Every finding on record at Crest View Nursing Home

Based on interview and record review the facility did not ensure each residents medication regimen was free of unnecessary psychotropic medications for 1 of 5 Residents (R16) reviewed for unnecessary medications. R16's physician orders include, in part: Lorazepam (a psychotropic medication used for anxiety) 0.5mg every 2 hours as needed with a start date of 7/12/24. There is no evidence of a documented end date or provider rational for extending beyond 14 days. Evidenced by: The facility policy entitled Guidelines for Safe Administration and Management of Medications, undated, states, in part: . PURPOSE: Safely and accurately administer oral medications. Medications encompass substances used for their pharmacological effects in diagnosing, treating, or preventing illnesses, including both over the counter and prescription items. Establish secure procedures for acquiring, storing, distributing, utilizing, and disposing of drugs and biologicals. PROCEDURE: . I. Psychoactive Medications (also known as psychotropic drugs are substances that alter the brain's chemistry to treat mental health conditions): . g. As needed (PRN) orders for psychotropic drugs are limited to 14 days. If the attending physician believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she needs to document their rationale in the resident's medical record & indicate the duration for the PRN order . R16 was admitted to the facility on [DATE] and has diagnoses that include dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment) and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations). R16's Minimum Data set (MDS) Quarterly Assessment, dated 11/5/24, shows that R16 has a Brief Interview of Mental Status (BIMS) score of 10 indicating R16 has moderate cognitive impairment. R16's Physician Progress Note, dated 1/3/25, shows order for: Lorazepam 2 mg/mL(milligrams)/(milliliters) Oral Concentrate: 0.5mg PO (by mouth) every 2 hours PRN agitation, anxiety, dizziness. Start: 7/12/24 . No Stop Date R16's Psychotherapeutic Quarterly Medication Review, dated 11/20/24, states, in part: . Date: 7/12/24 Medication & Dose: Lorazepam 0.5 mg Every 2 hours PRN Diagnosis: Severe Anxiety, unable to take PO (by mouth) . On 1/17/25, at 1:34 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked, for a PRN psychotropic medication should there be a stop date of 14 days with a re-evaluation or if it extends 14 days a rationale. NHA A indicated yes. Surveyor asked if R16's lorazepam PRN order that was ordered 7/14/24 was re-evaluated after 14 days. NHA A looked and came back to inform Surveyor she could not find one. Surveyor asked if R16's PRN Lorazepam order should have a stop date and NHA A indicated yes.

Based on interview and record review, the facility failed to ensure 1 of 5 resident (R43's) plan of care included a sleep assessment and sleep monitoring/tracking to ensure R43 was attaining or maintaining R43's highest mental, physical and pyschosocial well-being. R43 is receiving Melatonin for sleep and did not have a sleep assessment/tracking completed. Findings Include: R43 was admitted to the facility on [DATE] with diagnoses that include, in part: Insomnia and Anxiety Disorder (A mental health condition that causes excessive and uncontrollable fear or worry). R43's physician orders include, in part: Melatonin 6mg (milligrams) by mouth at 5:00 PM for sleep aide. Order start date: 11/25/24. Surveyor requested a policy on sleep assessments/tracking and R43's sleep assessment and monitoring documentation. No sleep assessment/tracking for R43 was provided to the surveyor. On 1/16/25 at approximately 2:44 PM Surveyor interviewed NHA A (Nursing Home Administrator) who indicated they did not have a sleep assessment policy and that a sleep assessment should have been completed for R43.

Based on interview and record review, the facility failed to ensure a resident (R) with hearing impairment received proper treatment and assistive devices for 1 (R31) of 12 residents reviewed for hearing. R31's follow-up appointment(s) to address hearing loss were not scheduled by the facility and therefore hearing aides were not obtained. Findings Include: R31 was admitted to the facility on [DATE] with diagnoses that include, in part: Dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), Vascular Dementia (a type of dementia that occurs when blood flow to the brain is reduced or blocked), Anxiety (A mental health condition that causes excessive and uncontrollable fear or worry), and Impacted Cerumen, bilateral (A buildup of earwax that can cause pain, hearing loss, and other symptoms). R31's most recent Quarterly MDS (Minimum Data Set), target date 11/21/24, indicates a BIMS (Brief Interview for Mental Status) of 12, indicating R31 is cognitively intact. On 1/14/25 at 11:09 AM, Surveyor interviewed R31 during the initial screening process. R31 indicated a few months ago a doctor at a clinic told him he needed hearing aids, but he has not heard anything more. R31 indicated he told his guardian and a facility staff member, but could not remember who or when, and no one has followed-up with him. On 1/16/25 at 8:32AM Surveyor interviewed RN E (Registered Nurse) who indicated she was not aware of R31 going out to the doctor or seeing a provider in house at all since she started. (Of note, RN indicated she was an agency nurse and then took a permanent position in October 2024 with the facility.) RN E indicated that if R31 had notes from a provider they would be scanned into the computer. RN E indicated they look at the after visit summary and sign off on it and then it gets scanned into the computer. If the actual physician note doesn't come back with the resident they call to get it and then the floor nurse should review it. RN E indicated she was not sure if the DON (Director of Nursing) or anyone else reviews it, but that her thought process is that the DON would review it too. On 1/16/25 at 10:00 AM, Surveyor interviewed HUC F (Health Unit Coordinator) who indicated that if a resident returns from a provider visit and there is nothing in the packet they would call and ask for the report. HUC F indicates she does a lot of these calls but the nurses do too. HUC F indicated once they have the report, she makes sure there is no appointment needed. If they are supposed to have an appointment she would call the department and see who the resident should see and set it up. HUC indicated if she is unable to make the appointment right away she keeps a copy of the note in her basket until it's scheduled. HUC indicated that for R31, the ENT (Ear, Nose and Throat) appointment must have been missed. On 1/16/25 at 9:44 AM IDON B (Interim Director of Nursing) approached surveyor with information regarding R31's appointment. IDON B provided an audiology report for R31 dated 5/31/24 that included the following information, in part: Reason for Consult: Hearing Loss Date of Consult: 5/31/24 Orders: Binaural Amplification (Hearing Aides). Insurance will be reviewed. Prior Auth obtained. Hearing Aides will be ordered. Expect a month + wait. The document is signed by the audiologist. A received date of 5/31/24 is handwritten at the bottom with initials and a note that indicates, in part: needs to see ENT (Ear Nose and Throat) need medical clear. Then go back to Audiologist. IDON B indicated that R31's POAHC (Power of Attorney for Healthcare) had disengaged, and guardianship was pursued in July 2024. During this time R31's insurance coverage had lapsed and the facility had been working with the guardian to get that completed. IDON B also provided a ENT note from 6/19/24 that indicates, in part: Patient was initially scheduled for impacted cerumen. Per outside records, audiogram had been done after cerumen impaction was cleared and he had asymmetric hearing loss .Ears were examined showing patent canals and normal TM's (Tympanic Membranes-a thin, semi-transparent membrane that separates the outer ear from the middle ear.) We will plan to reschedule a virtual visit at some point in the future when his activated power-of-attorney can consent and they or a caregiver can attend. Surveyor asked IDON B what her expectation would be for a resident whose record indicates he was in need of hearing aides back on 5/31/24. IDON B indicated that R31 did not have a payor source. Surveyor asked IDON B, if surveyors had not asked about this, how would anyone have known this needed to be scheduled. IDON B indicated she could not answer this and that if this was pending on a schedule that the HUC has, she did not know. Surveyor asked IDON B if she would have expected the appointment(s) to be made once the payor source was in place. IDON B indicated she would.

Based on observation, interview and record review, the facility did not ensure routine dental care was provided to 1 of 3 sampled residents (R12). R12 reported her dentures were ill-fitting. The facility did not assist R12 in making an appointment or arrange transportation to and from the dental services location. The facility did not promptly, within 3 days, refer R12 for dental services. The facility did not document the extenuating circumstances that led to the delay. Evidenced by: Facility policy, titled Oral Care, undated, includes: . Residents can access regular and emergency dental care from their chosen dentist or local practitioner . Transportation is provided by Nursing Home or family, with assistance available, if needed . The nursing department arranges emergency dental care if the resident's regular dentist is unavailable . Any abnormal findings such as . ill fitting dentures . are documented by the nurse and the health care team is informed . Facility will provide access to dental services as appropriate If dentures are broken or chipped or if there is a problem with dentures fitting, the nurse will refer to dental services within 3 days . R12 admitted to the facility on [DATE]. Her most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 11/26/24, indicates R12's cognition is intact with a BIMS (Brief Interview for Mental Status) score of 15 out of 15. On 1/16/25 at 10:36 AM R12 apologized for not having her dentures on when Surveyor began to interview. R12 indicated she must remove her denture when she is not eating due to her dentures not fitting causing pain and canker sores to develop. R12 indicated she has talked to several staff about her dentures not fitting and staff say there is not a dentist in the area that will take Medicaid. R12 indicated she is not able to pay out of pocket for a dentist in the area. R12 stated, I would go to [NAME] if I had to. R12 indicated she would like the facility to look outside of the area for dental services to address her ill-fitting dentures. R12's Speech Language Pathologist Note, dated 11/22/24m includes: . Oral mechanism exam revealed ill-fitting lower denture that R12 reported is painful . Chewing was extended due to the pain . R12 is perceived to require softer foods in order to manage nutritional intake secondary to her painful bottom denture . R12's Registered Dietician Note, 11/29/24, includes: current body weight:106.231 kg (234 pounds) 1 month (10/26/24): 108.409 kg (238 pounds); 4 pound weight loss in 1 month 3 months (8/26/24): 111.697 kg (246 pounds); 12 pound weight loss in 3 months On 1/16/25 at 10:41 AM RN D (Registered Nurse) indicated if a resident reports ill-fitting dentures she would tell the office personnel to make her a dental appointment. RN D indicated R12 puts her dentures in only for meals due to them causing pain and discomfort and management is aware. On 1/16/25 at 10:44 AM Interim DON B (Director of Nursing) indicated ill-fitting dentures could contribute to weight loss and pain. DON B indicated she was aware R12 had complained about her dentures not fitting as Resident Care Coordinator C had reported this to her. On 1/16/25 at 10:50 AM Resident Care Coordinator/RN C indicated she was aware R12 was experiencing pain and discomfort related to her ill-fitting dentures. Resident Care Coordinator/RN C indicated R12 uses polygrip to hold the dentures in place while she eats and then removed the dentures when it is not meal time due to the pain and discomfort caused by the ill-fitting dentures. Resident Care Coordinator/RN C indicated there is no dentist in town that will accept Medicaid and R12 would have to go all the way to [NAME] for dental appointment. On 1/16/25 at 10:53 AM NHA A (Nursing Home Administrator) indicated the town is a dental desert when it comes to accepting Medicaid. NHA A indicated the facility has tried to get dental service companies to come into the building but have not been successful. NHA A stated, We are not finding a dentist in the area that will take Medicaid and R12 would have to go to [NAME]. NHA A indicated the facility has not offered to transport or make an appointment for R12 in [NAME]. (It is important to note R12's medical record had no indication which dentists were called or any information on efforts made by the facility to get R12 an appointment and transportation when becoming aware R12's dentures were ill-fitting causing her pain and discomfort.)

Based on observation and interview the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect 44 residents who reside in the facility. -Staff personal food and beverage items were stored amongst resident food and beverage items in facility walk in refrigerator. -Stove hood observed to be dust coated directly above food preparation -Expired milk cartons observed in unit refrigerators -Food removed from original containers and/or opened observed without open dates or use by dates Evidenced by- Personal food items in resident refrigerator: Facility policy, entitled Food and Nutrition, undated, includes, in part: All food brought in by patients and residents must be covered, labeled, dated and stored appropriately . On [DATE] at 9:38 AM during initial tour of the kitchen, Surveyor observed a Styrofoam container with leftovers, two containers with bread/buns, a container of dessert bars, and 4 partial drank beverages (3 with screw covers, 1 with lid and straw) together on a shelf in the walk in refrigerator. During an interview, DA D indicated the bread and bars were resident food and the drinks and Styrofoam container were staff personal items. DA D indicated these things should be dated and labeled. DA D indicated she was unaware if staff and resident food items should be stored together. During an interview, DFNS I (Director of Food and Nutrition Services) indicated staff should put their personal drinks and food in the staff refrigerator and not have it with resident food items. DFNS I indicated resident food items that are opened should have an open date on it. Stove hood: On [DATE] at 9:38 AM Surveyor, DA D, Cook E, and DFNS I observed the filters and pipes within the stove hood to be coated in dust. The dust observed was moving as the air shifted. Cook E was preparing food on the stove directly under the dust coated pipes. During an interview, Cook E, DA D, and DFNS I indicated there is potential for the dust to dislodge and contaminate the food directly underneath. Expired Milk and magic cups in unit refrigerators/freezer: Facility policy, entitled Food and Nutrition, undated, includes, in part: The original manufacturer's use by date is sufficient if the item is not opened . must be dated and discarded accordingly . On [DATE] at 9:38 AM during initial tour of the kitchen, Surveyor observed an opened gallon of whole milk with use by date of [DATE]. On [DATE] at 10:37 AM Surveyor observed 12 expired milk cartons in a unit refrigerator, 6 of which were chocolate and 6 were white. Also observed in the freezer were 2 orange cream magic cups in the freezer with use by date of [DATE]. On [DATE] at 10:49 AM Surveyor observed 12 expired milks in a second unit refrigerator, 6 chocolate and 6 white. On [DATE] at 12:05 PM during an interview, CNA C indicated milk that has a used by date of ,d+[DATE] should be tossed and she will make sure residents do not get served the outdated milks. CNA C indicated it is the kitchen staffs' responsibility to check dates on the unit refrigerator items. On [DATE] at 12:38 PM during an interview, DA D indicated milk dated ,d+[DATE] or ,d+[DATE] should not be served after the use by dates ,d+[DATE], ,d+[DATE] and the milk should have been removed from the refrigerator. Undated opened food: Facility policy, entitled Food and Nutrition, undated, includes, in part: All food items that are taken out of the original packaging must be dated with expiration date from the original package, the manufacturer's expiration date is sufficient . All food items prepared in the . must be labeled with a prepared date and a use by date . On [DATE] at 9:38 AM during initial tour of the kitchen, Surveyor observed an opened bag of pretzels, opened containers of flour and sugar, two different kinds of bread removed from the original packaging, an opened diet thickened cranberry juice. All of these items did not contain an open date or a use by date. DA D indicated these items should have a use by date or an open date on them and she did not know for sure when the items were opened. On [DATE] at 10:37 AM Surveyor observed 2 opened [NAME] juices with no open date and no name in a unit refrigerator. On [DATE] at 12:05 PM during an interview, CNA C indicated she was not sure if the [NAME] juices belonged to staff or residents and did not know when they were opened. CNA C indicated all food items that are opened should have a name and a date on them.

Based on observation, interview, and record review, the facility did not implement professional standards of practice to ensure that a resident does not develop pressure injuries (PIs) or prevent new PIs from developing for 1 of 3 Residents sampled for PIs out of a total sample of 12 Residents (R7). Surveyor observed R7 sitting on a deflated cushion. R7 indicated she has had an issue with her cushion deflating for at least a week and that she has a pressure injury on her bottom. Surveyor observed R7 sitting on a pressure relieving cushion with 4 layers between her and her cushion. The layers consisted of a soaker pad folded in half twice. This is evidenced by: ROHO manufacturer's recommendations for use, include, in part: Do not place any obstruction between the individual and the cushion, placing any other item directly under the individual, whether inside or outside the cover, will make the cushion less effective . Check the inflation frequently, at least once a day . Do not use an underinflated cushion . because the product benefits will be reduced or eliminated . R7 was admitted to the facility on [DATE]. Her most recent MDS (Minimum Data Set), with ARD (Assessment Reference Date) of 7/21/21, indicates R7 is cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 out of 15. Her MDS also indicates R7 requires the assistance of extensive physical assist of one staff member to meet her needs in bed mobility, transfer, and toileting. R7's Nurse Notes, dated 6/30/21, include, in part: . wound stage: unstageable . 1x0.8x0 . wound base: slough . Wound type: pressure . noted new area to right ischium . area is flat with yellow slough over all . On 9/27/21 at 3:50 PM Surveyor observed R7 sitting on a deflated pressure relieving cushion with 4 layers between her and the cushion. The layers consisted of a soaker pad folded in half two times. The addition of layers on top of the cushion affects the efficacy of the cushion. R7 indicated that the pressure relieving cushion keeps deflating and that it always needs air. R7 indicated that her leg falls asleep. On 9/27/21 at 3:57 PM Surveyor observed CNA H (Certified Nursing Assistant) enter R7's bedroom. Surveyor observed CNA H assist R7 to standing. CNA H indicated R7's wheelchair cushion was deflated but therapy are the ones who maintain wheelchair cushions. Surveyor observed CNA H fold a new soaker pad two times and place in wheelchair over the deflated cushion. Then CNA H assisted R7 back to sitting in her wheelchair (on deflated cushion and four layers on soaker pad). On 9/27/21 at 4:35 PM - 4:50 PM during an interview DON B (Director of Nursing) indicated he was unaware R7's wheelchair cushion was deflated. Surveyor and DON B walked to R7's room. DON B assisted R7 to standing and used his hand to feel the wheelchair cushion. DON B indicated the cushion is deflated and that it possibly is a defective cushion. Surveyor informed DON B of R7's concerns that the cushion has been deflating for a week, it was reported to staff, and there had been no change. DON B indicated he would replace the cushion with a different one. DON B indicated it is his expectation that a staff member follows up or reports equipment failures so they are addressed timely. On 9/28/21 at 8:30 AM Surveyor observed R7 sitting in her recliner chair on top of a soaker pad folded twice and a pressure relieving cushion. R7 indicated DON B brought her a new pressure relieving cushion on 9/27/21. It is important to note the four layers of soaker pad between R7 and her pressure reducing cushion. On 9/28/21 at 9:42 AM during an interview, RN G indicated R7's cushion has had trouble holding air for a couple weeks. RN G indicated that she, DON B, and NHA A have all refilled cushion with air. On 9/29/21 at 8:55 AM during an interview RN G indicated that if the cushion is deflated the expectation would be to let RN G or DON B know so they can find the problem or replace it. RN G also indicated CNA H should have put air in the cushion and/or reported it to her or DON B. On 9/29/21 at 10:42 AM during an interview CNA F indicated that they will inflate R7's cushion when R7 tells staff she is uncomfortable. CNA F indicated she emailed RN G and NHA A last Friday regarding R7's cushion. On 9/29/21 at 10:53 AM RN G indicated she has put air in R7's cushion at least three times and gave it back to her. RN G indicated R7's soaker pad folded in half two times underneath her could be too layers between her and her pressure reducing cushion. On 9/29/21 at 2:25 PM during an interview NHA A indicated when CNA H became aware of R7's deflated cushion, she should have made sure R7's cushion was inflated or passed the concern onto her nurse, DON B or NHA A.

Based on interview and record review, the facility failed to conduct COVID-19 testing based on parameters set forth by the Secretary. This has the potential to affect all 47 residents. The facility was not testing based on county positivity rates and did not inform state officials they were not testing. The facility did not begin testing until 10/12/20 during survey. Findings include: The facility's COVID-19 testing policy states the facility will conduct routine staff testing once a month when the county positivity rate is less than 5%, once a week when the county positivity rate is 5-10% and twice per week when the county positivity rate is greater than 10%. The policy also states that the frequency of testing assumes availability of Point of Care testing on-site. Center for Medicare and Medicaid Services QSO Memo 20-38 dated 8/26/20 states in part; 483.80(h) COVID-19 Testing. The long term care (LTC) facility must test residents, facility staff, including individuals providing services under arrangement and volunteers, for COVID-19. At a minimum, for all residents and facility staff, including individuals providing services under arrangement and volunteers, the LTC facility must: (iv) The criteria for conducting testing of symptomatic individuals specified in this paragraph such as the positivity rate of COVID-19 in the county .Surveying for compliance: .facility has documentation that demonstrates their attempts to perform and/or obtain testing in accordance with these guidelines (e.g., timely contacting state officials, multiple attempts to identify a laboratory that can provide testing results within 48 hours). The facility has a standing order, signed by the medical director on 9/24/20, for testing of COVID-19, to include [MEDICATION NAME] testing. The facility has a Point of Care [MEDICATION NAME] testing machine. This machine has been available for use since September 17, 2020. According to CMS (Centers for Medicare and Medicaid Services), Juneau County, where the facility resides, had a positivity rate of 15.4% from September 10 through September 23 and 14.3% from September 17 through September 30. The facility has had no known COVID positive residents, but has had positive staff. Facility documentation shows the facility had not tested staff or residents since July. On 10/12/20 at 12:06 PM, Surveyor interviewed NHA A (Nursing Home Administrator). NHA A stated that she was under the assumption that the [MEDICATION NAME] testing machine was for classified outbreaks or for symptomatic residents or staff. NHA A, who is also a registered nurse, also stated the facility uses CMS county reported data as its reference, and statred testing today 10/12/20. NHA A had not informed the state agency the facility had not been testing. The facility had a Point of Care (POC) [MEDICATION NAME] machine available to complete at least a round of facility testing as of September 17, 2020. The facility did not complete testing according to their positivity rate and did not inform state officials they were not testing.

Based on interviews and record review, the facility did not ensure full time DON (Director of Nursing) coverage. This has the potential to affect all residents. This is evidenced by: On 7/16/19 at 9:22 AM, the Surveyor met with the NHA A (Nursing Home Administrator) for an entrance conference. The NHA A stated in the conference that the facility has not had a DON since their DON resigned in (MONTH) of 2019. On 7/16/19 at 3:03 PM, Surveyor interviewed RN C (Registered Nurse). Surveyor asked, who is the current DON of the facility? RN C stated, Currently we don't have anyone. I go to NHA A or charge nurse if I have questions. On 7/16/19 at 3:10 PM , Surveyor interviewed HUC D (Health Unit Coordinator). Surveyor asked, who is the current DON in the facility? HUC D stated, We don't have one currently. We are to go to the NHA A with questions. On 7/16/19 at 3:12 PM, Surveyor interviewed RN E. Surveyor asked RN [NAME] who the current DON is for the facility. RN [NAME] stated, We don't have one right now, just NHA A. Go to NHA A with questions. On 7/16/19 at 3:46 PM, Surveyor interviewed NS F (Nursing Secretary). Surveyor asked NS F who the current DON is. NS F stated, We don't have a DON but NHA A is the IDON (Interim Director of Nursing). On 7/16/19 at 4:00 PM, Surveyor met with NHA A regarding the regulatory requirement for a full time DON. NHA A stated she would have someone named as interim DON today. The facility failed to ensure that it had full-time DON coverage.

Based on interview and medical record review, the facility did not determine a Significant Change Assessment should have been completed for 1 of 15 sampled residents (R29). R29 sustained a decline in functional status on 5/23/19 MDS (Minimum Data Set). A Significant Change Comprehensive Assessment was not conducted to reflect R29's decline in abilities. This is evidenced by: R29 was admitted to the facility, on 6/30/17, with the following diagnosis, in part: . Right shoulder dislocation, Tubular [DIAGNOSES REDACTED] of colon, Chronic [MEDICAL CONDITION] Disc Disease of the knee. The facility completed a Quarterly MDS assessment for R29 on 3/6/19. The assessment, as well as the Nurses Notes, revealed R29 had a BIMS (Brief Interview of Mental Status) of 12, indicating R29 has mild cognitive impairment, had no signs of [MEDICAL CONDITION] or change in mental status, and had no behaviors present. R29's Functional Status (G0110), Bathing (G0120), Balance During Transitions and Walking (G0300) indicated the following: Section G, Functional Status (G0110): Bed Mobility - Supervision of One; Transfer - Supervision of One; Walk in Room - Independent, no set-up help; Walk in Corridor - Independent, no set-up help; Locomotion on Unit - Supervision of One; Locomotion off Unit - Supervision of One; Personal Hygiene - Supervision of One. Section G, Bathing (G0120): Physical help limited to transfer only; one person physical assist. Section G, Balance During Transitions and Walking: Walking (with assistive device if used) - Not Steady, but able to stabilize without human assistance; Turning around and facing the opposite direction while walking - Not Steady, but able to stabilize without human assistance. The facility completed the next Quarterly MDS assessment for R29 on 5/23/19. The assessment, as well as the Nurses Notes, revealed R29 had a BIMS of 9, indicating R20 had moderate cognitive impairment, had no signs of [MEDICAL CONDITION] or change in mental status, and had no behaviors present. R29's Functional Statues (G0110), Bathing (G0120), Balance During Transitions and Walking (G0300) indicated the following: Section G, Functional Status (G0110): Bed Mobility - Limited Assistance of One; Transfer - Limited Assistance of One; Walk in Room - Supervision with One assist; Walk in Corridor - Extensive assistance of One; Locomotion on Unit - Extensive assist of One; Locomotion off Unit - Extensive assist of One; Personal Hygiene - Extensive of One. Section G, Bathing (G0120): Physical help in part of bathing activity; one person physical assist. Section G, Balance During Transitions and Walking: Walking (with assistive device if used) - Not Steady, only able to stabilize with human assistance; Turning around and facing the opposite direction while walking - Not Steady, only able to stabilize with human assistance. It is important to note that, on 5/23/19, R29 had 10 separate areas of functional decline noted on the MDS. On 7/18/19 at 9:40 AM, Surveyor interviewed the IDON B (Interim Director of Nursing) regarding a Significant Change in Status MDS assessment. The IDON B stated a Significant Change in Status MDS should be completed when there has been a change in more than one section. Surveyor asked IDON B to review assessments completed on 3/6/19 and 5/23/19. IDON B reviewed assessments and stated, A Significant Change in Status MDS should have been completed for R29 on 5/23/19. I have no excuses for that. I will be putting in a Significant Change Comprehensive Assessment today. The facility failed to ensure a Significant Change Comprehensive Assessment was completed when R29 sustained a decline in functional status on 5/23/19.

Based on observation, interview and record review, the facility did not establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. The facility does not have documentation to consistently show when precautions are implemented for all resident illnesses (or potential infectious agents) on a monthly line list, and does not maintain a record of incidents and corrective actions related to infections. This has the potential to affect 51 of 51 residents in the facility. It was also observed that staff did not complete hand hygiene for 1 of 13 hand hygiene observations, and did not assure that dressing supplies were set on a clean surface during a wound treatment. Resident 15 was not placed in precautions for an eye infection (conjunctivitis). The facility does not have documentation to show tracking and trending of all illnesses or potential infectious agents on a monthly line list. The facility did not analyze monthly infection rates in order to determine if data was accurate and/or corrective actions were warranted. RN D did not wash her hands or use alcohol based hand sanitizer after glove removal, and did not assure that dressings were set on a clean surface during a dressing change. This is evidenced by: The facility's Infection Control procedure, Subject: Isolation of a Resident with a Communicable Disease, (effective May 1975 and reviewed 6/2012) states in its entirety: Purpose: to prevent nursing home residents from contracting a communicable disease. Procedure: When the resident is diagnosed as having a communicable disease, he/she will be transferred to the hospital or to a private room. 1. His/her belongings are transferred with the resident. 2. The family is notified of the transfer. 3. The unit is cleaned and disinfected by the nursing assistant and housekeeping department. 4. In case there was a roommate at the time of transfer, the physician is consulted about procedures to follow for his/her protection. 5. The attending physician is responsible for reporting the disease to the proper authority. 6. Isolation technique as in the procedure manual is followed. It is important to note that this policy does not reference a standard of practice such as the CDC (Center for Disease Control) Guidelines, nor does the policy address placing residents in precautions with symptoms of illness that could be communicable to others without a diagnosis. The facility's Infection Control policy states in part: C. All infectious cases will be reviewed with the Nursing Home Infection Preventionist or designee and he/she shall advise staff as to proper action taken concerning each case .Purpose: to devise an orderly manner to collect and communicate data concerning infectious processes in the nursing home. The facility's Hand Hygiene policy states in part: 2. cleaning with Alcohol-based product: A. if hands are not visibly soiled may use an alcohol based hand rub for routinely decontaminating hands. Examples are: 6) after removing gloves. Example 1 In reviewing the facility's November 2015 Infection Report and geographical map, it was noted that 3 residents on the 200 unit had skin infections, Resident 15 was one of the 3 and was noted to have an eye infection. Record review for Resident 15 nurse notes state in part: - 11/29/15 at 10:49 PM: Resident (15) left eye-sclera, slightly reddened and resident c/o (complained of) being itchy. Some mattery discharge noted. Resident states, I'm pretty much blind in my left eye now. Warm cloth applied and helped. Fax sent to Dr. (name) to update. -11/30/15 at 6:02 PM: Dr. (name responded to fax regarding resident's left itchy red eye. New orders . -12/1/15 at 3:25 AM: Resident (15) c/o left eye being itchy and continues to be red. Small amount of yellow-green drainage. Awaiting eye culture results. Has some difficulties seeing out of left eye. Poor vision. -12/1/15 10:05 PM: Resident's left eye is extremely red in color with yellowish discharge. Most of the time he keeps his eye closed [MEDICATION NAME] drops stared this evening. No complaints of burning in his eye. Right eye is slightly red, but has no discharge. Awaiting left eye culture results. -Lab report dated 12/1/15: Eye Culture: Large amount of Staphylococcus Aureus organism. On 11/29/15 when Resident 15 was noted to have symptoms of an eye infection, there was no documentation in Resident 15 record, on the facility's 24 hour Report log or on the facility's line listing for infections to indicate that Resident 15 was placed in Contact isolation precautions for these symptoms. It is important to note that the facility would not have known if Resident 15's eye infection was viral or bacterial in nature until the eye culture report returned on 12/1/15 and should have placed Resident 15 on Contact precautions until the source of his symptoms was known. On1/14/16 at 1:30 PM Surveyor interviewed RN J about Resident 15 eye infection on 11/29/15 and asked if the facility had any evidence that Resident 15 was placed in precautions for symptoms of an eye infection. No further information was provided. On 1/14/16 at 2:00 PM, when Surveyor asked NHA A if Resident 15 left his room during the time he had symptoms of an eye infection (conjunctivitis), NHA A stated that it is likely that Resident 15 went to the dining room for meals during this time and probably should not have. Example 2 On 1/14/16 at 9:30 AM, Surveyor met with RN (Registered Nurse) J who oversees the facility's infection Control Program, and NHA (Nursing Home Administrator) A. Surveyor asked RN J and NHA A about how the facility tracks and trends residents with symptoms of infections, RN J explained that residents with symptoms are placed on the 24 Report log and then are monitored by staff for continuation of symptoms. If resident symptoms meet McGeer's criteria for an infection, then the resident is placed on the monthly infection line list, however there is no evidence that resident symptoms of infections are tracked or trended unless the resident is treated with antibiotics or there is an outbreak identified. Additionally, the facility uses a computer based program (IQI) to track and trend infection rates. Review of this data showed: -June 2015: Total HAI/Nosocomial infection rate of 0.00, even though 6 infections were identified: (3 Respiratory, 1 Urinary tract infection and 2 skin infections) -October 2015: Total HAI/Nosocomial infection rate of 8.81 (19 Respiratory, 5 Urinary tract infection and 3 skin infections) -November 2015: Total HAI/Nosocomial infection rate of 5.02 (4 Respiratory, 2 Urinary tract infection and 9 skin infections) -December 2015: Total HAI/Nosocomial infection rate of 13.06 (23 Respiratory, 7 Urinary tract infection, 4 skin infections and 6 gastrointestinal infections) On 1/14/16 at 9:30 AM Surveyor interviewed RN J and NHA A reviewing and asking about the facility's infection rates for 6/15, 10/15, 11/15 and 12/15. RN J and NHA A could not explain why 6/15 rate was 0.00 nor why the rates for 10/15, 11/15 and 12/15 were so high (keeping in mind that average census is about 55 residents). NHA A stated that RN J would look into the infection control rates. When Surveyor asked RN J and NHA A about their process for reviewing and analyzing infection control data NHA A stated that infection control data is reviewed with the team at monthly QA (Quality Assurance) meetings and quarterly with the Medical Director. On 1/14/16 at 1:30 PM Surveyor asked RN J if she had any information on the infection control rates, RN J stated that she had gone into the facility's computer based infection control program (IQI) and printed off new sheets and the data was corrected to reflect what actually happened. The new data reviewed showed: -June 2015: Total HAI/Nosocomial infection rate of 5.41, with 9 infections identified: (3 Respiratory, 2 Urinary tract infection and 4 skin infections) -October 2015: Total HAI/Nosocomial infection rate of 4.07 (1 Respiratory, 4 Urinary tract infection and 1 skin infections) -November 2015: Total HAI/Nosocomial infection rate of 3.03 (0 Respiratory, 2 Urinary tract infection and 3 skin infections) -December 2015: Total HAI/Nosocomial infection rate of 6.22 (1 Respiratory, 4 Urinary tract infection, 1 skin infections and 4 gastrointestinal infections) Surveyor asked if RN J had made any adjustments to the data and RN J stated no that she had just gone into the computer based infection control program (IQI), printed new pages and the data populated correctly, and was not sure what had happened or why the data was inaccurate in the first reports. While the facility tracked and trended infection rates (and had rates segregated for type of infections), it is important to note that the facility did not analyze the infection control rates for 6/15, 10/15, 11/15 and 12/15 to determine if the data was accurate or if corrective action was warranted; with the significance in the results of the data, the facility should have completed this analysis. Example 3 On 1/12/16 at 2:45 PM, Surveyor observed RN (Registered Nurse) D completed a treatment for [REDACTED]. RN D changed her gloves after cleansing Resident 3's wound on her buttock, but did not wash or sanitize her hands after removing her soiled gloves and before putting on clean gloves. Surveyor interviewed RN D, RN D stated that she usually brings hand sanitizer with her when she does treatments but forgot it this time; RN D stated she did not sanitize her hands between clean and dirty and she should have. Example 4 On 1/13/16 at 9:38 AM Surveyor observed RN (Registered Nurse) D complete Resident 4's treatment to open areas on Resident 4's left buttock, RN D placed a tube of ointment and unwrapped 4 x 4 gauze pads directly onto to arm of Resident 4's cloth covered recliner (without any barrier between the dirty surface of the chair and the clean dressings). RN D proceeded to squirt cleanser onto the 4 x4's and then cleanse Resident 4's open areas. On 1/13/16 at 9:50 AM Surveyor interviewed RN (Registered Nurse) D about Resident 4's treatment, RN D stated that she probably should have laid a barrier down under the clean dressing supplies and did not.

Based on record review and interview, in 5 of 8 total residents reviewed (Resident 5, 9, 2, 10, and 8), the facility did not ensure that each residents' medication regime was free from unnecessary medications. Resident 5 has a [DIAGNOSES REDACTED]. There is no evidence the facility has attempted a gradual dose reduction (GDR) for this black boxed warning medication. Resident 9 has no Dyskinesia Identification System: Condensed User Scale (DISCUS) completed since 9/4/2014 to ensure Resident 9 has no adverse side effects from the use of [MEDICATION NAME]. Resident 2 has a [DIAGNOSES REDACTED]. There is no evidence in the medical record that the use of the antipsychotic medication is necessary for the treatment of [REDACTED]. In addition, there has been no Dyskinesia Identification System Condensed User Scale (DISCUS) completed to ensure Resident 2 has no adverse side effects from this antipsychotic medication. Resident 10 has a [DIAGNOSES REDACTED]. There is no evidence the facility has attempted a gradual dose reduction (GDR) for this black boxed warning medication. Resident 8 takes [MEDICATION NAME], an antipsychotic, there is no DISCUS completed. This is evidence by: Wisconsin Chapter 50.08 (3) (a) Except as provided in sub. (3m) or (4), before administering a [MEDICAL CONDITION] medication that has a boxed warning under 21 CFR 201.57 to a resident who has [MEDICAL CONDITION] brain disorder, a nursing home shall obtain written informed consent from the resident or, if the resident is incapacitated, a person acting on behalf of the resident, on a form provided by the department under par. (b) Or on a form that contains the same information as the form under par. (b). (f) A resident, or a person acting on behalf of the resident, may withdraw consent, in writing, at any time. (fm) At the time a resident, or a person acting on behalf of the resident, signs the informed consent form, the nursing home shall orally inform the resident, or the person acting on behalf of the resident, of all of the following: 1. That the resident, or the person on behalf of the resident, may withdraw consent, in writing, at any time. 2. That, unless consent is withdrawn sooner, the informed consent is valid for the period specified on the informed consent form or for 15 months from the date on which the resident, or the person acting on behalf of the resident, signs the form, whichever is shorter. The facility's policy entitled Review of Behavior Altering Drug Therapy dated 5/1992 states in part; 2. Monitor for documentation of need assessment of antipsychotic therapy on an ongoing basis. i. Monitor for physician justification of need at least every six months, in the progress notes or the [MEDICAL CONDITION] drug monitoring summary update. ii. Monitor for physician justification when GDR are not attempted at least twice during one year of therapy when the patient is stable to achieve minimum dose. 3. Monitor for physician and nursing action when side effects are observed. Focus attention to side effects of Tardive dyskinesia. Example 1 Resident 5 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Resident 5's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/18/15 indicates Resident 5 has moderate impairment, no behaviors, and the mood severity of score of 0 indicating no mood symptoms present. Resident 5's comprehensive care plan entitled Problem: Mood, dated 3/12/15, interventions include in part: Administer [MEDICAL CONDITION] medication ([MEDICATION NAME]) as ordered, Observe for targeted behaviors, i.e. withdrawn not coming out of room, not wanting to change clothes,comb her hair or do ADL ' s, Rude comments to staff or other resident, difficulty sleeping. Provide non-medication interventions i.e. Comfort (pain, position, activities, redirection, 1-1 interaction, snack, toileting, touch/backrub, reassurance/emotional, visit with daughter, watch TB (enjoys news in am), visiting with other residents especially during mealtimes. Encourage and remind Resident to speak kindly to others. Resident thinks she owns the table she sits at in the MDR. She is possessive of her table, can be rude to others. Resident 5's physician's orders [REDACTED]. Resident 5's MAR, (Medication Administration Record) dated 4/2015 includes the following order: Date: 10/7/14, [MEDICATION NAME] 100 mg Take 1 Tablet once daily. Hand written underneath indicates DO NOT TAPER. Resident 5's Behavior Monitoring Record, dated 5/20/15 indicated Resident 5's behaviors from 5/1/15 to 5/7/15 were two episodes of rude comments to others. Resident 5's physician's orders [REDACTED].½ tablets (150 mg) once daily. Resident 5's MAR indicated [REDACTED]½ Tablets (150 mg) once daily. Hand written underneath indicates DO NOT TAPER. The facility's has a form entitled [MEDICAL CONDITION] Medication Review the form has a statement at the bottom which states Continued use is in accordance with the current standard of practice a GDR attempt at this time is likely to impair this individual's function or cause psychiatric instability by exacerbating an underlying medical condition or psychiatric disorder. There is no further indication as to why Resident 5 should not have a GDR attempted. Resident 5's [MEDICAL CONDITION] Medication Review Form dated 2/19/15 states [MEDICATION NAME] 100 mg po (orally) daily. On 2/18/15 there is no indication this medication has had a GDR since being initiated on 10/7/14 and no indication in Resident 5's medical record indicating her targeted behavior are persistent or harmful. Resident 5's [MEDICAL CONDITION] Medication Review Form dated 12/3/15 states [MEDICATION NAME] 150 mg po (orally) daily. On 12/3/15 there is no indication this medication has had a GDR since being initiated on 5/7/15 and no indication in Resident 5's medical record indicating her targeted behavior are persistent or harmful. On 1/13/16 at 1:45 pm Surveyor interviewed LPN (Licensed Practical Nurse) O. LPN O stated Resident 5's Power of Attorney does not want Resident 5's [MEDICATION NAME] decreased. LPN O stated the hand written DO NOT TAPER in Resident 5's MAR indicated [REDACTED]. On 1/13/16 at 1:50 pm Surveyor interviewed FM (Family Member) P. FM P is Resident 5's Activated Power of Attorney for Healthcare. FM P stated she did not want Resident 5's [MEDICATION NAME] tapered. FM P stated she had requested the increase in [MEDICATION NAME] in 5/2015 due to Resident 5 was yelling at her more. On 1/13/16 at 2:15 pm Surveyor interviewed NHA (Nursing Home Administrator) A. NHA A stated FM P requested Resident 5's [MEDICATION NAME] not to be tapered and NHA A stated that facility should have spoken with FM P to talk about Resident 5's behaviors prior to increasing the [MEDICATION NAME] in 5/2015. Example 2 Resident 9 [DIAGNOSES REDACTED]. Resident 9's physician's orders [REDACTED]. Take one tablet once daily. Resident 9's Medical Record included a DISCUS; dated 9/4/2014 indicating Resident 9 had no symptoms of TD (Tardive Dyskinesia). The DISCUS also indicated the next exam date as 2015. No other DISCUS forms were found in Resident 9's record. On 1/14/16 at 2:30 pm Surveyor interviewed RN (Registered Nurse) I. RN I stated she could not find another DISCUS in Resident 9's medical record. RN I stated a DISCUS should have been completed annually. Example 3 Resident 2 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Resident 2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/8/15 indicates a Brief Interview of Mental Status (BIMS) score of 3 indicating Resident 2 has severe cognitive impairment. The Behavior section E0100 [MEDICAL CONDITION] indicates Resident 2 has no delusions or hallucinations. E0200 A. Physical Behavior is marked as 0. B. Verbal Behavior is marked as 0. C. Other Behavior is marked as 0. E 0800 Rejects Care is marked as 0. E 1000 Wandering is marked as 0. Resident 2's Physician order [REDACTED]. [MEDICATION NAME] (antipsychotic medication) 0.25 milligrams (mg) give take one tablet by mouth daily at bedtime. [MEDICATION NAME] (antipsychotic medication) 0.5 milligrams (mg) give take one tablet by mouth twice daily. An Informed Consent for [MEDICATION NAME] was signed on 2/22/15, with reason: [MEDICAL CONDITION]. Under the black box warning section it states in part; this drug is not approved for the treatment of [REDACTED]. Resident 2's comprehensive care plan entitled Problem: Maintain highest level of cognition., An approach to this care planned problem states in part; redirect inappropriate sexual behavior; provide explanation with all cares; use good eye contact when speaking with resident. Resident 2's behavior monitoring for October 2015 indicates the following: Targeted Behaviors for: Medication: [MEDICATION NAME]- exploring into others rooms/trying to leave, sexually inappropriate comments; yelling/swearing at staff; calling out constantly hey, hey, hey. October behavior sheet indicates Resident 2 had 1 day of - exploring into others rooms/trying to leave dated 10/19/15. Resident 2's behavior monitoring for November 2015 indicates the following: Targeted Behaviors for: Medication: [MEDICATION NAME]- exploring into others rooms/trying to leave, sexually inappropriate comments; yelling/swearing at staff; calling out constantly hey, hey, hey. November targeted behavior sheet indicates Resident 2 had 2 days of yelling/swearing at staff on dates 11/9/15 and 11/21/15. Resident 2's behavior monitoring for December 2015 indicates the following: Targeted Behaviors for: Medication: [MEDICATION NAME]- exploring into others rooms/trying to leave, sexually inappropriate comments; yelling/swearing at staff; calling out constantly hey, hey, hey. December targeted behavior sheet indicates Resident 2 had 1 day of calling out constantly hey,hey,hey dated 12/28/15. The facility's has a form entitled [MEDICAL CONDITION] Medication Review the form has a statement at the bottom which states Continued use is in accordance with the current standard of practice a GDR attempt at this time is likely to impair this individual's function or cause psychiatric instability by exacerbating an underlying medical condition or psychiatric disorder. The facility uses this form for all of their [MEDICAL CONDITION] drug reviews this form has the same response checked marked for 1/22/15, 5/15/15, 9/10/15 and 12/4/15. There is no further indication in Resident 2's medical record to indicate why Resident 2 should not have a GDR completed and no indication that Resident 2's behaviors were persistent and/or harmful. In addition, Resident 2 had a Discus last completed 09/14/14. A Discus should be completed at least annually to monitor for adverse side effects related to antipsychotic medications. There was no indication in Resident 2's medical record that a Discus had been completed within the last year. On 1/14/16 at 1:45 PM Surveyor interviewed Registered Nurse H regarding the Resident 2's medication use. Surveyor asked RN H what the medical [DIAGNOSES REDACTED]. RN H stated [MEDICAL CONDITION]. Surveyor asked RN H if these behaviors are persistent and harmful to Resident 2. RN H stated no. On 1/14/16 at 2:40 PM Surveyor reviewed Resident 2's behavior monitoring which indicates tracking behaviors for exploring into others rooms/trying to leave, sexually inappropriate comments; yelling/swearing at staff; calling out constantly hey, hey, hey. Surveyor reviewed Resident 2's medical record with Nursing Home Administrator (NHA) A. Resident 2's medical record shows no indication that Resident 2's behaviors are persistent and harmful to Resident 2 or others. Surveyor asked NHA A how the facility reviews [MEDICAL CONDITION] medication usage and how it is decided if medications are reduced. NHA A stated the facility had a designated nurse who completed [MEDICAL CONDITION] medication monitoring and this nurse has recently left the facility. The facility discusses [MEDICAL CONDITION] medication usage at the pharmacy meeting on a quarterly basis. The nurse fills out the [MEDICAL CONDITION] Medication Review form and sends to the physician for signature; NHA A stated since the nurse has left this has just fallen off. Surveyor asked NHA A if an Discus should be completed annually NHA A stated since the nurse has left this has just fallen off. Resident 2 has a [DIAGNOSES REDACTED]. There is no indication in Resident 2's medical record indicating that Resident 2's behaviors are persistent and harmful to himself or others. Resident 2 is receiving an antipsychotic medication without adequate indication for its use. Example 4 Resident 10 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Resident 10's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/13/15 indicates a Brief Interview of Mental Status (BIMS) score of 2 indicating Resident 10 has severe cognitive impairment. The Behavior section E0100 [MEDICAL CONDITION] indicates Resident 2 has no delusions or hallucinations. D0100 Mood indicates D0200 B. feeling down, depressed or hopeless = never or 1 day and D. Feeling tired or having little energy = 7-11 days. Resident 2's Physician order [REDACTED]. [MEDICATION NAME] 10 mg 1 tablet once daily. Resident 10's comprehensive care plan entitled Problem: Will accept staff reassurance and emotional support ., An approach to this care planned problem states in part; administer medication as ordered ([MEDICATION NAME]) observe for targeted behaviors spitting out medications, yelling/striking out at staff during toileting, crying wanting to stay in bed. Provide non-medication interventions: re-direct, snack, toileting, reassurance, backrub. The facility's has a form entitled [MEDICAL CONDITION] Medication Review the form has a statement at the bottom which states Continued use is in accordance with the current standard of practice a GDR attempt at this time is likely to impair this individual's function or cause psychiatric instability by exacerbating an underlying medical condition or psychiatric disorder. There is no further indication as to why Resident 10 should not have a GDR completed. Resident 10's [MEDICAL CONDITION] Medication Review Form dated 1/22/15 states [MEDICATION NAME] 10mg was started on 8/5/14. There is no indication this medication has had a GDR since being initiated on 8/5/14 and no indication in Resident 10's medical record indicating her behavior is persistent or harmful. On 1/14/16 at 2:40 PM Surveyor reviewed Resident 10's behavior monitoring which indicates tracking behaviors for spitting out medications, yelling/striking out at staff during toileting, crying, wanting to stay in bed. Surveyor reviewed Resident 10's medical record with Nursing Home Administrator (NHA) A. Resident 10's medical record shows no indication Resident 10's behaviors are persistent and harmful to Resident 10 or others. Surveyor asked NHA A how the facility reviews [MEDICAL CONDITION] medication usage and how it is decided if medications are reduced. NHA A stated the facility had a designated nurse who completed [MEDICAL CONDITION] medication Example 3 Resident 2 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Resident 2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/8/15 indicates a Brief Interview of Mental Status (BIMS) score of 3 indicating Resident 2 has severe cognitive impairment. The Behavior section E0100 [MEDICAL CONDITION] indicates Resident 2 has no delusions or hallucinations. E0200 A. Physical Behavior is marked as 0. B. Verbal Behavior is marked as 0. C. Other Behavior is marked as 0. E 0800 Rejects Care is marked as 0. E 1000 Wandering is marked as 0. Resident 2's Physician order [REDACTED]. [MEDICATION NAME] (antipsychotic medication) 0.25 milligrams (mg) give take one tablet by mouth daily at bedtime. [MEDICATION NAME] (antipsychotic medication) 0.5 milligrams (mg) give take one tablet by mouth twice daily. An Informed Consent for [MEDICATION NAME] was signed on 2/22/15, with reason: [MEDICAL CONDITION]. Under the black box warning section it states in part; this drug is not approved for the treatment of [REDACTED]. Resident 2's comprehensive care plan entitled Problem: Maintain highest level of cognition. An approach to this care planned problem states in part; redirect inappropriate sexual behavior; provide explanation with all cares; use good eye contact when speaking with resident. Resident 2's behavior monitoring for October 2015 indicates the following: Targeted Behaviors for: Medication: [MEDICATION NAME]- exploring into others rooms/trying to leave, sexually inappropriate comments; yelling/swearing at staff; calling out constantly hey, hey, hey. October behavior sheet indicates Resident 2 had 1 day of - exploring into others rooms/trying to leave dated 10/19/15. Resident 2's behavior monitoring for November 2015 indicates the following: Targeted Behaviors for: Medication: [MEDICATION NAME]- exploring into others rooms/trying to leave, sexually inappropriate comments; yelling/swearing at staff; calling out constantly hey, hey, hey. November targeted behavior sheet indicates Resident 2 had 2 days of yelling/swearing at staff on dates 11/9/15 and 11/21/15. Resident 2's behavior monitoring for December 2015 indicates the following: Targeted Behaviors for: Medication: [MEDICATION NAME]- exploring into others rooms/trying to leave, sexually inappropriate comments; yelling/swearing at staff; calling out constantly hey, hey, hey. December targeted behavior sheet indicates Resident 2 had 1 day of calling out constantly hey,hey,hey dated 12/28/15. The facility's has a form entitled [MEDICAL CONDITION] Medication Review the form has a statement at the bottom which states Continued use is in accordance with the current standard of practice a GDR attempt at this time is likely to impair this individual's function or cause psychiatric instability by exacerbating an underlying medical condition or psychiatric disorder. The facility uses this form for their entire [MEDICAL CONDITION] drug reviews this form has the same response checked marked for 1/22/15, 5/15/15, 9/10/15 and 12/4/15. There is no further indication in Resident 2's medical record to indicate why Resident 2 should not have a GDR completed and no indication that Resident 2's behaviors were persistent and/or harmful. In addition, Resident 2 had a Discus last completed 09/14/14. A Discus should be completed at least annually to monitor for adverse side effects related to antipsychotic medications. There was no indication in Resident 2's medical record that a Discus had been completed within the last year. On 1/14/16 at 1:45 PM Surveyor interviewed Registered Nurse H regarding the Resident 2's medication use. Surveyor asked RN H what the medical [DIAGNOSES REDACTED]. RN H stated [MEDICAL CONDITION]. Surveyor asked RN H if these behaviors are persistent and harmful to Resident 2. RN H stated no. On 1/14/16 at 2:40 PM Surveyor reviewed Resident 2's behavior monitoring which indicates tracking behaviors for exploring into others rooms/trying to leave, sexually inappropriate comments; yelling/swearing at staff; calling out constantly hey, hey, hey. Surveyor reviewed Resident 2's medical record with Nursing Home Administrator (NHA) A. Resident 2's medical record shows no indication that Resident 2's behaviors are persistent and harmful to Resident 2 or others. Surveyor asked NHA A how the facility reviews [MEDICAL CONDITION] medication usage and how it is decided if medications are reduced. NHA A stated the facility had a designated nurse who completed [MEDICAL CONDITION] medication monitoring and this nurse has recently left the facility. The facility discusses [MEDICAL CONDITION] medication usage at the pharmacy meeting on a quarterly basis. The nurse fills out the [MEDICAL CONDITION] Medication Review form and sends to the physician for signature; NHA A stated since the nurse has left this has just fallen off. Surveyor asked NHA A if an Discus should be completed annually NHA A stated since the nurse has left this has just fallen off. Resident 2 has a [DIAGNOSES REDACTED]. There is no indication in Resident 2's medical record indicating that Resident 2's behaviors are persistent and harmful to himself or others. Resident 2 is receiving an antipsychotic medication without adequate indication for its use. Example 4 Resident 10 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Resident 10's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/13/15 indicates a Brief Interview of Mental Status (BIMS) score of 2 indicating Resident 10 has severe cognitive impairment. The Behavior section E0100 [MEDICAL CONDITION] indicates Resident 2 has no delusions or hallucinations. D0100 Mood indicates D0200 B. feeling down, depressed or hopeless = never or 1 day and D. Feeling tired or having little energy = 7-11 days. Resident 2's Physician order [REDACTED]. Resident 10's comprehensive care plan entitled Problem: Will accept staff reassurance and emotional support ., An approach to this care planned problem states in part; administer medication as ordered ([MEDICATION NAME]) observe for targeted behaviors spitting out medications, yelling/striking out at staff during toileting, crying wanting to stay in bed. Provide non-medication interventions: re-direct, snack, toileting, reassurance, backrub. The facility's has a form entitled [MEDICAL CONDITION] Medication Review the form has a statement at the bottom which states Continued use is in accordance with the current standard of practice a GDR attempt at this time is likely to impair this individual's function or cause psychiatric instability by exacerbating an underlying medical condition or psychiatric disorder. There is no further indication as to why Resident 10 should not have a GDR completed. Resident 10's [MEDICAL CONDITION] Medication Review Form dated 1/22/15 states [MEDICATION NAME] 10mg was started on 8/5/14. There is no indication this medication has had a GDR since being initiated on 8/5/14 and no indication in Resident 10's medical record indicating her behavior is persistent or harmful. On 1/14/16 at 2:40 PM Surveyor reviewed Resident 10's behavior monitoring which indicates tracking behaviors for spitting out medications, yelling/striking out at staff during toileting, crying, wanting to stay in bed. Surveyor reviewed Resident 10's medical record with Nursing Home Administrator (NHA) A. Resident 10's medical record shows no indication Resident 10's behaviors are persistent and harmful to Resident 10 or others. Surveyor asked NHA A how the facility reviews [MEDICAL CONDITION] medication usage and how it is decided if medications are reduced. NHA A stated the facility had a designated nurse who completed [MEDICAL CONDITION] medication monitoring and this nurse has recently left the facility. The facility discusses [MEDICAL CONDITION] medication usage at the pharmacy meeting on a quarterly basis. The nurse fills out the [MEDICAL CONDITION] Medication Review form and sends to the physician for signature; NHA A stated since the nurse has left this has just fallen off. Resident 10 has a [DIAGNOSES REDACTED]. There is no indication in Resident 10's medical record indicating that Resident 10 has had a recent GDR. Example 5 Resident 8's [DIAGNOSES REDACTED]. The original order for Resident 8's [MEDICATION NAME] was written on 9/2/15. The order states 0.25 milligrams (mg) every pm. Resident 8's most current physician's orders [REDACTED]. Surveyor requested copies of Resident 8's DISCUS on three separate occasions and the facility did not provide any documentation. There is no evidence that a DISCUS is completed related to the use of the [MEDICATION NAME], to monitor Resident 8 for any adverse side effect from the medication.

Based on observation and interview the facility did not promote care for residents in a manner that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality for 4 of 12 Residents observed (Residents 2, 10, 15, and 11 ). Resident 2 was assisted to the restroom the staff did not provide for Resident 2's privacy while in the restroom. Resident 10 was asleep with her head resting on the dining room table staff did not assist Resident 10 to lay down or provide for her dignity. Staff did not assure privacy and dignity for Resident 15 while providing morning cares after an episode of incontinence. Staff did not assure privacy when assisting Resident 11 in the bathroom. This is evidenced by the following: Example 1 Resident 2 has the following Diagnoses: [REDACTED]. A Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/8/15 indicates a Brief Interview of Mental Status (BIMS) score of 3 indicating Resident 2 has severe cognitive impairment. Section G0100 Activities for Daily Living I. Toileting indicates Resident 2 requires extensive assist of 1 staff for toileting. On 1/12/16 at 1:00 PM Surveyor observed Certified Nursing Assistant (CNA) C toilet Resident 2. CNA C transferred Resident 2 to the toilet CNA C did not shut the restroom door, Resident 2's room door or pull the privacy curtain prior to toileting Resident 2. On 1/12/16 at 1:15 PM Surveyor interviewed CNA C regarding providing privacy for Resident 2 when toileting. CNA C stated she should have shut the bathroom door. On 1/14/16 at 2:40 PM Surveyor interviewed Nursing Home Administrator (NHA) A regarding privacy when providing care. NHA A stated the restroom door should be closed when toileting a resident. Example 2 Resident 10 has the following Diagnoses: [REDACTED]. A MDS with an ARD of 11/13/15 indicates a BIMS score of 2 indicating Resident 10 has severe cognitive impairment. Section G0100 Activities for Daily Living indicates Resident 10 requires extensive assist of 1 staff for bed mobility and transfers. On 1/13/16 Surveyor completed continuous observations of the 300 unit breakfast meal service from 7:50 AM to 9:00 AM. On 1/13/16 at 7:50 AM Surveyor observed Resident 10 sleeping with her head lying on the dining room table. On 1/13/16 at 8:07 AM Surveyor observed Certified Nursing Assistant (CNA) F approach Resident 10 and state to Resident 10 can you sit up it's going to be breakfast time. Resident 10 did not lift her head and CNA F walked away. On 1/13/16 at 8:28 AM Surveyor observed CNA C stated to Resident 10 can you wake up you have some yogurt, gave bite of yogurt. Here you can eat this CNA C sat the yogurt in front of Resident 10 and walked away. On 1/13/16 at 8:29 AM Surveyor observed Resident 10 with her head on the table. On 1/13/16 at 8:32 AM Surveyor observed CNA F give ice cream to Resident 10. CNA F stated to Resident 10 here is your ice cream. Resident 10 sat up. On 1/13/16 at 8:33 AM Surveyor observed Resident 10 with her head lying on the table. On 1/13/16 at 8:38 AM Surveyor 3166 observed Director of Nursing (DON) B approach Resident 10. DON B stated to Resident 10 try to wake up. Resident 10 was lying with her head on the table. DON B spoke to Registered Nurse (RN) H and RN H stated we have been trying to work with her. On 1/13/16 at 8:50 AM Surveyor observed CNA G approach Resident 10. CNA G was not previously working on the 300 unit. CNA G sat next to Resident 10; Resident 10 was lying with her head on the table. CNA G woke Resident 10 and assisted Resident 10 to eat and drink. On 1/13/16 at 9:10 AM Surveyor interviewed CNA C regarding Resident 10 lying with her head on the table for over an hour. CNA C stated she is sleepy at times she always wants to go back to bed. Surveyor asked CNA C if the staff should have assisted her back to bed. CNA C stated we try to get her to eat something then we will usually have her take a nap. On 1/13/16 at 9:22 AM Surveyor interviewed CNA G regarding assisting on the 300 unit and assisting Resident 10 to eat. CNA G stated that she was working on the 200 unit and DON B asked her to come to the 300 unit and help with Resident 10. On 1/14/16 at 1:50 PM Surveyor interviewed RN H regarding Resident 10. Surveyor asked RN H if the staff should have assisted Resident 10 to bed when she was lying with her head on the table. RN H stated that the staff should have assisted her back to her room. On 1/14/16 at 2:40 PM Surveyor interviewed Nursing Home Administrator (NHA) A regarding the observation with Resident 10. NHA A stated the staff should have assisted her to a more comfortable place whether it was in her bed, recliner or a recliner in the day room. Surveyor was unable to interview Resident 10 due to her severe cognitive impairment. Using the reasonable person concept the facility did not maintain Resident 10's dignity when allowing Resident 10 to lie with her head on the table for an hour. Example 3 Resident 15 [DIAGNOSES REDACTED]. Resident 15's annual MDS (Minimum Data Set) on 10/12/15 indicates a BIMS (Brief interview for Mental Status) score of 9 indicating some cognitive impairment, and that Resident 15 is frequently incontinent of urine (Section H0300). On 1/14/16 at 7:55 AM Surveyor was at the charting area adjacent to Resident 15's room (approximately 20 feet away entrance to Resident 15's room), Surveyor observed that a privacy curtain was pulled across the entry to Resident 15's room but the door to the room was wide open, Surveyor overheard staff say: (Resident 15 name) you peed your pants we have to change your pants now. At 8:00 AM Surveyor interviewed CNA (Certified Nursing Assistant) Q and asked her what she said to Resident 15, CNA Q stated that she said (Resident 15 name) you peed your pants we have to change your pants now, CNA Q said that she should have lowered her voice and just said that we need to change your clothes. On 1/14/16 at 10:40 AM Surveyor interviewed NHA (Nursing Home Administrator) A about what CNA Q said to Resident 15, NHA A stated that CNA Q could have better chosen her words and lowered her voice, and that NHA A thinks staff leave resident's doors open during cares so that they can hear what is going on, on the unit, but that they should be careful when communicating with residents. On 1/14/16 at 1:05 PM Surveyor asked Resident 15 how he felt about what CNA Q said to him when getting him up, Resident 15 stated it's nothing, sometimes I don't hear well, they're real good to me here. Example 4 Resident 11's quarterly MDS (Minimum Data Set) on 12/30/15 noted a BIMS (Brief Interview for Mental Status) score of 7 indicating severe cognitive impairment. On 1/14/16 at 12:50 PM Surveyor observed CNA (Certified Nursing Assistant) R assist Resident 11 into the bathroom and transfer Resident 11 onto the toilet. CNA R left the door to the bathroom completely open as well as the door to Resident 11's room. There was no privacy curtain in place to protect Resident 11 from view from the hallway or from inside the room. While Resident 11 was sitting on the toilet, LPN (Licensed Practical Nurse) S entered Resident 11's bathroom to apply medication to her groin folds and another staff member brought Resident 11's roommate into the room leaving Resident 11 exposed while sitting on the toilet. On 1/14/16 at 1:00 PM Surveyor interviewed CNA R and LPN S asking how staff provides privacy when toileting residents, LPN S noted that there was no privacy curtain in place in Resident 11's room to block the view to the bathroom, stating I don't know why the privacy curtain is not up, perhaps it is in laundry being washed, LPN S also stated that staff should have shut the door to Resident 11's room and should not have brought Resident 11's roommate into the room until Resident 11 was done in the bathroom, but staff did not do this.

Based on observation, interview and record review the facility did not ensure that a resident who enters the facility without a pressure ulcer does not develop a pressure ulcer unless the resident's condition demonstrates that they were unavoidable and a resident with a pressure ulcer receives necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing for 2 of 9 residents with pressure ulcers (Residents 1 and 4). Resident 4's open area on her left ischium was not identified as a Stage 2 pressure ulcer, the treatment was not appropriate to effectively promote healing and there was no evidence of education provided to Resident 4 to promote assistance in pressure ulcer prevention. Resident 1 was admitted to the facility without a pressure ulcer (PU) and was identified to be at risk for PU development. Resident 1 has re-occurring friction and shearing which has resulted in PU development. The facility failed to assess the root cause for Resident 1's friction, shearing, and PU development and failed to implement additional interventions to prevent Resident 1 from developing a PU. Resident 1 developed an avoidable; Stage 2 PU to the right buttock while in the facility. In addition, the facility failed to complete weekly skin assessments when impaired skin integrity was noted and failed to recognize the development of a Stage 2 PU. This is evidenced by: According to Advances in Skin and Wound Care June 2004; Volume 17 - Issue 5- p 222 Friction and shear are mechanical forces contributing to pressure ulcer formation. The tissue injury resulting from these forces may look like a superficial skin insult. Shear and friction are 2 separate phenomenon's, yet they often work together to create tissue ischemia and ulcer development. Shear is a mechanical force that acts on an area of skin in a direction parallel to the body ' s surface. Shear is affected by the amount of pressure exerted, the coefficient of friction between the materials contacting each other, and the extent to which the body makes contact with the support surface. <http://journals.lww.com/aswcjournal/fulltext/2004/ /did_you_know__the_difference_between_friction_and.6.asp This this insult and compromise to the blood supply creates ischemia and leads to cellular death and tissue necrosis. Shear and friction go hand in hand-one rarely occurs without the other. Shear injury will not be seen at the skin level because it happens beneath the skin. Elevation of the head of the bed increases shear injury in the deep tissue, and may account for the number of sacral ulcers seen in practice. Unlike shear injury, friction injury will be visible. Friction is the mechanical force exerted when skin is dragged across a coarse surface such as bed linens. Friction then combines with shearing forces and the ultimate outcome may be a pressure ulcer. Tissues subjected to friction are more susceptible to pressure ulcer damage. The 3 mechanical forces (pressure, friction, and shear) may act in concert to create tissue damage. The facility's policy entitled Assessment, treatment and Prevention of All Skin Integrities, undated, states in part; Procedure: 2. a. If a resident has impaired skin integrity, a Registered Nurse (RN)/Licensed Practical Nurse (LPN) will write a comprehensive assessment in the nurses' notes. C. Reassessment: i. Reassess and document weekly. II. Treatment /Intervention: C. Implement and/or revise pressure relieving interventions to prevent from further skin breakdown. III. Daily Skin Prevention: A. Wash with a mild soap or no soap rinse solution, dry thoroughly. Avoid hot water and excessive friction. F. Lift do not slide resident. Example 1 Resident 4 was admitted to the facility on [DATE] with including [MEDICAL CONDITION] Arthritis, [MEDICAL CONDITION] and Anorexia. Resident 4's MDS (Minimum Data Set) assessment on 12/27/15 indicated a BIMS (Brief Interview for Mental Status) score of 14 indicating that Resident 4 is cognitively intact. It is important to note that Resident's 4's weight on 1/7/16 is 60 pounds. Resident 4's care plan dated 4/2/14 states in part: Skin will remain intact; (Resident 4) would like to remain free from further skin breakdown. Remains at risk due to low body weight and nutritional risk. Observe skin daily with cares and report any alterations in skin integrity to nurse promptly, provide cushion in wheelchair, air overlay mattress on bed repositioning schedule as Resident 4 allows .Notify MD (Medical Doctor) with any findings of skin alteration .monitor pressure reduction measures .encourage position changes .encourage to sleep in bed vs (versus) recliner to decrease risk of shearing. Resident 4's physician orders [REDACTED].# 3 ointment to areas twice a day and PRN (as needed). On 1/13/16 at 9:38 AM Surveyor observed RN (Registered Nurse) D completing Resident 4's wound treatment to her left buttock. Surveyor observed that there was a thick layer of white barrier ointment (Sensi- Care 3) caked on and adhered to an abraded area on Resident 4's left buttock (below and to the left of Resident 4's coccyx) measuring 0.8 cm x 0.6 cm and also observed the thick layer of ointment covering a round shaped open area on Resident 4's left ischium (also measuring 0.8 cm x 0.6 cm.). RN D attempted to remove the ointment with 4 x 4 saturated with wound cleanser, as RN D was attempting to remove the ointment the top layer of skin peeled away, RN D stated oh shoot, I created that (abraded area to skin). It is important to note that it was difficult to visualize the wound edges or wound bases due to the thick layer of ointment on the wounds. On 1/13/16 at 9:55 AM Surveyor asked RN D if Sensi-Care 3 was an appropriate treatment for [REDACTED]. RN D stated that her understanding was that Sensi-Care 3 could be placed on a wound, and then wipe off the top layer of ointment and that the remaining of ointment would act as a dressing, but she was not sure and that she would call the representative for the product. Surveyor asked RN D how she describes and codes these open areas, RN D stated that she assesses and describes the areas as shear and stated, I hate to call anything a pressure ulcer. Surveyor asked if shear could cause a pressure ulcer, RN D state yes there could be mixed causes to open areas. RN D was also asked how she would describe the open area on Resident 4's ischium; she stated that it was probably a Stage 2 pressure ulcer and that she would correct the documentation and would notify the physician for any new orders. On 1/13/16 at 1:00 PM RN D provided Surveyor with a faxed document (from another facility) regarding the use of skin protectant and stated to Surveyor that the Sensi-Care 3 could be removed with mineral oil. However the information referenced Seni-Care R, Surveyor asked RN D if the Sensi Care R information that she gave me was the same as the product, Sensi Care 3, in reviewing the information, RN D stated I'm learning new things, I will plan to get the product representative here to provide more education for us. There was no other information provided regarding Sensi-Care 3. On 1/14/16 at 8:45 AM Surveyor asked RN (Registered Nurse) D if she had provided education to Resident 4 about the risks and benefits of sitting up in her wheelchair for long periods of time, sleeping in her recliner and off-loading pressure to her buttocks, RN D stated that the staff encourages Resident D to lay down and reposition, but that she had no documentation of education for Resident 4 and that there should be. Example 2 Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's Braden assessment, dated 11/24/15, indicates Resident 1 scored a 13 indicating Resident 1 was at moderate risk for PU development. Resident 1's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/14/15, indicates A Brief Interview for Mental Status (BIMS) was completed with Resident 1 scoring a 2 indicating severe cognitive impairment. Section M0150 of the MDS indicates Resident 1 is at risk for developing a PU. Section G0110, Activities of Daily Living (ADL's) indicates Resident 1 requires 2 staff and extensive assistance for transfers and extensive assist and 1 staff assist for bed mobility. Resident 1's comprehensive care plan entitled Skin will remain intact has thin skin with history of blisters and shearing dated 2/10/14 states in part; check skin with AM and night cares daily, report findings to nurse, weekly skin assessment, maintain repositioning schedule, cream to buttocks as ordered, provide pressure reduction cushion in wheelchair (w/c), head of bed elevated as tolerated, air mattress overlay to bed, check function and placement every shift skin treatment as ordered by physician. Telephone Consultation Form dated 10/20/15 states in part; blister noted on right buttock 1.4.cm x 0.6 cm may we treat with Sensicare #3 twice daily and as needed until resolved. Physician orders [REDACTED].#3 twice daily and as needed to affected area until healed. Nursing notes dated 10/21/15 at 10:07 PM state in part; blister to right buttock new order Sensicare #3 twice daily as needed to affected area until resolved. Of note, there is no skin assessment for the weeks of 10/28/15, 11/4/15 and 11/11/15. Nursing notes dated 11/16/15 at 9:29 PM states in part; right buttock sore is scabbed and healing. Sensicare # 3 is applied to area twice daily (BID) for protection/healing. Nursing notes dated11/23/15 at 9:47 PM states in part; right buttock sore is scabbed and healing. Sensicare #3 is applied to area BID for protection/healing. Nursing notes dated 11/24/15 at 5:04 PM states in part; no scab on right buttock, skin to buttocks intact. Nursing notes dated 11/30/15 at 9:12 PM states in part; right buttock sore is healed. Sensicare #3 is applied to area BID for continued protection. Telephone Consultation Form dated 12/15/15 has a 0.4 cm x 0.4 cm shear to left buttock. Physician order [REDACTED]. Nursing notes dated 12/15/15 at 6:32 AM states in part; Resident has a 0.4 centimeter (cm) x 0.4 cm shear to left buttock; applying Sensicare #3 BID and as needed. Nursing notes dated 12/15/15 at 1:27 PM states in part; pressure reduction measures in place with wheel chair cushion, air overlay, position changes, and assist with toileting hygiene; area very superficial Sensicare used to treat area. Nursing Skin monitoring Form dated December 15, 2015 states in part; left buttock shear. Nursing notes dated 12/16/15 at 5:42 AM states in part; Sensicare applied to left buttock shear; superficial. Nursing notes dated 12/16/15 at 9:16 PM shear to left buttock appears superficial. Nursing notes dated 12/17/15 at 6:52 AM continues to have superficial shear to left buttock. Sensicare #3 applied per order. Nursing notes dated 12/17/15 at 1:42 PM state in part; no complaints from noted shear on left buttock. Nursing notes dated 12/17/15 at 9:32 PM states in part; left buttock shear is unchanged; appears superficial; Sensicare #3 applied; MD to examine on 12/21/15. Telephone Consultation Form dated 12/22/15 states in part; has a 2.1 cm X 1.6 cm open area on the right buttock area cleaned, covered with Duoderm area around very fragile please advise. Physician order [REDACTED]. Wound Notes dated 12/22/15 at 4:36 PM state in part; right buttock 2.1 cm x 1.6 cm; superficial wound base: granulation tissue. Nursing notes dated 12/22/15 at 5:13 PM state in part; resident has 2.1 cm x 1.1 cm on right buttock; MD notified he will see on next visit for buttock wound. On 1/14/16 at 12:12 PM Surveyor interviewed RN I regarding the wound documentation dated 12/22/15 RN I stated she was pretty certain the open area was on the right buttock not the left - RN I stated I'm thinking I do not think I charted on the wrong side. Of note; there was no explanation for the difference in wound documentation on the same day. Telephone Consultation Form dated 12/27/15 states in part; noted to have Stage 2 superficial open area on left buttock 3 cm x 3cm area. Sensicare #3 ineffective. May we go to [MEDICATION NAME] dressing to open area; change every 3 day and as needed to protect area. Nurses notes dated 12/28/15 state in part; facsimile sent to MD regarding skin breakdown of left buttock 3 cm x 2.5 cm area. Sensicare #3 ineffective. Of note, on 1/14/16 at 1:45 PM Surveyor interviewed RN H regarding the above documentation the facsimile sent to the physician on 12/28/15. RN H state the Stage 2 was on the right buttock not the left buttock as documented. Of note, during nurse interviews it was difficult to ascertain if the open area was on the right or left buttock physician progress notes [REDACTED]. Assessment: Early decubitus; Plan: Routine skin care with Duoderm to protect and frequent changes in position. Wound Notes dated 12/29/15 at 1:12 PM state in part; right buttock length 0 cm x width 0 cm; Summary of Findings: Area intact but very fragile; treatment is with Duoderm after cleansing. Has Sensicare to protect other areas on buttock. Medication Administration Record [REDACTED]. Physician order [REDACTED]. Nursing notes dated 1/4/16 at 9:51 PM states in part; weekly skin assessment right buttock remains open 1 cm x 2 cm; wound bed is whitish/pink. Left buttock sheer is scabbed over and almost healed. Wound documentation dated 1/5/16 at 1:33 PM states in part; right buttock; length 2.0 cm x width 1.2 cm; depth superficial; wound base granulation. Telephone Consultation Form dated 1/5/16 states in part; area on right buttock is again open 2.6 x 0.1; very Superficial; current treatment cleanse, Duoderm dressing every 3 days and as needed; Sensicare # 3 as needed to other areas. Physician orders [REDACTED]. On 1/12/16 at 1:20 PM Surveyor observed Resident 1 being transferred to her bed and wound care being provided by RN D. RN D and Certified Nursing Assistant (CNA) C transferred Resident 1 with a full body lift from her wheelchair to bed. Resident 1 has an air overlay mattress on her bed; RN D and CNA C laid Resident 1 on her bed. Resident 1 was laid on top of her comforter and on top of a soaker pad Resident 1's overlay mattress was under the soaker pad and comforter. (of note, for an overlay to be the most effective; as few layers as possible should be between the resident and the overlay mattress). Surveyor asked RN D to describe Resident 1's wound. RN D stated to Surveyor that the area was a shear not a PU as it was not on a bony prominence. RN D removed the old Duoderm dressing and Surveyor observed a circular, pea-sized, crater with a light pink wound bed given the appearance of a Stage 2 PU. RN D measured the area and stated to Surveyor that the area measured 0.6 cm x 0.3 cm. Surveyor noted 3 areas of discoloration/scarred areas as would appear from previous PU's on Resident 1's right buttock. Surveyor asked RN D about these areas; RN D stated Resident 1 has had re-occurring shearing to her bottom. Surveyor asked RN D why Resident 1 was having re-occurring shear and RN D stated Resident 1's skin is very fragile. Of note, the facility has not determined the root cause of continued sheering causing a Stage 2 PU. Wound notes dated 1/12/16 state in part; right buttock length 0.6 cm x 0.3 cm superficial with granulation tissue. Shear area continues to show slow healing, remains free of signs of secondary infection. On 1/14/16, at 12:12 PM, Surveyor interviewed RN D and RN I regarding Resident 1's PU. RN D is the facility's nurse for wound care; RN D is not wound care certified. Surveyor asked RN D if Resident 1 was at risk for PU development. RN D stated Resident 1 was at risk for PU development. Surveyor asked RN D if shearing can cause PU's RN D stated based on what I know now yes. Surveyor asked RN D if Resident 1 has a Stage 2 PU RN D stated based on what I know now yes. Surveyor asked RN D based on Resident 1 being at risk for PU development and re-occurring shearing/PU development what has the facility determined as the root cause of the shearing and what the facility has done to decrease or prevent shearing/PU development. RN D stated well I am sure we have done things but we have just have not documented what we have done. Surveyor asked RN D if the facility has changed Resident 1's plan of care with the re-developing PU's. RN D stated I doubt we have documented any changes. Surveyor asked RN D what the facility has in place to prevent Resident 1 from continuing to develop PU's. RN D stated Resident 1 is on an overlay mattress, has a cushion in her wheelchair and is to be repositioned every 2 hours. Surveyor asked RN G if the facility has a standard of practice for PU prevention if a resident is at risk for PU development. RN D stated the Wound Care Education Institute (WCEI). RN D stated the facility has not determined a root cause for Resident 1's shearing/PU development. Surveyor asked RN D if the facility has educated the frontline staff on ways to prevent shearing and PU interventions particularly for Resident 1; RN D stated probably nothing recently for PU's/shearing I'm sure it's been a while. Surveyor asked RN D how frequently wound care documentation should be completed RN D stated she completes weekly assessments. Surveyor asked RN to review the wound documentation for Surveyor pointed out the missing documentation for 10/28/15; 11/4/15 and 11/11/15 after the blister developed RN D reviewed wound documentation on the computer and stated I do not see documentation for these dates. Surveyor asked RN D to review the wound documentation starting 11/24/15 to 1/12/16. Surveyor asked RN D if the wound documentation for these dates particularly 12/17/15 and 12/22/15 if there was left and right buttock involvement. RN I stated I completed the assessment on 12/22/15. RN I stated she was pretty certain the open area was on the right buttock not the left - RN I stated I'm thinking I do not think I charted on the wrong side. RN D and RN I did not have an explanation if there was a wound on the right and on the left however RN D stated I am sure it was just one but you should ask RN J she documented the left buttock on 12/15/15. On 1/14/15 at 12:35 PM Surveyor interviewed RN J about her wound note on 12/15/15; RN J stated she was pretty certain it was the left buttock. Of note, it was very difficult to determine if Resident 1 had a PU on her right or left buttock and if the facility was dealing with one or two areas. According to the MAR indicated [REDACTED]. Surveyor observed a Stage 2 to the right buttock. Resident 1 developed an avoidable; Stage 2 PU to the right buttock. Resident 1 was identified as at risk for PU development and has documented re-occurring shearing and impaired skin integrity including a current Stage 2 PU. The facility failed to assess the root cause of Resident 1's re-occurring shearing and implement interventions to prevent PU development and failed to educate frontline staff regarding shearing/ PU prevention strategies to prevent additional facility acquired PU's for Resident 1. In addition, the facility failed to completed weekly wound documentation.

Based on observation, interview and record review, the facility did not ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 12 residents reviewed (Resident 1). Resident 1 requires total assistance with her breakfast meal. Resident 1 did not receive assistance with her meal for 43 minutes. Example 1 On 1/13/16 at 8:58 AM Surveyor completed continuous observations of the 300 unit breakfast meal service from 7:50 AM to 9:00 AM. Resident 1 was admitted to the facility on [DATE] and has the following Diagnoses: [REDACTED]. Resident 1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/14/15 indicates Resident 1 Brief Interview of Mental Status (BIMS) is a 2 indicating Resident 1 has severe cognitive impairment. Section G0110 H. indicates Resident 1 requires total assistance of 1 staff member for eating. At 8:15 AM Surveyor observed Resident 1 receive a can of Chocolate Ensure and a container of Strawberry/Banana yogurt. At approximately 8:22 AM Surveyor observed Resident 1 receive a waffle with syrup and a bowl of cream of wheat with brown sugar. Resident 1 sat unassisted at the table until 8:58 AM when Certified Nursing Assistant (CNA) C pulled a chair up next to Resident 1 and sat next to Resident 1 and gave her a sip of Ensure and a bite of yogurt before Surveyor could intervene. Resident 1's Ensure and yogurt had sat in front of her for 43 minutes and her waffle and cream of wheat sat in front of her for 36 minutes before she received any assistance. Surveyor asked CNA C if we could take the temperature of Resident 1's food. The following temperatures were taken: Cream of wheat, temperature 101.9 degrees Fahrenheit (F). Waffle, temperature 86.3 degrees F. Ensure temperature 56.8 degrees F. Yogurt, temperature 50.0 degrees F. Surveyor interviewed CNA C regarding Resident 1 sitting without assistance for 43 minutes. Surveyor asked if the unit has a system for serving the residents their meals. CNA C stated usually the residents that are able to feed themselves are served first then the residents that need assistance are served. Surveyor asked CNA C if Resident 1 is able to feed herself CNA C stated Resident 1 is not able to feed herself. CNA C stated I do not know what happened today. Resident 1 requires total assistance of 1 staff for eating. Resident 1 sat with food and fluids in front of her at the table for a total of 43 minutes without staff assistance. Resident 1's food was no longer at appropriate temperatures when staff began to assist Resident 1. On 1/14/16 at 1:45 PM Surveyor interviewed Registered Nurse (RN) H regarding observations of Resident 1 sitting at the table unassisted for a total of 43 minutes. RN H stated I am not sure what happened we usually serve residents that need assistance last. RN H stated Resident 1 should have received assistance once she received her meal.

Based on interview and record review the facility did not have evidence that all background checks were fully completed for 3 of 8 staff reviewed for background checks (Certified Nursing Assistant (CNA) K, Licensed Practical Nurse (LPN) L, and Registered Nurse (RN) M). CNA K was hired on 10/5/15. CNA K's out of state background check was not completed. LPN L was hired on 11/16/15. LPN L's out of state background check was not completed. RN M was hired on 10/20/11. The facility did not obtain reference checks for RN M. This is evidenced by: Example 1 CNA K was hired by the facility on 10/5/15. CNA K's Background Information Disclosure, dated 10/2/15, indicated CNA K lived in the state of Minnesota within the last 3 years. On 1/14/16 at 8:15 am, Surveyor requested CNA K's Minnesota Background check information. No Minnesota information was provided to Surveyor for CNA K. On 1/14/16 at 1:36 PM, Surveyor interviewed Human Resources Assistant (HRA) N. HRA N stated the facility did not request background information from Minnesota for CNA K. Surveyor asked HRA N if she should have requested background information from Minnesota. HRA N stated, Yes, I will make it the process going forward. HRA N stated the facility should have requested background information from Minnesota. Example 2 LPN L was hired by the facility on 11/16/15. LPN L's Background Information Disclosure, dated 11/16/15, indicated LPN L lived in the state of California within the last 3 years. On 1/14/16 at 8:15 am, Surveyor requested LPN L's California Background Information. No Minnesota information was provided to Surveyor for LPN L. On 1/14/16 at 1:36 PM, Surveyor interviewed HRA N. HRA N stated the facility did not request background information from California for LPN L. Surveyor asked HRA N if she should have requested background information from Minnesota. HRA N stated, Yes, I will make it the process going forward. HRA N stated the facility should have requested background information from California. Example 3 RN M was hired by the facility on 10/20/11. The facility did not obtain any reference checks for RN M. On 1/14/16 at 8:15 am, Surveyor requested RN M's reference checks. No reference check information was provided to Surveyor for RN M. On 1/14/16 at 1:36 PM, Surveyor interviewed HRA N. HRA N stated the facility did not request reference checks for RN M. HRA N stated that RN M had worked at Fair View Nursing Home, their sister facility. HRA N stated she checked with Fair View and they did not complete reference checks for RN M either. HRA N stated she should have completed reference checks.

Based on observation and interview the facility did not ensure food was stored, prepared, distributed and served under sanitary conditions. This has the potential to affect all 51 residents. The dish machine rinse temperature was higher than manufacturer's recommendations. The large mixer was found with dried food particles on the undercarriage. The microwave in the 100 wing dining room was found with dried food particles on the inside surfaces. Evidenced by: The facility's "Food and Nutrition Services Sanitation" Policy, undated, included the following: 27. All work surfaces, utensils and equipment should be cleaned and sanitized after each use. Example 1 On 9/29/14 at 9:00 AM Surveyor observed the dish machine in use. The dish machine final rinse temperature was 198 degrees F (Fahrenheit) during the two rinse cycles observed. The manufacturer's tag on the dish machine stated the final rinse temperatures should be between 180 degrees F and 194 degrees F. The facility's "Food and Nutrition Department Dish Machine Temperature Log", dated 9/2014, included the following: If final rinse temps (temperatures) aren't within the 180 - 194 range or sanitizer strip has incorrect reading, you must call maintenance for service, and dishes must be done manually to ensure proper sanitizing. The log had a total of 85 dish machine rinse temperatures logged, 63 rinse temperatures were above 194. On 9/29/14 at 9:05 AM Surveyor interviewed Dietary Aide (DA) C. DA C stated the dish machine rinse temperature needed to be above 180. DA C stated she did not know there was a high range the dish machine rinse temperature should not go above. DA C stated she should have read the information at the bottom of the "Food and Nutrition Department Dish Machine Temperature Log". DA C stopped the dish machine and called the maintenance department. DA C stated she would rewash the dishes that were already put thru the dish machine to ensure proper sanitation. On 9/30/14 at 8:20 AM Surveyor interviewed Dietary Manager (DM) D. DM D stated she would expect staff to follow the manufacturer's recommendations and call maintenance when the dish machine rinse temperature was out of range. Example 2 On 9/29/14 at 9:15 AM Surveyor observed the large mixer with dried food particles on the undercarriage. On 9/29/14 at 9:15 AM Surveyor interviewed Cook E. Cook E stated the large mixer should be clean. Cook E stated she would clean the large mixer. Example 3 On 9/29/14 at 10:00 AM Surveyor observed the microwave in the 100 dining room with dried food particles on the inside surfaces. On 10/01/14 at 9:15 AM Surveyor interviewed Dietary Manager (DM) D. DM D stated she would expect the microwave to be cleaned after each use.

Based on observation, interview and facility policy review the facility did not ensure employees wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice for 2 sampled Residents (Residents 2 and 7) and 1 supplemental Resident (Resident 15) out of 17 hand washing opportunities. After toileting Resident 2; Certified Nursing Assistant (CNA) H did not wash her hands or use alcohol based hand gel (ABHG) after emptying the commode and removal of gloves. Registered Nurse (RN) I did not wash her hands after wiping crumbs off the floor then touched Resident 15's medication cup. Certified Nursing Assistant J did not wash her hands when indicated during cares for Resident 7. This is evidenced by: The facility's policy for Hand Hygiene dated 3/1992 and revised 10/12, states in part; "Indications for hand washing: A. when hands are visibly dirty or soiled. Cleaning with alcohol based product: 1. before and after having direct contact with patients. 5. after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. 6. After removing gloves." Example 1 Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/6/14 indicates Resident 2's Brief Interview for Mental Status (BIMS) was a 15 indicating Resident 2 is cognitively intact and Resident 2 requires extensive assistance with toileting. On 9/30/15 at approximately 10:15 AM Surveyor observed toileting for Resident 2. Resident 2 used a commode for toileting; Resident 2 had a bowel movement during this observation. Certified Nursing Assistant (CNA) H gloved and emptied the commode; CNA H removed her gloves and did not wash her hands or use ABHG. CNA H proceeded to take a bath blanket off a chair and cover the commode with a bath blanket, handed Resident 2 her dark glasses, and emptied the garbage and exited the room to place the garbage in the soiled utility room. On 9/30/15 at 10:15 AM Surveyor interviewed CNA H regarding hand hygiene practices CNA H stated staff should wash hands when they are visibly dirty. Surveyor asked CNA H regarding washing her hands after emptying the commode. CNA H stated, "I did not wash my hands after removal of gloves and I should have". CNA H stated that nursing staff observe CNA's for proper hand washing technique about every 3 months. On 10/1/14 at 2:55 PM Surveyor interviewed Director of Nursing (DON) B regarding hand hygiene practices. DON B concurred CNA H should have washed her hands after emptying the commode. Example 2 Resident 15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 15's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/8/14 indicates Resident 15's Brief Interview for Mental Status (BIMS) was a 15 indicating Resident 15 is cognitively intact. On 9/30/14 at 8:03 AM Surveyor observed Registered Nurse (RN) I provide medication for Resident 15. RN I placed Resident 15's medication cup and plastic cup with water on Resident 15's tray table. RN I then proceeded to wipe up crumbs off of Resident 15's floor. RN I threw the crumbs in the garbage then touched Resident 15's medication cup and plastic cup in an attempt to move them closer to Resident 15. RN I did not wash her hands or use alcohol based hand gel (ABHG) after she had touched the floor. On 9/30/14 at 8:10 AM Surveyor interviewed RN I regarding washing her hands after touching the floor. RN I stated she thought she used ABHG after she touched the floor. Surveyor stated that the observation was made that RN I wiped the floor then threw the crumbs in the trash then touched Resident 15's medication cup and plastic water cup. RN I did not comment further. On 10/1/14 at 2:55 PM Surveyor interviewed DON B regarding hand hygiene practices. DON B agreed that RN I should have washed her hands after touching the floor. Example 3 On 9/29/14, at 11:56 AM, Surveyor observed Certified Nursing Assistant (CNA) J and CNA K assist Resident 7 with incontinence cares. CNA J and CNA K used the EZ stand mechanical lift to lift Resident 7 from his recliner. CNA J stated Resident 7 was incontinent and then CNA J provided pericares for Resident 7. Following the pericare CNA J did not remove her gloves or wash her hands. CNA J and CNA K assisted Resident 7 into his wheelchair. While still wearing the same gloves CNA J picked up the wet incontinent brief from Resident 7's recliner and placed it in a trash bag, she then took the container of cleaning wipes from the pouch attached to the lift and wiped the lift with a wipe. CNA J then removed her gloves and washed her hands before leaving the room. Following the above observation Surveyor interviewed CNA J. CNA J confirmed Resident 7 was incontinent of urine and she provided pericares for Resident 7. Surveyor asked CNA J if she washed her hands at any point during the process and CNA J stated yes just now before leaving the room. On 10/1/14, at 2:08 PM, Surveyor interviewed Director of Nursing B who confirmed the expectation that CNA J should have washed her hands after providing pericares and touching the soiled brief before touching clean items in the room or wiping down the lift.

Based on observation, interview and record review the facility did not ensure that residents who are incontinent of bladder receive appropriate treatment and services to prevent urinary tract infections for 1 of 7 residents (Resident 9) reviewed for incontinence care. Resident 9, a female resident, did not receive proper perineum care after urinary incontinence and toileting. Evidenced by: The facility's policy Peri Care dated 7/2004, states in part; "Purpose: to provide basic hygiene, decrease risk of urinary tract infection [MEDICAL CONDITION] and maintain skin integrity. Procedure: 4. Female: using soap, wash the perineal area of a female resident from front to back with one hand, retracting labia with the other hand. 10. Perineal care is also provided after incontinent episode. Disposable peri wipes/blue chux and per care foam may be used at that time following same cleansing procedure as with soap and water". Resident 9's [DIAGNOSES REDACTED]. Resident 9's most current MDS (Minimum Data Set) with an observation end date of 8/22/14, documents that Resident 9 needs extensive assistance with toileting. Resident 9's comprehensive care plan has a concern area dated 9/26/12, which states: "Toileting" an intervention to this care plan problem includes: "Follow toileting protocols". On 9/30/14 at 4:25 PM Surveyor observed CNAs' (Certified Nursing Assistant) F and G assist Resident 9 with toileting. CNA F checked Resident 9's incontinent brief, the brief was soaked with urine. CNA F assisted Resident 9 to the toilet and provided perineal care following toileting. CNA F stood Resident 9 at the grab bar in the restroom CNA F sprayed cleansing foam onto a blue chux (incontinent wipe) and wiped Resident 9 from buttocks to perineum in a back to front then a front to back motion. On 9/30/14 at 4:40 PM Surveyor interviewed CNA F. CNA F confirmed Resident 9 had been incontinent of urine. Surveyor asked CNA F regarding perineal care. CNA F stated that perineal care is provided after incontinence. CNA F stated the staff uses cleansing foam and the blue chux or soap and water to wash after incontinence. CNA F stated female residents should be washed from front to back. Surveyor asked CNA F if front to back care was provided for Resident 9; CNA F stated that she provided front to back care. Surveyor asked CNA F if what Surveyor observed; wiping from buttocks to perineum and then from perineum to buttocks in a back and forth motion would be an acceptable practice. CNA F stated it is not an acceptable practice. On 10/1/14 at 8:05 AM Surveyor interviewed CNA H regarding peri - care. CNA H stated the nurses watch the CNA's provide peri care when the assist with toileting and correct concerns at that time. CNA H stated CNA's are formally observed at least every 3 months. On 10/1/14 at 2:55 PM Surveyor spoke with Director of Nursing (DON) B and Nursing Home Administrator (NHA) A regarding several topics including the incontinence cares that were provided to Resident 9. DON B stated the facility's practice for incontinence care is to wipe female residents from front to back.

Based on observation, interview and record review the facility did not ensure services were provided in accordance with each resident's written plan of care for 2 of 12 residents (Residents 7 and 1). Resident 7's chair alarm was not in place during 2 observations as per his plan of care. Resident 1 did not have his Ankle foot orthosis (AFO) removed per his plan of care. This is evidenced by the following: Example 1 Resident 7's care plan, initiated 10/31/12, includes sensor alarm in bed and chair to alert staff of Resident 7 attempting to get up unassisted. On 9/29/14, at 11:56 AM, Surveyor observed Resident 7 sitting in his recliner in his room. Resident 7 did not have a chair sensor alarm in the chair. Surveyor observed Certified Nursing Assistant (CNA) J and CNA K assist Resident 7 from the recliner to his wheelchair. During the transfer CNA K left the room to obtain Resident 7's chair alarm. CNA J stated Resident 7 also sits in the recliner in the day room and the alarm was still in that recliner. CNA K returned with Resident 7's sensor alarm and placed it in the wheelchair. On 9/29/14, at 2:29 PM, Surveyor observed Resident 7 in the dining room eating a snack. Resident 7 was sitting in his wheelchair and there was not a sensor alarm in place. On 10/1/14, at 2:08 PM, Surveyor interviewed Nursing Home Administrator A who confirmed per Resident 7's care plan Resident 7 should have a senor alarm in place in any chair he is sitting in. Example 2 Resident 1's [DIAGNOSES REDACTED]. Resident 1's most current MDS (Minimum Data Set) with an observation look behind date of 9/15/14 documents Resident 1's BIMS (Brief Interview for Mental Status) was unable to be completed. Resident 1's comprehensive care plan documents a care plan problem dated 11/14/12 which states: "improves maintains activity of daily living (ADL) performance" an intervention to this care planned problem states: "Left AFO brace on only during transfers and walking. Off when sitting or lying down". Resident 1's Certified Nursing Assistant (CNA) care sheet dated 9/29/14 states: "Left AFO brace on only during transfers and walking. Off when sitting or lying down". On 9/29/14 at 11:57 AM Surveyor observed Resident 1 sitting in his wheel chair with the left AFO on. On 9/30/14 at 8:45 AM Surveyor observed Resident 1 in his room sitting in his wheel chair with the left AFO on. On 9/30/14 at 10:30 AM Surveyor observed Resident 1 in his room sitting in his recliner with left AFO on. On 9/30/14 at 12:45 PM Surveyor observed Resident 1 in his room sitting in his wheel chair with left AFO on. On 10/1/14 at 8:03 AM Surveyor observed Resident 1 in his room sitting in his wheel chair with left AFO on. On 10/1/14 at 10:45 AM Surveyor observed Resident 1 sitting in his recliner with left AFO on. On 10/1/14 at 11:20 AM Surveyor interviewed Certified Nursing Assistant (CNA) H. CNA H stated the staff leaves the left AFO on all day now since Resident 1's swelling has went down in his leg. Surveyor asked CNA H how long Resident 1 has been wearing the AFO all day. CNA H stated Resident 1 has been keeping the AFO on all day for several weeks now. CNA H stated the staff follows the "brain sheets", CNA care sheet, to guide them in providing care for the residents. CNA H was not aware that removing the left AFO was still on the CNA care sheet. On 10/1/14 at 2:55 PM Surveyor interviewed DON (Director of Nursing) B regarding several topics including Resident 1's comprehensive care plan regarding left AFO. DON B confirmed that the staff should be following the comprehensive plan of care as written.

Based on record review and interview the facility did not immediately consult with the resident's physician and legal representative when there was a significant change in the resident's physical status or a need to alter treatment for 1 of 13 residents (Resident 6). Resident 6 experienced a change of condition following a fall. Resident 6's physician was not immediately consulted with when changes occured and Resident 6's legal representative was not made aware of treatment options. This is evidenced by the following: Resident 6 is [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 6's son is her activated power of attorney for health care (POAHC). Resident 6's physician's orders [REDACTED]. -[MEDICATION NAME] 4 milligrams (mg) in the evening every day. -[MEDICATION NAME] 15 mg daily -Aspirin 81 mg daily On 9/29/14 at 2:30 AM, Resident 6 was found on the floor by Registered Nurse (RN) L. Resident 6's incident report completed by RN L indicates RN L heard the alarm sounding went to the unit and found Resident 6 on the floor with her walker on top of her. No injuries were noted and there were no complaints of pain. Resident 6 was assisted back into bed. The incident report indicates Resident 6's physician was notified, but does not indicate how and that family will be notified in the morning. On 9/29/14, at 2:50 AM, RN L sent a fax to Resident 6's primary physician informing him of the fall. The box "fax back" is checked. There is no indication the fax was received and/or reviewed. (As noted below the physician was out of town and not available) Resident 6's nursing notes include: -9/29/14 at 6:10 AM, Resident 6 had a fall. No injury. Bruising noted to left lower arm. -9/29/14 at 9:43 AM, No complaints of discomfort. Hand grasps equal and strong. Son here to visit and was updated regarding recent fall. -9/29/14 at 2:29 PM post fall assessment. Is there any injury-Yes, purple bruise on back of head 3 cm (centimeters) by 2.5 cm. (please note this is a change from previous assessment of no injury noted). On 9/29/14, at 2:32 PM, Surveyor observed Resident 6 in the dining room. Surveyor noted a very dark bruised area to the back of Resident 6's head On 9/30/14, at 9:41 AM, Surveyor interviewed Family Member N (Resident 6's POA). Family Member N stated he was updated on Resident 6's fall and that she hit her head via phone on Monday. Family Member N stated he is okay with calling the next morning if there is no injury. Resident 6's nursing notes: -9/29/14 at 10:30 PM, Resident 6 had episode of labored breathing, nurse noted resident was using accessory muscles and was exhibiting some confusion at hour of sleep oxygen at 84% on room air. Physician M at emergency room notified, administering oxygen via nasal cannula. Resident 6 stated felt short of breath and back pain from head all the way down. Right hand discomfort was also noted and Resident 6 stated "be careful of that hand." Range of motion was within normal limits. Noted was a large lump to back of Resident 6's head, new injury as result from fall from bed. Purplish in color and raised. Resident 6 denied any pain to head or headache. Stated only back pain all the way down her back and is unable to rate pain, although facial and body expression indicate discomfort. Resident 6 requested pain medication and ice pack applied to back of head. Rechecked resident was more alert and stated felt a little better. Will have oncoming shift continue to monitor (Please note the documentation does not indicate that the nurse told the on call physician that Resident 6 was on [MEDICATION NAME]- a drug that can significantly increase a risk for bleeding). On 9/30/14, at 4:30 PM, Surveyor interviewed Director of Nursing (DON) B. DON B stated the facility policy for falls is to assess the resident immediately, notify the physician and family of the fall or any injury and to assess the resident every shift for at least three days. Surveyor asked if nurses do anything different if they suspect a resident hit their head and DON B replied no unless their physician orders [REDACTED]. DON B stated she would expect the physician to be called. Surveyor asked for evidence Resident 6's physician was notified after the bruise was noted to the back of the head. DON B stated she would have to look into it. Resident 6's nursing notes: -9/30/14 at 6:11 PM, call to Resident 6's back up physician as Resident 6's primary physician is out of town, and notified of Resident 6's fall, bruise to her head, current medications, oxygen saturation/use, three day post fall assessments. Also notified of pain. No new orders. -9/30/14 at 9:46 PM and addendum was added that Physician M was made aware of entire note from 9/29/14 at 10:30 PM. -9/30/14 at 9:46 PM, 9:00 PM Resident 6's oxygen saturation 78% due to resident removing nasal cannula. Contacted emergency room (ER) physician to advise if should hold [MEDICATION NAME] tonight. Physician stated to send to ER for assessment. POA contacted felt transfer would be traumatizing to resident and would prefer to follow up with Resident 6's primary physician in the morning. ER physician updated and order to hold [MEDICATION NAME] and draw INR tomorrow. On 10/1/14 in the morning DON B brought e-mail correspondence between her and Physician M: -9/30/14 at 7:04 PM-DON B: please notify me regarding recent phone conversation of your notification last evening on Resident 6. -8:13 PM-Physician M: a [AGE] year old resident was noted to have visible bruising on the back of the head after a fall and [MEDICAL CONDITION] issues. I remember authorizing supplemental oxygen and commenting that a CT scan would generally be recommended for patients in this age group with [MEDICATION NAME] head injuries (they are at increased risk for intracranial bleeding compared to younger people). -8:49 PM-DON B: There is no order for CT scan. -9:30 PM-Physician M: I didn't order a CT scan; I just said it would be recommended in this age group. It would have been up to the patient or POA if they want to go through with this (if the person would not be a candidate for major surgery then it would be pointless to do a CT). Many, if not most, [AGE] year olds would not be considered candidates for major surgery, but every case is different. On 10/1/14, at 8:13 AM, Surveyor observed the transfer of Resident 6. It took 2 CNAs and 1 CNA in training with the use of the EZ stand mechanical lift to transfer Resident 6. Per Resident 6's plan of care typically she only requires 1 staff to assist with a gait belt. On 10/1/14, at 8:22 AM, Surveyor interviewed RN O who stated Resident 6 is stiffer this morning and has been complaining of pain more since her fall. On 10/1/14, at 9:40 AM, Surveyor again interviewed Family Member N. Family Member N stated he did not visit on Monday (9/29/14) due to the outbreak but that he spoke to Resident 6's nurse that morning. Family Member N was informed that Resident 6 had fallen and hit her head and a bruise was noted on the back of her head in the morning. Family Member N stated there was never a discussion about obtaining a CT scan at any point with him but he did not think he would want that anyway. Family Member N stated he is not opposed to sending Resident 6 to the ER if necessary but he did not want that on 9/30/14 because he was told Resident 6 was already in bed sleeping and he did not want to traumatize her by waking her up and sending her out in the middle of the night. Family Member N stated he is waiting for Resident 6's primary doctor to call the facility back and that Resident 6 was sick over the weekend, better yesterday, but not as perky today and felt it was all related to the illness that went around. On 10/1/14, at 10:12 AM, Surveyor interviewed RN O. RN O stated she spoke with Resident 6's primary physician this morning and updated him on everything: fall, bruise to back of head, increased pain/restlessness, oxygen levels and use, and the held dose of [MEDICATION NAME]. Resident 6's primary physician stated to resume the [MEDICATION NAME] and continue with comfort measures for Resident 6. RN O confirmed she noted the bruise on the back of Resident 6's head around noon on 9/29/14 and she failed to call the physician about it but should have. On 10/1/14, at 11:43 AM, Surveyor interviewed RN L via phone. RN L confirmed she is the one who responded to Resident 6's alarm and found her on the floor. RN L stated she completed an assessment and did not note any bruising or injury to Resident 6's head. RN L stated she updated Resident 6's primary physician by sending a fax to his office. Surveyor obtained the fax sent to Resident 6's primary which did not have any indication it was reviewed. On 10/1/14, at 12:47 PM, Surveyor interviewed Physician M via phone. Physician M stated he did recall the nurse calling to inform him about Resident 6 with a bruise to the back of her head. Physician M stated the nurse did not make him aware of Resident 6's medications including [MEDICATION NAME]. Physician M stated he commented that a CT scan would be advisable due to Resident 6's age and a blow to the head with bruising and to talk with the family about it. Physician M stated after the phone call with the facility he would have expected them to call the family and discuss if they wanted a CT scan or to send Resident 6 to the hospital and if so to follow up with him for the order because if the family would not want surgery it would not be worth doing the CT scan. Surveyor asked Physician M if he would have changed anything if he was aware Resident 6 was taking [MEDICATION NAME] and he stated no, she was already at risk due to her age and the blow to the head which is enough to recommend a CT scan the [MEDICATION NAME] would just increase her risk. The facility faxed the physician; with no response on 9/29/14 regarding Resident 6's fall. On 9/29 at 2:29 pm no physician was called when she developed a sign of a head injury. On 9/29/14 at 10:30 PM an on call physician was called and the facility reported a change of condition for Resident 6, but did not inform him she was on [MEDICATION NAME] (a blood thinner). When Resident 6's POA was called the nurse did not have a conversation with him regarding Resident 6 receiving a CT scan to rule out any injury.

Based on interview and record review, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 1 of 15 Residents reviewed (Resident 7). The Facility did not provide interventions and did not follow their bowel management program to help prevent constipation for Resident 7. This is evidenced by the following: The facility policy titled "Bowel Management", dated 4/97 indicates the following; Purpose: To routinely review and ensure residents are maintaining healthy bowel function as possible, with the use of dietary measures. Procedure: 1. Team will meet monthly and review all resident's recent bowel records, dietary interventions, fluid intake, and medication use (routine and as needed). 2. Standard PRN (as needed) medications per MD (Medical Doctor) may include: Milk of Magnesia - 30 cc (cubic centimeters) dose given on day 2 or 3 if no BM (bowel movement) ) prn followed by a Fleets enema or a Ducolax suppository/tabs if no bowel movement by day 3 or 4 depending on the resident. Milk of Magnesia and Fleets enema/Ducolax suppository repeated if no bowel movement by day 4 or 5 prn MD orders for constipation. No BM by day 5 (if unusual for resident) consult MD. 3. Other medications or interventions as ordered by MD, or recommendation by dietician. Resident 7 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. (It is important to note Resident 7's mobility and activity level was limited to a wheel chair or recliner secondary to her recent surgery. This decreased activity level also decreased Resident 7's ability to promote bowel motility.) Resident 7's medications on admission of 4/27/11 included: * [MEDICATION NAME] extended release (ER) 15 milligrams (mg) 3 times a day (to equal 45 mg per day). Constipation is a common side effect. * [MEDICATION NAME] 15 mg 1 tablet 3 times a day as needed. Constipation is a common side effect. * [MEDICATION NAME] 80 mg at bedtime. May cause constipation * [MEDICATION NAME] 250 mg every day. May cause constipation. * Oxybutrin 50 mg 2 times a day. Constipation is a common side effect. * [MEDICATION NAME] 100 mg 3 times a day. May cause constipation. * [MEDICATION NAME] 100 mg daily. May cause constipation. * [MEDICATION NAME] 40 mg daily. May cause constipation. Resident 7 did not receive a scheduled Laxative according to her Medication record of 4/27/11. Resident 7's History and Physical dated 4/22/1 (from Resident 7's hospital admission prior to being admitted to the nursing home) indicates Resident 7's medications had included [MEDICATION NAME] (laxative) orally daily. This report also indicated a past medical history of [REDACTED]. Resident 7's initial Care plan, dated 4/27/11, indicates the following; Problem: Altered Elimination Goal: Establish bowel/bladder routine to improve continence. Approaches: Bowel is not marked under approaches and there are no approaches for Resident 7 for Bowel pattern or to improve incontinence. Resident 7's comprehensive care plan, initiated 5/4/11, indicates the following: There is no bowel related care plan for Resident 7 prior to 5/24/11. Resident 7's nursing home admission assessment, dated 4/27/11, indicates Resident 7's date of last bowel movement is 4/26/11. Resident 7's form titled Bowel diary indicates the following 1. On 4/28/11 at 12:00 AM Incontinent of a little loose "a little smear" no further bowel movements (BM) on 4/28/11 2. On 4/29/11 no BM's are documented for the entire day. 3. On 4/30/11 no BM's are documented for the entire day. Comment in the result sections is "Not feeling Good" 4. 5/1/11 no BM's are documented for the entire day. Comment in the result sections is at 3:00 AM "complaining of being sick" and at 8:00 AM "vomited, pain and yelling". 5. On 5/2/11 no BM's are documented for the entire day. Resident 7's Monthly BM'S, dated May 2011, indicates Resident 7 had the following: There is no documentation or indication on the monthly BM record or the computerized Certified Nursing Assistant (CNA) charting that Resident 7 had a bowel movement on 5/3/11 or 5/4/11. 5/5/11 a Small BM (Certified Nursing assistant computer charting does not indicate a bowel movement) 5/6/11 No BM, and Milk of Magnesia was given. 5/7/11 No BM and Milk of Magnesia was given. 5/8/11 NO BM and Fleets enema was given with small results. Resident 7 did not have a bowel movement from 4/26/11 through 5/7/11,which indicates 11 days without a substantial bowel movement. Resident 7 did not have any medication interventions from 4/27/11 through 5/5/11, which is 9 days from Resident 7's last BM without any bowel management protocol implemented. Resident 7 did not have any bowel medication used until 5/6/11, which was 10 days from the last substantial BM. ( It is important to note according to the Facility bowel management protocol Resident 7 should have received Milk of Magnesia by 4/30/11 and a Fleets enema or a [MEDICATION NAME] suppository by 5/1/11.) On 5/6/11 at 9:30 AM Resident 7 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. (The facility staff did not follow the bowel management program. Resident 7 received MOM 9 days after Resident 7 was identified not to have a BM.) On 5/7/11 at 9:00 AM Resident 7 MAR indicated [REDACTED]. Resident 7's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Resident 7's Physician telephone, dated 5/6/11, indicates to increase Resident 7's [MEDICATION NAME] ER to 30 mg orally twice a day to equal 60 mg of [MEDICATION NAME] ER a day. Resident 7's Physician telephone order, dated 5/8/11, no time given, indicates to give Resident 7 [MEDICATION NAME] 17 grams (gm) in apple juice today. (This is the only order for [MEDICATION NAME] for the date of 5/8/11.) Resident 7's nursing notes, dated 5/8/11, at 10:07 AM indicates Resident 7 had a medium brown emesis of approximately 240 milliliters when getting up this morning... Resident 7's bowel sounds are heard in all quadrants but the bowel sounds are hypoactive (reduced)... Resident 7's physician was notified and new orders were given as follows: 1. Give [MEDICATION NAME] 5 mg tablet now. 2. Give [MEDICATION NAME] Suppository rectally now. (Follow with a fleets enema if no results from the suppository.) 3. No insulin this morning....5. Clear liquids today. 6. do not give [MEDICATION NAME] this morning. 7. Update Hospital emergency room Physician with Bowel sounds and results of fleets enema given. Resident 7's nursing notes, dated 5/8/11, at 11:28 AM indicates Resident 7 had a small amount of brown soft stool. Resident 7 was then given the Fleets enema. Resident 7 then had a small amount of brown soft stool... Resident 7's bowel sounds are in all quadrants but sluggish (very slow movement). Resident 7's Physician was notified of the results and the following order were given: 1. Offer fluids. 2. Give [MEDICATION NAME] 17 grams in apple sauce today (a bowel medication Resident 7 received prior to admission to the facility). Resident 7's nursing notes, dated 5/8/11, at 11:28 AM indicates Resident 7's interested family member was notified of Resident 7's current condition. Resident 7's interest family notified the facility that Resident 7 has had continued problems with constipation throughout Resident 7's use of [MEDICATION NAME]. (It is important to note there was no update to Resident 7's care plan with the family information nor was the physician consulted regarding Resident 7's current medications with lack of bowel regimen to prevent further constipation.) Resident 7's nursing notes, dated 5/8/11, at 1:47 PM indicates Resident 7 had no vomiting, abdomen was soft and Resident 7 had "No further BM's." There is no indication in the nursing notes an assessment of Resident 7's bowel sounds was completed after approximately 2 hours of bowel reducing from hypoactive to sluggish. Resident 7's nursing notes, dated 5/8/11 at 6:47 PM indicates the following Resident 7 complained of nausea. Resident 7 was lethargic and refusing to drink fluids. Resident 7's bowel sounds are absent in all 4 quadrants. (There is no documentation for approximately 7 hours on Resident 7's bowel sounds, since Resident 7's bowel sounds decreased at 11:28 AM.) Resident 7 was Transferred to the Hospital emergency room . Resident 7's emergency room report, dated 5/8/11, indicates the following; Resident 7 had no had a bowel movement all day, and she was not taking good fluids. Resident 7 developed some nausea, vomited once and was given a [MEDICATION NAME] suppository and a Fleets enema with poor results.... Resident 7 has a history of Obstipation for which she has been admitted . Resident 7's abdominal discomfort and Obstipation is probably related to the initiation of the [MEDICATION NAME] sulfate and resident 7's fall which is leading to some ileus... Resident 7's History and Physical (H&P), dated 5/9/11, indicates Resident 7's past medical history as Resident 7 has had a history of [REDACTED]. Assessment: Abdominal pain, nausea, and vomiting ... Resident 7's hospital physician indicate due to Obstipation (severe constipation) related to [MEDICATION NAME] use for the pain Resident 7 is experiencing. Plan: Resident 7 is admitted to the hospital for bowel care. Resident 7's medications at discharge on 5/10/11 include the following; [MEDICATION NAME] Immediate release 15 mg one 3 times a day as needed, [MEDICATION NAME] ER 15 mg twice a day, Oxybutrin 5 mg twice a day, [MEDICATION NAME] 100 mg daily, [MEDICATION NAME] 80 mg daily, [MEDICATION NAME] 250 mg four times a day, [MEDICATION NAME] sulfate 325 mg daily, and [MEDICATION NAME] 20 mg daily.. (It is important to note there is not a medication ordered for a schedule bowel management for Resident 7.) On 5/10/11 the date of Resident 7's readmission to the facility, Resident 7's care plan was not updated for recent hospitalization or for bowel management program related to current [DIAGNOSES REDACTED]. Resident 7's Monthly BM'S, dated May 2011, indicates Resident 7 had the following bowel movements. 5/10/11 No BM 5/11/11 Small BM . 5/12/11 No BM. Facility policy indicates Milk of Magnesia should be given by day 2 or 3 with no bowel movement; this was not done. 5/13/11 No BM and Milk of Magnesia (MOM) was given. MAR indicated [REDACTED] 5/14/11 No BM and Milk of Magnesia was given with no results. Resident 7's nursing notes, dated 5/15/11, at 1:24 AM indicates Resident 7 was not feeling well this morning. Resident 7 hurt all over and complained of a upset stomach. Resident 7 refused to get out of bed. Resident 7 was given a suppository for bowel care and has a medium BM. On 5/15/11 at 9:00 AM Resident 7 MAR indicated [REDACTED]. Resident 7's nursing notes, dated 5/16/11 at 1:48 PM indicates Resident 7 complained of nausea and did have one green emesis. Resident 7 was given a Fleets enema. On 5/16/11 at 9:45 AM Resident 7 MAR indicated [REDACTED]. 5/17/11 No BM 5/18/11 Small BM. MAR indicated [REDACTED]. 5/19/11 No BM. MAR indicated [REDACTED]. 5/20/11 Loose medium BM after Suppository given. 5/21/11 No BM 5/22/11 NO BM. MAR indicated [REDACTED]. Resident 7's Abdominal X-Ray, dated 5/22/11, completed for clinical indication of abdominal pain indicates the following, Resident 7's has a moderate to large amount of stool throughout the colon. 5/23/11 BM after [MEDICATION NAME] Suppository (7:40 AM) and [MEDICATION NAME] Tablet (4 PM) given. 5/24/11 Small BM 5/25/11 NO BM 5/26/11 Small BM 5/27/11 No BM On 5/24/11 resident 7's comprehensive care plan indicates Monitor bowel pattern every shift and provide interventions/medications to promote bowel regularity. Resident 7's nursing notes, dated 5/26/11, indicates Resident 7's Physician saw Resident 7 on rounds and reviewed Resident 7's bowel pattern and use of PRN laxatives and ordered [MEDICATION NAME] 17 grams twice a day. The nursing note also indicates Resident 7 was having dry heaves and a decrease in appetite. Resident 7's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident 7's Admission Minimum Data Set (MDS), dated [DATE], indicates Resident 7 is occasionally incontinent of bowel movements and Resident 7 is not currently on a bowel management program. Resident 7's MDS continues to indicate Resident 7 has "No" constipation with her bowel pattern. Resident 7's Nutrition Care Area Assessment (CAAs), dated 5/27/11, indicates the following, Resident 7's Monitoring and Evaluation section: Monitor weights, and diet texture tolerance. Available for nutrition education as needed until discharge. Resident 7's CAAs does not indicate any dietary assessment or need for Bowel Management. There is no indication a care plan or assessment was completed after 11 days of no bowel movement or use of PRN bowel management or a physician was consulted to evaluate Resident 7's past medical history of [REDACTED]. Resident 7's Bowel and Bladder data collection and assessment, dated 6/20/11, no time indicated, indicates the following;... A. Contributing [DIAGNOSES REDACTED]. B. Medication that may contribute to bladder dysfunction is narcotics and [MEDICAL CONDITION] Drugs. (Bowel dysfunction is not mentioned in this area.) C. Mobility Requires assist with ambulation... D. Normal bowel pattern is irregular, number per week is 3, Resident has constipation "yes"... E. If "yes" Bowel program: [MEDICATION NAME] BID (twice a day)... F. Summary of findings: Resident 7 has mixed incontinence, had recent surgery for [REDACTED]. (It is important to note Resident 7's Summary and plan did not evaluate Resident 7's bowel plan or Summarize what will be done for history of severe constipation or Resident 7's care plan was updated.) On 7/21/11 at 3:45 PM Surveyor spoke with Director of Nursing (DON) B regarding bowel management. DON B stated a Monthly bowel movement sheet is to be used every day and charted on by the CNAs. The Nurses are to review the bowel sheets and night nurse is to review the Monthly BM sheets to see if a resident has not had a BM in 2 days they are to watch them and add to a daily sheet. DON B also stated everyone is to follow the standard of going every 3 days unless assessed to have a BM pattern for more then 3 days. On the 3rd day the Nurses are to give a PRN according to the bowel management program and by the 4th day a Physician should be contacted if the resident still has not had a BM. DON B continued to state she would expect the Physician to be notified if a resident was given MOM for 2 days and no results or resident continued to complain of abdominal pain or a change in appetite. On 7/21/11 at 3:50 PM Surveyor spoke with DON B regarding Bowel Movement medications. DON B stated Resident 7 should have been readmitted on a scheduled bowel medications on 5/10/11 with a [DIAGNOSES REDACTED]. The facility did not follow the facility bowel management program or update Resident 7's care plan when Resident 7 did not have Bowel movement and when Resident returned from the hospital with the [DIAGNOSES REDACTED].