Every finding on record at Dove Healthcare - Regional Vent Center

Based on record review and interview, the facility did not notify the Ombudsman of residents who were transferred from the facility to a hospital for 5 of 5 residents (R) (R4, R7, R20, R31, R33).The facility was unable to locate a policy pertaining to ombudsman notification for transfers. Example 1 (R7) On 02/27/2026, R7 had a change in condition and was transferred to the hospital. On 04/15/2026 at 10:03 AM, Surveyor interviewed Nursing Home Administrator (NHA) A who stated he was unable to find documentation that the Ombudsman was notified of resident transfers and/or discharges. NHA A stated the staff member responsible for Ombudsman notification left in September of 2025 and NHA A was unable to locate the notifications to the Ombudsman requested. Example 2 R31 was admitted to the facility on [DATE], with diagnoses including respiratory failure, dependency on ventilator, and renal insufficiency/failure. Surveyor reviewed R31's medical record noting on 8/12/25, 12/24/25, 1/30/26, 3/18/26, and 4/3/26, R31 was transferred to the hospital. R31's medical record does not indicate documentation of ombudsman notification for any of R31s discharges. Example 3 R20 was admitted to the facility on [DATE], with a diagnosis including acute respiratory failure, neuromuscular dysfunction, unspecified cranial injury, and dependence on a ventilator. Surveyor reviewed R20's medical record noting on 9/24/25, 3/4/26, 3/7/26, and 3/31/26, R20 was transferred to the hospital. R20's medical record does not indicate documentation of ombudsman notification for any of R20's discharges. Facility was unable to provide evidence of ombudsman notification for R31's or R20's transfers to the hospital. Example 4 R33 was admitted to the facility on [DATE] with diagnosis of Guillain-Barre Syndrome requiring ventilator assist via tracheostomy. R33 was discharged to home on [DATE] following successful weaning off ventilator and tracheostomy removal. Review of R33's medical record does not indicate documentation of ombudsman notification of R33's discharge. Example 5 R4 was admitted to facility on 01/30/26, with diagnoses including, in part, acute chronic respiratory failure with hypercapnia, acute and chronic respiratory failure with hypoxia, unspecified protein-calorie malnutrition, type 2 diabetes mellitus with diabetic nephropathy, fusion of spine, post-polio syndrome, insomnia, hyperkalemia, scoliosis, anxiety disorder, gastrostomy status, tracheostomy, and dependence on respirator ventilator status. Surveyor reviewed R4's medical record and found R4 was hospitalized on [DATE]. Surveyor did not find that the ombudsman was contacted regarding R4's transfer to hospital on [DATE]. On 04/15/26 at 9:21 AM, Surveyor requested ombudsman notification from NHA A. NHA A stated, I will go look for the notification. No notification was provided.

Based on observation and interviews, the facility did not ensure the safety of food handling in accordance with professional standards for food service safety. This had the potential to affect all 13 of the 29 residents that eat orally.-Cook did not check the temperature of the fried eggs prior to serving.-Personal food was stored in the resident's refrigerator-Food was dished up in bowls with no label or date on dish or tray.-Cereal was not covered prior to leaving kitchen and going to resident's room.-Rectangular baking pans were on bottom shelf not enclosed, not covered, or inverted. -An open bag of macaroni was on kitchen shelf without an open on or use by date.Findings include:The facility's policy titled, Record of Food Temperatures reviewed on March 2024, states, Food temperatures will be checked on all items prepared in the dietary department. The facility's policy titled, Date Marking for Food Safety reviewed on 9/26/24, states, . 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared.On 4/13/26 at approximately 8:30 AM, during kitchen tour, Surveyor observed [NAME] H fry several eggs over easy for 3 residents' breakfast. [NAME] H did not check the temperature to ensure eggs reached a safe temperature before serving to the residents. Surveyor observed a brown neoprene lunch bag, not labeled in the resident refrigerator. Surveyor asked [NAME] H about content of the bag and [NAME] H replied it was her lunch. [NAME] H immediately removed it from the fridge and stated personal/staff food was not supposed to be in the resident's refrigerator and she should have put her lunch in the breakroom fridge downstairs.Surveyor noted cottage cheese was dished up in bowls on a tray in the refrigerator without a label or date on the tray or on the bowls. [NAME] H reported she had just dished them up for breakfast and did not put a date on them.Surveyor observed [NAME] H serve a bowl of cereal not covered to a resident eating in their room. Surveyor asked [NAME] H if cereal should be covered and [NAME] H stated she forgot to put a lid on it.Surveyor noted rectangular baking pans were on bottom shelf not enclosed, not covered, or inverted. [NAME] H was not sure why some pans were not inverted or covered.Surveyor found an open bag of macaroni on kitchen shelf without an open on or use by date. [NAME] H then dated open bag.On 4/13/26 at 2:30 PM, Surveyor met with Dietary Director (DD) I, who stated employees have a refrigerator downstairs they are supposed to put their lunches in. Staff are not to put their personal lunch bags in the resident refrigerator. DD I agreed that all prepared cooked food should have a temperature taken to ensure food is cooked to a safe temperature before serving to residents, clean dishes should be introverted or covered when stored, all food should be covered when leaving the kitchen, and all opened packaged foods should be dated with open by or use by dates.

Based on interview and record review, the facility did not immediately consult with the resident's physician when there is need to alter treatment for 2 of 5 residents (R4 and R13) reviewed for MD notification. -R4 began to have difficulty with nebulizer treatments with increased dyspnea and shortness of breath which were then held by nursing staff and not administered as physician orders specify. Staff did not notify the provider with condition change and holding of the nebulizer treatments for 2 days.-R13 had a change of condition with low oxygen saturations, and the MD was not notified of the change in respiratory status and low oxygen saturations. The next day R13 was transferred to the emergency room and was diagnosed with pneumonia. Findings include: Surveyor reviewed facility policy titled, Resident Change in Condition, last reviewed 08/25, which states, .RN notification: 1. LPN's RTs, medication aides, and other unlicensed personnel must report to the RN in charge of the resident's care, all residents experiencing a change in condition that warrants assessment and notification of the medical provider. Recognition: 3. When a change of condition does occur, the team will recognize that change from baseline and report appropriately. Surveyor reviewed facility procedure titled, The Society for Post-Acute and Long-Term Care Medicine (AMDA) Guidelines resource sheet, dated 2014-2024, which states, Immediate notification: any symptom or apparent discomfort that is: -acute or sudden in onset, and -a marked change in relation to unusual symptoms and signs, or-unrelieved by measures already prescribed. Example 1 R4 was admitted to facility on [DATE], with diagnoses including, in part, Acute chronic respiratory failure with hypercapnia, acute and chronic respiratory failure with hypoxia, unspecified protein-calorie malnutrition, type 2 diabetes mellitus with diabetic nephropathy, fusion of spine, post-polio syndrome, insomnia, hyperkalemia, scoliosis, anxiety disorder, gastrostomy status, tracheostomy, and dependence on respirator ventilator status. R4's Minimum Data Set (MDS) assessment, dated [DATE], identified on admission that R4 had a Brief Interview for Mental Status (BIMS) score of 13. This indicated R4 had intact cognition. The MDS assessment also identified R4 has impairment of upper and lower extremity bilaterally requiring total dependent assistance with bathing/showering self, transfer, and toileting. Surveyor reviewed R4's care plans: The resident [R4] is ventilator dependent related to respiratory care plan, initiated on [DATE]: -Assess for signs and symptoms of hypoxia, altered level of consciousness, irritability, listlessness, and cyanosis. -Monitor for changes in respiratory rate or death. Observe/document for use of accessory muscles. Notify MD if significant changes. The resident [R4] has oxygen therapy related to respiratory care plan, initiated on [DATE]. -Monitor for signs and symptoms of respiratory distress and report to MD as needed: Respirations, Pulse oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis, Cough, Pleuritic pain, Accessory muscle usage, Skin color changes to blue/gray. -Oxygen settings: O2 as ordered. -Monitor/document changes in condition, increased restlessness, anxiety, and air hunger. Surveyor reviewed R4's progress notes, which state, -On [DATE] at 7:25 AM, Vitals: 73% O2 on Vent. -On [DATE] at 7:25 AM, eAdmin Record, Nebulizer treatment respiratory evaluation: Document lung sounds four times a day. Resident [R4] appeared in distress. Registered Nurse (RN) suctioned scant, clear. Respiratory Therapist (RT) put on 10L O2. HR (heart rate) came down over 20 min. 0725 AM HR 86, sat 96 on 5L (liters) decreased now to 3L. Resident resting comfortably. -On [DATE] at 9:56 AM, Skilled Nursing Note: Respiratory rate regular. Lungs are clear to auscultation bilaterally. Resident with no cough. Resident with dyspnea. The resident utilizes oxygen continuously. Liter flow: 3L. Mental Status: Confusion/Disorientation: Lethargic/Comatose, Comments: resident had period of dyspnea during nebulizer treatment. RT notified. Required increased 02 for a short period of time. Pt. (patient) no longer having Shortness of Breath (SOB). -On [DATE] at 10:53 AM, eAdmin record: Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML, 3 ml via trach four times a day for wheezing or shortness of breath. On [DATE] at 10:53 AM, eAdmin Record: Note Text: Held nebulizer due to morning reaction during neb. Also, tried to change her to wean, but continued to low minute Vent alarm and appeared very breathless. Will try again later. -On [DATE] at 11:37 AM, Communication: Provider: Note Text: NP updated on blood sugar trends. See scanned sheet with written orders. -On [DATE] at 12:05 PM, Respiratory Therapy: Lung Assessments: RUL (right upper lobe) Clear. Comments: after her [R4]'s morning neb resident [R4] got SOB (short of breath) and lung sounds were a rubbing noise. She [R4] had to go on 10L O2 (oxygen) for about 20 min (minutes) until sats (oxygen saturation) remained above 90. -On [DATE] at 3:29 PM, Vitals taken, respirations 34 breaths/min. -On [DATE] at 3:31 PM, Respiratory Therapy (RT): Progress Note: RT tried weaning resident [R4], and heart rate increased, and respirations were where resident [R4] looked uncomfortable. Stopped weaning. When resident [R4] got back to baseline, RT tried giving nebs and after 4 minutes resident [R4] work of breathing and heart rate increased again, stopped neb early. Resident [R4] recovered after about 10 minutes. RT Director informed. -On [DATE] at 6:43 PM, Condition Note: Oxygen therapy: delivery route, amount, and oxygen saturation: 02 Room Air 02 SATS 94% Pulse 113 Respirations 32. Resident [R4] states she has shortness of breath on and off all day. -On [DATE] at 7:33 PM, eAdmin record: Note Text: declined to have breathing treatment (neb). -On [DATE] at 7:35 PM, eAdmin record: Note Text: Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML, 3 ml via trach four times a day for wheezing or shortness of breath. Resident [R4] chooses not to have, was having difficulty on the am shift nebs, chooses not to have tonight. -On [DATE] at 7:36 PM, eAdmin Record: Note Text: Sodium Chloride Inhalation Nebulization Solution 3 %, 4 ml via trach four times a day for Mucous Plugging. Resident [R4] chose not to have this shift, due to difficulty during the day with treatment. -On [DATE] at 11:06 AM, eAdmin Record: Note Text: Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML, 3 ml via trach four times a day for wheezing or shortness of breath. Held d/t (due to) resident [R4] desaturations and labored breathing when nebs are running. -On [DATE] at 11:07 AM, eAdmin Record: Note Text: Sodium Chloride Inhalation Nebulization Solution 3 %, 4 ml via trach four times a day for Mucous Plugging. Held due to desaturations while nebs are running. -On [DATE] at 12:00 PM, Respiratory Therapy: Lung Assessments: Action/Plan: 7:00 AM, breathing treatment administered. Resident [R4] began to feel SOB (short of breath) and breathing harder, O2 sat dropped from 98% to 90% after 5 minutes. Breathing treatment stopped and O2 sat went up to 96% and SOB resolved. Hold future breathing treatments today.Comments: Expiratory wheezes noted which improved with suction. Rhonchi bilaterally. -On [DATE] at 12:32 PM, Respiratory Therapy Progress note: Note Text: Resident [R4] wanted to try wean mode on her vent. After less than a minute, resident [R4] O2 sat down and resident [R4] said 'hard to breathe' and was switched back to her usual vent settings. -On [DATE] at 2:26 PM, Communication: Provider (telephone order): Cough assist QID (four times a day) and Q2 prn (every 2 hours as needed) for secretions clearance. -On [DATE] at 3:08 PM, eAdmin Record: Note Text: Sodium Chloride Inhalation Nebulization Solution 3 %, 4 ml via trach four times a day for Mucous Plugging. Held due to not tolerating. -On [DATE] at 3:08 PM, eAdmin Record: Note Text: Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML, 3 ml via trach four times a day for wheezing or shortness of breath. Held due to not tolerating. -On [DATE] at 7:26 PM, eAdmin Record: Note Text: Nebulizer post treatment: Nebulizers on hold, resident is having difficulty tolerating. -On [DATE] at 7:28 PM, eAdmin Record: Note Text: Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML, 3 ml via trach four times a day for wheezing or shortness of breath. Not tolerating nebs. -On [DATE] at 9:17 AM, eAdmin Record: Note Text: Sodium Chloride Inhalation Nebulization Solution 3 %, 4 ml via trach four times a day for Mucous Plugging. Held due to resident not tolerating. -On [DATE] at 11:26 AM, eAdmin Record: Note Text: Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML, 3 ml via trach four times a day for wheezing or shortness of breath. Resident not tolerating. -On [DATE] at 11:58 AM, Communication Provider (Telephone Order): Information: CXR (chest x-ray) for increased SOB. On [DATE] at 11:10 AM, Surveyor interviewed registered nurse (RN) E and asked about facility policy regarding a change of condition. RN E reported staff follow the AMDA (American Medical Director Association) guidelines which are in binder at the nurse's station. RN E walked over to binder and provided Surveyor with copy of change in condition guidelines to notify physicians. RN E reported to Surveyor that staff would notify nurse manager on unit to report change in conditions to provider. Surveyor asked RN E if there a resident presents with low O2 saturations, increasing liters of oxygen delivered, and holding a nebulizer treatment warrant a provider notification. RN E reported that Nurse Manager C, Assistant Director of Nursing (ADON) J, or Director of Nursing (DON) B, would be contacted, and they report to the provider on call. Surveyor asked how provider is notified on nights and weekends. RN E reported that all above are still notified of the COC (change of condition) and contact the provider on call. On [DATE] at 11:18 AM, Surveyor interviewed RN K and Nurse Manager M and asked RN K and Nurse Manager M about R4, and what would constitute a COC. RN K reported staff follow the AMDA Guidelines which are in binder at the nurse's station. Nurse Manager M stated, Yes, the acute change of condition guidelines are located at nurses' station. RN K reported that any kind of change in condition that is not R4's baseline gets reported right away. Surveyor asked RN K does the provider need to be contacted when staff hold a nebulizer medication. RN K stated that all medications being held need to be reported to provider right away so that if there are any further orders or change in medication, that R4 may need for continuity of care. On [DATE] at 11:27 AM, Surveyor interviewed ADON J and asked ADON J who is responsible for notifying the provider of change in condition of a resident's status. ADON J reported that all staff are to report changes in conditions to either Nurse Manager C, ADON J, or DON B. ADON J reported that then one of the 3 of us will review chart, and all pertinent information than call the provider once all information is together. Surveyor asked ADON J if Respiratory Therapist (RT) G notified provider of respiratory condition changes. ADON J reported that all RTs are to report change in condition to floor nurses as well as Nurse Manager C, ADON J, or DON B so that one of us three can inform the provider once all information is gathered. On [DATE] at 8:01 AM, Surveyor entered NHA A's office. Present in room, were NHA A, DON B, and RT Director. Surveyor interviewed DON B and RT G. Surveyor asked DON B and RT G what expectations or parameters are taken to ensure a provider on call is notified of a change in condition such as R4 having difficulty breathing and nebulizers being held. RT G reported to Surveyor that this is a unique facility handling ventilator respiratory needs. RT G reported that residents' lung sounds such as R4's changes every minute of every day and then are treated with many interventions such as a quick nebulizer might fix the SOB or lung sound concern, as well as repositioning, or cough assistance on a short-term basis without notifying provider on call. RT G reported that after a longer amount of time residents struggling with respiratory needs that can't be corrected would warrant a provider on call to be notified. DON B reported to Surveyor that that they need to formulate specific parameters with Medical Director L regarding when to notify provider if ventilation concerns/issues such as After bagging for a period of time with no resolution, increased SOB after so much time without correction. Surveyor asked RT G and DON B what the expectation is for holding a nebulizer medication for R4 and when should the provider on call been notified of the change in medication administration. DON B reported that all staff are to notify provider if there is a hold on a medication or need a change in a medication as soon as possible so that the provider on call can change the orders as needed. RT G reported to Surveyor that RT G should have notified provider on call in the change in nebulizer use for R4 sooner than provider was notified. On [DATE] at 10:32 AM, Surveyor interviewed Medical Director L and asked expectation for nursing staff to notify provider on call of a nebulizer medication being held when someone becomes SOB and having difficulty tolerating nebulizers. Medical Director L stated staff should notify the provider on call regarding a change in condition and needing medications held or changed. Medical Director L stated to Surveyor, Provider should be notified of condition of change, but this facility utilizes RTs, and they have the expertise and judgement to navigate respiratory concerns for short term management such as change in lung sounds, SOB, dyspnea, and increased heart rate when on ventilator. Once interventions are implemented such as repositioning, ventilator changes, cough assist, suctioning, and nebulizers and it cannot be corrected within a timely manner then provider needs to be notified as soon as possible. R4 had nebulizer treatments held due to inability to tolerate the treatments the MD was not promptly notified of this change in resident status. Example 2 R13 was admitted to the facility on [DATE] and has diagnosis that include dependance on ventilator due to chronic respiratory failure with hypoxia (low oxygen levels) and hypercapnia (high carbon dioxide levels), chronic obstructive pulmonary disease (COPD) and tracheostomy. R13 has a brief interview for mental status (BIMS) score of 15 which means cognitively intact. R13 makes own health care decisions. R13's medical record indicated R13 is full cardiopulmonary resuscitation (CPR). R13 care plan, last revised on [DATE], has Focus statements.The resident is night ventilator dependent related to respiratory failure. Goals include R13 will have no signs/symptoms of infection. Interventions include tracheostomy suctioning as necessary, ventilator at night and tracheostomy care. On [DATE] at 11:09 AM, Surveyor interviewed R13 if having thoughts/concerns using ventilator during the nighttime as ordered by R13's physician. R13 stated, I want to get out of here.I don't know why I have to have this trach (tracheostomy) in place. I don't need it. Record review of R13's medical chart: - On [DATE] at 7:20 AM, nursing documentation by registered nurse (RN) E indicated episode of R13 gasping. RN E placed R13 on ventilator with increased air flow and started to bag R13. RN E states in note resistance felt [during bagging] and unable to bag. R13's oxygen level per pulse oximetry was at 40%. RN E proceeded to perform lavage and suction R13. R13 had return of color and oxygenation levels of 94% while on ventilator. RT D presented upon scene and took over care of R13's respiratory monitoring. - No documentation in R13's record of provider notification of respiratory event on [DATE]. - On [DATE] at 7:45 AM, R13's went to an eye appointment and subsequently was transferred to the ED for a change in condition and returned to the facility same day with a diagnosis of pneumonia. On [DATE] at 12:11 PM, Surveyor interviewed Registered Nurse (RN) F, who was involved with R13's respiratory episode on [DATE]. RN F stated R13 had been refusing suctioning and using ventilator at night off and on. RN F stated R13 will refuse the ventilator until he ends up in the hospital. RN F could not confirm if a provider was updated on R13's status on [DATE] or [DATE]. Surveyor interviewed Respiratory Therapist (RT) D on R13's refusal of ventilator at night. RT D stated, He does this all the time.has been noncompliant for a long time. RT D stated R13 refuses the ventilator and suctioning or treatments, then ends up in the hospital. RT D stated nursing management is updated to a resident change in status and the provider is notified. RT D documents all assessments in medical records. Provider routine rounding progress notes dated [DATE], [DATE], [DATE], [DATE] and [DATE] had no indication that provider(s) was aware R13 refused ventilator at night and/or treatments. On [DATE] at 2:25 PM, Surveyor interviewed Director of Nursing (DON) B regarding staff expectations for reporting any changes in condition to a provider. DON B stated nursing manager (NM) C rounds in the mornings and speaks with staff. When staff identify a change in resident's condition or need to notify a physician, NM C gathers information from them and places a call to update the provider. It is expected that NM C documents provider notifications in the medical record. Surveyor asked DON B if the event on [DATE] for R13 required physician notification. DON B stated because it was felt R13 had a mucous plug requiring suctioning only, the physician would not need to be updated. Surveyor asked DON B since it was determined the next day after another respiratory event at outside facility that R13 had pneumonia, should that have required a physician notification earlier to possibly have prevented a transfer to the hospital. DON B confirmed it would fall under requirements for physician notification. DON B confirmed with Surveyor that R13 was full code status. DON B could not provide any documentation that a provider was notified of R13's change in respiratory status for [DATE] or [DATE].

Based on record review and interview the facility did not provide the accurate Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) thus did not provide the accurate potential financial liability to residents whose Medicare coverage ended for 1 of 1 resident reviewed (R7).R7 was receiving Medicare A benefits. R7's Medicare coverage ended on 12/12/25. R7 was not provided with a SNFABN form thus not provided with accurate financial liability. Evidenced by: Surveyor reviewed R7's beneficiary notices for Medicare Part A services ending. Surveyor could not find that a SNFABN Form was given to R7 to inform R7 of the financial liability. On 04/14/26 at 1:13 pm, Surveyor interviewed Nursing Home Administrator (NHA) A and asked for beneficiary notices for R7 when R7's Medicare benefits were ending. NHA A stated to Surveyor that NHA A admits to not giving R7 a SNFABN form when R7's benefits were about to end. NHA A reported that the person in charge of making sure beneficiaries are completed has not worked since September of 2025, so this SNFABN form was missed for R7.

Based on interview and record review, the facility did not develop a comprehensive person-centered care plan for the diagnosis of fluid overload and new anticoagulation medication administration post hospitalization for 1 of 16 residents (R) R4 reviewed for care plans.This is evidenced by: R4 was admitted to facility on 01/30/26, with diagnoses including, in part, acute chronic respiratory failure with hypercapnia, acute and chronic respiratory failure with hypoxia, unspecified protein-calorie malnutrition, type 2 diabetes mellitus with diabetic nephropathy, fusion of spine, post-polio syndrome, insomnia, hyperkalemia, scoliosis, anxiety disorder, gastrostomy status, tracheostomy, and dependence on respirator ventilator status. Surveyor reviewed R4's physician orders, which state, .-Apixaban 2.5 mg give 1 tablet via G-Tube two times a day for Deep Vein Thrombosis (DVT) based on age greater than 80 and weight less than 60kg.-Side effect: Anticoagulant-Monitor for side effects: Blood in urine/stool, black stool, severe bruising, prolonged nosebleeds, bleeding gums, vomiting/coughing up blood, every shift Complete documentation in progress note if side effects noted. Surveyor reviewed R4's hospital note from 02/25/26, which states, .[R4] has a history of restrictive lung disease secondary to post-polio syndrome, chronic hypoxic and hypercapnic respiratory failure, ventilator dependence via tracheostomy, type 2 diabetes with nephropathy, malnutrition with PEG, and recurrent ventilator associated pneumonia, who was admitted on [DATE] for acute on chronic respiratory failure with hypercapnia and hypoxia. On arrival [R4] is lethargic and significant pressure is necessary to sufficiently bag the patient for chest rise. Heart rate 121, and respirations 8. Physical examination: Lethargic, critically ill appearing, malnourished, moderate respiratory distress, toxic. For the acute pulmonary embolism, [R4] was initially treated with heparin infusion and subsequently transitioned to apixaban. Therapeutic thoracentesis was performed on 2/22, with removal of 1.1 L of serous fluid from the right pleural space, resulting in improved respiratory comfort. Record review identified R4 had fluid overload concerns with pitting edema when transferred to hospital on [DATE]. R4 was re-admitted to the facility on [DATE] after being diuresis in the hospital and placed on anticoagulation medication to take twice daily. Review of R4's care plan identified no problems or interventions related to R4's recent hospitalization with fluid overload and assessing for edema. Review of R4's care plan identified no problems or interventions related to R4's recent need of an anticoagulation. On 04/15/26 at 10:41 AM, Surveyor interviewed Director of Nursing (DON) B and asked if R4 should have a fluid overload and anticoagulation comprehensive care plan in place post hospitalization for stated above concerns to decrease complications or readmissions into hospitals. DON B reported that R4 should have both comprehensive care plans in place for fluid overload and anticoagulation therapy, so that staff have interventions to help assist R4 in R4's overall health. DON B reported that DON B would create R4's care plan for fluid overload and anticoagulation therapy.

Based on observation, interview and record review, the facility did not review/revise the resident's person-centered comprehensive care plan for 1 resident (R13) of 16 residents reviewed for care plans in a sample of 16 residents. The facility's interdisciplinary team (IDT) did not update/revise R13's care plan after each quarterly or comprehensive review assessments to reflect R13's refusals of using the ventilator at night and noncompliance to fluid restrictions, resulting in a possible decline in R13's physical health and hospitalization.Findings include:The facility policy, titled Care Plan Revisions Upon Status Change, last revised 05/05/2025, states, The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change.R13 was admitted to the facility on [DATE] and has diagnoses that include dependance on ventilator due to chronic respiratory failure with hypoxia (low oxygen levels) and hypercapnia (high carbon dioxide levels), chronic obstructive pulmonary disease (COPD), tracheostomy, chronic heart failure. R13 has a brief interview for mental status (BIMS) score of 15/15 which means cognitively intact. R13 makes own health care decisions. R13 care plan, last revised on 02/19/2026, has Focus statements, I have a nutritional problem related to.ventilator dependence at night. The resident is night ventilator dependent related to respiratory failure. Goals include R13 will maintain weight as evidenced by no significant weight gain and R13 will have no signs/symptoms of infection. Interventions include fluid restriction, tracheostomy suctioning as necessary and tracheostomy care. On 04/13/2026 at 8:50 AM, R13 was observed sitting at dining table eating breakfast independently. R13 did not have ventilator in place and was using portable oxygen. On 04/13/2026 at 11:09 AM, Surveyor interviewed R13 and asked if having thoughts/concerns using ventilator during the nighttime as ordered by R13's physician. R13 stated, I want to get out of here.I don't know why I have to have this trach (tracheostomy) in place. I don't need it. Record review of R13's medical chart:- R13 was admitted to facility with physician orders for ventilator use during nighttime hours to reduce episodes of hypoxia. R13 has a tracheostomy is place with oxygen use during daytime hours. - R13 has physician orders dated 02/12/2026 for fluid restriction - not to exceed 2200cc (milliliters) to 2800cc. Dietary amount: 1500cc; AM nursing amount 500cc, PM nursing amount 500cc; night (NOC) nursing amount 300cc. - R13 has physician orders dated 02/12/2026 to suction and/or lavage with normal saline.to clear catheter. - R13 has physician order dated 02/12/2026 for ventilator at night. Trach collar during the day. - Nursing documentation dated 02/12/2026 to current date, indicate R13 is noncompliant with fluid restrictions, taking in excess amounts of fluids. Dietary notations of R13's weight gain of 7.61% in past 90 days. R13 has had education of risks of excessive fluid intake by a dietician and nursing. - Nursing documentations indicate R13 repeatedly refuses cares that include suctioning of tracheostomy, nebulizer treatments and ventilator use at nighttime since 01/26/2026. - R13 was hospitalized for respiratory complications 01/30/26 to 02/12/2026. R13 was evaluated in the emergency department on 03/25/2026 for respiratory complications. - R13's care plan does not have revised risk/benefit or education provided to R13 regarding R13's choice to not follow physician ordered fluid restrictions. - R13's care plan does not have revised risk/benefit or education to R13 or alternative treatment interventions in place for R13's refusal of tracheostomy suctioning, nebulizer treatments or ventilator use during the night. On 04/14/2026 at 12:11 PM, Surveyor interviewed Registered Nurse (RN) F on R13's use of ventilator at night. RN F stated R13 has been refusing suctioning and using ventilator at night off and on because R13 believes he can have tracheostomy removed and go home. RN F stated R13 is also noncompliant with fluid restriction and drinks over the amount allowed, which results in R13's weight gain. On 04/14/2026 at 12:45 PM, Surveyor interviewed Respiratory Therapist (RT) D on R13's refusal of ventilator at night. RT stated, He does this all the time.has been noncompliant for a long time. On 04/14/2026 at 2:25 PM, Surveyor interviewed Director of Nursing (DON) B what staff expectations are for revising and updating a resident's care plan. DON B stated care plans are reviewed quarterly by the IDT (Interdisciplinary Team) and changes are made if needed. If there are any changes in a resident's plan of care outside of the quarterly review, including refusals of care or noncompliance of cares, it is to be communicated to a nursing manager, who then will update care plan.

Based on record review and staff interviews, the facility did not ensure 3 of 3 residents (R) reviewed, (R1, R2, and R3) who required oxygen with ventilator (Vent) and respiratory care were provided such services consistent with professional standards of practice, the resident's comprehensive person-centered care plan, and physician orders on the ventilator unit. R1 is ventilator dependent and requires oxygen continuously via the ventilator to maintain oxygen levels above 90% saturation. On [DATE], when R1 was put to bed, staff did not connect R1 to the stationary liquid oxygen tank, but left R1 connected to a portable oxygen tank that runs out of oxygen within ,d+[DATE] hours. Respiratory Therapist (RT) skipped ventilator spot checks for R1 at 2:00 AM on [DATE]. R1 was found at 6:00 AM on [DATE] with low saturations, no pulse, and died . The facility's failure to ensure R1 had oxygen supply during the night of [DATE] and respiratory therapy check at 2:00 AM, created a reasonable likelihood for serious harm and death which created a finding of immediate jeopardy that began on [DATE]. Nursing Home Administrator (NHA) A was notified of the immediate jeopardy on [DATE] at 12:10 PM. The immediate jeopardy was removed on [DATE]; however, the deficient practice continues at a scope/severity level D (potential for harm/isolated) as evidenced by the following examples. R2 and R3 are ventilator dependent with oxygen. RT spot checks were not documented as completed on several dates. Findings include: Facility policy titled, Oxygen Administration, dated reviewed on [DATE] states in part: .Procedure: 7. Residents receiving oxygen will be hooked up to the stationary liquid oxygen tank when they are in bed. Facility policy titled, Ventilator Checks, dated reviewed on ,d+[DATE] states in part: .Procedure: 7. Verify the vent is connected to an appropriate source of power. 9. Document the ventilator settings. 10. Document the residents measured parameters. 11. Document the residents pulse oximeter reading. 12. Document the residents heart rate. 13. If applicable, verify the amount of oxygen in the oxygen tank and switch over to a new source if necessary. 14. If resident is receiving oxygen verify the following: a. The oxygen tank is set to the appropriate setting and chart the LPM. 19. Document the number of minutes spent with resident . R1 was admitted on [DATE] with chronic respiratory failure with hypoxia, cardiac arrest due to other underlying condition, respiratory arrest, ventilator associated pneumonia, spontaneous pneumothorax, anoxic brain damage, dependence on respirator (ventilator) status, anxiety disorder, chronic obstructive pulmonary disease, paranoid schizophrenia, and tracheostomy. R1's Minimum Data Set (MDS) assessment, dated [DATE], had a Brief Interview for Mental Status (BIMS) score of 00 which indicated facility could not determine BIMS for R1 due to R1 was rarely/never understood. MDS indicated that R1 is totally dependent on staff for all cares. R1's care plan, dated [DATE], indicates: -Dependent on others for all cares. Needs assistance of 2 staff members to reposition every 2 hours and as needed. Assist 2 with Hoyer lift for transfers. -Trach in place and dependent on vent. Order to titrate oxygen as needed to keep my O2 greater than 89%. Surveyor reviewed R1's physician orders: -[DATE]-Respiratory Therapy standing orders have been approved for use. -[DATE]: *Initiate O2 to maintain SpO2>90%. *Refill portable unit every 4 hours when in use 9:30 am, 1:30 pm, and 5:30 pm. Progress notes: On [DATE], notes in part, .-11:26 am-Spot checks: 95% O2 on 4L, Resps-18 -1:49 pm-Lungs auscultated anterior bilaterally clear. -4:53 pm- 92% O2 on 4L . No further documentation in nurse notes. On [DATE]: Documentation indicates at: .-3:42 am-Length of tube 4 -6:02 am-Heels intact and elevated . Treatment Administration Record (TAR) indicated: -On [DATE], portable O2 tank refilled at 9:30 AM and 1:30 PM. Surveyor did not locate documentation for portable oxygen tank refilled at 5:30 PM on [DATE], as ordered. Respiratory spot checks indicated: On [DATE] at 11:26 am: 95 % on 4L, HR-85, Resp-18. On [DATE] at 3:56 PM, no spot check documentation. Oxygen checks indicated: On [DATE] in AM- 92%, PM- 92%, NOC-92%. Progress notes continued, [DATE] -11:06 AM - late entry - On [DATE], Writer RN was summoned to resident's room at approximately 6:08 am by RT. When writer entered resident's room two RT's were bagging resident due to low oxygen saturations. Resident had two pulse oximeters on right and left hand and they both indicated no pulse or O2 saturation present. Resident was unresponsive at this time and writer performed sternal rub and verbal command with no response from resident. RTs continued to bag resident while writer confirmed code status. Writer code status was confirmed DNR [do not resuscitate]. At approximately 6:12 am writer then felt popliteal, femoral, radial, and carotid pulse and no pulses were palpable. Writer then auscultated for heart sounds and agreed with writer's assessment. Bagging was stopped at 6:14 am. MD updated on resident's overall condition and no signs of life. See MD update note. -Call placed to DON at 6:20 am and updated. Writer called provider approximately 6:30 am to update of resident's condition change and not having a pulse or oxygen saturations. NP answered and suggested to call medical director. DON called Medical Director and orders given at 6:35 am, provider gave orders for time for time of death, release body to funeral home and to remove the ventilator . Interviews On [DATE] at 1:26 PM, Surveyor interviewed Medication Aide (MA) E. MA E indicated MA E worked on [DATE] from ,d+[DATE] PM on another hall but then started cares for R1 at 10 PM to 6 AM. MA E indicated that MA E saw the other two CNAs that were on night shift walk into R1's room to lay her down around 7:30 PM on [DATE]. MA E indicated that MA E observed R1's big liquid oxygen tank outside of R1's room and not in room where it should be. MA E indicated that MA E liked that it wasn't in the room because resident's room is always so cluttered and crowded. MA E indicated that through the night resident was fine and had checked and changed her at 11:30 PM, 1:30 AM, and 3:45 AM. MA E noted that the small portable tank was hanging on resident's ventilator. Surveyor asked MA E how long small portable tank lasts. MA E indicated it depends on how high the flow in liters is for oxygen, but resident should have been connected to the big liquid oxygen tank. Surveyor asked MA E if she was present for the events that happened at 6:00 AM. MA E indicated that MA E was clocking out and looked over and saw RT bagging resident. On [DATE] at 1:36 PM, Surveyor interviewed Certified Nursing Assistant (CNA) F who put R1 to bed on [DATE]. CNA F indicated that CNA F gathered all of R1's equipment in the common area such as continued tube feeding pump and vent and took R1 into room to lay down to bed. Surveyor asked if CNA F had brought the big liquid oxygen tank in resident's room and hooked R1 to it. CNA F indicated that CNA F did not hook big liquid oxygen tank up and left it outside the door. CNA F indicated that R1 had a small portable oxygen tank hanging on vent, so CNA F thought it was fine. Surveyor asked CNA F if CNA F checked the small portable oxygen tank to see how much oxygen was left in the tank. CNA F indicated that CNA F did not check the small portable oxygen tank. Surveyor asked whose job is it to check the small portable oxygen tanks. CNA F indicated it is everyone's job to check the portable tanks. Surveyor asked CNA F why the big liquid oxygen tank was in the hallway in the common area and not in R1's room. CNA F indicated that sometimes R1 will sit in common area to socialize and so the facility brings the big liquid oxygen tank outside the room to connect to R1 if resident is going to be a while in the common area. Surveyor asked CNA F if it is the process to bring the big liquid oxygen tank back in the room once resident is laid down for the night. CNA F indicated that is required. We bring big liquid oxygen tank back into room and connect resident once lying in bed. CNA F indicated that she did not do this. Surveyor asked CNA F if facility debriefed or educated CNA F on proper oxygen use after R1 passed away. CNA F indicated CNA F did not receive any training on the matter. On [DATE] at 9:25 AM, Surveyor interviewed CNA D, who was on the [DATE] day shift and found R1 in an unconscious state. Surveyor asked CNA D to walk Surveyor through the events on [DATE]. CNA D indicated that CNA D came on shift and entered R1's room. CNA D observed that the big liquid oxygen tank was outside R1's room. CNA D could see R1 was not herself, just lying there. CNA D quickly ran to RT G who was clocking out for the day, and RT G quickly ran to R1's room and started bagging R1. Surveyor observed CNA D crying, and CNA D indicated the big liquid oxygen tank should have been attached to R1 while resident was in bed. On [DATE] at 1:50 PM, Surveyor interviewed RT G who was on night shift on [DATE]. RT G indicated that RT G saw aides going in resident's room on [DATE] around 7:00 PM and laying resident down for the night. RT G noticed the big liquid oxygen tank outside resident's room and didn't think anything of it. RT G indicated that RT G heard R1's vent alarm going off around 10 PM. RT G went into R1's room and found the vent was unplugged from the wall. RT G connected vent back into the wall and walked out of R1's room. Of note, the vent does operate on battery for a period of time and was functioning properly on battery. Surveyor asked RT G why RT G did not hook resident up to big liquid oxygen tank. RT G indicated that RT G did not think anything of it at the time. RT G indicated that RT G did not see R1 for the rest of the night. RT G indicated that it was unusual that R1's vent did not alarm at all for rest of night. RT G indicated that R1 always has alarms going off every night, and RT G is usually in there periodically. Surveyor asked if RT G completed 2:00 AM spot checks. RT G indicated that RT G did not go back into R1's room and skipped 2:00 AM spot checks. Surveyor asked RT G what the correct process is for spot checks. RT G indicated that RT G completes spot checks at least every night at 2:00 AM but really RTs are supposed to be in rooms every 4 hours to complete spot checks for the ventilator. Surveyor asked RT G to explain what spot checks consist of. RT G indicated that spot checks are assessing heart rate (HR), O2 saturation, how many liters of oxygen resident is on, and checking ventilator settings. This is documented every time spot checks are completed. RT G indicated that RT G went to clock out at 6:04 AM when an aide stopped RT G and asked RT G to come to R1's room as something was wrong and R1 was not connected to big liquid oxygen tank. RT G entered R1's room and could see something was wrong. RT G grabbed big liquid oxygen tank and began bagging R1 and placed R1 on 10 liters of oxygen. RT G instructed CNA D to go get help from other RT on duty. RT G indicated that R1 had no pulse and found out resident was a DNR, so RT G stopped bagging R1. After nurse assessed for pulse and found no pulse, R1 was pronounced dead. Surveyor asked RT G if RT G was debriefed on the situation that occurred, trained or educated on the events and if administration concluded an investigation into the matter. RT G indicated that nothing was ever completed. RT G did not get debriefed on anything in particular. On [DATE] at 2:04 PM, Surveyor interviewed RT I, who was on day shift of [DATE]. RT I indicated that around 6:00 AM, CNA D came and grabbed RT I frantically to come assist in R1's room. RT I indicated that day shift CNA D had found R1 on small portable oxygen tank and immediately knew something was wrong. RT I indicated that RT I saw RT G bagging R1. RT I performed a sternum rub, and R1 did not respond. RT I checked pulses and no pulse was found. At that point RT I instructed CNA D to go get AED and code status. RT I indicated that shortly after RN C came back in and stated code status was DNR and bagging was stopped. Surveyor asked RT I what the process is for spot checks for residents on ventilators. RT I indicated that RT I can't speak for night shift but day shift RTs are supposed to do spot checks every 4 hours and spot checks consist of HR, resp rate, O2 flow, and ventilator settings. RT I indicated this is documented in the resident's chart right away and for each time performed. On [DATE] at 2:00 PM, Surveyor interviewed Registered Nurse (RN) C, who came on day shift on [DATE] at 6:00 AM. RN C indicated that RN C came in around 5:53AM. RN C indicated this was her first day on the floor by herself, and RN C noticed a big liquid oxygen tank outside R1's room and thought that was odd. RN C indicated that shortly after the start of her shift, RN C observed RT G in R1's room and CNA D run out of resident's room yelling for help. RN C ran into R1's room and observed both RTs bagging R1. RN C immediately observed a small portable oxygen tank hanging from the vent. RN C checked it to see how much oxygen was in the small tank, and RN C indicated it was empty. RN C observed RTs instruct to grab AED and find out R1's code status immediately. RTs were still bagging when RN C exited resident's room. RN C found that R1 was a DNR and immediately told RTs. RN C checked popliteal, femoral, radial, and carotid pulse and no pulses were palpable. RN C assessed no saturations for oxygen. RN C indicated RTs stopped bagging and started making phone calls to appropriate people such as DON B and provider. RN C indicated that DON B told RN C to leave everything as is until DON B arrived at facility. Surveyor asked RN C if RN C was educated or debriefed about the death of R1. RN C indicated that RN C was not educated or debriefed, and this has impacted RN C tremendously. Surveyor observed RN C crying, and RN C stated, I feel so bad for her. The facility failed her in more ways than one, and the facility has done nothing to fix the issue or investigate it. On [DATE] at 2:27 PM, Surveyor interviewed NHA A and Director of Nursing (DON) B and asked about the event with R1 on [DATE] into [DATE]. NHA A indicated that two CNAs put R1 down to bed around 7:30 PM and R1 was fine. Then on [DATE] the next morning, R1 passed away around 6:30 AM. and DON B was notified. DON B then notified NHA A. DON B arrived onsite around 7:15 AM and began creating timeline and gathering statements. NHA A indicated that CNA D on day shift observed something wrong with R1. RT G responded but R1 was still alive at that point and heart rate was in the 40s, which is low. NHA A indicated that RT then pulled big liquid concentrator into room and began bagging and had oxygen at 10 liters flow as per policy. R1 then had no pulse and was a DNR status. R1 passed away and appropriate calls were made. Surveyor asked NHA A and DON B if they completed a thorough investigation of the incident and what led to the events proceeding R1's death on [DATE]. NHA A indicated that facility did investigate and NHA A will gather the report to give to Surveyor. NHA A indicated that education and training was completed by the RT Director for RTs. NHA A admitted there has been lack of documentation that spot checks have been being completed as they should be, and they are aware of this issue. Surveyor asked NHA A and DON B what the facility process is for spot checks performed by RTs. NHA A indicated that spot checks should be completed regularly and would have to look at facility policy on spot checks. NHA A indicated that NHA A understands there was a system failure, and everyone has been educated on importance of spot checks. NHA A also indicated that NHA A and DON B educated aides and nurses about the correct use of the smaller portable oxygen tanks and the big liquid oxygen tanks. NHA A indicated that through their investigation of R1's death, the facility did not find that the RT not completing the spot check or the aides not connecting the big liquid oxygen tank was the cause of R1's death. NHA A indicated that NHA A and DON B have talked with Medical Director (MD) H and R1 most likely had a cardiac arrest event and died from that. Surveyor asked NHA A how NHA A can determine that was the cause of death. NHA A indicated that R1 was fine all night long and then suddenly wasn't fine with pulse down in the 40s. NHA A indicated that R1 has a history of cardiac arrest where R1 desats and that's how R1 had an anoxic brain injury months ago when she ended up here at the facility on ventilator and trach. Surveyor asked NHA A and DON B where the documentation was in the electronic health record (EHR) for R1's condition documenting a heart rate was present and in the 40s, when CNA D found the resident. NHA A and DON B indicated there is not much documentation in the EHR. NHA A indicated there is work to be done with educating staff on documenting more. On [DATE] at 8:43 AM, Surveyor interviewed MD H and asked MD H to recap the events that led to R1's death on [DATE]. MD H indicated that the facility called MD H that morning after R1 had passed. Facility completed an evaluation and investigation of the matter and then updated MD H that following Wednesday during rounds. MD H indicated that the facility made MD H aware that staff did not connect R1 to the stand-alone liquid oxygen tank when R1 was put to bed as per facility protocol and staff had kept R1 on small portable tank which only lasts roughly 4 hours depending on flow of oxygen. MD H indicated this resulted in R1 dying the morning of [DATE]. MD H indicated that since the death of R1, the facility has educated and trained staff on facility policy. On [DATE] at 8:57 AM, Surveyor interviewed NHA A and DON B and asked about the lack of signatures on the education that was given to Surveyor yesterday on [DATE]. NHA A and DON B indicated they had verbally educated staff back in February right after R1's death, but no one signed. NHA A indicated that NHA A and DON B stayed late last night to obtain employee signatures for the education on oxygen use. Surveyor asked for all signatures and education. NHA A indicated that NHA A is still trying to complete all education at this time. On [DATE] at 9:12 AM, Surveyor interviewed RN C and asked to clarify that education was not given to RN C as RN C stated yesterday on [DATE]. RN C indicated that staff were not educated, and administration pumped out education and signs to be placed throughout as reminders to connect big liquid oxygen tank yesterday during day when Surveyor was present and this morning as well. Surveyor reviewed the facility's investigation file. Surveyor could not confirm the accuracy of the statements due to lack of documentation in the EHR and investigation file. Surveyor did not find signatures from staff that they were educated as NHA A indicated. Surveyor did not find any documentation about R1 having a heart rate in the 40s when RT G entered resident's room. The failure to provide needed respiratory services of ongoing oxygen resulted in the reasonable likelihood for serious harm and death for R1 and led to a finding of immediate jeopardy. The facility removed the immediate jeopardy on [DATE] when it completed the following: RTs educated on expectation of completing oxygen checks and documentation/refusals of the 2am spot checks. CNAs educated on expectation of putting residents on stationary liquid tank when transferring to bed. Clinical staff educated on ensuring proper oxygen source prior to start of their next shift. Clinical staff educated on facility policy on oxygen administration prior to start of their next shift. Clinical staff educated on facility procedure for oxygen source switching prior to start of their next shift. Clinical staff educated on completing oxygen checks and completion of documentation/refusals as designated in the TAR. Clinical staff educated on oxygen safety check signs placed in resident rooms prior to start of next shift. On [DATE], facility reviewed policy and procedure of oxygen administration and updated to include the use of stationary liquid tanks when oxygen dependent residents are in bed. On [DATE], facility created a procedure for Oxygen Source Switching. On [DATE], facility updated Liquid Oxygen Portable Fill policy to reference source switching procedure. Clinical Managers will conduct audits on oxygen checks daily x 4 weeks, weekly x 4 weeks, bimonthly x 2 months Clinical Managers will conduct audits on appropriate oxygen source connection Monday-Friday x 4 weeks, weekly x 4 weeks, and bimonthly x2 months Results of the audits will be reviewed at QAPI meetings for further recommendations. The deficient practice continues at a scope/severity of D (potential for harm/isolated) as evidencd by: Example 2 On [DATE], Surveyor reviewed R2's medical record. R2 was admitted on [DATE] with diastolic heart failure with atrial fibrillation, chronic respiratory failure with vent status, tracheostomy, anxiety disorder, and major depressive disorder. Surveyor reviewed R2's respiratory spot checks that indicated: On [DATE]-[DATE]: No spot checks were documented for 2:00 AM. On [DATE]-[DATE]: No spot checks were documented for 2:00 AM. On [DATE]-[DATE]: No spot checks were documented for 2:00 AM. Example 3 On [DATE], Surveyor reviewed R3's medical record. R3 was admitted on [DATE] with chronic respiratory failure with vent status, anxiety disorder, and tracheostomy. Surveyor reviewed R3's respiratory spot checks that indicated: On [DATE]: No spot checks were documented for 2:00 AM, 11:00 AM, and 3:00 PM. On [DATE]: No spot checks were documented for 2:00 AM and 3:00 PM. On [DATE]-[DATE]: No spot checks were documented for 2:00 AM. On ,d+[DATE]-[DATE]: No spot checks were documented for 2:00 AM. On [DATE] at 2:27 PM, Surveyor interviewed NHA A and NHA A admitted there has been lack of documentation that spot checks have been being completed by RTs as they should be, and they are aware of this issue. NHA A indicated that spot checks should be completed regularly as per facility policy. NHA A indicated that NHA A understands there was a system failure, and everyone has been educated on importance of spot checks.

Based on observation and interview, the facility did not ensure proper sanitation and food handling practices to prevent the outbreak of foodborne illness by having a separate hand washing sink separate from those used for food preparation for 11 residents (R) (R4, R5, R8, R9, R12, R24, R17, R18, R19, R20, R27). Findings: Per the FDA Code: Food Employees shall clean their hands in a handwashing sink or approved automatic handwashing facility and may not clean their hands in a sink used for FOOD preparation or warewashing. On 02/12/25 at 11:39 AM, Surveyor observed [NAME] C wash hands in a single sink in the dinette kitchen and began to serve 11 lunch meal trays. On 02/12/25 at 11:48 AM, Surveyor observed [NAME] D enter dinette kitchen during meal service, wash hands in a single sink, wash cucumbers in same sink, then peel and slice cucumbers for another meal at a prep table. On 02/13/25 at 10:12 AM, Surveyor interviewed [NAME] D and [NAME] E regarding the single sink in the dinette kitchen where food preparation, dishwashing and hand hygiene is conducted. [NAME] D and [NAME] E both stated that hand washing is completed in the single sink in the dinette and the sink is also used for rinsing food, preparing food and washing dishes. They have not received education of ensuring hand hygiene or washing of dishes is not conducted during food preparation. On 02/13/25 at 10:44 AM, Surveyor observed sink area in kitchen dinette and noted that when staff wash hands, the water is able to splash onto countertop and after staff use the sink they need to turn and walk approximately 2 feet to obtain paper towel to dry hands, dripping water along the way. Further observation shows that approximately 2 feet to the right of the sink is the Robot Coup utilized to puree food for residents who have a different diet consistency. On 02/13/25 at 11:31 AM, Surveyor interviewed Dietary Manager F, via phone, along with NHA A and DON B in person. All three indicated they were never made aware of need of having to have separate hand washing sinks.

Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for 3 of 4 residents (R). (R3, R4, R5) Staff did not complete appropriate glove change and hand hygiene when providing personal cares for R3. Catheter bags were placed directly on the floor. This is evidenced by: The facility's policy titled Hand Hygiene with the last review date of 06/24, read in part, .2. g. Decontaminate hands if moving from a contaminated-body site to a clean-body site during resident care. h. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the resident. i. Decontaminate hands after removing gloves .7. e. Change gloves and perform appropriate hand hygiene during resident care if moving from a contaminated-body site to a clean-body site. On 11/04/24 at 9:10 a.m., Surveyor observed Certified Nursing Assistants (CNA) D and CNA C provide personal cares for R3. CNA D sanitized hands and applied gown and gloves and entered R3's room. CNA D with gloved hands touched the light switch, turned the sink faucet on, closed the door, pulled the privacy curtain, gathered R3's clean clothes, lifted the dirty laundry bin and moved it over. CNA D with the same contaminated gloves wet a washcloth and washed R3's face. CNA D wet a washcloth and applied soap, then picked up the garbage can and moved it to the other side of R3's bed. With the same contaminated gloved hands CNA D washed R3's underarms and hands. CNA D washed around R3's g-tube site, applied barrier cream with gloved hands, and applied a clean split gauze around the g-tube site. CNA D removed gloves and did not complete hand hygiene and applied clean gloves. CNA D applied tubi-grips to R3's legs and applied clothes on R3. CNA C sanitized hands, applied gown and gloves, and entered R3's room. CNA C removed R3's brief, removed gloves, sanitized, and applied clean gloves. CNA C performed frontal peri care, removed gloves, sanitized, and applied clean gloves. CNA C and CNA D rolled R3 to his left side. CNA C cleansed R3's peri area and buttocks of the bowel movement. Surveyor observed three times during CNA C's cleansing of the bowel movement some of the bowel movement got onto CNA C's gloves. CNA C had taken the wipes and cleaned the bowel movement off the gloves. CNA C completed cleansing R3's buttocks and peri area. With the same contaminated gloves CNA C took a washcloth that was prepared by CNA D and washed R3's back. CNA C with the same contaminated gloved hands applied a clean brief on R3. CNA C removed gloves and sanitized hands. On 11/04/24 at 1:08 p.m., Surveyor interviewed CNA D and asked if a glove change and hand hygiene were to be completed after touching multiple areas and dirty laundry bin. CNA D indicated hand hygiene should have been completed. Surveyor asked if hand hygiene should have been completed after touching and moving the garbage can before providing care for R3. CNA D indicated she should have changed gloves. Surveyor asked if washing hands or sanitizing hands after removing gloves was expected. CNA D indicated yes she should have cleaned her hands. On 11/04/24 at 1:19 p.m., Surveyor interviewed CNA C about providing R3 with peri care and gloves getting contaminated with bowel movement then without changing gloves and completing hand hygiene washed R3's back and applying a clean brief. CNA C indicated gloves should have been removed and washed hands. On 11/04/24 at 1:19 p.m., Surveyor interviewed Director of Nursing (DON) B about Surveyor's observations of CNA C and CNA D not conducting hand hygiene. DON B indicated hand hygiene should have been completed. DON B indicated infection control skills fairs are completed, and DON B completes audits while assisting staff with resident cares. DON B indicated education will be provided. Example 2 R5 and R4 were observed with Foley catheter drainage bags containing urine resting on the floor. This has the potential to result in Urinary Tract Infection (UTI) by bacteria present on the floor. Facility's policy entitled, Urinary Catheter Management with a most recent reviewed date of October 2024, states in part: .all residents receive the appropriate care and services to prevent catheter-associated urinary tract infections .Do not rest the bag on the floor. R5 has a chronic indwelling Foley catheter. R4 has a chronic indwelling Foley catheter. On 11/04/24 at 8:12 AM, Surveyor observed R5 lying supine in bed at low height. Surveyor observed Foley catheter drainage bag hanging from underside of bed, approximately half full of yellow urine, partially resting on the floor. No barrier protection/cover observed between Foley drainage bag and floor. On 11/04/24 at 8:15 AM, Surveyor observed R4 sitting upright in bed at a very low height of approximately 4 inches from floor. Surveyor observed Foley catheter drainage bag approximately 1/4 full of yellow urine resting on the floor. No barrier protection/cover observed between Foley drainage bag and floor. On 11/04/24 at 8:33 AM, Surveyor interviewed DON B in R4's room regarding observation of Foley catheter drainage bag resting on the floor. Surveyor pointed to Foley drainage bag on the floor and asked DON B if this was a common practice to have the drainage bag with urine on the floor. DON B stated that staff are expected to ensure the drainage bag is hung below the bladder, but not touch floor to ensure infection control.

Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections, such as COVID-19. During the three-day survey, two residents (R) on contact and droplet precautions, (R179 and R4) were observed in common areas outside of their rooms without source control masks when other residents and staff were present. During the three-day survey, two staff members were observed entering the room of a resident on contact and droplet transmission based precautions (TBP) without putting on the proper personal protective equipment (PPE). This had the potential to affect all 27 residents in the facility. Staff did not perform hand hygiene when changing gloves during [CONDITION(S)] cares for one of six observations of cares. Findings include: Facility policy entitled, Novel Coronavirus Disease (COVID-19) Transmission-Based Precautions, last reviewed October 2022, stated in part, .1. In general, new admissions and residents who leave the building greater than 24 hours, are not symptomatic, and the community transmission levels are high do not require empiric us of transmission-based precautions. 2. These residents should wear source control for the 10 days following their admission or return .4. Empiric use of transmission-based precautions may be considered at the discretion of the Director of Nursing if any of the following examples apply: a. Resident is unable to be tested or wear source control as recommended for 10 days following their admission or return .6. Note: Because of our high-risk population, regardless of the community transmission level, all new admissions and residents leaving the facility greater than 24 hours will be placed in empiric transmission-based precautions for 10 days following their admission . Example 1 Residents on Contact and Droplet precautions out of rooms without source control: On 11/08/22 at 9:50 AM, Surveyor observed an orange sign indicating Contact and Droplet TBP under the room number for R179's room. On 11/08/22 at 12:45 PM, Surveyor observed Nurse Manager (NM) F place an orange sign indicating Contact and Droplet TBP under the room number for R4's room. NM F informed Surveyor R4 just returned from a hospitalization and was placed on Contact and Droplet TBP for a 10-day quarantine. NM F stated R4 was not up to date on COVID-19 vaccinations and refused to wear source control mask. On 11/09/22 at 7:10 AM, Surveyor observed R179 seated at a table in the dining area of the East wing. R179 was not wearing a source control mask. On 11/09/22 at 9:46 AM, Surveyor observed a staff member wheel R4 out of the resident's room. R4 was not wearing a source control mask. Record review identified R22, who was seated within six feet of R179 in the dining area, had received one COVID-19 vaccination, and had declined further vaccinations. On 11/08/22 at 11:00 AM, Surveyor observed R179 sitting at the table in the common area on the east side of the building with no mask on. R179 is a new admit and is currently on droplet and contact precautions. On 11/08/22 at 12:19 PM, Surveyor observed R179 sitting in common area with 1 other resident, R22 and a staff member. R179 is a new admit and is currently on droplet and contact precautions. On 11/09/22 at 09:17 AM, Surveyor observed R4 sitting in dining room with no mask on and other residents present. R4 returned from the hospital 11/08/22 and is on contact and droplet precautions. On 11/09/22 at 11:58 AM, Surveyor observed R179 sitting at the table in the common area on the east side of the building with no mask on. R179 is a new admit and is currently on droplet and contact precautions. On 11/09/22 at 12:12 PM, Surveyor observed R179 sitting at a table eating lunch and a second resident, R22, came out and sat at the table next to R179 for lunch. The distance between the tables were about 3 feet apart. R179 is a new admit and is currently on droplet and contact precautions. Example 2 Staff not wearing proper PPE in Contact/Droplet TBP rooms: Facility policy entitled, Novel Coronavirus Disease (COVID-19) Transmission-Based Precautions, last reviewed October 2022, stated in part, .Transmission-Based Precautions in addition to Standard Precautions, requires the use of the following personal protective equipment (PPE) by healthcare personnel when entering the room of a resident with suspected or confirmed [CONDITION(S)]-CoV-2 infection: A NIOSH-approved particulate respirator with N95 filters or higher, Gown, Gloves, and Eye Protection (i.e., goggles or a face shield that covers the front and sides of the face.) . On 11/09/22 at 11:25 AM, Surveyor observed Respiratory Therapist (RT) D enter R4's room wearing a gown, gloves, surgical face mask, and face shield. R4's room had an orange sign by the room number indicating R4 was on Contact and Droplet TBP. RT D provided tracheal suctioning for R4 while in the room. Surveyor observed RT D remove the gown and gloves and use Alcohol Based Hand Rub (ABHR) while in R4's room. RT D exited R4's room, and went to room [ROOM NUMBER]. RT D donned a gown and gloves and entered that room with same face shield and surgical face mask that was worn in the Contact and Droplet TBP room. After RT D exited the resident room, Surveyor asked RT D what PPE was required to enter Contact and Droplet TBP rooms. RT D stated a gown, gloves, and they always wear a face shield and mask. Surveyor asked if it should be a surgical face mask or N95 respirator. RT D was not sure and stated it used to be an N95, but now RT D was not sure. A nurse at the desk said it should be an N95 respirator. RT D said, Oops sorry, I should have put on an N95 before entering R4's room. On 11/09/22 at 11:58 AM, Surveyor observed Certified Nursing Assistant (CNA) E enter R4's room, which was on Contact and Droplet TBP. CNA E was wearing a gown, gloves, N95 respirator, and regular glasses. CNA E was not wearing a face shield or other eye protection over the glasses. Surveyor interviewed CNA E after exiting R4's room about what PPE was required to enter the rooms on Contact and Droplet TBP. CNA E stated they were required to wear an N95 respirator, gown, and gloves, but not required to wear eye protection if not doing an aerosol generating procedure or emptying a catheter with risk of splashing. Example 3 Hand Hygiene Facility policy entitled, Hand Hygiene, last reviewed on June 2022, stated in part, .All staff should follow appropriate hand hygiene procedures to prevent the spread of infection and disease to other residents, staff and visitors. Indications for hand hygiene .Decontaminate hands after removing gloves . On 11/09/22 at 11:38 AM, Surveyor observed RT D provide [CONDITION(S)] cares for R7. RT D was wearing single use disposable gloves. RT set up [CONDITION(S)] tray and removed old split gauze dressing from R7's [CONDITION(S)] site. RT D removed the gloves and put on sterile gloves without using ABHR or washing hands. Following the procedure outside R7's room, Surveyor asked RT D if they should wash hands or use ABHR after taking off dirty gloves and prior to putting on sterile gloves. RT D stated yes, they probably should have used ABHR, but forgot. On 11/09/22 at 1:37 PM, Surveyor interviewed Director of Nursing (DON) B and Registered Nurse (RN) C about the above observations. Surveyor asked what guidance they were following to allow residents who are on Contact and Droplet TBP out of their rooms. RN C stated those residents should use source control masks if they are leaving their rooms. DON B stated they were allowing R4 and R179 out of their rooms to eat. Surveyor reported multiple observations of R179 at a table in the dining area throughout the day without source control on, even when not eating. DON B stated they make sure no other residents are within 6 feet of R179. Surveyor reported observations of R22 sitting at a table within 6 feet of R179 while eating, neither of the residents had source control on. R22 had refused COVID-19 vaccinations. Surveyor asked what PPE was required for staff to enter Contact and Droplet TBP rooms. RN C stated staff was required to wear gown, gloves, eye protection, and an N95 respirator at all times to enter those rooms. Surveyor reviewed the above observations of staff entering R4's with a surgical facemask and no eye protection. DON B and RN C stated those staff members should have worn an N95 respirator and eye protection to enter that room. Surveyor asked DON B what their expectation was for hand hygiene when staff changed gloves during a procedure. DON B stated the staff should perform hand hygiene after taking off soiled gloves and before putting on clean gloves. Surveyor reviewed the above observation of RT D during [CONDITION(S)] care. DON B stated RT D should have done hand hygiene prior to putting on the sterile gloves.

Based on observation, record review, and interview the facility did not perform perineal cares in an hygienic manner for 2 of 3 perineal care observations; Resident (R) R9 and R26. Facility staff touched other items in the environment during perineal cares without performing hand hygiene: R9. Facility staff touched other items in the environment during perineal cares without performing hand hygiene: R26. This is evidenced by: Resident #9 Bladder and Bowel Incontinence R9 was admitted to the facility on [DATE]. R9's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9 receives Hospice services. R9's Minimum Data Set (MDS) assessment, dated 06/12/21, indicated that R9 was incontinent of both bowel and bladder, and requires 1 person staff assistance with incontinence cares. R9's care plan, undated, with a target date of 90 days, states .Personal Hygiene: .I require assistance with . pericare by one staff person . R9's bowel/bladder assessment, dated 06/12/21, showed R9 is incontinent of bowel and bladder. On 09/08/21, at 09:35 a.m., Surveyor observed Certified Nursing Assistants (CNAs) E and CNA F assist R9 with hygiene cares. Upon entering the room, CNA E and CNA F performed hand hygiene and donned gloves. CNA E assisted R9 with undressing, applying a bath blanket when R9's skin was exposed to the air. CNA E cleansed R9's face and upper torso. Next, both CNAs assisted in removing bolsters and pillows that were in place for positioning. CNA E and CNA F next assisted R9 to remove a urine soaked brief by using a side to side motion. CNA E placed the used brief in a plastic garbage bag. CNA F performed peri care, using a front to back motion, with different sections of a washcloth. Next, CNA F rinsed and dried the areas, using a clean washcloth and towel, divided into clean sections in a front to back order. Without washing hands or changing gloves after disposing of the urine soaked brief, CNA E adjusted R9's head of bed, using the electric controls. Then CNA E removed gloves and performed hand hygiene. CNA F removed gloves and performed hand hygiene. After donning fresh gloves, CNA E and CNA F assisted R9 with dressing. After R9 was dressed, CNA E and CNA F transferred R9 into a wheelchair using a total lift. Resident #26 Bladder and Bowel Incontinence R26 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R26 has a Foley catheter due to [CONDITION(S)] bladder from past [CONDITION(S)]. R26's MDS, dated [DATE], indicated that R26 is incontinent of bowel. R26 requires 2 person assistance with hygiene cares. R26's care plan, undated, with a target date of 90 days, states .I need staff to assist me with pericare . R26's bowel and bladder assessment, dated 07/12/21, indicated that R26 is incontinent of bowel. On 09/09/21, at 08:17 a.m., Surveyor observed CNA F and CNA G assist R26 with hygiene cares. Both CNAs entered the room and performed hand hygiene. After donning gloves, CNA F gathered a pink basin, a bottle of liquid soap, and clean towels and washcloths. CNA G removed R26's gown, and covered R26 with a clean bath blanket. CNA G washed R26's face, and dried the area with a clean towel. Next, both CNAs washed resident's upper torso and noticed a reddened area under R26's left arm axila area. Registered Nurse (RN) D came into the room. RN D performed hand hygiene and donned gloves. CNA F and CNA G removed gloves and performed hand hygiene. Next, RN D examined the area. RN D removed gloves and performed hand hygiene. CNA F and CNA G next assisted R26 onto his right side. CNA F washed and dried R26's back, using a clean washcloth. CNA F removed brief tabs and tucked the front portion of brief, which contained stool, in between residents legs in a rolled fashion. Next, without removing gloves or performing hand hygiene, CNA G repositioned the catheter tubing next to the meatal opening. CNA G and CNA F assisted R26 to roll onto his right side, and without changing gloves or performing hand hygiene, CNA G pulled down R26's shirt. CNA F obtained a package of disposable wipes, and after removing the wipes, partially cleansed R26 rectal area. Then without changing gloves or performing hand hygiene, CNA F cleansed R26's buttocks then rectal area with a clean washcloth, using different areas. The buttock/rectal area was dried with a towel. After cleaning the rectal area, CNA F touched several items on the tray table, including a bottle of liquid soap, clean wash clothes, and the outside of the pink basin. CNA F and CNA G assisted R26 unto his back. Next, after changing gloves and performing hand hygiene, and using clean areas of a washcloth, CNA F washed R26's groin area, then moved to and cleaned the meatal area, using different sections of a clean washcloth. However; CNA F used the same towel and towel section to dry the meatal area as was used to dry the groin area. Then without changing gloves or performing hand hygiene, CNA F and CNA G assisted R26 in applying a clean brief. After applying this clean brief, CNA F and CNA G removed gloves and performed hand hygiene. On 09/09/21, at 08:56 a.m., Surveyor interviewed CNA F and CNA G. Surveyor asked both CNAs, Describe the training in infection control regarding hygiene assistance and hand washing. CNA F stated I have had training when I started here. I know I shouldn't have touched the bottle of soap without changing gloves. CNA G stated We have online and skills training. On 09/09/21, at 11:00 a.m., Surveyor interviewed DON B. DON B stated that the facility conducts infection control and handwashing training at least yearly or more often if needed. DON B stated that cross contamination should not occur during hygiene cares.

Based on observation, interview and record review, the facility did not update the comprehensive care plan for each resident, which includes measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs, that are identified in the comprehensive assessment. This occurred for 2 of 24 residents' care plans reviewed, Resident (R) R29 and R31. 1. R29 requires total assist with eating. The resident's care plan was not updated with R29's need for assistance with meals. 2. R31 takes [MEDICATION NAME] for [MEDICAL CONDITION]. The facility did not update the resident's care plan with non-pharmacological interventions to promote sleep. This is evidenced by: 1. R29's [DIAGNOSES REDACTED]. R29 is dependent on staff for activities of daily living (ADLs). R29's Brief Interview for Mental Status (BIMS) is listed as severe cognitive impairement. On 07/08/19, Surveyor observed R29 during the noon meal. R29's spouse was assisting R29 to eat. R29 did not attempt to eat independently. On 07/09/19, Surveyor observed R29 during the breakfast meal. Facility staff were assisting R29 to eat. R29 did not attempt to eat independently. Surveyor observed R29 during the noon meal. R29's spouse was assisting R29 to eat. R29 did not attempt to eat independently. On 07/10/19, Facility staff were assisting R29 to eat. R29 did not attempt to eat independently. On 07/08/19, during an interview with R29's power of attorney for health care (POA-HC), the POA stated R29 could not eat independently, and she had to assist him. Surveyor reviewed R29's plan of care. The plan of care stated, in part, I am able to feed myself at times. I may need encouragement or verbal cues and you should assist me by setting up my tray .assit if I am weak . On 07/10/19 at 10:00 a.m., Surveyor interviewed Registered Nurse (RN) H, who functions as the unit manager. RN H agreed R29 required total assistance with eating. 2. On 07/09/19, Surveyor reviewed R31's medical record. The resident has [DIAGNOSES REDACTED]. As of 07/01/19, the resident takes the following medications for [MEDICAL CONDITION]: -[MEDICATION NAME] 3 milligrams (mg) at bedtime, Sunday, Tuesday and Thursday -[MEDICATION NAME] 3 mg at bedtime, as needed, Monday, Wednesday, Friday and Saturday From 06/03/19 to 07/01/19, R31 was receiving the following medications for [MEDICAL CONDITION]: -[MEDICATION NAME] 3 mg at bedtime, Monday, Wednesday and Friday -[MEDICATION NAME] 3 mg at bedtime, as needed, Sunday, Tuesday, Thursday, Saturday There are no sleep assessments located in R31's medical record, for the use of the [MEDICATION NAME]. Surveyor reviewed the resident's care plan. The care plan states, in part, (06/24/19) .MY EMOTIONAL PATTERNS AND SYMPTOMS .I currently take [MEDICATION NAME] .to help with my sleep .I do have [MEDICAL CONDITION] at times .MY GOAL FOR THE NEXT 90 DAYS .To get restful sleep . The resident's care plan does not identify non-pharmacological interventions in order to promote sleep. On 07/10/19 at 10:50 a.m., Surveyor interviewed the Director of Nursing (DON). The DON stated the facility was not able to locate a sleep assessment for R31. Surveyor informed the DON there are no non-pharmacological sleep interventions identified on the resident's care plan. At 11:00 a.m., Surveyor interviewed Social Worker (SW) A. The SW stated she believes resident's sleep assessments should be completed quarterly, and stated there are no sleep assessments for R31. SW A stated she incorporates a resident's sleeping issues into the resident's mood care plan. Surveyor informed SW A there are no non-pharmacological sleep interventions identified on the resident's care plan.

Based on interview and record review, the facility did not ensure residents were free from unnecessary medications, based on the comprehensive assessment. This occurred for two of eleven residents (Residents (R) 56 and 3) who were reviewed for [MEDICAL CONDITION] medications. 1. R56 takes [MEDICATION NAME] ([MEDICATION NAME]) for [MEDICAL CONDITION]. The facility did not complete recent sleep assessments for the use of this medication, and did not identify non-pharmacological interventions on the resident's care plan. 2. R3 was started on a [MEDICAL CONDITION] medication to aid in sleeping. An assessment of sleep patterns or attempts at non-pharmacological interventions were not implemented prior to the start of the medication. This is evidenced by: 1. On 07/09/19, Surveyor reviewed R56's medical record. The resident has [DIAGNOSES REDACTED]. The resident has been taking [MEDICATION NAME] (a hypnotic medication) 30 milligrams (mg), as of 03/08/19 at bedtime, as needed. Surveyor reviewed R56's Medication Administration Record, [REDACTED]. The resident received the Temezepam medication 33 times, from 03/08/19 to 07/04/19. On 07/10/19 at approximately 9:03 a.m., Surveyor received and reviewed R56's Sleep Evaluation. The sleep evaluation, dated 01/24/18, states the following, in part, .Reason for Evaluation .Quarterly .Is a hypnotic/medication used to promote sleep .[MEDICATION NAME] 30 mg-daily (at bedtime) for [MEDICAL CONDITION] .What is the sleep concern: (Left blank) What was the bedtime routine prior to admission/home? 8:30 p.m., Watch TV, then go to bed .Do any of the following environmental factors impact on sleep? Noise, Temperature .Care provided disrupts sleep .Do any of the following behavioral factors impact on sleep? Getting into bed to (sic) early .Do any of the following psychological factors impact on sleep? Anxiety, was worried about surgery (and) Mom .Continue current (plan of care) . Surveyor reviewed the resident's care plan. The care plan states the following, in part, (06/28/19) .MY EMOTIONAL PATTERNS AND SYMPTOMS .have [MEDICATION NAME] for [MEDICAL CONDITION] .When I am anxious I can't seem to stop worrying and struggle to shut these feeling off. Change will often resort in increased anxiety .I feel like I sleep too much and that I am tired often but know this is related to my recovery from the stroke I had . The care plan does not identify non-pharmacological interventions to promote R56's sleep. On 07/10/19 at 10:50 a.m., Surveyor interviewed the Director of Nursing (DON). The DON stated the facility was not able to locate a more recent sleep assessment/evaluation for R56. Surveyor indicated there are no non-pharmacological interventions on the resident's care plan in order to promote sleep. At 11:00 a.m., Surveyor interviewed Social Worker (SW) A. The SW stated she believes resident's sleep assessments should be completed quarterly. SW A stated she incorporates a resident's sleeping issues into the resident's mood care plan. Surveyor informed SW A there are no non-pharmacological sleep interventions identified on the resident's care plan. At 11:54 a.m., Surveyor received and reviewed a facility policy, entitled, Psychoactive Medication Management Policy and Procedure. The policy, dated (MONTH) (YEAR), was last reviewed (MONTH) 2019. The policy states the following, in part, .Procedure .1. All medications are reviewed on admission, quarterly, annually and with significant changes in condition .3. Medication management includes the interdisciplinary team evaluation of: a. Indications for use of medication .e. Individualized non-pharmacological interventions in conjunction with pharmacological interventions .7. Hypnotics .g. A comprehensive sleep assessment will be completed as indicated for all residents who take medications to aid in sleep and/or have evidence of poor sleep hygiene .h. In order to monitor the effects of this classification of medication a target behavior must be identified that is individual to the resident and has individualized interventions in place in conjunction with medication administration. This behavior may often be the monitoring of sleep patterns along with the measurement of non-pharmacological interventions. i. A quarterly assessment is competed to assure that behavior monitoring is relevant . 2. R3 was admitted on [DATE] with [DIAGNOSES REDACTED]. The annual MDS with ARD of 06/22/19 documents trouble falling or staying asleep. Physician orders [REDACTED].> 05/13/19 [MEDICATION NAME] 25 mg ([MEDICAL CONDITION] medication) for [MEDICAL CONDITION] (trouble sleeping) at HS (bedtime) Surveyor reviewed the medical record and did not locate a sleep assessment. On 07/10/19 at 9:55 a.m., Surveyor interviewed Registered Nurse (RN) C who stated she does not believe they have a sleep assessment for R3. RN C stated the Social Worker is responsible for that. The facility has new staff who may not be aware they are to complete a sleep assessment. Surveyor requested a care plan that would list interventions to promote sleep for R3. A care plan for Emotional Patterns and Symptoms was received that includes in part, .I spend the majority of my time sleeping .Activities that can be offered to help me stay awake during the day . The care plan does not identify any interventions that would promote sleep currently or that have been tried prior to utilizing a [MEDICAL CONDITION] medication. On 07/10/19 at 12:45 p.m., Surveyor interviewed RN B who states the consent was signed, side effects were monitored. RN B indicates most likely the resident asked the doctor or Nurse Practitioner (NP) for the medicine. Surveyor reviewed the NP progress note, dated 5/13/19, which documents R3 did request medication for sleep. The NP ordered the [MEDICATION NAME] 25 mg on this date. Surveyor asked if the facility had done an assessment prior to the order for the medication to determine what R3's normal sleep habits are, what preferences R3 has to help her sleep, and if they were tried before the medication was ordered. RN B stated she would look for the information. RN B stated they did track sleep patterns but did not evaluate prior to the initiation of the [MEDICATION NAME]. The sleep tracking documents R3 was sleeping 6-8 hours a night, except one night the days prior to getting the order for the [MEDICATION NAME]. On 07/10/19 at 1:20 p.m., Surveyor interviewed Certified Nursing Assistant (CNA) D about R3's sleep patterns. CNA D states R3 sleeps a lot. CNA D has to wake her up every morning around 8:30 for breakfast, and often at lunch too because she is sleeping. Surveyor asked what R3's sleep patterns are like at night. CNA D indicated R3 sleeps at night too. Surveyor asked what helps with sleep. CNA D responded she was not sure. Surveyor asked if CNA D had a care plan to refer to. CNA D went to get the CNA care plan that states, Do not wake between 22:00 (10:00 p.m and 08:00 a.m.) The care plan contains no information for non-pharmacological interventions that would promote sleep for R3. On 07/10/19 at 1:30 p.m., Surveyor interviewed CNA C. Surveyor asked about R3's sleep patterns. CNA C indicated during the day R3 is always dozing, she probably sleeps at least 3 hours during the day shift. Surveyor asked if R3 sleeps during the night. CNA C indicated she has heard R3 asks for food like cheerios or drinks during the night. Surveyor asked if CNA C knows of any interventions to promote sleep for R3. CNA C states she does not know any. RN B was not able to provide a sleep assessment or care plan to the surveyor.

Based on interview and record review, the facility did not develop a plan of care which included measurable goals and non-pharmacologic interventions for one resident (R) with [MEDICAL CONDITION]. This occurred for one resident (R21) of 24 sampled residents. Facility did not develop a sleep care plan for 1 of 3 residents receiving [MEDICATION NAME] for sleep. R21 did not have a sleep assessment or plan of care for [MEDICAL CONDITION] and was receiving [MEDICATION NAME]. This is evidenced by R21's [DIAGNOSES REDACTED]. On 07/10/19, Surveyor reviewed R21's clinical record. The record showed that R21 has been receiving [MEDICATION NAME] (an over the counter sleep aide) 9.0 mg. (milligrams) beginning 10/31/17. While the hours of sleep were recorded, there was no sleep assessment sleep analysis, or plan of care for insomia completed for R21. Surveyor interviewed Social Worker (SW) G, who is responsible for developing psychological plan of cares for R21. SW G agreed there has not been an analysis of R21's sleep hours to determine sleep patterns, a sleep assessment was not completed and a care plan was not developed to include non-pharmocological interventions.

Based on interviews and record reviews, the facility did not develop a comprehensive care plan to meet 2 of 3 residents medical needs. R2 and R3's care plans did not include monitoring for side effects of medication. This is evidenced by: R2's [DIAGNOSES REDACTED]. On 11/09/18 at 10:30 a.m., Surveyor reviewed R2's clinical record. The physician's orders [REDACTED]. (milligrams) twice daily to prevent [MEDICAL CONDITION]. Surveyor reviewed R2's plan of care. The plan of care did not include monitoring for side effects of Eliquis (bleeding, bruising, epistaxis, internal bleeding). At 11:30 a.m., Surveyor interviewed Unit Manager (UM) B, who is responsible for management of the unit, including R2's medical management. UM B stated, I know that the residents who receive [MEDICATION NAME] have daily monitoring for bleeding, I'm not sure about the other ones (blood thinner medications). There is usually nursing monitoring .any resident on a blood thinner should have nursing monitor for bleeding. UM B acknowledged that R2 does not have instructions for the staff to monitor for bleeding while receiving Eliquis. Example 2: R3's [DIAGNOSES REDACTED]. On 11/09/18 at 10:00 a.m. Surveyor reviewed R3's clinical record. The record showed that R3 was receiving Xeralto (a blood thinner) 20 mg. daily. Surveyor reviewed R3's plan of care. The plan of care did not include monitoring for the potential side effects of Xeralto (bruising, bleeding, epistaxis, internal bleeding). At 11:30 a.m., Surveyor interviewed UM B, who is responsible for management of the unit, including R2's medical management. UM B stated, I know that the residents who receive [MEDICATION NAME] (a blood thinner) have daily monitoring for bleeding, I'm not sure about the other ones (blood thinner medications). There is usually nursing monitoring .any resident on a blood thinner should have nursing monitor for bleeding. At 2:40 p.m., Surveyor interviewed the Director of Nursing (DON). The DON acknowledged that R2 and R3's plan of care should have included monitoring for potential side effects (bleeding) of Eliquis and Xeralto. The DON stated that most, but not all, residents who receive these medications have bleeding precautions added to their plan of care.

Based on interview and record review, the facility did not provide medically-related social services for residents to attain or maintain their highest practicable physical, mental and psychosocial well-being. This occurred for one of 18 residents (Resident (R) 8). The facility did not provide medically-related social services to R8 in order to meet the resident's psychosocial needs and to identify coping skills for the resident's grief and loss. This is evidenced by: On [DATE] at 7:04 a.m., Surveyor interviewed R8. When Surveyor inquired about the resident's mood, R8 discussed the deaths of the resident's spouse, brothers, father and most recently the resident's sister. R8 stated she has not been able to grieve the loss of her family members. The resident stated she is a social worker, but would like to speak with a therapist about her grief and past traumatic issues. Surveyor asked if the facility social worker visits with R8 to discuss these issues. The resident shook her head, and replied the facility social worker does not visit with the resident. On [DATE], Surveyor reviewed R8's medical record. The resident has the following [DIAGNOSES REDACTED]. The resident was initially admitted to the facility in (MONTH) 2013. R8's most recent Brief Interview for Mental Status (BIMS) score, dated [DATE], was a 15 out of 15 possible points. According to the BIMS assessment, a score of 15 identifies the resident has intact cognitive function. The resident is dependent on staff for bed mobility, dressing, bathing, and personal hygiene. R8 requires the assistance of two staff and a full-body mechanical in-room ceiling lift for transfers. R8 has a physician's orders [REDACTED]. A dietary note, dated [DATE], identifies the resident's most recent weight is #515. Surveyor reviewed R8's comprehensive care plan. The care plan states the following, in part: .I am alert and oriented and am able to make my needs known. I know what is best for me and make decisions that I feel are in my best interest .I am able to communicate with writing messages, mouthing words or speaking .I enjoy talking and communicating with others .I worked for [AGE] years as a social worker in the mental health field . .MY EMOTIONAL PATTERNS AND SYMPTOMS .I continually struggle with my weight and am finding it difficult to follow a diet. I have poor self control and like to snack. I use eating as a coping mechanism and will also eat when I am bored .I have a history of being in a physically and emotionally abusive relationship. My husband died in 2010 .This loss was devastating to me. My health status was unstable and I used eating to comfort me. As my weight increased my health status declined further .At times I have panic attacks related to my difficulty breathing .I attempt to calm myself down by deep breathing. I also find .having someone to talk to either in person or on the telephone .is a good diversion for me when feeling anxious .I have a supportive family however they live quite a distance from me and I am lonely for them . .Activity or recreational interests I enjoy now include .spending time outdoors .I am currently dependant (sic) on staff for locomotion in my wheelchair .MY ACTIVITIES .I have enjoyed attending these types (of) programs .outdoor activities . The resident's activity logs were reviewed, from [DATE] to [DATE]. R8 has not participated in any outdoor activities (i.e. garden/patio), from [DATE] to [DATE]. The resident was offered and declined to go outdoors, on [DATE] and [DATE]. The reason for the resident's declinations were not documented in the medical record. Surveyor reviewed R8's nurses' and social service notes, from [DATE] to [DATE]. There are no documented visits with the resident from the facility social worker, from [DATE] to [DATE]. The notes state the following, in part: -[DATE]: .ATTENDED CARE CONFERENCE: Resident .(name of Registered Nurse Manager (RNM) B) .& (name of Social Worker (SW) A) .Wellbeing care plan reviewed and updated to include (name of R8) being encouraged to sit in the sun to help with her depressive symptoms. Wellbeing goal is partially met as (R8) has been requesting her PRN antianxiety more than twice daily . -[DATE]: [DATE] ATTENDED CARE CONFERENCE: Resident .(name of RNM B) .& (name of SW A) .(name of R8) spends the majority of her days in her room in either her bed or recliner. This is per her choosing a(nd) has been encouraged to eat her meals in the dining room. She does this on occasion however it takes a lot of effort for (R8) to transfer due to her [MEDICAL CONDITION] . -[DATE], written by Registered Nurse Manager (RNM) B: Writer spoke with resident's daughter .regarding her requests .to have the resident see a counselor. (Name of R8's daughter) would like resident to see a counselor in the facility. Writer updated (daughter) that there is not currently a mental health provider rounding at the facility. Writer stated we could try and set an appointment up with a mental health provider in the community but there are limited resources available. (Daughter) would like writer to try for an appointment but states she understands if it is not possible. (Daughter) stated she would prefer for someone to see resident in the facility .(Daughter) feels its very important for resident to speak with someone in mental health due to all the tragedy resident has experienced throughout her life starting from when she was a child . -[DATE], written by SW A: Met with (R8) on this date as staff note anxiety to be significantly heightened especially at night. Anxiety symptoms include frequent call light use .requests for food and fearfulness of being alone. PRN (antianxiety medication) has significantly increased .(R8) has requested to speak with writer about her concerns .Writer talked with (R8) about her anxiety. She agrees her anxiety has worsened which she attributes to past trauma in her life which is coming to the surface .(R8) admits that she uses food as a coping mechanism as it provides her comfort .Talked with (R8) about alternate means of coping with her anxiety. She cited music as being relaxing to her. She has a Whitney Houston CD (compact disc) which comforts her but would like to have a wider variety of her music. (R8) has given writer permission to purchase additional CD's with money .These were obtained on this date. Also discussed journal as a means to express her emotions and feelings. (R8) notes she would be willing to try this .Writer to increase 1:1 (one-to-one) visits . -[DATE], written by SW A: Message left with (name of local mental health center) to inquire as to availability of a mental health therapist to come to this facility to see (name of R8). Awaiting a return call. Call placed to the (name of county Aging Disability Resource Center) to inquire as to possible resources for mental health services .Call was transfer to . Message left regarding need. Awaiting a return call. On [DATE] at 9:15 a.m., Surveyor interviewed RNM B. RNM B stated R8 has not yet seen a therapist. The RNM stated the facility social worker was going to call the (name of local mental health center) to see if a therapist would be willing to come and visit with the resident at the facility. On [DATE] at 9:41 a.m., Surveyor interviewed SW A. The SW stated R8 is lonely and misses her family. Surveyor asked if SW A has made visits with the resident to meet the psychosocial needs of the resident. SW A replied she visited with the resident, on [DATE], when she provided the resident with more music CDs and encouraged the resident to journal. SW A stated prior to [DATE], she would check in with the resident, and touch base with R8, but the SW wouldn't necessarily have visits with the resident. SW A stated R8 has asked the SW to come and see/visit the resident at times, but SW A replied she is not a mental health therapist. During the continued interview, Surveyor asked if SW A has met with the resident prior to [DATE], to discuss coping skills with R8, besides eating. SW A indicated the resident has a Master's Degree in social work and has worked in the mental health field for several years, so the resident should already know what coping skills to use. SW A replied the resident eats to cope when R8 is stressed or when the resident does not know what to do. Surveyor asked if the first time SW A called for a therapy/counseling referral, was on [DATE]. SW A reviewed the progress notes, and confirmed the first time SW called to make a referral for counseling/therapy services, was on [DATE]. SW A stated she will not know until next week if a counselor would be willing to provide services to R8 in the facility. SW A further stated the other agency called the SW back on this date, and stated they would not be able to provide counseling services to the resident in the facility.

Based on interview and record review, the facility did not ensure a final discharge summary was completed for residents who are discharged . This occurred for one of two closed sampled residents (Resident (R) 67). R67 was discharged to a hospital, and then to another nursing faclity, in (MONTH) (YEAR). The facility did not complete a discharge summary for this resident. This is evidenced by: On 08/14/18 at 2:06 p.m., Surveyor reviewed R67's medical record. On 07/11/18, the record identifies the resident was sent to the emergency room and was hospitalized with a [DIAGNOSES REDACTED]. As of 08/16/18, the resident is not residing in the facility. There are no nurses' or social services notes indicating if the resident was discharged from the facility, or if R67 is still hospitalized . There is no discharge summary, which provides a synopsis of the resident's stay at the facility, and where the resident was discharged to after R67 was hospitalized . On 08/16/18 at 9:41 a.m., Surveyor interviewed Social Worker (SW) A. The SW indicated after R67 was hospitalized in (MONTH) (YEAR), the resident's family called the facility and decided to seek placement for the resident at another facility. SW A stated R67 was not readmitted to this facility after the resident's hospitalization . Surveyor asked if R67 has a discharge summary in the medical record. SW A reviewed the resident's nurses' and social services notes, then stated R67 does not have a discharge summary. SW A stated the resident's discharge summary may have gotten missed, due to the resident's initial discharge to the hospital. The SW indicated she normally completes discharge summaries after a resident is discharged from the facility.

Based on observation, interview, medical record review and facility policy review, facility staff did not provide care in a manner to prevent infection for 2 of 6 residents (R3 and R1) observed for personal cares. R3 and R1 received incontinence care from Certified Nursing Assistants (CNAs) who did not wash their hands according to accepted professional practice. This is evidenced by: The facility policy entitled Hand Washing dated 06/2011 states in part, 1. All personnel should wash their hands to prevent the spread of infection and disease to other residents, staff and visitors. c. Decontaminate hands after contact with body fluids or excretions, mucous membrane and non-intact skin, or wound dressings as long as hands are not visibly soiled. d. Decontaminate hands if moving from a contaminated body site to a clean body site during resident care. Example 1 On 08/07/17 at 10:30 a.m., Surveyor reviewed R3's medical record. R3 has a history of Methicillin-Resistant Staphylococcus Aureus (MRSA) infection. R3 is incontinent of bowel and requires staff assistance with toileting. On 08/07/19 at 12:35 p.m., Surveyor observed personal cares performed on R3 by CNA B. R3 was incontinent of bowel. CNA B had washed her hands and gloved. CNA B cleaned the buttocks and rectal area with disposable wipes. CNA B did not remove her gloves and perform hand hygiene. CNA B then applied barrier cream to rectal and buttock areas and applied a clean incontinence brief. On 08/08/17 at 1:10 p.m., Surveyor interviewed Infection Preventionist (IP) C related to the facility's infection prevention program. Surveyor questioned IP C as to when should staff perform hand hygiene. IP C stated staff should perform hand hygiene when changing gloves, when hands are visibly soiled and when going from dirty to clean. IP C stated she performs weekly audits on different staff during personal cares, dressing changes, catheter and incontinent cares. On 08/09/17 at 11:00 a.m., Surveyor informed Nurse Manager (NM) A of the care observation of R3 with lack of hand hygiene. NM A stated CNA B should have degloved and washed her hands after providing incontinence cares prior to applying a clean brief. Example 2 R1's Care Plan, not dated, states: Personal Hygiene: .pericare by one staff person. On 08/08/17 at 12:40 p.m., Surveyor observed R1 being assisted with toileting by CNA D and another staff person. After R1 had voided on the toilet and was standing, CNA D performed pericare on R1. CNA D then placed the disposable wipes in the garbage, and continued with contaminated gloves. CNA D pulled up R1's pants, picked up the portable oxygen tank, assisted R1 to sit in the wheelchair touching R1's arm, secured the fabric straps of the oxygen tank to R1's wheelchair, removed R1's gait belt, placed the foot pedals on R1's wheelchair and then removed the contaminated gloves and washed her hands. On 08/09/17 at 12:45 p.m., Surveyor meet with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) and explained the observation of CNA D's failure to remove the contaminated gloves and washing her hands before touching other objects in the room.

Based on interview and record review, the facility did not develop a comprehensive care plan, in order to meet a resident's identified medical, nursing, and mental/psychosocial needs, for 3 of 17 residents (Residents #4, 5 and 2) whose care plans were reviewed. 1. Resident #4 takes as needed [MEDICATION NAME] to promote sleep and a care plan was not developed. 2. Resident #5 receives [MEDICATION NAME] 50 mg (anti-depressant) every bedtime for [MEDICAL CONDITION] and a care plan was not developed. 3. Resident #2 did not have an individualized plan of care to address several areas of daily living when non-compliant and often refuses. This is evidenced by: 1. On 07/11/16, Surveyor reviewed Resident #4's medical record and identified [DIAGNOSES REDACTED]. According to Resident #4's medical record, Resident #4 was started on scheduled [MEDICATION NAME] to promote sleep, 25 milligrams at bedtime on 05/09/16. Resident #4 received [MEDICATION NAME] as follows from 05/09/16 to 07/12/16: -May 2016: 17 times -June 2016: 14 times -July 2016: 7 times out of the first twelve days Resident #4's care plan was reviewed. The care plan does identify a sleep hygiene plan, including non-pharmacological interventions to promote sleep. On 07/13/16 at 9:35 a.m., Surveyor interviewed Social Services Director (SSD) B. SSD B stated the facility has not completed a sleep hygiene care plan for Resident #4. At 12:53 p.m., the above information was discussed with the Director of Nursing (DON). 2. Resident #5 was admitted to the facility on [DATE] with an order for [REDACTED]. Surveyor reviewed Resident #5's medical record and did not identify a care plan for sleep hygiene that is comprehensive, individualized addressing sleep and with non-pharmological interventions to promote sleep. Surveyor reviewed the above information with the DON. 3. On 07/12/16 at 8:00 a.m., Surveyor reviewed the record of Resident #2. Resident #2 has [DIAGNOSES REDACTED]. Resident #2 has a Brief Interview for Mental Status (BIMS) of 15 which indicates intact cognition. Resident #2 refuses being weighed at the facility on bath day due to the fact that Resident #2 is weighed on Monday, Wednesday and Fridays at [MEDICAL TREATMENT]. Resident #2 at times refuses body audits, diabetic nail care, tubi-grips as needed for [MEDICAL CONDITION], hot packs for a swollen area on the resident's breast and a brace for the left ankle. The facility did not develop a plan of care to addresses Resident #2's non-compliance or refusals. Charting identifes that Resident #2 has a plan of self directed care but is not re-educated or reapproached when refusing daily activities and the potential for harm if these activities are not performed. On 07/13/16 at 4:30 p.m., Surveyor discussed the concern regarding a care plan for non-compliance with Registered Nurse (RN) A. RN A stated there is a care plan for self directed care. RN A agreed there were no interventions or approaches for staff to use or educated Resident #2.

Based on interview and record review, the facility did not have evidence of a thorough investigation of bruises of unknown origin and staff did not report a bruise of unknown origin for 1 of 17 residents reviewed for abuse and neglect. This is evidenced by: The facility policy titled, Abuse and Neglect Prevention, dated December 2007 states in part, Purpose: To assure that Dove Healthcare-Wissota Health and Regional Vent Center is doing all that is within its control to prevent occurrences of mistreatment, involuntary seclusion, neglect, and abuse of residents and misappropriation of resident property. Abuse and neglect prevention will include seven key components: Screening, Training, Prevention, Identification, Investigation, Protection and Reporting . 6. Investigation-All of the following are promptly investigated per applicable policy .All resident accidents and incidents including: Bruising, skin tears, lacerations, and abrasions .Injury of unknown origin .All investigations will be thorough, well-documented, and immediate to determine if mistreatment occurred, and, if so, to what extent. A thorough investigation may include: Interviewing alleged victim(s) and witness(es); Interviewing accused individual(s) including staff, visitors, resident's relatives, etc.) allegedly responsible for mistreatment, or suspected of causing an injury of unknown source; .Interviewing staff who worked previous shifts to determine it they were aware of an injury or incident .Reporting- All staff will immediately report suspected mistreatment, abuse, neglect, misappropriation of resident property, and injury of unknown source to the Administrator. On 07/12/16, Surveyor reviewed Resident #1's medical record. Resident #1 has a [DIAGNOSES REDACTED].#1 scored a 2 for severe impairment in cognition on the Brief Interview for Mental Status Assessment. Resident #1's current care plan states the resident transfers with a walker and assistance of one to two staff. On 05/14/16 at 9:36 a.m., a nurse's note stated, Incident type: Bruise to left upper arm, small bruises noted to area, this area measures 7.8 x 6.5 cm (centimeters), area light red in color. Body site of injury: Left upper arm. Date of incident : 05/14/16 Time of incident: 6:30. Reported by: Certified Nursing Assistant (CNA) D's name .Description of incident: CNA was getting resident up for the day when she noticed the bruises. Resident explanation of what happened: Resident was unable to say what happened. People involved: Resident. Res state of mind: Disoriented. Injury: Bruise. Where injury occurred: unknown. Environment at the time of fall/incident: unknown. Activity at the time: unknown. Assistive device: Walker. Wheelchair. Res status: No c/o of pain. Staff involved: No staff involved . On 07/12/16, Surveyor requested a copy of the facility's investigations of Resident #1's bruises that occurred on 05/14/16. The surveyor was provided with the facility investigation that included two CNA statements of staff who were on duty when the bruise was found. The two CNAs stated they were not involved in the occurrence of the bruises. The facility did not interview staff from the previous shifts to determine if an incident had occurred that may have caused the bruises to rule out resident abuse. On 05/31/16 at 9:17 a.m., a nurse's note stated, Incident type: Bruise. Body site of injury: Left side of chin. Date of incident: 05/31/16 Time of incident: 07:00 Reported by: CNA F .Description of incident: Bath aide found bruise when she was giving this bath. Resident explanation of what happened: Unable to say. People involved: Resident. Res State of mind: Per usual (describe) confused. Injury: Bruise. Appearance/Measurements: 1.5 x 1.5 cm, red in color. Where injury occurred: Unknown. Environment at the time of fall/incident: Floor dry. Call light in reach Furniture in usual place. Activity at the time: alone. Assistive device: walker. Res status:no c/o of pain. Staff involved: No staff involved . On 07/12/16, Surveyor requested a copy of the facility's investigation of Resident #1's bruises that occurred on 05/31/16. The surveyor was provided with the facility investigation that included two statements from CNAs who were currently working when the bruise was reported. Both CNAs stated they were not involved with the occurrence of the bruises. CNA E's statement stated, 3. If you were not involved or a witness, did you notice the bruise or skin tear the last time you cared for this resident? 5/30/16. If yes to #3 when did you notice it? 05/30/16. The statement does not include a time CNA E noticed the bruise. There are no other staff interviews included in the facility's investigation of staff who worked previous shifts to rule out abuse/neglect. CNA E did not report the bruise. The bruise was not reported until 05/31/16 by CNA F. On 07/12/16 at 2:30 p.m., Surveyor reviewed Resident #1's bruise incident reports of 05/14/16 and 05/31/16 with Registered Nurse (RN) G, the Unit Manager. RN G stated the floor nurse or the unit nurse have staff complete statements related to incidents. RN G stated the facility has a bruise huddle including the assistant manager, unit manager and the director of nursing who investigate bruises. On 07/13/16 at 12:50 p.m., Surveyor reviewed the investigations of Resident #1's bruises with the Director of Nursing (DON). Surveyor asked for additional information as follows: additional staff interviews from previous shifts, why CNA E did not report the bruise she observed on 05/30/16 and if CNA E and all staff were re-educated related to reporting bruises. The DON stated she would check and get back to Surveyor . On 07/13/16 at 2:35 p.m., the DON told Surveyor that she had no further information for the surveyor. The DON further stated she had now just re-educated CNA E on reporting bruises found on residents.

Based on record review and interviews, the facility did not ensure that care and services were provided to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 of 19 residents (Resident #3) reviewed for quality of care. The facility did not provide pain relief for Resident #3, who experienced recurring pain when provided incontinence care after a bowel movement due to the fistulas near his rectum. As evidenced by: On 06/03/15 at 2:40 p.m., Surveyor reviewed the medical record for Resident #3 and noted the following: - Minimum Data Set (MDS), dated [DATE], indicated Resident #3 was cognitively impaired and was at risk for pain. - Resident #5 has a current [DIAGNOSES REDACTED]. - Current physician orders [REDACTED]. [MEDICATION NAME] lotion has [MEDICATION NAME] properties to assist with pain during incontinent cares. Current physician orders [REDACTED]. four hours as needed for pain and/or fever. - Comprehensive nursing care plans, received 06/03/15, stated Resident #3 was at risk for pain due to arthritis and gout. Care plans did not indicate Resident #3 as having any pain with bowel movements and turning and repositioning. Care plan did not indicate staff were to use [MEDICATION NAME] lotion, which has [MEDICATION NAME] properties, to assist with discomfort during incontinent care. Care plan did not indicate Resident #3 had opened fistulas near the rectal area. - Certified Nursing Assistant (CNA) care plan, received 06/03/15, did not indicate Resident #3 as having pain during bowel movements and cares and with turning and repositioning. Comprehensive Care plan did not indicate Resident #3 was having pain with bowel movements and turning and repositioning. Care plan did not indicate staff were to use [MEDICATION NAME] lotion, which has [MEDICATION NAME] properties, to assist with discomfort during bowel movements care. Care plan did not indicate Resident #3 had opened fistulas near the rectal area. On 06/04/15 at 9:15 a.m., Surveyor observed both CNA I and CNA J perform personal cares for Resident #3. CNA I and CNA J placed Resident #3 in the bed to perform incontinence cares. CNA J rolled Resident #3 onto his right side while CNA I removed his incontinence pad. CNA I noted Resident #3 had a bowel movement and needed to be cleaned. CNA I took moist wipes and began wiping the bowel movement away from Resident #3's rectal area. Surveyor noted Resident #3 to yell out loudly, That hurts. Resident #3 continued to yell out, That hurts repeatedly until CNA I completed cleaning the rectal area. Surveyor asked both CNA I and CNA J why Resident #3 was in pain during rectal cares and CNA I stated Resident #3 had open areas near the rectum that were painful especially if fecal matter gets into them. CNA I then showed Surveyor the open areas near the rectum and at this time Resident #3 started to have another bowel movement. CNA I continued to clean Resident #3's rectal area from the new fecal matter. While cleaning the area, Surveyor heard Resident #3 repeatedly yell out in pain and requested for CNA I to stop. CNA I stated, I'm almost done and continued to wipe and did not stop when requested to stop by the resident. CNA I finished cleaning the rectal area and then rolled the resident onto the left side. CNA J, who was on the opposite side of the resident, applied a cream to the rectal area. Surveyor asked CNA J what she was applying and CNA J showed Surveyor a cream tube which stated A&D ointment. CNA J stated this is a barrier cream and is what staff apply to the buttock and rectal area after cares to help protect the skin. After applying the A&D barrier cream, CNA J noted Resident #3 to have another large bowel movement. CNA J used moist wipes to start cleaning Resident #3's rectal area. During this time, Resident #3 continued to yell out in pain and requested the staff to stop. Surveyor noted that CNA J did not stop cleaning when asked to stop by the resident. Surveyor asked both CNA I and CNA J if Resident #3 had this type of pain when having a bowel movement and needing to be cleaned. Both CNA J and CNA I stated, Yes. Surveyor asked both CNA I and CNA J if the nursing staff were aware of this pain and if he was premedicated. Both CNA I and CNA J stated the nursing staff were aware and they believed he had been given pain medication prior to his personal cares. Surveyor did not observe either CNA J or CNA I apply the [MEDICATION NAME] lotion to the buttock/rectal area of the resident. Surveyor noted Resident #3 to calm down when cares were completed. On 06/04/15 at 9:40 a.m., Surveyor interviewed Registered Nurse (RN) K who was responsible for Resident #3's nursing cares. Surveyor asked RN K if she was aware of Resident #3 having severe pain during incontinent cares and RN K stated, Yes. RN K stated Resident #3 has scheduled pain medication to be given in the morning and in the evening. RN K stated Resident #3 had not yet received his morning dose of pain medication because she was behind in her medication pass. RN K stated nursing can premedicate the resident with a PRN pain medication but he usually has only a little pain. RN K stated she was beginning to prepare his pain medication now and was going to go give it to him. On 06/08/15 at approximately 10:00 a.m., Surveyor reviewed the Medication Administration Record [REDACTED] - March 2015: The MAR for March 2015 indicate no as needed [MEDICATION NAME] or [MEDICATION NAME] was given to Resident #3 for the entire month. - April 2015: The MAR for April 2015 indicate no as needed [MEDICATION NAME] or [MEDICATION NAME] was given to Resident #3 for the entire month. On 06/04/15, Surveyor reviewed nursing notes for Resident #3 from 03/01/15 - 06/03/15 and was unable to identify any nursing documentation/monitoring or Resident #3 having pain or discomfort while incontinent cares were being done. Surveyor was unable to identify any nursing documentation in regard to the physician being notified on pain with incontient cares. On 06/08/15 at approximately 10:00 a.m., Surveyor reviewed weekly wound update communication entries for Resident #3 from 03/04/15 - 06/02/15 which were faxed updates to the physician. Surveyor was unable to identify within these faxes to the physician where the facility notified the physician that Resident #3 was having pain and/or discomfort with incontinent cares. On 06/08/15, Surveyor reviewed the medical record for Resident #3 and was unable to identify where the facility had updated the physician on increased pain with incontinent cares. On 06/08/15 at approximately 10:00 a.m., Surveyor reviewed weekly skin assessments by facility nursing staff for the open fistulas near the rectum of Resident #3 from 03/13/15 - 06/04/15. Surveyor noted the assessments indicated Resident #3 did not complain of pain during the assessment. On 06/04/15 at 2:00 p.m., Surveyor requested all comprehensive pain assessments for Resident #3 from RN G and received the following pain assessments: - 02/19/15: Assessment indicated Resident #3 was confused but was able to express pain. The assessment stated, LOCATION OF PAIN: rectal area secondary to medical condition: Fistula.PAIN SEVERITY: Present level of pain: 0. Worst Pain got in the last 24 hours: 6 Best pain got in the last 24 hours with medications or treatments: 0. Acceptable level of pain/pain goal: 1. WHAT RELIEVES PAIN: [MEDICATION NAME], cleansing the rectal area, position changes, rest, sitting in the recliner. WHAT INCREASES PAIN: Having a BM (bowel movement). CURRENT medications: [REDACTED]. EFFECTIVENESS OF MEDICATIONS/NON-PHARMACOLOGICAL INTERVENTIONS: Meds/txs appear effective at this time at reducing the resident's pain. - 05/14/15: Assessment indicated Resident #3 was confused but was able to express pain. The assessment stated, LOCATION OF PAIN: rectal area secondary to medical condition: Fistula.PAIN SEVERITY: Present level of pain: 1. Worst Pain got in the last 24 hours: 7 Best pain got in the last 24 hours with medications or treatments: 1. Acceptable level of pain/pain goal: 1. WHAT RELIEVES PAIN: [MEDICATION NAME], cleansing the rectal area, position changes, rest, sitting in the recliner. WHAT INCREASES PAIN: Having a BM (bowel movement).PLAN/SUMMARY: Non-medication interventions (list): rest, repositioning, laying down, sitting in recliner. Continue current treatment plan. On 06/08/15, Surveyor reviewed all nursing home visit progress reports from the physician in regard to Resident #3 and noted the following: - 11/26/14: Progress report states, He does have known fistulas on his bottom but those have been stable for several months. Surveyor was unable to identify if the physician had been updated on Resident #3 experiencing pain during incontinent cares and was unable to identify within the progress note that the physician addressed pain. - 02/02/15: Progress report states, He denies any pain. Surveyor was unable to identify if the physician had been updated on Resident #3 experiencing pain with incontinent cares. - 04/07/15: Progress note states, Chronic pain. Continue with scheduled [MEDICATION NAME]. His behavior has improved significantly since start of scheduled medication. Surveyor was unable to identify within the progress note that the physician had been updated on Resident #3 having severe pain with incontinent cares. On 06/04/15 at 3:10 p.m., Surveyor interviewed CNA L in regard to Resident #3's pain with incontinent cares. CNA L stated Resident #3 has had the fistulas for a very long time and does yell out in pain while staff do incontinent cares. CNA L stated she did not know what medication he gets. On 06/04/15 at 3:12 p.m., Surveyor interviewed CNA M in regard to Resident's #3's pain with incontinent cares. CNA M stated, that while doing cares, Resident #3 will have pain every once in while and will yell out, You're hurting me and please stop. CNA M stated sometimes Resident #3 will just state, It's cold. CNA M stated she does not know if the nursing staff premedicates the resident prior to cares to assist with pain. On 06/04/15 at 3:14 p.m., Surveyor interviewed Licensed Practical Nurse (LPN) N in regard to Resident #3's pain with incontinent cares. LPN N stated Resident #3 does have pain with incontinent cares and the CNAs usually tell her because the resident is able to express pain. LPN N stated Resident #3 is treated with a PRN pain medication and also has a scheduled pain medication. LPN N stated the scheduled pain medication usually takes care of all his pain. On 06/08/15 at 1:15 p.m., Surveyor interviewed the Director of Nursing (DON) in regard to Resident #3's scheduled [MEDICATION NAME]. The DON provided Surveyor a copy of a physician order [REDACTED]. Resident has been taking his prn 5 mg [MEDICATION NAME] tablet daily for chronic left hip pain that he rates from 2-10 on a scale of 0-10. Resident has also been taking his prn Tylenol 650 mg. Would you consider scheduling the [MEDICATION NAME]? Any other ideas/concerns/ Thanks for your time! The fax had a return order from the physician which stated, [MEDICATION NAME] 5 mg PO (oral) BID AM (morning) and PM (evening) with Tylenol (pain)[MEDICATION NAME] 5 mg PO PRN Q (every) 4-6 hours for pain. Surveyor asked the DON if the physician had been contacted in regard to the increase in pain Resident #3 had been having during incontinent cares and the DON stated nothing has been documented in regard to the physician being notified of the pain. Surveyor asked the DON if Resident #3 had been having pain during bowel movements, why Resident #3 had not been receiving any PRN pain medications. The DON did not reply. On 06/08/15 at 10:35 a.m., Surveyor interviewed the Nursing Home Administrator (NHA) and DON in regard to concerns with Resident #3 experiencing severe pain with incontinent cares and no PRN pain medication was being given. Surveyor discussed concerns in regard to the physician not being notified in regard to the increase in pain. The DON stated RN Manager (RNM) G was currently re-assessing Resident #3 and was requesting a [MEDICATION NAME] be ordered to assist with pain. On 06/08/15, Surveyor reviewed nursing note entry, dated 06/08/15, for Resident #3 and noted the following entry: - COMPREHENSIVE PAIN OBSERVATION TOOL: REASON FOR OBSERVATION: Routine Monitoring BEEN ON A SCHEDULED PAIN MEDICATION REGIMENT IN THE LAST 5 DAYS? Yes. RECEIVED PRN PAIN MEDICATION IN THE LAST 5 DAYS? No. PRN PAIN MEDICATION OFFERED AND DECLINED? No. RECEIVED NON-MEDICATION INTERVENTION FOR PAIN IN THE LAST 5 DAYS? Yes. MENTAL STATUS: confused, able to express pain. MAKES SELF UNDERSTOOD: Usually understood. LOCATION OF PAIN: Pain appears to be related to a variety of things. Resident has a [DIAGNOSES REDACTED]. ORIGIN OF PAIN: Musculo-skeletal secondary to medical condition (describe): Fistula site. DESCRIPTION OF PAIN: Resident is unable to describe the pain. MANNER OF EXPRESSING PAIN: Moaning and verbally expressing pain. WHAT RELIEVES PAIN: Rest. WHAT INCREASES PAIN: Position changes, turning and repositioning, wiping when having a bowel movement. NON-PHARMACOLOGICAL INTERVENTIONS: resting or lying down or sitting in recliner. - FAX SENT TO: (physician) URGENT CONCERNS: Resident has been having issues with increased pain lately, within the past 3 months. Resident has been having issues with pain several times per week. Resident will have pain related to his fistula sites and being wiped, but also when repositioning and turning and related to his bilateral hand contractures. Resident is currently on [MEDICATION NAME] 5 mg BID scheduled and also 650 mg of [MEDICATION NAME] BID. Resident also has PRN [MEDICATION NAME] and [MEDICATION NAME]. 1. Due to the increases in pain, will plan to schedule a specific times prior to cares for the scheduled medications to be administered. 2. Due to the increases in pain with turning and repositioning and with the stooling, that is very frequent, do you feel like a [MEDICATION NAME] that would provide pain relieve on a more consistent basis would be more appropriate? If in agreement, please provide a script for the [MEDICATION NAME]. - ONSET OF PAIN: Recent (within last 3 months) PAIN MANAGEMENT PLAN/SUMMARY: Writer spoke with staff regarding the resident and pain. Staff relay that he has pain several days per week. Staff have expressed that his pain has been increased over the past three months. Staff state it is whenever he is being moved, but that it is more in the AM than in the afternoon. Staff state it is when he is getting wiped after having a BM, but also when he is being assisted with turning and repositioning. As a result of the increased pain, will send an update to the MD to request better pain control for the resident. Writer is questioning a [MEDICATION NAME] as the resident is frequently found stooling from the fistula site and this will provide more consistent pain medication for the resident. Writer also has adjusted the times of the current pain medications to schedule them to be administered at specific times prior to the resident getting up to promote better pain control at those times. On 06/08/15 at 2:40 a.m., Surveyor interviewed RNM G and the NHA in regard to Resident #3. RNM G stated staff are to apply the [MEDICATION NAME] lotion to Resident #3's bottom and rectal area after cares to assist with pain. RNM G stated [MEDICATION NAME] lotion has an [MEDICATION NAME] property to assist with discomfort. Surveyor discussed concerns in regard to CNA I and CNA J not applying the [MEDICATION NAME] lotion to Resident #3 while observing personal cares on 06/04/15. RNM G stated the staff should have used the [MEDICATION NAME] lotion and did not understand why they did not. The NHA stated Resident #3 did have episodic periods of pain with incontinent cares but the staff would use the intervention of distraction to help alleviate the pain which seemed to work. Surveyor discussed concerns in regard to the resident's care plan not addressing pain to the rectal area with incontinent cares, the fistula sites, pain treatment options, the [MEDICATION NAME] lotion and no physician notification of the pain. RNM G stated she would immediately look into the situation.