Every finding on record at Edenbrook of Appleton North

Based on interview and record review, the facility did not appropriately notify a physician after a change of condition for 1 resident (R) (R6) of 3 sampled residents.Registered Nurse (RN)-C administered three doses of nitroglycerine (a fast-acting medication used to relieve/prevent chest pain) to R6. RN-C notified the physician via fax instead of the on-call service. Findings include: The facility's Policy and Procedure Change in Condition, revised 11/13/24, indicates: Purpose: To ensure prompt notification of the resident, the attending physician .of changes in the resident's physical, psychosocial, and/or mental condition and/or status .2. Specific information that requires prompt notification includes, but is not limited to .Instructions to notify the physician of changes in the resident's condition .R6 was admitted to the facility on [DATE] and had diagnoses including congestive heart failure, atherosclerotic heart disease of native coronary artery with other forms of angina pectoris, and anxiety. On 6/17/26, Surveyor reviewed R6's medical record which included an order for nitroglycerine sublingual tablet 0.4 milligrams (mg) give 1 tablet sublingually as needed for chest pain 2 tabs under the tongue every 5 minutes, maximum 3 doses (take full set of vitals before and after dosage and update MD) (start date: 6/9/25).R6's Medication Administration Record (MAR) indicated R6 received nitroglycerine on 3/19/26 at 11:35 PM and 11:50 PM and on 3/20/26 at 12:01 AM. All doses were administered by Registered Nurse (RN)-C.A progress note written by RN-C on 3/20/26 at 4:46 AM included the nitroglycerine administration, a summary of the night shift from 3/19/26 into 3/20/26, and indicated the physician was updated. (Of note: The method used to update the physician was not mentioned in the progress note.) On 6/17/26 at 12:00 PM, Surveyor interviewed RN-C who stated nurses have to notify the physician after administering three doses of nitroglycerine. RN-C indicated they faxed the physician and wrote a progress note. On 6/17/26 at 4:18 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed nurses should notify the physician after administering the third dose of nitroglycerine as stated in the physician order. DON-B indicated nurses should notify the physician via the on-call service, not via fax.

Based on staff interview and record review, the facility did not ensure adequate supervision was provided for 1 resident (R) (R1) of 3 sampled residents at risk for wandering/elopement.R1 had a hsitory of elopement and WanderGuard (WG) removal (a device placed on a person to alert facility staff if the person is exiting an area unsupervised). Despite the fact that R1 removed the WG multipe times and exited the facility unsupervised, the facility failed to implement increased supervision for R1 or increased monitoring for WG placement. On 11/17/26 at approximately 10:00 PM, staff discovered R1 was not in the facility during rounds. R1 was last seen by staff in the dining room at approximately 9:45 PM. Staff searched the facility and surrounding area and located R1 in the bathroom of a local business one block away. Staff assisted R1 back to the facility and noted R1's WG had been removed. R1's medical record indicated R1 attempted to elope from the facility on 10/23/25, 11/2/25, 11/6/25, 11/10/25, and 11/13/25 and had removed R1's WG on 11/6/25, 11/10/25, and 11/13/25. The facility did not increase supervision for R1 or increase the frequency of WG checks for placement and function. Staff did not consistently implement other interventions related to wandering such as offering to take R1 outside or engage in specific activities. In addition, staff did not consistently check the placement and functioning of R1's WG, determine if the WG was in place, or determine how R1 continued to remove the WG.The facility's failure to provide adequate supervision for a resident at risk for elopement created a finding of immediate jeopardy that began on 11/6/25. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on 3/3/26 at 12:50 PM. The immediate jeopardy was removed on 3/3/26, however, the deficient practice continues at a scope/severity level D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include:The facility's Elopement Risk and Prevention policy, revised 6/2/22, indicates: All residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or conditions that put them at risk for wandering/elopement. All residents so identified will have these issues identified in their individual care plan .The resident's arm/leg monitor bracelet (WanderGuard) will be checked every shift for placement and daily to ensure the device is functioning properly .Residents identified as at risk for elopement will have interventions put in place .In the instance that a resident walks away from the facility and cannot be located by staff, all staff are responsible to assist with searching every room and bathroom .During the initial 15-30 minutes, cover a radius of approximately 1 mile from the facility, interview staff, and determine who last saw the resident and what they were wearing.On 3/2/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including dementia, seizure disorder, schizoaffective disorder, and bipolar disorder. R1's most recent Minimum Data Set (MDS) assessment, dated 12/3/25, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R1 had intact cognition. R1 had a Guardian upon admission. R1 discharged to another skilled nursing facility on 12/17/25.R1's medical record contained a protective placement document that was registered with the local courthouse on 8/20/25. The document stated R1 required placement on a secured unit due to previous absconding attempts and indicated safety could not be assured on an unsecured unit. R1's comprehensive care plan, initiated 5/7/25, stated R1 was an elopement risk/wander risk and continued to leave the facility without notice/unauthorized. Initial interventions included: Monitor for/document episodes of wandering and triggers; Wander risk assessment per policy; WanderGuard (WG) placement; Add to elopement risk binder/list; Identify pattern of wandering; and Discuss expectations of signing out before leaving (otherwise privileges may be restricted to supervised). An initial Elopement Risk Assessment, dated 5/5/25, indicated R1 was at low risk for elopement.A nursing note, dated 5/7/25 at 1:41 PM, indicated a WG was applied after R1 attempted to call friends/others to take R1 home. The note indicated R1 kept asking to go home to get things. R1's Guardian did not want R1 to leave the facility except for appointments because he did not think R1 would return to the facility. A WG was applied to R1's left wrist. A significant change Elopement Risk Assessment, dated 5/7/25, indicated R1 was at risk for elopement.A care conference note, dated 8/13/25 at 2:31 PM, indicated R1 was not permitted to go outside the facility alone.On 8/27/25, there was an added focus to R1's elopement care plan that indicated R1 historically cut off the WG. (Despite the fact the facility knew R1 had a history of cutting off the WG, there was no additional supervision or increased checks to ensure R1's WG was in place.)A quarterly Elopement Risk Assessment, dated 8/29/25, indicated R1 was at high risk for elopement.A psychiatric visit note, dated 9/2/25, indicated R1's Fanapt (an antipsychotic medication used to treat schizophrenia-type disorders) was stopped while R1 was hospitalized . R1 did not agree to restart the medication despite encouragement. The note indicated R1 had delusional thinking about staff and lacked insight into R1's role in ongoing problems at the facility.A behavior note, dated 10/23/25 at 2:23 PM, indicated R1 was in the guest restroom for over an hour with R1's wheelchair and personal belongings and refused to talk to staff. A behavior note, dated 10/23/25 at 3:19 PM, indicated R1 walked up and down the hallways wearing a coat. R1's clothing and belongings were piled on R1's wheelchair. A behavior note, dated 10/23/25 at 7:30 PM, indicated RN-F observed R1 in the dining room. Several minutes later, RN-F attempted to ask R1 about dinner but could not find R1. A code was called. Staf found R1 hiding behind the therapy door in the courtyard (fully enclosed). R1 was asked to come back inside due to cold weather. R1 made nonsensical comments to staff.A behavior note, dated 11/2/25 at 12:07 PM, indicated R1 exited the facility and was in front of the building. R1 stated a friend was on the way to help pack R1's belongings for another facility. Staff attempted twice to have R1 wait inside and offered to call the friend, however, R1 remained outside. A Certified Nursing Assistant (CNA) watched R1 through the window and was instructed to inform RN-I if R1 moved away.A nursing note, dated 11/3/25 at 9:04 AM, indicated a new WG was applied to R1's right wristA nursing note, dated 11/4/25 at 12:10 PM, indicated R1 had an appointment with a psych provider. Despite multiple attempts to get R1 to go, R1 refused. R1 stated R1 did not believe staff, staff lied about R1's ride, and R1 had never seen a psych provider. R1's wheelchair was stacked with R1's belongings.A behavior note, dated 11/6/25 at 6:48 PM, indicated R1 cut off the WG and walked to the parking lot from the main entrance before RN-F brought R1 back inside. R1 stated the WG fell off and did not state where R1 was going. R1 was not wearing a coat and was pushing a wheelchair full of belongings. A new WG was applied to R1's right wrist.On 3/3/26 at 10:57 AM, Surveyor interviewed RN-F regarding R1's elopements and WG removals. RN-F verified RN-F worked when R1 exited the facility on 10/23/25 and 11/6/25. On 10/23/25, RN-F noted that R1 had been missing for a few minutes and was found hiding behind the door to therapy in the enclosed courtyard. RN-F stated R1's WG was in place at that time. RN-F stated an alarm did not sound because the door did not have a WG alarm. RN-F stated R1 walked out to the parking lot from the main entrance on 11/6/25 and RN-F brought R1 back inside. R1 did not state where R1 was going and said the WG fell off. R1 was not wearing a coat and was pushing a wheelchair full of belongings. A new WG was applied. When asked how R1 removed the WG, RN-F thought R1 obtained scissors from the reception desk. A behavior note, dated 11/10/25 at 4:27 PM, indicated R1 cut off the WG and was outside near the front parking lot to get fresh air. The weather was below 30 degrees and R1 was not dressed appropriately. R1 was encouraged to tell staff when R1 wanted to go outside. RN-J redirected R1 to go inside. A new WG was applied to R1's right wrist.(This was the second tine R1 cut of the WG in a matter of days. Despite the fact that R1 cut of the WG, there was no evidence the faciity addressed how R1 was cutting off the WG or that the facility increased supervision to prevent R1 from exiting the facility.)Interventions added to R1's elopement care plan on 11/11/25 included: Engage R1 in conversations about religion, flowers, or engage in rock painting/craft activities; Offer to go outside with staff and ensure adequate dress for the weather; Offer to assist with calling brother to obtain needed items or to remind of upcoming appointments; WG placed under wheelchair as R1 does not go anywhere without wheelchair but is known to remove WG on person. NHA-A also added triggers for elopement (scheduled appointments, needing items, wanting to go outside to pray) and de-escalation techniques (reminding R1 of scheduled transportation, offering to assist R1 with obtaining items, and offering to go outside) to R1's care plan at that time. (Although the facility placed a WG on R1's wheelchair, it should be noted manufacturer's recommendations discourage the placement of a WG near metal as it can interfere with radio frequency and decrease the capability of the WG's function.)A behavior note, dated 11/13/25 at 9:54 PM, indicated at approximately 6:40 PM, RN-H noted R1 left the facility through the front door without a walker or wheelchair. The WG alarm did not sound. R1 attempted to get into a visitor's vehicle and wanted a ride to [NAME] Bay. A CNA assisted R1 back inside. R1's WG had been cut off and was found on the 100 unit. A new WG was applied to R1's right wrist. An added focus was added to R1's elopement care plan to monitor for tailgating behaviors. On 3/4/26 at 2:13 PM, Surveyor interviewed RN-H regarding R1's elopements and WG removals. RN-H verified RN-H worked on 11/13/25 when R1 exited the facility and attempted to get into a visitor's vehicle. RN-H stated a visitor approached RN-H and stated a resident was attempting to get a ride with them. RN-H saw R1 exit the front door without a wheelchair or walker. RN-H escorted R1 back inside and noted R1's WG was missing. RN-H put a new WG on R1. RN-H did not recall ever offering to take R1 outside or engage R1 in discussions about religion or rock painting/crafts.A nursing note, dated 11/17/25 at 9:30 PM, indicated RN-C checked on R1 who stated R1 would come back to the 300 unit. A nursing note at 11:00 PM indicated R1 was nowhere to be found. A CNA stated they saw someone outside a local store one block away. RN-C went to the store and found R1 in the bathroom. R1 stated someone dropped R1 off there. RN-C and R1 walked back to the facility. A nursing note at 11:20 PM indicated R1 cut off the WG and staff were looking for a new one.On 11/17/25, an intervention was added to R1's elopement care plan to check daily if R1 needs items from outside the facility and assist with obtaining the items.Surveyor reviewed a facility-reported incident (FRI) that was submitted to the State Agency regarding the elopement on 11/17/25. The initial report stated staff discovered R1 was not in the facility during routine rounds on 11/17/25 approximately 10:00 PM. R1 had been seen less than 15 minutes prior. Staff searched the facility and the perimeter and located R1 outside a store across the street within 10 minutes. The investigation included a statement by RN-C that stated at approximately 7:00 PM, R1 was in the 100 unit dining room and received medication. At approximately 9:45 PM, RN-C was in the dining room again when R1 stated R1 would come back to the unit shortly for bed. During routine rounds and report with the night (NOC) shift at approximately 10:00 PM, RN-C could not locate R1. A code was called and staff searched the building. A NOC shift CNA reported that they saw a bag lady across the street at a store. RN-C searched the store, found R1 in the bathroom, and walked R1 back to the facility. R1 refused a skin assessment and anxiety medication. The facility's door did not alarm because R1 had cut off R1's WG and hid it in the front lobby. The facility's investigation did not contain any other staff interviews or statements. Staff were provided education on 11/17/25 on the facility's Elopement and Leave of Absence policies. Surveyor noted that the education did not include specific information related to R1 such as behaviors, personalized elopement interventions, and/or R1's continued removal of the WG. In addition, the investigation included a document titled Elopement Past Non-Compliance (PNC) that stated the facility identified that they could have potentially failed to keep R1 safe as R1 had cut off the WG. Surveyor reviewed a map of the area and noted R1 was found at a store approximately 0.1 miles from the facility. The temperature was approximately 35 degrees, and it was dark. While it is unknown which route R1 took to the store, the store is located on a busy street. An Elopement Risk Assessment, dated 11/17/25, indicated R1 was at high risk for elopement. A nursing note, dated 11/18/25 at 3:01 AM, indicated PM staff reported R1's wheelchair was missing after R1 left the facility. R1's wheelchair was later found in the front guest restroom stacked with R1's belongings. Staff found R1's WG in a drawer in R1's room and reapplied the WG to R1's left wrist.R1's Treatment Administration Record (TAR) contained an order to check R1's right wrist for WG placement and function once per shift. The order was not updated to reflect that R1's WG was applied on 11/18/25. A nursing note, dated 11/20/25 at 1:10 AM, indicated R1 was no longer wearing the WG that was on R1's left wrist at the start of the shift. R1 stated R1 scratched at the WG and it fell off. Staff could not find the WG. Frequent checks were in place. A nursing note at 3:29 AM indicated staff observed R1 attempt to exit the building at 2:46 AM with a coat, a cane, and a purse. R1 stated R1 was going outside for fresh air and had chest pain. R1 was sent to the hospital for evaluation. An Elopement Risk Assessment, dated 12/2/25, indicated R1 was at risk for elopement. A psychiatric visit note, dated 12/4/25, inidicated R1 was hospitalized several times since September (2025). The note indicated R1 had poor judgement and insight based on recent behavior and was not overtly manic or psychotic, however, the provider was worried. The note also indicated R1 struggled with lack of insight into R1's current presentation which affected R1's physical and mental health.R1's TAR contained an order to check R1's right wrist for WG placement and function once per shift. There was no documentation for WG checks on the following dates/shifts: 10/21/25 PM shift, 11/5/25 PM shift, 11/7/25 AM shift, 11/19/25 PM shift, 11/28/25 NOC shift, 11/29/25 AM, PM, and NOC shifts, 11/30/25 AM, PM, and NOC shifts, 12/1/25 AM, PM, and NOC shifts, 12/2/25 AM, PM, and NOC shifts, 12/3/25 AM, PM, and NOC shifts, 12/4/25 AM, PM, and NOC shifts, and 12/4/25 AM, PM, and NOC shifts. Surveyor noted the order was discontinued on 11/26/25 after R1 went to the hospital and was not restarted until 12/5/25. R1's hospital record indicated R1 returned to the facility on [DATE] which meant there were no documented WG checks for 6 days after R1 returned to the facility.A nursing note, dated 12/16/25 at 5:29 PM, indicated staff observed R1 going through the receptionist's desk and puttting things in R1's pocket. R1 denied taking anything from the desk. On 3/2/26 at 1:12 PM, Surveyor interviewed NHA-A and Director of Nursing (DON)-B regarding R1's elopement attempts and safety interventions. NHA-A stated the facility did not attempt to increase supervision at regular intervals or increase checks for R1's WG despite multiple elopement attempts and WG removals. NHA-A and DON-B stated increased supervision and WG checks would increase R1's paranoia/delusions and increase R1's elopement attempts. NHA-A verified there was no documentation related to frequent/increased checks for R1. NHA-A also verified no new interventions related to wandering/elopement were added to R1's care plan after the 11/6/25 and 11/13/25 elopements because the Interdisciplinary Team (IDT) felt the current interventions were appropriate. On 3/3/26 at 11:25 AM, Surveyor interviewed CNA-G regarding R1's elopements and WG removals. CNA-G did not recall specific elopement attempts but indicated R1 locked R1's self in the bathroom, carried R1's belongings around the facility in a wheelchair, and removed R1's WG. CNA-G did not recall ever offering to take R1 outside, do crafts, or talk about religion. CNA-G was not sure how R1 removed the WG but thought R1 bit or chewed it off.On 3/4/26, Surveyor reviewed additional information provided by the facility, including a statement from RN-I regarding R1's elopement on 11/2/25. The statement indicated R1 went outside on R1's own and was not redirectable. Staff notified police who were also unable to redirect R1 back inside. Surveyor also reviewed a statement from RN-J regarding R1's elopement on 11/10/25. The statement indicated RN-J followed R1 outside to the front parking lot as R1 was observed cutting the WG off prior to going outside. R1 was redirected back into the facility and a new WG was applied. R1 stated R1 wanted to get fresh air. RN-J reminded R1 not to leave the building without staff. The failure to provide adequate supervision for a resident with a history of elopement and WG removal created a reasonable likelihood for serious harm and led to the finding of immediate jeopardy. The facility removed the jeopardy on 3/3/26, however, the deficient practice continues at a scope/severity level D (potential for more than minimal harm/isolated) as the facility continues to implement the following action plan:Reviewed and revised care plans for all residents who display exit seeking behavior and/or scored at risk on their Elopement Risk Assessment.Reviewed the facility's Elopement Risk and Prevention policy and procedure to ensure it meets current standards of practice.Educated staff on the following: Ensuring each resident receives adequate supervision and assistive devices to prevent accidents; the facility's Elopement Risk and Prevention policy; How to properly respond and interventions to put in place if a resident exit seeks, leaves the facility, removes a WG, or searches for/is provided tools to remove a WG.Implemented weekly, bi-weekly, and monthly elopement audits and elopement drills.Reviewed and updated the Facility Assessment.

Based on observation, staff interview, and record review, the facility did not ensure appropriate fall interventions were in place for 2 residents (R) (R1 and R4) of 2 sampled residents. R1's falls care plan was not updated with an intervention after a fall on 12/12/24.R4's falls care plan contained an intervention for a urinal at bedside following a fall on 8/12/25. The intervention was not consistently followed.Findings include:The facility's Post Fall Policy, revised 10/13/23, indicates: .Notification and Communication: Communicate with staff on unit that a fall has occurred and intervention put in place to reduce risk of another fall. Documentation: Immediate intervention put in place.On 9/2/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including cellulitis of right lower limb, non-pressure chronic ulcer of right lower leg, dysphagia, adjustment disorder with anxiety, macular degeneration, hypertension, insomnia, and overactive bladder. R1's Minimum Data Set (MDS) assessment, dated 11/20/24, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R1 had moderate cognitive impairment. R1 had an activated Power of Attorney for Healthcare (POAHC). R1 discharged to the hospital on [DATE] due to a change in condition and did not return to the facility. R1's falls care plan, revised 11/19/24, indicated R1 was at moderate risk for falls related to impaired physical mobility, self-care deficit, activity intolerance, fatigue, generalized weakness, decreased muscle strength, incontinence, and a history of mood disorder. The care plan also indicated R1 received antidepressant medication. Following a fall on 11/25/24, an intervention was added for a Dycem (an anti-slip pad) under R1's recliner cushion.A progress note, dated 12/12/24 at 10:02 AM, indicated R1 fell at approximately 7:30 AM and was on aspirin and Eliquis (a blood thinning medication). R1 was not sure if R1 hit R1's head. A nurse completed an assessment, including vital signs and neuro checks. R1 reported buttocks pain at a level 4 out of 10 and had a skin tear on the left elbow. The Nurse Practitioner (NP) responded. A progress note, dated 12/12/24 at 12:15 PM, indicated staff should complete post fall monitoring and fall precautions per the facility's protocol and monitor for any bruising or bleeding due to anticoagulation/antiplatelet use. Staff should also monitor and update with any new or worsening symptoms or further concerns and update physician services with follow-up vital signs. The NP agreed with bordered foam for skin tear treatment and indicated to implement orders as stated. A risk management report for R1's fall on 12/12/24 indicated: Certified Nursing Assistant (CNA) informed writer that R1 was found on the floor at 7:30 AM with R1's head toward the dresser. and wearing Prevalon boots (used to reduce pressure on the heels and help prevent pressure injuries). R1 was incontinent of bowel and bladder. It was unknown if R1 hit R1's head. Neuro checks were within normal limits. R1's pulse was 118. R1 reported buttocks pain and had a skin tear on the left elbow. Notifications were completed and R1 was transferred via Hoyer lift into bed. The report indicated the Interdisciplinary Team (IDT) reviewed the incident on 12/22/24 and concluded that R1 attempted to self-transfer while wearing Prevalon boots which caused the fall. An intervention was added to float heels when in bed and wear boots when in wheelchair or recliner. R1's care plan was reviewed and updated. On 9/2/25 at 1:28 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated the facility's process was to add an immediate intervention following a fall. NHA-A checked R1's medical record and indicated NHA-A could not find an immediate intervention that was added to R1's care plan. 2. On 9/2/25, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including hypoxic ischemic encephalopathy, peripheral vascular disease (PVD), insomnia, and anoxic brain damage. R4's MDS assessment, dated 8/27/25, had a BIMS score of 0 out of 15 which indicated R4 had severe cognitive impairment.R4's falls care plan, revised 8/20/25, indicated R4 was at high risk for falls related to anoxic encephalopathy, impaired physical mobility, self-care deficit, fatigue, generalized weakness, cognitive impairment, decreased cardiac function, and hearing deficit. The care plan also indicated R4 received antipsychotic and diuretic medication. R4 was noted to remove gripper socks and attempted to self-transfer due to impaired cognition and was observed self-transferring alone without notifying staff of R4's needs. The care plan contained an intervention to have a urinal at R4's bedside which was initiated after a fall on 8/12/25. On 9/2/25 at 2:15 PM, Surveyor observed R4 in bed without a urinal at R4's bedside. On 9/2/25 at 2:30 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-C who confirmed R4 did not have a urinal at the bedside. LPN-C checked R4's bathroom and did not see a urinal there either.On 9/2/25 at 4:30 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed fall interventions should be in place for residents, however, DON-B needed to review R4's care plan and was unsure if R4 was capable of using a urinal.

Based on observation, staff interview, and record review, the facility did not ensure pressure injury wound care was provided for 1 resident (R) (R1) of 2 sampled residents.R1 had a deep tissue injury on the right heel and a wound care order for daily dressing changes. R1's wound care order was not consistently followed.Findings include:The facility's Procedure Clean Dressing Change policy, dated 2/24/23, indicates: .1. Verify physician's order for the procedure/treatment. 2. Review the resident's care plan, current orders, and diagnoses as applicable to determine if there are special resident needs .16. Date and initial wound dressing when applied .Medical record documentation and follow-up as applicable: 1. The date and time the dressing was changed. On 9/2/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including sepsis, cellulitis of right lower limb, non-pressure chronic ulcer of other part of right lower leg with fat layer exposed, and abrasion of left elbow. R1's Minimum Data Set (MDS) assessment, dated 11/20/24, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R1 had moderately impaired cognition. R1 had an activated Power of Attorney for Healthcare (POAHC). R1's medical record contained the following orders:~ Treatment - Right Heel - Betadine daily and as needed (PRN) every day shift for wound care (start date 11/26/24).~ Treatment - Right Heel - Clean with wound cleanser, pat dry, apply Santyl to wound bed, apply Telfa, wrap in Kerlix daily and PRN every day shift for wound care (start date 12/3/24).R1's December 2024 Treatment Administration Record (TAR) indicated R1's dressing change was not completed on 12/4/24.A Nurse Practitioner (NP) note, dated 12/10/24, indicated R1 had what appeared to be a deep tissue injury (DTI) on the right heel that measured 1.5 centimeters (cm) x 3.5 cm x 0.1 cm. The surface area measured 5.25 square centimeters (cm2) with 80% eschar and 20% slough. There was light serous exudate, no induration, and the edges appeared cliff-like. The peri-wound was normal in temperature and color. The note indicated the wound deteriorated overall due to nutritional compromise. R1 was started on Prostat, vitamin C, and a multivitamin. On 9/2/25 at 3:01 PM, Surveyor interviewed Director of Nursing (DON)-B who verified R1's dressing change was not completed on 12/4/24 and confirmed R1's DTI dressing should be changed daily. DON-B stated DON-B expects staff to follow orders for daily wound care and indicated R1's wound care should be completed daily and documented.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 68 residents residing in the facility. The facility did not monitor and document food cooling temperatures. The walk-in cooler and dry storage area contained multiple undated and unlabeled items. The facility did not test Quaternary sanitizing solution used to sanitize food preparation areas in accordance with the manufacturer's instructions. The facility did not monitor warewashing temperatures to ensure minimum surface temperatures were achieved to prevent the spread of foodborne illness.Findings incude:Food Cooling:The 2022 Federal Food and Drug Administration (FDA) Food Code documents at 3-501.14 Cooling: (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 57 Celsius (C) (135 Fahrenheit) (F) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less. (B) Time/temperature control for safety food shall be cooled within 4 hours to 5 C (41 F) or less.The 2022 FDA Food Code documents at section 3-501.15 Cooling Methods: (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3-501.14 by using one or more of the following methods based on the type of food being cooled: (1) Placing the food in shallow pans; (2) Separating the food into smaller or thinner portions; (3) Using rapid cooling equipment; (4) Stirring the food in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods.During an initial kitchen tour that began on 8/4/25 at 8:09 AM, Surveyor observed the following pre-cooked and cooled foods in the walk-in cooler:~ An unlabeled plastic container that appeared to contain cooked ground meat (dated 8/2/25)~ An unlabeled steam table container that contained a red sauce (dated 7/3/25)~ An undated steam table container labeled for puree that contained what appeared to be roast beef~ Three steam table containers labeled puree fish (dated 7/18/25)~ Three steam table containers labeled puree peas (dated 7/29/25) ~ Three steam table containers labeled puree turkey dated 7/29/25~ Two covered and undated steam table containers labeled taco meat for Tuesday Surveyor also observed five uncovered steam table containers on a cart. Surveyor interviewed [NAME] (CK)-I who indicated CK-I left the containers out to cool before CK-I obtained temperatures and put the items in the walk-in cooler for future resident consumption. CK-I confirmed CK-I leaves food on the counter or a rolling cart to cool prior to putting it in the walk-in cooler and confirmed the containers were removed from the steam table after breakfast on 8/4/25. Surveyor and CK-I confirmed the following:~ Two containers of Cream of Wheat~ One container each of oatmeal, scrambled eggs, and sausage crumblesDuring a continuous kitchen observation that began on 8/5/25 at 10:54 AM, Surveyor toured the walk-in cooler with Dietary Manager (DM)-H who confirmed the following items in the cooler were pre-cooked, cooled, and stored for future resident consumption:~ An unlabeled plastic container with what appeared to be cooked ground meat (dated 8/2/25)~ An unlabeled steam table container that contained a red sauce (dated 7/3/25)~ An undated steam table container labeled for puree that contained what appeared to be roast beef ~ Three steam table containers labeled puree fish (dated 7/18/25)~ Three steam table containers labeled puree peas (dated 7/29/25) ~ Three steam table containers labeled puree turkey (dated 7/29/25)~ Two covered and undated steam table containers labeled taco meat for TuesdaySurveyor did not observe the containers of Cream of Wheat, oatmeal, scrambled eggs, and sausage crumbles listed above in the walk-in cooler on 8/5/25. DM-H indicated the items were served for breakfast on 8/5/25. CK-I indicated the items observed cooling on the cart on 8/4/25 were left out to cool for a few minutes, temped, and then put in the cooler. DM-H indicated the items observed in the walk-in cooler were pre-cooked and frozen and fish was served every Friday. DM-H indicated frozen, pre-cooked items are pulled from the freezer a few days before they are served and put in the walk-in cooler to thaw. DM-H could not confirm if the following items were dated the day they were cooked, frozen, or pulled from the freezer and put in the walk-in cooler:~ Three steam table containers labeled puree fish (dated 7/18/25)~ Three steam table containers labeled puree peas (dated 7/29/25) ~ Three steam table containers labeled puree turkey dated (7/29/25)DM-H also could not confirm the date the two steam table containers labeled tacos for Tuesday were cooked, cooled, or put in the walk-in cooler and could not identify the contents of the unlabeled steam table container that contained a red sauce, the contents of the undated steam table container labeled for puree, or the date the for puree was cooked, cooled, and put in the cooler. Surveyor and DM-H reviewed the facility's August 2025 food cooling log. Surveyor noted and DM-H confirmed the following items were not documented on the log:~ Two covered and undated steam table containers labeled taco meat for Tuesday~ An undated steam table container labeled for puree that contained what appeared to be roast beef~ An unlabeled plastic container that contained what appeared to be cooked ground meat (dated 8/2/25)~ Two steam table containers of Cream of Wheat and one steam table container each of scrambled eggs and sausage crumblesSurveyor noted the cooling log contained an entry for oatmeal listed as Oat that contained a temperature of 140 degrees F and indicated the oatmeal was 80 degrees F in the 2nd hour of cooling. The log did not indicate the food was cooled to a temperature of 70 degrees F and did not indicate when the cooling process started or ended with a temperature of 80 degrees F.On 8/5/25, Surveyor reviewed the facility's July 2025 food cooling log which did not contain entries for the following items:~ Three steam table containers labeled puree fish (dated 7/18/25)~ Three steam table containers labeled puree peas (dated 7/29/25) ~ Three steam table containers labeled puree turkey (dated 7/29/25)~ Two covered and undated steam table containers labeled taco meat for Tuesday~ An unlabeled steam table container that contained a red sauce (dated 7/3/25)~ An undated steam table container labeled for puree that contained what appeared to be roast beef Expired/Undated/Improperly Stored Foods:During an initial kitchen tour that began on 8/4/25 at 8:09 AM, Surveyor observed the following items in the dry storage area:~ Three undated boxes of Quaker Cream of Wheat~ Five cans of La Choy fancy bean sprouts (dated delivered 10/7/22 with an expiration date of 9/2024)~ Four cans of La Choy chow mein noodles (dated delivered 6/17/22 with an expiration date of 5/7/23)~ One dented can of Musselman's sliced apples~ An undated bin of brown rice that contained a Styrofoam bowl used as a scoop~ A container of white sugar that contained a condiment cup used as scoop~ An unlabeled and undated container of white powder~ Four unlabeled and undated containers of what appeared to be cereal During a continuous kitchen observation that began on 8/5/25 at 10:54 AM, Surveyor and DM-H observed the items listed above in the dry storage area. DM-H indicated the items should not be in the dry storage area and should be discarded. DM-H indicated the container of white powder was thickener used to thicken food and liquid and should be dated. DM-H indicated all food items in the dry storage area, including boxes of food, cereal, and food removed from its original container and stored in another container, should be labeled and dated to ensure safety. DM-H also indicated scoops should not be stored in food containers which is a cross-contamination concern. Surveyor and DM-H also observed the following expired/potentially expired items in the walk-in cooler: ~ A steam table container of red sauce (dated 7/3/25)~ An undated steam table container labeled for pureeDM-H indicated food items put in the walk-in cooler from the freezer or saved as leftovers should be dated and discarded after seven days. DM-H indicated undated food should be discarded. Quaternary Sanitizer:During an initial kitchen tour that began on 8/4/25 at 8:09 AM, Surveyor observed a sanitizer log in the dish room. The log contained a spot to document water temperature, however, there were no water temperatures documented. During a continuous kitchen observation that began on 8/5/25 at 10:54 AM, DM-H confirmed the facility uses Hydrion Quaternary test strips to test parts per million (PPM) of the sanitizing solution. Surveyor and DM-H verified the Hydrion Quaternary test strip package insert indicates the water temperature should be between 65 and 75-degree Fahrenheit (F) when the solution is tested for PPM. DM-H indicated the temperature of the water used to mix the sanitizing solution is not tested prior to using the sanitizing solution to sanitize food contact surfaces. Dishwasher (Ware washer) Surface Temperatures:The 2022 FDA Food Code documents at 4-302.13 Temperature Measuring Devices, Manual Ware washing: Water temperature is critical to sanitization in ware washing operations. This is particularly true if the sanitizer being used is hot water. The effectiveness of cleaners and chemical sanitizers is also determined by the temperature of the water used. A temperature measuring device is essential to monitor manual ware washing and ensure sanitization. Effective mechanical hot water sanitization occurs when the surface temperatures of utensils passing through the ware washing machine meet or exceed the required 71 C (160 F). Parameters such as water temperature, rinse pressure, and time determine whether the appropriate surface temperature is achieved. Although the Food Code requires integral temperature measuring devices and a pressure gauge for hot water mechanical ware washers, the measurements displayed by these devices may not always be sufficient to determine that the surface temperatures of utensils are reaching 71 C (160 F). The regular use of irreversible registering temperature indicators provides a simple method to verify that the hot water mechanical sanitizing operation is effective in achieving a utensil surface temperature of 71 C (160 F).During an initial kitchen tour that began on 8/4/25 at 8:09 AM, Surveyor observed an August 2025 dishwasher temperature log that indicated to check the surface temperature once daily and document. The log indicated the surface temperature should reach 160 degrees F. Surveyor noted the log did not contain any documented surface temperatures for 8/1/25 through 8/4/25. During a continuous kitchen observation that began on 8/5/25 at 10:54 AM, Surveyor observed DM-H attempt to use a disc to obtain the dishwasher surface temperature, however, DM-H was unable to use the disc and indicated the battery was dead. DM-H was unsure when the battery died and confirmed staff are required to obtain and document surface temperatures daily. Surveyor reviewed the July 2025 dishwasher temperature log and noted all documented daily surface temperatures in July did not reach 160 degrees F. Surveyor reviewed the August 2025 dishwasher temperature log and noted the documented daily surface temperature on 8/5/25 did not reach 160 degrees F.

Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 4 residents (R) (R62, R1, R9, and R42) of 6 sampled residents. During an observation of pericare for R62, Certified Nursing Assistant (CNA)-D did not appropriately remove gloves and cleanse hands.R1 was on enhanced barrier precautions (EBP). During an observation of catheter irrigation, Licensed Practical Nurse (LPN)-G did not wear appropriate personal protective equipment (PPE). Following the provision of care, staff did not remove PPE and complete hand hygiene when exiting R9's room.R42 had a history of chronic urinary tract infections (UTIs). R42's uncovered catheter bag was observed on the floor.Findings include: The facility's Enhanced Barrier Precautions Policy, dated 3/26/24, indicates: It is the policy of this facility that enhanced barrier precautions (EBP) .will be implemented during high-contact resident care activities when caring for residents who have an increased risk for acquiring a multidrug-resistant organism (MDRO) such as a resident with chronic wounds requiring a dressing, indwelling medical devices, or residents with infection or colonization with an MDRO .EBP requires gown and glove use for residents with a novel or targeted MDRO or any resident with a wound or indwelling medical device during specific high-contact resident care activities. Novel or targeted MDROs include methicillin-resistant Staphylococcus aureus (MRSA), extended-spectrum beta-lactamase (ESBL) producing Enterobacterales .High-contact resident care activities include dressing, bathing/showering, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube), wound care (any skin opening requiring a dressing) .The purpose of EBP is to prevent opportunities for transfer of MDROs to employees' hands and clothing. The facility's Hand Hygiene Policy, revised 5/8/24, indicates: Staff will perform hand hygiene by either using soap and water (when hands are visibly dirty or soiled with blood or other body substances) or alcohol-based hand gel (when hands are not visibly soiled). Hand hygiene should be performed under the following conditions: Before applying gloves and after removing gloves or other personal protective equipment (PPE); After handling items potentially contaminated with blood, body fluids, or secretions; Before moving from a contaminated body site to a clean body site during resident care; example: after providing peri-care, before applying moisture barrier, or other treatments; If exposure to infectious disease is suspected or proven; Before handling clean or soiled dressings, gauze pads, etc.; After contact with inanimate objects in the immediate vicinity of the resident. The facility's Foley Catheter Management Policy, revised 1/28/25, indicates: .4. Catheter bags will be covered at all times. 1.From 8/4/25 to 8/6/25, Surveyor reviewed R62's medical record. R62's most recent admission to the facility was on 8/14/24. R62 had a diagnosis of end stage renal disease (ESRD) and a permacath (a catheter used for dialysis to provide access to the bloodstream for patients with kidney failure) on the right side of the chest. R62 was on EBP. A Minimum Data Set (MDS) assessment, dated 6/4/25, indicated R62 had moderate cognitive impairment. R62 made R62's own healthcare decisions. On 8/5/25 at 2:12 PM, Surveyor observed CNA-D complete pericare for R62. CNA-D donned a gown and gloves prior to initiating care for R62 who was incontinent of bowel and bladder. CNA-D cleansed R62's buttocks/rectal area which contained a smear of stool then touched R62's clean brief, Chux pad, shirt, bedding, bedside table, water pitcher, and bed control without removing gloves and cleansing hands. On 8/5/25 at 2:24 PM, Surveyor interviewed CNA-D who confirmed CNA-D should have removed gloves and completed hand hygiene after completing pericare. On 8/5/25 at 4:09 PM, Surveyor interviewed Director of Nursing (DON)-B who verified CNA-D should have removed gloves and completed hand hygiene after pericare and before touching R62 and items in R62's environment. 2. On 8/4/25, Surveyor reviewed R1's medical record. R1 had diagnoses including cerebral palsy, delusional disorder, epilepsy, depression and hemiplegia following a cerebral vascular accident. R1 made R1's own medical decisions. An MDS assessment, completed on 5/14/25, indicated R1 had intact cognition. On 8/4/25 at 10:23 AM, Surveyor observed LPN-G completed hand hygiene, don gloves, place a disposable Chux pad on R1's bed, and unhook a catheter from R1's leg. LPN-G then opened 3 normal saline 10 milliliter (ml) syringes and alcohol prep pads. LPN-G removed gloves, completed hand hygiene, and donned clean gloves. LPN-G unhooked a Foley catheter bag from the Foley tubing, placed the tip of the tubing in a basin, cleansed the catheter end and tip of a 10 ml syringe with alcohol, and inserted the syringe into the catheter. LPN-G pushed normal saline into the catheter with no resistance. LPN-G indicated there was usually a better connection, however, LPN-G did not have the correct syringe. LPN-G then wiped the catheter and tubing with an alcohol pad, re-attached them, and secured the tubing to R1's leg. LPN-G removed the basin and Chux pad, removed gloves, and completed hand hygiene. Surveyor noted LPN-G did not wear a gown during the procedure. On 8/4/25 at 10:33 AM, Surveyor interviewed LPN-G who indicated LPN-G should have worn a gown when completing catheter irrigation. On 8/5/25 at 1:44 PM, Surveyor interviewed DON-B who verified LPN-G should have worn a gown when completing catheter irrigation for R1. 3. From 8/4/25 to 8/6/25, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, ESBL resistance, history of chronic UTIs, and type 2 diabetes. R9's MDS assessment, dated 5/29/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R9 had intact cognition. R9's had an activated Power of Attorney for Healthcare (POAHC). A care plan, with a revision date of 2/17/25, indicated R9 was on EBP due to a history of ESBL. On 8/4/25 at 10:20 AM, Surveyor observed an EBP sign on R9's door and a PPE cart outside R9's door. On 8/4/25 at 10:24 AM, Surveyor observed CNA-E exit R9's room in a gown and gloves and enter a utility room. CNA-E disposed of trash and then removed CNA-E's gown and gloves. CNA-E exited the utility room without completing hand hygiene. On 8/4/25 at 11:57 AM, Surveyor interviewed CNA-E who verified CNA-E wore a gown and gloves while completing cares in R9's room and exited the room without removing the gown and gloves. CNA-E verified CNA-E should have removed the gown and gloves and completed hand hygiene prior to exiting R9's room. On 8/6/25 at 12:34 PM, Surveyor interviewed DON-B who was aware CNA-E exited R9's room and walked in the hallway without removing PPE. DON-B indicated CNA-E should have disposed of the gown and gloves prior to exiting R9's room. DON-B acknowledged R9 was on EBP and confirmed staff should complete hand hygiene prior to exiting residents' rooms. 4. From 8/4/25 to 8/6/25, Surveyor reviewed R42's medical record. R42 was admitted to the facility on [DATE] and had diagnoses including ESBL resistance, history of chronic UTIs, and flaccid neuropathic bladder. R42's MDS assessment, dated 5/14/25, had a BIMS score of 15 out of 15 which indicated R42 had intact cognition. R42 had an activated POAHC. A care plan, with revision date of 5/12/25, indicated R42 had a Foley catheter related to flaccid neuropathic bladder with history of recurrent ESBL infections. The care plan contained interventions for EBP, educate about transmission of organism, and provide a privacy bag for urine collection. R42 was diagnosed with recurrent urinary tract infections on 1/25/25, 5/2/25, and 6/5/25. On 8/4/25 at 12:54 PM, Surveyor observed R42's uncovered Foley catheter bag on the floor. On 8/6/25 at 12:34 PM, Surveyor interviewed DON-B who indicated catheter bags should be off the floor. DON-B also indicated R42's catheter bag should have been covered with a dignity bag.

Based on staff interview and record review, the facility did not ensure 2 residents (R) (R11 and R8) of 4 sampled residents received the necessary care and services to prevent or monitor weight loss.R11 had a significant weight loss of 6.1% from 6/2/25 to 7/1/25. The facility did not implement interventions to address R11's weight loss.R8's medical record indicated R8 had a 7.1% weight loss over a 1 month period. The facility did not address R8's weight loss when it was identified. Findings include: The facility's Resident Height and Weight policy, revised 1/7/25, indicates: .Nursing department, staff, and the Dietitian will cooperate to prevent, monitor, and provide interventions for undesirable weight variances for our residents .A significant weight change is defined as a 5% weight change over 30 days, a 7.5% weight change over 90 days, or a 10% weight change over 180 days .4. All monthly weights are to be completed by the seventh of the month and any reweights needed are to be completed by the 10th of the month .6. Weekly or daily weights are recommended if any of the following are present: .b. Significant unplanned weight loss in 30, 90, or 180 days .8. Any weight change of 5 pounds or greater within 30 days will be retaken within 24 hours for verification and a re-weight will be documented .Once an accurate weight is verified, the inaccurate weight should be struck out with the appropriate explanation .9. If a re-weight verifies a significant, unplanned weight change, it is communicated to the resident's physician, Power of Attorney (POA), dietitian, and any others deemed necessary by the Interdisciplinary Team. The weight change will be addressed and reviewed by the dietitian in cooperation with the Interdisciplinary Team and appropriate interventions will be implemented, reviewed, and revised as needed. Care plan to be updated with interventions provided. 1.From 8/4/25 to 8/6/25, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, moderate protein-calorie malnutrition, and irritable bowel with constipation. R11's Minimum Data Set (MDS) assessment, dated 7/7/25, had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R11 had moderately impaired cognition. R11 had an activated Power of Attorney for Healthcare (POAHC). R11 was admitted to the facility following a hospitalization from 5/18/25 to 5/21/25 for adult failure to thrive. A care plan, dated 5/23/25 with a revision date of 6/9/25, indicated R11 had a potential for altered nutritional status with a goal to maintain stable nutrition and hydration with no significant weight fluctuations. The care plan contained the following interventions: Regular diet; Provide food choices, Registered Dietitian (RD) to evaluate and recommend diet changes as needed; Report gastrointestinal complaints to nursing; Weigh per facility policy as ordered; Notify Medical Director/Nurse Practitioner per order of with significant changes. R11's medical record contained the following orders: ~ Obtain and record monthly weight. One time a day starting on the 1st and ending on the 2nd every month (dated 6/12/25 with a start date of 7/1/25) ~ Regular diet: Level 7 regular texture, Level 0 thin (regular) consistency (dated 5/21/25) R11's medical record contained the following weights: ~ On 8/4/25 at 1:50 PM, R11 weighed 179.1 pounds (standing) ~ On 8/1/25 at 10:42 AM, R11 weighed 177.7 pounds (standing) ~ On 7/1/25 at 11:36 AM, R11 weighed 182.0 pounds (standing) ~ On 6/16/25 at 1:08 PM, R11 weighed 192.7 pounds (standing) ~ On 6/9/25 at 11:35 AM, R11 weighed 193.5 pounds (standing) ~ On 6/2/25 at 12:49 PM, R11 weighed 193.9 pounds (standing) ~ On 5/26/25 at 11:24 AM, R11 weighed 193.0 pounds (standing) ~ On 5/23/25 at 12:50 PM, R11 weighed 193.3 pounds (standing) ~ On 5/21/25 at 8:21 PM, R11 weighed 193.7 pounds (standing) A weight change note, dated 7/3/25 at 11:08 AM and written by Registered Dietitian (RD)-C indicated R11 weighed 182.0 pounds on 7/1/25 which was a 6.1% weight change over 29 days. The note indicated nursing was notified of the need for a re-weigh to verify R11's weight. (R11's next documented weight was on 8/1/25.) On 8/5/25 at 11:24 AM, Surveyor interviewed RD-C who indicated R11 flagged for a significant weight loss on 7/1/25 and RD-C requested a re-weight for R11 on 7/3/25. RD-C indicated R11 was not re-weighed and R11's next weight was on 8/1/25. RD-C verified R11's plan of care had not been revised since 6/9/25 and indicated R11's significant weight loss was discussed with Director of Nursing (DON)-B, R11, and R11's POA on 8/4/25. On 8/6/25 at 12:34 PM, Surveyor Interviewed DON-B who indicated significant weight loss is assessed by RD-C who requests a re-weigh from the nurse. DON-B verified R11's re-weigh was not completed until 8/1/25 and indicated RD-C did not follow-up on R11's weight loss. DON-B confirmed there were no interventions implemented for R11's significant weight loss. 2. On 8/4/25, Surveyor reviewed R8's medical record. R8 had diagnoses including aftercare after joint replacement surgery, depression, history of traumatic brain injury, schizophrenia, and alcohol abuse. R8 made R8's own medical decisions. An MDS assessment, completed on 5/15/25, indicated R8 had intact cognition. R8's medical record indicated R8 weighed 210.4 pounds on 7/1/25 and 195.4 pounds on 8/1/25 which was a 7.1% weight loss in 1 month. A progress note, date 6/20/25 and written by RD-C, indicated R8 had a 10% weight loss over the previous 180 days. The note indicated R8's intake was adequate and the weight loss was favorable. R8's intake percentages indicated R8 consistently ate between 50-100% of meals during July of 2025. R8 did not have any documented issues with diarrhea or vomiting. On 8/5/25 at 2:31 PM, Surveyor interviewed RD-C who verified R8 had a 7.1% weight loss and indicated R8 should have been flagged for weight loss. RD-C indicated RD-C found the flag, however, it had been cleared. RD-C stated only RD-C or another dietitian should clear flags. RD-C indicated when a resident flags for weight loss, RD-C has staff re-weight the resident. RD-C also reviews eating patterns and speaks with nursing staff to identify a potential reason for the weight loss. RD-C indicated RD-C would have R8 re-weighed immediately. On 8/5/25 at 2:54 PM, RD-C informed Surveyor that R8 was re-weighed and R8's current weight was 209.7 pounds which indicated R8 did not have a 7.1% weight loss. On 8/5/25 at 3:09 PM, Surveyor interviewed Registered Nurse (RN)-F who indicated nurses should document weights in a resident's medical record. RN-F indicated if an approximate 15 pound weight loss is identified, the first thing RN-F would do is have staff re-weigh the resident. If the weight was accurate, RN-F would immediately assess the resident and notify the physician. On 8/5/25 at 4:00 PM, Surveyor interviewed DON-B who indicated the nurse who received the weight that indicated R8 had a 15 pound weight loss should have had R8 re-weighed immediately and entered the correct weight in R8's medical record. DON-B indicated nursing staff should notify the physician immediately if the weight loss is accurate.

Based on staff interview and record review, the facility did not ensure 1 resident (R) (R29) of 4 sampled residents was monitored for adverse reactions to antibiotic medication. The facility did not monitor R29 for side effects or adverse reactions to ciprofloxacin (an antibiotic medication).Findings include:The facility's Antibiotic Stewardship Policy, revised 5/8/24, indicates: Purpose: To promote appropriate use of antibiotics for quality of care, successful resident outcomes and reduction of potential adverse consequences related to antibiotic use .7. The nurse will observe and document effectiveness of antibiotics, side effects, and potential adverse consequences .Resident will be observed for potential side effects of the antibiotic. From 8/4/25 to 8/6/25, Surveyor reviewed R29's medical record. R29 was most recently admitted to the facility on [DATE] and had diagnoses including dementia, diabetes, chronic ulcer right lower leg, methicillin-resistant Staphylococcus aureus (MRSA) leg wound, and extended spectrum beta lactamase (ESBL) resistance. R29's Minimum Data Set (MDS) assessment, dated 7/11/25, indicated R29 had intact cognition. R29 made R29's own healthcare decisions.A right lateral shin culture, dated 7/22/25, indicated R29 had MRSA requiring isolation.R29 was prescribed ciprofloxacin HCl oral tablet 500 milligrams (mg) by mouth twice daily for wound infection for 7 days on 7/29/25.A care plan indicated R29 had a history of ESBL. The care plan contained interventions for enhanced barrier precautions (EBP) and antibiotic per Medical Doctor (MD) order. Surveyor noted R29 did not have orders to monitor for side effects or adverse reactions to ciprofloxacin or interventions to do so on R29's care plan. On 8/5/25 at 4:04 PM, Surveyor interviewed Director of Nursing (DON)-B who verified R29 had an order for ciprofloxacin. DON-B confirmed R29 should have orders and interventions in R29's plan of care to monitor for side effects and adverse reactions to ciprofloxacin.

Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection. This practice had the potential to affect more than 4 of the 72 residents (R) residing in the facility. Numerous supply carts for residents on enhanced barrier precautions (EBP) contained expired sanitizing wipes and/or expired hand sanitizer. Findings include: The facility's Infection Control Program policy, dated [DATE], indicates: The infection control program exists to assure a safe, sanitary, and comfortable environment for residents and personnel. It is designed to help prevent the development and transmission of disease and infection .The intent of this policy is to assure through the infection control program a system is in place to: .Prevent and control outbreaks and cross-contamination using transmission-based precautions in addition to standard precautions .Elements of the program include: .Education, including training in infection prevention and control practices to ensure compliance with facility requirements as well as state and federal regulations .A system for detection, investigation, and control of outbreaks of infectious diseases .Infection control policies, procedures, and practices which promote consistent adherence to evidence-based infection control practices. Process to evaluate and enforce proper environmental controls. Process to evaluate and enforce proper infection control practices by personnel . On [DATE] at 11:02 AM, Surveyor observed personal protective equipment (PPE) carts outside the rooms of residents on EBP and noted expired bleach (sanitizing) wipes in carts for 6 resident rooms. The bleach wipes contained expiration dates of February 2025, February 2024, and [DATE]. Surveyor also noted multiple bottles of hand sanitizer that contained expiration dates of [DATE]. On [DATE] at 11:18 AM, Surveyor observed staff who walked ahead of Surveyor in the 100 hall remove bleach wipes from PPE carts Surveyor had not yet observed and replace them with different containers of bleach wipes. On [DATE] at 11:18 AM, Surveyor interviewed Nurse Schedule Coordinator (NSC)-H who did not know if expired bleach wipes and hand sanitizer were still effective. On [DATE] at 11:34 AM, Surveyor observed NSC-H throw away thirteen containers of bleach wipes that had been removed from PPE carts. Surveyor noted the discarded wipes were expired and requested to see where the wipes were stored. At 11:43 AM, Surveyor observed the storage area where PPE carts and supplies were kept and noted a full case of bleach wipes with expiration dates of [DATE] and another full case of bleach wipes with expiration dates of [DATE]. Surveyor and NSC-H also observed two full containers of bleach wipes with expiration dates of [DATE] and a PPE cart with a container of bleach wipes that expired on [DATE]. Surveyor also noted a bottle of hand sanitizer in the cart had an expiration date of [DATE] and observed hand sanitizer on a shelf with an expiration date of [DATE]. On [DATE] at 11:42 AM, Surveyor interviewed Registered Nurse (RN)-I who did not know who was supposed to check or if there was a schedule to check expiration dates of bleach wipes and hand sanitizer in PPE carts. On [DATE] at 11:58 AM, Surveyor observed Housekeeper (HK)-J walk down the 100 wing and enter the soiled linen room with an armful of hand sanitizer bottles. On [DATE] at 11:59 AM, Surveyor interviewed HK-J who indicated HK-J threw away the hand sanitizers because they were expired. HK-J indicated expired bleach wipes and hand sanitizer are not effective and should not be used. On [DATE] at 1:01 PM, Surveyor interviewed Director of Nursing (DON)-B who did not know if expired bleach wipes and hand sanitizer were still effective and indicated staff should have contacted the manufacturer to find out. DON-B indicated PPE carts should be checked and stocked on Mondays and items that expired more than three years ago should have been discarded. DON-B indicated DON-B was aware there could be a significant infection control issue if bleach wipes and hand sanitizer are not effective. On [DATE] at 5:31 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated NHA-A orders infection control items monthly. NHA-A indicated expiration dates for bleach wipes and hand sanitizer should be checked on arrival, prior to use, and prior to putting them in PPE carts.

Based on observation, staff and resident interview, and record review, the facility did not ensure residents were provided a home-like dining experience. This practice had the potential to affect more than 4 of the 72 residents (R) residing in the facility. Residents were served meals on disposable Styrofaom dishware. In addition, residents were not always given the option to eat in the dining room. Findings include: The facility's Dining and Food Service policy, revised 2/12/25, indicates: Individuals will be provided with nourishing, palatable, attractive meals that meet daily nutritional and special dietary needs, making reasonable accommodations to consider the preferences of each resident. Individuals will be provided with services to maintain or improve eating skills. The dining experience will enhance the individual's quality of life and be supportive of the individual's needs during dining. Staff will utilize sanitary precautions when serving residents, including, but not limited to proper handling of glasses, flatware, and plates to prevent infection and foodborne illnesses .The Dining Services Director will perform meal rounds routinely to determine if the meals are attractive and nutritious and meet the needs of the individual. The Dining Services Director will observe meals to ensure food preferences, portion sizes, temperature, flavor, variety, and accuracy are appropriate. The Dining Services Director will refer all appropriate concerns to the Administrator, Nursing Director, Registered Dietitian (RD) or other necessary staff. On 6/30/25, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] and had diagnoses including metabolic encephalopathy, asthma, and diabetes. R9's Minimum Data Set (MDS) assessment, dated 6/19/25, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R9 had intact cognition. R9 made R9's own medical decisions. On 6/30/25 at 4:45 PM, Surveyor interviewed R9 who indicated R9 wished food was served on real plates instead of disposable plates. R9 indicated R9 would like staff to ask if R9 would like to eat in the dining room. R9 stated R9 does not want to eat in the dining room but has never been asked and would like to be offered. On 6/30/25, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had diagnoses including congestive heart failure and diabetes. R10's MDS assessment, dated 5/25/25, had a BIMS score of 15 out of 15 which indicated R10 had intact cognition. R10 made R10's own medical decisions. On 6/30/25 at 4:58 PM, Surveyor interviewed R10 who indicated R10 would like to be offered to eat in the dining room. R10 indicated R10 has a hard time walking, but would like staff to offer to push R10 in a wheelchair to the dining room sometimes. On 6/30/25 at 11:58 AM, Surveyor observed staff serve nine residents lunch in the 100 wing dining room. Surveyor noted all meals were served on non-disposable plates. On 6/30/25 at 4:43 PM, Surveyor observed staff deliver dinner trays to resident rooms on the 400 wing. Surveyor noted the food was served on disposable dishware. Surveyor noted canned fruit, three-bean salad, and chicken pieces were served in disposable bowls. Five of the bowls were not covered. Surveyor also noted each tray contained covered drinks and a breadstick wrapped in plastic wrap. On 6/30/25 at 4:46 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-C who was delivering meal trays on the 400 wing. CNA-C indicated dinner is typically served on disposable or take-out dishes. On 6/30/25 at 4:48 PM, Surveyor observed staff deliver dinner trays to resident rooms on the 300 wing. Surveyor noted the food was served on disposable dishware. Surveyor observed canned fruit, three-bean salad, and chicken pieces served in disposable bowls. Surveyor also noted each tray contained uncovered cups of coffee and a breadstick wrapped in plastic wrap. On 6/30/25 at 4:48 PM, Surveyor interviewed CNA-D who was delivering trays to residents on the 300 wing. CNA-D indicated CNA-D had seen dinner served on disposable dishes. On 6/30/25 at 4:50 PM, Surveyor interviewed Director of Nursing (DON)-B who did not know why dinner was served on disposable dishware and indicated meals were served on disposable dishes a while ago when the dishwasher was broken. On 6/30/25 at 4:51 PM, Surveyor interviewed [NAME] (CK)-E who indicated evening meals have been served on disposable dishware for at least a couple of months because the kitchen is short staffed. CK-E indicated food is served on disposable dishware per Dietary Supervisor (DS)-F's direction and DS-F orders the disposable dishware. CK-E indicated NHA-A is also aware dinner is served on disposable dishware. On 6/30/25 at 5:06 PM, Surveyor observed staff serve supper to five residents in the 100 wing dining room. Surveyor noted the meals were served on disposable dishware. On 6/30/25 at 5:09 PM, Surveyor noted one resident in the dining room had disposable bowls of fruit and green beans and used a spoon to eat a turkey sandwich from a foil wrapper. On 6/30/25 at 5:15 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who was not aware residents were served meals on disposable dishware. On 6/30/25 at 5:28 PM, Surveyor interviewed Dietary Aide (DA)-G who had worked at the facility for approximately one year. DA-G indicated meals were served on disposable dishware for approximately six months due to lack of staff. DA-G indicated DS-F orders the dishware. On 6/30/25 at 5:31 PM, Surveyor interviewed NHA-A who was aware sandwiches were served in foil for dinner and other meals. NHA-A indicated foil was used to keep food hot and keep some items more crisp. NHA-A indicated residents can eat in the dining room if it is their preference and stated sometimes residents eat in the dining room and sometimes they don't.

Based on staff interview and record review, the nurse staffing posting did not accurately reflect the number of nursing staff working in the facility and was not posted at the beginning of each shift or on weekends. This had the potential to affect all 67 residents residing in the facility. The nurse staffing posting did not accurately reflect the actual number of nursing staff who worked the 12/12/24 night (NOC) shift and was not posted at the start of the 12/13/24 AM shift. In addition, the facility did not post nurse staffing hours on the weekends. Findings include: The facility's Staff Posting Information policy, revised 10/19/23, indicates: To provide public information regarding the number of licensed and unlicensed direct caregivers and hours worked per shift .2. At the beginning of each shift, the facility will verify that the hours are posted in a clear and readable format: .g. Actual time worked for the specific categories of nursing staff, including split shifts. On 12/13/24 at 5:01 AM, Surveyor observed a nursing staff posting, dated 12/12/24, near the front entrance of the facility. Surveyor noted the NOC shift section of the form indicated there were 4 Certified Nursing Assistants (CNAs) plus 1 CNA in training working from 10:00 PM - 6:00 AM. On 12/13/24 between 5:00 AM and 5:10 AM, Surveyor observed 2 nurses and 3 CNAs present on the NOC shift. On 12/13/24 at 5:15 AM, Surveyor interviewed Registered Nurse (RN)-D who indicated there was a call-in and there were only 3 CNAs working the NOC shift. On 12/13/24 at 6:10 AM, Surveyor noted the 12/12/24 nursing staff posting was still displayed even though the 12/13/24 AM shift had already started. On 12/13/24 at 6:45 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated Nurse Scheduler (NS)-C updated the daily posting when NS-C came in on the AM shift and updated the previous NOC shift posting if there were call-ins or deviations from the original schedule. On 12/13/24 at 9:55 AM, Surveyor noted the 12/12/24 nursing staff posting was still displayed and the 12/13/24 posting was not posted yet. On 12/14/24 at 10:00 AM, Surveyor interviewed NS-C who indicated NS-C posted the current day's nursing staff posting on week days following morning meeting. On Friday, NS-C developed and printed the postings for Saturday and Sunday and updated the weekend postings with changes on Monday when NS-C returned to work. NS-C confirmed nurse staffing hours were not posted on the weekends. NS-C confirmed when there were changes to the original schedule, the posting were not updated during those particular shifts. On 12/13/24 at 10:21 AM, Surveyor noted the 12/12/24 nursing staff posting was still displayed and the 12/13/24 posting was not posted yet. On 12/13/24 at 10:50 AM, Surveyor interviewed NHA-A who indicated morning meeting was at 9:00 AM each week day. NHA-A indicated the facility would develop a process for posting the nurse staffing hours on the weekends.

Based on staff interview and record review, the facility did not ensure protective placement was obtained for 1 resident (R) (R49) of 20 residents reviewed for advanced directives. R49 had a legal guardian. The facility did not petition or obtain court-ordered documents for protective placement when R49's stay in the facility exceeded 60 days from admission on 3/10/23. Findings include: Wisconsin State Statue Chapter 55.055(1)(b) contains the following information: The guardian of an individual who has been adjudicated incompetent may consent to the individual's admission to a nursing home or other facility not specified in par. (a) for which protective placement is otherwise required for a period not to exceed 60 days. In order to be admitted under this paragraph, the individual must be in need of recuperative care or be unable to provide for his or her own care or safety so as to create a serious risk of substantial harm to himself or herself or others. Prior to providing that consent, the guardian shall review the ward's right to the least restrictive residential environment and consent only to admission to a nursing home or other facility that implements that right. Following the 60 day period, the admission may be extended for an additional 60 days if a petition for protective placement under s. 55.075 has been brought, or, if no petition for protective placement under s. 55.075 has been brought, for an additional 30 days for the purpose of allowing the initiation of discharge planning for the individual. Between 6/10/24 and 6/12/24, Surveyor reviewed R49's medical record. R49 was admitted to the facility on [DATE] with diagnoses including vascular dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, hemiplegia (weakness on one side of the body), hemiparesis (paralysis on one side of the body), and aphasia (a language disorder that affects a person's ability to communicate) following cerebral infarction affecting the right dominant side. R49's Minimum Data Set (MDS) assessment, dated 4/25/24, indicated R49 was rarely to never understood and had severely impaired cognition. A staff assessment for mental status indicated R49 had short and long-term memory problems, poor recall ability, and was severely impaired with daily decision making. Guardianship due to R49's incompetency was filed on 4/26/23. R49's medical record did not contain a court order for protective placement. On 6/12/24 at 12:51 PM, Surveyor interviewed Director of Nursing (DON)-B who verified protective placement was not obtained for R49. On 6/12/24 at 1:22 PM, Surveyor interviewed Social Service Director (SSD)-E who confirmed R49 had a court- ordered guardianship. SSD-E stated a few months ago SSD-E contacted R49's guardian ad item who informed SSD-E that R49 was not protectively placed. SSD-E verified no further action was taken to obtain or file a petition for protective placement with the county.

Based on staff interview and record review, the facility did not ensure their abuse policy was implemented for 1 employee (Certified Nursing Assistant (CNA)-C) of 8 employees reviewed for background checks. CNA-C was hired on 11/10/15. CNA-C's most recent background check was dated 11/8/19 which was not within the last 4 years. Findings include: The facility's Vulnerable Adult Abuse and Neglect Prevention policy, with a review date of 1/14/22, indicates: Screen potential employees for a history of abuse, neglect, exploitation, or mistreatment as defined by the applicable requirements at 48.13(C)(1)(ii) (A) and (B). This includes attempting to obtain information from previous employers and/or current employers, and checking with the appropriate licensing boards and registries. On 6/11/24 at 10:37 AM, Surveyor reviewed the Background Information Disclosure (BID) form and Department of Justice and Information Background Integration System (IBIS) letters for CNA-C. When Director of Nursing (DON)-B provided the information, DON-B stated to Surveyor that CNA-C's background check was run on 6/11/24 because the Human Resources department did not have one on file that was completed within the last 4 years. DON-B stated background checks are completed at the corporate level and DON-B contacted corporate staff who could not locate a recent background check for CNA-C. DON-B confirmed CNA-C's background check should have been completed sooner. On 6/12/24 at 11:13 AM, Surveyor interviewed DON-B and asked when CNA-C's background check was last completed prior to 6/11/24. DON-B stated CNA-C's background check was last completed on 11/8/19.

Based on staff interview and record review, the facility did not ensure a Preadmission Screen and Resident Review (PASRR) for 1 resident (R) (R26) of 5 sampled residents was submitted for additional screening after the resident was diagnosed with a new mental illness and prescribed additional antipsychotic medication. R26's PASRR Level I Screen was completed upon R26's admission to the facility on [DATE]. A PASRR Level II Screen was completed on 8/23/22. On 11/29/22, R26 received a new mental illness diagnosis of chronic paranoid schizophrenia and on 1/24/23, R26 was prescribed Vraylar (an antipsychotic medication) for paranoid schizophrenia. The facility did not update R26's PASRR Level I Screen and did not submit for a new PASRR Level II Screen. Findings include: From 6/10/24 through 6/12/24, Surveyor reviewed R26's medical record. R26 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, anxiety disorder, borderline personality disorder, and depression. R26 had physician orders for alprazolam (an antianxiety medication), sertraline (an antidepressant medication), mirtazapine (an antidepressant medication), Seroquel (an antipsychotic medication), Depakote (an anticonvulsant medication also used to treat psychiatric disorders), and buspirone (an antianxiety medication). R26's PASRR Level I Screen, dated 6/22/22, contained the aforementioned diagnoses and medications. A referral for a PASRR Level II Screen was submitted on 7/21/22 and completed on 8/23/22. On 11/29/22, R26 was seen by a psychiatrist who diagnosed R26 with a new mental illness of chronic paranoid schizophrenia. On 1/24/23, R26 was prescribed Vraylar (an antipsychotic medication). R26's medical record did not indicate the facility updated R26's PASRR Level I or submitted a new referral for additional Level II screening to determine the need for specialized services. On 6/12/24 at 1:22 PM, Surveyor interviewed Social Services Director (SSD)-E who stated SSD-E was not employed at the facility at the time a new PASRR Level II Screen should have been obtained. SSD-E confirmed an additional Level II referral was not submitted since R26 received the new mental illness diagnosis or was prescribed an additional antipsychotic medication. On 6/12/24 at 1:33 PM, Surveyor spoke with Behavioral Consulting Services Consultant (BCSC)-N who confirmed facilities should submit a new referral if there is a change or addition to a resident's mental illness diagnosis.

Based on staff and resident interview, and record review, the facility did not provide pharmaceutical services to ensure the accuracy of admission orders and medication administration for 1 resident (R) (R276) of 6 sampled residents. R276 missed 3 doses of antirejection medication over a 3 day period until the medication order was clarified for proper dosage. In addition, R276 was administered 3 doses of medication from R276's home supply because staff could not locate R276's antirejection medication after it was delivered by the pharmacy. Findings include: From 6/10/24 through 6/12/24, Surveyor reviewed R276's medical record. R276 was admitted to the facility on [DATE] with diagnoses including post kidney transplant x 2, post pancreatic transplant x 2, renal dialysis, and end stage renal disease. R276's most recent Minimum Data Set (MDS) assessment, dated 6/3/24, documented R276 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R276 had intact cognition. Surveyor reviewed R276's admission medication orders and noted the following order for antirejection medication: ~ Cyclosporine oral capsule 25 mg (milligrams). Give 3 capsules by mouth one time a day for renal transplant. Surveyor noted R276's hospital discharge orders indicated to administer cyclosporine one time per day; however, R276's discharge summary stated to administer cyclosporine two times per day. R276's medical record indicated cyclosporine was increased to twice daily on 5/31/24. A nursing progress note, dated 5/29/24, indicated: Cyclosporine oral capsule 25 mg. Give 3 capsules by mouth one time a day for renal transplant. R276 took medication R276 brought from home because the medication was not yet received from pharmacy. A nursing progress note, dated 6/3/24, indicated: Cyclosporine oral capsule 25 mg. Give 3 capsules by mouth two times a day for renal transplant. Used home supply. A nursing progress note, dated 6/8/24, indicated: Cyclosporine oral capsule 25 mg. Give 3 capsules by mouth two times a day for renal transplant. R276 took from R276's home supply and was frustrated there was not a supply on hand at the facility. Writer will touch base with pharmacy to check on the concern. On 6/10/24 at 9:10 AM, Surveyor interviewed R276 who stated R276 questioned nursing staff on 5/28/24, 5/29/24, and 5/30/24 about missing R276's evening cyclosporine dose and explained to staff that R276 was prescribed the medication two times per day. R276 stated nursing staff stated cyclosporine was ordered once per day and did not call the physician for clarification of the order. On 6/10/24 at 9:32 AM, Surveyor interviewed Family Member (FM)-F who stated R276 called daily with frustration that the facility did not provide R276 with the proper dose of cyclosporine. FM-F agreed to bring R276's home supply of cyclosporine to the facility on [DATE]. R276 stated R276 and FM-F met with Assistant Director of Nursing (ADON)-I to discuss the discrepancy on 5/31/24. On 6/11/24 at 1:56 PM, Surveyor interviewed Director of Nursing (DON)-B who stated R276's cyclosporine supply was at the facility, but there was staff confusion about where the medication was stored. DON-B stated a banner was placed in R276's medical record so staff knew where to find the medication. DON-B verified staff administered R276's home supply of cyclosporine on 5/29/24, 6/3/24, and 6/8/24. DON-B stated the facility will replenish R276's home supply when R276 is discharged . On 6/12/24 at 1:09 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-M who stated if LPN-M questioned a medication order, LPN-M would double check the resident's orders, review the hospital discharge summary, and clarify the order with the physician. On 6/12/24 at 1:12 PM, Surveyor interviewed ADON-I who stated nursing staff should have clarified what medication R276 was referring to and called the physician for clarification. ADON-I stated R276's cyclosporine was in the facility on 6/3/24 and 6/8/24; however, staff could not locate the medication because it was stored in a different place in the medication cart. ADON-I stated staff were educated that a banner was placed in R276's medical record and the medication's location was documented on the 24 hour report (a document that staff use to share daily updated resident information). ADON-I verified antirejection medication is a life-sustaining medication. On 6/12/24 at 1:18 PM, Surveyor interviewed DON-B who stated if there is a question about an order, staff should call the ordering provider to find out how the medication should be ordered. DON-B verified antirejection medication is a life-sustaining medication.

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe and sanitary environment to prevent the transmission of communicable disease and infection for 3 residents (R) (R19, R28, and R5) of 3 residents. R19 and R28 were on droplet precautions. During observations on 6/10/24, staff did not wear appropriate personal protective equipment (PPE) when they entered R19 and R28's rooms. R5 had a stage 3 pressure injury and was not on enhanced barrier precautions (EBP) as indicated. Findings include: The facility's policy Isolation Precautions policy, with a revision date of 3/26/24, indicates: ~ Droplet Precautions: Implement droplet precautions for a resident with suspected or confirmed to be infected with a communicable disease/infection transmitted via droplets generated by sneezing, talking, or during procedures such as suctioning. 3. Prior to entering the isolation room, the following steps are required: a. Perform hand hygiene and apply gloves, gown, and mask prior to entering the room; .c. Remove gown and gloves and perform hand hygiene before leaving the room . ~Enhanced Barrier Precautions: 1. Expands the use of PPE beyond situations in which exposure to blood and body fluids is anticipated, refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multi-drug resistant organisms (MDROs) to staffs' hands and clothing. Examples of high-contact resident care activities requiring gown and glove use for enhanced barrier precautions include: - Dressing - Bathing/showering - Transferring - Providing hygiene - Changing linens - Changing briefs or assisting with toileting - Device care or use of a device; central line, urinary catheter, feeding tube, tracheostomy - Wound care: any skin opening requiring a dressing 1. On 6/10/24 at 11:22 AM, Surveyor noted R28's call light was activated and observed a droplet precautions sign on R28's door. The sign contained 2 stop signs on the top, and indicated: Droplet Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Make sure their eyes, nose, and mouth are fully covered before room entry. Remove face protection before room exit. On 6/10/24 at 11:24 AM, Surveyor observed Hospitality Aide (HA)-D enter R28's room. Prior to entering the room, HA-D did not perform hand hygiene and did not don a gown, gloves, or a face mask. Surveyor interviewed HA-D who stated HA-D was taking the Certified Nursing Assistant (CNA) class and did not need to gown or glove if HA-D did not touch R28. HA-D stated HA-D entered the room to see what R28 needed because R28's call light was on. Surveyor then observed HA-D speak to another staff and observed both staff don gloves, enter R28's room, and shut the door. HA-D and the other staff did not perform hand hygiene or don a gown and a face mask prior to entering the room. Surveyor then observed both staff exit R28's room while R28's call light was still on. On 6/10/24 at 11:29 PM, Surveyor observed CNA-G enter R28's room. CNA-G did not perform hand hygiene or don a gown, gloves, or a face mask prior to entering the room. Surveyor also observed another staff follow CNA-G into the room without performing hand hygiene or donning a gown, gloves, or a face mask. On 6/10/24 at 11:31 AM, Surveyor interviewed CNA-G who stated R28 told CNA-G that R28 needed to be changed. When asked about the droplet precautions sign on R28's door, CNA-G stated CNA-G thought CNA-G only needed to wear PPE if CNA-G touched R28 and was unsure why the droplet precautions sign was on R28's door. On 6/10/24 at 12:03 PM, Surveyor observed CNA-H enter R19's room with a lunch tray. Surveyor noted R19's room had droplet precaution and EBP signs. CNA-H did not perform hand hygiene or don a gown, gloves, or a face mask prior to entering the room. Surveyor interviewed CNA-H after CNA-H exited the room. CNA-H stated CNA-H delivered a lunch tray and only needed to don PPE if CNA-H performed cares. On 6/11/24 at 10:37 AM, Surveyor interviewed Director of Nursing (DON)-B who verified R28 and R19 were on droplet precautions due to respiratory symptoms. DON-B was aware that staff did not don the appropriate PPE prior to entering R28 and R19's rooms. Surveyor noted additional signage was placed on R28 and R19's doors with education regarding PPE. DON-B confirmed staff should have donned and doffed PPE prior to entering and exiting R28 and R19's rooms. 49010 2. Between 6/10/24 and 6/11/24, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including congestive heart failure, chronic kidney disease, and type 2 diabetes. While at the facility, R5 acquired a stage 3 pressure injury on the sacrum. On 6/10/24 at 3:28 PM, Surveyor interviewed R5 who confirmed R5 had an open sore on R5's sacrum. A wound care summary, dated 6/4/24, included follow-up notes from the physician regarding care and treatment of R5's pressure injury. R5's plan of care contained a revision, dated 5/22/24, that indicated R5 was at risk due to a stage 3 pressure injury on the right buttock. R5's plan of care also indicated: Infection: R5 has an open wound on the sacrum requiring enhanced barrier precautions. Enhanced barrier precautions (Date initiated: 6/11/24). R5's medical record contained the following wound treatment orders: ~ Right buttock: Clean with wound cleaner, apply Hydrofera Blue to wound bed, cover with bordered foam to be changed daily and as needed (PRN). Every evening shift for open area. (Dated: 5/28/24; Discontinued: 6/3/24). ~Sacrum buttock: Clean with wound cleaner, apply Hydrofera Blue to wound bed, cover with bordered foam to be changed daily and PRN. Every evening shift for open area. (Dated: 6/3/24; Discontinued: 6/4/24). ~ Sacrum buttock: Clean with wound cleaner, apply Medihoney to wound bed followed by bordered gauze to be changed daily and PRN. Every evening shift for open area. (Dated: 6/4/24; Discontinued: 6/11/24). ~ Sacrum: Cleanse wound with wound cleanser, pat dry, apply Medihoney. Apply a 4 x 4 bordered foam/gauze island to be changed daily and PRN every evening shift. (Dated: 6/11/24). ~ Check integrity to sacral wound every shift. (Dated: 6/3/24). Surveyor observed R5 on several occasions throughout the survey and did not observe an EBP sign on R5's door or a PPE cart near R5's door. Surveyor also noted there was not a garbage can near the exit of R5's room to dispose of used PPE upon exit of R5's room. Surveyor observed the following: ~ 6/10/24 at 10:26 AM and 3:26 PM: No EBP sign, cart, and no garbage can. ~ 6/11/24 11:50 AM and 3:43 PM: No EBP sign, no cart, and no garbage can. ~ 6/12/24 1:40 PM and 2:15 PM: No EBP sign, no cart, and no garbage can. On 6/10/24 at 12:16 PM, Surveyor observed Assistant Director of Nursing (ADON)-I, who was also the facility's Infection Preventionist (IP), post EBP signs on multiple residents' doors. On 6/10/24 at 12:22 PM, Surveyor interviewed ADON-I who stated ADON-I did not initiate new EBP for residents, but put up new/additional information to supplement existing EBP signs already posted on doors of residents previously designated to be on EBP. On 6/11/24 at 3:58 PM, Surveyor interviewed CNA-J who stated CNA-J can tell if a resident is on EBP because there is an EBP sign on the resident's door. CNA-J stated a resident on EBP should also have a garbage can in their room for PPE disposal and a cart with PPE in the hallway. On 6/11/24 at 4:06 PM, Surveyor interviewed CNA-K who stated CNA-K can tell if a resident is on EBP because there is an EBP sign on the resident's door. CNA-J stated a resident on EBP should also have a garbage can in their room for PPE disposal and a cart with PPE in the hallway. On 6/11/24 at 4:14 PM, Surveyor interviewed Registered Nurse (RN)-L who stated a resident on EBP should have an EBP sign on their door. RN-L also stated a resident on EBP should also have a garbage can in their room for PPE disposal and a cart with PPE nearby in the hallway. On 6/11/24 at 4:24 PM, Surveyor interviewed ADON-I who stated staff know if a resident is on EBP because there is a sign on the resident's door. When asked how else staff know if a resident is on EBP, ADON-I stated EBP would also be specified in the resident's plan of care. ADON-I stated a resident on EBP should have a garbage can for PPE located inside the room near the exit and a PPE cart should be in the hallway nearby. On 6/11/24 at 4:36 PM, Surveyor interviewed DON-B who stated a resident on EBP should have a sign on the door and EBP should be listed in the resident's care plan. DON-B also stated a resident on EBP should have a garbage can inside the room before the exit and a PPE cart nearby. DON-B stated ADON-I was responsible for making sure residents on EBP have a sign on the door, a garbage can, and a PPE cart. DON-B stated Unit Registered Nurse (RN) mangers also have a list of residents who are on EBP and can put EBP precautions in place. On 6/12/24 at 1:53 PM, Surveyor interviewed ADON-I who confirmed a resident with a stage 3 pressure injury should be on EBP. On 6/12/24 at 2:05 PM, Surveyor interviewed DON-B who confirmed a resident with a stage 3 pressure injury should be on EBP. DON-B stated DON-B thought R5 was actively on EBP and had a sign on R5's door.

Based on staff interview and record review, the facility did not ensure vaccinations were reviewed, offered, or administered for two residents (R) (R14 and R40) of 5 sampled residents. R14's Power of Attorney (POA) signed consent forms on 9/15/23 and 2/22/24 for R14 to receive the PCV20 (Prevnar 20(R)) vaccine. The facility did not administer the vaccine. The facility did not offer R40 the PCV20 vaccine. Findings include: Abbreviations (www.cdc.gov): PCV13: 13-valent pneumococcal conjugate vaccine (Prevnar13(R)) PCV15: 15-valent pneumococcal conjugate vaccine (Vaxneuvance(R)) PCV20: 20-valent pneumococcal conjugate vaccine (Prevnar 20(R)) PPSV23: 23-valent pneumococcal polysaccharide vaccine (Pneumovax23(R)) The most recent Centers for Disease Control and Prevention (CDC) recommendations for pneumococcal vaccinations indicate: For adults [AGE] years or older who have only received PPSV23, the CDC recommends: Give 1 dose of PCV15 or PCV20. The PCV15 or PCV20 dose should be administered at least 1 year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For those who have received PCV13 and 1 dose of PPSV23, the CDC recommends you give 1 dose of PCV20 at least 5 years after the last pneumococcal vaccine. For adults [AGE] years or older who have received PCV13, give 1 dose of PCV20 or PPSV23 at least 1 year after PCV13. Regardless of vaccine used, their vaccines are then complete. The facility's Pneumococcal Vaccination Policy and Procedure, with a revision date of 6/28/23, indicates: All residents will be assessed for appropriateness of receiving the pneumococcal vaccine. Residents who have been deemed appropriate for receiving the pneumococcal vaccine and who consent to receiving the vaccine will be given the vaccine following the CDC guidelines for the administration of PPSV23, PCV13, PCV15, and PCV20 per the recommendations on the CDC website . 1. R14 was admitted to the facility on [DATE] and had diagnoses including congestive heart failure, chronic kidney disease, dementia, and type 2 diabetes. R14 had an activated POA for medical decisions. R14 received a PPSV23 vaccine on 10/29/15 and a PCV13 vaccine on 3/15/16. R14 was due to be offered the PCV20 vaccine on 10/29/20 (five years after the last vaccine). The facility received a signed consent from R14's POA to administer the PCV20 vaccine on 9/15/23 and again on 2/22/24. R14's medical record did not indicate R14 was administered the PCV20 vaccine. 2. R40 was admitted to the facility on [DATE] and had diagnoses including chronic kidney disease and type 2 diabetes. R40 had a legal guardian. R40 received a PPSV23 vaccine on 7/18/17 and a PCV13 vaccine on 3/23/15. R40 was due to be offered the PCV20 vaccine on 7/18/22 (five years after the last vaccine). R40's medical record contained appropriate signed consents/refusals for pneumococcal vaccines prior to 7/18/22. R40's medical record also contained a signed consent, dated 6/5/24, for the PCV20 vaccine when R40 was readmitted to the facility on [DATE] following a hospital stay. The consent indicated R40 already had the PCV20 vaccine. The consent form did not indicate when R40 received the vaccine. R40's medical record did not indicate R40 was offered or administered the PCV20 vaccine after R40 became eligible on 7/18/22 and did not contain a date that indicated R40 received the vaccine elsewhere. On 6/11/24 at 10:33 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-I who was also the facility's Infection Preventionist (IP). ADON-I stated the facility follows their vaccination policy and checks the Wisconsin Immunization Record (WIR) for residents' vaccination records. ADON-I stated WIR information is usually uploaded into residents' electronic health records. ADON-I stated if a resident says they received a vaccine but there is no record of the vaccination, staff talk to the resident or guardian and see if they can verify when and where the resident received the vaccine, including looking up information to verify if the vaccine was administered in another state and not documented on the WIR. On 6/11/24 at 12:41 PM, Surveyor interviewed Director of Nursing (DON)-B who stated if the facility has consent for a vaccine the facility offers, staff should administer the vaccine barring any contraindications. On 6/11/24 at 2:07 PM, Surveyor interviewed DON-B who stated the facility follows their vaccination policies. DON-B indicated residents should be offered vaccines per CDC recommendations and residents' preferences. DON-B indicated staff should check the WIR and enter vaccination information in residents' electronic health records. DON-B stated if a resident's vaccinations cannot be verified, the facility does research, including calling previous long-term care residences if applicable. DON-B stated if staff cannot verify if a vaccine was given, staff should offer the resident the vaccine, allow the resident to receive or refuse the vaccine, and include the updated vaccination information in the resident's medical record. DON-B indicated DON-B expects staff to check a resident's vaccination status and offer the appropriate vaccines within a week's timeframe.

Based on observation, staff and resident interview, and record review, the facility did not implement the comprehensive care plan for 1 Resident (R) (R1) of 16 residents reviewed for care plan implementation. The facility did not provide toileting for R1 as indicated in R1's person-centered comprehensive plan of care. Findings include: R1 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, cognitive communication deficit, altered mental status, need for assistance with personal care, and weakness. R1's most recent Minimum Data Set (MDS) assessment contained a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R1 had severe cognitive impairment. R1 had an activated Power of Attorney (POA) for health care. On 7/13/22, Surveyor reviewed R1's medical record, including R1's Kardex (an abbreviated care plan used by nursing staff), which indicated: Check and change R1 as needed due to incontinence; if refusing to toilet encourage R1 to go and remind R1 you will bring R1 right back; Incontinence care after each incontinent episode; Offer and assist R1 to bathroom every 2-3 hours and as needed. If refused, check and change as R1 allows; toilet use assist of one. On 9/23/23, R1 was assessed as incontinent of bladder and wore incontinence briefs. During a continuous observation on 11/13/23 from 9:10 AM to 10:00 AM, Surveyor observed R1 in R1's wheelchair in the dining room. Surveyor ended the observation at 10:00 AM when an activity started. During a continuous observation on 11/13/23 from 10:56 AM to 1:26 PM, Surveyor observed R1 in the dining room seated at a table with a completed puzzle and then observed R1 eat lunch. On 11/13/23 at 1:24 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-G who worked on the unit where R1 resided. CNA-G stated R1 usually asks staff to go to the bathroom, however, R1 did not ask to go to the bathroom that day during the AM shift. On 11/13/23 at 1:26 PM, Surveyor interviewed R1 who indicated R1 does not ask to use the bathroom and stated staff ask R1 and if R1 has to use the bathroom. R1 stated R1 will say yes if R1 has to use the bathroom. On 11/13/23 at 1:31 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-D who worked on the unit where R1 resided. LPN-D stated R1 lets staff know when R1 needs to use the bathroom and verified R1 did not ask LPN-D to use the bathroom on the AM shift that day. At the same time, Surveyor interviewed CNA-E who stated R1 notifies staff when R1 needs to use the bathroom by self-propelling to R1's room. On 11/13/23 at 1:48 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-C who stated R1 does not typically ask to go to the bathroom any more. ADON-C stated staff ask R1 if R1 needs to use the bathroom. ADON-C stated ADON-C educated staff on how to approach and communicate with R1. ADON-C indicated ADON-C assisted with resident care on the AM shift that day and verified ADON-C did not ask R1 if R1 needed to use the bathroom. During the interview, Surveyor observed Activity Director (AD)-H assist R1 to an activity. When ADON-C stated R1 should be offered use of the bathroom, AD-H stated to R1, We're going to go to the bathroom first, okay? R1 responded, Okay. On 11/13/23 at 1:54 PM, Surveyor observed CNA-F assist R1 to the bathroom and interviewed CNA-F immediately afterward. CNA-F indicated R1 tells me when R1 has to use the bathroom.

Based on observation and staff and resident interview, the facility did not provide adequate privacy curtains in double occupancy rooms for 2 Residents (R) (R32 and R39) of 17 sampled residents. R32 and R39 resided in double occupancy rooms with roommates. R32 and R39's rooms did not contain a full privacy curtain between the beds or around the shared sink to allow for privacy during the provision of care and personal hygiene. In addition, a shared sink was across from both beds in each room and in direct view of bed A as well as anyone who entered the room. Findings include: The facility's Privacy and Dignity policy, revised on 1/10/22, contained the following information: Policy: It is the policy of [NAME] Senior Care to always provide dignity and privacy for our residents. Procedure: .4. Privacy is provided during cares. On 5/23/23, Surveyor reviewed R32's medical record. R32's most recent Minimum Data Set (MDS) assessment contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R32 was not cognitively impaired. R32 was independent with most activities of daily living (ADLs). R32 received assistance of one staff with ADLs at times due to lack of motivation and was encouraged to assist and perform ADLs independently as much as possible. On 5/23/23 at 10:21 AM, Surveyor interviewed R32 who stated R23 did not have enough privacy in R32's double occupancy room. R32 stated the privacy curtain in the room did not fully enclosed R32's sleeping area or allow R32 privacy during cares. R32 also stated the room's shared sink did not contain a full privacy curtain that allowed R32 to wash up or use the sink in private. R32 expressed a desire to use the shared sink out of view of R32's roommate and other individuals who may enter the room. Surveyor noted the room contained a half curtain located between both beds. On 5/23/23 at 11:42 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated staff provide privacy during cares as well as resident preferred times by pulling the privacy curtain in double occupancy rooms. NHA-A stated all double occupancy rooms have a U-shaped curtain that is used to provide full privacy for residents. On 5/23/23, Surveyor reviewed R39's medical record. R39's most recent MDS assessment contained a BIMS score of 15 out of 15 which indicated R39 was not cognitively impaired. R39 received assistance of one staff for ADLs due to lack of motivation or follow through to complete most ADLs independently. On 5/23/23 at 1:40 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-E who stated full privacy was provided for residents during cares or at preferred times by the full privacy curtain in double occupancy rooms. Surveyor requested CNA-E demonstrate how the curtain was used to provide privacy in R39's room. When CNA-E entered R39's room to demonstrate, CNA-E asked, Oh, where is the other curtain? R39 stated R39 did not have another curtain, pointed to the small curtain that separated the two beds and said only that one. R39 pointed to the curtainless U-shaped curtain track on the ceiling above R39's bed and stated R39 did not have privacy because there never was a curtain there. CNA-E then stated staff couldn't provide full privacy during cares and if residents in double occupancy rooms wanted to privately wash up in the shared sink, they could not do so as there was no privacy curtain provided.

Based on staff interview and record review, the facility did not ensure assessments were accurate for 2 Residents (R) (R8 and R12) of 4 sampled residents. R8 had diagnoses of schizophrenia, major depressive disorder, and anxiety. R8's Minimum Data Set (MDS) assessment, dated 2/1/23, indicated R8 did not have a serious mental health diagnosis. R12 had diagnoses of major depressive disorder and anxiety. R12's MDS assessment, dated 4/16/23, indicated R12 did not have a serious mental health diagnosis. Findings include: The facility's MDS 3.0 Process, revised 2/18/22, states the purpose is to provide guidance to conduct, initially and periodically, a comprehensive, accurate and standardized reproducible assessment of each resident's functional capacity through utilization of the MDS 3.0 RAI (Resident Assessment Instrument) User's Manual. 1. R8 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, major depressive disorder, and anxiety. R8's MDS assessment, dated 2/1/23, contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R8 was not cognitively impaired. On 5/22/23 and 5/24/23, Surveyor reviewed R8's medical record. R8's Preadmission Screening and Resident Review (PASRR), dated 6/22/22, indicated R8 had a serious mental illness. Surveyor noted R8's MDS assessment, dated 2/1/23, indicated at question A1500 that R8 did not have a serious mental health diagnosis. 2. R12 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder and anxiety. R12's MDS assessment, dated 4/16/23, contained a BIMS score of 13 out of 15 which indicated R12 was not cognitively impaired. On 5/22/23 and 5/24/23, Surveyor reviewed R12's medical record. R12's MDS assessment, dated 4/16/23, indicated at question A1500 that R8 did not have a serious mental health diagnosis; however, R12 was being treated for major depressive disorder and anxiety. On 5/24/23 at 9:12 AM, Surveyor interviewed MDS Coordinator (MDS)-C who stated a resident's MDS should reflect their mental health diagnoses. On 5/24/23 at 9:15 AM, Surveyor interviewed Social Worker (SW)-D who verified SW-D incorrectly coded R8 and R12's MDS assessments.

Based on interview and record review, the facility did not ensure 1 Resident (R) (R3) of 5 residents was free of a significant medication error. R3 received in error clonidine (an antihypertensive medication,) losartan potassium (an antihypertensive medication,) and furosemide (a diuretic medication) which resulted in the need for intravenous (IV) (a needle or tube inserted into the vein) therapy to improve hypotension (low blood pressure). Findings include: R3 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's dementia, congestive heart failure, chronic kidney disease, and diabetes. R3's Minimum Data Set (MDS) dated [DATE], contained a Brief Interview for Mental status (BIMs) score of 13 out of 15 which indicated R3 had intact cognition. R3's medical record documented conversations to pursue gardianship. The facility's Medication Error and Drug Interactions policy, dated 8/15/22, contained the following information: 2. A detailed account of the error will be recorded in the resident's medical record. Such documentation must include, but not be limited to: A. timing and date of the incident. B. name, strength and dosage of the medication administered. C. resident's reaction to the medication. E. Any treatment administered. F. date and time the physician was notified and what instructions were given. 4. The nurse will be responsible for completing a Point Click Care (PCC) risk management report. 5. All medication error/incident reports relating to medication errors and drug reactions will be reviewed by the Quality Assurance committee at their next regularly scheduled meeting. On 2/21/23 at 10:42 AM, Surveyor attempted to interview R3 in R3's room. Each time Surveyor asked a question, R3 stated yeah. R3 also stated take me out and did not want to spend time talking with Surveyor. During the interview, Activity Director (AD)-C entered R3's room to take R3 to an activity. AD-C stated R3 was hard of hearing and yeah was a common answer given. On 2/21/23, Surveyor reviewed R3's medical record. Documentation included a medication variance, dated 12/19/22; however, a description of the variance was not contained in R3's medical record. An assessment indicated R3's blood pressure was 96/64 millimeters of mercury (mmHg). Following the sudden decline in R3's blood pressure, a verbal order to administer IV therapy of normal saline (NS) 500 milliliters (ML) per hour was obtained. An IV was placed in R3's left antecubital (inside area of the elbow) and ran as ordered. At approximately 12:00 PM, R3 pulled out the IV. Nursing applied pressure to bleeding at the IV site and updated the physician. At that time, R3 had only received 200 ML of NS. R3's physician ordered R3's medications not be given as ordered on 12/19/22 due to the medication variance. Documentation indicated R3's blood pressure continued to fluctuate. On 12/20/22, R3's blood pressure was 80/40 mmHg. On 12/21/22, R3's blood pressure was 78/56 mmHg. R3's furosemide was held on 12/19/22, 12/20/22, and 12/21/22 due to the medication variance. Close laboratory monitoring was initiated which included a basic metabolic panel (BMP) on 12/20/22 and 12/22/22 to monitor electrolytes, calcium, glucose, and kidney function. Lab results were reviewed by R3's physician on 12/22/22 and indicated R3 had a mildly elevated potassium level of 5.1 (normal range 3.6 to 5.2) which was a suspected result of the need to hold R3's furosemide on 12/21/22 due to hypotension. In response to the lab results from 12/22/23, R3's physician stated since R3 was not on potassium supplements or potassium sparing diuretics, R3 should resume R3's current dose of furosemide (which was being held due to the medication variance) and continue further laboratory monitoring. On 2/21/23, Surveyor requested the incident report for R3's medication variance. A medication error report, dated 12/19/22, did not contain documentation of the name, strength or dose of the medication administered, a description of the error, the root cause of the error, or an indication of how to prevent future errors and provide safe medication administration to all residents. On 2/21/23 at 2:42 PM, Surveyor interviewed Director of Nursing (DON)-B who assisted with the medication variance on 12/19/22. DON-B stated R3 was given another resident's medication due to lack of proper identification by the nurse who administered the medication. As a result of the error, R3 did not receive all of R3's ordered medications due to potential side effects. In addition, R3 received extra fluids administered via IV therapy for a significant drop in blood pressure. DON-B stated there was not an incident report that described the events of the medication error. DON-B printed R2's medication administration record (MAR) and highlighted the medications R3 received on the morning of 12/19/22 due to the incident. At that time, it was noted R3 received 13 medications in error that were prescribed to R2 (another resident in the facility). DON-B stated the nurse who administered the medications in error was educated; however, all nursing staff were not educated on the five rights of medication administration, including the right person. In this instance, instead of asking R3 to state R3's name or verifying R3's identity via an identity bracelet, the nurse who administered the medication asked R3, who was noted to be hard of hearing, if R3 was R2 to which R3 replied yeah. Surveyor reviewed R2's medication orders and noted R3 received the following medications: Keflex (an antibiotic), potassium chloride (an electrolyte supplement), simbrinza suspension (eye drops) to left eye, acetaminophen (pain), clonidine, metformin (antidiabetic), vitamin D3, lactobacillus (a supplement), losartan potassium, ferrous sulfate (an iron supplement), fexofenadine (an antihistamine), furosemide and esomeprazole (an antacid). It was identified that clonidine, losartan potassium, and furosemide could have all caused a significant drop in blood pressure. On 2/21/23 at 3:18 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and DON-B who did not provide any further evidence of an investigation of the incident.

Based on observation, record review and staff interview, the facility did not consult with the physician when there was need to alter treatment significantly for 1 (Resident 1) of 6 sampled residents. Example 1 Resident 1 was admitted to the facility with a stage 2 pressure injury. The resident's pressure injury declined in condition and subsequently Resident 1was hospitalized with a stage 4 pressure injury [MEDICAL CONDITION]. The resident's food/fluid intake had also significantly declined. Appropriate protein and fluid intake must be maintained to assist with pressure injury healing. The facility did not consult with the physician regarding the deteriorating condition of the pressure injury nor the significant decrease in oral intake. Example 2 (Resident 1 but with an additional example) Staff were observed completing a dressing change to Resident 1's stage 4 pressure injury. The resident expressed pain verbally and nonverbally throughout the dressing change. Staff did not update the resident's physician regarding the ineffective pain medication. The failure of the facility to consult with the physician when the pressure injury was deteriorating and oral intake had significantly decreased that is needed for wound healing, resulted in an avoidable stage 4 pressure injury to decline in condition from a stage 2 pressure injury that Resident 1 was admitted to the facility with. This created a situation of Immediate Jeopardy, which began on 09/03/16 when the pressure injury had a significant decline in condition. On 10/03/16 the NHA (Nursing Home Administrator) was formally notified that an Immediate Jeopardy situation existed. The Immediate Jeopardy was removed on 10/03/16, however the deficient practice continues at a scope/severity level of G (actual harm/isolated). Findings include: According to the Hospital Discharge Summary, dated 08/27/16, Resident 1 was readmitted to the facility with a closed [MEDICAL CONDITION] femur (upper leg) neck which required surgical repair. The hospital discharge summary did not contain any information regarding a pressure injury or treatment of [REDACTED]. On 8/27/16 at 21:56 (9:56 p.m.), LPN A documented in the progress notes that Resident 1 has 1.3 cm (centimeters) by 1.2 cm open area on the coccyx with surrounding areas pink but blanchable. On 8/28/16, LPN A completed an Admission Assessment/Data Collection Tool. The tool indicated there was an open area on the coccyx measuring 1.3 cm by 1.2 cm. The tool has an area that is to be checked if a pressure reducing mattress or cushion in a chair is being utilized. These areas were left unchecked. On 09/28/16 at 11:25 a.m., Surveyor conducted a telephone interview with LPN A regarding the condition of the pressure injury of the coccyx on 08/27/16. LPN A stated the wound bed was red and there was no other tissue type in the wound bed. Surveyor reviewed Resident 1's TAR (Treatment Administration Record) dated August 2016. This TAR did not include documentation that the resident's pressure injury treatment was not initiated until 08/31/16. In addition, Resident 1's medical record did not include a physician's orders [REDACTED]. A plan of care was not developed until 08/29/16, entitled Risk for impaired skin integrity related to decreased mobility, [MEDICAL CONDITIONS], incontinence. The following interventions were included: ~ Assist to reposition PRN (as needed) ~ Barrier cream after each incontinent episode and PRN ~ Braden scale upon admission, then weekly for 4 weeks, quarterly or significant change or PRN (Braden scale is a tool to identify residents that might be at risk for pressure injuries) ~ Keep skin clean and dry ~ Reposition approximately every 2-3 hours ~ Update MD (medical doctor) PRN A physician documented progress notes on 08/30/16, indicating Resident 1 was seen for an Admission Nursing Home History & Physical. This progress note did not include documentation regarding the resident's pressure injury. Under the Review of Systems Skin: No rash and no itching was documented. Under the Physical Exam Skin: No [DIAGNOSES REDACTED] (redness) and no rash. Skin is warm to touch was documented. The Progress Note dated 08/30/16 entered as a Late Entry for the Weekly Nursing Summary documented Resident 1 .is generally continent of bowel and bladder, however due to a recent hip surgery and decreased mobility, the resident is generally incontinent of bowel and bladder. Resident is on a check and change schedule and is able to verbalize the need to be changed. On 10/06/16 at 2:15 p.m., Surveyor received a computerized physician's orders [REDACTED]. The Progress Note dated 08/31/16, entered as Skin/Wound Note documented RN B assessed Resident 1's open area to the coccyx that was noted upon admission. area measures to be 2.4 cm by 1.6 cm with no depth noted. Wound bed is dark red tissue with a slight amount of slough around the wound bed. Periwound is pink and blanchable. No odor present. Serosanguinous (fluid leaving a wound that is yellowish with small amounts of blood) drainage noted, appears to be a moderate amount .wash area to coccyx with wound wash, apply skin prep place [MEDICATION NAME] ag (silver) foam cover with dermaview (dressing) and change every shift and as needed. A physician's correspondence note, dated 08/31/16, indicated RN V called the physician to informed Resident 1's wound to coccyx was stage 2 and the facility was requesting [MEDICATION NAME] ag foam covered with dermaview to be changed every day and as needed. The physician responded and stated to proceed with wound care as requested. On 09/30/16 at 12:15 p.m., Surveyor interviewed RN B regarding Resident 1. RN B stated prior to 08/31/16, the resident's MDS (Minimum Data Set) assessment included documentation that the resident had a reddened area, so she spoke with LPN A and LPN A indicated the area was reddened. RN A indicated she did not review LPN A's documentation regarding the wound and did not visualize the coccyx wound. RN B stated she does not expect LPNs to complete assessments and document a pressure injury. RN B stated she is one of the facility's wound care nurses and the other wound care nurse was ADON (Assistant Director of Nursing) C. RN B stated they are to be notified of pressure injuries and then they will complete assessments. RN B stated she requested AG foam for Resident 1 because the foam would collect the drainage and the silver would treat the slough. RN B indicated she did not think Resident 1's pressure injury required a [MEDICATION NAME] agent. RN B verified Resident 1's medical record did not include documented measurements of the amount of slough the pressure injury contained. RN B stated she called the physician's office on 08/31/16 and notified the office nurse of the condition of the resident's pressure injury. RN B stated she did not write on the correspondence the resident's pressure injury was a stage 2. RN B indicated she thought the office nurse must have indicated the pressure injury was a stage 2. When interviewed what stage a pressure injury would be when slough is present, RN B stated a stage 3. On 09/30/16 at 1:00 p.m., Surveyor interviewed ADON C regarding Resident 1. ADON C stated she was aware of the 8/27/16 pressure injury assessment and that an RN assessment had not been completed until 08/31/16, because wound rounds are conducted on Wednesdays and 08/31/16 was a Wednesday. ADON C stated by looking at the LPN's documentation of the pressure injury on 08/27/16, she would stage the pressure injury as a stage 2. ADON C indicated she was not a certified wound nurse and graduated from ADN (Associate Degree Nursing) school 2 years ago and completed 100 hours of preceptor training in nursing school with a certified wound nurse. ADON C commented she has reviewed videos on pressure injuries. ADON C stated by reading the notes on 8/31/16, the pressure injury had increased in size and would be classified as a stage 3. ADON C indicated the condition of the pressure injury would be hard to say for sure, because she would have had a better picture if she saw the pressure injury herself. When interviewed regarding if the documentation on 08/31/16 followed current standards of practice, ADON C stated it was. The Progress Note dated 09/03/16 at 16:03 (4:03 p.m.) entered as Skin/Wound Note documented RN B assessed Resident 1's open area coccyx that was noted upon admission. Area measures to be 2.3 cm by 1.5 cm with a 0.4 cm depth. wound bed is 100 % slough. periwound is pink and blanchable. no odor is present, with moderate amount of serosanguineous drainage noted .dressing type changed to [MEDICATION NAME] AQ rope with [MEDICATION NAME] to cover and to be changed daily. The Progress Note dated 09/03/16 at 23:29 (11:29 p.m.) entered as Medication Administration Note documented Resident 1 received [MEDICATION NAME]/[MEDICATION NAME] per request for complaint of butt pain. On 09/30/16 at 12:15 p.m., Surveyor interviewed RN B regarding the 09/03/16 documentation. RN B stated she changed the dressing treatment to a rope dressing because there was a little depth and it would be easier to pack. When interviewed regarding Resident 1 having a physician's orders [REDACTED]. RN B indicated she was not wound certified and ADON C was not wound certified. RN B indicated she graduated from ADN school in December of 2015 and received wound training during nursing school. On 09/30/16 at 1:00 p.m., Surveyor interviewed ADON C regarding the 09/03/16 documentation. ADON C indicated by the documentation it appears the pressure injury was deteriorating and the documentation did not follow current standards of practice. ADON C indicated depth can not be measured when the wound is covered by 100% slough. ADON C stated the facility changed the treatment, the silver component of the dressing would help to kill the bacteria. ADON C indicated the facility's policy and procedure is the current standard of practice for pressure injury. The facility completed a Braden Scale (a tool used to identify pressure injury risk) on 09/03/16 & 09/04/16. Both scales indicated Resident 1 was at low risk for pressure injury development. The facility completed a Significant Change in Condition MDS assessment with an ARD (Assessment Reference Date) of 09/03/16. The MDS documented Resident 1 was alert and oriented, required extensive assist of 2 staff for transfers and bed mobility, not ambulatory, was frequently incontinent of bladder and occasionally incontinent of bowel. The MDS indicated Resident 1 was at risk for pressure injury development and the resident had 1 unstageable pressure injury and 1 unstageable pressure injury on admission to the facility. The measurement of the pressure injury in this MDS was 2.3 cm by 1.5 cm by 0.4 cm, with slough as being the most severe tissue of the pressure injury. The MDS triggered a CAA (Care Area Assessment) to be completed for the pressure injury. The CAA documented will care plan with goals for improvement in skin impairment. Will continue to monitor daily for increased size, signs/symptoms of infection or other potential complications. Will measure weekly. MD and care plan will be updated as needed. The Progress Note dated 09/06/16 at 13:08 (1:08 p.m.) entered as Health Status Note documented Resident 1 .was assessed by writer, resident at this time is refusing to drink or eat as reported by the floor nurse that resident is having difficulty swallowing. resident is unable to state date, situation and is unaware of location. resident is requesting to go to the hospital. resident stated pain was a 10 out of 10 and is not being controlled despite PRN and scheduled medication. resident is refusing to be repositioned. Physician was called to inform of resident being sent to ER (emergency room ). The Progress Note dated 09/06/16 at 22:46 (10:46 p.m.) entered as Health Status Note documented Resident 1 .returned from the emergency room at 1930 (7:30 p.m.). [MEDICATION NAME] was ordered for a UTI (urinary tract infection). Report from nurse at (hospital) stated that (the resident) was given some fluids but no other problems were noted. The Dietary Profile completed on 09/07/16 documented Resident 1 had a recent [MEDICAL CONDITION] with surgical repair on 08/23/16, [MEDICAL CONDITIONS], Hypertension (high blood pressure) and [MEDICAL CONDITION]. The profile indicated Resident 1 required 73 grams of protein and 1525 cc (cubic centimeters) plus of fluids and the coccyx area was reddened. Resident 1's weight listed as 178 pounds. The comment area indicated the resident is familiar to the facility, readmitted on [DATE] s/p (status [REDACTED]. Is on a general diet, eating 50% of meals with no reported tolerance issues. Weight is down 2.7% since 02/2016 but not significant .Will watch skin integrity with less mobility s/p femur fracture. Encourage intakes greater than 50% at meals to meet estimated needs. Plan of care is in place. Will update as needed. The facility documented Resident 1's food/fluid intake on an unnamed computer-generated report from 08/27/16 through 09/15/16 with the following results: ~ 8 of the days listed had missing fluid intake amounts for 1 or more meals ~ The total documented fluid intake of the three meals ranged from 300 cc to 900 cc; an average of less than 20 % to less than 60% of the daily recommended fluid estimated needs. ~ Documentation indicates the resident's meal intake was 25% or less for 21 of the 47 meals that were documented during this period, 9 of the 21 meals documented only bites and 3 of the 21 meals documented refused. ~ Documentation indicates the resident's meal intake was 50% for 16 of the 47 meals that were documented during this period. Resident 1's Progress notes, MAR (Medication Administration Record, [REDACTED]. Resident 1's medical record did not include additional assessments and/or documentation regarding identifying Resident 1's poor and decreasing food/fluid intake that is essential for protein intake to promote wound healing and fluid intake to maintain hydration status as fluids serve as a solvent for vitamins, minerals, glucose and other nutrients and transports nutrients and waste products throughout the body. Resident 1's Progress notes, MAR, TAR and plan of care did not include documentation that a supplement was offered to Resident 1 in an attempt to increase protein intake. The Progress Notes dated 09/08/16 8:06 a.m., entered as Physician Notification documented RN B assessed Resident 1's wound on coccyx with ADON. May we change dressing orders to silvakollagen gel and sacral dressing to cover to be changed every other day or as needed? Please advise. Although the physician responded on 9/9/16 at 9:20 p.m. with the orders requested, Resident 1's TAR included documentation on 9/8/16 that the treatment was completed on the evening shift. The September 2016 TAR included documentation that Resident 1's pressure injury treatment was completed by a LPN on 5 of the 8 evening shifts from 09/08/16 through 09/15/16. On 09/30/16 at 12:15 p.m., Surveyor interviewed RN B regarding Resident 1's treatment change requested on 09/08/16. RN B stated the treatment was changed because Resident 1's pressure injury was further deteriorating in condition. RN B verified a written assessment of the pressure injury had not been documented to reflect the deterioration and/or condition of the pressure injury. RN B verified the physician was not notified and/or updated regarding the pressure injury's current condition. RN B stated she entered the treatment change to be done every other day, but ADON C thought it should be done everyday, so that is why the change is written on the TAR. On 09/30/16 at 1:00 p.m., Surveyor interviewed ADON C regarding Resident 1's pressure injury on 09/08/16. ADON C verified the medical record did not have documentation of the resident's pressure injury assessment on 09/08/16 and indicated she was unable to recall what the pressure injury looked like on 09/08/16 or why the treatment was changed. The Progress Note dated 09/10/16 at 02:26 (2:26 a.m.), entered as Health Status Note documented Resident 1 .has been incontinent more often. The Weekly Skin Observation record, dated 09/11/16, documented by LPN A 3 cm X 3 cm and .5 cm in depth with black center noted Small amt (amount) of serosang. (serosanguineous) drainage noted. 0.5 am X .5 cm dark red area near coccyx area. On 09/28/16 at 11:25 a.m., Surveyor conducted a telephone interview with LPN A regarding documentation on Resident 1's Skin Observation sheet in which the LPN completed. LPN A verified black tissue was present in the pressure injury A and stated the observation was completed on a weekly skin assessment that is done on the resident's shower day. LPN A stated she usually notifies ADON C by a note or passes the information to other nurses in the 24 hour report sheet, but could not recall if she had completed either on 9/11/16. Surveyor reviewed the 24 hour report record from 08/27/16 through 09/15/16. The 24 hour report record did not include any documentation regarding Resident 1's pressure injury. On 09/30/16 at 12:15 p.m., Surveyor interviewed RN B regarding Resident 1's Skin Observation form dated 09/11/16. RN B stated she was not aware of the documentation. On 09/30/16 at 1:00 p.m., Surveyor interviewed ADON C regarding Resident 1's Skin Observation form dated 09/11/16. ADON C stated that it made sense that the area was black because silver can cause that. When Surveyor interviewed ADON C regarding if a RN assessment had been completed after the pressure injury presented with a blackened area, ADON C verified an assessment had not been completed after the blackened area was observed. ADON C stated she did not assess the pressure injury after the blackened area was noted and she did not see any documentation on the Skin Observation sheet. ADON C indicated the facility's wound care nurses document weekly on wounds, but was unable to recall a reason why Resident 1 did not have a documented assessment after 09/03/16 of Resident 1's pressure injury. The facility initiated a Skin Impairment plan of care on 09/11/16 that indicated: open area coccyx, unstageable r/t (related to) slough. The plan of care listed the following interventions: ~ Measure wound weekly ~ Observe for signs/symptoms of infection: increased redness, foul odor, increased drainage, pain to area ~ Treatment as ordered ~ Update MD PRN The Progress Note dated 09/12/16 at 05:47 (5:47 a.m.) entered as Medication administration Note documented [MEDICATION NAME] (an antianxiety medication) take 0.5 mg (milligrams) by mouth every 8 hours as needed: per request for c/o anxiety, resident crying, stating I think I sat too long meaning 9/11 pm shift. The Progress Note dated 09/12/16 entered by a PA (Physician's Assistant) on 09/12/16 documents Resident 1 continues to complain of a significant amount of pain. (Resident) was seen in the ED (Emergency Department) on 09/06/16 due to pain and dehydration. (Resident) had been refusing to eat or drink related to pain. (Resident) was given intravenous fluids and sent back from the ED. (Resident) was also found to have a UTI and started on an antibiotic. (Resident) has been on TID (three times daily) [MEDICATION NAME] which helps somewhat. The scheduled doses are due to end on 09/14/16. (Resident) has a PRN [MEDICATION NAME] available which nursing notes (resident) is using on a daily basis. (Resident) has not been eating well and refuses cares at times due to pain. (Resident) remains on [MEDICATION NAME] (an anticoagulant) with an unknown end date, however patient is very immobile currently. Plan: Discontinue scheduled [MEDICATION NAME]. Start [MEDICATION NAME]/APAP ([MEDICATION NAME]) 5/325 mg, 1 tab PO (by mouth) TID times 14 days. Under the Subjective section of the note documented Resident 1's .biggest complaint is ongoing pain. Per nursing, some times are better than others and it is not constant. (Resident) has been using her PRN [MEDICATION NAME] on a daily basis, especially in the AM .Appetite has been fair. The PA's assessment did not include documentation of an assessment of Resident 1's pressure injury and did not include information provided by the nursing department regarding the same. The Progress Note dated 09/12/16 at 14:14 (2:14 p.m.) entered as physician's orders [REDACTED]. The Progress Note dated 09/12/16 documented at 21:29 (9:29 p.m.) entered as Health Status Note documents .No behavior issues this shift but was whimpering with cares. When asked about pain, pain was related to pressure sore on coccyx. PRN pain medication was administered. The Progress Note dated 09/13/16 at 11:29 a.m., documented by RD (Registered Dietician) that Resident 1 continues on a general diet, however noted intakes down over the past week, 25%-50%. Resident currently on ABT (antibiotic) for a UTI and suspect this may be source of decreased intake. Goal for intakes to return to greater than 50% without impact on weight. Current body weight is 177.6 pounds which is stable over the past month. Continue current plan of care. This progress note documented by the RD referred to the current weight of 177.6 pounds that was recorded in Resident 1's medical record on 8/5/16. Resident 1's weight summary indicated the resident's next recorded weight of 165.1 pounds was on 09/24/16, which was an additional loss of 12.5 pounds. The Progress Note dated 09/14/16 at 16:23 (4:23 p.m.) entered as Medication Administration Note documented Resident 1 requested [MEDICATION NAME]/[MEDICATION NAME] .rates pain 7 to buttock. The facility utilizes a 1-10 pain scale. The Progress Note dated 09/14/16 at 21:41 (9:41 p.m.) entered as Health Status Note documented Resident 1 .is comfortable at this time. Dressing to buttocks changed and dated. Resident is on side off (resident's) buttocks. Resident stated that it feels better laying off (resident's) buttocks. The Progress Note dated 09/15/16 at 04:20 a.m. entered as Health Status Note documented Resident 1 .does have pain related to coccyx sore. resident is being repositioned Q (every) 2 hours with extensive 2 assist and given PRN pain meds as requested. Dressing intact to coccyx area. Changed on PMs. Resident had no complaints of pain or behaviors indicative of pain on shift. Resident asleep at this time. The Progress Note dated 09/15/16 at 11:18 a.m. entered as Health Status Note documented Resident 1 .still some complaints of pain in her knee and back. (Resident) rates it a 2/10 before the med and 4/10 after. Seems as though the pain goes up when sitting in (resident's) chair. The Progress Note dated 9/15/16 at 13:45 (1:45 a.m.) entered as Health status Note documented ADON C .was called to the therapy gym to assess resident. Resident was sitting up in a broda chair. The resident was unable to squeeze writer's hands equally. (Resident) had a slight facial droop to right side and was having difficulty swallowing .Writer called MD to update and orders received to send to the ED for evaluation. The Hospital History & Physical dated 09/15/16 documented Resident 1 .was brought in because increased confusion .About 3 weeks ago (resident) had a femur fracture .hospitalized had surgery and .back at the nursing home .has been incontinent of urine and now has a recognized deep sacral decubitus ulcer .Decubitus ulcer of the sacral region, stage 4 Assessment/Plan: Significant decubitus ulcer which will need surgical evaluation and possible debridement. We'll place a urinary catheter at this time to keep (resident) from becoming wet and (resident) will need a specialty mattress as well. CKD ([MEDICAL CONDITION]) stage 3 Assessment/Plan: Moderate worsening of (resident's) [MEDICAL CONDITION]. This is probably due to finding depletion. The Hospital Discharge Summary dated 09/24/16 documented Resident 1 admitted with confusion [MEDICAL CONDITION] and initially though that she was having pneumonia so she was started on [MEDICATION NAME] (an antibiotic) .it was realized that (resident's) source [MEDICAL CONDITION] was the decubitus ulcer for which general surgery was consulted and (resident) underwent debridement and subsequently had a wound VAC placed. On 09/28/16 at 9:05 a.m., Surveyor interviewed CNA (Certified Nursing Assistant) G regarding Resident 1. CNA G stated when Resident 1 returned from the hospital after the [MEDICAL CONDITION], the resident was dependent on staff for ADL's (activities of daily living). CNA G indicated the resident was admitted with an every 2 hour repositioning schedule and was repositioned from side to back. CNA G indicated Resident 1's repositioning schedule remained at every 2 hours and was never told to increase repositioning time to offload pressure from the coccyx. CNA G stated the resident was admitted with an open area but was it was not as bad as when last left for the hospital (9/15/16). CNA G stated she was not aware of any time the resident would refuse repositioning, as the resident always accepted repositioning when CNA G worked with Resident 1. On 09/28/16 at 9:10 a.m., Surveyor interviewed CNA H regarding Resident 1. CNA H stated she did not work with Resident 1 very often, but recalls the resident was on an every 2 hour turning schedule since return from the hospital and Resident 1 never refused repositioning. On 09/28/16 at 11:00 a.m., Surveyor interviewed RN I regarding Resident 1. RN I stated there was not any information about an infection or deterioration of Resident 1's pressure injury in the 24 hour shift report that would have been passed on to other shifts regarding any concerns. RN I stated PM shift did the treatment to the pressure injury and would/should have reported any concerns. RN I indicated Resident 1 was not on intake monitoring of fluids and was unaware if CNAs document the resident's fluid intake. RN I verified Resident 1 was at some risk for dehydration due to dependence and staff should have kept trying to offer fluids. RN I indicated there was not any area in the medical record that would have fluid intake information unless a physician ordered the specific fluid intake monitoring. On 09/28/16 at 2:00 p.m., Surveyor interviewed CNA F regarding Resident 1. CNA F stated Resident 1 required extensive assist of 2 staff since the resident's [MEDICAL CONDITION] and was minimally repositioned every 2 hours. CNA F indicated Resident 1's food and fluid intake has always been poor and would only take sips of fluids at the bedside. CNA F stated staff document fluid intake, but only from meals. CNA F indicated she has expressed concerns about Resident 1's fluid intake to other CNAs and nurses. CNA F stated the nurses just say to push fluids. CNA F indicated no changes were made to encourage intake or repositioning for Resident 1. On 09/28/16 at 2:30 p.m., Surveyor interviewed CNA K regarding resident 1. CNA K indicated Resident 1 has required extensive staff assist since the resident sustained [REDACTED]. CNA K indicated the resident would use a straw and CNA K noticed there were times the resident would not be able to suck hard enough to get the fluid into her mouth, but there were other times when the resident would get a small amount of fluid. CNA K stated she has told nurses of the resident's intake concerns, but was always told to push fluids. On 09/28/16 at 2:30 p.m., Surveyor interviewed LPN L regarding Resident 1's fluid intake. LPN L stated the resident would be at risk for hydration concerns because the resident requires staff to give her fluids. Surveyor asked LPN L if there was an area in the medical record that would notify staff of the specific fluid requirements for Resident 1, LPN L responded she did not know how to locate specific fluid requirements in the computerized medical record as she was computer illiterate. LPN L indicated she would go by what she thinks her own fluid needs would be to feel hydrated and that would be what Resident 1 requires. On 09/28/16 at 3:15 p.m., Surveyor interviewed CNA M regarding Resident 1. CNA M stated the resident's food intake has been poor, but she thought fluid intake was good as the resident would always be asking for a drink. CNA M indicated when the she assisted Resident 1 with a drink, the resident would only take sips. On 09/30/16 at 10:00 a.m., Surveyor interviewed RN J regarding Resident 1. RN J stated the resident was repositioned at least every 2 hours, but if complained of pain or was uncomfortable then would be repositioned more often. RN J indicated she was aware of complaints of pain on occasion and the resident ate and drank well, drank all fluids. RN J indicated she was not aware of any area in the medical record where she could look for Resident 1's specific fluid requirements and the CNAs would notify nurses if there were concerns with intake. 2. According to the pain assessment dated [DATE], Resident 1 was at risk for pain and expressed pain verbally and nonverbally. Nonverbal cues were identified as grimacing, moaning, irritability, and crying. Resident 1's TAR dated 9/27/16 directed staff to monitor and document the resident's pain each shift. The TAR indicated an acceptable level of pain for Resident 1 was less than a 2 on a 1-10 pain scale. On 9/28/16 the resident's pain was documented as a 6 during the day shift, a 0 during the evening shift, and a 6 during the night shift. On 9/29/16 the resident's pain was documented as a 6 during the day shift. The facility developed a pain care plan for Resident 1. The care plan was initiated on 9/27/16 and directed staff to administer pain medication before therapy, prior to moving the resident, and prior to providing cares to the resident. The care plan directed staff to allow time for medication to work. The care plan also directed staff to document the resident's pain level every shift, report pain to the nurse, and notify the physician if the resident's pain is not controlled. Resident 1 had a physician's orders [REDACTED]. The resident had another physician's orders [REDACTED]. According to Resident 1's 9/2016 MAR, on 9/28/16 the resident received the scheduled [MEDICATION NAME] dose at 8:00 a.m. and 2:00 p.m. The MAR indicated [REDACTED] On 9/28/16 at 2:10 p.m., Surveyor observed ADON C and RN B perform a dressing change to Resident 1's stage 4 pressure injury to the coccyx. As ADON C removed the old dressing, the resident stated Oh that hurts! ADON C then cleansed the wound with saline. As the nurse was continuing the treatment and applying skin prep to the peri-wound, the resident cried Oh please, I cant stand it! You're pulling on my skin! I can't take it! The resident then stated she needed water, so ADON C stopped while the resident had a drink of water. As ADON C continued the treatment the resident continued to cry out stating Oh I hurt so much. (Crying) Give me water. The nurses continued with the dressing change until the treatment was completed at 2:30 p.m. On 9/28/16 at 2:45 p.m., Surveyor interviewed RN B, who verified the resident was in pain during the dressing change. RN B stated if she were to rate the amount of pain the resident expressed during the observation it would be a 6 on a 1-10 pain scale. RN B indicated this score was based on the resident'

Based on record review and staff interviews, the facility did not provide the necessary treatment and services to promote healing and prevent infections for 1 (Resident 1) of 6 sampled residents. On 08/27/16, Resident 1 was readmitted from the hospital with an open area on the coccyx. The care plan indicated the resident required repositioning every 2-3 hours. A pressure reducing mattress was in place. The facility did not document the open area per current standard of practice, nor did the facility initiate a treatment for 4 days. On 08/31/16, the pressure injury increased in size and developed slough (necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, & stringy at times). The facility updated a nurse at the physician's office regarding the condition of the pressure injury and requested a treatment. The physician did respond and returned written correspondence that indicated to proceed with wound care as requested. The treatment was initiated on the PM shift, which mostly consisted of LPNs (Licensed Practical Nurses) completing the treatment. On 09/03/16, Resident 1's pressure injury continued to deteriorate in condition. Although the facility requested a change to the current dressing, the facility did not update the physician regarding the assessment of the pressure injury. The facility utilized the same chemical treatment and only changed the type of dressing applied. This physician's orders [REDACTED]. On 09/08/16, the facility notified the physician regarding the treatment change to a debridement agent, but did not consult with the physician regarding the continued deterioration of the pressure injury. This physician's orders [REDACTED]. On 09/11/16, an LPN documented Resident 1's pressure injury having a black center. The documentation was not completed per standard of practice, nor was there an RN (Registered Nurse) assessment of the deterioration of the pressure injury. On 09/15/16, the resident experienced a significant change in condition and was transported to the hospital. The resident was diagnosed with [REDACTED]. The hospital documentation indicated the pressure injury was the source of [MEDICAL CONDITION]. During the continued decline of Resident 1's pressure injury, the facility did not increase offload time to the coccyx area, nor did the facility evaluate the pressure reducing mattress to assess if the mattress was appropriate when the resident's pressure injury deteriorated to a Stage 3 pressure injury. The facility did not document an assessment of the pressure injury per the current standard of practice. The facility did not change the scheduled treatment time to day shift, to allow the RNs to assessment the pressure injury while completing the treatment when a continuous decline in condition was documented. Resident 1's medical record included a physician's orders [REDACTED]. The facility allowed RN B and ADON (Assistant Director of Nursing) C to make changes to the treatments to the resident's pressure injury without a physician's orders [REDACTED]. Resident 1's food and fluid intake continually decreased and the facility did not assess protein and fluid intake needs of the resident to enhance pressure injury healing, nor did the facility consult with the resident regarding the resident's wishes when the appropriate intake could not be obtained until after the resident was diagnosed with [REDACTED]. Resident 1's pain increased with new complaints of coccyx pain. The facility did not identify the increased pain and deterioration of the pressure injury could possibly be a sign of a pressure injury infection. The resident's medical record did not include documentation that a comprehensive assessment had been completed regarding the increased pain of the resident's coccyx area. The failure of the facility to implement appropriate preventative and treatment interventions for Resident 1, resulted in the stage 2 pressure injury that Resident 1 was admitted to the facility with to an avoidable stage 4 pressure injury that resulted in a decline in condition. This created a situation of Immediate Jeopardy, which began on 09/03/16 when the pressure injury had a significant decline in condition. The NHA (Nursing Home Administrator) was formally notified on 10/03/16 that an Immediate Jeopardy situation existed. The Immediate Jeopardy was removed on 10/03/16, however the deficient practice continues at a scope/severity level of D (potential for harm that is not immediate jeopardy/isolated). Findings include: The facility's policy and procedure titled Pressure Injury and Wound Treatment Policy, with a revision date of 09/23/16 indicated the following: ~ An initial assessment will be performed by the designated Wound nurse at admission or if injury/wound is not present at admission, at the time of the discovery of the injury/wound. This assessment will include: a. Type b. Location c. Periwound condition d. Length, width, and depth e. Undermining f. Sinus tract h. Tunneling i. Exudates j. Necrotic tissue k. Pain i. Presence or absence of granulation tissue and [MEDICATION NAME]. (The policy and procedure does not direct a pressure injury to be Staged). ~ Physician will be notified of injury/wound and assessment findings. Appropriate orders will be obtained. ~ Following the initial assessment of the injury/wound, the designated Wound Nurse will implement an individualized treatment plan based on identified risk factors and resident specific needs and strengths. ~ Injury/wound's response to treatment plan will be monitored by licensed nurse and reviewed weekly by the Wound Committee. Ulcer/wound's response to treatment plan will be documented in the clinical record no less often than weekly. ~ Injury/wound assessments, treatment plans and response to treatment plans will be readily accessible to physicians. Physicians may document assessment of ulcer/wound and review of treatment plan of physician progress notes [REDACTED]. ~ Daily and as needed observations will be made by licensed nurse of the injury/wound site if the wound is visualized or of the dressing and periwound if dressing remains intact with documentation in the nurses notes and/or wound progress notes when a change in injury status is noted. ~ If evidence of heeling is not seen within 2 to 4 weeks, the designated Wound Nurse will reassess the injury/wound, the treatment plan, the resident's adherence to the treatment plan, and the resident's clinical condition. The designated Wound Nurse will direct changes that may be made at this time to the treatment plan to address individualized resident needs and promote wound healing. ~ Upon injury/wound healing, the designated Wound Nurse will reassess the area and guide changes that may be made to the injury prevention plan of care to prevent future breakdown. ~ During the care plan review, education will be provided to the resident and/or resident representative regarding the reasons for interventions and how the interventions help move the resident towards having a positive outcome. ~ Education regarding injury/wound treatment shall be provided to all licensed nurses at the time of hire and no less frequently than annually for existing employees. According to the NPUAP's (National Pressure Ulcer Advisory Panel) Prevention and treatment of [REDACTED]. The Pressure Ulcer Assessment indicates to assess and document physical characteristics that include: ~ location ~ category/stage ~ size ~ tissue type(s) ~ color ~ periwound condition ~ wound edges ~ sinus tracts ~ undermining ~ tunneling ~ exudate ~ odor The NPUAP indicated to determine repositioning frequency with consideration to the individual's: ~ tissue tolerance ~ level of activity and mobility ~ general medical condition ~ overall treatment objectives ~ skin conditions ~ comfort Under the Mattress and Bed Support Surfaces for Individuals with Existing Pressure Ulcers in the NPUAP's Quick Reference Guide indicated: ~ Consider replacing the mattress with a support surface that provides more effective pressure redistribution, shear reduction and microclimate control for the individual if she or he: a. cannot be positioned off the existing pressure ulcer b. fails to heal or demonstrates ulcer deterioration despite appropriate comprehensive care c. is at high risk for additional pressure ulcers Select a support surface that provides enhanced pressure redistribution, shear reduction and microclimate control for individuals with Category/Stage 3/4 and unstageable pressure ulcers. The NPUAP under the section Protein Intake indicated to provide adequate protein for positive nitrogen balance for adults with a pressure ulcer. Offer 1.25 to 1.5 grams protein/kilogram body weight daily for adults with an existing pressure ulcer who are assessed to be at risk of malnutrition when compatible with goals of care, and reassess as condition changes. Offer high calorie, high protein nutritional supplements in addition to the usual diet to adults with nutritional risk and pressure ulcer risk, if nutritional requirements cannot be achieved by dietary intake. The NPUAP under the section Hydration indicated to provide and encourage adequate daily fluid intake for hydration for an individual assessed to be at risk of or with a pressure ulcer. This must be consistent with the individual's colorblind conditions and goals. Monitor individuals for signs/symptoms of dehydration including change in weight, skin turgor, urine output, elevation serum sodium and/or calculated serum osmolality. Provide additional fluid for individuals with dehydration. Example: According to the Hospital Discharge Summary, dated 08/27/16, Resident 1 was readmitted to the facility with a closed [MEDICAL CONDITION] femur (upper leg) neck which required surgical repair. The hospital discharge summary did not contain any information regarding a pressure injury or treatment of [REDACTED]. On 8/27/16 at 21:56 (9:56 p.m.), LPN A documented in the progress notes that Resident 1 has 1.3 cm (centimeters) by 1.2 cm open area on the coccyx with surrounding areas pink but blanchable. On 8/28/16, LPN A completed an Admission Assessment/Data Collection Tool. The tool indicated there was an open area on the coccyx measuring 1.3 cm by 1.2 cm. The tool has an area that is to be checked if a pressure reducing mattress or cushion in a chair is being utilized. These areas were left unchecked. On 09/28/16 at 11:25 a.m., Surveyor conducted a telephone interview with LPN A regarding the condition of Resident 1's coccyx pressure injury on 08/27/16. LPN A stated the wound bed was red and there was no other tissue type in the wound bed. Surveyor reviewed Resident 1's TAR (Treatment Administration Record) dated August 2016. This TAR did not include documentation that the resident's pressure injury treatment was not initiated until 08/31/16. In addition, Resident 1's medical record did not include a physician's orders [REDACTED]. A plan of care was not developed until 08/29/16, entitled Risk for impaired skin integrity related to decreased mobility, [MEDICAL CONDITIONS], incontinence. The following interventions were included: ~ Assist to reposition PRN (as needed) ~ Barrier cream after each incontinent episode and PRN ~ Braden scale upon admission, then weekly for 4 weeks, quarterly or significant change or PRN (Braden scale is a tool to identify residents that might be at risk for pressure injuries) ~ Keep skin clean and dry ~ Reposition approximately every 2-3 hours ~ Update MD (medical doctor) PRN A physician documented progress notes on 08/30/16, indicating Resident 1 was seen for an Admission Nursing Home History & Physical. This progress note did not include documentation regarding the resident's pressure injury. Under the Review of Systems Skin: No rash and no itching was documented. Under the Physical Exam Skin: No [DIAGNOSES REDACTED] (redness) and no rash. Skin is warm to touch was documented. The Progress Note dated 08/30/16 entered as a Late Entry for the Weekly Nursing Summary documented Resident 1 .is generally continent of bowel and bladder, however due to a recent hip surgery and decreased mobility, the resident is generally incontinent of bowel and bladder. Resident is on a check and change schedule and is able to verbalize the need to be changed. On 10/06/16 at 2:15 p.m., Surveyor received a computerized physician's orders [REDACTED]. The Progress Note dated 08/31/16, entered as Skin/Wound Note documented RN B assessed Resident 1's open area to the coccyx that was noted upon admission. area measures to be 2.4 cm by 1.6 cm with no depth noted. Wound bed is dark red tissue with a slight amount of slough around the wound bed. Periwound is pink and blanchable. No odor present. Serosanguinous (fluid leaving a wound that is yellowish with small amounts of blood) drainage noted, appears to be a moderate amount .wash area to coccyx with wound wash, apply skin prep place [MEDICATION NAME] ag (silver) foam cover with dermaview (dressing) and change every shift and as needed. A physician's correspondence note, dated 08/31/16, indicated RN V called the physician to informed Resident 1's wound to coccyx was stage 2 and the facility was requesting [MEDICATION NAME] ag foam covered with dermaview to be changed every day and as needed. The physician responded and stated to proceed with wound care as requested. On 09/30/16 at 12:15 p.m., Surveyor interviewed RN B regarding Resident 1. RN B stated prior to 08/31/16, the resident's MDS (Minimum Data Set) assessment included documentation that the resident had a reddened area, so she spoke with LPN A and LPN A indicated the area was reddened. RN A indicated she did not review LPN A's documentation regarding the wound and did not visualize the coccyx wound. RN B stated she does not expect LPNs to complete assessments and document a pressure injury. RN B stated she is one of the facility's wound care nurses and the other wound care nurse was ADON C. RN B stated they are to be notified of pressure injuries and then they will complete assessments. RN B stated she requested AG foam for Resident 1 because the foam would collect the drainage and the silver would treat the slough. RN B indicated she did not think Resident 1's pressure injury required a [MEDICATION NAME] agent. RN B verified Resident 1's medical record did not include documented measurements of the amount of slough the pressure injury contained. RN B stated she called the physician's office on 08/31/16 and notified the office nurse of the condition of the resident's pressure injury. RN B stated she did not write on the correspondence the resident's pressure injury was a stage 2. RN B indicated she thought the office nurse must have indicated the pressure injury was a stage 2. When interviewed what stage a pressure injury would be when slough is present, RN B stated a stage 3. On 09/30/16 at 1:00 p.m., Surveyor interviewed ADON C regarding Resident 1. ADON C stated she was aware of the 8/27/16 pressure injury assessment and that an RN assessment had not been completed until 08/31/16, because wound rounds are conducted on Wednesdays and 08/31/16 was a Wednesday. ADON C stated by looking at the LPN's documentation of the pressure injury on 08/27/16, she would stage the pressure injury as a stage 2. ADON C indicated she was not a certified wound nurse and graduated from ADN (Associate Degree Nursing) school 2 years ago and completed 100 hours of preceptor training in nursing school with a certified wound nurse. ADON C commented she has reviewed videos on pressure injuries. ADON C stated by reading the notes on 8/31/16, the pressure injury had increased in size and would be classified as a stage 3. ADON C indicated the condition of the pressure injury would be hard to say for sure, because she would have had a better picture if she saw the pressure injury herself. When interviewed regarding if the documentation on 08/31/16 followed current standards of practice, ADON C stated it was. The Progress Note dated 09/03/16 entered as Health Status Note documented at 01:15 (1:15 a.m.) Refusing to sleep on side at present time. The Progress Note dated 09/03/16 at 16:03 (4:03 p.m.) entered as Skin/Wound Note documented RN B assessed Resident 1's open area coccyx that was noted upon admission. Area measures to be 2.3 cm by 1.5 cm with a 0.4 cm depth. wound bed is 100 % slough. periwound is pink and blanchable. no odor is present, with moderate amount of serosanguineous drainage noted .dressing type changed to [MEDICATION NAME] AQ rope with [MEDICATION NAME] to cover and to be changed daily. The Progress Note dated 09/03/16 at 23:29 (11:29 p.m.) entered as Medication Administration Note documented Resident 1 received [MEDICATION NAME]/[MEDICATION NAME] per request for complaint of butt pain. On 09/30/16 at 12:15 p.m., Surveyor interviewed RN B regarding the 09/03/16 documentation. RN B stated she changed the dressing treatment to a rope dressing because there was a little depth and it would be easier to pack. When interviewed regarding Resident 1 having a physician's orders [REDACTED]. RN B indicated she was not wound certified and ADON C was not wound certified. RN B indicated she graduated from ADN (Associate Degree Nursing) school in December of 2015 and received wound training during nursing school. On 09/30/16 at 1:00 p.m., Surveyor interviewed ADON C regarding the 09/03/16 documentation. ADON C indicated by the documentation it appears the pressure injury was deteriorating and the documentation did not follow current standards of practice. ADON C indicated depth can not be measured when the wound is covered by 100% slough. ADON C stated the facility changed the treatment, the silver component of the dressing would help to kill the bacteria. ADON C indicated the facility's policy and procedure is the current standard of practice for pressure injury. The facility completed a Braden Scale (a tool used to identify pressure injury risk) on 09/03/16 & 09/04/16. Both scales indicated Resident 1 was at low risk for pressure injury development. The facility completed a Significant Change in Condition MDS assessment with an ARD (Assessment Reference Date) of 09/03/16. The MDS documented Resident 1 was alert and oriented, required extensive assist of 2 staff for transfers and bed mobility, not ambulatory, was frequently incontinent of bladder and occasionally incontinent of bowel. The MDS indicated Resident 1 was at risk for pressure injury development and the resident had 1 unstageable pressure injury and 1 unstageable pressure injury on admission to the facility. The measurement of the pressure injury in this MDS was 2.3 cm by 1.5 cm by 0.4 cm, with slough as being the most severe tissue of the pressure injury. The MDS triggered a CAA (Care Area Assessment) to be completed for the pressure injury. The CAA documented will care plan with goals for improvement in skin impairment. Will continue to monitor daily for increased size, signs/symptoms of infection or other potential complications. Will measure weekly. MD and care plan will be updated as needed. The Progress Note dated 09/06/16 at 13:08 (1:08 p.m.) entered as Health Status Note documented Resident 1 .was assessed by writer, resident at this time is refusing to drink or eat as reported by the floor nurse that resident is having difficulty swallowing. resident is unable to state date, situation and is unaware of location. resident is requesting to go to the hospital. resident stated pain was a 10 out of 10 and is not being controlled despite PRN and scheduled medication. resident is refusing to be repositioned. Physician was called to inform of resident being sent to ER (emergency room ). The Progress Note dated 09/06/16 at 22:46 (10:46 p.m.) entered as Health Status Note documented Resident 1 .returned from the emergency room at 1930 (7:30 p.m.). [MEDICATION NAME] was ordered for a UTI (urinary tract infection). Report from nurse at (hospital) stated that (the resident) was given some fluids but no other problems were noted. The Dietary Profile completed on 09/07/16 documented Resident 1 had a recent [MEDICAL CONDITION] with surgical repair on 08/23/16, [MEDICAL CONDITIONS], Hypertension (high blood pressure) and [MEDICAL CONDITION]. The profile indicated Resident 1 required 73 grams of protein and 1525 cc (cubic centimeters) plus of fluids and the coccyx area was reddened. Resident 1's weight listed as 178 pounds. The comment area indicated the resident is familiar to the facility, readmitted on [DATE] s/p (status [REDACTED]. Is on a general diet, eating 50% of meals with no reported tolerance issues. Weight is down 2.7% since 02/2016 but not significant .Will watch skin integrity with less mobility s/p femur fracture. Encourage intakes greater than 50% at meals to meet estimated needs. Plan of care is in place. Will update as needed. The facility documented Resident 1's food/fluid intake on an unnamed computer-generated report from 08/27/16 through 09/15/16 with the following results: ~ 8 of the days listed had missing fluid intake amounts for 1 or more meals ~ The total documented fluid intake of the three meals ranged from 300 cc to 900 cc; an average of less than 20 % to less than 60% of the daily recommended fluid estimated needs. ~ Documentation indicates the resident's meal intake was 25% or less for 21 of the 47 meals that were documented during this period, 9 of the 21 meals documented only bites and 3 of the 21 meals documented refused. ~ Documentation indicates the resident's meal intake was 50% for 16 of the 47 meals that were documented during this period. Resident 1's Progress notes, MAR (Medication Administration Record, [REDACTED]. Resident 1's medical record did not include additional assessments and/or documentation regarding identifying Resident 1's poor and decreasing food/fluid intake that is essential for protein intake to promote wound healing and fluid intake to maintain hydration status as fluids serve as a solvent for vitamins, minerals, glucose and other nutrients and transports nutrients and waste products throughout the body. Resident 1's Progress notes, MAR, TAR and plan of care did not include documentation that a supplement was offered to Resident 1 in an attempt to increase protein intake. Resident 1's medical record did not include documentation that a discussion had occurred with Resident 1 regarding the resident's wishes when or if adequate food/fluid intake was unable to be attained due to the resident's clinical condition until 09/28/16. The Progress Note dated 09/28/16 at 8:12 a.m., entered as Social Services Note documented Social Worker met with the resident in (resident's) room along with nursing management to discuss resident's goal for plan of care. Resident tearful at first but then spoke coherently. Resident's eyes remained closed until resident was asked to open them. Resident was encouraged to drink, eat and take medication. Resident made aware (resident) will decline without eating or drinking. This writer asked resident if (resident) wanted to continue with treatment or comfort measure-resident responded she wanted to get better. Resident was asked if (resident) would like IV's (intravenous) if became dehydrated and responded yes The Progress Notes dated 09/08/16 8:06 a.m., entered as Physician Notification documented RN B assessed Resident 1's wound on coccyx with ADON. May we change dressing orders to silvakollagen gel and sacral dressing to cover to be changed every other day or as needed? Please advise. Although the physician responded on 9/9/16 at 9:20 p.m. with the orders requested, Resident 1's TAR included documentation on 9/8/16 that the treatment was completed on the evening shift. The September 2016 TAR included documentation that Resident 1's pressure injury treatment was completed by a LPN on 5 of the 8 evening shifts from 09/08/16 through 09/15/16. On 09/30/16 at 12:15 p.m., Surveyor interviewed RN B regarding Resident 1's treatment change requested on 09/08/16. RN B stated the treatment was changed because Resident 1's pressure injury was further deteriorating in condition. RN B verified a written assessment of the pressure injury had not been documented to reflect the deterioration and/or condition of the pressure injury. RN B verified the physician was not notified and/or updated regarding the pressure injury's current condition. RN B stated she entered the treatment change to be done every other day, but ADON C thought it should be done everyday, so that is why the change is written on the TAR. On 09/30/16 at 1:00 p.m., Surveyor interviewed ADON C regarding Resident 1's pressure injury on 09/08/16. ADON C verified the medical record did not have documentation of the resident's pressure injury assessment on 09/08/16 and indicated she was unable to recall what the pressure injury looked like on 09/08/16 or why the treatment was changed. The Progress Note dated 09/10/16 at 02:26 (2:26 a.m.), entered as Health Status Note documented Resident 1 .has been incontinent more often. The Weekly Skin Observation record, dated 09/11/16, documented by LPN A 3 cm X 3 cm and .5 cm in depth with black center noted Small amt (amount) of serosang. (serosanguineous) drainage noted. 0.5 am X .5 cm dark red area near coccyx area. On 09/28/16 at 11:25 a.m., Surveyor conducted a telephone interview with LPN A regarding documentation on Resident 1's Skin Observation sheet in which the LPN completed. LPN A verified black tissue was present in the pressure injury A and stated the observation was completed on a weekly skin assessment that is done on the resident's shower day. LPN A stated she usually notifies ADON C by a note or passes the information to other nurses in the 24 hour report sheet, but could not recall if she had completed either on 9/11/16. Surveyor reviewed the 24 hour report record from 08/27/16 through 09/15/16. The 24 hour report record did not include any documentation regarding Resident 1's pressure injury. On 09/30/16 at 12:15 p.m., Surveyor interviewed RN B regarding Resident 1's Skin Observation form dated 09/11/16. RN B stated she was not aware of the documentation. On 09/30/16 at 1:00 p.m., Surveyor interviewed ADON C regarding Resident 1's Skin Observation form dated 09/11/16. ADON C stated that it made sense that the area was black because silver can cause that. When Surveyor interviewed ADON C regarding if a RN assessment had been completed after the pressure injury presented with a blackened area, ADON C verified an assessment had not been completed after the blackened area was observed. ADON C stated she did not assess the pressure injury after the blackened area was noted and she did not see any documentation on the Skin Observation sheet. ADON C indicated the facility's wound care nurses document weekly on wounds, but was unable to recall a reason why Resident 1 did not have a documented assessment after 09/03/16 of Resident 1's pressure injury. The facility initiated a Skin Impairment plan of care on 09/11/16 that indicated: open area coccyx, unstageable r/t (related to) slough. The plan of care listed the following interventions: ~ Measure wound weekly ~ Observe for signs/symptoms of infection: increased redness, foul odor, increased drainage, pain to area ~ Treatment as ordered ~ Update MD PRN The Progress Note dated 09/12/16 at 05:47 (5:47 a.m.) entered as Medication administration Note documented [MEDICATION NAME] (an antianxiety medication) take 0.5 mg (milligrams) by mouth every 8 hours as needed: per request for c/o anxiety, resident crying, stating I think I sat too long meaning 9/11 pm shift. The Progress Note dated 09/12/16 entered by a PA (Physician's Assistant) on 09/12/16 documents Resident 1 continues to complain of a significant amount of pain. (Resident) was seen in the ED (Emergency Department) on 09/06/16 due to pain and dehydration. (Resident) had been refusing to eat or drink related to pain. (Resident) was given intravenous fluids and sent back from the ED. (Resident) was also found to have a UTI and started on an antibiotic. (Resident) has been on TID (three times daily) [MEDICATION NAME] which helps somewhat. The scheduled doses are due to end on 09/14/16. (Resident) has a PRN [MEDICATION NAME] available which nursing notes (resident) is using on a daily basis. (Resident) has not been eating well and refuses cares at times due to pain. (Resident) remains on [MEDICATION NAME] (an anticoagulant) with an unknown end date, however patient is very immobile currently. Plan: Discontinue scheduled [MEDICATION NAME]. Start [MEDICATION NAME]/APAP ([MEDICATION NAME]) 5/325 mg, 1 tab PO (by mouth) TID times 14 days. Under the Subjective section of the note documented Resident 1's .biggest complaint is ongoing pain. Per nursing, some times are better than others and it is not constant. (Resident) has been using her PRN [MEDICATION NAME] on a daily basis, especially in the AM .Appetite has been fair. The PA's assessment did not include documentation of an assessment of Resident 1's pressure injury and did not include information provided by the nursing department regarding the same. The Progress Note dated 09/12/16 at 14:14 (2:14 p.m.) entered as physician's orders [REDACTED]. The Progress Note dated 09/12/16 documented at 21:29 (9:29 p.m.) entered as Health Status Note documents .No behavior issues this shift but was whimpering with cares. When asked about pain, pain was related to pressure sore on coccyx. PRN pain medication was administered. The Progress Note dated 09/13/16 at 11:29 a.m., documented by RD (Registered Dietician) that Resident 1 continues on a general diet, however noted intakes down over the past week, 25%-50%. Resident currently on ABT (antibiotic) for a UTI and suspect this may be source of decreased intake. Goal for intakes to return to greater than 50% without impact on weight. Current body weight is 177.6 pounds which is stable over the past month. Continue current plan of care. This progress note documented by the RD referred to the current weight of 177.6 pounds that was recorded in Resident 1's medical record on 8/5/16. Resident 1's weight summary indicated the resident's next recorded weight of 165.1 pounds was on 09/24/16, which was an additional loss of 12.5 pounds. The Progress Note dated 09/14/16 at 16:23 (4:23 p.m.) entered as Medication Administration Note documented Resident 1 requested [MEDICATION NAME]/[MEDICATION NAME] .rates pain 7 to buttock. The facility utilizes a 1-10 pain scale. The Progress Note dated 09/14/16 at 21:41 (9:41 p.m.) entered as Health Status Note documented Resident 1 .is comfortable at this time. Dressing to buttocks changed and dated. Resident is on side off (residen

Based on record review and staff interviews, the facility did not ensure 1 (Resident 1) of 7 sampled residents was provided with sufficient fluid intake to maintain proper hydration. Resident 1 was sent to the ED (emergency department) on 9/6/16, diagnosed with [REDACTED]. The facility did not complete a hydration assessment and did not enhance fluid monitoring. When Resident 1 continued to decline in oral intake, further increasing the resident's risk for dehydration, the facility did not identify this risk, did not implement measures to prevent dehydration, and did not complete resident hydration assessments. The resident ultimately required hosptalized on [DATE] relating to [DIAGNOSES REDACTED]. Findings include: Resident 1's Hospital Discharge Summary dated 08/27/16 documented the resident was readmitted to the facility with [DIAGNOSES REDACTED]. Prior to this hospitalization , the facility completed a BMP (Basic Metabolic Panel) on Resident 1 with the following results: ~ Sodium: 139 mmol/l (millimole/liter) - (normal range: 134-143 mmol/l) ~ BUN (blood urea nitrogen): 22 mg/dl (milligram/deciliter) - (normal range: 8-26 mg/dl) ~ Creatinine: 1.51 mg/dl - (normal range: 0.44-1.00 mg/dl) ~ GFR (glomerular filtration rate): Non African American- 33 ml/min (milliliter/minute) - (normal range > 60 ml/min) The facility completed an Admission Assessment, dated 08/27/16, which included a Dehydration Risk Assessment. The risk assessment indicated Resident 1 required assistance with fluid intake and did not include documentation if Resident 1 was or was not at risk for dehydration. The facility completed a Significant Change in Condition MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 09/03/16. The MDS assessment documented Resident 1 was alert and oriented and required extensive assist for consuming fluids. Dehydration did not trigger as a concern to prompt the facility to complete a CAA (Care Area Assessment). The Progress Notes dated 09/06/16 at 13:08 (1:08 p.m.) documented Resident 1 was assessed by (facility) writer. Resident at this time is refusing to drink or eat as reported by the floor nurse. The resident is having difficulty swallowing. Resident is unable to state date, situation and is unaware of location. Resident is requesting to go to the hospital. Resident states pain was a 10 out of 10 and is not being controlled despite PRN (as needed) and scheduled medications .Send to the ER (emergency room ). The ER report dated 09/06/16 diagnosed Resident 1 with a UTI (urinary tract infection) and Anorexia (eating disorder that causes people to lose weight) and placed the resident on an antibiotic. The hospital sent information to the facility regarding treatment of [REDACTED]. The bacteria gets onto the skin around the opening of the urethra. From there, it can get into the urine and travel up to the bladder, causing inflammation and infection. This usually happens because of: dehydration. The list included multiple reasons under the cause. Under The Care and Prevention section indicated Drink plenty of fluids to prevent dehydration and flush out the bladder. Do this unless you must restrict fluids for other health reasons, or your doctor told you not to. Resident 1's ER laboratory values drawn 9/6/16 at 3:18 p.m. are as follows: ~ BUN: 46 mg/dl; high ~ Creatinine: 1.39 mg/dl; high ~ GFR: Non African American- 37 ml/min; low ~ Sodium: 142 mmol/l Resident 1's Progress Notes dated 09/06/16 at 22:46 (10:46 p.m.) documented the resident returned from the emergency room at 1930 (7:30 p.m.). [MEDICATION NAME] (an antibiotic) was ordered for a UTI. The nurse at the hospital stated (the resident) was given some fluids, no other problems were noted. Although the facility identified Resident 1's increased risk for dehydration related to the UTI and assessed a need for staff assistance for fluid intake, the facility did not complete a hydration assessment or enhance fluid monitoring for the resident. In addition, the facility did not consult with Resident 1 with regard to the resident's wishes if fluid intake requirements could not be met through oral intake. The Dietary Profile completed on 09/07/16 documented Resident 1 had a recent [MEDICAL CONDITION] with surgical repair on 08/23/16, [MEDICAL CONDITIONS], Hypertension (high blood pressure) and [MEDICAL CONDITION]. The profile indicated Resident 1 required 1525 plus cc (cubic centimeters) of fluids and the resident's coccyx area was reddened. The profile listed Resident 1's weight to be 178 pounds. The comment area indicated the resident is familiar to the facility, readmitted on [DATE] s/p a right femoral neck fracture following a fall on 08/22/16. Weight is down 2.7 percent since 02/2016 but not significant .Will update as needed. The facility developed a plan of care titled, Risk for dehydration related to antibiotic use dated 09/07/16. The following interventions were included: ~ Hydration assessment PRN (as needed) ~ Monitor for early signs/symptoms of dehydration: decreased urine output, dry and sticky mouth, headache ~ Push fluids as the resident allows ~ Update MD (Medical Doctor) PRN The facility documented Resident 1's fluid intake on an unnamed computer-generated report from 09/07/16 through 09/15/16 with the following results: ~ 09/07/16; B 60 cc, L 120 cc, S no documentation ~ 09/08/16; B 180 cc, L not applicable (documentation indicates the resident was in the facility), S 240 cc ~ 09/09/16; B 120 cc, L 60 cc, S 120 cc (total of 300 cc) ~ 09/10/16; B 120 cc, L 120 cc, S 240 cc (total of 480 cc) ~ 09/11/16; B 120 cc, L 120 cc, S 360 cc (total of 600 cc) ~ 09/12/16; No documentation for all meals ~ 09/13/16; B 120 cc, L 20 cc, S 240 cc (total of 380 cc) ~ 09/14/16; B 180 cc, L 120 cc, S 360 cc (total of 660 cc) ~ 09/15/16; B 100 cc, L 60 cc, S not available (sent to the hospital per notes) Resident 1's fluid needs were calculated by the RD (Registered Dietician). The facility did not assess the Resident 1's clinical condition related to the possible development of dehydration. Staff indicated documentation of resident fluid intake was obtained only from meals, which was significantly lower than the amount of 1525 cc calculated by the RD for Resident 1. Documentation indicated Resident 1 was seen by the PA (Physician's Assistant) on 09/12/16. The progress note indicated the patient continues to complain of a significant amount of pain. (Resident) was seen in the ED (Emergency Department) on 09/06/16 due to pain and dehydration. (Resident) had been refusing to eat or drink related to pain. (Resident) was given intravenous fluids and sent back from the ED. (Resident) was also found to have a UTI and started on an antibiotic . The Progress Notes dated 09/13/16 written by the RD (Registered Dietician) documented the resident is currently on an antibiotic for a UTI and suspect this may be source of decreased intake. Goal for intakes to return to greater than 50% without impact on weight. Current body weight is 177.6 pounds which is stable over the past month. Continue current plan of care. There was not an additional weight listed in the progress notes indicating a current weight was taken related to this note. This note does not contain any further assessment of Resident 1 regarding fluid intake related to fluid requirements. The Progress Notes dated 9/15/16, documented ADON C was called to the therapy gym to assess Resident 1. Resident 1 was sitting up in a Broda chair. The resident was unable to squeeze (facility) writer's hands equally. The resident had a slight facial droop to right side and was having difficulty swallowing. The resident was unable to stick her tongue out at writer or puff cheeks out. When asked what city we are in, the resident replied appropriately. Resident only able to give one word answers. Writer called MD to update and orders received to send to the ED for evaluation. The Hospital H&P (History & Physical) dated 09/15/16, documented Resident 1 was being evaluated for a chief complaint of confusion. The H&P recognized Resident 1's stage 3 CKD, stating moderate worsening of her (Resident 1) CKD. This is probably due to depletion. The hospital laboratory values, dated 09/15/16 indicated the following: ~ BUN: 43 mg/dl; high ~ Creatinine: 1.47 mg/dl; high ~ GFR: non African American- 34 ml/min; low ~ Sodium: 146 mml/l; high Resident 1's medical record did not include additional assessments and documentation regarding the facility's identification of Resident 1's poor/decreasing fluid intake in order to maintain the resident's hydration status. In addition, the medical record did not include documented discussions with Resident 1 regarding what the resident's wishes were if adequate fluid intake was unable to be attained due to the resident's clinical condition until 09/28/16. A review of Resident 1's weight summary indicated the resident's weight on 09/24/16 was 165.1 pounds, which noted a 12.5 pound decrease in weight from 177.6 pounds from 08/05/16. The facility documented no other weights during this time period. The Progress Notes dated 09/28/16, written by the facility's SW (Social Worker) documented the SW met with the Resident 1 in resident's room along with nursing management to discuss the resident's goal for the plan of care. Resident tearful at first then spoke coherently. Resident's eyes remained closed until resident was asked to open them. Resident was encouraged to drink, eat and take medication. Resident made aware she will decline without eating or drinking. This (facility) writer asked resident if she wanted to continue with treatment or comfort measure. Resident responded that she wanted to get better. Resident was asked if she would like IV's (intravenous) if she became dehydrated and responded 'yes' . Resident 1 was sent to the ED on 09/28/16 and the Hospital H&P (History & Physical) dated 09/28/16, documented Resident 1 was being evaluated for a chief complaint of failure to thrive and electrolyte abnormalities. The H&P indicated the resident presented with increased confusion and was found to have [MEDICAL CONDITION], [DIAGNOSES REDACTED], increasing [MEDICAL CONDITION] and decreasing PO (oral) intake. Resident's physical exam included an assessment of her mouth/throat that indicated the mucous membranes are pale and dry. On 09/28/16 at 11:00 a.m., Surveyor interviewed RN I regarding Resident 1. RN I indicated Resident 1 was not on a fluid input monitoring regime. RN I stated she was unaware if CNAs document fluid intake. RN I stated Resident 1 was probably at some risk for dehydration due to dependence and staff should have kept trying to offer fluids. RN I stated Resident 1's medical record did not have an area to obtain fluid monitoring. RN I indicated the only time a specific fluid intake monitoring would be implemented is if a physician ordered it. On 09/28/16 at 2:00 p.m., Surveyor interviewed CNA F regarding Resident 1. CNA F stated Resident 1 required extensive assist of 2 staff since the resident fractured a hip. CNA F indicated Resident 1's fluid intake has always been poor and would only take sips of fluids at the bedside. CNA F stated staff only document fluid intake from meals. CNA F indicated she has expressed concerns about Resident 1's fluid intake to other CNAs and nurses and stated the nurses just say to push fluids. On 09/28/16 at 2:30 p.m., Surveyor interviewed CNA K regarding resident 1. CNA K indicated Resident 1 has required extensive staff assist since the resident sustained [REDACTED]. CNA K indicated the resident would use a straw and noticed at times the resident would not be able to suck hard enough to get the fluid into her mouth. CNA-K stated other times Resident 1 would get a small amount of fluid and she told the nurses of Resident 1's intake concerns, but was always told to push fluids. On 09/28/16 at 2:30 p.m., Surveyor interviewed LPN L regarding Resident 1's fluid intake. LPN L stated the resident would be at risk for hydration concerns because the resident requires staff to give her fluids. When asked, LPN L stated she does not know how to locate specific fluid requirements in the computerized medical record as she is computer illiterate. LPN L indicated she would go by what she thinks her own fluid needs would be to feel hydrated and that would be what Resident 1 requires. On 09/28/16 at 3:15 p.m., Surveyor interviewed CNA M regarding Resident 1. CNA M stated Resident 1's food intake has been poor and she thought the resident's fluid intake was good, as the resident would always be asking for a drink. CNA M indicated when she assisted Resident 1 with a drink, the resident would only take sips. On 09/30/16 at 10:00 a.m., Surveyor interviewed RN J regarding Resident 1. RN J stated Resident 1 drank all fluids provided and indicated she was not aware of an area in the medical record where she could look up Resident 1's specific fluid requirements. RN J stated the CNAs should notify nurses if there were concerns with intake, and she's not aware of any concerns with Resident 1.

Based on observation, interview, and record review, the facility did not ensure 1 (Resident 1) of 6 sampled residents received the necessary care and services to attain and maintain the highest practicable well-being in accordance with the resident's pain management plan of care. Resident 1 has a stage 4 pressure injury (visible bone or tendon) to the coccyx. The facility identified the resident to be at risk for pain and had a pain care plan in place. Although the resident received scheduled pain medication has an order for [REDACTED]. Findings include: Resident 1's pain assessment dated [DATE] documented the resident is cognitively impaired. The assessment documented Resident 1 was at risk for pain and expressed pain verbally and nonverbally. Nonverbal cues were identified as grimacing, moaning, irritability and crying. Resident 1's Progress Notes included the following documentation: ~ 8/29/16 at 22:18 (8:18 p.m.); complained of severe pain this shift .received prn pain medication at 1626 (4:26 p.m.) and 2028 (8:28 p.m.) .states that the pain pill helps for a little while. ~ 8/31/16 at 1938 (7:38 p.m.); .was having too much pain today and did not want this dressing changed this shift. ~ 9/3/16 at 10:26 a.m.: .c/o (complained) pain rated at 8/10 in right hip .crying uncontrollably, grimacing, guarding hip. ~ 9/3/16 at 11:12 a.m.; .in too much pain this AM to get out of bed quite tearful r/t (related) to pain in hip. ~ 9/6/16 at 13:08 (1:08 p.m.); requesting to go to hospital .stated pain was a 10 out of 10 and is not being able to be controlled despite PRN and scheduled medication. ~ 9/6/16 at 14:31 (2:31 p.m.); .has been teary eyed this past week due to pain. ~ 9/15/16 at 11:18 a.m.; Still some c/o pain in knee and back .rates it a 2/10 before the med and 4/10 after. Seems as though the pain goes up when sitting in chair. The facility completed a MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 09/03/16. The MDS indicated Resident 1's is alert and oriented. The Progress Notes dated 09/15/16, documented Resident 1 was transferred to the hospital related to a sudden change in condition. The Hospital History & Physical dated 09/15/16, documented the resident was brought to the hospital due to increased confusion .About three weeks ago the resident had a femur fracture, was hospitalized , had surgery and subsequently has been back at the nursing home .not ambulatory .has been incontinent of urine and now has a recognized deep sacral decubitus ulcer .Assessment/Plan: Decubitus ulcer of the sacral region, stage 4. Significant decubitus ulcer which will need surgical evaluation and possible debridement. Resident 1's physician's orders [REDACTED]. An additional physician's orders [REDACTED]. Resident 1's TAR (Treatment Administration Record) dated 9/27/16 directed staff to monitor and document the resident's pain each shift. The TAR indicated an acceptable level of pain for Resident 1 was less than 2 on the 1-10 pain scale. The facility developed a pain care plan for Resident 1 initiated on 9/27/16, directing staff to administer pain medication before therapy, prior to moving the resident and prior to providing cares to the resident. The care plan directed staff to allow time for medication to work and to document Resident 1's pain level every shift, report pain to the nurse and notify the physician if the resident's pain is not controlled. Resident 1's 9/28/16 MAR (Medication Administration Record) included documentation that Resident 1 received the scheduled dose of [MEDICATION NAME] at 8:00 a.m. and 2:00 p.m. and received a dose of [MEDICATION NAME] at 12:03 p.m. On 9/28/16 at 2:10 p.m., Surveyor observed ADON (Assistant Director Of Nursing) C and RN B complete Resident 1's stage 4 pressure injury dressing change to the resident's coccyx. Resident 1 cried out Oh that hurts! as ADON C removed the soiled dressing. ADON C then cleansed the pressure injury with saline. As the nurse continued the treatment and applied skin prep to the peri-wound, Resident 1 cried Oh please, I cant stand it! You're pulling on my skin! I can't take it! The resident then asked for water and ADON C stopped the treatment while the resident drank some water. ADON C then continued the treatment as Resident 1 cried out stating Oh I hurt so much. (Crying) Give me water. Resident 1 continued to cry out until 2:30 p.m., as the nurses completed the resident's dressing change. On 9/28/16 at 2:45 p.m., Surveyor interviewed RN B regarding the observation of Resident 1 crying out in pain during the dressing change. RN B stated if she were to rate the amount of pain Resident 1 expressed during the treatment change observation, it would be a 6 on a 1-10 pain scale. RN B indicated this score was based on the resident's facial grimacing. RN B verified a pain assessment was not completed during or after the dressing change. On 9/28/16, the resident's pain was documented as a 6 during the day shift, a 0 during the evening shift and a 6 during the night shift. On 9/29/16 the resident's pain was documented as a 6 during the day shift. On 9/30/16 at 9:35 a.m., Surveyor interviewed ADON C regarding the observation of Resident 1's dressing change. ADON C verified Resident 1 was anxious during the dressing change on 9/28/16. ADON C verified she did not assess the resident's pain or ask the resident to rate her pain because the resident was crying. When asked why she thought the resident was crying, ADON C stated because the resident was anxious. On 9/30/16 at 12:20 p.m., Surveyor interviewed CNA (Certified Nursing Assistant) F regarding Resident 1. CNA F indicated Resident 1 almost always makes a whimper sound. CNA F stated she would know if the resident was in pain because the resident would vocalize it. CNA F indicated Resident 1 did not constantly voice pain and if the resident did, then she would know to report this to the nurse. On 9/30/16 at 12:30 p.m., Surveyor interviewed CNA G regarding Resident 1. CNA G verified Resident 1 almost always makes a whimper noise, but she would know if the resident were in pain, because the resident would say so. CNA G stated complaining of pain is not normal for Resident 1, but whimpering was.

Based on observations, record review, staff and resident interviews, the facility did not ensure that a resident who entered the facility without pressure ulcers did not develop pressure ulcers and a resident having or at risk for pressure ulcer development received necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing for 5 (resident #1, #3, #28, #25 and #26) of 10 sampled and supplemental sampled residents reviewed for pressure ulcers and pressure ulcer risk. Resident #1 was at risk for the development of pressure related ulcers. The facility was aware that the resident was unable to ambulate, move legs and needed extensive assistance with transfers and bed mobility. The resident's plan of care did not include heel protection until after the development of a stage II pressure ulcer to the right heel and a stage III pressure ulcer to the left heel. In this citation, resident #1 is considered actual harm isolated (G level); Residents #3, #28, #25 and #26 are considered examples at a lower severity level (level 2, potential for harm that is not immediate jeopardy). Resident #3 was assessed to be at risk for the development of pressure ulcers. The resident was admitted to the facility with multiple wounds including a stage III pressure ulcer to the right heel. The resident's plan of care included a blue boot (a pressure reducing boot) to the right foot while in bed. That intervention was not consistently implemented. Resident #28 was assessed to be at risk for the development of pressure ulcers related to decreased mobility. Resident #28 required extensive staff assistance for bed mobility. The resident's plan of care did not include a turning and/or repositioning schedule until after the development of the pressure ulcer. Resident #25 was assessed to be at risk for the development of pressure ulcers related to decreased mobility. Resident #25 required extensive staff assistance for bed mobility. Resident #25 was observed sleeping in bed with the heels in direct contact with the mattress. Resident #25 was observed making minimal movements independently while in bed and was observed shearing heels on the mattress. Although staff indicated resident #25's heels should be free floated while in bed, the Heelz-up cushions were observed on a chair in the room next to the bed. Resident #26 was assessed to be at risk for the development of pressure ulcers related to decreased mobility. Resident #26 required extensive staff assistance for bed mobility. Although resident #26 sat in the recliner all day, to include meals, a cushion is not utilized in the recliner to minimize pressure to resident #26's coccyx and ischial tuberosities while sitting. Resident #26 did express at times (resident's) buttocks gets sore from sitting. Findings Include: On 3/19/15 at 11:40 a.m., surveyor # interviewed WCRN (Wound Care Registered Nurse)-BB. WCRN-BB indicated the facility follows the NPUAP (National Pressure Ulcer Advisory Panel) guidelines for pressure ulcer prevention. The NPUAP published an article entitled "Prevention and treatment of [REDACTED]. ~ Category/Stage II: Partial Thickness Skin Loss- Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed without slough. May also present as an intact or open/ruptured serum-filled blister. ~ Category/Stage III: Full Thickness Skin Loss- Full thickness skin loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of the tissue loss. The depth of a category/stage III pressure ulcer varies by anatomical location. Repositioning for Preventing Heel Pressure Ulcers: ~ Ensure the Heels are free of the surface of the bed. Heels should be free of all pressure. A state sometimes called 'floating heels'. ~ Use heel suspension devices that elevate and offload the heel completely in such a way as to distribute the weight of the leg along the calf. Heel suspension devices are preferable for long term use, or for individuals who are not likely to keep their legs on the pillows. Seating Support Surfaces to Prevent Pressure Ulcers: ~ Use a pressure redistributing seat cushion for individuals sitting in a chair whose mobility is reduced. Repositioning Seated Individuals: ~ Regularly reposition the older adult who is unable to reposition independently. ~ Continue to turn and reposition the individual regardless of the support surface in use. Establish turning frequency based on the characteristics of the support surface and the individual's response. ~ Modify sitting time schedules and re-evaluate the seating surface and the individual's posture if the ulcer worsens or fails to improve. ~ Select a cushion that effectively redistributes the pressure away from the pressure ulcer. The facility's Policy and Procedure undated and titled, "Pressure Ulcer Prevention" indicated, "Purpose: to assure each resident that enters the facility without a pressure ulcer does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable. Protocol: All residents will be assessed upon admission by a licensed nurse. The admission assessment will include: head to toe skin check, completion of pressure ulcer risk assessment, review of clinical conditions that compounds residents' risk for the development of pressure ulcers, history of ulcers/skin conditions, current ulcers, nutrition and hydration needs...The nurse manager will screen upon admission, quarterly, and with significant change in condition for mobility needs, positioning needs, appliances and/or other therapeutic needs related to pressure ulcer prevention. When a risk for pressure ulcer development is identified, an initial plan of care will be implemented based on the risk assessment findings and residents' individualized needs and strengths. The interdisciplinary team will review initial protocols for appropriateness and formulate and individualized plan of care. Pressure reducing or relieving devise should be placed in seating area as appropriate for the resident (e.g. recliners, wheelchairs).... 1. Resident #1's face sheet dated 10/17/14, indicated the resident had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's admission MDS (Minimum Data Set) assessment dated [DATE], documented the resident was non ambulatory, required extensive assistance from staff to transfer and perform bed mobility, was at risk for the development of pressure related ulcers and had no pressure ulcers. Additionally the MDS assessment dated [DATE], documented the resident scored a 10 of 15 on the cognition screen (the higher the score, the more cognizant). A skin alteration assessment dated [DATE], documented resident #1 had no current ulcers or areas of concern to the right or left heel. Resident #1's initial plan of care dated 10/17/14, did not include any pressure ulcer prevention interventions. Resident #1 was assessed on 10/17/14, per a Braden scale for the prediction of pressure ulcer risk, to be at risk for the development of pressure related ulcers. Surveyor # reviewed resident #1's "at risk for impaired skin integrity plan of care related to diabetes, bladder incontinence and decreased mobility" dated and initiated on 10/30/14. The plan of care included a goal that the resident would have no skin breakdown through the next review period. Interventions included to assist the resident to reposition, keep skin clean and dry, provide pericare after each incontinent episode, and provide a pressure reducing cushion in the wheelchair. Resident #1's medical record included a nursing entry dated 11/4/14, that documented the resident had presented with a right heel blister 1.5 cm (centimeters) by 1.5 cm and a left heel open area 4.5 cm by 1 cm by greater than 0.1 cm in depth. The resident's care plan was not updated at this time to protect the resident's heels. A second nursing entry dated 11/5/14 documented "Both heels measured and assessed. Right heel blister measures 1.5 cm x (by) 1.5 cm. Blister is intact. Blister to left heel measures 6 cm x 8 cm. Open area to the center of the blister measures 4.5 cm x 3 cm." The resident's care plan was not updated at this time to protect the resident's heels. A document noted in resident #1's medical record, dated 11/12/14, indicated the resident's "left heel blister measures 4 cm x 6 cm. Eschar to center of the wound measures 3.5 cm x 3.5 cm. Eschar is soft. Resident has two blisters to the right heel. Blister #1 measures 0.7 cm x 1 cm. Blister #2 measures 1.8 cm x 1.7 cm." Resident #1's MD (Medical Doctor) was updated, an order for [REDACTED]. until 11/14/14, when a new intervention was added "free float heels when in bed, recliner and wheelchair." A podiatrist note in resident #1's medical record, dated 11/17/14, documented "Resident #1 presents to the office on an emergent basis for bilateral heel ulcers which are black in color. Wife present and states resident #1 did not have any wounds until (resident) ended up at the facility...Left heel measures 5.5 cm x 3.9 cm x 0.3 to a red granular base to a stable eschar and right heel measures 1.5 cm round and 0.1 cm to a red granular base." On 3/17/15 10:50 a.m., surveyor # interviewed resident #1. Resident #1 stated "Both of my heel sores developed here in the facility. I don't know how it happened...I can't remember if staff free floated my heels, I know they do now...I have never refused staff to elevate my legs or feet." Resident #1 verified not being able to walk or move legs since admission to the facility. On 3/18/15 at 10:10 a.m., surveyor # interviewed CNA (Certified Nursing Assistant)-U regarding resident #1. CNA-U indicated resident #1 did not walk when he was admitted to the facility, slept in bed at night, and did not move legs. CNA-U stated, "I do not believe the facility had us free float (resident's) heels until after (resident) got the pressure ulcers. I believe resident #1 developed the heel ulcers because (resident) was lying in bed without heels being free floated...resident #1 always allows staff to free float heels...has never refused." On 3/18/15 at 10:30 a.m., surveyor # interviewed CNA-A regarding resident #1. CNA-A indicated resident #1 did not walk when he was admitted to the facility, slept in bed at night, and did not move legs. CNA-A stated, "they didn't have us free float (resident's) heels until after (resident) got the pressure ulcers. I believe resident #1 developed the heel ulcers because heels were not being free floated...resident #1 has never refused to allow staff to free float heels." On 3/18/15 at 12:40 p.m., surveyor # interviewed DON (Director of Nursing)-F regarding resident #1's heels. DON-F stated "I do not know the cause of resident #1's pressure ulcer development to the right and left heel. Resident #1 was noncompliant with repositioning and liked to keep (resident's) feet positioned on the floor." DON-F was unsure if refusals were documented. DON-F verified resident #1's plan of care had not included an intervention to protect the heels, until after the resident presented with a stage II pressure ulcer on the right heel and a stage III pressure ulcer on the left heel. On 3/18/15 at 1:45 p.m., surveyor interviewed LPN (Licensed Practical Nurse)-B regarding resident #1. LPN-B stated, "I do not know how resident #1's heel ulcers developed. I'm not educated on pressure ulcers. Resident #1 has not ambulated since admission." LPN-B indicated resident #1 allows staffs to free float heels and was unaware of any refusals. On 3/19/15 at 12:50 p.m., surveyor # interviewed WCRN-BB regarding resident #1. WCRN-BB indicated she began employment with the facility in December of 2014, and was not employed during the development of resident #1's heel ulcers. WCRN-BB stated, "by looking at resident #1's wound documentation for November 2014, I would have classified the left heel as a stage III and the right heel as a stage II." WCRN-BB verified both heel ulcers were pressure related. On 3/19/15 at 1:35 p.m., surveyor # interviewed DPM (Doctor of Podiatric Medicine)-GG via telephone. DPM-GG verified she specializes in wounds and examined resident #1's heels during an office visit on 11/17/14. DPM-GG further verified resident #1's left heel was a stage III pressure ulcer and the right heel was a stage II pressure ulcer during the visit. DPM-GG stated her documentation of the 11/17/14 visit did not include that the left and right heel ulcers where pressure related. DPM-GG stated, "I should have included that in my documentation. Resident #1's heel ulcers are definitely from pressure and absolutely not from [MEDICAL CONDITION]. [MEDICAL CONDITION] only pertains to the legs not the heels. Resident #1's heel ulcers have been improving, but were 100% pressure related and 100% preventable...Prevention for resident #1 should have included to elevate and protect the heels." On 3/19/15 at 4:20 p.m. during daily exit, NHA (Nursing Home Administrator)-X and DON-F indicated the facility developed an action plan on 11/14/14, following the development of resident #1's heel ulcers. NHA-X stated "we conducted skin audits and skin sweeps of the building. We educated nurses and CNAs regarding assessments and documentation of wounds. We also conducted audits on free floating of the heels throughout the building." NHA-X provided surveyor # with an "Unavoidability Statement for Impaired Skin Integrity" for resident #1 that was signed by MD-HH. The statement indicated, resident #1's heel ulcers were due to "[MEDICAL CONDITION] with known history of venous ulcers requiring treatment." On 3/20/15 at 2:00 p.m., surveyor # interviewed MD-HH via telephone regarding the above signed statement. MD-HH stated "I have not focused on resident #1's heels, that is why I referred the resident to DPM-GG. I was just told to sign something, not really knowing what it was. Resident #1's heel wounds are not my area of expertise." MD-HH went on to say a specialty referral was made to DPM-GG that clarified the [DIAGNOSES REDACTED]. On 3/24/15 at 4:30 p.m., no further documentation was provided regarding resident #1's refusals. 2. The face sheet dated 3/14/15, and contained in the medical record, indicated resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #3's most recent MDS assessment dated [DATE], documented the resident required extensive assistance with bed mobility, transfers, toileting, daily hygiene and was non-ambulatory. The MDS indicated resident #3 was at risk for the development of pressure ulcers. Resident #3's admission MDS assessment dated [DATE], documented the resident was admitted to the facility with six unstageable pressure ulcers. Resident #3 was assessed on 3/6/15, per a Braden scale for the prediction of pressure ulcer risk, to be at moderate risk for the development of pressure related ulcers. The Pressure Ulcer Evaluation Weekly Record dated 3/17/15, documented resident #3 had a stage III pressure ulcer to the right ankle that measured 6 cm by 5.2 cm by 0.1 cm, a stage III pressure ulcer to the right buttock that measured 6.5 cm by 3 cm by 1 cm, a stage III pressure ulcer to the left stump that measured 3 cm by 2.1 cm by less than 0.1 cm, a stage III pressure ulcer to the coccyx that measured 3 cm by 3.2 cm by 1 cm, and a stage III to the left hip that measured 2.1 cm by 1.7 cm by 0.1 cm. The weekly records indicated the wounds were improving. The 10/13/14 CAA (Care Area Assessment) indicated, resident #3 was admitted to the facility with multiple wounds. Resident was living at home and was followed by the wound clinic. Resident #3's baseline was getting up to sit in the wheelchair for the day. Resident #3 was admitted to the hospital from home following a wound clinic visit. Risk factors included impaired mobility, altered mental status and diabetes. Interventions in place included, a regular repositioning schedule, a pressure reducing mattress, and a pressure reducing seat cushion. Resident #3's plan of care related to "at risk for impaired skin integrity" dated 10/2/14, directed staff to place a blue boot on the right foot when the resident was in bed. The CNA cue sheet dated 3/18/15, directed staff to place a blue boot on resident #3's right foot when in bed. On 3/17/15 from 11:30 a.m. to 12:00 p.m., surveyor # observed resident #3 lying in bed on the resident's back. No blue boot was observed on the right foot, resulting in the right heel resting in direct contact with the mattress. During this observation, surveyor # noted a blue boot sitting in resident #3's wheel chair. On 3/18/15 from 8:50 a.m. to 9:10 a.m., surveyor # observed resident #3 lying in bed on the resident's back. No blue boot was observed on the right foot, resulting in the right heel resting in direct contact with the mattress. During this observation, surveyor # noted a blue boot sitting on a chair in the corner of the resident's room. On 3/18/15 at 9:10 a.m., surveyor # interviewed RN (Registered Nurse)-C regarding resident #3. RN-C verified the resident had a pressure ulcer to the right heel and was at risk for the development of pressure related ulcers. RN-C further verified resident #3's right foot should be placed in the blue boot. RN-C then obtained the blue boot that was on the chair in the corner of the room and placed it on resident #3's right foot. RN-C stated "the aides must of forgot to put it on." 3. On 3/24/15, surveyor # reviewed resident #28's medical record. According to the face sheet dated 12/02/14, resident #28 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. The facility completed an annual MDS assessment with an ARD (assessment reference date) of 11/5/14. The MDS documented resident #28 had long and short term memory deficits, moderate impaired cognitive for daily decision making skills, required extensive assistance of two staff for bed mobility, was at risk for pressure sore development and was not on a turning/repositioning program. The facility completed a CAA for pressure sore that correlated with the annual MDS. The CAA documented the resident does not have any current skin problems from pressure. Has advanced dementia and has difficulty with communicating needs. Requires staff assist with repositioning and toileting. Up to a broda chair and is laid down between meals. Has weight loss related to her dementia, failure to thrive and gradual declining condition...Has nutritional supplements and pressure reducing mattress and wheel chair for prevention. The facility completed a quarterly MDS assessment, with an ARD of 2/1/15. The MDS documented resident #28's cognitive status had declined. Resident #28 continued with short and long term memory deficits with severe cognitive impairment. The MDS assessment documented resident #28 continued with extensive two assist for bed mobility, was at risk for pressure sore development and was not on a repositioning/turning program. The facility developed a plan of care for "Risk for impaired skin integrity related to bladder and bowel incontinence, decreased mobility, declining condition, receiving hospice services and decreased oral intake of food/fluids" initiated on 12/31/12 and revised on 11/14/14. The plan of care contained an intervention to assist to reposition PRN (as needed), dated 12/31/12. The plan of care had no additional interventions listed regarding repositioning resident to reduce skin integrity concerns over bony prominence's. Resident #28's "Weekly Skin Observation" sheet dated 2/2/15, documented resident #28 developed a pressure ulcer over the coccyx. The area is red and blanchable, measures 5.5 cm by 5.0 cm. Center is black and blue that measures 1.5 cm by 1.0 cm. Resident #28's progress note, dated 2/2/15 documented area to coccyx noted during skin check this AM. Area measures 5.5 cm by 5.0 cm. This area is reddened and blanchable. In the center is a black and blue area that appears to be a deep tissue that measures 1.5 cm by 1.0 cm. No complaints of pain when touching coccyx. Duoderm applied. Will put on a turning schedule to reposition every two hours....... Resident #28's "Pressure Ulcer Evaluation Weekly Record" dated 2/4/15, documented resident #28 acquired a stage two pressure ulcer over the coccyx, with an onset date of 2/3/15. The record documented the pressure ulcer was 0.2 cm by 0.3 cm with a depth less than 0.1 cm. The surrounding skin is dark red/purple. Area was cleansed and [MEDICATION NAME] dressing applied for protection. The report indicated an air mattress put on bed right away. The progress notes indicated the following: * 2/2/15- Turned every 2 hours. * 2/3/15- Turned every two hours while lying down to relieve pressure. * 2/4/15- Repositioned every 2 hours. * 2/5/15- Turned every 2 hours to protect hips and help coccyx heal. * 2/12/15- Pressure area to coccyx is not healed. Small area of granulation is visible. Resident remains on a low air loss mattress with frequent turning and repositioning as (resident) is high risk for breakdown. On 3/24/15 at 9:30 a.m., surveyor # interviewed CNA-NN regarding resident #28's initiation of a turning/repositioning schedule. CNA-NN stated she could not specifically recall a date, but indicated she thought it was a recent intervention to reposition resident #28 every 2 hours. CNA-NN indicated resident #28 is totally dependent and would not have been able to reposition self. On 3/24/15 at 9:35 a.m., surveyor # interviewed CNA-OO regarding resident #28's initiation of a turning/repositioning schedule. CNA-OO indicated she started employment in February 2015 and it was implied by the CNA trainers the reposition/turning schedule had just started. CNA-OO stated resident #28 was dependent on staff to reposition resident. 4. On 3/18/15, surveyor # reviewed resident #25's medical record. According to the face sheet, dated 3/18/15, resident #25 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. The facility completed a MDS with an ARD of 11/14/14. The MDS documented resident #25 had long and short term memory deficits and had severe cognitive impairment, required extensive staff assist of two for bed mobility and was at risk for pressure sore development. The facility completed a CAAs for pressure ulcer which documented there was no current skin problems. Potential for skin breakdown due to incontinence and decreased mobility. Resident has cognitive impairment and unable to express needs or identify need to reposition. The facility completed a quarterly MDS with an ARD of 2/8/15. The MDS documented resident #25 had long and short term memory deficits with moderately impaired decision making skills, required extensive staff assist of two for bed mobility and that resident #25 was at risk for pressure ulcer development. The facility developed a plan of care for "Risk for Impaired Skin Integrity" related to bladder and bowel incontinence, dated 12/4/12. The plan of care did not include any interventions related to repositioning, nor had the plan indicated that resident #25 required extensive staff assistance for bed mobility. The CNA cue card, dated 3/11/15, did not include that resident #25's heels should be free floated. The CNA cue card indicated resident #25 was independent with repositioning. The "Weekly Nursing Summary" dated 2/12/15, documented resident #25 repositions self when in bed. On 3/18/15 at 7:45 a.m. to 10:00 a.m., surveyor # observed resident #25 lying in bed with heels in direct contact with a pressure reducing mattress. There were blue Heelz up cushions observed in the chair next to the bed. At 9:45 a.m., surveyor # observed resident #25 making slight movement of legs. Resident #25 was observed dragging heels across the bed. At 9:55 a.m., resident #25 had removed bed covers and was observed shearing heels across the mattress. On 3/18/15 at 10:10 a.m., surveyor # interviewed CNA-E regarding resident #25. CNA-E verified resident #25's Heelz up cushion was not utilized and located in the chair. CNA-E stated the Heelz up cushion is to be used to free float resident #25's heels, but at times the resident kicks out the cushion. CNA-E verified resident #25 heels would drag across the mattress. CNA-E stated the Heelz up cushion is usually found in the chair when she comes to work on the day shift. CNA-E indicated the Heelz up cushion was probably applied, but removed as the resident would kick the cushion out. On 3/18/15 at 10:10 a.m., surveyor # observed CNA-E and CNA-D assist resident #25 with morning cares and then transfer into a wheel chair. The resident's wheel chair did not have a cushion on the seat to reduce pressure to resident #25's coccyx and ischial tuberosities when in a sitting position. On 3/18/15 at 10:30 a.m., surveyor # interviewed CNA-E regarding resident #25. CNA-E indicated resident #25 doesn't utilize a pressure reducing cushion when sitting in the wheel chair. On 3/19/15 at 7:55 a.m., surveyor # observed resident #25 lying in bed with heels in direct contact with a pressure reducing mattress. The blue Heelz up cushions were observed in the chair next to the bed. On 3/19/15 at 8:00 a.m., surveyor # observed CNA-E and CNA-DD provide morning cares for resident #25 and transfer the resident into a wheel chair. The resident's wheel chair did not have a cushion on the seat to reduce pressure to resident #25's coccyx and ischial tuberosities when in a sitting position. On 3/23/15 at 10:45 a.m., surveyor # interviewed RN-KK regarding resident #25. RN-KK stated resident #25 is at risk for pressure ulcer development related to decreased mobility, unable to make full movements in bed and incontinence. RN-KK reviewed resident #25's CNA cue card and comprehensive plan of care with surveyor # . RN-KK stated the CNA cue card was inaccurate, as resident #25 is not independent with repositioning. RN-KK verified resident #25 does utilize the Heelz up cushion when in bed. RN-KK verified the CNA cue card and the comprehensive plan of care did not include the use of the Heelz up cushion to free float the resident's heels. 5. On 3/19/15, surveyor # reviewed resident #26's medical record. According to the face sheet dated 3/18/15, resident #26 was re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The facility completed an MDS assessment with an ARD of 1/4/15. The MDS documented resident #26 had severe cognitive impairment, required extensive staff assistance for bed mobility and was at risk for pressure ulcer development. The facility developed a plan of care for "Impaired Skin Integrity" relating to bladder incontinence, decreased mobility and history of skin tear, with a revision date of 7/7/14. The plan of care directed staff to reposition PRN. The plan of care also indicated a specialty cushion in wheel chair; foam with gel. The resident's plan of care did not address the use of a specialty cushion to be utilized when resident #26 sat in the recliner. The CNA cue card dated 3/11/5, indicated resident #26 was independent with repositioning, likes to sit in recliner and to encourage repositioning. The CNA cue card indicated a wheel chair cushion to be utilized. The CNA cue card did not indicate a pressure reducing cushion to be utilized while resident #26 sat in the recliner to reduce pressure to the coccyx and ischial tuberosities. On 3/18/15, surveyor # observed resident #26 sitting in the recliner in the resident's room throughout the day. On 3/18/15 at 10:10 a.m., surveyor # interviewed LPN-W regarding resident #26. LPN-W stated resident #26 is forgetful but able to make needs know to staff. LPN-W indicated resident #26 sits in the recliner all day, and for meals, but does lay down in bed at night. On 3/18/15 at 10:45 a.m., surveyor # interviewed resident #26. Resident #26 stated (resident) sits in the recliner all day, and lays down only at bedtime. Resident #26 indicated was able to make slight movements while seated in the recliner, but not too much movement as the resident is tired. Resident #26 verified not sitting on a pressure reducing cushion when in the recliner, and indicated at times the resident's "butt gets sore." On 3/18/15 at 11:30 a.m., surveyor # interviewed CNA-D regarding resident #26. CNA-D verified resident #26 sat in the recliner all day without a pressure reducing cushion in the recliner. On 3/18/15 at 3:15 p.m., surveyor # interviewed CNA-PP regarding resident #26. CNA-PP indicated resident #26 sits up most of the PM shift and consumed meals while seated in the recliner. CNA-PP stated resident #26 is assisted to bed between 8:00 p.m. to 8:30 p.m. CNA-PP verified resident #26 doesn't utilize a pressure reducing cushion while seated in the recliner. On 3/19/15 from 7:55 a.m. until 12:15 p.m., surveyor # observed resident #26 seated in the resident's recliner before staff assisted to the bathroom. A pressure reducing cushion was not observed in resident #26's recliner. On 3/23/15 at 11:00 a.m., surveyor # interviewed RN-KK regarding resident #26. RN-KK verified the comprehensive plan of care directed staff to utilize a wheel chair cushion, although the resident doesn't sit in the wheel chair. RN-KK confirmed resident #26 sits in the recliner all day and the pressure reducing cushion should be placed in the recliner.

Based on observation, record review and staff interview, the facility did not ensure that a resident that is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and/or to restore as much normal bladder function as possible for 5 (residents #26, #25, #27, #3 and #13) of 13 sampled and supplemental residents. Resident #26 was assessed to have been continent of bladder on the MDS (minimum data set) assessment dated ,[DATE]. The facility completed an additional MDS assessment 5/2014, which documented resident #26 had declined to occasionally incontinent of bladder. The MDS assessment dated ,[DATE] documented resident #26 further declined in bladder status to frequently incontinent of bladder. A 3 day voiding study was completed in 10/2014, which indicated resident #26 had 14 documented episodes of bladder incontinence. Although the voiding study was incomplete, the facility indicated resident #26 had functional incontinence and set up a toileting schedule for the resident to be assisted to the bathroom, before meals and at bedtime and offer if awake on rounds on the night shift. The written toileting schedule was added to the plan of care located in the computer for licensed staff. The CNA (Certified Nursing Assistant) cue card that CNAs utilize to provide care for residents was not updated with the toileting schedule. The facility did not complete a comprehensive assessment related to bladder incontinence, or an assessment when the MDS documented resident #26 had experienced a decline in bladder continence. Although the facility developed a plan of care based upon an incomplete voiding study, the CNAs stated resident #26 wasn't on a toileting schedule and staff only assisted the resident to the bathroom when the resident placed the call light on. In addition, resident #26 was incontinent of bladder after waiting for the call light to be answered, then the CNA utilized dry toilet tissue instead of providing complete perineal care. In this citation, resident #26 is considered at an actual harm isolated (G level); Residents #25, #27, #3 and #13 are considered to be examples at severity level 2 (potential for harm that is not immediate jeopardy). Resident #25 had a plan of care that directed staff to toilet the resident in attempt to allow the resident to be as continent as possible. The plan of care was not consistently followed. Resident #27 had episodes of bladder continence and incontinence. The facility did not complete a three day voiding study or a comprehensive bladder assessment in attempt to determine the causal factors for the incontinence. The facility did not develop and implement a plan of care in attempt to promote continence. Resident #3's uncovered catheter drainage bag and tubing was observed underneath the bed wheel in full contact with the floor. Resident #13 was at risk for skin breakdown and had a [MEDICATION NAME] dressing to the coccyx for an open area of macerated skin. During the provision of perineal cares for resident #13, CNA-D did not cleanse the resident's buttocks or apply barrier cream after the resident was incontinent of bowel and bladder. Findings include: The facility's undated Peri Care policy states: PURPOSE- To help treat and prevent perineal [MEDICAL CONDITION], protect skin from minor irritation associated with perineal [MEDICAL CONDITION], cleanse, moisturize, deodorize and provide a protective barrier to seal out wetness to the skin. POLICY- Perineal care will be provided to residents who are incontinent of bowel and/or bladder after each incontinent episode. PROCEDURE- 3. Remove wet or soiled undergarment. 4. If needed, gently remove large amounts of fecal material with underpad (chux), toilet tissue, wipes, etc. 5. With clean gloves, cleanse perineal area with clean wash cloth or personal wipes. Use as many cloths as necessary to remove urine and/or feces from skin. Be sure to include all areas of the buttocks, hips and any folds. 6. Inspect perineal area for incontinence-associated [MEDICAL CONDITION] or other skin condition. 7. Apply barrier cream as directed in the plan of care. 9. Report any skin changes to nurse. 10. Repeat procedure after each episode of urinary and/or fecal incontinence. 1. On 3/18/15, surveyor # reviewed resident #26's medical record. According to the MDS, with an ARD (assessment reference date) of 4/22/14, resident #26 was continent of bladder and required set up assist only for toilet use. The CNA documentation from 4/15/14 through 4/22/14 indicated resident #26 was continent of bladder at all times. The facility completed an MDS assessment with an ARD of 5/12/14. The MDS documented resident #26 required one staff assist to use the bathroom and had declined to occasionally incontinent of bladder. The facility completed a change in condition MDS with an ARD of 10/8/14, that documented resident #26 required extensive assist from staff for toilet use and now was frequently incontinent of bladder. The facility completed a urinary incontinence CAA (care area assessment) dated 10/17/14. The CAA indicated the resident has dementia and is not aware of her need for toileting. In addition, the resident has difficulty communicating needs, receives hospice services and staff assist with toileting. The CNA documentation from 10/1/14 through 10/8/14, verified resident #26 had been incontinent of bladder 12 times during the assessment week. The facility completed a 3 day voiding study from 10/4/14 through 10/6/14. The study indicated resident #26 had been incontinent of bladder 14 times during the 3 day study timeframe (which were included in the 7 day look back period for the MDS documentation). The voiding study was not completed correctly and the information regarding urine stream strength, condition of pad and amount of urine incontinence of pad was not consistently documented. The facility developed a plan of care for Impaired skin integrity related to bladder incontinence, and decreased mobility, with a revision date of 7/7/14. The plan of care had an intervention directing staff to follow a scheduled toilet program before meals, at bedtime and offer if awake on rounds on the night shift. This intervention was initiated on 11/24/14. The facility did not develop a specific plan of care related to the resident's decline in bladder incontinence. The CNA cue card dated 3/11/15, indicated resident #26 had mixed incontinence and required staff assistance of one for toilet use. The CNA cue card did not include when resident #26 was to be assisted to the bathroom. On 3/19/15 from 7:55 a.m. to 12:15 p.m., surveyor # observed resident #26 continuously. Resident #26 was observed sitting in the recliner in the resident's room during this 4 hours and 20 minute observation. On 3/19/15 at 11:30 a.m., surveyor # interviewed CNA-II regarding resident #26's cognitive and continence status. CNA-II stated resident #26 is able to voice the need to use the bathroom and is always continent of bladder. CNA-II verified resident #26 was not on a toileting program, and staff wait for the resident to place the call light on and request to use the bathroom. On 3/19/15 at 12:15 p.m., surveyor # observed resident #26 place the call light on. CNA-II responded to resident #26's call light and assisted the resident with ambulation to the bathroom. Resident #26 was observed to void on the toilet, and had been incontinent of bladder. CNA-II removed the incontinent pad and wiped the resident's perineal area with dry toilet tissue. CNA-II then placed a clean pad on resident #26 and assisted the resident back to the recliner. On 3/19/15 at 12:20 p.m., surveyor # interviewed CNA-II regarding the observation of resident #26's toileting. CNA-II verified the resident had been incontinent of bladder and indicated she only used dry tissue to cleanse resident #26's perineal area, because she only utilized wet incontinence wipes when a resident is incontinent of bowel, because when using the wet wipes, some residents perceive they are still wet. On 3/19/15 at 12:25 p.m., surveyor # interviewed CNA-E regarding resident #26's bladder continence status and toileting schedule. CNA-E verified resident #26 has intermittent confusion and stated the resident usually is continent of bladder with very rare episodes of bladder incontinence. CNA-E confirmed resident #26 was not on a specific toileting schedule and staff wait for resident #26 to place the call light on and ask for assistance. On 3/19/15 at 3:40 p.m., surveyor # interviewed CNA-QQ regarding resident #26. CNA-QQ stated resident #26 has intermittent confusion and is not on a specific toileting schedule. CNA-QQ indicated the resident has bladder incontinence, but was usually continent of bladder. CNA-QQ stated if resident #26 didn't put the call light on to request to use the toilet, she tries to ask the resident if the resident needs to use the bathroom. On 3/23/15 at 11:00 a.m., surveyor # interviewed RN (Registered Nurse)-KK regarding resident #26. RN-KK reviewed the voiding schedule that was completed in October 2014. RN-KK verified the voiding study was incomplete and stated "I don't know why a schedule is set up like that." RN-KK indicated the urinary incontinence CAA was not accurate, as the resident is able to voice the need to use the bathroom. RN-KK indicated the CNA staff use the CNA cue cards for directions to care for residents. RN-KK verified the toileting schedule that was placed on the nursing care plan was not added to the CNA cue cards, so the CNAs would not have known resident #26's toileting schedule. RN-KK stated she could not locate the comprehensive bladder assessment that indicated why resident #26 had a decline in continence status and assumed it must be because the resident required more staff assistance to get to the bathroom. On 3/24/15 at 12:15 p.m., RN-KK informed surveyor # that after the surveyor was asking questions regarding resident #26's bladder incontinence, and reviewing previous facility documentation, it was determined a new voiding study and comprehensive bladder assessment needed to be completed. RN-KK verified the previous documentation was not thorough and needed to be completed, to develop a plan in attempt to decrease resident #26's bladder incontinence episodes. 2. On 3/18/15, surveyor # reviewed resident #25's medical record. According to the MDS with an ARD of 2/18/15 resident #25 is always incontinent of bladder, requires the extensive assistance of two staff for toilet use and was not on a toileting plan. The facility developed a plan of care for "The resident has functional bladder incontinence and is always incontinent of bladder related to dementia, cognitive deficit", with a revision date of 7/15/14. The plan of care indicated the resident is able to sit on the toilet, but does not always understand what to do. Assist to toilet with check and change. The CNA cue card dated 3/11/5 indicated resident #25 is incontinent of bladder and requires one staff assist for toilet use. On 3/18/15 at 10:10 a.m., surveyor # observed CNA-E and CNA-D provide morning cares for resident #25 while in bed. The resident was observed to have been incontinent of bladder at that time. CNA-E and CNA-D transported resident #25 to the dining room after cares were completed and did not toilet the resident prior to going to the dining room, as per plan of care. On 3/19/15 at 8:00 a.m., surveyor # observed CNA-E and CNA-DD conduct morning cares for resident #25 while in bed. The resident was observed to have been incontinent of bladder. CNA-E and CNA-DD transported resident #25 to the dining room after cares were provided and did not toilet the resident prior to going to the dining room, as per plan of care. On 3/19/15 at 10:15 a.m., surveyor # observed CNA-E and CNA-II transfer resident #25 into bed and complete incontinence cares. After cares were completed, CNA-E left the room and CNA-II completed additional tasks for the resident. Resident #25 was not toileted, as per plan of care. On 3/19/15 at 10:30 a.m., surveyor # interviewed CNA-II regarding resident #25's incontinence status. CNA-II stated resident #25 was unable to voice the need to use the bathroom. CNA-II indicated resident #25 does void on the toilet at times, and "should be placed on the toilet." CNA-II stated resident #25 was not placed on the toilet today because she requires two staff to assist to the toilet for safety and because the resident was tired. CNA-II stated it was unsafe for the resident to be seated on the toilet. 3. On 3/18/15, surveyor # reviewed resident #27's medical record. According to the face sheet dated 2/19/15, resident #27 was admitted to the facility on [DATE]. The facility completed an MDS with an ARD of 2/25/15. The MDS documented resident #27 had long and short term memory deficits and had moderate cognitive impairment for decision making skills. The MDS documented resident #27 required limited staff assistance of one for toilet use and was occasionally incontinent of bladder. Surveyor # reviewed resident #27's comprehensive care plans. A care plan specific to the problem of "bladder incontinence" could not be located. The facility had developed a plan of care for "Risk for skin Integrity related to bladder incontinence" that was dated 3/17/15. This skin integrity plan of care did not include a toileting program for resident #27. The CNA cue card, dated 3/11/15, indicated resident #27 was incontinent of bladder and required 1 or 2 staff assist for toileting. Resident #27's medical record did not include documentation that a voiding study or a comprehensive bladder assessment had been completed for resident #27. Surveyor # reviewed CNA staff documentation regarding resident #27's incontinence. The documentation from 2/19/15 through 3/19/15 indicated the resident had been incontinent of bladder 28 times. Surveyor # reviewed the admission bowel and bladder assessment, dated 2/19/15. The assessment was completed by LPN (Licensed Practical Nurse)-W. The assessment was incomplete. On 3/18/15 at 12:45 p.m., surveyor # interviewed LPN-W regarding resident #27's admission bladder assessment. LPN-W verified the assessment was not complete and follow up needed to be done. On 3/18/15 at 1:05 p.m., surveyor # interviewed CNA-E regarding resident #27's continence status. CNA-E stated resident #27 was always continent of bladder and was not on a toileting schedule. CNA-E indicated resident #27 would notify staff when needed to use the bathroom. On 3/18/15 at 1:10 p.m., surveyor # interviewed RN-KK regarding resident #27. RN-KK verified a 3 day voiding study and a comprehensive bladder assessment had not been completed for resident #27. RN-KK stated a voiding study and a comprehensive assessment was required to develop a plan of care in attempt to keep a resident as continent as possible. On 3/18/15 at 3:10 p.m., surveyor # observed CNA-PP assist resident #27 to the bathroom. Resident #27 was observed to have been incontinent of bladder, and voided while seated on the toilet. On 3/18/15 at 3:12 p.m., surveyor # interviewed CNA-RR regarding resident #27. CNA-RR stated resident #27 is incontinent of bladder at times and can verbalize the need to use the bathroom. CNA-RR indicated staff assist resident #27 to the bathroom before and after meals and when the resident verbalizes the need to void. On 3/18/15 at 3:15 p.m., surveyor # interviewed CNA-PP regarding resident #27. CNA-PP indicated resident #27 is usually continent of bladder, but is incontinent at times. CNA-PP stated every resident that resides on the unit needs to be assisted to the bathroom before and after meals and some residents will verbalize the need to use the bathroom. On 3/23/14 at 11:15 a.m., surveyor # interviewed RN-KK regarding resident #27. RN-KK stated after reviewing resident #27's medical record, a voiding study and a comprehensive bladder assessment was initiated to determine causal factors for incontinence. RN-KK stated there wasn't a specific comprehensive plan of care for bladder incontinence and there wasn't a toileting plan located on the CNA cue card for resident #27. 3. According to the face sheet dated 3/14/15, resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #3's most recent MDS assessment documented resident #3 required extensive assistance with ADLs (activities of daily living), and had an indwelling Foley catheter. Resident #3's medical record included documentation that the resident had a UTI during a hospital stay dated 2/6/15. On 3/18/15 at 8:50 a.m. and 9:10 a.m., surveyor # observed resident #3 awake in bed. Resident #3's uncovered catheter drainage bag and tubing on the right side of the bed underneath the bed wheel and in full contact with the floor. On 3/18/15 at 9:15 a.m., surveyor # interviewed RN (Registered Nurse)-C regarding resident #3's catheter placement. RN-C verified resident #3's uncovered catheter drainage bag was underneath the bed wheel and in full contact with the floor. RN-C indicated the drainage bag and tubing should be placed in a catheter holding bag off the floor. RN-C then placed the uncovered drainage bag into a catheter holder bag that was hanging off the right side of the bed frame. 5. On 3/23/15, surveyor # reviewed the medical record for resident #13 and it indicated the resident was admitted to the facility with multiple [DIAGNOSES REDACTED]. The resident's most recent MDS assessment dated [DATE], documented the resident was incontinent of bowel and bladder and needed assistance of staff for toileting and personal cares. The resident's Impaired Skin Integrity plan of care dated 5/30/14, included interventions for pericare after each incontinent episode, barrier cream after each incontinent episode and PRN (as needed) and to keep skin clean and dry. A nursing note dated 12/3/14, documented the resident had a stage 3 coccyx pressure ulcer present since 5/25/14, measuring 2.0 by 0.5 by 0.3 cm (centimeters). On 3/19/15 at 10:45 a.m., surveyor # interviewed DON (Director of Nursing)-F regarding resident #13. DON-F indicated the resident had an open area that healed and had since re-opened. DON-F indicated the area was blanchable macerated skin that resulted from wiping and not pressure. On 3/23/15 at 7:55 a.m., surveyor # interviewed RN (Registered Nurse)-W regarding resident #13. RN-W indicated the resident had a [MEDICATION NAME] dressing in place for a small excoriated area on the coccyx. On 3/23/15 at 12:10 p.m., surveyor # observed CNA-D and CNA-E provide incontinence care for resident #13. While wearing gloves, CNA-D and CNA-E assisted the resident via EZ stand from a sitting to a standing position. CNA-D lowered the resident's pants and removed the resident's soiled incontinence brief. Surveyor # observed the brief and it was noted to contain urine and stool. CNA-D opened a package of wipes, removed 2 wipes and began anterior pericare. After wiping the resident, CNA-D retrieved more wipes, wiped the resident again and repeated the process 2 more times. Upon completion of anterior pericare, CNA-D removed gloves and applied clean gloves. CNA-D again retrieved 2 wipes and continued with posterior pericare. CNA-D was positioned to the side of the resident and was unable to visualize the area being wiped. CNA-D wiped the resident's rectal area from front to back 10 times until stool was no longer visible on the last wipe. CNA-D did not cleanse the resident's buttocks or apply barrier cream per the resident's plan of care. Immediately following the observation, surveyor # interviewed CNA-D regarding the observation of incontinence care. CNA-D verified the resident's buttocks had not been thoroughly cleansed. CNA-D acknowledged that prior to pericare, the resident was sitting in a wheelchair wearing an incontinence brief that was soiled with urine and feces. CNA-D verified she was unable to see the resident's [MEDICATION NAME] dressing and, therefore, could not determine whether it was soiled with stool and needed to be changed. CNA-D stated she would have LPN-W assess the dressing.

Based on observation, interview, and record review, the facility did not ensure 2 (resident #11 and resident #18) of 6 residents reviewed for falls were free from accident hazards as was possible and 2 (residents #24 and #25) of 2 sampled residents room were accessible by staff without delay in the event of an emergency. Resident #24 had a locked room door with limited key accessibility by direct care staff. Resident #24 was able to open the door from the inside, but CNA (Certified Nursing Assistant) staff would be unable to immediately enter resident #24's room because an extra key was not outside the room in the shadowbox and because the nurse, who was the only staff who had a key to open the of room, was not always on the unit. In the event of a medical emergency, where resident #24 was calling out for help and was unable to get to the door, or in the case of a fire, tornado etc, CNA staff would have to first locate the nurse to obtain the key to the room before being able to assist resident #24. The failure to ensure that resident #24 could be immediately reached in the event of a medical emergency or natural disaster created a finding of immediate jeopardy, which began on [DATE]. Surveyor # informed NHA (Nursing Home Administrator)-G of the jeopardy on [DATE]. The facility removed the jeopardy on [DATE], but the deficient practice continues at a scope/severity of D (potential for more than minimal hard that is not immediate jeopardy/isolated) as evidenced by the following: Resident #25 had a locked room door. Although, the key to resident #25's door was usually located in the shadow box outside of resident #25's room, there was at least one known time from 10:00 PM until 4:00 PM the next day that the key was taken out of the facility by a CNA. Resident #25 was able to open the door from the inside, but CNA staff would be unable to immediately enter resident #25's room because the nurse was the only staff who had a key to the room. In the event of a medical emergency, where resident #25 was calling out for help and was unable to get to the door, or in the case of a fire, tornado etc., CNA staff would have to first locate the nurse (who was not always on the unit) to obtain the key to the room before being able to assist resident #25. Resident #11 had a history of [REDACTED]. Staff was observed transferring the resident without the use of a gait belt, as directed by facility policy. Resident #18 had a history of [REDACTED]. Staff was observed transferring the resident from the resident's wheelchair with an EZ stand lift, and back to the wheelchair without ensuring the wheelchair was locked. Findings include: 1. On [DATE], surveyor # reviewed resident #24's medical record. According to the MDS (minimum data set), dated [DATE], resident #24 had [DIAGNOSES REDACTED].#24 had moderate cognitive impairment and was independent with transfers/ambulation. The MDS indicated resident #24 has resided at the facility since 2012, resident #24's resided on the 400 unit which is a locked unit for dementia care. Resident #24 has a BIMS (Brief Interview of Mental Status) score of 7, meaning that he has severe cognitive impairment. Resident #24's POA (power of attorney) signed a "Plan for Emergency Care and Intensity of Treatment," dated [DATE], which directed staff to perform CPR (cardiopulmonary resuscitation) as necessary and transport to the hospital.... The facility developed a plan of care, dated [DATE], for "Potential to demonstrate verbally abusive behaviors r/t (related to) dementia, infective coping skills, poor impulse control", "The resident has a history of increased paranoia that peers are stealing items from his room." The plan of care listed the following interventions: * Secured lock added to resident's room to promote safety and control. Resident has key. Staff have key in memory box and RN (Registered Nurse) has key for safety reasons. The facility developed a plan of care for "Resident has a lock on his door, Nurses have key", dated [DATE], with the following one intervention: *Staff to report to nurse if resident is no longer able to manage the key/lock. Resident #24's Plan of Care regarding falls documents an update on [DATE] to educate staff to room key placement to access resident in room. On [DATE] at 10:52 a.m., surveyor # requested and received a copy of the CNA care card (utilized by CNA's as a quick reference for resident care) from LPN (Licensed Practical Nurse)-O which includes care information for all residents for 400 unit. The CNA care card had no information regarding resident #24's lock or key. On [DATE] at 10:10 a.m., surveyor # interviewed night shift CNA-BB regarding staffing when CNA-BB stated "I am uncomfortable" charting for resident #24 because a key is not readily available to resident #24's room unless the night nurse, who is shared between the 300 and 400 unit, is physically present. CNA-BB stated resident #24's room has a lock on the door but it was not until a recent fall by resident #24 that a key was placed in the shadowbox. CNA-BB stated "I know (resident #24)'s ok if (resident #24) yells out in response or opens the door" when CNA-BB knocks on the door at night. On [DATE] at 10:30 a.m., surveyor # observed resident #24's room door to be closed with an active lock. On [DATE] at 8:23 a.m., surveyor # interviewed day shift CNA-DD regarding resident #24's room door lock and key. CNA-DD stated there was no room key available in resident #24's shadowbox (memory box) prior to resident #24's fall and the key was an intervention put in place in response to resident #24's fall. CNA-DD said a room key was previously kept in resident #24's shadowbox but was removed at some point. CNA-DD stated "I don't know when" resident #24's room key was removed from the shadowbox. On [DATE] at 9:06 a.m., surveyor # asked CNA-DD how she would get in resident #24's room in an emergency prior to the room key being placed in the shadowbox. CNA-DD stated the nurse has a key and the nurse can be found by looking for the medication cart or at the nurses station. CNA-DD stated the day nurse passes keys off to the 300 unit nurse during lunch or breaks. CNA-DD stated she would have to walk or run to the 300 unit to get the key from the nurse in an emergency. On [DATE] at 9:25 a.m., surveyor # interviewed day shift CNA-DD again. CNA-DD stated resident #24 never had a key in the shadow box that she was aware of. CNA-DD indicated the unit nurse had a key, and there was a key to his room located in the medication cart. CNA-DD stated resident #24 also carried a key and was able to unlock his door independently from the outside to enter his room. CNA-DD indicated if there was an emergency and staff needed to immediately get into his room, staff would need to ask the nurse for the key. CNA-DD stated the day shift nurse stays on the unit, and if she would need to leave the unit she would notify staff that she was leaving the unit. CNA-DD indicated some nurses leave the unit for breaks, and break in the breakroom, and other nurses take there break on the unit. CNA-DD stated she thought if the nurse left the unit to take her break, the nurse might have given resident #24's room key to the 300 unit nurse, but wasn't positive. CNA-DD indicated day shift has a nurse that works just on the unit, and if she was on the unit, staff would have to search the unit for her. CNA-DD stated staff on the day shift do not carry any communication devices for quick communication, but would have to search for the staff. On [DATE] at 6:23 a.m. surveyor # interviewed night shift CNA-BB via phone regarding resident #24's room door lock and key. CNA-BB stated she requested a key to resident #24's room from RN-HH. CNA-BB stated resident #24's room key was missing from the med cart at one point in time and she doesn't remember the date. CNA-BB said she also left a note for the day nurse requesting a key. CNA-BB stated she asked DPC (Dementia Program Coordinator)-CC about a key during a day she was mandated to stay working on day shift and was told "the nurses should have it." CNA-BB said there has been no key in resident #24's shadowbox the entire time since hire date (5 months) until resident #24 fell last week. CNA-BB said the night nurse response time at night can be ,[DATE] minutes in a non-emergency. CNA-BB stated if there is an emergency at night, one night nurse isn't "good with cell (cellphone) so CNA-BB would call from CNA-BB's personal cellphone to the personal cellphone of a CNA on 300 unit and that CNA would have to locate the nurse for CNA-BB. CNA-BB stated the other night nurse is reachable by cellphone in an emergency. On [DATE] at 9:14 a.m., surveyor # interviewed Hskg-FF (housekeeper) regarding resident #24's room door lock and key. Hskg-FF stated resident #24's room door has had a lock on it for about 2 years. At that time, Hskg-FF slid the glass panel up on resident #24's shadowbox, pointed to a key and said "the key is here." On [DATE] at 8:30 a.m., surveyor # interviewed Hskg-FF regarding how long the room key was in the shadowbox. Hskg-FF stated the room key "was always there (the shadowbox) that I'm aware of. (Resident #24) usually let's me in (resident #24's) to his room. I give the key back to (resident #24) when I'm done cleaning." Surveyor # observed resident #24's room doorknob to have a keyhole from the exterior and a smooth handle with no locking/unlocking mechanism from the interior. On [DATE] at 8:58 a.m., surveyor # interviewed DPC-CC regarding resident #24's room door lock and key. DPC-CC stated "the key was put in the shadowbox when the lock was added to the door. The nurse has a key as well." DPC-CC stated no one conveyed to DPC-CC that the key was not in the shadowbox. On [DATE] at 12:50 p.m., surveyor # interviewed DPC-CC. DPC-CC indicated resident #24 was having difficulty with other residents believing they were taking his personal property. IDT (interdisciplinary team) met and decided resident #24 could have a lock on his door, and this decreased his anxiety. DPC-CC stated resident #24 has a key, the nurse has a key, and a key was placed in his shadow box outside is door. DPC-CC indicated the key was placed in the shadow box a little over a year ago. DPC-CC stated staff would knock on resident #24's door and he would answer the door. DPC-DD indicated if there would be a time that resident #24 would not answer the door, CNA's would utilize the key in the shadow box to enter resident #24's room. DPC-CC stated that staff alerted her "today" there was a time when the key was missing and the staff needed to get a replacement key. DPC-CC indicated she did ask how the key became missing but the staff person didn't seem to know. DPC-CC stated it has never been missing any other time and the nurse always had a back up key. DPC-CC indicated 21 residents that resided on the special care unit were independently ambulatory and confused and there was 1 resident that was confused and self propelled her wheelchair. DPC-CC stated residents remove items on the unit/walls and the housekeepers find the items and places back where they belong. DPC-CC indicated the unit was designed for residents to remove items. DPC-CC stated resident #24 had never removed the key from the shadow box to her knowledge. DPC-CC indicated there was never a concern about resident #24's safety because there was always a key in the shadow box for CNA staff to enter the room in case of an emergency. On [DATE] at 9:03 a.m., surveyor # interviewed day shift LPN-D regarding resident #24's room door lock and key. LPN-D stated there is "now a key in the shadowbox and the nurse has a key; before only the nurse had a key because the resident accused staff of stealing." LPN-D stated that prior to the week of survey, LPN-D last worked on the 400 unit in February and at that time only the nurse had a key. On [DATE] at 10:35 a.m., surveyor # interviewed LPN-D regarding access if there was an emergency and a CNA needed access to resident #24's room prior to the room key placement in the shadowbox. LPN-D stated the 400 unit nurse tell staff when they are off the unit and the nurse leaves keys with the 300 unit nurse during lunch or breaks. LPN-D stated the CNA's would need to call from one nurse station to the other and or the CNA's may need to run to the 300 unit if no one answers the phone at the nurses station. On [DATE] at 9:35 AM, surveyor # interviewed day shift CNA-TT. CNA-TT verified resident #24 key to his door, would need to be retrieved from the unit nurse if staff ever needed to enter resident #24's room, and he did not answer his door. CNA-TT stated the nurse always tell staff when she would leave the unit. CNA-TT indicated the nurse was currently on the unit, but would have to search for her, because she doesn't know where she is. On [DATE] at 9:40 AM, surveyor # observed LPN-O enter the unit through the locked doors. On [DATE] at 9:45 AM, surveyor # interviewed LPN-O. LPN-O stated resident #24's room door has been locked from the outside hall for a little over a year. LPN-O indicated the door was locked due to his paranoia of other residents stealing his personal property. LPN-O stated a room key was placed in his shadow box outside the door after resident #24 sustained a fall last week. LPN-O indicated a key was never placed in the shadow box prior because resident #24 always answered the door if staff had knocked. LPN-O stated in an event of an emergency, and resident #24 had not answered his door, staff would have to locate the nurse to get a key to open the door. LPN-O stated she always told the staff when she left the unit. Surveyor # stated she had observed LPN-O enter the unit at 9:40 AM, and questioned LPN-O if she had notified the staff that she had left the unit. LPN-O indicated she hadn't told the staff she left the unit because she only went to Central Supply and was gone for a few minutes. On [DATE] at 9:36 a.m., surveyor # interviewed night RN (Registered Nurse)-HH via phone regarding resident #24's room door lock and key. RN-HH stated "there's a key in the med (medication) cart and I believe there is another key. I'm not sure where." RN-HH stated the night nurse covers both the 300 and 400 units at night and RH-HH spends the majority of the night on unit 3 (300 unit) due to the acuity level. RN-HH stated RN-HH's personal practice of checking-in on the 400 unit a minimum of three times a night. RN-HH stated a check-in visit could be brief or up to 45 minutes depending on what's going on. On [DATE] at 10:25 AM, surveyor # interviewed night shift RN-UU. RN-UU stated she thought there was a key located in resident #24's shadow box, but the key would become missing as resident #24 would remove the key himself, as she was told by housekeeping staff. RN-UU stated resident #24 was "very high functioning dementia resident and too smart for his own good". RN-UU indicated the "Avenue" special care unit (where resident #24 resides) night shift staffs with 1 CNA and 1 nurse which works on two separate units. RN-UU stated she had no idea if there was, for sure, a key or not in resident #24's shadow. RN-UU stated she had safety concerns regarding staff accessibility into resident #24's room in the event of an emergency. RN-UU indicated in the event of an emergency, the CNA would have to locate the nurse, and probably the nurse would be located on another unit of the facility. RN-UU indicated if there was another emergency in the facility on the night shift, she could be assisting the other nurse, (2 nurses in the facility on night shift to cover 4 units) and wouldn't be able to immediately respond to a CNA's call. RN-UU indicated night shift staff carry their personnel cell phones to call each other if help was needed. RN-UU indicated she only went on the "Avenue" special care unit usually twice a shift for a quick assessment, and tried to go another time and spend an hour on the unit. On [DATE] at 10:52 a.m., surveyor # interviewed AM/day shift CNA-II via phone regarding resident #24's room door lock and key. CNA-II stated resident #24 has a key and the nurse on duty as a key. CNA-II stated a key was added to the shadowbox last week. CNA-II stated the practice prior to a key being available in the shadowbox was for the nurse to open the door if needed. CNA-II stated "most nurses tell us where they will be or if they are leaving the floor. CNA-II said the 400 unit CNAs are allowed to carry personal cell phones in case there is a behavior and a call light is not accessible. CNA-II said the break room has a phone that can be called from the nurse's station in case of an emergency. On [DATE] at 12:00 p.m., surveyor # interviewed DON-B (Director of Nursing). DON-B stated she had no idea when resident #24's door became locked. DON-B indicated she had been employed at the facility since ,[DATE], and had concerns regarding the locked door. DON-B stated she had brought her concerns in meetings with all the department heads, but was told the locking of the door was approved by previous management. DON-B verified the unit nurse had resident #24's room key. DON-B indicated the lab technician left a note after resident #24 had fallen last week indicated that staff didn't know where a key was to open resident #24's door. DON-B stated she had told the DPC-CC regarding the note, and DPC-CC stated there was a room key located in resident #24's shadow box next to the outside of the door. Surveyor # told DON-B that a staff person indicated resident #24 removed his own key from the shadow box. DON-B stated she wasn't aware of that. Surveyor # asked DON-B how night shift staff communicated with each other in an event of an emergency and the CNA needed to enter resident #24's room, since the unit is staffed with 1 CNA and a shared nurse. DON-B indicated she wasn't aware how night shift staff communicated with each other. DON-B stated she was concerns regarding resident #24's safety in the event of an emergency, even if there was a key located in the shadow box, because the "Avenue" special care unit, was designed to remove items from the walls, and residents that reside on the unit are always removing items. DON-B indicated housekeeping staff are always returning items to where they are suppose to be. DON-B stated her concern was that residents might remove resident #24's key in the shadow box and the key would be missing. DON-B questioned surveyor # if there was a concern with residents doors having been locked. Surveyor # indicated the facility completes an individual assessment regarding locked doors for residents, but concerns were the immediacy of CNA staff obtaining access to resident #24's room in the event of an emergency and that CNA staff need to search for a nurse to obtain a key to get access to the room. On [DATE] at 2:20 p.m., surveyor # interviewed PM CNA-VV. CNA-VV stated she heard "today" in shift report that a key was being placed in resident #24's shadow box for CNA staff to use to enter resident #24's room in case of an emergency. CNA-VV indicated prior to today, the nurse had a key and resident #24 had a key. CNA-VV stated when she would knock on resident #24's room, he usually would answer the door, but if he didn't she would notify the nurse. CNA-VV stated the nurse usually would be on the unit, but did notify staff if was leaving the unit. CNA-VV indicated some nurses take their breaks in the breakroom and other nurses will take their break on the special care unit. CNA-VV stated if she needed the key for resident #24's room she would look for the medication cart, and if the cart wasn't out, she would need to search the unit for the nurse to obtain the key. Surveyor # asked CNA-VV how she would enter the room in the event of an emergency and the nurse was off the unit. CNA-VV responded she hadn't given that any thought in an event an emergency arose and the nurse was off the unit. CNA-VV indicated she wasn't aware if the unit nurse kept the key herself or gave the key to the 300 unit nurse when the nurse left the unit. On [DATE] at 2:10 p.m., surveyor # interviewed PM CNA-WW. CNA-WW stated she was informed today during shift report that a room key for resident #24's room was to be placed in the shadow box for CNA staff to enter the room in case of an emergency. CNA-WW indicated resident #24 usually answered the door when she knocked on the door, but there were times when he hadn't answered. CNA-WW indicated at times she was held over to work on the night shift, and she would pass fresh water and would knock on resident #24's door, but resident #24 hadn't responded. CNA-WW verified there wasn't a key in the shadow box prior to today when she was notified a key was to be placed in the box. CNA-WW indicated some nurses take their break on the unit and other nurses break in the breakroom. CNA-WW stated if staff needed to get the key from the nurse while she was on break in the breakroom, staff would have to call the breakroom. CNA-WW indicated the unit nurse kept the keys and wasn't aware if the keys were given to the 300 unit nurse when the nurse left the unit on the PM shift. CNA-WW indicated there were 2 CNA's and one nurse that worked on the unit on the PM shift. CNA-WW indicated when she was trained for the night shift, she was told when she was passing water, and resident #24 didn't respond to just place the water on top of the shadow box. CNA-WW stated she proceeded with the night shift routine never told the nurse that resident #24 didn't respond when she knocked on the door. CNA-WW indicated she hadn't reported to the nurse that resident #24 hadn't responded to her knock on the door because the nurse was never on the unit. On [DATE] at 2:30 p.m., surveyor # interviewed PM LPN-L. LPN-L stated the unit nurse kept a key to resident #24's room. LPN-L indicated if CNA staff needed to enter resident #24's room in the event of an emergency, staff would need to locate the nurse for the key. LPN-L stated she took her breaks in the break room and the CNA's would need to call on the telephone if they needed me. LPN-L indicated she gave her keys to the 300 unit nurse when she left the unit in case any residents needed anything while she was off the unit. The failure to ensure that staff could immediately respond over an extended period of time to emergency medical needs for resident #24 or to quickly evacuate resident #24 during a life-threatening event such as a tornado or fire created a finding of immediate jeopardy. The jeopardy was removed on [DATE] by which time the facility had removed all resident locks in the building. 2. On [DATE], surveyor # reviewed resident #25's medical record. According to the admission MDS, dated [DATE], resident #25 was admitted to the facility with [DIAGNOSES REDACTED]. On [DATE] at 8:00 a.m., surveyor # observed resident #25's door closed. Surveyor # attempted to enter resident #25's room and the door was locked from the outside. A key was observed in the shadow box which was located outside of resident #25's door. On [DATE] at 9:25 a.m., surveyor # interviewed CNA-DD. CNA-DD stated resident #25 had her own key to open her door, and staff can enter the room with the key that was located in her shadow box. CNA-DD indicated resident #25's key was always located in the shadow box for staff to use in the event of an emergency and staff needed to have immediate access to the room. On [DATE] at 12:00 p.m., surveyor # interviewed DON-B. DON-B indicated she had concerns regarding resident #25's safety in the event of an emergency, even if there was a key located in the shadow box. DON-B indicated housekeeping staff are always returning items to where they are suppose to be. DON-B stated her concern was that other residents might remove resident #25's key in the shadow box and the key would be missing. DON-C indicated she was not aware if resident #25's key was ever missing from the shadow box. On [DATE] at 12:50 p.m., surveyor # interviewed DPC-CC. DPC-CC indicated resident #25 was having difficulty with other residents with other residents entering her room. IDT (interdisciplinary team) met and decided resident #25 could have a lock on his door, and this decreased her anxiety. DPC-CC stated resident #25 has a key, the nurse has a key, and a key was placed in his shadow box outside her door. DPC-CC stated the room key has never been missing, and the nurse always had a back up key. DPC-CC indicated 21 residents that resided on the special care unit were independently ambulatory and confused and there was 1 resident that was confused and self propelled her wheelchair. DCP-CC stated residents remove items on the unit/walls and the housekeepers find the items and places back where they belong. DPC-CC indicated the unit was designed for residents to remove items. DPC-CC indicated there was never a concern about resident #25's safety because there was always a key in the shadow box for CNA staff to enter the room in case of an emergency. On [DATE] at 2:10 p.m., surveyor # interviewed CNA-WW. CNA-WW indicated the key to resident #25's room was always located in the shadow box, outside of her room, for staff to utilize in case of an emergency. CNA-WW stated there was one occasion when she reported to work for the PM shift and was told that resident #25's room key was missing from the shadow box since 10:00 PM the previous night. CNA-WW stated there was another CNA that worked the previous PM shift also and wondered if she may have taken the key home with her by mistake. CNA-WW indicated the other CNA left the facility around 4:00 PM and went home and looked through her pockets of the clothing she had worn on the previous PM shift and located resident #25's room key. CNA-WW stated resident #25's room key was then replaced in the shadow box. CNA-WW indicated that was the only time she was aware of that resident #25's room key was missing. On [DATE] at 10:45 a.m., HR-XX (Human Resources) provided surveyor # measurements in distance from the "Avenue" special care unit to the break room, where nurse staff frequently take their breaks. The break room was listed as 289 feet from the unit. HR-XX also indicated the length of the hall of the special care unit, in which staff would need to search for the nurse for the key to resident #24's room in the event of an emergency. The distance of the unit was indicated to be 295 feet. 3. According to the facility's "Gait Belt Transfers" policy and procedure dated ,[DATE], gait belts were to be used to assist staff to safely transfer or ambulate residents. The policy noted "Unless otherwise noted in residents care plans, a gait belt should be utilized for all residents during manual transfers". The policy also directed staff to "Always make sure that the wheelchair is locked prior to attempting to transfer a resident". According to the MDS, dated [DATE], resident #11 required extensive physical assist for transfers. The MDS indicated the resident had not fallen in the facility, but did have a history of falls prior to admission. According to the mobility deficit plan of care dated [DATE], resident #11 required one staff assist with transfers. On [DATE] at 12:16 p.m. surveyor # observed CNA-A transfer resident #11 from the wheelchair to the toilet. CNA-A brought the resident into the bathroom in the wheelchair. CNA-A locked the wheelchair brakes and without using a gait belt touched the resident's arms and hips while the resident used the wheelchair arms and wall grab bars to stand up and transfer onto the toilet. When the resident was completed on the toilet CNA-A assisted the resident to stand, cleansed the resident's buttock area, pulled up the resident's brief and pants, and transferred the resident back to the wheelchair. The resident did not appear to be unsteady during the transfer, however CNA-A did not follow the facility's safety policy and use a gait belt. On [DATE] at 12:19 p.m. CNA-A verified to surveyor # a gait belt should have been used while transferring resident #11. On [DATE] at 11:05 a.m. DON-B verified to surveyor # staff "should always use a gait belt during assisted transfers". 4. On [DATE], surveyor # reviewed the medical record for resident #18. The resident was admitted to the facility with multiple [DIAGNOSES REDACTED]. The resident's most recent MDS, dated [DATE], indicated the resident had unsteady balance and required extensive assistance of staff for transfers. The resident's Self Care/Mobility Deficit care plan, initiated [DATE], indicated the resident was non-ambulatory and required 1 assist for transfers with an EZ Stand lift. On [DATE] at 11:30 a.m., surveyor # was talking to resident #18 in the resident's bedroom when the resident indicated a need to use the bathroom. Resident #18 pushed the call light button and CNA-J entered the room a short time later. CNA-J then left the room and returned approximately 3 minutes later with an EZ Stand lift. CNA-J placed the lift in front of the resident, placed the sling around the resident's back and fastened a belt around the resident's waist. CNA-J then situated the resident's feet on the lift stand, fastened the calf strap and attached the sling to the lift. Without locking the wheelchair, CNA-J raised the resident up and transferred the resident to the toilet. After the resident finished using the bathroom and peri-care was completed, CNA-J transferred the resident back to the wheelchair. The resident's wheelchair remained unlocked during both transfers. On [DATE] at 11:50 a.m., surveyor # interviewed CNA-J regarding the transfer. CNA-J stated, "I should've locked the brakes before and after the transfer."

Based on observations, record review, staff and resident interviews, and based on the resident's comprehensive assessment, the facility had not ensured that 5 (resident #14, #25, #8, #1, and #3) of 10 residents reviewed for incontinence received appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible. In this citation, Resident #14 and #25 are considered that is actual harm isolated (G level); Resident #8, #1 and #3 are considered less than actual harm, isolated (D level). Resident #14 was assessed to have been incontinent of bladder. The past two current MDS's (minimum data sets) indicated resident #14 had a decline in bladder incontinence. The facility completed a 3 day voiding trial which indicated resident #14 had episodes of bladder incontinence, and the voiding study was incomplete. The facility did not complete a comprehensive assessment related to bladder incontinence, nor had the facility completed an assessment when the MDS indicated resident #14 had experienced a decline in bladder incontinence. The facility did not develop and implement a plan of care in attempt to restore as much normal bladder function as possible. Resident #14 was observed to have had her call light on for 40 minutes for assistance to use the toilet. Resident #14 had been incontinent waiting for staff to assist. Resident #25 had episodes of bladder incontinence. The facility completed a voiding study upon admission. The facility placed resident #25 on a toileting schedule that consisted of 1st, 2nd and 3rd night shift round, upon rising/before breakfast, after breakfast, before and after lunch, before and after supper and at bedtime. The facility completed a quarterly MDS, three months after admission, which indicated resident #25 continued with episodes of bladder incontinence, which had not shown a decline in status, and the facility continued with the same toileting schedule. Staff indicated resident #25 remained continent and incontinent of bladder, but staff did not assist or encourage resident #25 to use the bathroom as directed by the plan of care. The facility completed an additional voiding study, which was incomplete and also indicated resident #25 was independent with toileting needs. The Nurse Practitioner increased resident #25's [MEDICATION NAME] (urinary [MEDICATION NAME]) on 01/15/14, due to resident #25's increased concerns of urinary incontinence. Resident #25 was observed to have been incontinent of bladder, after 3 hours and 45 minutes of observation, without any staff cueing or assistance to the bathroom. Staff indicated resident #25's incontinence could have been due to her forgetfulness to take herself to the bathroom. Resident #8 was assessed to have been incontinent of bladder. The facility did not thoroughly and adequately assess and develop a plan for resident #8 to assure the proper provision of care and services to attain and/or maintain the highest practicable level of bladder function. Resident #1's medical condition required use of a chronically indwelling Foley catheter. Staff had not followed the facility's policy regarding placement of the urinary collection bag during a Hoyer transfer. Resident #3 was assessed by the facility to be frequently incontinent of bladder. The resident had a plan of care intervention in place to include a specifically timed toileting program. Staff had not consistently implemented the toileting program and had not ensured the resident remained as continent as possible. Findings include: According to the American Medical Directors Association, (AMDA) Clinical Practice Guidelines for Urinary Incontinence in the Long Term Care Setting dated 2012, Patients with Urinary Incontinence, (UI) ought to have a trial of a toileting plan such as prompted voiding unless there is a documented reason not to do so. A toileting trial should include observations of at least 3 days of toileting patterns with prompting to toilet, with results documented in a bladder record or voiding diary. Document the results of the toileting trial in the patient's clinical record. If the patient responds well, continue with the toileting program. If the patient does not respond and does not try to toilet, manage him or her supportively with a check-and-change strategy. The facility's Continence Assessment, (IDE Management dated 5/2013) stated the following: Policy Statement Each resident's incontinence will be assessed no less often than quarterly to assure proper provision of care and services to attain and/or maintain the resident's highest practicable level of function. The Policy Interpretation and Implementation portion stated the following: 1. The Bowel and Bladder monitoring record will be initiated upon admission and during the assessment reference period for all subsequently scheduled MDS (minimum data set) assessments. 2. The Bowel and Bladder monitoring record will be completed for 72 consecutive hours. 3. The continence care plan will be based on the resident's comprehensive assessment including but not limited to the Bowel and Bladder Monitoring record. 4. The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. 5. The Care Planning/Interdisciplinary Team is responsible for maintaining care plans on a current status. The facility's current policy entitled "Catheter Care," no date noted indicated to keep drainage bag below level of bladder. 1. On 04/09/14 at 7:00 a.m., surveyor # observed resident #14's call light to be on. Surveyor # maintained a continuous observation of the call light having been on until 7:35 a.m., and at that time (7:35 a.m.) surveyor # entered resident #14's room and asked her if she needed assistance. Resident #14 responded that she needed to use the bathroom and needed staff assistance. Resident #14 indicated there just wasn't enough staff to assist residents. Resident #14 stated it frequently takes 1/2 hour for staff to answer the call light or staff enter and say they will be right back and "that right back is a long time." Resident #14 indicated she was aware when she needed to use the bathroom, but she has "accidents," because she has to wait so long for staff to answer her call light. Resident #14 indicated she gets "embarrassed" because she has wet her bed. Resident #14 stated at least staff haven't yelled at me yet for wetting the bed. Surveyor # remained in resident #14's room. On 04/09/14 at 7:40 a.m., surveyor # observed CNA (Certified Nursing Assistant)-C respond to resident #14's call light. CNA-C entered resident #14's room and asked resident #14 what she needed. Resident #14 indicated she would like to go to the bathroom and get dressed. CNA-C assisted resident #14 to the bathroom with the assistance of a sit/stand mechanical lift. Resident #14 was observed to have been wearing an incontinent brief, which appeared to have contained a moderate amount of bladder incontinence with a minimal amount of fecal incontinence. Resident #14 also was observed to void on the toilet. On 04/09/14 at 7:50 a.m., surveyor # interviewed CNA-C regarding resident #14's incontinence. CNA-C stated resident #14 was able to voice her need to use the bathroom, was alert and oriented "for the most part." CNA-C verified resident #14 had been incontinent of bladder. CNA-C stated resident #14 must have just become incontinent, as the urine contained in the brief was still very warm. CNA-C indicated it was probable that resident #14 became incontinent that AM, because she had to wait for so long for staff to answer her call light. CNA-C stated there are not enough staff to assist residents as needed. CNA-C indicated he had been aware that resident #14's call light had been on for a long period of time, but was busy with other residents and was unable to answer the call light. CNA-C stated resident #14 wasn't on any toileting schedule, and staff assist resident #14 to the bathroom when she requests. On 04/09/14, surveyor # reviewed resident #14's medical record. According to a physician's progress note, dated 04/02/14, resident #14 had [DIAGNOSES REDACTED]. The facility completed an annual MDS, dated [DATE], which indicated resident #14 had mild cognitive impairment, required staff assistance of one for toilet use, and was occasionally incontinent of bladder (less than 7 episodes of incontinence in a 7 day period). The MDS indicated a trial of a toileting program had been attempted since urinary incontinence was noted in the facility. The CAA (care area assessment) for bladder incontinence was reviewed. The facility had not assessed which type of incontinence resident #14 was experiencing. The facility completed a three day voiding study which always indicated resident #14 was consistently incontinent of bladder at 7:00 a.m., and had other isolated daily episodes of bladder incontinence during the study. The study was not completed on 12/09/14 at noon or 1:00 p.m. The CNA documentation for the observation time for the MDS assessment (12/04/13 - 12/11/13) indicated resident #14 had been continent of bladder on five shifts. The facility had not developed or implemented a specific toileting program for resident #14's bladder incontinence. The bladder incontinence was identified in an additional problem for risk for impaired skin integrity. The facility hadn't addressed a toileting program, but had directed staff to perform pericare after each incontinent episode. A quarterly nursing assessment was completed on 02/28/14, and indicated resident #14 was continent of bladder and had medication risk factors that could predispose resident #14 to develop urinary incontinence. The facility completed an MDS, dated [DATE], which indicated resident #14's bladder incontinence had declined to frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding). Resident #14's cognitive and toileting status had remained unchanged. The MDS indicated a trial of a toileting program had not been attempted since urinary incontinence was noted in the facility. The facility completed a three day voiding study which was not thoroughly completed. Surveyor # reviewed the CNA documentation regarding resident #14's bladder status. The CNA documentation for the observation time for the MDS assessment (02/28/14 - 03/05/14) indicated resident #14 had been incontinent every shift. (Documentation from the MDS assessment and CNA documentation showed a decline in bladder incontinence.) The facility continued to not have developed or implemented a specific toileting program for resident #14's bladder incontinence. The bladder incontinence was identified in an additional problem for risk for impaired skin integrity related to bladder incontinence. The facility hadn't addressed a toileting program, but had directed staff to perform pericare after each incontinent episode. The CNA Kardex (without a date when developed) hadn't contained any directions for staff to follow to improve resident #14's bladder incontinence. On 04/09/14 at 9:45 AM, surveyor # interviewed MDS RN(Registered Nurse)-E regarding resident #14. MDS-RN-E verified resident #14 had experienced a decline in bladder incontinence. RN-E stated the facility had not completed a comprehensive bladder assessment that included the type of incontinence resident #14 was experiencing. RN-E indicated the physician had not diagnosed what type of bladder incontinence resident #14 was experiencing, as nurses were unable to determine that. RN-E verified the voiding studies were incomplete. RN-E stated she only reviewed the CNA bladder documentation when she completes the MDS, and the voiding study was only used for care plan development if needed. RN-E verified resident #14 was not on any type of toileting program in attempt to restore bladder continence. On 04/09/14 at 11:00 a.m., surveyor # interviewed CNA-C. CNA-C verified that resident #14 had told him in the past that she was embarrassed of her bladder incontinence. 2. On 04/14/14, surveyor # reviewed resident #25's medical record. According to the admission MDS assessment, dated 09/19,13, resident #25 was admitted to the facility with [DIAGNOSES REDACTED]. The MDS indicated resident #25 has severe impairment of cognitive status, and required limited assistance of staff for toilet use. The MDS also indicated resident #25 was frequently incontinent of bladder, and a toileting program was being utilized to manage resident #25's bladder incontinence. The facility completed a urinary incontinence CAA that indicated resident #25 was incontinent of bladder...She is able to make her needs known. She is independent in transfers. She is able to toilet herself but requires staff assist at times. Resident #25 had multiple [DIAGNOSES REDACTED]. Resident #25 was admitted to the facility with [MEDICATION NAME] XL (medication for urinary [MEDICATION NAME]) 10 mg. (milligrams) every day, according to the hospital discharge summary dated 09/11/13. The facility completed a three day voiding study from 09/13/13 - 09/15/13, which revealed resident #25 was incontinent of bladder 8 times on the first day of the assessment, but had decreased to twice daily on the 2nd and 3rd day of the study. The voiding study indicated resident #25 had never requested assistance from staff for toileting needs, and had never refused staff assistance when offered. The facility developed a plan of care, dated 09/23/13, for "At risk for impaired skin integrity related to bladder incontinence, decreased mobility. The plan of care indicated to follow toileting schedule. The facility developed a toileting schedule for resident #25, which indicated resident #25 should be assisted to the bathroom on 1st, 2nd and 3rd rounds on night shift and before/after meals and at bedtime. Resident #25 was seen by the APNP (Advanced Practice Nurse Practitioner) on 01/15/14. The progress note indicated resident #25's main concern is urinary frequency and she asks "is it normal for someone to go to the bathroom all the time?" She denies drinking a lot of fluids. She denies dysuria (painful urination) also. She is currently on [MEDICATION NAME] XL - will increase dose and see if any relief is noted in her symptoms. The APNP increased resident #25's [MEDICATION NAME] to 15 mg. every day. The facility completed a quarterly MDS dated [DATE]. The MDS indicated resident #25 had severe cognitive impairment, was supervised with toileting and continued to have been frequently incontinent of bladder, and has not had a trial of a toileting program while residing in the facility. The facility completed a three day voiding study from 03/08/14 - 03/10/14. The voiding study indicated areas where resident #25's continence/incontinence status was not completed. Areas of the voiding study also indicated resident #25 was independent with toileting, and other areas, which were completed by staff indicated resident #25 had multiple episodes of incontinence daily, had not requested staff assistance for toilet use nor had refused staff assistance for toileting. On 04/14/14 at 8:30 a.m., resident #25 was observed to be sitting in the dining room/lounge area. Surveyor # made observations every 15 minutes and resident #25 remained in the dining room/lounge area until 11:45 a.m. On 04/14/14 at 10:15 a.m., surveyor # interviewed CNA-DD regarding resident #25. CNA-DD stated resident #25 was alert, but depended on the day about memory recall. CNA-DD indicated there were days resident #25 might recall after 5 minutes and there were other days that she would not. CNA-DD indicated she observed resident #25 take herself to the bathroom at approximately 8:00 AM. CNA-DD stated resident #25 was independent with toileting and staff would only assist if she requested. CNA-DD verified the plan of care indicated to assist resident #25 to the bathroom approximately every 2 hours, but stated she didn't know why the care plan directed a toileting schedule, as resident #25 was independent. CNA-DD indicated resident #25 was both continent and incontinent of bladder, but was not aware as to why she was incontinent. CNA-DD stated when resident #25 was incontinent, at times she would request staff assistance for personal hygiene, and other times she performs her own personal hygiene. CNA-DD indicated resident #25 could be more incontinent of bladder than staff were aware of because of resident #25's independent status. On 04/14/14 at 10:30 a.m., surveyor # entered resident #25's bathroom. The bathroom had a pungent urine odor smell. There was a clothes basket in the bathroom. The clothes basket contained a blue pair of pants that were dry, but contained a strong urine odor. The clothes basket also contained a night gown that was wet and contained a strong urine odor. There was a bag of disposable pull ups observed on the floor next to the toilet. On 04/14/14 at 10:35 a.m., surveyor # interviewed CNA-II. CNA-II stated resident #25 can hold an appropriate conversation but can be forgetful at times. CNA-II indicated staff just wake resident #25 up in the morning and she does her own care independently. CNA-II stated staff do not stay with resident #25 when she conducts her cares. CNA-II stated resident #25 can be incontinent of bladder when she awakes in the a.m., and possibly could be because she "sleeps too hard." CNA-II indicated resident #25 was usually continent of bladder during the day, but on occasion will be incontinent. CNA-II stated she wasn't aware why resident #25 was incontinent of bladder, but could possibly be because she forgets sometimes to take herself to the bathroom. CNA-II indicated resident #25, on occasion will ask for staff assistance to perform personal hygiene when she had been incontinent. Surveyor # and CNA-II went to resident #25's bathroom. CNA-II stated she could not smell any urine odors in the bathroom due to her allergies [REDACTED].#25's nightgown was wet. On 04/14/14 at 10:45 a.m., surveyor # interviewed LPN-I regarding resident #25. LPN-I stated resident #25 was alert and held appropriate conversations, but did have some forgetfulness. LPN-I indicated when resident #25 was first admitted to the facility, she was on a toileting schedule but currently was independent with toileting. LPN-I indicated resident #25 was both continent and incontinent of bladder. LPN-I stated she wasn't aware why resident #25 was incontinent, but possibly could be because she forgets to take herself to the bathroom. LPN-I stated resident #25 usually can not locate the bathroom independently and staff assist with the location. LPN-I indicated she had cued resident #25 to use the bathroom in the past, and resident #25 indicated she becomes so involved with activities that she had forgotten to use the bathroom. LPN-I stated she wasn't aware why resident #25's [MEDICATION NAME] was increased in strength. LPN-I indicated she wouldn't know if resident #25's continence status as declined, because resident #25 was independent with toileting. LPN-I stated staff do encourage resident #25 to use the bathroom every 2 hours, but do not assist resident #25. On 04/14/14 at 10:50 a.m., surveyor # made continuous observation of resident #25 until 11:45 a.m. Resident #25 was observed to have been attending activity programing in the dining room/lounge area. At 11:45 a.m., surveyor # observed resident #25 ambulate to her room with the use of a walker. Resident #25 was observed to place herself on the toilet. Resident #25's pull up incontinent brief was observed to have contained a large amount of bladder incontinence and a scant amount of feces. Resident #25 voided on the toilet, and utilized dry toilet tissue to wipe herself. Resident #25 stood and began to pull up her soiled incontinent product and pants. Surveyor # asked resident #25 if her incontinent product was soiled. Resident #25 stated it was soiled and she probably should change it. Resident #25 sat back on the toilet and removed her pants and the soiled pull up, placed a clean pull up and raised the pull up and pants. Resident #25 left her bathroom. On 04/14/14 at 11:50 a.m., surveyor # interviewed resident #25. Resident #25 indicated she didn't know why she had to go to the bathroom more often. Resident #25 indicated she didn't like being incontinent, but stated she is more incontinent because she probably forgets to go sometimes. When resident #25 completed the interview with surveyor # she ambulated back to the dining room/lounge area. On 04/14/14 at 11:55 a.m., surveyor # updated CNA-DD regarding the above observation. CNA-DD indicated she would assist resident #25 with personal hygiene. On 04/15/14 at 8:10 a.m., surveyor # interviewed MDS RN-E regarding resident #25's incontinence assessment. RN-E verified the voiding study was incomplete. RN-E could not explain why a generalized toileting plan was scheduled, when there was not a comprehensive assessment completed. RN-E stated the plan of care was set up for approximately every 2 hours, and was generalized and not individualized, as she didn't want to miss any opportunities. RN-E verified the facility had not completed a comprehensive assessment related to resident #25's incontinence and was unaware of why resident #25 was incontinent of bladder. RN-E stated the facility needed to improve on completing bladder assessments and developing individualized toileting programs. 3. The MDS assessment dated [DATE] for resident #8, indicated the resident was alert and oriented. Resident required extensive assist with transfers, ambulation, dressing, grooming, bathing, toileting, is frequently incontinent and had physical limitations of the right upper extremity. The CAA dated 3/30/14, indicated resident #8 is able to make needs known, had urinary urgency, required staff assist with toileting due to limited function of the right upper extremity and is incontinent of urine at times. The "Physical Assessment" dated 3/30/14, indicated resident #8 was "Continent." The (72 hour) Bladder Diary which concluded on 3/31/14, indicated the resident was incontinent 7 times. No other Urinary Incontinence assessment was found in the physical or electronic medical record which identified patterns of, or the type of incontinence resident #8 had. Review of the current "Toileting Schedule for 3 North" did not include resident #8 for a toileting plan. (The facility completes a toileting schedule for all residents on the unit on a separate paper, that was kept at the nurses' station). Review of resident #8's current care plan with a revised date of 3/30/14, indicated no individual problem regarding incontinence, but included interventions under the skin and falls care plan problems. The Risk for falls focus interventions directs staff to "monitor and assist with toileting" and "stay with resident while toileting. The Self care/Mobility focus interventions instruct staff to "check and change for incontinence approximately every 2 hours and PRN (as needed)" and "1 A, (1 assist) may need 2 A, ( 2 assist). On 4/9/14 at 8:18 a.m., surveyor # observed CNA-H provide peri-care for resident #8 who was incontinent. Resident #8 stated the accidents usually only happen at night because (the resident) sleeps so soundly. On 4/9/14 at 9:48 a.m., surveyor # observed surveyor # interview MDS RN-E. RN-E stated a full assessment of incontinence is not done to identify the type of incontinence. "I believe that's an area we need to improve in." On 4/9/14 at 12:15 p.m., surveyor # interviewed resident #8 regarding urinary incontinence. When resident #8 was asked if (resident) had accidents at home, the resident stated, "No." 4. Resident #1's readmission face sheet indicated the resident had [DIAGNOSES REDACTED]. The resident had been recently hosptalized on [DATE], with a [DIAGNOSES REDACTED]. The resident's current bedside Kardex, no date included, utilized by direct care staff had an intervention to ensure that urinary drainage bags remain below the level of the bladder for each transfer. On 4/10/14 at 8:05 a.m., surveyor # observed CNA-C and CNA-N during the provision of morning cares for resident #1. After the cares had been completed, the staff transferred the resident into a gerichair with a use of a Hoyer lift. The resident's urine collection bag was secured to the lift bar and during transfer, the bag was above the level of the resident's bladder. The surveyor noted that urine was fluctuating in the catheter tubing. The surveyor immediately interviewed both staff. Both CNA-C and CNA-N verified to the surveyor that the facility directs staff to place urinary collection bags below the level of the bladder to prevent urinary tract infections. On 4/10/14 at 1:45 p.m., surveyor # interviewed DON-B. DON-B stated, "Staff are taught to keep urinary collection bags below the level of the bladder to prevent back flow of urine into the bladder which could result in a urinary tract infection. We have CNA competency check list that indicated that directive when staff are audited during care of catheters." 5. Resident #3's admission face sheet dated 3/5/12 indicated the resident was admitted to the facility after a fall at home which resulted in a fractured left hip. The resident's most recent MDS dated [DATE] indicated the resident was assessed to moderate cognitive impairment, required extensive assistance from staff to transfer, and was frequently incontinent of bladder. The facility conducted a 3 day bladder diary for the resident from 3/29/14-3/31/14 which indicated the resident had a pattern of being incontinent of urine at 2:00 a.m., 7:00 a.m., between 10:00 a.m. and 12:00 p.m. and between 4:00 p.m. and 6:00 p.m. on all 3 days of the study. During the other hours of the study, the documentation indicates the resident was continent. The facility had implemented a scheduled toileting plan for the resident to include prompted toileting on the 1st, 2nd and 3rd night rounds, upon rising/before breakfast, after breakfast, after lunch and after supper. The facility created a care plan regarding self care/mobility deficit related to generalized weakness on 11/19/12, which indicated an intervention to assist resident in following toileting schedule. This intervention was revised on 5/8/13. An incontinence CAA dated 1/14/14, was created for resident #3 which indicated, "Resident is alert and able to communicate her needs. Has incontinence at times. She is on a toileting schedule. She is not expected to improve in toileting or continence. She requires staff assistance with toileting and transferring." The resident's current bedside Kardex, no date included, indicated an intervention to follow toileting schedule. On 4/8/14 at 1:00 p.m., surveyor # interviewed CNA-M. CNA-M stated, "She (#3) is incontinent of urine at times and is continent at times. When we toilet her, she is usually already wet with urine. She puts her light on when she is ready to use the toilet. She usually lets us know in the morning, before meals and after meals, but once she calls, she is wet by then." On 4/9/14 at 11:30 a.m., surveyor # located daily documentation and a toileting schedule for resident #3 located in a binder in the nurses station. The form indicated that staff were to initial each box as completed. Review of resident #3's documented toileting schedule from 3/25/14-4/9/14 indicated that not all applicable toileting times relating to resident #3's toileting schedule were initialed as completed by staff. On 4/9/14 at 11:30 a.m., surveyor # interviewed CNA-C regarding resident #3. CNA-C stated, "I know about the sheets (toileting schedule forms). I just wasn't aware of her (#3) toileting schedule." On 4/8/14 at 11:00 a.m., surveyor # interviewed CNA-C. CNA-C stated, "She (#3) calls us regularly to use the bathroom. When she gets up in the morning, she is usually wet, but 40 % of the time during the day, she is dry. She is good about calling us when she wants to go to the bathroom. We don't cue her, she is very alert. Two out of three times she asks to toilet, she is already wet. She isn't on a toileting schedule and we don't prompt her to use the bathroom. I didn't toilet her today after breakfast because she went straight to an activity."

Based on record review, staff and family interviews, the facility did not immediately consult with 2 (resident #1 and #9) of 5 residents reviewed for physician notification when there was significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications); or a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences. Resident #1 presented with a change in condition as evidenced by a red, hot, painful, bruised abdomen. RN (Registered Nurse) staff did not thoroughly assess the resident, did not develop a plan of action and did not give clear directives to an LPN (Licensed Practical Nurse) regarding physician notification of the resident's change in condition. Ultimately, the resident was not evaluated by a physician until almost 24 hours later, at which time the resident was hospitalized for [REDACTED]. Resident #9 has a history of chronic pain and has received scheduled [MEDICATION NAME] and [MEDICATION NAME]es, [MEDICATION NAME] and [MEDICATION NAME] for pain management. Resident #9 also can receive prn (as needed) [MEDICATION NAME]. Resident #9 was observed in pain, and staff indicated resident #9 was crying due to pain. When resident #9 verbalized she continued to be in pain, the nurse stated that she needed to wait 2 more hours before receiving any pain medications. The facility did not update the physician when resident #9 displayed verbal and non-verbal signs and symptoms of ongoing pain and when the current medication regime was not effective for treating resident #9's pain until staff were interviewed regarding resident #9's pain by surveyor # . Findings include: 1. Resident #1 had [DIAGNOSES REDACTED]. The resident was scheduled to have 9 teeth extracted on 3/13/14, and the resident's physician had ordered a bridging from [MEDICATION NAME] to [MEDICATION NAME] injections to be initiated on 2/28/14. Monitoring of INR's (International Normalization Ratios) were being conducted frequently during the bridging of the medications to ensure blood anticoagulation therapy was effective without complications. All INR's were within the normal range, effective to prevent clotting, due to [MEDICAL CONDITION] and [MEDICAL CONDITION] flutter and were not indicative of blood anticoagulation therapy having been excessive to cause bleeding. Resident #1 received twice daily injections of the blood thinner [MEDICATION NAME] to the abdomen prior to and after the dental procedure. Review of the resident's medical record indicated from 3/16/14 - 4/1/14 did not include documentation of abdominal bruising, abdominal pain, redness or swelling. A nursing entry in resident #1's medical record dated 4/2/14 at 9:33 p.m. indicated,"Writer and POA (Power of Attorney) had concerns of resident's abdomen, due to [MEDICATION NAME] shots, left lower abdomen is red, warm and hard with total abdominal bruising through out. Also right upper abdomen near naval area has protrusion (hernia like in nature). Abdomen area is very tender touch. DON (Director of Nursing) was called and updated, will pass on to days to make sure PCP (primary care provider) is called ASAP (as soon as possible) in a.m. POA updated with plan of care." The entry was signed by LPN-JJ. No further entries were documented in the resident's medical record until 4/3/14 at 11:30 a.m., when the entry signed by LPN-I indicated "Doctor just called and said to monitor now for infection." Review of the 24 hour report indicated the above information regarding resident #1's change in condition had been entered onto the report. On 4/10/14 at 11:00 a.m., surveyor # interviewed LPN-D regarding resident #1. LPN-D stated, "I let the doctor know the resident's (#1) POA wanted her to see her regular doctor on Friday (4/4/14) but the POA changed her mind on 4/3/14 and wanted the resident sent to the emergency room . I saw the resident on the day shift of 4/3/14 and I talked to the RN. Her abdomen was red at the injection sites more like bruising, and her entire abdomen was red. I called the doctor late morning on 4/3/14 and he felt it wasn't an emergent situation and that the bruising was from the shots. I know the hospital listed [MEDICATION NAME] as an allergy." On 4/14/14 at 1:10 p.m., surveyor # interviewed LPN-I regarding resident #1. LPN-I stated, "I know (LPN-D) had called the doctor (for resident #1) the morning of 4/3/14. The doctor called back at 11:30 a.m. that morning and I talked to him. He told us just to monitor now for infection." On 4/14/14 at 2:00 p.m., surveyor # interviewed DON-B regarding resident #1. DON-B stated, "(LPN-JJ) had called me the evening of 4/2/14 regarding her (#1) abdomen. She told me that the resident had some areas of redness and warmth and an area of protrusion that looked like a hernia. She told me the bruising was in the area of the protrusion. In my head, I had a visual that the bruising was only at the site of protrusion. She didn't say the resident had bruising throughout the abdomen. It sounded like a hernia with questionable [MEDICAL CONDITION]. I told her to call the doctor. I can't recall if I told her specifically to contact the doctor that night, I meant that but I'm not sure how she interpreted that. An RN supervisor is in the building during the p.m. shift and staff know they need to relay the information to that RN so the RN can complete an assessment, and they know they also need to inform me. I thought the issue was just local due to [MEDICATION NAME] shots and maybe some [MEDICAL CONDITION] by what I was told." On 4/14/14 at 2:40 p.m., surveyor # interviewed RN-X regarding resident #1. RN-X verified to the surveyor that she had been the p.m. supervisor in the facility the evening of 4/2/14, working 2:00 p.m. until 10:00 p.m. RN-X stated, "(LPN-JJ) asked me to assess her (#1) abdomen for bruising, redness and firmness. She told me the resident was getting [MEDICATION NAME] shots in the abdomen. I looked at the resident's abdomen and I saw redness in the left lower abdominal quadrant 8 cm (centimeters) x 5-6 cm. The whole abdomen was bruised with purples, greens, and yellows. There was a firm area in the epigastric (the upper central region of the abdomen) region which I questioned to be a hernia. Per (LPN-JJ), the resident had pain with palpation of the abdomen. She was told to call the DON, the resident's POA and the doctor. I wasn't sure if she was going to call or fax the doctor. She called me to the unit just to make sure she was doing the right thing. I was unaware of what the resident's vital signs had been. I didn't know what her INR's were running. I thought it could wait. I've seen a lot of abdomens look like that with [MEDICATION NAME]. I didn't think it was acute to the point where the resident needed to be shipped out. I didn't know the resident's history and I didn't look at her medical record. I was surprised that the doctor wasn't notified that evening. I didn't know how many [MEDICATION NAME] injections she had gotten. (LPN-JJ) just wanted me to look at the resident to see if I should call the doctor and DON. I didn't document my assessment. I should have. I thought the DON would guide (LPN-JJ) on what to do. The doctor should have been notified by phone not faxed that evening." On 4/14/14 at 2:50 p.m., surveyor # interviewed LPN-L regarding resident #1. LPN-L stated, "On 3/14/14 when I noticed the bruise on her (#1) abdomen, I notified the RN and she said it was just due to the [MEDICATION NAME]. I noticed the resident only had one bruise, at that time, at the site of the [MEDICATION NAME] shot. I work regularly on her (#1) unit, and her abdomen was not like mentioned it was written in the nurses note on the p.m. of 4/2/14 prior to that. It was an all of a sudden thing." On 4/14/14 at 3:00 p.m., surveyor # interviewed LPN-JJ via the telephone. LPN-JJ stated, "I told the nursing supervisor that she (#1) was on [MEDICATION NAME] shots. Her whole abdomen was in different stages of bruising and I noted bruising throughout her abdomen. Her (#1) daughter was there earlier in the shift and was concerned. I'm not sure if I took any vitals on the resident. The nursing supervisor (RN-X), myself and (RN-W) all looked at the resident on the p.m. shift of 4/2/14. They agreed with me to have the resident's doctor updated in the morning. I passed that message onto nights to have them tell the day shift to call the doctor. I didn't think it was acute. I assumed it was due to the [MEDICATION NAME]. It is not in the scope of my practice to assess." On 4/14/14 at 3:30 p.m., surveyor # interviewed LPN-D via the telephone. LPN-D stated, "I looked at her (#1) abdomen before I called the doctor (on 4/3/14). Her abdomen looked like she had some fresh dark bruises and healing bruises across her entire abdomen. She was getting injections and the round bruising was surrounding her belly button. The rest of her abdomen was reddened. Normally I would have documented that, and I'm not sure why I didn't. I knew her INR levels and I was aware of her hemoglobin levels." On 4/15/14 at 8:00 a.m., surveyor # interviewed RN-W via the telephone. RN-W stated, "I believe I did go look at the resident (#1) on 4/2/14 on the p.m. shift. I am not familiar with the resident at all. The left side of her abdomen was really red if I remember right. I don't remember but I think she said it hurt. I don't recall if I touched her abdomen. I didn't look at her chart. I let the staff know they needed to get a hold of the doctor. I knew the resident was getting [MEDICATION NAME] injections. I was wondering if she had an infection. I wasn't the supervisor that evening so I didn't document anything. (RN-X) was the supervisor and I thought she was going to do that. The RN's are supposed to be doing the physical assessments, but a lot of times, the LPN's do the assessments. I guess I thought they called me just for an opinion." Review of resident #1's physician's office nurse triage call notes documentation record dated 4/3/14 at 10:22 a.m., indicated that LPN-D had called the physician and left a message to include, "(Resident #1) is having abdominal pain and bruising, red, warm to touch with 4-5 protrusions. She is currently receiving [MEDICATION NAME] injections. This was noted last night, and has constant abdominal pain. She states with palpation resident had 1 inch wide to 4 inches protrusion in the abdominal area that are round in shape. She states her pain is at 6 on pain scale (using a 1 - 10 pain scale), is eating and drinking okay, she is urinating and having BMs (bowel movements), she denies dizziness. The larger protrusions are at the LLQ (left lower quadrant) and RUQ (right upper quadrant) by naval. Vital signs included BP (blood pressure) 76/42. Recheck was 84/40. Normal temperature, pulse and respirations. POA want an appointment tomorrow. Okay to monitor especially lower BP as she is scheduled with you tomorrow morning at the POA's request?" The information relayed to resident #1's physician by LPN-D did not include the extensiveness of bruising and redness of the abdomen the resident had been displaying. Further review of resident #1's physician's office nurse triage call notes documentation indicate the resident's physician responded on 4/3/14 at 10:56 a.m. to indicate, "I would watch closely, history of urosepsis (is a life threatening infection that complicates a urinary tract infection), can deteriorate rapidly. Low BP is concerning though she can have low normal readings. Is staff concerned this is an infection injection site? Could consider antibiotic start." On 4/3/14 at 11:29 a.m., the facility again contacted the physician via the office triage nurse. The correspondence indicated, "The staff is more concerned about the abdominal pain and protrusion but they are red and warm to touch. Tried to clarify if this could be infection from [MEDICATION NAME] shots and they are not sure." On 4/3/14 at 11:04 a.m., the physician response was, "Monitor for now, hold off on antibiotics." On 4/3/14 at 11:31 a.m., the facility again corresponded with the office triage nurse and indicated, "(LPN-I) aware and will monitor for now and call if needed." A nursing entry dated 4/3/14 at 1:38 p.m. indicated, "Resident has appointment with doctor tomorrow regarding abdominal issues. While on phone with doctor, vital signs stable except BP of 76/42. Recheck and repositioning 104/50. No c/o (complaints of) dizziness. No SOB (shortness of breath). Per doctor, will continue to monitor. Resident afebrile (without fever). No bleeding noted. No sore throat." The entry was signed by LPN-D. No additional documented evaluations and/or assessments of the resident's abdomen had been completed since 4/2/14 at 9:33 p.m. Review of the 24 hour report dated 4/3/14 indicated the a.m. shift indicated that the resident had, "a doctors appointment for her abdomen on 4/4/14 at 10:40 a.m. Monitor in meantime for significant changes. Afebrile. No bleeding." The p.m. entry on the 24 hour report indicated, "afebrile." On the bottom on the 24 hour report dated 4/3/14 indicated that resident #1, "sent to ER(emergency room ) at 8:15 p.m.." Review of the resident's hospital history and physical examination [REDACTED]. emergency room physician discussed case with general surgery service and aspiration of hematoma was suggested and done. Aspirated material was blood without purulent content. Patient admits to abdominal wall pain. Patient was taken to the medical surgical floor for further medical management. The physical assessment indicated that the resident exhibited abdominal distension and anterior abdominal wall had multiple bruises and painful to touch hematomas (protruded areas). A CT (Computerized Tomography) was completed on the resident which indicated multiple anterior abdominal wall masses in the range of 5.2 x 2.8 cm and smaller, new as compared to the prior CT study dated 7/9/13, consistent with subcutaneous hematomas. The plan listed multiple abdominal wall hematomas: patient is on [MEDICATION NAME] and [MEDICATION NAME]. Hold [MEDICATION NAME] and [MEDICATION NAME] and aspirin. Pain management. Acute blood loss [MEDICAL CONDITION]: bleeding into anterior abdominal wall. Transfuse if hemoglobin drops further. During the course of the resident's hospital admission, her hemoglobin dropped to the degree that she required blood [MEDICAL CONDITION]. The hospital discharge summary completed for resident #1, dated 4/6/14 indicated final [DIAGNOSES REDACTED]. Patient should not receive bridging therapy for future interruptions in anticoagulation. A hand drawn image of the resident's abdomen was added to the summary that indicated observed bruising to 3/4 of the resident's abdominal wall. On 4/15/14 at 7:00 a.m., surveyor # interviewed resident #1's activated POA via the telephone. POA-OO stated, " I saw (#1) abdomen on 4/2/14. It looked like an infection. Her entire abdomen was red and bruising was old and new. She was complaining of pain in her abdomen. I called (LPN-JJ) in to show her. No one had notified me of anything. (LPN-JJ) told me (#1's) abdomen was like that because of the [MEDICATION NAME] shots and I told them that I thought it was more than just that. (LPN-JJ) told me the doctor said to just observe her for now. We had made an appointment to see the doctor on the 4th (4/4/14) but later her abdomen didn't look better so I called the hospital nurse on call and she suggested that (#1) needed to be seen at the emergency room so I called the nursing home and told them to send her." Further review of physician's office nurse triage call notes documentation indicated that on 4/3/14 at 7:51 p.m., LPN-JJ called from the nursing home regarding resident #1 stating "patient has been receiving [MEDICATION NAME] and has a large amount of bruising to abdomen . Also states an area of redness that is suspicious for [MEDICAL CONDITION]. States has appointment with primary care physician tomorrow a.m., but POA wanted resident #1 to be seen tonight in emergency room . Calling on call provider for orders." The resident was sent to the emergency room at 8:15 p.m. on 4/3/14 upon the insistence of her POA. On 4/14/14 at 3:30 p.m., surveyor # interviewed MD (Medical Doctor)-MM regarding resident #1. MD-MM stated, "Had the nursing home called at 9:30 p.m. (on 4/2/14) and told me that night the whole picture of what the (#1) abdomen looked like, I would have had the resident evaluated at the emergency room then. I know the family and what they would have wanted. The resident is a full code. I know our office phone staff doesn't always relay information properly, so that may have been some of the issue. I don't know if hospitalization sooner would have really changed the resident's outcome." 2. On 04/08/14 at 9:30 a.m., surveyor # while conducting the initial tour of the 300 unit, resident #9's call light was on and was answered by CNA (Certified Nursing Assistant)-S. CNA-S was observed exiting the room and stating to LPN-I that resident #9 was complaining of pain in "her butt." Surveyor # looked into resident #9's room. Resident #9 was lying in bed and facial grimacing was observed from the hall. On 04/08/14 at 9:37 a.m., surveyor # observed CNA-S assist resident #9 with personal cares. Resident #9 was observed to have been lying in bed and had her eyes closed tightly and presented with facial grimacing. CNA-S started to assist resident #9 in lifting her legs. Resident #9's facial grimacing observed to have tightened. CNA-S was looking at resident #9 and stated, "That hurts. I'm not going to do it then." CNA-S assisted resident #9 to sit at the side of the bed and scooted resident #9 forward by pulling on the protective cloth pad that resident #9 was sitting on in bed. Resident #9 was observed to be very guarded with movement. Resident #9 was assisted to the toilet with the mechanical assistance of a sit/stand lift. CNA-S asked resident #9 if she was experiencing any pain. Resident #9 responded not right at the moment, but did request something additional for pain. CNA-S left the room and returned with LPN-I. CNA-S was observed to wipe resident #9's buttocks, and resident #9 flinched when touched, and presented with facial grimacing. CNA-S and LPN-I assisted resident #9 back into bed. Resident #9 appeared to have very guarded body language with movement and presented with facial grimacing with the transfer. On 04/08/14 at 9:40 a.m., surveyor # interviewed resident #9. Resident #9 stated "my butt hurts so bad. I have a hole in my butt and I need to relocate my butt" (Meaning reposition). Resident #9 stated the staff administers pain medications and they do help "somewhat", but always have pain. Resident #9 indicated her pain was a 7, using a 1 - 10 pain scale. Resident #9 stated she was crying earlier in the day because "I hurt so bad." Resident #9 indicated the pain feels like a knife going through her butt and she is always in pain. Resident #9 indicated at times her pain is tolerable, but most of the time it isn't. Resident #9 also indicated some days are better than others. Surveyor # questioned resident #9 if the facility ever spoke to her about her goals for pain and what she would want. Resident #9 indicated she would rather be pain free and sleepy then to experience the pain she has. Resident #9 verified she is very guarded with movement because at any time her pain can become very severe and she always seems to be waiting for this to happen. Resident #9 indicated pain is not usually significant, when not moving. On 04/08/14 at 9:50 a.m., surveyor # observed LPN-I assist resident #9 to sit at the side of the bed. Medications were given to include [MEDICATION NAME]. Resident #1 presented with significant facial grimacing. LPN-I stated to the resident "take a deep breath" and proceeded to lie resident back into bed. LPN-I asked, "Is that better?", and resident #9 shook her head yes. CNA-S was present in the room. LPN-I and CNA-S left the room and CNA-S stated, "I hope your hinder gets better." On 04/08/14 at 9:55 a.m., surveyor # interviewed CNA-S regarding resident #9. CNA-S indicated when she entered resident #9's room earlier that day, resident #9 was crying because of the pain she was experiencing. CNA-S indicated the pain resident #9 complains of is "in her butt." CNA-S stated resident #9 previously had a pressure ulcer, but has healed. CNA-S indicated resident #9's pain has worsened lately. Surveyor # questioned CNA-S why she told resident #9 she "wasn't going to do that", when cares were provided. CNA-S stated that she meant she wasn't going to remove the pillow from below her knees as she was aware resident #9 was experiencing pain and it seemed like the pain is increasing in intensity. CNA-S stated resident #9 jerked in pain when she wiped her buttocks, but was unable to visualize if resident #9 was displaying facial signs/symptoms of pain. CNA-S indicated resident #9 also had refused cares lately due to pain and the APNP (Advanced Practice Nurse Practitioner) indicated to try and encourage resident #9 to get out of bed for at least one hour a day in hopes to help with the pain. CNA-S indicated resident #9 typically will stay in bed due to pain. CNA-S stated that she thought resident #9 was afraid to sit up in her wheelchair because she worried that staff would not return to her timely to put her back into bed when she requested. On 04/08/14 at 12:15 p.m., surveyor # interviewed SW (Social Worker)-LL regarding resident #9's ability to be accurate in her statements. SW-LL indicated resident #9 was able to voice her concerns, and would be able to voice pain accurately. On 04/08/14 at 12:30 p.m., surveyor # observed resident #9 resting in bed and without facial grimacing. Resident #9 stated she was still having pain but is more tolerable as long as she doesn't move. Resident #9 indicated her pain was still at a 7 with movement. On 04/08/14 at 12:45 p.m., surveyor # observed resident #9 place her call light on. Resident #9 was seated upright in bed, at approximately a 45 degree angle, and was displaying facial grimacing. Resident #9's lunch tray was observed on an overbed table in front of her. At 12:50 p.m., surveyor # interviewed resident #9 regarding her pain. Resident #9 stated the pain is "so bad now." Resident #9 indicated the pain worsened when she was repositioned to eat lunch. Surveyor # left resident #9's room. At 12:54 p.m., CNA-C entered resident #9's room and exited the room at 1:00 p.m. On 04/08/14 at 1:05 p.m., surveyor # interviewed CNA-C regarding resident #9. CNA-C stated resident #9 complained of butt/low back pain when he entered her room. CNA-C indicated resident #9 appeared to almost be in tears when he entered the room and had a tearful sound to her voice when she reported the pain. CNA-C stated he needed to notify the nurse of resident #9's complaints of pain. CNA-C indicated today was the worst that he has seen her complain of pain. CNA-C indicated resident #9 always had pain and at times does request pain medications. CNA-C stated resident #9 always stays in bed but was unaware as to why, as he usually works at the other end of the hall, and just helps out on the end where resident #9 resided to answer call lights. CNA-C stated he was aware that resident #9 was alert and oriented with intermittent confusion but is able to voice her needs and complaints of pain. On 04/08/14 at 1:35 p.m., surveyor # interviewed LPN-I regarding resident #9's pain. LPN-I stated she has worked on the unit for approximately 2 months and resident #9 has constant pain. LPN-I stated that resident #9 has described to her that it felt like "something is shoved in there" (meaning the coccyx area). LPN-I indicated that resident #9 indicated her pain was usually at a 6 (1 - 10 scale). LPN-I stated staff will try to reposition resident #9, if she is unable to have any prn pain medications, if she hasn't waited the prescribed time between medications. LPN-I indicated the pain seems to worsen when she sits up in bed. LPN-I stated there was a metal support bar that is horizontal across the bed where resident #9 would sit, and believes the metal bar might be contributing to her pain. Surveyor # asked LPN-I if the bed was ever replaced with a different bed, and LPN-I responded "no." LPN-I stated the APNP would like resident #9 to get out of bed and sit in her chair for at least an hour a day to see if that would help alleviate her pain, but resident #9 refused today and half the time will refuse due to pain. LPN-I verified resident #9 appeared very guarded when she is moved. Surveyor # asked LPN-I if she was told that resident #9 was crying earlier in the day because of the pain she was experiencing. LPN-I responded, "no." Surveyor # informed LPN-I of CNA-S and CNA-C's interviews stating that resident #9 was crying or near crying due to pain. LPN-I re-iterated she was not told by either CNA's regarding resident #9's crying because of pain. Surveyor # questioned LPN-I regarding resident #9's pain management program. LPN-I stated resident #9 has been on the same pain management program since she started working on the unit. LPN-I indicated the APNP was at the facility recently and that was when it was recommended resident #9 get out of bed. On 04/08/14 at 1:50 p.m., surveyor # interviewed resident #9. Resident #9 was observed to be lying in bed with significant facial grimacing. Resident #9 stated she continued to be experiencing pain. Resident #9 stated she has not seen a nurse since CNA-C had left the room at approximately 1:00 p.m. Surveyor # went to LPN-I and updated her regarding resident #9's pain. Surveyor # and LPN-I went to resident #9's room. On 04/08/14 at 2:00 p.m., surveyor # observed LPN-I ask resident #9 what she would like the nurse to do regarding her pain, because she can't have any more pain medication for 2 hours. LPN-I offered to reposition or to massage the painful area. Resident #9 did accept repositioning. LPN-I was observed to tell resident #9 "to take a deep breath and blow it out" while she removed a pillow from under her lower extremities. While resident #9 remained lying on her back, LPN-I was observed taking her hand and placing it under resident #9's buttocks and was pushing on different areas and asking if it hurt? LPN-I then pressed on a specific area and resident #9 "jerked", and presented with significant facial grimacing and stated "Please don't play with my back." LPN-I removed her hand and assisted resident #9 to lie slightly on her right side so the buttock area was visible. Resident #9 was displaying facial grimacing of pain and cried out, "ow." A protective dressing was visible over the coccyx with a date of 04/06/14. LPN-I stated to resident #9 if an Aqua K (a heated water filled pad that is used for moist heat, for a large area of the body) pad might help, and resident #9 replied "yes." LPN-I then asked resident #9 what she did at home when she had pain and resident #9 replied, "cry." LPN-I and surveyor # left the room. On 04/08/14 at 2:05 p.m., surveyor # interviewed LPN-I regarding if the physician was notified of resident #9's pain and if she thought resident #9's was experiencing significant pain. LPN-I verified resident #9 was experiencing real pain and it was not a behavior. LPN-I stated the MD was not notified of resident #9's pain as the APNP was at the facility the other day and wanted resident #9 to get out of bed. (APNP was at the facility on 04/02/14 and indicated to encourage to get resident #9 out of bed). Surveyor # stated the APNP was at the facility on 04/02/14 and it was 6 days later and resident #9 continued with pain and was not getting out of bed due to pain. LPN-I told surveyor # the facility had to give it time before calling the MD. On 04/08/14 at 2:10 p.m., surveyor # interviewed PM shift LPN-NN regarding resident #1's pain. LPN-NN stated the nurses' document refusals when resident #9 doesn't get out of bed. Surveyor # asked LPN-NN if she was aware of why resident #9 refuses to get out of bed, and LPN-NN stated she has never asked resident #9 why she doesn't want to get out of bed. LPN-NN indicated the CNA's ask and are told she doesn't want to. LPN-NN indicated she was aware at times, resident #9 would state it was because of pain. LPN-NN indicated it was just a recent order from the APNP to get out of bed, so it would be too soon to update the physician or the APNP regarding the pain that resident #9 was experiencing. On 04/08/14 at 2:45 p.m., surveyor # interviewed PM shift CNA-K regarding resident #9's pain. CNA-K stated 2 days prior to this interview, on Sunday, resident #9 complained of butt pain and wanted the nurse. CNA-K indicated resident was crying, but there wasn't any tears, but definitely a crying complaint. CNA-K indicated she went and told LPN-NN and was told to reposition her and to report back if she continued to complain of pain. CNA-K stated resident #9 was displaying facial grimacing. CNA-K indicated it has been the last month or so that resident #9's pain seems worse. On 04/09/14 at 7:10 a.m., surveyor # questioned LPN-I if the physician was notified of resident #9's ongoing complaints of pain and if she had spoken with the CNA's that reported resident #9 crying with pain to surveyor # on 04/08/14. LPN-I verified she had updated the physician on 4/8/14 regarding resident #9's complaints of pain and requested an Aqua K pad to be used. LPN-I stated the facility is waiting for the Aqua K pad to arrive. LPN-I indicated she had spoken with both CNA's regarding resident #9 crying with pain and educated them if resident #9 was crying because of pain, the nurse needs to be notified immediately. The facility developed a plan of care for "Potential for pain related to nerve pain and generalized discomfort" dated 09/19/12. The following were interventions listed to treat pain. The interventions listed were dated the same date the plan of care was developed without any revisions. * Report pain to the nurse * Update MD (medical doctor) if pain is not controlled The APNP assessed resident #9 on 04/02/14 and indicated resident #9 continued without any change in her low back pain regarding her symptoms. The APNP progress note indicated resident #9 reported that her pain is primarily in her "butt" and she was unable to give more specifics about this pain and does spend the entire day in bed. When asked why she does this, she states that if she gets up, she has pain in her legs and back. Pain medications are encouraged, as is getting out of bed at least once a day-coinciding with a meal is ideal. She currently verbalizes understanding and agreement. The APNP's physical exam indicated resident #9 was in no acute distress, was awake, conversant and cooperative. The medical record contained "physician's orders [REDACTED]. The order sheet indicated resident #9 requested comfort measures only, which includes medication, positioning and other measures are used to relieve pain and suffering...If comfort measures fail, contact physician.

Based on record review and staff interviews, the services provided or arranged by the facility did not meet professional standards of quality in 1 (resident #1) of 21 sampled residents. Resident #1 presented with a change in condition as evidenced by a red, hot, painful, bruised abdomen. RN (Registered Nurse) staff did not thoroughly assess the resident, did not document their findings and did not give clear directives to an LPN (Licensed Practical Nurse) regarding development of a nursing care plan, interventions and evaluation of the resident's condition. Ultimately, the resident was not evaluated by a physician until almost 24 hours later at the family's insistence, at which time the resident was hospitalized for [REDACTED]. Findings include: The Standards of Practice for Registered Nurses and Licensed Practical Nurses Chapter N 6, published in 2001 by the Board of Nursing indicates An RN shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to LPN's or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. The position paper entitled "Delegation", published on 6/20/04 by the Board of Nursing indicates that based on the standards of practice for RN's contained in Chapter N 6 of the Standards of Practice for Registered Nurses and Licensed Practical Nurses, an RN is directly responsible for ensuring that Assessment, Planning, Intervention and Evaluation are performed in order to maintain, health, prevent illness, or care for the ill. The only portion of the Nursing Process that contains nursing acts that can be delegated to LPN's or less skilled assistants is the Intervention phase, which includes the collection of data (vital signs etc.) necessary to continuously Assess, Plan and Evaluate care. Resident #1 had [DIAGNOSES REDACTED]. The resident was due to have 9 teeth extracted on 3/13/14, and the resident's physician had ordered bridging from [MEDICATION NAME] to [MEDICATION NAME] injections be initiated on 2/28/14. Monitoring of INR's (International Normalization Ratios) were being conducted frequently during the bridging of the medications to ensure anticoagulation therapy was effective without complications. All INR's were within the normal range effective to prevent clotting due to [MEDICAL CONDITION] and [MEDICAL CONDITION] flutter and were not indicative of blood anticoagulation therapy having been excessive to cause bleeding. The resident had a care plan developed regarding risk for bleeding/bruising related to anticoagulation therapy on 11/26/12 which included a goal of no uncontrolled bleeding and an intervention to monitor for any bruising and to report any bruising or bleeding to the nurse. The resident received twice daily injections of [MEDICATION NAME] (anticoagulation medication) to the abdomen prior to and after the dental procedure. Review of the resident's medical record included documentation dated 3/14/14 which noted "Resident has large bruise approximately 5 cm (centimeters) in width by 6 cm in length on right abdomen, dark purple in color, skin intact, related to [MEDICATION NAME] injection. Supervisor notified of bruising. RN supervisor stated just to document in progress note." This note was documented by LPN-L. Additional nursing documentation dated 3/16/14 indicated, "bruising to abdomen due to [MEDICATION NAME] shots." This entry was documented by LPN-JJ. From 3/16/14 - 4/1/14, resident #1's medical record did not include additional documentation of the resident's abdominal bruising or the resident's complaints of abdominal pain, redness or swelling. The nursing documentation dated 4/2/14 at 9:33 p.m., indicated "Writer and POA (Power of Attorney) had concerns of resident's abdomen, due to [MEDICATION NAME] shots, left lower abdomen is red, warm and hard with total abdominal bruising through out. Also right upper abdomen near naval area has protrusion (hernia like in nature). Abdomen area is very tender to touch. DON (Director of Nursing) was called and updated, will pass on to days to make sure PCP (primary care provider) is called ASAP (as soon as possible) in a.m. POA updated with plan of care." This entry was signed by LPN-JJ. No additional documentation was included in the resident's medical record until 4/3/14 at 11:30 a.m., the documentation indicated "Doctor just called and said to monitor now for infection." This entry was signed by LPN-I. Review of the 24 hour report (used for shift to shift communication) indicated that the above information regarding resident #1's change in condition had been entered onto the 24 hour report. Nursing documentation in the resident's medical record dated 4/3/14 at 1:38 p.m. indicated "Resident has appointment with doctor tomorrow regarding abdominal issues. While on phone with doctor, vital signs stable except BP (blood pressure) of 76/42. Recheck and repositioning 104/50. No c/o (complained of) dizziness. No SOB (shortness of breath). Per doctor, will continue to monitor. Resident afebrile (without fever). No bleeding noted. No sore throat." This entry was signed by LPN-D. No additional documented assessment or evaluation of the resident's abdomen had been completed since 9:33 p.m. on 4/2/14. Review of the 24 hour report dated 4/3/14 indicated the a.m. shift documented that the resident had "a doctors appointment for her abdomen on 4/4/14 at 10:40 a.m. Monitor in meantime for significant changes. Afebrile. No bleeding." The p.m. entry on the 24 hour report documented, "afebrile." On the bottom on the 4/3/14 24 hour report sheet indicated that resident #1, "sent to ER (emergency room ) at 8:15 p.m.." Nursing documentation in resident #1's medical record did not include any RN assessments from 4/2/14 - 4/3/14 regarding the resident's acute abdomen changes. Review of resident #1's hospital history and physical examination [REDACTED]. emergency room physician discussed case with general surgery service and aspiration of hematoma was suggested and completed. Aspirated material was blood without purulent content. Patient admits to abdominal wall pain. Patient was taken to the medical surgical floor for further medical management. The physical assessment indicated that the resident exhibited abdominal distension and anterior abdominal wall had multiple bruises and painful to touch hematomas. A CT (Computerized Tomography) was completed on the resident which indicated multiple anterior abdominal wall masses's in the range of 5.2 x 2.8 cm and smaller, new as compared with the prior CT study of 7/9/13, consistent with subcutaneous hematomas. The plan listed multiple abdominal wall hematomas: patient is on [MEDICATION NAME] and [MEDICATION NAME]. Hold [MEDICATION NAME] and [MEDICATION NAME] and aspirin. Pain management. Acute blood loss [MEDICAL CONDITION]: bleeding into anterior abdominal wall. Transfuse if hemoglobin drops further. During the course of the resident's hospital admission, her hemoglobin dropped to the degree that she required blood [MEDICAL CONDITION]. The hospital discharge summary completed for resident #1 on 4/6/14, indicated final [DIAGNOSES REDACTED]. Patient should not receive bridging therapy for future interruptions in anticoagulation. A hand drawn image of the resident's abdomen was added to the summary which indicated observed bruising to 3/4 of the resident's abdominal wall. On 4/10/14 at 11:00 a.m., surveyor # interviewed LPN-D regarding resident #1. LPN-D stated, "I let the doctor know the resident's (#1) POA wanted her to see her regular doctor on Friday (4/4/14) but the POA changed her mind on 4/3/14 and wanted the resident sent to the emergency room . I saw the resident on the day shift of 4/3/14 and I talked to the RN. Her abdomen was red at the injection sites more like bruising, and her entire abdomen was red. I called the doctor late morning on 4/3/14 and he felt it wasn't an emergent situation and that the bruising was from the shots. I know the hospital listed [MEDICATION NAME] as an allergy." On 4/14/14 at 1:10 p.m., surveyor # interviewed LPN-I regarding resident #1. LPN-I stated, "I know (LPN-D) had called the doctor (for resident #1) the morning of 4/3/14. The doctor called back at 11:30 a.m. that morning and I talked to him. He told us just to monitor now for infection." On 4/14/14 at 2:00 p.m., surveyor # interviewed DON-B regarding resident #1. DON-B stated, "(LPN-JJ) had called me the evening of 4/2/14 regarding her (#1) abdomen. She told me that the resident had some areas of redness and warmth and an area of protrusion that looked like a hernia. She told me the bruising was in the area of the protrusion. In my head, I had a visual that the bruising was only at the site of protrusion. She didn't say the resident had bruising through out the abdomen. It sounded like a hernia with questionable [MEDICAL CONDITION]. I told her to call the doctor. I can't recall if I told her specifically to contact the doctor that night, I meant that but I'm not sure how she interpreted that. An RN supervisor is in the building during the p.m. shift and staff know they need to relay the information to that RN so the RN can complete an assessment, and they know they also need to inform me. I thought the issue was just local due to [MEDICATION NAME] shots and maybe some [MEDICAL CONDITION] by what I was told." On 4/14/4 at 2:40 p.m., surveyor # interviewed RN-X regarding resident #1. RN-X verified to the surveyor that she had been the p.m. supervisor in the facility the evening of 4/2/14, working 2:00 p.m. until 10:00 p.m. RN-X stated "(LPN-JJ) asked me to assess her (#1) abdomen for bruising, redness and firmness. She told me the resident was getting [MEDICATION NAME] shots in the abdomen. I looked at the resident's abdomen and I saw redness in the left lower abdominal quadrant 8 cm x 5-6 cm. The whole abdomen was bruised with purples, greens, and yellows. There was a firm area in the epigastric (the upper central region of the abdomen) region which I questioned to be a hernia. Per (LPN-JJ), the resident had pain with palpation of the abdomen. She was told to call the DON, the resident's POA and the doctor. I wasn't sure if she was going to call or fax the doctor. She called me to the unit just to make sure she was doing the right thing. I was unaware of what the resident's vital signs had been. I didn't know what her INR's were running. I thought it could wait. I've seen a lot of abdomens look like that with [MEDICATION NAME]. I didn't think it was acute to the point where the resident needed to be shipped out. I didn't know the resident's history and I didn't look at her medical record. I was surprised that the doctor wasn't notified that evening. I didn't know how many [MEDICATION NAME] injections she had gotten. (LPN-JJ) just wanted me to look at the resident to see if I should call the doctor and DON. I didn't document my assessment. I should have. I thought the DON would guide (LPN-JJ) on what to do. The doctor should have been notified by phone not faxed that evening." On 4/14/14 at 2:50 p.m., surveyor # interviewed LPN-L regarding resident #1. LPN-L stated, "On 3/14/14 when I noticed the bruise on her (#1) abdomen, I notified the RN, and she said it was just due to the [MEDICATION NAME]. I noticed the resident only had one bruise at that time at the site of the [MEDICATION NAME] shot. I work regularly on her (#1) unit, and her abdomen was not like it was mentioned in the nurses note on the p.m. of 4/2/14 prior to that. It was an all of a sudden thing." On 4/14/14 at 3:00 p.m., surveyor # interviewed LPN-JJ via the telephone regarding resident #1. LPN-JJ stated, "I told the nursing supervisor that she (#1) was on [MEDICATION NAME] shots. Her whole abdomen was in different stages of bruising and I noted bruising throughout her abdomen. Her (#1) daughter was there earlier in the shift and was concerned. I'm not sure if I took any vitals on the resident. The nursing supervisor (RN-X), myself and (RN-W) all looked at the resident on the p.m. shift of 4/2/14. They agreed with me to have the resident's doctor updated in the morning. I passed that message onto nights to have them tell the day shift to call the doctor. I didn't think it was acute. I assumed it was due to the [MEDICATION NAME]. It is not in the scope of my practice to assess." On 4/14/14 at 3:30 p.m., surveyor # interviewed LPN-D via the telephone regarding resident #1. LPN-D stated, "I looked at her (#1) abdomen before I called the doctor (on 4/3/14). Her abdomen looked like she had some fresh dark bruises and healing bruises across her entire abdomen. She was getting injections and the round bruising was surrounding her belly button. The rest of her abdomen was reddened. Normally I would have documented that, and I'm not sure why I didn't. I knew her INR levels and I was aware of her hemoglobin levels." On 4/15/14 at 8:00 a.m., surveyor # interviewed RN-W via the telephone regarding resident #1. RN-W stated, "I believe I did go look at the resident (#1) on 4/2/14 on the p.m. shift. I am not familiar with the resident at all. The left side of her abdomen was really red if I remember right. I don't remember but I think she said it hurt. I don't recall if I touched her abdomen. I didn't look at her chart. I let the staff know they needed to get a hold of the doctor. I knew the resident was getting [MEDICATION NAME] injections. I was wondering if she had an infection. I wasn't the supervisor that evening so I didn't document anything. (RN-X) was the supervisor and I thought she was going to do that. The RN's are supposed to be doing the physical assessments, but a lot of times, the LPN's do the assessments. I guess I thought they called me just for an opinion." Review of resident #1's Doctors office nurse triage call notes included the following documentation: * 4/3/14 at 10:22 a.m. - LPN-D had called the physician and left a message to include, "(Resident #1) is having abdominal pain and bruising, red, warm to touch with 4-5 protrusions. She is currently receiving [MEDICATION NAME] injections. This was noted last night, and has constant abdominal pain. She states with palpation resident had 1 inch wide to 4 inches protrusion in the abdominal area that are round in shape. She states her pain is at 6 on pain scale (1 - 10 pain scale), is eating and drinking okay, she is urinating and having BM (bowel movement), she denies dizziness. The larger protrusions are at the LLQ (left lower quadrant) and RUQ (right upper quadrant) by naval. Vital signs included BP 76/42. Recheck was 84/40. Normal temperature, pulse and respirations. POA want an appointment tomorrow. Okay to monitor especially lower BP as she is scheduled with you tomorrow morning at the POA's request?" The information relayed to resident #1's physician by LPN-D did not include the extensiveness of bruising and redness of the abdomen the resident had been displaying.

Based on observation, record review and staff and resident interview, the facility did not ensure that each resident received and 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 #9) of 16 sampled residents. Resident #9 has a history of chronic pain and has received scheduled [MEDICATION NAME] and [MEDICATION NAME]es, [MEDICATION NAME] and [MEDICATION NAME] for pain management. Resident #9 also can receive PRN (as needed) [MEDICATION NAME]. Resident #9 was observed to be in pain, and staff indicating resident #9 was crying due to pain. Although, resident #9 received scheduled [MEDICATION NAME] at 8:00 a.m. and a PRN [MEDICATION NAME] at 9:57 a.m., resident #9 continued to be in pain and presented with both verbalizations of pain and non verbal signs/symptoms of pain. When resident #9 verbalized she continued to be in pain, the nurse stated the resident needed to wait 2 more hours before receiving any more pain medications. The facility did not provide appropriate pain management nor did the facility update the physician until the afternoon regarding resident #9's pain, until after interviewed by surveyor # . Findings include: On 04/08/14 at 9:30 a.m., surveyor # observed resident #9's call light on and it was answered by CNA-S (Certified Nursing Assistant). CNA-S was observed exiting the room and stating to LPN-I (Licensed Practical Nurse) that resident #9 was complaining of pain in "her butt." Surveyor # looked into resident #9's room. Resident #9 was lying in bed and facial grimacing was observed from the hall. On 04/08/14 at 9:37 a.m., surveyor # observed CNA-S to assist resident #9 with personal cares. Resident #9 was observed to have been lying in bed and had her eyes closed tightly and presented with facial grimacing. CNA-S started to assist resident #9 in lifting her legs. Resident #9's facial grimacing observed to have tightened. CNA-S was looking at resident #9 and stated, "That hurts. I'm not going to do it then." CNA-S assisted resident #9 to sit at the side of the bed and scooted resident #9 forward by pulling on the protective cloth pad that resident #9 was sitting on. Resident #9 was observed to be very guarded with movement. Resident #9 was assisted to the toilet with the mechanical assistance of a sit/stand lift. CNA-S asked resident #9 if she was experiencing any pain. Resident #9 responded not right at the moment, but did request something additional for pain. CNA-S left the room and returned with LPN-I. CNA-S was observed to wipe resident #9's buttocks, and resident #9 flinched when touched, and presented with facial grimacing. CNA-S and LPN-I assisted resident #9 back into bed. Resident #9 appeared to have guarded body language with movement and presented with facial grimacing with the transfer. On 04/08/14 at 9:40 a.m., surveyor # interviewed resident #9. Resident #9 stated, "My butt hurts so bad. I have a hole in my butt and I need to relocate my butt" (Meaning reposition). Resident #9 stated the staff administers pain medications and they do help "somewhat", but she always has pain. Resident #9 indicated her pain was a 7, using a 1 - 10 pain scale. Resident #9 stated she was crying earlier in the day because "I hurt so bad." Resident #9 indicated the pain feels like a knife going through her butt and she is always in pain. Resident #9 indicated at times her pain is tolerable, but most of the time it isn't. Resident #9 also indicated some days are better than others. Surveyor # questioned resident #9 if the facility ever spoke to her about her goals for pain and what she would want. Resident #9 indicated she would rather be pain free and sleepy then to experience the pain she has. Resident #9 verified she is very guarded with movement because at any time her pain can become very severe and she always seems to be waiting for this to happen. Resident #9 indicated pain is not usually significant when not moving. On 04/08/14 at 9:50 a.m., surveyor # observed LPN-I assist resident #9 to sit at the side of the bed. Medications were given to include [MEDICATION NAME]. Resident #1 presented with significant facial grimacing. LPN-I stated to "take a deep breath" and proceeded to lie resident back into bed. LPN-I asked, "Is that better?" and resident #9 shook her head yes. CNA-S was present in the room. LPN-I and CNA-S left the room and CNA-S stated, "I hope your hinder gets better." On 04/08/14 at 9:55 a.m. surveyor # , interviewed CNA-S regarding resident #9. CNA-S indicated when she had entered resident #9's room earlier, that she was crying because of the pain she was experiencing. CNA-S indicated the pain that resident #9 complains of is "in her butt." CNA-S stated resident #9 previously had a pressure ulcer, but has healed. CNA-S indicated resident #9's pain has worsened lately. Surveyor # questioned CNA-S about why she told resident #9 she "wasn't going to do that", when cares were provided. CNA-S stated that she meant she wasn't going to remove the pillow from below her knees, as she was aware resident #9 was experiencing pain and it seemed like the pain is increasing in intensity. CNA-S stated that resident #9 jerked in pain when she wiped her buttocks, but was unable to visualize if resident #9 was displaying facial signs/symptoms of pain. CNA-S indicated resident #9 also had refused cares lately due to pain, and the APNP (Advanced Practice Nurse Practitioner) indicated to try and encourage resident #9 to get out of bed for at least one hour a day, in hopes to help with the pain. CNA-S indicated resident #9 typically will stay in bed due to pain. CNA-S stated that she thought resident #9 would not get out of bed because she was afraid that staff would not return to her in time to put her back into bed when she requested. On 04/08/14 at 12:15 p.m., surveyor # interviewed SW (Social Worker)-LL regarding resident #9's ability to be accurate in her statements. SW-LL indicated resident #9 was able to voice her concerns, and would be able to voice pain accurately. On 04/08/14 at 12:30 p.m., surveyor # observed resident #9 resting in bed and without facial grimacing. Resident #9 stated she was still having pain but the pain is more tolerable as long as she doesn't move. Resident #9 indicated her pain was still at a "7" with movement. On 04/08/14 at 12:45 p.m., surveyor # observed resident #9 place her call light on. Resident #9 was seated upright in bed, at approximately a 45 degree angle, and was displaying facial grimacing. Resident #9's lunch tray was observed on an overbed table in front of her. At 12:50 p.m., surveyor # interviewed resident #9 regarding her pain. Resident #9 stated the pain is so bad now. Resident #9 indicated the pain worsened when she was repositioned to eat lunch. Surveyor # left resident #9's room. At 12:54 p.m., CNA-C entered resident #9's room and exited the room at 1:00 p.m. On 04/08/14 at 1:05 p.m., surveyor # interviewed CNA-C regarding resident #9. CNA-C stated resident #9 complained of butt/low back pain when he entered her room. CNA-C indicated resident #9 appeared to almost be in tears when he entered the room, and had a tearful sound to her voice when she reported the pain. CNA-C stated he needed to notify the nurse of resident #9's complaints of pain. CNA-C indicated today was the worst that he has seen her complain of pain. CNA-C indicated resident #9 always had pain and at times does request pain medications. CNA-C stated resident #9 always stays in bed, but was unaware as to why, as he usually works at the other end of the hall, and just helps out on the end where resident #9 resided, to answer call lights. CNA-C stated he was aware that resident #9 was alert and oriented with intermittent confusion but is able to voice her needs and complaints of pain. On 04/08/14 at 1:35 p.m., surveyor # interviewed LPN-I regarding resident #9's pain. LPN-I stated she has worked on the unit for approximately 2 months and resident #9 has constant pain. LPN-I stated that resident #9 has described to her that it felt like "something is shoved in there" (meaning the coccyx area). LPN-I indicated that resident #9 indicated her pain was usually at a "6" (1 - 10 scale). LPN-I stated staff will try to reposition resident #9 if she is unable to have any PRN pain medications if she hasn't waited the prescribed time between medications. LPN-I indicated the pain seems to worsen when she sits up in bed. LPN-I stated there was a metal support bar that is horizontal across the bed where resident #9 would sit, and believes the metal bar might be contributing to her pain. Surveyor # asked LPN-I if the bed was ever replaced with a different bed, and LPN-I responded "no." LPN-I stated the APNP would like resident #9 to get out of bed and sit in her chair for at least an hour a day to see if that would help alleviate her pain, but resident #9 refused today and half the time will refuse due to pain. LPN-I verified resident #9 appeared very guarded when she is moved. Surveyor # asked LPN-I if she was told that resident #9 was crying earlier in the day because of the pain she was experiencing. LPN-I responded, "no." Surveyor # told LPN-I of CNA-S and CNA-C's interviews stating that resident #9 was crying or near crying due to pain. LPN-I re-iterated she was not told by either CNA's regarding resident #9's crying because of pain. Surveyor # questioned LPN-I regarding resident #9's pain management program. LPN-I stated resident #9 has been on the same pain management program since she started working on the unit. LPN-I indicated the APNP was at the facility recently and that was when it was recommended resident #9 get out of bed. On 04/08/14 at 1:50 p.m., surveyor # interviewed resident #9. Resident #9 was observed to be lying in bed with significant facial grimacing. Resident #9 stated she continued to be experiencing pain. Resident #9 stated she has not seen a nurse since CNA-C had left the room at approximately 1:00 p.m. Surveyor # went to LPN-I and updated her regarding resident #9's pain. Surveyor # and LPN-I went to resident #9's room. On 04/08/14 at 2:00 p.m., surveyor # observed LPN-I ask resident #9 what she would like the nurse to do regarding her pain, because she can't have any more pain medication for 2 hours. LPN-I offered to reposition or to massage the painful area. Resident #9 did accept repositioning. LPN-I was observed to tell resident #9 "to take a deep breath and blow it out" while she removed a pillow from under her lower extremities. While resident #9 remained lying on her back, LPN-I was observed taking her hand and placing it under resident #9's buttocks and was pushing on different areas and asking if it hurt? LPN-I then pressed on a specific area and resident #9 "jerked", and presented with significant facial grimacing and stated "Please don't play with my back." LPN-I removed her hand and assisted resident #9 to lie slightly on her right side so the buttock area was visible. Resident #9 was displaying facial grimacing of pain and cried out, "Ow." A protective dressing was visible over the coccyx with a date of 04/06/14. LPN-I stated to resident #9 if an Aqua K (a heated water filled pad that is used for moist heat, for a large area of the body) pad might help, and resident #9 replied, "Yes." LPN-I then asked resident #9 what she did at home when she had pain and resident #9 replied, "Cry." LPN-I and surveyor # left the room. On 04/08/14 at 2:05 p.m., surveyor # interviewed LPN-I regarding if the physician was notified of resident #9's pain and if she thought resident #9's was experiencing significant pain. LPN-I verified resident #9 was experiencing real pain and it was not a behavior. LPN-I stated the MD (medical doctor) was not notified of resident #9's pain as the APNP was at the facility the other day and wanted resident #9 to get out of bed. (The medical record indicated the APNP was at the facility on 04/02/14 and indicated to encourage to get resident #9 out of bed). Surveyor # stated the APNP was at the facility on 04/02/14 and it was 6 days later and resident #9 continued with pain and was not getting out of bed due to pain. LPN-I told surveyor # the facility had to give it time before calling the MD. On 04/08/14 at 2:10 p.m., surveyor # interviewed PM shift LPN-NN regarding resident #1's pain. LPN-NN stated the nurses' document refusals when resident #9 doesn't get out of bed. Surveyor # asked LPN-NN if she was aware of why resident #9 refuses to get out of bed, and LPN-NN stated she has never asked why she doesn't want to get out of bed. LPN-NN indicated the CNA's ask and are told she doesn't want to. LPN-NN indicated she was aware at times, resident #9 would state it was because of pain. LPN-NN indicated it was just a recent order from the APNP to get out of bed, so it would be too soon to update the physician or APNP regarding the pain that resident #9 was experiencing. On 04/08/14 at 2:45 p.m., surveyor # interviewed PM CNA-K regarding resident #9's pain. CNA-K stated 2 days prior to this interview, on Sunday, resident #9 c/o butt pain and wanted the nurse. CNA-K indicated resident #9 was crying, but there wasn't any tears but definitely a crying complaint. CNA-K indicated she went and told LPN-NN and was told to reposition her and to report back if she continued to complaint of pain. CNA-K stated resident #9 was displaying facial grimacing. CNA-K indicated it has been the last month or so that resident #9's pain seems worse. On 04/09/14 at 7:10 a.m., surveyor # questioned LPN-I if the physician was notified of resident #9's pain and if she had spoken with the CNA's that reported crying with pain to surveyor # on 04/08/14. LPN-I verified she had updated the physician regarding resident #9's complaints of pain and requested an Aqua K pad to be used. LPN-I stated the facility is waiting for the Aqua K pad to arrive. LPN-I indicated she had spoken with both CNA's regarding resident #9 crying with pain and educated them if resident #9 was crying because of pain, the nurse needs to be notified immediately. On 04/09/14 at 7:20 a.m., surveyor # interviewed resident #9. Resident #9 stated today was a much better day for her regarding her pain level. Resident #9 indicated she has good days and bad days regarding her pain, and yesterday was a very bad day for her. On 04/09/14, surveyor # reviewed resident #9's medical record. According to the face sheet, dated 01/02/14, resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The medical record contained "physician's orders [REDACTED]. The order sheet indicated resident #9 requested comfort measures only, which includes medication, positioning and other measures are used to relieve pain and suffering........If comfort measures fail, contact physician. The facility developed a plan of care for "Potential for pain related to nerve pain and generalized discomfort dated 09/19/12. The following were interventions listed to treat pain. The interventions were listed as the same date of the plan of care development and without any revisions. * Administer pain medications PRN * Allow time for medication to work prior to moving or providing cares PRN * Document pain level PRN * Assess physical symptoms upon onset PRN * Offer non-pharmacological interventions such as; positioning, ice, exercise, diversion and distraction * Report pain to the nurse * Update MD if pain is not controlled * Use numerical scale According to resident #9's Quarterly MDS (minimum data set) dated 11/06/13, resident #9 had almost constant pain, and the pain has made it hard for her to sleep at night and has limited her day to day activities because of pain. The facility did not complete a comprehensive pain assessment and revise resident #9's plan of care related to the MDS pain data. Resident #9's Annual MDS, dated [DATE], indicated resident #9 continued with almost constant pain, and pain has made it hard for her to sleep at night and again has limited her day to day activities. The facility did complete a CAA's (care area assessment) regarding resident #9's pain. The CAA's for pain indicated this concern was an actual problem and the nature of the problem was summarized as "Resident has chronic pain. She receives scheduled and PRN [MEDICATION NAME]. She is alert and able to communicate discomfort. She prefers to spend most of her time in bed. She is monitored daily for pain. Resident has a [DIAGNOSES REDACTED]." Surveyor # reviewed the pain CAA's worksheet for resident #9. The areas of diseases and conditions that may cause pain, characteristics of the pain, frequency and intensity of pain, non verbal indicators of pain and associated signs and symptoms of pain were not assessed. The assessment of resident #9's pain related to MDS data was not comprehensive. The physician's orders [REDACTED].#9 received [MEDICATION NAME] 5% patch to the coccyx daily with a start date of 07/30/11, [MEDICATION NAME] 150 mg (milligrams) twice daily with a start date of 10/21/11, [MEDICATION NAME] 50 mcg (micrograms) patch, to change every 3 days with a start date of 07/18/12, [MEDICATION NAME] 1 tab 5/325 twice daily and every 6 hours PRN with a start date of 03/06/14. Resident #9 was previously on [MEDICATION NAME] 1 tablet 5/500 twice daily and every 6 hours PRN, but was changed on 03/06/14 due to the manufacturer no longer made the 5/500 strength of [MEDICATION NAME]. The original start date of the [MEDICATION NAME] 5/500 strength was 09/19/12. The APNP assessed resident #9 on 04/02/14 and indicated resident #9 continued without any change in her low back pain regarding her symptoms. The APNP progress note indicated that resident #9 reported that her pain is primarily in her "butt." She was unable to give more specifics about this pain and does spend the entire day in bed. When asked why she does this, she states that if she gets up, she has pain in her legs and back. Pain medications are encouraged, as is getting out of bed at least once a day-coinciding with a meal is ideal. She currently verbalizes understanding and agreement. The APNP's physical exam indicated resident #9 was in no acute distress, was awake, conversant and cooperative.

Based on record review and staff interview, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical well-being for 1 (resident #1) of 1 sampled residents, with two examples. Example 1: Resident #1 was admitted to the facility after a fall. Resident was experiencing significant pain with movement. The facility contacted the physician regarding pain, and received an order for [REDACTED]. Although, the facility administered [MEDICATION NAME], resident #1's pain continued with movement. The facility did not have a CAM boot to be placed for stabilizing resident #1's left ankle until he could be seen by the orthopedic physician. The facility did not update the physician and request alternative treatment for [REDACTED].#1. Staff indicated resident #1 yelled out in pain with movement. The facility did not develop a plan of care to control pain when the fracture was diagnosed . Example 2: Resident #1 received a removable aircast boot from the orthopedic physician. Orders were received to check skin integrity daily. The facility implemented CMT (color, motion, temperature) assessments daily in the evening. Although, the documentation indicated the assessments were completed nightly, staff indicated resident #1 wore a sock that was not removed during the assessment. Resident #1 also received a shower on 2/18/13, prior to a physician's appointment. The staff that had assisted with the shower indicated she had never observed resident #1's plantar aspect of his left foot. Resident #1 saw the PA's (physician's assistant) on 2/18/13, and was diagnosed with [REDACTED]. The facility RN (Registered Nurse), who was also wound care certified, indicated the area was on the distal aspect of resident #1's arch of the left foot, and had not developed from pressure, but appeared to have developed from moisture and was a denuded (loss of epidermis, top layers of the skin) area. The facility had not completed the daily assessments as ordered by the PA on 1/4/13, and staff that had assisted with the shower had not completed a skin sweep to check for breaks in skin integrity. The facility was unaware of the break in skin integrity on resident #1's plantar aspect of the left foot until the PA's office had updated the facility. Findings include: Example 1: On 4/2/13, surveyor # reviewed resident #1's medical record. According to the hospital emergency room report, date 12/25/12, resident #1 was seen at the hospital related to pain of his left leg, knee and hip after a fall that was sustained at home. Resident #1 was discharged to the facility with orders for Tylenol #3 to have been administered as needed. The progress notes, dated 12/26/12 at 9:44 AM indicated the physician's office was contacted related to resident #1's continued pain to the left foot and ankle despite Tylenol #3 administration. Received orders for STAT (immediate) X-ray of the left foot and ankle. Request given to "whether or not something different could be used to manage pain. Awaiting orders." The physician's office sent a fax to the facility dated 12/26/12, for the following orders: * OK for order for stat foot x-ray.....No physical therapy at this time. * Can also have order for [MEDICATION NAME] 5/500 mg. (milligrams), 1 -2 tablets every 6 hours as needed for foot pain. Do not take Tylenol #3 when taking [MEDICATION NAME]. * Recommend cam walker left lower leg and an orthopedic consult. An X-ray was completed on 12/26/12, by Accurate Imaging, a mobile X-ray company. The X-ray report, dated 12/26/12, indicated resident #1 had an acute nondisplaced [MEDICAL CONDITION] shaft of the fibula. The progress notes, dated 12/27/12 at 3:56 PM, indicated patient returned from orthopedic appointment at 3:30 PM... Orders to be non weight bearing status on injured limb, w/c (wheelchair) only, no physical therapy at this time and to elevate ankle. Gray aircast walker boot is to be worn at all times except for bathing..... According the the facility staffing schedule, CNA's (Certified Nursing Assistants) A, B and C were working on resident #1's unit on 12/26/12. On 4/2/13 at 12:40 PM, surveyor # interviewed CNA-A regarding resident #1's pain. CNA-A stated resident #1 was a hoyer lift for transfer due to pain. CNA-A indicated resident #1 would holler and yell out very loudly in pain when he was moved. CNA-A stated resident #1 would yell so loudly that he was heard in the hallway. CNA-A indicated the nurses were aware but was unsure if any pain medication was administered. On 4/2/13 at 12:50 PM, surveyor # interviewed CNA-B regarding resident #1's pain. CNA-B stated resident #1 was alert and oriented with episodes of confusion, but was able to make his needs known. CNA-B stated resident #1 was initially a 2 assist transfer, but due to pain was changed to a hoyer transfer because of pain and the [DIAGNOSES REDACTED]. CNA-B indicated the nurses were aware of resident #1's pain with movement. CNA-B stated resident #1's pain minimized quickly when the aircast was placed. On 4/3/13 at 10:05 AM, surveyor # conducted a telephone interview with CNA-C regarding resident #1's pain. CNA-C stated resident #1 had significant pain at times with movement. CNA-C indicated resident #1 complained of left ankle pain. CNA-C indicated resident #1 would yell out in pain when he was assisted with movement of the left leg. CNA-C indicated the nurses were aware of resident #1's pain. CNA-C stated she only recalled the aircast that was placed on resident #1's ankle and there was nothing placed earlier for stabilization of the left ankle. On 4/2/13 at 3:35 PM, surveyor # interviewed RN-G (Registered Nurse) regarding resident #1's pain. (According to the schedule RN-G worked at the facility on 12/25 & 12/26/12. RN-G stated resident #1 had significant pain when the foot was moved, but was without pain when at rest. On 4/3/13 at 8:30 AM, surveyor # interviewed LPN-D (Licensed Practical Nurse) regarding resident #1. LPN-D verified he had received the fax from the physician on 12/26/12 regarding the CAM boot order. LPN-D verified resident #1 had not received a CAM boot for stabilization of the left foot on 12/26/12. LPN-D stated he had updated RN-F Unit Manager regarding the order and he and PT-E (Physical Therapist) were working on getting the CAM boot. LPN-D stated he could not recall if anything was used to stabilize resident #1's ankle prior to the aircast provided by the physician on 12/27/12. LPN-D indicated resident. LPN-D verified resident #1 had a significant amount of pain, but the pain was present only with movement. LPN-D indicated due to the level of pain was why he asked for a stronger pain medication. On 4/3/13 at 8:40 AM, surveyor # interviewed PT-E regarding the CAM boot. PT-E stated he had spoken to RN-F regarding the CAM boot physician order [REDACTED]. PT-E stated the facility does not stock CAM boots and had to have been ordered. PT-E indicated physical therapy was not involved because the physician did not want physical therapy at that time. PT-E stated he would not know if resident #1's ankle was stabilized after the fracture was diagnosed , because he wasn't involved. The progress note dated 12/27/12 at 3:54 AM, indicated resident #1 had no complaints of pain and the CAM boot was utilized on the left foot. On 4/3/13 at 9:15 AM, surveyor 5 interviewed RN-F Unit Manager regarding resident #1's pain and stabilization of the left ankle. RN-F stated he wasn't aware that resident #1 was having significant pain as there was no documentation regarding pain. RN-F verified he had discussed the CAM boot with PT-E after the [DIAGNOSES REDACTED]. RN-F indicated he ordered the CAM boot and it was to have been delivered on 12/27/12. RN-F stated he had not called the physician to request alternative devices that could have been used for stabilizing the left ankle due to pain with movement. RN-F indicated the CAM boot arrived at the facility after resident #1 returned from the physician's office on 12/27/12, and already had an aircast boot in place. RN-F indicated he wasn't aware of any device used to stabilize resident #1's ankle prior to receiving the aircast at the physician's office. R RN-F indicated he had seen the documentation on 12/27/12 at 3:54 AM, that resident #1 was wearing a CAM boot, and thought that was strange, as there wasn't a CAM boot at the facility. RN-F indicated after reading the documentation that resident #1 was wearing a CAM boot, he went to resident #1's room to see if there was anything in the room, but couldn't recall any further specifics. RN-F verified an acute plan of care for pain was not developed when resident #1 was diagnosed with [REDACTED]. Example 2: On 4/2/13, surveyor # reviewed resident #1's medical record. According to the hospital emergency room report, date 12/25/12, resident #1 was seen at the hospital related to pain of his left leg, knee and hip after a fall that was sustained at home. According to an x-ray report dated 12/26/12, resident #1 was diagnosed with [REDACTED]. Resident #1 was seen by an orthopedic PA on 12/27/12, when a aircast boot was placed on resident #1's left lower extremity. Resident #1 was again seen by the orthopedic PA on 1/4/13, and orders were received to check the skin daily. The TAR (treatment administration record) and MAR (medication administration record) for February 2013 indicated in the evening, the nurse was to remove the CAM boot and check CMT's daily (color, motion and temperature) daily. The MAR indicated [REDACTED]. The TAR and MAR indicated [REDACTED]. On 2/18/13, resident #1 was seen by the orthopedic PA for follow up of the left fibula fracture. The written report again indicate for facility staff to complete daily skin checks. The report indicated resident #1 had developed a 1 inch by 2 inch area of pressure ulcer developing on the plantar aspect of his heel. There was no surrounding [DIAGNOSES REDACTED]. It is very superficial at this point. On 4/2/13 at 10:15 AM and on 4/3/13 at 10:45 AM, surveyor # interviewed RN-F regarding resident #1's skin integrity concerns of the left plantar foot. RN-F stated he was a wound certified nurse and when he received the report of the concerns of the left plantar foot he went to assess the area. RN-F indicated the area was located on the proximal arch of the left foot and the heel was not involved. RN-F indicated he had thought the area was not from pressure, but was macerated from moisture. RN-F verified the area was approximately 1 by 2 inches with only a few layers of skin sloughing away. RN-F indicated he thought the area was denuded. RN-F stated when he removed resident #1's aircast, the foot was very sweaty or he also thought it was possible the foot was not completely dried after he had received a shower that morning. RN-F indicated the daily skin checks would have been completed when the CMT's were completed in the evening. RN-F stated he placed a foam dressing over the denuded area, but resident #1 discharged from the facility prior to completing another measurement of the denuded area. RN-F stated he was unaware of any skin integrity concerns of resident #1's left plantar aspect of his foot until the physician's office had notified the facility. On 4/2/13 at 5:20 PM, surveyor # conducted a telephone interview with RN-H regarding the CMT evening assessment. RN-H stated resident #1 wore a heavy sock under the air cast. RN-H verified she had removed the aircast each evening she worked, but had never removed the sock to assess color, temperature. RN-H verified she could not have assessed skin integrity as she hadn't removed the sock. Surveyor # questioned RN-H if the Vicks [MEDICATION NAME] was placed on resident #1's toenails per the physician's orders [REDACTED]. RN-H verified she only placed the Vicks [MEDICATION NAME] on resident #1's toenails on his right foot. On 4/3/13 at 10:00 AM, surveyor # interviewed CNA-A regarding resident #1's shower which was given on 2/18/13, prior to the physician's appointment. CNA-A verified she was assisting with giving resident #1's shower on 2/18/13, but verified she had not conducted a skin sweep of resident #1's bottom of his feet. CNA-C indicated she was training another CNA (who no longer worked at the facility) and so she, (herself) was in and out of the shower room, and had not stayed with the trainee.

Based on record review, resident and staff interviews, the facility did not ensure that all allegations involving mistreatment, abuse, neglect, injuries of unknown source and misappropriation of resident property were reported immediately to the administrator of the facility and to other officials in accordance with State law (including the State survey and certification agency) for two examples involving 1 (resident #1) of 4 sampled residents. The facility did not conduct an immediate investigation and did not take steps to prevent further potential abuse from occurring while an investigation was underway. 1. Resident #1 was assessed to be totally cognitively impaired and resided on a secured unit of the facility. Resident #1 had unsupervised visits with her spouse, resident #2, who resided on a separate secured unit of the facility. Documentation indicated that resident #1 had periodic episodes of vaginal bleeding. On 2/8/13, resident #1's physician documented that two weeks prior, the resident experienced vaginal bleeding after a visit with her spouse. Staff informed resident #1's physician that the resident's spouse engaged in sexual intercourse with her against her will and that resident #1 was visibly shaken and crying after their visit. This information had not been relayed to the staff responsible for initiating an investigation into the incident, per the facility's policy. Subsequently, the facility did not conduct a thorough investigation into the allegation of abuse and allowed resident #1 to continue previously established, daily, unsupervised contact with her spouse. Resident #1 had notable vaginal bleeding on 2/10/13 and had vaginal bleeding on 2/11, 2/12, 2/13, and 2/14/13. 2. Resident #2 alleged that a staff member had intercourse with his spouse, resident #1, on 2/21/13. The facility did not ensure that a reasonable suspicion of a crime committed against a resident of that facility was reported to at least one law enforcement agency of jurisdiction until 4 days after the allegation of sexual abuse had been reported. The facility's failure to investigate the incident regarding the suspected sexual abuse by resident #1's spouse and its failure to prevent further potential abuse to resident #1 while the investigation was in progress created a finding of immediate jeopardy (situation has caused or is likely to cause serious harm and there is a reasonable degree of predictability of similar situation occurring in the future) that began on 2/8/13. The facility was notified of the immediate jeopardy on 2/25/13. The immediate jeopardy was removed on 2/25/12. The deficient practice continues at a scope/severity level of D (potential for harm that is not immediate jeopardy/isolated) because the facility has yet to fully implement its corrective action plan. Findings include: 1. Resident #1's admission face sheet dated February 2012 indicated the resident had [DIAGNOSES REDACTED]. Resident #1 was admitted to a secured unit of the facility and had guardianship in place. Resident #1's admission MDS (minimum data set) dated 2/15/12 indicates the resident was assessed to have scored a 1 of 15 on the cognition screen (the lower the score, the less cognizant), had no mood indicators or behaviors, and was independent in ambulation, transfers and eating. A significant change MDS completed for resident #1 on 5/2/12 indicated the resident's cognition, ability to eat independently, mood indicators and behaviors had not changed, but the resident was now assessed to require limited assistance from one staff to ambulate and to accomplish transfers. An additional MDS dated [DATE] indicated that resident #1 now required extensive assistance to perform personal hygiene in comparison with the previous two assessments. The MDS dated [DATE], indicated resident #1 now required extensive assistance to ambulate and transfer, and required increased limited assistance to perform eating. Resident #1'S most current MDS dated [DATE] indicated the resident now required extensive assistance to perform eating. All of the above-mentioned MDS assessments completed for resident #1 indicated that the resident sometimes understands others and responds adequately to simple and direct communication. Resident #2, who was resident #1's spouse, was admitted to the facility on [DATE] in the same room as resident #1. Resident #1's admission face sheet indicated the resident had [DIAGNOSES REDACTED]. Resident #2 had guardianship in place. Resident #2's admission MDS dated [DATE] and an additional MDS dated [DATE] indicated the resident had scored a 7 of 15 on the cognitive screen and was independent in all areas of functional status. These MDS assessments indicated resident #1 usually could be understood by others, had difficulty communicating some words or finishing thoughts (was able if prompted and given time), sometimes understood others and responds adequately to simple and direct communication. A nursing entry in resident #2's medical record documented that on 7/6/12, "resident was being intimate with (resident #1) this morning. (Resident #1) made the comment that she "hurt. " (Resident #1) made a comment telling (resident #2) to leave after breakfast. " A Social Services note in resident #2's medical record documented that on 7/6/12, "Resident noted to have intimate relations with wife. Writer made aware by staff of relations. Writer contacted daughter to notify that intimate relations where occurring during the night shift last night. " A nursing entry in resident #2's medical record dated 7/8/12 indicated, "Excessive agitation this shift. Was attempting to help spouse with a.m. cares when spouse fell . Had verbal outbursts towards spouse, peers and staff. Spouse was removed from the situation, agitation continued, placed on 1:1 monitoring. " A nursing entry in the resident #2's medical record dated 7/12/12 indicated, "Spouse came to visit for lunch. (Resident #2) very upset with her, he accuses her of cheating on him. After lunch, he wanted to take spouse to room so he could "talk to her. " When the staff went to check on them, he had (resident #1) on his bed with her pants half way down. (Resident #1) was taken back to her room on unit 2. " On approximately 7/8/12, resident #1 was moved to a separate secured unit of the facility due to the resident's decline in functional status and safety concerns relating to resident #2 assisting her to transfer that had resulted in resident #1 falling. Documentation and staff interviews indicate that resident #1 and resident #2 continued to daily spend scheduled time together, from approximately 11:30 a.m. until 2:00 p.m. and also whenever resident #2 requested visitation. A Social Services note located in resident #2's medical record and dated 7/13/12 indicated, "Reviewed with direct care staff. Resident is able to be in room with wife. Resident and wife are able to be in room by themselves. Direct care staff will continue to monitor situations when residents are together: offering privacy and ensuring that safety is maintained. " On 7/17/12, DCC (Dementia Unit Care Coordinator)-D met with the Ombudsman to review the relationship status between resident #1 and resident #2. Questions were reviewed with the residents to determine and understand their meaning. Both residents answered yes to the questions regarding the nature of their sexual conduct. Documentation of indicated "Will continue to review this should residents continue to have intimate relations. At this time, residents are visiting in the common areas and there has been no indication that the residents are having sexual intercourse. " The above form had attached an article entitled "Issue Related to Sexual Intimacy and Consent" which indicated that consent, as used in the Sexual Assault section in the Wisconsin Statutes, means "words or overt actions by a person who is competent to give informed consent indicating a freely given agreement to have sexual intercourse or sexual contact. " The Statute goes on to say, "the following persons are presumed incapable of consent but the presumption may be rebutted by competent evidence: * a person suffering from a mental illness or defect with impairs capacity to appraise personal conduct. * a person who is unconscious or for any other reason is physically unable to communicate unwillingness to an act. For some types of sexual assault, consent is not an issue. In other words, even if the person consented, it is still sexual assault. For example: * Any person having sexual contact with someone who is physically unable to communicate a refusal, or who is suffering from a mental illness or defect to the extent it impairs capacity to appraise personal conduct. A discussion filed on 11/6/1997 during a Wisconsin Court of Appeals case indicates Wisconsin would probably require a relatively high degree of capacity and knowledge to be able to consent to sexual intimacy. Wisconsin would require a showing that: * The person understands the distinctively sexual nature of the conduct. In other words, the person is able to understand the physical nature of the sexual acts in question, and that the acts have a special status as "sexual. " * The person understands that his/her body is private and that he/she has the right to refuse to engage in sexual activity and to have that refusal respected. * The person understands that he/she may be subject to social taboos or other societal responses to the conduct. On 2/25/13 at 12:45 p.m., surveyor # interviewed DCC-D regarding resident #1 and resident #2. DCC-D indicated, "I wasn't made aware of any further incidences (of sexual contact) between (resident #1 and #2). I would have re-asked the questions that the Ombudsman suggested regarding the resident's understanding of the nature of their sexual conduct and would have interviewed staff if I would have known about the physician's note in (resident #1's) record dated 2/8/13. " A nursing entry in resident #2's medical record dated 8/26/12 indicated, "Resident very upset and yelling at peers to leave him alone. Very angry and agitated. Kept saying his wife was cheating on him and stated, 'two men came to his room and said that his wife was sleeping with them and that's why she (resident #1) can't walk.' He said he was very mad at (resident #1) and she was in his room crying. She was removed from his room. Resident continued to get louder and louder about how his wife was sleeping around and he'll get her back. " A Social Services note located in resident #2's medical record dated 8/28/12 indicated, "Will continue to monitor interactions with spouse. Set visitation times have been discussed and implemented to ensure interactions are positive for both residents. " Review of resident #1's nursing entries in the medical record indicated the resident presented on several occasions since admission to the facility with intermittent, occasional vaginal bleeding. On 10/27/12, resident #1's physician documented an entry that noted, "Vaginal bleeding episodes; blood in brief and some at vaginal introitus on 3 occasions without evidence of pain or discharge. Possible sexually active with spouse. See nurses charting. No dysuria/chronic pattern of incontinence. Plan. Agree with monitoring vaginal bleeding looking with potential correlations. May need further investigation but will get more social and physical info first. " The physician's orders [REDACTED].#1's) exam: external genital exam and underwear for bleeding after her visit with her husband. " Review of resident #1's flow sheet dated 10/27/12 - 11/9/12 indicated the resident was monitored for vaginal bleeding after visiting with her husband with no evidence noted of vaginal bleeding after the visits during that time period. On 11/9/12, the resident's physician ordered discontinuation of the monitoring. A physician's compliance visit note dated 12/18/12, located in resident #1's medical record indicated, "She had complaints of vaginal bleeds intermittently that have resolved and have not been noted within the last 1.5 months. " An off-site facility visit progress note, documented on 1/1/13 by resident #2's physician and located in resident #2's medical record stated, "discussed with spouse's primary care provider. Spouse with rare episodic vaginal spotting in underpants. No clear linkage to visits noted. Visits at this point seem to be going well as long as limited. Shared meals and some activities together on unit. Alone time is permitted with periodic checks. " On 1/27/13, resident #1's antidepressant medication [MEDICATION NAME] was decreased. Nursing entries in resident #1's medical record dated 1/28/13 through 2/10/13 indicated the resident had no behavioral changes due to decrease in the medication. A fax regarding resident #1 was sent to the resident's physician on 1/28/13 which indicated, "This is to inform you that tonight, (resident #1) had another incident of vaginal bleeding. Blood clots in brief, in toilet when urinating from vaginal area. " The physician responded to the fax on 1/31/13 which indicated, "Spoke to caretaker at 12:00 p.m. " Review of resident #1's nurse ' s notes from 1/27/13 to 2/6/13 did not include documentation in the nurse ' s notes to assess the resident's emotional status after visitation with her spouse. A nursing entry dated 1/31/13 indicated "Physician is aware of history of vaginal bleeding and has spoken with guardian regarding the issue. No new orders. " A physician's compliance visit note dated 2/8/12, located in resident #1's medical record indicated, "There is a concern about minimal amount of blood seen in her undergarments by her caretakers. The episodes are sporadic and infrequent. Last time documented/witnessed 2 weeks ago. Addendum: CNA (Certified Nursing Assistant) volunteers information about the vaginal bleeding that (resident #1) had 2 weeks ago. She had her visit time with her husband. (Resident #1) was visibly shaken and crying. There is a thought that her husband (resident #2) engages in sexual intercourse with (resident #1) against her will. Plan: To discuss with attending physician, possibly family and devise a plan. " Despite this allegation of potential abuse, the facility did not report the allegation, did not conduct an immediate investigation, and did not put measures in place to prevent further potential abuse. Review of the resident #1's nursing entry in the medical record indicated that on 2/10/13, the resident had returned from a visit with her spouse and had blood in her brief coming from the vagina. On 2/10/13, the facility faxed information to resident #1's physician to indicate notable bleeding coming from the resident's vagina. The physician's response indicated, "Keep documenting. Will schedule to have an ethics conference with family to decide on her (resident #1) visits with husband. Attending physician updated. " Additional nursing entries in resident #1's medical record dated 2/11/13 through 2/14/13 also documented that the resident had presented with vaginal bleeding on all of those dates. On 2/25/13 at 7:55 a.m., surveyor # interviewed LPN (Licensed Practical Nurse)-I. LPN-I stated, "(Resident #1) has been on report before because she had been upset after visiting her husband. She can't form complete sentences and has a hard time understanding questions. A lot of times, she answers yes to all questions. She seems to now be her usual self. " On 2/25/13 at 8:15 a.m., surveyor # interviewed RN (Registered Nurse)-A. RN-A stated, "(Resident #2) cognition varies. He is alert but his confusion comes and goes. He can get agitated when he is more confused. He spends time with his wife and doesn't understand that he is more cognitively impaired and gets upset and yells at her. At that point, we intervene. He accuses her of doing inappropriate things with other men and staff. He has told me that he thinks men are trying to recruit his wife for sexual things. His accusations vary. A couple of weeks ago, his visits with his wife were good, but in the last several days he has been angry with staff and then he has been angry with his wife. " On 2/25/13 at 9:00 a.m., surveyor # attempted to interview resident #1. Resident #1 was unable to answer any questions and displayed non understandable confabulated speech patterns during the conversation. On 2/25/13 at 9:00 a.m., surveyor # reviewed resident #1's medical record. The surveyor could not locate indications that an ethics conference had been completed as suggested by resident #1's primary care physician on 2/10/13. The surveyor reviewed resident #1 and resident #2's current plans of care and care plan Kardex's. There was no indication that changes had been implemented regarding increased supervision of daily visits between resident #1 and resident #2, after a physician suspected abuse relating to staff reports of resident #1's vaginal bleeding and change in behavior after unsupervised visits with resident #2. On 2/25/13 at 9:50 a.m., surveyor # interviewed DCC-D and RN-B regarding resident #1 and resident #2. DCC-D and RN-B verified to the surveyor that they had not been made aware of the 2/8/13 physician compliance note suspecting resident #1's had displayed behavioral and physical symptoms after a visit with her spouse 2 weeks prior, which may have correlated with sexual contact between resident #1 and resident #2 and may have been against resident #1's will. DCC-D and RN-B indicated that they had not been made aware of suggestions that an ethics conference was suggested by the physician on 2/10/13. DCC-D and RN-B verified that, to date, an ethics conference had not been completed and a date for the conference had not been established. DCC-D stated, "There is nothing about increased supervision with visits between the two residents on either of their plans of care or Kardex's. The residents still have established visits, almost daily and whenever he (resident #2) asks to see her (#1) at other times. (Resident #1) has a history of depression and had periods when she did cry. Staff would interview her to see why she was crying. I don't do physical assessments. A physical assessment and the reason she was upset on 1/28/13 should have been completed by staff. " RN-B stated, "We had looked into the vaginal bleeding (resident #1) to determine if it was due to sexual intercourse versus pathological bleeding. Her guardian didn't want to put the resident through a pelvic exam, because even if there was pathological findings, the guardian would not want any course of treatment. I brought up to the guardian that I had concerns that intercourse may have been going on. I didn't mind if the two visited, but I felt the visitation times should have been shorter and more supervised." RN-A verified that an investigation into a possible sexual assault of resident #1 by her spouse between 1/28/13 and 2/25/13 had not been initiated. On 2/25/13 at 10:15 a.m., surveyor # interviewed SW (Social Worker)-C. SW-C verified to the surveyor that she had not been involved in resident #1 and resident #2's issues and was unaware that the physician made a statement of possible abuse or the initiation of an ethics conference. On 2/25/13 at 10:20 a.m., surveyor # interviewed RN-A. RN-A stated, "She (resident #1) comes daily to see her husband for about 2 hours a day. We try to keep them within site, but they do go to his room. We try to keep the door open, but he does close the door. I know she (resident #1) comes back after visits with him (#2) with vaginal bleeding. It has happened before he (#2) was admitted here, but he did visit several times a week. We try to keep them supervised, but it isn't on their plan of care and the supervision isn't strict. We do make frequent checks on them because he tries to toilet her. I've heard that she leaves the unit and is crying. I've seen her cry after he (#1) was yelling at her. It hasn't been a one-time thing. Sometimes he is yelling at her and she is crying and other times she is just visually upset. " On 2/25/13 at 12:10 p.m., surveyor # interviewed RN-A. RN-A verified to the surveyor that staff was directed 10 minutes prior to supervise resident #1 and #2 at all times when there were together. The surveyor observed resident #1 and resident #2 seated at a dining room table with staff in attendance in the dining room. On 2/25/13 at 12:12 p.m., surveyor # interviewed CNA-H. CNA-H stated, "We check in on them (resident #1 and #2) when they are alone in his room. We try to keep the door open, but they do have periods where they are unsupervised. " On 2/25/13 at 12:15 p.m., surveyor # interviewed CNA-E. CNA-E stated, "I was never told that they (resident #1 and #2) could not be alone in his room. There are periods of time when they are in his room alone and unsupervised. I have seen her cry after visits with him. I've noticed him yelling at her. He thinks she is sleeping with other men. She gets tearful and upset. " On 2/25/13 at 3:30 p.m., surveyor # interviewed Ombudsmen-K. Ombudsmen-K verified to the surveyor that she had contact with the facility on 7/12 regarding the sexual relationship between resident #1 and #2, and had suggested that the facility interview both residents to determine if they were able to consent to sexual contact with one another. Ombudsmen-K stated, "I also encouraged them to follow up and monitor if circumstances changed. I haven't had any contact with the facility regarding the two (#1 and #2) residents since 7/12. " On 2/26/13 at 6:53 a.m., the facility faxed a report to surveyor # that based upon the above information, an investigation had been initiated focusing on resident #1's and #2's relations and related issues. 2. Review of a facility self- report investigation indicated that on 2/21/13, resident #2 reported an allegation that a staff member had inappropriate contact with his spouse, resident #1, a few days prior. The facility conducted a timely and through investigation, and placed the staff member in question on leave pending results of the investigation. The facility reported the incident within 24 hours to the state certification agency. On 2/25/13, at approximately 7:15 a.m., surveyor # entered the facility and requested the name of the investigating officer and their phone number in regards to the above self-report of a reasonable suspicion of a crime. On 2/25/13 at 8:45 a.m., surveyor # observed PO (Police Officer)-L, standing in an administrative office in the facility. PO-L verified to the surveyor that he had just received a call from the facility that morning, and was unsure at this time of what the issues were that he had been called for to investigate. On 2/25/13 at 9:10 a.m., surveyor # requested a copy of the facility's reporting reasonable suspicion of a crime policy from NHA-M. NHA-M indicated that he was unaware of such a policy. On 2/25/13 at 9:20 a.m., NHA-M gave surveyor # the above policy which he indicated had been posted in the employee lounge area. NHA-M stated, "I missed that. I should have called the police (regarding the allegation of abuse reported by resident #2). I guess I was so busy with the investigation, it slipped my mind. " On 2/25/13 at 9:20 a.m., surveyor # interviewed PO-L. PO-L stated, "I talked with my Lieutenant at the unit. He feels the evidence at this time is tainted. We would have liked to have been able to talk to the alleged perpetrator before the facility had. We discourage suspect interviews by the facility before we have had a chance to talk to the suspect. Since the allegation was not reported to us right away, there is no physical evidence that we can obtain at this point. I will be referring this issue to the Sensitive Crimes Investigator for follow up. " The facility ' s failure to promptly report and investigate an allegation of abuse and its failure to take steps to prevent further potential abuse from occurring created a finding of immediate jeopardy. The facility removed the jeopardy on 2/25/15 by which time: The facility had conducted a full investigation of the incident involving resident #1 and resident #2 that was discovered on 2/8/13. Resident #1 and resident #2's plans of care were reviewed and revised on 2/25/13 The facility revised the policy for reporting suspected abuse to include notification of the local police in the event of an allegation. The facility educated their staff regarding the requirements of investigation and reporting suspected abuse to the local police will be provided starting 2/25/13 and ongoing prior to working their next scheduled shift. The facility completed an audit to ensure staff understanding of the requirements of the policy and procedure for reporting suspected abuse and that complete investigations are completed following suspected or alleged abuse. The facility's Quality Assessment and Assurance Committee has held an Ad Hoc meeting to discuss and approve the above plan of action for removal of the immediate jeopardy to the facility. Completed by NHA and Quality Assessment and Assurance Committee members on 2/25/13. The attending physician, Social Service/Program Coordinator, Director of Nursing and NHA will meet with resident #1 and resident #2's daughters on 2/27/12 at 5:30 p.m., to discuss intimate relations and issues related to the issues, continued surveillance for protection of residents, care plan, and plans going forward.

Based on staff interview and record review, the facility did not develop and implement written policies and procedures that prohibit mistreatment, neglect and abuse of in 2 instances involving 1 (resident #1) of 4 sampled residents. 1. The facility did not follow their policy regarding suspected abuse when a concern regarding possible sexual abuse of resident #1 was documented by her physician on 2/8/13. ( " (Resident #1) was visibly shaken and crying. There is a thought that her husband (#2) engages in sexual intercourse with (resident #2) against her will. " ) The facility did not conduct a timely investigation of the issue, protect the resident during the investigation, report the incident to the appropriate staff and state agencies, and modify the resident's care plan to protect resident #1 from potential recurrent abuse during the investigation period. Vaginal bleeding continued to be noted on 2/10, 2/11, 2/12, 2/13, and 2/14/13. 2. Resident #1's spouse had alleged sexual contact between a facility staff and the resident on 2/21/13. The facility did not report the reasonable suspicion of a crime to at least one law enforcement agency of jurisdiction per its policy. The facility's failure to follow its policies and procedures by failing to immediately conduct an investigation into suspected sexual abuse of resident #1 by her spouse and to prevent further potential abuse created a finding of immediate jeopardy (situation has caused or is likely to cause serious harm and there is a reasonable degree of predictability of a similar situation occurring in the future) that began on 2/8/13. The facility was notified of the immediate jeopardy on 2/25/13 and the immediate jeopardy was removed on 2/25/12. The deficient practice continues at a scope/severity level of D (potential for harm that is not immediate jeopardy/isolated) until the facility fully implements its corrective action plan. Findings include: The facility's policy and procedure regarding suspected resident abuse, neglect, misappropriation of property, resident to resident abuse and injuries of unknown origin dated September 2009 indicates the facility prohibits the mistreatment, neglect, and abuse of residents and misappropriation of resident property by anyone including staff, family, friends, etc. The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident abuse, neglect, mistreatment, and/or misappropriation of property. The shift supervisor is identified as responsible for immediate initiation of the reporting process. The Administrator and Director of Nursing are responsible for investigation and reporting. They are also ultimately responsible for the following as they relate to abuse, neglect, and/or misappropriation of property standards and procedures: * Implementation. * Ongoing monitoring. * Reporting. * Investigation. * Tracking and trending. Implementation and ongoing monitoring consist of the following: * Screening. * Training. * Prevention. * Identification. * Protection. * Investigation. * Reporting. The facility acknowledges the following definitions: * Sexual Abuse. Includes but is not limited to humiliation, harassment, coercion, or assault. * Resident to resident abuse. Includes contact of a resident by another resident of the facility (i.e. physical, verbal, sexual). Prevention. Identify, correct, and intervene in situations where abuse, neglect and/or mistreatment are more likely to occur. Identification. Identify events, such as bruising or residents, occurrences, patterns, and trends that may constitute abuse, neglect, and/or mistreatment and investigate. Instruct staff, resident, family, visitor, etc. to report immediately any knowledge or suspicion of suspected abuse. Initiate an incident report immediately upon identification of actual or suspected abuse. Complete a comprehensive record review to include plan or care, progress notes, flow sheets, physician's orders [REDACTED]. Investigation. Interview all potential witnesses. Document a brief, concise, objective description, in the medical record, or what was actually observed. Identify who was involved, determine what occurred, determine when the incident occurred, and where the incident occurred. Data analysis. Summarize analysis of facts gathered that establish reasonable cause for the incident or need for further investigation before a reasonable cause of the incident can be established. Reporting. Notify the Administrator, Director of Nursing or designee, immediately if suspected abuse, neglect or mistreatment alleged resident abuse occurs. The charge nurse supervisor is responsible for notifying, reporting the incident to the Director of Nursing and Administrator in their absence from the facility. Notify the appropriate State agency(s) immediately after identification of alleged/suspected incident. Initiate process according to State specific regulations. Notify the legal guardian or responsible family member of the alleged or suspected abuse within 24 hours. Protection. If the incident involves a resident to resident contact, to protect the safety of all residents the resident that was the aggressor should be placed on 15 minute checks or provided one on one supervision which will be determined by the charge nurse, depending on the type, intent, and significance of the contact. The type of supervision should be determined by what is deemed necessary to prevent a reoccurrence of an incident. 1. Resident #1's admission face sheet dated February 2012 indicated the resident had [DIAGNOSES REDACTED]. The resident was admitted to a secured unit of the facility and had guardianship in place. Resident #1's admission MDS (minimum data set) dated 2/15/12 indicates the resident was assessed to have scored a 1 of 15 on the cognition screen (the lower the score, the less cognizant), had no mood indicators or behaviors, and was independent in ambulation, transfers and eating. A significant change MDS completed for the resident on 5/2/12 indicated resident #1's cognition, ability to eat independently, mood indicators and behaviors had not changed but she now required limited assistance from one staff to ambulate and to accomplish transfers. An MDS dated [DATE] completed on resident #1 indicated that the resident now required extensive assistance to perform personal hygiene in comparison with the previous two assessments. An additional MDS completed for the resident dated 10/17/12 indicated resident #1 now required extensive assistance to ambulate and transfer, and required increased limited assistance to perform eating. The most current MDS completed for resident #1 dated 1/9/13 indicated the resident now required extensive assistance to perform eating. All of the above-mentioned MDS assessments completed for resident #1 indicated that the resident sometimes understands others, responds adequately only to simple and direct communication, and adequately responds to simple, direct communication. Resident #2, who is resident #1's spouse, was admitted to the facility on [DATE] in the same room as resident #1. The resident's admission face sheet indicated the resident had [DIAGNOSES REDACTED]. Resident #2's admission MDS dated [DATE], and MDS dated [DATE] indicated the resident had scored a 7 of 15 on the cognitive screen. The MDS assessments both indicated the resident usually could be understood by others but had difficulty communicating some words or finishing thoughts but was able if prompted and given time, sometimes understood others and responds adequately to simple, direct communication only. A nursing entry in resident #2's medical record indicated that on 7/6/12, "resident was being intimate with (resident #1) this morning. (Resident #1) made the comment that she "hurt. " (Resident #1) made a comment telling (resident #2) to leave after breakfast." A Social Services note, located in resident #2's medical record dated 7/6/12 indicated, "Resident noted to have intimate relations with wife. Writer made aware by staff of relations. Writer contacted daughter to notify that intimate relations where occurring during the night shift last night. " A nursing entry in resident #2's medical record dated 7/8/12 indicated, "excessive agitation this shift. After lunch, he wanted to take spouse to room so he could "talk to her. " When the staff went to check on them, he had (resident #1) on his bed with her pants half way down. (Resident #1) was taken back to her room on unit 2. " On approximately 7/8/12, resident #1 was moved to a separate secured unit of the facility due to decline in functional status and due to safety concerns relating to resident #2 assisting her to transfer resulting in a fall by resident #1. The residents continued to spend scheduled time together daily from approximately 11:30 a.m. until 2:00 p.m. and also whenever resident #2 requested visitation. On 7/17/12, DCC (Dementia Unit Care Coordinator)-D met with the Ombudsman to review the relationship status between resident #1 and resident #2. Questions were reviewed with residents to determine and understand their meaning. Both residents answered yes to the questions regarding the nature of their sexual conduct. The write up of the above indicated "will continue to review this should residents continue to have intimate relations. At this time, residents are visiting in the common areas and there has been no indication that the residents are having sexual intercourse. " The above form had attached an article entitled "Issue Related to Sexual Intimacy and Consent" which indicated that consent, as used in the Sexual Assault section in the Wisconsin Statutes, means "words or overt actions by a person who is competent to give informed consent indicting a freely given agreement to have sexual intercourse or sexual contact. " On 10/27/12, resident #1's physician documented an entry that noted, "vaginal bleeding episodes; blood in brief and some at vaginal introitus on 3 occasions without evidence of pain or discharge. Possible sexually active with spouse. " An off-site facility visit progress note, documented on 1/1/13 by resident #2's physician and located in resident #2's medical record stated, "discussed with spouse's primary care provider. Spouse with rare episodic vaginal spotting in underpants. No clear linkage to visits noted. Visits at this point seem to be going well as long as limited. Shared meals and some activities together on unit. Alone time is permitted with periodic checks. " A physician's compliance visit note dated 2/8/12, located in resident #1's medical record indicated, "There is a concern about minimal amount of blood seen in her undergarments by her caretakers. The episodes are sporadic and infrequent. Last time documented/witnessed 2 weeks ago. Addendum: CNA (Certified Nursing Assistant) volunteers information about the vaginal bleeding that (resident #1) had 2 weeks ago. She had her visit time with her husband. (Resident #1) was visibly shaken and crying. There is a thought that her husband (#2) engages in sexual intercourse with (resident #2) against her will. Plan: To discuss with attending physician, possibly family and devise a plan. " The facility did not investigate this allegation of possible abuse and did not put measures in place to prevent further potential abuse from occurring. The facility did not report the allegation to the state agency within 24 hours. Review of the resident #1's nursing entry in the medical record indicates that on 2/10/13, the resident had returned from a visit with her spouse and had blood in her brief coming from the vagina. On 2/10/13, the facility faxed information to resident #1's physician to indicate notable bleeding coming from the resident's vagina. The physician's response indicated, "Keep documenting. Will schedule to have an ethics conference with family to decide on her (resident #1) visits with husband. Attending physician updated. " The facility had not put measures in place to prevent further potential abuse and had not changed the resident's plan of care to ensure no further incidences occurred. Additional nursing entries in resident #1's medical record dated 2/11/13 through 2/14/13 also noted that the resident had presented with vaginal bleeding on all of those dates. On 2/25/13 at 9:50 a.m., surveyor # interviewed DCC-D and RN-B regarding resident #1 and resident #2. DCC-D and RN-B verified to the surveyor that they had not been made aware of the 2/8/13 physician compliance note suspecting resident #1's had displayed behavioral and physical symptoms after a visit with her spouse 2 weeks prior, which may have correlated with sexual contact between resident #1 and resident #2 and may have been against resident #1's will. DCC-D and RN-B verified that they had not been made aware of an ethics conference that was suggested by the physician on 2/10/13. DCC-D and RN-B verified that to date, no ethics conference had been completed and a date for the conference had not been established. DCC-D stated, "There is nothing about increased supervision with visits between the two residents on either of their plans of care or Kardex's. The residents still have established visits, almost daily and whenever he (resident #2) asks to see her (#1) at other times. I brought up that I had concerns that intercourse may have been going on. I didn't mind if the two visited, but I felt the visitation times should have been shorter and more supervised." On 2/25/13 at 12:45 p.m., surveyor # interviewed DCC-D. DCC-D indicated, "I wasn't made aware of any further incidences (of sexual contact) between (resident #1 and #2). I would have re-asked the questions that the Ombudsman suggested regarding the resident's understanding of the nature of their sexual conduct and would have interviewed staff if I would have known about the physician's note in (resident #1's) record dated 2/8/13. " The facility failed to follow its abuse policy regarding investigating potential abuse, protecting the resident from further potential harm during the investigation period and notifying the proper facility authorities and the state agency. On 2/26/13 at 6:53 a.m., the facility faxed a report to surveyor # that based upon the above, an investigation had been initiated focusing on resident #1's and #2's relations and related issues. 2. The facility's policy for reporting reasonable suspicion of a crime in a long term care facility, section 1150 B of the Social Security Act requires specific individuals in applicable long term care facilities to report any reasonable suspicion of crimes committed against a resident of that facility. Reports must be submitted to at least one law enforcement agency of jurisdiction and the Division of Quality Assurance. Review of a facility self-report investigation indicated that on 2/21/13, resident #2 alleged that a staff member had inappropriate contact with his spouse, resident #1, a few days prior. The facility conducted a timely and through investigation and placed the staff member in question on leave pending results of the investigation. The facility reported the incident within 24 hours to the state certification agency. On 2/25/13, at approximately 7:15 a.m., surveyor # entered the facility and requested the name of the investigating officer and their phone number in regards to the above self-report of a reasonable suspicion of a crime. On 2/25/13 at 8:45 a.m., surveyor # observed PO (Police Officer)-L, standing in an administrative office in the facility. PO-L verified to the surveyor that he had just received a call from the facility that morning, and was unsure at this time of what the issues were that he had been called for to investigate. On 2/25/13 at 9:10 a.m., surveyor # requested a copy of the facility's reporting reasonable suspicion of a crime policy from NHA (Nursing Home Administrator)-M. NHA-M indicated that he was unaware of such a policy. On 2/25/13 at 9:20 a.m., NHA-M gave surveyor # the above policy which he indicated had been posted in the employee lounge area. NHA-M stated, "I missed that. I should have called the police (regarding the allegation of abuse reported by resident #2). I guess I was so busy with the investigation, it slipped my mind. " The facility's failure to promptly report and investigate and to prevent further possible abuse while an investigation was underway created a finding of immediate jeopardy. The jeopardy was removed on 2/25/13 when the facility:

Based on record review and staff interviews, the facility did not ensure that 1 (resident #1) of 4 sampled residents received adequate supervision to prevent accidents. Resident #1 and #2 (wife and husband) were known to have engaged in sexual intercourse and were assessed in July 2012 regarding each party's ability to consent to this type of intimacy. On 2/8/13, resident #1's physician documented concerns of vaginal bleeding and change in behavior and related suspicions that resident #1's spouse was engaging in sexual contact with the resident against her will: "(Resident #1) was visibly shaken and crying. There is a thought that her husband (#2) engages in sexual intercourse with (resident #2) against her will." Despite the physician's concern, facility staff allowed the residents to continue with daily unsupervised contact. Additionally, the facility did not reassess resident #1 to ensure she was still capable of consenting to sexual contact with her husband. Notable vaginal bleeding was noted on 2/10/13 and vaginal bleeding was documented each day from 2/11 to 2/14/13. The facility's lack of supervision of the residents after a suspicion of abuse created a finding of immediate jeopardy (situation that has caused or is likely to cause serious harm and there is a reasonable degree of predictability of similar situation occurring in the future) that began on 2/8/13. The facility was notified of the immediate jeopardy on 2/25/13. The immediate jeopardy was removed on 2/25/13. The deficient practice continues at a scope/severity level of D (potential for harm that is not immediate jeopardy/isolated). Findings include: Resident #1's admission face sheet dated February 2012 indicated the resident had [DIAGNOSES REDACTED]. The resident was admitted to a secured unit of the facility and had guardianship in place. Resident #1's admission MDS (minimum data set) dated 2/15/12 indicates the resident was assessed to have scored a 1 of 15 on the cognition screen (the higher the score, the more cognizant), had no mood indicators or behaviors, and was independent in ambulation, transfers and eating. Additional MDS's dated 5/2/12, 7/25/12, 10/17/12 and 1/9/13 indicated resident #1's cognitive status had remained as assessed on admission, but had a noted decline in functional status for ambulation, transfer, eating assistance and need for increased assistance with personal hygiene. All of the above-mentioned MDS assessments completed for resident #1 indicated the the resident sometimes understands others and responds adequately only to simple, direct communication. Resident #2 is the spouse of resident #1 and his admission MDS dated [DATE] and an additional MDS dated [DATE] indicated the resident had scored a 7 of 15 on the cognitive screen and was independent in all areas of functional status. The above-mentioned MDS assessments indicated the resident usually could be understood by others, but had difficulty communicating some words or finishing thoughts and was able if prompted and given time, sometimes understood others and responds adequately to simple, direct communication only. A Social Services note, located in resident #2's medical record dated 7/6/12 indicated, "Resident noted to have intimate relations with wife. Writer made aware by staff of relations." A nursing entry in resident #2's medical record dated 7/8/12 indicated, "excessive agitation this shift. After lunch, he wanted to take spouse to room so he could "talk to her." When the staff went to check on them, he had (resident #1) on his bed with her pants half way down. (Resident #1) was taken back to her room on unit 2." On approximately 7/8/12, resident #1 was moved to a separate secured unit of the facility due to decline in functional status and due to safety concerns relating to resident #2 assisting her to transfer, resulting in resident #1 falling. The residents continued to spend scheduled time together daily from approximately 11:30 a.m. until 2:00 p.m. and also whenever resident #2 requested visitation. On 7/17/12, DCC (Dementia Unit Care Coordinator)-D met with the Ombudsman to review the relationship status between resident #1 and resident #2 after being made aware by staff that the two residents were observed having sexual relations. Questions were reviewed with residents to determine and understand their meaning. Both residents answered yes to the questions regarding the nature of their sexual conduct. The write up of the above indicated "will continue to review this should residents continue to have intimate relations. At this time, residents are visiting in the common areas and there has been no indication that the residents are having sexual intercourse." The above form had attached an article entitled "Issue Related to Sexual Intimacy and Consent" which indicated that consent, as used in the Sexual Assault section in the Wisconsin Statutes, means "words or overt actions by a person who is competent to give informed consent indicting a freely given agreement to have sexual intercourse or sexual contact." The Statute goes on to say, "the following persons are presumed incapable of consent but the presumption may be rebutted by competent evidence: * a person suffering from a mental illness or defect with impairs capacity to appraise personal conduct. * a person who is unconscious or for any other reason is physically unable to communicate unwillingness to an act. For some types of sexual assault, consent is not an issue. In other words, even if the person consented, it is still sexual assault. For example: * Any person having sexual contact with someone who is physically unable to communicate a refusal, or who is suffering from a mental illness or defect to the extent it impairs capacity to appraise personal conduct. A discussion filed on 11/6/1997 during a Wisconsin Court of Appeals case indicates Wisconsin would probably require a relatively high degree of capacity and knowledge to be able to consent to sexual intimacy. Wisconsin would require a showing that: * The person understands the distinctively sexual nature of the conduct. In other words, the person is able to understand the physical nature of the sexual acts in question, and that the acts have a special status as "sexual." * The person understands that his/her body is private and that he/she has the right to refuse to engage in sexual activity and to have that refusal respected. * The person understands that he/she may be subject to social taboos or other societal responses to the conduct. On 10/27/12, resident #1's physician documented an entry that noted, "Vaginal bleeding episodes; blood in brief and some at vaginal introitus on 3 occasions without evidence of pain or discharge. Possible sexually active with spouse." A fax regarding resident #1 was sent to the resident's physician on 1/28/13 which indicated, "This is to inform you that tonight, (resident #1) had another incident of vaginal bleeding. Blood clots in brief, in toilet when urinating from vaginal area." The physician responded to the fax on 1/31/13 which indicated, "Spoke to caretaker at 12:00 p.m." A physician's compliance visit note dated 2/8/12, located in resident #1's medical record indicated, "There is a concern about minimal amount of blood seen in her undergarments by her caretakers. The episodes are sporadic and infrequent. Last time documented/witnessed 2 weeks ago. Addendum: CNA (Certified Nursing Assistant) volunteers information about the vaginal bleeding that (resident #1) had 2 weeks ago. She had her visit time with her husband. (Resident #1) was visibly shaken and crying. There is a thought that her husband (#2) engages in sexual intercourse with (resident #1) against her will. Plan: To discuss with attending physician, possibly family and devise a plan." Review of the resident #1's nursing entry in the medical record indicated that on 2/10/13, the resident had returned from a visit with her spouse and had blood in her brief coming from the vagina. On 2/10/13, the facility faxed information to resident #1's physician to indicate notable bleeding coming from the resident's vagina. The physician's response indicated, "Keep documenting. Will schedule to have an ethics conference with family to decide on her (resident #1) visits with husband. Attending physician updated." On 2/25/13 at approximately 1:00 p.m., surveyor # interviewed RN (Registered Nurse)-N regarding resident #1 and resident #2. RN-N verified to the surveyor that she had sent the fax to resident #1's physician on 2/10/13, but had not been present in the facility when the physician responded. RN-N stated, "I didn't take the order, but this should have put on the 24 hour report and followed up on to ensure it (ethics committee meeting) was scheduled. I guess the thought was that the doctor was going to take care of setting up the meeting." Additional nursing entries in resident #1's medical record dated 2/11/13 through 2/14/13 noted that the resident had presented with vaginal bleeding on all of those dates. Review of resident #1's medical record did not include documentation that described the resident's emotional state after visiting with her spouse from 1/28/13 to date. Upon review of resident #1's medical record, a plan had not been devised per the physician's suggestion on 2/10/13. Resident #1 and #2 continued scheduled time together, with no increase in supervision during the visits from 2/8/13 until 2/25/13. No changes in supervision for the couple had been incorporated to prevent further incidences. A follow up had not been completed to ascertain whether resident #1 was still able to consent to sexual relations with her spouse. On 2/25/13 at 7:55 a.m., surveyor # interviewed LPN (Licensed Practical Nurse)-I. LPN-I stated, "(Resident #1) has been on report before because she had been upset after visiting her husband. She can't form complete sentences and has a hard time understanding questions. A lot of times, she answers yes to all questions. She seems to now be her usual self." On 2/25/13 at 8:15 a.m., surveyor # interviewed RN-A. RN-A stated, "(Resident #2) cognition varies. He is alert but his confusion comes and goes. He can get agitated when he is more confused. He spends time with his wife and doesn't understand that he is more cognitively impaired and gets upset and yells at her. At that point, we intervene. He accuses her of doing inappropriate things with other men and staff. He has told me that he thinks men are trying to recruit his wife for sexual things. His accusations vary. A couple of weeks ago, his visits with his wife were good, but in the last several days he has been angry with staff and then he has been angry with his wife." On 2/25/13 at 9:00 a.m., surveyor # attempted to interview resident #1. The resident was unable to answer any questions and displayed non understandable confabulated speech patterns during the conversation. On 2/25/13 at 9:00 a.m., surveyor # reviewed resident #1's medical record. The surveyor could not locate indications that an ethics conference had been completed as suggested by resident #1's primary care physician on 2/10/13. The surveyor reviewed resident #1 and resident #2's current plans of care and care plan Kardex's. There was no indication that changes had been implemented regarding increased supervision of daily visits between resident #1 and resident #2 after a physician suspected abuse relating to staff reports of resident #1's vaginal bleeding and change in behavior after unsupervised visits with resident #2. On 2/25/13 at 9:50 a.m., surveyor # interviewed DCC-D and RN (Registered Nurse)-B regarding resident #1 and resident #2. DCC-D and RN-B verified to the surveyor that they had not been made aware of the 2/8/13 physician compliance note suspecting resident #1 had displayed behavioral and physical symptoms after a visit with her spouse 2 weeks prior, which may have correlated with sexual contact between resident #1 and resident #2 and may have been against resident #1's will. DCC-D stated, "There is nothing about increased supervision with visits between the two residents on either of their plans of care or Kardex's. The residents still have established visits, almost daily and whenever he (resident #2) asks to see her (#1) at other times. RN-B stated, "We had looked into the vaginal bleeding (resident #1) to determine if it was due to sexual intercourse versus pathological bleeding. Her guardian didn't want to put the resident through a pelvic exam, because even if there was pathological findings, the guardian would have not wanted any course of treatment. I brought up that I had concerns that intercourse may have been going on. I didn't mind if the two visited, but I felt the visitation times should have been shorter and more supervised." Both staff verified to the surveyor that to date, an ethics committee meeting had not been initiated to discuss resident #1 and resident #2's relationship. Both staff also verified to the surveyor that they had not been made aware of the physician's suggestions of such a meeting and had not been made aware of the physician's concerns dated 2/8/13, that resident #2 may have been having sexual intercourse with resident #1 against her will. On 2/25/13 at 10:20 a.m., surveyor # interviewed RN-A regarding resident #1 and resident #2. RN-A stated, "she (resident #1) comes daily to see her husband for about 2 hours a day. We try to keep them within site, but they do go to his room. We try to keep the door open, but he does close the door. I know she (resident #1) comes back after visits with him (#2) with vaginal bleeding. It has happened before he (#2) was admitted here, but he did visit several times a week. We try to keep them supervised, but it isn't on their plan of care and the supervision isn't strict. We do make frequent checks on them because he tries to toilet her. I've heard that she leaves the unit and is crying. I've seen her cry after he (#1) was yelling at her. It hasn't been a one time thing. Sometimes he is yelling at her and she is crying and other times she is just visually upset." On 2/25/13 at 10:45 a.m., surveyor # strongly encouraged the facility to strictly monitor resident #1 and #2 during their scheduled meeting that day from 11:30 a.m. until approximately 1:30 p.m. On 2/25/13 at 12:10 p.m., surveyor # interviewed RN-A. RN-A verified to the surveyor that staff were directed 10 minutes prior to supervise resident #1 and #2 at all times when they were together. The surveyor observed resident #1 and resident #2 seated at a dining room table with staff in attendance in the dining room. On 2/25/13 at 12:12 p.m., surveyor # interviewed CNA (Certified Nursing Assistant)-H. CNA-H stated, "We check in on them (resident #1 and #2) when they are alone in his room. We try to keep the door open, but they do have periods where they are unsupervised." On 2/25/13 at 12:15 p.m., surveyor # interviewed CNA-E. CNA-E stated, "I was never told that they (resident #1 and #2) could not be alone in his room. There are periods of time when they are in his room alone and unsupervised. I have seen her cry after visits with him. I've noticed him yelling at her. He thinks she is sleeping with other men. She gets tearful and upset." On 2/25/13 at 12:45 p.m., surveyor # interviewed DCC-D. DCC-D indicated, "I wasn't made aware of any further incidences (of sexual contact) between (resident #1 and #2). I would have re asked the questions that the Ombudsman suggested regarding the resident's understanding of the nature of their sexual conduct and would have interviewed staff if I would have known about the physician's note in (resident #1's) record dated 2/8/13." On 2/25/13 at 12:45 p.m., both resident #1 and #2's written care plans were revised to include an intervention to have supervised visits when together and that visits would be completed in a common area. The facility has conducted a full investigation of the incident involving resident #1 and resident #2 that was discovered on 2/8/13. Resident #1 and resident #2's plans of care were reviewed and revised on 2/25/13 The facility has revised the policy for reporting suspected abuse to include notification of the local police in the event of an allegation. The facility educated their staff regarding supervision during 1:1 visits between resident #1 and resident #2 or the need to provide supervision should a like situation arise and the updated policy and procedure for reporting suspected abuse on 2/25/13 and ongoing prior to working their next scheduled shift. The facility completed an audit for supervised visits between resident #1 and resident #2 has been created to ensure compliance with their updated plans of care. The facility's Quality Assessment and Assurance Committee has held an Ad Hoc meeting to discuss and approve the above plan of action for removal of the immediate jeopardy to the facility. Completed by NHA and Quality Assessment and Assurance Committee members on 2/25/13. The attending physician, Social Service/Program Coordinator, Director on Nursing and NHA will meet with resident #1 and resident #2's daughters on 2/27/12 at 5:30 p.m., to discuss intimate relations and issues related to the issues, continued surveillance for protection of residents, care plan, and plans going forward.