Every finding on record at Dove Healthcare - Superior

Based on observation, interview, and record review, the facility did not maintain mechanical and/or electrical equipment in safe operating condition, having the potential to affect all 58 residents in the facility. Surveyor observed top of a freezer in the kitchen broken with orange duct tape and being held shut with syrup bottles to keep the lid closed. Findings include: On 05/11/2026 at 9:38 AM, Surveyor toured kitchen with [NAME] K. Surveyor observed 3 freezers sitting in an extra room down the hall from the kitchen. [NAME] K walked Surveyor into room and explained the 3 freezers are for kitchen use in storing frozen food for all residents in the facility. Surveyor observed the middle freezer to have orange duct tape taped to the bottom of the freezer lid which had 2 big heavy syrup bottles on top to hold the freezer lid closed. Surveyor asked [NAME] K to open the freezer. Surveyor observed the top of the freezer lid sagging with orange duct tape holding the freezer lid in place. Surveyor observed ice build-up along the sides at the entrance of the top of freezer lid around the cracked seal. Surveyor observed a gallon Ziploc bag dated 05/06, with what appeared to be two sections of a roast in the Ziploc bag. Surveyor observed ice build-up on the inside of the Ziploc bag covering the roast and it appeared freezer burnt. Surveyor observed fried rice in a package with ice build-up on the inside of food indicating freezer burn. The freezer was full of frozen foods. On 05/11/2026 at 9:42 AM, Surveyor interviewed [NAME] K and asked how long the freezer with the orange tape has been broken. [NAME] K reported when [NAME] K discovered the freezer was broken [NAME] K placed orange tape on it and reported this to the Director of Nutritional Services L, who then reported the issue to Maintenance Director N. [NAME] K reported the freezer has been broken for over 6 months. On 05/11/26 at 12:04 PM, Surveyor observed Maintenance Director N walking with [NAME] K to the freezer room. Surveyor followed. Surveyor observed Maintenance Director N review the freezer with [NAME] K. Maintenance Director N reported to [NAME] K that Maintenance Director N can order the needed part. On 05/11/26 at 12:06 PM, Surveyor interviewed Maintenance Director N and asked if Maintenance Director N knew about the broken freezer having orange duct tape, not shutting correctly, and needing to be held down with two-gallon syrup containers. Maintenance Director N reported Maintenance Director N is unsure if staff reached out to Maintenance Director N or not. Surveyor asked Maintenance Director N if it was appropriate to store frozen food in the broken freezer. Maintenance Director N reported to Surveyor if the thermometer is still under freezing temperatures, then it is appropriate, but the kitchen manager is in charge of the decision on food in the freezer. On 05/12/26 at 4:18 PM, Surveyor interviewed Director of Nutritional Services L and asked if aware upon review of freezers, the middle freezer contains orange duct tape, is being held down with two syrup bottles, and the freezer contains freezer burnt pot roast and stir fry. Surveyor reported to Director of Nutritional Services L that Surveyor observed ice build-up on all sides of the freezer. Director of Nutritional Services L reported to Surveyor the freezer has been broken for months, and kitchen staff have to chip away at the ice build-up in freezer. Surveyor asked Director of Nutritional Services L if Maintenance Director N was notified of the broken freezer. Director of Nutritional Services L reported to Surveyor Maintenance Director N was informed of the broken freezer 6 months ago.

Based on observation, interview, and record review, the facility failed to ensure the garbage in dumpster was covered. This had the potential to affect all 58 residents residing in the facility.Findings include: Surveyor reviewed facility policy titled Disposal of Garbage and Refuse dated last revised 06/13/25 which states: .7. Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded so insect/rodent attractions are minimized. During the kitchen tour and observation of garbage dumpsters with [NAME] K on 05/11/26 at approximately 9:28 AM, two dumpsters for garbage were located at the backside of the building with their lids opened. Surveyor interviewed [NAME] K and asked if garbage dumpsters were supposed to be covered. [NAME] K reported to Surveyor dumpsters are to be covered but it is hard to keep the neighboring apartment complex from using dumpsters and leaving lids open. [NAME] K reported to Surveyor other staff also utilize the dumpsters. On 05/12/26 at approximately 2:01 PM, Surveyor observed the same dumpster's lid still open, and dumpster not covered while not in use. There were multiple garbage bags inside the dumpster. On 05/12/26 at 4:18 PM, Surveyor interviewed Director of Nutritional Services L and asked what the expectation is for dumpsters being covered when not in use to minimize rodent attraction. Director of Nutritional Services L reported to Surveyor the expectation is dumpsters stay covered when not in use.

The facility did not prepare food in accordance with professional standards for food service safety which had potential to affect all 58 residents. -Foods items in kitchen not labeled with an expiration or use-by date.-Thermometers in 3 kitchen freezers were not functioning properly.-Cook K washed dishes, contaminating [NAME] K's clothes while prepping/serving food.-Cook M touched food with contaminated gloves while preparing ready to eat food.-Cook K prepared lunch meals without taking the temperature of all foods before serving.This is evidenced by: Example 1 Surveyor reviewed the facility policy titled Food Safety Requirements dated last revised 02/26 which states: .1. B. Storage of food in a manner that helps prevent deterioration or contamination of the food, including growth of microorganisms. 3. Facility staff should inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage. c. Practices to maintain safe refrigerated storage include i. monitoring food temperatures and functioning of the refrigeration equipment daily, iv. Labeling, dating, and monitoring food, including, but not limited to leftovers, so it is used by its use-by date, or frozen/discarded. On 05/11/2026 at 9:38 AM, Surveyor toured the facility kitchen with [NAME] K. Surveyor observed 3 freezers sitting in an extra room down the hall from the kitchen. [NAME] K walked Surveyor into room and explained the 3 freezers are for kitchen use in storing frozen food for all residents in the facility. Surveyor observed the middle freezer to have orange duct tape taped to the bottom of the freezer lid. Surveyor asked [NAME] K to open the freezer. Surveyor observed the top of the freezer lid sagging a little with orange duct tape holding the freezer lid in place. Surveyor observed a build-up of ice noted along sides at the entrance of the top of freezer lid around the cracked seal. Surveyor observed a gallon Ziploc bag dated 05/06, with two sections of a roast in the Ziploc bag, and a box of hamburger patties which were visible. Surveyor observed build-up of ice on the inside of the Ziploc bag all over the roast, which appeared to be freezer burnt. Surveyor observed fried rice in a package with ice build-up on the inside of the package with two manual dates 0/27 and 04/07 written on the package with no identifiable label stating what the food was and when it will expire. Surveyor did not observe a manufacturing expiration date on the package. Surveyor observed this freezer was full of frozen foods for the residents. On 05/11/2026 at 9:41 AM, Surveyor interviewed [NAME] K and asked what the meat was in the Ziploc bag. [NAME] K stated, It appears to be very freezer burnt; it is a pot roast. I am going to go ahead and take that out now and throw it away. Surveyor asked if temperatures are being checked in the freezer. [NAME] K reported temperatures do get checked. Surveyor asked [NAME] K to review the thermometer. [NAME] K grabbed thermometer and reported to Surveyor that the thermometer had a broken piece of plastic, and the gauge did not move to register a temperature. Surveyor asked [NAME] K if [NAME] K knew how long the thermometer was broken. [NAME] K stated, I actually forget about checking these freezer temperatures all the time, so I am not sure how long the thermometer has been broken. Surveyor observed two other freezers which also had thermometers which did not have working gauges. Surveyor could not find any other thermometer to ensure the proper temperature. Surveyor asked [NAME] K how long the fried rice was good for. [NAME] K reported [NAME] K was unsure about the frozen fried rice as it had two different dates written on it and no manufacturing expiration date. [NAME] K stated, It is not in its original box to see the manufacturing expiration date, making it difficult to figure out how long it is good for in the freezer. [NAME] K stated, I would normally probably discard within a month if it didn't have a label. On 05/11/26 at 9:42 AM, Surveyor asked [NAME] K to review temperature logs. [NAME] K showed Surveyor temperature logs which were checked every day but confirmed with Surveyor the temperature gauges in all 3 freezers in this room are broken. [NAME] K stated other staff must have filled in the temperatures on the logs, because [NAME] K had not. Surveyor observed the temperatures on the logs, and all were documented with proper temperatures, but there was no working thermometer in the kitchen. On 05/12/26 at 4:18 PM, Surveyor interviewed Director of Nutritional Services L and asked if she was aware the freezer thermometers were not working. Director of Nutritional Services L reported to Surveyor that [NAME] K informed Director of Nutritional Services L of the broken thermometers today and [NAME] K did replace the thermometers. Surveyor asked Director of Nutritional Services L what the expectation is for labeling foods. Director of Nutritional Services L stated, There is not a regulation that states kitchen staff must have an open date and a use by date on the label. One or the other is fine. Surveyor asked Director of Nutritional Services L how staff would know when a food item is past the use by date if it is not needed on the label. Director of Nutritional Services L stated to Surveyor, I usually just educate them to use the 5-day mark although some will tell you 7 days is fine. I just try to play it safe and tell staff anything is open 5 days past the opened date it will be discarded. Example 2 Surveyor reviewed the facility policy titled Food Safety Requirements dated last revised 02/26 which states: .7. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. A. Staff should wash hands according to facility procedures. B. Staff shall not touch food with bare hands, exhibiting appropriate use of gloves, tongs, deli paper, and spatulas. On 05/11/2026 at 11:25 AM, Surveyor observed [NAME] K walk to the 3-compartment sink and start to wash blender parts. Surveyor did not observe [NAME] K don a gown to protect [NAME] K's clothing from contamination. Surveyor observed [NAME] K's shirt touching and hanging over the sink. Surveyor observed water and food particles splashing around the sink and landing on [NAME] K's shirt. Surveyor observed [NAME] K dry hands with a towel and walk back to the food line and begin pureeing food for the lunch meal. Surveyor did not observe [NAME] K perform any hand hygiene prior to pureeing food. On 05/11/26 at 11:30 AM, Surveyor interviewed [NAME] K and asked about the process for washing dishes in between prepping residents' foods. [NAME] K reported that usually [NAME] K does not have to wash dishes, but if [NAME] K was to wash dishes, [NAME] K should have applied a gown to protect clothing when prepping foods. On 05/11/2026 at 11:39 AM, Surveyor observed [NAME] K walk over to the dishwashing area where the 3-compartment sink was located. Surveyor observed [NAME] K's shirt touching the sink while water was splashing throughout the sink. Surveyor did not observe [NAME] K apply a gown to protect shirt from contamination. Surveyor observed [NAME] K finish washing dishes and walk over to prepping table with contaminated shirt. On 05/12/26 at 4:18 PM, Surveyor interviewed Director of Nutritional Services L and asked what the expectation is for [NAME] K washing dishes while prepping food for lunch. Director of Nutritional Services L reported to Surveyor that [NAME] K should apply a gown/apron to protect clothes while washing dishes, then remove the gown/apron, and wash hands prior to prepping resident foods. Example 3 Surveyor reviewed the facility policy titled Food Safety Requirements dated last revised 02/26 which states: .7. H. Gloves will be worn when directly touching ready-to-eat foods when serving residents. Surveyor reviewed facility policy titled Handwashing Guidelines for Dietary Employees dated last revised 03/26 which states: .6. Frequency of hand washing: b. After hands have touched anything unsanitary i.e., garbage, soiled utensils/equipment, dirty dishes, etc. f. While preparing food, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. J. After engaging in any activity that may contaminate the hands. On 05/11/2026 at 11:32 AM, Surveyor observed [NAME] M walking around the kitchen while holding onto [NAME] M's pants with gloved hands and grabbing items off the counters for prepping food. Surveyor observed [NAME] M continue to walk around the kitchen with the same gloves touching kitchen surfaces such as kitchen counter, kitchen utensils, and dishes. Surveyor observed [NAME] M walk to the refrigerator, grab the door with the same gloves, and reach into the refrigerator to get the ranch dressing. [NAME] M grabbed the ranch dressing container and placed it on the prepping table while wearing the same gloves. Surveyor observed [NAME] M gather little plastic containers and separate the tops and the bottoms while wearing the same gloves. [NAME] M then poured ranch dressing into the containers. Surveyor observed [NAME] M place tops on the sauces while wearing the same gloves and place them in the refrigerator. Surveyor observed [NAME] M walk out of the kitchen, grab [NAME] M's pants to pull them up wearing the same gloves, and then walk into the freezer room down the hallway. On 05/11/2026 at 11:41 AM, Surveyor observed [NAME] M walk out of the freezer room wearing the same gloves, walk down the hallway, and back into the kitchen holding a frozen hamburger patty out of the package. Surveyor heard [NAME] K state, You [Cook M] will need to have that burger in a container. [NAME] M replied, Yea, I don't see why. Surveyor observed [NAME] M walk through the kitchen to the grill and place the frozen hamburger patty on the grill while wearing the same gloves. On 05/11/26 at 11:43 AM, Surveyor interviewed [NAME] M and asked why [NAME] M keeps touching [NAME] M's pants and pulling them up with gloves on. [NAME] M reported to Surveyor that [NAME] M's belt broke. [NAME] M stated, I just now used my apron to tie my pants to it so they will stay up while I am working. Surveyor asked [NAME] M if [NAME] M should be using gloved hands to pull pants up. [NAME] M reported to Surveyor that [NAME] M does wash hands often but did not wash hands after touching [NAME] M's pants. Surveyor reported to [NAME] M that Surveyor observed [NAME] M touch many different surfaces all morning while wearing the same gloves and cook a burger without washing hands. [NAME] M stated, Yeah, I guess I should have washed my hands. On 05/12/26 at 4:18 PM, Surveyor interviewed Director of Nutritional Services L and asked what the expectation is for hand hygiene while handling frozen hamburger patties, sauce cups, and kitchen equipment after touching contaminated surfaces. Director of Nutritional Services L reported [NAME] M should have washed hands after touching contaminated surfaces. Director of Nutritional Services L expects the kitchen staff to not wear gloves during the whole process of prepping food but continually wash hands often. Director of Nutritional Services L reported expectation is for staff to wear gloves when touching ready-to-eat food. Example 4 Surveyor reviewed the facility policy titled Record of Food Temperature dated last revised 04/26 which states: .1. Food temperatures will be checked on all items prepared in the dietary department. 6. Measure and record the temperatures for each food product, Record temperature on temperature log. 7. When holding hot foods for service, food temperature should be measured when placing it on the steam table line. On 05/11/2026 at 11:45 AM, Surveyor observed [NAME] K perform food temperature checks on the steam table. Surveyor observed [NAME] K take the temperature of the roasted seasoned regular chicken, pureed chicken, and regular noodles. Surveyor observed [NAME] K start to prep resident trays. Surveyor did not observe [NAME] K take the temperature of the pureed noodles, creamed corn, ground mechanical soft chicken, or the non-seasoned plain chicken. On 05/11/26 at 11:49 AM-12:15 PM, Surveyor observed [NAME] K prep and serve:-R22 pureed chicken and pureed noodles.-R46 mechanical soft chicken and creamed corn.-R54 mechanical soft chicken and creamed corn.-R58 pureed chicken and pureed noodles. On 05/11/26 at 12:21 PM, Surveyor interviewed [NAME] K and asked why [NAME] K did not take the temperature of other food on the steam table before serving residents. [NAME] K stated to Surveyor, I was wondering why the temp list does not have that option, but the regular chicken is the same as the puree or mechanical soft chicken. Both are on the same steam table. But I guess I probably should have temped everything on steam table. On 05/12/26 at 4:18 PM, Surveyor interviewed Director of Nutritional Services L and asked what the expectation is for [NAME] K with taking the temperature of the foods on the steam table. Director of Nutritional Services L reported all items on the steam table should have temperature taken before serving residents for food safety practices. Director of Nutritional Services L reported to Surveyor that [NAME] K should have taken the temperature of all foods including mechanical soft and pureed.

Based on observation, interview and record review, [NAME] K did not follow a recipe to make pureed and mechanical soft chicken and noodles for 8 of 8 residents who receive pureed and mechanical soft diets out of 58 residents. This resulted in the potential for 4 residents (R22, R46, R54, and R58) not receiving the nutrients necessary at lunch meal to meet nutritional needs and 4 of 15 residents (R14, R29, R53 and R25) verbalized food was not palatable. Findings include: According to the National Food Service Management Institute, recipes will ensure that nutritional values per serving are valid and consistent - nutrients per serving for a recipe can be altered significantly when a recipe is not followed. Example 1 On 05/11/2026 at 11:16 AM, Surveyor observed [NAME] K take chicken pieces out of the oven and place them in a blender. [NAME] K walked over to kitchen sink and filled blender with a little bit of water and [NAME] K started blending chicken with water to make puree. Surveyor observed [NAME] K finish the mixing of chicken and water and then poured mixture into a pan. [NAME] K stated, Puree is complete. On 05/11/26 at 11:28 AM, Surveyor observed [NAME] K, walk over to the kitchen sink and place an unknown amount of water with noodles in the blender. [NAME] K blended mixture, poured pureed noodles into a pan, and placed it on the steam table. Surveyor reviewed facility policy titled, Puree Food Preparation, dated last revised 04/26, which states: .#5. Do not use water as an additive to prepare pureed foods. 7. Puree food preparation guidelines per serving: -Poultry: Add 1 teaspoon chicken broth or chicken gravy. -Noodles: Add 1 teaspoon margarine. On 05/11/26 at 11:33 AM, Surveyor interviewed [NAME] K and asked if there is a puree recipe that [NAME] K follows when preparing pureed foods. [NAME] K stated, There is no recipe, but I just ballpark how much water I need. On 05/11/26 at 11:49 AM-12:15 PM, Surveyor observed [NAME] K prep and serve: -R22 pureed chicken and pureed noodles. -R46 mechanical soft chicken and creamed corn. -R54 mechanical soft chicken and creamed corn. -R58 pureed chicken and pureed noodles. On 05/12/26 at 4:18 PM, Surveyor interviewed Director of Nutritional Services L and asked what the expectation is for [NAME] K to prepare pureed diets. Director of Nutritional Services L reported to Surveyor [NAME] K should follow the puree recipe policy that states adding substitutions when prepping puree such as use of margarine, broth, gravy, or depending on which food is chosen when prepping. Director of Nutritional Services L reported to Surveyor that [NAME] K should not have used water in puree preparation. Example 2 On 05/11/26 at 1:00 PM, Surveyor observed lunch in the first-floor dining room. Three residents (R14, R29, & R53) were attempting to eat their lunch and reported to Surveyor the chicken was very dry, and they were unable to chew/eat it. A 4th resident (R25), who had already received a lunch tray in R25's room prior to this observation, reported to Surveyor R25 only ate the garlic bread, as the chicken was too dry and R25 could not eat it. Surveyor observed R29 as R29 attempted to cut the chicken, and it appeared very dry and tough. Surveyor observed R29 take a bite of chicken, attempt to chew it, and spit it back out. On 05/11/26 at 1:05 PM, Surveyor observed activity staff offering residents snacks and iced coffee while still in the dining room eating lunch. R14, R29, R53, and R25 accepted a snack of a fruit pouch or nutrition bar, and iced coffee in place of lunch. On 05/12/26 at 8:25 AM, Surveyor observed three residents (R14, R29, & R53) eating breakfast. All 3 residents had scrambled eggs which appeared very dark (brown/black) in several areas and appeared hardened in those areas. Surveyor asked all three residents about the eggs. R14 and R53 reported the eggs were burnt. R53 reported the eggs were tough. R8 was present in the dining room and reported to the Surveyor R8 was upset because there was no meat for breakfast and the menu had stated sausage links. No sausage links were observed for any of the residents present in the dining room. R8 was not aware the menu had been changed.

Based on observation, interview, and record review, the facility did not provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections which had the potential to affect all 29 residents on the first floor.-Personal soaps and shampoos were in the basket hanging in the shower.-A disposable razor was present in the basket hanging in the shower.Findings include:Facility policy titled, Shower, last revised 01/2025, includes .Assist the resident to the shower room and bring all necessary supplies .Help the resident back to their room and return personal hygiene products to their designated spot.On 05/11/26 at 11:03 AM, Surveyor observed personal body soaps, shampoo, and a disposable razor present in the basket hanging in the shower on the 112-127 hall shower room. On 05/12/26 at 8:50 AM, Surveyor interviewed Certified Nursing Assistant (CNA) J about what should be done with resident's personal shower toiletries upon completion of a shower. CNA J reported the supplies should be put away when done using them.On 05/13/26 at 10:15 AM, Surveyor interviewed Director of Nursing (DON) B about the expectations of personal shower toiletries. DON B stated all personal supplies should be kept separate. DON B acknowledged personal soaps, shampoos, and disposable razors should not be left in the shower.

Based on interview and record review, the facility did not implement policy and procedures related to screening employees for a prior history of abuse, neglect, exploitation of residents, or misappropriation of resident property for 1 (Cook O) of 8 employees reviewed. The facility did not ensure their abuse policy was implemented when one employee's (Cook O) background information disclosure (BID) was not obtained before employee started working at facility. Findings include: The facility's Abuse, Neglect, and Misappropriation of Property policy dated 08/24 indicates, Pre-employment background screening is mandated for all facility employees. On 05/12/26 at 2:45 PM, Surveyor reviewed 8 staff BIDs, which were selected randomly. [NAME] O was hired on 01/15/26. Surveyor was reviewing a BID for [NAME] O. The form was dated 01/15/26 with the question, Have you resided outside the state of Wisconsin in the last 3 years. The box was marked yes and stated in Minnesota. Surveyor reviewed the BID and found no BID was completed for the state of Minnesota. On 05/12/26 at 3:03 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked for [NAME] O's BID for living in Minnesota in the last 3 years. NHA A reported that [NAME] O's BID was not reviewed for out of state. NHA A reported the facility is completing the BID now for [NAME] O.

Based on observation, interview and record review, the facility did not develop and implement a comprehensive care plan for one resident (R10) of 15 sampled residents reviewed for comprehensive care plans.The facility did not develop and implement a person-centered comprehensive care plan to address R10's dysphagia (difficulty swallowing) needs. R10's care plan did not include alternative interventions or monitoring guidelines to address R10's choice to not comply with speech therapy recommendations to reduce risks of choking/aspiration. Findings include:R10 was admitted to the facility on [DATE] with diagnoses including unspecified schizophrenia, dementia with behavioral disturbances, avoidant personality disorder and dysphagia. R10 has a Brief Interview for Mental Status (BIMS) score of 03/15 which indicates severe cognitive impairment. R10's care plan, last revised 09/09/2025, with a target date of 05/211/2026, states, Self-care deficit related to weakness, impaired mobility, impaired cognition. [R10] dictates his own care, resistive at times. Interventions for eating include Independent after set up. Between 05/11/2026 at 12:12 PM and 05/13/26 at 8:19 AM, Surveyor observed R10 eating breakfast and lunch meals while in bed, supine (on back) position with head of bed (HOB) elevated to less than 45 degrees. Certified Nursing Assistants (CNA) G set up meal tray on R10's bedside table positioned over the bed at R10's waist level. CNA G did not remain in room during meal. CNA G did not attempt to raise R10's HOB during setting up of R10's meals. On 05/13/2026 at 8:19 AM, Surveyor observed R10 have 3 coughing episodes after drinking a liquid. On 02/09/2024, R10's medical record documents a speech therapy (ST) evaluation completed for R10 with recommendations stating, One to one supervision.bed or chair fully upright. On 11/06/2025, R10's medical record documents a physician order for the following diet: consistent carbohydrate diet, regular - 7 texture [regular, easy to chew], regular/thin fluid consistency. On 05/08/2026, R10's medical record documents a Nutritional Risk Assessment (NRA) completed by a registered dietician (RD) stating, Nutritional risk related to recent incidence of swallowing difficulty with dysphagia diagnosis. On 05/12/2026 at 7:58 AM, Surveyor interviewed CNA G about R10 staying in bed. CNA G indicated R10 refuses to get out of bed. CNA G stated, We put the head of bed up, but he puts it back down. CNA G confirmed R10 was capable of operating bed controls on bed to raise or lower HOB. On 05/13/2026 at 8:26 AM, Surveyor asked Medication Assistant (MA) I and CNA F what position R10 should be in when eating meals in bed. MA I stated, We try to put it up and he yells at us and puts it back down. MA I stated R10 complains of pain when HOB is elevated and prefers to lay flat. CNA F stated, You don't want to be on his bad side, referring to R10's history of aggressive behaviors of yelling and resisting cares. On 05/13/2026 at 8:22 AM, Surveyor interviewed R10 on preferences while eating in bed. R10 stated, Do you know how hard it is when I can only bend my neck? Surveyor asked R10 if he was able to change the elevation of HOB, and R10 pointed to the bed control panel located to R10's left side and stated, I don't want to mess it up. R10 became agitated during conversation and Surveyor was unable to further complete interview. Surveyor reviewed R10's medical record. R10's care plan did not identify R10's preference to eat all meals in bed. R10's care plan did not have approaches or interventions in place for R10 's preference to eat all meals in bed. R10's care plan did not have alternative approaches/interventions in place if R10 refused to have HOB elevated while eating meals in bed. R10's care plan did not have approaches/interventions in place for monitoring for risk of R10 choking or aspirating foods/liquids secondary to dysphagia while eating meals in bed. On 05/13/2026, Surveyor asked Director of Nurses (DON) B who can add or make changes to a resident's care plan. DON B stated staff notify DON B or the nurse manager if changes need to be made and it is done as needed or at a minimum quarterly. DON B could not provide Surveyor with care plan approaches or interventions for R10's refusal to get up for meals, or have HOB elevated during meals to ensure proper positioning to prevent choking/aspiration. DON B stated R10's care plan should include R10's preferences for meals, as well as monitoring tools for risks of R10 choking or aspirating.

Based on observation, interview, and record review, the facility did not ensure 1 of 15 residents (R5) stored medication safely and securely. R5 was observed to leave nicotine lozenges on the dining room table and not stored safely or securely.Findings include:Facility policy titled, Resident Self-Administration of Medication, last revised 02/2026, includes: The intent of the policy is to support residents who are evaluated as capable of administering their medications while ensuring resident safety, proper oversight, and regulatory compliance.When determining if self-administration is clinically appropriate for a resident, the interdisciplinary team should at a minimum consider the following.the resident's ability to ensure that medication is stored safely and securely.The following conditions are met for bedside storage to occur.the manner of storage prevents access by other residents.On 05/11/26, Surveyor reviewed R5's electronic health record. R5 was admitted to the facility on [DATE].R5's most recent Minimum Data Set (MDS) assessment on 03/26/26 shows a Brief Interview for Mental Status (BIMS) score of 9/15 indicating moderate cognitive impairment.On 05/11/26 at 12:15 PM, Surveyor observed a bottle of Nicotine lozenges on a dining room table left by R5. R5 left the dining room. R14, R29, & R53 were present in the dining room at this time.On 05/11/26 at 12:17 PM, Surveyor observed R5 return to the dining room table.On 05/11/26 12:20 PM, Surveyor observed R5 leaving the dining room, leaving the lozenges on the table unattended.On 05/11/26 at 12:21 PM, Surveyor observed Certified Nursing Assistant (CNA) J enter and exit the dining room. CNA J did not acknowledge the bottle of nicotine lozenges sitting on the dining room table.On 05/11/26 at 12:24 PM, Surveyor observed R5 return to the dining room table.On 05/11/26 at 12:27 PM, Surveyor observed R5 leaving the dining room. On 05/11/26 at 12:30 PM, Surveyor observed R5 return to the dining room table for lunch.On 05/12/26, Surveyor reviewed R5's self-administration assessments. Assessment completed on 10/21/24 indicated R5 was unable to self-administer medications and had been unable prior to admission to the facility. The assessment completed on 06/25/25 indicated R5 was fully capable of ensuring medications were kept in a secure location in R5's room. No quarterly self-administration assessments completed since 06/25/25.On 05/12/26, Surveyor reviewed R5's physician orders which include Nicotine Polacrilex Mouth/Throat Lozenge 4mg. Give 1 lozenge by mouth every 4 hours as needed for smoking cessation.On 05/12/26, Surveyor reviewed R5's Medication Administration Record (MAR) in relation to the administration of the lozenges.In November 2025 1 administration was documented on 11/28/25.In December 2025 1 administration was documented on 12/29/25.In January 2026 1 administration was documented on 01/04/26.In February 2026, March 2026, April 2026, and May 2026, there was no documentation of Nicotine Lozenges administered to R5.On 05/12/16, Surveyor reviewed R5's care plan in relation to self-administering Nicotine lozenges but was unable to find any information.On 05/13/26, at 9:13 AM, Surveyor interviewed Licensed Practical Nurse (LPN) P about self-administered medications. When asked who determines if a resident is able to self-administer medications, LPN P stated the nursing staff interact with the physician if the resident is requesting it and if the physician states it is appropriate, the facility would document it in the resident's care plan. When asked how the medications are monitored, LPN P stated LPN P would usually hang around and talk with the resident or stop back in 10-15 minutes to make sure the medication was taken. When asked about as needed medications, LPN P stated LPN P tries to get the resident to take the medication while LPN P is present. Surveyor asked LPN P how R5's Nicotine lozenges are monitored. LPN P stated R5 keeps the bottle of lozenges with R5 and mostly carries them for comfort. LPN P stated nursing staff usually only give R5 about 10 lozenges in the bottle at a time. LPN P stated they don't count the number of remaining lozenges each shift or each day. Surveyor asked what LPN P would do if LPN P observed the bottle of Nicotine lozenges left on a table unattended. LPN P stated LPN P would take them and put them in the medication cart. LPN P stated LPN P had to re-educate R5 previously on not leaving them out unattended and stated R5 is difficult to re-educate. When asked if LPN P would find it appropriate to perform a new assessment in relation to recurrence of leaving the medication unattended, LPN P stated, It might be worth a try.On 05/13/26 at 10:15 AM, Surveyor interviewed Director of Nursing (DON) B about residents self-administering medications. When asked who completes the self-administering assessments, DON B stated DON B and other nurse managers complete the assessments. DON B stated the assessments are based on requests from residents, verified it is appropriate by physician, and observation by the person completing the assessment. DON B stated medication kept in resident rooms are in a lock box which has a key, and nursing has an extra key. When asked how these medications are monitored, DON B stated expectation is nursing staff would keep a log of medication use and the nurses would be checking for compliance. DON B stated the self-administration assessments should be completed quarterly at a minimum. When asked if it would be appropriate for a resident to leave a medication in a common area unattended, DON B stated, It would not be advised. When asked what the expectation is for observing a medication left unattended, DON B stated DON B would give the medication to a nurse, provide the resident with re-education, and complete a new assessment. DON B acknowledged Surveyor's observation of R5's Nicotine lozenges being left unattended in the dining room with no staff intervening. DON B acknowledged there has been no self-administration assessment completed since 06/25/25 and the care plan did not include any interventions related to self-administration of Nicotine lozenges.

Based on observation, interview, and record review, the facility did not ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 3 residents (R) reviewed for mobility/positioning (R34).-R34 requested a trapeze for bed mobility assistance, and it was not addressed timely.-R34 has a trapeze in place with no assessment conducted or documentation of R34 having a trapeze.-R34 had a decrease in bed mobility during Minimum Data Set (MDS) Assessment dates of 10/31/25 to 01/26/26.Findings include:Facility policy titled, Use of Assistive Devices, last revised 04/2026, includes: Facility staff will provide appropriate assistance to ensure hat the resident can use the assistive devices safely. This may include assessment, education, or therapy sessions for training on the use of the device, set up assistance, supervision, or physical assistance as needed.On 05/11/26 at 9:48 AM, Surveyor interviewed R34 in relation to bed mobility. R34 reported it was difficult to get things requested at times and stated R34 finally got a trapeze to help with bed mobility after asking for 6 months. Surveyor observed R34's bed has a trapeze and half-side rails on both sides of the bed that are used for bed mobility.On 05/12/26 at 7:00 AM, Surveyor reviewed R34's medical record. R34 was admitted to the facility on [DATE].R34's most recent MDS assessment, completed on 03/10/26, showed a Brief Interview for Mental Status (BIMS) score of 14/15 indicating no cognitive impairment.Surveyor reviewed R34's progress notes, physician orders, and care plan, and noted no information regarding the trapeze. Surveyor reviewed R34's MDS assessments from 10/31/25 and 01/22/26 in relation to bed mobility and noted a decline from substantial/max assist to dependent.On 05/12/26 at 12:34 PM, Surveyor interviewed Certified Nursing Assistant (CNA) J about how a resident would obtain an assistive device for bed mobility. CNA J stated if a resident requested an assistive device such as side rails or a trapeze, CNA J would let therapy know so they could do an evaluation. CNA J stated CNA J would also talk to nursing to have them assess if a trapeze would be safe and necessary.On 05/12/26 at 12:45 PM, Surveyor interviewed CNA R about assistive devices. CNA R stated CNA R would tell therapy if applicable, if a resident asked for a trapeze or side rails. CNA R stated CNA R would also tell the nurse. If found to be appropriate, CNA R stated CNA R would tell maintenance so they can put it in place. CNA R believes R34 has had the trapeze for about 3-4 weeks, and it is working well for R34.On 05/12/26, Surveyor reviewed R34's assessments, which indicated a side rail re-assessment was completed on 05/11/26. No documentation regarding a trapeze assessment.On 05/12/26 at 1:39 PM, Surveyor interviewed Director of Rehab Services (DRS) E about assessing residents for assistive devices for bed mobility. DRS E stated when a resident is admitted , DRS E or another therapy staff will complete an assessment to see if side rails are appropriate. DRS E stated they don't complete assessments for a trapeze. DRS E stated if therapy feels a trapeze would be beneficial, they will get one for a resident. When asked about R34's trapeze, DRS E stated DRS E was not aware R34 had one. DRS E stated DRS E did not see it while completing the assessment on 05/11/26.On 05/12/26 at 2:57 PM, Surveyor interviewed CNA C about R34's trapeze. CNA C stated R34's trapeze has been on R34's bed for about a month and a half and maintenance placed it. CNA C was unsure about how long R34 had been asking for one but did state there was talk prior to R34 receiving one.On 05/12/26 at 3:00 PM, Surveyor interviewed DRS E about any further information about R34's trapeze. DRS E stated DRS E did find out Maintenance Technician (MT) S placed the trapeze for R34. MT S had asked Occupational Therapist (OT) T if it would be appropriate for R34's bed. DRS E stated DRS E spoke with R34 and R34 stated the trapeze is helping with bed mobility. DRS E told Surveyor the trapeze was placed on 03/26/26. DRS E stated DRS E remembers CNAs (not sure which ones) reporting R34 wanted a trapeze about 2-3 months prior and stated, I guess it never really went anywhere. DRS E stated a therapy assessment will be conducted in relation to the trapeze to make sure it is appropriate.On 05/13/26 at 9:21 AM, Surveyor interviewed OT T about R34's trapeze. OT T stated MT S had been looking for a trapeze for R34 and asked if OT T thought the one found would work for R34's bed. OT T stated OT T figured MT S had a work order for it. OT T stated OT T had never worked with R34.On 05/13/26 at 9:30 AM, Surveyor interviewed MT S about R34's trapeze. MT S stated MT S was asked to place a trapeze on R34's bed but could not recall who asked MT S to do so. MT S stated that MT S placed the trapeze on 03/26/26. MT S stated orders are given to MT S through text messages, by word of mouth, and sometimes in passing.On 05/13/26 at 10:15 AM, Surveyor interviewed Director of Nursing (DON) B about assistive devices for bed mobility. DON B stated DRS E assesses residents for such devices. DON B stated if deemed appropriate, someone from maintenance would be informed, take measurements, get the parts, and put the device in place. When asked about documentation, DON B stated the provider would be updated, a progress note would be placed in the resident's medical record, and the information would be added to the care plan. DON B stated that R34 had asked for a trapeze several months prior to receiving one. DON B acknowledged R34 had no documentation in the progress notes, orders, or care plan regarding the trapeze. DON B acknowledged an assessment was not completed in relation to the trapeze and R34 had a decline in bed mobility prior to receiving the trapeze.

Based on observation, interview and record review, the facility failed to ensure supervision to prevent choking for 1 (R10) of 15 residents reviewed. R10 was assessed to require supervision with meals due to choking risk. R10 did not have supervision in place and observations were made of R10 coughing with meals.Findings include:R10 was admitted to the facility on [DATE] and has diagnoses of unspecified schizophrenia, dementia with behavioral disturbances, avoidant personality disorder and dysphagia. R10 has a Brief Interview for Mental Status (BIMS) score of 03/15 which indicates severe cognitive impairment. R10 does not have a documented care plan for risk of choking or aspiration related to dysphagia. On 05/08/2026, a Nutritional Risk Assessment (NRA) done by a Registered Dietician (RD) Q stated, Nutritional risk related to recent incidence of swallowing difficulty with dysphagia diagnosis. A therapy referral was placed by RD Q for a speech therapy screening to be done related to swallowing difficulties on CNA task documentation. CNA task documentation for R10 included a question, Did the resident choke or cough during the meal or when swallowing meds? During a 30 day look back period, CNAs documented yes on 3 separate dates. On 05/13/2026 at 8:19 AM, Surveyor observed R10 having 3 coughing episodes after drinking a liquid while lying in bed eating breakfast and head of bed (HOB) elevated to less than 45 degrees. R10 did not have dentures in place. On 05/12/2026 at 7:58 AM, Surveyor interviewed CNA G about R10 lying in bed. CNA G indicated R10 refuses to get out of bed. CNA G stated, We put the head of bed up, but he puts it back down. On 05/13/2026 at 8:26 AM, Surveyor asked medication assistant (MA) I and CNA F what position R10 should be in when eating meals in bed. MA I stated, We try to put it up and he yells at us and puts it back down. On 05/12/2026, Director of Rehabilitation Services (DRS) E, who is also an Occupational Therapist (OT), performed a speech therapy screening on R10. DRS E's documentation states, The reason for screen is due to a staff referral/recommendation for a screen. Speech therapy is not indicated at this time.discussed with CNAs and nursing. They report no current issues with swallow.no speech language pathology intervention warranted at this time.On 05/13/2026 at 11:00 AM, Surveyor interviewed DRS E and asked what the facility screening process is for residents who have a referral for therapy services. DRS E stated staff communicate a referral request when concerns are identified via a paper form titled Hey Therapy Form. DRS E stated OT can perform speech therapy screenings and make recommendations if speech therapy evaluations are indicated by observation of the resident during meals and it must be a hands-off approach. DRS E stated the screening cannot last longer than 15 minutes duration. DRS E stated a resident with a known history of dysphagia would be a concern for aspiration or choking and their HOB should be always elevated. DRS E confirmed a speech therapy screening was done by DRS E that day and no actual observation of R10 was done. DRS E stated the decision for no speech therapy evaluation for R10, was determined through DRS E's interviews with CNAs and nurses working that day who had not personally witnessed R10 coughing/choking. DRS E confirmed there was CNA task documentation of R10 having 3 witnessed coughing/choking episodes within the past 30 days. DRS E stated, I did not talk to the resident, and I should have. DRS E confirmed an observation of R10 during meals should have been conducted before deciding no further interventions were warranted.

Based on record review and staff interviews, the facility did not ensure that an alleged abuse of R1 was reported to the State Agency (SA).The facility did not report the alleged abuse of Licensed Practical Nurse (LPN) D hitting R1 on the buttocks to the SA.Findings include:The facility's policy titled, Resident Abuse, Neglect, Misappropriation of Property, and Exploitation Prevention Program revised October 2025 states in part, .7. Reporting and Response: The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment. are reported per Federal and State laws. Reporting allegations immediately: a. But no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse .R1 was admitted to the facility on [DATE]. Diagnoses included vascular dementia, major depressive disorder, anxiety disorder, and pain.Most recent Minimum Data Set (MDS) assessment, completed on 1/20/26, indicated that R1 required assist with ambulation, no behaviors indicated and has a Brief Interview for Mental Status (BIMS) score of 03/15, which indicates severe cognitive impairment.Record review of R1's electronic medical record indicated no documentation of an incident occurring around 1/9/26 or any follow up investigation/documentation in relation to the allegations of abuse to R1. Incident reports provided by the facility upon admission did not include any documentation of the alleged incident.On 2/3/26 at 11:50 AM, Surveyor called R1's son, primary contact, who reported, sometime in January, unsure of date, he received a call from the Director of Nursing (DON). He was told R1 had been slapped in the butt by a nurse, in a playful nature, and the nurse was joking around. He denied any concerns or notable changes in R1's behavior.On 2/3/26 at 12:15 AM, Surveyor interviewed Executive Administrator C, who reported there was a Quality Assurance (QA) report from 1/9/26, when a nurse tapped R1 on the bottom. The nurse was reportedly sent home, and DON B investigated the report. Surveyor requested facility provide all documentation on the incident. Executive Administrator C stated she was just made aware of this and agreed this was an allegation of abuse and should have been reported to the State Office immediately and was not.Surveyor reviewed incident report which stated, On 1/9/26 [R1] was in her gown at the nurses' station and had her backside open towards the dining area. [R1] was wearing only a brief. Staff attempted multiple times to cover [R1] up, but when [R1] moved gown would open again. Nurse then tied gown in back and tapped resident on bottom. [R1] initially said, don't do that, I don't like that. When attempting to interview (R1) the next day, resident was in and out of sleep and didn't remember that happening the night before. Report stated [LPN D] was immediately talked to and was sent home until investigation was complete. CNA's who witnessed were interviewed. No staff member said the action looked or seemed sexual in nature or seemed to have been done in harm or shame the resident. CNA's and nurse said she was trying to be funny. [LPN D] was assigned to Relias education regarding professionalism and conduct and given coaching and learning. No injuries observed at the time of incident.Surveyor reviewed DON's written CNA interviews, noting CNA F reported she saw LPN D get up and smack R1's brief. R1 said, I don't like that, and LPN D smacked R1 on the brief again. R1 then raised her fist in the air and said, I don't like that, I told you. LPN D responded by laughing. CNA F felt uncomfortable.On 2/3/26 at 1:22 PM, Surveyor interviewed LPN D, who reported the events to be accurate as previously indicated in report. LPN D felt it was more of a playful boop on the butt, and she did it a second time just before R1 told her not to and R1 did get upset with her but just at that moment. LPN D stated she realizes now it was inappropriate behavior but did not mean to cause R1 harm.On 2/3/26 at 2:15 PM, Surveyor called CNA F who confirmed the incident occurred as stated in the DON's interview report.On 2/3/26 at 1:38 PM, Surveyor interviewed CNA E, who reported she did not witness but does care for R1 and has not noted any negative changes in R1's behavior nor has R1 ever spoken of incident.On 2/3/26 at 12:45 PM, Surveyor interviewed DON B, who investigated the incident. DON B stated the incident was not reported because after she did an investigation, it was determined LPN D did it in fun and did not intentionally hurt the resident. DON B stated she now understands the allegation was of abuse and should have been reported immediately to the State Agency.

Based on interview and record review, the facility did not ensure a thorough investigation was conducted when receiving a report of alleged physical abuse.The facility did not thoroughly investigate to rule out abuse of a Resident (R1). No interviews were conducted with other residents to ensure there had been no further incidents of abuse, a thorough physical exam/skin assessment or a psycho-social exam were not conducted. The acting administrator was not notified of the incident. Findings include:The facility's policy titled, Resident Abuse, Neglect, Misappropriation of Property, and Exploitation Prevention Program revised October 2025 states in part, .5. Investigation- A thorough investigation is an investigation that adequately addresses the circumstances of the allegation. The facility will promptly and thoroughly investigate reports of abuse that includes mistreatment. Designated facility personnel will begin the investigation immediately and will collect information that corroborates or disproves the incident and document the findings for the incident. the information gathered is reviewed by the Administrator and facility grievance officer(s).R1 was admitted to the facility on [DATE]. Diagnoses included vascular dementia, major depressive disorder, anxiety disorder, and pain.Most recent Minimum Data Set (MDS) assessment completed on 1/20/26 indicated that R1 required assist with ambulation, no behaviors indicated and has a Brief Interview for Mental Status (BIMS) score of 03/15, which indicates severe cognitive impairment.Record review of R1's electronic medical record indicated no documentation of an incident occurring around 1/9/26 or any follow up investigation/documentation in relation to the allegations of abuse to R1. Incident reports provided by the facility upon admission did not include any documentation of the alleged incident.On 2/3/26 at 11:50 AM, Surveyor called R1's son, primary contact, who reported, sometime in January, unsure of date, he received a call from the Director of Nursing (DON). He was told R1 had been slapped in the butt by a nurse, in a playful nature, and the nurse was joking around. He denied any concerns or notable changes in R1's behavior.On 2/3/26 at 12:15 AM, Surveyor interviewed Executive Administrator, who reported there was a Quality Assurance (QA) report from 1/9/26, when a nurse tapped R1 on the bottom. The nurse was reportedly sent home, and DON B investigated the report. Surveyor requested facility provide all documentation on the incident. Executive Administrator agreed this was an allegation of abuse and she had not been aware of the allegation until now.Surveyor reviewed incident report which stated, On 1/9/26 [R1] was in her gown at the nurses' station and had her backside open towards the dining area. [R1] was wearing only a brief. Staff attempted multiple times to cover [R1] up, but when [R1] moved gown would open again. Nurse then tied gown in back and tapped resident on bottom. [R1] initially said, don't do that, I don't like that. When attempting to interview (R1) the next day, resident was in and out of sleep and didn't remember that happening the night before. Report stated the LPN was immediately talked to and was sent home until investigation was complete. CNA's who witnessed were interviewed. No staff member said the action looked or seemed sexual in nature or seemed to have been done in harm or shame the resident. CNA's and nurse said she was trying to be funny. LPN was assigned to Relias education regarding professionalism and conduct and given coaching and learning. No injuries observed at the time of incident.Surveyor reviewed DON's written CNA interviews, noting CNA F reported she saw LPN D get up and smack R1's brief, R1 said, I don't like that, and LPN D smacked R1 on the brief again. R1 then raised her fist in the air and said, I don't like that, I told you. LPN D responded by laughing. CNA F felt uncomfortable.On 2/3/26 at 1:22 PM, Surveyor interviewed LPN D, who reported the events to be accurate as previously indicated in report. LPN D felt it was more of a playful boop on the butt, and she did it a second time just before R1 told her not to and R1 did get upset with her but just at that moment. LPN D stated she realizes now it was inappropriate behavior.On 2/3/26 at 2:15 PM, Surveyor called CNA F who confirmed the incident occurred as stated in the DON's interview report.On 2/3/26 at 1:38 PM, Surveyor interviewed CNA E, who reported she did not witness but does care for R1 and has not noted any negative changes in R1's behavior nor has R1 ever spoken of incident.On 2/3/26 at 12:45 PM, Surveyor interviewed DON B, who investigated the incident. DON B stated the incident was not reported because after she did an investigation, it was determined LPN D tapped R1 in the butt in fun and did not intend hurt the resident. The facility did not provide documentation of a physical exam, skin assessment or psychosocial assessment of R1 after incident. There was no indication the investigation was reviewed by the Administrator or facility grievance officer. The facility did not report alleged abuse to the State per Federal and State laws. On 2/3/26 at 12:15 PM, Surveyor interviewed Executive Administrator C, who stated this allegation of abuse was not reported to her or to the State Survey and Certification Agency as it should have been.

Based on observation and interview, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. This affected 1 out of 3 residents (R) reviewed. (R4) Certified Nurse Assistant (CNA) E did not doff contaminated gloves after emptying urine from catheter into graduate before continuing R4's cares. Findings include: The facility policy, titled Enhanced Barrier Precautions, revised January 2025, states:.4. High contact resident acre activities include:e. Changing linens.f. Changing briefs or assisting with toileting.g. Device care or use. Urinary catheters.Surveyor reviewed R4's record, which indicated R4 is on enhanced barrier precautions (EBP) for history of extended-spectrum beta-lactamase (ESBL) in the urine and R4 has a suprapubic catheter. On 08/26/25 at 3:15 PM, Surveyor followed CNA E into R4's room. Surveyor observed CNA E don Personal Protective Equipment (PPE) before entering R4's room. CNA E pushed R4 into a shared bathroom which is used for R4 and R4's neighbor. R4 stood up and stand pivoted to toilet and sat down. CNA E pulled R4's pants down and proceeded to empty R4's catheter into graduate. CNA E threw used brief onto floor and not in garbage in the shared bathroom. CNA E opened catheter and emptied in graduate. CNA E closed catheter tubing and placed graduate off to the side on floor. CNA E then used same contaminated gloves to cleanse R4's bottom and pulled R4's pants back up. CNA E opened bathroom door with contaminated gloves and R4 walked out of bathroom. CNA E walked R4 over to wheelchair and then touched wheelchair with contaminated gloves. CNA E wheeled R4 to bed and assisted R4 to bed. CNA E took R4's shoes off with contaminated gloves. CNA E rearranged R4's bedside table that had lunch tray on bedside table. CNA E placed R4's call light within reach with contaminated gloves and then walked to R4's door. CNA E then doffed PPE and contaminated gloves then washed hands. On 08/26/25 at 3:25 PM, Surveyor interviewed CNA E and asked CNA E the process for utilizing PPE in an EBP room. CNA E reported that CNA E should have changed gloves right after emptying graduate with urine before touching other surfaces and CNA E did not. On 08/27/25 at 10:52 AM, Surveyor interviewed Director of Nursing (DON) B and asked expectation of staff utilizing PPE and hand hygiene practices in an EBP room and suprapubic catheter. DON B reported expectation is PPE is to be donned upon entering and frequent glove changes are to be performed. Surveyor reported to DON B the observation of inappropriate glove use by CNA E. DON B reported that CNA E should have discarded contaminated gloves after emptying R4's urine in graduate, sanitized, and then reapplied new gloves.

Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect all 62 residents in the facility. -The facility did not have a water management program to reduce the risk of growth and spread of Legionella and other opportunistic waterborne pathogens. -Facility surveillance does not provide adequate evidence of tracking and monitoring infections. -Residents with known infections were not placed on precautions or placed on incorrect precautions. -Bins for discarding personal protective equipment (PPE) were placed in the hallways. Soiled PPE was hanging outside of the bins and exposed. -Clean linens were not covered during transport. Clean linens were stored in shower rooms inside shower stall and on shower bench. -Staff did not sanitize mechanical lifts between use. -Staff provided a resident with a wheelchair to attend an appointment. The wheelchair was borrowed from a resident on precautions for Clostridium difficile (C Diff, a bacterium in the large intestine that is highly contagious). -Shared shower room contained used bars of soap and used disposable razors. -No hand hygiene and glove change by Certified Nursing Assistant (CNA) when performing cares on a resident. Findings: Example 1 WATER MANAGEMENT The facility's policy titled Water Management, read in part, .This procedures purpose it to reduce the risk of growth and spread of Legionella and other waterborne pathogens. 1. Our facility has a Water management Team to specifically address safe water management . The facility's policy titled Legionella Surveillance, read in part, .It is the policy of this facility to establish primary and secondary strategies for the prevention and control of Legionella infections. 1. Legionella surveillance is one component of the facility's water management plans for reducing the risk of Legionella and other opportunistic pathogens in the facility's water systems . On 03/11/25 at 11:04 AM, Surveyor interviewed Environmental Services Director (ESD) Z. ESD Z stated he was not familiar with the facility having a water management program. Surveyor requested evidence of a description of the facility's water system, identification of areas in the water system that could be potentially hazardous, control measures for potentially hazardous areas, and monitoring of control measures. ESD Z stated he did not have the information Surveyor was requesting. On 03/12/25 at 10:09 AM, Surveyor interviewed Director of Nursing (DON) B. DON B reported the facility had a water management program and this would be provided to Surveyor. On 03/12/25 at 2:47 PM, Nursing Home Administrator (NHA) A provided update to Surveyor. NHA A reported the facility does not have a water management program. NHA A provided a blank document titled Water Management-Weekly Flushes. NHA A stated the facility was implementing the monitoring of areas identified as potentially hazardous. Example 2 SURVEILLANCE The facility's policy titled Infection Surveillance, read in part, .2. Outcome surveillance is accomplished in the following manner and is completed for both residents and staff. a. Infections or potential infections related to residents are identified and reported through the nurse charting system, verbal communication, and review of antibiotic use. e. The facility tracks existing cases of infections both old and new. g. Documentation will be completed on a line listing form tracking symptoms that may be representative of potential infective processes. This information is evaluated by the Director of Nurses or designee on an ongoing basis . On 03/11/25, the facility provided a Performance Improvement Plan (PIP) titled, Infection Control Line Listing of Staff. This document read in part, .Was noted that staff line listing was not being completed routinely with DON change over. ICP module in Point Click Care was purchased to easily track/trend resident and staff. The ICP module provides data for potential outbreaks and tracking and trending. -Action taken for affected staff: immediately start line listing, implementation of PCC IP Module. For Jan paper line listing. Regional VP of Clinical Ops set up binder for DON and [name] to complete while working through ICP module in PCC. Status (ongoing or completed with date of completion), 01/01/25. -Identification of other potentially affected residents and action: All staff. Status (ongoing or completed with date of completion), 02/01/25. -Systemic measures to prevent recurrence: 1) Staff are to notify nurse on call of s/s infection. 2)Nurse manager will ensure DON or designee enters the data into PCC for line listing module. Status (ongoing or completed with date of completion), 02/01/25. -Performance effectiveness and monitoring (must include review by QA Committee): 1) Scheduler and DON will meet in morning review and staff call offs. 2) Line listing will be kept on PCC for documentation of staff call offs r/t infection. 3) ICP Module will be reviewed at QAPI each month to determine and track trends. 4) QAPI will determine if further audits are needed and substantial compliance. Status (ongoing or completed with date of completion), Ongoing . On 03/11/25, the facility provided a printed line list of resident infections, beginning 01/02/25 through current date. Surveyor reviewed document and noted the following: -Laboratory testing and diagnostic testing was not completed. Notably for residents diagnosed with pneumonia, influenza A, and Clostridium difficile. -Criteria for infection was not included on the line list. -Residents with known multidrug-resistant organism (MDRO) were not included on the line list, (R25). -Isolation precautions were blank for residents with open wounds and drainage. Isolation start and end dates was completed with N/A. -Residents prescribed antibiotics were not included on the line list, (R41). On 03/11/25, the facility provided a staff line list for dates 02/26/25-current. Surveyor reviewed document and noted all entries, except for one, indicated staff had influenza A infection. Documentation did not identify signs and symptoms, and date staff returned to work. On 03/12/25 at 10:09 AM, Surveyor interviewed DON B. DON B indicated surveillance is documented and monitored via an electronic system. DON B indicated the information missing on the printed line list was being monitored via electronic surveillance. Surveyor requested access for the facility's electronic surveillance monitoring. Surveyor was not provided access to the facility's electronic surveillance monitoring. Example 3 TRANSMISSION BASED PRECAUTIONS The Centers for Disease Control (CDC) recommends contact precautions be implemented for individuals with Extended Spectrum Beta Lactamase (ESBL), a type of MDRO. On 03/10/25 at 11:13 AM, Surveyor observed R25 had an indwelling catheter. Surveyor observed R25 was not placed on enhanced barrier precautions (EBP). On 03/10/25 at 12:18 PM, Surveyor observed staff placing EBP signs on R25's room door and PPE bins outside of room. Surveyor reviewed R25's record and noted R25 was diagnosed with an MDRO. Surveyor reviewed urinalysis completed on 02/13/25, indicating R25 was actively infected with ESBL, a type of MDRO. On 03/11/25 at 8:23 AM, Surveyor interviewed Certified Nursing Assistant (CNA) H. CNA H reported licensed nursing staff places signage, PPE, and bins for transmission-based precautions, to correspond with type of precautions the resident should be on. On 03/12/25 at 10:09 AM, Surveyor interviewed DON B. DON B indicated R25 not being placed on precautions initially, and then being placed on EBP, must have been a mistake. Example 4 PPE On 03/10/25 at 10:09 AM, Surveyor observed R43 was on contact precautions related to C. Diff infection. Surveyor observed PPE bin outside of R43's room which contained soiled PPE, which was not contained within the bin, and soiled PPE was sticking out and hanging from the bin. On 03/11/25 at 8:06 AM, Surveyor observed PPE bin outside of R43's room which contained soiled PPE, which was not contained within the bin, and soiled PPE was sticking out and hanging from the bin. On 03/12/25 at 10:09 AM, Surveyor interviewed DON B. DON B stated the facility's policy and expectation is that PPE bins are kept inside the resident's room, and staff are to discard PPE in the room and before exiting the room. DON B did not provide further statement or clarification related to PPE bins located outside of resident rooms. Example 5 LINENS On 03/12/25 at 7:42 AM, Surveyor observed a clean linen cart with linens, cart was uncovered. On 03/12/25 at 7:49 AM, Surveyor interviewed Laundry Aide (LA) AA. LA AA reported she brings clean linens in laundry cart from basement where laundry room is located. LA AA reported she fills the cart as full as she can to prevent multiple trips to the basement. LA AA did not make any statements related to clean linens required to be covered. On 03/12/25 at 8:27 AM, Surveyor observed clean linens in shower room. Clean linens were placed in shower stall, over handrailing in shower stall, and on shower bench. On 03/12/25 at approximately 9:35 AM, Surveyor toured laundry facility with LA AA. Surveyor observed resident clean clothing was covered. Surveyor observed clean linen cart. LA AA confirmed she does not cover clean linen cart when transporting linens. On 03/12/25 at 10:09 AM, Surveyor interviewed DON B. DON B confirmed clean linens should be covered during transport. Example 6 MECHANICAL LIFTS On 03/11/25 at 7:39 AM, Surveyor observed two CNAs assist a resident using a mechanical hoyer lift for transfer. Surveyor observed after completing the transfer, CNA H removed the lift from the resident's room and placed it in the hallway. Surveyor noted the lift did not contain wipes or equipment to disinfect lift. CNA H spoke with another CNA briefly and then began walking towards a different hallway. Surveyor interviewed CNA H. CNA H reported lifts are to be disinfected after use with each resident and/or between resident use. CNA H reported this lift is generally only used on this hallway. CNA H confirmed there are usually disinfecting wipes in the bag attached to the lift. CNA H stated she would ask maintenance to bring some wipes for cleaning the lift. Surveyor observed CNA H come back with purple top wipes, clean the lift, and place the wipes in the attached bag. Surveyor noted R43 resides on this hallway and has an active C. diff infection. R43's PPE bin is located outside of his room in the hallway and soiled PPE is exposed, hanging out of the bin. On 03/12/25 at 10:09 AM, Surveyor interviewed DON B. DON B confirmed staff should be disinfecting mechanical lifts after use with each resident. Example 7 SHARED DURABLE MEDICAL EQUIPMENT On 03/11/25 at 2:11 PM, Surveyor interviewed R7. R7 was unavailable for interview on 03/10/25 as she had an appointment for an endoscopy procedure. R7 reported she was frustrated as the facility has not provided her with a wheelchair (w/c) for approximately eight or more weeks, (see citation F588 for reasonable accommodation of needs). Surveyor asked R7 how she was able to attend her appointment on 03/10/25 if she did not have a wheelchair. R7 stated staff borrowed R43's w/c, as it is a bariatric w/c. Surveyor noted R43 was currently on contact precautions related to a C. diff infection. Surveyor immediately interviewed CNA I. CNA I stated, Ok, I had nothing to do with this. I helped [R7] get ready for her appointment yesterday morning. I don't know why she doesn't have a w/c. I asked Nursing Home Administrator (NHA) and DON what I should do, and they told me to use [R43's] w/c, as [R7] needed a bariatric w/c. I knew [R43] had C. Diff. They told me to clean the w/c before I used it. I was not going to be responsible for someone getting C. diff because I didn't clean the chair properly. I mean, I don't have time to be cleaning w/c's with bleach. I told them to clean it. NHA and [Nurse Manager (NM) BB] cleaned the w/c and brought it to [R7's] hallway for me. When I got the w/c, I know they did not clean it with bleach because I could not smell bleach. I could smell the purple top wipes. I know what those smell like. Example 8 SHOWER ROOM On 03/11/25 at 8:16 AM, Surveyor observed clean linens in shower room on railings, inside shower stall, and on shower bench. Personal care items including a bar of soap and disposable razor were present inside shower in an open metal rack. On 03/11/25 at 8:27 AM, Surveyor observed clean linens lying on a shower cot and on top of a cabinet, as well as a personal sweatshirt. On 03/11/25 at 9:09 AM, Surveyor interviewed CNA Y. CNA Y reported staff get the items they need prior to giving a shower. Resident personal items are taken in the shower room for use and taken back to their rooms after. The facility items are kept on shelves in the shower room. On 03/11/25 at 9:17 AM, Surveyor interviewed CNA H. CNA H stated personal items and linens are taken in at the time of the shower. Dirty linens and personal care items are also removed when done. CNA H stated at times, clean linens that are extra get left in the shower room, but if they remove them, then they would have to be considered dirty and put into laundry. CNA H also reported any disposable razors get placed in sharps containers after use. When asked about facility soaps, CNA H only stated they retrieve them from the supply room. On 03/12/25 at 10:09 AM, Surveyor interviewed DON B. DON B made a note of Surveyor's observations of the shower room. DON B did not offer additional information. 48793 Example 9 On 03/11/25 at 7:35 AM, Surveyor observed CNA T enter bath house to assist CNA U with transfer of R57. CNA U and CNA T began pushing stand lift to R57 and instructed R57 to help stand. Surveyor observed CNA U take a dry towel and wipe R57's groin and buttock area without wearing gloves. CNA U then dropped the dry towel as R57 was in the process of sitting down. Surveyor observed CNA U don gloves, and CNA U and CNA T began standing R57 again. CNA U then used dry towel again to dry off groin area and buttock area. Surveyor observed R57 in the process of sitting on bath chair. CNA U then readjusted R57's hair out of R57's face with the soiled gloves on. CNA U then instructed R57 to stand again while CNA U pulled brief and pants up for R57 with soiled gloves. Surveyor observed CNA U grab wheelchair and place under R57. R57 sat down in wheelchair. Surveyor observed CNA U exit bath house with soiled gloves on and wheeled R57 to the dining room. Surveyor observed CNA U rearrange two dining room chairs to make room for R57 with same soiled gloves on. Surveyor observed CNA U lock wheelchair brakes on R57's wheelchair with soiled gloves and then placed a clothing protector/towel on R57. Surveyor observed CNA U then take soiled gloves off in dining room and throw in the trash. Surveyor observed CNA U walk back to the bath house and started cleaning the bath house. Surveyor did not observe CNA U sanitize hands. On 03/11/25 at 8:05 AM, Surveyor interviewed CNA U and asked CNA U what is the correct process for hand hygiene after peri cares are completed on resident. CNA U indicated that CNA U should have applied gloves the first time before cleaning R57's peri area, then sanitized hands after and before placing gloves on. CNA U indicated that before leaving the shower room CNA U should have sanitized hands again before taking R57 to the dining room for breakfast. On 03/11/25 at 9:13 AM, Surveyor interviewed DON B and asked DON B what expectation does DON B have with staff and hand hygiene when staff are completing peri cares on a resident. DON B indicated hands should be sanitized before and after glove use, and when exiting resident care areas.

Based on observation, interview and record review, the facility did not ensure that snack/nourishment refrigerators on the first floor and third floor were maintained with the proper temperatures and food items are dated and labeled to prevent the potential for food-borne illness. This has the potential to effect all residents on the first floor and third floor. Findings include: According to the US Food and Drug Administration (FDA) Food Code 2022: Annex 3-123 .Date marking is the mechanism by which the Food Code requires active managerial control of the temperature and time combinations for cold holding. Industry must implement a system of identifying the date or day by which the food must be consumed, sold, or discarded. Date marking requirements apply to containers of processed food that have been opened and to food prepared by a food establishment, in both cases if held for more than 24 hours, and while the food is under the control of the food establishment . According to the US FDA Food Code 2022: Annex 3-164 to 165: .A permanent temperature measuring device is required in any unit storing time/temperature control for safety food because of the potential growth of pathogenic microorganisms should the temperature of the unit exceed Code requirements. In order to facilitate routine monitoring of the unit, the device must be clearly visible .The required incremental gradations are more precise for food measuring devices than for those used to measure ambient temperature because of the significance at a given point in time, i.e., the potential for pathogenic growth, versus the unit's temperature. The food temperature will not necessarily match the ambient temperature of the storage unit; it will depend on many variables including the temperature of the food when it is placed in the unit, the temperature at which the unit is maintained, and the length of time the food is stored in the unit . On 03/11/25 at 8:36 AM, Surveyor observed the snack/nourishment refrigerator located at the third floor nurses' station. The temperature log on the front of the refrigerator had each date completed with temperatures within appropriate limits for the refrigerator and freezer. Surveyor observed the internal thermometer in the refrigerator read 38 degrees F. Surveyor observed there was no internal or external thermometer in the freezer. Surveyor asked Licensed Practical Nurse (LPN) C who checked the refrigerator and freezer temperatures. LPN C stated dietary staff checked the unit refrigerators. On 03/11/25 at 8:44 AM, Surveyor checked the snack/nourishment refrigerator at the first floor nurses' station. Surveyor observed LPN G remove a bottle of salad dressing and an uncovered cup of liquid to dispose of them. The salad dressing bottle was opened and half empty and the cup of liquid was uncovered. Neither item was marked with a date opened or a use-by date. LPN G stated dietary staff was supposed to make sure food and beverage items were labeled and stored correctly in the unit refrigerators. Surveyor observed the temperature tracking log on the front of the refrigerator had each date completed and all temperatures recorded for the refrigerator and freezer were within acceptable limits. Surveyor observed the internal freezer thermometer read 4 degrees. Surveyor observed there was no internal thermometer in the refrigerator. On 03/11/25 at 9:59 AM, Surveyor observed [NAME] N using a hand-held device to check the ambient temperatures in the unit refrigerator and freezer on the third floor. Surveyor interviewed [NAME] N, who stated they always used the hand-held device to check the internal temperatures of the refrigerators and freezers because the internal thermometers often go missing. [NAME] N said dietary staff is also supposed to make sure that all opened foods and beverages are labeled with the date opened, are covered, and stored correctly in the unit refrigerators and freezers. On 03/12/25 at 2:09 PM, Surveyor interviewed Dietary Manager (DM) F and reviewed the above observations and interviews related to the unit refrigerators on the first floor and third floors. DM F stated the dietary staff should have caught and removed the uncovered and undated food items and disposed of them when they did their morning checks. Surveyor asked if it was acceptable according to the US FDA Food Code to use the hand-held ambient temperature device to measure the internal temperatures of the unit refrigerators and freezers if the internal thermometers were missing. DM F thought it was an acceptable way to measure the unit temperatures. Surveyor provided the correct information from the US FDA Food Code and informed DM F the hand-held devices to measure temperatures was not following the Food Code guidance.

Based on interview and record review, the facility did not ensure medication reviews were completed for 5 out of 5 residents (R) reviewed (R65, R17, R53, R41, and R61) for unnecessary medications. Medication reviews were not completed at least monthly by a licensed pharmacist and documentation of review was not maintained in the resident's medical records. Findings include: The facility policy titled, Consultant Pharmacist Reports IIIA1: Medication Regimen Review revised December 2019, states in part, .B. The consultant pharmacist the medication regimen of each resident at least monthly . H. At least monthly, the consultant pharmacist reports any irregularities to the attending physician, medical director and the director of nursing, at a minimum . The policy titled, Consultant Pharmacist Reports IIIA2: Documentation and Communication of the consultant Pharmacist Recommendations revised December 2019, states in part, .A. A record of the consult pharmacist's observations and recommendations is made available in an easily retrievable form to nurses, prescribers, and the care planning team. This should include: 1) Documentation of the date each medication regimen review is completed and notation of the findings in the medical record or other designated manner . Example 1 R65 was admitted to the facility on [DATE] with diagnoses including, orthopedic after care following surgical amputation, type 2 diabetes mellitus, obsessive compulsive disorder, adult failure to thrive, major depressive disorder with suicidal ideations, and history of pulmonary embolism. Surveyor reviewed R65's medication orders and noted the following: Aripiprazole oral tablet 5 MG (Aripiprazole) Give 1 tablet by mouth one time a day for major depressive disorder. Active 2/5/2025. Fluoxetine HCl Oral Capsule 40 MG (Fluoxetine HCl) Give 2 capsule by mouth one time a day for major depressive disorder. Active 2/4/2025. Insulin aspart subcutaneous solution pen-injector 100 unit/ml (Insulin Aspart): Inject as per sliding scale: if 191 - 220 = 1 unit; 221 - 250 = 1 unit; 251 - 280 = 2 units; 281 - 310 = 2 units; 311 - 340 = 3 units; 341 - 370 = 3 units; 371 - 400 = 4 units; 401 - 430 = 4 units; 431 - 460 = 5 units; 461 - 490 = 5 units; 491 - 520 = 6 units; 521 - 550 = 6 units; 551 - 580 = 7 units; 581 - 610 = 7 units; 611 - 999 = 8 units, subcutaneously at bedtime for Diabetes. Active 2/4/2025. Insulin aspart subcutaneous solution pen-injector 100 unit/ml (Insulin Aspart) Inject as per sliding scale: if 161 - 190 = 1 unit; 191 - 220 = 2 units; 221 - 250 = 3 units; 251 - 280 = 4 units; 281 - 310 = 5 units; 311 - 340 = 6 units; 341 - 370 = 7 units; 371 - 400 = 8 units; 401 - 430 = 9 units; 431 - 460 = 10 units; 461 - 490 = 11 units; 491 - 520 = 12 units; 521 - 550 = 13 units; 551 - 580 = 14 units; 581 - 610 = 15 units; 611 - 999 = 16 units, subcutaneously with meals for diabetes. Active 2/4/202. Eliquis oral tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for major depressive disorder take with breakfast and supper. Active 2/4/2025. Cyanocobalamin oral tablet 1000 MCG (Cyanocobalamin) Give 1 tablet by mouth one time a day for . Active 2/4/2025. Clonazepam oral tablet 1 MG (Clonazepam) Give 1 tablet by mouth two times a day. Active 2/4/2025. Buprenorphine HCl-Naloxone HCl sublingual film 12-3 mg (Buprenorphine HCl-Naloxone HCl Dihydrate) Give 1 film sublingually three times a day for withdrawals ***Follow the order in the computer*** and give 1 film sublingually one time only for withdrawals until 02/07/2025 23:59. Active 2/7/2025 13:30. Buspirone HCl oral tablet 10 MG (Buspirone HCl) Give 2 tablet by mouth three times a day for anxiety and give 2 tablets by mouth one time only for anxiety until 02/07/2025 23:59. R65 did not have documentation that a pharmacist reviewed R65's medications in the month of February 2025 or that any recommendations made were acknowledged by a physician. R65's medication orders do not indicate reasons for prescribing cyanocobalamin or clonazepam. On 3/13/25 at 7:48 AM, Surveyor interviewed Director of Nursing (DON) B about R65's medication orders missing indications of use. DON B acknowledged missing information in R65's medication orders and a plan to have orders corrected. Example 2 R17 was admitted to the facility on [DATE] with pertinent diagnosis including, schizophrenia, unspecified on admission, 3/27/2017, residual schizophrenia, 11/27/2024, and anxiety. Surveyor reviewed R17's medication orders and noted the following: Seroquel oral tablet 25 MG (Quetiapine Fumarate) Give 1 tablet by mouth as needed for . related to generalized anxiety disorder and residual schizophrenia for 14 Days 25mg one time daily as needed. Active 2/27/2025 Seroquel Oral Tablet 25 MG (Quetiapine Fumarate) Give 3 tablet by mouth at bedtime for anxiety related to schizophrenia. Active 9/20/2024 Zoloft tablet (Sertraline HCl) Give 100 mg by mouth one time a day for anxiety. The facility provided no documentation of a pharmacy review. Documentation of staff monitoring R17's and R65's behaviors was provided. On 3/13/25 at 7:51 AM, Surveyor interviewed DON B. Surveyor requested monthly pharmacy reviews and any documented physician follow up for sampled residents. DON B acknowledged the facility does not have a system in place to monitor monthly pharmacy reviews. DON B is unable to verify there has been any pharmacy review of medications. DON B reported a secure email had been sent from the current contracted pharmacy in January and February, but these emails can no longer be opened as they were sent with a timed security code. DON B provided a printout of the pharmacy email indicating a locked attachment from pharmacy for January and February 2025. DON B stated, That's all I have. On 3/13/2025 at 9:30 AM, Surveyor met with Nursing Home Administrator (NHA) A. NHA A acknowledged there are no pharmacy review documents or evidence of follow up on recommendations. 48793 Example 3 Record review identified R53 was admitted to the facility on [DATE] with the following diagnoses, in part, Alzheimer's disease with late onset dementia with moderate behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R53's medical record identified pharmacy was not reviewing R53's medications on a consistent monthly basis. Pharmacy reviews are missing and/or pharmacy signatures for 01/24, 02/24, 03/24, 09/24, 11/24, 12/24, 01/25, and 02/25. Example 4 R41 was admitted to the facility on [DATE], readmitted on [DATE], with the following diagnoses, in part, Alzheimer's disease, atherosclerotic heart disease, essential primary hypertension, and depression. R41's medical record identified pharmacy was not reviewing R41's medications on a consistent monthly basis. Pharmacy reviews are missing and/or pharmacy signatures for 01/24, 03/24, 04/24, 06/24, 07/24, 08/24, 09/24, 10/24, 11/24, 12/24, 01/25, and 02/25. 44863 Example 5 R61 was admitted to the facility on [DATE]. Diagnoses included atrial fibrillation, history of stroke, dementia, anxiety, cognitive impairment, delusional disorders, abnormal weight loss, and malnutrition. R61's MDS assessment, completed on 01/28/25, confirmed R61 scored 07/15 during BIMS, indicating severe cognitive impairment. R61 experiences hallucinations. R61's care plan included: -Impaired cognitive function/dementia or impaired thought process related to dementia, impaired decision making, psychotropic drug use. Diagnoses include anxiety, mild cognitive impairment, and delusional disorder. Interventions included: Review medications and record possible causes of cognitive deficit. Date initiated 11/05/24, revised 11/05/24. -I use psychotropic medications related to behavior management. I take an antidepressant and antipsychotic medication. Interventions: Consult with pharmacy, MD to consider dosage reduction when clinically appropriate, at least quarterly. Date initiated 11/05/24. R61's physician orders included: -Citalopram for anxiety, 09/11/24. -Eliquis for atrial fibrillation, 09/11/24 -Risperidone for delusional disorders, 09/11/24. On 03/13/25, Surveyor reviewed R61's record and noted pharmacy reviews were not conducted on a consistent monthly basis. Review of record confirmed pharmacy reviews were missing from record, not conducted, or documentation of follow-up of pharmacist recommendations was not evident in the record. Pharmacy reviews are not completed or documentation is not evident for 08/24, 09/24, 10/24, 12/24, 01/25, and 02/25.

Based on observation, interview and record review, the facility did not ensure that sufficient nursing staff was provided for the third floor to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident (R). This has the potential to affect all 14 residents residing on the third floor. Residents on the third floor have had multiple falls with injuries. A resident (R19) had an unwitnessed fall and no staff responded to calls for help until Surveyor intervened. R9 who is frequently incontinent of urine did not receive assistance with repositioning or toileting for 4 1/2 hours. Findings include: Facility Assessment, dated 02/03/25, stated in part: .Information About Our Staffing Patterns section stated Average Nurse Aide/Resident Ratio (Direct Care Staff) Average about 1 Nurse Aide to 10 Residents . Surveyor reviewed the daily staffing postings and nursing schedules for the past month. The schedule showed one nurse and one Certified Nursing Assistant (CNA) scheduled for 3rd floor, with one additional CNA who was scheduled for 1:1 care of one resident. That CNA was not available to answer call lights and provide direct care to any other residents on the unit. The daily census on third floor during the survey was 14 residents. During the day and evening shifts on 03/10/25, and on the morning of 03/11/25, Surveyor observed one nurse and one CNA providing direct care on the third floor for 14 residents. On the morning of 03/11/25, Surveyor observed one Licensed Practical Nurse (LPN) and one CNA working on the third floor. At 9:44 AM, Surveyor heard a loud noise from one of the rooms toward the end of the hall farthest from the nursing station. A couple of minutes later, Surveyor heard a resident calling for help from room [ROOM NUMBER]. CNA D was in another resident room and did not hear or respond to the call for help. LPN C was passing medications to a resident on a different hall and did not hear or respond to the call for help. After two minutes, Surveyor walked down to room [ROOM NUMBER] and observed R19 lying on the floor by the bathroom. Surveyor alerted LPN C that R19 had fallen and was calling for help. LPN C finished giving medications to a resident and then went to the room and found R19 on the floor by the bathroom. LPN C yelled for help from the doorway, but CNA D did not hear or respond to the call for help. After a few minutes, Surveyor observed Registered Nurse (RN) X walking down a different hall and headed for the elevator. Surveyor informed RN X a resident had fallen and LPN C needed assistance. RN X responded to the room to assist. On 03/11/25 at 10:22 AM, Surveyor interviewed LPN C who stated R19 was supposed to be up with assistance, but R19 frequently forgot to call for help. LPN C stated with just one CNA and one nurse working on the unit, it was hard to hear R19 when she got up independently. LPN C stated R19 did get a small skin tear on one arm from the fall this AM. Surveyor interviewed LPN C about staffing patterns on the third floor. LPN C stated when she works the third floor they consistently have one nurse and one CNA working on the unit for both day and PM shifts. LPN C stated there are typically about 14 to 15 residents on the unit. LPN C stated they have a staff person scheduled to provide 1:1 care for R58, but that person cannot leave R58's room to help answer call lights or help with cares for residents. LPN C stated they just called in another CNA to help assist with resident cares on the floor after R19 fell , but it probably only happened because the Surveyors were in the building. LPN C stated in her experience they never call extra help up to the third floor. LPN C stated there have been a lot of resident falls on the third floor and they need two CNAs on the unit all the time to try to prevent the falls. On 03/11/25 at 10:53 AM, Surveyor interviewed CNA D who stated they usually worked on the third floor. CNA D stated they usually scheduled just one nurse and one CNA working on the unit for about 15 residents. CNA D stated they had a really busy morning, and it was good that they called in extra help. CNA D stated they try to call in help extra help sometimes, but it was rare that someone agreed to come in. CNA D said it would be better for the residents if they had two CNAs scheduled for the third floor. On 03/11/25 at 10:56 AM, R3 requested to speak to Surveyor in her room. R3 stated she was the resident council president and she had brought up staffing concerns at their meetings in the past, but nothing was ever done about it. They usually have one nurse and one CNA working on the floor for 14-15 residents. R3 stated she is fairly independent, and does not need a lot of physical assistance from the staff, but R3 believes the residents who are more dependent don't get the care they deserve because there is not enough help. R3 stated she had observed multiple residents, who are dependent and can't speak for themselves, left in their chairs at the dining room for many hours, sometimes from before breakfast until after lunch. R3 stated that many of the falls that have occurred are due to not enough staff to assist the residents to the bathroom or with transfers. On 03/12/25 at 8:21 AM, Surveyor observed R19, who had fallen the day before, get up and begin walking with a 4-wheeled walker toward the bathroom. R19 did not press the call light or call for help. R19 appeared unsteady on her feet and there was no staff around to observe or assist R19. Surveyor alerted CNA E who at at the other end of the hall providing 1:1 care for R58. CNA E was able to locate CNA D, who came down the hall to assist R19 to the bathroom. On 03/12/25 from 7:06 AM to 11:35, AM, Surveyor had a continuous observation of R9 seated in one position without being assisted to go to the bathroom, or checked for incontinence. Record review identified R9 had severe cognitive impairment, required substantial or maximal assistance for all mobility and toileting, and was frequently incontinent of urine and always incontinent of bowel. R9 was also assessed at risk for development of pressure injuries. R9 had care plan interventions instructing staff to assist with toileting every 2-3 hours and as needed. On 03/12/25 at 7:14 AM, Surveyor interviewed LPN G who was an agency staff member working at the facility since November. LPN G stated she frequently worked on the third floor. LPN G said there is usually one CNA and one nurse scheduled for the third floor when LPN G worked on there. LPN G stated there were usually around 15 residents on the unit and a lot of them have a history of frequent falls. LPN G stated they could use more help on the third floor to try to prevent some of the falls. On 03/12/25 at 7:29 AM, Surveyor interviewed CNA E who was working on the third floor. CNA E stated she usually works on first floor, but was called in extra today and asked to float to the 3rd floor. CNA E she had been assigned to work on the third floor for the first time on 02/14/25 when R58 had a fall. CNA E stated she was the only CNA working the floor and there was another CNA doing 1:1 care with R58. CNA E stated when the other CNA left the unit for a break, the nurse told CNA E to cover the 1:1 care for R58. CNA E was not told she could not leave the room when doing 1:1 care for R58 and the nurse was not answering lights and covering the floor while CNA E was in R58's room. CNA E left to answer call lights on the unit and that is when R58 fell . CNA E stated one nurse and one CNA scheduled for third floor was not enough to safely meet the residents' needs and that is why there were so many falls on that unit. On 03/12/25 at 12:12 PM, Surveyor interviewed Director of Nursing (DON) B about R19's fall on 03/11/25 and explained continuous observation of R9 not repositioned or assisted to the bathroom for 4 1/2 hours. Surveyor also informed DON B of interviews from staff and residents reporting inadequate staffing on the third floor resulting in delayed cares and falls. Surveyor asked DON B if they had considered if some of the resident falls were related to inadequate staffing levels on the third floor. DON B stated they would review staffing levels.

Based on observation, interview and record review, the facility did not ensure the resident's environment remains as free of accident hazards as possible. The facility did not ensure staff followed transfer precautions and supervision when needed to prevent accidents which had the potential to affect 21 out 62 residents. -Surveyor observed Certified Nurse Assistant (CNA) U bathe R57 in bath house without a call system in place for emergencies during bath/shower cares. -R41 was at risk for falls. Facility did not implement new interventions put into place post falls. -Staff ambulated R41 without gait belt in place during ambulation transfer process. -R58 had a history of frequent falls with major injury and the facility failed to ensure adequate supervision and implementation of interventions to prevent further falls. Findings include: Example 1 Facility policy titled, Fall Prevention Program, dated reviewed on [DATE], states in part: .#6. When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify the provider and resident representative. e. Review the resident's care plan and update as indicated. f. Document all assessments/observations and actions. g. Obtain witness statements in the case of injury. -Neruo checks will be completed of any unwitnessed fall or witnessed fall where a resident hits their head. -Initially, then EVERY (Q)15minutes x3, then, -Q4 hours x 2, then, -Q8 hours x 8, staff to alert provider of any abnormal findings from the neuro checks. #7. Review each fall/fall investigation during the next morning meeting/clinical meeting with the Interdisciplinary team (IDT). Actions may include: a. Review investigation and determination of potential root cause of fall. b. Review of fall risk care plan and updates. c. Additional revisions to the care plan. d. Education of staff to as any care plan revisions as needed. e. Scheduling care conferences. f. Verification of timely notification of provider and responsible party . Facility policy titled, Safe Resident Handling/Transfers, dated revised on [DATE], states in part, .#5. Handling aides may include gait belts, transfer boards, and other devices . R41 was admitted to the facility on [DATE], readmitted on [DATE], with following diagnoses, in part, Alzheimer's disease, atherosclerotic heart disease, essential primary hypertension, and depression. R41's minimum data set (MDS) assessment, completed on [DATE] confirmed R3 scored ,d+[DATE] during a brief interview for mental status (BIMS), indicating intact cognition. R3 was at risk for falls. R3 requires substantial maximal assistance from staff for toileting, sit to stand, transferring, dressing lower body, and putting on/taking off footwear. R41's Activities of Daily Living (ADL)s care plan states: -Transfer: Assist of 1 with gait belt, assure proper footwear is on before standing initiated on [DATE]. R41's fall care plan states: *Falls on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. -Resident will be safe and free from falls through the review date, initiated on [DATE]. -Keep room clean and free of clutter, initiated on [DATE]. -Keep call-light within reach, initiated on [DATE]. -Grabber or reacher provided to resident, initiated on [DATE]. -Resident to wear gripper socks at night, initiated on [DATE]. -Gripper strips to floor next to toilet, bed and couch, initiated on [DATE]. -Dycem to recliner, initiated on [DATE]. -Pharmacy medication review, initiated on [DATE]. -Pharmacist alerted for request for medication review. Care conference has been scheduled initiated on [DATE]. Surveyor reviewed nurse progress notes for R41's falls: -On [DATE], unwitnessed fall sent to ER. Facility did not implement any new fall interventions until [DATE]. -On [DATE], R41 had an unwitnessed fall. R41 to have neuros for fall follow up. Fall intervention: Dycem to recliner added to R41's care plan. Surveyor reviewed R41's Electronic Health Record (EHR) and did not find documentation of neuros completed for R41 after unwitnessed fall on [DATE] per the facility falls policy. -On [DATE], R41 had another fall. Care plan intervention added to add a chair in hallway at nurses' station to sit and rest while ambulating. Surveyor reviewed R41's EHR and did not find documentation of neuros completed for R41 after fall on [DATE]. -On [DATE], R41 had unwitnessed fall. Surveyor reviewed R41's EHR and did not find documentation of neuros completed for R41 after [DATE] fall per the facility fall policy. Surveyor did not find any significant interventions implemented for unwitnessed fall. -On [DATE], R41 had fall next to the nurse's station. New intervention was to place a chair at the nurse's station for R41 to help give R41 a rest if needed while ambulating. Surveyor did not observe a chair placed at nurses' station for R41 during 4 day observation of R41 ambulating on the unit. -On [DATE], R41 had a fall. Surveyor reviewed R41's EHR and did not find documentation of medication review as care planned after R41 suffered a fall on [DATE]. Surveyor did not find any other significant interventions implemented for R41's fall. -On [DATE], R41 had an unwitnessed fall, found on floor. Surveyor reviewed R41's EHR and did not find documentation of neuros completed for R41 after [DATE] fall per the facility policy. Surveyor did not find any significant interventions implemented for unwitnessed fall. -On [DATE], R41 had an unwitnessed fall, found on floor. -On [DATE], R41 had witnessed fall by wife. R41 fell out of recliner. On [DATE] 10:14 AM, Surveyor observed R41 sitting against wall in dining room. On [DATE] at 1:33 PM, Surveyor observed Trained Medication Aide (TMA) V and CNA R transfer R41 from dining room chair and ambulate with R41 down hallway to room. Surveyor observed R41 very unsteady on R41's feet and staff highly encouraged R41 to stand straight and take steps forward. Surveyor did not see TMA V and CNA R utilize a gait belt when ambulating R41. Surveyor observed staff holding onto R41's hands, and R41 kept trying to let go of staff's hands while walking down the hallway towards R41's room. Surveyor did not observe a chair at the nurse's station to provide R41 a rest with R41's unsteadiness. On [DATE] at 1:45 PM, Surveyor interviewed TMA V and asked if R41 should have gait belt on when ambulating to room from dining room. TMA V indicated that R41 should have gait belt on because R41 is sometimes unsteady with gait. On [DATE] at 8:33 AM, Surveyor observed CNA U, CNA T, and CNA R enter R41's room. Surveyor observed CNAs provide peri cares and get R41 up for the day. Surveyor observed CNA U and CNA R swing R41's legs over to the edge of bed and sit R41 up. CNA U and CNA R stood R41 up by grabbing hands and under arm pits to a standing position. CNA U and CNA R had R41 take a step forward and tried to get R41 to lift feet to place shoes on. R41 was confused and did not cooperate well. CNA U and CNA R had to sit R41 back down in the bed and then CNA U suggested to CNA R to apply gait belt. CNA R applied gait belt. Upon placing shoes onto R41, CNAs let go of R41 while R41 was leaning in bed, and R41 fell backwards and hit R41's head into the wall. CNAs quickly grabbed under arms and gait belt and lifted R41 forward to sitting position. CNA R rubbed back of R41's head and finished getting R41 up out of bed. CNA R and CNA U ambulated R41 out of room and down the hall. Surveyor did not observe a chair at the nurse's station to provide R41 a rest with R41's unsteadiness. On [DATE] at 9:42 AM, Surveyor interviewed CNA U and asked if R41 is supposed to have gait belt on when ambulating or transferring. CNA U indicated that CNA U should have told CNA R to apply gait belt before CNA U and CNA R stood R41 up the first time. On [DATE] at 1:20 PM, Surveyor interviewed CNA U and asked if CNA U had reported R41's fall and hitting head to appropriate staff on duty. CNA U indicated that CNA U reported the event to MDS Coordinator P who was on floor at the time. CNA U indicated that once MDS Coordinator P reported off the floor to RN Q, then CNA U reported to Registered Nurse (RN) Q that R41 had fallen and hit head on wall. On [DATE] at 1:31 PM, Surveyor interviewed RN Q what time RN Q came on shift. RN Q indicated that RN Q arrived around 10:00 AM. Surveyor asked RN Q if RN Q was told in report any issues or concerns with R41. RN Q indicated that only issue that was reported was the staff member who had almost passed out. Surveyor asked RN Q if RN Q was aware that R41 fell backwards in bed and hit R41's head on the wall. RN Q indicated that RN Q did not know about the fall and needs to do something immediately. Surveyor asked RN Q what the facility policy is for resident falls. RN Q indicated that staff should report the fall to nursing. Nursing should have assessed R41, completed vitals, neuros, and notified provider right away. RN Q indicated that next steps would be to open a risk management incident and follow facility protocol. Surveyor asked RN Q if the proper measures have been completed for R41. RN Q indicated no none of this has been done as this is the first time RN Q was notified of the event. RN Q asked Surveyor to follow Surveyor upstairs to MDS Coordinator P's office on 3rd floor to ask MDS Coordinator P about the incident. On [DATE] at 1:45 PM, Surveyor interviewed MDS Coordinator P and asked if MDS Coordinator P was told in report any issues or concerns with R41. Surveyor asked MDS Coordinator P if MDS Coordinator P was aware that R41 fell backwards in bed and hit R41's head on the wall. MDS Coordinator P indicated that MDS Coordinator P did not know about the fall. Surveyor asked MDS Coordinator P what the facility policy is for resident falls. MDS Coordinator P indicated that staff should report the fall to nursing. MDS Coordinator P indicated staff should have assessed R41, completed vitals, neuros, and notified provider right away per the facility falls policy. On [DATE] at 2:33 PM, Surveyor interviewed Director of Nursing (DON) B and asked if DON B was notified of R41 falling this morning. DON B indicated that MDS Coordinator just left DON B's office and made DON B aware of the issue. DON B indicated the correct process that staff should have completed for R41 this morning would be immediately start a risk management incident and complete the work up that includes assessment of R41, vitals, neuros, contact provider and POA, and continue to follow up with frequent assessments through the day. Surveyor indicated to DON B that Surveyor could not find that any of the actions for R41 falling were completed. DON B indicated that staff would get on top of the incident right away and that it was not completed for R41. Surveyor indicated to DON B that Surveyor observed TMA V and CNA R transfer R41 from dining room to bedroom without gait belt. Surveyor observed CNA U and CNA R transfer R41 from bed to standing position and R41 took a step forward and was wobbling in place. Surveyor indicated to DON B that R41 was unsteady on R41's feet and CNA U asked R41 to lift each foot to place shoes on but R41 could not without swaying backwards and to the side. CNA U and CNA R then sat R41 down on the bed and applied gait belt. DON B indicated that staff should always use gait belt with R41 when R41 is standing and ambulating. On [DATE] at 9:23 AM, Surveyor observed CNA U and CNA R set R41 in R41's recliner. Surveyor did not observe R41 to have a Dycem pad in R41's recliner. Surveyor interviewed CNA U and CNA R and asked if R41 has a dycem pad in R41's recliner. CNA U and CNA R indicated there is no Dycem pad in R41's recliner and never has been. Surveyor had CNA U and CNA R check R41's closet. CNA U indicated there is no Dycem pad in R41's closet and has never seen one. Surveyor observed no grip strips in front of recliner in R41's room. On [DATE] at 9:23 AM, Surveyor observed CNA U and CNA R set R41 in R41's recliner. Surveyor did not observe R41 to have a Dycem pad in R41's recliner. Surveyor interviewed CNA U and CNA R and asked if R41 has a Dycem pad in R41's recliner. CNA U and CNA R indicated there is no Dycem pad in R41's recliner and never has been. Surveyor had CNA U and CNA R check R41's closet. CNA [NAME] indicated there is no Dycem pad in R41's closet and has never seen one. Surveyor observed no grip strips in front of recliner in R41's room. On [DATE] at 11:21 AM, Surveyor interviewed DON B and asked if any neuros were completed for R41's previous fall on [DATE]. DON B indicated that DON B does not see any neuros completed for R41 post fall for [DATE], [DATE], [DATE], nor for [DATE]. DON B indicated there were no new interventions put into place post falls for [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. DON B indicated that DON B was unaware of the lack of interventions put into place post falls and would be educating staff on correct expectation. Surveyor indicated to DON B that after R41's fall on [DATE], staff care planned for R41 to have a chair in hallway at nurses' station for R41 to sit and rest while ambulating. Surveyor did not observe a chair at the nurses' station readily available for R41. DON B indicated that staff should have had a chair out at the nurses' station as R41's care plan states to have chair at nurses' station readily available for unsteadiness or exhaustion. Surveyor asked DON B what occurred with the intervention of a medication review post fall for R41 on [DATE]. DON B indicated that there was not a med review until [DATE] and should have been completed for R41 back in September when R41 fell . Example 2 Facility policy titled, Call light, dated, [DATE],states in part, .Policy Explanation and Compliance Guidelines: #7. The call system must be accessible to the resident at each toilet and bath or shower facility. The call system should be accessible to a resident lying on the floor. #8. Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied . (Examples include: replace Call light, provide a bell or whistle, increase frequency of rounding, etc) . Record review identified R57 was admitted to the facility on [DATE] with following diagnoses, in part, vascular dementia moderate with delusional behaviors, dysphagia, cerebral infarction due to embolism, and essential hypertension. On [DATE] at 7:22 AM, Surveyor observed CNA U look out of bath house and ask TMA V for assistance as R57 was falling forward out of the bath chair. TMA V indicated to CNA U that TMA V will send someone in as soon as TMA V sees someone walking by. Surveyor observed CNA U go back in bath house. On [DATE] at 7:26 AM, Surveyor entered bath house to observe CNA U with R57. Surveyor observed R57 sitting back in bath chair. CNA U indicated that CNA U assisted R57 back into bath chair. On [DATE] at 7:28 AM, CNA U asked Surveyor if Surveyor could wait in bath house while CNA U goes to get a brief CNA U forgot for R57 in R57's room. Surveyor indicated to CNA U that Surveyor cannot be left alone to supervise R57. Surveyor asked CNA U if this happens often where CNA U will leave R57 in bath house in bath chair. CNA U stated, Not usually, just thought since another person was here, I could grab it since i forgot it. Surveyor asked CNA U what CNA U would normally do. CNA U indicated that CNA U would normally call for assistance. Surveyor looked around for call light and could not find one. Surveyor asked CNA U where the call light was in the bath house. CNA U pointed to the wall near shower and stated, We use to have one in here, but maintenance took it out and placed this panel over the hole. Surveyor asked CNA U what if there is an emergency or like the situation that just occurred when CNA U needed assistance because R57 was falling forward out of the bath chair. CNA U stated, I would peek my head out the door or scream really loud for help. Surveyor asked CNA U if CNA U has any walkie talkies to ask for assistance. CNA U indicated that CNA U does not have walkies. Surveyor then observed CNA U pop head back out from the bath house and ask for assistance. Lack of a call light in the bath house has the potential to affect 21 residents on the second floor. On [DATE] at 7:35 AM, Surveyor observed CNA T enter bath house to assist CNA U with transfer of R57. CNA U and CNA T began pushing stand lift to R57 and instructed R57 to help stand. CNA U and CNA T grabbed underneath R57's arm pits and began lifting. Surveyor did not observe CNAs utilize a gait belt when lifting R57 from bath chair. Surveyor observed CNA U take a dry towel and wipe R57's groin and buttock area without wearing gloves. CNA U then dropped the dry towel as R57 was dropping to sit down. Surveyor observed CNA U don gloves and CNA U and CNA T began standing R57 again. CNA U then used dry towel again to dry off groin area and buttock area. Surveyor observed R57 drop again to sitting on bath chair. CNA U then instructed R57 to stand again while CNA U pulled brief and pants up for R57 with soiled gloves. Surveyor observed R57 was weak and difficult to stand. Surveyor observed R57 kept dropping down to sit instead of standing. CNA U and CNA T had to re-lift R57 under R57's arm pits 5 times before CNA U could pull R57's brief and pants up. On [DATE] at 7:51 AM, Surveyor interviewed CNA U and CNA T. Surveyor asked if CNA U and CNA T should use a gait belt with transfers from bath chair to stand lift as R57 kept dropping to sit down due to weakness. CNA U indicated that usually R57 is easy to stand but today R57 must be feeling weak. CNA U indicated to Surveyor that CNA U probably should have used gait belt instead of lifting under R57's arm pits. On [DATE] at 10:01 AM, Surveyor interviewed Maintenance Director W and asked if Maintenance Director W knew there was no call light in the bath house on second floor. Maintenance Director W indicated that Maintenance Director W was not aware and unsure time frame that the call light became inactive. Surveyor asked Maintenance Director W to visualize no call light in the bath house on second floor. Surveyor and Maintenance Director W entered bath house on second floor. Maintenance Director W observed no call light near the shower where all call lights are supposed to be located. Maintenance Director W observed further in the back of bath house where the bathtub was, and Maintenance Director W indicated there was no call light for that either. Maintenance Director W indicated it is necessary to have a call light in the bath house. Maintenance Director W indicated there must have been a work slip put in a while back and something went wrong that one of the Maintenance Technicians must have taken light out, capped the hole to prevent water from getting in there and then never came back to re-install a call light in bath house. Surveyor asked Maintenance Director W if Maintenance Director W could find when the work slip was placed and how long the call light system has been inoperable. On [DATE] at 10:59 AM, Surveyor interviewed DON B and asked DON B if DON B had knowledge there was not a call light in the bath house on second floor down North wing. DON B indicated that DON B was unaware of a call light issue in the bath house on second floor, which could affect 21 residents on that floor. DON B indicated that all CNAs have walkie talkies that staff utilize if they do need assistance. Surveyor indicated to DON B that Surveyor interviewed CNAs, and CNAs noted they do not have walkie talkies on them. Surveyor asked DON B what DON B would consider to be appropriate for using to call for assistance when CNAs don't have the walkie talkie on them. DON B stated, I guess the CNAs will need to yell out for help. On [DATE] at 8:45 AM, Maintenance Director W approached Surveyor and indicated that Maintenance Director W could not find the work slip that bath house on 2nd floor call light had issues and wasn't working. Maintenance Director W indicated to Surveyor that sometimes staff let maintenance crew know verbally about issues and Maintenance Director W knows that call light has been in failure for at least the last month. 40181 Example 3 R58 was admitted to the facility on [DATE] with the following diagnoses in part, unspecified dementia with psychotic disturbance, Alzheimer's disease, age-related physical debility, osteoporosis, unspecified visual disturbance, weakness, and abnormalities of gait and mobility. R58's Minimum Data Set (MDS) assessment, dated [DATE], identified R58 had a Brief Interview for Mental Status score of 03 out of 15, which indicated R58 had severe cognitive impairment. The MDS identified R58 had disorganized thinking behaviors that fluctuated and varied in severity. R58 also had hallucinations and delusions present during the MDS assessment period. R58 had a fall risk assessment score of 20 on [DATE] which indicated R58 was high risk for falls. R58 had two recent falls resulting in a left humerus fracture and a left femoral neck fracture. R58 had the following care plan focus in place: At risk for falls r/t [related to] history of repeated falls r/t Confusion, Deconditioning, Gait/balance problems, Unaware of safety needs. She is non compliant with wearing her knee brace and her sling. Has order brace and for knee brace and arm sling. She does not use assistive device as recommended for ambulation. She lowers herself to her knees to go in her drawers or look for something and gets herself up and also to clean up spills or just wipe up on the floor. She attempts to rearrange furniture. [DATE]- Fall [DATE]- Fall [DATE]- [R58] was witness to lose her balance and regain her balance when she stumbled. She did not fall but she did report this as a fall. [DATE]- Fall [DATE]- Fall [DATE]- Fall [DATE]-Fall Date imitated [DATE] Goal: [R58] will be free of falls through the review date and not sustain serious injury through the review date. Date Initiated: [DATE] Revision on: [DATE] Interventions: [DATE]- Being sent out to ER. Date Initiated: [DATE] [DATE]- [NAME] has been removed from my room for safety. Date Initiated: [DATE] [DATE]- encourage wearing tennis shoes when up in my wheelchair. Date Initiated: [DATE] [DATE]- Soft touch call light in place. Date Initiated: [DATE] [DATE]- Resident was moved to a different room once returned back from ER. Date Initiated: [DATE] [DATE]- Resident placed on direct 1:1. Update-[DATE]- Direct 1:1 supervision-Staff to stay with her at all times. Stay at arm's length of her. Arrange for 1:1 replacement to be with [R58] at all times before leaving her. Date Initiated: [DATE] Revision on: [DATE] [DATE]. Encourage [R58] to be in the social areas at all times when not in bed. Date Initiated: [DATE] [DATE]- Grippy socks to be worn when out of bed. Date Initiated: [DATE] Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Date Initiated: [DATE] Revision on: [DATE] Encourage to transfer/change positions slowly. Date Initiated: [DATE] Revision on: [DATE] Ensure that the resident is wearing appropriate non-skid footwear when ambulating or mobilizing in w/c. Date Initiated: [DATE] Revision on: [DATE] Pt evaluate and treat as ordered or PRN. Date Initiated: [DATE] Recreation Dept. provided [R58] with a laundry/cleaning cart to fold linens and dust to help keep her busy. Supervise her with this activity. Date Initiated: [DATE] Remind, Educate, assist [R58] to wear her knee brace and sling as ordered. Date Initiated: [DATE] Revision on: [DATE] S/P Fall [DATE] Intervention Toilet [R58] every ,d+[DATE] hours and as needed. Date Initiated: [DATE] Revision on: [DATE] R58's Activities of Daily Living self-care performance deficit care plan had the following intervention in place, .TRANSFER: Stand pivot transfer with assist of 1, using gait belt. Date initiated: [DATE] Revision on: [DATE] . R58 had the following treatment orders in place, dated [DATE], Direct 1:1 supervision-Staff to stay with her at all times. Stay at arm's length of her. Assigned 1:1 staff member needs to Arrange for 1:1 replacement to be with [R58] at all times before leaving her. On [DATE] at 6:41 AM, Surveyor observed the ambulance team arrive on 3rd floor with a stretcher and Nursing Home Administrator (NHA) A directed them to R58's room. Surveyor asked NHA A what happened and NHA A said R58 fell again and hit her head and she was being transferred to the hospital for evaluation. On [DATE] at 7:52 AM, Surveyor interviewed Licensed Practical Nurse (LPN) K, who was working at the time of R58's most recent fall. LPN K stated she was sitting at the nurses' station completing end of shift documentation when she heard a thump and then a female voice swearing down the hall. LPN K had just sent the Certified Nursing Assistant (CNA) downstairs to take out trash, so she was the only one on the floor other than the 1:1 CNA in R58's room. LPN K got up and checked all the rooms on the hall where the sound came from, but didn't go into R58's room first because CNA L was in that room providing 1:1 care. When LPN K did not find any problems in the other rooms, she entered R58's room and CNA L was just coming to the door of the room and stated R58 fell . LPN K stated R58 was lying in bed and rubbing the back of her head when LPN K entered the room. R58 had the gait belt around her waist and gripper socks on. LPN K immediately assessed and felt a lump at the back of R58's head, but no bleeding or break in skin observed. LPN K did neuro checks and vital signs and assessed for any other injuries, but did not find any other injuries. They applied an ice pack to the back of R58's head, called Director of Nursing (DON) B, notified the provider and got orders to transport R58 to the hospital for evaluation. LPN K asked CNA L what happened and CNA L stated she was assisting R58 with a transfer while holding the wheelchair and instructing R58 to turn and sit in the chair. R58 turned and sat on the very edge of the bed instead and slid off and landed on the floor, hitting her head on the side rail. Surveyor asked if CNA L was holding the gait belt to assist with the transfer. LPN K was not sure, but said it sounded like CNA L was not holding the gait belt, but behind the wheelchair. Surveyor asked if R58 was safe to transfer with just one staff person. LPN K stated R58 was assessed as a one-person transfer with a gait belt. Surveyor asked what that meant. LPN K stated staff should hold onto the gait belt during the transfer. Surveyor asked if CNA L put R58 back in bed before a nurse completed an assessment on R58. LPN K stated R58 was lying in bed when LPN K entered the room, so CNA L must have put R58 in bed. On [DATE] at 8:32 AM, Surveyor interviewed Physical Therapy Assistant (PTA) M who stated she worked with R58 and was familiar with R58's safety issues and therapy-approved transfer status. PTA M stated R58 was safe with a one-person transfer using a gait belt. Surveyor asked what that meant. PTA M stated staff should have the gait belt securely around the resident's torso and should be holding the gait belt and supporting and guiding the resident to pivot when doing a transfer. On [DATE] at 8:46 AM, Surveyor interviewed DON B about R58's fall earlier that morning and asked if they interviewed CNA L about R58's fall. DON B stated they interviewed CNA L prior to sending her home. CNA L reported R58 was seated in the wheelchair folding laundry while CNA L carried bags of soiled laundry and trash to the doorway of the room for end of shift. CNA L turned and observed R58 stand from the wheelchair and before CNA L could get to R58, R58 turned and sat at the very edge of the bed. R58 then slid off to the floor and hit her head on the bed. CNA L got LPN K who assessed R58. Surveyor asked DON B if CNA L followed the care plan to stay within arms length of R58. DON B stated CNA L stated she had carried bags to the door when R58 stood and fell . Surveyor asked if CNA L transferred R58 back into bed before a Registered Nurse assessed R58 for injuries. DON B stated CNA L did transfer R58 to bed before calling for help. Surveyor asked if that was an acceptable practice, DON B stated no, the nurse should have assessed R58 before moving her. DON B stated they pulled CNA L from the floor and provided immediate education on the fall policy and procedure and the need to have nurse assess residents before moving them after a fall.

Based on interview and record review the facility did not provide written notice of bed-hold policy to the resident or their representative for 5 of 6 residents (R) reviewed for hospitalization. (R58, R68, R25, R57, and R41) Findings include: Example 1 R58 was admitted to the facility on [DATE]. R58 had a Brief Interview for Mental Status (BIMS) score of 08/15, indicating R58 had moderate cognitive impairment. The record identified R58 had a legal guardian who was responsible for R58's medical decision-making. The record showed R58 was hospitalized on [DATE] and on 02/04/25 after falls at the facility. On 03/10/25 at 1:39 PM, Surveyor interviewed R58's legal guardian who reported the facility did call before transferring R58 to the hospital, but the guardian did not remember receiving anything in writing about a bed-hold policy. Surveyor reviewed R58's medical record and was not able to find a written bed-hold notice for the hospitalizations. Surveyor requested copies of the written bed-hold notice for the two hospitalizations. On 03/11/25 at 12:15 PM, Surveyor received a copy of a bed-hold notice document for R58's hospital transfer on 01/25/25, but did not receive a bed-hold notice for the hospital transfer on 02/04/25. On 03/11/25 at 3:48 PM, Surveyor interviewed Nursing Home Administrator (NHA) A about the missing bed-hold notice form for R58's hospital transfer on 02/4/25. NHA A stated they usually do provide a written bed-hold and notice of transfer to residents or their representatives when someone is sent to the hospital, but some of them did not get completed. Example 2 R68 was admitted on [DATE] from acute care hospitalization after a fall. R68 had a BIMS score of 13/15, indicating R68 was cognitively intact. R68 was her own decision-maker. The medical record identified R68 was hospitalized with urosepsis on 12/26/24. Surveyor was unable to identify a written bed-hold notice document on R68's record. On 03/12/25 at 2:40 PM, Surveyor interviewed NHA A about the written bed-hold notice for R68's transfer to the hospital on [DATE]. NHA A stated there was no bed-hold notice completed for R68's transfer to the hospital due to a misunderstanding. They have identified the problem and have begun education to correct this problem. Example 3 R25 was admitted to the facility on [DATE]. Diagnoses included lung cancer, diabetes mellitus, repeated falls, malnutrition, and kidney failure. R25's MDS assessment completed 02/21/25, confirmed R25 scored 09/15 during BIMS, indicating moderately impaired cognition. R25 was hospitalized [DATE]-[DATE] for sepsis related to urinary tract infection. Surveyor was unable to locate written notice of bed-hold in R25's record. Example 4 Record review identified R57 was admitted to the facility on [DATE] with the following diagnoses including vascular dementia moderate with delusional behaviors, dysphagia, cerebral infarction due to embolism, and essential hypertension. R57's medical record identified R57 was transferred to the hospital on [DATE]. No written notice of bed hold policy was identified in R57's medical record. Example 5 Record review identified R41 was admitted to the facility on [DATE], with following diagnoses including Alzheimer's disease, atherosclerotic heart disease, essential primary hypertension, and depression. R41's medical record identified R41 was transferred to the hospital on [DATE]. No written notice of bed hold policy was identified in R41's medical record.

Based on interview and record review, the facility did not provide written notice of transfer to the resident or their representative and did not send a copy of the notice of transfer to the hospital to a representative of the Office of the State Long-Term Care Ombudsman for 6 of 6 residents (R) reviewed for hospitalization. (R58, R68, R10, R25, R57, and R41) Findings include: Example 1 R58 was admitted to the facility on [DATE]. R58 had a Brief Interview for Mental Status (BIMS) score of 08/15, indicating R58 had moderate cognitive impairment. The record identified R58 had a legal guardian who was responsible for R58's medical decision-making. The record showed R58 was hospitalized on [DATE] and on 02/04/25 after falls at the facility. On 03/10/25 at 1:39 PM, Surveyor interviewed R58's legal guardian who reported the facility did call before transferring R58 to the hospital, but the guardian did not remember receiving anything in writing. Surveyor reviewed R58's medical record and was not able to find a written notice of transfer for the hospitalizations. Surveyor requested copies of the written notice of transfer for the two hospitalizations. On 03/11/25 at 12:15 PM, Surveyor received a copy of a bed-hold/notice of transfer document for R58's hospital transfer on 01/25/25, but did not receive a bed-hold/notice of transfer document for the 02/04/25 hospital transfer. Surveyor reviewed the list of resident discharges and hospital transfers that was sent to the Ombudsman for January and February 2025. R58's hospital transfers on 01/25/25 and 02/04/25 were not on the list sent to the Ombudsman. On 03/11/25 at 3:48 PM, Surveyor interviewed Nursing Home Administrator (NHA) A about Ombudsman notification of discharges and transfers. NHA A stated they had sent notification of discharges to the Ombudsman, but they did not send the list of residents who were transferred to the hospital due to a misunderstanding. They were working on sending that now. Surveyor asked again for the bed-hold/notice of transfer form for R58's hospital transfer on 02/4/25 that was not received previously. NHA A stated they usually do provide a written bed-hold and notice of transfer to residents or their representatives when someone is sent to the hospital, but some of them did not get completed. Example 2 R68 was admitted on [DATE] from acute care hospitalization after a fall. R68 had a BIMS score of 13/15, indicating R68 was cognitively intact. R68 was her own decision-maker. The medical record identified R68 was hospitalized with urosepsis on 12/26/24. Surveyor was unable to identify a written notice of discharge/transfer to the hospital document on R68's record. Surveyor reviewed the list of discharges/hospital transfers sent to the Ombudsman for the month of December and R68 was not on the list. On 03/12/25 at 2:40 PM, Surveyor interviewed NHA A about the written notice of transfer and Ombudsman notification for R68's transfer to the hospital on [DATE]. NHA A stated there was no bed-hold/notice of transfer or Ombudsman notification completed for R68's transfer to the hospital due to a misunderstanding. They have identified the problem and have begun education to correct this problem. Example 3 R10 was admitted to the facility on [DATE]. Diagnoses included depression, dementia, mood disturbance, and anxiety. R10's MDS assessment completed on 02/21/25 confirmed R10 scored 13/15 during BIMS indicating intact cognition. R10 is dependent on staff for transfers to the toilet and dressing lower body. R10 requires substantial assistance with bathing, showering, and personal hygiene. R10 was hospitalized [DATE]-[DATE] related to chest pain. On 03/12/25 at 9:01 AM, Surveyor reviewed the list of hospital transfers/discharges provided to the Ombudsman for the month of February. Surveyor noted R10 was not included in the list. Example 4 R25 was admitted to the facility on [DATE]. Diagnoses included lung cancer, diabetes mellitus, repeated falls, malnutrition, and kidney failure. R25's MDS assessment completed 02/21/25, confirmed R25 scored 09/15 during BIMS, indicating moderately impaired cognition. R25 was hospitalized [DATE]-[DATE] for sepsis related to urinary tract infection. On 03/12/25 at 9:01 AM, Surveyor reviewed the list of hospital transfers/discharges provided to the Ombudsman for the month of February. Surveyor noted R25 was not included in the list. Example 5 Record review identified R57 was admitted to the facility on [DATE] with the following diagnoses including vascular dementia moderate with delusional behaviors, dysphagia, cerebral infarction due to embolism, and essential hypertension. R57's medical record identified R57 was transferred to the hospital on [DATE]. On 03/12/25 at 8:24 AM, Surveyor did not receive the bed hold notification form for R57's hospitalization on 03/02/25 and did not receive a written notice of discharge or transfer form. Example 6 Record review identified R41 was admitted to the facility on [DATE], with the following diagnoses including Alzheimer's disease, atherosclerotic heart disease, essential primary hypertension, and depression. R41's medical record identified R41 was transferred to the hospital on [DATE]. On 03/12/25 at 8:24 AM, Surveyor did not receive the bed hold notification form for R41's hospitalization on 08/06/24 and did not receive a written notice of discharge or transfer form.

Based on observation, interview and record review, the facility did not ensure 3 of 3 residents reviewed for pressure injuries (R69, R59 and R39), received care consistent with professional standards of practice in relation to prevention or worsening of pressure injuries (PI). - R59 developed two Stage 3 pressure injuries while in the facility that then became unstageable. R59 had no care plan for pressure injuries and did not have heel suspension boots provided for Stage 3 heel pressure injuries. The facility did not provide an appropriate mattress to promote healing. - R69 has a history of Stage 3 pressure injuries (PIs) to his heels. The facility did not encourage repositioning or protective device placement to prevent decline. The PI assessment did not have full description of the wounds, such as physical characteristics of the wound bed and periwound condition, presence or absence of pain, wound edges, sinus tracts, undermining, tunneling, necrotic tissue, odor, presence/absence of granulation tissue, and epithelialization. -R39 did not have comprehensive weekly wound assessments to monitor and ensure healing and prevent infection. This is evidenced by: The NPIAP advises, For individuals with Stage 3 or greater heel pressure injury elevate the heels with a specifically designed heel suspension device, offloading the heel completely . Example 1 R59 was admitted to the facility on [DATE]. R59's diagnoses include in part: Parkinson's, hallucinations, urinary retention, restlessness and agitation, dementia, unstageable left and right heel pressure injuries, adult failure to thrive, and muscle weakness. R59's Minimum Data Set (MDS) significant change assessment dated [DATE] states that R59 is usually understood and usually understands. Brief Interview for Mental Status (BIMS) has a score of 5 which indicates severe cognitive impairment. R59 requires extensive assist for bed mobility, transfers, locomotion, toileting, and hygiene. R59 is frequently incontinent of bowel and uses an indwelling foley catheter. R59 receives pressure reducing devices for bed and chair and has no current skin breakdown. Care Plan - There is no care plan related to Pressure Injury for R59. Braden Scale completed on 09/13/22 notes R59 is at moderate risk for pressure injuries. Surveyor reviewed weekly skin assessments, no assessments were completed by the facility staff, only by the visiting NP from Integrated Wound Care. ~10/19/22 Integrated Wound Care: Initial exam Stage 1 right heel change weekly and prn, stage 2 left heel change daily and prn. (This is the first documentation identifying a pressure injury) ~10/26/22 Integrated Wound Care: added bilateral blue boots. Mild odor noted to left heel. Progress note states no change. ~11/02/22 Integrated Wound Care: diagnosis changed to stage 3 pressure ulcers to both heels. Note on left heel states dry black eschar. Left heel measures 2cm x 2cm x 0.1cm. ( Black eschar is unstageable, therefore there is an error that the physical exam does not match the diagnoses). ~11/09/22 Integrated Wound Care: Progress note states no change. Noted dry scab on both heels. Left heel measures 1.5cm x 1.5cm x 0.1cm. ~11/16/22 Integrated Wound Care: Both heels unstageable 100% eschar both heels both tender with cleansing but progress note states no change. Weekly assessments were completed for the pressure injuries and the physician was updated with changes. Physician orders include: ~04/07/22 Wound care to coccyx identified as moisture associated skin damage. Protect with bordered foam. Change as needed. Off load pressure frequently as needed for wound care. ~10/20/22 Elevate footrest to relieve pressure on heels every shift for wound care orders. ~11/17/22 wound care to right and left heels. Cleanse with wound cleanser and apply bordered foam. Change weekly and as needed with soiling. Float heels off recliner. The heel boots noted on the 10/26/22 NP assessment above were discontinued, and pillows were used as of 11/17/22 in the recliner. The facility provided no evidence that a heel suspension boot was being used in October. There is no other direction on use of the pillow or boots for when R59 is in bed. On 11/29/22 at 7:26 AM, Surveyor observed that R59 had heels wrapped with ace bandages and there was no air mattress on the bed. Certified Nursing Assistant (CNA) M entered R59's room and explained that R59 has sores on both heels, coccyx. Surveyor observed pillows being used under the heels of R59 when in the recliner during the 4 day survey. The pillow does not provide offloading for the Stage 3 pressure injury, as a heel suspension boot would. On 11/30/22 at 2:20 PM, Surveyor reviewed type of mattress and manufacturer instructions that was provided by Director of Nursing (DON) B. Mattress is a Medline Hi-Resiliency Waffle Foam used for those at high risk for pressure ulcers or have stage 1 and/or stage 2 pressure ulcers for residents admitted to the facility. R59 obtained ulcers at a stage 3 or more, which was determined on 11/02/22, this would no longer qualify R59 for this type of mattress. On 12/01/22 at 11:24 AM, Surveyor asked DON B what interventions would you expect from your staff when a resident develops a pressure ulcer. DON B's response, Repositioning, change mattress, offloading, and weekly skin tracking. I am new to this position and will be taking wound classes. Surveyor informed DON B of concerns regarding no care plan for Pressure injury, lack of heel suspension boots and the mattress that was not effective for Stage 3 PIs. 17661 Example 2 According to Prevention and Treatment of Pressure Ulcers Quick Reference Guide, NPIAP (National Pressure Injury Advisory Panel) 2019, EPUAP (European Pressure Ulcer Advisory Panel), and PPPIA (Pan Pacific Pressure Injury Alliance), 2014 Pressure Injury Assessment should be conducted initially and reassessed at least weekly. R69 has medical diagnoses that include but are not limited to Vascular Dementia with Behavioral Disturbance, Anxiety Disorder, Type 2 Diabetes Mellitus, Vitamin D Deficiency, Severe Protein-Calorie Malnutrition, Chronic Kidney Disease Stage 3, Avoidance Personality Disorder, Conduct Disorder-Aggressive Behavior and recently, Sepsis Methicillin Susceptible Staphylococcus Aureus. A review of R69's Minimum Data Set Assessments (MDSAs) completed by the facility were completed. This consisted of an Admission assessment dated [DATE] and a Significant Change in Status assessment (SCSA) dated 9/12/22. According to these assessments, R69 requires extensive staff assistance with basic Activities of Daily Living (ADL) tasks such as bed mobility, transfers, dressing, bathing, personal hygiene and toileting. He is nonambulatory. R69 is frequently incontinent of bladder function and always incontinent of bowel function. R69 has a Brief Interview of Mental Status score of 8/15, indicating moderate cognitive impairment. According to these assessments, upon admission to the facility (7/11/22), R69 had no PIs. The SCSA coded R69 as having 2 facility acquired PIs located one on each heel, each coded as Stage 3, in which R69 developed Septicemia. R69 was coded as refusing cares. A review of the Care Plan developed for R69 was completed and Surveyor noted the following: 7 .Resident has hx of using threatening gestures towards staff, and not keeping boots on feet as prescribed (Initiated-7/13/22 and last revised on 9/2/22) Interventions for this plan included: - Resident is often non compliant with heel boots, leaving heels elevated, repositioning, and ADLS. Continue to encourage heel boots, repositioning, elevated heels, and ADLS as resident allows. - Monitor and document mood state/behaviors upon occurrence. 8. Alteration in skin integrity on both heels r/t continued pressure and shearing and coccyx area open (Initiated 8/13/22 and revised on 8/30/22) GOAL: Further breakdown of heels will be prevented with identified interventions. (Initiated 8/13/22, the Target Date for revision is listed as 9/25/22, which was not yet completed) Interventions: - Booties to feet as resident allows. Float heels as resident allows. (8/19/22) - Monitor skin integrity daily during cares. Weekly skin inspection by nurse. (8/13/22) - Treatment to open areas per order (8/13/22) - Turn and reposition or reminders to offload q 2-3 hours and PRN (8/13/22) - Has Air Mattress to bed. (8/31/22) On 11/28/22 at 3:02 PM, Surveyor interviewed Registered Nurse (RN) R regarding R69 and his wounds. RN R stated that R69 has two Stage 3 PIs, one on each heel, and that R69 is very noncompliant and won't wear the boots, won't float his heels and refuses wound care at times. RN R stated that when she completes the treatment to R69, she would notify Surveyor. On 11/29/22 at 7:00 AM, Surveyor noted R69 lying in bed on his back. An air mattress was underneath R69 and the heels were floating on two pillows, but the right leg was resting half on and half off the pillows so that heel was actually on the mattress. There were no Prevalon boots on either foot. At 9:29 AM, R69 was still in bed on his back as noted earlier. Note: The air mattress in use for R69 was a Stat 5000 C , set at a weight of 180 pounds. This mattress is effective for Stage 2 to Stage 4 PIs per the manufacturer's instructions. Surveyor then interviewed Certified Nursing Assistant (CNA) D, who was responsible for R69's care on this day. CNA D stated that she washed him up around 9:00 AM and that R69 accepted his morning cares but refused to get up for the day. At 11:13 AM, Surveyor noted R69 still in bed on his back as noted all morning. CNA D completed morning bathing for R69. Following cares, she adjusted R69's feet on two bed pillows for floating of his heels. She did not offer or attempt to assist R69 into a chair for the day, nor did she offer or attempt to put on the Prevalon boots. CNA D also did not offer or encourage R69 to position onto his side to alleviate pressure on the heels. She then left the room. R69 was monitored by Surveyor throughout the rest of the morning, and various staff entered and exited his room, but none offered or attempted to get R69 up into the wheelchair, place the boots on his feet or reposition him onto a side to redistribute any pressure off of the heels. At 11:34 AM, Surveyor interviewed CNA D once again and asked what the expectations for R69 included. CNA D stated that R69 won't allow staff to reposition him onto his side. She further stated, We used to put a pillow at his back to keep him on his side, but he just takes it out and goes onto his back. Sometimes he will get up in the wheelchair, but most days, he wants to stay in bed. I can try to ask him. I didn't do that yet. When asked if she was to offer the boots for his heels, CNA D stated, We are supposed to put them on. I need to check the Care Plan again to make sure we are still to try them. I can try, but I didn't offer them this morning. I should have. Surveyor then approached LPN O regarding treatment conduction. LPN O stated that Integrated Wound Care (IWC) would be coming in on this day to conduct R69's treatment. LPN O stated the nurse comes in weekly to do all the treatments in the facility. Surveyor then reapproached LPN O and asked if he had completed any recent assessments of R69's wounds. LPN O stated that he observed the heels 4 -5 days ago and the right looks good, scabbed but the left continues to need dressing changes. LPN O stated that the facility nursing does not document wounds, the IWC nurse comes in and does the full assessment weekly and that she does the documentation. The only time facility nursing completes the assessments is if there is something out of the ordinary. An attempt to complete the treatment was made by LPN O and DON B; however, R69 adamantly refused. R69 had a PI care plan in place 8/13/22 with interventions. Surveyor reviewed the past month documentation of R69's existing pressure injuries and noted the following: - 10/26/22: IWC documentation: Right Heel: 2.0 cm L x 1.0 cm W with no drainage and 100% epithelial tissue; progress documented as No Change as remained a scabbed area and treatment remained unchanged Left Heel: 2.5 cm L x 2.5 cm W x 0.1 cm D with moderate Serous drainage and no odor with 100% granulation. Progress of wound was documented as No Change Still the treatment in place since 9/7/22 was not changed. - 11/2/22: IWC documentation: Right Heel: 2.0 cm L x 1.0 cm W x 0.1 cm D with moderate Serosanguinous drainage and 100% granulation. Progress documented as Improving when in fact, this is actually a decline in the wound with serosanguinous drainage Left Heel: 2.0 cm L x 2.0 cm W x 0.1 cm D with moderate Serosanguinous drainage and no odor, with 100% granulation; Progress documented as Improving Treatment to both heels was the former mentioned wound cleanser followed by Collagen Sprinkles, and ABD (abdominal) with Kerlix wrap daily and to float heels - 11/9/22: IWC documentation: Right Heel: 1.5 cm L x 0.5 cm W x 0.1 cm D with moderate serous drainage and 100% granulation. Progress of wound was documented as Improving Left Heel: 1.5 cm L x 1.5 cm W x 0.1 cm D with moderate amount serous drainage and 100% granulation. Wound progress documented as Improving - 11/16/22: IWC documentation: Right Heel: 1.5 cm L x 0.5 cm W with moderate serous drainage and no odor, dry scab. Progress documented as No Change No changes made to the treatment Left Heel: 3.5 cm L x 3.0 cm W x 0.1 cm D with moderate serosanguinous drainage and 100% granulation Note: the wound progress was documented as No Change when in fact, the wound worsened with the doubling of size and serosanguinous drainage versus the previous week with serous drainage. -11/23/22 No assessment was documented as being completed As with National Standards of Practice, there is no full description of the wounds, such as physical characteristics of the wound bed and periwound condition, presence or absence of pain, wound edges, sinus tracts, undermining, tunneling, necrotic tissue, odor, presence/absence of granulation tissue, and epithelialization in the weekly assessments. On 12/01/22 at 9:42 AM, Surveyor interviewed DON B regarding the expectations of repositioning and pressure injury prevention and care for R69, and complete assessments. DON B stated that staff should be offering R69 repositioning, to get up in the wheelchair and to place the boots on his feet. Staff need to make the attempt. If R69 refuses, then staff need to clearly document all refusals. DON B will be taking a wound class to improve documentation. 31086 Example 3 Review of R39's medical record documented current diagnoses dementia without behavioral disturbance, vascular dementia, anxiety disorder, major depressive disorder, obsessive compulsive disorder, anemia, pressure ulcer of sacral region, DM, and irritable bowel syndrome. Review of physician orders documented, in part: on 11/17/22 Wound Care: Left Coccyx Pressure Ulcer: Wound Cleanser. Hydrogel. Bordered foam. Change daily one time a day for related to PRESSURE ULCER OF SACRAL REGION, UNSPECIFIED STAGE Minimum Data Set (MDS) dated [DATE] quarterly assessment: Section M documented R39 at risk for pressure injury and has one stage 3 pressure injury. Review of previous MDS does not document R39 as having a prior pressure injuries. Review of progress notes: 10/16/2022 15:41 SBAR - Change of Condition Situation: Previously healed wound to left of tailbone has reopened. Open area is approx 1cm x 1 cm, depth is superficial. Surrounding skin is reddened, blanchable and appears dry. No Assessment (RN)/Appearance (LPN): Assessment: Open area is approx 1cm x 1 cm, depth is superficial. No drainage from site. Surrounding skin is reddened, blanchable and appears dry. Res states area is sore. Response: Area cleansed c wound cleanser, skin prepped and dressed c a foam dressing. Res advised to reposition frequently while in bed. Recommendations: No further facility wound documentation in the progress notes about the wound. Surveyor was provided wound documentation from a wound care company. The documentation dated 10/26/22 documented the wound as a stage 1 with measurements of 1 x 1 x 0.1 and is a dry ulcer. The assessment portion of the documented has a diagnosis of a pressure ulcer of sacral region, stage 2. The facility does not have their own nursing staff wound assessment. On 11/02/22, the wound care company documentation of the wound as a stage 3 with measurements of 0.8 x 0.8 x 0.2 with exudate of moderate Serosanguinous and 100% slough and recommended Santyl for treatment. The facility does not have their own nursing staff wound assessment and no physician notification of a change in condition. On 11/16/22, the wound care company documentation of the wound as a stage 3 with measurements of 0.5 x 0.5 x 0.2 with exudate of moderate serous and 100% slough and note as a dry ulcer. The facility does not have their own nursing staff wound assessment. The week of 11/23/22 the facility and wound care company do not have weekly wound documentation. Review of care plan: Alteration in skin integrity Date Initiated: 08/07/2020 Resident will remain free from skin breakdown Date Initiated: 08/07/2020 Revision on: 10/22/2020 Target Date: 01/30/2023 Air bed for Stage 3 pressure ulcer per MD. Date Initiated: 03/03/2022 Nurse Monitor skin integrity daily during cares. Weekly skin inspection by nurse. Date Initiated: 08/07/2020 NSG Document on skin condition and keep MD or PA-C informed of changes Date Initiated: 08/12/2021 On 11/29/22 at 9:28 a.m., Surveyor interviewed Licensed Practical Nurse (LPN) I asking about the open areas on the coccyx. LPN I indicated R39 is non-compliant with repositioning and is able to transfer self and bed mobility independently. Have tried an air mattress and R39 refused and when educated and requested to reposition resident would refuse or reposition and then position self back. R39 is obsessive with wiping buttocks when toileting and rubs the areas open again. 11/29/22 at 9:32 a.m., Surveyor observed LPN I provide wound care. When entering room R39 is in the bathroom. Surveyor observed R39 continually wipe buttock area with toilet paper, the toilet paper was not soiled and R39 continued to wipe the area. R39 was able to transfer self from toilet and walk with a walker to her bed. Areas on sacral area is red and dry and appears superficial and a red area in the center of the vertebrae and this is not open. Surveyor did not observe or identify a stage 3 open area on the buttocks. 11/29/22 at 11:45 a.m., Interview with Director of Nursing (DON) B asking about weekly wound documentation. The wound opened on 10/16/22 and was set to see wound clinic on 11/02/22. Surveyor asked was there a weekly wound assessment completed between 10/16/22 and 11/02/22. DON indicated it would have been her responsibility to complete the assessments and she had just started in this facility. Surveyor asked if there was an assessment completed for the week of 11/20/22. DON indicated the wound clinic did not come to the facility due to the holiday. Surveyor asked when the wound clinic is not scheduled to come into the facility, who would complete the weekly wound assessment. DON B indicated the nurses document on the wound daily. Surveyor asked who would complete the full assessment of measurements, description of wound bed, odors to compare to previous assessments to assess of a change. DON B indicated it would be her responsibility and the facility will have a nurse round with the wound clinic.

Based on observation, record review, policy review, and interviews the facility did not provide adequate assistive devices to prevent accidents for 1 (R1) out of 3 sampled residents reviewed for safe mobility using a power wheelchair. R1 has used a power wheelchair for greater than [AGE] years due to [CONDITION(S)] following a motor vehicle accident in 1998. R1 had no sensation and no movement of self from the lower chest area down and was taking a blood thinner to prevent blood clots. R1 was dependent on staff for transfers in and out of the power wheelchair. Once seated in the power wheelchair, R1 required 2 leg straps, one around the mid thigh and the other around the mid calf, to keep legs together and on the foot platform due to paraplegic status. These straps were not provided when R1 left the building on [DATE] in the power wheelchair. R1's legs fell off the platform and her right foot dragged four blocks on the sidewalk, causing significant bleeding. R1 was sent to the hospital via ambulance, treated for hypovolemic (low blood volume) shock to include intravenous fluids, intravenous antibiotics, and two units of packed red blood cells. Once R1 was medically stable, R1's 4th and 5th toes on the right foot were amputated and the remaining abrasions and toes were surgically debrided. R1 was readmitted to the facility following the hospital stay on [DATE]. The facility's failure to assess and care plan R1's safe power wheelchair use on all terrains and to implement a plan that would keep her safe created a finding of immediate jeopardy that began on [DATE]. Regional Director notified Director of Nursing of the immediate jeopardy on [DATE] at 3:00 p.m. The immediate jeopardy was removed on [DATE]; however, the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its removal plan. This is evidenced by: Surveyor requested and reviewed the policies titled, Power Operated Vehicle and Scooter Policy, and, Leave of Absence and Against Medical Advice Process and Acknowledgement Policy. The power chair policy included the completion of an assessment for the safe use of the power chair, residents acknowledgment and agreement to the safe handling of the power chair, and residents were provided a copy of the facility policy for power chair use. There was no evidence that R1 was provided with an assessment, policy, or acknowledgment of the use of power chairs. The LOA (Leave of Absence) process was for the resident to sign out on a form kept at the nursing desk. The form included the name of the resident, date and time of departure, signature of responsible person accepting responsibility for resident, destination, contact phone number, and expected time of return. R1 had been leaving the facility almost daily according to facility records, care plan, and staff interviews, however, R1 had never signed out using the LOA process so that the facility would know R1's destination and have the ability to assist R1 when on leave out of the building. R1 was admitted to this facility on [DATE] for 30 days of rehabilitation then discharge to home to live with daughter in Wisconsin. R1 was transferred from a sister nursing facility in Minnesota to this facility to establish residency in Wisconsin. R1 had the following, but not all inclusive, diagnoses: [CONDITION(S)], end stage renal (kidney) disease on [CONDITION(S)], heart failure, [CONDITION(S)] on [MEDICATION(S)], and post motor vehicle vehicle accident in 1998 that resulted in [CONDITION(S)]. According to the interdisciplinary progress notes, R1 was alert and oriented and able to make needs known. The facility completed an admission MDS (Minimum Data Set) assessment for R1 on [DATE], however, Section C, cognition, was not completed and there was no brief mental status interview conducted. On [DATE] at 12:50 p.m., Surveyor interviewed FM (family member of R1)-F. FM-F stated R1 had used a power wheelchair for decades and has had only one incident when R1's foot fell off of the platform and caused an ankle fracture. FM-F stated since that incident, R1 has used leg straps to secure both legs and prevent them from falling off of the platform. FM-F stated because R1 cannot move her legs, the use of the mid-thigh leg strap and mid-calf strap were imperative to keep R1's feet on the platform. FM-F also stated R1 was to wear utility style work boots on both feet once up in the power wheelchair to prevent the shoes from falling off and to protect R1's toes and feet in the event of an accident. FM-F stated at the time of admission, she had a phone conversation with NM (Nurse Manager)-D and SS (Social Service)-E regarding the need for the two leg straps once R1 was seated in the power wheelchair. FM-F stated R1 required staff to assist with the leg strap placement as R1 could not reach forward safely. In addition, FM-F stated she also reminded the transferring nursing facility to send the two leg straps along with the power wheelchair. Review of the activity care plan dated [DATE], R1 was, independent and uses power chair to enhance independence with paraplegic diagnosis. Resident likes to go outside and will frequently leave the building on her own in her power chair. Surveyor reviewed the comprehensive care plan and there was no other mention of the power wheelchair and donning 2 leg straps for R1. Review of the CNA (Certified Nursing Assistant) care plan had no additional information on R1's ability to safely use the power wheelchair or the need for the leg straps to secure R1's legs. On [DATE], at approximately 11:00 a.m., R1 left the facility in the power wheelchair and did not sign out or make her plans known per facility policy. R1 left without any cellular phone or means to call for help if needed. At approximately 11:30 to 12:00 noon, R1 came upon a young man mowing lawn. R1 stopped and asked the young man to help with her shoe and sock. The young man saw the extensive injuries with visible bone tissue to R1's right foot with the bleeding and called 911. R1 stated she, passed out and remembers waking up in the ambulance. According to the facility investigation that was initiated on [DATE], R1 was found on [NAME] Street which was four blocks from the facility. The police and ambulance arrived and the police noted a trail of blood extending four blocks and ending where R1 was seated in her power wheelchair with a pool of blood around R1's right foot. R1 was transferred to the hospital emergency department for treatment of right foot injuries. Surveyor requested a copy of the facility investigation, but these documents were not provided. DON-B (Director of Nurses) stated she had submitted the investigation; however, the evidence provided did not support the facility reported incident had been completed. On [DATE] at 12:50 p.m., Surveyor interviewed FM (family member R1)-F. FM-F stated she was told by the emergency department provider at the hospital R1 was not wearing any leg straps when R1 arrived on [DATE]. FM-F stated the police and local ambulance noted R1 had lost a shoe and sock and had left a blood trail for four city blocks before finding a bystander to call for help. FM-F stated the hospital emergency department provider told her R1 had lost a lot of blood and likely could have died within minutes of calling for help. Review of the hospital records did confirm FM-F statement about the absence of the right shoe. In addition, the hospital notes did state R1 passed out while waiting for the ambulance to arrive. The hospital history and physical noted hypovolemic shock with a low blood pressure of ,d+[DATE]. R1 was treated with intravenous fluids, intravenous antibiotics, and 2 units of packed red blood cells prior to surgery. R1 required amputation of the 4th and 5th toes on the right foot and debridement of the other remaining toes and an abrasion of the right foot. On [DATE] at 12:15 p.m., Surveyor interviewed DON-B regarding R1's power wheelchair incident. DON-B stated R1 was her own decision maker and had frequently gone outside using her power wheelchair. DON-B stated residents are expected to sign out if they want to leave the facility. DON-B stated she was alerted to R1's problems with the power wheelchair prior to the [DATE] event and had been proactive by requesting therapy evaluations of all power wheelchairs in the facility but stated that did not happen. DON-B stated she had reported her concerns with R1's power wheelchair to her superiors but again there was no support to get the power wheelchair assessments completed. DON-B stated the facility contracted therapy services. DON-B stated she was very displeased with therapy services regarding R1 and others with power wheelchairs. DON-B stated she did not recall how she learned of R1's problems with the power wheelchair and had made no other changes to R1's care plan. DON-B stated her inkling for problems regarding R1 was correct and stated she knew something bad could happen to R1 because of her power wheelchair. Surveyor asked if there were any other interventions to R1's safety and DON-B responded there were no other interventions considered. On [DATE] at 1:30 p.m., Surveyor interviewed RD (Rehab Director)-H regarding power wheelchairs. RD-H stated there had been no power wheelchair assessments completed prior to today. RD-H stated she was unaware of any power wheelchair assessments completed for R1 since her admission on [DATE]. RD-H stated R1's power wheelchair assessment would be done today. On [DATE] at 11:55 a.m. and again at 1:45 p.m., Surveyor interviewed OT (Occupational Therapist)-C who stated he had worked with R1 since the time of admission. OT-C stated on [DATE] he observed R1 in the power wheelchair but did not recall seeing any leg straps in place. OT-C stated R1 was safe with the power wheelchair for mobility but was totally dependent on staff for all lower body movement due to paraplegic status. OT-C stated R1 had mentioned the use of gait belts around her legs to keep legs securely on the platform; however there were no gait belts in place on [DATE] during the evaluation. Review of therapy evaluations and notes did not reveal any mention of leg straps or gait belts to be used to secure R1's legs. OT-C stated when evaluating a power wheelchair he assesses for safe mobility and also assesses for any current and additional modifications to the power wheelchair. OT-C stated the leg straps would be considered a modification to the standard power wheelchair. OT-C stated R1 had an incident on [DATE] when her feet came off of the foot platform and caused injuries to her toes. OT-C stated R1 was hospitalized and had two toes amputated due to the injury. OT-C stated R1 returned to the facility on [DATE] and planned discharge to live with daughter soon. OT-C stated R1 was awaiting a new power wheelchair but this was held up due to insurance issues. OT-C stated since R1's return from the hospital on [DATE], R1 used a manual wheelchair with elevating foot rest due to lower extremity [CONDITION(S)] since surgery. OT-C stated the power wheelchair R1 owned had an elevating foot rest feature but it was not working. OT-C also stated R1 was given a manual wheelchair because she was not safe to operate a power wheelchair at this time. OT-C did complete a power wheelchair evaluation for R1 on [DATE]. Noted in that evaluation was R1's feet fell off of the platform with minimal side pressure and a recommendation to modify the wheelchair with a padded foot box was made. On [DATE] at 2:06 p.m., Surveyor interviewed SS-E. SS-E stated she had a phone conversation on [DATE] from FM-F regarding R1's leg straps not in place on [DATE]. SS-E provided a copy of the email she sent on [DATE] to DON-B and others stating FM-F stated the leg straps need to be on anytime R1 was in the power wheelchair. The email further stated the transferring facility did not have a care plan indicating the use of leg straps. The email also stated information regarding R1's care plan and power wheelchair assessment were not provided to the facility at the time of the transfer. On [DATE] at 11:55 a.m., Surveyor observed LPN (Licensed Practical Nurse)-G complete R1's right foot dressing change. Surveyor observed the right foot which had sutures intact on the inner aspect of the distal right foot as well as at the amputation of the 4th and 5th toes. The great toe, 2nd, and 3rd toe all had healing abrasions on the dorsal (top) side. There was no evidence of infection. LPN-G cleaned the surgical incisions with normal saline then painted the incisions and abrasions with [MEDICATION(S)]. The incisions were covered with gauze and wrapped with kerlix. R1 experienced no sensation during the dressing change. There was moderate dependent [CONDITION(S)] of both legs and feet. The failure to assess and develop a care plan for R1's power wheelchair use on all terrains and to implement this plan created a finding of Immediate Jeopardy. The facility removed the immediate jeopardy on [DATE] when it had completed the following: On [DATE] facility reviewed policy and procedure on POV/scooter policy, including assessment schedule, change in condition, and resident safety plan. POV/Scooter policy updated to reflect need for Occupational Therapy safety assessment upon admission, quarterly, and PRN. Education was completed with Director of Nursing, Social Services Director, and Remedy Therapy on [DATE]. Updated procedure for communication of Therapy POV evaluation. Education completed with Remedy Therapy, Director of Nursing, and Director of Social Services regarding implementation of new communication process. All residents who utilize POV/Scooters were reassessed for safety and educated on new POV/Scooter Policy and Acknowledgment form. Resident in question's POV/scooter was removed upon return from the hospital until Occupational Therapy could complete a new assessment. Upon assessment by occupational therapy, resident was found to be appropriate for a POV/Scooter but scooter had new equipment recommendations for safety. Resident will not have access to POV/Scooter until necessary modifications have been completed. All residents who currently utilized POV/Scooter policy, leave of absence policy, acknowledgment form which includes resident specific safety plan and occupational therapy recommendations, educated on POV/Scooter policy updates. Full house audit of all residents who utilize electric wheelchairs. Currently, five residents utilize electric wheelchairs and all five have been reassessed as of [DATE] for safety. Upon completion of Occupation Therapy assessment, all recommendations will be provided to the Director of Nursing and Director of Social Services in a written and verbal format. All residents who utilize POV/Scooters Care Plans were reviewed and updated per OT recommendations as needed. Form initiated for residents who utilize POV/Scooter. Form shall review safety plan during use of POV/Scooter and risk of utilization of POV/Scooter. This will include Occupational Therapy recommendations that are included in resident's care plan. All staff education on changes for current POV/Scooter users care plan, updated policy, and new acknowledgment form. Staff education initiated on [DATE] regarding resident's right to be free of accident/hazards or Supervision. Staff education initiated on [DATE] from Remedy therapy regarding being aware of and reporting change in condition with use of POV.

Based on interview and record review, the facility did not provide appropriate supervision based on the resident's assessed needs, resulting in death to 1 resident (R1) out of 1 residents with feeding precautions. R1 had a history of [REDACTED]. A referral to ST (Speech Therapy) was not made until after the second episode. At that time, ST indicated R1 required 1 to 1 close supervision with verbal and tactile cues to slow down, take small bites, and to swallow. On [DATE], R1 was given a Magic Cup (high calorie ice cream supplement). She was seated in the dining room, approximately 12 feet away from the nearest staff with her back to the staff. R1 was heard gurgling and found to have the entire contents of the Magic Cup in her mouth. R1 was transferred to the hospital and found to have bilateral aspiration pneumonia and died 2 days later. The immediate jeopardy began on [DATE], when the facility did not provide R1 with appropriate supervision based on the ST evaluation and plan of care. The immediate jeopardy was identified on [DATE]. The NHA and DON were informed of the immediate jeopardy on [DATE] at 11:35 a.m. The immediate jeopardy was removed on [DATE] but noncompliance continues at the lower scope/severity level of D (potential for more than minimal harm/isolated) as the facility continues to implement its removal plan. This is evidenced by: R1 was admitted to the facility on [DATE] following a fall at home that resulted in a [MEDICAL CONDITION]. R1's other [DIAGNOSES REDACTED]. Prior to admission, R1 had all teeth extracted to prepare for full dentures. The admission MDS (Minimum Data Set Assessment) dated [DATE] indicated R1 had a BIMS (Brief Interview for Mental Status) of 15 out of 15 (cognitively intact), had no mood or behavior symptoms, and was independent in eating. R1's care plan dated [DATE] included a problem of At risk for choking/aspiration r/t (related to) eating too fast, not fully chewing food before taking another bite. The goal was for R1 to be safe when eating. Interventions included separate food items into cups and give one item at a time dated [DATE]. On [DATE], an intervention of 1:1 supervision in room was added. R1's medical record including the following entries: ~[DATE], DM (Dietary Manager) documented R1 was on a mechanical soft diet and made a ST referral for diet recommendations. ~[DATE], the NHA (Nursing Home Administrator) noted a referral for diet texture recommendation due to R1 having no teeth or dentures. There was no evidence a referral was made to ST at this time. There is no evaluation or recommendations. ~[DATE], RN-B (Registered Nurse) documented R1 does not chew food items but rather shoves whole food into her mouth. RN-B observed R1 put a whole banana in her mouth. ~[DATE], nursing documented R1 would gobble all her dinner and would cram food in her mouth. On [DATE], R1 received her new dentures. ~[DATE] nursing documented R1 was Choking on food when cramming in mouth a whole banana at a time and trying to swallow it at once, also half a grilled cheese trying to stuff in her mouth at once. ~[DATE], RN-B documented R1 was taking food from other residents' trays. RN-B noted R1 would cough at meals due to eating too fast. ~[DATE], nursing notes indicated the [MEDICATION NAME] Maneuver was used on R1 to dislodge a piece of chicken from her throat. The physician was contacted and ordered mechanical soft meats and a swallow study. Review of R1's medical record of a referral found no evidence of an evaluation or treatment by ST. ~[DATE] the DM documented R1's diet was changed to pureed by nursing. ~[DATE] nursing notes indicate R1's diet was changed to puree due to R1's bingeing food and risk for choking. Nursing documented R1 attempted to, push the entire length of unbroken bacon down her throat. The physician was notified. ~[DATE], RN-B documented R1 will require 1:1 supervision in her room for all meals. This intervention was already included on the care plan as of [DATE]. Due to rapid decline in in her cognition and the increase in behaviors, R1 was seen by psychiatry, neurology and also had an inpatient psychiatric hospital stay from [DATE] through [DATE]. R1 demonstrated obsessive behaviors related to food and fluids and was observed overfilling her oral cavity at meals to the point of choking. According to the psychiatrist, R1 has perseverative behaviors associated with daily tasks including eating. All physicians involved in R1's care determined R1 had frontotemporal lobe dementia. Frontotemporal lobe dementia is characterized by dramatic changes in personality and become socially inappropriate, impulsive, or emotional. According to (MONTH) Clinic, the most common signs and symptoms of frontotemporal lobe dementia involve extreme changes in behavior and personality include changes in eating habits, predominantly overeating According to the physician's orders [REDACTED]. Then on [DATE], the diet was changed to pourable puree with nectar thickened liquids. ~[DATE] the DON (Director of Nursing) documented R1 was Shoveling her food into her mouth at breakfast and started having a hard time swallowing d/t (due to) how much food was in her mouth. ~[DATE] ST referral There was no evidence the ST referral was made and no evidence an evaluation was completed. ~[DATE], DM documented R1 was placed on a pureed diet with nectar liquids and food is served in bowl due to R1 stuffing her mouth with food all at once. ~[DATE], RN-B noted R1 was on a pureed diet with nectar thickened liquids and required 1:1 supervision for all meals. RN-B documented R1's dentures fit well. ~[DATE] physician progress notes [REDACTED]. ~[DATE] physician progress notes [REDACTED]. The physician also documented R1 had perseverative behaviors. ~[DATE] RN-B documented R1 requires 1:1 supervision during meals, but can feed herself. ~[DATE] the physician documented R1 had several chocking episodes while on a puree diet with nectar liquids and ordered a ST referral. There was no evidence the ST referral was made and no evidence an evaluation was completed until [DATE]. On [DATE], R1 was evaluated by ST. The goal of ST was to teach R1 strategies for safe swallowing, strengthening of the swallowing mechanism, to promote independence with meals, and to provide a safe diet. The ST evaluation indicated R1 was at risk for aspiration due to delayed swallowing, severe dysphagia (difficulty swallowing), overfilling of the oral cavity, wet vocal quality while eating, and a rapid eating pace. ST recommendations were close 1:1 supervision with assist, cueing in a quiet environment with limited distractions. Additional interventions included position R1 upright 90 degrees, keep pace slow, encourage small amounts, ensure oral cavity is clear of residual food, cue to keep chin tucked position, monitor for wet vocal quality and cue to clear throat, and stop feeding if coughing present or signs of aspiration. ST notes indicated R1 required maximum staff assist with eating, verbal and tactile cues to slow the pace, take small bites, swallow, sweep mouth with tongue, tuck chin, and clear throat. The ST noted with close supervision and cues, R1 was able to follow directions. On [DATE], R1's care plan was updated to include 1:1 supervision with all meals. ~[DATE] nursing documented R1 was given a Magic Cup while seated in the dining room. R1 began to choke and gurgle on Magic Cup. Blood pressure was ,[DATE], pulse 137, oxygen saturation of 77%. R1 was transferred to the hospital. R1 was admitted to the hospital. On [DATE], R1 expired at the hospital. The facility submitted an investigation of this incident. The investigation indicated R1 was brought to the dining room and seated at the north end of the dining room with her back to the nurses station. CNA-I (Certified Nursing Assistant) gave R1 a Magic Cup and went to the nurses station. No staff at the nurses were aware R1 had any food. On [DATE] at 3:30 p.m., Surveyor measured the distance from the nursing station to the table where R1 was seated on [DATE] and found the distance to be approximately 12 feet apart. Based on the facility self-reported investigation, staff would not have been able to implement the ST recommendations from their position at the nurses station in relation to R1's position. Although the DON (on [DATE] at 2:40 p.m.) and the DON (on [DATE] at 9:30 a.m.) stated that 1:1 supervision meant close supervision or oversight but had no distance requirement, this was not the working defintion used by staff or intended by ST. On [DATE] at 12:10 p.m., Surveyor interviewed CNA-F regarding R1's care needs. CNA-F stated R1 required extensive staff assistance and required 1:1 supervision with food and fluids. CAN-F stated 1:1 supervision means staff are to sit next to or across from the resident so the staff can watch them and help if needed. CNA-F stated R1 required verbal cueing to slow down and sometimes required staff to feed her. On [DATE] at 12:25 p.m., Surveyor interviewed CNA-G regarding R1's care needs. CNA-G stated R1 required 1:1 staff supervision to give her verbal cues to slow down as she was at risk for choking. On [DATE] at 12:30 p.m., Surveyor interviewed RN-H regarding R1's care needs. RN-H stated R1 required 1:1 supervision from staff for all food and fluids. RN-H defined 1:1 supervision as staff to sit next to the resident or in front of the resident to watch them. RN-H stated R1 was very anxious and frequently would stuff her mouth with food. RN-H stated R1 was at risk for choking with every meal. On [DATE] at 1:30 p.m., Surveyor interviewed RN-A regarding R1's choking incident. RN-A stated she was called to the 2nd floor dining room by the night shift LPN (Licensed Practical Nurse) because R1 was choking. RN-A stated she did not assess R1, but did assist the LPN with preparing the transfer documents. RN-A stated CNA-I reported she gave R1 a Magic Cup and stayed with R1 for awhile until the night shift was ready to give report. CNA-I stated she left R1 alone at the table with her back toward the nursing station. CNA-I went to the nursing station to receive shift report from the night shift CNA. CNA-I and CNA-E heard R1 gurgling and called for help from the night shift LPN. RN-A stated R1 had a history of [REDACTED]. RN-A stated R1 should have been fed because of her obsessive behaviors with food. RN-A stated R1 would shovel food in and not swallow until she would choke. RN-A stated this behavior was R1's routine. RN-A stated R1 often required staff to place their hand over R1's hand to slow down the shoveling of food into her mouth. RN-A stated staff should have been close to her and not at the nursing station. RN-A stated having no staff present at the table did not constitute 1:1 supervision when R1 was given the Magic Cup. On [DATE] at 2:40 p.m., Surveyor interviewed the ADON regarding safe feeding practices. The ADON stated R1 had a history of [REDACTED]. The ADON stated R1's care plan was followed because R1 was the only person in the dining room and staff were in close proximity. On [DATE] at 3:12 p.m., Surveyor interviewed RN-B regarding R1's care needs. RN-B stated she had been the nurse manager of the 2nd floor for approximately 2 years and was familiar with R1's care needs. RN-B stated R1 lacked impulse control, had a history of [REDACTED]. RN-B stated R1 would overfill her mouth, would not stop filling her mouth, would take large portions and put whole food items into her mouth, and was able to feed herself but required a ton of verbal cues. RN-B stated R1's behavior was consistent at every meal and R1 required 1:1 supervision at every meal. RN-B stated all 3 CNA staff were at the nursing station and R1 was seated at the first table in the dining room with her back toward the nurses station. RN-B stated staff did not follow R1's care plan and did not provide 1:1 supervision to R1. RN-B stated neither CNA-E nor CNA-I were able to see R1 eat and were not able to provide R1 the necessary verbal cues to slow the pace down. RN-B stated had staff followed the care plan and provided R1 with 1:1 supervision, R1 would have been able to feed herself the Magic Cup and not choke. On [DATE] at 3:40 p.m., Surveyor interviewed the SLP (Speech Language Pathologist) regarding R1's care needs. The SLP stated R1 had been evaluated by a SLP on [DATE] and had 3 follow up visits on [DATE], [DATE], and [DATE]. The SLP had identified R1 at risk for choking due to her delayed swallow, absent gag reflex, history of overfilling the oral cavity, impulsivity, lack of insight due to dementia, and history of choking on puree food items as well as regular texture food items. The SLP stated R1 required close one to one supervision with staff to assist with eating and provide verbal and tactile (touch) cues to slow down, take small bites, swallow, drink fluids, and clear throat. The SLP defined 1:1 supervision as staff seated next to R1 and maintain line of sight any time R1 had food or fluids present. On [DATE] at 4:47 p.m., Surveyor interviewed RN-D regarding R1's care needs. RN-D stated she was familiar with R1 and had worked the evening shift of [DATE]. RN-D stated R1 had no signs of respiratory distress or aspiration. RN-D stated R1 required 1:1 supervision for all food and fluids provided. RN-D stated R1 would shovel in food and overfill her mouth with whole food items such as a banana and a strip of bacon. RN-D stated R1 required staff to sit next to her at the table and cue R1 to slow down and take small bites. RN-D stated R1 would follow staff cues and would safely eat her meals. RN-D stated when staff followed the 1:1 supervision on the care plan, R1 was safe with eating and drinking. On [DATE] at 8:05 a.m., Surveyor interviewed CNA-C who was identified as a witness to R1's choking episode on [DATE]. CNA-C stated R1 was seated at the first table in the dining room with her back towards the nurses station. CNA-C stated she observed CNA-I give R1 a Magic Cup and stand next to her for a few minutes. CNA-C stated she was seated at the nurses station preparing her shift assignment when CNA-I walked around the nurses station and sat next to CNA-C. After a few minutes, both CNA-C and CNA-I heard R1 gurgling. CNA-C stated R1 sounded like she had water in her lungs and was gurgling. CNA-C called for the nurse to help. CNA-C was asked by the night LPN to obtain R1's vital signs. CNA-C stated R1's pulse was fast and her breathing was gasping. CNA-C stated her oxygen saturation was very low in the 70's. CNA-C stated the night shift LPN began suctioning R1 to remove some of the Magic Cup. CNA-C provided reassurance and tried to help R1 calm down and breathe. CNA-C stated R1 was transferred to the hospital. CNA-C confirmed R1 was to have 1:1 supervision with all food and fluids. CNA-C defined 1:1 supervision as staff to sit next to the resident, watch the resident's face, and help if needed. CNA-C stated R1 would take huge bites of food and staff would cue her to take small bites and slow her eating down. CNA-C stated she would often feed R1 to provide her with safe eating. On [DATE], CNA-C stated she thought R1 had finished the Magic Cup and that was why CNA-I sat down at the nurses station. CNA-C stated staff did not follow the care plan for R1 on [DATE] when CNA-I walked away from R1 while eating the Magic Cup. On [DATE] at 8:00 a.m., Surveyor requested from the NHA the ST evaluations and progress notes for the [DATE], [DATE], [DATE], and [DATE] referrals. The NHA stated R1 was pending Medicaid and the facility needed to obtain prior authorization from Medicaid before therapy services would be covered. Surveyor then asked for evidence of the prior authorization requests and denials from Medicaid. On [DATE] at 8:30 a.m., the NHA reported to the Surveyor that R1 was eligible for Medicaid benefits effective [DATE] which included 35 visits from ST without prior authorization. Surveyor again asked evidence R1 was seen by ST for the referrals noted above. No ST notes or evidence of the referrals were received. On [DATE] at 9:00 a.m., the SLP confirmed R1 had only been seen by ST for swallowing problems on [DATE]. The SLP stated a referral for ST services was never received on [DATE], [DATE], or [DATE]. On [DATE] at 11:55 a.m., Surveyor interviewed the RD (Registered Dietician) regarding her role in diet changes. The RD stated her practice was to defer to ST for any consistency or texture changes. The RD stated it was the facility policy to allow nursing or the DM to downgrade resident's diet but for any advancement or upgrade must be recommended through ST. The RD stated her employment started in May, (YEAR). The RD stated R1 had diet changes on the following dates: ~[DATE] mechanical soft due to having no dentures/teeth. ~[DATE] nursing changed to puree meats following the choking episode. ~[DATE] puree diet with thin liquids per her readmission orders [REDACTED] ~[DATE] puree diet with nectar thick liquids per nursing recommendations to help R1 slow down the pace of drinking fluids. The RD stated another ST referral was made on same date. The immediate jeopardy that began on [DATE] was removed on [DATE] when the facility: ~Reviewed all current residents on altered texture diets to ensure each was receiving appropriate supervision; ~Educated all nursing staff on definitions of dining supervision and different types of supervision needed by residents; and, ~Developed a plan to ensure all staff received the training prior to the start of their next scheduled shift.

Based on interview, observation, and record review, the facility did not ensure that each resident receive appropriate care to prevent the development of or promote the healing of pressure injuries for 2 of 4 sampled residents (R2 and R1). A nurse applied an ace wrap to R2's right ankle. There was no follow up to the placement of the ace wrap which remained on R2's ankle for 4 days, resulting in the development of 2 unstageable pressure injuries to R2's ankle. R1 was admitted to the facility with an immobilizer brace on the right leg and pressure injuries to the right heel and right foot. The facility did not have policies and procedures for inspecting skin under a medical device. There was inconsistent weekly wound measurements to R1's pressure injuries. This is evidenced by: 1. R2 was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. R2's Minimum Data set (MDS) assessment, dated 05/20/17, indicated R2 was unable to complete the Brief Interview for Mental Status (BIMS) assessment and staff determined R2 had modified independence. R2 does have a guardian. The MDS assessment indicated R2 required extensive physical assist of two persons for bed mobility and dressing. The MDS identified R2 as having two unstageable pressure injuries related to suspected deep tissue injury. R2's Care Plan, with a revision date of 05/24/17, states: Pressure Ulcer Risk: The resident has potential for pressure ulcer development related to impaired mobility, moisture d/t (due to) incontinence, potential for shearing -5/10/17: Pressure ulcer to right ankle as a result of ace wrap having been placed upon his right lower extremity. - 5/22/17: Wound Clinic appointment. Ankle was debrided and area on lateral RLE (Right Lower Extremity) will now be included in overall measurements of front ulcer. Interventions include in part: Air overlay mattress on bed. Surveyor did not observe air overlay on bed. R2's care plan does not include measurable objectives or time frames for the pressure injury. R2's care plan does not give individualized interventions to promote healing to R2's pressure injuries. R2's Kardex, which is a care plan to communicate information on a resident to nursing staff and Certified Nursing Assistants (CNA), states under category Skin Care: Apply moisture barrier with each each incontinent change Cushion in w/c (wheelchair) Do not scrub off barrier creams. Cleans (sic) soiled/BM (Bowel Movement) off and OK if residue of cream remains. Maintain the bed as flat as possible to reduce shear. -(R2's first name) has an electric bed and frequently/independently raises HOB (Head of Bed) and lowers foot of bed. (R2's first name) has received education and verbalizes consent of understanding of risk for shearing. Reposition at least every 2 hours, more often as needed or requested This Kardex does not identify R2 having a pressure injury to the right lower extremity or any interventions for the pressure injury. R2 has a Physician order [REDACTED]. On 05/06/17 at 3:14 a.m., Registered Nurse (RN) E documented: Resident c/o (complained of) R. (Right) ankle pain and requested to have ankle wrapped and Tylenol. There is no other documentation related to the ace wrap on R2's right ankle. On 05/10/17 at 11:30 a.m., RN A, who is also the Assistant Director of Nursing, documented: Staff removed Ace Wrap from resident's Right Lower extremity. Light Gray areas were present both on the front and rear of the resident's ankle. Front of ankle, extending to top of foot measure 10x8.1 cm (centimeters) and is light gray in color. Light gray area present on rear of resident's ankle and measures 6cmx10cm, extending horizontally. Pedal pulses present bilaterally. (R2's first name) c/o (complaints of) tingling sensations to extremity. Scar present to lateral right leg and top of ace wrap was near middle of scar. Small amount of dried blood present on ace wrap and area of approximately 2cm x2cm is pink, on top of scar. PAC (Physician's Assistant) was paged to notify. On 05/10/17 at 2:00 p.m., RN A, documented: Previously gray areas are now burgundy in color with surrounding petechial, increasing total area. Fluid filled, intact blister present on lateral ankle. Per-usual [MEDICAL CONDITION] has returned to the right lower extremity and it is consistent in size/[MEDICAL CONDITION] to the left side. (R2's first name) denies pain to this extremity. PAC notified and ordered XRay to rule out internal injury. The facility's investigation included in part: .All staff that worked with (R2's first name) from May 6th - May 10th were questioned for knowledge of the ace wrap. The C.N.A's that worked with (R2's first name) during the day and afternoon, noticed the wrap, and thought he had it on for a reason. None of the nurses that cared for (R2's first name) in that time frame recall seeing the ace wrap on him. None of the nurses can recall (RN E's first name), RN, telling them that (R2's first name) had an ace wrap on his leg. There is no mention of (R2's first name) having an ace wrap on his leg in the 24 hour report. Medical Doctor (MD) F's progress note, dated 05/11/17, states: .IMPRESSION: Pressure necrosis Right leg from ACE dressing left on too long . On 05/27/17, R2's Weekly Wound Evaluation identified R2 as having an unstageable pressure injury to the front of the ankle that is 12 cm in length, 8.1 cm in width and 0.2 cm in depth. The back of ankle has an unstageable pressure injury that is 8 cm in length, 11 cm in width and 0.2 cm in depth. The wound had 75% slough and 25% eschar. There was heavy tan drainage. The wound progress note documented the wound declined, as evidenced by: debridement at recent appointment resulted in depth and presence of slough/eschar. Surveyor reviewed R2's Treatment Administration Record (TAR). It was documented that a nurse signed off on doing the daily diabetic foot assessments at bedtime on 05/06/17, 05/07/17 and 05/09/17. There was no documentation of daily diabetic foot assessment on 05/08/17. On 05/31/17 at approximately 3:30 p.m., Surveyor observed Registered Nurse (RN) A, who is also the Assistant Director of Nursing, and LPN C change R2's dressing to the right ankle. R2 did not have an air overlay on the bed, which was identified as an intevention on the care plan. RN A told surveyor that R2 had refused the air overlay and it was removed from the bed. RN A explained to Surveyor that R2 has been wearing a boot when R2 is up in the wheelchair, because he cannot wear a shoe on that side. On 06/01/17 at approximately 8:20 a.m., Surveyor asked the Director of Nursing (DON) and Nursing Home Administrator (NHA) who the nurse's initial were on the TAR that assessed R2's feet. The DON and NHA gave names of the nurses. The DON stated it was her understanding the ace wrap did not extend down to the foot. Surveyor asked the DON if the nurses would assess a resident's heels while doing a foot assessment. The DON replied, Their recollection was that they did not notice an ace wrap. R2 needs extensive physical assist of two persons for bed mobility and dressing. R2 has [MEDICAL CONDITION] and [MEDICAL CONDITION] on the right side. R2 would not have the ability to hold the right foot off of the bed for the nurse to assess the bottom of R2's heels. A nurse would have to physically pick up R2's foot to assess the foot. Surveyor asked the DON and NHA if there was any education provided to the nurses regarding diabetic foot checks. The NHA replied: I don't think diabetic foot checks were in question. Surveyor asked if the CNAs were provided any education on notifying a nurse when they observe a medical device on a resident that is not listed on their care plan. The DON stated no. The DON told Surveyor that often times an ace wrap would not be on the CNA care plan or Kardex as the nurse is the one who would have the order to put this on and take it off. 2. R1 was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. R1's MDS assessment, dated 04/12/17, indicated R2 has moderate impairment with cognition and decision making, requires extensive physical assist of two persons with bed mobility and dressing, has impairments in range of motion to both lower extremities, was admitted with one unstageable pressure injury and one other open lesion to foot. R1's initial care plan, dated 04/05/17, states in Skin Integrity: PREVENT ANY FURTHER BREAKDOWN AND ATTEMPT TOP (sic) HEAL THAT WHICH IS INJURED DUE TO PRESSURE AND SHEARING FORCE. R1's Care Plan, with a revision date of 04/17/17, states: Alteration in skin integrity related to immovable device. Resident admitted to facility with pressure areas. The goal, with a target date of 04/25/17, states: Areas will show signs of healing or be healed by next review. Interventions/Tasks include: Resident has a history of vascular ulcers and pressure ulcers. Pressure reduction boots on, bilaterally, at all times. Resident family would like her to be up in recliner. They would prefer resident be in recliner than in bed. Spoke with assisted living facility, prior to admitting here, resident had pressure area that was unstageable to her right heel that they attributed to her immobilizer. Resident also had a pressure area to her right leg, related to the immobilizer. Turn and reposition or reminders to offload every two hours and as needed. Wound clinic appointments as ordered by the doctor. Monitor skin integrity daily during cares. Weekly skin audit/evaluation by nurse on bath days. Treatment to open areas per order. Pressure redistribution mattress to bed. Encourage adequate fluid intake. Staff to perform pericare after each incontinent episode and as needed. Heel lift boots. R1's Kardex states in part: .Pressure reduction boots on, bilaterally, at all times. Resident will be seated in recliner between meals as resident allows .Resident family would like her to be up in recliner. They would prefer resident be in recliner rather than in bed. Turn and reposition or reminders to offload q2 (every two) hours and PRN (as needed) . R1's care plan does not indicate how often R2's skin should be inspected under a medical device. The National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance documents in Prevention and treatment of [REDACTED]. Inspect the skin under and around medical devices at least twice daily for the sign of pressure related injury on the surrounding tissue .1.1 Conduct more frequent (greater than twice daily) skin assessments at the skin-device interface in individuals vulnerable to fluid shifts and/or exhibiting signs of localized or generalized [MEDICAL CONDITION] . On 06/01/17 at approximately 8:20 a.m., the NHA told Surveyor the facility does not have a policy on inspecting skin under a medical device and they use standards of practice. Surveyor asked which standard of practice the facility follows. The NHA replied she will check on that. At approximately 12:50 p.m., the DON provided Surveyor with Chapter N6 Standards of Practice for Registered Nurses and Licensed Practical Nurses. Surveyor asked if this was specific to inspecting skin under a medical device, the DON replied: No, nothing specific. On 06/01/17 at approximately 8:45 a.m., Surveyor asked the DON and NHA how often R1's skin was inspected under the immobilizer when R1 was admitted to the facility. The DON replied she would have to check on that. At approximately 10:00 a.m., the DON provided Surveyor with an order from the wound clinic, dated 04/19/17, and stated the order was to check under the immobilizer every shift. Surveyor asked the DON before the facility received the order from the wound clinic on 04/19/17, how often was R1's skin inspected under the immobilizer. The DON replied she would check. At approximately 10:30 a.m., the DON stated the skin was inspected at least weekly, but would say more often as the family is here every day wanting to see R1's skin, but there's nothing documented on those skin inspections. Surveyor reviewed wound measurement documentation for R1: 04/05/17 Skin Evaluation by Licensed Practical Nurse (LPN) B: - Site: Right heel, Type: pressure, Length: 4 cm, Width: 6 cm, Stage: Unstageable - Site: Top of foot, Type: blister, Length: 7.5 cm, Width: 3 cm, Stage: Unstageable - Site: Right medial leg, Type: Other echymosis (bruising), Length: 15 cm, Width: 9 cm 04/05/17 Progress Note by Registered Nurse (RN) G: .Breakdown: R (Right) medial (sic) leg 15x9 cm Medial Malleolus R foot has 2x3 cm reddened area and start of pressure breakdown Right heal (sic) 4x6 cm is black and soft and appears as though it may open up soon. Anterior aspect of foot has pressure breakdown 7.7x3 cm with internal blister 4.5x2 cm that may open at any time .+2-+3 [MEDICAL CONDITION] on both lower extremities . 04/06/17 Skin Evaluation by RN H: - Site: Left heel, Type: Pressure, Length: 4 cm, Width: 6 cm, Stage: blank - Site: Right knee (front), Type: echymosis (bruising), Length: 15 cm, Width: 9 cm - Site: Right toes(s), Type: Blister, Length 7.5 cm, Width: 3 cm, Stage: blank 04/13/17 Skin Evaluation by RN H: - Site: Left heel, Type: Pressure, Length: 4 cm, Width: 6 cm, Stage: blank - Site: Right toe(s), Type: Blister, Length: 7.5 cm, Width 3 cm, Stage: blank 04/15/17 at 12:35 p.m. Progress Note by RN I: Resident up in wheelchair. Immobilizer on Right leg. I did release all velcro and adjusted brace to upper thigh are adjusted approx. 2 (inches) previous abrasion was noted to be reddened and deep purple in center. Blister is now open with sloughing skin noted. No drainage on bracing or noted to be present upon assessment. No signs or symptoms of infection noted Left foot heel base is reddened and dark purple black subcutaneous bruising is still noted. Skin was intact and no drainage noted . No measurements are documented in note. 04/15/17 at 11:35 p.m. Progress note by LPN J: Resident was noted to have an abrasion on top of right foot, measuring approximately 7x5 cm (rectangle shape). Resident also has dark area on right heel, measuring 7 x 5 cm . 04/17/17 Skin Evaluation by RN K: - Site: Right heel, Type: Pressure, Length: 10 cm, Width 8.2 cm, Stage: Unstageable - Site: Left heel, Type: Pressure, Length: 3.2 cm, Width: 2 cm, Stage N/A (Not Applicable) - Site: Right top foot, Type: pressure, Length: 6.3 cm, Width: 4 cm, Stage: Unstageable - Site Right inner ankle, Type: Pressure, Length: 2 cm, Width: 0.5 cm, Stage: 2 -Site: heel rear open, Type: Pressure, Length: 1.2 cm, Width: 0.2 cm, Stage: 2 04/17/17 Progress Note by RN K: Measured residents wounds left heel boggy area 3cm by 2 cm applied allevyn heel and wrapped with [MEDICATION NAME] right heel necrotic tissue 10cm x 8.2 cm small open area 1.2 cm by 0.2 cm applied triple antibiotic ointment covered with allevyn heel protector and [MEDICATION NAME] right inside ankle 3 mall area 2cm x 0.5 cm including reddened skin - applied 2x2 [MEDICATION NAME] right outside ankle closed reddened area achilles tendon reddened - applied 2x2 [MEDICATION NAME] will cont to monitor. Follow up for wound clinic made by HUC (Health Unit Coordinator) . 04/20/17 Skin Evaluation by RN E: No measurements are documented on form. Summary: No new skin issues observed. Right heel and top of foot appear to be doing well. Rest of skin is WDP (unsure of acronym) and CDI (clean, dry, intact). 04/23/17 Progress note by RN K: .Wound beds necrotic on both the superior aspect of foot and heel wound .Left heel boggy with white skin blister covering . No measurements are documented. 04/27/27 Skin Evaluation by RH H: - Site: Left Heel, Type: white tissue, Length: 4 cm, Width: 2 cm summary: Dressing on wounds on right foot/heel. All other skin CDI (clean, dry and intact). There are no other wound measurements on form. 05/04/17 Progress Note by RN L: Detailed skin assessment completed on resident's right lower extremity. There are two pressure related spots, related to her immobilizer, noted on her anterior mid shin. The first red spot measures 2cm x 0.7cm. The second red spot is firm to the touch with no soft areas felt. that is located 1cm above the first red spot. It measures 0.2cm x 0.6cm. On the anterior part of her right foot she has intact eschar noted. It The eschar spot measures 6.2cm x 3.5cm. There is no drainage noted. On her inner ankle she has a small scabbed area noted that measures 0.2cm x 0.4cm. Scab is intact and light purple in color. No drainage noted. Eschar intact on right heel. No drainage noted. Eschar on right heel measures 7cm x 10cm. Edges are approximated and light pink in color. No warmth r swelling noted. There is a small intact scab noted on her upper heel, next to the eschar spot, that measures 1.2cm X 0.6 cm. Right lower foot is dry and flaky. Resident denies pain to lower extremity or wounds. Cream applied to lower extremities bilaterally. Immobilizer readjusted. Dry dressing changed applied per TAR (Treatment Administration Record). Will continue to treat per orders. this was the first documentation of measurements of wounds from since 04/17/17. It is unclear if these are new areas, as some of these areas were not previously documented. 05/11/17 Skin Evaluation by RN H: -Site: Left heel, Type: white, soft, Length: 3 cm, Width: 2 cm, Stage: blank -Site: Right lower leg (front), Type: reddened, Length: 2 cm, Width: 1 cm, Stage: blank -Site: Right ankle (outer), Type: eschar, Length: 6 cm, Width: 2.5 cm, Stage: blank -Site: Right heel, Type: eschar, Length: 5 cm, Width: 7 cm, Stage: blank 05/16/17 Progress Note by RN L: Measurements on wound were taken and as follows: 1) Upper Left shin - Red pressure area 2. 7cm x 1.0 cm oval shaped. Intact, no drainage. 2) Right above issue number one is a small 1 cm x 0.2 cm red pressure area. Intact, no drainage. 3) Above inner ankle 1 cm x 1.4 cm circular red pressure area. Intact, no drainage. 4) Ankle inner intact scab with no drainage measuring that is tan/red in color. 0.8 cm x 0.6cm 5) Anterior left medial ankle 6 cm x 4 cm that is brown/black eschar. Intact with no drainage. Eschar is firma and intact. Area is dry around the edges. Top of eschar detaching. 6) Medial to number 5 is a 1cm x 0.5 cm intact brown/red scab. No drainage noted. 7) second toe on right foot has a small red area on top of toe that is 0.4cm x 0.4cm 8)Black, intact, firm eschar noted to left heel. Total area is 6. 7cm x 9.4 cm. No drainage noted. Purple edge to top of eschar noted that (sic) measures 2cm x 4. 2cm. No drainage noted on purple edge. 9) Outer ankle has red pressure related circular area measuring 2cm x 0.8 cm. 10) Medial outer calf has reddened pressure related area noted measuring 6.0 cm x 0.8 cm. Intact and no drainage noted. Will continue to treat and monitor per orders. On 06/01/17 at 9:45 a.m., the DON told Surveyor that the above note was documented incorrectly and was regarding R1's right side not left. The DON also stated that R1 never had a pressure injury to the left heel, the left heel has an old scar from a pressure injury. 05/25/17 Skin Evaluation by RN H: - Site: Left heel, Type: white, soft Length 6 cm, Width: 3 cm, Stage: blank - Site: Right heel, Type: eschar, Length: 9 cm, Width: 7 cm, Stage: blank - Site: Right ankle (outer), Type: eschar, Length: 6 cm, Width: 4 cm, Stage: blank The above wound documentation is not consistent. It is unclear if new areas developed and if the pressure injuries are healing or declining. On 04/05/17, the right heel measured: Length 4 cm and Width 6 cm. On 05/25/17, the right heel measured: Length: 9 cm and Width: 4 cm. On 04/05/17 R1's wound is described as top of foot and on 05/25/17, the wound is described as right outer ankle. It is unclear if the note is describing the same wound. Some of the above notes describe the left heel as a pressure injury, the DON stated R1 has a scar on the left heel. On 06/01/17 at 8:10 a.m., the DON told Surveyor that the nurse managers on each floor assess wounds weekly and complete measurements. The DON stated the nurse managers are not Wound Care Certified.

Based upon observation, interview and record review, the facility did not ensure Resident #7 received proper treatment and care for the special services of [MEDICAL CONDITION] care, tracheal suctioning, and respiratory care for 1 of 2 sampled residents with a [MEDICAL CONDITION]. Resident #7 [MEDICAL CONDITION]. There were no available suction catheters when Resident #7 required suctioning, no [MEDICAL CONDITION] available when the wrong size inner cannula was placed, and the nebulizer treatment was given without oxygen, when Resident #7 had orders for oxygen continuously. These failures created a finding of immediate jeopardy that began on 07/31/16. On 10/11/16 at 2:40 p.m., Surveyor and Surveyor notified the Director of Nursing (DON) and Nursing Home Administrator (NHA) of the immediate jeopardy. The facility removed the jeopardy on 10/11/16; however, the deficient practice continues at a scope/severity of D (potential for more than minimal harm that is not immediate jeopardy/isolated) as the facility continues to implement and monitor the effectiveness of its removal plan. This is evidenced by: Facility Policy [MEDICAL CONDITION] Care Procedure Guidelines: Miscellaneous 7. A replacement [MEDICAL CONDITION] must be available at the bedside at all times. 8. Suction machine, supply of suction catheters, exam and sterile gloves, and flush solution, must be available at the bedside at all times. Administering Medication through a .Nebulizer Steps in the procedure: 6. Obtain baseline pulse, respiratory rate and lung sounds. 26. Obtain post-treatment pulse, respiratory rate and lung sounds. Resident #7 was admitted [DATE] with a history of [MEDICAL CONDITION], comatose state, [MEDICAL CONDITION] after suffering a fall from a roof. Resident #7 was readmitted to the hospital 05/06/16 with discharge [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) for a significant change in status, dated 07/18/16, documents Resident #7 is dependent for all mobility and activities of daily living, with severe cognitive impairment. The current physician orders [REDACTED]. Oxygen at 8 LPM (liters per minute) This was the order on the current signed physician orders. The nurses' notes document as of 09/10/16, O2 at 10 lpm (to keep O2 (oxygen) sats (saturation) > 92% Ipatrop/albut 0.5 -3 mg/3 ml for [MEDICATION NAME] .inhale 1 vial via nebulizer every 4 hours around the clock for respiratory 06/25/16 Suction every 3 - 4 hours [MEDICAL CONDITION] Change inner cannula every day and as needed The nurses' notes in part: 07/19/16 Oxygen challenge test, current order is oxygen at 8 lpm [MEDICAL CONDITION] keep spO2 > 92 %. O2 at 95 % on O2 at 8 lpm. SpO2 decreased to 90% on r/a (room air) within 5 minutes. 07/31/16 Writer was alerted by a CNA (certified nursing assistant) who ran down the stairs to request assistance. Resident was cyanotic around the lips and making a gasping noise through the trach. He was lying with the Neb mask occluding his trach, the mask was not connected to anything. His oxygen had been unplugged in order to access the nearest receptacle (electrical outlet). The mask was removed, O2 [MEDICAL CONDITION] applied. Resident was suctioned for a large amount of phlem (sic)- the foaming sputum from his mouth was suctioned. Residents color returned to baseline. No further incidents through the NOC (night). Surveyor reviewed the nurses' notes and noted no follow up documentation to this incident. Nurse's notes continue: 08/03/16 Large amount of thick yellow phlem (sic) noted . 08/12/16 Resident suctioned x 4 this shift with large amount of thick phlem (sic). Nebulizer tx (treatment) done and inner cannula changed . 08/22/16 Oxygen challenge test, current order is at 8 lpm [MEDICAL CONDITION] to keep sats > 92%. Went in nurse [MEDICAL CONDITION] resident sats off, O2 79%. 08/30/16 Resident suctioned x i (one) for large amount of thick brownish drainage from trach. 09/02/16 [MEDICAL CONDITION] done along with suctioning x 2 for very large amount of thick brownish some blood tinged secretions. Res tol (tolerated) very well with O2 sats at 90% . 09/10/16 Resident given neb and suctioned [MEDICAL CONDITION] completed at which time noted resident suing abd (abdominal) muscles to breath. Continued to monitor neb at 0400 at which time suctioned sat noted at 73% on 8 lpm, increased O2 to 10 lpm [MEDICAL CONDITION]. [MEDICAL CONDITION] completed sats on increased to 83% noted low grade temp 99.4, .chest X-ray for decreased LS (lung sounds) and decreased sats .spoke with resident's daughter to find out what she would like us to treat. She stated she wanted us to do what we could at the the facility, but if he needed to see doctor send him in. Suctioned resident at 0645 a.m. sats ranging from 84- 90% .on call called with x-ray results .ordered [MEDICATION NAME] 20 mg . [MEDICATION NAME] 500 mg daily x 7 days . 09/26/16 .Dr .ordered repeat chest x-ray to ensure treatment resolved or showed improvement from last x-ray . 09/28/16 Resident deep suctioned x 3 on pm shift .large amount of yellowish/brownish phlem (sic) on each suctioning . O2 sats between 84 -94 % on 10 lpm . 10/04/16 Suctioned x 4 this shift for copious yellow milky secretions. Resident sats 90% on 10 lpm [MEDICAL CONDITION] . 10/10/16 Resident sent to essentia health for replacement of [DEVICE] .[MEDICAL CONDITION] cares completed x 2 this shift . 10/11/16 23:07 (11:07 p.m.) Resident deep suctioned x 2 this shift for large amount of secretions. O2 sats between 80 -87% during suctioning [MEDICAL CONDITION]. 10/12/16 0202 a.m., .decreased spO2 sats prior to suction was 78% on 10 lpm [MEDICAL CONDITION]. Course lung sounds bilateral .suctioned resident for copious amount of cream secretions .resident having a difficult time maintaining saturation over 90%, resident is showing decline in condition as evident by 94/56, 99.5, 92, 30 at 0107 a.m. (This is the first assessment and vital signs taken since the observation by Surveyor on 10/11/16 at 7:40 a.m.) Nurse's note continued: 10/12/16 Dr .gave order to send resident in for further evaluation .transported to (local hospital name) . On 10/11/16 at 7:40 a.m., Registered Nurse (RN) F approached Surveyor and said that she was ready to [MEDICAL CONDITION] for Resident #7. Surveyor noted the O2 concentrator was set at 10 lpm (liters per minute). At 7:45 a.m., RN F suctioned Resident #7. RN F had to unplug the humidifier compressor machine to plug in the suction machine as there were only two electrical outlets to utilize. Resident #7 had thick yellow to cream colored secretions coming from his trach. RN A did not perform any assessment of Resident #7's lung sounds or oxygen saturation levels before or during the procedure. After suctioning, Resident #7 coughed up more yellow phlegm. At 7:52 a.m., RN F unplugged the oxygen concentrator, to plug in the updraft (nebulizer) machine. RN F administered the Nebulizer treatment with [MEDICAL CONDITION], without any oxygen. Surveyor asked if this is the way they usually administer the nebulizer treatment. RN F replied, Yes, it seems strange we have to unplug things, but that is the way it is. The other two outlets are used by the tube feeding, and the bed. Surveyor could observe that the O2 concentrator, suction machine, updraft machine, and the humidifier compressor all needed an electrical outlet. There were only two available electrical outlets. RN F completed the nebulizer treatment, without assessing any lung sounds or oxygen levels. At 8:05 a.m., RN F plugged the oxygen in and put [MEDICAL CONDITION] with O2 back on Resident #7. At this time, Resident #7 was coughing up thick secretions that occluded [MEDICAL CONDITION], but after coughing could clear some of the secretions. RN F stated, I need to suction him again, but I do not have another suction catheter. RN F left the room at 8:08 a.m., to get a suction catheter. RN F returned to the room at 8:10 a.m with the suction catheter and again suctioned Resident #7, who had large amounts of cream colored secretions. At 8:15 a.m., RN F took out the inner cannula and stated she would be changing it. RN F took the inner cannula from her sterile field and attempted to put in in place. RN F tried a few times and stated, It will not go in. I do not know what is wrong, this has never happened before. Surveyor asked if it was the right size. RN F looked at the package and said, It is the wrong size. I have to go get the right size, and started to walk out the door. Surveyor asked if RN F was going to leave the resident. RN F replied, I suppose I should not do that. At this time, Surveyor asked RN F if there was an emergency kit in the room. RN F replied, We have [MEDICAL CONDITION] with the whole set. RN F then put the call light on and had CNA J hold [MEDICAL CONDITION] with the O2 over [MEDICAL CONDITION] RN F went to find an inner cannula. RN F returned at 8:18 a.m., and stated, We have no inner cannulas of the right size on the floor. I have asked (RN H) to go to the basement and find the right size. RN F did not assess Resident #7's respiratory status. At 8:22 a.m., Surveyor asked about the humidifier compressor and noted there was no liquid in the humidifier bottle, which had been empty since the start of the observations. RN F replied, I see it is empty. I will put some water in it. Surveyor asked RN F how long the inner cannula can be out. RN F replied, I am not sure. This has never happened before. Resident #7 was observed having some coughing episodes with his face turning red, but no cyanotic color noted. At 8:27 a.m., Surveyor asked what kind [MEDICAL CONDITION] RN F had received. RN F replied, When this resident came in we had a training. Surveyor asked what RN F should be doing now, since there was no inner cannula available. RN F replied, I do not know. They never talked about something like this. Surveyor asked if they talked about having the emergency supplies available. RN F replied, No, just having the [MEDICAL CONDITION] in the room. Surveyor asked what RN F was going to do now, since she had no way to communicate with the nurse looking for the supplies, and it had been several minutes. Surveyor asked who RN F's supervisor was today. RN F replied, It is the Director of Nursing (DON). Surveyor asked if she should notify the DON of the situation. RN F then put the call light on. CNA G came to the room. RN F told CNA G to get the DON and find RN H. At 8:35 a.m., Surveyor asked RN F why she was not using the emergency supply. RN F stated, It is the whole kit, and I only need one piece. At 8:36 a.m., Surveyor again asked what RN F was going to do in this situation. At 8:37 a.m., RN F said, I suppose I will have to use the emergency kit. RN F then went through all the bedside drawers, the dresser drawers, and the closet and stated, I guess we do not have one of those either. At 8:37 a.m., RN H brought in a supply of three inner cannulas 8 mm size, which was the correct size. At 8:38 a.m., RN F inserted the correct size inner cannula. RN F had still not assessed Resident #7's respiratory status. RN F then continued to cleanse [MEDICAL CONDITION], changed [MEDICAL CONDITION], and replaced the gauze under the trach. At 8:50 a.m., RN F plugged in the humidifier compressor, which had been unplugged since the start of the observation so the suction machine and the oxygen concentrator could be plugged in. Surveyor asked RN F if she was going to check an oxygen saturation level for Resident #7 and if that is usually done [MEDICAL CONDITION]. RN F replied, Yes, I suppose I should have done that. RN F had to leave the room to go and get the oximeter. Resident #7 had [MEDICAL CONDITION] on with 10 lpm oxygen for two minutes when RN F returned. The oxygen saturation was 90%. At 9:40 a.m., Surveyor interviewed the DON and asked about education for [MEDICAL CONDITION] care and updrafts. The DON stated the respiratory therapist had trained the staff, and gave Surveyor the contact information. On 10/11/16 at 9:50 a.m., Surveyor called the respiratory therapy company and spoke with Respiratory Therapist (RT) K to ask about the training she had provided staff. RT K replied, I have not been there for a long time, and all I did was set up the oxygen and humidifier compressor machine. Surveyor asked if she had trained the staff on administering an updraft with the oxygen. RT K replied, I did not know he was on an updraft treatment when I was there. I did not train on that. On 10/11/16 at 10:30 a.m., Surveyor interviewed the DON to ask about the note on 07/31/16. The DON reviewed the note and stated she was not aware of the incident. Surveyor shared the concerns of the nebulizer treatment without oxygen and the lack [MEDICAL CONDITION] for Resident #7. The DON replied, I am sure we give it with oxygen. Respirator therapy trained everyone. We always have multiple supplies in [MEDICAL CONDITION]. On 10/11/16, Surveyor requested [MEDICAL CONDITION] education that had been provided to staff. Surveyor received a list of 6 licensed staff out of a possible 16 licensed nursing staff that had been educated [MEDICAL CONDITION] 07/13/16. On 10/11/16 at 12:55 p.m., Surveyor interviewed RN F and asked if she had received any training on the proper way to administer the nebulizer treatment with oxygen. RN F replied, I was taught to do it without oxygen. Surveyor asked who did the training. RN F stated it was the Assistant Director of Nursing, Licensed Practical Nurse (LPN) A, but that Resident #7 may not have been getting nebulizer treatments at that time. Surveyor then asked about the training for emergency supplies. RN F replied, We were taught to have an [MEDICAL CONDITION] in the room. Surveyor asked if anyone was assigned to check for supplies to ensure they were available. RN F stated, I think the night nurse should check for supplies. Surveyor then asked if RN F had told anyone about the electrical outlet situation, having to unplug one piece of equipment to plug in another. RN F replied, Yes, I have told maintenance a few times, but nothing happened. On 10/13/16 at 8:00 a.m., the NHA came to Surveyor and explained that Resident #7 had been out for an appointment on 10/10/16, and his emergency obturator went with him, and Resident #7 returned without the supply. The night nurse did not notice the emergency supplies were not there. The failure to have suction catheters when the resident required suctioning, the failure to have [MEDICAL CONDITION] available when the wrong size inner cannula was placed, and the giving of a nebulizer treatment without oxygen when Resident #7 had orders for oxygen continuously created a finding of immediate jeopardy. The immediate jeopardy was removed on 10/11/16 when the facility began face to face training with staff before their shift on [MEDICAL CONDITION] care, suctioning, nebulizer administration, and oxygen administration. Emergency kits with additional supplies were placed in rooms of residents with trachs and residents with power equipment were transferred to rooms with adequate power sources for all equipment to be continuously plugged in.

Based on medical record review, policy review, interview and observation, 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 9 of 24 sampled residents. The facility did not apply fundamental principles of care for persons with dementia focusing on the needs of the resident as well as the needs of other residents in nursing home. Individualized person-centered interventions were not implemented to address behavioral expressions of distress in persons with dementia. Resident #1 had incidents of hitting multiple residents (Residents #2, #4, #8, #11, #15 and #17) and staff, was found in bed with a female resident, and was found kissing another female resident (Resident #18) on the lips as she slept. Resident #1 ate BCL ointment which was in another resident's room. Resident #10 had incidents of hitting other residents (Residents #18, #17, #13's daughter, and #11). Residents #4 and #9 were found unclothed together on two occasions. Residents #10 and #13 were also found unclothed together. The facility's approach to care for residents with dementia failed to follow systematic care process. The facility did not supervise the residents closely to prevent vulnerable residents from getting hit or from being verbally abused by other residents. The facility did not closely screen the residents who were admitted so they were sure to be able to meet the residents' needs, nor did the facility effectively protect other residents from physical and mental harm. The facility did not provide medically-related social services to address the residents' need for intimacy and again did not protect vulnerable residents from unwanted sexual advances. The facility did not develop comprehensive, individualized care plans relating to the care for residents with dementia, including their psychosocial needs. All these factors led to a situation of immediate jeopardy, which began on 02/24/14. The facility was notified of the immediate jeopardy on 03/27/14 and removed the jeopardy on 03/31/14. This citation continues at a scope/severity level of E (potential for more than minimal harm that is not immediate jeopardy/pattern) because not all staff have been adequately trained to care for residents with dementia and aggressive and sexual behaviors. This is evidenced by: 1. Resident #1's medical record states he is diagnosed with [REDACTED]. Resident #1's wife told activity staff that he was an officer in the military, was in command of around 300 people, likes to be in control, and does not like to take orders from women. According to Resident #1's nurses' notes, he was admitted to the facility on [DATE]. His first nurse's note stated that he was "Very combative with toileting. Hit staff in the face with the force of a six (with 10 being the hardest you could be hit). Resident does not respond appropriately when questioned or asked to do something." A nurse's note written on 12/05/13 at 8:00 p.m. states, "Res (Resident) has been found laying in other res. beds several times. Redirected to own room/bed...Res wanders ad lib, urinating in hallway...no return call or fax re: (regarding) admission orders [REDACTED] Other nurses' notes are as follows. 12/06/13, 9:00 p.m.:. Res wanders up & down hallways in & out of other res rooms. Lays on their beds. Urinates in hallway... 12/07/13, 3:00 a.m.: "admission orders [REDACTED]. Speech nonsensical. Pleasant, smiling. No aggression noted." 12/07/13, 5:30 a.m.: "Res awoke, wandered into another Res room attempting to lay in bed. Res grabbed ahold of room divider curtain & resistive to letting go. Res stated, 'No, just leave it, what the hell?' Res eventually let go p (after) 3 minutes & was assisted back to his room & to BR (bathroom). Res had been incontinent of urine & BM (bowel movement). Res resistive to (delta sign for changing) brief, unable to understand/follow short clear cues. No combativeness. Res back to bed now." 12/07/13, 11:59 p.m.: "Resident twisted the arms of 2 CNAs (Certified Nursing Assistants). Struck both CNAs & this nurse & another resident this shift. Resident was given scheduled dose of [MEDICATION NAME]. Supervisor was notified of his behaviors & activity staff stayed c (with) him much of the remainder of the evening. Resident layed down on the bed of another resident & was cooperative c moving out of the room. At this time he is lying in the bed next to another resident & will not go back to his room." 12/08/13, 4:00 a.m.: "Res assisted to own room at 0005 (12:05 a.m.)...3:25 p.m.: Res wandering, entering into residents rooms. No combativeness noted on this shift. Res takes meds well with a spoon. Speech is nonsensical, res touches everything, and is very hard to redirect." 12/08/13, 11:59 p.m.: "Resident grabbed CNA's arms & spat on her face. Later in the evening resident was found in the bed of another resident wearing only his Depends & spooning the resident who was wearing her pajamas & covered in her blankets. The other resident stated that he kissed her on the lips." Resident #1's care plan is not comprehensive and individualized. It does not address specific behaviors of getting into other residents' beds, kissing female residents, aggression etc. The above note does not specifically state what Resident #1 was actually doing when he was "spooning" the other resident, or who the other resident was. 12/09/13, 7:40 a.m.: "...Res awake & up to N. S. (nurse's station) Xi (times one) dressed only in depends. Redirection to room & BR then back into bed s (without) issue. No wandering into others rooms." 12/10/13 (actually 12/09/14), 3:25 p.m.: "Res combative w/ (with) staff. Punched staff in L (left) cheek w/force of a 6. Res wandering, entering others rooms." 12/09/14, 3:30 p.m.: "Sps (Spouse)/POA (Power of Attorney) contacted informed of incident last night of res getting into bed with a female resident. Sps thankful for call." 12/10/13, 5:00 a.m.: "Res (arrow indicating up) in hallway Xi c motion door alarm sounding. Res had been incont (incontinent). Res toileted, changed & then back to sleep s issue." 4:22 p.m.: "Res was combative w/staff and other Res no injuries to anyone. Res continues to wander." 12/11/13, 4:10 p.m. "Res wandering into other residents rooms. Urinating and having bowel movement on floor and on other residents beds. Res combative towards staff. Swung at staff with fist and missed. Res very hard to direct. Is very nonsensical does not understand or take commands. Undirectable." Another nurse's note states that at 4:00 p.m., Resident #1 was "combative, hitting, pulling staffs hair, spiting (sic) in staffs face uncooperative c staff assisting to clean up res p incont of BM. Wanders ad lib, no c/o (complaint) voiced, Activities here til 1930 (7:30 p.m.) worked c res." On 12/12/13, the high risk committee met, but did not discuss Resident #1's behaviors. A note written by Minimum Data Set (MDS) Nurse K addressed Resident #1's nutritional status. 12/13/13, late entry for 12/10/13: "Res struck another resident in chest on 12/10/13. Resident was being assisted by staff into room, (Resident #17's name) was following them and (Resident #1) struck (Resident #17) in the chest." (As noted above.) 12/13/13, 4:18 p.m."Res wandering into others rooms. No combativeness during shift. Difficult to redirect." 12/14/13, 4:53 p.m.: "Res was pushing res (Resident #11) when she hit him in the stomach. He hit her back in the nose. seperated (sic) and fine after. wandering but no other combativeness." 7:00 p.m.: "Activity here til p supper keeping res entertained." The "Steps Taken to Prevent Recurrence" in the investigation states that the residents were separated and given verbal cues. 12/15/13, 6:30 a.m.: "[MEDICATION NAME] 2 mgm (milligram) po (by mouth) given; Res diff (difficult) to redirect; disconnecting Christmas decoration inserted piece of decoration c sharp points Res. Attempting to slide piece between fingers making jabbing motions at staff. Res ref. to keep clothing on; swearing at staff slapping @ them if they get too close." 6:00 p.m.: Res likes to visit & put hands on other staff/res shoulders/arms when speaking res wanders ad lib in hall way." 12/17/13, 5:00 a.m.: Res awake most of (night) shift, wandering halls & entering other Res rooms. Resistive to cares swinging & spit @ writer during wet brief (change). Res entered another Res room, writer attempted to redirect Res then became angry, swung out @ writer & chased writer down hallway into N.S. Res quickly calmed, ate snack & healed into bed. [MEDICATION NAME] 1 mg po given @ 0345 (3:45 a.m.) for (increased) agitation/combativeness. Asleep @ present." 12/17/13, 4:00 p.m.: "At 1345 (1:45 p.m.) staff witnessed res hit another res, two times in the face. Spouse was notified. Onsite left for (Geriatric Nurse Practioner). DON notified. Res was sent out to hospital for a psych eval, with MD (Medical Doctor) orders. Res left facility at approx (approximately) 1500 (3:00 p.m.) with a police escort." According to the facility's investigation, the resident who was hit was Resident #8. The investigation states that Resident #1 walked by Resident #8, "in lounge and slapped/hit (Resident #8) two times before staff could intervene." CNA P, who saw the incident wrote in the investigation, "I was coming by the desk looking in the lounge. I saw (Resident #1) slap (Resident #8) - I started running, but (Resident #1) hit him again before I could get there. I moved (Resident #1) and (CNA Q) moved (Resident #8)." CNA Q wrote the following statement, "(CNA P) yelled (Resident #1) just hit (Resident #8) and I looked up and as I looked up, (Resident #1) swung against (Resident #8) again. (CNA P) & I both went & separated (Residents #1 & #8). Staff took (Resident #8) to clean up the blood." Resident #1 was readmitted to the facility on [DATE]. Nurses' notes are as follows. 01/14/14: (Night shift) "Combative X1, then very pleasant with last rounds." 01/15/14: (time not documented) "Res wanders about in hallways ad lib. ref v/s (refused vital signs) combative c ADL's (activities of daily living). Res likes to put hand on arm/shoulders when talking." 01/16/14, 2:30 a.m.: "3 person extensive assist to (change) bed linens p incont voiding. Res. combative; doesn't follow directions c cues; hit CNA in face when she explained what they were attempting to do." 01/17/14, 4:30 a.m.: Cont to be physicially combative c C/C (check and change) during noc (night). 3A (assist) req (required) for bed linen (change)...hitting & pinching." Resident #1 continued to wander ad lib during the next few days. On 01/23/14 at 7:20 a.m., Resident #1 was found lying on the floor next to Resident #3's bed. His feet were on the mat and the rest of his body was on the tile. He had no apparent injury. 01/27/14, 3:35 p.m.: "Combativeness w/staff when trying to change clothes and assist to bathroom." There are no nurses' notes written between 01/31/14 and 02/06/14. On 02/06/14, the IDT (interdisciplinary team) met and wrote a note in Resident #1's chart regarding his behavioral management. This note states that from 01/13/ - 01/31/14, Resident #1 had twenty behavioral episodes. It also stated that he had adverse effects to some psych meds while he was hospitalized , plus his wife did not want him to receive them. A trial of increased pain management has had "appropriate positive effects on behavior." This note did not mention specific individualized interventions which could be used to manage Resident #1's aggressive or sexual behavior. The care plan was not developed to guide staff in Resident #1's care needs. 02/10/14, no time documented: "Ate ointment which appeared to be BCL cream (used as a barrier on residents' genitals/peri area/buttocks) from another resident's room." This concern was not addressed on Resident #1's care plan. Resident #1 was monitored, and he had no signs or symptoms of an adverse reaction. 02/16/14: (At 6:30 p.m.) "Res was grabbing @ another res walking stick there was a struggle & they both fell on the floor." (Cross reference F 223.) 02/22/14, 2:30 p.m.: "Res assisted into BR c 2 CNAs. Res slapped CNA in face." 02/25/14: "F/U (follow-up) fall 2/16 - walking stick removed, PT (Physical Therapy) screened, therapy not indicated." 03/01/14, 2:30 p.m.: "Cont (continues) c q (every) 15 min (minute) (check mark)s. No aggression noted this shift. Does wander into others rooms needs frequent redirection." 10:00 p.m. "Res remains on 15 min checks, aggression to staff, hitting & spitting, wanderin in other res rooms." 03/02/14, 1:30 p.m.: "Resident holding hands c another F (female) res. walking in hallway. Staff redirected residents." 03/03/14, 3:00 p.m. "Res hit another res R (right) arm with gait belt. Supervisor notified"...remains on 15-minute checks." The facility's investigation, which was self-reported, has a statement written by Activity Aide (AA) Z, which states, "(Resident #1) took (Resident #2)'s gait belt out of her bag that is in back of (Resident #2's) wheehchair. (Resident #2) tried to get it back. (Resident #1) was about to hit (Resident #2) with the gait belt and I wheeled (Resident #2) away from (Resident #1)'s reach. (Resident #1) had a angry look on his face & towered over me with the gait belt raised up & ready to hit me...I backed up (Resident #2 with me) (Resident #1) hit (Resident #2) with gait belt on her right arm close to her wrist. I called for the nurse. (Nurses names) came to remove (Resident #1) away from (Resident #2) and I . (Resident #1) punched (Nurse's name) in the face." Resident #2's nurses' notes state on 03/03/14 at 8:00 p.m, "Res voices concerns that Res (#1's medical record number) scares her & she's afraid he will come into her room tonight. States, 'he's crazy.' Reassured that staff is here to protect her and she can call for help if she needs it. 03/04/14, 8:00 p.m., "Res states she's scared of res & starts yelling for him to get away when he walks by her." 03/09/14, 4:30 p.m. Resident #2 complains of increased "nervousness due to 'feeling like another res stalking her & shes affraid (sic) of him.' Reassured res staff here & call if she needs help." Surveyor interviewed Resident #2, who was hit with the gait belt by Resident #1, on 03/27/14 at 11:10 a.m. Resident #2 remembered the incident, and was upset about it. She stated, "He took it (the gait belt) out (of her bag) and I tried to get it back and he hit me with it (she pointed to her right forearm)." She stated that her arm did hurt at the time, and stated, "I probably still have a mark." No mark was seen on Resident #2's right forearm by Surveyor . Resident #2 also stated, "I don't dress like a floozy. I don't want to be anywhere near him. My grandpa taught me how to fight, and he told me the bigger they are the harder they fall." Resident #1's nurses' notes continue as follows. 03/05/14, 3:10 p.m.: "Resident was seen by a CNA in another residents room kissing her on the lips as she slept in her w/c (wheelchair). Resident redirected." According to the facility's investigation, the resident who Resident #1 was kissing was Resident #17, whose family has moved her to another nursing home. The IDT met to discuss Resident #1's behaviors on 03/05/14, mentioning that Resident had hit another resident with the gait belt, and that on 02/27/14, he loosely wrapped the call light cord around another resident's neck. No injury to other resident, no recollection by either resident, residents were separated and placed on 15-minute checks, with Resident #1 temporarily placed on 1:1, and his call light cord was removed from his room. "He has dementia and does not use the call light appropriately." Nothing was written about this incident in Resident #1's chart on 02/27/14. Surveyor asked the Director of Nursing (DON) for a copy of the investigation regarding the above incident on 03/31/14 at 3:12 p.m. The DON stated that she was not aware of this incident. The Nursing Home Administrator (NHA) told Surveyor on 04/01/14 at 8:50 a.m. that there was no investigation. She stated that staff had initially noticed that Resident #1's call light was not in his room, then saw that it was draped around Resident #11's shoulders, not actually around her neck, so no investigation was warranted. On 03/05/14, staff added the following interventions to Resident #1's care plan. -15-minute checks -call light removed from room -psych eval 03/07/14 (no time documented of actual incident, but was written at 3:00 p.m. in Resident #4's chart) "This resident struck another Res (Resident #4) on the L side of face next to ear c closed fist. No injury apparent to Res hand. Resident were seperated (sic) 1:1 attention provided, No further aggression noted. Cont c 15 min checks." At 10:00 p.m. on 03/07/14, the nurse's note states, "Resident walked behind resident (#4) at nurse's station at 1800 (6:00 p.m.) (Resident #4) made contact c closed fist to (Resident #1's) L arm. No apparent injuries. Residents separated." Cross reference F 223. 03/08/14, 2:30 p.m.: Res hit CNA c closed hand @ 0725 this AM. No apparent injury noted to either of Res hands. Res requiring frequent 1:1 attn (attention) this shift to distract from touching others. Wanders into other res rooms. No further aggressive behaviors...Continues on q 15 " (minute) checks." 03/09/14, 4:00 p.m.: Cont to wander into others rooms needing frequent redirection/distraction." 03/10/14, 2:45 p.m.: At 1035 CNA was assisting Res to stand & pull up pants in Res room when Resident hit CNA in face with closed fist...1:1 provided for rest of shift." There are no nurses' notes written about an altercation with Resident #4 on 03/11/14. On 03/12/14, the IDT met and MDS Nurse K wrote a note saying that Resident #1 "approached another res & attempted to take walking stick, other res did not let go, (Resident #1) struck other res." This note does not address Resident #4 later hitting Resident #1 that evening, nor the altercation with Resident #4 on 03/11/14. On 03/11/14, a facility investigation completed by LPN M states that at 7:30 a.m., Resident #4 approached Resident #1 and "stated, 'give me my shirt back' then immediately hit other res c closed fist in shoulder & cont (continued) trying to hit other res. as myself & and aide broke up the fight. Res. watch was broken & sl (slight) skin tear to R (right) hand/finger." The report also stated that Resident #4 stated, "He took my damn clothes. If he does it again I'll take him down." It also stated that Resident #4 "began punching at him & made contact c a couple of them." CNA N's statement included in the above facility's investigation states, "I walked into the hall and saw (Resident #4) going after (Resident #1). He was throwing punches and so was (Resident #1). (Resident #1) ripped off and broke (Resident #4's) watch. (LPN M) was intervening already when I ran up to help her seperate (sic) them." There were no nurses' notes in Resident #1's or Resident #2's chart written about the incident until RN K wrote in Resident #4's nurse's notes on 03/12/14, "Res to Res aggression 3/11 - thought another res wearing his shirt, approached other res & struck other res & continued to hit other res as staff intervened, sustained skin tear to finger & broke watch. Residents separated, had 1:1 supervision for remainder of shift, on 15" (15-minute) checks." 03/17/14, 4:00 p.m. "Res walking in hallway holding another females hand. Staff intervened res upset c staff & attempted to hit staff. Cont on 15 min checks." 03/18/14, 5:00 a.m. Resident was up and wandering, going into other residents rooms and getting agitated. Gave 650 mg [MEDICATION NAME] prn (as needed) for pain and resident is laying down and resting comfortably." 8:00 p.m.: "Res has followed his usual wandering routine walking in hallway holding hands c another res - staff intervened. No agitated behaviors noted." 03/19/14, 7:00 p.m.: "CNA reported Res (Resident #15) reported 'res had came into his room (Resident #15's room number) before supper & when he tried to get him to leave, he hit him in the face" (Resident #1 hit Resident #15). The facility added a mesh gate with a stop sign across Resident #15's door to deter Resident #1 from entering Resident #15's room. 03/23/13: "At 1035 (a.m.) this resident hit another Res (Resident #11) c open hand c force on her L cheek. Staff immediately intervened & 1:1 attn provided for rest of shift. No injury apparent to this res...(Resident #1) was found eating rocks that belonged to (another resident's initials). Rocks were removed from mouth, no rocks were ingested." According to the facility's investigation for the above incident of hitting another resident, Resident #11 was sitting in her wheelchair in the hallway, talking loudly per her norm. Resident #11's nurse's note states "Res had been talking loudly about her 'mother' just prior." At 10:35 a.m., Resident #1 walked up to Resident #11 and "struck her in the face with his open hand c force." (Note below that Resident #11 was also hit by Resident #10 at 4:30 p.m. the same day.) Surveyor performed a facility tour of the second floor dementia care unit on 03/26/14 beginning at 10:10 a.m. Surveyor met Resident #1 in the hallway, who walked into a female resident's room, and CNA S told him, "That's a lady's room" and guided him back to the hallway. Resident #1 smelled of urine. CNA O and LPN M provide personal cares for Resident #1 on 03/27/14 at approximately 11:00 a.m. Resident #1 had been walking in the hallway, and had wet through his disposable incontinence brief, and had spots of urine on his jogging pants down to his ankles. Resident #1's disposable brief was sagging on him. CNA O and LPN M pulled down Resident #1's jogging pants and tried to get Resident #1 to sit on the toilet in his room so he could be changed, and Resident #1 would not sit down. He talked nonsensically. CNA O was able to remove the wet brief while Resident #1 stood up, and she cleansed his peri area with a disposable wipe. She placed the wet brief on the floor, stating that Resident #1 is not allowed to have a garbage can in his room, because he "takes the contents out." (This concern is not addressed on Resident #1's care plan.) After Resident #1 refused to sit in the bathroom, LPN M recommended that Resident #1 walk to his bed and sit there, which he was assisted to do. A washable pad was placed on the bed, and Resident #1 did sit down on the bed so that the caregivers could put a clean brief and clean pants on him. He was then guided to the hall, where he walked independently. During the weekend of 03/28 - 30/14, Resident #1 was discharged to an area Behavioral Health facility. 2. Resident #10 states she was admitted to the facility on [DATE], and her first nurses' notes state, "Res wanders, goes into other residents rooms." Other nurses' notes are as follows. 12/14/13, 6:30 a.m.: "OOB (Out of bed) @ 0530 lounge disrobing, unrinated on the floor. Easily distracted by writer, returned to room for ADLs. Walking/wandering in hallways." 8:00 p.m.: "Likes to hold others hands." 12/15/13, 8:00 p.m.: "Res wants to walk & hold hands of other res. Encouraged to keep hands to self." The fact that Resident #10 likes to hold other residents' hands is not addressed on her care plan. 01/13/14, no time documented: "Resident pushing another resident's w/c. The other resident stated that this resident scratched her & this resident was struck by the other resident & she was found to have a small skin tear on her R hand & some bruising." Resident #10's care plan was not updated with interventions addressing resident-to-resident altercations. The facility's documentation of this incident stated that it occurred at 7:05 p.m. The other resident was identified as Resident #18. According to staff statements, Resident #10 was observed trying to push the wheelchair of Resident #18, and noticed the skin tear and bruise on Resident #10's hand. Resident #18 had scratches on her arm, stated that Resident #10 had scratched her, and she hit Resident #10's hand. The "Steps Taken to Prevent Recurrence" was to "trim & file residents' nails." 01/14/14, 4:45 p.m.: "Res was witnessed by staff punching another resident in the left arm when that res stopped walking with them...therapy referral put in to see if can have walker or wheelchair for res to hold onto when walking. Orders for psych consult received 1/9/14" (there were no nurse's notes written between 01/03/14 and 01/10/14). In the investigation for this incident, the other resident who was hit by Resident #10 was Resident #17. On 01/15/14, there was a high risk review completed by MDS nurse K, who reviewed Resident #10's nutritional status. This note did not address behaviors. 01/18/14: late entry: at 7:20 a.m., "res was touching another res (Resident #18) w/c. Res was asked to stop, 'Get away' said (Resident #18). Res (#10) then kicked (Resident #18) in the right shin. No injury noted to res. According to the facility investigation, this incident occurred on 01/17/14. According to a statement written by the DON, "(Resident #18) was sitting by the nurses cart, (Resident #10) came by and was touching (Resident #18's) wheelchair. (Resident #18) said for (Resident #10) to leave her alone. (Resident #10) was then seen kicking (Resident #18) in her right shin and (Resident #18) said 'she kicked me.'" The "Steps Taken to Prevent Recurrence" was "Try to keep both residents seperated" (sic). 01/19/14, 6:00 p.m.: "Daughter called back & notified of incident above. Daughter wonders about her Mom needing additional medication. Notified daughter we can discuss this c MD, however, reassured daughter that she is having less problems c combative behavior than she did 1 month ago." There are no nurses' notes written between 01/19/14 and 01/25/14. 01/25/14, 5:50 p.m.: "Another residents family member states res was taking napkin off of table, family member said told res to leave it and res slapped the other residents family member on left side of face. Approx. 30 min prior res hit the same family member in left arm without provocation...Staff witnes sin lounge at time states she redirect (Resident #10) and did get her to another table when she saw going by (Resident #13) and family member." 9:00 p.m.: Has had several approx 3 - 4 short periods of (arrow up indicating increased) agitation noted. Redirected c encouragement." According to the facility's investigation, the 2 incidents occurred at 4:15 and 4:45 p.m. The "Steps Taken to Prevent Recurrence" were, "Educate res family to alert staff if another resident is bothering them." 01/26/14, 8:00 p.m.: "Res has hit staff in stomach during staff trying to redirect res. away from other residents." 01/29/14, 12:30 p.m.: "Combative with staff when res was trying to take other peoples lunch items. Res given own lunch and no further issues." 4:00 p.m.: When walking by another resident in the main lounge, (Resident #10) was kicked in the R thigh by another res. No bruising noted at this time." According to the investigation, the incident occurred at 2:00 p.m., and the other resident was Resident #24. The investigation states that (Resident #24) was agitated in the main lounge, Resident #10 was walking by Resident #24. Resident #24 yelled, "Get her away from me" and Resident #24 kicked Resident #10 in the right thigh. There are no nurse's note written between 02/01/14 and 02/05/14. On 02/06/14, the behavioral managment team met, and documented that Resident #10 "had 26 behavioral episodes for the month of January 2014, however 50% of the episodes were pacing/wandering. Resident is stable on current floor c current meds." There are no nurses' notes written between 02/14 and 02/19/14. 02/20/14, 8:17 p.m.: "Called and spoke to family concerning resident found in room (number) without clothes resident was not distressed or appear to have been forced into taking clothes off. Daughter laughed asked if there was anything she could do to help, stated resident on 15 min checks and staff aware to watch for behavior." According to the facility's investigation, Resident #10 was found with Resident #13 in a room together, both residents were undressed, and Resident #13 had his hand on Resident #10's thigh. The "Steps Taken to Prevent Recurrence" were to place the residents on 15-minute "visual safety checks." There are no nurse's notes written on 02/21, 02/22/nor 02/23/14. 03/02/14, 1:30 p.m.: "Res holding hands c M (male) resident walking in hallway. Staff redirected residents." There are no nurses' notes written from 03/10 - 03/15/14. The facility monitored Resident #10's behaviors after reducing her dose of [MEDICATION NAME]. 03/23/14: "(Resident #10) hit (Resident #11) in the lounge. She made contact to (Resident #11's) left arm & chest. (Resident #11) was immediately moved by the CNA to a different table. (Note that Resident #1 also hit Resident #11 at 10:35 a.m. on this date as stated above.) According to the facility's investigation, this incident occurred at 4:30 p.m., when Residents #10 and #11 were sitting together at a table in the lounge. Resident #11's nurse's note states, "Res sitting to her left slapped her L arm and chest area. Other res were also sitting at table & res was talking continuously." On 03/27/14 at 9:05 a.m., Surveyor reviewed the papers on the clipboard where staff documents 15-minute checks. Residents #1, #3, #4 and #21 currently are on 15-minute checks. For the logs dated 03/25 - 26/14, there were no 15-minute checks documented between 10:15 a.m. and 1:45 p.m. for the four residents. For the logs dated 03/26 - 27/14, there had been no 15-minute checks documented since 6:00 a.m. as of 9:05 a.m. for the four residents. Surveyor observed the lounge area in the dementia care unit from 1:30 p.m. to approximately 3:30 p.m. on 03/26/14. There were ten residents seated in the lounge area, and the television was playing a Lawrence Welk video, but no residents appeared to be watching it. Four of the residents had their eyes closed. Resident #11 was seated in her wheelchair, holding a doll. She smiled at Surveyor . Resident #1 was seated at a table near the window alone. He looked very tired. CNA O brought Resident #19 to the day area at 1:34 p.m. CNA O walked to Resident #10 and rubbed her back and said her name twice. Resident #10 did not react. At 1:35 p.m. Resident #1 stood up and walked to the men's bathroom, but was unable to open the door. The back of his jogging pants was wet. He walked down the hall and entered the room of another resident. A caregiver walked down the hall and found Resident #1 within two minutes in the other resident's room. During the observation, Resident #3 was in her Broda chair, halfway down the west wing by herself. At times she put her legs up in the air as she normally does, and at times she propelled herself with her feet. The above observation continued, and Resident #20 stood up and walked with her walker to the women's bathroom. She left the door open approximately three inches as she toileted herself, which was visible from the table where Surveyor was sitting. A caregiver told CNAs "both of these residents need some attention" and CNA S took Resident #1 down to his room, and the other CNA took the other male resident down the south hall. Resident #21 was in and out of the lounge area, sometimes sitting for up to a minute at a time, and other times walking in the hallway. At 1:45 p.m. a visitor entered the unit from the stairwell and walked by the lounge area, stating, "She (Resident #21)'s trying to get out the door. I just thought I'd tell you." Resident #21 then sat down at the table where Resident #11 was seated. The Lawrence Welk video rewound itself, and CNA W pushed a button to play it again. At 1:50 p.m., CNA O returned to the lounge area, walking hand in hand with Resident #1, who was now wearing clean pants. At 1:55 p.m., CNA W sat down in the chair where Resident #1 had stood up with wet pants, and had an activity basket for Resident #1. She also gave Resident #1 a hunting magazine which he was reading. At times he would read words out loud. CNA W asked Activity Aide (AA) T, "Do you want to do Bingo? Are you here until 7:00?" AA T stated that she would just be here

UNCORRECTED AT VERIFICATION VISIT (Previous Survey Event ID: 1NUF11) Based on interview and medical record review, the facility did not ensure each resident received or the facility provided the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, for 1 (Resident #4) of 1 resident reviewed with distressing behaviors does not receive medications for these behaviors. Resident #1's behaviors are not evaluated quantitatively to establish an effective behavior management program. This is evidenced by: Resident #4 has a [DIAGNOSES REDACTED]. Resident #4's medical record read in part: -Psychosocial Assessment with signatures dated 03/28/14 read in part: "Behavior Tracking Intervention Initiated - Yes" -Nurses' notes dated 05/24/14 read in part: "Res (resident) displayed extreme agitation/paranoia early day shift at breakfast and shortly after. Loudly yelling about bombs in the facility, bad air and 'we're all gonna die.' Attempted to exit front entrance in WC (wheelchair) several times. Brought outside with staff PRN (as needed). 1 on 1 attention, redirection required all of shift until nap after lunch." -Psychiatric consult note dated 04/10/14 read in part: "Reason for evaluation: sexual and aggressive behaviors. History of Present Illness: She (sic) reports feeling frustrated and angry. At some point states he 'will become a wild animal' if he's not allowed to go home. Staff reports she (sic) has been sexually inappropriate times (sic) and has displayed some aggressive behaviors. Upon reviewing the records have a level (sic), this (sic) behaviors have been sporadic and inconsistent. However staff reports the patient had made some inappropriate advances on vulnerable females... There was another incident where the patient struck another resident... He has voiced passive suicidal statements while being frustrated but denies active suicidal thoughts at time of our assessment. Only one occasion, as far as I can tell, he had some paranoid like statements they (sic) are not present at the time of our interview. treatment plan: [REDACTED]. This could be decreased to 15-minute checks as per nursing discretion. Follow up: 2 weeks." -Psychiatric consult note dated 05/01/14 read in part: "Reason for evaluation: History of disruptive behaviors. History of Present Illness: For this assessment I reviewed my prior notes, discussed the case with nursing staff and interviewed the patient. He has only intermittent disruptive behaviors but not the aggressive ones. They are sporadic and inconsistent. Follow up: 6 weeks." -Care plan problems read in part: "Inappropriate language/gestures; at risk of elopement, HX (history) of increased expression of sexuality; Seeking intimacy/socialization with other residents inappropriately; History of expression of need for intimacy/touch." -Behavior Monitoring Record sheet for May 2014 contained only one targeted behavior, "Obsessive Behaviors - change in living/social situation." All dates were either blank or contained zeros, with the exception of a questionable mark made on the 24th for both day and pm shift. -Behavior Management Documentation sheet for May 2014 read in part: "Behaviors: inappropriate language, inappropriate gestures, trying to kiss staff, obsessing about finances, etc. New Behaviors: Anxiety over daily funct (function)." The documentation showed behaviors occurred on 05/19, 05/24, 05/25 and 05/27. On 05/28/14 at 10:15 a.m., Surveyor met with Director of Nursing (DON), Business Office Worker (BOW) Y and Social Services (SS) A. Surveyor asked for an explanation on the difference between the Behavior Monitoring Record (BMR) and the Behavior Management Document (BMD). DON explained the BMR is kept in the Medication Administration Record [REDACTED]. BOW Y stated the details should be found in a nurse's note. DON explained the BMD is completed by the Certified Nursing Assistants (CNAs). BOW Y explained the behaviors and interventions are developed by social services and the interdisciplinary team; CNA staff do the recording and they are tallied at month's end. DON explained it was documented if the behavior occurred on that shift, but not every time it occurred. Surveyor asked how would you know if the behavior happened once or 50 times that shift. DON stated she understood what Surveyor was saying; SW A nodded in agreement. Surveyor asked if they would expect quantitative data be collected on the aforementioned behaviors to provide to the psychiatrist to aid in treatment. DON stated, "Yes." Surveyor asked if they felt the BMR and BMD documents would provide the data necessary to support psychiatry visits to determine an appropriate treatment plan. DON stated, "No." On 05/28/14 at 9:45 a.m., Surveyor interviewed Licensed Practical Nurse (LPN) CC. Surveyor asked LPN CC if she was trained in using the new BNR form. LPN CC stated, "They showed us, nothing in depth, but yes." Surveyor asked LPN CC who is to complete the form. LPN CC stated they should come filled out with target behaviors on them and they come from the social worker in the changeover packet every month (noting the particular one LPN CC looked at in the MAR indicated [REDACTED]. Surveyor asked LPN CC how the forms are used. LPN CC stated, "A check is acknowledging we've looked at it and no behaviors. If behaviors happened then a plus or how many doses they got." On 05/28/14 at 9:52 a.m., Surveyor interviewed Registered Nurse (RN) L. Surveyor asked RN L if she was trained in using the new BNR form. RN L stated, "No, but I know how to use it." Surveyor asked RN L who is to complete the form. RN L stated, "The nurses complete it." Surveyor asked RN L how the forms are used. RN L stated, "Normally would have behaviors written down (noting the particular one RN L looked at in the MAR indicated [REDACTED]. In the nurse's note I could write how many times it happened and what we tried to do and if it was effective." Surveyor asked RN L if she would definitely write a nurse's note and she replied, "No, possibly I would."

Based on medical record review, review of facility investigations and interview, the facility did not ensure that medically-related social services were provided to attain or maintain the highest practicable physical, mental and psychosocial well-being for 5 of 15 sampled residents. Residents #4 and #9 live on a dementia care unit, and were found unclothed together on two occasions. The facility did not provide social services to address their need for intimacy, and did not prevent the second incident from occurring. After Resident #9 was discharged , Resident #4 continued to pursue other vulnerable female residents who have dementia. Not providing medically-related social services created a situation of immediate jeopardy, which began on 02/27/14, and was removed on 03/31/14, when Resident #4 was placed on 1:1 and moved to a room in another hallway after he was again found in a female resident's room with his pants down, and with the female resident's incontinent brief in disarray. This citation continues at a scope/severity level of E, because of additional examples of lack of social service documentation for residents with behaviors affecting other residents, and because all staff have not been adequately trained in the importance of providing medically-related social services. Resident #5 had no social service notes from his admission, until the day of discharge, and did not have a discharge care plan developed by the social worker. Resident #8 had no social service notes since 12/2013 to address his psychosocial needs. Resident #7 had several episodes of verbal abuse towards other residents and staff, and was abruptly discharged on [DATE]. There are no social service notes after 02/12/14. This is evidenced by: 1. Resident #4's medical record states he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #4's Brief Interview for Mental Status (BIMS) score, with 15 being the highest possible score, was 10. Resident #4 is protectively placed at the facility and has a court-ordered guardian. Resident #9's medical record states she has [DIAGNOSES REDACTED]. Resident #9's BIMS score is 15, however she does have hallucinations and delusional behavior. Resident #9 has a court-ordered guardian. The medical record states that Resident #9 has had delusions of thinking she is the queen, Marilyn Monroe, the president of the military, and that she is having a baby. On 02/24/14, Resident #4's nurse's note states, "This nurse (Licensed Practical Nurse -LPN B) was called into residents room by the CNA (Certified Nursing Assistant). She found resident completely naked standing above his bed with resident (Resident #9's initials) laying on the bed also completely nude. This resident had his hands in her genital region. Both residents were (then) dressed and this resident was placed back to bed and placed on 15 minute checks. There were no more incidents this shift. Message out to DON (Director of Nursing), supervisor notified." Surveyor interviewed CNA C, who was the CNA mentioned in the above note, on 03/31/14 at 3:32 p.m. CNA C stated she had checked Residents #4 and #9 on the previous rounds, and they were both fine in their own rooms at 12:05 a.m. She stated that on the next rounds, she was going to walk down the private hall (south hallway with private rooms) while on rounds, but decided to go down the east hall instead. She noted that Resident #9 was not in her room, and that Resident #4's door was closed. When she entered she saw the scene described in the note above. She stated that when Resident #4 looked up and saw her, he pulled his hands away from Resident #9's genital area. She stated she had Resident #4 move away from the bed, and then asked LPN C to come to the room. CNA C stated that Resident #9 did not want to get out of Resident #4's bed, saying that Resident #9 thought Resident #4 was her husband. CNA C stated that Resident #9 kept saying, "What did I do wrong? I'm so sorry." She stated that Resident #9 was yelling loudly, and was asked to get in her wheelchair so she could go back to her room. CNA A stated that Resident #9 wanted to keep going by Resident #4. CNA C stated that the facility staffed the dementia care unit with one nurse and one CNA on the night shift, but in the past week or so, the facility added another CNA on the unit at night. Resident #4's nurses' notes state that on 02/25/14, Resident #4 kissed Resident #9 in the hallway. "CNA noticed it right away and separated them. They are already on 15 minute (checks sign) for the same issue that happened earlier in the week." Surveyor reviewed the Social Service notes in Resident #4's chart and noted there was nothing written about the above incidents. Resident #4's care plan does not address the above incidents. Resident #4's nurse's note written on 02/27/14, written by LPN B, states, "During 15 minute checks (at 2:15 a.m.) resident was found in room (Resident #9's room) undressed in bed with (Resident #9) undressed also. Resident was removed and brought back to his room. He thinks they are married. 15 minute checks continue and supervisor updated." Surveyor interviewed LPN B on 04/01/14 at 7:00 a.m. LPN B stated that after the above incident, Resident #9 was upset because she thought that she and Resident #4 were married. She also stated that Resident #4 "wanted to go through with what they were wanting to do." LPN B stated that Resident #9 was very upset, and initially was in her wheelchair near the nurses' station, and then wheeled down to her room and entered and closed her door. She stated that Resident #4 was on 15-minute checks, and she checked him more often than that. Neither Resident #4 or Resident #9's care plans addressed any concern for their intimacy needs. There were no social service notes written pertaining to the above two incidents. There is no documentation any attempts of the Social Worker interviewing either resident after the incidents. Resident #9 was hospitalized for [REDACTED]. Surveyor discussed the above incidents with the Nursing Home Administrator (NHA) and Director of Nursing (DON) in an interview which began on 03/27/14 at 2:00 p.m. The NHA stated that Resident #9 was fully capable of getting herself onto Resident #4's bed, and there was no evidence to indicate that he had lifted her, and that Resident #9 was "very capable of yelling" if she did not like something. She stated that because it looked like a consensual act, the facility chose to not self-report the incidents. She also stated that one day when Resident #4's jacket was missing, it was found on Resident #9's bed. The NHA stated she understood that the care plan should have addressed the above incidents, and that the residents' guardians should have input for the residents' needs for intimacy. Additional nurse's notes are as follows. Resident #4's nurses' notes continue as follows. 02/27/14 , 11:00 p.m.: Res (resident) has made several inappropriate comments to staff this shift. Asking for a kiss, to go to bed with him, stay with him tonight. (No) inappropriate behavior noted c (with) other res." 03/01/14, 6:00 a.m.: Resident remains on 15 minute checks and is sleeping throughout shift. No inappropriate or sexual behaviors towards staff or other residents. 03/02/14, 2:00 p.m.: Staff reported inappropriate comments made this AM. 03/05/14 (no time noted): Res making inappropriate comments to staff. "Looking for a woman I really need one." Requesting hugs & kisses redirected with much encouragement. Taken out of (Room numbers of Residents #14 and #10)." Residents #14 and #10 were both unable to complete the BIMS test to determine their level of cognitive impairment. 03/07/14, 3:30 p.m: "1:1 attention given from breakfast until dtr (daughter) arrived at 1355 (1:55 p.m.) d/t (due to) res attempting to bring a female Res X2 into his room & writer observed this Res attempt to kiss other Res. Writer seperated (sic) Residents & this Res stated 'She's my girlfriend's daughter & we had sex so now I'm afraid she's my daughter so I can kiss her & go out the front door with her too.' Writer told Res that he could not take other Residents into his room. Res then stated, 'Come into the closet with me & I'll treat you good.' Cont c 15 min (minute) security checks. Will continue to monitor." Surveyor asked the DON and NHA who the female resident was who Resident #4 attempted to bring into his room, and was told that it was Resident #11. Resident #4 continued to be on 15-minute checks, although he was already on 15-minute checks when the above incidents occurred. There were no Social Service notes written pertaining to this incident, The care plan was updated to place a motion detector on Resident #4's door to alert staff that he was out of his room. 03/08/14: Continues on 15-minute checks. 03/12/14, 5:40 p.m.: Res wanders about hall way ad lib. Needs reminders to use walker. No inappropriate behaviors noted. Surveyors and met with the NHA and DON on 03/27/14 at 4:30 p.m. The NHA stated she understood that the facility needs to provide medically related social services to address residents' intimacy needs, and to provide protection for all vulnerable residents. 2. Resident #4's nurses' notes, written by LPN B, state that on 03/31/14, Resident #4 was found in Resident #14's room, sitting next to her bed in her wheelchair. "He had his pants around his knees and he was leaning over (Resident #14) who was asleep. Resident (#14's) pad (incontinence brief) was in disaray (sic). The CNA asked resident to leave the room. The nurse was called the nurse went to this resident's room to check to see how he was. He did not want to talk about it. He ignored this nurse." Surveyor interviewed LPN B, as stated above, on 04/01/14 at 7:00 a.m. LPN B stated that yesterday morning she was called at 6:30 a.m. to Resident #14's room, and was told by the CNAs that Resident #3 was found, sitting in Resident #14's wheelchair, and Resident #4's pants were down to his knees, he was leaning over her, and her blankets were pulled off her, her pants were pulled down (she had been washed and dressed in bed that morning) to the lower edge of her brief. LPN B stated that since the facility added an extra CNA on the night shift, that it has been easier to monitor the residents' behaviors. However, the most recent incident had just happened the previous morning. LPN B stated that Resident #4 has been moved to a room down another hallway, and is 1:1, with a chair and a desk parked outside of his room for the staff to monitor him. Surveyor met with the DON on 04/01/14 at 8:50 a.m., who stated that the facility was still investigating the incident which occurred on 03/31/14 with Residents #4 and #14. She stated she was not sure how far Resident #14's pants were pulled down, and not sure of the exact position of her blankets. The DON also stated the facility was investigating why the alarm on Resident #4's door did not sound when he left his room. This meeting was also attended by the NHA, Social Worker (SW) A, and by Corporate Consultant R. 3. Resident #5 was admitted to the facility on [DATE]. The social service notes contain a list of items that are checked off as completed; there is no narrative note on the admitted . The care plan titled, Discharge Planning to provide for the most appropriate environment of care, is a print out with prewritten statements. There are no checkmarks or initials to identify what the discharge planning is. This is dated 06/24/13 in the margin, with one entry on the bottom, dated 06/24/13. LTC- long term care, home- will discuss closer to when rehab knows more. The resident continued in therapy and then was discharged home on[DATE]. The only social service note is dated 10/09/13 and states in part: "Writer met with resident and daughter...re: discharge home as soon as possible...Family plans to share in home care giving of 3 siblings, seeking nurses from agency and has equipment in place for prior living at home. RN is seeking doctor order to discharge home...SW (social worker) will follow up w/call to resident in a couple of weeks to see if successful at home." On 03/31/14, Surveyor interviewed Registered Nurse (RN) K about Resident #5. Surveyor asked why Resident #5 was discharged suddenly. RN K said he would check the social worker notes. RN K came back and stated, "There is not much here," and gave it to the surveyor. 4. Resident #8 was admitted to the facility 09/16/13, hospitalized and readmitted on [DATE]. Resident #8 is currently on hospice for end of life care at the facility. Resident #8 also has prescribed antipsychotic medication for aggressive behaviors. Dose adjustments were made 03/04/14. The following entry on 12/03/13 states, "Resident to return from hospital stay that began 11/27/13 ...arrival expected about 1500 today. son...was contacted and had planned on coming here to sign any paperwork..." There are no further social service notes to address the psychosocial needs of Resident #8 since 12/03/13 (end of life, aggression ect). On 03/31/14 at 3:00 p.m., Surveyor interviewed SW A asking how often they do social service documentation. SW A stated, "We do it quarterly with every care conference, and then more often if concerns arise." Surveyor asked if SW A was familiar with Resident #8. SW A stated she recently took this position and so she does not know why there are not more notes in his medical record. 5. Resident #7 was admitted on [DATE] for skilled nursing needs after a total knee replacement. Resident #7's medical record documented several behavior concerns. There is a pre-printed care plan titled, Risk for Social Isolation, dated 01/27/14 with the problem, needs for socialization, and past activity level checked. The goal: To participate in independent activates 3 x week and to participate in activities of choice...Initial interventions/approaches: worked at caterpillar tractor company, offer independent activities for the room, TV, magazines. Provide religious music,..non-denominational, Provide reminders and assistance to activities, introduce resident to peers with similar interests...(There are no updates to this care plan.) The grievance file was reviewed and documented incidents where he had been verbally abusive to residents and family members on three separate occasions (2/10, 2/12, and 2/22/14). The nurses' notes also include the following behavior concerns in part: 02/03/14 "Therapy reported to writer that resident has been going down stairs to use the bathroom. Resident was educated on safety with transfers and reminded that he is assist of 1 with transfers and needs to use a walker. Resident refused..." 02/05/14 "High risk review:...Behaviors noted, verbally abusive toward others including roommate..." On 02/10/14, the social service notes document an emergency care conference meeting. The notes include in part: "Conference held to discuss inappropriate sexual comments made during evening dinner...resident educated on abuse and made aware of consequences including a possible 30 day notice..resident also 'crashed a party' on 4th floor this weekend 02/8/14 with another resident...there have been numerous other issues with resident including racist statements and rude comments. He called a housekeeper a 'squaw', and also said to dietary staff, 'hey bulbar, I see you are moving up in the world." Nursing notes continue in part: 02/11/14 "Spoke to resident due to he put his urinal 1/2 full on room mates side table, explained he could not do that and he stated it was that or drop it on the floor." Social Service Note on 02/11/14, "Care conference held today. CCCW (Community Care Wisconsin) present along with social services, admin, dietary and RN supervisor. Admin again reminded of polices of respect to to her res and staff. SS has reminded that there is zero tolerance for discriminatory language. Res again reminded that a 30 day notice may be issued if behaviors continue..." Nursing notes continue in part: 02/12/14 "High risk review...Behaviors reviewed, ...inappropriate sexual comments...rude to others, redirected multiple times, and has not changed behavior. resident has been educated on what constitutes abuse, and possibility of 30 day notice if behavior does not change." Social Service Notes on 02/12/14, "It was brought to the attention of social services that at breakfast on 2/12 that resident was seen accepting money from another resident. Statements taken, interviews conducted. Other resident stated resident picked him up smoke less tobacco and he was paying him back...he then proceeded to call the administrator 'a Nazi'. This a.m. resident was also witnessed telling another female resident that she looked like 'Joe Camel'...and the government killed him'. He admitted to this when questioned. Resident issued 30 day notice.." 02/14/14 "Resident was noncompliant with safety related to speed of electric wheelchair. "...Overheard by staff CNA and staff nurse saying to another resident in the dining room."you have diarrhea of the mouth and constipation of the brain." (Resident #16) was very upset and tearful-crying about comments that were made...Resident was found smoking by sliding doors of front entrance when asked about smoking habits, resident claimed he had no knowledge of smoking rules for facility, claimed it was his first and last cigarette smoked while here..." The social service notes that follow this incident, 02/14/14 "Resident dropped off a box of chocolates for office/floor staff for Valentine's Day. Resident stated he purchased them 'before we all conspired against him.' This is the last social service note documented. There is no documentation of investigating why the resident is acting out, or assessing ways to meet his psychosocial needs. Nursing Notes include: 02/17/14 "...Very sarcastic and belligerent to staff. Non compliant with cares..." 02/19/14 "High risk review...continues to make inappropriate comments to staff and other residents despite redirection." 02/22/14 "Grievance was filed against resident from another resident nursing spoke to resident letting him know to knee negative comments to himself..." 02/22/14 2300 (11:00 p.m.), "Resident asked to eat in Solarium or his room due to comments made to other residents. When another resident asked for staff to wheel her down he hall. resident said (Resident #16 name) could be assisted down the stairs. ...Administration informed of situation and resident was then issued invitation to dine elsewhere-except for dining room. care plan will be updated." 02/23/14 "Resident's breakfast tray was brought to resident in his room this AM due to resident still in his room and because resident had been asked to eat elsewhere due to incident at dinner previous night..Resident then cam flying out of room on motorized scooter screaming down hall. Resident stated,'He will f------eat where he was f------ ate since he f------ got here.' Resident was then reminded that screaming in the hallways was inappropriate and needed to stop...CCW (Community Care of Wisconsin) was then updated and they informed staff to call police and have him escorted out if he creates another scene or threatens staff or residents...Administrator and on coming staff updated on occurrence and steps to take if further incidents occur." 02/24/14 09:45 a.m. "Call received from..Royalton Manor report that (Resident #7 name) was once again harassing tenants and had been all weekend...notified police and he returned to the facility... (There is no previous documentation of this occurring.) 02/24/14 1800 (06:00 p.m.), "resident discharged from St. Francis to home per Freedom transport." The documentation does not address any part of the discharge process or how discharge planning was put in place for the abrupt discharge. On 03/27/14 at 10:30 a.m., Surveyor interviewed SW A about the incidents above. Surveyor asked when they had determined that Resident #7 had behavior problems. SW A stated, "I realized it after the first few days." Surveyor asked what was done about the behaviors. SW A stated, "I talked with the resident and educated him." Surveyor asked when a care plan was put in place to address his psychosocial needs and the behaviors. SW A stated, "The care plan is dated 02/22/14." Surveyor asked about the discharge process. SW A stated, "He was given his 30 day notice on 02/12/14, and then there was another incident that pushed it over the edge." Surveyor asked if that occurred on 02/24/14. SW A said, "I believe so." Surveyor stated that the social service notes do not address anything that happened surrounding his discharge, and wondered if the resident left willingly. SW A said, "Yes, I think he did."

Based on medical record review, interview, and observation, the facility did not ensure that each resident is free from physical, verbal and mental abuse for 5 of 15 sampled residents. Residents #1 and #4 reside on the dementia care unit. Residents #1 has shown aggressive behaviors to residents and staff. Resident #1 got into a physical altercation with Resident #4 on 02/16/14, and the residents were placed on 15-minute checks. Despite the 15-minute checks, on 03/07/14, and on 03/11/14, Residents #1 and #4 got into subsequent physical altercations where they threw punches at each other. Residents #4 and #1 were upset and angry after the altercations. The facility did not develop individualized, comprehensive care plans to guide staff in the care of residents with aggressive behavior. Resident #1 hit Resident #2 on the arm with a gait belt on 03/03/14. Afterward, Resident #2 was upset about the incident for several days. Resident #16 filed a complaint with the facility on two occasions, stating that Resident #7 had been sexually suggestive and verbally abusive. Resident #10's family also filed a complaint regarding Resident #7 entering their private party with Resident #10 present, and yelling at the children attending the party and telling them to shut up. Appropriate interventions were not put into place timely to stop the above abuse. This is evidenced by: The facility policy titled Resident Abuse/Neglect/Mistreatment: Program General Guidelines, dated August 1999, includes in part: Statement of Policy: It is the policy of this facility to maintain an environment free of abuse and neglect. Each resident has the right to be free from verbal, sexual, physical, and mental abuse...residents will not be subjected to abuse from anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident... 1. Resident #1's medical record states that he has [DIAGNOSES REDACTED]. Resident #1 was admitted to the facility in December of 2013, and was discharged to a mental health unit because of violent behaviors, and was re-admitted to the facility on [DATE]. The facility's nurses' notes document multiple times when Resident #1 was combative with staff. An initial activity assessment states that Resident #1's wife stated he was an officer in the military, had 300 people who worked under his command, and he does not like to take orders from women. This information was placed on his care plan addressing activities. On 02/06/14, the facility requested and received an order for [REDACTED]. On 02/16/14, Resident #1's nurses' notes state, "Res (Resident) was grabbing @ (at) another res walking stick there was a struggle & they both fell on the floor. Res is on neuros, 24 (circle to indicate the word hour) report no apparent injuries @ this time." The resident with the walking stick was Resident #4. Resident #4's medical record states that he has [DIAGNOSES REDACTED]. Resident #4's nurse's note of 02/16/14 states that after the above struggle with Resident #1 and the fall, Resident #4 had a bruised left knee. On 02/19/14, Registered Nurse (RN) K wrote in the nurses' notes that Resident #1's walking stick was removed from the floor, and that his behaviors were stable. According to Resident #4's nurses' notes and facility investigation, on 03/07/14 at 3:00 p.m., Resident #4 was struck by Resident #1 "on the L (left) side of face near ear c (with) closed hand. Res daughter (name) here, had brought Res his walking stick. CNA (Certified Nursing Assistant) observed Res being hit...daughter re-educated to not bring walking stick..." A CNA who witnessed the incident wrote the statement, "Was standing at desk when I saw (Resident #1) come up to (Resident #4) full force and punch him in the ear." After the incident, Resident #4's daughter took Resident #4 on an outing. According to a nurse's note written at 9:00 p.m. on 03/07/14, at approximately 6:00 p.m., Resident #1 came up near Resident #4, and Resident #4 punched Resident #1 with a closed fist on his left arm. Resident #4 stated, "He came up to me & sucker punched me. I'm giving him a warning." The nurse's note also states that the residents were promptly separated. The investigation of the incident states that Resident #4 also stated, "This guy is going to get it" and that both residents are on 15-minute checks. Although Resident #4 is diagnosed with [REDACTED].#1, three hours prior, and was still upset about being hit. Resident #1's Power of Attorney was issued a 30-day notice to find alternate placement. On 03/11/14, a facility investigation completed by LPN M states that at 7:30 a.m., Resident #4 approached Resident #1 and "stated, 'give me my shirt back' then immediately hit other res c closed fist in shoulder & cont (continued) trying to hit other res. as myself & and aide broke up the fight. Res. watch was broken & sl (slight) skin tear to R (right) hand/finger." The report also stated that Resident #4 stated, "He took my damn clothes. If he does it again I'll take him down." It also stated that Resident #4 "began punching at him & made contact c a couple of them." CNA N's statement included in the above facility's investigation states, "I walked into the hall and saw (Resident #4) going after (Resident #1). He was throwing punches and so was (Resident #1). (Resident #1) ripped off and broke (Resident #4's) watch. (LPN M) was intervening already when I ran up to help her seperate (sic) them." There were no nurses' notes in Resident #1's or Resident #4's chart written about the incident until RN K wrote in Resident #4's nurses' notes on 03/12/14, "Res to Res aggression 3/11 - thought another res wearing his shirt, approached other res & struck other res & continued to hit other res as staff intervened, sustained skin tear to finger & broke watch. Residents separated, had 1:1 supervision for remainder of shift, on 15" (15-minute) checks." Surveyor reviewed Resident #1's care plan on 03/26 - 27/14, and noted that he had a care plan entitled, "HealthPrime Behavior Management Resident Plan of Care". The problem/need was "Demonstrating inappropriate behavior as evidenced by:" and there was nothing filled out in this area. It appeared to be a pre-written care plan. Staff did add on 03/05/14 that Resident #1 was on 15-minute checks and that the call light was removed from his room, and that he was to have a psych evaluation. On 03/19/14, a care giver added to keep a soft gate up on room [ROOM NUMBER] at all times. The care plan did not describe potential behaviors or triggers for behavior, the care plan was not comprehensive and individualized for Resident #1's aggressive behaviors. 2. According to a facility self-report, on 03/03/14 at 3:00 p.m., Resident #1 took a gait belt out of a bag on Resident #2's wheelchair. When she tried to get it back, he hit her arm with the gait belt. The facility's investigation has a statement written by Activity Aide (AA) Z, which states, "(Resident #1) took (Resident #2's) gait belt out of her bag that is in back of (Resident #2's) wheehchair. (Resident #2) tried to get it back. (Resident #1) was about to hit (Resident #2) with the gait belt and I wheeled (Resident #2) away from (Resident #1's) reach. (Resident #1) had a angry look on his face & towered over me with the gait belt raised up & ready to hit me...I backed up (Resident #2) with me (Resident #1) hit (Resident #2) with gait belt on her right arm close to her wrist. I called for the nurse. (Nurse's names) came to remove (Resident #1) away from (Resident #2) and I. (Resident #1) punched (Nurse's name) in the face." Resident #2's nurses' notes state on 03/03/14 at 8:00 p.m, "Res voices concerns that Res (#1's medical record number) scares her & she's afraid he will come into her room tonight. States, 'he's crazy.' Reassured that staff is here to protect her and she can call for help if she needs it. 03/04/14, 8:00 p.m., "Res states she's scared of res & starts yelling for him to get away when he walks by her." 03/09/14, 4:30 p.m. Resident #2 complains of increased "nervousness due to 'feeling like another res stalking her & shes affraid (sic) of him.' Reassured res staff here & call if she needs help." Surveyor interviewed Resident #2 on 03/27/14 at 11:10 a.m. Resident #2 remembered the incident, and was upset about it. She stated, "He took it (the gait belt) out (of her bag) and I tried to get it back and he hit me with it (she pointed to her right forearm)." She stated that her arm did hurt at the time, and stated, "I probably still have a mark." No mark was seen on Resident #2's right forearm by Surveyor . Resident #2 also stated, "I don't dress like a floozy. I don't want to be anywhere near him. My grandpa taught me how to fight, and he told me the bigger they are the harder they fall." Surveyor interviewed the Director of Nursing (DON) on 03/27/14 at 11:35 a.m., and asked who is responsible to develop and update residents' care plans. The DON stated that the floor nurses are responsible. Surveyor asked if the facility had a director for the dementia care unit, and the DON stated that the facility plans to put someone in that role. Surveyor mentioned to the DON that the care plans for residents with dementia and aggressive behaviors are to be individualized and comprehensive, and the DON stated that she understood that, and agreed that the care plans are not currently adequate. Surveyor interviewed CNA C on 03/31/14 at 3:32 p.m. CNA C stated that she has worked for the facility for several years and had what she considers adequate training to provide care to residents with dementia and aggressiveness. CNA C stated that some of the newer aides need training, and some are "terrified" to work in the dementia care unit; they're afraid of getting hit by residents. Surveyors and met with the Nursing Home Administrator (NHA) and DON on 03/27/14 at 4:30 p.m. The NHA stated that when Resident #1 was ready to return to the facility after his hospitalization , the faciltiy was reluctant to re-admit him. She stated, "He was basically left on our doorstep." She stated that around 70 other nursing homes had denied admission for Resident #1. She stated she understood that if the facility is going to admit residents with aggressive behaviors, the facility needs to be able to meet the residents' needs, and protect other residents from harm. Resident #1 has also hit other residents; cross reference F 309 K. 3. On 03/26/14, Surveyor reviewed the complaint file and found documentation in part: Resident Grievance/Complaint Form, dated 02/10/14 Resident #7 made sexually suggestive comments directed toward a female resident when the CNA asked her when she wanted to go to bed. -If other person involved name them: Resident #16, CNA D -What actions or recommendations do you feel need to be taken? Immediate conference with Administration and social Services. -Recommendations: Educated on verbal abuse, sexual harassment, and improper language, as well as consequences. Resident #7 thank us and stated he had "a lot of food for thought." 4. Resident Grievance/Complaint form dated, 02/12/14 Date the incident occurred: 02/08/14 -Incident: Another resident's family held a buffet style birthday party for her on the 4th floor sky lounge. The men 'crashed' the party and were being quite rude. They hollered at the children and told them to shut up. It was at this point the family asked them to leave. The men refused and the nurse supervisor intervened. The situation was handled appropriately by the nurse supervisor and the men eventually left after causing a scene. -Recommendations: Residents educated on inappropriate behavior 5. Resident Grievance/Complaint Form -Name of person filing the grievance: (Resident #16) -Date incident occurred: 02/22/14 -Describe the nature of the grievance: States that she was talking to another resident, and Resident #7, interrupted conversation and stated, "that son of a [***] asked who he was and he stated, you know." Resident #16 states he always has something negative to say about everyone and everything, and states it makes her feel nervous and he must be stopped. Resident #7's medical record was reviewed and the nurses' notes include in part: 02/14/14 "...Overheard by staff CNA and staff nurse saying to another resident in the dining room, "you have diarrhea of the mouth and constipation of the brain." (Resident #16) was very upset and tearful-crying about comments that were made. 02/18/14 "...continues to make inappropriate comments to staff and other residents despite redirection." 02/22/14 "Grievance was filed against resident from another resident. Nursing spoke to resident letting him know to keep negative comments to himself while dining with other residents, if he was unable to do so he was fee to dine in solarium..." 02/22/14 at 2300 (11:00 p.m.), resident asked to eat in solarium or his room due to comments made to other residents when another resident asked staff to wheel her down the hall, Resident #7 said, '(Resident #16) could be assisted down the stairs. Administrator informed of situation and resident was then issued invitation to dine elsewhere-except for dining room. Care plan will be updated. Corrective Actions: Resident educated about abuse, what it is and what may happen if one resident were to make abusive comments to another, (Resident#7) stated he understood. On 03/27/14 at 10:30 a.m., Surveyor interviewed Social Worker (SW) A and the DON to ask about the above incidents. Surveyor asked what interventions were put in place after the first incident on 02/10/14. There was no response. Then Surveyor asked what did you do to protect your other residents from the verbal abuse. The DON stated, "I guess we educated him, and then nothing until the update on the care plan 02/22/14." Surveyor asked SW A if she felt that Resident #16 had been verbally abused. SW A said, "Yes, it did upset her at the time." Surveyor reviewed the care plans for Resident #7. There had been no behavior care plan in place to identify interventions to protect other residents from verbal abuse until 02/22/14.

Based on observation, interview and record review, the facility failed to ensure the resident environment remains as free from accidents as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 5 residents reviewed for falls. Resident #8 experienced five falls in January, a root cause analysis was not completed to determine the reason for the falls. The fall on 01/19/14 resulted in a laceration to Resident #8's forehead, with an emergency room visit and liquid sutures for the laceration. Maintenance supplies were observed in an accessible, unlocked area. Resident personal care items and disinfectant sprays containing warning labels, which included to get medical help or contact a poison control center immediately, were stored in accessible areas in resident rooms and unlocked areas. This is evidenced by: The facility policy titled: Falls- Clinical Protocol, dated 2005 Med-Pass, Inc., revised April 2007, includes in part: Assessment and recognition 5. The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc. Cause Identification 1. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. a. Causes refer to factors that are associated with or that directly result in a fall; for example, a balance problem caused by an old or recent stroke. 2. If the cause of a fall is unclear, if the fall may have a significant medical cause...or if the individual continues to fall despite attempted interventions, a physician will review the situation and help identify contributing causes. 3. The staff and physician will continue to collect and evaluate information until either the cause of falling is identified, or it is determined that the cause cannot be found or that finding a cause would not change the outcome or the management of falling and fall risk. Treatment Management 1. Basked on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls... a. Examples of such interventions may include calcium and vitamin D supplementation...hip protectors, addressing medical issues such as hypertension and dizziness, and tapering, discontinuing, or changing problematic medications... Monitoring and Follow up 4. If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling...and will re-evaluate the continued relevance of current interventions. 5. As needed, the physician will document the presence of uncorrectable risk factors, including reasons why any additional search for causes is unlikely to be helpful. Resident #8's Minimum Data Set, dated dated [DATE], documents a history of falls, and a brief interview for mental status staff interview indicating severe cognitive impairment. Resident #8 needs extensive assist of two persons for transfers. The care plan titled, High Risk for Falls, undated, includes in part: -Goal: Will remain free of falls through next review. Fall 1/29/14, In event of fall, will not experience injury related to fall. -Approaches: Fall risk assessment to be completed on admission, quarterly, and in the event of a fall by licensed nurse. Tabs in w/c, pressure alarm in bed, Observe resident for adverse side effect/toxicity of medications..., If receiving behavior altering drugs, review for possible dose reduction at least 90 days and document findings, Maintain resident environment free of clutter and safety hazards, Place items frequently used by resident within easy reach, to avoid resident reaching for items, Provide environment with adequate lighting, free of glare. New intervention added 01/22/14 Dismex pad to w/c (wheelchair) seat to help prevent sliding out of w/c. The nurses' notes and falls investigation were reviewed and contain in part: 01/04/14 "Resident found on floor at bedside. Hoyer lift used to transport resident back to bed. Vital sings taken-unremarkable. On site to ...re fall. Message left for ...No apparent injuries. Small reddened area in middle of back..." Falls investigation in part: -Describe exactly what happened, the causes...Bed alarms no turned on. -Steps taken to prevent reoccurrence, Education with staff members about importance of safety alarms... 01/11/14 4:45 p.m. "Hear alarm CNA (Certified Nursing Assistant) entered room found resident on floor by bed and wheelchair. No injures noted. moves extremists x 4. Neuros started. ...RN supervisor notified. On site prepared for ...CNP (Certified Nurse Practitioner), left for son...See neuro flow sheet for V/S (vital signs) and findings." Falls investigation in part: -Describe exactly what happened, the causes, Heard alarm entered room resident laying on floor in front of wheelchair by bed. -Steps taken to prevent recurrence: Referral to PT (physical therapy) to check w/c sitting. Physical Therapy note 01/14/14 after the 1/11/14 fall includes in part: -Problem: Resident leans forward when sitting in w/c could you maybe eval for wafer or tilt chair. 1/11/14 -Actions taken upon receipt of referral: Patent already has wedge cushion in w/c. Pt not appropriate for tilt chair. Patent sits in standard w/c with appropriate posture for sitting. CNAs have been educated to lay patient down when he starts leaning, it means he is tired. He can not stay up in w/c all day. The therapy evaluation occurred three days after the fall and no interventions were added to the care plan based on therapy recommendations. 01/19/14 3:05 p.m., "Resident fell in room today, landed on floor face down. Witnessed by staff. DON/Nurse supervisor notified...Resident had two skin tears with a lot of bleeding to forehead. Gauze was applied to forehead to help stop bleeding. The hoyer lift was used to transfer resident from floor to the bed. Resident was sent non emergent to ER (emergency room ) for evaluation. Resident left facility at 10:25 a.m. by ambulance. Resident returned to facility at 1505 (3:05 PM.) by ambulance. Resident did not have any new orders..." Falls investigation in part: -Time of incident: 9:20 a.m.. -Describe what happened, the causes, Resident was witnessed by staff getting up from wheelchair and falling face first on the floor in resident room next to the bed. Injuries suffered: laceration to forehead. -Steps taken to prevent reoccurrence, Resident will be the first to lay down after meals. (This information is not on the nursing care plan or the CNA care plan.) The emergency room discharge information was reviewed and included in part: [DIAGNOSES REDACTED]. The nurses' notes on 01/22/14 state in part: "Forehead laceration has dried blood on it and liquid stitches..." 01/22/14 "Resident slid out of w/c in ding room. Fall was witnessed and did not hit head. No injuries noted at this time...desmax (sic) pad was placed on w/c to help with sliding out of wheelchair." Falls investigation in part: -Time of incident: 4:30 p.m. Describe what happened, the causes; Resident was sitting in w/c in dinging room and slide (sic) himself forward and down t to the floor. -Steps taken to prevent recurrence: disamex pad was placed in residents w/c. 01/29/14 1:00 p.m., "CNA responded to resident bed alarm and upon entering resident room found resident on floor next to bed. Resident assisted back to bed with hoyer lift and assist of one CNA...abrasion to upper right back measuring 0.2 cm x 0.1 cm. Ice applied to head. ...care plans updated with new intervention to keep tabs alarm on side of bed next to wall. .." (This intervention was added to the CNA care plan.) Falls investigation in part: -Time: 11:00 a.m. -Witness statements: CNA reports she hear bed alarm in resident room upon entering room found resident on the floor next to bed. -Interventions implemented to reduce resident risk for further accident/incidents: Tabs alarm placed on side of bed near wall to alert staff faster if resident moving forward edge of bed. 03/19/14 "Resident was up for meals. Resident's alarm went off aide went in and found resident on floor next to bed. Hoyered off floor. No injures noted..." Falls investigation in part: -Time of incident 11:00 a.m. -Describe exactly what happened; the causes, alarm was going off aide came out and stated he was on floor next to bed. -Steps taken to prevent recurrence; alarm set up next to wall rail. (This intervention is the same intervention as the previous fall on 01/29/14.) -Resident statement: He was hungry and wanted to go to lunch. None of the above falls investigations or witness statements do a root cause analysis to determine what is causing Resident #8 to be moving and fall. The investigation does not address if the resident is in pain, if he is hungry, thirsty, anxious, or if he may have toileting needs. On 04/01/14 at 8:30 a.m., Surveyor interviewed the Director of Nursing (DON) to ask for a more detailed emergency room report or dictation for the 01/19/14 ER visit. The DON stated, "What is in the chart is all we get." Surveyor asked if she recalled that Resident #8 had liquid sutures. The DON stated, "Yes, I believe so." Surveyor asked if the DON could explain the root cause for the falls that Resident #8 has experienced. The DON agreed the investigation was not clear on the possible causes of the fall. On 04/04/14 at 10:30 a.m., Surveyor interviewed the Nursing Home Administrator (NHA) and Registered Nurse (RN) K and shared the concerns above. The NHA stated, "When I have been doing my inservices this week we have been discussing falls, and the importance of finding the root cause of the fall." 2. On 04/14/14 at 3:40 p.m., Surveyor toured second floor (dementia unit) and observed residents entering and exiting rooms, walking up and down each of the four halls and opening doors. Surveyor observed the following items which contained warning labels that were visible upon entering the rooms: Room 234 contained the following products with: Keep Out of Reach of Children (KOCH) -Two 8 ounce bottles of Old English Scratch Cover for Dark Wood. The label included: Danger - Harmful or Fatal if swallowed. Contains petroleum distillates. Call a physician immediately. -An open 50 pound bag of TEG Accu Color Sanding Grit. The label identified in case of eye contact flush with water for 15 minutes and call a physician. -1 gallon liquid Armstrong Underlayment Additive. The label identified to contact a physician immediately if swallowed or eye contact. -Five 33.8 fluid ounce containers of EZ Foam Yellow. The warning label identified if swallowed contact a physician or poison control center. -3.5 gallon container of TEC Double Duty Ceramic Tile Adhesive. The warning label except for KORC was covered with a white substance. -12 pound container of Sheet Rock - All Purpose Joint Compound. The warning label except for KORC was covered with a white substance. -1 gallon of white vinegar -1 gallon of Pittsburgh Paint - Ultra Interior Latex -1/2 gallon of TEC Grout Accu Color Easy. Additional items stored in Room 234 included loose screw parts, screw drivers, trowels and power tools. Surveyor observed personal care products stored on sinks, bedside stands, toilets and/or closets with the doors open, which contained warning labels to get medical help or contact a poison control center immediately: -Bottles of Total Body Foam Cleanser - Antimicrobial Skin Cleanser were found in rooms 203, 205, 220, 222, 247 and 247. -A tube of Smith & Nephew Protectant Ointment found in room 227 -A tube of Aquaphor Healing Ointment - Advanced Therapy was found in room 203. -A 19 ounce can of Lysol Disinfectant Spray was found in room 203. -A box of Polident 3 Minute tablets was found in room 250. Room 229, the soiled utility room, was unlocked. Under the cupboard was a 32 fluid ounce bottle of Chlorox HC Bleach Germicidal Cleaner spray. The warning label identified to KOCH, causes moderate eye irritation and avoid contact with eyes or clothing. At 4:41 p.m., Surveyor interviewed Licensed Practical Nurse (LPN) M who stated residents do keep their personal grooming products in their rooms. LPN M stated the items are to be kept in the closets. The doors of the closets are to be closed and the items are to be kept out of reach. LPN M stated there were residents on second floor who did wander into other resident rooms and other areas. At 4:50 p.m., Surveyor informed the Administrator of her observations. The Administrator stated the items in Room 234 belonged to maintenance and the door was to be locked when maintenance staff was not present. On 04/15/14 at 9:00 a.m., the Administrator informed Surveyor all the resident care items had been placed in bins on the upper most shelf in all rooms. Bathrooms and nightstands had also been inspected. The Environmental Services Director had investigated Room 234 and discovered it did not latch properly. The door was properly closed and maintenance staff will repair the latch this morning. The Administrator stated a CNA informed the Environmental Services Director she was aware of the door to room 234 not locking when it was closed. The CNA stated she had not filled out a maintenance slip.

UNCORRECTED AT VERIFICATION VISIT (Previous Survey Event ID: 1NUF11) Based on interview and record review, the facility did not ensure the residents' environment remained as free from accidents as is possible and that each resident received adequate supervision to prevent accidents for 1 of 4 residents (Resident #13) reviewed for falls. Staff placed a soiled linen cart across the width of a hallway in order to prevent a resident with dementia (Resident #13) from entering another section of the unit. Resident #13 was brought into the hallway, across from the linen cart, where he later walked to the cart, leaned against it and fell . The resident hit his head on the bottom of the linen cart and received 53 sutures in his forehead. This is evidenced by: On 05/28/14, Surveyor reviewed Resident #13's medical record. The resident resides in the facility's dementia unit and has [DIAGNOSES REDACTED]. Resident #13 receives scheduled Aspirin 81 milligrams (mg) daily, Prozac (an antidepressant medication) 40 mg daily, Ativan (an antianxiety medication) 0.5 mg twice a day, and Trazodone (an antidepressant medication used for insomnia) 25 mg at bedtime. The resident's most recent Minimum Data Set (MDS), dated [DATE], indicates Resident #13 walks independently. The resident had also been wandering throughout the unit, one to three days during the previous week. Resident #13 was unable to complete the Brief Interview for Mental Status (BIMS) assessment due to his poor cognition. The MDS assessment indicates the resident has short and long term memory impairments, and has moderately impaired decision making skills. Surveyor also reviewed Resident #13's comprehensive care plan. The care plan identifies the resident can be physically and verbally aggressive towards others, and it identifies the resident is at risk for falls. The care plan states, in part: "Problem: 04/28/14, High Risk for Falls... Interventions/Approaches: Ensure (resident) has and wears non-skid properly fitting foot wear...Maintain (resident) environment clutter free..." Resident #13's CNA care plan also identifies Resident #13 should use "Grippy socks." Surveyor reviewed an incident report, dated 05/19/14, which was completed by Registered Nurse (RN) BB. The incident report identifies Resident #13 fell by the nurses' station in the dementia unit, at 10:20 p.m. The incident report states the following, in part: "...Nature of Injury: Avulsion (a soft tissue injury when the skin and/or soft tissue is partially or completely torn away) to center of forehead, skin tear to bridge of nose. Witness Statement: Resident last seen by (approximately 10:15 p.m.) resting in bed by CNA (Certified Nursing Assistant). States she (CNA) saw resident emerge from room start up hallway and fell to floor (approximately) 7-10' from (resident's) room. See witness investigation statements. Resident Statement: 'Come here there's a lot of blood.' Environment: N/A (Not Applicable)... Ambulation Status: Independent... Summary of Accident/Incident: I (RN BB) was in charting room...heard loud noise like someone hitting the floor. CNA called for help noticed resident lying on floor facedown (with) hands outstretched (with) large (amount) of blood flowing from head... Intervention: Ensure Dirty Linen cart is stored in its proper location. Staff education regarding incident." Witness statements were attached to the incident report and reviewed by Surveyor . A witness statement, dated 05/19/14 and completed by CNA AA, states the following, "I put the cart in front of the North hallway to keep (Resident #17) from going into the Ladies rooms. (Resident #13) came out slipped on the floor and hit his head on cart." A witness statement, dated 05/19/14 and completed by CNA N, states the following, in part: "As I was rounding the corner...I saw (Resident #13) go down past the counter and heard a crash. I ran to (Resident #13) and found him laying on the bottom part of the dirty linen cart bleeding from his head. When I saw him and knelt down next to him, I yelled for the nurse. (I did not see the whole fall I was coming from a different wing, so the CNA station counter was in the way)." A second witness statement from CNA N, dated 05/21/14, states the following: "Before the incident, (Resident #13) had been repeatedly getting out of bed and trying to pick things up off the ground that were not there. The resident was also moving furniture from his room into the hall. He was very confused and the shift before (night shift) had reported that to me and my coworker." After Resident #13's fall, the resident was transferred to the emergency room (ER), and received 53 sutures to his 5 centimeter (cm), circular-shaped forehead avulsion. Nurses' notes, prior to Resident #13's fall were reviewed by Surveyor . Documentation, dated 05/19/14 at 7:05 p.m., states, "Resident rested in room this (night) shift. Was to the nurses station x 1 to ask where his room was, then back to bed. (No) complaints voiced, (no) behaviors noted." Documentation by the Director of Nursing (DON) on 05/23/14, indicates a different account of Resident #13's fall. The note states, in part: "IDT (Interdisciplinary Team) review of resident fall on 05/19/14...according to staff witness statements res (resident) was up and down all shift, (resident) hallucinating, trying to pick up nonexistent items from floor. (Resident) brought chair from room to sit, staff set up chair by nurses station. (Resident) was sitting quietly. According to staff, a call light went off that they went to answer. When came back resident was up walking, (resident) was leaning against dirty linen cart, cart moved and (resident) fell . Resident assessed by RN, sent to ER for assessment..." There is no other documentation related to Resident #13's behaviors prior to his fall on 05/19/14. CNA N's witness statement does not identify a time in which Resident #13 was repeatedly getting out of bed and moving furniture into the hallway. The witness statements, attached to the incident report, do not identify Resident #13 was brought to the nurses' station and was sitting in a chair. The incident report does not identify the placement of the dirty linen cart in the hallway, nor does it identify how the linen cart was a contributing factor in Resident #13's fall. Surveyor also reviewed Resident #13's nurses' notes after the fall. Nurses' notes, dated 05/20/14, state in part: --"(2:50 a.m.) Resident returned to facility via Gold Cross Ambulance...Received report from St. Luke's Hospital nurse. Resident received 53 stitches to the front of the head...White at the ER resident was given 5 mg Haldol (antipsychotic medication) IM (intramuscular injection) and 1 mg Ativan IM for behaviors. Vital signs upon arrival back at facility T (temperature) 96.8 (degrees), P (pulse) 79, R (respirations) 14, B/P (blood pressure) 166/87, and O2 (oxygen saturation) 96% on room air. Resident was experiencing delusions and was very agitated when back. (One-to-One supervision) for resident's safety only intervention that was effective. Resident very unsteady on his feet. At 4:30 (a.m.) writer called (physician's name)...and received an order for [REDACTED]. Med given but not effective. CAT (Computerized Axial Tomography) scan done at ER and was clear..." --"(At) 8:00 (a.m.) B/P: 91/64, P: 83, R:28, T:97, O2: 94% on room air. Resident unable to respond to verbal commands during neuro (neurological) (checks). Bilateral pupils sluggish to respond to light. (No) c/o (complaints of) N/V (nausea/vomiting). Resident had garbled speech. Bilateral LS (lung sounds) diminished. Unable to cough up audible phlegm...Resident sent to St. Luke's ER..." The resident was admitted to the hospital on [DATE], and remained hospitalized as of 05/28/14. On 05/28/14, Surveyor received and reviewed Resident #13's History and Physical assessment from the hospital, dated 05/20/14. The assessment states, in part: "...LABORATORY DATA: White (blood) count 9...UA (urine analysis) negative for infection...Chest x-ray does show some likely interstitial changes bilaterally consistent with pneumonia. ASSESSMENT AND PLAN:...closed head injury, negative CAT, but does have some confusion/[DIAGNOSES REDACTED] (brain disease or damage) related to trauma and underlying dementia. Additionally he has what appears to be pneumonia. Question if pneumonia was primary to process and started this decompensation, more like I suspect he did have aspiration, or other process happened after the fall and laceration..." On 05/28/14 at approximately 10:20 a.m., Surveyor interviewed the DON. Surveyor , Social Worker (SW) A and Business Office Worker (BOW) Y were also present during the interview. Surveyor discussed the different accounts related to Resident #13's fall. The DON provided a map of the dementia unit to Surveyor . The map identifies the location of the soiled linen cart, across the width of the hall and perpendicular to nurses' station. The map also identifies Resident #13 was sitting approximately a few feet away from cart, and in front of the nurses' station. During the continued interview, the DON stated CNA AA, on 05/19/14, placed a three-compartment (hamper-style) soiled linen cart, on wheels, across the width of the hallway to prevent Resident #17 from entering another part of the unit. The wheels of the linen cart were not locked. The DON also stated prior to Resident #13's fall, the resident was agitated and wanted to be out of his room, but no time was indicated as to when the resident was displaying these behaviors. The resident was then brought to the nurses' station and was sitting in a chair. The DON further stated, the two CNAs on the dementia unit left the area by the nurses' station to answer a call light. The DON then stated Resident #13 stood up from the chair, leaned against the linen cart, and the linen cart rolled/moved, thus causing Resident #13 to fall. The resident hit his head on the bottom part of the linen cart. During the continued interview, Surveyor asked if the placement of the soiled linen cart, across the hallway, was an appropriate intervention to deter a resident from another part of the unit. The DON replied the linen cart should have been placed against the wall, and it was not used appropriately the evening of 05/19/14. Surveyor also asked to review the education provided to staff, as identified as an intervention on the incident report. On 05/28/14 at 1:15 p.m., Surveyor received and reviewed two forms entitled, "Employee Warning Notice," from the DON. Both forms indicate CNAs N and AA were in violation of "Carelessness, Violation of Company Policies or Procedures, and Violation of Safety Rules." The "Employer Statement" on each form states the following, "Date of Incident: 5/19/14...A resident fell and was injured due to carelessness and improper placement of dirty linen cart. This is unacceptable and could have possibly been prevented, had care plan and facility policy have been followed..." One form indicates CNA N was given this "written warning" by the DON on 05/28/14. The other form for CNA AA, who placed the dirty linen cart in the hallway prior to Resident #13's fall, had not been re-educated or retrained as of 05/28/14. Documentation provided by the DON indicates CNA N worked in the facility from 05/20/14 to 05/23/14 without being re-educated or retrained regarding Resident #13's fall. The documentation also indicates CNA AA worked in the facility from 05/20/14 to 05/22/14, and from 05/25/14 to 05/27/14, without being re-educated or retrained. No other staff were re-educated or retraining regarding this incident, or for proper placement of the linen carts, or other equipment in order to prevent resident injuries. On 05/28/14 at 1:45 p.m., Surveyor conducted a second interview with the DON regarding staff re-education and retraining. The DON stated she spoke with CNA A on 05/21/14 regarding re-education and retraining about Resident #13's fall. The DON stated this conversation was not documented. During the continued interview, the DON also indicated CNAs N and AA were supposed to complete Silverchair computerized training after Resident #13's fall. Surveyor asked if the two CNAs completed this computerized training prior to returning to work. The DON stated she is not sure if CNAs N and AA have completed the training as of 05/28/14. It is noted staff inappropriately placed the soiled linen cart across the width of the hallway, as a deterrent for a resident entering another section of the dementia unit. Resident #13 was sitting at the nurses' station, when he walked to the linen cart, leaned against it, thus causing it to move. Resident #13 sustained a significant injury to his forehead due to the fall and required 53 sutures. Resident #13 has dementia, is confused and was able to walk to the linen cart independently. The resident's fall and injury may have been prevented if the soiled linen cart was properly placed out of the resident's environment, and against a wall. The resident's care plan was also not followed to keep the environment "clutter free." Staff were allowed to continue working in the facility after the incident, and were not re-educated or retrained regarding appropriate safety interventions, and facility policies. This presents a risk of other residents becoming injured. Cross reference F 225 and F 226.

Based on record review, staff interview and the facility investigation report, the facility did not ensure 1 of 9 sampled residents received adequate supervision and assistance devices to prevent accidents. Resident #23 was given a tub bath and then transferred from the bathtub to her electric scooter/wheelchair with the use of a Hoyer lift and two staff. Resident #23 exited the shower room and began to slide from her electric scooter because her safety seatbelt had not been fastened by the facility staff. The staff lowered her onto the foot pedals which resulted in this resident receiving a bruise to her left buttocks, abrasions to her forearms and a laceration to her buttocks, which required an emergency room visit, multiple sutures and pain management. This is evidenced by: Resident #23 is an alert and oriented individual who has a [DIAGNOSES REDACTED]. Resident #23's most recent Minimum Data Set (dated 08/30/10 and 05/31/10) identified she requires extensive assist with transferring, dressing, hygiene and bathing. Resident #23 has a right hand brace that is worn eight hours of the day for contracture prevention. Resident #23's weekly nursing summaries (dated 08/13/10 and 09/16/10) identified she has been assessed by the facility as needing total assistance for her cares with two staff and a Hoyer lift for all transfers. Resident #23's most recent falls assessment (dated 09/10/10) identified her at a high risk for falls. Resident #23's physician orders [REDACTED]. - Seatbelt and foot straps in wheelchair. Therapy Referral/New Orders form (dated 05/21/10) identified the following: "Problem identified: Is there a lumbar cushion or something that we can use in (Resident #23's) w/c (wheelchair) to keep her from sliding when reclining chair? "Action taken upon receipt of referral: Spoke with nurse and pt. (patient) and checked w/c. Pt. has seatbelt that she wears all the time, foot pedals and tilt in w/c. Pt. able to tilt/recline safely and has not had any positioning problems. No further equipment is felt to be necessary at this time." Resident #23's current care plan identified the following interventions in three different places: - Make sure seatbelt is in wheelchair for security - Safety seatbelt - Seatbelt in w/c, request for security due to leg spasms. The facility investigation report (dated 08/18/10) identified the following: - On 08/18/10, Resident #23 was in her motorized, reclining wheelchair near the nurses' desk when she was observed to be sliding forward. Licensed Practical Nurse (LPN) K and her assigned certified nursing assistant (CNA), CNA I, observed her sliding forward out of her wheelchair. The facility staff immediately intervened and lowered Resident #23 to the floor. Resident #23 was lifted with the mechanical sling lift from the floor into her wheelchair. As Resident #23 was being transferred, Registered Nurse (RN) L noticed drops of blood on the floor. Resident #23 was taken to her room, placed in her bed and was examined by nursing. The area on her right buttocks was cleansed and she was sent to the emergency room where the laceration on her right buttocks was sutured and a tetanus shot was administered. Pegs on the wheelchair pedal that holds the heel support strap in place caused the laceration and bruising to her buttocks. The facility investigation identified Resident #23 was returning to her room from the bathing area where she had just had her bath. CNA I had just lifted Resident #23 from the tub using the sling mechanical lift. As the CNA was wiping up the water dripping from the wet sling, Resident #23 backed her electric wheelchair out of the bathing area and into the hallway. CNA I placed two cloth waterproof pads under Resident #23 and did not apply the safety belt. "Both conditions contributed to (Resident #23) sliding from her wheelchair, which was in a reclining position." A Patient Transfer Form for Resident #23 (dated 08/18/10) identified the following. - Resident #23 slipped out of her wheelchair, landing on the foot pedals which have a peg on them, obtaining a deep gash in her right buttocks with moderate amount of bleeding. An incident report (dated 08/18/10) identified the following: - "Resident was returning to her room after a tub bath and began to slip down in her chair. She (Resident #23) stopped in the hall and this writer (LPN K) and the CNA lowered her to the floor. She (Resident #23) received a wound due to being lowered onto the pegs of the wheelchair footrests, and abrasions due to sliding against the chair and bath blanket." Resident #23 received: - A laceration to her right buttocks - Bruising to her left buttocks - Abrasions to forearms bilaterally The incident report identified Resident #23 has a history of falls. This report also identified, "Resident was lowered to the floor as she was slipping out of her wheelchair. She received a puncture wound and bruise and abrasions." This report identified the following: care plan not followed - "Seatbelt was not on." The nurses' notes for Resident #23 identified the following: - 08/18/10 at 10:30 a.m. - After taking a bath, resident was in her wheelchair going back to her room and when in front of the nurses' station, CNA I asked LPN K to assist in repositioning the resident. Resident #23 stopped her chair and began to slide downward out of her seat. The resident was lowered down and LPN K stabilized the resident while CNA I positioned the lift machine. The resident was returned to her wheelchair and to her room. Upon assessment with RN L and RN J, a puncture wound was found on her right buttocks and a pink bruised area on her left buttocks, and abrasions were found on her forearms, bilaterally. The puncture wound and bruise were caused by the foot pegs on the wheelchair, and the abrasions were due to the resident's arms making contact with the chair and bath blanket as she slid downward. The puncture produced frank blood and it was cleansed. - 08/18/10 at 8:00 p.m. - Sutures to buttocks are intact with a small amount of serosanguineous drainage. Given two Tylenol for pain. - 08/19/10 - Tylenol 650 mg (milligrams) given for pain. - 08/19/10 - Tylenol 650 mg for pain, old gauze saturated with sanguineous drainage. - 08/19/10 - Resident in mild pain (scale of 7/10). Resident request the nurse to call the doctor for additional pain medication. Darvocet N 100 one tablet by mouth every four hours as needed for pain was obtained from the physician. - 08/20/10 - Received Tylenol 650 mg for pain. - 08/22/10 - Darvocet N 100 one tablet given for pain (scale of 6/10). - 08/24/10 - Tylenol 650 mg for pain. - 08/25/10 - Resident has a laceration between vagina and anus, was probably due to getting stitches in left buttocks and needing to spread area. - 08/28/10 - Excoriated areas on buttocks show no improvement. - 08/31/10 - Slight amount of bloody drainage from lacerated perineum. - 08/31/10 - Small amount of serosanguineous drainage on gauze in area of removed sutures. Resident's bottom remains pink and light red in the upper area of buttocks bilaterally. - 09/01/10 - Small amount of bleeding-tip of the "V." Bilateral buttocks excoriated/sheared areas and they remain red-slightly less redness. - 09/02/10 - Old excoriated areas to upper buttocks bilaterally remain. - 09/08/10 - Suture line on buttocks edges approximated except for the "point," small amount of bleeding. - 09/08/10 - Dressing was changed at 7:50 p.m. serosanguineous drainage from "point" of suture line. The facility investigation interview with LPN K on 08/18/10 at 10:30 a.m. identified she was behind the nurses' station as the resident was in the hall, going back to her room from the tub room. Resident #23 stopped in front of the nurses' station and CNA I asked for assistance with repositioning as the resident began to slip downward and out of her chair. CNA I and LPN K lowered this resident safely to the floor. CNA I moved the mechanical lift in front of the resident and the resident was lifted back into the chair. "We observed drops of blood coming from the resident." The facility investigation interview with RN L on 08/18/10 at 10:45 a.m. identified she looked down the first floor hallway and observed Resident #23 sitting on the foot pedals of her electric wheelchair. Resident calling out, "OW." CNA I and LPN K standing on both sides of the wheelchair. The three staff took the straps of the lift sheet, attached them to the lift and lifted the resident to the seat of the wheelchair. "There was no seatbelt around res (resident)." While the resident was being lifted, RN L saw small drops of blood dripping to the floor. The staff assisted Resident #23 to her room and RN L checked Resident #23's buttocks and observed a gash on the right inner buttocks with a piece of skin hanging out. The facility investigation interview with CNA I on 08/18/10 at 12:00 p.m. identified staff typically used a Hoyer to transfer Resident #23 out of the tub and into her wheelchair. When CNA I was asked by the facility if she had the seatbelt on Resident #23, she answered, "No, she took herself out of the rm (room), backwards in her w/c, scooted out, she took off. NSE (nursing) had assisted to Hoyer resident out of the tub. (LPN K listed)." During an interview conducted by Surveyor on 09/21/10 at 9:10 a.m., CNA I stated she and LPN K Hoyer-lifted Resident #23 from the bathtub into her wheelchair. CNA I told Resident #23 to move her electric scooter backwards so CNA I could wipe up the water on the floor. CNA I put two soaker type pads under Resident #23 so her scooter chair would not get wet. At this time, LPN K opened the bathroom door. Resident #23 left, went to the nurses' station and stated she was falling. CNA I was there and she and another nurse lowered Resident #23 to the floor. CNA I stated they (LPN K and CNA I) did not apply the Velcro seatbelt around Resident #23 while she was in her chair. CNA I stated she wondered if the belt would have held her even if it was on. At this time, CNA I and Surveyor went to the storage room and observed Resident #23's electric scooter. CNA I hooked the Velcro belt together and, with the force of CNA I and Surveyor each pulling on one side of the belt, it did not dislodge which demonstrated it would have likely kept Resident #23 from sliding out of her wheelchair. On 09/21/10 at 8:15 a.m., Surveyor interviewed Resident #23 who was in her bed at the time of the interview. Resident #23 stated she slid from her chair and got hurt, so was sent to the hospital where she needed seven stitches in her bottom. Resident #23 also stated it has been painful and she has had to spend most of her time in her bed now until this is completely healed. "My bottom got it." During an interview conducted by Surveyor on 09/21/10 at 9:45 a.m., RN L stated a skin condition report of Resident #23's wound identified it was a V-shaped and approximately 4 cm (centimeters) by 1.5 cm puncture-type wound. This report identified Resident #23 had continued assessments on the following dates: - 08/25/10 - tip of wound had small amount of blood - 09/01/10 - sutures were removed on 08/30/10 - 09/08/10 - small serosanguineous drainage noted The physician's orders [REDACTED]. - 08/18/10 - Send to hospital for treatment related to the fall - 08/20/10 - Darvocet N 100 one tablet by mouth every four hours as needed for pain - 08/27/10 - Leave sutures in until appointment on 08/30/10 - 09/03/10 - Limit resident time up in her wheelchair The emergency room discharge paperwork (dated 08/18/10) identified Resident #23 had sutures placed and Tylenol or Ibuprofen ordered for pain. Surveyor conducted an interview with RN J on 09/21/10 at 9:50 a.m. RN J stated Resident #23 cannot apply the seatbelt independently. She also stated Resident #23 has limited mobility in her right hand and wears a splint for prevention of contractures. RN J stated Resident #23 is to have the seatbelt on whenever she is in her wheelchair. Resident #23's husband informed the facility she had a history of [REDACTED]. RN J stated they have talked with the CNAs in the past about the importance of following care plans but have not done any recent training accept with CNA I. An interview with the Director of Nursing and Nursing Home Administrator on 09/21/10 at 10:05 a.m. with Surveyor and Surveyor identified they trained CNA I after this 08/18/10 incident, but did not do an all-staff training/inservice on the importance of following care plans as they had trained staff on 08/05/10 when they received a citation regarding one-to-one observation of a resident who displayed behavioral problems.