Every finding on record at Cornell Health Services

Based on observation and interview, the facility did not store and follow proper sanitation and food handling practices to prevent foodborne illnesses for 41 residents who consume food out of 41 residents who reside at facility. The facility:-Did not ensure food in dry storage was properly stored in containers after opened and exposed to air and was not dated when opened.-Did not ensure all foods in resident refrigerator in common area was labeled and dated when opened for a possible 5 residents (R3, R17, R18, R19, R27).-Did not ensure juices and milk were dated when opened in resident dining room refrigerator.-Did not ensure food was a minimum of 6 inches off the floor in walk in freezer.-Did not ensure dietary staff properly contained hair within hair nets.-Did not ensure dietary staff did not directly handle food with bare hands.-Did not ensure temping of foods was done in a sanitary manner by wiping thermometers with alcohol prior to inserting into food. Findings:The facility policies, titled Food: Preparation and Food Storage, and Safe Handling for Foods from Visitors, state, Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination.All food items will be stored 6 inches above the floor.All foods will be stored, wrapped or in covered containers, labeled and dated.Residents will be assisted in properly storing and safely consuming food brought into the facility for residents by visitors.Label foods with the resident name and the current date.Daily monitoring for refrigerated storage duration and discard of any food items that have been stored for greater than 7 days.On 07/13/2026 at 6:00 AM, Surveyor observed a resident refrigerator/freezer in common area with the following:-A jar of pickles with R27's initials and not labeled with an opened date-A jar of opened olives not labeled with a resident name or opened date-An opened package of swiss cheese slices not labeled with a resident name or opened date-A clear plastic container with pasta and unknown sauce without a resident name or opened date-A partial container of ice cream with R3's initials and not labeled with an opened date in freezer-A partial box of popsicles and a container of ice cream, both labeled with a last name only that match 3 residents (R17, R18, R19) who share same last name, in freezer without an opened date. -Signage on outside refrigerator door informing staff to check refrigerator daily and to label and date all foods brought in for residents by family/visitors. On 07/13/2026 at 6:03 AM, Surveyor observed during an initial tour of facility kitchen:-A opened bag of butterscotch chips that was exposed to air and not labeled with opened date in dry food storage area-A partial opened box of pancake mix not labeled with opened date in dry food storage area-A partial bag of dried cranberries with an open date of 03/22/2026 in dry food storage area-A cardboard box containing 2 unopened bags of frozen vegetable blend on the floor of the walk-in freezerOn 07/13/2026 at 6:23 AM, Surveyor observed the following in refrigerator in resident dining room:-An opened and partial gallon jug of white milk not labeled with opened or to use by dates-A pitcher of orange juice not labeled with opened or to use by dates-Individual containers of prune juice with no expiration datesOn 07/13/2026 at 8:19 AM and at 8:25 AM, Surveyor observed dietary cook (DC) D grab a slice of bread out of a bread bag with bare hands and place on a resident's plate. On 07/13/2026 at 8:20 AM, Surveyor observed dietary manager (DM) C, DC D and dietary aide (DA) F to all have several strands of hair protruding arounds sides and back of hair nets. DC D had 2 strands of loose, unattached hair observed on back of shirt. On 07/13/2026 at 12:00 PM, during Surveyor's observation of temperature checks on lunch foods in steamer table, DC D cleaned thermometer probe with alcohol wipe, placed probe onto counter surface, then picked probe up and inserted into food without cleaning probe again. Surveyor observed DC D repeat this action three times. On 07/14/2026 at 7:17 AM, Surveyor observed the refrigerator in resident dining room to have an opened, partial gallon jug of milk with no opened date. Surveyor also observed an unopened gallon of chocolate milk with expiration date of 07/13/2026. On 07/14/2026 at 7:49 AM, Surveyor asked DM C what the facility policy was for storage of all foods. DM C stated all foods needed to be labeled with a date when food was opened and dated for food to be used by. DM C confirmed the bag of butterscotch chips was exposed to air and should have been transferred to a covered container and labeled with opened date. DM C stated all foods needed to be at least 6 inches off of the floor and foods needed to be checked often for expiration dates. DM C confirmed food thermometers needed to be cleaned with alcohol prior to, in-between and after temping all foods and should not touch any other surfaces before being inserted into foods. DM C stated staff should have hair contained within hair nets and the facility hair nets were not optimal for long hair. DM C stated it was the floor and nursing staff's responsibility to check both the resident refrigerator in the common area and dining area for foods to be labeled, dated and disposed of. On 07/14/2026 at 10:40 AM, Surveyor asked Director of Nursing (DON) B whose responsibility it was at the facility for monitoring, labelling, dating and disposing of foods brought in by visitors for residents. DON B stated it was floor staff's responsibility to label any foods brought in by family/visitors for residents with the residents' name and date when brought in. DON B stated after 3 days of date, any food left in refrigerator is disposed of by staff. DON B confirmed there was more than one resident with same last name residing at the facility.

Based on observation, interview and record review, the facility did not ensure residents are free of any significant medication errors for one resident (R47) of 3 residents observed during medication administration in a sample of 13 residents. The facility failed to implement safe medication administration measures which include checking correct timing of a PRN (as needed) medication that could have led to an accidental overdose of a narcotic medication to R47 by giving it 2 hours early according to physician orders.Findings: The facility policy, titled Medication Administration General Guidelines, dated 01/2026, states, Verify medication is correct three (3) times before administering the medication; when pulling medication package from cart, when dose is prepared, and before dose is administered.the individual who administers the medication dose, records the administration on the resident's MAR (Medication Administration Record) immediately following the medication being given.R47 was admitted to the facility on [DATE] with diagnoses that include chronic pain syndrome and osteomyelitis of right foot and ankle. R47 has a BIMS score of 15 which means cognitively intact. On 07/13/2026, record review of R47's physician orders: Oxycodone HCO oral tablet 5 mg - Give 2 tablets by mouth every 6 hours as needed for pain scale of 7 to 10. Note: Oxycodone is a potent opioid analgesic used to manage moderate-to severe pain. Common side effects may include nausea, vomiting, drowsiness and dizziness. Severe risks include slow or shallow breathing (respiratory depression), extreme sedation, and overdose.On 07/13/2026 at 7:43 AM, Surveyor observed Licensed Practical Nurse (LPN) E prepare medications to administer to R47. Surveyor observed LPN E retrieve 2 tablets of oxycodone 5mg from pharmacy bubble packaging. Surveyor observed R47's electronic MAR to indicate last dose of Oxycodone was administered on 07/13/2026 at 4:32 AM in red lettering directly above a Y tab to document administration of medication. Prior to entering R47's room with the medications, Surveyor asked LPN E how it is determined when a last dose of PRN medication was given. LPN E then looked at R47's MAR and stated, Oh, it is too early for her to have oxycodone. On 07/14/2026 at 10:40 AM, Surveyor asked Director of Nursing (DON) B what the facility expectations were for safe administration of medications to residents. DON B stated nurses are to check all medications 3 times prior to administering a medication to a resident. Surveyor shared the concern with DON B that LPN E would have administered R47's oxycodone too early resulting in possible overdosing if Surveyor first had not asked LPN E how a PRN medication last dosing time was determined. DON B stated a pop-up alert will let nurses know if a PRN medication is attempting to be administered too early. Surveyor asked DON B if by checking the Y tab, if the electronic medical record's (EMR) intent of indicating the medication was already administered to a resident. DON B could not confirm that. DON B stated the medications are not actually documented until a Save tab is clicked on. Surveyor asked DON B if the practice to click on the Y tab prior to administering medications was consistent amongst all nursing staff and DON B could not confirm that. Surveyor asked DON B if some nurses administered medications first, then returned to the EMR and clicked on the Y, therefore not noticing a pop-up alert until the medication was already given. DON B confirmed it was a possibility. Surveyor asked DON B to demonstrate to Surveyor a pop-up alert for R47's oxycodone medication. Prior to DON B clicking on the Y to retrieve the pop-up alert on R47's oxycodone, Surveyor asked DON B if the last time PRN oxycodone was administered to R47 was visible in red lettering above the Y and DON B confirmed it was.

Based on observation, interview and record review, the facility did not ensure that food was prepared, distributed, and served in accordance with professional standards for food service safety. Kitchen staff had beard hair exposed and uncovered while preparing food. This had the potential to affect all 39 of 39 residents residing in the facility. Findings include: The facility policy, titled Personal Hygiene states, Hair must be kept clean and kept restrained with a hair net or cap covering all hair. Beards must be restrained using a beard net. On 05/05/25 at 8:20 AM, Surveyor conducted initial tour of kitchen and observed [NAME] C standing at breakfast steam table with beard net on that did not cover facial hair along both sides of face or mustache. On 05/05/25 at 12:35 PM, Surveyor observed [NAME] C preparing and serving food at steam table with beard net on that did not cover facial hair along both sides of face or mustache. On 05/06/25 at 9:44 AM, Surveyor interviewed [NAME] C regarding observation of beard net not fully covering facial hair along sides of face and mustache during food service. [NAME] C stated being unaware the side facial hair needed to be covered and indicated the beard net provided does not stay positioned to cover mustache. On 05/06/25 at 9:45 AM, Surveyor interviewed Dietary Manager (DM) D regarding observations of improper facial covering. DM D stated the expectation would be to have all facial hair covered and looked at [NAME] C and stated DM D will immediately start looking into more appropriate facial hair covering.

Based on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect 17 residents (R) on the 200 Hall. The facility did not ensure the standards of practice for applying and removing Personal Protective Equipment (PPE) to prevent the spread of infection while providing high contact care for COVID-19 positive R4. Housekeeper observed not sanitizing hands between resident rooms when delivering clean linens. Findings include: Surveyor requested and reviewed the facility policy titled Personal Protective Equipment, which stated in part, .c. Face/eye protection: ii. Wear goggles or face shield as added face/eye protection. Personal eyeglasses with side protectors are not a substitute for goggles or a face shield . Surveyor requested and reviewed the facility policy titled Infection Prevention and Control Program, which stated in part, .11. Linens: a. Laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infection . R4 was admitted on [DATE] with diagnoses which included in part: COVID-19 positive, dementia, and diabetes. R4's Minimum Data Set (MDS) assessment, dated 06/23/24, identified R4 scored 4 during a Brief Interview for Mental Status (BIMS), indicating impaired cognition. On 09/04/24 at 11:50 AM, Surveyor observed Certified Nursing Assistant (CNA) C and CNA D sanitize hands and apply fluid shield 3 N95 particulate filter respirator mask, gowns, and gloves. CNA D applied goggles and CNA C kept personal glasses on and entered R4's room. Surveyor did not observe CNA C apply protective goggles before entering COVID-19 positive room. On 09/04/24 at 12:07 PM, Surveyor observed CNA C exit R4's room and doff PPE. CNA C sanitized CNA C's regular glasses. On 09/04/24 at 12:11 PM, Surveyor observed CNA D doff PPE. CNA D laid contaminated goggles on the top of the PPE cart outside R4's room to wipe goggles down with sanitizing wipe. Surveyor did not observe CNA D wipe down the top of the PPE cart after contaminated goggles were touching the PPE cart. On 09/04/24 at 12:20 PM, Surveyor observed Housekeeper E remove clean linens from linen cart. Housekeeper E placed a pile of clean linens underneath Housekeeper E's arm pit and placed another set of clean linens under the other arm while holding the clean linens against Housekeeper E's scrubs. Then Housekeeper E approached PPE cart outside R4's door. Housekeeper E moved items around with bare hands and then placed R4's clothes on top of the contaminated PPE cart. Housekeeper E went directly into R5 and R8's room, opened the closet door and delivered the other clean linens that were being held under Housekeeper E's arm. Housekeeper E exited R5 and R8's room. Surveyor did not observe hand hygiene being performed before or after entering or exiting R5 and R8's room. Housekeeper E walked down hallway and grabbed more residents' clean linens and held clean linens against Housekeeper E's body touching Housekeeper E's scrubs. Housekeeper E ambulated down the hallway to R6 and R7's room and delivered clean linens to R6 and R7's closet. Surveyor did not observe hand hygiene performed before or after entering and exiting R6 and R7's room. On 09/04/24 at 1:10 PM, Surveyor interviewed Housekeeper E and asked Housekeeper E what expectation for hand hygiene and infection control practices were during clean linen delivery. Surveyor indicated to Housekeeper E that Surveyor observed Housekeeper E carry clean linens against Housekeeper E's body and then deliver clean linens, and Surveyor observed no hand hygiene between Housekeeper E entering, exiting, and delivering clean linens to residents' rooms. Housekeeper E indicated that Housekeeper E was never really taught that Housekeeper E needed to sanitize hands between rooms after touching closets and clean linens. Housekeeper E indicated that Housekeeper E should not let clean linens touch Housekeeper E's clothes. On 09/04/24 at 1:12 PM, Surveyor interviewed CNA C and asked if CNA C knows what type of eye protection is supposed to be used in a droplet precaution room. CNA C indicated that CNA C was never really told that CNA C could not wear CNA C's personal glasses. On 09/04/24 at 1:14 PM, Surveyor interviewed CNA D and asked what the correct process was for doffing PPE when exiting droplet precautions room. CNA D stated, I know I placed my dirty goggles on PPE cart outside the COVID-19 positive room and didn't mean to. I should have wiped goggles down right away and not placed them on the PPE cart contaminated. On 09/04/24 at 1:17 PM, Surveyor interviewed Infection Preventionist (IP) F and asked IP F what guidelines does IP F follow to implement and educate staff on current standards of practice. IP F indicated that IP F follows the CDC guidelines and facility protocols. Surveyor asked IP F if IP F can walk Surveyor through the process for donning and doffing PPE. IP F indicated that staff are to don gown, mask, eye protection, and gloves. Surveyor asked was it normal for staff to doff PPE on the outside of the COVID-19 positive room. IP F indicated that IP F has never been taught any other way. Surveyor indicated to IP F that Surveyor observed staff doffing PPE outside COVID-19 positive room and throwing PPE into trash located on outside door in common hallway. IP F indicated that IP F was not aware that trash can needed to be in the COVID-19 positive room. Surveyor asked IP F what expectation is for staff when doffing PPE and how do they sanitize goggles after being contaminated. IP F indicated that staff are to doff PPE and sanitize goggles before placing goggles down on any surface. Surveyor indicted to IP F that Surveyor observed CNA D exit COVID-19 positive room, doff gown, gloves, and then grabbed goggles and placed contaminated goggles on the PPE cart outside R4's room before wiping contaminated goggles down. CNA D then opened PPE cart drawers and grabbed a wipe to clean contaminated goggles. Surveyor did not observe CNA D wipe down the PPE cart. IP F indicated that CNA D should have not laid contaminated goggles on PPE cart. IP F indicated that CNA D should have wiped the goggles down with sanitizing wipe before laying directly on the PPE cart. Surveyor asked IP F what expectation of hand hygiene between Housekeeper E delivering clean linens room to room. IP F indicated that Housekeeper E is expected to be using hand sanitizer between rooms when delivering clean linens. Surveyor indicated to IP F that Surveyor observed Housekeeper E grab clean linens, press clean linens against scrubs, walk down hallway to COVID-19 positive room and rearrange contaminated items on top of PPE cart to make room for clean linens. Housekeeper E then walked across the hall to another resident room and delivered the other clean linens that were being held under Housekeeper E's arm. Surveyor did not observe Housekeeper E sanitize hands or use any hand hygiene practices. IP F indicated that Housekeeper E should be practicing good hand hygiene between delivering clean linens and expectation would be to sanitize or wash hands between rooms.

Based on observation and interview, the facility did not ensure the privacy and confidentiality of resident medical records. Staff left the Medication Administration Record (MAR) open and visible when unattended during medications administration. This occurred for 1 of 8 residents (R) during medications administration. (R19). Findings: The facility policy titled, COMPLIANCE-HIPAA Sanctions date implemented 7/15/22 states in part: 6. Examples of violations include, but not limited to: .d. The intentional or negligent mishandling, altering or destruction of confidential information or media/workstations that house such information. e. Leaving a secured application unattended while logged on . On 04/08/24 at 9:01 AM, Surveyor approached the medication cart located outside of the nurses station. No one was present by the cart. Surveyor noted that R19's MAR was up on the screen and visible to anyone who walked by the medication cart. Several facility staff walked by the medication cart. R18 was in a wheelchair sitting in the hallway, having the ability to see R19's MAR. On 04/08/24 at 9:09 AM, Registered Nurse (RN) K returned to the medication cart 8 minutes later and logged off of R19's MAR. On 04/10/24 at 11:04 AM, Surveyor interviewed RN K about the observation made the first day. RN K replied, I know I left the screen up on the computer, I saw you there. Thank you for pointing this out. On 04/10/24 at 11:17 AM, Surveyor interviewed RN K regarding HIPPA training the facility provided staff. RN K replied, I get training in Relias about not having personal information up on the computer screen at least every year. On 04/10/24 at 12:41 PM, Surveyor interviewed Director of Nursing (DON) B. Surveyor informed DON B of the observations made of the computer screen and asked what the expectation is. DON B replied, I tell them if they have the computer screen facing the resident's room in a private room that is fine, but it is better if you close the screen.

Based on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Staff did not perform hand hygiene during 1 of 3 observations (R7) of personal care. Staff did not perform hand hygiene during 1 of 7 residents (R29) observed during medication pass. Findings include: Surveyor requested and reviewed the facility policy titled Hand hygiene dated last review November 2022. The policy in part reads: .#6 Additional considerations: -a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Surveyor reviewed the facility policy titled Hand Hygiene Table dated last review November 2022. The table in part reads: .Either soap and water or Alcohol Based Hand rub (ABHR is preferred) -Between resident contacts. -Before applying and after removing personal protective equipment (PPE), including gloves/ -Before preparing or handling medications. -After handling potentially contaminated blood, body fluids, secretions, or excretions. -When, during resident care, moving from a contaminated body of the site to a clean body site. -After assistance with personal body functions (e.g., elimination, hair grooming, smoking). Example 1 R7 was admitted on [DATE] and the current diagnoses, in part: non-Alzheimer's dementia, diabetes mellitus, stroke with hemiparesis, anemia, hypertension, and heart failure. Surveyor completed record review of the Minimum Data Set assessment (MDS), dated [DATE], which indicates the resident's most recent Brief Interview for Mental Status (BIMS) score was a 15 out of 15 total points. According to the BIMS assessment, a score of 15 indicates the resident has intact cognition. The MDS documents R15 is dependent on staff for activities of daily living and maximum assistance of staff to roll in bed. R15 is dependent on staff for transfers with a Hoyer lift assist of 2. On 04/09/24 at 9:17 AM, Surveyor observed Certified Nursing Assistant (CNA) E and CNA F take Hoyer lift into R7's room to transfer to bed for incontinent care. Surveyor observed CNA E used gloved hands to clean incontinent BM off R7's bottom. Surveyor observed CNA F roll R7 to the left side of the bed and CNA F used a wipe to clean R7's bottom off once rolled. CNA F tucked the dirty incontinent pad under R7's bottom to the left side. CNA F then rolled R7 back to his back. CNA E grabbed the dirty incontinent pad and threw it in the garbage. CNA E requested CNA F to go grab R7's urinal out of the bathroom. CNA F grabbed the urinal from the bathroom with soiled gloved hands and repositioned the urinal between R7's legs. CNA F grabbed R7's penis with CNA F's left gloved hand and placed R7's penis in the urinal. R7 requested CNA F to take R7's glasses from R7's eyes and place them on the bedside table. R7 also requested the head of the bed be raised. CNA F grabbed R7's glasses from R7's face with both soiled gloved hands and placed them on the bedside table. Surveyor did not observe CNA F take her soiled gloves off before removing R7's glasses. CNA F continued with R7's care, readjusting bed height, and turning the bedside light off by pulling the light string on the wall with both soiled gloved hands. Surveyor observed CNA F reposition the bedside table closer to R7's bed and then CNA F removed soiled gloves and threw them in the trash. CNA F exited R7's room, grabbed an antibacterial wipe, and wiped down the Hoyer lift. CNA F walked down the hallway, pushed the keypad on the door, and then pushed the Hoyer lift into the storage room. CNA F exited the storage room and relocked the doorknob on the keypad. Surveyor did not observe hand hygiene being performed by CNA F before exiting R7's room or after exiting R7's room. Surveyor did not observe hand hygiene being performed before or after sanitizing the Hoyer lift and entering the locked keypad storage room. CNA F then entered back into R7's room and sanitized hands. On 04/09/24 at 9:34 AM, Surveyor interviewed CNA F and asked about hand hygiene and glove use practices during R7's care. CNA F indicated that gloves are supposed to be changed as needed, changed often and hand sanitizer is used before and after resident care. On 04/10/24 at 11:02 AM, Surveyor interviewed Assistant Director of Nursing (ADON) C and asked about hand hygiene during peri care and other care during resident care. ADON C indicated that CNA F should be changing gloves often and using good hand hygiene. ADON C indicated it was not correct for CNA F to use soiled gloves to take R7's glasses off and place them on the bedside table. ADON C indicated the correct process is for staff to change gloves often and sanitize hands going from peri care to other tasks. 46694 Example 2 On 04/09/24 at 7:12 AM, Surveyor observed Registered Nurse (RN) J administer medications to R29. Proper hand hygiene was performed using Alcohol Based Hand Rub (ABHR) before entering R29's room. After medication administration was finished, RN J did not perform hand hygiene, put on a pair of single use gloves, rinsed R29's dentures in the sink and attempted to put R29's dentures in R29's mouth. R29 refused the denture. RN J put the dentures back in the denture cup. RN J removed gloves and performed hand hygiene using soap and water at the sink in R29's room. On 04/10/24 at 11:13 AM, Surveyor asked RN K, What is the expectation for hand hygiene? RN K replied, Before I put on gloves I sanitize my hands. I also sanitize my hands when I am passing medications and before and after leaving a resident room, or I wash them. On 04/20/24 at 12:42 PM, Surveyor interviewed Director of Nursing (DON) B regarding observations made of no hand hygiene performed during medication pass between residents. DON B replied, They know better. They know that hand hygiene is expected between residents' cares and before and after glove use.

Based on observation and interview, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections. The facility staff did not perform hand hygiene during personal cares for 1 Resident (R) 6 of 1 care observation. The facility staff did not clean or sanitize the mechanical lift between 3 Residents (R6, R15, and R20) of 3 observations, or use appropriate infection control practices for catheter care for R31. Facility staff provided personal cares for R6 and did not wash or sanitize hands after removing contaminated gloves. Facility staff used the mechanical lift for R6, R15, and R20 and did not sanitize the mechanical lift after each use. Staff did not use appropriate hand hygiene and Personal Protective Equipment (PPE) when providing catheter care and handling catheter bag and tubing for R31. This is evidenced by: Review of facility's policy for Handwashing/Hand Hygiene, with the revised date of 08/19, read in part: .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .b. Before and after direct contact with residents; .h. Before moving from a contaminated body site to a clean body site during resident care; i. After contact with a resident's intact skin; j. After contact with blood or bodily fluids; l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; m. After removing gloves; . Review of facility policy for Cleaning and Disinfection of Resident-Care Items and Equipment, with the revised date of 08/09, read in part: Policy Statement: Resident-care equipment, including reusable items and durable medical equipment, will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard .d. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment) . 1. On 01/18/22 at 11:55 a.m., Surveyor observed cares being provided to R6. Certified Nursing Assistant (CNA) C and CNA D transferred R6 from recliner to bed using the mechanical lift. CNA D applied gloves and CNA C applied gloves without washing or sanitizing hands. CNA C gathered wipes and a clean brief. CNA C wiped frontal peri area with a wipe and then rolled R6 to his side and cleansed buttock area removed gloves and did not wash or sanitize hands then applied clean gloves. CNA C cleansed the buttock area with a clean wipe and applied barrier cream. CNA C removed gloves and did not wash or sanitize hands before applying clean gloves. CNA C applied a clean brief and rolled R6 back and then gave R6 the urinal. CNA C removed gloves and did not wash or sanitize hands and applied clean gloves. After R6 was done with urinal CNA C applied the clean brief and transferred R6 with the mechanical lift to the recliner. CNA D removed gloves and did not wash or sanitize hands. CNA D did not sanitize the mechanical lift and left R6's room and went to R15's room. CNA C brought garbage to a bin and did not sanitize hands. CNA C went to R15's room to assist with the mechanical lift transfer. CNA C and CNA D exited R15's room and went to R20's room to transfer R20 with the mechanical lift. At 12:17 p.m., Surveyor interviewed CNA C asking if at any time did CNA C or CNA D sanitize the lift. CNA C indicated he does not sanitize the lift between uses and thinks it will get cleaned between shifts. On 01/19/22 at 12:31 p.m., Surveyor was given the policy for lift cleaning. DON (Director of Nursing) B indicated the lifts are to be cleaned between residents. DON B indicated immediate education was provided to CNA C and to other staff that the lifts are to be sanitized after each resident use. 01/19/22 at 2:31 p.m., Surveyor interviewed DON B asking about when hand hygiene should be completed. Surveyor reviewed observation with CNA C and CNA D of hand hygiene not being completed when gloves were removed. DON B indicated education will be provided. Surveyor reviewed with DON B, observation of the lifts not being cleaned after each resident use. DON B indicated hearing Surveyor interviewing CNA C and immediate education was provided and education was provided to all staff. 2. R31 was admitted to the facility on [DATE] with an indwelling Foley catheter for diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 01/19/22 at 07:28 AM, Surveyor observed Certified Occupational Therapy Assistant (COTA-E) change R31's urinary overnight drainage bag to a leg drainage bag. Surveyor observes COTA-E enter R31's room to get R31 for morning exercise; from hallway, Surveyor overhears COTA-E say, I'll need to switch to your leg bag before we go. Surveyor knocks and asks to observe; R31, who was sitting in wheelchair, agreed. COTA-E already had donned a pair of gloves. COTA-E went into bathroom and brought out a leg bag and a plastic trash liner. COTA-E laid the leg bag on the clean trash bag and used an alcohol pad to wipe connector of leg bag; COTA-E then set the trash bag and leg bag on R31's bed. COTA-E then set an empty collection container on the floor next to R31's wheelchair. COTA-E was unable to reach connector while R31 had pants on, so she placed 4-wheeled walker in front of R31 and assisted him to stand to lower pants and sit back down. COTA-E used hand to pinch Foley connection tube above connector and disconnected the overnight bag. COTA-E, while still pinching tube closed, handed the disconnected tube to R31 to hold while she wiped the Foley connection tube end with an alcohol wipe and connected the leg drainage bag. COTA-E then picked up the empty collection container from floor and placed it on the counter next to the sink; there was also a hair comb, toothpaste tube, and kidney basin sitting next to the collection container. COTA-E took the overnight drainage bag from R31 and held it over the collection container and drained urine from bag. COTA-E then wiped drainage valve with alcohol wipe, placed in plastic bag and put in bathroom. COTA-E exited bathroom, touched bathroom door knob, picked up gait belt hanging on back of door, and placed belt on R31. COTA-E then touched 4-wheeled walker handles and supported R31 while he stood up; COTA-E pulled R31's pants up, tied the drawstring, and assisted him back to sitting. At that time COTA-E removed the gloves she had been wearing throughout the entire procedure and washed hands for approximately 10 seconds. COTA-E then pushed R31 in wheelchair out of room to go to exercise. On 01/19/22 at 12:13 PM, Surveyor interviewed COTA-E. Surveyor asked how often COTA-E provided catheter care to residents. COTA-E stated if a resident was on her schedule for the morning and they were getting ready for the day, she would incorporate it into the Occupational Therapy (OT) session. Surveyor asked what type of training COTA-E had received specifically related to handling of catheter bags and tubing. COTA-E stated the general training over her [AGE] year career; including training with her COTA schooling. Surveyor reviewed the observation and discussed concerns with PPE use, hand washing, and emptying the urine drainage bag over the counter with R31's personal hygiene supplies nearby. COTA-E stated she normally would wash her hands several times throughout the procedure, but because she was dealing with catheter throughout, she hadn't changed gloves today. COTA-E also stated things had been out of sequence that morning because R31 was already up out of bed when she arrived. On 01/19/22 at 02:00 PM, Surveyor discussed observation concerns with Director of Nursing (DON-B). DON-B agreed that gloves should have been changed and hand hygiene performed during procedure. DON-B also agreed urinary drainage bag should not have been drained over countertop with R31's personal hygiene products.

Based on observation, interview and record review, the facility did not provide an ongoing program to support resident's choice of activities, designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident. This affects 10 of 29 residents (R). (R1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) Residents were not offered or provided a variety of engaging activities based on their individual preferences since the activity director position was unfilled for the past month. Findings include: Example 1: On 12/07/21 at 9:50 AM, Surveyor observed R1 sitting in the recliner in the resident's room. There was a half-eaten breakfast tray on the over bed table in front of R1. The TV was on, but R1's eyes were closed and R1 appeared to be sleeping. Surveyor knocked on the door, and R1 opened his eyes and gave Surveyor permission to enter. R1 stated he dozed off after breakfast as all he had to do each day was sit in his room in front of the TV, and it got boring. R1 stated the breakfast tray was still sitting in his room because no one came in his room to get it until he put his call light on. R1 stated he felt trapped in his room because he was dependent on oxygen. Surveyor asked if he could leave his room with portable oxygen. R1 stated he could ask the staff to fill the portable oxygen tank, but there was nothing to do outside of the room, so he did not bother to ask. Surveyor asked if the facility staff ever provided, or invited R1, to any group activities. R1 stated last week they had a cake party that he attended. R1 stated he did not remember any other group activities offered in the recent past. Surveyor asked if any staff ever came into R1's room to visit with him individually, or provide games, reading materials, or other activities to pass the time. R1 stated the only time staff entered his room was when he put the call light on to ask for help. R1 stated no one ever provided any activities or socialization. R1 stated the only thing he had to do was watch the TV and visit with his friend when she came to see him. R1 stated he was discouraged and sick of sitting in his room alone all the time, with only the TV for company. Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE]. R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Brief Interview for Mental Status (BIMS) score was 8, which indicated R1 had a moderate cognitive impairment. R1's Minimum Data Set (MDS) assessment dated [DATE] indicated R1 required extensive assistance with most activities of daily living (ADLs). The mood section of R1's MDS showed R1 had a PHQ-9 (depression indicator) score of 11, which meant R1 had symptoms of depression. The activity assessment section of the MDS assessment indicated R1 enjoyed listening to music, being around animals or pets, keeping up with the news, doing things with groups, and going outside when the weather was good. Surveyor reviewed R1's care plan which included, in part, Focus [R1] prefers to rest in room most of the day. He enjoys individual activities like puzzles, listening to country music, visiting with family, and watching westerns on TV .Interventions Enjoys: puzzles, listening to country music, visiting with family, and watching westerns on TV. Offer activities consistent with resident's known interest, physical and intellectual capabilities. Provide options of various activities scheduled Focus [R1] requires assistance with walking as evidenced by need for support and walker for all mobility. He has a goal to walk at least once a day, preferably three times a day if he can tolerate it .Interventions Nursing Restorative: Walking program: Walk with [R1] IN HALL at least once per day with walker .Focus [R1] needs time to adjust to long term care setting .Interventions Engage in conversation about occupation and hobbies . Surveyor requested to see documentation of activity participation or attendance for R1 in the past month. DON B stated there was no documentation of activity participation for the past month. On 12/07/21 at 11:45 AM, Surveyor observed R1 sleeping in the recliner in his room with the TV playing. At 12:10 PM, Surveyor observed R1 eating lunch in his room by himself. At 1:45 PM, Surveyor observed R1 asleep in his recliner with the TV on. Example 2: On 12/07/21 at 10:15 AM, Surveyor observed R2 sitting in a wheelchair in her room with her eyes closed. No TV or music was on in the room. A roommate was in a wheelchair the room, facing the window. Surveyor attempted to interview R2. R2 opened her eyes, but was not able to answer any questions. Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 was unable to complete the BIMS assessment, which indicated R2 had severe cognitive impairment. The admission activity assessment dated [DATE] on R2's medical record indicated R2 enjoyed listening to music, being around animals or pets, keeping up with the news, going outside when the weather was good, and participating in religious services. The most recent MDS assessment dated [DATE] indicated R2 required extensive assistance with most ADLs. Surveyor reviewed R2's care plan, which included, in part, FOCUS [R2] has a history of being a very avid [NAME]. [R2] has fished with her husband all of their married life, and in the past had an interest in working in her flower beds as well .Interventions 1:1 time, talking and wheeling around facility. [R2] has a baby doll that she likes to carry around with her. When she seems agitated or upset, offer her her baby and it may calm her. [R2] loves Hershey's chocolate and Pepsi. Offer to her at times when she is feeling agitated or upset . Surveyor requested to see documentation of activity participation or attendance for R2 in the past month. DON B stated there was no documentation of activity participation for the past month. On 12/07/21 at 11:15 AM, Surveyor observed R2 sitting in the same position in the wheelchair in her room, as an hour previously. R2's eyes were closed. There was no music or TV on in the room. At 12:00 PM, Surveyor observed R2 in her wheelchair in the social services office. R2 was seated between two desks. One staff member was eating her lunch at her desk, and the other staff member was working at her desk. Surveyor observed for several minutes and did not observe either staff member communicate or engage with R2. At 1:30 PM, Surveyor observed R2 sitting in the wheelchair in her room. The wheelchair was positioned beside the bed. There was an over bed table in front of R2 with a cup of water on it. There were no books, magazines, or any other activity items on the table. There was no music playing or TV on in the room. At 2:00 PM, Surveyor observed R2 seated in the same position with eyes closed and chin resting on chest. Example 3: On 12/07/21 at 9:15 AM, Surveyor observed R3 sitting in a Broda chair with an over bed table in front of him. There was a breakfast tray in front of him. The TV was on, and R3 was facing the TV. R3's roommate was seated in a wheelchair facing the TV, eating breakfast. There was a curtain pulled between the two residents. Surveyor interviewed R3, who reported he spends all day in his room watching TV. R3 stated the days seem very long. Surveyor asked R3 if he participated in any activities offered by the facility staff. R3 stated there had been no activities provided by the facility for about the past month, since the activity director quit. Surveyor asked R3 if the staff offered or provided any individual activities, or one on one time to help pass the time. R3 stated the staff is too busy and he did not want to bother them. R3 stated he would like more activities during the day because it got very lonely never leaving his room. Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's BIMS score dated 09/17/21 was 14, indicating no cognitive impairment. An Activity Participation Review dated 09/16/21 stated, in part, .Enjoys attending resident council meetings. Sometimes [R3] will attend baking groups and enjoys eating whatever is made. [R3] likes to watch TV in his room. He likes crime shows and movies. He likes actively visiting groups where he enjoys to socialize with staff and peers. [R3] enjoys listening to music on the radio in the activity room and singing along. He also likes to go to live entertainment when it is held in the facility. [R3] enjoys attending Happy Hour and any parties or gatherings that may be held in the facility. He likes to have 1-2 beers and socialize with his peers and staff during this time. R3's care plan included, in part, .FOCUS [R3] enjoys socializing with peers and participating in activities with groups. He also can be found relaxing in his room watching TV .Interventions Assist to transport to and from activities. [R3] jokes with individuals often. Group activities: card games, BINGO, happy hour, discussion/reminiscing groups, live music/entertainment, Lutheran church services. Individual activities: watching TV, reading newspaper. Interests: animals, hunting, fishing, outdoors. Likes to have a beer during social events . Surveyor requested to see documentation of activity participation or attendance for R3 in the past month. DON B stated there was no documentation of activity participation for the past month. On 12/07/21 at 10:45 AM, Surveyor observed R3 seated in the Broda chair in his room, beside the bed, facing the TV, which was on. The curtain was drawn between R3 and his roommate, who was seated facing the TV as well. At 12:10 PM, Surveyor observed R3 seated in the same position, eating lunch in his room. The curtain was pulled between R3 and his roommate. At 1:40 PM, Surveyor observed R3 in bed with eyes closed. Example 4: On 12/07/21 at 9:00 AM, Surveyor observed R4 propelling self in wheelchair in the 100 hallway. Surveyor attempted to interview R4, but R4 was pleasantly confused, and unable to answer any questions. At 10:00 AM, Surveyor observed R4 in wheelchair in her room, sitting by the door and looking out into the hallway. There was no music or TV on in the room. At 12:15 PM, Surveyor observed R4 sitting in wheelchair in her room with a lunch tray in front of her on an over bed table. R4 was not eating. At 1:50 PM, Surveyor observed R4 lying in the bed in her room with eyes closed. Surveyor reviewed R4's medical record. R4 was readmitted to the facility on [DATE], following a hospitalization . R4 had diagnoses, in part, unspecified dementia without behaviors, [CONDITION(S)] and major depressive disorder. R4's BIMS score dated 08/28/21 was 10, indicating R4 had moderate cognitive impairment. The activity interest assessment from R4's MDS assessment dated [DATE] indicated R4 enjoyed participating in religious services and listening to music. R4's care plan included, in part, .Focus Enjoys activities such as Bingo occasionally, spiritual activities, 1:1 conversations .Interventions Remind and invite [R4] to available activities, escort to activities when she agrees to go .Focus Prefers not to attend group activities often. Goals Will actively engage in in-room/1:1 activities such as social conversations and past experiences. Will actively participate in activities that are consistent with resident's likes and interests such as Bingo and baking groups. Interventions Respect choice in regard to limited/no activity participation. Surveyor requested to see documentation of activity participation or attendance for R4 in the past month. DON B stated there was no documentation of activity participation for the past month. Example 5: On 12/07/21 at 9:00 AM, Surveyor observed R5 in a recliner in his room talking on the telephone. The TV was on in his room. At 10:50 AM, Surveyor interviewed R5, who stated he mostly spent the days in his room reading or watching TV, because the facility staff did not provide or offer other activities to participate in. Surveyor asked if this was a long-standing problem or just recent. R5 stated they used to provide Bingo regularly; now that was rarely offered. R5 stated they used to have someone visit with a dog for pet therapy, but they no longer allow that. R5 stated they used to provide music entertainment, but that is no longer offered. R5 was not sure how long this had been going on. R5 stated he did enjoy those activities, and felt sad and depressed due to the lack of socialization. He stated he would get angry and yell at the staff at times, due to frustration with this situation. Review of R5's medical record identified R5 was originally admitted to the facility on [DATE], and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . At 12:30 PM, Surveyor observed R5 in his recliner reading a book. At 1:30 PM, Surveyor observed R5 sitting in his recliner with his eyes closed, and the TV was on in the room. Example 6: On 12/07/21 at 10:15 AM, Surveyor observed R6 sitting in a wheelchair in her room doing a word search puzzle, and the TV was also on in her room. Surveyor interviewed R6 who stated she mostly did word search puzzles and watched TV all day because there was nothing else to do. R6 stated she wished there was more to do to help pass the time, because she got bored and lonely. R6 stated they used to do more activities in the past, but now there were rarely any group activities offered. R6 stated everyone just stayed in their rooms all day, and it got very lonely. R6 stated that about a month ago they offered exercise bingo, and that was very fun. R6 stated she wished they would offer that again, but they only did it one time. R6 stated she thought the staff was too busy to visit, or offer activities on a regular basis. At 12:20 PM, Surveyor observed R6 sitting in the same chair, in the same position eating lunch from a tray on an over bed table in front of the wheelchair. At 1:55 PM, Surveyor observed R6 sitting in the same position working on a word find puzzle with the TV on in her room. Example 7: On 12/07/21 at 10:10 AM, Surveyor observed R7 sitting in a recliner in the corner of the resident room beside the window. The curtain was drawn down the middle of the room, so R7 could not be seen from the doorway. The recliner was not reclined. R7 was seated with head and upper body tipped to the right, and her eyes were closed. R7 opened her eyes and stated her name when Surveyor introduced herself. R7 appeared groggy and did not answer any other questions. There was no music playing, no TV on and no books or magazines, or activity items in front of R7. At 12:04 PM, Surveyor observed R7 in the same position, tipped to the right side, with eyes closed. At 1:00 PM, Surveyor observed R7 in the same position, with eyes closed and head and upper body tipped to the right. There was an uneaten sandwich on a plate on the over bed table in front of her. At 1:45 PM, Surveyor observed R7 still seated in the same position, with eyes closed, and the uneaten sandwich in front of her. Example 8: On 12/07/21 at 10:10 AM, Surveyor observed R8 seated in a chair beside the bed in her room. There was an empty over bed table in front of her. The TV was on in the room. R8 did not appear to be watching the TV. R8 was looking out the door to the room, and would occasionally call out to staff who walked by the room, but no staff members were observed entering the room after R8 called out. Surveyor attempted to interview R8, but R8 was not able to answer any questions. At 12:02 PM, Surveyor observed R8 sitting in the same position, with the TV on, and an empty over bed table in front of her. R8 was looking out the door into the hallway. At 1:30 PM, Surveyor observed R8 in the bed in her room with a blanket over her and her eyes closed. Example 9: On 12/07/21 at 10:10 AM, Surveyor observed R9 seated in a wheelchair in the same room as R8. R9 was facing the second bed in the room and was fiddling with a green, circular ring, that appeared to be a hand weaving device. R9 did not respond to Surveyor's questions or conversation. At 12:02 PM, Surveyor observed R9 seated in the same position, still manipulating the green device with her hands. At 1:30 PM, Surveyor observed R9 lying in bed, with the green device in her hands. Her eyes were open and she was still fiddling with the device. R9 did not respond to Surveyor's questions. Example 10: On 12/07/21 at 10:21 AM, Surveyor observed R10 seated in a chair in her room, watching TV. R10 told Surveyor that for the past month there was not much to do at the facility. R10 stated she mostly just sat in her room watching TV all day. R10 stated she was bored and lonely, and the days felt like they were very long. R10 stated there used to be more activities and opportunities to socialize offered, but thinks this stopped after the activity person quit. R10 stated she wished there were more things to do during the day, but no one offers anything. At 12:20 PM, Surveyor observed R10 seated in the same chair, eating lunch from a tray on the over bed table in front of her. The TV was on, and R10 was alone in her room. At 1:55 PM, Surveyor observed R10 seated in the same chair in her room, watching TV. Surveyor requested to view the activity calendar for the past month. DON B stated there had not been a formal activity calendar developed for the past month since the activity director left. DON B stated the management team, and therapy department had provided some group activities in the interim. DON B provided a flyer identifying exercise bingo was offered for residents on Monday, October 25th by therapy staff. The flyer also identified bowling was offered for residents on Thursday, October 28th by therapy staff. The flyer had a post-it note attached that indicated these activities were also provided two weeks prior to these dates. DON B also provided a document that indicated a cake social was offered to residents at 2:00 PM on November 30th. On 12/07/21 at 2:00 PM, Surveyor interviewed DON B about the activity program, and residents' reports that there were not enough activities offered. DON B reported the activity director resigned, but a new activity director was hired and starting tomorrow. DON B was not certain of the exact date of the resignation, but stated the position had been vacant for the entire month of November. DON B stated during the interim, the management team and therapy department had been trying to offer group activities for the residents. DON B thought those group activities were being offered about once per week, but there was no documentation to show what had been provided, or which residents participated. DON B stated staff was also attempting to provide more one on one interaction with the residents. Surveyor asked to see documentation of activity participation, or one on one activity offerings provided to residents. DON B stated there was no record of activity participation, or one on one activity provided since the activity director left. Surveyor asked if there were any other opportunities for socialization for the residents, such as communal dining. DON B stated due to staffing shortages and COVID vaccination status of staff, communal dining was not being offered in the facility. DON B stated all residents were eating in their rooms. DON B stated the residents had the opportunity to gather in the activity room, or in the TV room for socialization. Surveyor noted during all observations throughout the day, both of those rooms were empty.

Based on observations, interviews and record review, the facility did not ensure reconciliation and accounting of all controlled drugs was maintained for 1 of 1 residents (R1) reviewed for missing narcotics. Findings include: The facility policy, entitled Medication Storage in the Facility, revised January 2018, states: At each shift change or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items is conducted by two licensed nurses and is documented. R1 was admitted to the facility on [DATE], and has diagnoses that include [CONDITION(S)], hypertensive heart disease and arterial fibrillation. On or around 11/02/21, R1 had a significant change in his health condition, was placed on Hospice and an order was received for Lorazapam concentrate 2 mg/ml. give 0.25 ml by mouth as needed for anxiety. Surveyor investigated a complaint about missing medications. While reviewing the missing medication, the investigation revealed that the medication was last given on 11/07/21 by Registered Nurse E who had accidentally spilled the Lorazapam and did not notify anyone of the error. It was not until 11/10/21 when staff was looking in the refrigerator for R1's Lorazapam that it was reported to Director of Nursing B as missing. The facility did not complete a physical invenetory of all controlled substances by two nurses at each shift change from 11/07/21 through 11/10/21.

Based on record review and interview, the facility did not ensure that 1 of 3 Residents (R3) reviewed for accidents had adequate assistive devices and interventions in place to prevent accidents. R3, identified as a fall risk, sustained six documented falls at facility since admission on 6/29/21. The facility did not identify a root cause for each documented fall, revise the care plan, or implement individualized, resident-centered interventions to reduce risk of future falls. Findings include: R3 was admitted to the facility on [DATE], with diagnoses that included: Dementia, [CONDITION(S)], [CONDITION(S)] Disorder, Alcohol-Induced Disorder, Muscle Weakness, Difficulty in Walking, and Cognitive Communication Deficit. R3's Admission MDS (Minimum Data Set) dated 7/3/2021 documents a BIMS (Brief Interview for Mental Status) score of 3, indicating severe cognitive impairment. Section G (Functional Status) documented R3 required extensive assistance and two-person physical assist for transfers, bed mobility, and activities of daily living (ADL) needs. Section J (Health Conditions) indicated R3 had a fall within the past 1 month prior to admission, as well as two or more falls since admission. Admission Progress Note dated 6/29/21, read in part: . Resident is also a high fall risk, is a 2 assist with walker and gait belt . R3 sustained falls on 7/2/2021, 7/3/2021, and 7/4/2021. Surveyor requested fall investigation reports and progress notes related to each fall: 7/2/2021: Post-Fall assessment dated [DATE] for R3's fall on 7/2/2021 indicated new immediate intervention to be new air mattress with bolster, faxed MD for floor mats .Care Plan updated? Yes. Surveyor found no evidence a Care Plan related to R3's fall-risk was in place or updated at that time. Progress Note dated 7/12/2021, read: IDT (Interdisciplinary Team) met and reviewed fall that occurred on 7-2-21 .Root cause: Resident had fallen out of bed due to air mattress being deflated .Right and left floor matt (sic) ordered to prevent injury . Surveyor requested documentation of fall interventions in place prior to R3's initial fall on 7/2/2021. No documentation was provided. 7/3/2021: No Post-Fall Assessment or completed Fall Investigation provided for R3's fall on 7/3/2021. Progress Note dated 7/9/2021, read: IDT review of fall from 7/3/2021 when resident fell from his bed. Resident's family reported to staff that he typically sleeps in a recliner at home, not in a bed. A recliner was placed in resident's room on 7/3/2021 for him to sleep in should he choose to .Plan of care remains appropriate at this time. Surveyor found no evidence a Care Plan related to R3's fall-risk was in place or updated at that time. 7/4/2021: Post-Fall assessment dated [DATE] for R3's fall on 7/4/2021 indicated new immediate intervention: Sat resident in recliner, POA (Power of Attorney) stated he never sleeps in bed, only in his chair .Care Plan updated? No. Progress Note dated 7/12/2021, read: IDT met and reviewed fall that occurred on 7-4-21 .Resident was found next to his bed on his landing pad .Immediate intervention: resident was assessed for pain, injury and changes in neurological and ROM (range of motion). Resident was then assisted to his wheelchair. Air mattress removed from bed and family states he sleeps in his recliner at home. Staff will assist to his recliner at bed time . R3 was hospitalized from 7/10/2021 through 7/12/2021 for reasons unrelated to falls. R3's Baseline Care Plan, dated 7/12/2021, read in part: History of falls/At risk-Intervention(s): bed in low position, call light in reach, floor mats to sides of bed (bilateral) R3's Comprehensive Care Plan for falls was initiated 7/14/2021. Interventions included: -Follow therapy recommendations for transfers, mobility and ambulation. Date Initiated: 07/14/2021 -Review information on past falls and attempt to determine cause of falls for prevention and to minimize injuries. Date Initiated: 07/14/2021 -Sleeps in recliner for best comfort. Date Initiated: 07/14/2021 -Right and left landing pad to bed as resident has been sleeping in his bed at times. Date Initiated: 07/21/2021 No revisions to R3's Care Plan for fall-risk noted since 7/21/2021. R3 sustained three additional falls on 7/23/2021, 7/25/2021, and 7/28/2021. Surveyor requested fall investigation reports and progress notes related to each fall: 7/23/2021: Post-Fall assessment dated [DATE], identifies no new interventions. Progress Note dated 8/5/2021, read: IDT met and reviewed fall that occurred on 7-23-21 .Root cause is unclear as resident was unable to state what he was trying to do .was started on comfort cares on 7-19-21 due to being very lethargic and unresponsive. Medications were discontinued on 7-19-21 and resident started to become more awake and impulsive. Immediate intervention: resident was assisted back to his chair and provided with independent activity at the nurses station .Resident has been working with PT, OT and ST to increase strength and independence and now has a new wheelchair and walking program and will continue to work with therapy. POC (Plan of Care) reviewed and appropriate. 7/25/2021: Post-Fall assessment dated [DATE], identifies no new interventions. Progress Note dated 8/6/2021, read: IDT met and reviewed fall that occurred on 7-23-21 .Root cause is unclear as resident was unable to state what he was trying to do .was started on comfort cares on 7-19-21 due to being very lethargic and unresponsive. Medications were discontinued on 7-19-21 and resident started to become more awake and impulsive. Immediate intervention: resident was assisted back to his chair and provided with independent activity at the nurses station .Resident has been working with PT, OT and ST to increase strength and independence and now has a new wheelchair and walking program and will continue to work with therapy. POC (Plan of Care) reviewed and appropriate. Progress Note is verbatim from note dated previous day (8/5/2021), including reference to fall on 7-23-21; the only difference is the note's effective date: 8/6/2021. 7/28/2021: Post-Fall assessment dated [DATE], identifies no new interventions. Progress Note dated 8/4/2021, read: IDT review of fall from 7/28, resident had fallen from his Broda chair stating he was trying to get up. Resident had recently had a bout of unresponsiveness/signs of significant decline so was placed on comfort cares with all oral medications being discontinued on 7/19. Resident has been more alert since the d/c of oral medications. Walking program was implemented on 8/2 to encourage safe movement. Care plan appropriate. On 9/21/2021 at 10:00am, Surveyor interviewed Certified Nursing Assistant (CNA) C. Surveyor asked how staff was made aware of residents' care needs, including fall interventions. CNA C stated each resident had a Kardex (CNA Care Plan) in the computer system for staff to refer to. The Kardex is updated periodically as changes occur. Surveyor asked what fall interventions were in place for R3? CNA C could not recall any interventions off the top of her head, but stated she thought he used to have floor mats next to bed, but not any longer. On 9/21/2021 at 10:06am, Surveyor interviewed R3. R3 has severe cognitive impairment but was able to answer some questions. R3 stated he could not recall what happened during his falls, but he does know he has not fallen in about 2 months. R3 stated he prefers to sleep in his bed at night. R3 has a private room, there are two beds and a recliner in the room. Surveyor observed R3 self-propelling in wheelchair in room and hallway throughout survey. On 9/21/2021 at 10:14am, Surveyor spoke to Nursing Home Administrator (NHA) A and Director of Nursing (DON) B. Surveyor expressed concerns with lack of information included in fall investigation reports. NHA A and DON B provided no explanation as to why R3's Care Plan was not initiated until 7/14/2021, and why it was not updated after each fall as indicated. Surveyor asked how direct-care staff were to know what interventions to implement in order to reduce R3's risk for falling. NHA A stated any information, such as R3's preference to sleep in the recliner, would be relayed verbally during shift report. DON B stated staff can also refer to the Kardex, which is on the computer, as well as a printed copy that is kept in a binder for each hall. Surveyor reviewed R3's current Kardex as of 9/21/2021, which read in part: Safety: Sleeps in recliner for best comfort .Skin: 1 ASSIST for bed mobility Sleeps in recliner and in bed .Mobility: 1-ASSIST for walking with 2WW Wheelchair to follow for safety. Manual high-back wheelchair for mobility Able to self-propel. DON B stated facility does not keep previous copies of Kardex; therefore Surveyor is unable to determine what was in place at time of R3's falls.

Based on interview, record review and policy/procedure review, the facility did not establish an Infection Control Program under which it investigates, controls and prevents infections in the facility, or implement procedures such as isolation to prevent the spread of infections such as Covid 19. This has the potential to affect all 40 residents that reside in the facility. The facility did not implement their infection prevention and control program in a timely manner. They did not: -Maintain their procedure for accurately tracking all residents and staff with signs/symptoms of acute respiratory symptoms through daily surveillance -Utilize the surveillance to identify that an outbreak had occurred on 03/05/20. One staff member Certified Nursing Assistant (CNA) C on 3/04/20 with fever, cough and myalgia. On 03/05/20, Resident (R) 2, R3, and R15 became symptomatic with 2 or more respiratory symptoms. An additional 6 residents living on the same unit had at least one respiratory symptom of coughing on 03/05/20. -Implement aggressive measures (isolation) to prevent the spread of the infection in a timely manner -Notify appropriate agencies with accurate and complete information at the time of the outbreak -Assure housekeeping immediately initiated a more intensive cleaning procedures -Document return to work dates for employees that were ill, to ensure they were not symptomatic and to prevent spread of infection. -Identify and isolate suspected Covid 19 residents and seek prompt testing This is evidenced by: Surveyor reviewed the facility's Infection Control policy. The policy states that the facility Infection Control Officer provides oversight of the infection control program. SURVEILLANCE Under the heading Daily, the policy states: 1. Infection Control log 2. Facility Spot Map 3. Infection report for each infection using the Criteria for Determining an Infection. File a report in the clinical record/scan to the EMR (Electronic Medical Record) . Surveyor reviewed a policy entitled Suspected or Confirmed COVID-19 Management Policy that includes in part, The center will implement isolation procedures (contact and droplet) for residents who are positive for or suspected positive for Covid-19 . The center's Infection Preventionist will follow the center's Infection Control surveillance policy and CMS/CDC/state agency/local and state public health department guidance for resident and staff monitoring to promote early detection. All residents will be screened for signs/symptoms of respiratory illness and/or fever at least each shift. Licensed staff will document the assessment in the electronic medical record. Any concerns identified during screening will be addressed including primary care provider notification, resident/representative notification, Medical Director notification, DON notification and Infection Preventionist notification. If a resident develops a fever and/or any respiratory symptoms, isolation will immediately be implemented. On 05/20/20, Surveyor initiated a remote investigation. Surveyor requested and received a respiratory line list for an influenza outbreak that occurred in March 2020. Surveyor requested daily surveillance for respiratory illnesses for March, April and May. Surveyor reviewed the influenza outbreak timeline, that identifies the outbreak as occurring on 03/06/20. The line list does not identify the type of isolation or dates of isolation for the ill residents. The line list identifies CNA C as the last person listed on the active line list. Employee C had fever, cough and myalgia on 03/04/20, becoming the first ill staff or resident. An influenza swab was collected on 03/04/20 for suspicion of influenza. The facility was informed of the positive influenza result on 03/06/20. A symptom resolution date of 03/11/20 is documented; there is no information for a return to work date. The timeline provided documents all ill residents were isolated in their rooms on 03/06/20. The respiratory line list contains 3 additional staff members that became ill. The list contains a resolution date of symptoms but no information on well date to determine return to work status. Surveyor interviewed the Infection Preventionist, Registered Nurse (RN) D, to ask what hall CNA C worked. RN D stated at that time staff were working both halls. The line list identifies 6 residents that reside on the 100 hall (R11, R12, R13, R3, R4, R14) had at least one respiratory symptom on 03/05/20. In addition R2 is on the line list 03/05/20 with two symptoms of respiratory illness, cough and myalgia. Surveyor reviewed the nurses' notes that identify R2 had respiratory symptoms start on 03/04/20. The line list is inaccurate for R2. R3 had fever, cough, and myalgia with onset of 03/05/20. R15 is on the line list with onset date of 03/05/20 with symptoms of fever, myalgia and cough. This is the fourth illness of staff and residents that meet the definitions below. The facility provided Surveyor with CDC influenza guidelines and the Department of Public Health memo regarding influenza. Surveyor asked RN D which one they use. RN D stated, I think it is always CDC. The CDC guideline instructs, .Influenza testing should occur when any resident has signs and symptoms that could be due to influenza, and especially when two residents or more develop respiratory illness within 72 hours of each other. The DPH memo instructs, If 3 residents with 2 or more acute respiratory symptoms occur within 72 hours an outbreak may be occurring. The facility met both of these definitions on 03/05/20. Surveyor reviewed the nurses' notes of R4 who is on the line list with onset date of 3/06/20. The nurses' notes document the respiratory symptoms of dry cough, sneezes, and nasal drainage started 03/05/20. R5 has an onset date of 03/06/20 on the line list. Surveyor reviewed R5's nurses' notes that identify 2 respiratory symptoms of dry cough and hoarse voice started on 03/05/20. The line list is inaccurate with the onset dates of respiratory illnesses for R4 and R5. Surveyor reviewed R11's nurses notes' that identify symptoms of a fever of 102.3. The fever is not marked as a symptom on the line list. The documented surveillance list for respiratory symptoms is inaccurate in several areas. This would prevent prompt identification of a respiratory outbreak in the facility. On 05/21/20 at 9:30 a.m., Surveyor interviewed RN D and Director of Nursing (DON) B. Surveyor asked when they identified the respiratory outbreak. RN D indicated 03/06/20. Surveyor reviewed the definitions of an outbreak and the line list with RN D asking what date the facility met the definition of an outbreak per the CDC definition or State of Wisconsin DPH memo. RN D stated, It was on 03/05/20; we missed it. Surveyor reviewed the medical records of residents with respiratory symptoms for isolation dates. The medical record contains no information on isolation type or dates. The line list does not identify dates or types of isolation for ill residents with respiratory symptoms. Surveyor noted the only documented isolation for the ill residents is noted on the timeline provided as starting 03/06/20, one day after the outbreak should have been identified. The facility did not initiate notification of public health, enhance cleaning, do prompt isolation, discontinue activities, or notify the medical director until 03/06/20. On 05/20/20 at 4:00 p.m., Surveyor interviewed the Nursing Home Administrator (NHA) A and DON B asking again for daily surveillance for April and May. DON B stated they do not have a sheet unless there would be an outbreak. DON B went on to say they do Covid Tracker charting in the Electronic Health Record each day. Surveyor asked if a nurse on one hall enters a resident and a nurse on the other hall enters 2 residents, who will know when they have a cluster of 3 residents with respiratory symptoms. The DON B stated it would be in report and it would go on a clinical follow up tool. Surveyor asked to review these for April and May. Surveyor received the clinical follow up tool. This is used as a 24 hour report for all residents. It contains resident information for falls, medication changes, labs etc. The tool does not contain any area for signs and symptoms of a respiratory illness, isolation type or dates of onset. Surveyor received the Monthly Line List/Monthly Healthcare Associated Infection Incidence Rate reports for March, April and May. Surveyor compared the May report above with the clinical follow up tool for May 2020. The infection control line list/monthly HAI Incidence Rate report for May contains the type of infection, culture result and antibiotic used. It does not contain specific signs and symptoms of an infection for daily surveillance to identify an outbreak. Surveyor reviewed the nurses' notes of R6 who is listed on the clinical follow up tool 05/19/20. R6 is not listed on the infection control line list/monthly HAI log in May. The nurses' notes document R6 started with respiratory symptoms of increased shortness of breath, and change in lung sounds on 05/11/20. The Covid tracker is completed the same day and does not identify any symptoms. On 05/18/20, the nurses' notes document R6 has complaints of shortness of breath and an O2 saturation of 88% on 3.5 L of oxygen. The Covid Tracker documents no symptoms on this date. The listed symptoms in the nurses' notes do meet the signs and symptoms outlined by CDC for the elderly for potential Covid. R6 was hosptalized on [DATE]. R6 was put on the clinical follow up tool 8 days after respiratory symptoms had started. R6 did test negative for Covid 19 at the hospital on [DATE]. Surveyor reviewed nurses' notes for R7 who had symptoms of feeling sleepy with oxygen saturations of 84-85% on room air on 05/16/20. The Covid Tracker completed the same date marks O2 sat less than 90% and no symptoms present. R7 is not on the monthly line listing/HAI incidence report, or the clinical follow up report on 05/16/20. On 05/18/20, R7 was more confused, O2 sat at 78 room air, no appetite, bilateral lobe crackles. The Covid Tracker identifies abnormal lung sounds, but not O2 saturations less than 90%. A chest X-ray was performed on 05/18/20 that was negative for TB, pneumonia, and [MEDICAL CONDITION]. R7 is not on the clinical follow up tool list until 05/19/20, 3 days after the onset of respiratory symptoms. The clinical follow up tool sheet does not identify specific symptoms or isolation. R7 had respiratory symptoms that meet the definition for possible Covid in the elderly population. R7 was hosptalized on [DATE] with inability to maintain her oxygen saturation levels. R7 is on the monthly line listing/HAI Incidence rate report sheet with onset of 5/16/20 with admitted to hospital [DIAGNOSES REDACTED]. R7 did test negative for Covid 19 at the hospital. SYMPTOMS: The CDC defines COVID-19 symptoms in the elderly as: Cough, fever (100.0), shortness of breath or difficulty breathing, muscle or body aches, fatigue, headache, nausea or vomiting, diarrhea, chills, sore throat, congestion or runny nose and loss of taste or smell . Older adults with COVID-19 may not show typical symptoms such as fever or respiratory symptoms. Atypical symptoms may include new or worsening malaise, new dizziness, or diarrhea .(cdc.gov/coronavirus 05/20). KEY STRATEGIES TO PREPARE FOR COVID-19 IN LONG TERM CARE FACILITIES CDC 05/20/20. Identify infections early: Actively screen all residents daily for fever and symptoms of COVID-19; if symptomatic, immediately isolate and implement appropriate Transmission-Based Precautions . Identification of these symptoms should prompt isolation and further evaluation for COVID-19. Notify your state or local health department immediately (<24 hours) if these occur: Severe respiratory infection causing hospitalization or sudden death Clusters (=3 residents and/or HCP) of respiratory infection Individuals with suspected or confirmed COVID-19. Surveyor reviewed a list of current residents on transmission based precautions for current compliance with isolation dates. Surveyor reviewed the medical record, and infection control monthly line list/HAI incidence rate to find the dates and types of isolation for R8, R9 and R10. Surveyor could not locate the dates for initiation of precautions. Surveyor interviewed RN D asking where to find the information. RN D indicated it would be on the care plan for each resident. Surveyor went into the electronic medical record after the interview and located care plans with isolation type and dates that were created after the interview. The care plans were all dated 05/20/20. Surveyor noted during review of the clinical log follow up reports, that on weekends there is no information entered for infection surveillance. On 05/27/20 at 9:45 a.m., Surveyor did a telephone interview with the NHA and RN D to review the concern with daily infection control surveillance. The symptoms in the nurses' notes for ill residents are not on the Covid Tracker electronic charting or accurately on surveillance lists. Surveyor asked RN D if the Covid Tracker is the system she is using to identify respiratory outbreaks. RN D and NHA A indicate they can see the confusion. NHA A stated the clinical log is a daily report sheet, and the monthly line list/HAI monthly incidence rate report is tracking actual infections. NHA A stated the facility is implementing a system to do accurate daily surveillance. Surveyor asked about Covid testing process for residents with respiratory illness. Surveyor asked why R6 and R7 were not tested as soon as they manifested respiratory symptoms per CDC guidance. The NHA indicated the facility has decided to do facility wide testing and has ordered testing supplies.

Based on interview and record review, the facility did not develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and goals in order to meet a resident's medical, nursing, and psychosocial needs, which are identified in the comprehensive assessment. This occurred for 1 of 3 sampled residents (Resident (R) 1) whose care plans were reviewed. R1 did not have a care plan developed for [MEDICATION NAME] care visits with measurable objectives and goals to meet R1's psychosocial needs. This is evidenced by: R1 is [AGE] years old, married and has one young child. R1 was admitted to the facility on [DATE] after suffering a cerebral infarction resulting in left sided [MEDICAL CONDITION] and [MEDICAL CONDITION] (inability to use the left side). The most recent quarterly Minimum Data Set (MDS) documents R1 has a Brief Interview for Mental Status Score of 15, meaning she is alert and oriented and able to answer questions accurately. Surveyor interviewed 6 alert and oriented residents to ask about visitation restrictions during the coronavirus pandemic and how it was affecting them. Five of the six residents indicated they were not leaving the building, and no visitors were coming in. On 05/21/20 at 2:20 p.m., Surveyor interviewed R1 about visits. R1 stated she goes out to the park about once a week. Surveyor asked how she gets to the park. R1 indicated Social Worker (SW) pushes her down the street. Surveyor asked if any other people are at the park when R1 goes there. R1 indicated a few people but they stay far away from her. R1 informed Surveyor a mask is worn at all times when R1 leaves the building. On 05/21/20 at 3:40 p.m., Surveyor interviewed SW E to ask about visitation restrictions. SW E indicated no visitors are allowed, and residents only go out for medical appointments. Surveyor asked about R1 going to the park. SW E indicated R1 does go to the park about once a week. Surveyor asked why this one resident was going to the park. SW E indicated R1 was very young and has a young child that would not be allowed in the building due to potential asymptomatic spread of [MEDICAL CONDITION]. Surveyor asked if R1 is visiting with her husband and child at the park. SW E stated Yes, they wear masks and stay 6 feet apart. Surveyor asked if the young child understands to keep the distance. SW E indicated that SW E reminds and redirects to keep the needed distance. Surveyor asked how long the visits have been occurring. SW E indicated since the end of April. On 05/21/20 at 3:50 p.m., Surveyor interviewed Certified Nursing Assistant (CNA) F to ask if R1 is on precautions. CNA F indicated R1 is not on precautions as she never leaves the building. Surveyor had reviewed the medical record prior to this interview and noted no social services notes or assessment for [MEDICATION NAME] care visits. The care plan did not contain any information on [MEDICATION NAME] care visits. On 05/21/20 at 4:00 p.m., Surveyor interviewed the Nursing Home Administrator (NHA) and asked if R1 was leaving the building for visits. NHA indicated R1 was going out for [MEDICATION NAME] care visits due to her young age, having a young child and a planned surgery June 16th to replace part of skull that was removed during surgery post [MEDICAL CONDITION]. The NHA indicated it will be a very risky surgery and R1 may not survive. Surveyor asked for the assessment and care plan for the [MEDICATION NAME] care visits. The NHA indicated it would be in the care plan. After the interview, Surveyor went into the electronic health record and noted a care plan for [MEDICATION NAME] care was developed on 05/21/20 after the surveyor interview.

Based on observation, interview and record review, the facility did not always serve food that was palatable and served at the right temperature. This was voiced for 3 of 14 sampled residents and 3 supplemental residents (R) (R31, R4, R18, R28, R3, and R10). R31 stated the food served did not taste good and was often served cold. During Resident Council interview R4, R18, R28, R3 and R10 all voiced that the food was often served cold and unpalatable. One test tray during survey found food temperatures were cold. Findings include: On 02/09/20 at 11:19 AM, Surveyor interviewed R31 who stated the food served was not good. R31 stated the food served to R31's room was sometimes cold, and did not taste good. R31 stated these concerns were voiced at the resident food meeting, but the food temperatures or palatability did not improve. Record review showed R31's most recent Brief Interview for Mental Status score was 15. This indicated R31 was cognitively intact. On 02/09/20 at 12:39 PM, Surveyor observed R31 served a lunch tray in R31's room. R31 stated the food was lukewarm. R31's spouse was present and stated the food is often cold by the time it is served to R31's room. On 02/10/20 at 11:05 AM, Surveyor interviewed the Resident Council group about food palatability and temperatures. R4, R18, R28, R3 and R10 all expressed concern that the food often does not taste good or is served cold. R4 stated menu selections, the quality of food, how it is prepared, and the serving temperatures have been ongoing problems that are discussed at every meeting. On 02/10/20, a test tray was delivered to the conference room at 12:41 PM from the cart that delivered trays to resident rooms. Surveyors tested the temperatures of the food immediately. The meat (pork loin) was 90 degrees. The meat, when tasted, was moist and flavorful, but lukewarm. The carrots were 89 degrees, and tasted cold. The rice was 90 degrees, and tasted barely warm and pasty. The milk was 50 degrees, and tasted warm and unpalatable. On 02/10/20 at 1:25 PM, Surveyor interviewed Dietary Manager (DM) D. Surveyor informed DM D of the food temperatures on the test tray delivered to the conference room at 12:41 PM. Surveyor informed DM D the food temperatures were measured by this Surveyor immediately with three Surveyors as witness. DM D stated those food temperatures were not okay. DM D stated the foods measured appropriate temperatures prior to serving in the kitchen. Surveyor informed DM D that R31 and spouse reported food was often cold and unpalatable when delivered to R31's room. Surveyor informed DM D that multiple residents voiced concerns about the food temperatures and palatability at resident group interview.

Based on interview and record review, the facility failed to develop the comprehensive care plan to accurately reflect the current status for 1 of 17 residents, whose care plans were reviewed, Resident (R) 34. R34's care plan had not been developed to include constipation. This is evidenced by: R34 was admitted to the facility on [DATE] and did not have a [DIAGNOSES REDACTED]. On 02/09/20 at 10:19 AM, Surveyor interviewed R34 during initial tour. R34 stated she was constipated at times, but received medication for the constipation. R34 stated the medication relieved the constipation. On 02/09/20, Surveyor reviewed R34's medical record. The physician progress notes [REDACTED]. The physician stated due to R34's history of urinary tract infections [MEDICAL CONDITION], constipation can worsen urinary symptoms. The physician ordered [MEDICATION NAME] 17mg po (by mouth) daily for constipation Constipation Assessments were done on 1/16/19, 3/4/19, and 6/3/19. These assessments indicated R34 had bowel movements (BM) 1-2 times per 1-2 days and R34 had zero duration of years for constipation. The constipation assessment on 1/24/20, indicated R34 had a BM 1-2 times per every 1-2 days, but had 5-[AGE] years of constipation. The assessment stated resident receives [MEDICATION NAME] for constipation and stated it had been effective. R34's medication orders stated [MEDICATION NAME] powder-give 17 grams by mouth daily, [MEDICATION NAME] suppository-insert 1 unit rectally as needed for constipation (start date 5/5/19), and Milk of Magnesia-give 30 ml (milliliters) every 24 hours as needed for constipation(start date 3/31/19). Surveyor reviewed R34's bowel record for (MONTH) 2019, (MONTH) 2019, (MONTH) 2020 and (MONTH) 2020. Bowel movements were recorded every 1-3 days. Milk of Magnesia (MOM) was given to R34 on 1/4/20 and 1/6/20. Surveyor reviewed R34's care plan. Care plan had not been developed to include constipation, interventions, or goals. On 02/11/20 at 10:15 AM, Surveyor interviewed Nursing Home Administrator (NHA) [NAME] Surveyor asked NHA A if she was aware R34 had no care plan for constipation and was receiving medications for constipation. NHA stated, No. NHA A stated the issue would be worked on right away.

Based on interview and record review, the facility did not provide necessary care and services in order to attain or maintain the highest practicable physical, mental, and psychosocial well-being. This occurred for 2 of 3 sampled residents being reviewed for constipation, Resident (R) R11, R25. R11 had 8 incidents of constipation from 12/29/19 - 02/08/20. The facility did not follow the bowel protocol for constipation or add interventions to decrease constipation for R11. R25 had four incidents of constipation since admission on 12/20/19. The facility did not follow the bowel protocol for constipation or add interventions to decrease constipation for R25. This is evidenced by: 1. During the initial tour on 02/09/20 at 11:58 AM Surveyor interviewed R11 and asked if there are any issues with constipation. R11 replied and said, I am real constipated for a long time. Surveyor asked if R11's medications for constipation have been adjusted. R11 stated, I don't know but I'm still constipated and they manually help get it out. I wish they didn't have to do that. Facility policy in part, Bowel Management Program, 06/2017, Purpose: To avoid constipation, to restore the resident' dignity and self respect .Assessment: Review bowel movement flow sheets .2.Ensure the resident is well hydrated and constipation has been addressed by dietary and or medical interventions .6. After third day, if resident has not had a bowel movement assess diet and hydration, consider a laxative as ordered by the physician .7. Is the stool is hard, consider a stool softener .9. Resident should not be allowed to go for more than three days without a bowel movement. R11 was admitted on [DATE] with [DIAGNOSES REDACTED]. Care plan in part: (Resident name) exhibits an alteration in elimination of bowel AEB occasional constipation and usual incontinence of bowel r/t immobility, medications, MS . will have a normal, soft bowel movement at least every 3 day . will not experience skin breakdown or complications from bowel incontinence. Encourage to be up at least once daily in wheelchair, Medications as ordered- scheduled stool softeners, Monitor bowel movement schedule and administer PRN stool softeners or notify MD when needed. Physician orders [REDACTED].>[MEDICATION NAME] Sodium Tablet Give 200 mg by mouth two times a day for constipation. Pharmacy Active 11/8/2019. [MEDICATION NAME] Tablet (Sennosides) Give 1 tablet by mouth one time a day for constipation. Pharmacy Active 9/4/2019. As needed (prn) laxative orders: [MEDICATION NAME] Powder (Polyethylene [MEDICATION NAME] 3350) Give 17 gram by mouth as needed for constipation daily in AM as needed. Pharmacy Active 7/8/2019. Senna-[MEDICATION NAME] Sodium Tablet 8.6-50 MG (Sennosides-[MEDICATION NAME] Sodium) Give 1 tablet by mouth as needed for constipation take daily as needed. Pharmacy Active 7/8/2019. Milk of Magnesia Suspension 1200 MG/15ML (Magnesium [MEDICATION NAME]) Give 30 ml by mouth as needed for constipation daily as needed. Pharmacy Active 7/8/2019 16:45. [MEDICATION NAME] Suppository 10 M[NAME] Insert 1 suppository rectally as needed for constipation daily prn. Pharmacy Active 7/8/2019 16:45. Surveyor requested the bowel record for R11 from 12/29/19 to present. The documentation is as follows: 12/29/19 - Medium Bowel Movement (BM) 01/04/20 - Large BM (Day 6 with no bowel movement) 01/06/20 - Large BM 01/11/20 - Large BM (Day 5 with no bowel movement) 01/15/20 - Large BM (Day 4 with no bowel movement) 01/21/20 - Large BM ( Day 6 with no bowel movement) 01/28/20 - Large BM (Day 6 with no bowel movement) 02/05/20 - Small BM (Day 8 with no bowel movement) 02/08/20 - Large Bowel Movement (This is day 10 before R11 has a normal sized bowel movement) Surveyor requested the as needed Medication Administration Record [REDACTED]. Surveyor received the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The dates were 01/04/20 and 01/13/20. R11 did not receive any of the four ordered as needed laxatives when the bowel record shows multiple days without a bowel movement. Surveyor reviewed the nurses' notes and did not identify any documentation of manual removal of bowel. The scheduled laxative medication was not changed, the as needed laxative given, nor dietary changes made to help prevent constipation for R11. On 02/10/20 at 2:30 p.m., Surveyor interviewed Director of Nursing (DON) B to ask if any other medications had been given or changes to the scheduled medications for constipation. DON B stated she was alarmed when the bowel record was reviewed. The facility is creating a new policy and will do education with the nursing staff on the bowel protocol. 2. R25 was admitted on [DATE], and has [DIAGNOSES REDACTED]. R25's admission Minimum Data Set (MDS) documents a Brief Interview for Mental Status (BIMS) score of 15, meaning R25 is cognitively intact. The MDS documents R25 has constipation. Upon admission, R25 had Physician orders [REDACTED].>1. [MEDICATION NAME] Sodium 100mg by mouth twice daily for constipation. 2. [MEDICATION NAME]/[MEDICATION NAME] 7.5mg/325mg: 1 tablet every 4 hours PRN (as needed) for pain. *[MEDICATION NAME] is an Opioid, known to cause Opioid-Induced Constipation. 3. [MEDICATION NAME] Suppository 10mg rectally once daily PRN for constipation. 4. Polyethylene [MEDICATION NAME] (Clear Lax Powder) 17grams mixed in liquid PRN for constipation. 5. New order started on 2/5/2020 for Polyethylene [MEDICATION NAME] ([MEDICATION NAME] Powder) 17 grams scheduled in the morning for constipation. Surveyor reviewed medical record for bowel patterns and medication administration. Surveyor noted the following documentation: R25 received [MEDICATION NAME] Sodium twice daily every day since admission; no missed doses. 12/20/2019: Large bowel movement (BM). 12/28/2019: Medium BM (8th day with no BM and no PRN constipation medications administered) 12/29/2019: 2 medium BMs. 12/30/2019: 1 dose of PRN Polyethylene [MEDICATION NAME] administered (1st day with no BM) 1/8/2020: Medium BM (10th day with no BM) 1/11/2020: 1 dose of PRN Polyethylene [MEDICATION NAME] administered (3rd day with no BM) 1/12/2020: [MEDICATION NAME] Suppository administered at 1:07 PM (4th day with no BM) 1/12/2020: 1 large BM at 3:07 PM and 1 small BM at 9:37 PM. 1/14/2020: 1 small BM at 12:24 PM. 1/14/2020: [MEDICATION NAME] Suppository administered at 4:25 PM (2nd day with no BM) 1/14/2020: 1 large BM at 9:08 PM. 1/17/2020: 1 dose of PRN Polyethylene [MEDICATION NAME] administered (3rd day with no BM) 1/20/2020: [MEDICATION NAME] Suppository administered at 8:01 PM. (6th day with no BM) 1/20/2020: Large BM at 9:17 PM. 1/27/2020: Small BM (7th day with no BM and no PRN constipation medications administered) On 2/9/2020 at 10:36 AM, Surveyor interviewed R25. R25 stated her pain is effectively being treated, but the medication causes constipation. R25 stated this was a continued struggle. Surveyor asked if R25 took any medications to help with constipation. R25 stated she takes medication to help, but it doesn't work.

Based on observation, interview and record review, the facility did not attempt the use of alternatives, or assess for the risk of entrapment prior to the use of bed rails for 2 of 5 sampled residents (R) with bed rails (R42, R92). R42 and R92 had bed rails applied before alternative measures were attempted. A risk for entrapment was not documented before the bed rails were applied. This is evidenced by: 1. R42 was admitted on [DATE] with acute diastolic [MEDICAL CONDITION], chronic [MEDICAL CONDITION] with [MEDICAL CONDITION], and weakness. Nurses notes in part, 12/13/2019 14:59 Admission Summary Note Text: Resident arrived at 1400 with CHS van and driver with self. History of [MEDICAL CONDITION], Acute on chronic diastolic [MEDICAL CONDITION], allergic rhinitis, anxiety, chronic [MEDICAL CONDITION] (stage 3), chronic [MEDICAL CONDITION] with [MEDICAL CONDITION] and hypercapnia, diabetes mellitus type 2, [MEDICAL CONDITIONS] reflux, GERD, HTN, interstitial lung disease, migraine headache, [MEDICAL CONDITIONS] HTN, reactive airway disease, situational depression, Von Willebrand disease, weakness. Resident was oriented to room with call light in place, remote for tv, introduced to roommate. Resident resting comfortably in bed with [MEDICAL CONDITION] per resident's request. 12/14/2019 21:33 General Note Note Text: Resident refused meal, remains in bed. Needs Frequent repositioning and anxiety of oxygen. 12/16/2019 13:37 General Note Note Text: IDT met and reviewed: Discussed risk areas upon admission . falls- Not at high risk, is transferring with a hoyer lift. Is comfort cares only. Enrolling in hospice today . Weight loss/Dehydration- high risk, resident is refusing most meals. Enrolling in Hospice today. 12/16/2019 15:03 Social Service Note Text: 72 hour care conference held on this day. D/t cognition (Resident name) was unable express how things have been going since admission . At this time Heartland Hospice is unable to admit to hospice d/t (Resident Name) not responding . Surveyor notes the medical record documents R42 is admitted in a weak condition with inablility to understand and consent to a hospice admission. R42 is her own person at this time. R42 would not be unable to understand the risks of the bed rails in this condition. Physician orders, Bilateral grab bars for bed mobility. No directions specified for order. 12/16/2019 On 02/11/20, Surveyor looked for a bed rail assessment in the Electronic Health Care Record (EHR) and could not locate an assessment. At 8:10 a.m., Surveyor requested the assessment from Nursing Home Administrator (NHA) [NAME] Surveyor reviewed the baseline care plan; it does not contain any updated information on bed rails being used for R42. At 8:55 a.m., NHA A came to Surveyor and stated they do not have an assessment for the bed rails for R42. On 02/11/20 at 10:40 a.m., Surveyor interviewed NHA A and asked if any alternatives were tried prior to installing the bed rails on R42 as a new admission to the facility. NHA A indicated no other interventions were tried prior to getting the order for the rails. Surveyor asked if there was consent for the rails. NHA A indicated no consent was obtained. 2. R92 was admitted on [DATE] with a history of a [MEDICAL CONDITION] mass, on comfort cares. R92 has not had the Brief Interview for Mental Status completed on the Minimum Data Set at this time. During the initial tour on 02/09/20 Surveyor attempted to interview R92. R92 was confused and unable to answer any questions accurately. R92 has a history of a fall occurring on 01/31/20, increasing R92's risk for entrapment in a bed rail. Surveyor observed bed rails on R92's bed during the initial tour on 02/09/20, and on 02/10/20. Physician order [REDACTED].>Bilateral Grab Bars for bed mobility. No directions specified for order. Active 2/3/2020 Side Rail Assessment 01/28/20 1. [NAME] Is resident able to state preference to utilize side rails on their bed? No B. Could this resident medically benefit by utilization of side rails? No. If any of the answers in the above section are No - stop here .exit the assessment. The side rails assessment was continued on and filled out with: C. Resident's cognitive status: confused, safety impaired, poor long and short term memory. D. Resident is able to follow directions? No E. Resident is able to the retain safety information? No 2. [NAME] Does the rail/grab bar restrict movement? Unanswered. 4. B. Is resident able to state preference about side rail/grab bar? Yes (This contradicts the answer in 1. [NAME]) Surveyor reviewed R92's baseline care plan, which did not identify the use of bed rails. On 02/10/20 at 2:30 p.m., Surveyor interviewed Director of Nursing (DON) B about the assessment asking if R92 has cognitive issues putting her at risk. Surveyor asked if the first two answers are no on the assessment if that means the resident is determined not safe for bed rails. DON B indicated that was her fault as she did that assessment. Surveyor asked where in the assessment the risk for entrapment is identified. DON B indicated it is not on the assessment. It was brought up last year during survey but corporate made no changes to the form. Surveyor asked what alternatives had been attempted prior to the installation of the rails. DON B indicated there were none. R92 would try to get up by herself so the rails were to help. Surveyor shared observations of R92 during survey, noting R92 was weak and confused, needing assistance with all transfers. Surveyor asked DON B if she thinks R92 is at risk to get entangled in the bed rail and has the cognitive ability to know what to do if her arm gets in the bed rail. DON B stated, No at this time she would not understand.

Based on record review and interview, the facility did not provide adequate monitoring to ensure the drug regimen was free of unnecessary [MEDICAL CONDITION] medications for 2 of 6 Residents (R) reviewed for unnecessary medications, R11 and R12. R12 had two orders for PRN (as needed) [MEDICATION NAME] (an anti-anxiety medication) with no indicated duration or documented rationale for the PRN order extending beyond 14 days. R11's PRN order for [MEDICATION NAME] ([MEDICAL CONDITION] medication for anxiety) did not have a rationale for continued use beyond 14 days. This is evidenced by: Example 1: R12 was admitted to facility on 12/11/2018, with [DIAGNOSES REDACTED]. R12 had current physician's orders [REDACTED].>1. [MEDICATION NAME] Tablet 0.5mg: Give 0.25 mg by mouth one time nightly PRN for anxiety. Start date for order: 1/7/2019; end date not indicated. 2. [MEDICATION NAME] Solution 2mg/mL: Give 0.5mg (0.25mL) sublingually every 2 hours PRN for anxiety or restlessness. Start date for order: 6/13/2019; end date not indicated. R12's most recent Minimum Data Set Assessment, dated 11/29/2019, indicated a Brief Interview for Mental Status (BIMS) score of 11, meaning moderate cognitive impairment. On 2/10/2020, Surveyor asked Director of Nursing (DON) B for a copy of the documented Physician's rationale for PRN [MEDICATION NAME] order extending beyond 14 days. Facility provided two Pharmacy Consultation Reports, as follows: Pharmacy Consultation Report, dated 4/11/2019, reads: R12 has a PRN order for an anxiolytic, which has been in place for greater than 14 days without a stop date: [MEDICATION NAME] Tablet 0.5 mg .Please select a duration: 1 month, 2 months, 3 months, 6 months .Recommendation: If the medication cannot be discontinued at this time, current regulations require that the prescriber document the indication for use, the intended duration of therapy, and the rationale for the extended time period. The Physician wrote the word palliative next to the circled duration of 6 months, signed and dated 4/23/2019. This would indicate the order would end in (MONTH) 2019; however, the order remained active and unchanged as of the date of survey. Pharmacy Consultation Report, dated 01/28/2020, reads: R12 has a PRN order for an anxiolytic, which has been in place for greater than 14 days without a stop date: [MEDICATION NAME] for anxiety .Recommendation: If the medication cannot be discontinued at this time, current regulations require that the prescriber document the indication for use, the intended duration of therapy, and the rationale for the extended time period. The Advanced Practice Nurse Practitioner (APNP)'s response: Stop date 6/1/2020. Diagnosis: [REDACTED]. Response signed and dated 2/10/2020 (same day Surveyor asked for documentation). Consultation report did not indicate which of the two [MEDICATION NAME] orders were being addressed. Surveyor received printed copy of R12's Physician order [REDACTED]. On 2/11/2020 at 7:33 AM, Surveyor interviewed DON B. Surveyor asked why end dates had not been updated following Physician's response on 4/23/2019. DON B was unable to provide answer. Surveyor asked for clarification of R12's current orders for two separate doses of [MEDICATION NAME]. DON Bwas unable to provide answer. DON B agreed that situation was confusing, and stated she would look into it further. 2. R11 was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of 10, meaning R11 has mild cognitive impairment. Anxiety care plan states in part: (Resident name) exhibits episodes of anxiety r/t: getting up, being social with peers (especially in dining room), temperature changes- gets hot and cold easily, and receiving new roommates. This is usually when she gets up in wheelchair, goes to dining room for meals, takes a shower, or is adjusting to new environment or changes. · Anxiety level will not interfere with ADL functioning. · (Resident name) will accept new roommates. · (Resident name) will be introduced to new roommates. · Administer medications as ordered. · Evaluate effectiveness and side effects of medications for possible decrease/elimination of [MEDICAL CONDITION] drugs PRN. · Offer choices to enhance sense of control. · Remove to quiet area and reassure. Physician orders [REDACTED].>[MEDICATION NAME] Tablet 0.25 MG Give 0.25 tablet by mouth every 12 hours as needed for anxiety. Pharmacy Active 12/9/2019. Surveyor reviewed the medical record for rationale of the continued antianxiety medication beyond 14 days. The medical record does not document rationale by the physician. Surveyor interviewed DON B asking for a progress note with physician rationale to continue beyond 14 days with the as needed [MEDICATION NAME]. DON B indicated she would provide that. At 10:00 a.m., Assistant Director of Nursing (ADON) C brought Surveyor a progress note, dated 08/27/19, 3 1/2 months prior to the 12/09/19 [MEDICATION NAME] order. It does not address rationale or duration for the [MEDICATION NAME] use. On 02/10/20 at 2:15 p.m., Surveyor interviewed DON B to ask if there was any additional information that would support the rationale for using the [MEDICATION NAME] beyond 14 days. DON B stated they do not have that information. The facility was not aware of the need to document the rationale. DON B has done education with the nurse practitioner today.

Based on observation, interview and record review, the facility failed to post daily staffing information in a prominent place, easily readable, and with the required information. This deficient practice affected all 41 of 41 residents in the facility This is evidenced by: On 2/10/20 at 2:00PM, Surveyor observation revealed the daily staffing posting was displayed on the side of a post at the nursing station. This location was not in a prominent place accessible to residents and visitors. Residents in a wheelchair could not see the daily staffing form as it was posted. The daily staffing form is posted at height of 5 feet, and not visible from the angle the residents would approach the nurse's station from. Review of the daily staffing form, dated 2/10/20, revealed the size of the print was too small to be read from a distance of approximately one foot. Further Review of the POS [REDACTED]. On 2/11/20 at 8:00AM, Surveyor observation revealed that the daily staffing posting was displayed on the side of a post at the nursing station. This location was not in a prominent place accessible to residents and visitors. Review of the daily staffing form, dated 2/11/20, revealed the size of the print was too small to be read from a distance of approximately one foot. Further Review of the POS [REDACTED]. A review of the daily staffing postings from 11/28/19 through 02/11/20, revealed all 69 postings failed to include the total number of hours worked by the registered nurses, the licensed practical nurses, and the certified nurse aides. On 02/11/20 at 10:15 AM, Surveyor interviewed Nursing Home Administrator (NHA) [NAME] Surveyor asked NHA A if she was aware the daily staff posting did not include the number of hours worked by registered nurses, the licensed practical nurses, and the certified aides. NHA A stated she was aware the total hours were not on the postings. Surveyor asked if the posting was accessible in a prominent place where residents and visitors could clearly read the format. NHA A said it was posted on the side post at the nursing station so the staff would be reminded to fill it out. NHA A stated she thought the residents would just come up to the desk and ask if they had questions.

Based on interview and record review, the facility did not ensure each resident's drug regimen is free from unnecessary drugs, without adequate indications for use. This occurred for one of one residents (Resident (R) 35) who were reviewed for antibiotic use. R35 is taking a [MEDICATION NAME] medication to prevent urinary tract infections. The resident has been taking the antibiotic without a clinical rationale for its use. This is evidenced by: According to the Centers for Disease Control (CDC) campaign, and the American Medical Directors Association (AMDA), Long term care facilities should have clear policies and procedures to ensure patients are not started on antibiotics without a credible clinical picture. Facilities should establish minimum criteria for initiating antibiotics, using the McGeer, Loeb, or modified Loeb criteria as a starting point (AMDA Common Infections in the LTC Setting, 2011). On 03/18/19, Surveyor reviewed R35's medical record. The resident has [DIAGNOSES REDACTED]. The resident was admitted to the facility, on 02/08/19. The resident has an indwelling Foley catheter and has had the catheter since admission. The resident has been taking the following medication for the prevention of UTIs (i.e. [MEDICATION NAME] of UTIs): -[MEDICATION NAME] (an antibiotic medication) 250 milligrams, at bedtime, since 02/08/19. The medical record does not identify a clinical rationale for the continuous use of R35's [MEDICATION NAME] antibiotic. Surveyor reviewed R35's care plan. The care plan does not identify the resident is receiving a scheduled antibiotic for the prevention of UTIs. Surveyor reviewed the resident's nurses' notes. A note, dated 03/01/19, states the following, in part, .On AM shift, (R35) thought she 'gave birth' and was asking questions about the baby she gave birth to. Res (Resident) was asked where she was and she reported 'hospital' .After a bit, res understood it was just a BM (Bowel Movement) and she did not give birth. UA (Urine Analysis to check for UTI) was requested from res PCP (Primary Care Physician). It was found R35 was positive for a urinary tract infection. On 03/19/19, Surveyor asked the Nursing Home Administrator for the physician's rationale for the use of the [MEDICATION NAME] for the prevention of UTIs. At approximately 3:00 p.m., Surveyor received a fax cover sheet, dated 03/19/19, which states the following, in part, .To: (Name of R35's primary physician) .Please provide rationale for (Name of R35) [MEDICATION NAME]? .Urogenital implant, recurrent UTI . On 03/20/19 at 10:18 a.m., Surveyor interviewed the Director of Nursing (DON). The DON stated the facility did not have a clinical rationale from a physician for R35's use of the [MEDICATION NAME] antibiotic, until 03/19/19. The DON stated the facility is planning on discontinuing the use of the [MEDICATION NAME] medication. The facility uses the McGeer criteria to define UTIs and for their antibiotic stewardship policies.

Based on observation, interview and record review, the facility did not ensure the environment remained free of accident hazards and each resident received adequate supervision and assistive devices to prevent accidents for 1 of 10 residents (Resident 1) reviewed. On 12/02/16, Resident 1 (R1) had a seizure and fell out of bed, and R1's left hip touched the hot baseboard heater and sustained a second degree burn. The facility did not continue to provide supervision and assistance devices needed to prevent falling out of bed and onto or against the heater. The facility's failure to identify a potential environmental hazard and for failing to provide the supervision and assistance devices needed to prevent R1, who had a history of [REDACTED]. The Nursing Home Administrator was informed of the immediate jeopardy on 01/04/17 at 11:10 a.m. The facility removed the immediate jeopardy on 01/04/17; however, the deficient practice continues at a scope and severity D as the facility continues to implement its action plan. This is evidenced by: R1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], documents R1 as being severely cognitively impaired. Review of R1's medical record documented in the physician History and Physical hospital note dated 10/14/16: .She has got severe dementia and seizure disorder. Came to the emergency room because of seizures and fever .Past Medical History: She has a history of dementia, seizures, TIAs, seizures .Labs: .valproic acid is 21. (Normal range is 50 -100). She got a valproic load in the ER. I am going to put her on valproic IV . Review of physician orders [REDACTED].>02/08/16 Valproic Acid 250 mg / 5 ml soln, Give 10 ml (=500 mg) by mouth once daily for seizure 02/08/16 Valproic Acid 250 mg / 5 ml soln, Give 15 ml (=750 mg) by mouth at bedtime for seizure 11/07/16 right 7 left landing pad to promote safe exit from bed right & left grab bar to assist with bed mobility, perimeter mattress to promote safe bed mobility . 12/09/16 Notify (Dr. Name) MD A if more than 4 seizures in a 24 hr. period. Give Lorazepam for more than 1 seizure in a 24 hr. period may dissolve under tongue if needed. Review of the Medication Administration Record documented valproic acid medication not given or refused on: 10/20/16 and 10/21/16 a.m. dose and 10/19, 20, 21, 24/16 h.s. (at night) dose, 11/05/16 h.s. dose not signed as given or refused and 12/01, 02, 03 and 08/16 h.s. dose. FALLS Fall occurrence reports read in part: 02/07/16 6:30 a.m., .Type: Fall . Activity: In bed . Nurse's notes: Summoned to resident room found resident laying on the right side of bed on her right side curled up, Night RN, assessed situation and resident . Care prior to fall: Visually Observed 02/07/16 5:45 a.m .Recommendation: Toilet q (every) 2 hours while awake 03/26/16 8:00 p.m., .Type: Fall . Activity: In bed . Nurse's notes: I was walking by the residents room and noticed resident halfway out of bed. I went in there to get her back in bed and she slid on to the mat next to the bed .General Follow up Procedures: .All of her physical needs were met 30 minutes prior to the fall . Recommendations: None Noted . 04/04/16 9:00 p.m., .Type: Fall . Activity: In bed . Nurse's notes: CNA (Certified Nursing Assistant) reported that Resident was sitting on floor next to bed. Appeared that resident had slid out of bed Writer has observed resident swinging her legs out of bed in the past, repositioned when this occurs, offered fluids and checked to see that she was comfortable. Resident states no needs . General Follow up Procedures: .Will speak to the MD for input if the resident may have restless leg syndrome . Recommendation: Placed on MD rounding sheet to assess possibility of restless leg syndrome . 08/09/16 10:15 p.m., .Type: Fall . Activity: In bed . Nurse's notes: Aid informed nurse resident was on her knees on the floor . Care prior to fall: Repositioned 08/09/16 9:15 p.m General Follow up Procedures: .All physical care needs had been met . Recommendation: All staff education to have resident/offer to watch TV after supper, TV programs like Gunsmoke, Bonanza etc. offer a HS snack. Provide reposition/toileting during this time . 10/12/16 8:50 p.m., .Type: Fall . Activity: Other . Nurse's notes: At 22:50 on routine check, res observed lying on her right side on floor mat next to bed. It appears that res rolled out of bed. She was covered with a blanket which res must have put on . Position when found: Lying on her right side next to bed (floor mat in place & bed in low position). Head on her right . General Follow up Procedures: Resident was found on the floor mat next to her bed. Resident unable to communicate what she was doing was visualized in bed sleeping 15 minutes prior to that. Were attempting to do a sleep study to assess actual sleep pattern, was sent out to hospital on 10-13-16, so no sleep study done at this time. will (sic) do when returns from hospital . Recommendations: None Noted . Review of R1's care plan documented R1 was started on Remeron on 10/04/16. 12/02/16 9:00 p.m., .Type: Fall . Activity: In bed . Immediate Actions Taken: .Monitor reddened area on left hip for bistering (sic) . Nurse's notes: resident found on floor adjacent to radiator, reddened area noted left hip . Care prior to fall: Visually Observed: 12/02/16 8:30 p.m . Repositioned: 12/02/16 8:45 p.m General Follow up Procedures: Resident has history of seizure and was noted to have a seizure that day and resident is now on comfort cares. Resident will at time refuse medication and this includes anti seizure medication. Resident had perimeter mattress and bilaterally landing pads to prevent injury. Was found to left hip burn from heat register on her left hip, MD called and ordered bacitracin to site with light dressing. Will remain on comfort cares. No labs ordered in regards to seizure activity . Recommendations: None noted . Review of R1's care plan documented on 12/02/16 the bed was to be placed next to wall and was discontinued on 12/09/16. SEIZURES Review of nurse's notes document seizure activity, read in part: The SBAR Communication Form documents on 10/13/16 at 2:55 p.m. a change of condition of seizure 10/12/16 6:00 a.m. and on 10/12/16 R1 had a fall with the primary [DIAGNOSES REDACTED]. Review of the nurse's notes did not document R1's fall or seizure on 10/12/16. On 10/13/16 11:00 a.m., Resident noted in bed - had Lg Inc BM- also noted by CNA to be very sleepy- this nurse noted res. skin warm-sl. damp- and res having blowing respirations - res does have a hx of seizures . 10/19/16 9:45 p.m., .Noted to have tremors during mealtime . 10/20/16 9:45 a.m., .8:10 a.m. CNA informed of Res. having a seizure, limbs shaking & upper body, lasting approx < 1 minute 5:30 p.m. Having seizure activity @ 1700 - 1710 (5:00 p.m. - 5:10 p.m.) . 9:45 p.m., Orders from MD A for Lorazepam 1 mg po q 4 hours per seizures. 11:20 p.m . Res appears to be post-ictal, not talking & staring straight ahead . 10/21/16 12:30 p.m., t/o (telephone order) .comfort cares only . 12/01/16 12:15 p.m., just before lunch was summoned by CNA's Res having seizure activity, lasting couple minutes shaking of limbs . 6:30 p.m., Resident has short 30-45 sec seizures activity . 6:30 p.m., Seizure activity started again lasting 1 - 2 min 12/02/16 9:15 p.m., Resident fell out of bed, 2 seizure comfort care status. Left hip with mild burn 3 in. (inch) wide, 5 in. long with 1/4 welt in middle of burn. Director of Nursing (DON) notified .New Order .Bacitracin to burn with light dressing, call for blistering . 12/03/16 1:00 a.m . Left hip area with 3 in X 5 in area of redness and has blister (~ 2 in X 1/2 in) in middle of red area; blister intact . 12/03/16 1:00 a.m. Weekly skin assessment .perimeter mattress in use. (PM shift put mattress on floor after fall last evening). Bed next to wall on her right side and floor mat on her left side) . 12/08/16 9:30 p.m., Resident continues to have seizure activity this shift today X 3. Seizures lasting 30 - 45 sec. each . On 01/03/16 at 1:00 p.m., Surveyor observed cares being provided to R1. R1's bed was located approximately three feet from the wall with the baseboard heater and with the landing mat on the floor on the right side of bed. After the transfer to bed, the CNA placed another landing mat on the floor of the left side of the bed. On 01/03/16 at 3:00 p.m., Surveyor observed R1's bed located approximately three feet from the wall. The baseboard heater is four-foot long electric baseboard heater mounted approximately three inches above the floor. Surveyor touched the baseboard heater and immediately pulled hand back and received a red mark. The thermostat on the wall had a note over the front that read Leave (R1's roommate's Name) heat on High! Thanks. Surveyor observed a resident's room next door to R1. The heater was on and very hot to touch. Surveyor asked to see the maintenance director, who was not in the building at the time. Surveyor asked the Nursing Home Administrator (NHA) if he could get a thermometer to test the outside of the baseboard heater. The NHA got an instant read thermometer and tested the area that was touched by Surveyor ; this area read 189 degrees Fahrenheit. On 01/03/16, Surveyor interviewed the DON. The DON indicated R1's bed was moved back to the original location on 12/09/16 as the last seizure was on 12/08/16 and the MD had ordered Lorazepam and R1 is taking her medications now. It's safe to have the bed away from the wall and the seizures are stabilized and that was the root cause of the fall. Review of the care plans did not offer interventions of safety when R1 refuses to take medications to control seizures. On 01/04/16 at 7:35 a.m., Surveyor interviewed Maintenance Supervisor (MS) B about R1's burn. MS B indicated he did not know R1 received a burn from the heater. MS B stated, The heaters are very hot. MS B indicated the facility did not ask him if there could be something done different with the heater in R1's room to make it safe. MS B indicated the only thing would be is to move R1 away from the heater. MS B indicated all of the heaters get very hot when they are on. MS B indicated the heaters in the rooms are supplemental heat and the residents can turn them on or ask for the heaters to be turned on. MS B indicated he knows R1's roommate wants the heat on high. MS B indicated around the year 2009 or so he had taken the temperatures of the internal heater and it was around 300° F. MS B indicated each year he puts up signs to remind staff that the heaters are hot and to make sure to keep the heaters clear of blankets, etc. and don't touch. MS B gave Surveyor a copy of the posting that was in the employee break room, which read: Oct. 7, 16, Staff, Please be aware, wall heaters in Resident rooms have been turned on. The registers get very hot. Lets all make sure, no fabric, blankets, or clothing, or walkers, are touching the heat registers. (Thanks). At 9:00 a.m., Surveyor observed MS B look at R1's room thermostat setting at 75° F; this is at the highest setting. Surveyor observed MS B take the temperature of the baseboard heater with an instant read thermometer. The top of the baseboard heater read from 173° F to 176° F and the face of the baseboard heater read from 111° F to 123° F. MS B had a thermometer inside the heater touching the filament which read 431° F. At 9:55 a.m., Surveyor interviewed Registered Nurse (RN) C. RN C indicated R1's mattress was put onto the floor next to the wall by the PM shift and at the end of RN C's shift, staff put the mattress on the bed frame and was put back in the normal position. RN C indicated she has never witnessed R1 having a seizure. RN C indicated R1 is known to roll mostly to her left side and has rolled to her right side also. RN C indicated the resident beds are approximately three to four feet away from the baseboard heaters. The failure to protect this resident, who had a history of [REDACTED]. The immediate jeopardy that began on 12/02/16 was removed on 01/04/17 when the facility removed the resident from the heat source by repositioning the bed. The facility completed a sweep to identify residents that are totally dependent and/or cognitively impaired and at risk for falling out of bed. All staff were educated prior to working their next shift on the removal plan. The noncompliance remained at the scope and severity of D, while the facility continues to implement its action plan.

Based on observation, interview, medical record review and policy/procedure review, the facility did not ensure each resident received care and services to attain or maintain the highest practicable physical and mental well-being for 1 of 13 sampled residents reviewed for pain and comfort. Resident #6 complained of back, leg, buttock and shoulder pain during surveyor observations with transfers, turning and while Resident #6 was just sitting in her wheelchair in her room. The facility had completed a pain assessment 11/04/11. A routine pain medication was started 11/05/11 and was given once daily in the morning at 6:00 a.m. The facility did not complete a further pain assessment to determine if this resident continued to have pain later in the day and especially during cares of transfers and turning. This is evidenced by: The facility pain policy and procedure dated 07/2011 read in part as follows: "Extendicare Health Services, Inc (EHSI) recognizes that a resident's response to pain is subjective and individual. "Pain refers to any type of physical pain or discomfort in any part of the body. Pain may be localized to one area, or may be more generalized. It may be acute or chronic, continuous or intermittent, or occur at rest or with movement. Pain can also be expressed through behaviors in both verbal and non-verbal residents. The pain experience is very subjective; pain is whatever the resident says it is. "A full evaluation of pain includes: Origin, Location, Frequency, Type of pain, Severity, Alleviating factors, Exacerbating factors, Current treatment and Response to treatment. "Additional expressions of pain that need to be included in an evaluation include: "a. Vocalization of pain; Crying/Whining, Yelling, Gasping, Sighing, Moaning/Groaning/Grunting, Verbal Outburst. "b. Vocal complaints of pain; 'That hurts...Stop...Ouch'... "18. Screen residents for pain regularly through asking resident if they have pain, observing the resident during daily care, and/or observing for signs/symptoms of pain." On 01/09/12, Surveyor observed personal cares for Resident #6 beginning at 1:28 p.m. Surveyor observed Certified Nursing Assistants (CNAs) J and O transfer Resident #6 from her wheelchair to her bed using the mechanical total lift. During the transfer, Resident #6 moaned several times and CNA J stated to Resident #6, "You remember how it hurts your back when you go to bed." On 01/10/12 at 9:17 a.m., Surveyor was in the hallway and observed Resident #6 sitting in her wheelchair in her room; Surveyor heard Resident #6 say "Ow" twice. At 9:22 a.m., Surveyor spoke with Resident #6 and Surveyor re-introduced herself to Resident #6 and asked Resident #6 if it was alright with her if the surveyor watched the CNAs help her to bed. Resident #6 said "Yes," and then stated "This thing I am sitting on is hurting my butt." Resident #6 said this twice in the presence of Surveyor and CNAs H and I. Surveyor asked the CNAs if Resident #6 could be sitting on the mechanical lift sling. CNA I said, "No, it's on the sides." Surveyor observed CNAs H and I transfer Resident #6 from her wheelchair to her bed. During the transfer, Resident #6 said, "Ow, ow, it hurts my leg." CNA I asked which leg was hurting and Resident #6 identified it was her left leg. During the transfer, while Resident #6 was up in the lift, CNA H pushed the wheelchair away while Resident #6's urinary catheter bag was still attached to the bottom of the wheelchair, causing the catheter tubing to be pulled. Once Resident #6 was on the bed CNA I asked Resident #6 how she was doing and Resident #6 said my leg is hurting but not my back. CNA I said to Resident #6, "Now we have to roly poly you to get the sling out." CNA I then said to Surveyor "That's her term." When CNAs H and I turned Resident #6 onto her right side, Resident #6 complained her shoulder hurt, the one she was laying on, which was her right shoulder. Resident #6 moaned several times during the turning and when the CNAs placed her on the bedpan. CNA I attempted to adjust Resident #6's right shoulder to be more comfortable for her. On 01/10/12 beginning at approximately 1:52 p.m. during an interview with the Director of Nursing (DON), Surveyor spoke with the DON regarding Resident #6, including sharing the care observations made by Surveyor and Resident #6's verbalizations of pain during cares on 01/09/12 and 01/10/12. During this interview the DON stated, "She really did improve with the added pain med, we don't want to over-sedate her." Surveyor reiterated Resident #6 had verbalized having pain during the above observations made by Surveyor on 01/09/12 and 01/10/12. On 01/11/12 at 9:05 a.m., Surveyor observed Resident #6 from the hallway; she was seated in her wheelchair in her room. There were no staff in the room, only Resident #6's roommate. Resident #6 said, "My back hurts, I want to lay down." Resident #6 said this at least twice that Surveyor heard. Surveyor told CNA G that Resident #6 was asking to lay down and her back hurt. CNA G and another CNA assisted Resident #6 to lay down at 9:12 a.m. Surveyor also discussed Resident #6's complaint of her back hurting with Licensed Practical Nurse (LPN) E. At approximately 9:06 a.m., Surveyor asked LPN E if Resident #6 has something available for pain. LPN E looked at Resident #6's medication administration records and stated she has a prn (as needed) [MEDICATION NAME] order, but it's not time because it is ordered every six hours prn and she gets it every morning at 6:00 a.m. LPN E also stated, "We have several who cry out." On 01/11/12, Surveyor reviewed Resident #6's medical record and identified a pain data collection and assessment form dated on page 1 as 11/07/11, but it was signed by Registered Nurse (RN) N on page 2 with the date of 11/04/11. The form identified data collection information was obtained from Resident #6 and from staff. A question that read "Over the past five days, have you limited your day-to-day activities because of pain?" The choices were yes, no or unable to answer. There was no answer selected. Below this the form read "Indicate specific changes in activities or habits if applicable:" Change in mood/emotions was checked. The pain scale rating that read "Verbal Numeric Pain Scale (0-10) for cognitively intact residents" asks: "1. On a scale of 0-10, with 0 being 'no pain' and 10 being the 'most intense pain imaginable,' what would you rate the severity or intensity of your pain right now?" This was documented as 2-3 for Resident #6. "2. How would you rate your pain when moving around, getting up to the bathroom, or performing activities?" This was documented as 8-9. The pain assessment also included sections for "Vocalizations of Pain: ...Crying/Whining" was checked. "Vocal Complaints of Pain: ...Ouch" was checked. "Facial Expressions: ...Grimaces" was checked. "Protective Body Movements or Postures: ...Guards" was checked. "Non-verbal Cues/Behaviors: ...Tense body language" was checked. The form also read, "Over the past five days, what precipitates/exacerbates pain:" The answer wrote in was "Turning & Transfer bed to chair." In the summary section the following was written, "Resident has been weepy & crying out when transferred & repositioned - has been put on a scheduled [MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME]) 5/325 @ (at) 6 am to assist to keep comfortable /c (with) cares." Then a date of 11/7 read, "Seemed more comfortable today." It did not identify the time of the day or if this was during transferring or turning. Another entry on the summary section dated 12/12/11 read, "Increase use of pain med has (an arrow pointing down which indicated decreased) crying." This entry was signed by the DON. Review of Resident #6's last full Minimum Data Set (MDS) assessment dated [DATE] did not trigger pain as a care area. A care area assessment summary (CAAS) was then not completed for this resident based on that assessment. Resident #6's quarterly MDS completed 12/02/11 addressed the question, has the resident been on a scheduled pain medication regimen, the response was 0 which indicated No. Review of Resident #6's 11/2011 medication administration record (MAR) by Surveyor identified Resident #6 was started on a [MEDICATION NAME] 5/325 mg (milligram) one tablet daily at 6:00 a.m. beginning 11/05/11, and this medication has continued on a daily basis. On review of Resident #6's 11/2011 MAR, Surveyor identified Resident #6 received an additional [MEDICATION NAME] on 11/17/11 at 4:30 p.m. for pain all over and was rated a 6 on a 0-10 pain scale. On 11/25/11, Resident #6 was given a [MEDICATION NAME] at 11:55 p.m. for leg pain with a pain rating of 8 on a 0-10 scale. After further review of Resident #6's 11/2011 MAR, Surveyor identified an entry that read, "Is your pain program effective for you? If no provide pain rating." For each shift 11/01/11-11/04/11, the answer was charted as "Y" for yes, despite the pain assessment completed on 11/04/11 that identified Resident #6 had been weepy and crying out when transferred and repositioned and that pain assessment prompted the addition of the routine [MEDICATION NAME] being given daily at 6:00 a.m. On review of Resident #6's 12/2011 MAR, Surveyor identified Resident #6 received an additional [MEDICATION NAME] on 12/13/11 at 1:00 p.m. for general pain rated at a 6. On review of Resident #6's 01/2012 MAR, Surveyor identified Resident #6 continued to receive the routine [MEDICATION NAME] daily at 6:00 a.m. Resident #6 had not received any additional prn (as needed) pain medication in January 2012 until after Surveyor reported Resident #6 complaining of her back hurting while she was sitting in her wheelchair in her room on the morning of 01/11/12. Surveyor reviewed Resident #6's 01/12 MAR and identified the entry, "Is your pain program effective for you? If no provide pain rating." For the day shift dates of 01/09/12, 01/10/12 and 01/11/12, "Y" for yes was documented despite Surveyor 's observations of Resident #6 vocalizing signs and symptoms of pain each of these days. On 01/11/12, Surveyor was provided with the 08/08/11 Occupational Therapy (OT) plan of care note. The note read in part, "Referred to OT for increased pain in B (both) UE's (upper extremities) with self cares." Under the "Initial Assessment, Underlying Impairments" the following were included: Pain Intensity - 7/10, Effect of Pain on Function - severe effect on function. On 01/11/12 at 2:45 p.m., Surveyor interviewed Resident #6 and asked Resident #6 if she was having any pain or if she was hurting at that time. Resident #6 said, "No." Resident #6 was lying in her bed during this interview. Surveyor asked Resident #6 if she has pain when they turn her. Resident #6 said, "Yes." Surveyor then asked Resident #6 if she has pain when they move her from her bed to her wheelchair or from her wheelchair to the bed. Resident #6 replied, "I don't know." During the final exit meeting on 01/11/12, a discussion was held with the management staff, which included the Nursing Home Administrator (NHA), DON and RN D beginning at 3:48 p.m. During this discussion, the DON stated a pain assessment had been done for Resident #6 last evening (01/10/12). The DON stated Resident #6 will cry when they try to take her oxygen (O2) sat (saturation). At 3:55 p.m. on 01/11/12, RN D stated, "Anytime anything is done with (Resident #6) it's like an avoidance, she would just as soon lay there, she doesn't want to go." During review of Resident #6's plan of care by Surveyor on 01/09/12-01/11/12, Surveyor did not find documentation of behaviors that Resident #6 will cry for simple procedures such as taking her O2 sat level or that she will cry out anytime anything is done with her as facility staff indicated. The pink care delivery card contained an undated entry that read "Fear of falling" with the intervention to "Give short 1-step instructions." The white computer printout, also called the care delivery card, which the CNAs can carry on them, identified Resident #6 had "Fears of falling esp (especially) when rolled." Resident #6's cognitive assessment plan of care, reviewed by Surveyor on 01/11/12, did not identify Resident #6 exhibited behaviors as identified above. Resident #6's mood and behavior symptom assessment plan of care contained a section for diagnosis. A handwritten entry read "Anxiety & depression." Surveyor did not find a [DIAGNOSES REDACTED]. Resident #6's mood and behavior symptom assessment/plan of care did not identify Resident #6's fear of falling and what interventions staff are to use. It also did not identify Resident #6 would cry when procedures such as having her O2 sats checked or when other cares are provided. A review of Resident #6's Comprehensive Care Plan Review Summary dated for the assessment reference date of 12/02/11 identified Resident #6 had mood issues. Under the behavior section; "No behavior issues was checked." Resident #6's care plan most recently dated 12/12/11 titled "Pain Management" identified Resident #6 had chronic arthritis discomfort. The goal being "Will not have signs and symptoms of unrelieved pain." Both "No complaints of pain when questioned" and "No vocalization related to pain" were checked on Resident #6's care plan. During the survey, Surveyor observed Resident #6 to verbalize pain when questioned and to vocalize complaints of pain. Interventions identified for Resident #6 on her pain management care plan included "Administer pain medications as ordered." A handwritten entry read, "Started on scheduled [MEDICATION NAME] 11/07/11. Monitor and record effectiveness, side effects of medication PRN and Observe/notify Provider for s/s (signs/symptoms) of constipation." Page 2 of Resident #6's pain management care plan read, "Provide alternative comfort measures such as: (The following interventions were circled) Position change, Elevate HOB (head of bed)/extremity, Smooth linens, Massage, Offer and provide diversional activities to distract from pain." The care plan format also read (Place date at intervention to initiate); there were no dates by these interventions. During the final exit meeting on 01/11/12 at 4:00 p.m., the DON stated an order was obtained for Bio-Freeze (a topical [MEDICATION NAME]) yesterday (01/10/12) by RN M. Surveyor asked if the Bio-Freeze had been used and if it had been effective in relieving or helping Resident #6's pain. RN D left the conference room and went to check on that. When RN D returned to the conference room she stated, "Can't tell if they used it or not, there is nothing in the chart." The concerns regarding Resident #6's pain had been discussed with the DON on 01/10/12 and again on 01/11/12 with RN D and the NHA present.

Based on observations, medical record review, hospital record review, interviews and facility policy/procedure reviews, the facility did not ensure 1 resident reviewed for weight loss from a total sample of 12, maintained acceptable parameters of nutritional status, such as weight loss. Resident #7 experienced a significant weight loss of 28.8# (pounds), a 19.5% weight loss, from admission [DATE] through [DATE]. There were neither assessments nor interventions in place to determine the cause of the significant weight loss or prevent further weight loss until Surveyor brought the concern from the family to the facility on [DATE]. This is evidenced by: According to an article titled, "Identifying and Assessing the Cause of Weight Loss," page 177, from the Journal of Medical Directors Association-Medical Management, "It is important to identify the presence of previous weight loss immediately and may continue if not identified and addressed. Equally important is to identify a de-novo weight loss as soon as it occurs, to prevent complications. When there is a significant weight loss meeting MDS criteria or even a trend that does not meet the criteria, weekly or more frequent weights must be measured for at least a month or until stable. When significant weight loss of 5% or more in 1 month, 7.5% or more in 3 months or 10% or more in 6 months occurs or if a trend which does not meet the above criteria is observed over time, timely communication to all members of the care team is in order. Assessment for the cause of weight loss generally starts when the loss is unintended and meets MDS criteria as above. A reassessment of nutritional status should be done when weight loss is identified. It is important to start intervention immediately upon identification of unintended weight loss to prevent complications. It is important for a nutrition professional to observe each new resident and periodically thereafter, during several meals to review habits, intake and needs that may not be apparent from history taking or examination. Also, each resident should be supervised and monitored during meals (by the professional) to ensure food and fluid intake is accurately documented from meal consumption, snacks, nourishments and supplements. Therefore, all residents' food and fluid intake must be monitored regularly. Research has shown that nursing home staff consistently overestimate intake." During a family interview on [DATE] at 11:00 a.m., Surveyor was informed Resident #7 had lost almost 30# since being admitted to the facility on [DATE]. Resident #7 had no known history of weight loss according to the family interview. Surveyor reviewed Resident #7's medical record from ,[DATE] - ,[DATE]. Resident #7 was admitted to the facility on [DATE] following hospitalization for a fall at home with subsequent [MEDICAL CONDITION] and need of a surgical repair. Resident #7 also experienced various heart arrhythmias, ischemia ([MEDICAL CONDITION]) while in the hospital. Other [DIAGNOSES REDACTED]. Resident #7's Health Care Power of Attorney (HCPOA) was activated when he was hospitalized and remained activated at the nursing facility. An [DATE] Initial MDS and care plan identified Resident #7's height at 67" and weight at 175# while on a mechanically altered diet. A problem area for Nutritional Status stated: "On mechanically altered diet. Resident has no teeth and requires a mechanical consistency to prevent any choking instances." A problem area for oral/dental care stated: "Resident has some teeth missing but chooses not to replace them. He is on a mechanical soft diet with thin liquids. Eats fair and weight has remained stable." Surveyor reviewed the medical record from ,[DATE] - ,[DATE] for weights, intake monitoring, nutritional assessments and interventions. According to the weekly weight sheets where CNAs document weekly weights and then give them to the RN who enters the weights on the computerized "Weight Detail Record," and the Registered Dietician's (RD) notes related to weight changes and poor appetite, Surveyor found Resident #7 had a weight loss of 28.8# from [DATE] to [DATE]. RN B gave Surveyor a copy of the weight record which identified the following decline in weight: ~[DATE]: 171.6 (The RD did initial assessment on this date and used hospital weight of 175#.) ~[DATE]: 176.6 ~[DATE]: 169.4 ~[DATE]: 167.6 ~[DATE]: 170.8 ~[DATE]: 167.2 ~[DATE]: 154.8 with reweigh of 156.9 ~[DATE]: 150 ~[DATE]: 149.2 (on CNA weight record and MD progress note ([DATE]) weight was 147.2.) ~[DATE]: 155.4 ~[DATE]: 153.6 ~[DATE]: 149# this was a requested reweigh due to significant weight loss. According to the Journal of Medical Directors Association (JAMDA) Medical Management article, "Delivery of Nutrition and Hydration Care in Nursing Homes: Assessment and Interventions to Prevent and Treat Dehydration, [MEDICAL CONDITION] and Weight Loss" by Jacob Dimant, MD, CMD: "The first step in establishing an effective weight monitoring system is obtaining a baseline weight at the time of admission. The usual body weight before the event that precipitated the admission, such as hospitalization , should be obtained and used as baseline. Ideal Body Weight based on weight-for-height tables has not been standardized in the elderly. (Therefore, the ideal body weight in the initial assessment should not be used according to JAMDA). Per medical record review on [DATE], the initial nutritional assessment was completed on [DATE] by RD U. The assessment identified: "Weight from hospital at 175#; BMI (body mass index) 27.4; Total fluids to meet estimated needs=,[DATE] cc's daily; Total daily calories=,[DATE]; Total protein+80g. Ideal body weight range ,[DATE]#. Resident is at high risk based on data. Appetite so far is good as well as good fluid intake. Is quite confused and does not answer questions appropriately. Has no teeth (Resident #7 does have some teeth) and requires a mechanical consistency and soft foods. [MEDICATION NAME] 3.9, (which was done during the resident's hospitalization ) (this test measures the amount of protein in the fluid part of the blood) WNL (within normal limits), Hgb/HCT is down 12XXX,[DATE].3. (Hgb--Hemoglobin is the main component of red blood cells, is an iron-rich protein that carries oxygen from the lungs to all parts of the body. HCT--hematocrit is the percentage of blood that is made up of red blood cells- it is a measure of the number and size of red blood cells your body is making. A low hematocrit level can indicate [MEDICAL CONDITION]). Is on FeSO4 (Iron) 3 times a day. ST (speech therapy) to eval. (evaluate) for Dysphasia diet and nursing to check on peanut and corn allergy. Relatives state resident's nose runs when he eats these items. Until eval is done peanuts and corn will be substituted when on the menu. Peanuts and corn are not on mechanical soft diet in whole form." On [DATE], a Medicare 30-day assessment MDS identified Resident #7's height at 67" and weight at 169#. No nutritional at risk measures were implemented. RD U did a quarterly assessment on [DATE] which stated the following: "[DATE] (Quarterly) Wt. (weight) 154 (#) Question on admission wt (weight). Assessment done with hosp (hospital) wt. Does not appear to have lost 22#. Appetite is good at ,[DATE]%. Also question the weight of the wheelchair used on admission. Wt. on ,[DATE] - 167. Wt on ,[DATE] - 155#. Wt on wheelchair he is in now is 43#. Will continue to monitor wt. and weigh weekly. Will continue same diet. Nursing to check on wheelchair he was in at admission." signed by RD U. According to Resident #7's medical record and interviews, there was no evidence nursing ever checked on the wheelchair that was used at admission for Resident #7. Neither RD U nor the facility staff did any further assessments or put interventions in place related to Resident #7's significant weight loss of 22#. On [DATE] A Medicare 60-day assessment MDS identified Resident #7's height at 67" and weight at 155# while on a mechanically altered diet (pureed). A weight loss at loss of 5% or more in last month or loss of 10% or more in last six months was checked "YES" on the MDS and Resident #7 was not noted as on a physician-prescribed weight -loss regimen. No nutritional at risk measures were implemented. According to the medical record review on [DATE] by Surveyor , Resident #7's lab values revealed the following: ~[DATE]---Hgb. 10.8; Hct. 32.8 ~[DATE]---Hgb. 11.1; Hct. 33 There was no evidence Resident #7's [MEDICATION NAME] was monitored during this weight loss. There were no other significant lab values to report. On [DATE] a quarterly MDS identified Resident #7's height at 67" and weight 154# while on a mechanically altered diet (pureed). A weight loss of "5% or more in the last month or loss of 10% or more in last six months" was checked "YES." Resident #7 was not noted as on physician-prescribed weight-loss regimen. No nutritional at risk measures were implemented at the time of this assessment. In interview with Surveyor on [DATE] at approximately 10:15 a.m. MDS (Minimum Data Set) RN A stated, "The RD keeps track of weights and she reports them to the DON and then we go from there. I was not aware of any weight loss until you told me." Surveyor observed Resident #7 on [DATE] at 12:40 p.m. during lunch hour. Resident #7 was sitting at a dining room table with two table mates. All three residents needed cueing and assistance with feeding from the CNAs. Resident #7 was observed patting pureed peas and carrots, potatoes, gravy and meat with his spoon and was totally oblivious to the cues from staff. He was talking in disorganized/fragmented sentences and kept looking out the window. CNA G tried to assist Resident #7 by cueing, offering a spoonful of pureed turkey and mashed potatoes. Resident #7 took very small bites of mashed potatoes, approximately 30%. The remainder of the meal was not eaten. Approximately 120 cc (4 ounces) of fluids were taken at this meal observation. According to the lunch food and fluid intake record, Resident #7 was documented as taking 300 cc's (10 ounces) of fluids and 75% of food. According to Surveyors 's observation of Resident #7's intake, it was 120 cc's of fluids and ,[DATE]% of food. Surveyor observed Resident #7 at breakfast on [DATE] from 8:00 - 9:45 a.m. Resident #7's breakfast consisted of a large scoop of pureed scrambled eggs and toast, ? cup of cream of wheat cereal, 120 cc's of orange juice and milk and 90 cc's of coffee. The following observations were made during the meal observation: ~8:00 a.m. all fluids were placed in front of Resident #7. (He never took a drink at this time.) ~8:37 a.m. CNA G put pureed egg mix on a spoon and told Resident #7 to start eating. Instead, he sat patting food with a spoon and ate nothing. ~8:45 a.m. CNA G gave him a teaspoon of cream of wheat cereal. He ate two bites. Then, CNA G gave him one teaspoon of egg mixture which he spit into the glass of orange juice and said; "I don't want it." CNA G left Resident #7 alone while assisting other residents at different tables. ~8:56 a.m. CNA G returned and gave Resident #7 a teaspoonful of cereal and encouraged him to take a bite while it was warm. Resident #7 finished the cereal with the complete assistance of CNA G by 9:00 a.m. ~9:12 a.m. Dietary Cook (DC) I entered the dining room and removed Resident #7's soiled clothing protector, empty cereal bowl and plate with all of egg/toast mixture on it. DC I left the fluids in front of the resident. DC I stated to Surveyor , "Resident #7 usually leaves a lot of food. He'll drink somewhat of his fluids. He is not a good eater." (DC I is the full time cook and is also assigned to clears tables after meals.) ~9:20 a.m. CNA BB handed Resident #7 coffee and said, "I'd like you to take a drink of coffee." He did take a couple sips and then asked for cough drops. (~9:23 a.m. Medication nurse gave crushed medications in applesauce with one sip of milk to follow. Resident #7 grimaced and said, "Yuck." ~9:26 a.m. CNA F was calculating on the dietary intake sheet that Resident #7's food and fluid intake consisted of 180 cc's of coffee and 50% of food. Surveyor informed CNA G that Resident #7 had only 90 cc's of coffee to start with and then showed CNA F there was at least two-thirds of the coffee remaining in the cup. The 120 cc of juice was untouched and he had taken one small sip of milk with his crushed medications in applesauce. According to CNA G's entry of breakfast food and fluid intake into the computer, she credited Resident #7 with taking 90 cc's of fluids and 49% of food. Surveyor 's calculation of the above breakfast meal identified Resident #7 had taken ,[DATE] cc's of fluids and ? cup of cereal. Surveyor observed Resident #7 on [DATE] at 12:25 p.m. for the lunch meal intake. Resident #7 was served pureed stuffed green peppers, green beans and mashed potatoes. CNA G started to feed him some mashed potatoes, which he was eating. CNA G left to help someone else. Resident #7 started patting the pureed food with a spoon and moving the plate away. CNA E cued Resident #7 to eat the mashed potatoes. Resident #7 ate all of the mashed potatoes and CNA G asked the kitchen staff for another helping of potatoes. Resident #7 ate ? of the second helping of mashed potatoes. After reviewing the calculated dietary intakes documented in the computer from admission to [DATE], it appeared the calculations for Resident #7 were not always accurate. Also, Resident #7 did not receive any snacks mid-morning or afternoon. The evening snack was entered as refused the majority of the evenings. The following interviews identified a more accurate picture of Resident #7's eating habits and intake: In interview with Surveyor on [DATE] at 10:00 a.m., CNA BB stated, "(Resident #7) leaves a lot of his food due to his poor level of concentration. If he is eating one item of food real well, I will ask the kitchen to give him more of it. I know he has lost weight but did not know it was that much. We weigh all the residents on Sundays and write down the weight on our weight sheet. If someone is up or down 5# from the last weight, we reweigh them and tell the nurse." In interview with Surveyor on [DATE] at 12:00 noon, CNA E stated, "I work full time days. Resident #7 usually leaves lots of food on his plate. We really have to push fluids at meal time and we are not always successful. Even his wife has some difficulty getting him to eat or drink. He does not like to be fed. He does not drink anything in his room. I have seen him drink a little fluid after the nurse gives him medicines. He does not like to drink." In interview with Surveyor on [DATE] at 12:05 p.m., CNA H stated, "I work full time days. Resident #7 does not eat a full meal-- Most of the time he may eat half of his meal. He does not like orange juice and coffee and he gets it all the time. He will usually try his milk and water. I do not think he's ever been on intake and output records." In interview with Surveyor on [DATE] at 12:08 p.m., CNA G stated, "I work full time days. Resident #7 will take whatever he likes. He did not like his mixed egg/toast puree for breakfast, so he spit one bite of it in the glass of orange juice. He does not like orange juice either and he gets it almost every day. He needs lots of cueing. He does not like to be fed. It takes a lot of time with him. He has dignity about himself and wants to feed himself. He is very much like a hyper-active child--very distracted all the time and busy pulling on his napkin, protector or patting his food. We do weights every Sunday and write the weights on a weight sheet. The charge nurse will compare weights and determine if we need to reweigh someone." On [DATE] at 9:50 a.m. Surveyor met with RD C, who was at the facility for the first time to review records for nutritional concerns. RD C had reviewed Resident #7's medical record, weight sheets, intake sheets, etc. that morning. RD C told Surveyor , "I will be reviewing and making recommendations for Resident #7. I noticed Resident #7 was not on any enhanced foods or supplements. I will start Resident #7 on enhanced cereal potatoes, half and half cream on cereal and a supplement of 30 cc TID (three times a day) with medication pass. I have also asked for a reweigh today. I plan to call (Resident #7's) daughter to get his usual weight since there was some discrepancy with his admission weight. I will be monitoring his weight every week." Resident #7's daughter told RD C on [DATE] that her father normally weighed in the 170 pound range. On [DATE] RD C wrote a summary in the medical record of the nutritional assessment and interventions to be started on [DATE]. It read as follows: "Resident's wife (who is the HCPOA) stated to surveyor yesterday that he has lost 30# since admission. Also reported that wife stated he had not been eating well when first admitted . Meal intake as recorded was--83% at that time and 84% now. SLP (Speech Language Pathologist) has been working with him and diet texture changed to pureed-Dysphasia 1 with thin liquids. Call left with resident's daughter R/T (related to) resident's UBW (usual body weight). Current weight is 153.6# (which was taken on [DATE]) down 13% since admission. He had 7.2# wt. loss (4.1%) in the first week. Weight was stable x 1 mo (month), then 12.4# (7.4%) loss in 1 week and now has been stable for p (past?) month--,[DATE]#. Enhanced cereal and potatoes and ? &? will be added to cereal when available. Also will request 30 ml (= 1 ounce) house supplement with meds TID (three times a day). These interventions will add--670 KCal daily. Care plan updated. Meds:... ADDENDUM: Increased assistance with meals will be implemented. Reweigh will be obtained. There is question of w/c (wheelchair) wt, foot rest wt of 7# on w/c. He is now more mobile." Signed RD C. In interview with Surveyor on [DATE] at 1:00 p.m., the Director of Nursing (DON) stated, "I think the problem with Resident #7's weights is due to the different weights of the wheelchairs that have been used when weighing him." The DON showed Surveyor how heavy a wheelchair leg was. The DON could not confirm the different weights of the wheelchairs, nor if indeed was this the real problem. Neither the DON nor any other professional nurse had observed the staff weigh, reweigh or review any of Resident #7's weights since admission. Also, the DON did not have a policy and procedure available related to how weights are done at the facility. In interview with Surveyor on [DATE] at 7:45 a.m., Dietary Manager (DM) D stated, "I do not review weights on a regular basis. Nurses generally leave a note for the RD and I will then look at the note as well. I was not aware of Resident #7's huge weight loss until it was mentioned to me yesterday ([DATE])." In interview with Surveyor on [DATE] at 11:25 a.m., RN CC stated, "Resident #7 was reweighed this morning and his weight was 149#. He is able to stand on the scale for weights now." (This weight was also identified on the CNA's weight sheet.) According to the nurses' notes from admission to [DATE], there are only general statements made about Resident #7's appetite, such as: "Ate 100%, Appetite 100%, Ate 100% of Level 1 Dysphasia diet, Appetite 50%, has good appetite, Appetite 75%." There is no documentation about weight loss in the nurses' notes. According to the Speech Pathology Therapist (SPT), the notes identified evaluation and treatment related to Resident #7's coughing and choking when eating. The SPT did work with Resident #7 during some meals to determine what diet would be best and gave direction to the staff to remind the resident to swallow before taking another bite and not to talk when his mouth was full to prevent choking and aspiration. Resident #7 tolerated the SPT program very well. The following interviews were done by Surveyor on ,[DATE] and ,[DATE]: During a [DATE] 7:30 a.m. interview, the DON and RN S, Education and Training Director, provided to Surveyor a copy of the [DATE] physician progress notes [REDACTED]. When questioned if Dr. V was made aware of weight loss prior to this, the DON stated Dr. V stated he remembered RN B calling him about weights, but was not sure when. This could not be confirmed through review of [DATE] physician progress notes [REDACTED]. Facility staff weighs all residents every Sunday. When the RD comes she runs off a report of all residents' weights and checks for weight loss and meets with the DON to review those residents she has concerns about related to weights. The RD is the person who checks every week to see if there has been weight gain or loss. If there is a question, the CNAs reweigh the resident that day; the RD writes a note and a plan including enhanced food, supplements, vitamins or labs. When questioned if anyone checked to verify if Resident #7's weights were accurate after the [DATE] RD note, the DON stated no. The DON stated a corporate report titled "E21" utilizes information submitted by the facility on issues including weight changes to compile the report, which is then forwarded to the facility. Review of the E21 reports back to ,[DATE] by the DON identified the only report related to unplanned weight loss with Resident #7 was on [DATE] and only documentation for unplanned weight loss was Resident #7's name. DON stated the prior RD's last day was [DATE]. Nurses should be looking at weights in the weight change report in the computer, which includes all weights recorded on the residents. The handwritten weights are recorded weekly on the monthly weight sheets. If residents receive supplements, those are recorded on the Medication Administration Record (MAR). A review of the ,[DATE], ,[DATE] and [DATE] MAR by Surveyor and the DON revealed no supplements were directed or administered for Resident #7. During a [DATE] 7:45 a.m. interview, the DON verified there was no RD in the facility between ,[DATE] and [DATE]. The DON stated the nurses would have been monitoring the weights then. When questioned if there was anything on the 24-hour reports related to Resident #7's weight loss prior to survey, the DON stated there was not. During a [DATE] 7:30 a.m. interview, RN B told Surveyor she has had a lot of concerns about Resident #7. When questioned about reviewing weight loss with the MD, RN B stated [DATE] was when they specifically talked about the weight loss. The resident had been seen by the MD on ,[DATE] and [DATE] and there may have been some discussion about weight loss prior to [DATE], but she could not remember. RN B stated she usually notifies the RD if there is a 5-pound change in weights after completing a reweigh. During a [DATE] 3:30 p.m. interview, MDS RN A told Surveyor she was unaware of Resident #7's weight loss until it was brought up by surveyors last week. RN A stated the RD fills in the residents' weights, completes the weight nutrition section of the MDS and completes that summary. RN A stated she herself does not. RN A stated there was no written policy on completion of the MDS, just what is directed on the form itself. During a [DATE] 3:40 p.m. interview, RN Consultant Q told Surveyor she did not think the facility documented well nor did they reweigh Resident #7 with change in wheelchairs/leg extenders-meaning going from leg extenders to none on the wheelchairs. She believed Resident #7 was still within his ideal weight range of ,[DATE] #. She said the facility should have noticed a change in condition with that actual weight loss. During a [DATE] 9:00 a.m. interview, Surveyor reviewed Resident #7's weight loss with Dr. V. Dr. V stated he became aware of the weight loss on [DATE], as documented in his progress note. Dr. V stated it seemed to him someone may have told him about the weight loss prior to this, but he could not honestly remember when. He remembered "we were concerned with weights and we didn't want tube feedings." When questioned what criteria he would expect for weight loss notification, Dr. V stated he has never had one at this facility because they have always notified him. In general, he would like to be notified of a ,[DATE]% loss, but it would have to be an acute loss. Dr. V stated he would not expect to be notified of a gradual loss over one to two months. He would go with more of a poundage loss about "10 pounds over a couple weeks to notify maybe." If he was expected to round during the week of the weight loss, he would not expect a call necessarily. Surveyor reviewed the lack of interdisciplinary team assessment with continued weight loss for Resident #7. Dr. V stated he would have expected the RD to notice and assess the weight loss and do something about it. Weight system and additional information on Resident #7's wheelchairs: During a [DATE] interview at 7:30 a.m., CNA N and Certified Occupational Therapy Assistant (COTA) K told Surveyor that Resident #7 had two different wheelchairs since being admitted to the facility and at times used wheelchair leg extenders/foot rests. A set of extenders/foot rests was in Resident #7's closet, but not in use recently. COTA K stated the resident's wheelchairs were switched last Thursday ([DATE]). CNA N identified weights are completed every Sunday on residents. Wheelchairs, footrests, wheelchair pads, etc. are weighted separately and the weight of those devices is written on tags attached to the wheelchair. Surveyor observed Resident #7's current wheelchair had a tag attached with the following information written on it: *54.5# wheelchair with pedals, *40.8# wheelchair without pedals. COTA K showed Surveyor the previous wheelchair utilized by Resident #7, currently in use for another resident and this also had a tag attached with weight of the wheelchair on it, etc. CNA N stated when weighing residents in wheelchairs, if the tags do not contain weight information on the wheelchair or other equipment on the wheelchair, those items are weighed separately and recorded on the tag. The wheelchair and other equipment weights are subtracted from the total weight if residents are weighed in the wheelchair, to give the resident's actual weight. If there is about a 5-pound discrepancy in the weight from the previous weight, the wheelchair and equipment are weighed again at that time, as well as the resident to determine if the equipment weight and resident weight was accurate. Equipment weight is updated on the tag if it was not accurate upon reweigh. Reweighs and information are provided to the nurse on the same shift. CNA N stated she reports to the nurse, writes it on the nurse's report sheet and this system has been in place approximately a year. Surveyor observed other wheelchairs in the facility had the same tags with wheelchair and other equipment weight information recorded on them. During a [DATE] 7:50 a.m. interview, CNA G explained to Surveyor the same system for weighing residents with wheelchairs and equipment as identified by CNA N, with the exception that she records the final weight after the reweigh on the weight sheets; these are reviewed by the nurse. She also tells the nurse of a 5-pound difference from the previous weight. During a [DATE] 7:45 a.m. interview the DON verified the process of weighing wheelchairs and equipment separately, documenting the weights on tags on the wheelchairs and subtracting that from the total weight if residents are weighed with those items in place. The DON stated a "physician rounds master list" is filled out with the most current week vital signs and weight of the residents he is to see during rounds that week and faxed to the physician prior to his visit. The physician may review all weights available at the facility during rounds. According to the facility policy and procedure named, "WEIGHT MONITORING," the facility failed to follow: CNA RESPONSIBILITIES ~2. Weigh the resident the first three days of admission and readmission or until accuracy has been verified by the licensed nurse. LICENSED NURSE RESPONSIBILITIES: ~Verify accuracy of the weight by comparing the weight with the most recently recorded weight. ~Compare weights using the Weight Change Grid to determine 3% weight change ~Supervise the CNA while re-weighing the resident to ensure correct process is followed, if the weight has changed with a loss of 3% or greater. ~Monitor weight reports for significant changes and for gradual insidious changes that may indicate a risk factor for nutrition or hydration status and/or clinical condition. ~Report changes of 3% or more on the 24-hour report for review in the Daily Triage Meeting and possible follow-up at the Daily Clinical Review Meeting. NUTRITION SERVICES MANAGER RESPONSIBILITIES ~Review significant weight change reports daily for review in Daily Triage Meeting ~Review the weight reports at least weekly to ensure all residents with significant weight change are reviewed and assessed for nutrition risk factors. Surveyor received a fax from the DON on [DATE]. The fax was a time line of Resident #7's documented weights, appetite documentation in the nurses' notes, the MD progress notes from [DATE], the SPT notes and Lab values. (Surveyor had copies made of all of the above on ,[DATE]-,[DATE].) There was no information included in the fax to show what interventions had been implemented during the time of Resident #7's significant weight loss from admission until [DATE]. According to an article "Evaluating and Treating Unintentional Weight Loss in the Elderly" by the American Family Physician magazine, Volume 65, Number 4, it reads: "Unintentional weight loss in elderly patients is associated with increased morbidity and mortality. One study showed nursing home patients had a significantly higher mortality rate in the six months after losing 10% of their body weight, irrespective of [DIAGNOSES REDACTED]. In patients with [MEDICAL CONDITION], weight loss correlates with disease progression and a weight loss of at least 5% is a significant predictor of death." The Western Regional Office received a faxed letter on [DATE] which was written on [DATE] by Dr. V. Excerpts from this faxed letter read as follows: "Since his (Resident #7) admission on [DATE] patient has had significant weight loss.....We are going to strive for his current weight, I think he is at an ideal body weight and he is doing so well. This weight loss did not harm this patient in any way; in fact, he is in much better shape now than he was prior to his admission to the Cornell Area Care Center." Resident #7 died on [DATE].