this morning and will be held again tonight. Res was up in his w/c (wheelchair) all shift and laid down after lunch. When he laid down he had about a quarter sized spot of blood in his brief. Urine was orange in color. Res denied any pain. On 1/24/25 at 8:51 PM, a Nurses Note is written that states: follow-up: Traumatic bleeding UT: Resident had no c/o (complaint) pain no blood in catheter however there was a small amount in brief. On 1/25/25, with no time indicated, a Physician's Telephone Order is written that provides an order to hold R32's Eliquis for his HS dose and to reassess this order tomorrow if R32 has continued bleeding. On 1/25/25 at 4:52 AM, a Nurses Note is written that states, in part: Catheter change/hematuria/ATB (antibiotic): Cipro (Ciprofloxacin) follow up: Indwelling catheter is patent and draining to gravity. Urine is light/clear yellow. Small amount of blood on catheter tubing and on left thigh . Denies any pain or discomfort . On 1/25/25 at 7:10 PM, a Nurses Note is written that states, in part: follow-up: GU bleeding. CNA alerts writer to blood coming from residents urethra at HS. Blood in brief and in bed after standing in EZ stand as it leaked around and down the catheter. On call MD was updated. Received orders to hold HS dose of Eliquis (Apixaban) tonight . On 1/26/25 at 5:31 AM, a Nurses Note is written that states, in part: Taking Cipro/monitoring for traumatic bleeding following a catheter change and hematuria . Resident continues on Cipro .No complaints of pain or discomfort . Indwelling foley catheter is patent and draining to gravity. Urine is light yellow, no hematuria. Small amount of dried blood along ridge of brief. No active bleeding from urethra . On 2/19/25 at 10:30 AM, Surveyor interviewed CNA E (Certified Nusing Assistant). Surveyor asked CNA E what issues with a catheter she would report to the nurse. CNA E states she would report fluid that looked white, creamy, red, and any bleeding in and around the catheter to the nurse so that they could come and assess the resident. Surveyor asked CNA E how quickly she would notify the nurse if CNA E observed those things. CNA E states, you report it right away when you see it. Surveyor asked CNA E if she was on shift on 1/22/25. CNA E confirms she was and that she was working on R32's unit. Surveyor asked CNA E to describe what happened. CNA E indicates that she saw some blood in the tubing even prior to getting R32 out of bed. She was transferring him to the toilet so he could use the restroom. Once standing in the bathroom, she pulled down R32's brief so he could sit on the toilet. Once she pulled his pants down, she observed blood in his brief and blood was free flowing out of his urethra. CNA E indicates she ensured the resident's safety by sitting him down on the toilet and immediately called the nurse to the room. CNA E states LPN F immediately responded to the room to assess the resident. Surveyor asked CNA E what time this happened. CNA E indicates around 7:30 AM to 8:00 AM, before breakfast. Surveyor asked if R32 was asked if he wanted to go to the hospital. CNA E indicates she believes that they would assume the bleeding would slow on its own. CNA E indicates the resident was asked, however he refused because he wanted to go to an activity that morning. Surveyor asked CNA E what happened after the activity. CNA E indicates R32 was being transferred from his wheelchair to the toilet and when his brief was pulled down, the bleeding coming from his penis was even worse. CNA E indicates R32 was then sent to the hospital. On 2/19/25 at 10:41 AM, Surveyor interviewed LPN F (Licensed Practical Nurse). Surveyor asked LPN F if facility nursing staff have received any recent training on foley catheters. LPN F indicates they have not had any. Surveyor asked LPN F to describe the process for inserting a foley catheter. LPN F indicates you wash your hands, set up your equipment, open the package, maintain a sterile procedure and use sterile gloves, utilize betadine to clean the insertion area, dip catheter into the lubricant, insert the catheter until you get urine return in the tubing, and if you don't get urine, you don't inflate the balloon. Surveyor asked LPN F if you can advance the catheter tubing after the catheter has been inserted and left in the resident for a few hours. LPN F indicates that she does not and has never been taught to do that. Surveyor asked LPN F why it would be important not to do that. LPN F indicates there is a high risk for contamination and that she would get a new kit and start the procedure over if there was something wrong with the catheter placement. Surveyor asked LPN F what scenarios would prompt her to notify a physician of problems with a catheter. LPN F indicates if there is good urine output that suddenly stopped, if there was an order without a specific size catheter, any hematuria, and signs and symptoms of infection. Surveyor asked LPN F if it is normal to have blood return when inserting a catheter. LPN F indicates no, and that she would be concerned and contact a physician. Surveyor asked LPN F if she was on shift on 1/22/25. LPN F confirms she was and that she was working on R32's unit. Surveyor asked LPN F to describe what happened. LPN F indicates that her shift occurred 1-2 shifts after R32's catheter was placed. LPN F recalls being called into R32's room because he was bleeding from the urethra. LPN F indicates there was a gross amount of blood, so much so that she doesn't know if she could call it hematuria, that it was just [NAME] bleeding. LPN F also indicates she observed clotting around the urethra, along with blood in the tubing, and a significant amount in the toilet. Surveyor asked LPN F what she did after making these observations. LPN F states she took vital signs, called a RN to perform an RN assessment, and held R32's morning Apixaban. Surveyor asked LPN F if she notified a physician. LPN F states she did. Surveyor asked if it should be documented, along with the timing of the notification. LPN F indicates this information should be documented in R32's medical record. Surveyor asked LPN F how long she has been working at this facility. LPN F indicates she has been employed by this facility for [AGE] years. Surveyor asked LPN F what she believed was the cause of R32's bleeding. LPN F indicates she would agree with the diagnosis from the ER of the traumatic foley insertion. On 2/19/25 at 11:05 AM, Surveyor interviewed UM G (unit Manager). Surveyor asked UM G if the facility has provided nursing staff with any recent education regarding foley catheters. UM G indicates she does not think so. Surveyor as UM G what the process is for inserting a foley catheter. UM G indicates you make sure you have an order, obtain your equipment, maintain a sterile procedure, utilize sterile gloves, clean the insertion area with iodine, apply lubricant to the tubing, and insert the tubing, making sure urine flows into the tubing. Surveyor asked UM G how long she would wait for urine return before contacting a physician or reattempting the procedure. UM G indicates she would have to check the facility policy but believes 5-10 minutes. UM G also indicates she would notify the physician if she was unable to get urine return. Surveyor asked UM G if you can advance the catheter tubing after the catheter has been inserted and left in the resident for a few hours. UM G states that if there is bleeding, she probably wouldn't advance the tubing. Surveyor asked UM G if she thinks there would be a risk of infection if that tubing was advanced. UM G indicates that there would be a risk of infection. Surveyor asked UM G what scenarios would prompt her to notify a physician of problems with a catheter. UM G indicates hematuria, clots, no output, and signs and symptoms of infection. Surveyor asked UM G if it is normal to have blood return when inserting a foley catheter. UM G states some blood return, but you would have to know your resident. Surveyor asked UM G what she believes caused R32's bleeding. UM G indicates she believes it is from the traumatic foley insertion, like the ER said. UM G then stated, [Staff Member Name] should probably have some catheter education. On 2/19/25 at 2:07 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if the nursing staff have received any recent education regarding foley catheters. DON B indicates they have not received any training in at least the past 6 months. Surveyor asked DON B to describe the process of inserting a foley catheter. DON B indicates you obtain the equipment, prepare the resident, clean your hands, prepare your equipment maintaining a sterile procedure, clean the insertion area, lubricate the tubing, insert the catheter until you achieve urine return in the tubing, advance the tubing a little farther, inflate the balloon, and attach the drainage bag. Surveyor asked DON B if you can advance the catheter tubing after the catheter has been inserted and left in the resident for a few hours. DON B indicates, if you felt like there wasn't any further urine return you might try to deflate the balloon and try. Surveyor asked DON B if doing this might cause an infection risk. DON B indicates it could potentially cause an infection risk. Surveyor asked DON B what scenarios would prompt her to notify a physician of problems with a catheter. DON B indicates, if there was bleeding around the area of insertion she would be concerned for trauma, signs and symptoms of infection, hematuria, foul odor, and changes in urine output. Surveyor asked DON B if it is normal to have blood return when inserting a foley catheter. DON B indicates if it is an abnormal finding or if they've had multiple changes there may be some irritation or trauma to the urethra, especially if the resident is taking anticoagulant medication. Surveyor asked DON B that since R32's catheter was placed at 8:00 PM and the catheter tubing was advanced at 10:00 PM, instead of advancing the catheter should a new catheter have been inserted instead. DON B indicates staff should have just replaced the catheter. Surveyor asked DON B if a physician should have been updated regarding R32's two and a half hours without urine output and the need to readjust the catheter. DON B states, yes, however it would be ok to update in the morning instead of calling the on-call line overnight. Surveyor asked DON B if the physician should have been updated on the clotting occurring overnight. DON B indicates, if it occurs once it is ok to wait until morning, if it happens more than once I would expect staff to call the on-call provider. Surveyor asked DON B if the physician should have been notified after R32's initial substantial bleeding episode around 8:00 AM on 1/21/25. DON B indicates the physician should have been contacted at that point.

Based on interviews, record review, and facility policy review, it was determined the facility failed to ensure that misappropriation/exploitation of resident and or property does not occur or 1 of 3 sampled residents. (R47). Registered Nurse (RN) D admitted having been aware of CNA E having the resident's debit card in her possession for several months but did not report this to administration, which placed the resident at risk for misappropriation/exploitation. While the card was in her possession, CNA E used the card to purchase items for her own use, without the resident's knowledge or consent. Findings included: Review of a Face Sheet revealed the facility admitted Resident 47 on 08/04/2020. Review of an annual Minimum Data Set (MDS), dated [DATE], revealed Resident 47 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. The MDS indicated the resident was totally dependent on the assistance of two or more people for bed mobility. A review of Resident 47's Plan of Care Summary, not dated, revealed one of the resident's goals was to feel comfortable in the resident's surroundings and feel safe and secure. A review of a facility investigation summary, dated 09/08/2022, revealed the facility began an investigation on 09/01/2022 and substantiated that Certified Nursing Assistant (CNA) E knowingly violated Resident 47's rights as well as misappropriated the resident's funds by using the resident's personal bank card for her own personal purchases. The summary indicated the facility notified law enforcement and terminated the employment of CNA E on 09/01/2022. The summary indicated CNA E acknowledged to both the Director of Nursing (DON) and the Sheriff's deputy that she had used Resident 47's debit card to purchase personal items for herself without Resident 47's permission or knowledge. A review of a Sheriff's Office Incident #22-33047 report, dated 09/01/2022, revealed CNA E was issued a misdemeanor citation for theft less than or equal to $2500, for the unauthorized use of Resident 47's bank card, with a mandatory court date of 11/30/2022. The report noted CNA E used funds from the bank card on three occasions for items for her house. The report indicated there were four separate charges on the resident's bank statement that were not authorized by the resident and totaled $449.56. An interview on 01/04/2023 at 12:05 PM with Registered Nurse (RN) D revealed she was aware that CNA E had possession of Resident 47's debit card for months prior to the unauthorized charges occurring in August 2022. RN D stated she knew that CNA E used the resident's debit card to purchase personal items for the resident with the resident's permission. RN D stated she was made aware that Resident 47 had some concerns about some transactions, but she reminded the resident that the charges were from the store where CNA E usually bought the resident's snacks. RN D stated that was the end of the conversation and she did not report the resident's concerns to anyone at that time. RN D stated she was aware it was a violation of facility policy for staff to take money from any resident. She acknowledged that if she had reported CNA E's possession of the debit card when she first became aware of it, the misappropriation of Resident 47's funds may have been prevented. RN D stated she felt very bad about this and understood going forward, to report any similar concerns. Review of the facility's investigation documentation revealed RN D was interviewed during the investigation; however, there was no indication that she informed the facility of her prior knowledge regarding CNA E being in possession of the resident's debit card. During an interview on 01/05/2023 at 2:28 PM, Director of Nursing (DON) B revealed staff should notify their supervisor right away of any concerns related to abuse/exploitation and indicated it was against facility policy for staff to take any money from residents. DON B stated it did not matter if the money was to buy items for the resident; staff were not allowed to take the money but were allowed to gift residents with items. DON B stated she was not involved in the investigation of misappropriation for Resident 47; therefore, she did not have any specific knowledge of it. DON B stated she was not aware of whether the facility ever identified that RN D had prior knowledge of CNA E having the resident's debit card in her possession for months prior to the unauthorized transactions being made. DON B indicated the CNA having the resident's debit card was a violation of the facility's policy as well. DON B stated she would have expected any staff member who may have been aware of the CNA having possession of a resident's debit card to report that to Social Services or herself immediately. DON B also stated that if RN D had reported to her that CNA E was in possession of a resident's debit card, it would most likely have prevented the unauthorized charges from being made, and the misappropriation might never have occurred. During an interview on 01/05/2023 at 2:56 PM, Nursing Home Administrator (NHA) A revealed any concerns of any type of abuse/exploitation should be reported immediately to the nurse supervisor or a manager in the building. NHA A stated that prior to the incident occurring with Resident 47 and CNA E, it was never clearly defined that a staff could not take a resident's debit card but acknowledged it would not have been appropriate for any staff to take a resident's debit card and keep it in their possession. NHA A indicated she was not sure if the handbook specified that this was a violation of policy; however, she acknowledged there was a possibility that the charges could have been prevented if RN D had reported that CNA E had possession of Resident 47's bank card. NHA A stated she was unaware that RN D had prior knowledge that CNA E was in possession of the resident's card, but she would have expected RN D to report this immediately, as soon as she became aware. NHA A stated if this had been reported, the bank card would have been removed from CNA E's possession and the charges would not have occurred. NHA A stated the prior DON completed the investigation, and she was not sure if RN D's prior knowledge of the situation was ever identified during the investigation. She stated she did not know if RN D was asked about this during the investigation.

Based on interview, record review, and facility policy review, it was determined that the facility failed to ensure a care plan was developed to address the necessary monitoring for therapeutic and potential adverse effects from high-risk medications for 2 (Resident 5 and Resident 10) of 5 residents reviewed for unnecessary medications. Findings included: A review of a facility policy titled, Care Planning, dated 12/31/2019, revealed, The care plan should address the key areas of importance for the new admit - for example: hip fracture - focus on transferring, positioning, pain, etc. [et cetera]. As well as any other significant issues, i.e. [such as] blind, diabetic, fall risk, cancer, etc. The policy also indicated, The care plan will be reviewed to assure that it: reflects the resident's current needs, strengths, preferences and choices and has measurable goals and individualized approaches. 1. A review of Resident #10's admission Minimum Data Set (MDS), dated [DATE], revealed the resident had active diagnoses of heart failure and diabetes mellitus. The MDS revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS indicated the resident required extensive assistance with bed mobility and received anticoagulant (blood thinner) medications and insulin injections on seven of the past seven days. A review of Resident 10's Physician Orders, revealed orders dated 11/07/2022 for apixaban (blood thinner) 5 milligrams (mg) by mouth twice a day for prevention of stroke, insulin (to lower blood sugar) 10 units three times a day at meals for diabetes mellitus, and insulin per sliding scale three times a day at meals. Further review of Resident 10's Physician Orders revealed an order dated 11/08/2022 for insulin glargine (to lower blood sugar) 30 units daily in the morning for diabetes mellitus. A review of Resident 10's Care Plan, with care plan problems dated from 09/24/2021 through 12/23/2022, revealed bleeding precautions and monitoring for potential adverse effects of apixaban were not addressed. Additionally, the care plan did not address the necessary monitoring related to the use of insulin, including signs/symptoms of hypo/hyperglycemia. 2. A review of Resident 5's quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had an active diagnosis of acute embolism. The MDS revealed Resident 5 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required extensive assistance with bed mobility and transfer. According to the MDS, the resident received anticoagulant medications on seven of the past seven days. A review of Resident 5's Physician Orders, dated 01/05/2023, revealed an order dated 11/12/2020 for apixaban (blood thinner) 5 milligrams (mg) by mouth twice a day for chronic deep vein thrombosis (blood clot). A review of Resident 5's Care Plan revealed bleeding precautions and monitoring for potential adverse effects of apixaban were not addressed. During an interview on 01/05/2023 at 11:40 AM, Registered Nurse (RN) C indicated she had never done care plans for specific medications other than psychotropic medications. During an interview on 01/05/2023 at 2:41 PM, the Director of Nursing (DON) B indicated she would expect for the insulin and blood thinners to have been addressed on the care plan for monitoring of bleeding and blood sugar. During an interview on 01/05/2023 at 2:56 PM, Nursing Home Administrator (NHA) A indicated if the medications were addressing active health problems, they should have been addressed on the care plan.

Based on observation, staff interviews, and record review the facility did not ensure food was stored and prepared in a safe and sanitary manner which had the potential to affect all 66 residents at the facility. Unit and Kitchen refrigerator temperature monitoring logs were incomplete. Foods in refrigerators and coolers were not labeled per regulation and/or were expired. Findings include: Missing Temperatures Facility policy titled, Refrigerators and Freezers indicated: Policy Statement: The facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Policy interpretation and implementation: 2. Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures. 4. Food service Supervisors or designated employees will check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening. 7. All food shall be appropriately dated to ensure proper rotation by expiration dates.Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened. On [DATE] at 9:45 AM, Surveyor began initial kitchen tour with Dietary Manager (DM-C). During the tour, DM-C indicated that staff should be completing temperatures twice daily for each refrigerator and cooler. DM-C further indicated that there are unit refrigerators located on each unit as well as in the Center area of the facility. On [DATE] during the initial kitchen tour, Surveyor noted the following missing temperatures for the Reach Thru Cooler, Juice Cooler, and Glass door refrigerator located in the main kitchen: ,d+[DATE] - PM Temperature ,d+[DATE] - PM Temperature ,d+[DATE] - PM Temperature ,d+[DATE] - AM Temperature ,d+[DATE] - PM Temperature ,d+[DATE] - AM and PM Temperatures ,d+[DATE] - AM Temperatures On [DATE] during the initial kitchen tour, Surveyor noted the following missing temperatures for the kitchen walk-in cooler and freezer: [DATE] - AM [DATE] - AM On [DATE] at 10:54 AM, Surveyor reviewed the refrigerator located in the Center. The following missing temperatures were noted for the refrigerator and freezer: ,d+[DATE] - PM ,d+[DATE] - AM and PM ,d+[DATE] - AM and PM ,d+[DATE] - PM ,d+[DATE] - Fridge temp AM / Freezer temp PM ,d+[DATE] - AM and PM ,d+[DATE] - AM and PM ,d+[DATE] - PM On [DATE] at 11:28 AM, Surveyor reviewed unit refrigerator located on Almond wing. The following missing temperatures were noted: ,d+[DATE] - AM and PM ,d+[DATE] - AM and PM ,d+[DATE] - PM ,d+[DATE] - PM ,d+[DATE] - AM On [DATE] at 10:06 AM, the Surveyor observed the unit refrigerator located on Evergreen wing. The only temperature logged on the daily temperature monitoring log for the month of October was [DATE]. All other dates (,d+[DATE] thru ,d+[DATE]) were blank. On [DATE] at 11:30 AM, the Surveyor again observed unit refrigerator located on Evergreen wing. The only temperature logged on the daily temperature monitoring log for the month of October was [DATE]. All other dates (,d+[DATE] thru ,d+[DATE]) were blank. On [DATE] at 11:33 AM, the Surveyor interviewed Licensed Practical Nurse (LPN)-D who indicated that the dietary department staff are responsible for checking the unit refrigerator temperatures daily and then logging the temperatures on the temperature monitoring form. On [DATE] at 11:55 AM, the Surveyor interviewed Director of Nursing (DON)-B who confirmed it is the responsibility of the dietary department staff to check the unit refrigerator temperatures and log them on the temperature monitoring form. Improperly dated or expired items The Wisconsin State Food Code at ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking: .refrigerated, ready to eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature and time combination of 5 degrees Celsius (C) (41 degrees Fahrenheit (F)) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Commercially processed food open and hold cold .refrigerated, ready to eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked at the time the original container is opened in a food establishment and, if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in paragraph (A) of this section and; (1) The day the original container is opened in the food establishment shall be counted as Day 1 . On [DATE] during the initial kitchen tour, Surveyor noted the use of stickers on some items that had lines to fill out for open date and use by date and some items located in the coolers and refrigerators did not have sticker, but contained only handwritten dates. DM-C indicated that sometimes staff forgot, being consistent can be challenging. On [DATE] during the initial kitchen tour, Surveyor noted a box of bananas located in the walk-in cooler in the kitchen with a delivery date of [DATE]. DM-C indicated in interview at this time that the box of bananas should be tossed after 7 days and noted there was a more recent box of bananas delivered next to it with a date of ,d+[DATE]. DM-C removed the bananas from the walk-in cooler. On [DATE] at 11:28 AM, Surveyor reviewed items in the Almond Unit refrigerator and noted the following: -2 - 46 ounce (oz) Sysco thickened water cranberry flavored with no open date. -1 container of Grace Jones Fruit covered with plastic with a best by date of [DATE]. -1 Styrofoam cup of applesauce that had no label. On [DATE] at 10:54 AM, Surveyor reviewed items located in Center fridge and noted the following: -1 - 4 oz Gelatin Lemon Prosource with a slit in the cover -1 container of chocolate flavored syrup with no open or use by date. -1 bottle of ketchup with no open or use by date. On [DATE] at 11:05 AM, the Surveyor observed the unit refrigerator located on Birch wing and noted the following: -An open container of grape jelly with a manufacturer best-by date of [DATE]. No open dated was noted. -An open half gallon of chocolate milk with a no open date. -An open half gallon of white milk with no open date. On [DATE] at 11:28 AM, Surveyor interviewed DM-C who indicated items should not be outdated and should be labeled when located in the unit refrigerators. On [DATE] at 10:06 AM, the Surveyor observed the unit refrigerator located on Evergreen wing. Food items in the refrigerator contained labels which had lines to fill in dates for which the food item was pulled/delivered, opened or to be tossed. The following was noted: - An open half-gallon container of chocolate milk with no open date. - An open half-gallon container of white milk with no open date. - Pitcher of orange juice with a sticker labeled ,d+[DATE] - Pitcher of cranberry juice with a sticker labeled ,d+[DATE] - A 4 oz. Mighty Shake with a label that read: Pull date ,d+[DATE], toss date ,d+[DATE]. - A Magic Cup with a label that read: Pull date ,d+[DATE], toss date ,d+[DATE]. - An open bag of sliced bread with a label that read: Pull date ,d+[DATE] and the toss date entry of the label was not filled in. Manufacturer best-if-used-by date was [DATE]. - An open carton of grape juice; delivery date read ,d+[DATE] and the open or toss dates were not filled in. - An open 12 oz bottle of waffle syrup. The pull date was labeled ,d+[DATE]. - An open bottle of ketchup with no labels. On [DATE] at 11:31 AM, the Surveyor observed the unit refrigerator located on Evergreen wing again and noted the following: - An open container of prune juice with a delivery date of ,d+[DATE], no open or toss date. - An open container of prune juice with a delivery date ,d+[DATE] and no open or toss date. On [DATE] at 11:33 AM, the Surveyor interviewed LPN-D who indicated it was the responsibility of whoever opened a food container to write in the open date on the label or container. On [DATE] at 11:55 AM, the Surveyor interviewed DON-B who confirmed it was the responsibility of whoever opened the food item to complete the label on the food item to include the date the food container was opened.

Based on observation, interview and record review, the facility did not ensure biological's had accurate labeling to facilitate safe administration of medications for 4 residents (R72, R16, R68, R62) during 1 of 3 medication carts observations. R72 had two bottles of sodium chloride solution, one without an open date and the other exceeded the 28 day beyond use date. R16 had one bottle of [MEDICATION NAME] eye drops that exceeded the 28 day beyond use date. R68 had one bottle of artificial tears and 1 bottle of [MEDICATION NAME] eye drops, both exceeded the 28 day beyond use date. R62 had one bottle of [MEDICATION NAME] eye drops that exceeded the 28 day beyond use date. This is evidenced by: Facility policy entitled Storage and Stability of Bulk Medications, revised ,[DATE], states, in part: In general, most multi-dose medications (ointments, creams, drops, etc.) do not expire until the manufacturer's expiration dating . Facility policy entitled Storage and Stability of Bulk Medications, revised on ,[DATE], states, in part: In general, most multi-dose medications (ointments, creams, etc.) do not expire until the manufacturer's expiration dating. All eye drop medications are only good for 28 days after opening . On [DATE] at 12:22 PM, Surveyor conducted a medication cart observation with RN F (Registered Nurse) and LPN H (Licensed Practical Nurse) on the ,[DATE] unit. The following was observed: Example 1 One bottle of 5% sodium chloride ophthalmic hypertonicity (eye drops), solution without an open date for R72. Manufacturer expiration date of ,[DATE]. One bottle of 5% sodium chloride ophthalmic hypertonicity solution, with an open date of [DATE] for R72. Manufacturer expiration date of ,[DATE]. Example 2 One bottle of [MEDICATION NAME] ophthalmic solution, with an open date of [DATE] for R16. Manufacturer expiration date of ,[DATE]. Example 3 One bottle of artificial tears 1.4 % solution, with an open date of [DATE] for R68. Manufacturer expiration date of ,[DATE]. One bottle of [MEDICATION NAME] 0XXX,[DATE].5% Solution, with open date of [DATE] for R68. Manufacturer expiration date of ,[DATE]. Example 4 One bottle of [MEDICATION NAME] 1% suspension, with an open date of [DATE] for R62. Manufacturer expiration date of ,[DATE]. (Please note all the medications listed above were not discarded after 28 days of use.) During this observation, Surveyor interviewed LPN H and RN F. LPN H indicated the eye drops are expired and should have open dates. LPN H then consulted RN F. RN F indicated to Surveyor that her understanding is that eye drops are good until the manufacturer expiration date. RN F indicated she has to check to see how long eye drops are good for. RN F contacted DON B (Director of Nursing) at this time and informed Surveyor to speak to DON B regarding the eye drops. On [DATE] at 12:45 PM, Surveyor spoke with DON B regarding eye drops. DON B indicated their pharmacy policy indicates they're good until the manufacturer expiration date. DON B indicated to Surveyor she would look into it and get a hold of pharmacy for the medication packet inserts. On [DATE] at 8:45 AM, Surveyor interviewed DON B regarding expired eye drops. DON B indicated their pharmacy writes their policy. DON B indicated she contacted the pharmacy and the pharmacy came in May, June, and (MONTH) to do audits, which indicated no concerns. DON B indicated after Surveyor spoke with her, on [DATE], they replaced every eye drop in the building and started a nursing in-service to follow the 28 day expiration/beyond use date. DON B indicated she contacted the pharmacy, and the facility and nurses were following their pharmacy's directive. DON B indicated she has requested a new policy from their pharmacy. Surveyor and DON B reviewed the pharmacy audits, there is no indication that medications were expired or beyond the use date for any of the six medication carts within the facility. DON B started education, on [DATE], regarding eye drops expiring 28 days after being opened.

Based on observation, interview and record review, the facility did not ensure palatability or a proper appetizing temperature for 2 out of 3 test trays. R22 voiced food concerns regarding how the food tastes and temperature. R67 voiced food concerns regarding taste of the food and that meats are tough to cut and chew. This is evidenced by: Example 1 On 7/23/19 at 12:25 PM, Surveyor spoke with R22 regarding food. R22 indicated veggies are hard to keep warm. R22 indicated he wants good tasting food, made properly. Example 2 On 7/23/19 at 12:33 PM, Surveyor spoke with R67 who indicated the food is terrible, we've had stuff made that looks like somebody had a bad night. R67 indicated the beef the other night, R67 wouldn't eat it due to tasting like nothing and looked like a pressed cube of meat. R67 indicated most time his meals come hot, but once in a while veggies are on the cold side. R67 indicated meats are tough to cut and chew. R67 indicated he told the NHA A (Nursing Home Administrator) it's not good. On 7/25/19 at 2:30 PM, R67 indicated he brought food up in the Resident Council meeting with facility. On 7/23/19 at 1:00 PM, Surveyor conducted an observation of a test tray on the 600 unit. The hamburger had a temperature of 136.2 F (Fahrenheit) and tasted bland. Chili fries tasted bland and the fries that were not under the chili had a temperature of 123 degrees F and tasted cool and had a soft and mushy texture. On 7/29/19 at 12:45 PM, Surveyor conducted an observation of test tray in the main dining area. The sweet potatoes had a temperature of 128.3 degrees F and tasted luke warm and bland. Carrots and wax beans tasted bland. The ham had a temperature of 138.4 degrees F, tasted warm in the center, but outer edge pieces tasted luke warm. The ham was tough to cut with a fork. On 7/29/19 at 1:23 PM, Surveyor interviewed DM I (Dietary Manager) regarding test trays. DM I indicated the fries should be at 135 degrees and above and should be warm to the taste. DM I indicated 135 degrees is generally hot and they batch fry their fries, and indicated it was a fresh batch of fries from the fryer. DM I indicated the sweet potato and all hot foods should be 135 degrees or above. DM I indicated they were to put butter and brown sugar on the sweet potatoes. DM I indicated residents usually get thinner slices of ham, which makes it easier to cut. DM I indicated she would expect ham to be easier to cut. DM I also indicated all individuals should be offered condiments. DM I indicated she asks every month at Resident Council about food temperatures, and has tried in the past to have a Food Committee but no one attends.

Based on observation, interview and record review, the facility did not ensure each resident received the necessary care and services in accordance with professional standards of practice to meet each resident's physical needs for 1 of 2 residents reviewed for wounds of 24 sampled residents (R19). R19 was assessed to be at risk for skin breakdown and, on 6/20/19, was assessed to have a dry patch of skin with a .2 x (by) .2 CM (centimeter) scab to her right heel. The facility did not complete weekly detailed assessments of the wound/foot checks, per standard of practice, and the wound deteriorated. The facility did not complete a documented detailed assessment of her right heel after the scab fell off, on 7/20/19, until requested during the survey on 7/29/19. R19's wound had increased in size to 1.1 CM x 0.8 CM x undetermined, with wound bed fully covered in slough. R19 refused interventions and the facility failed to implement alternative interventions to prevent skin breakdown. Evidenced by: The facility's Pressure Injury Policy, updated 9/23/16, includes the following: Under forms it includes Weekly Pressure/Stasis Injury assessment. Procedure: Skin breakdown assessment: The Braden Scale assessment is done to determine risk of breakdown. If the resident scores 15-18 they are at mild risk . As the number decreases more preventative measures are required to prevent skin breakdown . Under Pressure Injury Treatment: Contact the physician with detailed assessment of new wound and obtain treatment orders, initiate Pressure Injury (PI) assessment and write STCP (Short Term Care Plan); Fill out initial information completely, including current treatment plan, current measurements in CM and detailed description of wound bed, periwound and exudate; Re-measure and describe injuries on pressure injury assessment on weekly basis .; Monitor healing process and notify physician if injury enlarges or deteriorates and to obtain change in treatment orders. The form Pressure/Stasis Ulcer Assessment Record, attached to the policy, includes the following: open area location, date of initial assessment, stage, size (cm) length, width, depth; surrounding skin tissue, [DIAGNOSES REDACTED], maceration, induration; sinus tract; tunneling; undermining; necrotic tissue, slough, eschar; exudate, serous, serosanguinous, purulent; pain; healing process, granulation, [MEDICATION NAME]; Improvement noted: treatment appropriate; Current Treatment; Recommendations; Comments/Assessment: . The facility policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol, revised (MONTH) (YEAR), states, the following, in part: Assessment and Recognition: The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s). In addition, the nurse shall describe and document/report the following: Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; pain assessment; Resident's mobility status; Current treatments, including support surfaces; and all active [DIAGNOSES REDACTED]. R19 has the following Diagnoses: [REDACTED]. R19 is [AGE] years old with an activated Power of Attorney (POA) and receives comfort care at the facility. On 3/6/19, R19 was discharged from the hospital after surgery for [REDACTED]. the patient had worsening symptoms of confusion and dementia. The patient had a difficult time working with physical therapy and occupational therapy . The patient's goals of care were then discussed with her daughter and her granddaughter and decision was made to transition her to hospice care given poor recovery postoperatively. (Of note, R19 had a right [MEDICAL CONDITION] which puts her at an increased risk for developing a heel ulcer due to increase immobility of the right lower extremity.) A Nutrition Assessment was completed for R19, on 4/23/19, where it was noted she had refused 6 meals in the past week. These refusals are a decline in eating vs last quarter . R19's Minimum Data Sets (MDS), completed on 7/19/19 and 4/29/19, show R19 scored a 9 on the Brief Interview for Mental Status (BIMS), indicating she had moderate cognitive impairment. On 3/17/19, R19's Doppler Report for the right lower extremity states the findings: Incomplete compression greater saphenous? Common femoral junction to the distal superficial femoral vein. Subacute thrombus. Remainder of exam unremarkable. Soft tissue swelling. Conclusion: Subacute [MEDICAL CONDITIONS] as above. R19 had a Braden Assessment, completed on 5/6/19, with a score of 17 and, on 7/23/19, with a score of 16. Her Braden, on 5/6/19, states she already had interventions in place of repositioning, ROHO mattress and ROHO wheelchair cushion, to float her heels in bed. R19's care plan, updated 7/29/19, states, in part: she requires assistance with all ADLs (activities of daily living) because of [MEDICAL CONDITION], dizziness episodes, generalized weakness, right [MEDICAL CONDITION], decreased level of cognition . Report restlessness or pain to nurse. If R19 is resistive to cares, step back and re-approach later or try having a different staff member approach her. She repositions in bed with 1 staff assistance; transfers with 1 staff assistance stand pivot using a gait belt and four wheeled walker, reposition at least every 2 hours, ROHO wheelchair cushion, ROHO mattress, float heels on pillow . R19 is at risk for skin breakdown with additional interventions to take precautions to prevent bumping as she bruises easily and encourage leg elevation between meals. The facility started a STCP, on 6/20/19, that stated problem: Scab right heel - fell off 7/20/19; Goal: To resolve/prevent skin breakdown; Interventions: 1. Make sure heels are afloat when in bed. 2. Nurse to monitor twice daily. Apply skin prep twice daily (the skin prep was discontinued on 7/20/19), Contact MD (Medical Doctor) if worsens or no improvement. 3. Added 7/20/19: dressing changes as ordered. 4. Added 7/24/19: L-emental for wound supplement. R19's Progress Notes include, on 6/20/19, an initial assessment as follows: Area 1 right heel; Onset date: 6/20/19 . Wound type: Unstageable - scabbed area; Tissue type: Scab; Drainage: none noted; Surrounding tissue: Dry; Healing progress: N/A (not applicable) new area; Area: length (CM) 1.0, width (CM) 1.2 with a 0.2 x 0.2 scab in the center of the dry patch of skin; length x width (SQ CM (square centimeter)) = 1.44; Area 1 exudate amount none; Writer discussed with Floor Nurse that resident should have BLE (bilateral extremities) heels floated while in bed. Writer feels that resident often sits on edge of the bed and the risk of falls increases if we were to use blue boots. Writer had applied skin prep to area and instructed Floor Nurse to contact MD for update and treatment recommendations. On 6/20/19, R19 received a physician's orders [REDACTED]. This was discontinued on 7/20/19. R19's Progress Note, on 6/21/19, states under skin condition: No change to area on right heel - order obtained, on 6/20/19, for skin prep - applied as ordered and heels floated while in bed to prevent further issues . Will monitor. R19's Progress Note, on 6/23/19, states under skin condition: Skin prep to right heel skin intact, no concerns, no tenderness per res (resident). On 6/27/19, R19 was seen by a podiatrist with the following documented, in part: . all 8 of her toes, 2nd to 5th were Hammertoes; she had a partial amputation of her right great toe, Left Dorsalis Pedis non-palpable. Left Posterior Tibial diminished. Right Dorsalis Pedis non-palpable. Right Posterior Tibial diminished. (This note did not include there was a scab to her right heel.) (Of note, there is no weekly assessment of the right heel/foot checks per standard of practice.) R19's Progress Note, on 7/2/19, states under skin condition: .Skin prep to right heel, site is dry with no redness or inflammation. Resident complained of discomfort when staff attempt to put shoes on per resident request. Staff encouraged and resident agrees to wearing nonskid socks. (Of note, there is no weekly assessment of the right heel.) R19's Nutrition Assessment, completed on 7/16/19, states her weight is stable now at 121 lbs (pounds). She selects menu items but sometimes doesn't eat the meal, but snacks afterward. She eats 25% to 100%, with most meals of 50% or more. Only a rare missed meal. R19's Progress Note, on 7/23/19, states under skin condition: Late entry for 7/20/19: 7/20/19 scab came off right heel. Unable to visualize wound as resident was kicking at Writer to leave her alone, but glimpse of wound appears to be approximately 1.5 CM x 1.5 CM x < (less than) 0.1 CM, whitish in color with no surrounding redness, and moist in appearance. Unit Nurse updated on call MD and orders were received for culture if draining and for a dry dressing daily until healed. (There was no evidence of other attempts to do a detailed assessment of the wound.) On 7/20/19, R19 received a physician's orders [REDACTED]. The order included: If drainage should start, please do a wound culture. R19's Progress Note, on 7/21/19, states under skin condition: Dressing to right heel completed per order - no redness, warmth or inflammation noted - no drainage present to previous dressing and resident denies any discomfort - will monitor. R19's Progress Note, on 7/23/19, states under skin condition: PMD (Primary Medical Doctor) here for rounds and gave new orders for right heel area. Also will decrease unnecessary meds and add pain control medications due to resident refusing treatment due to pain and complaint of foot/leg pain more frequently. Goal is to maintain comfort. Informed PMD of resident noncompliance to float heels, reposition, and occasionally refuse meds. See PMD notes and new orders. On 7/23/19, R19 received an order for [REDACTED]. On 7/23/19, Physician C (R19's primary physician) wrote after her visit with R19: Exhibiting decline - also increased pain with cares, complains of legs and hips hurting. Having issues with skin breakdown on right heel and right and left toes. Will not cooperate with waffle boots and staff is trying to float heels when possible . Sometimes does not take her meds so recommend [MEDICATION NAME] in addition. Extremities no pulses/cool . right heel open area scab is gone now with some drainage noted no odor no redness. [MEDICAL CONDITION] - add [MEDICATION NAME] to heel area. Due to lack of blood flow and resident unable to tolerate shoes/off load pressure area - may be hard to heal ultimately. Pain [MEDICATION NAME] monitor for sedation and effectiveness. R19's Progress Note, on 7/24/19, states under skin condition: At 11:30 AM, Applied dry dressing to right heel for protection . Resident did not allow Writer to float heels, will continue to encourage. Pain meds administered. No redness or inflammation to right heel. At 1:55 PM .Mood is pleasant and resident cooperative although did not allow staff to float heels. Pressure relief mattress in place. Resident also does not allow repositioning; resident prefers to rest on back in bed. Resident is able to reposition self. R19's Progress Note, on 7/25/19, states under skin condition: Applied new dry dressing to right heel for protection - previous dressing must have fallen off at some point in the night time - no active drainage - no redness or warmth noted - resident slept during treatment with no concerns - care plan followed as ordered and resident did allow Writer to float heels this AM (morning). On 7/25/19 at 8:07 AM, Surveyor observed R19's right heel covered with white gauze type dressing. Surveyor observed CNA D (Certified Nursing Assistant) transfer R19 with a gait belt from sitting at her bedside to her wheelchair. R19 stood and stated that her heel hurt during the pivot transfer to her wheelchair. Her mood was pleasant and she was talkative and laughing. She told Surveyor about having a lot of pain in right foot and up her ankle at the present time. R19's Progress Note, on 7/27/19, states under skin condition: .Right heel treatment completed as ordered - resident complaint of discomfort to heel and ankle area - wound bed is pink in color and surrounding tissue is whitish color with no surrounding redness - no warmth, inflammation or drainage present - resident did allow Writer to float heels while in bed but staff reports resident moves pillow and does not float heels for long - this Writer approached on 3 different occasions so far this shift to remind resident the importance of floating heels - resident does state that while heels are floating it makes my foot feel better - will continue to encourage and monitor area. R19's Progress Note, on 7/28/19, states under skin condition: .Right heel treatment completed as ordered - denies discomfort tonight and expresses no signs of discomfort - wound bed remains pink in color and surrounding tissue slightly white with no redness - no inflammation or drainage present and care plan followed - resident allows heels to be floated without any complaints. In the morning, after R19 ate breakfast, on 7/29/19, Surveyor observed LPN (Licensed Practical Nurse) [NAME] take R19's gripper sock off her right foot and apply [MEDICATION NAME] to her right heel, Surveyor viewed an approximate size of a nickel opening with white or yellow in the center. Later, Surveyor asked DON B (Director of Nursing) if a facility nurse could assess the wound. At 10:15 AM, Surveyor observed RNM G (Registered Nurse Manager) assess R19's right heel wound as follows: it measured 1.1 CM x 0.8 CM x undetermined, Center fully covered in slough, has ring of granulation tissue with callous around area on side of heel, edges distinct, painful to touch when blanching peri-wound, (R19 retracted right foot away and indicated that was enough, kept pulling foot away from RNM G, RNM G waited a minute then allowed to measure.) peri wound has pinkish/purple discoloration and is blanchable. 10:25AM - RNM G indicated R19 has poor circulation could be diabetic ulcer, since on pressure point area on heel could be a pressure injury. RNM G indicated she's not familiar with R19 and the wound looks to be eschar/slough injury, which she indicated as being Unstageable, if it is a pressure injury. (This was the first assessment completed by the facility since the scab was found on 6/20/19.) On 7/29/19 at 9:00 AM, Surveyor interviewed LPN [NAME] who regularly worked on R19's unit. Surveyor asked what the Progress Note that she wrote, on 6/23/19, meant when it stated skin intact? LPN [NAME] stated there was a scab there and it was intact at that time. She said they do not measure scabs, because it is not an open area. She agreed that if R19 would not allow staff to measure the wound, she would re-approach to measure the wound many times to ensure it was measured once a scab fell off. On 7/29/19 at 9:10 AM, Surveyor interviewed RNM F who is the unit manager of R19's unit. Surveyor asked if R19 had a scab to her right heel and RNM F verified that since 6/20/19 the scab had been on R19's right heel. Surveyor asked RNM F to help Surveyor understand R19's wound progression after 6/20/19. RNM F stated, I think they were charting it was getting smaller. The Surveyor asked, How do you know how big the scab was? RNM F responded, I don't think we measure scabs. Surveyor asked if the Physician Notes would have measurements of the wound. She said probably not. On 7/29/19 at 12:58 PM, Surveyor interviewed DON B who agreed she would expect R19's heel wound to be assessed and measured weekly. She explained she would not necessarily need to measure the scab weekly, unless there was a change, but it wouldn't hurt to measure the scab weekly. DON B explained the RN, who discovered the scab had fallen off, did contact the physician, even with the approximation, which was good. She also agreed that if a resident refuses an assessment, she would expect staff to re-approach again that shift or each shift, until they were able to assess a wound. DON B stated they do follow NPUAP as a standard of practice and did not have more specific wound policies that spoke to vascular wounds. DON B explained there was no clear [DIAGNOSES REDACTED]. DON B further stated that the nursing staff looked at her heel with every treatment of [REDACTED]. On 7/29/19 at 2:30 PM, Surveyor interviewed Physician C who has been R19's primary physician for the past 2 years. In her judgement, R19 does have [MEDICAL CONDITION]. She stated R19 does not have any pulses to her legs and is [AGE] years old. She felt when she viewed the open area to R19's right heel, on 7/23, that it was due to lack of blood flow to the area. She stated R19 would not wear shoes and the IDT (Interdisciplinary Team) had discussed using waffle boots and blue boots to protect R19's heel, but felt that she was a fall risk and had 3 falls since the beginning of June. She stated R19 has definitely shown to be more tired and declining the last few months. Surveyor asked, if the facility had updated Physician C with weekly assessments of R19's heel wound, would she have changed the way she treated the wound. Physician C stated she couldn't say, but I don't think so. She also stated it was a non-healing vascular wound. Physician C stated she had not spoken to R19's representative about the heel wound specifically, but had previously discussed the care for R19, and her representative wanted common sense comfort for R19. R19 was at risk for impaired skin integrity. R19 had a right [MEDICAL CONDITION] which increased R19's risk for impaired skin integrity to the right lower extremity. R19 developed a scabbed area to the right heel. The facility failed to complete weekly skin assessments/checks of the feet/impaired skin per standards of practice. The area to R19's heel worsened, opened up, with visible slough in the wound bed. R19 refused floating her heels at times however the facility did not implement additional interventions or review risk and benefits with R19's responsible party.

Based on observation, interview and record review, the facility did not ensure that each resident received adequate supervision to prevent accidents for 1 of 8 residents reviewed with falls out of a total sample of 29 (R42). R42 had a fall with fracture and no displacement to her right arm on 8/14/17. After that fall, the facility put 3 interventions into place; one of those interventions was 15 minute checks. This intervention was not completed. R42 fell again on 9/6/17 and displaced the fracture to her right arm from the previous fall. This is evidenced by: R42 is a long term resident of the facility. R42's most recent quarterly Minimum Data Set (MDS) documents that she scored 00 on her Brief Interview of Mental Status (BIMS), which indicates that she is severely cognitively impaired. R42 has the following Diagnoses: [REDACTED]. The facility does not have a policy for 15 minute checks. R42's Fall Assessment, dated 7/28/17, documents a score of 5, which indicates that resident is at low risk for falls. The following interventions are listed on this assessment: frequent used items within reach, make sure her pathway free of clutters, and allow uninterrupted use of bathroom, and decreased any distraction when she was involved in her routine self-care in the bathroom. R42's Guideline for Daily Care states, in part: .Mobility, I transfer without help, even I need supervision, because I am not going to wait, I can do it; Toileting, I use the bathroom without help even I might need someone to help me, I will park the wheelchair outside the bathroom then get up walk to the toilet . 15 Minute Check Documentation from 8/14/17 through 9/6/17 is not complete. During this span of 24 days the facility documentation provided for fall risk show 3 entries for 7 days, 2 entries for 9 days, one entry for 4 days and no documentation for 4 days. The documentation provided is not in 15 minute increments, it is per shift (AM, PM, N[NAME]). Per R42's Nurse's Note on 8/14/17 at 1:30 PM, R42 had a fall in her room in which she tripped over the wet floor sign (floor was not wet at this time). R42 complained of pain to her right arm. The facility completed an assessment of R42 and contacted her Nurse Practitioner (NP). The NP gave an order to X-ray her right arm. R42's Power of Attorney (POA) requested the facility avoid sending R42 to the hospital, unless it was necessary. Prior to this fall, R42 had the following intervention documented as in place: a soft touch call light in place for her to use to request assistance. After this fall, the following 3 interventions were put into place: 1) keep environment free from clutter, 2) supervise while ambulating, and 3) 15 minute checks. X-ray results showed a fracture involving the proximal humerus with no displacement (right arm, in alignment). R42 was then sent to the emergency room (ER). R42 returned later that evening with a sling in place to right arm to be worn at all times. Per R42's Nurse's Note on 9/6/17 at 5:30 PM, R42 had another fall in her room. This fall R42 was found to have her pants not pulled up all the way. R42 was half lying and half holding her body up with her arm (documentation does not identify which arm). R42's physician was contacted and ordered an X-ray of multiple areas. Prior to this fall, R42 had the following interventions documented as in place: low bed, mat on floor next to bed, and pancake call light (flat). X-ray results, 9/7/17, showed fracture involving right humeral head and neck with displacement (right arm, not in alignment). Surveyor observed the following interventions in place on 5/1/18 at 10:00 AM: wheelchair next to bed locked, bathroom light on, shoes on feet, walker folded and put away and anti-lock/roll back brakes on wheelchair. On 5/1/18 at 10:15 AM, Surveyor interviewed LPN D (Licensed Practical Nurse). Surveyor asked LPN D how 15 minute checks were completed; LPN D replied we walk by with visual check on the resident. Surveyor asked LPN D when 15 minute checks were conducted. LPN D explained that they are done initially to obtain a resident's routine, but sometimes they are used as a fall intervention. Surveyor asked LPN D if the 15 minute checks are documented or just a visual check; LPN D said a visual check. On 5/1/18 at 10:24 AM, Surveyor interviewed CNA C. Surveyor asked CNA C how 15 minute checks were completed. CNA C said a visual check of the resident every 15 minutes. Surveyor asked CNA C if the 15 minute checks are documented or just a visual check. CNA C said they are a visual check, no documentation. On 5/1/18 at 12:38 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B where 15 minute checks are documented; DON B said the CNA's document in the computer system. DON B further stated R42's 15 minute checks are not in there, as I'd expect to see. Surveyor asked DON B how the staff is to complete the 15 minute checks. DON B explained she is sure the staff walk by and see her every 15 minutes, but that her expectation is to chart when they do their charting for the shift. Surveyor asked DON B if she had a policy explaining 15 minute checks. DON B reviewed policy book and stated we do not have a policy on 15 minute checks.

Based on observation, interview, and facility policy review, the facility staff did not ensure disposal of expired medications. R38's insulin that was used daily was expired and was still in use. This is evidenced by: According to< http://products.sanofi.us/[MEDICATION NAME]/[MEDICATION NAME].html> 16.2 Storage [MEDICATION NAME] should not be stored in the freezer and should not be allowed to freeze. Discard [MEDICATION NAME] if it has been frozen. Protect [MEDICATION NAME] from direct heat and light. 10 mL Vial Until expiration date 28 days 28 days Refrigerated or room temperature 3 mL [MEDICATION NAME] prefilled pen Until expiration date 28 days 28 days Room temperature only (Do not refrigerate) 1. During medication storage observation, R38's [MEDICATION NAME] was expired. R38's Physician order [REDACTED]. R38's insulin was opened on 3/20/18 and was currently being used on 4/25/18. The [MEDICATION NAME] should have been destroyed after 4.17.18. On 4/30/18 at 10:00 AM, DON B said the insulin should have been disposed of on the 28th day it was opened.

Based on observation, interview and record review, the facility did not ensure pain management is provided to residents who require such services consistent with professional standards of practice, their Comprehensive Person-Centered Care Plan, and the residents' goal and preferences, for 1 of 5 Residents (R78) for pain out of a total sample of 29. R78 received per request needed (PRN) pain medication 77 times between 3/1/18 and 5/1/18, and no follow-up pain evaluation/assessment is indicated for 67 out of 77 times R78 received PRN pain medication. There is no indication on R78's care plan what an acceptable pain level is for R78 This is evidenced by: Facility policy entitled Pain - Clinical Protocol, dated (MONTH) 2013, states, in part: Assessment and Recognition. 2. The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain.Treatment/Management, .4. Staff will provide the elements of comforting environment and appropriate physical and complementary interventions; for example, local heat or ice, repositioning, massage, and the opportunity to talk about chronic pain Monitoring, 1. The staff will reassess the individual's pain and related consequences at regular intervals; at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain . Example 1: R78 was admitted to the facility after a fall with [MEDICAL CONDITION] on 6/27/17 and readmitted on [DATE], after being hospitalized , with [DIAGNOSES REDACTED]., [MEDICAL CONDITION], Adult Failure to Thrive and Major [MEDICAL CONDITION] (MDD). R78's Minimum Data Set (MDS), with a target date of 3/19/18, indicates he has a Brief Interview of Mental Status (BIMS) of 13 out of 15, which indicates R78 is cognitively intact. Section G indicates R78 is an extensive 2 person physical assist with bed mobility, transfers, dressing and toileting. He uses a wheelchair for locomotion and has no impairments to his extremities. Section J's pain assessment indicates R78 has pain frequently, his pain has made it hard to fall asleep and participate in activities of daily living (ADL) in the last 5 days prior to assessment. This section indicates R78 rated his pain intensity at a 08. Physician Telephone Orders (T.O.) is as follows: 3/20/18 T.O: Give 2 tabs (tablets) PO (orally) BID (twice a day) for pain [MEDICATION NAME]/Tylenol 5/325 MG (milligrams) for pain. 3/21/18 T.O: Change scheduled [MEDICATION NAME] order to Q (every) 6 hours PRN 2 tabs PO [MEDICATION NAME]/Tylenol (5/325 MG Q 6 hrs (hours) PRN for pain), D/C (discontinue) [MEDICATION NAME]. 3/23/18 T.O: Change [MEDICATION NAME] to 100 MG PO TID (three times a day) for pain. 3/23/18 T.O: Change [MEDICATION NAME]/Tylenol order to 1 tab po q 6 hrs. R78's Physician Orders, dated 5/1/18, indicate R78 has orders for the following medication: [MEDICATION NAME] (Tylenol) 325 MG tab, take 2 tabs by mouth every 4 hours prn for body pain. (Ordered 3/12/18) [MEDICATION NAME] 100 MG capsule 1 capsule by mouth TID AM, PM, HS for L foot pain. (Ordered 3/23/18). [MEDICATION NAME] - [MEDICATION NAME] ([MEDICATION NAME]) 5 MG-325 MG tab 1 tab po q 6 hours prn for moderate to moderately severe pain. (Ordered 3/23/18). (Previously ordered on [DATE] [MEDICATION NAME] - APAP 5 MG - 325 MG 2 tablets po BID AM PM for moderate to moderately severe pain (D/c'd on 2/11/18).) (Please note: R78 is currently receiving an antibiotic [MEDICATION NAME]-Pot Clavulanate ([MEDICATION NAME]) 875 MG - 125 MG tab po TID for 10 days for an infection to his L lateral foot Stage III PI. R78's Certified Nursing Assistant (CNA) Care Plan states, in part: I need to not be in pain, to keep my pain at a minimum. Approach: I need my aides to be extra gentle with me, tell the nurse if I hurt, be patient with me, keep my chair comfortable, make my bed comfortable, offer to help me with range of motion (ROM) exercises, help me to change position. R78's Care Plan states, in part: Need/Preference: 3/25/18 - I need to not be in pain, to keep my pain at a minimum. Because I: have chronic hop/leg pain and back pain at times. Approach: 3/25/18 - I need my nurse to ask me if I hurt, offer me pain medication, tell me about my medicine. I need my aides to be extra gentle with me, tell the nurse if I hurt, be patient with me, keep my chair comfortable, make my bed comfortable, offer to help me with ROM exercises, help me to change position. Goal: 3/25/18 - My goal is to maintain my pain at an acceptable level, maintain a level of comfort that allows me to participate in the activities I want to. Goal time: Three months. R78's PRN Medication Notes and Medication Administration Records (MARs) indicate the following: March (YEAR): [MEDICATION NAME] (APAP) 325 MG 2 tablets po q 4 hours were given on: 3/14/18 at 7:00 AM for pain level of an 8 to his knees. (No non-pharmacological (non-pharm) interventions indicated, and no Follow-Up Pain Assessment indicated.) 3/14/18 at 9:51 PM PRN given, for pain level of a 4 to his back. (No non-pharm interventions indicated, and no Follow-Up Pain Assessment indicated.) 3/17/18 at 4:58 AM PRN given, for pain level of a 5 all over, non-pharmacological used were distraction and position changes. (No Follow-Up Pain Assessment indicated.) 3/17/18 at 10:14 AM PRN given (No indication of pain rating prior to medication, no non-pharm interventions indicated and no Follow-Up Pain Assessment indicated.) 3/17/18 at 8:12 PM PRN given (No indication of pain rating prior to medication, no non-pharm interventions indicated and no Follow-Up Pain Assessment indicated.) 3/19/18 at 2:45 AM PRN given for vocal complaints of pain my left foot is killing me. (No indication of pain level prior to medication, no non-pharm interventions indicated, and no Follow-Up Pain Assessment indicated.) 3/19/18 at 9:50 PM PRN given for a pain of 2 all over, non-pharm interventions of rest and position changes. (No Follow-Up Pain Assessment indicated.) 3/20/18 at 8:03 AM PRN given for a pain of 6 in legs, position changes. (No Follow-Up Pain Assessment indicated.) 3/21/18 at 2:11 AM PRN given for vocal complaints of pain in L foot, non-pharm used rest, distraction and position changes. (No indication what pain level was prior to medication and no Follow-Up Pain Assessment indicated.) 3/27/18 at 9:49 PM PRN given for a pain level of 4 to his back. (No indication of non-pharm interventions indicated and no Follow-Up Pain Assessment indicated.) 3/29/18 at 6:45 PM PRN given (No indication of pain level prior to medication, no non-pharm interventions indicated, and no Follow-Up Pain Assessment indicated.) [MEDICATION NAME] 5 MG/325 MG (1 tab) po q 6 hours PRN was given on: 3/1/18 at 3:22 AM PRN given (1 tab) for vocal complaints of pain in hips, used rest, distraction and position changes. (No Follow-Up Pain Assessment indicated.) 3/1/18 at 7:43 PM PRN given (1 tab) for pain level of 5 (No indication of non-pharm interventions, and no indication of a Follow-Up Pain Assessment.) 3/2/18 at 8:59 PM PRN given (1 tab) for pain level of 6. (No indication of non-pharm interventions or a Follow-Up Pain Assessment being done.) 3/3/18 at 12:31 PM PRN given (1 tab) for pain level of 7 in right hip. (No indication of non-pharm interventions or a Follow-Up Pain Assessment.) 3/4/18 at 8:00 AM PRN given (1 tab) (No pain level prior to medication, no indication of non-pharm intervention use or a Follow-Up Pain Assessment.) 3/4/18 at 7:40 PM PRN given (1 tab) (No pain level prior to medication, no indication of non-pharm interventions use or a Follow-Up Pain Assessment.) 3/22/18 at 3:11 AM PRN given (2 tabs) for a 6 all over pain, indicated rest and position changes used. (No Follow-Up Pain Assessment indicated.) 3/23/18 at 3:16 AM PRN given (2 tabs) for a pain level of 8 in right leg. (No non-pharm interventions or Follow-Up Pain Assessment indicated.) 3/24/18 at 3:16 AM PRN given (1 tab) for pain level of 8 in left leg, indicated use of rest, distraction and position changes. (No indication of a Follow-Up Pain Assessment.) 3/25/18 at 4:31 AM PRN given (1 tab) for a pain level of 7 in left leg. (No non-pharm interventions or Follow-Up Pain Assessment indicated.) 3/28/18 at 8:45 PM PRN given (1 tab) for a pain level of 6 to his foot, usage of rest and position changes and indicated a follow-up pain level of 0. 3/30/18 at 1:56 AM PRN given (1 tab) for a pain level of 8 in left foot, along with use of rest, distraction and position changes. (No indication of a Follow-Up Pain Assessment.) 3/30/18 at 9:36 AM PRN given (1 tab) for a pain level of 6 in both feet, along with distraction. (No indication of a Follow-Up Pain Assessment) 3/30/18 at 8:42 PM PRN given (1 tab) for pain level of 7, along with the use of rest, and position changes. Follow-up assessment indicated pain level of 0. R78 received a total of 11 doses of Tylenol/[MEDICATION NAME] and 14 doses of [MEDICATION NAME], between 3/1/18 - 3/31/18. A Follow-Up Pain Assessment/Evaluation was completed 2 times out of 25 opportunities to do so for (MONTH) of (YEAR). April (YEAR) APAP 325 MG 2 tablets po q 4 hours were given on: 4/2/18 at 3:38 PM PRN given. (No indication of pain level prior to medication, if non-pharms were used, or a Follow-Up Pain Assessment.) 4/3/18 at 5:22 AM PRN given for vocal complaints of pain in both feet my feet are on fire. (No indication of non-pharm use or follow-up) 4/5/18 at 6:58 PM PRN given for discomfort. (No indication of pain level prior to medication, use of non-pharms, or a Follow-Up Pain Assessment.) 4/11/18 at 6:38 PM PRN given for pain level of 4 to back, used rest and position changes. Pain level after med 0. (Please note R78 received a [MEDICATION NAME] at 6:03 PM prior to this.) 4/22/18 at 8:21 AM PRN given for pain level of 8 in foot, legs and back, used position changes and distraction. (No indication of Follow-Up Pain Assessment.) 4/26/18 at 4:58 PM PRN given for pain level of 9 in left foot and back, used rest, distraction and position changes. (No indication of a Follow-Up Pain Assessment.) [MEDICATION NAME] 5 MG / 325 MG 1 tablet by po q 6 hours PRN was given on: 4/1/18 at 8:50 AM PRN given (1 tab) (No indication of pain level prior to medication, if non-pharm intervention were used, or a Follow-Up Pain Assessment.) 4/2/18 at 11:39 PM PRN given (1 tab) for vocal complaints of pain in left foot, used rest, distraction and position changes. (No indication of a Follow-Up Pain Assessment.) 4/3/18 at 9:25 AM PRN given (1 tab) (No indication of pain level prior to medication, if non-pharm interventions were used or a Follow-Up Pain Assessment.) 4/4/18 at 4:04 AM PRN given (1 tab) for a pain level of 8 in left foot (No indication of non-pharm usage, no indication of a Follow-Up Pain Assessment.) 4/4/18 at 7:48 PM PRN given (1 tab) for a pain level of 7 in left foot, indicated use of gentle massage and rest. (No indication of Follow-Up Pain Assessment.) 4/6/18 at 8:48 AM PRN given (1 tab) (No indication of pain level prior to medication, if non-pharms were used, or a Follow-Up Pain Assessment.) 4/9/18 at 1:23 AM PRN given (1 tab) for pain level of 8 in foot (No indication if non-pharms were used, or a Follow-Up Pain Assessment.) 4/9/18 at 8:46 AM PRN given (1 tab) (No indication of pain level prior to medication, if non-pharms were used or a Follow-Up Pain Assessment was done.) 4/9/18 at 6:33 PM PRN given (1 tab) given for discomfort (No indication of pain level prior to medication, if non-pharms were used or that a Follow-Up Pain Assessment was done.) 4/10/18 at 5:37 AM PRN given (1 tab) for vocal complaints of pain in both legs, with usage of rest, distraction and position changes. (No indication of a Follow-Up Pain Assessment.) 4/10/18 at 3:00 PM PRN given (1 tab) for pain level of 7 in both feet, used rest and distraction, at 8:36PM medication indicated as effective. 4/11/18 at 6:03 PM PRN given (1 tab) for a pain level of 7 to back, used rest, and position changes. Pain level after med indicated as a 2. 4/13/18 at 8:05 AM PRN given (1 tab) for a pain level of 8 to left foot, used rest. (No indication of a Follow-Up Pain Assessment.) 4/14/18 at 7:52 AM PRN given (1 tab) (No indication of pain level prior to medication, if non-pharms were used, or a Follow-Up Pain Assessment.) 4/14/18 at 3:06 PM PRN given (1 tab) for a pain level of 7 to back, used position changes, rest, and distraction. (No indication of a Follow-Up Pain Assessment.) 4/15/18 at 12:59 AM PRN given (1 tab) for pain level of 8 to left foot. (No indication of non-pharm usage, and no Follow-Up Pain Assessment.) 4/15/18 at 5:33 AM PRN given (1 tab) for a pain level of 7 to left foot. (No indication of non-pharm usage and no Follow-Up Pain Assessment.) 4/15/18 at 7:53 AM PRN given (1 tab) (No indication of pain level prior to medication, if non-pharms were used and no Follow-Up Pain Assessment.) 4/16/18 at 1:26 AM PRN given (1 tab) for vocal complaints of pain in left leg and used rest, distraction, and position changes. (No indication of a Follow-Up Pain Assessment.) 4/16/18 at 8:53 AM PRN given (1 tab) (No indication of pain level prior to medication, if non-pharms were used or if a Follow-Up Pain Assessment was done.) 4/16/18 at 9:54 PM PRN given (1 tab) for a pain level of 5 in his back and used rest and position changes. (No indication of a Follow-Up Pain Assessment.) 4/17/18 at 7:20 AM PRN given (1 tab) (No indication of pain level prior to giving medication, if non-pharms were used or a Follow-Up Pain Assessment.) 4/18/18 at 7:30 AM PRN given (1 tab) for a pain level of 8 to back and foot. (No indication of non-pharm interventions or a Follow-Up Pain Assessment.) 4/19/18 at 4:02 AM PRN given (1 tab) for a pain level of 7/10. (No indication of non-pharms being used or that a Follow-Up Pain Assessment was done.) 4/19/18 at 7:29 AM PRN given (1 tab) for a pain level of 8/10. (No indication of non-pharms being used or that a Follow-Up Pain Assessment was done.) 4/19/18 at 5:53 PM PRN given (1 tab) for a pain level of 6 to back, used rest, and position changes. R78's follow-up pain level was a 0. 4/20/18 at 12:35 AM PRN given (1 tab) for a pain level of 8 in left foot and used rest, distraction and position changes. (No indication of a Follow-Up Pain Assessment.) 4/20/18 at 8:25 AM PRN given (1 tab) given for itching. (No indication of pain level prior to medication, if non-pharms were used or a Follow-Up Pain Assessment.) (Narcotic was given for itching not for pain) 4/20/18 at 7:20 PM PRN given (1 tab) for pain. (No indication of pain level prior to medication, if non-pharms were used or that a Follow-Up Pain Assessment was done.) 4/21/18 at 8:42 AM PRN given (1 tab) for a pain level of 8 in foot and back. (No indication of non-pharms used.) 1:48 PM Follow-Up Assessment indicated pain level of 3 at 9:30 AM. 4/21/18 at 8:56 PM PRN given (1 tab) for a pain level of 6 to back, used position changes and rest. Pain level after indicated as 0. 4/22/18 at 3:27 AM PRN given (1 tab) for a pain level of 8 in left foot, used rest, distraction and position changes. (No indication of a Follow-Up Pain Assessment.) 4/22/18 at 10:03 AM PRN given (1 tab) for a pain level of 6 in legs, Tylenol helped but not enough and also treatment to back and foot will be done soon. Usage of distraction and activity. Follow-up indicated at 2:20 PM pain level after med was a 3 at 12:15 PM. 4/22/18 at 6:49 PM PRN given (1 tab) for a pain level of 7 to back, used rest and position changes. 6:49 PM follow-up after med pain level 0. 4/23/18 at 7:56 AM PRN given (1 tab) for pain level of 7. (No indication of non-pharm use, or a Follow-Up Pain Assessment.) 4/24/18 at 3:30 AM PRN given (1 tab) for vocal complaints of pain in left leg, used rest, distraction and position changes. (No indication of a Follow-Up Pain Assessment.) 4/24/18 at 9:18 PM PRN given (1 tab) for vocal complaints of pain in legs and feet. (No indication of non-pharm use or a Follow-Up Pain Assessment.) 4/25/18 at 7:40 AM PRN given (1 tab) for pain level of 7 to back. (No indication of non-pharm usage or a Follow-Up Pain Assessment.) 4/26/18 at 8:46 AM PRN given (1 tab) for pain level of 7 to back and foot. (No indication of non-pharm usage or a Follow-Up Pain Assessment.) 4/28/18 at 11:29 AM PRN given (1 tab) for pain level of 8 to back. (No indication of non-pharm interventions or a Follow-Up Pain Assessment.) 4/29/18 at 7:45 AM PRN given (1 tab) for pain level of 9 to back, used rest, and position changes. (No indication of a Follow-Up Pain Assessment.) 4/29/18 at 2:55 PM PRN given (1 tab) for pain level of 7 to back, used rest, distraction and position changes. (No indication of a Follow-Up Pain Assessment.) 4/30/18 at 4:51 AM PRN given (1 tab) for vocal complaints of pain in left leg, used rest, distraction and position changes. (No indication of a Follow-Up Pain Assessment.) 4/30/18 at 12:33 PM PRN given (1 tab) for pain level of 8 to left foot and back, used rest and position changes. 1:41 PM no further complaints. 4/30/18 at 7:24 PM PRN given (1 tab) for pain level of 7 to left foot and back, used rest, distraction and position changes. (No indication of a Follow-Up Pain Assessment.) 5/1/18 at 5:08 AM PRN given (1 tab) for pain level of 8 to left leg and back, used rest, distraction and position changes. (No indication of a Follow-Up Pain Assessment.) R78 received a total of 6 Tylenol/[MEDICATION NAME] doses and 46 [MEDICATION NAME] doses between 4/1/18 - 5/1/18. A Follow-Up Pain Assessment was completed 8 times out of a total of 52 opportunities during this time frame. 4/11/18 physician progress notes [REDACTED]. Peripheral [MEDICAL CONDITION] stable with [MEDICATION NAME]/PRN [MEDICATION NAME], care to balance sedation from narcotics .ongoing burning paresthesia (pins and needles) in the foot .Advanced [MEDICAL CONDITION] .recommend [MEDICATION NAME] ointment (not gel) 5% to feet at bedtime for neuropathic pain. (Please note the [MEDICATION NAME] ointment order is not on R78's current Physician order [REDACTED]. On 4/25/18 at 9:54 AM, Surveyor interviewed R78 regarding his pain. R78 indicated he has pain due to a broken hip. Staff is treating his pain now. R78 indicated he experiences pain every day and that his pain is relieved by pain killers, as long as they're on it. Indicated that pain prevents attendance of activities and that staff do check on him often for pain. On 4/26/18 at 10:21 AM, Surveyor observed RN F (Registered Nurse) and LPN G (Licensed Practical Nurse) complete R78's wound care. R78 was lying in bed on left side, has body pillows for positioning behind him and a pillow under his calf area. R78 visibly jerking/moving both feet while treatment was being done. After wound care, RN F placed R78's gripper sock back on his left foot. RN F stated, Has [MEDICAL CONDITION] in his feet too. On 4/26/18 at 10:42 AM, RN F went to remove gripper sock from L foot in order to date and initial bandage. R78 was visibly flinching when RN F removed gripper sock, and could see R78 jerking his L foot a little. Surveyor asked R78 about his pain at this time and R78 indicated a pain level of a 9 out of 10, then R78 indicated pain is usually an 8. LPN G asked where R78's pain was and R78 indicated pain is equal in his back and foot. LPN G provided water to R78 while RN F provided 2 tabs of PRN Tylenol to R78. R78 indicated to Surveyor that his pain usually isn't this bad. R78 stated, Just get it over with, when asked if he wanted to wait. R78 indicated pain usually isn't this bad. On 4/26/18 at 11:04 AM, R78's L lateral foot is lying directly on his air mattress; L heel is the only area remaining on the pillow. RN F asked how R78 was doing at this time. R78 indicated he was doing ok. On 5/1/18 at 9:35 AM, Surveyor interviewed R78 regarding his pain. R78 indicated his pain is like having a burnt, black, fiery brick under his arch, and that it just burns, just on the foot. R78 indicated having continuous soreness all the way from his foot up to the groin. R78 indicated the back blister (R78 has a PI to his spine area) is sore and it spreads and I feel that when I want to go to bed. R78 indicated his pain is normally an 8 and that maybe a 6 would be considered comfortable. R78 stated, No, indicating his pain never gets down to a 6. R78 indicated that pain pills relieve his pain. R78 shook his head in no motion when asked if things such as lying down, an ice pack, or a hot pack would help his pain. R78 stated, You just don't feel the pain when you use the pain pill. R78 indicated he is able to sleep at night as long as he gets a pain pill. R78 indicated he considers not going to activities due to pain, but does go especially to Bingo. R78 stated, In pain right now, the hot brick and swelling under the arch, it would be an 8 right now maybe 7 and a half. R78 indicated that sometime staff are on break and are not aware of his pain and thinks staff treat his pain when aware of it. I have pain at an 8, but with the pain pills I have zero pain. R78 indicated that [MEDICAL CONDITION] between 8 & 9 o'clock at night through the morning. On 5/1/18 at 12:50 PM, R78 stopped Surveyor in the hallway and indicated my body aches in the bones. Surveyor asked R78 if staff come back in and asked how he is or how his pain is. R78 indicated they have enough problems, than propelled himself down the hallway in his wheelchair. On 5/1/18 at 1:03 PM, Surveyor interviewed RN E regarding R78's pain medication follow-ups. RN E indicated that if someone reports pain, you would do a pain assessment and ask where they're having pain, ask if its new or not, to rate it if they can and then check back within an a half hour to see how the pain is. RN E indicated follow-up documentation is done if the pain is new, but if it's chronic, she wouldn't. RN E indicated that if a resident is rating their pain between 7 - 9, at some point, a doctor should be called, because they probably need something stronger. RN E indicated a Medical Doctor (MD) is to be called if PRN narcotic usage happened more than a couple times. RN E indicated that some individuals have dementia, so they can't always verbalize their pain. RN E stated, That's a good question, should be more specific, when asked what R78's care plan means by acceptable pain level. RN E indicated pain levels were documented on before and after pain medication when the facility used paper MARs. RN E indicated there is no prompt for nurses to document a pain level after in the electronic MARs. RN E indicated it is the nurse's responsibility to asses if the medication is helping or not. RN E indicated that pain regimens are reviewed upon admission, change of condition and every three months. RN E indicated the nurse should be checking back and documenting. RN E indicated that if a resident has an episode of pain rated at an 8 and given pain medication and it lowers the pain, she wouldn't call the MD for one incident, but if it continues, RN E would call an MD. RN E indicated that after 2 incidents you would call a MD. RN E indicated monitoring pain should be an ongoing thing and that the nurse should be checking back and documenting. On 5/1/18 at 1:21 PM, Surveyor interviewed the DON B (Director of Nursing) regarding Pain Follow-Up Assessments for R78. DON B indicated that R78 is capable of telling staff if he is still in pain. DON B indicated staff should be documenting a Follow-Up Pain Assessment/Evaluation. DON B indicated there is a glitch in the software, as sometimes a follow-up box will appear and other times it will not. DON B asked Surveyor to call DR H (Doctor) regarding R78. On 5/1/18 at 2:16 PM, Surveyor spoke with DR. H over the phone regarding R78's pain. DR H indicated R78's baseline is dementia, has hesitancy towards Sundowning, not sure if it's due to dementia or [MEDICAL CONDITION]. DR H indicated that it's very difficult to assess if R78's pain is truly an 8. If R78 gets more than one [MEDICATION NAME] tablet every 8-12 hours he is significantly sedated. DR H indicated when he comes to visit, if it's been more than a half hour after pain medication has been given, he gets drowsy and sleepy on him. DR H indicated that if R78 decides to get up, he could fall, due to the drowsiness. DR.H indicated that if R78 is distracted, all of a sudden his pain becomes far less and is better, which Dr. H has witnessed when R78's family member is here chatting and reminiscing; his painful parts become not a concern anymore. DR H stated, I'm not saying not to go back to re-evaluate it, but it comes down to his dementia and that he's not reliable on this indicator. It's not consistent and he has a neuropathic component, especially if that foot is swollen, demonstrated this even before the ulcer. In my opinion, it's due to the [MEDICAL CONDITION] and neuropathic issues. DR H indicated an acceptable level of pain for R78 was not something he has discussed with R78, due to at times he's very lucid and other times he's not, especially after receiving pain medication.

Based on record review and interview, the facility did not ensure the Minimum Data Set (MDS) data was completed/encoded within the 7 day timeframe, or transmitted within 7 days of completion of the assessment for 2 of 2 supplemental residents (R1 and R2) selected for the Resident Assessment task. R1's Admission MDS was not completed within 14 calendar days after admission or submitted within 7 days of completion. R2's Admission MDS was not completed within 14 calendar days after admission or submitted within 7 days of completion. This is evidenced by: Example 1: R1 admitted to facility on 4/9/2018; R1's Admission MDS has a target date of 4/16/2018. (Please note 14 calendar days after R1's admission would be 4/23/18 and 7 days after completion would have been 4/30/18, if the MDS was not completed per timeframes.) R1's Admission MDS on 5/1/18 had the following sections that were incomplete: Section B: Hearing, Speech and Vision Section G: Functional status Section H: Bladder and Bowel Section J: Health Conditions Section M: Skin conditions Section N: Medications Section P: Restraints and Alarms Section V: Care Area Assessment (CAAs) On 5/1/18 at 3:45PM, Surveyor interviewed DON B (Director of Nursing) asking why R1's Admission MDS is indicated as Held. DON B indicated it wasn't signed off on. DON B indicated that all sections should be completed and the MDS should have been submitted in the appropriate timeframe. Example 2: R2 was admitted to the facility on [DATE]; R2's Admission MDS has a target date of 4/16/2018. (Please note 14 calendar days after R2's admission would be 4/23/18 and 7 days after completion would have been 4/30/18, if the MDS was completed per timeframes.) R2's Admission MDS on 5/1/18 had the following sections that were incomplete: Section B: Hearing, Speech and Vision Section G: Functional status Section H: Bladder and Bowel Section J: Health Conditions Section M: Skin conditions Section N: Medications Section P: Restraints and Alarms Section V: CAAs On 5/1/18 at 3:45 PM, Surveyor interviewed DON B asking why R2's Admission MDS is indicated as Held. DON B indicated it wasn't signed off on. Surveyor asked DON B to look at specific section for completion. DON B indicated that all sections should be completed and the MDS should be submitted in the appropriate timeframe.

Based on interview and record review the facility did not ensure that the resident has the right to formulate an advance directive for 13 of 18 residents reviewed (Residents 4, 5, 6, 18, 1, 2, 3, 16, 11, 14, 7, 8, and 12). Residents 4, 5, 6, 18, 1, 2, 3, 16, 7, 8, 12, 11 and 14 had signed a do not resuscitate form within each resident's medical record. There was no order from Resident 4, 5, 6, 18, 1, 2, 3, 16, 7, 8, 12, 11 or 14's physicians for a Do Not Resuscitate status. This is evidenced by the following: The facility's policy Advanced Directives dated [DATE], states in part Purpose: Advanced Directives will be respected in accordance with state law and per Columbia Health Care facility policy. Procedure: d. Upon admission the Social Services Director or designee will also discuss and document requests and preferences for CPR on the 'Statement of Preferences' form. h. Nursing will contact the attending physician to ensure orders for care and treatment is current. 2011 Wisconsin Code Chapter 154. Advance directives. 154.19 Do- not- resuscitate order. States in part, 154.19 (1) No person except an attending physician may issue a do- not- resuscitate order. 154.19 (c) The order is in writing. On [DATE] at 3:00 PM Surveyor and Surveyor interviewed Nursing Home Administrator (NHA) A regarding code status and the need for a signed physician order [REDACTED]. NHA A was given the Wisconsin Statute 154.19 to review. On [DATE] at 9:10 AM Surveyor interviewed Registered Nurse (RN) H. RN H is the Birch Unit Manager. RN H stated the facility does not get physician's orders [REDACTED]. RN H stated we go by the resident preferences. Example 1 On [DATE], Surveyor reviewed Resident 4's most recent signed physician orders [REDACTED]. Resident 4's Statement of Preference sheet signed and dated [DATE], by the AHCPOA (Activated Health Care Power of Attorney) indicates that Resident 4 does not want Cardio [MEDICAL CONDITION] Resuscitation (CPR) if her heart stops beating. Example 2 On [DATE], Surveyor reviewed Resident 5's most recent signed physician orders [REDACTED]. Resident 5's Statement of Preference sheet signed and dated [DATE], by the AHCPOA indicates that Resident 5 does not want CPR if her heart stops beating. Example 3 On [DATE], Surveyor reviewed Resident 6's most recent signed physician orders [REDACTED]. Resident 6's Statement of Preference sheet signed and dated [DATE], by the AHCPOA indicates that Resident 5 does not want CPR if her heart stops beating. On [DATE] at 9:15 AM, Surveyor interviewed Licensed Practical Nurse (LPN) D regarding code status and how the staff knows who is a DNR or Full Code. LPN D indicated that the staff would always look at the preference sheet. LPN D opened a chart and showed Surveyor where the preference sheet is located. LPN D indicated that there is not a physician signature. Example 4 On [DATE], Surveyor reviewed Resident 18's most recent signed physician orders [REDACTED]. Resident 18's Statement of Preference sheet signed and dated [DATE], by the AHCPOA indicates that Resident 18 does not want CPR if his heart stops beating. On [DATE] at 9:40 AM, Surveyor interviewed Social Worker (SW) E regarding resident code status. SW E indicated once the resident is admitted , the social worker will work with the resident or AHCPOA to fill out the Preference form. Surveyor asked SW E is the physician signs an order for [REDACTED]. SW E indicated if there is a change in code status the nurse would handle that. Example 5 Resident 1 was admitted on [DATE] and most recently admitted on [DATE]. Resident 1 is her own decision maker. Resident 1's Statement of Preference, signed [DATE], by Resident 1, indicates I do not want CPR (Cardiopulmonary Resuscitation) if my heart stops beating. Resident 1's most recent physician's orders [REDACTED].>Example 6 Resident 2 was admitted on [DATE]. Resident 2 has an Activated HealthCare Power of Attorney (AHCPOA). Resident 2's Statement of Preference, signed [DATE] by Resident 2's HCPOA, indicates I do not want CPR (Cardiopulmonary Resuscitation) if my heart stops beating. Resident 2's most recent physician's orders [REDACTED].>Example 7 Resident 3 was admitted on [DATE]. Resident 3 is her own decision maker. Resident 3's Statement of Preference, signed [DATE], indicates I do not want CPR (Cardiopulmonary Resuscitation) if my heart stops beating. Resident 3's most recent physician's orders [REDACTED].>Example 8 Resident 16 was admitted on [DATE]. Resident 2 has a Guardian. Resident 16's Statement of Preference, signed [DATE] by Resident 16's Guardian, indicates I do not want CPR (Cardiopulmonary Resuscitation) if my heart stops beating. Resident 16's most recent physician's orders [REDACTED].>On [DATE] at 9:10 AM Surveyor interviewed Registered Nurse (RN) H. RN H is the Birch Unit Manager. RN H stated the facility does not get physician's orders [REDACTED]. RN H stated we go by the resident preferences. Example 9 Resident 11 admitted to the facility on [DATE] with most recent admission of [DATE]. Resident 11 has [DIAGNOSES REDACTED]. Resident 11's Statement of Preference form signed on [DATE], by AHCPOA (Activated Health Care Power of Attorney), indicates Resident 11 does not want Cardio [MEDICAL CONDITION] Resuscitation (CPR) if his heart stops. Resident 11's most recent signed physician orders [REDACTED]. Surveyor interviewed Medical Records G, on [DATE] at 1:40 pm, who stated there is not a DNR order for Resident 11. Example 10 Resident 14 was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. Resident 14 is her own decision maker. Resident 14's Statement of Preference form signed on [DATE] is marked I do not want CPR if my heart stops beating. Upon record review by Surveyor Resident 14's most recent signed physician orders [REDACTED]. No DNR order observed in Resident 14's chart on [DATE] during record review Example 11 Resident 7 was admitted on [DATE] and most recently admitted on [DATE]. Resident 7 has an AHPOA (Activated Power of Attorney for Health Care). Resident 7's Statement of Preference, signed [DATE] by Resident 7's HCPOA, indicates I do not want CPR (Cardiopulmonary Resuscitation) if my heart stops beating. Review of Resident 7's current signed Physician order [REDACTED]. On [DATE] the facility did provide Surveyor a copy of Resident 7's History and Physical report from the hospital dated [DATE] signed by a nurse practitioner which included the statement The patient is a DNR according to the paperwork from the nursing home. However this document is not a physician order [REDACTED]. Example 12 Resident 8 was admitted on [DATE] and most recently readmitted on [DATE]. Resident 8 is his own decision maker. Resident 8's Statement of Preference, signed by Resident 8 on [DATE] indicated I do not want CPR (Cardiopulmonary Resuscitation) if my heart stops beating. Resident 8's current signed Physician orders [REDACTED]. Example 13 Resident 12 was admitted [DATE]. Resident 12 is her own decision maker. Resident 12's Statement of Preference signed [DATE] by Resident 12 indicates I do not want CPR (Cardiopulmonary Resuscitation) if my heart stops beating. Resident 12's current physician orders, signed [DATE] does not include orders for Resident 12's preference of no CPR. The facility did provide Surveyor Resident 12's Physician Plan of Care form signed by the physician dated [DATE] which included Code Status: No code, however this document was from 2014 and Resident 12's code status was not noted on the current orders ([DATE]) for Resident 12. Surveyor reviewed Resident 12's signed nursing home physician visit on [DATE] which listed DNR, however this document is not a physician order.

Based on observation, interview and record review the facility did not provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 5 medication storage areas observed. This affected 1 resident (Resident 19). Resident 19 had 2 opened vials of insulin that were not dated when opened thus not ensuring that they were used within 28 days of opening or storing at room temperature, per manufacturers guidelines. Evidenced by: The facility's Storage and Stability of Insulin Products table revised on 2/2014 notes the following: The following tables address specific expiration or beyond-use dating that applies to insulin products that have been opened, mixed or pre-drawn. Maximum Storage Conditions for Insulin Vials Room Temperature 59-86 degrees Fahrenheit (vial) Opened/Unopened: . Humalog 28 days (and) . Lantus 28 days. Resident 19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 19's Physician order [REDACTED]. -Lispro (human) 100 Unit/ML (milliliter) Solution sub-Q (subcutaneously) scheduled dose: (0.07 ml/7 unit) three times a day Breakfast Noon Supper first date: 8/25/2015 -Insulin Glargine (Lantus) 100 Unit/ML Solution sub- Q (subcutaneously) scheduled dose: (0.25 ml/25 units) daily Supper first date: 10/16/2015 On 3/7/16 at 7:55 AM Surveyor and LPN (Licensed Practical Nurse) M made observation of the Evergreen Medication Room (600 unit) noting a vial of Lantus (Glargine) Insulin for Resident 19 in the refrigerator. The vial had been opened and there was no open date on the vial, LPN M stated that she had pulled the vial from Resident 19's locked cupboard in her room to send back to pharmacy because it was not dated. Surveyor asked LPN M when the Lantus insulin expired; LPN M stated the vial was good for 28 days after it was opened, but did not know the open date. Surveyor asked LPN M where Resident 19's insulin vials were stored for administration; LPN M stated that they were stored in a locked cupboard in Resident 19's room (at room temperature). Surveyor and LPN M then went to Resident 19's room and observed in the locked cupboard that Resident 19 had an opened vial of Lispro insulin that also did not include an open date on the vial, this vial was dated as delivered on 2/3/16, LPN M stated the vial should have pulled out of the cupboard to be replaced but was not. Surveyor asked LPN M if she knew when the vial was open and stated she did not, LPN M stated the insulin vial should have been dated when opened by the nurse and was not. LPN M removed the vial from Resident 19's cupboard to return to pharmacy and stated she would also order a new vial of Lispro insulin for Resident 19 and inform the other nurses. It is also important to note that the manufacturer directs that maximum storage of Resident 19's insulin vials at room temperature opened or unopened is 28 days.

Based on observation and interview the facility did not ensure staff provided appropriate infection control practices during wound care for 1 of 2 residents (Resident 2) observed for wound care Registered Nurse (RN) I did not use aseptic technique when completing Resident 2's wound care. Evidenced by: Resident 2 was admitted to the facility on [DATE]. Resident 2's [DIAGNOSES REDACTED]. Resident 2's physician's orders [REDACTED]. On 3/2/16 at 3:15 PM Surveyor observed Registered Nurse (RN) I complete wound care on Resident 2's right outer ankle. RN I put a towel under Resident 2's right leg, proceeded to complete the wound care treatment. RN I, with gloved hands, picked up the container of normal saline and poured the normal saline down Resident 2's right outer ankle. The liquid ran down Resident 2's ankle over the top open area and continued to run over the lower open area. RN I then took gauze and wiped both areas with the gauze at the same time. RN I placed santyl on 2 applicators and wiped the applicators on one area then the other area, using the same 2 applicators. RN I removed the towel under Resident 2's leg after the treatment was complete, placed the towel on top of Resident 2's over the bed table, picked up the towel and placed it on the medication cart, then picked up the towel and took it to the laundry bin. RN I did not sanitize the over bed table or the medication cart after removing the used towel from the surfaces. On 3/2/16 at 3:30 PM Surveyor interviewed RN I. RN I stated he considered the 2 areas one wound and therefore only used one applicator for the both of them. RN I also stated he should have sanitized the top of the over the bed table and the medication cart after removing the towel from those areas. On 3/2/16 at 3:30 PM Surveyor interviewed RN K. RN K is the wound care nurse. RN K stated there were not 2 open areas, that one of the areas was closed. RN K stated RN I should not have applied the santyl to the two areas with one applicator.

Based on record review and interview, the facility did not conduct a comprehensive assessment of for the use of a noodle as a device for 5 (Residents 5, 6, 2, 15, and 7) of 15 residents reviewed for appropriate devices. Resident 5 did not have a comprehensive device assessment in her medical record. Resident 6 did not have a comprehensive device assessment in her medical record. A device assessment was not completed for Resident 2's fall prevention device, noodle. A device assessment was not completed for Resident 15's fall prevention devices, body pillow and moxi-mattress. The facility did not complete an assessment for the use of noodles, devices the facility used to prevent falls from bed, for Resident 7. This evidenced by: On 3/7/16 at 5:00 PM, Surveyor was given the following information from the facility on the use of noodles. Falls Management & Restraint Reduction dated 10/25/11, by Quality Improvement Organization, states in part, Use pool noodles and hip protectors. Creating a Safe Environment to Prevent Falls and Injuries Due to Falls dated 3/7/02, states in part, Swimming noodles as artificial side rails-but fire hazard. To be noted, the document had an asterisk next to this sentence. Avoiding Restraints in Patients with Dementia dated 3/2008 by the American Journal of Nursing (AJN), states in part, Bed bumpers (a concave mattress, or a swimming pool noodle or rolled blankets placed under the edge of the mattress) can be used to demarcate the bed perimeter. Example 1 Resident 5's [DIAGNOSES REDACTED]. Resident 5's initial care plan: Fall precautions dated 1/23/12, states in part, Noodles on edge of bed. Resident 5's care plan: Self -Transferring from bed dated 6/27/12, states in part, Noodle to exit side of bed. Resident 5's care plan: At Risk for Falls dated 1/15/16, states in part, Low bed with mat, Noodle. On 3/7/16 at 9:40 AM, Surveyor interviewed Licensed Practical Nurse (LPN) D regarding Resident 5's assessment for the noodle device. LPN D indicated that the facility will care plan the noodle that is used to prevent more falls. LPN D stated, There is not a consent or assessment filled out for the noodle. On 3/7/16 at 5:00 PM, during the end of the day meeting with the facility, Surveyor asked Registered Nurse (RN) C if there was an assessment for the noodle device. RN C stated, We do not assess the noodles, they are not a restraint- we know they are not, we just know they are not. On 3/8/16 at 1:20 PM, Surveyor interviewed Certified Nursing Assistant (CNA) F regarding Resident 5 and the use for the noodle. CNA F stated, We put it in her bed so she does not roll out. There was no evidence of a comprehensive assessment for the noodle intervention as a fall device in Resident 5's medical record. Example 2 Resident 6's [DIAGNOSES REDACTED]. Resident 6's care plan: At Risk for Falls dated 10/16/15, states in part, Left side of bed noodle. On 3/7/16 at 9:40 AM, Surveyor interviewed Licensed Practical Nurse (LPN) D regarding Resident 6's assessment for the noodle device. LPN D indicated that the facility will care plan the noodle that is used to prevent more falls. LPN D stated, There is not a consent or assessment filled out for the noodle. There was no evidence of a comprehensive assessment for the noodle intervention as a fall device in Resident 6's medical record. Example 3 Resident 2 was admitted to the facility on [DATE]. Resident 2's [DIAGNOSES REDACTED]. Resident 2's Short-Term Care Plan/Self Transferring, Fall Risk, dated 1/22/16, includes, in part, the following intervention: noodles exit side. It is important to know an assessment for the fall prevention device, noodle, could not be found in Resident 2's medical record. On 3/8/16 at 9:05 AM Surveyor interviewed Certified Nursing Assistant (CNA) J. CNA J stated the noodle is put under Resident 2's bottom sheet on top of the mattress on the exit side of the bed when Resident 2 is in the bed. On 3/8/16 at 9:15 AM Surveyor interviewed Registered Nurse (RN) H. RN H stated the noodle used as a fall prevention device for Resident 2 is not assessed. Example 4 Resident 15 was most recently admitted to the facility on [DATE]. Resident 15's [DIAGNOSES REDACTED]. Resident 15's Short-Term Care Plan/Fall/Rolled out of bed, dated 2/27/16, includes, in part, the following intervention: Use body pillow when positioning resident to help prevent rolling out of bed. Resident 15's Short-Term Care Plan/Recent Falls, dated 2/9/15, includes, in part, the following intervention: Moxi-mattress. It is important to know that a moxi-mattress has 4 built in bolsters, one on each corner edge. On 3/8/16 at 9:35 AM Surveyor interviewed Certified Nursing Assistant (CNA) J. CNA J stated the bolstered mattress and the body pillow are used to help Resident 15 to not fall out of bed. On 3/8/16 at 9:50 AM Surveyor interviewed Registered Nurse (RN) H. RN H stated there is no assessment for the moxi-mattress or the body pillow for Resident 15 because the devices are not restraints. Example 5 Resident 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 7's quarterly MDS (Minimum Data Set) assessment dated [DATE] shows a BIMS (Brief Interview for Mental Status) score of 10 indicating mild cognitive impairment. Resident CAA (Care Area Assessment) Safety Risk notes Goal: Will have no falls incident, Will have no injury, See safety approaches , spend 1:1 time if anxious or depressed. Resident 7's Care Approaches/Preferences dated 10/27/15, under Safety notes that Resident 7 is at high risk for falls, interventions include: Low bed with landing mat, Noodles, Body pillow . remind to use call light, reorient as needed .15 minute checks. Resident 7's Care Plan dated 12/22/15 notes: confusion at times, wanting to exit from bed .swing legs over edge of bed, Goal: No injury or falls out of bed . On 3/2/16 at 10:00 AM while observing cares, Surveyor observed Resident 7 in bed with foam noodles placed under the bottom sheet, on top of the mattress, on the right and left edge of her mattress. Surveyor asked RN (Registered Nurse) L what are the noodles used for on Resident 7's bed, RN L stated that the noodles are for fall prevention. On 3/8/16 at 1:30 PM Surveyor interviewed asking if Resident 7 could remove the noodles from her bed if she wished, RN L stated that Resident 7 had enough functional arm movement that she could remove the noodles from under the sheet if she wished to and could roll over the noodle to get out of bed if she wished to. Surveyor requested a device assessment for Resident 7's use of the noodles, no further information besides Resident 7's Care Plan and Care Area Assessment was provided. There was no evidence that the facility assessed the current necessity or benefit of the placement of the noodles to Resident 7's bed.

Based on record review and interview, in 6 of 20 total residents reviewed (Residents 3, 5, 6, 17, 11 and 15) the facility did not ensure each resident's drug regimen was free from unnecessary drugs. In addition, the facility did not ensure residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Resident 3 receives [MEDICATION NAME] (antipsychotic). The facility did not attempt a timely gradual dose reduction. Resident 5 receives [MEDICATION NAME] (anti-depressant) the facility did not complete a written consent for this [MEDICAL CONDITION] medication. Resident 6 receives [MEDICATION NAME] (anticonvulsant) the facility did not review the written consent for this [MEDICAL CONDITION] medication. Resident 17 receives [MEDICATION NAME] (anti-depressant) the consent for this medication was undated. Resident 11's [MEDICAL CONDITION] medication consent for [MEDICATION NAME] was not signed by a facility staff member and was not dated. Resident 15 has been taking [MEDICATION NAME] HCL 10 mg daily for depression since his admission over a year prior to this review. The facility did not ensure he received a gradual dose reduction or have a documented contraindication for not receiving a gradual dose reduction. This is evidenced by the following: Example 1 Resident 3's [DIAGNOSES REDACTED]. Resident 3's current physician orders [REDACTED]. Resident 3's most current Psychiatry note dated 10/29/13 states: "... With the amount of things that (Resident 3 is) responding to (internal stimuli), cannot consider (reduction) [MEDICATION NAME]. Would (increase) except for some appearance of sedation." Resident 3's PCP (Primary Care Physician) progress notes for 5/10/14, 7/5/14, 8/27/14, 10/22/14, and 12/17/14 all indicate Resident 3's psychiatric medications are managed by Psychiatry. Resident 3's [MEDICATION NAME] use and potential reduction was not addressed at all in 2014. On 1/27/15 at approximately 1:30 pm Surveyor spoke with LPN (Licensed Practice Nurse) D regarding Resident 3's use of [MEDICATION NAME] and GDRs (gradual dose reductions) or justification for continued use of [MEDICATION NAME] at the current dose. LPN D was unable to find any psychiatry notes in Resident 3's record and contacted the medical records department to provide the most recent psychiatry note (noted above from 10/29/13). On 1/27/15 at approximately 4:30m (daily exit meeting) Surveyor spoke with DON (Director of Nursing) B regarding concerns about Resident 3 [MEDICATION NAME] use and the lack of documentation regarding continued use at the current dose or GDRs. DON B noted the concern and would follow up with Surveyor . On 1/27/15 Resident 3's record documents an order to decrease the use of [MEDICATION NAME] to 175 mg daily at hs. Example 2 Resident 11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 11's current physician orders [REDACTED]. This medication was increased on 1/27/15 to 150 mg in the morning and 200 mg at hour of sleep. Resident 11's informed consent form for [MEDICATION NAME] indicates an anticipated dosage range of 100-300 mg. The consent form does not include a name of a staff member who was present at the discussion of the medication. There is no date to indicate when the form was signed by Resident 11's power of attorney for health care. On 1/28/15, at 7:58 AM, Surveyor interviewed Registered Nursing Manager (RN) M. RN M stated the Social Worker typically reviews the consents for medications on admission then nursing does them yearly or for new medications. RN M confirmed there is no date or indication when the consent for the [MEDICATION NAME] was last reviewed. RN M also acknowledged a new consent should have been obtained the previous day when the medication was increased above the anticipated dosage. RN M stated she will get an updated consent immediately. Example 3 Resident 5 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Resident 5's Physician order [REDACTED]. The facility records did not include a written consent for this [MEDICAL CONDITION] medication. On 1/28/15, Surveyor interviewed Registered Nurse (RN) C regarding the facility policy and procedure for [MEDICAL CONDITION] medications. RN C stated that prior to administering [MEDICAL CONDITION] medications the facility obtains verbal consent then a written consent form is either signed by the resident or the resident's family member. Surveyor asked RN C if Resident 5 should have had a written consent for [MEDICATION NAME] RN C stated Resident 5 should have a written consent. Example 4 Resident 6 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Resident 6's Physician order [REDACTED]. Resident 6's consent for [MEDICATION NAME] had not been reviewed since 2012. On 1/28/15, Surveyor interviewed Registered Nurse (RN) C regarding reviewing written consents for [MEDICAL CONDITION] medications. RN C stated that she was not aware that the facility needed a written consent for [MEDICATION NAME]. Example 5 Resident 17 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Resident 17's Physician order [REDACTED]. Resident 17 had a signed consent for this [MEDICAL CONDITION] medication, but the consent was not dated by the nurse or the activated health care power of attorney. Surveyor interviewed Registered Nurse (RN) L regarding written consents for [MEDICAL CONDITION] medications. RN L stated that the consents should have been dated. Example 6 Resident 15 has [DIAGNOSES REDACTED]. His most recent Minimum Data Set completed 12/17/14 indicates he has severe cognitive impairment. Resident 15's physician orders [REDACTED]. It is important to note that he has not received a gradual dose reduction since his admission about 15 months ago. Resident 15's medical record includes a note from his physician on 12/17/14 that states he has dementia and to continue the [MEDICATION NAME] but does not include an explanation that a reduction would be contraindicated for Resident 15.

Based on observation, interview and record review the facility did not provide services in accordance with each resident's written plan of care for 4 of 17 residents (Residents 10, 11, 9, and 3). Resident 10 did not receive thickened coffee or a magic cup as per the plan of care. Resident 11 did not have nonskid socks on as per the plan of care. Resident 9 was not assisted to lie in bed after lunch to position her off her buttocks per her care plan. Resident 3's care plan instructs staff to use a nosey cup when assisting him with fluids. Observations were made when this care planned intervention was not followed. This is evidenced by the following: Example 1 Resident 10's care plan, updated 1/8/15, includes the concern area of potential for alteration in nutrition. Approaches include nectar thick liquids and a Magic cup (supplement) at lunch and supper. On 1/26/15, at 12:49 PM, Surveyor observed Resident 10 being served lunch. Surveyor noted Resident 10's dietary card sitting at the table indicated nectar thick liquids and Magic cup at lunch and supper. Resident 10 did not have a Magic cup. Resident 10 was also drinking coffee that did not appear to be thickened. On 1/26/15, at 1:28 PM, Surveyor interviewed Certified Nursing Assistant (CNA) O. CNA O and Surveyor noted the consistency of Resident 10's coffee. Resident 10 had drunk about 50% of the coffee at this point. CNA O stated it did not appear to be nectar thick. Surveyor noted it to be thin. CNA O stated she could not remember if she thickened the coffee but probably did not. Resident 10 did not receive the Magic cup at the lunch meal. On 1/27/15, at 12:25 PM, Surveyor observed Resident 10 in the dining room for lunch. Resident 10 did not have a Magic cup but other residents did prior to the meal being served. Surveyor interviewed CNA N who stated the CNAs give out supplements with meals including Magic cups. At 12:53 PM, Resident 10 was served his meal and was not served a Magic cup. Surveyor again interviewed CNA N. CNA N stated all the residents had been served everything for their lunch. Surveyor then asked CNA N to note the consistency of Resident 10's coffee. CNA N stated she thought the coffee was thickened. Surveyor then asked Licensed Practical Nurse (LPN) P if Resident 10's coffee was nectar thick. LPN P stated there is some thickener in it but it is not thick enough for nectar consistency. CNA O then stated she thickened it with the nectar thick milk. Surveyor asked if she felt that would make the coffee nectar thick and she replied no. Then CNA O stated she had put Resident 10's Magic cup in the freezer and was going to give it to him. CNA O gave Resident 10 the Magic cup and he began eating it. Note Resident 10 only ate bites of his meal. On 1/28/15, at 8:02 AM, Surveyor interviewed Registered Nursing Manager (RN) M. RN M stated Resident 10 is to have nectar thick liquids including coffee. On 1/28/15, at 9:30 AM, Surveyor interviewed Dietary Manager (DM) Q. DM Q stated the Magic cups were added to Resident 10's care plan on 1/8/15 due to his risk for weight loss. DM Q stated the Magic cups are sent up on the beverage cart and the CNAs should be giving it to Resident 10 at lunch and supper. Example 2 Resident 11's care plan was updated on 12/18/14 and includes: Nonskid socks to be worn at all times and with shoes, so if resident removes shoes he will stiff have nonskid socks on. On 1/27/15, at 7:37 AM, Surveyor observed Resident 11 awake in the recliner in the day room. Resident 11's shoes were not on, and were not in site. Resident 11 had regular socks, not nonskid socks on. On 1/28/15, at 1:08 PM, Surveyor observed Resident 11 sleeping in the recliner in the day room. Resident 11 had one shoe off. Resident 11 was wearing regular, not nonskid socks. Surveyor interviewed Certified Nursing Assistant (CNA) N. CNA N stated Resident 11 only wears nonskid socks at night or if he is up in his wheelchair and does not have on shoes. On 1/28/15, at 1:15 PM, Surveyor interviewed Registered Nurse Manager (RN) M. RN M stated Resident 11 is to have nonskid socks on at all times even during the day as he kicks his shoes off at times. Example 3 Resident 3's [DIAGNOSES REDACTED]. Resident 3's most current MDS (Minimum Data Set) with an end observation date of 11/19/14 documents that Resident 3 is on a therapeutic mechanically altered diet and needs extensive assistance with oral intake. Resident 3's comprehensive care plan addresses the topic of "Self Care Deficit" (dated 6/4/11). Interventions to this care plan problem include: "11/26/14... Feeding: 1 assist, use short / small nose cups..." In addition, Resident 3's comprehensive care plan addresses the topic of "Potential for alteration in nutrition due to advanced dementia" (dated 2/15/13). Interventions to this care plan problem include: "4/9/13... Adaptive equip. (equipment): small nosey cups..." A nosey cup is a cup with a cut out on the non - drinking side. This allows the cup to be tilted up without interference by the nose. This helps maintain a proper position of the head and neck when swallowing, thus making drinking easier. On 1/26/15 at 12:32 pm Surveyor observed CNA (Certified Nursing Assistant) E assist Resident 3 with his lunch water provided in a small paper cup. On 1/27/15 at 8:51 am Surveyor observed CNA F assist Resident 3 with his breakfast fluids which included water and supplemental shakes. These fluids were provided in small paper cups. On 1/28/15 at 8:55 am Surveyor observed LPN (Licensed Practice Nurse) D assist Resident 3 with his breakfast fluids which included supplemental shakes. These shakes were provided in small paper cups. Nosey cups were noted on the table in front of Resident 3, however they were not used. On 1/28/15 at 9:14 am CNA F takes over for LPN D in assisting Resident 3 with his breakfast. CNA F continues to assist Resident 3 with his breakfast fluids provided in a small paper cup. Resident 3's diet card directs staff to use nosey cups when assisting him with fluids. On 1/28/15 at 12:55 pm Surveyor spoke with LPN D regarding Resident 3's use of nosey cups. LPN D stated that "sometimes" a nosey cup is used with Resident 3, but stated: "I just use the Dixie cup." Surveyor asked LPN D why she uses the Dixie cup. LPN D stated: "No special reason." On 1/28/15 at 1:00 pm Surveyor spoke with CNA E regarding Resident 3's use of a nosey cup versus a paper cup. CNA E stated she thinks Resident 3 drinks better with the use of a paper cup. On 1/28/15 at 1:07 pm Surveyor spoke with CNA F regarding Resident 3's use of a nosey cup versus a paper cup. CNA F stated it is easier for Resident 3 when a paper cup is used instead of a nosey cup. Example 4 Resident 9 has [DIAGNOSES REDACTED]. Her care plan printed 1/26/15 states she is at risk for impaired skin integrity. It includes the intervention to "Lay resident (9) down in bed positioned off buttocks for at least 2 hours after lunch daily" unless a special event is scheduled. On 1/26/15 at 2:55 PM Surveyor observed Resident 9 sleeping with her torso at a 45 degree angle in her recliner. At 3:40 PM Surveyor observed CNA J and CNA I transfer Resident 9 from her recliner into her wheelchair. Surveyor questioned CNA I who stated Resident 9 had been transferred to her recliner today after lunch. CNA I explained that sometimes they transfer her to bed and sometimes to the recliner. On 1/28/15 at 12:15 PM Surveyor interviewed Director of Nursing B who agreed she would expect residents care plans to be followed by staff.

Based on observation, interview and record review the facility did not ensure that a resident who has a pressure ulcer receives necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing for 1 of 8 residents reviewed for pressure ulcers (Resident 15). Resident 15's dressing over his open area was observed to have fallen off by CNA G and CNA H and they did not immediately notify the nurse. Evidenced by: Resident 15 has [DIAGNOSES REDACTED]. His most recent Minimum Data Set completed 12/17/14 indicates he has severe cognitive impairment. Resident 15's nurses notes state he acquired a Stage 3 pressure ulcer on his right ischial tuberosity described as partial thickness loss of skin layers, 20% Slough, and measured 5 cm length and 1.3 cm width on 12/2/14. The most recent note dated 1/21/14 describes that the wound is "becoming smaller and appears more clean granulation (sic)" and measures 1.6 cm length and 1.1 cm width. On 1/28/15 at 8:30 AM Surveyor CNA G and CNA H assist Resident 15 with cares. During the cares Surveyor asked if Resident 15 had a dressing over his open area and CNA H said it was not in place. CNA H confirmed that the open area is usually covered with a dressing. CNA G looked in Resident 15's brief that had urine and feces in it and did not see the dressing. When Resident 15 was transferred CNA G observed the dressing in his bed. CNA G and CNA H finished assisting Resident 15 into a clean brief then into his wheelchair, complete hygiene, and he was assisted to the dining room for breakfast. CNA G did explain that he would receive a bath right after breakfast. CNA G and CNA H did not attempt to tell the nurse LPN K that his open area was not covered with a dressing prior to taking him to the dining room. Resident 15 was assisted into the bath room to receive a bath at 9:55 AM. At 9:56 AM Surveyor questioned LPN K who stated that she had been informed that Resident 15's dressing had come off. On 1/28/15 at 12:15 PM Surveyor interviewed Director of Nursing (DON) B who stated that if a CNA found that a resident's dressing over an open area had come off she would expect the staff to notify the nurse while they were still giving cares in the room. DON B agreed CNA G and CNA H should have informed the nurse right away when they noticed Resident 15's dressing had come off. On 1/28/15 at 1:45 PM Surveyor interviewed the Wound Nurse R who stated an open area that should be covered to hold moisture in and could be open to infection if not covered.

Based on observation, interview and record review, the facility did not provide medically related social services to attain or maintain the highest practicable psychosocial well-being of 1 (Resident 2) of 21 residents reviewed. Resident 2 experienced disturbing hallucinations and was not scheduled for a psychiatry consult as ordered by her physician. Assessments and interventions by the social worker were also not adequately documented in the medical record. This is evidenced by: Resident 2 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED].) Resident 2's Quarterly Minimum Data Set (MDS) assessment dated [DATE] lists a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicates no cognitive impairment. On [DATE] at 3:00 PM, Surveyor introduced self to Resident 2 and asked her how she was doing. Resident 2 stated that there is a man that needs to be killed. Resident 2 stated that there was a massacre this morning and that her daughter-in-law was killed. Resident 2 stated that if she gets too close to the man he will "cut her head off." Resident 2 was speaking quietly and was not visibly distressed by these comments. On [DATE] at 8:30 AM, Surveyor observed Resident 2 at breakfast. On [DATE] at 12:35 PM, Surveyor observed Resident 2 at lunch. On [DATE] at 1:10 PM, Surveyor observed Resident 2 while she was being transferred from her wheelchair to the bed. On all occasions, Resident 2 was quiet and calm. Resident 2 was not observed to make disturbing statements to her peers or to the staff assisting her. Resident 2 was able to make her needs known when asked but did not speak unless spoken to and then spoke very quietly. Resident 2 did not appear distressed during these observations and appeared to function normally. On [DATE] at 8 AM, Surveyor observed Resident 2 in her wheelchair in the doorway to her room. Surveyor asked Resident 2 "How are you?" Resident 2 stated that there is a man who needs to be killed and cut up for what he has done. Resident 2 was speaking quietly and did not appear visibly distressed. When asked if she wanted to talk to the nurse about the man, Resident 2 stated that the nurse would just tell her that there is no man. A review of Resident 2's nursing notes for November and [DATE] indicates the following: [DATE] 2:28 PM - "upset this am, stating 'my brother billy died at 8:00 this morning'. resident caled (sic) daughter and was reassured..." [DATE] 01:48 PM - "talking about hearing 'the man' and is fearful. 1:1 and redirected." [DATE] 02:05 PM - "confused today. thinks family is being held hostage. difficult to redirect..." [DATE] 11:00 PM - "Resident talking a lot about 'the man' this evening. Resident thought 'the man' threw someone in the lake...Spent much one on one with resident, unable to redirect." [DATE] 02:59 PM - "states the man is back and going to shoot my daughters eyes out." 10:23 PM - "Spoke with social services regarding need for psych eval consent form. Order received from PMD (Primary Doctor) for psych eval, consent needed." 10:27 PM "This evening resident concerned about 'the man' asking about daughter and daughter-in-law. At one point resident stated 'that man is trying to rape my daughter, can't you hear that?' Staff able to redirect resident..." [DATE] 02:38 PM - "continues to have hallucinations. looking for daughter...sitting out in hallway stopping staff and peers wanting police called, that man raped my daughter..." 02:17 PM "(Resident 2) stopped me in the hallway and asked me to call the police...(Resident 2) said 'They need to come and get that guy. I think he is upstairs now...." 02:48 PM "resident continues with hallucinations 'that man is doing something to my daughter, what's wrong w/ you people'. difficult to redirect. resident called 911 from her phone. social services informed and came to speak with resident..." [DATE] 10:26 PM - "CNA (Certified Nursing Assistant) reported resident was talking about 'the man' and that he was 'going to get my daughter-in-law'..." Resident 2 has a Physician Telephone Order in her medical record dated [DATE] which states: "psych eval Dx (diagnosis) delusions (arrow) Parkinsonian?" There is no psychiatric evaluation or consult in the medical record. On [DATE] at 8:40 AM, Surveyor interviewed Unit Manager RN (Registered Nurse) L. RN L stated that Resident 2 has a [DIAGNOSES REDACTED]. RN L stated that Resident 2 is now back on Seroquel. (Note: There is a physician order [REDACTED].) RN L stated that the Social Worker (SW M) is called whenever Resident 2 has delusional thoughts and can't be redirected. RN L stated that she did not know if there was a psychiatric consult or evaluation for Resident 2 in the record and stated she would find out. On [DATE] at 10:40 AM, RN L followed up with Surveyor . RN L stated that Resident 2 was on the October (2013) list to be seen by (name of psychiatrist) MD O in October. RN L stated she does not know why Resident 2 was not seen. RN L stated that maybe MD O was too busy that day. On [DATE], Surveyor spoke with Social Worker (SW) M. SW M stated that Resident 2 has had a recent progression to more "significant" statements. SW M stated that in the past when Resident 2 has spoken of 'the man' it has been a presence off in the distance. When Surveyor described Resident 2's comments of ,[DATE] and ,[DATE], SW M stated that those comments are more violent than comments that he has heard Resident 2 make. SW M stated that he meets with Resident 2 frequently. SW M stated that there was a recent period where he met with Resident 2 daily for ,[DATE] days per week. SW M stated that for example, on one occasion, Resident 2 was worried that "the man" was coming back at 3 PM so SW M met with Resident 2 at 3 PM to sit with her and reassure her. Surveyor asked if any of these meetings with Resident 2 were documented in the medical record. SW M stated that he usually only documents quarterly and annual assessments and does not document day to day visits. (Note: the last Social Services Note on Record for Resident 2 was a Quarterly Review dated [DATE].) SW M stated that SW N makes the schedule for the psychiatrist MD O. SW M stated that when a psych eval was ordered in August, he thinks he remembers that Resident 2 refused it. SW M stated he does not know if this refusal is documented (Note: Surveyor could not find documentation related to any refusals of treatment.) SW M stated that Resident 2 currently makes her own decisions and does not have an activated power of attorney (POA). SW M stated that perhaps MD O would be able to provide some perspective on whether the POA needs to be activated (if/when Resident 2 has a psychiatric evaluation done by MD O.) SW M stated that MD O is in the building doing evaluations 1 time per month. On [DATE] at 1:20 PM, Surveyor interviewed Licensed Practical Nurse (LPN) E who is the nurse who works on the day shift on Resident 2's unit. LPN E stated that there was a period where Resident 2 was very upset and unable to be redirected and had even called 911. LPN E stated that Resident 2 was very upset in this period because her daughter was being hurt and we were not doing anything. LPN E stated that SW M was informed of these behaviors and he was aware that they were extreme behaviors because he had to call Resident 2's daughter after the 911 call (which occurred on [DATE] per nursing notes.) LPN E stated that she knows "we had orders for psych" and we couldn't figure out why a psych eval was not done. LPN E stated that she feels that the behaviors have improved since the increase in Seroquel earlier this month. A review of Social Service Notes shows the last entry for Resident 2 was a quarterly review on [DATE]. This note states in part "...Of significant concern as of late is the fact that (Resident 2) has been reporting having seen things that are not there...(Resident 2) continues to report a "man" wanting to meet with her...although she is not afraid of him...No new referrals are needed at this time." There are no social service notes after this date in regards to the period documented in the nursing notes ,[DATE] to ,[DATE] when Resident 2 was noted to be distressed (and in fact called 911 at one point) even though Social Services was noted to be involved at that time and making frequent visits to Resident 2. No efforts to schedule a psych evaluation as per the doctor's order were noted. On [DATE] at 2:15 PM, Surveyor interviewed the Social Work Supervisor (SW) N. SW N stated that when we (the Social Services Department) get a physician order [REDACTED]. SW N stated that MD O comes one time per month. SW N stated that MD O cannot see all of the residents on the list for that month because there is not time. SW N stated that they have to prioritize which residents need to be seen most. SW N stated that they could do consults over the phone with MD O if a resident has an acute episode between MD O's visits. SW N stated that Resident 2's doctor was handling medication changes. SW N stated that MD O was last here on [DATE] and did not see Resident 2 as she was not a high priority. SW N stated that MD O is scheduled again on [DATE]. When asked if Resident 2 would be seen, SW N stated that she would only be given priority if the hallucinations are affecting her (Resident 2's) ability to function or if nursing staff let her know that there are current problems. Residents with physician orders [REDACTED]. Thus, the [DATE] order for a psych eval for Resident 2 had not been completed yet on [DATE]. SW N stated that she would expect SW M to document the acute changes that occurred for Resident 2 in the period from ,[DATE] to ,[DATE] if those interactions were out of the ordinary. Even though Resident 2 had acute changes and had periods of fearfulness related to her hallucinations, a psych evaluation was not set up or prioritized in the facility's current system. Even though Resident 2 currently does not show visible signs of distress, her current comments continue to be of a nature that would cause a reasonable person some distress. These behaviors have not been fully evaluated in the social service charting and no plan has been set up for a psychiatric work-up in the facility's current process.

Based on observation, interview and record review the facility did not provide or arrange services by qualified persons in accordance with each resident's written plan of care for 3 of 21 residents (Residents 11, 7 and 2). Resident 11's calf was not elevated off of surfaces as directed in her plan of care. Resident 7 did not have a rubber mat in place for meals as indicated in the plan of care. Resident 2 has a physician order [REDACTED]. This is evidenced by the following: Example 1 Resident 11 was readmitted to the facility on [DATE] with multiple health issues including a recent fracture in her left leg. Resident 11 had a short term care plan developed on 11/5/13 to address the open area on the back of her left calf. The interventions include: Off load open area to left calf. Position calf board on wheelchair foot rests, put pressure relief boot on left foot, check to make sure open area on left calf is free of any pressure. When in bed Resident 11 needs a pillow above and below open area on the backs of left calf so there is no pressure on the open area. On 12/12/13, at 8:12 AM, Surveyor observed Certified Nursing Assistant (CNA) F assist Resident 11 with morning cares. Resident 11's left leg was directly on the mattress when Surveyor and CNA F entered the room. On 12/12/13, at 8:44 AM, Surveyor observed Resident 11 in her wheelchair in the dining room. Resident 11's wheelchair leg rests had a padded calf board and a wheelchair seat cushion on top of the calf board. Resident 11 had a boot on her left foot however her left calf was resting directly on the wheelchair seat cushion. On 12/12/13, at 12:33 PM, Surveyor again observed Resident 11 in the dining room. Again Resident 11's foot rests had the padded calf board with the wheelchair cushion on top and her left calf resting on the cushion. At 1:53 PM, CNA F and CNA G assisted Resident 11 into bed. CNA F offered to place a pillow under Resident 11's feet and Resident 11 refused. Resident 11 was wearing the boot on the left foot in bed. At 2:18 PM, Surveyor observed Licensed Practical Nurse (LPN) H complete the treatment to Resident 11's wounds. Upon completion of the treatments LPN H replaced the boot on the left foot. Resident 11's left calf was directly on the mattress. LPN H did not offer or attempt to float Resident 11's left calf off the mattress. On 12/17/13, at 2:50 PM, Surveyor interviewed Wound Nurse C and Physical Therapist (PT) I regarding Resident 11. Wound Nurse C stated per Resident 11's care plan Resident 11's heels should be floated and a boot on the left foot to relieve pressure on her calf. PT I stated the wheelchair cushion on the leg rests is one Resident 11's spouse brought in from home and she was not sure of what type of cushion it was. PT I stated Resident 11's spouse keeps putting the cushion on the wheelchair in the afternoons when visiting and the staff do remove it when he is not present. PT I stated she educated the spouse not to do so; however there was no documentation of this education. PT I confirmed Resident 11 should only be using the padded calf board and boot not the wheelchair cushion so there is no pressure where the wounds are. Resident 11's spouse was not in the facility at the time of Surveyor 's observations. Example 2 Resident 7's plan of care for nutrition, with a goal date of 3/14, states the following: Adaptive equip: lipped plate, rubber mat, covered cups and glasses. Resident 7's dietary card states, Lipped Plate, Rubber Mat, Covered Cups and Glasses. On 12/12/13 at 8:20 AM, Surveyor observed Resident 7 sitting in the dining room for breakfast. Surveyor noted that Resident 7's plate was on a plain paper placemat, and Resident 7's beverages were in uncovered cups. On 12/17/13 at 8:20 AM, Surveyor observed Resident 7 sitting at the table for breakfast. Surveyor observed Resident 7's plate on a paper place mat. On 12/18/13 at 8:55 AM, Surveyor observed Resident 7 eating breakfast. Resident 7's plate was on a plain paper placemat. On 12/18/13 at 9:05 AM, Surveyor asked AA (Activity Aid) K, who was assisting in the dining room what the rubber mat was on Resident 7's dietary card and if the rubber mat should be in place. AA K stated," The rubber mat is here in the drawer and should be in under Resident 7's plate." Surveyor observed AA K place the rubber mat under Resident 7's place. On 12/18/13 at 9:15 AM, Surveyor interviewed RN/ UM (Registered Nurse/Unit Manager) J regarding if the rubber mat should be in place for Resident 7. RN/UM J stated, "If the care plan says for rubber mat it should be in place." Example 3: Resident 2 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED].) Resident 2 has a Physician Telephone Order in her medical record dated 8/17/13 which states: "psych eval Dx (diagnosis) [MEDICAL CONDITION] (arrow) Parkinsonian?" There is no psychiatric evaluation or consult in the medical record. On 12/18/13 at 8:40 AM, Surveyor interviewed Unit Manager RN (Registered Nurse) L regarding the physician order [REDACTED]. On 12/18/13 at 10:40 AM, RN L followed up with Surveyor . RN L stated that Resident 2 was on the October (2013) list to be seen by (name of psychiatrist) MD O. RN L stated she does not know why Resident 2 was not seen. RN L stated that maybe MD O was too busy that day. On 12/18/13, Surveyor spoke with Social Worker (SW) M regarding Resident 2's recent history with hallucinations (cross-reference F250) and the physician order [REDACTED]. SW M stated he does not know if this refusal is documented (Note: Surveyor could not find documentation related to any refusals of treatment.) SW M stated that MD O is in the building doing evaluations 1 time per month. On 12/18/13 at 2:15 PM, Surveyor interviewed the Social Work Supervisor (SW) N. SW N stated that when we (the Social Services Department) get a physician order [REDACTED]. SW N stated that MD O cannot see all of the residents on the list for that month because there is not time. SW N stated that they have to prioritize which residents need to be seen most. SW N stated that MD O was last here on 11/28/13 and did not see Resident 2 as she was not a high priority. SW N stated that MD O is scheduled again on 12/31/13. When asked if Resident 2 would be seen, SW N stated that she would only be given priority if the hallucinations are affecting her (Resident 2's) ability to function or if nursing staff let her know that there are current problems. Residents with physician orders [REDACTED]. Thus, the 8/17/13 order for a psych eval for Resident 2 had not been completed yet on 12/18/13.