Every finding on record at Edenbrook of Wisconsin Rapids

Based on observation, staff and resident interview, and record review, the facility did not ensure assistance for activities of daily living (ADLs) was provided in a timely and consistent manner for 4 residents (R30, R13, R1, and R38) of 5 sampled residents. R30's call light was shut off prior to staff completing R30's request. Staff did not return in a timely manner to complete cares for R30. R1 stated staff typically take 30 minutes to respond to R1's call light. R13's call light was activated for 14 to 24 minutes before staff provided care. R1 (who lived across the hall) was interviewed and stated R13's call light was previously on for 60 minutes. R38 stated it can take 30 minutes for staff to respond to a call light. Staff verified residents may have to wait for their needs to be met. Findings include: Between 5/19/26 and 5/20/26, Surveyor reviewed the facility's Resident Council minutes. The April 2026 minutes indicated residents had concerns with long call light response times on weekends. Residents also had concerns with staff turning lights off without providing care and not returning to provide care. 1.On 5/19/26, Surveyor reviewed R30's medical record. R30 was admitted to the facility on [DATE] and had a diagnosis of paraplegia. R30's Minimum Data Set (MDS) assessment, dated 4/10/26, stated R30 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The MDS assessment indicated R30 was dependent on staff for toileting, showering, transfers, and lower body dressing and required partial to moderate assistance for upper body dressing. On 5/19/26 at 1:31 PM, Surveyor noted R30's call light was activated. On 5/19/26 at 1:39 PM, Surveyor observed Activity Director (AD)-C enter and exit R30's room. R30's call light was no longer on. On 5/19/26 at 1:41 PM, Surveyor asked R30 if R30's needs were met prior to AD-C exiting the room. R30 stated AD-C said the Certified Nursing Assistants (CNAs) were busy and would be in after they finished assisting another resident. R30 verified AD-C turned off R30's call light. R30 stated R30 wanted to get up for the day because R30 had a visitor coming. On 5/19/26 at 2:00 PM, Surveyor entered R30's room to see if staff had been in to provide care. R30 was still in bed and stated staff must have forgotten again. R30 indicated it occurred more frequently in the last 2 weeks and R30 was sick of it. R30 indicated R30 needed assistance with transferring and getting ready and was concerned R30 would not be ready when R30's family arrived. Surveyor observed a bell on R30's window. R30 indicated R30 could use the bell in case staff did not respond timely. On 5/19/26 at 2:09 PM, Surveyor exited R30's room and observed multiple CNAs at the nursing station for shift change. At 2:11 PM, Surveyor observed staff enter R30s room. On 5/19/26 at 3:03 PM, Surveyor interviewed AD-C who verified R30 wanted to get up for the day but staff were busy. AD-C indicated a CNA (AD-C could not recall which one) told AD-C to turn R30's call light off. Surveyor informed AD-C that staff did not return timely to meet R30's needs. (See interview under example 3.) 2. On 5/19/26, Surveyor reviewed R13's medical record. R13 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. R13's MDS assessment, dated 4/23/26, stated R13 had a BIMS score of 15 out of 15, indicating intact cognition. The MDS assessment indicated R13 was either dependent or required substantial staff assistance for most ADLs, including toileting, bathing, and personal hygiene. On 5/19/26 between 1:00 PM and 1:10 PM, Surveyor interviewed R1 who lived across the hall from R13. Surveyor noted some time between 1:00 and 1:10 PM, R13's call light was activated as indicated by the light above R13's room. As Surveyor exited R1's room, R13 was sitting in a wheelchair in the door of R13's room. Surveyor continued to observe R13's call light. At 1:23 PM, Surveyor interviewed R13 who stated R13 activated the call light approximately 20 minutes ago. R13 stated R13 needed R13's brief changed before therapy. At 1:24 PM, two staff answered R13's call light and provided assistance. R13's call light was on between 14 and 24 minutes. On 5/19/26 at 11:17 AM, Surveyor interviewed R1 who stated call lights are typically answered in 30 minutes, although some staff answer sooner. R1 stated R13's call light had been on previously for approximately 60 minutes. (R1's MDS assessment, dated 3/23/26, stated R1 had a BIMS score of 15 out of 15, indicating intact cognition.) (See interview under example 3.) 3. On 5/19/26, Surveyor reviewed R38's medical record. R38 was admitted to the facility on [DATE] and had diagnoses including stroke and fall with fracture. R38's MDS assessment, dated 5/4/26, stated R38 had a BIMS score of 11 out of 15, indicating moderately impaired cognition. The MDS assessment indicated R38 was either dependent or required substantial assistance of staff for most ADLs, including toileting, bathing, and personal hygiene. On 5/19/26 at 10:11 AM, Surveyor interviewed R38 who indicated staff can take up to 30 minutes to answer R38's call light. On 5/19/26 at 1:46 PM, Surveyor interviewed CNA-D who indicated CNA-D tries to answer call lights within 10 to 20 minutes which is not always possible. CNA-D indicated there are 2 CNAs and a float for the unit and residents have to wait at times when 2 staff are required for a transfer. CNA-D indicated the call light system does not indicate who is waiting the longest. CNA-D stated staff might exit a room and see multiple call lights on. CNA-D indicated staff prioritize call lights through knowledge of the residents and their schedules. On 5/19/26 at 4:36 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated the facility does not tell staff to meet residents' needs in a certain amount of time, just that it be timely. DON-B confirmed staff should not turn a call light off prior to meeting a resident's needs.

Based on observation, staff and resident interview, and record review, the facility did not provide wound care as ordered for 1 resident (R) (R4) of 1 sampled resident. R4 developed a skin tear over a recently healed left posterior thigh wound. Physician orders were not transcribed in R4's medical record to continue treatment to protect the wound. R4's medical record did not indicate the wound was treated or covered as ordered between 5/8/26 and 5/15/26. Findings include: Between 5/19/26 and 5/20/26, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including chronic venous hypertension with ulcer and inflammation of left lower extremity and peripheral vascular disease (PVD). R4's most recent Minimum Data Set (MDS) assessment, dated 4/17/26, stated R4 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition.R4's medical record contained the following orders: ~ Left posterior thigh: Cleanse with soap and water. Apply petroleum gauze over wound, cover with 4x4 Allevyn (absorbent foam dressing). Change dressing every 3 days (ordered 4/30/26 at 5:44 PM; discontinued 5/8/26 at 12:57 AM)~ Check on wound dressings every shift to ensure dressings are in place. Replace dressings as needed if dressing missing or not adhered every shift for excoriated area on posterior upper left leg (ordered 5/15/26 at 11:02 PM; discontinued 5/19/26 at 8:06 AM)~ Cleanse area to posterior left thigh with soap and water. Apply petroleum gauze to wound bed. Cover with 4x4 border foam one time only until 5/19/26 at 11:59 PM (ordered 5/19/26 at 5:08 PM)~ Cleanse area to posterior left thigh with soap and water. Apply petroleum gauze to wound bed. Cover with 4x4 border foam one time a day every 3 days (ordered 5/19/26 at 5:08 PM) A note by Director of Nursing (DON)-B, dated 5/5/26, indicated: . will continue wound orders until new orders received. On 5/7/26, R4 was seen by the wound clinic. Documentation indicated the wound was healed. The wound clinic provided a treatment order to continue care for the healed wound site. R4's next wound clinic appointment was scheduled for 5/21/26. (Of note: The wound care order above was discontinued on 5/8/26 at 12:57 AM by LPN-G.)A progress note, dated 5/15/26 and written by LPN-I, indicated LPN-I notified the provider the wound had opened and R4 had a skin tear on the left posterior thigh. (Of note: R4's medical record did not contain documentation to indicate R4's left posterior thigh wound was treated or covered between 5/8/26 and 5/15/26.)On 5/19/26 at 3:41 PM, Surveyor interviewed R4 who stated R4 had an upcoming wound clinic appointment on 5/21/26 which should be R4's last appointment. R4 stated there was a wound on the back of R4's left leg. On 5/19/26 at 3:56 PM, Surveyor interviewed DON-B who stated R4 had skin issues on the right and left posterior thighs upon admission. DON-B stated R4's left posterior thigh wound was healed as of 5/5/26 and was R4's last open wound. When asked if R4 had any current open wounds, DON-B stated R4's wounds were healed. DON-B stated there was documentation of excoriation on R4's left posterior thigh on 5/15/26. DON-B stated R4's medical record contained a note written by LPN-I that indicated R4's provider was notified via the online messaging system. The provider responsed, May have above treatment order. The order to check wound dressings every shift to ensure dressings are in place and replace dressings as needed if missing or not adhered for excoriated area on the posterior upper left leg was transcribed on 5/15/26 at 10:02 PM by LPN-I. The order was discontinued on 5/19/26 at 8:06 AM by DON-B because DON-B thought the wound was healed. On 5/19/26 at 4:03 PM, Surveyor, DON-B, and Wound Nurse (WN)-H viewed R4's left posterior thigh. DON-B removed a foam border dressing that was dated 5/15 and initialed by of LPN-I. DON-B described R4's left posterior thigh and dressing while Surveyor observed: the dressing contained dried, yellow serous drainage; the skin tear was on the healed scar tissue and appeared superficial; the surrounding skin contained slight excoriation and did not show signs of infection. On 5/19/26 at 4:40 PM, Surveyor interviewed DON-B who stated the confusion with R4's wound care order was an oversight on DON-B and the nurse's part. DON-B stated DON-B discontinued the wound treatment that was entered on 5/15/26 because DON-B thought R4's wound was healed. DON-B was not aware of the skin tear that occurred over R4's scar on 5/15/26. DON-B stated the order should have been continued as ordered according to the 5/7/26 wound clinic document (even though the wound was healed) in order to protect the area. On 5/19/26 at 4:56 PM, DON-B verified DON-B could not find documentation from the provider to discontinue R4's 5/5/26 order. DON-B stated because a wound is healed does not mean it cannot remain covered and staff should have followed the orders or notified DON-B or the provider for clarification.

Based on staff interview and record review, the facility did not ensure an allegation of misappropriation was thoroughly investigated for 1 resident (R) (R68) of 1 sampled resident.Housekeeping Supervisor (HS)-E used R68's credit card to pay $1501.97 of personal bills after R68 used HS-E's phone to make purchases. The facility did not thoroughly investigate the allegation of misappropriation.Findings include:The facility's Vulnerable Adult Abuse and Neglect Prevention policy, revised 3/25/25, indicates: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, neglect, mistreatment, or exploitation. The facility will follow the federal guidelines dedicated to the prevention of abuse and timely and thoroughly investigate allegations. On 5/20/26, Surveyor reviewed R68's medical record. R68 was admitted to the facility on [DATE]. A Minimum Data Set (MDS) assessment, dated 2/16/26, stated R68 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. R68 was R68's own decision maker and there were no next of kin on R68's contact list. R68 passed away at the facility on 3/10/26.A facility-reported incident (FRI) submitted to the State Agency on 3/27/26 that indicated HS-E contacted Nursing Home Administrator (NHA)-A on 3/22/26 and stated HS-E was going to turn HS-E's self into the police because HS-E was stupid and let R68 use HS-E's phone a few weeks ago to order items online. HS-E indicated HS-E did not know R68 saved R68's bank card in the wallet of HS-E's phone. HS-E stated HS-E recently paid bills and did not realize the payments were made with R68's card until HS-E saw the email confirmations. HS-E found R68's card in HS-E's phone wallet and deleted it. HS-E contacted the companies to whom bills were paid but they stated they would not reverse the charges. HS-E indicated HS-E was going to report the situation to the police and understood if NHA-A needed to fire HS-E. The facility suspended HS-E and initiated an investigation. The police were notified and indicated they put the allegation on file. HS-E also filed a police report which the police indicated was put on file since there was no way to prove anything. Other residents and staff were interviewed with no concerns. The investigation contained a statement from HS-E that indicated HS-E let R68 use HS-E's phone because R68's phone and iPad were dead and not charging and R68 wanted to order items online. HS-E allowed R68 to use HS-E's phone but did not know R68 saved R68's bank card in the phone. The investigation indicated HS-E paid bills on 3/15/26 with R68's card and did not realize HS-E chose R68's card instead of HS-E's card. HS-E paid an electric bill, a cable/internet bill, and a gas bill for a total of $1501.97. HS-E read emails on 3/22/26 that contained payment confirmation for the bills and realized HS-E did not use HS-E's card. HS-E contacted the gas company who indicated the charge could not be reversed and stated HS-E needed to contact the financial institution. The cable/internet company indicated they were unable to reverse the charge and HS-E would have to dispute the charge with the bank. HS-E contacted the electric company but had not heard back. HS-E deleted R68's card from HS-E's phone and did not have a record of what bank the card was from. The investigation included screenshots of HS-E asking the gas company and cable/internet company to reverse the charges. The facility determined HS-E unintentionally used R68's card which did not meet the definition of misappropriation as there was no evidence to indicate R68 intentionally took R68's funds. The facility identified a breach of policy related to professional boundaries and using a personal device for a resident's financial transaction. The facility re-educated HS-E and all staff. The investigation did not include copies of HS-E's bills or email receipts from the dates HS-E paid the bills to verify R68's statement. The investigation did not include follow-up communication with the gas company or proof that HS-E communicated with the electric company. The investigation also did not indicate if HS-E paid back the $1501.97 from R68's funds.On 5/20/26 at 12:44 PM, Surveyor interviewed NHA-A and Director of Nursing (DON)-B who indicated HS-E did not have the card on HS-E's phone so they were unable to contact R68's bank. When Surveyor asked if HS-E heard from the gas company, NHA-A stated NHA-A didn't think so but would check. NHA-A indicated the facility did not review copies of HS-E's bills, email receipts of bills, or payment history as part of the investigation. When asked if any of the funds were recovered from HS-E, NHA-A was not sure who HS-E would pay back.On 5/20/26, Surveyor interviewed Business Office Manager (BOM)-F who indicated the facility will not be paid from 3/5/26 through 3/10/26 for R68's stay. BOM-F indicated R68 was private about financial matters and had no personal accounts listed with the facility. On 5/20/26 at 1:34 PM, 2:20 PM, and 2:53 PM, Surveyor interviewed HS-E about R68's belongings and who cleaned out R68's room. HS-E indicated HS-E cleaned R68's room after R68 passed away. HS-E indicated HS-E doesn't go through personal items when cleaning out a room. HS-E stated R68's personal items were kept for a couple days and then thrown away. HS-E asked NHA-A if HS-E could dispose of the belongings because R68 did not have family or friends to claim them. HS-E provided information to Surveyor that indicated HS-E paid higher monthly amounts than usual for the 3 bills that were paid with R68's bank card. HS-E indicated the facility had not offered HS-E a way to pay back the money. HS-E stated HS-E called the gas company who had no record of any communication. HS-E stated the gas company uses a third party for concern emails/questions and all of HS-E's communications with them had been deleted. HS-E indicated the gas company stated to re-send the information and they would review it immediately. HS-E provided a copy of the communication which was sent on 5/20/26.On 5/20/26 at 2:36 PM and 3:10 PM, Surveyor informed NHA-A the facility's investigation did not contain proof R68 contacted the gas company. NHA-A provided an email from HS-E to NHA-A that indicated HS-E emailed the gas company, but did not take a screen shot. NHA-A acknowledged the facility did not follow-up to see if HS-E had heard back from the gas company or if HS-E was able to retrieve any of the funds. NHA-A indicated NHA-A had not seen copies of the bills that were paid and the facility had not worked with or offered HS-E a way to pay back the money.

Based on observation, staff interview, and record review, the facility did not ensure a medication cart was locked when unattended and that medications were stored appropriately. This practice had the potential to affect more than 4 of the 51 residents residing in the facility. On 7/25/25, staff left a medication cart unlocked and unattended on multiple occasions. In addition, staff left medications on top of an unattended medication cart. Findings include:The facility's Administering Medications policy, revised 1/22/24, indicates: .Medication will remain secured in a locked cabinet/cart unless in direct view of the individual administering the medication. 1.On 7/25/25 at 8:28 AM, Surveyor observed Licensed Practical Nurse (LPN)-C prepare medication. LPN-C then walked down the 500 wing to ask a question and left the medication cart unlocked. Eight residents were in the vicinity of the cart at the time.On 7/25/25 at 8:34 AM, Surveyor interviewed LPN-C who confirmed the medication cart should have been locked when unattended. On 7/25/25 at 10:42 AM, Surveyor approached the nurses' station between the 500 and 600 wings and noted the 600 wing medication cart was pushed against the wall near the outside door. The cart was unlocked and unattended and out of LPN-C's view.On 7/25/25 at 10:42 AM, Surveyor interviewed LPN-C in the nurses' station who confirmed the medication cart should have been locked when unattended. Two residents were in the lobby at the time. 2. On 7/25/25 at 8:46 AM, Surveyor observed LPN-C prepare medications. LPN-C then walked down the 600 wing to administer the medications and left five medication cards and two bottles of medication unattended on top of the medication cart. On 7/25/25 at 8:57 AM, Surveyor observed Director or Nursing (DON)-B inform LPN-C that medications were left unattended on top of the medication cart. LPN-C returned to the cart and secured the medications.On 7/25/25 at 2:13 PM, Surveyor interviewed DON-B who confirmed medication carts should be locked when unattended and medications should not be left on top of an unattended medication cart.

Based on observation, staff interview, and record review, the facility did not ensure staff completed proper hand hygiene during the provision of cares for 1 resident (R) (R28) of 3 residents. On 2/26/25, Certified Nursing Assistant (CNA)-D did not complete appropriate hand hygiene during the provision of cares for R28. Findings include: The facility's Hand Hygiene policy, revised 5/8/24, indicates: To provide guidelines to staff for proper and appropriate hand washing and hygiene techniques that will aid in the prevention of the transmission of infections .3. Hand hygiene is always the final step after removing and disposing of personal protective equipment (PPE) .Using alcohol-based hand gel: 1. If hands are not visibly soiled, use an alcohol-based hand rub for all the following situations: .d. Before applying gloves and after removing gloves or other PPE .f. Before moving from a contaminated body sit to a clean body site during resident care; example: after providing peri-care, before applying moisture barrier or other treatments . On 2/26/25, Surveyor reviewed R28's medical record. R28 was admitted to the facility on [DATE] and had diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (also known as stroke) affecting the left non-dominant side. R28's Minimum Data Set (MDS) assessment, dated 12/28/24, indicated R28 was dependent on staff for personal hygiene. On 2/26/25 at 11:38 AM, Surveyor observed CNA-C and CNA-D provide incontinence care for R28. During the provision of care, Surveyor observed CNA-D provide rear perineal care and remove R28's soiled brief with gloved hands. With the same soiled gloves, CNA-D placed a clean brief under R28, applied protective cream to R28's buttocks, and assisted CNA-C with repositioning R28. CNA-D then removed gloves and completed hand hygiene. After R28 was repositioned in bed, Surveyor observed CNA-D remove gloves, raise the head of the bed, and place R28's call light within reach before completing hand hygiene. On 2/26/25 at 11:45 AM, Surveyor interviewed CNA-D who verified CNA-D should have completed hand hygiene immediately following glove removal. CNA-D also verified CNA-D should have changed gloves and completed hand hygiene after CNA-D provided perineal care and removed R28's brief and before CNA-D provided a clean brief and applied protective cream. On 2/26/25 at 11:56 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff are expected to complete hand hygiene before moving from dirty to clean tasks and immediately following glove removal.

Based on staff interview and record review, the facility did not ensure 1 resident (R) (R10) of 5 sampled residents was monitored for adverse reactions to a high-risk medication. R10 was prescribed furosemide (a diuretic medication). R10's care plan did not contain monitoring interventions for adverse reactions to the high-risk medication. Findings include: According to medlineplus.gov, furosemide may cause side effects including, but not limited to: frequent urination, blurred vision, headache, constipation, diarrhea, fever, ringing in the ears, loss of hearing, rash, hives, blisters or peeling of the skin, itching, difficulty breathing or swallowing, or yellowing of the skin or eyes. Between 2/24/25 and 2/26/25, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had diagnoses including dementia, Alzheimer's disease, hypertension (high blood pressure), restless leg syndrome, bradycardia (slow heart beat), and presence of aortocoronary bypass graft and coronary heart disease. R10's Minimum Data Set (MDS) assessment, dated 1/6/25, had a Brief Interview for Mental Status (BIMS) score 15 out of 15 which indicated R10 had intact cognition. R10 had a physician order for furosemide 20 milligrams (mg) by mouth once daily for edema (dated 9/3/24). R10's care plan did not indicate R10 received diuretic medication or include monitoring interventions for adverse reactions to furosemide. On 2/26/25 at 12:37 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed R10's plan of care should contain monitoring interventions for adverse reactions to furosemide. On 2/26/25 at 12:56 PM, Director of Nursing (DON)-B confirmed R10's plan of care did not contain monitoring interventions for furosemide. DON-B indicated DON-B added monitoring interventions to R10's plan of care and planned to audit other residents' plans of care

Based on observation, interview and record review, the facility did not provide the necessary services, care, and to prevent urinary tract infection for 1 of 3 residents (R) reviewed with urinary catheter (R31). This is evidenced by: Surveyor received policy titled, Hand Hygiene, with the most recent revision date of 01/16/23 which states in part: Staff will perform hand hygiene by washing hands before applying gloves and after removing gloves. Surveyor also received policy titled, Foley Catheter Insertion, with the most recent revision date of 02/09/18 which states in part to: .verify physician's order for procedure. Policy also states, After completing perineal care, perform hand hygiene. Arrange supplies on a clean surface within easy reach. Open catheter tray using sterile technique. Apply sterile gloves. Once sterile procedure of catheter insertion is completed, Remove gloves and complete hand hygiene. Surveyor reviewed R31's record and noted his diagnosis includes neuromuscular bladder dysfunction. R31's admission MDS dated [DATE] and quarterly MDS dated [DATE] show R31 was admitted with and has an indwelling catheter. R31's care plan indicates: Actual alteration in elimination r/t (related to) suprapubic catheter in place due to neurogenic bladder secondary to multiple sclerosis, urge incontinence. Resident will have no complications r/t indwelling catheter through next review. Apply barrier cream to peri area after each incontinent episode. Catheter size 22 F 10 ml (There is no order in place specifying this catheter size). Change suprapubic catheter as ordered. (There is no physician order in place regarding catheter change). Check and change resident as needed due to incontinence. Monitor/document/report s/sx (signs and symptoms) of UTI (urinary tract infection): fever, abd (abdominal) pain, mental status change, weakness, functional decline, nausea, vomiting, dark cloudy urine, foul smelling urine, blood in urine, pus in urine. R31's physician orders include: 05/25/23: Flush catheter with acetic acid solution 60 ml QID. Use the hemostat to clamp catheter and leave solution in for 10 minutes, then open and allow to drain four times a day. 08/01/23: Urology consult/orders: continued scheduled SP (suprapubic) tube changes & flushes eval/Tx (evaluation and treatment) for uti (urinary tract infection) only if symptomatic (bladder spasm, suprapubic pain, hematuria, fever). The orders did not have listed scheduled SP tube changes and catheter size. R31's record shows no facility clarification from urology provider's order from 08/01/23 of when scheduled SP tube changes, size, and flushes are to be conducted. The facility did not clarify orders from the 11/01/23 follow-up urology appointment. Orders did not include any information regarding when suprapubic catheter is to be changed and size of catheter. Surveyor completed record review of nursing care provided for R31 and found the following: 10/05/23: Catheter changed 22 foley. 11/09/23: Catheter change due to clogging 20f with 20cc NS. Provider, POA, DON notified. 11/24/23: Suprapubic catheter was changed this morning after unsuccessful attempt to flush. Little output in cath at beginning of shift and wet x1. Urine returns with slight blood tinge due to change. 22fr placed with 20cc NS. On-call provider and DON notified. On 12/06/23 at 10:20 AM, Surveyor was observing Certified Nursing Assistant (CNA) D provide R31 with personal cares when Licensed Practical Nurse (LPN) C entered R31's room to complete his catheter flush. LPN C completed hand hygiene and donned gloves. LPN C set the supplies on bedside table next to wash basin filled with water, soap, towels, and resident personal items. There was no cleaning of the table or barrier applied. LPN C disconnected the catheter bag tubing, kinked tube, and capped end. LPN C attempted to insert the acetic acid and was unable to flush the catheter. LPN C uncapped R31's catheter, wiped with alcohol pad and reconnected Foley bag. LPN C unclamped the catheter and indicated the tube won't flush, so will change suprapubic catheter. LPN C removed her gloves but did not perform hand hygiene. At 10:28 AM, LPN C returned to R31's room with new Foley catheter supplies and placed the items on R31's bedside table with wash basin. LPN C did not complete hand hygiene and removed sterile glove pack from kit and donned gloves. LPN C deflated the catheter balloon leaving catheter inserted and placed the syringe in the garbage. LPN C removed her gloves but did not perform hand hygiene. LPN C left the room to get a new Foley kit as the first one was not correct. With sterile gloves on, LPN C holding the new catheter kit, instructed CNA D to grab Foley catheter to open the packaging. LPN C took the catheter out of the in sterile pack and placed directly on R31's bare abdomen. The catheter was now not sterile as it has touched R31's skin. LPN C removed the old catheter tube and placed in garbage. LPN C placed the new catheter in catheter kit tray with lube. LPN C with the same gloves was observed touching dirty area of suprapubic site. LPN C took a cotton ball with betadine to clean insertion site 3 times. LPN C with the same contaminated gloves proceeded to grab new catheter tube and inserted new catheter tubing to R31's suprapubic site. LPN C had CNA D get another Foley bag while she was holding catheter. CNA D with the same contaminated gloves from providing personal cares disconnected the new bag that was attached to the first new Foley catheter that was not used. LPN C took the new Foley bag and connected to new catheter tube. LPN C discarded supplies, removed gloves, and washed her hands with soap and water at sink. LPN C applied clean gloves and applied a new stat lock to secure catheter and placed gauze under R31's tube at site. LPN C discarded the gloves, emptied the trash, and did not perform hand hygiene and left R31's room. On 12/06/23 at 11:02 AM, following the observation, Surveyor interviewed LPN C. Surveyor asked LPN C about sterility and education on the importance of it during catheter treatment. Surveyor explained area of concern with infection control breaches. LPN C stated understanding. LPN C commented she has been doing this job for many years and is disappointed in self. On 12/06/23 at 4:33 PM, Surveyor interviewed Director of Nursing (DON) B about the observation and repeated breaks in sterility and infection prevention errors during observed catheter change. DON B stated the expectation for staff completing task would be to follow hand hygiene practices stated in Foley catheter management policy. DON B also stated the expectation would be the nurse carrying out the task would know what size catheter to use and how much to inflate the balloon inside the bladder. DON B indicated she is aware the order for R31's catheter did not meet these expectations. DON B further stated that it would be expected for nursing staff to question physician orders if they do not meet expectations of providing all necessary information to include size and frequency.

Based on interview and record review, the facility did not notify the residents of a room change in writing nor notify them of the reason they were being moved for 4 of 4 residents reviewed, Resident (R) R5, R6, R7, and R8. The facility did not explain to residents who were being moved, why they were being moved, nor did they provide written notice. R5 was moved from room [ROOM NUMBER] to 610 on 3/9/23. R5 had a BIMS score of 14 indicating they were cognitively intact. R5 was responsible for self. R6 was moved from room [ROOM NUMBER] to room [ROOM NUMBER] on 3/13/23. R6 had a BIMS score of 15 indicating they were cognitively intact. R6 was responsible for self. R7 was moved from room [ROOM NUMBER] to room [ROOM NUMBER] on 3/9/23. R7 had a BIMS score of 14, indicating they were cognitively intact. R7 was responsible for self. R8 was moved from room [ROOM NUMBER] to room [ROOM NUMBER] on 3/9/23. R8 had a BIMS score of 13 indicating they were cognitively intact. R8 was responsible for self. On 3/14/23, Surveyor interviewed R5 regarding satisfaction with care. At that time R5 told Surveyor that she had been moved from the front of the building to the back recently. R5 stated that she did not know why she was moved, and that she was not notified of the move. R5 asked Surveyor to look into this. Surveyor interviewed R6 and R7 regarding the move. Both residents stated that they had been moved, that they did not know why, and that they were not notified in writing. R8 was not available to interview as he was sleeping. On 3/14/23, Surveyor interviewed Registered Nurse (RN) C who functions as the facility case manager and Social Services person. RN C had been functioning in this role since August of 2022. Surveyor asked why residents were moved from the front to the back of the building. RN C stated that in the past few months a lot of long term residents had gone home, and they needed to open up some rehab rooms up front. Surveyor asked if the residents were notified of the moves, and RN C stated that yes, the person that moves them lets them know. RN C stated further that recently they were trying to give notice a day in advance of the move. Surveyor asked if there was a note made on the moves in the resident's medical record and RN C stated only if they had to notify the POA. RN C stated that if the resident is responsible for self, the Housekeeper is the one who moves them and tells them they are moving. On 3/14/23, Surveyor interviewed Nursing Home Administrator (NHA) A regarding the moving of residents. Surveyor asked who notifies residents that they will be moving. NHA A stated the Housekeeping Supervisor. Surveyor asked how this notification is done, and NHA A stated the Housekeeping Supervisor talks to them, has a conversation. Surveyor asked if written notice was given and NHA A stated no. Housekeeping Supervisor was not in the building or available to interview regarding the moving of residents. On 3/14/23, Surveyor reviewed the facility policy on Room Changes. Under Procedure it states: 1. Notify and explain the reason for transfer to the resident and or family or responsible party of the resident. 2. Obtain residents'/DPOA agreement to transfer. On 3/14/23, Surveyor reviewed a document that the NHA presented that residents sign on admission, this document is titled Center Room Change/Bed Change Policy. This document is an acknowledgement of the policy at the time of admission, and consent to a future room change should it become necessary based on changes to the payor source. Surveyor notes that the residents had signed. However, these room changes were not based on payor source, nor were they given notification of an eminent room change or room mate change. The facility was not providing written notice of a room change, nor giving an explanation to the residents of the reason for the change.

Based on observation, resident interview and staff interview, the facility did not reassess the effectiveness of interventions and revise the plan of care to meet the resident's needs for 1 Resident (R) (R41) of 2 residents reviewed for nutritional needs. R41's plan of care did not reflect the assistance R41 needed to eat. Per medical record review, R41 admitted to the facility on [DATE] after an acute hospital stay for treatment of a fractured arm. R41 had diagnoses to include severe protein-calorie malnutrition, macular degeneration, cataract, elder neglect, fecal impaction, adult failure to thrive, repeated falls and muscle wasting. R41 was cognitively impaired. On 11/7/22 at 12:00 PM, Surveyor observed R41 during the noon meal. R41 was sitting in R41's room in a wheelchair with a meal tray on a table in front of R41. Surveyor observed the tray which contained a partitioned plate with noodles, broccoli, a piece of meat, a bowl of fruit cocktail and a piece of garlic bread. Surveyor observed R41 pick up a noodle with R41's fingers and place the noodle in R41's mouth. R41 also picked several pieces of fruit from the bowl and placed them in R41's mouth. R41 then removed the pieces of fruit from R41's mouth and placed them on the tray. R41 picked up the piece of meat and asked, What is this? Surveyor told R41 it was a piece of meat and asked if R41 wanted staff to cut up the meat. R41 said, Yes. Surveyor asked a staff person to assist R41 with cutting the meat. R41 picked up a piece of meat with R41's fingers, placed the meat in R41's mouth, chewed the meat, removed the meat from R41's mouth and placed the meat on the tray. R41 stated, I can't swallow it. Surveyor observed R41 feel around the tray, pick up a spoon, attempt to poke the food with the spoon and put the empty spoon in R41's mouth. R41 was unable to reach the fluids on R41's tray. R41 indicated to Surveyor that R41 was hungry. Surveyor noted R41 was motivated to eat and was active in attempting to eat. R41 indicated R41 had difficulty seeing items on the food tray and was unable to swallow some of the food. R41 did not consume any of the meat or broccoli. R41 ate a couple of the noodles and a few pieces of fruit. R41 also ate the inner part of the garlic bread, but left the crust on the tray. R41 then stated to Surveyor that R41 was tired and needed to lay down. On 11/8/22 at 8:00 AM, Surveyor observed R41 during the breakfast meal. R41 was eating in R41's room while sitting up in bed with a food tray on a table in front of R41. R41 was holding a piece of sausage. Surveyor observed R41 takes bites of the sausage, chew the sausage, remove the sausage from R41's mouth and place the sausage on the tray. R41 stated to Surveyor, I need help with the oatmeal. Surveyor observed Med Tech (MT)-E looking in R41's room and asked Surveyor if R41 needed anything. Surveyor responded that R41 needed assistance with eating. MT-E indicated to Surveyor that R41 ate well on R41's own; that R41 Licked the platter clean, look at her, she's eating now. Surveyor indicated R41 removed all bites of the sausage and placed the sausage on the tray. MT-E asked another staff person, Certified Nursing Assistant (CNA)-D, to assist R41. CNA-D assisted R41 with the breakfast meal. R41 stated to CNA-D, I need help with the oatmeal. R41 asked for sugar for the oatmeal. CNA-D left to get sugar and placed sugar in R41's oatmeal. CNA-D assisted R41 with drinking fluids and with eating the oatmeal. CNA-D stated CNA-D would ask the speech therapist to evaluate R41 due to R41's difficulty with eating. On 11/8/22 at 10:35 AM, Surveyor interviewed Speech Therapist (ST)-C who indicated ST-C had not assessed R41 since admission to the facility as staff had not alerted ST-C of any problems. ST-C stated ST-C was going to observe R41 during the noon meal. On 11/8/22 at 12:10 PM, Surveyors observed R41 with a meal tray in R41's room. Staff were not in the room assisting R41 with eating. The meal tray contained meat, green beans and cut up potatoes with skin. Two Surveyors observed R41 feel around the tray, place food in R41's mouth, chew, remove the food and place the food on the tray. The Surveyors noted R41 chewed the softer part of the potato from the skin and placed the skins on the tray. On 11/8/22 at 2:00 PM, ST-C approached Surveyor and stated ST-C observed R41 eat and noted R41 removed food from R41's mouth and placed the food on the tray. ST-C stated ST-C did not know if that was a behavior of R41 or if there was something else going on. ST-C stated an order was requested of the provider for a speech therapy evaluation. R41's medical record contained a care plan for nutrition risk. The care plan was initiated on 10/7/22 (the day of admission) with revisions on 11/1/22 to include use of a divided plate and adaptive silverware. R41's medical record contained a comprehensive assessment, dated 10/14/22, that indicated R41 needed extensive assistance of one staff (physical assist) for eating. R41's plan of care was not revised after the comprehensive assessment was completed to reflect R41's need for extensive assistance with eating. On 11/9/22 at 11:00 AM, Surveyor interviewed Director of Nursing (DON)-B who stated DON-B was unaware how the coordinator for comprehensive assessments received information to code R41 as needing extensive assistance with eating. (The coordinator was out of work the week of the survey). On 11/9/22 at 11:50 AM, Surveyor interviewed Certified Occupational Therapy Assistant (COTA)-F who stated R41's care plan was revised to include a divided plate and adaptive silverware so the food would not spill off the plate. COTA-F stated other therapy staff indicated R41 was legally blind so staff could tell R41 where the food was on the divided plate. Therapy indicated R41 always used R41's hands to eat and, due to being blind, had to feel around the plate for food. On 11/9/22 at 12:45 PM, Surveyor observed R41 in the dining room sitting at a table with three other residents and two staff. R41's food was cut into small pieces. R41 was actively eating the meal including the cut-up meat. R41 stated to Surveyor that R41 enjoyed eating in the dining room. On 11/9/22 at 1:00 PM, Nursing Home Administrator (NHA)-A indicated NHA-A learned R41's comprehensive assessment was coded that R41 required extensive assistance with eating because staff documented on three occasions during the assessment period that R41 required extensive assistance with eating and thus had to code R41 as requiring such.

Based on record review and staff interview, the facility did not notify the physician of a significant weight loss for 1 Resident (R) (R38) of 24 sampled residents. R38 lost a significant amount of weight (defined as a 10% loss in 6 months, a 7.5% loss in 3 months, or a 5% loss in 1 month) between 8/11/22 and 9/7/22. The facility did not notify the physician of the significant weight loss. Findings include: The facility's undated policy titled Resident Heights and Weights states, All residents will be weighed upon admission and subsequently as the policy directs to provide a baseline and ongoing record for monitoring stability of weight as an indicator of nutritional status and medical condition over a period of time. Purpose .It is also to provide guidelines for MD (Medical Doctor) notification and documentation of significant weight changes. 12. The Dietician and/or designee will review individual weights recorded in the EMR (Electronic Medical Record) monthly to identify trends over time. Unplanned weight trends will be assessed and addressed by the Dietician and MD notification will be made by nursing staff if applicable. On 11/7/22, the Surveyor reviewed R38's medical record which documented diagnoses of unspecified dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety. R38's MDS (Minimum Data Set), dated 9/10/22, section K0300 was marked yes for weight loss and not on a physician prescribed weight loss program. R38's care plan titled I have a potential for altered nutritional status had an intervention of weigh resident per facility policy, or as ordered. Notify MD/NP (Nurse Practitioner) per order or with significant changes. R38's documented weight in pounds on 8/11/22 was 115.6 and on 9/7/22 was 109 which indicated a significant weight loss of 5.71%. The facility was not able to provide documentation to the Surveyor of physician notification for R38's significant weight loss. On 11/8/22 at 8:30 AM, the Registered Dietician (RD)-H explained to the Surveyor that physician notification of weight loss was nursing's responsibility per the facility's policy. RD-H provided the facility Resident Heights and Weights policy to the Surveyor. On 11/8/22 at 10:04 AM, the Surveyor interviewed Director of Nursing (DON)-B regarding physician notification of R38's significant weight loss. DON-B told the Surveyor it was DON-B's understanding when the Dietician completed residents' dietary assessments, reviewed weights, and identified weight concerns, the Dietician then updated residents' physicians with the findings.

Based on observation and interviews the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases, infection and COVID-19. This has the potential to affect 23 out of 46 residents who reside in the facility. Observations of staff working the COVID unit (300 hallway) and also working on the precautions unit (200 hallway) that were not COVID positive has the potential to transfer COVID -19 to the 7 residents residing on the precaution unit. Observations of staff not wearing Personal Protective Equipment (PPE) appropriately while working on the COVID unit. Observations of staff going in the COVID unit not wearing appropriately PPE to get supplies to restock a non COVID unit (600 hallway) that has 16 residents. PPE supplies of gloves, masks, gowns and hand sanitizer are stored on the COVID unit for the whole facility. This is evidenced by; On 11/04/20 Surveyor observed signs posted on the double doors leading into the COVID unit that read in part, Stop Check With Nurse Before Entering - Contact Precautions (In addition to Standard Precautions), STAFF and Physicians; Gloves - Always hand hygiene before donning, Gown - Always . On 11/04/20 at 9:00 a.m., Surveyor observed Certified Nursing Assistant (CNA) C working on the COVID unit. At 9:45 a.m. surveyor observed CNA C working on the precaution unit entering room [ROOM NUMBER] to answer a call light wearing goggles, a surgical mask and gloves. At 9:10 a.m., Surveyor interviewed CNA C and asked if she worked other hallways. CNA C indicated she did because she would get called in on the weekends when no one else wanted to work. At 2:50 p.m., Surveyor interviewed Director of Nursing (DON) B and asked if staff are scheduled to work other hallways. DON B indicated that due to staff shortages staff have to be scheduled to work different halls. Nursing Home Administrator (NHA) A asked how they should handle staff shortages. Surveyor responded that they should refer to their emergency staffing procedure. At 9:00 a.m., Surveyor observed Certified Nursing Assistant (CNA) C working on the COVID unit coming out of a residents room wearing gloves, gown, goggles and a surgical mask. The surgical mask was positioned under the nose and only covering CNA C's mouth. At 2:50 p.m., Surveyor interviewed DON B and asked if audits of appropriate use of PPE have been done. DON B indicated that there have been several trainings on proper use of PPE. At 9:20 a.m., Surveyor observed Registered Nurse (RN) D entering the COVID unit, RN D was observed wearing a face shield and surgical mask. RN D went on the COVID unit to find a staff member that had the key to the supply storage room to gather supplies to take to the 600 hallway. RN D did not wear a gown, gloves or perform hand hygiene before entrance into the COVID unit. Upon exit of the COVID unit RN D did not perform hand hygiene. Surveyor interviewed DON B asking what PPE should be worn when going down the COVID unit. DON B indicated that full PPE should be worn when going into the COVID unit. Surveyor toured the storage room of PPE supplies on the COVID unit with RN E. At 2:50 p.m., Surveyor asked DON B if the storage unit on the COVID unit was for the whole facility. DON B indicated that was the storage of PPE for the whole facility.

Based on observation, interview and record review, the facility did not ensure hand hygiene procedures were followed by staff involved in direct resident care for 1 of 5 sampled residents (R52) observed for cares. CNA-D (Certified Nursing Assistant) did not follow hand hygiene practices consistent with accepted standards of practice when completing morning cares for R52. This is evidenced by: At 7:40 a.m. CNA-D returned to R52's room and donned gloves. Again CNA-D did not wash her hands or perform hand hygiene. CNA-D washed R52's face, hands, under arms and [MEDICATION NAME] area in bed. CNA-D assisted R52 with dressing and transferred her to her wheelchair. CNA-D did not remove the soiled gloves or perform hand hygiene. R52 was brought to the bathroom to perform oral care. CNA-D obtained R52's toothbrush and toothpaste from the bathroom cupboard, wet the tooth brush and applied tooth paste to the toothbrush. CNA-D provided the toothbrush to R52 to brush her teeth. CNA-D rinsed the toothbrush, returned it to the toothbrush holder and placed it in the cupboard after R52 brushed her teeth. CNA-D obtained a glass at resident bedside, filled it with water and provided it to R52 for rinsing her mouth. After completion of cares Surveyor spoke with CNA-D about the observation. CNA-D also indicated she should have removed her gloves, washed her hands and donned clean gloves before proceeding to oral care from resident cares. On 11/05/19 at 02:37 PM Surveyor spoke with DON-B (Director of Nursing) and RN-C (Registered Nurse) who is also the facility's Infection Control Preventionist. RN-C indicated the facility would expect hand hygiene when entering a resident room to assist with cares prior to staff donning gloves. Additionally RN-C expressed she would expect staff to remove their gloves, wash their hands and don clean gloves whenever going from one task to another task or when going from a dirty task to a clean task. On 11/06/19 at 7:10 AM RN-C provided Surveyor with staff training records demonstrating CNA-D was trained on hand hygiene 03/2019 as part of the annual training. Surveyor asked RN-C if CNA-D had been audited or observed for hand hygiene during the past year. RN-C responded no formal audits were done with CNA-D since last survey.

Based on record review and interview, the facility did not inform the resident or resident's representative of a psychoactive medication that required informed consent for administration for 2 of 5 residents (R10, R27) reviewed for unnecessary medications. R10 was given the antipsychotic medication Quentiapine 12.5mg twice a day and the antianxiety medication [MEDICATION NAME] 0.5mg at bedtime. The facility did not have an informed consent from R10's representative for Quentiapine. The informed consent on file for [MEDICATION NAME] was noted to have been verbal consent, without getting written consent, and was dated 3/23/17. Informed consents are to be updated at least every 15 months. R27 was given the antianxiety medication [MEDICATION NAME]. The facility did not have an informed consent form from R27's representative. This is evidenced by: Example 1 R10 was admitted to the facility 2/2/15. [DIAGNOSES REDACTED]. R10 has been prescribed the Quentiapine historically for Dementia with behavioral disturbances. R10 has been prescribed [MEDICATION NAME] historically for Anxiety Disorder. Review of R10's medical record revealed there was no informed consent for the Quentiapine and an outdated informed consent for the [MEDICATION NAME]. On 11/6/19 at approximately 11:30AM, Surveyor interviewed DON-B (Director of Nursing) who stated they have looked through everything and were unable to find any additional or updated consent forms for R10. Example 2 R27 was admitted to the facility 9/19/18. [DIAGNOSES REDACTED]. R27 was prescribed [MEDICATION NAME] 0.25mg twice a day for Generalized Anxiety Disorder. This medication was started on 9/12/19. Review of R27's medical record revealed there was no informed consent for [MEDICATION NAME]. On 11/6/19 at approximately 11:30AM, Surveyor interviewed DON-B who stated they have looked through everything and were unable to find a consent form for R27.

Based on family and staff interview and record review, the facility did not consistently update the responsible party for 1 of 6 residents reviewed (R3) when there was a change in condition. R3 fell and sustained an injury in two separate instances. R3's HCA (Health Care Agent) was not updated on either. This is evidenced by: R3 has medical [DIAGNOSES REDACTED]. R3's POA document was activated 5/11/12, naming HCA-C as the responsible party. An entry in R3's medical record on 5/21/19 at 3:00 PM, indicated R3 was up walking with her walker, unassisted. R3 was to have assistance of staff for ambulation. The CNA (Certified Nursing Assistant) assisted R3 to a wheelchair and when she tried to remove the walker, R3 sustained a skin tear to the base of her right index finger that required first aid of steristips. According to the record, the DON (Director of Nursing) was notified; however, there is no evidence HCA-C was notified. On 9/18/19 at 10:00 AM, Surveyor met with HCA-C and other family members. HCA-C stated on 5/22/19, during a visit with R3, family noticed the dressing to R3's right hand and inquired of the cause. It was at this time the family was given the information regarding the incident. On 9/17/19 at 2:48 PM, the surveyor interviewed the NHA (Nursing Home Administrator) regarding the injury to R3's finger. The NHA stated the nurse on duty at the time did not complete an incident report, so the injury was not investigated until the family approached her with their concern on 5/22/19. An entry dated 7/12/19 indicated R3 had sustained a fall on 7/12/19. The facility felt the cause of the fall was as a result of R3 wearing slippers, which prevented a good grip to the floor when she walked. In reviewing the Nursing Progress Notes regarding this fall (7/12/19) there was no indication of the POA or designee being updated on this event. The surveyor then reviewed the Interdisciplinary Team fall review for this event dated 7/12/19 and last revised on 8/27/19. The form indicates that the POA was notified on 7/12/19 at 6:08 PM. at the same exact time that the physician and the Unit Manager were updated. During an interview with R3's HCA and family, the family stated that they were not notified of this fall until 7/15/19 when the facility approached them of obtaining a different pair of shoes for R3. During the interview with the family to verify this information, POA and all family members denied being updated at the time of the fall. On 9/17/19 at 2:30 PM Surveyor interviewed the Unit Manager (UM) where R3 resides. The UM stated staff are to do an assessment of the resident, implement an immediate intervention, notify the physician and the responsible party, family or HC[NAME]

Based on resident, family and staff interviews and record review the facility did not ensure that 1 of 6 sampled residents were free from significant medications errors (R1). R1 was admitted to the facility from the hospital on [DATE]. Hospital orders indicated insulins were held at discahrge, and to complete accuchecks twice a day. The facility did not start doing the accuchecks until 09/13/19 at which time, R1's blood sugars were high and insulin was restarted. This is evidenced by: R1 was admitted to the facility from the hospital on [DATE]. Admitting [DIAGNOSES REDACTED]. R1's hospital discharge medications includes, blood sugar test strips, blood glucose meter (test n'go blood glucose system), garlic 1,000 mg cap every day and Lancets Misc test 2 times a day. The report also states, He is normally on NPH (insulin) and [MEDICATION NAME]. He has required less than 5 units of insulin daily. All insulin and oral meds for diabetes have been held at discharge. I ordered blood glucose checks bid (twice a day). Review of R1's medical record reveals the following physician's telephone order sheet dated 08/09/19 which indicates the following: D/C Lancets/BS (discontinue blood sugar). D/C all insulin at hospital. This order, which is not consistent with the hospital discharge orders, is unsigned by either the nurse or the physician. R1's physician orders [REDACTED]. There was no evidence of blood glucose monitoring being completed two times a day. A lab report dated 08/13/19 indicates R1's blood glucose level was 183 and flagged as High. The physician signed off on this lab report with no new order. Surveyor reviewed the facility complaint/grievance log from (MONTH) 2019. On 09/12/19, Family B reported a concern that R1 was not receiving insulin or having his blood sugar checks. Family B indicated R1 had been completing blood glucose monitoring and taking insulin prior to his hospitalization . R1's lab report from 09/13/19 states, Glyco (Hgb A1c) (Hemoglobin) results 9.3 (flagged as high with the reference range of 4.3-5.6 %) and MBG (mean blood glucose) results 220 (flagged as high with the reference range 93-133 mg/dl). The physician signed off on this lab and ordered, Please resume his usual meds for DM (Diabetes Mellitus) when notified by family. Surveyor reviewed R1's physician order [REDACTED].[MEDICATION NAME] Tablet 5mg Give 2.5 mg (milligram) by mouth in evening for DM II. Hold if blood sugar is less than 80. [MEDICATION NAME] Tablet 5 MG Give 2.5 mg by mouth in the morning for DM II hold if blood sugar is less than 80 [MEDICATION NAME] N Suspension (Insulin NPH (Human [MEDICATION NAME]) Inject 15 unit subcutaneously in the evening for DM. [MEDICATION NAME] N Suspension (Insulin NPH (Human [MEDICATION NAME]) Inject 15 unit subcutaneously in the morning for DM. On 09/17/19 at 11:10 a.m., Surveyor spoke with R1 in his room. R1 incidicated that he came to the facility from the hospital after having a motor vehicle accident and hurting his back. R1 indicated that when he was at home he had been taking insulin for a few years for his diabetes. R1 said that the physician had recently restarted his insulin and they started checking his blood sugars. On 09/17/19 at 1:15 p.m., Surveyor spoke with the DON (Director of Nursing). The DON said R1 went to the see the urologist on 09/09/19 for [MEDICAL CONDITION] and the urologist had asked why R1 was not on the insulin. The DON said that R1's daughters had questioned this also, with Family B calling her on 09/12/19. The DON said Family B also questionedg why R1's blood sugars were not checked in addition to not being on insulin. The DON said that she had told the family that the insulin was not ordered when coming from the hospital. Surveyor and the DON reviewed R1's discharge summary and medication order sheet from 08/09/19 and the unsigned physician's telephone order sheet from 08/09/19. The DON said they should have had a order for the discontinuation of the blood sugar checks and garlic pill. The DON said they were not doing blood sugar checks until 09/13/19. The DON also indicated the physician had reviewed the high glucose lab that R1 had on 08/13/19. On 09/17/19 at 1:40 p.m., Surveyor spoke with LPN A (Licensed Practical Nurse/Clinical Manager). LPN A said she had entered R1's orders on the day of his admission from the hospital on [DATE]. LPN A said she had never entered the accucheck order and the garlic tablet order. LPN A said he doctor should have been called to discontinue those orders and the ADON (Assistant Director of Nursing) would have double checked those orders and had written the physician's telephone order sheet. On 09/18/19 at 7:15 a.m., Surveyor spoke with the ADON (Assistant Director of Nursing). The ADON said she had written the physician telephone order sheet for R1 on 08/09/19 discontinuing the blood sugar checks but she did not sign the telephone order and neither did the doctor. The ADON said she did not call the doctor. The ADON said she did not see the comments in the discharge summary from the hospital recommending continuing the accuchecks and the holding of the insulin and the [MEDICATION NAME].

Based on interviews and record reviews, the facility did not consistently ensure medical records for 1 of 6 residents reviewed (R3) was complete and accurate. R2 sustained a fall in which the investigation indicated was witnessed. Information identified later, indicated it was not witnessed. The facility did not complete a correction to their investigation, which presents false information regarding the event in R3's medical record. This is evidenced by: R3 has medical [DIAGNOSES REDACTED]. R3 sustained a fall on 5/13/19 at 11:02 PM. According to the fall investigation, this fall was witnessed. The witness statement states, I was sitting at the nurses station and I saw (R3) ambulating with her walker and she was in front of the glass door in the dining on 300 wing. She turned so she could sit down and her feet came up and out from underneath her and she fell backwards. She landed on her back. Her head came to rest on the right side on the medication cart. She was awake and talking. I went and got the nurse. On 9/17/19 at 2:48 PM, Surveyor interviewed the NHA (Nursing Home Administrator) regarding the above fall. The NHA stated that the original statement from the CNA was that she witnessed the fall occur but could not get to the resident in time to prevent the fall. Later, the CNA came back to her and stated she actually did not witness the fall. The NHA stated the CNA was fearful of being honest with the NH[NAME] The CNA was educated by the NHA regarding honesty in reporting. There was no correction made to the medical record to indicate the fall was unwitnessed.

Based on interview and record review, the facility did not ensure that it provided each resident with sufficient fluid intake to maintain proper hydration and health and maintain acceptable parameters of nutritional status, such as body weight, unless the resident's clinical condition demonstrates this is not possible for 1 of 3 residents reviewed (R1). R1 had a change of condition and documented findings of poor oral intake of food and fluids. R1 had significant weight loss of 29.8 pounds in a 6 month period (April (YEAR) - (MONTH) (YEAR)) which calculates out to a 19.23 percent loss. Weight loss wasn't identified timely as well as interventions put into place timely. No documented RD (Registered Dietician) assessment found in medical record from (MONTH) (YEAR) until (MONTH) (YEAR). R1 was hospitalized [DATE] for urinary tract infection [MEDICAL CONDITION] and dehydration. The facility did not assess R1's fluid intake to determine if interventions were needed to prevent dehydration and meet fluid needs. R1 was sent back to the local hospital on [DATE] with elevated lactic acid levels, acute kidney failure, and [MEDICAL CONDITION] and transferred to another hospital for critical care management where she had [MEDICAL CONDITION] with resuscitation, acute [MEDICAL CONDITION], multilobar likely aspiration pneumonia, and shock with R1 passing away on [DATE]. This is evidenced by: The facility policy entitled Hydration/Prevention and treatment of [REDACTED]. Policy: 1. The Dietician will assess all residents for hydration adequacy at least quarterly, and more often as necessary per resident need .3. Minimum fluid needs will be calculated and documented on initial, annual, and significant change assessments, using current standard of practice. These will be taken into consideration when developing an individualized plan for residents at high risk (as well as cardiac and renal history) . 6. Nursing will monitor for signs and symptoms of dehydration during daily care . 8. If potential inadequate intake and/or signs and symptoms of dehydration are observed, interventions will be initiated and incorporated into the care plan. ADL status, diagnosis, individual preferences, habits, and cognitive and medical status will be considered in all interventions. Physician will be informed. 9. Orders may be written for extra fluids to be encouraged between meals and/or with medication passes. A specific minimum amount should be included in the order (e.g. 240 ml fluids BID with medication pass). Force fluids is not an appropriate order. Encourage fluids is not an adequate order .11. Laboratory tests may be ordered to assess hydration if intake and symptoms indicate possible significant dehydration. 12. If laboratory results are consistent with actual dehydration, the physician may initiate IV hydration. hospitalization will be recommended, as necessary. 13. Nursing will monitor and document fluid intake and the Dietician will be kept informed of status. 14. Interdisciplinary team will update care plan and document resident response to interventions until team agrees that fluid intake and relating factors are resolved. The facility policy entitled Change in Condition, dated [DATE], states, in part: Purpose: To ensure prompt notification of the resident, the attending physician, and Durable Power of Attorney/Responsible Party of changes in the resident's physical, psychosocial and/or mental condition and/or status. Procedure: .2. Specific information that requires prompt notification include, but is not limited to: .e. Significant weight change (gain/loss of 5% or more in past thirty days, 7.5% or more in past 3 months, or 10% or more in past 6 months); .n. Refusal of treatment or medications (i.e. two (2) or more consecutive times); o. a need to transfer the resident to a hospital/treatment center .8. The care plan will be updated as necessary. R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1 was admitted with activated HCPOA (Health Care Power of Attorney)/guardianship. R1's MDS (minimum data set), with an ARD (Assessment Reference Date) of [DATE], indicates R1 has a BIMS (Brief Interview of Mental Status) completed indicating moderately impaired cognition. Section G indicates that R1 required extensive assist of ,[DATE] persons for most ADLs (activities of daily living) especially with eating assistance. Section J1550 C indicates R1 was not dehydrated. Section K0300 indicates R1 had no weight loss. Section K0510 indicates R1 was on a mechanically altered therapeutic diet. R1's comprehensive plan of care, initiated [DATE], states, in part: Focus: Resident at risk for dehydration/fluid imbalance related to mechanically altered diet, therapeutic diet, hx (history) of [MEDICAL CONDITION] of stomach, dx (diagnosis) of dysphasia. Goals: Maintain adequate fluid volume as evidenced by moist mucous membranes and demonstrate stable wight/hydration status or progressive gain/improvement toward goal with normalization of lab values based on individual norms. All interventions are dated as initiated on [DATE] and include: Assess/monitor and report signs and symptoms of dehydration, ie., dry mouth, cracked lips, poor skin turgor or decreased urinary output, .evaluate need for frequency of weights and weight resident as ordered. monitor for change in mental status, . provide additional fluids at medication pass and supplements as ordered. See MAR for specific instructions, provide assist with eating as needed, provide between meal and bedtime snacks as ordered, refer to dietician as needed, refer medication regimen with physician and/or pharmacist as needed. R1's comprehensive plan of care, initiated on [DATE], states in part: Focus: Self determination Advanced Directives with goal: Facility will honor wishes related to advanced directives. Interventions include, in part: .Full Code, resident has a durable power of attorney for health care, resident wishes full treatment. use intubation, advanced airway interventions, mechanical ventilation and cardio version as indicated. Transfer to hospital. include intensive care, resident wishes to have a feeding tube, resident wishes to have IV fluids/antibiotics if deemed appropriate, resident wishes to receive antibiotics, and review advance directives during P[NAME] (plan of care) meetings to clarify existing advance directive care instructions and whether the resident/health care agent/legal representative wishes to change or continue these instructions. R1 had a Registered dietician (RD) progress note in (MONTH) (YEAR) and no other RD documentation/assessment was found in chart until [DATE] when RD did an assessment after readmission from hospital stay [DATE] to [DATE]. (Please note that R1 had a quarterly MDS done in (MONTH) but no RD assessment/documentation was found in chart for that time frame and R 1 was starting to lose weight in July.) R1's weights include, in part: [DATE] was 155# [DATE] was 152.6# [DATE] was 151.6# [DATE] was 146.2# - 5.4# loss in 1 month from (MONTH) to (MONTH) - 3.56% in 1 month - no new interventions or RD assessment was noted in chart for weight loss or fluid status. Care plan was not updated [DATE] was 134.2# - 12# loss in 1 month from (MONTH) to (MONTH) - 8.21% in 1 month - no new interventions or RD assessment was noted in chart for weight loss or fluid status. Care plan was not updated [DATE] was 130.4# [DATE] was 125.2# - 5.2# loss in 1 month from Sept to Oct - 3.99% in 1 month; 21# (14.36%) loss in 3 months from (MONTH) to Oct; 29.8# (19.23%) loss in 6 months from (MONTH) to Oct. (Please note that the only interventions noted that were added were [MEDICATION NAME] 15 MG PO QHS on [DATE] and high-protein nutritional shake liquid (nutritional supplements) give 120 ML PO BID for supplement on [DATE].) R1 meal intake documentation key: 0 = ,[DATE]%; 1 = 26%-50%; 2= 51%-75%; 3= 76%-100% September (YEAR) 0800: refusals = 10 x's; 0 = 15 x's; 1 = 5 x's, 2 = 0 x's, 3 = 0 x's 1200: refusals = 18 x's; 0 = 9 x's; 1 = 1 x; 2 = 0 x's; 3 = 1 x's; 1 blank spot without documentation 1700: refusals = 3 x's; 0 = 6 x's; 1 = 8 x's; 2 = 7 x's; 3 = 5 x's October (YEAR) (was in hospital 5 days) 0800: refusals = 16 x's; 0 = 7 x's; 1 = 2 x's; 2 = 0 x's; 3 = 0 x's; 1 blank spot without documentation 1200: refusals = 21 x's; 0 = 2 x's; 1 = 0 x's; 2 = 0 x's; 3 = 0 x's; 1 blank spot without documentation 1700: refusals = 11 x's; 0 = 9 x's; 1 = 5 x's; 2 = 1 x; 3 = 0 x's; 1 blank spot without documentation November (YEAR) (1st-8th; sent to hospital in evening on [DATE]) 0800: refusals = 4 x's; 0 = 4 x's; 1 = 0 x's; 2 = 0 x's; 3 = 0 x's 1200: refusals = 7 x's; 0 = 0 x's; 1 = 1 x's; 2 = 0 x's; 3 = 0 x's 1700: refusals = 5 x's; 0 = 0 x's; 1 = 0 x's; 2 = 1 x; 3 = 0 x's; 2 blank spots without documentation (Please note that meal intakes were substantially lower in (MONTH) than (MONTH) than (MONTH) with many more refusals documented.) R1's fluid intakes average: August (YEAR) = 747 ml/day September (YEAR) = 654 ml/day [DATE]-5th (YEAR) = 580 ml/day - was hospitalized on [DATE] with dehydration and UTI Readmission [DATE] [DATE] thru [DATE] = 487 ml/day No documentation could be found of what R1's daily fluid needs were supposed to be. A standard of practice (SOP) for calculating what daily fluid requirements should be, can be found on the website Consultant 360, Nutrition 411. This SOP dated [DATE], entitled, Fluid Requirements in Adults, indicates Method 1 for calculating fluid needs is: Weight (kilogram (kg)) x ,[DATE] milliliter (mL) = mL fluid required daily: indicators to use for calculation are: 25 mL/kg for [MEDICAL CONDITION] or [MEDICAL CONDITION]; 30 mL/kg for average adults; 35 mL/kg for patients with infection or draining wounds. With this formula, calculating R1's needs at her lowest weigh of 125.2# would mean that R1 should have been receiving at a minimum 1423 mL/day. As noted above, R1 averaged: * 747 mL/day in (MONTH) (52.5% of calculated need), * 654 mL/day in Sept (46.0% of daily need), * 580 mL/day from ,[DATE] to ,[DATE] (40.7% of calculated need), and * 487 mL/day from ,[DATE] to ,[DATE] (34.2% of calculated need). On [DATE], R1 was transferred to the hospital where her admitting History and Physical indicate that she has an UTI, Dehydration, Generalized weakness, and Diabetes. R1 remained at the hospital until [DATE] when she returned to the facility. R1's comprehensive care plan does not indicate that it was updated with any interventions to ensure that she would receive adequate foods/fluids/hydration. RD assessment was done on [DATE] but this does not address R1's fluid status needs and her dehydration risk seeing how she was just admitted for dehydration and facility indicates in charting that resident is not eating or drinking adequately. R1's diet was changed to pureed on this date. R1's comprehensive care plan indicates that she is a FULL CODE and wishes full treatment including feeding tube and IV fluids. There is documentation in medical record that facility addressed food/fluid intake with R1, R1's HCPOA/guardian, or physician to inquire if a feeding tube or IV fluids would be in R1's best interest. R1 continued to eat and drink poorly as evidenced by intakes mentioned previously and weight continued to decline as mentioned previously. No further interventions were put into place. On [DATE] at 6:07 PM, R1 was noticed to have increased pulse (36 beats per minute) and had audible excessive upper airway secretions. R1's son/HCPOA/guardian was called and indicated that he would come to facility to look at her and tell facility what he wanted to do when he saw R1. R1's son/HCPOA/guardian reminded facility that R1 was a full code. Upon arriving at facility, R1's son/HCPOA/guardian indicated that he wanted R1 to go to hospital so she was transported via ambulance to local hospital where she became unresponsive and experienced [MEDICAL CONDITION] and received 4 minutes of resuscitation shortly upon entering the emergency department. R1 was intubated and started on 4 different drips of medication to assist in her critical care management. R1's preliminary labs done at 9:00 PM revealed, in part: Sodium: 148 high (normal range is ,[DATE] mEq/L) Potassium: 8.9 critical high (normal range is 3XXX,[DATE].0 mEq/L) BUN: 100.0 (normal range is 8XXX,[DATE].0 mg/dl) Creatinine: 4.71 critical high (normal range is 0XXX,[DATE].20 mg/dl) (Please note that these elevated (some critically elevated) lab levels above indicate severe dehydration leading to kidney failure.) Lactic acid level: 12.7 high (normal range is 0XXX,[DATE].9 mmol/L) Hemoglobin: 7.5 low (normal range is 11XXX,[DATE].7 g/dl) Hematocrit: 27.1 low (normal range is 35XXX,[DATE].6%) Blood cultures: positive for gram negative rod (E coli) R1 was stabilized and then transferred to another hospital for critical care management. Her disposition [DIAGNOSES REDACTED]. R1 was admitted to secondary hospital and experienced another [MEDICAL CONDITION] and expired shortly after being admitted . Shock was listed on hospital problem list. On [DATE] at 3:10 PM, Surveyor interview MD C about R1 and stay at facility. MD C was familiar with R1. MD C stated he became aware of R1 not eating or drinking well a few days before she was sent to hospital. Surveyor asked MD C if anyone had suggested tube feedings or IV fluids for R1. MD C stated that neither family nor facility staff suggested tube feedings or IV fluids to help resident meet her food/fluids needs. On [DATE] at 4:15 PM, Surveyor interviewed DON B about R1 and decline in food and fluid intake. Surveyor asked if anyone from facility discussed R1's wishes with her or HCPOA/guardian to see if she/they would like to have tube inserted or IV fluids to assist resident with food/fluids needs. DON B could not find documentation that this occurred. DON B stated that she had a conversation on [DATE] with R1 about tube feeding and that R1 had indicated she didn't want one but this was never documented in the medical record or addressed with physician. There was no documentation that MD was ever asked about whether tube feedings or IV therapy should be considered. Surveyor asked DON B if any new interventions were added to ensure that R1 was receiving/meeting adequate food/fluid goals. DON B could not show where any new interventions were put into place to ensure food/fluids needs/goals were being met. Surveyor asked DON B if there should have been discussion with physician about fluid/food status and whether to do tube feeding/IV fluids and she indicated that there should have been. The facility failed to identify timely when R1 was losing weight and not receiving adequate amounts of food and fluid to prevent significant weight loss and dehydration. R1 was hospitalized for [REDACTED]. R1's self determination/advance directive wishes were not considered or re-evaluated when she wasn't eating or drinking adequately. R1 ended up being re-hospitalized and expired.

Based on observation, interview, and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents in 4 of 7 total residents reviewed (R65, R28, R48, R50). R65's care plan was not updated timely with fall interventions. Fall interventions were not in place when R65 had falls. R65 was not assessed by an RN (Registered Nurse) after a fall. R65 fractured her hip. R48 was observed without a working chair alarm. Staff left R48 unattended without fall intervention after being made aware. The facility did not ensure that, after R28 and R50 fell , their care plans were updated and the identified interventions were in place to prevent them from falling. This is evidenced by: Facility policy (does not include facility name), Fall Reduction Policy, revision date of 9/29/17, includes, in part: Identified risk factors should be discussed in CAA (Care Area Assessment) documentation and addressed in the Resident's care plan to assure individualized interventions to reduce the risk are implemented . a.) Provide emergency first aid treatment as applicable . b) Notify the physician . c) Notify the responsible party . The care plan should be reviewed after every fall and updated with a new intervention, when applicable .identify root cause, effectiveness for interventions, and make care plan revision as appropriate . R65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R65's Minimum Data Set (MDS), dated [DATE], indicated that R65's cognition is severely impaired with a Brief Interview of Mental Status (BIMS) score of 2. It also indicates that R65's speech clarity is unclear, with slurred or mumbled words, and her ability to make self understood is sometimes R65 is understood - responds adequately to simple direct communication only and her ability to understand others is sometimes R65 understands - responds adequately to simple, direct communication only. R65's Comprehensive Care Plan, initiated 1/17/18, includes, in part: Focus: Resident at risk for falls, secondary to impulsive behavior related to dementia, fall in past 30 days, wandering, using garbage can for toilet . Goal: Resident will not receive injury, if fall occurs, through the next 90 days . Interventions added: 1/17/18: -provide bedside commode to prevent resident attempting to void in garbage can. 5/29/18: -anti roll backs to wheelchair -call light and frequently used items in resident reach as she allows -Dycem to wheelchair, pressure relieving cushion to prevent cushion from slipping, ensure balance in wheelchair as much as resident allows -nonslip socks or sturdy shoes, diabetic and circulatory ankle socks on in AM, off at HS (bedtime). -encourage resident to hang purse from handles of wheelchair instead of behind her on the seat -offer toileting every 2 hours and as needed as she allows -peri care after each incontinent episode -wide bed in lowest position, while resident is in bed, with mat at bedside, position resident in the middle of the bed 7/3/18: -remove wheelchair from resident's room to help deter her from self-transfers 9/5/18: - pressure chair and bed alarm in place to alert staff of movement 9/29/18: -mat at bedside -bed in lowest position -remove foot pedals from wheelchair to allow to self-propel and protect heels R65's Fall Reports include, in part: 4/19/18: Incident Description: Resident was moved from 600 Wing to 100 Wing to the secured Unit. Resident went into one of the bathrooms on the Unit and fell . fell and began speaking Polish and was not able to understand . Immediate Action Taken: All doors for unused rooms will be kept closed to assist with resident staying in familiar area . *It is important to note that the root cause of this fall was R65's need to eliminate. 5/25/18: (R65) Incident Description: was found on her buttock sitting next to her bed facing the bathroom door . Resident unable to give (sic) . Immediate Action Taken: Assessed resident and found no injuries . New gripper strips placed at side of bed. Dycem placed under mattress between frame and mattress. *It is important to note the root cause of this fall was R65's need to eliminate. 5/31/18: Witnessed Fall Incident Description: The resident was found by the CNA (Certified Nursing Assistant) after she heard a noise in the resident's room. It was found that the resident had pulled down her pants and she attempted to use the trash can as a toilet, the trash can fell over when she lowered herself down to sit on the trash can, the trash can tipped over and she slid to the floor . She had to go to the bathroom and the door would not open . Immediate Action Taken: The resident was assessed for injury and pain. No injuries noted or statements of pain. The resident was assisted up to her wheelchair and the CNA went around and unlocked the door to the adjoining room. A commode was obtained and will be left in her room in case the bathroom is unavailable. The door knobs to both doors were turned around so the locks would be on the outside so neither resident can forget to unlock the other side . preventing the resident from having access to the bathroom. Resident will be assisted to be toileted on rounds as she allows . *It is important to note the root cause of this fall was R65's need to eliminate. *It is important to note facility provided no evidence of a new toileting schedule/intervention. *It is important to note facility provided no evidence of witness statements for this fall. - On 10/15/18 at 8:00 AM, during an interview, DON B (Director of Nursing) indicated that when R65 moved wings her commode was not moved with her. *It is important to note that one of R65's care planned interventions (1/17/18) was to have a commode in her room. 6/15/18 Incident Description: Resident self-transferred to toilet from wheelchair . Immediate Action Taken: Alarm added to alert staff when she is attempting to stand up. Start bowel and bladder . NOTE: Resident is compulsive and is self-determined to self-transfer . *It is important to note the root cause of this fall was R65's need to eliminate. *It is important to note that facility did not provide evidence of a bowel and bladder program for R65. It is also important to note that R65's intervention of alarm was not added to R65's Comprehensive Care Plan until 9/5/18, after R65 fell 4 more times, resulting in two hospital visits and a fractured left hip. 7/3/18 10:00 unwitnessed . Incident Description . Resident was found on the floor between wheelchair and bed. Denies pain and no injury noted. Immediate Action Taken: move wheelchair away from bed when the resident isn't using it. Resident declines to use right side rail . Notes: resident declines to ask for assistance and will self-transfer, even though she is aware she can't stand up . 7/3/18 (12:51) unwitnessed . Incident Description: Resident was found sitting on the floor next to bed. When trying to sit up, resident slid off edge of the bed . head-to-toe assessment revealed no injury at this time. Neuros and vitals within normal limits. Unable to determine the full extent of fall due to resident speaking Polish, but resident stated she slid off of bed. Denies any pain or injury. Immediate Action Taken: head-to-toe assessment, neurological assessment, vitals taken. No injury found. MD (Medical Doctor) notified . Notes: Unable to determine how oriented resident is due to language barrier . 8/16/18 unwitnessed . Incident Description: Resident propelled self from dining room in to lounge area of the 300 Wing. Writer heard yelling from the lounge area. Upon arrival to lounge, Writer noted resident was lying on the floor in between the resident's wheelchair and the couch. Resident was speaking Polish loudly, calling for help. Resident only stated that she wanted to sit on the couch and then she began speaking Polish . Immediate Action Taken: Neuros initiated per facility protocol. Full range-of-motion without abnormalities. No lengthen or shorting of legs, no external or internal rotations noted. Offered ice. Resident was able to help staff with getting up with 3 assist. At 3 PM, order obtained for X-ray of left femur and pelvis due to tenderness noted after resident used her left leg to reposition herself and a grimace was noted. Updated MD for X-ray. Resident declined to go to emergency room (ER) and Power of Attorney (POA) was updated . Note: Resident used her left leg to reposition self and she grimaced once. MD notified of increased discomfort and X-ray ordered. (Name of X-ray Company) notified for stat X-ray. Resident was also asked if she wanted to go to hospital and she vigorously shook her head no. Assisted to bed with 2; hip precautions observed until results of X-ray comes back. Ice offered and refused. 8/17/2018 1:13PM - Late entry from 8/16/18 at 315 PM: I was sitting with resident in the dining room and she was sitting in her wheelchair with her feet on the floor. She was propelling herself around the dining room without any complaints of pain and no facial expressions of pain. Prior to her falling asleep, I palpated her right femur, starting at the distal end and going up to the greater trochanter and down the back side of her coccyx. She did not complain of pain, grimace in pain. I asked if she wanted an ice pack and she shook her head no. Resident fell asleep holding my hand and was content. Approx (Approximately) 10 minutes later she went to self-reposition and pushed with her L foot down to the floor and pushed herself back in her wheelchair and the expression came over her face of pain. I notified the RN (Registered Nurse) and the Dr. on call and an X-ray was ordered in-house due to resident not wanting to go. Resident was laid down and appeared comfortable and asleep. (DON B) *It is important to note that this assessment of R65's hip done by DON B was performed after she had been assisted off of the floor and into her wheelchair. 8/16/2018 2:48 PM - Order for X-ray of L (left) femur/pelvis obtained, related to resident complaint of pain to area. Will continue to monitor. 8/16/2018 11:34 PM - Called residents POA, informed her of the resident's fracture of L hip. Explained that we could send her to the ER or keep her in the facility until morning, and then get treatment in the AM. POA wanted to keep resident in the facility and get her treated in the morning. 8/17/2018 9:25 AM - Resident was sent to the ER after report to ER . transferred to ER for evaluation. Resident did have X-ray and showed a non-displaced fracture to her L hip. Resident had previous [MEDICAL CONDITION], unsure what side. Resident denied going to hospital at first, but then said she wanted to go hospital for the doctor to help her. [MEDICATION NAME] given via IV (Intravenous) and resident appeared comfortable. Staff sent to hospital with resident per her request. Report provided by ambulance service, dated 8/17/18, includes, in part: After arriving at the scene, the Unit found a patient . The patient's chief complaint was severe hip pain. The provider's impression was injury- hip . patient with a [MEDICAL CONDITION] which was confirmed by X-ray . Patient suffered a fall last evening. Patient was evaluated, but family, who are patient's guardian, refused transport last evening. Patient was having minimal pain at that time. A portable X-ray was obtained which showed a non-displaced left [MEDICAL CONDITION]. Today, when staff was moving patient in bed, patient stretched her leg out and suddenly screamed out in pain. Patient began having continuous pain following that. Staff received orders from guardian and attending physician to have patient transported to ER for evaluation of possible displacement of previous [MEDICAL CONDITION] .patient speaks minimal English, thus making communication with patient and assessment difficult. Patient's pain level was estimated to be 8 out of 10, as patient is grimacing and moaning in pain. Left leg looks to be shorten, but unable to ascertain if leg was rotated outward . Due to patient being in severe pain, IV was established while patient laid in bed . Patient was given an initial dose of 25 mcg (micrograms) of [MEDICATION NAME] for pain . Hospital Summary, dated 8/17/18, includes, in part: Hip X-ray shows mildly displaced sub-capital left femoral neck fracture. Impaction is seen at the site of fracture with approximately quarter shaft width displacement noted . The patient's POA is not currently at bedside. We will try to get in touch with her to get final approval for surgery. Again, studies have shown that within the first 48 hours after [MEDICAL CONDITION] intervention has more successful outcome. So will try to get in touch with her right away . Hospital Summary, dated 9/3/18, includes, in part: Patient is an [AGE] year old female, Polish speaking . who was approximately 2 weeks status [REDACTED]. Patient was trying to use the bathroom and fell to the floor .contacted orthopedic surgeon on call to discuss dislocation. Orthopedic surgeon recommends, if we are comfortable, trying to attempt to reduce the dislocation using conscious sedation. I discussed this with supervising physician who is in agreement that we may attempt this .we were successfully able to reduce dislocated left hip .were able to successfully reduce dislocated prosthetic hip . Will place order for abduction pillow . 9/3/18 unwitnessed . Resident was found lying on floor next to bed with right side leaning against bed and left leg bent up. Left leg appears shorter than right. Resident stated, I fall down. Immediate Action Taken: Neuro check initiated and resident not moved after complaints of left hip pain. CNA with resident until ambulance arrived. Bed was swapped out with a low bed and thick mat will be on floor at bedside whenever resident is in bed. Wheelchair to be removed from room when not in use to help deter resident from self-transferring to wheelchair . -On 10/15/18 at 8:00 AM, during an interview, DON B indicated that she was unsure why R65 did not already have a low bed and that the bed was changed and the mat on the floor was changed out with a thicker mat after fall on 9/3/18. *It is important to note that intervention of wide bed in lowest position, while resident in bed, with mat at bedside, position resident in middle of the bed was in place on care plan as of 5/29/18 and this Fall Report states, bed was swapped out with low bed . 9/24/18 unwitnessed . Incident Description: Resident placed in room in wheelchair and CNA went to staff to transfer resident with Hoyer into bed. Resident attempted self-transfer from wheelchair. Resident slid her bottom to the edge of the wheelchair seat with her legs extended and elevated in front of her. Resident's chair tipped forward and her bottom slid down the leg rests. Alarm sounded and CNA re-entered the room to find resident crawling off of the wheelchair leg rests. I'm having a bad day . Immediate Action Taken: Resident assessed. No abnormal rotation of the hips. No pain in the hips. No lengthening of either leg. Resident did not bump her head, no bruising of buttocks. Resident had no elbow or shoulder pain with palpation. Resident able to move all extremities on command . Dycem in place. Alarm in place and functioned normally. Foot pedals removed from wheelchair, resident to not be left unattended in room while (sic) . R65's Nurse Notes include, in part: 10/15/18 6:47 AM - This note is a follow-up to 8/16/2018 14:12:00 Incident Note: Department: Nursing Position: Registered Nurse Created By: (RN G), Created Date: 10/15/2018 06:47:44, was alerted by CNA that res (resident) was sitting on floor in lounge area. LPN J in room with resident. Resident was sitting on floor in front of couch. No lengthening or shortening of extremities, no internal or external rotation of extremities. no complaints of pain with movement of extremities. Vss. pupils equal and reactive to light. Hand grasps equal. Res was wearing gripper socks at time of fall. *It is important to note the creation date of 10/15/18 at 6:47 AM and that this Incident Note is a follow-up to an 8/16/18 incident and was added to R65's medical record, almost 2 months after incident. On 10/11/18 at 4:18 PM, during an interview, LPN J (Licensed Practical Nurse) indicated that she assessed R65 but RN G was also present and did an assessment after R65's fall on 8/16/18. LPN J indicated that she wrote the Incident Note that included the assessment and RN G did not type a note or create an assessment at the time of fall. When asked if it is ok for LPN J to assess someone who has fallen, LPN J indicated that she always calls an RN over for that extra set of eyes. On 10/11/18 at 4:22 PM, during an interview, DON B indicated that RNs do assessments after a fall and the assessment should be signed by the person's name who performed the assessment in the medical record. *It is important to note that the facility provided only one Incident Note/Fall Report with assessment signed by LPN J and no evidence was provided that RN G performed an assessment of R65 after fall on 8/16/18. On 10/15/18 at 8:00 AM during an interview, DON B indicated that LPN J does assessments with an RN there. DON B also indicated that she has a number somewhere for staff to use for translator services and that she would look it up, educate staff, add it to R65's care plan, and get number posted for future use. DON B indicated that staff doesn't always offer the toilet on rounds but they do check and change R65 if she has a soiled brief and DON B indicated that R65's cognition, language barrier, and behaviors make it difficult for her to communicate her needs. DON B stated, I will look into a toileting schedule. On 10/15/18 at 3:00 PM, during a phone interview, EMT Q (Emergency Medical Technician) indicated that, on 8/17/18 at 8:18 AM, the ambulance service was notified that R65 had an X-ray on 8/16/18 that confirmed a [MEDICAL CONDITION] and R65's family refused transportation services, but they approved of it now. EMT Q also indicated that IV [MEDICATION NAME] was given to R65 for pain before transporting her to the ER due to R65 being in pain, rated 8/10. On 10/15/18 at 3:12 PM, during a phone interview, POA R indicated that she did receive a call from the facility on 8/16/18 at about 2:00 PM. POA R indicated that the facility told her that R65 had fallen and was calling out, but they think she is faking, because there were no injuries identified and there was no mention of an X-ray or hospital visit during this call. POA R indicated that the facility does not know what R65 is saying because she does not speak English much anymore and facility makes no attempts to understand her Polish words. POA R also indicated that she received another call around 10:00 PM, on the same day, from the facility stating that R65 had an X-ray and it revealed a broken hip. POA R stated that the facility said someone needed to go to the hospital with R65 and asked her to take R65 to the hospital, but POA R has a handicapped child at home, who was in bed, and was not able to go to the hospital at this time. POA R indicated that the facility did not offer to send a staff member along to hospital and did not mention that R65 refused to go. POA R said the facility would keep R65 there for the night and give her pain medicine, then send her in the morning when POA R could attend. POA R indicated that the facility did not explain the risks and benefits of R65 waiting until the morning to go to the hospital versus going out that night. POA R indicated the next call she received was the next day (8/17/18) from the hospital and they were asking her to come sign papers. POA R stated that she did not refuse ambulance services on 8/16/18, but that she was unable to transport or go along with R65 to the hospital at that hour. Example 2: R48 was admitted to facility on 8/22/18 with [DIAGNOSES REDACTED]. R48's MDS, with an assessment reference date of 8/29/18, indicates R48's cognition to be severely impaired, with a BIMS score of 02. R48's Comprehensive Care Plan, initiated 8/29/18, includes, in part: Focus: Resident at risk for falls secondary to disease process, fall in the past 30 days, use of [MEDICAL CONDITION] drugs . Goal: resident will not receive injury if fall occurs, through the next 90 days .Interventions: alarm to bed and chair to alert staff of self-transfers . On 10/11/18 at 2:10 PM, Surveyor observed R48 sitting in the dining room on the 300 Hallway Is it Hallway or Wing by herself. Her chair pad alarm battery hung by wires under the chair alarm box behind R48. On 10/11/18 from 2:19 - 2:40 PM Surveyor asked CNA N if R48 had a dressing to her coccyx and CNA N indicated that she was unsure. Surveyor asked CNA N when she will be working with R48 next. CNA N indicated that she would offer R48 the toilet. CNA N pushed R48 to her room and assisted R48 to standing position. R48's alarm did not sound. R48 refused to go into the bathroom. CNA N assisted R48 back to sitting in her wheelchair. CNA N pushed R48 from her room back into the dining room, up to the table and left the dining room. R48 was alone in the dining room. During an interview, Surveyor asked if R48 can be left unattended. CNA N indicated that she thought it was ok. Surveyor asked CNA N why alarm did not sound when R48 stood up and CNA N indicated that she was not sure why R48's alarm did not sound and stated it should have sounded. CNA N indicated that she would fix it and walked across the hallway to get assistance from another staff member. Together the two pushed the pieces of the alarm and wires. Alarm made a sound, indicating it powered on. Example 3 R28 is his own person. R28's care plan created by the facility on 7/31/18 states he required one staff to assist him with transfers. A Care Plan for Falls was initiated on 9/4/18, with interventions added as follows: 9/2/18 a Reacher to assist with picking up items, 9/10/18 - R28 has a larger wheelchair, and 9/19/18 - anti-rollbacks added to his wheelchair. (It is important to note that the Dycem was not on R28's care plan nor was it added for staff to check the placement or encourage to keep the dycem in place.) On 8/28/18, therapy noted that they offered a facility wheelchair for R28, but he refused it. The facility documentation for R28 stated he had an unwitnessed fall on 9/1/18. He was found sitting on floor of his room in front of easy chair. R28 said he was in his wheelchair and reached out to get something when his wheelchair cushion slid forward, causing him to slide to the floor. The facility added the intervention of a Dycem (non-slip product) to both top and underside of his wheelchair cushion to prevent further sliding out of chair; however, this was not added to his care plan. R28 was educated to ask for assistance and a Reacher. The facility documentation for R28 stated he had an unwitnessed fall on 9/5/18. He was found sitting on floor with back up against recliner and the Dycem was in the wrong place. The action taken was to move the Dycem from the top of the wheelchair cushion to be underneath it. R28 was reminded to lock his wheelchair before attempting to get out of it and therapy was asked to evaluate if he needed a larger wheelchair. The facility documentation for R28 stated he had an unwitnessed fall on 9/7/18. R28 was found on the floor. The action taken was his wheelchair was exchanged for a larger one, as his clothes were caught on it when he fell . Therapy documented that on 9/11/18 they switched out R28's wheelchair with a larger facility wheelchair. There was no documentation that the larger wheelchair was offered to R28 since 8/28/18. The facility documentation for R28 stated he had an unwitnessed fall on 9/15/18. He was found sitting on floor and had slipped from his wheelchair. It was noted that the Dycem was on his bed, rather than on the wheelchair. R28 said he had taken it off his cushion and put it on his bed. He was educated to leave Dycem on the wheelchair cushion as it is to help him not slip from chair. As of 10/9/18, when Surveyor received R28's care plan on the survey, the facility had not added a Dycem to his care plan. Therapy documented that on 9/19/18 an anti-rollback device was added to R28's wheelchair. On 10/15/18 at 9:06 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked when she would expect a resident's care plan to be updated after a fall. She explained the nurse would write it on the Kardex (that CNAs (Certified Nursing Assistants) follow for care) and she would update it when she was updated about the resident's fall. Example 4 R50 is his own person. The facility created a care plan for falls for him on 9/4/18, indicating he had a fall within the last 30 days. His fall care plan did not include the intervention of a Dycem to his recliner. The facility documentation for R50 stated he had unwitnessed fall on 8/14/18. He was found on floor, in front of recliner, with his head resting on the foot of the recliner, at a 45 degree angle, not touching the floor. The action taken was to add a Dycem to his recliner to prevent him from sliding out. On 10/15/18 at 9:06 AM, Surveyor interviewed DON B. Surveyor asked when she would expect a resident's care plan to be updated after a fall. She explained the nurse would write it on the Kardex and she would update it when she was updated about the resident's fall.

Based on interview and record review, the facility did not ensure that its Infection Control Program investigates, controls, and prevents the spread of infection in the facility and maintains a record of incidents and corrective actions related to infections. This has the potential to affect 59 of 59 residents. The facility did not complete contemporaneous infection surveillance including tracking and trending of all illnesses, potential infectious agents, or monitoring of resident signs and symptoms of infection or potential infection. The facility's monthly Infection Control Surveillance Logs are incomplete; frequently pathogens are not listed, onset and well dates are not documented, isolation is not consistently documented and implemented. R27 (Resident) is on the Line List in (MONTH) for [MEDICAL CONDITION] and was not put on isolation. R67 who was on the Line List in April, for an upper respiratory infection, was not put on isolation. The facility failed to analyze infection data concurrently, which would help the facility to recognize a trend or patterns of infections. The facility did not complete mandatory monthly CRE (Carbapenem-Resistant [MEDICATION NAME]) surveillance reporting to NHSN (National Healthcare Safety Network). HSKP D (Housekeeper) is not donning isolation gear before cleaning isolation rooms (VRE ([MEDICATION NAME]-Resistant [MEDICATION NAME]),[MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus Aureus), etc.) HSKP D is not using a single mop duster for isolation rooms, but instead is reusing it in other non-isolation rooms. HSKP D is not disinfecting the broom, mop, or dust pan after cleaning an isolation room and before cleaning non-isolation rooms. HSKP D is not performing hand hygiene before and after cleaning an isolation room. CNA E (Certified Nursing Assistant) and CNA F are not disinfecting a Hoyer lift with bleach wipes as instructed by a note on the lift written by the DON B. R50 has a [DIAGNOSES REDACTED]. Surveyor interviewed staff who did not use appropriate cleaner to wipe down a Hoyer after use with R3, who is on isolation precautions. This is evidenced by: The facility's policy Infection Control, dated 9/17/18, states, in part: The facility's 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 facility establishes a program under which it: Investigates, controls, and prevents infections in the facility; Decides what procedures such as isolation, should be applied to an individual resident; and maintains a record of incidents and corrective actions related to infections. Preventing Spread of Infection: When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident. The facility must require staff to clean their hands after each direct resident contact using the most appropriate hand hygiene professional practices. This is accomplished by maintaining effective methods for investigating the incidence of infection, controlling transmission, and preventing infections. Intent The intent of this policy is to assure, through the Infection Control Program a systems in place to: Provide surveillance, investigation and monitoring to prevent, to the extent possible, the onset and the spread of infection. Prevent and control outbreaks and cross-contamination using transmission-based precautions in addition to standard precautions. Prevent outbreaks by clustering or cohorting of residents to reduce spread of infection; Develop, implement, maintain nursing home processes using data records of incidents, corrective action taken, and staff education to improve infection outcomes. Determine nursing home precautions (e.g. isolation) as a means of preventing contamination; Implement hand hygiene practices consistent with accepted standards of practice; and Demonstrate proper storage, handling processing, and transport of linens to minimize contamination. Infection Control Program Structure The Infection Control Program functions under the direction APIC Committee. The members of this committee include persons who have day-to-day responsibility for infection control practices as well as members of the Interdisciplinary Team (IDT). Elements of the Program Include Program oversight including planning, organizing, implementing, operating, monitoring and maintaining all the elements of the program and ensuring that the facility's IDT is involved in infection prevention and control. Surveillance, including process and outcome surveillance, monitoring, data analysis, documentation and communicable diseases reporting (as required by State and Federal law and regulation). Education, including training in infection prevention and control practices, to ensure compliance with facility requirements as well as State and Federal regulations. Surveillance based on systematic data collection to identify infections in residents. A system for detection, investigation, and control of outbreaks of infectious diseases. An isolation and precautions system to reduce the risk of transmission 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 control. An employee health program. A system for antibiotic review and control. Communicable disease reporting to appropriate public health authorities. The facility's policy and procedure, Cleaning an Isolation Room, dated 9/17/18, states, in part: To ensure appropriate cleaning procedures using an EPA (Environmental Protection Agency) approved germicide (1: (to) 10 dilution of household bleach) for disinfection of isolation room surfaces and equipment to reduce potential transmission to other residents. 2. Provide hand hygiene with soap and water (do not use alcohol-based hand gel). 3. Put on gown and gloves prior to entering the room. 6. Using the 1:10 bleach solution, wipe off all non-porous hard surface items such a toothpaste tubes, shaving cream, combs, etc. Place these items in trash bag until finished sterilizing room being careful not to re-contaminate items. 8. Wash window sills, counters, ledges, sink, faucet, and handles with bleach solution. 13. Thoroughly mop entire floor with 1:10 bleach water solution (under furniture, behind doors, along baseboards.) Mop your way out the door and place wet floor sign in doorway. 14. All cleaning items such as mop heads and cleaning rags need to be put in isolation bag and laundered on isolation cycle. 15. Synthetic brooms and broom handles must be cleaned and sanitized with bleach water solution. After sanitizing a small bag should be placed around the broom and let set overnight. 16. All mop buckets, mop handles, wringers, Housekeeping cars, and floor signs used must also be cleaned with solution. 17. Remove gloves and provide hand hygiene. The facility has 4 households: 100 Unit (107-116), 200 Unit (201-215), 300 Unit (301-315), 500 Unit (501-517), and 600 Unit (601-616). *It is important to note that the facility's monthly Infection Reports lists only residents who were receiving antibiotics and does not include the monitoring of residents with symptoms of illness that might be infectious. There were no surveillance forms or other data collection forms indicating the facility contemporaneously completed tracking and trending for all illnesses, potential infectious agents or monitored resident symptomology for sign and symptoms of infection or potential infection. Example 1 On 10/10/18 at 9:15 AM, Surveyor observed CNA E and CNA F provide perineal and catheter care for R50. After changing R50's brief and providing catheter care, Surveyor observed CNA F reach inside of her isolation gown, into the pocket of her scrubs (pant), pull out her hand sanitizer, use the hand sanitizer, and put it back in her pant pocket. There was a Hoyer lift in R50's room with a sign that states Attention: Please use bleach wipes located in the closets after each use with the DON B's name. Surveyor asked CNA E and CNA F if they clean the lift after use. Both CNA E and CNA F stated they no longer clean the lift with wipes, since it has been designated to R50's room. Surveyor asked CNA E and CNA F if there are bleach wipes in the resident room; CNA E and CNA F both state there are no wipes in R50's room. CNA F stated, after a lift was designated to R50's room, the bleach wipes were removed from R50's room and placed in a locked closet across the hallway. Staff does not have convenient access to bleach wipes /disinfecting wipes. On 10/10/18 at 10:20 AM, Surveyor spoke with HSKP D. Surveyor asked HSKP D what is her process when she cleans resident rooms. HSKP D states for regular daily cleaning she high dusts, dusts the baseboards, collects garbage, walks around the room and dusts with disinfectant. HSKP D showed Surveyor the bottle of disinfectant she uses (Peroxide Multi-Surface Cleaner and Disinfectant). HSKP D states she sprays this on a cloth, wipes down the sink, commode. She scrubs the toilet, sweeps and mops. Surveyor asked HSKP D if she uses a different cleaning cloth for each room. HSKP D stated she uses a different cleaning cloth for each room to avoid cross contamination. HSKP D stated she uses a mop head for high dusting. Surveyor asked HSKP D if she uses that for multiple rooms. HSKP D stated, yes, and that she sprays it with the Peroxide Multi-Surface Cleaner and Disinfectant. Surveyor asked HSKP D what cleaner she uses for the floor. HSKP D stated she usually uses an Ecolab product, but it's not in, so she showed Surveyor the bottle she has been using, DON-Lemon Air Plus. Surveyor asked HSKP D if she does anything differently when she cleans R50's room. HSKP D stated she asked the nurses and they said I don't have to worry about it, because I don't touch the resident. HSKP D stated she cleans R50's room like all the other resident rooms. Surveyor asked HSKP D what about the other rooms with isolation bins (MRSA) on this Unit. Do you clean those any differently than the other rooms; HSKP D stated no. On 10/10/18 at 10:34 AM, Surveyor spoke with CNA F. Surveyor asked CNA F if she knows what R50 is on isolation for. CNA F stated, His urine, I couldn't tell you exactly what it's called. Surveyor asked CNA F what was she educated to wear when she goes into R50's room. CNA F stated, Always gown and gloves. Surveyor stated, I noticed after you performed perineal care and threw away the brief, you removed your gloves, reached into your pant pocket under your isolation gown, pulled out hand sanitizer, used the hand sanitizer, and put it back in her pant pocket. Surveyor asked CNA F if she should be reaching into her pockets for hand sanitizer when she is in an isolation room. CNA F stated, No. On 10/10/18 at 10:45 AM, Surveyor observed HSKP D cleaning resident rooms on the 600 Hall. One resident on this Hall (R50) is on isolation for CRE and 2 residents are on isolation [MEDICAL CONDITION]. Another resident is on isolation [MEDICAL CONDITION] on the 500 Hall. Surveyor observed HSKP D cleaning R50's room. HSKP D used a small washable cloth mop head attached to a pole to dust high surfaces, in addition to dusting the baseboards next to the floor. Surveyor observed HSKP D spray the small mop head with Peroxide Multi-Surface Cleaner and Disinfectant spray cleaner and put the small cloth mop head back in the housekeeping cart. Surveyor observed HSKP D scrub R50's floor and place the mop back in the bucket of water on the housekeeping cart. Surveyor observed HSKP D not wearing any PPE (Personal Protective Equipment), such as a gown and gloves. Surveyor observed HSKP D did not wash her hands before or after she exited R50's room. On 10/10/18 at 10:49 AM, Surveyor observed HSKP D enter the shared room of R62 and R47. HSKP D pulled the small washable mop head attached to a pole from the housekeeping cart and wiped down the vents, curtain rod, lights (2), floor by the baseboards, bathroom vent, and bathroom light. HSKP D returned the small washable cloth mop head to the cart, sprayed it with Peroxide Multi-Surface Cleaner and Disinfectant spray cleaner. HSKP D emptied the garbage. HSKP D donned gloves, used a cloth, sprayed it with Peroxide Multi-Surface Cleaner and Disinfectant spray and wiped down the surfaces in the room. HSKP D touched the resident's book, mug, basin, magazines and Word Find books, window sill, overbed table (2), moved clothes on a nightstand and wiped the nightstand. HSKP D removed her gloves. HSKP D did not wash her hands. HSKP D swept the floor and emptied the dustpan in the housekeeping cart. HSKP D was touching the bottom of the dustpan with her bare hands. On 10/10/18 at 11:00 AM, Surveyor observed HSKP D enter R9's room. HSKP D sprayed small washable mop head with Peroxide Multi-Surface Cleaner and Disinfectant spray cleaner. HSKP D touched files, clock, curtain rod lights, and then put the duster back in the cart. HSKP D emptied the garbage can with gloves and with the same gloves on, wiped the sink, counter, chair, overbed tables. HSKP D pulled keys from her pocket, locked the cart, and removed gloves. HSKP D did not wash her hands at any time during Surveyor's observations. Surveyor asked HSKP D what rooms she has mopped with the water in the bucket. HSKP D stated R50 (isolation for CRE), R9, R37 and Surveyor also observed R47 and R62. (It is important to note that HSKP D cleaned R50's room, who is on isolation for CRE, and then continued to clean rooms of residents not on isolation with the same small washable duster, broom, dustpan, and mop, and mop water.) On 10/10/18 at approximately 12:45 PM, Surveyors spoke with NHA A (Nursing Home Administrator), RN C (Regional Nurse), and DON B regarding infection control concerns with housekeeping. On 10/10/18 at 11:10 AM, Surveyor spoke with HSKP D. Surveyor asked HSKP D if she could show me what cleaner she usually uses on the floors. HSKP D took Surveyor to the 100/200 Unit, showed Surveyor a bottle of Maxx Dual Action Floor Cleaner Bright Speed. On 10/10/18 at 4:10 PM and 10/15/18 at 1:35 PM, Surveyor spoke with DON B regarding infection control. DON B stated that she tracks antibiotic usage in Point Click Care (PCC) on a daily basis. DON B does not complete infection surveillance including tracking and trending of all illnesses, potential infectious agents, or monitoring of resident signs and symptoms of infection or potential infection. Surveyor asked DON B if the facility Infection Logs should be complete. DON B stated, yes. Surveyor asked DON B if the Infection Logs should include symptomology, onset date, well date, if isolation is implemented, the type of isolation implemented, and pathogen. DON B stated yes. The facility failed to analyze infection data concurrently, which would help the facility to recognize a trend or patterns of infections. Surveyor asked DON B if R27 on the Line List in (MONTH) for [MEDICAL CONDITION] was put on isolation. Surveyor asked DON B if he should have been. DON B stated yes, he should have been on droplet precautions. Surveyor asked DON B if R67 who was on the Line List in (MONTH) for an upper respiratory infection was on isolation. DON B stated, No, she was not. Surveyor asked should she have been. DON B replied, Yes. Surveyor asked DON B to show me the computer screen so that I can see that the facility has conferred rights to report CRE to the NHSN and is reporting CRE. DON B and Regional RN D were unable to document that this is being reported monthly. Surveyor contacted the State and confirmed reporting is not being completed by the facility for CRE. Surveyor asked DON B if it is acceptable for staff to reach into the pants pocket under their isolation gown to pull out hand sanitizer and then place the hand sanitizer back in their pocket. DON B stated, No. Surveyor asked DON B if she expects staff to sanitize R50's lift after each use as indicated on the sign. DON B stated yes. Surveyor asked DON B if housekeeping should donn isolation gear before going into an isolation room. Surveyor asked DON B what type of isolation should housekeeping be wearing when they enter the room. DON B stated a gown and gloves. On 10/15/18 at 12:50 PM, Surveyor spoke with NHA A regarding Quality Assurance (QA). NHA A There is not a program currently for Infection Control. Example 2 On 10/9/18 at 7:38 AM, Surveyor observed CNA P and CNA T enter R3's room on isolation with a Hoyer lift to assist R3. CNA P stated R3 was on isolation for[DIAGNOSES REDACTED]. R3s care plan, initiated on 9/12/18, indicated she [MEDICAL CONDITION] related to her skin. Upon completion of cares, CNA T assisted R3 to the dining room. R3, R28, R40, and R50 were observed to be on isolation precautions on the 600 Unit. On 10/9/18 at 8:43 AM, Surveyor questioned CNA T who stated they had started working at the facility today. Surveyor asked CNA T what training they received for the Unit CNA T was working on; CNA T explained they came at 5 AM and did 1 hour of orientation. CNA T explained further they did not have any specific training for what should be done for each of the residents on isolation on the 600 Unit, but was told the organisms of shingles [MEDICAL CONDITION]. She stated did not know how to clean the lift, but stated they used the Procare wipes to clean it after each resident. Surveyor then interviewed CNA P who said she wiped down the Hoyer with Procare wipes after she used it with R3. Surveyor asked her to show the package and she did. CNA P stated she just wipes it down after use and that's it. Upon viewing the Procare wipes package they contain no alcohol. On 10/09/18 at 8:48 AM, Surveyor interviewed CNA P who stated they ensure that for residents on isolation precautions, they do wash their hands after entering and before leaving rooms, especially with res (resident) on isolation. She said that she does wash hands entering and leaving the room and uses sanitizer on the wall in rooms. On 10/09/18 at 12:50 PM, Surveyor interviewed DON B (Director of Nursing) regarding use for Procare wipes. DON B indicated they were for peri care, to clean cath (catheter) tubing, and wash res hands. Surveyor asked her if they should be used to wipe down a lift after use with a resident on isolation precautions. She stated they have purple bleach wipes that should be used to wipe down lifts after use with residents on isolation. She explained the bleach wipes are kept locked at the Nurses Station and the CNAs have to ask the nurse for them. On 10/9/18 at 3:05 PM, DON B provided a list of the 600 Hall residents who use the Hoyer (R50, R61, R3, R37). Later, during the survey, DON B explained that R50 used a bariatric lift and it was kept in his room. Example 3 On 10/11/18 at 7:49 AM, Surveyor interviewed DON B and interview LPN K (Licensed Practical Nurse), who completed R50's wound treatment and was observed by a Surveyor to take a scissors out from under her isolation gown to use on R50's dressing and place them in a pocket under their gown after, without cleaning them. On 10/11/18 at 8:00 AM, Surveyor interviewed LPN K. Surveyor asked when LPN K put the scissors in their pocket she said she had cleaned the night prior and put them in her personal bag with her pens, lunch and other personal items. LPN K wiped it off with the bleach wipes prior to putting it in bag the night before. LPN K explained they did not use them with any other resident prior to R50's wound. Example 4 On 10/10/18 at 10:20 AM, Surveyor observed a dressing change for R50 with LPN K and CNA P. LPN K opened packages of dressing change items and placed them on a barrier on the bedside table, along with a pair of scissors that was removed from underneath gown in LPN K's uniform pocket. After cleansing the wound on coccyx, LPN K took the scissors they removed from pocket and cut off a piece of Calcium Alginate (used for wound debridement) without first cleaning the scissors. After completion of dressing change, Surveyor interviewed LPN K asking if they should have cleaned the scissors after removing them from pocket and prior to using them to cut off a piece of Calcium Alginate. LPN K stated, that's right I should have cleaned them prior to using them. On 10/11/18 at 7:57 AM, an interview was conducted with LPN K. LPN K was asked if she had used the scissors prior to coming into R50's room. LPN K stated, No, I clean them every night and I just put them in my pocket. R50 is the first person I have used them on. Example 5 On 10/15/18 at 3:43 PM, Surveyor observed CNA L and CNA M come out of R28's room. R28 is on isolation precautions, requiring the use of gowns and gloves. Neither CNA L nor CNA M was wearing gowns. At 4:05 PM, an interview was conducted with DON B and Regional RN C regarding what PPE was needed for R28's room. DON B stated that staff should be wearing gowns and gloves when going into R28's room. Surveyor informed DON B and Regional RN C that CNA L and CNA M had both been in R28's room without the proper PPE while doing cares.

Based on interview and record review the facility did not maintain acceptable parameters of nutritional status for body weight for 4 of 8 residents (R28, R47, R50, and R65) reviewed for nutrition. The facility did not endure R28, R47, and R50 were weighed per the frequency stated in their policy, reweighed when they had greater than 2% change in weight, monitored their weight pattern, and ensure proper interventions were added. R65 experienced a severe unexplained weight loss. The facility failed to identify the loss, update R65's Medical Doctor (MD), or take aggressive measures to prevent further unexplained weight loss. Evidenced by: Surveyor requested the facility policy/procedure for the facility regarding weights. Surveyors were provided a policy that had a different facility name on it and without a date. Surveyors were told that it was from a sister facility and was effective (MONTH) 1 of (YEAR) by DON B (Director of Nursing). It states the following: It is the policy of the facility to assure that all residents are weighed routinely in compliance with all state and federal regulations and those weights are evaluated and changes responded to appropriately. Procedure: 1. All new admissions are weighed within 24 hours of admission. 2. Weekly weights will begin unless there is a MD (medical doctor) order for weights to be taken more frequently. 3. Weekly weights are taken by NAR's (this abbreviation was not explained) and entered on a bath sheet. The CDM (Certified Dietary Manager) will review the bath sheets and ask for reweights if there is a change of +/- 3# or 2% in the week. 4. Once the reweighs are taken, the CDM will enter the weights in AHT (electronic health record). 5. If the CDM notices a weight change of +/- 3# or 2% they will notify the Nurse Manager and report to IDT (interdisciplinary team) to be discussed with the interdisciplinary team. 6. Any weight loss or gain of 3 pounds or 2% will be monitored for another week if pattern continues MD will be notified and intervention will be put in place as ordered by MD. On 10/15/18 at 10:26 AM, Surveyor interviewed RD S (Registered Dietician). RD S stated they comes to the facility on ce a week to review residents that are due for a Minimum Data Set (MDS) to be completed, readmitted residents, residents with pressure ulcers, on [MEDICAL TREATMENT], or with any tube feedings. RD S stated they review weights along with lab results, and other documentation that might relate. RD S documents notes in the facility electronic health record. RD S started in (MONTH) of (YEAR). RD S explained that typically they would expect that residents are weighed on admission and weekly after that for 4 weeks and then monthly. On 10/15/18 at approximately 1:00 PM, Surveyor interviewed DON B who stated they would expect residents who are newly admitted to be weighed, each day for 3 days, then weighted monthly I believe I will look at that. Surveyor asked who reviews the weights taken and DON B explained that, When the dietician comes in 1 time a week, DON B would look at and review the weights. Surveyor asked what if there was a weight change of 5 or more pounds in a week. DON B stated the nurse would review it and notify the physician. Example 1 R28's care plan, initiated on 7/28/18, has chronic venous ulcers and pressure ulcers. R28 was admitted to the facility on [DATE]. R28's care plan provided by the facility, on 10/9/18, did not include any specific care planning regarding his nutrition/hydration except for skin. The intervention of nutrition or hydration program to promote healing as ordered. Encourage 75% (percent) or more intake was added on 7/31/18. R28's medical record shows the following documentation regarding his weights: 7/1/2018 22:56 (10:56 PM) 205.0 lbs. (pounds) Wheelchair (This was a hospital weight) 7/26/2018 22:51 (10:51 PM) 194.8 lbs. - this was taken in the facility - this is a 4.98 % weight loss from R28's hospital weight with no evidence that R28 was reweighed. 7/31/18 - 205 lbs. - this is a 4.98 % weight gain On 7/31/18, R28 had a Nutrition Assessment completed that did not include R28's most recent weight or typical weight. No supplements were noted and no significant weight changes were noted. With Goals marked to maintain adequate nutritional status as evidenced by maintaining weight without significant weight changes . and weigh at same time of day and record as per facility protocol for new residents. There was a RD Note on 8/13/18 that noted R28's weight of 194.8, but did not include the other facility weight. 8/19/2018 5:56 196.3 lbs. - this is a 4.43% weight loss and the most recent weight in R28's medical record. On 9/27/18, R28's Physician's Note includes most recent weight of 196.3 from 8/19/18. The facility did not ensure R28 was weighed per the frequency stated in their policy, reweighed when greater than a 2% change in weight, and monitor weight pattern. Example 2 R47 was admitted to the facility on [DATE] and has a care plan created on 6/26/18 for decreased cardiac output, altered tissue perfusion and cardiac complications related to hypertension and on 6/19/18 a care plan for a nutritional problem due to history of macerated skin, and fair intakes and one of her interventions is to, weigh at same time of day and record, per facility protocol for new admissions, also initiated on 6/19/18. The facility documentation regarding R47's weight is as follows: On 6/14/2018 at 3:18 PM, R47 weighed 175.0 lbs. R47 had a Nutrition Assessment completed on 6/19/18. It included R47's most recent weight, but not R47's usual body weight. It included R47's history of being a diabetic, current wound, current [MEDICAL CONDITION], which noted to likely affect R47's weekly and monthly weights. Intakes are independent and 25-75% at that time. On 7/18/2018 at 7:08 PM, R47 weighed 184.4 lbs., which is a weight gain of 5.37%. The physician was consulted earlier that day at 6:13 PM, but there was no documentation that R47's weight gain was discussed. This is over a month after R47's initial weight. On 8/29/2018 at 9:46 PM, R47 weighed 156.0 lbs., which is a weight loss of 15.4%. Again this is over a month since R47's previous weight and there is no evidence R47 was reweighed or R47's physician was notified. On 9/19/2018 at 9:56 PM, R47 weighed 166.3 lbs. which is a weight gain of 6.6%. On 9/26/2018 at 4:11 PM, R47 weighed 165.5 lbs. On 10/3/2018 at 10:29 PM, R47 weighed 164.0 lbs. R47 had a Nutrition/Dietary Note completed on 10/8/18 at 11:07 AM which stated: RD Quarterly Assessment with weight change: R47's weight has been fluctuating significantly. Was admitted 3 months ago at 175#'s (pounds). R47 went up to 184#'s, then dropped to 156 and this past month has been stable around 164#'s. R47 is on a diuretic and at obese weight status. R47 does not seem to eat well at meals here, but family brings in food often - reported as pizza or burger. R47 is able to give food preferences when asked. Recently noted R47 does not like scrambled eggs - now gets a fried egg each morning. R47's diet here: CCD (Consistent Carbohydrate Diet). R47 is on a B12 supplement and Vitamin D but no K+ (potassium), [MEDICATION NAME] dose is low and R47 may not need this supplement if R47 can maintain dietary intake. Plan to monitor labs and any reports of symptoms consistent with deficiency. Example 3 R50 was admitted to the facility on [DATE]. R50 had a care plan initiated on 9/4/18 that R50 rejected care, used verbally abusive language due to anxiety and depression. The facility also initiated a care plan on 9/4/18 for R50's nutritional problem due to class III obesity, [MEDICAL CONDITION], diabetes, and cardiomegaly with the intervention to, weigh at same time of day and record, per facility protocol for new admissions. On 7/17/2018 at 11:57, R50 weighed 381.3 lbs. R50 had a Nutrition Assessment completed on 7/17/18 that included R50's most recent weight, comorbidities, intakes of 50-75%, labs results. The RD attempted to interview R50, but R50 dismissed the RD from room, not wanting to talk. The goal noted was to have a gradual weight loss through the review date, maintain weight without significant weight gain among others. On 8/7/2018 at 13:16 (1:16 PM), R50 had a Nutrition/Dietary Note that stated the RD was informed of wound issues received this date; R50 was admitted with blisters on right toes; treatment continues. (MONTH) weight is pending. Continue diet Rx (Treatment): CCD/NAS mech (No added salt / mechanical). RD review prn (as needed). (R50 had only had the initial weight taken at this point with no evidence of refusing to be weighed.) On 8/10/2018 at 1:15 PM, R50 was weighed at 326.0 lbs. This is a 14.5% weight loss with no documentation of a reweigh, physician or RD notification regarding weight. On 8/17/2018 at 10:59 AM, R50 weighed at 320.6 lbs. This is an additional 1.66% weight loss to previous weight loss. R50's Progress Notes, the same date, stated R50 had an appointment with physician the next day. R50 had no other documented weights completed prior to being admitted to the hospital on [DATE]. R50 returned to the facility on [DATE] with Physician order [REDACTED]. On 9/14/2018 at 5:30 AM, R50 weighed 311.4 lbs., which is an additional 2.87% weight loss. This was the first documented weight since readmission on 9/4/18. From 9/4/18 to 9/18/18, when R50 went out to the hospital again, R50 had no weights documented by the facility. On 9/20/2018 at 10:41 PM, R50 weighed 345.0 lbs. on readmission to the facility, which was now a gain of 10.79 % in 6 days. There was no facility documentation if this was noted by the facility or his physician. This was the most recent weight completed prior to the entry to the facility by the survey team on 10/8/18. R50's Physician Note, dated 9/21/18, noted current weight of 345 lbs. On 9/24/2018 at 1:53 PM, the facility had a Nutrition/Dietary Assessment for R50 that stated it was the RD Assessment upon readmission: R50 was readmitted ,[DATE] at 345#'s. This was a significant weight gain from a week prior at 311.4#'s. It's possible readmission weight was from a bed weight in the hospital - requesting weight recheck (which was not completed). Writer talked with R50 about R50's intake today and R50 noted poor appetite, R50's been picky about what he eats - likes zucchini and spaghetti. We discussed risk with LBM (Lean Body Mass) loss and importance of eating adequate protein. Unsure of (R50's) comprehension. (R50) didn't have any complaints or concerns. Willing to have weight rechecked. Example 4: R65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R65's Minimum Data Set (MDS), dated [DATE], indicated that R65's cognition is severely impaired with a Brief Interview of Mental Status (BIMS) score of 2. It also indicates that R65's speech clarity is unclear with slurred or mumbled words and her ability to make self understood is sometimes R65 is understood- responds adequately to simple direct communication only and her ability to understand others is sometimes R65 understands- responds adequately to simple, direct communication only. R65's Physician order [REDACTED]. 3/19/18 - (MONTH) institute high density calorie supplements if weight loss is >5%. 5/7/18 - Weekly weight every day shift every Monday. R65's Comprehensive Plan of Care, initiated 5/29/18, states, in part: Focus: Nutritional and Hydration - at risk for alteration in nutritional status related to diabetes, diuretic, hoards food, and other items, therapeutic diet . Goal: Resident will not experience significant weight changes or fluid imbalance . Approach: 5/29/18-Assist with meals as needed, opening milk, packets, etc. as resident allows. 5/29/18- honor food preferences, offer alternative food choices by name such as grilled cheese, soups, puddings, etc . 5/29/18- resident has dentures, but chooses not to wear them . 9/04/18- Resident likes coffee, white milk, and red juice in cups with handles . 5/29/18- show resident snacks and allow her to choose what she would like at snack times . *It is important to note R65's care plan did not include weekly weights as ordered by R65's physician and has not been updated with new interventions to address weight changes since 5/29/18. Nutrition/Dietary Note, dated 3/19/2018, includes, in part: Registered Dietician (RD) Assessment - annual: (R65) reports good appetite and no problems chewing or swallowing. While R65 doesn't have a recent weight recorded in chart at this time, R65 reports no evidence of weight change and most recent weights show stable around 175# . Plan to continue current diet and monitor for weight change considering medication regimen puts R65 at higher risk for weight changes. R65's weights are noted to be as follows: 9/25/2018 167.0 lbs. (Pounds) 8/31/2018 181.2 lbs. 8/29/2018 180.6 lbs. 8/27/2018 177.4 lbs. 8/27/2018 117.3 lbs. 8/17/2018 180.0 lbs. 8/7/2018 184.2 lbs. 7/25/2018 182.2 lbs. 7/22/2018 181.0 lbs. 7/9/2018 182.4 lbs. 7/8/2018 185.0 lbs. 7/4/2018 187.8 lbs. 7/2/2018 182.2 lbs. 6/23/2018 182.6 lbs. *It is important to note the missing weights between 6/23 -7/2, 7/9-7/22, 7/25-8/7, 8/7-8/17, 8/17-8/27, 8/31-9/25, 9/25-10/15. *Also important to note is the 14.2 lb loss that occurred between 8/31/18 and 9/25/18. This loss is calculated out to be a 7.84% decrease in 1 month. On 10/15/18 at 10:50 AM, during an interview, RD X indicated that she was unaware of R65's weight loss of 7.84% in one month. RD X indicated that RN G (Registered Nurse) looks at weights and the expectation is that RN G would report the weight change to RD X. RD X also indicated that if Physician order [REDACTED]. *It is important to note that facility did not provide evidence of RD X or R65's MD being notified of this change. On 10/15/18 at 12:43 PM, during a second interview, RD X indicated again that they were not aware of R65's weight change until Surveyor drew her attention to it. RD X indicated that they asked facility staff for a current weight and staff weighed R65 today and current weight is 158.8 lbs., which calculates out to be another 8.2 lb. decrease in a month. RD X stated, I will notify the physician of this change. The nursing should get weights on re-admissions as well as admissions and report changes to me. *It is important to note that R65's 10/15/18 weight of 158.8 calculates another loss of 4.91% in a month, at least an 11.78% decrease in 3 months, and a 13.03% decrease in 6 months.

Based on observation, interview and record review, the facility did not ensure the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision to prevent accidents/hazards for 2 of 10 residents who are assessed to be elopement risks (Residents 1 and 2). R1 (Resident) was assessed to be at risk for elopement upon admission. R1 refused to wear a WanderGuard bracelet, which would have alerted staff that R1 was leaving the facility. R1 was known by staff to wander throughout the facility and facility grounds unsupervised. The facility did not have a plan in place to ensure R1 would stay in the facility or on the facility grounds. On 8/15/17, at 2:30 PM, the facility was notified by the local police department that R1 was in a bank, looking for directions to Tennessee. The bank was approximately 10 miles from the facility. The facility was unaware that R1 had eloped until called by the police department. Upon return to the facility, R1 was put on 1 on 1 with staff. On 8/21/17, R1 was observed by a Surveyor to be alone in a 300 wing lounge unsupervised. The failure to ensure adequate supervision when R1 was known to wander throughout the facility and facility grounds unsupervised created a finding of Immediate Jeopardy (IJ) that began on 8/15/17. NHA A (Nursing Home Administrator) was notified of the IJ on 8/22/17, at 10:30 AM. The IJ was removed on 8/21/17, and the deficient practice continues at a severity/scope of D (no actual harm/isolated) until all the components of training are completed. However, immediate jeopardy was identified again at the partial extended survey on 8/28/17, with a beginning date of 8/27/17. R2 was assessed to be at risk for elopement. R2 was known to staff to wander throughout the facility. R2 was an elopement risk and was known to attempt to elope through windows. R2 had a chair pressure alarm and a WanderGuard bracelet. R2 was on 15 minute checks, which were not completed. Resident 2 was found standing on a chair attempting to climb out a window the prior month with no interventions put in place to deter this occurring again. On 8/27/17, at 9:45 PM, oncoming night shift staff found R2 lying on the ground outside the facility dining room; R2 had fallen out of a window while attempting to elope. R2's chair pressure alarm was not sounding. R2 was sent to the hospital and diagnosed with [REDACTED]. On 8/28/17, R2 returned to the facility. The administrator and the Director of Nursing were notified of the immediate jeopardy on 8/28/17 at 4:40 PM. The jeopardy was not removed by the conclusion of the survey on 8/28/17. Evidenced by: The facility's policy and procedure on Unsafe Wandering and Elopement Prevention Protocol Missing Resident Protocol, revised 9/2016, includes, in part, the following: 1. All residents who are at risk for harm because of unsafe wandering will be assessed by the Interdisciplinary Care Planning Team. 3. The resident's care plan will be modified to indicate the resident is at risk for elopement episodes. Staff will be informed at shift change of the modifications to the resident's care plan. 4. Interventions for unsafe wandering and elopement attempts will be entered onto the resident's care plan and medical record. 5. Should an elopement occur, the contributing factors, as well as the interventions' tried, will be documented on the Nurse Notes. 6. If a resident is discovered to be missing, a search shall begin immediately, per the missing person's protocol. 3. Upon return of the resident to the facility, the Director of Nursing (DON) or Charge Nurse should: e. Make appropriate notations in the resident's medical record. f. Complete an Elopement assessment. g. Add Resident Elopement Risk Information form with picture to the elopement risk binder. Example 1 R1's [DIAGNOSES REDACTED]. R1 has a Guardian and has a petition for protective placement. R1's most recent MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 6/7/15, indicates R1 has moderate cognitive impairment and needs supervision with ambulating. R1's Hospital History and Physical, dated 2/12/17, included, in part, the following: . His son takes care of the patient, and the patient does wander, but the son will then follow him in the car. The patient walked a full 5 miles or so apparently, then suddenly collapsed, agonal respirations, and EMS came to the scene. R1's Admission Evaluation Data, dated 5/31/17, includes, in part, the following: Cognitive/Communication: Short Term Memory: Memory Problem, Long Term Memory: Memory Problem. Cognitive Skills for Decision Making: Needs assist with decisions at this time. Behavioral Symptoms: HX (history) of wandering. Risk for Elopement/Wandering Review: Does the resident have a history of: Elopement while at home: Yes. Leaving facility without need of supervision: Yes. Leaving facility without informing staff: Yes. R1's Risk for Elopement/Wandering Review, dated 6/17/17, includes, in part the following: Side One: Is the resident cognitively impaired with poor decision making skills: Yes. (If yes, comment on side two.) Does the resident have a pertinent [DIAGNOSES REDACTED].? Yes. (If yes, comment on Side Two). Does the resident ambulate independently with or without the use of an assistive device? Yes. Does the resident have any hearing, vision, or communication problems? No. Does the resident have a history of: Elopement while at home? Yes is checked, crossed off and Error is written, then No is checked. Leaving facility without need of supervision? No. Leaving facility without informing staff? Yes is checked, crossed off and Error is written, then No is checked. Has the resident verbally expressed the desire to go home, packed belongings to go home or stayed near exit door? Yes. Does the resident wander aimlessly or non-goal-directed? No. Has the resident been recently admitted or readmitted (within the past 30 days) and not accepting the situation? Yes is checked, crossed off and Error is written, then No is checked. Does the resident receive any medications that increase restlessness or agitation? No. Is this a new behavior, have there been any changes in the resident's status or routine? No. Has the family/responsible party voiced concerns that would indicate the resident may have wandering tendencies or try to leave? No. Side Two: Summary of Review: Resident is at risk for elopement/wandering as evidenced by: Res (Resident) has Dx (diagnosis) of dementia, has gone outside x (times) 1, res has verbalized desire to go home. Attempted to place Wander-guard on res, res became agitated and stated if it was put on he would rip it off. Resident is checked frequently. R1's Risk for Elopement/Wandering Review, dated 7/7/17 and 8/9/17, found R1 to not be at risk for elopement/wandering. R1's Care Plan Problem Risk for altered protection related exit seeking with no rational purpose, seemingly oblivious to safety needs, attempted to leave facility, history of elopement, start date 6/1/17, included, in part, the following approaches: ask resident to assist you with a talk, assist with toileting PRN (as needed), encourage family to bring in personal possessions, engage in activities, evaluate for elopement as needed, have familiar object in room as available, implement facility system for identifying residents (specify name band, picture, etc.), involve the resident in decision making regarding daily choices as condition permits, observe pattern of wandering and for changes in sxs (symptoms), offer fluids, offer snack if hungry, refuses Wander alert bracelet, wandering management program. R1's Immediate Plan of Care At Risk for Elopement, dated 8/15/17, included, in part, the following interventions: Evaluate risk for elopement as needed, Observe for unmet needs, 1 to 1's, Involve resident in facility activities of their liking, Introduce resident to other residents in the building, Wandering management program initiated 1 to 1 monitor, Escorted outside, Involve the resident in decision making regarding daily choices. R1's Resident Transfer/Lift Screening, completed 6/29/17, by Physical Therapy, includes, in part, the following information: Weight bearing status: Full. Recommended transfer: Independent. Comments: I (independent) using single point cane in room and through facility. R1's Nurse's Notes include, in part, the following entries: 6/14/17 - 2:30, Resident resting in room. (No) episodes of resident wandering, trying to contact his family on the phone, resident discusses leaving to go to Chicago. Frequent checks to ensure no episodes of elopement. 6/19/17 - 1900 (7:00 PM), Resident continually wants to go home, says his daughter will pick him up. Explained that he is here for therapy. 6/27/17 - 7:00 PM, Resident resting comfortably in room. Resident frequently asks about leaving. 7/15/17 - 9:00 AM, Res was outside taking a walk. CNA (Certified Nursing Assistant) went out and walked (with) him back to door. Res had appropriate foot wear and was using his cane. 7/27/17 - 1400 (2:00 PM), Res transferred to Villa (other side of the building) at this time. Family aware. 7/28/17 - 3:50 AM, Resident confused about room (change). Was found in old room on main side. When redirected back to room, did not want to go to bed. Is currently sitting in dining room chair. Will continue to monitor. 7/28/17 - 9:00 AM, Res up/amb (ambulating) - confused. Telling writer he needs to go to VA (Veteran's Administration) clinic. Ate usual for bkfst (breakfast). Sitting outside on porch (with) peers. Comfortable. Continue to monitor. 7/28/17 - 1300 (1:00 PM), Offer n/c (no complaints). Rm (change) to ( ). Observed sitting in recliner. Has been up all day. 7/29/17 - N(NAME) (night shift) Resident Room (change) to ( ). Has been in room all night. 8/7/17 - 1630 (4:30 PM), Res outside on porch and decided to take a walk around facility grounds. Res re-educated on safety and the need to stay visible (with) other peers. CP (care plan) followed. Increase checks to 15 mins (minutes) at this time for safety. 8/8/17 - 10:15 (AM), Remains on 15 min checks. Resident outside and walking around building. No complaint of pain or discomfort, will continue to monitor. 8/8/17 - 2 - 6 AM, Resident up wandering facility per his norm. Remains on 15 min (checks). Did go outside and sit on patio several times. Has been resting comfortably through the N(NAME). Will continue to monitor. 8/12/17 - 11:10 AM, Remains on frequent checks. Resident walking around facility. 8/15/17 - 4:00 AM, Continues with frequent (checks). Has remained in room thus far. Will continue to monitor. R1's Interdisciplinary Progress Notes include, in part, the following entries: 6/16/17 - Wander assessment completed, refused to wear. Continue to frequently monitor. 8/9/17 - Contacted Guardian to receive approval for him to go outside w/o (without) supervision with checking out with staff. 8/9/17 - Guardian returned phone call. Permission granted for resident to go outside (without) supervision. (Note: Guardian disputes this. See interview below.) 8/9/17 - Resident evaluated for wandering. No problems noted. 8/15/17 - Resident assessed for wander after elopement. Resident found to be at risk since he eloped this afternoon, approached with WanderGuard, resident became agitated and raised fist. Resident now a 1:1 when he is not in his room. Full evaluation of what resident was wearing - 3 short sleeved shirts layered, black hat, jeans, brown loafer shoes, and socks. Also had his single point cane. Resident received full body assessment. Found bilateral top of ears and forehead reddened. Noted and denies pain. Guardian updated. R1's Physician Interim/Telephone Orders include, in part, the following: 8/9/17 - (no time documented), Guardian gave permission for resident to ambulate outside of facility. (It is important to know this telephone order was not signed by the physician.) 8/9/17 - (no time documented) May go outside alone. Signed by the physician 8/17/17. R1's medical record included, in part, the following Dietary Intake documentation: 8/15/17 Breakfast 100/360 Lunch R/R (Refused/Refused) Dinner (Blank) The Police Department Offense Report, dated 8/15/17, included, in part, the following narrative: On 8/15/17, at approximately 2:06 PM, I was approached by a citizen concerned about a disoriented elderly man in the area of 100 Market Street that was asking for directions to Tennessee. I advised Wood County dispatch of this complaint and they acknowledged that they also received a complaint about this and were about to dispatch officers. I responded and located the elderly subject inside of (Bank Name) located at (address of bank). I spoke with the subject who was subsequently identified as R1. R1 appeared tired and confused and my initial assessment was that he was suffering from dementia or a similar ailment. . I made contact with (Facility Name) and they had no knowledge that R1 was missing from their facility. It should be noted that when measured in a direct line, (Facility Name) is approximately 7.8 miles from Nekoosa and it would have taken R1 quite some time to walk this route. We did speak with R1 and it is our belief that R1 did, in fact, walk this route. Witnesses at (Gas Station Name) stated they observed R1 to be in the area, since approximately 10 AM, which would mean that R1 would have been missing from the facility for some time. It should also be noted, that between (Facility Name) and Nekoosa there are areas of high traffic volume and the route is along the Wisconsin River - which is quite dangerous for a person in R1's condition. I contacted County Human Services reference this incident and explained my concern with R1 returning to a facility that had failed to notice his absence until I contacted them. I was advised that he needed to stay at the facility due to a court order. Staff from (Facility Name) did come and transport R1 back to the facility. The facility's Quality Assessment and Assurance Investigation Report, dated 8/15/17, includes, in part, the following: 14. Results of Investigation: Resident was in the building on 8/15/17 and was last seen at 1345 (1:45 PM) by LPN E (Licensed Practical Nurse). Resident states he left after breakfast and walked to Nekoosa, approx. (approximately) 3 hrs (hours) 5 min (minutes), 11 miles to (street name). Call received to Police Dispatch at 1406 (2:06 PM), 1424 (2:24 PM) resident was detained until staff Unit Mgr (Manager) could pick him up at approx. 3 - 3:30 (PM). No injuries noted. Denies pain. States he walked all the way himself. Person Preparing Report: DON B, Date: 8/16/17. The facility's Misconduct Incident Report, dated 8/15/17, includes, in part, the following: VII. Describe below or attach a copy of the entity's investigative records concerning the incident. R1 is an [AGE] year old resident of (Facility Name). He was admitted to the facility on [DATE]. R1 [DIAGNOSES REDACTED]. His BIM score is a 9. On 8/9/17, an elopement assessment was completed on R1 showing that he was not at risk for elopement and per his request his care plan was updated for him to be able to walk outside of the building unsupervised with frequent checks by staff. On 8/9/17 he was personally shown the boundaries of the facility property by DON B, who monitored him outside for several days by observing him walking the facility grounds. On 8/9/17 Guardian C was contacted and gave her permission for him to walk outside the building unsupervised. On 8/9/17 R1's Primary Care Physician and Medical Director, signed an order approving his care plan change (please note this order was not until 8/17/17 after R1 eloped). August 15, 2017 Prior to breakfast, R1 was seen in the Library of the 100 wing by CNA D. This is where the phone is located for resident use. He was also seen by RN K, heading toward the Dining Room. At 8:15 AM - R1 was in the Dining Room eating his breakfast. At 8:30 AM - R1 was seen again in the Library by CNA D. At 9:00 AM - R1 was given his morning medications by MAA G (Medication Administration Assistant), by the Villa Nursing Station. He then walked toward his room. At 11:45 AM - CNA L spoke with R1 about going to lunch. He replied that he wasn't going to eat lunch and went to his room. Between 11:45 AM and 12:15 PM - R1 was observed by BOM M (Business Office Manager) walking with other residents toward the Dining Room. Before lunch was served at 12:15 PM - R1 was also seen in the facility by CNA J and CNA N who stated that R1's mood was good. At 1:20 PM - R1 was seen by CNA L on the Villa side of facility. At 1:45 PM - R1 was observed by LPN E lying down on his bed in his room. At 2:30 PM - NHA A received a phone call from PO F (Police Officer); Nekoosa Police Department stating that an elderly gentleman named R1 was at the (Bank Name) in Nekoosa. PO F went on to say that he contacted R1's son who stated that his father lived at (Facility Name). NHA A acknowledged that R1 was a resident at (Facility Name) and informed him that a member of the staff would be sent shortly to pick him up. At 2:35 PM - RN O, Unit Manager of the Villa, left (Facility Name) to pick up the resident in Nekoosa. During their return to (Facility Name) R1 shared with RN O that the reason he had been outside walking around the property so much is that he had been practicing. He went on to say that he had planned on leaving the facility and that he would try it again warning that he would hit anyone who got in his way. At 2:35 PM a complete roster check of all residents at facility was started and completed by 2:45 PM. All residents were accounted for except for R1. At 3:30 PM - R1 returned to facility with RN O, Unit manager, and was assessed and interviewed. During the interview, R1 was asked how he got to Nekoosa to which he responded that he walked. At 3:45 PM - elopement assessments were completed on all residents residing in facility. At 3:45 PM - one on one staffing with resident started. At 3:45 PM - DON B contacted both cab companies in Wisconsin Rapids to see if they had picked R1 up from facility and transported him to Nekoosa. Neither company reported picking R1 up. At 3:45 PM - DON B contacted (Bank Name) . She stated that R1 entered the bank at approximately 2:20 PM at which time she contacted the Nekoosa Police Department. The Nekoosa Police Department arrived at the bank at 2:30 PM. At 4:00 PM - Guardian C was updated. At 4:30 PM - RN P interviewed (Facility Resident Name) a resident at facility who R1 was often seen talking with. (Facility Resident Name) shared that R1 spoke of leaving often, but did not feel that he would actually attempt to leave. (Facility Resident Name) shared that R1 also shared that he would listen to R1 and often remind him of how good he had it at facility. He went on to say that he would let R1 vent, but always encouraged him to stay at the building. At 8:30 PM - DON B arrived at (Facility Name) to continue to educate staff on elopement policy and procedure. As she was educating staff, R1 came to the Villa Nursing Station and told her that he would do it again. He shared with her that he walked to his son's house in Nekoosa . but he was not home. R1 then stated that he asked for directions to Tennessee from someone at the BP gas station. He has a daughter that currently resides there. An employee at (Bank Name) had stated that he wanted directions to Chicago. He has a daughter that resides there. DON B assured R1 THAT (Facility Name) was working with APS I and Guardian C to look for an assisted living or senior apartment for him. R1 then shared with DON B that his son .had come to the facility the night before to give him back his bank cards. He then brought up his concern that someone was taking his money. DON B explained to him that leaving the building unassisted could jeopardize his discharge to another living arrangement. He then stated he would not leave the building. 8/16/17 At 8:00 AM - a message left for APS I. At 8:15 AM - DON B met with R1 prior to breakfast. He stated he had a chaperone which was his one to one staffing. DON B reiterated the importance of not leaving the building unattended to which R1 smirked. At 11:00 AM - DON B left a message for Guardian C, R1's Guardian, to return her call. Guardian C called back and it was discussed with her at length what had occurred and that R1 stated that he would leave again, warning that he would hit anyone who tries to stop him. Guardian C shared with DON B that she had contacted APS I, because he had found out there was more money withdrawn by R1's son and they were working on this. At 3:15 PM - R1 came to DON B's office with a staff member to share with her that he spoken with his son .who told him Strawberry Lane was going to send him away from his family and lock him away. DON B assured him that was not true and that his son should not have said such a thing. Then R1 let it slip that he saw his son the day before. When DON B asked him when he saw his son . attempted to cover it up by saying that he spoke with him on the phone. This was witnessed by RN O, Admissions Q, and DON B. Summary and Conclusion: While it can be substantiated that on August 15 (sic), 2017 R1 eloped from Strawberry Lane Medical and Rehabilitation Center, it cannot be substantiated that his elopement from the facility was due to mistreatment, abuse, or neglect. As the investigation shows, before R1's care plan was changed, to allow him to walk the facility grounds unsupervised, an elopement assessment was completed which showed him not to be at risk; Guardian C, R1's Guardian, was involved in the process and decision. R1's Primary Care Physician, the facility's Medical Director and R1's physician, was involved in the process and decision, and the DON B visually monitored him for several days when he was outside. As the investigation also shows the most likely causes for R1's elopement were personal in nature which included the fear that someone outside the facility was taking his money, his son returning his bank cards to him the day before the incident, the son placing fear in his father's mind regarding the facility, and R1's desire to be in a less restrictive environment. Because of this, Strawberry Lane Medical and Rehabilitation Center is working closely with Guardian C, R1's Guardian, and APS I to help R1 find the best environment for him. The facility is also working with them to assure that R1's money is not being illegally taken away from him. In fact, Guardian C has contacted the Police Department regarding her concerns and they are currently in the process of investigating. On 8/22/17, at 9:30 AM, Surveyor interviewed Guardian C via telephone. Guardian C stated she was called by the facility to ask if it would be alright for R1 to go outside with supervision. Guardian C stated that she agreed to R1 going outside as long as staff were supervising him. Guardian C stated he had eloped from his son's home prior to admission and was a flight risk. Guardian C stated she would have never agreed to allow R1 to go outside unsupervised, because of his dementia and history of eloping. Guardian C stated when the facility called to inform her of his elopement, she did not understand how he could get 10 miles away and no one knew he was gone. On 8/21/17, at 3:00 PM, Surveyor interviewed R1. R1 stated to Surveyor, Are you my new babysitter. Surveyor stated to R1, I am a Nursing Home Inspector. R1 stated, Oh, are you here because I left here. Surveyor stated, you left the facility; can you tell me about that. R1 stated he walked to Nekoosa because he wanted to go home. I went out the gate and walked East on 1st Street. R1 stated it took him a quite a few hours and he has bad legs, but those bad legs went a long way and his cane held him up. R1 stated, I made a mistake though, I stopped and asked for directions and they called the police. Surveyor asked how R1 got back to the facility. R1 stated someone picked him up and brought him back; now he has a babysitter and laughed. Surveyor asked R1 where were you headed? R1 said to Tennessee; I am going to move to Tennessee. R1 stated, He was determined too. I would have slept by the roadside if I had to. I was in the Army. I know all about survival. On 8/25/17, at 9:45 AM, Surveyor interviewed GSE R (Gas Station Employee). GSE R stated she saw R1, at 10:00 AM, outside the gas station walking thru the parking lot and then went down the alley next to the Gas Station. GSE R stated R1 was dressed in a black hat, had 3 shirts on, and was using a cane. GSE R stated, about approximately 1 hour to 1 1/2 hours later, she saw R1 walk down the street on the other side of the Gas Station. R1 proceeded to continue down this street. GSE R stated, about 1:45 PM - 1:50 PM, R1 entered the Gas Station and asked for directions to Chicago. GSE R stated she gave R1 directions and R1 exited the Gas Station and proceeded to walk down the sidewalk to the corner intersection. GSE R stated she thought R1 was somewhat confused. She stated she called her manager, who suggested she call the police department. GSE R stated she then called the police department about 2:05 PM and informed them of what she knew of R1 and asked for a welfare check. GSE R stated no one except the police have inquired about what she knows about R1. On 8/21/17, at 4:28 PM, Surveyor spoke with Dr. Y (Doctor) regarding R1. Surveyor asked Dr. Y if he had spoken with facility staff regarding R1 going outdoors independently. Dr. Y stated I don't recall having a conversation with the facility about R1 going out doors independently. Surveyor explained to Dr. Y a telephone order was written on 8.9.17, which states R1 may go outside alone and was signed on 8/17/17. Dr. Y stated if the facility wrote the order, I may have spoken with them. From what I recall, R1 is not a very competent man; this just surprises me. I'm not sure why he would be outdoors independently. Surveyor asked Dr. Y if he was aware R1 eloped and allegedly walked to Nekoosa. Dr. Y stated, he was not aware. That surprises me; that is a really long walk. I can't believe he had the stamina to walk that far. That is about a 10 mile hike; I am not sure I can walk 10 miles. Maybe he got a ride from someone and he is not telling you. On 8/15/17, at 10:00 AM, Surveyor drove from (Bank Name) to (Facility). (Bank Name) is on the intersection where Highways 73 and 54 merge to cross the Wisconsin River. The route wound around with many streets without sidewalks or a sidewalk on one side only. There are paper mills in the area, a hydroelectric plant, and road construction on 5 blocks of road, just before you get to the facility. The facility is on a cul de sac and there is no other way to get to or from the facility, without going out onto to the road with construction, which runs adjacent to the Wisconsin River and has no barrier from the river. On 8/21/17, at 12:44 PM, Surveyor spoke with RN O (Registered Nurse) regarding R1 and the day R1 eloped. RN O stated R1 was frequent checks when outside. RN O defined frequent checks as checking on the person frequently; no specified time frame. RN O stated R1 became 15 minute checks a week prior to the elopement, as R1 was made independent to be outdoors and would frequently roam from the back porch to the front of the building. When R1 began to frequently walk from the back to the front, R1 was placed on 15 minute checks. RN O defined this as being checked every fifteen minutes and R1's whereabouts is documented on a 15 minute check log. Surveyor asked RN O about the day of the elopement. Surveyor asked RN O if R1's 15 minute checks were being completed on the day of elopement. RN O stated the 15 minute checks were being completed. RN O stated, I am not sure how he could have possibly walked that far; that is a 30 minute drive. RN O stated that she was called by the police, between 2:00 and 2:30 PM, and was alerted that R1 was at a bank in Nekoosa. Police told me they had calls, from about 10 AM, regarding R1. RN O stated that is not possible as staff saw R1 here at the building just 45 minutes before the police called me. RN O stated she left the building to go get R1. RN O stated R1 told her that he had a plan and that he was practicing and that this was his plan all along. RN O stated R1 told her he felt like a prisoner and that he wanted to be a man and he was afraid someone was stealing from him. RN O stated R1 told her he would do it again and he would kill anyone who tried to stop him. Surveyor asked RN O if the facility has a system or way of communicating if R1 gets outdoors and is not able to be re-directed indoors, such as a phone or walkie-talkie. RN O stated the facility does not have an established system to communicate. On 8/21/17, at 11:00 AM, Surveyor interviewed CNA U; CNA U was working on the 500/600 wing. Surveyor asked CNA U how she is made aware of the residents who are at risk for wandering. CNA U stated the facility hangs a picture and identifying information, by the time clock, for each resident identified as at risk for wandering. Surveyor asked CNA U if she could identify the residents at risk for wandering on the 500/600 unit. CNA U identified R1 as a resident at risk for wandering. Surveyor asked CNA U where R1 was currently located. CNA U stated she was not certain, but thought R1 may be with management staff. Surveyor asked CNA U who was responsible for R1 today and R1's whereabouts. CNA U stated we all are responsible. Surveyor asked CNA U to locate R1. CNA U walked off the 500/600 unit and pointed to R1, who was located in the lounge between the 500/600 unit and the dining room area. R1 was seated and conversing with the Admissions Q. Surveyor asked CNA U if R1 was able to be outdoors independently. CNA U stated R1 was able to go outside and sit on the porch and when he was outdoors R1 was frequent checks. Surveyor asked CNA U to define frequent checks. CNA U stated that if staff saw R1 go outside, the staff would watch him close. Surveyor asked CNA U how staff knew R1 went outside; did R1 have to check in or sign out? CNA U stated R1 did not sign out or check in. CNA U stated staff would have liked for R1 to tell them he was going outside but due to his dementia R1 did not remember to let them know. CNA U stated staff usually would see R1 out on the porch sitting on the bench and they were aware R1 was outdoors. CNA U stated the staff would just watch him close. Surveyor asked CNA U who was responsible to watch R1 when R1 was outdoors. CNA U stated all staff was responsible. CNA U stated R1 would normally just sit on the porch bench, then more recently the past few weeks or so, R1 started walking up front and in the parking lot. CNA U stated if R1 went up front, staff would call and alert the front that R1 was out front. Surveyor asked CNA U if R1 ever left the building or grounds. CNA U stated, Yes, he was found recently in Nekoosa. Surveyor asked CNA U since R1 left the facility grounds, did R1's plan of care change? CNA U stated R1 was 15 minute checks when he returned to the facility, but he is frequent checks now. Surveyor asked CNA U do you document frequent checks. CNA U stated we just eyeball R1 every 10 - 15 minutes. Surveyor asked if 15 minute checks are documented. CNA U stated, Yes, we have a sheet we write 15 minutes checks on, but R1 is frequent checks now. On 8/21/17, at 11:11 AM, Surveyor observed R1 seated in the lounge between the 500/600 (TRUNCATED)

Based on observation, interviews, and record review, the facility did not ensure 2 out of 7 residents reviewed for pressure ulcers received the necessary services and treatments to prevent new pressure ulcers and to promote healing of pressure ulcers. Resident #2 developed 4 stage 2 pressure ulcers and 1 stage 3 pressure ulcer between 6/30/12 and 7/18/12 while at the nursing home. The facility did not update Resident #2's care plan to include interventions to prevent the development of pressure ulcers once the facility was aware Resident #2 was at high risk for development. The care plan was updated on 8/8/12, once several of the ulcers had healed to include off-loading of the pressure areas and treatment/dressing to fragile newly healed areas. On 8/14/12, Resident #2 was observed seated in a wheelchair for 2 hours 29 minutes without being repositioned. Resident #2's pressure ulcers were observed to have no dressing intact to promote skin integrity. When care was provided, Resident #2 was observed to have 4 newly open areas on the inner buttocks. The inner buttocks had been documented as healed on 8/8/12. Resident #8 was admitted with a stage 3 pressure ulcer. Surveyor observed Resident #8 with no dressing on the pressure ulcer and complaining of pain while lying on her buttocks. This is evidenced by: According to the American Medical Directors Association, Pressure Ulcers in the Long-Term Care Setting: "Repositioning schedules should be individualized according to a patient's needs, care goals, tissue tolerance, and response to treatment. Tissue tolerance is the ability of the skin and its supporting structures to endure the effects of pressure without care goals, tissue tolerance, and response to treatment. Tissue tolerance is the ability of the skin and its supporting structures to endure the effects of pressure without adverse effects. Tissue tolerance varies among individuals. "Nursing staff should document when turning and positioning occurs. The documentation should note whether the presence of multiple ulcers complicates positioning and when conditions or risk factors (e.g., aspiration risk requiring head elevation, the patient's inability to cooperate, the presence of contractures) affect the desired positioning. "Step 11: Cover and protect the ulcer and surrounding skin. The goals of dressing an ulcer are to: ~Keep the ulcer bed moist and the surrounding skin dry; ~Protect the ulcer from contamination; and, ~Promote healing." Example #1: Resident #2 was readmitted from the hospital on [DATE]. On 6/16/12, the facility completed a readmission data collection sheet which identifies no red areas or pressure ulcers, only bruises to the arms. On 6/17/12, 6/23/12, and 6/29/12, and 7/15/12, the facility completed a Braden Scale for predicting pressure sore risk, which indicated a score of 16 for each date. A total score of 12 or less represents a high risk for developing a pressure ulcer. Review of the admission MDS (Minimum Data Set) assessment dated [DATE], indicated the following: ~Long and short term memory problem; ~Cognitive status is moderately impaired; ~Extensive assistance with one staff for transfers, bed mobility, ambulation, and toilet use; ~Two stage 2 pressure ulcers and one stage 3 pressure ulcer. Skin and Ulcer treatments are pressure reducing device for chair and for bed, ulcer care, application of non-surgical dressings and application of ointments/medications. Review of the care plan in use at the time of Resident #2's readmission, was dated 3/1/12 and stated, "Potential for Alteration in skin integrity r/t dx. (related to diagnosis) of diabetes [MEDICAL CONDITION] and chronic bilateral lower extremity [MEDICAL CONDITION]. Goal: Skin will remain intact. Approach: ...Assist resident with repositioning as needed..." No new interventions were noted when readmitted on [DATE]. Review of Certified Nurse Card (undated) indicates, "offloading schedule Mod. Skin Conditions OA (observation assessment) to buttocks x 3 & L inner thigh x 2 (fragily healed). Pressure reducing measures air mattress. ...Intake/Output (I&O) through 6/17/12." Surveyor # requested the repositioning policy and procedure and the meaning of offload per protocol and what Mod means. On 8/14/12, Surveyor received a policy and procedure titled "Repositioning" with last reviewed/revised date of 3/23/11. There were no references listed or signatures on who reviewed this policy. The following was listed: ~"Interventions/Care Strategies: A turning/repositioning program includes a continuous consistent program for changing the resident's position and realigning the body. A program is defined as a specific approach that is organized, planned, documented, monitored and evaluated. 1. Residents who are in bed should be on a q (every) 2 hour turning program. 2. For residents with a Stage I or above pressure ulcer, q 2 hour turning is inadequate. 3. Residents who are in a chair should be on a q hour repositioning program. 4. If ineffective, the turning and repositioning frequency will be increased.... ~"Documentation: The following information should be recorded in the resident's medical record: 1. The position in which the resident was placed. This may be on a flow sheet. 2. The name and title of the individual who gave the care. 3. Any change in the resident's condition. 4. Any problems or complaints made by the resident to the procedure. 5. If the resident refused the care and the reasons(s) why... 7. The signature and title of the person recording the data." The Wound/Skin Record indicates the following: Site A ~6/30/12, Right buttocks/gluteal fold, Stage II measuring 2 x 1.5 x 0.01 (size in cm (length x width)x (depth cm). ~7/13/12, Right buttocks/gluteal fold, Stage II measuring 2 x 1.5 x 0. ~7/18/12, Right buttocks/gluteal fold, Stage II measuring 3 x 2 x 0.1. ~7/25/12, Right buttocks/gluteal fold, Stage II measuring 2.4 x 1 x 0.1. ~8/1/12, Right buttocks/gluteal fold, Stage II measuring 2.0 x 0.7 x 0.1. ~8/8/12, Right buttocks/gluteal fold, Stage II measuring 0 x 0 x 0 continue with barrier after cares. Site B ~7/9/12, Inner Right buttocks. ~7/13/12, Inner Right buttocks, Stage II measuring 2.1 x 1.8 x 0. ~7/18/12, Inner Right buttocks, Stage III measuring 1.5 x 1.0 x 0.1. ~7/25/12, Inner Right buttocks, Stage II measuring 2 x 0.9 x 0.1. ~8/1/12, Inner Right buttocks, Stage III measuring 2.0 x 0.7 x 0.1. ~8/8/12, Inner Right buttocks, Stage III measuring 0/0/0 healed, fragile [MEDICATION NAME] tissue present. Continue with [MEDICATION NAME] x one week (for one week) to protect new tissue. Site C ~7/9/12, Left inner buttock. ~7/13/12, Left inner buttock, Stage II measuring 1.3 x 1.5 x 0. TCP (temporary care plan) offloading as directed. ~7/25/12, Left inner buttock, Stage II measuring 1.0 x 1.0 x 0.1 ~8/1/12, Left inner buttock, no stage documented measuring 2.0 x 1.6 x 0.1. ~8/8/12, Left inner buttock, healed. Fragile [MEDICATION NAME] tissue present, continue with [MEDICATION NAME] for one week to protect tissue. Site D ~7/18/12, Superior left thigh, Stage II measuring 0.9 x 0.8 x 0.1. ~7/25/12, healed, continue with preventative measures. Site E ~7/18/12, Inner left thigh, Stage II measuring 0.8 x 0.5 x 0.1. ~7/25/12, Inner left thigh, healed continue with preventative measures. Review of care plan dated 8/7/12 noted, "8/8/12 Potential for alteration in skin integrity r/t diabetes, [MEDICAL CONDITION] disorder, decreased mobility m/b (manifested by) pressure areas to R (right) gluteal fold, R inner buttocks, L (left) inner buttocks, L inner thigh x 2." This is highlighted in yellow and a written date of 8/8/12 "healed fragily (sic)." "Approach: ...Offload per protocol and as resident allows...8/9/12 Preventative tx (treatment) measures ordered." On 8/13/12 at 12:02 p.m., Surveyor # started a continuous observation for Resident #2. Resident #2 was not repositioned or offloaded until 2:00 p.m., at which time CNA-B (Certified Nurse Aide) had her stand up using the rail, then sit back down in her wheelchair. According to the facility's protocol, chair bound residents should be repositioned every hour. Resident #2 was not afforded the opportunity to off-load pressure to the buttocks for 1 hour and 58 minutes. On 8/14/12 at 6:50 a.m., Surveyor # observed CNA-J and CNA-K completing Resident #2's morning cares. Resident #2 was standing up as the CNAs were starting to pull up her brief over the catheter. Surveyor # observed a folded [MEDICATION NAME] on Resident #2's left buttock area. Nothing on the right buttock area where the Stage 3 had just healed on 8/8/12. Neither CNA reported the missing dressing to the right buttock or that the dressing on the left buttock was not on appropriately. On 8/14/12 at 7:00 a.m., Surveyor # started a continuous observation of Resident #2. Resident #2 was sitting on a cushion in her wheelchair. At 9:29 a.m. (2 hrs. and 29 min.), CNA-J and CNA-P stood Resident #2 up for 15 seconds then sat her back down. At that time, Surveyor # observed open areas on Resident #2's left and right buttock areas; the [MEDICATION NAME] was barely attached to the skin. CNA-P stated she was going to inform the nurse. Staff again did not implement the facility's protocol to reposition Resident #2 every hour. On 8/14/12 at 10:04 a.m., Resident #2 was brought to the 500 Hall by the Director of Nursing (DON) to lay down. CNA-B and CNA-S entered Resident #2's room and assisted her to the bed. After removing the slacks and incontinent brief, Surveyor # noted no [MEDICATION NAME] or dressing on Resident #2's buttocks' wounds. The resident's buttocks were red and wrinkled and there were areas in which a white substance was caked. There were four small areas, each less than .25 centimeters in diameter, located on the left inner buttock. On the right inner buttock, one area measured approximately .5 cm long by .25 cm wide. It was a dark red open area and dry in appearance. This area had been previously documented as healed on 8/8/12. On 8/14/12 at 9:35 a.m., Surveyor # spoke with the Director of Nurses (DON) who stated the expectation is that if a dressing is rolling and no longer covering the wound, a new one would have to be applied. The DON stated she would expect staff to let the nurses know and the nurse should address this. Surveyor # requested any evidence to show Resident #2 was repositioned. The DON stated the facility does not document when residents are repositioned. This does not follow the facility's policy and procedure. On 08/14/12 at 9:40 a.m., Surveyor # spoke with Anonymous-E. Anonymous-E said Resident #2 has a pressure ulcer. Anonymous-E said Resident #2 was not being toileted as necessary and changed as necessary, and felt this was a contributing factor to the development of the ulcers. On 8/13/12, Surveyor # spoke to an anonymous CNA who stated sometimes the residents who are 2 assist have to wait to be toileted because during meal times, there is only one CNA to pick up trays, answer call lights, and toilet people. Example #2: Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident was admitted with a stage III coccyx pressure ulcer. Surveyor # reviewed the Wound/Skin Record which indicated the following: ~7/30/12, Coccyx, Stage III measuring 1.0 x 1.0 x 0.2. [MEDICATION NAME] ordered. ~8/8/12, Coccyx, Stage III measuring 1.8 x 1.2 x 0.1. [MEDICATION NAME] change every 3 days for 2 weeks then reevaluate. On 8/14/12 at 10:35 a.m., Surveyor # observed Resident #8's dressing change. Resident #8 had no dressing on her Stage III coccyx pressure ulcer. LPN-H asked Resident #8 if she had any pain. Resident #8 stated, "Oh yes, when I sit on it." LPN-H was unaware the dressing was off and did not know how long it had been off. Resident #8 stated when the [MEDICATION NAME] is on, the area feels better.

Based on observations, interviews, and record reviews, the facility failed to provide care and treatment to promote healing and prevent pressure ulcers from recurring resulting in development of a Stage 4 pressure ulcer to 1 resident out of 7 sample and supplemental sample residents reviewed for pressure ulcer care. Resident #6 had a Stage 4 pressure ulcer that was surgically repaired in January 2012. This area reopened. The resident was observed continuously for 4 hours 32 minutes on 2/7/12, in which no position change attempts or offers to reposition were done by staff. Additionally, an ordered treatment to be done twice daily was not done on 2/7/12. The following day, the resident's pressure ulcer was significantly larger than it had been previously. Failure to provide the care needed to promote the healing of a stage 4 pressure ulcer created an immediate jeopardy situation for Resident #6. The immediate jeopardy began on 2/7/12 when the facility failed to ensure proper repositioning and did not provide the physician ordered treatment. The Nursing Home Administrator was notified of the immediate jeopardy at 11:20 a.m. on 2/8/12. The immediate jeopardy was removed 2/8/12, but noncompliance continues at the lower scope and severity level of G (actual harm/isolated). The facility failed to provide care and treatment to prevent the development of new pressure ulcers, and/or to promote the healing of existing pressure ulcers resulting in actual harm or potential for harm for an additional 3 sampled residents (#8, #12, and #3) out of the 7 sampled and supplemental sampled residents reviewed for pressure ulcers. Resident #8 had a reoccurring stage II pressure ulcer and the facility did not change the care plan or implement services to prevent the ulcer from reoccurring. In addition, improper wound care technique was observed during pressure ulcer care for Resident #8. Resident #8 developed excoriations on his buttocks on 11/17/11. There was documentation of the excoriated areas healed 01/09/12. Resident #8's excoriated buttock redeveloped on 01/10/12. Observations of the wounds after not having an appropriate dressing in place found Stage 3 and Stage 2 pressure ulcers. With the wound deterioration, the facility did not implement new pressure ulcer prevention interventions. Resident #12 was not repositioned in order to off-load pressure on her bottom for 3 hours and 30 minutes. Resident #12 was not given her prescribed skin barrier treatment to her buttocks after two incontinence episodes. Resident #12 has a history of pressure ulcers on her buttocks as recent as 1/19/12. Surveyor # observed 5 times during the survey that Resident #3's heels were not afloat nor were booties placed on the feet. This is evidenced by: The facility policy for Repositioning includes the following information: ~ Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief; ~ Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning; ~ Positioning the resident on an existing pressure ulcer should be avoided since it puts additional pressure on tissue that is already compromised and may impede healing; ~ Assess residents who sit or recline in a chair with the back of the chair (or the back of the bed) elevated to or above a 30 degree angle: Does the resident need hourly position changes? Does the resident need position changes more frequently than hourly? According to Wound Care Education Institute (WCEI) there are three levels to skin breakdown: 1. Hyperemia (redness) is the first phase and will occur within 30 minutes of sustained, or unrelieved pressure. 2. The second phase of skin breakdown is tissue ischemia, which begins within 2-6 hours of sustained pressure, depending on various factors (shearing, friction, moisture or incontinence, immobility, medical conditions, nutrition, mental status, etc.). and age. Tissue ischemia is marked by deep redness over the skin surface. It takes approximately 36 hours to dissipate once the pressure is removed. 3. The third level of skin breakdown is tissue necrosis, which begins after 6 hours of continuous pressure. The skin becomes gray or blue and may be indurated and recovery from this level of skin breakdown is highly variable depending on risk factors (see #2). WCEI also recommends under "Protocols for Risk Prevention, Seating Interventions," that weight shifts should be done every 15 minutes, if unable to weight shift, position changes should be done every hour. Example #1: Resident #6 has medical [DIAGNOSES REDACTED]. Resident #6 also has a history of Osteo[DIAGNOSES REDACTED] to the right ankle. Resident #6 was admitted to the facility 9/28/11 following hospitalization for a [DEVICE] placement (9/22/11) to heal a stage 4 pressure ulcer on her midline sacrum/coccyx and an indwelling Foley catheter. She also was admitted with a second wound, a stage 2 pressure ulcer to her right buttocks, which had [MEDICATION NAME] or closed on 10/10/11. The hospital surgical report dated 9/22/11 states, "...5 cm (centimeter) circular decubitus with some necrotic (dead) skin around the edges. Necrotic skin was excised to the patient's right. There was a large amount of undermining of necrotic tissue...The decubitus went down to the sacrum and there was exposed bone. The fascia (fibrous tissue that covers, supports, and separates muscles and also unites skin with underlying tissues) over some of this was necrotic and all the necrotic soft tissue was excised. This consisted of skin, subcutaneous tissue, muscle, and fascia. There was also bone debrided...A wound vac dressing was applied..." The degree of suctioning was 125 mmHg (millimeters of mercury). Note: A [DEVICE] is a negative pressure treatment which can be set to various levels of suction, to draw fluid out of the wound and increase blood flow to the wound. The hospital discharge report dated 9/28/11 states, "...The wound...is granulating and is clean but does not show tremendous healing..." Resident #6 was then admitted to the facility on [DATE]. Review of the wound clinic notes include the following: ~10/3/11- Coccyx wound measurement was 4.5 cm L (length) x 3.1 cm W (width) x 3 cm D (depth) with undermining (tissue destruction under intact skin along wound margins) present from 12 o'clock to 6 'clock, a large amount of exudate (drainage) and maceration (softening of tissue by soaking in fluids). Note: Length measurements are in the direction of head-to-toe and width measurements are from left side of the body to the right side of the body. Also, when a wound is described with a clock method, the measurement is in a clock-wise direction. The discharge instructions from the wound clinic to the facility included offloading, turn side-to-side every two hours, and may be up in the chair three times a day for 1 hour at a time. It was noted by Surveyor # that the facility wound measurements all state from this point through 11/30/11 that the measurements were copied from the wound clinic notes. There is no evidence the facility completed thorough assessments of the wound including measurements during treatments/dressing changes. Wound clinic notes continue: ~10/10/11- Coccyx wound measurement was 4.5 cm L x 2.5 cm W x 3 cm D. Undermining was apparent from 12 o'clock to 6 o'clock, with a large amount of serosanguineous (yellowish-pink) exudate. ~10/17/11- Coccyx wound measurement was 3.7cm L x 2.7cm W x 2.5 cm D with undermining from 8 o'clock to 3 o'clock with a measurement of 3 cm at its greatest depth. There was documentation of a large amount of serosanguineous exudate present and a medium amount of granulation present. Note: Granulation is the formation of healing tissue composed of newly formed small blood vessels. It is generally beefy-red in appearance. Discharge instructions following this appointment were the same as with the 10/3/11 appointment, except to also place foam into the undermining tissue. ~10/24/11- Coccyx wound measurement was 3.9 cm L x 2.2 cm W x 2 cm D. The documented assessment on this date indicated undermining present from 11 o'clock to 3 o'clock, with the greatest depth of 3 cm. This indicates there is healing present as the measurement from 8-10 o'clock is now closed in. There continues to be moderate amount of serosanguineous exudate and a small amount of red granulation tissue present. However, also documented was a small amount of yellow necrotic [MEDICATION NAME] and slough present. When slough is present, a wound cannot heal, as slough represents a yellowish stringy dead tissue. The documentation does not indicate the location of the slough as represented by the clock method of description. The discharge instructions to the facility was documented as, "May increase activity level by being up in chair for 1 hour for craft activities daily..." ~10/31/11- Coccyx wound measurement was 3.8 cm L x 2.5 cm W x 2 cm D with undermining present from 11 o'clock to 1 o'clock with the greatest depth of undermining measured at 2.5 cm. There was a medium amount of granulation tissue present that was documented as being pink in color. There was also a small amount of tissue necrosis present but the documentation, again, does not indicate the location. The discharge instructions included turn side-to-side every 2 hours, may be in chair three times daily for 1 hour at a time, may be up in wheelchair for 1 hour daily for activity. ~11/07/11 - Coccyx wound measurement was 3.5 cm L x 2 cm W x 1.5 cm D from 1 o'clock to 3 o'clock, with the deepest area of the wound measured as being 2.5 cm. Again, this documentation indicates the wound is filling in and healing. Documentation indicated a large amount of pink granulation present and no necrotic tissue apparent. Documentation indicated a small amount of serous exudate present. This documentation also indicates there is no longer any undermining. Note: Serous drainage resembles a thin, watery, and clear to light yellow substance. Discharge instructions remain as previously noted. ~11/14/11- 3 cm L x 2 cm W x 1.2 cm D with undermining present at 11 o'clock. The wound was described as having a small amount of serosanguineous exudate present, as well as a medium amount of pink granulation tissue. There was no necrotic tissue visible. This documentation indicates the size of the wound is decreasing but the undermining has changed. Discharge instructions remain as previously noted. On 11/21/11, Physician notes state, "...female with debilitating neurological disease...had a sacral wound which has been present since at least July. She currently has a wound vac in place...On examination today, her wound vac dressing was not under suction and completely filled with stool...recommendations would be...fecal diversion with probably a permanent [MEDICAL CONDITION] access with a PEG tube...probably a rotational flap or advancement flap using the gluteal muscle..." Note: The [DEVICE] was not attached to suction and as a result, the vacuum could not perform as expected. The doctor cleaned and redressed the wound, but there was no indication in the documentation that any debridement was conducted. Wound clinic documentation continues: ~11/22/11- Coccyx wound measurement was 3 cm L x 2.8 cm W x 2 cm D with an undermining from 9 o'clock to 1 o'clock and a depth of 3 cm at 12 o'clock. The wound description was documented as having a moderate amount of serosanguineous exudate and a large amount of red granulation present with no necrosis. Note: This indicates an increase in size from the previous assessment. Discharge instructions were to place white foam to the undermining and to increase the wound vac suction to 150 mmHg (was previously at 125 mmHg). ~11/29/11- Coccyx wound measurement was 3.4 cm L x 2 cm W x 2.5 cm D with undermining present from 12 o'clock to 6 o'clock with the deepest area being 2.5 cm. According to the documentation, the wound presented with a moderate amount of serous exudate and a large amount of necrotic tissue. The description does not indicate the location of the necrotic tissue. The periwound was also described as being macerated. No changes were made to the discharge instructions. On 12/07/11, Resident #6 was admitted to the hospital and had a PEG (Percutaneous Endoscopic Gastrostomy) tube for nutritional support and a [MEDICAL CONDITION] placed, as well as the surgical procedure of removing a portion of the resident's gluteal muscle and tissue and placing this over the wound to create wound closure. The resident was hospitalized until 1/3/12. The discharge summary dated 1/3/12 states, "...At discharge the wound was healing nicely..." Resident #6 was then readmitted to the facility on [DATE] with orders for extreme decubitus precautions with offloading and turning. The facility nurse's note documentation for Resident #6's readmission on 1/3/12, states the wound is "... now healed per staff at hospital..." Physician follow-up notes dated 1/09/12 states, "...status [REDACTED]. The facility nurse's notes for this date state, "...Area (wound) is closed and stable..." Facility documentation of the wound includes the following: ~1/28/12 - The wound measurements were documented as being 0.8 cm L x 2 cm W x 2.1 cm tunneling, with scant serous/purulent drainage. RN-F (Registered Nurse) documented the wound separated on the left buttocks. She then notified the Physician Assistant who in turn, directed her to notify the surgeon. According to documentation by the DON (Director of Nursing), the original surgeon was not available and the on-call physician was contacted. The order was received to wash the wound with soap and water, pat dry, and apply a dry dressing everyday. ~1/31/12 - The wound measurements were documented as being 0.9 cm L x 1.5 cm W x no depth with small purulent and serosanguineous drainage. The above two documented entries are the only two wound assessments found in the residents medical record by the facility themselves. On 2/1/12 a hospital note stated, "...they (facility) noted a slight change in her wound. She was brought back in...On the upper medial aspect of the rotational flap there is approximately a 3 cm area which is slightly separated and undermined by about 2 cm with no purulent (pus) material and no evidence of surrounding infection..." Impression: Wound dehiscence with tunneling. Note: Wound dehiscence is the separation of the outer layers of the joined incision and may be caused by pressure, shear, improper lifting, vascular compromise, infection, or skin weakness caused by certain medications. Tunneling is a channel or pathway that extends in any direction from the wound through the subcutaneous tissue or bone, resulting in dead space with a potential for the development of an abscess. The doctor then ordered packing twice daily to the wound and stated, "...I think that as long as she keeps up her nutrition and keeping off of this as long as this does not get larger, this could hopefully be healed in by a secondary intention." Note: Secondary intention healing is allowing the body's normal process to heal the wound through the granulation process. Because the wound is left open to heal by granulation, the time taken can be much longer than for primary healing. Primary healing of a wound is through stitches, staples, steri-strips, etc. There is no evidence in the documentation that debridement was conducted. The facility initiated discharge planning for Resident #6 to be discharged back to the group home where she originally resided prior to the hospitalization in September. The plans were for discharge on 2/2/12. However, this was deferred related to the wound decline. A note on 2/6/12 from the wound clinic indicates the wound characteristics were measurements and description were documented as being 0.5 cm L x 1 cm W x 0.2 cm D with tunneling present from 1 o'clock to 5 o'clock and 12 cm at its greatest depth. Also documented was a moderate amount of serosanguineous exudate and a small amount of necrosis. Note: There is confusion here regarding the size of the wound, as in the above consultation report from the physician on 2/1/12, the wound was sizably larger than what is documented by the wound clinic. The discharge instructions were offloading and turn side-to-side every two hours. According to the admission Minimum Data Set (MDS) assessment completed by the facility for Resident #6, with an assessment reference date of 1/10/12, Resident #6 is totally dependent on staff to meet all her basic daily tasks of bathing, dressing, eating, transfers, mobility, and personal/oral hygiene. She is transferred with the use of a mechanical, full-body lift and two staff. Resident #6 is unable to assist with many of her cares related to muscular deformities and contractures, and is very soft spoken and oftentimes difficult to hear. She is 63 inches tall and on 1/12/12 weighed 100 pounds. Resident #6's Care Plan, dated 1/3/12 directs staff to reposition her "...every 2 hours as indicated..." The most recent Braeden Pressure Ulcer Risk Assessment was completed on 1/17/12 in which the facility scored Resident #6 an 11 (12 or less indicates a high risk for the development of pressure ulcers). The following scores were noted on the Braeden Assessment: 1. Sensory Perception- 2 (Very Limited, responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness, or has a sensory impairment which limits the ability to feel pain or discomfort over 1/2 of body.) 2. Moisture- 2 (Often moist- Skin is often but not always moist. Linen must be changed at least once a shift.) 3. Activity- 2 (Chairfast- Ability to walk severely limited or nonexistent. Cannot bear own weight and/or must be assisted into chair or wheelchair.) 4. Mobility- 2 (Very Limited- Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.) 5. Nutrition- 2 ( Probably Inadequate- Rarely eats or completes a meal and generally eats only about 1/2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement, or receives less than optimum amount of liquid diet or tube feeding.) 6. Friction and Shear- 1 ( Problem- Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. [DIAGNOSES REDACTED], contractures, or agitation leads to almost constant friction.) Resident #6 sits on a Roho cushion in her Broda chair and sleeps on an Air-Pro overlay mattress in bed. On 2/7/12 at 7:40 a.m., Surveyor # approached RN-F (Registered Nurse) regarding the need to observe the treatment to Resident #6's pressure ulcer. RN-F stated she was awaiting clarification from the wound clinic as the resident was seen at the clinic on 2/6/12 and the treatment was changed. On 2/7/12 from 8:10 a.m. through 8:55 a.m., Surveyor # observed CNA-A (Certified Nursing Assistant) providing Resident #6 with cares. A continuous observation was then conducted by Surveyor # , with the assistance of Surveyor # , beginning at 8:45 a.m.: ~ 8:45 a.m., Resident #6 was placed into her Broda chair with the use of a mechanical lift by CNA-A and CNA-B. ~ 8:58 a.m.- Resident #6 was taken to the assisted dining area for the morning meal service. Here the resident remained until 9:45 a.m., at which time she was taken to the 500/600 Unit television area/nursing desk. ~ 9:50 a.m.- Resident #6 was taken back to the assisted dining area in preparation for a church service. ~11:10 a.m., Resident #6 was taken back to her room. Surveyor # followed. Staff did not offer or attempt to reposition Resident #6 off her buttocks at this time. ~ 11:13 a.m., RN-F approached Resident #6's room with the medication cart. Surveyor # observed the administration of medications through the resident's PEG tube. The medication administration process took RN-F 20 minutes to complete. RN-F stated she was still waiting for the Wound Clinic to call her back for treatment clarification. Staff did not offer or assist Resident #6 with repositioning. ~ At 11:35 a.m., RN-F left the room and Surveyor # asked Resident #6 about her care, including how her buttocks was feeling at the time. Resident #6 stated, "It hurts," and cringed. ~ 11:50 a.m., The meal cart arrived on the 500 Unit. ~ 12:20 p.m., The Activity Director brought Resident #6 to the assisted dining area. Surveyor # followed. Staff did not offer or attempt repositioning. ~ 12:23 p.m., Surveyor # resumed the observation of Resident #6. ~ 12:45 p.m., Resident #6 received her meal and CNA-G assisted her to eat. ~ 12:55 p.m., Surveyor # observed Resident #6 during the dining service. No staff offered or attempted to provide Resident #6 with repositioning. ~ 1:00 p.m., Surveyor # resumed the observation. ~ 1:18 p.m., CNA-G and CNA-B took Resident #6 back to her room. ~ 1:22 p.m., Resident #6 was placed in her bed and offloaded from the Stage 4 pressure ulcer on her coccyx. The resident's buttocks was dark pink to light red with numerous wrinkled areas from her clothing. Surveyor # then asked Resident #6 if her sore was hurting her at this time. The resident responded "yes" with a nod of her head and a painful look on her face with the crinkling of her eyebrows and slowly closing her eyes. She also stated she was very tired. Resident #6 was then positioned onto her right side by the two staff. Note: The treatment ordered twice daily was not conducted on this day, as the nurse was still waiting for clarification orders. On 2/8/12 at 7:42 a.m., Surveyor # observed RN-I conduct the treatment to Resident #6's coccyx. RN-I measured the wound as being 1.4 cm L x 3.5 cm W x 2.7 cm D with undermining apparent from 3 o'clock to 9 o'clock. During the treatment RN-I stated she had noticed a decline in the wound. She stated last week when she did the treatment there was slight tunneling in one spot and now there was undermining. She was unsure if any debridement was done at Resident #6's appointment on 2/6/12. She also stated the treatment was not done the previous day (2/7/12) as the nurse could not get in contact with the wound clinic for clarification of orders. On 2/8/12 at 11:15 a.m., Surveyor # met with the facility DON regarding resident position changes. Surveyor asked the DON how any resident's repositioning schedule is determined. The DON stated everyone is a two-hour change regardless of what the risk for development of pressure ulcers is. The DON stated it was the responsibility of the CNAs to ensure positioning is being done, then the staff nurse, then the Unit Managers, and finally the DON. She stated the facility utilizes various methods to determine risk, but that all residents are on a minimum two hour reposition change schedule, if needed. If a greater risk is determined, the resident should be repositioned more often. On 2/8/12 at 12:43 p.m., Surveyor # again approached the DON regarding the repositioning of Resident #6 and the apparent size in the wound from what it was at the wound clinic on 2/6/12. The DON stated the resident had excision of tissue done from the doctor in between this time and is the cause of the increase in the wound size. Surveyor # requested documentation from the doctor regarding the treatment she stated he conducted. The DON and Surveyor # then placed a telephone call to the wound clinic and spoke with Resident #6's Case Manager, who sees the resident on a weekly basis at the wound clinic. The facility's Regional Clinical Coordinator was also in the room. Resident #6's Case Manager stated they had measured the wound on 2/6/12 as being 0.5 L (length) x 1.0 w (width) x 0.2 d (depth) and that there was a huge pocket of undermining visible. The Case Manager stated the resident should be positioned side-to-side in bed and when up in the Broda chair, was to be on an alternating pressure pad, with limited amount of time. She stated she thought the repositioning schedule for Resident #6 was every two hours. Surveyor # explained the extended observation made of Resident #6 not being offloaded for 4.42 hours the previous day and asked what Resident #6's potential for harm was regarding this. The Case Manager stated, "She's going to break down more and fast. She doesn't have much there but bone." On 2/8/12 at 2:10 p.m., the facility received orders for antibiotic therapy for Resident #6, [MEDICATION NAME] 500 milligrams daily for 10 days for wound infection. The immediate jeopardy that began on 2/7/12 was removed on 2/8/12 when the facility: 1. Completed a total house skin sweep to ensure there are no unidentified pressure ulcers. This was conducted by 4 nurses. 2. Unit Managers were re-educated by the DON on walking rounds and re-instituted walking rounds with a care sheet to ensure residents with pressure ulcers are appropriately repositioned and to monitor for pressure relieving devices, to include cushions. 3. Re-education was conducted by 3 nurses to all nursing staff on pressure ulcer prevention. All nursing staff will be re-educated prior to their working shifts. Nursing staff that are not currently in the facility were contacted and informed that this is a required training prior to them working their next shift. 4. Two nurses conducted training to all nursing staff on the turning and repositioning policy. All nursing staff will be re-educated prior to their working shift. Nursing staff that are not currently in the facility were contacted and informed that this is a required training prior to them working their next shift. 5. All residents on admission (weekly x 4), quarterly, and with a change in condition will receive a Braeden Scale. Anyone who triggers at risk will be reassessed to ensure that they have appropriate doctor orders and treatment plans. 6. Assessing at risk residents include sensory perception/ cognition, moisture, activity, mobility, nutrition/hydration, and friction/shearing. The assessment will also take into consideration comorbidities, medications, and [MEDICATION NAME] risks due to aging. Resident refusals would also be taken into consideration. 7. Based on the risk factors of the individual resident a turning and repositioning program will be developed. At risk residents will be turned and repositioned minimally every two hours or as needed depending on the resident's needs. All residents at risk will have an individualized and appropriate offloading care plan in place. A teachable resident will be taught to lift his/her weight approximately every 15 minutes while sitting in a chair as much as the resident will allow. 8. Weekly pressure ulcer report will continue to be reviewed at the weekly standards of care meeting. Recommendations by the IDT (Interdisciplinary Team) will continue to be shared and initiated as appropriate. 9. Consultations will continue by the AMT (American Medical Technologies) consultant as needed. 10. This information will be brought to the QA (Quality Assurance) committee for the purpose of tracking and trending and soliciting any necessary updates. Example #2: Resident #8 was admitted to the facility on [DATE] and readmitted multiple times with the most recent being on 12/29/11. Resident #8 had the following, but not all inclusive, Diagnoses: [REDACTED]. The facility completed an annual MDS (Minimum Data Set) assessment for Resident #8 on 03/09/11, with the following data noted: ~Able to understand and make self understood; ~Required extensive assist of staff for bed mobility, transfers, walk in room, dressing, hygiene, toilet use, bathing, and locomotion on and off unit; ~Had a catheter; ~Was at risk for pressure ulcers; however had no pressure ulcers; ~Was provided with a pressure reducing device in bed and chair; and, ~Required application of dressings to feet and ulcer care. The facility completed a quarterly MDS assessment for Resident #8 on 11/09/11, with the following data noted: ~Able to understand and make self understood; ~Had short and long term memory deficits; ~Was moderately impaired with daily decision making; ~Required total assist of 2 or more staff for bed mobility, walk in room, and toilet use; ~Required total assist of staff for locomotion on and off unit, dressing and hygiene; ~Required extensive assist of 2 or more staff for transfers; ~Had a catheter; ~Was at risk for pressure ulcers however had no pressure ulcers; and, ~Was provided with a pressure reducing device in bed and chair. The facility completed another admission MDS assessment for Resident #8 following a hospital stay of 4 days with return anticipated. The MDS was completed on 01/09/12 with the following data: ~Able to understand and make self understood; ~Had short and long term memory deficits; ~Was moderately impaired with daily decision making; ~Required total assist of 2 or more staff for bed mobility, transfers, dressing, and toilet use; ~Required total assist of staff for locomotion on unit, hygiene, and bathing; ~Was always incontinent of bladder and on no toilet program; ~Had a UTI in the last 30 days; ~Was at risk for pressure ulcers; however the presence of pressure ulcers was not assessed; ~Was provided with a pressure reducing device in bed and chair; and, ~Required application of nonsurgical dressing, ointments, and application of dressings to feet. Review of the care plan titled "Alteration in Skin Integrity..." was developed 03/10/10 and was last updated 2/2012. The goal was for the skin problems to heal without complications. The approaches were to respect resident's right to be noncompliant with education on possible consequences; air overlay pressure-reducing bed mattress added on 3/23/11, and Roho cushion added on 6/20/11. During the initial tour conducted on 02/06/12 by Surveyor # with CNA-U, Resident #8 was reported to have a "sore butt that was real bad." Review of Resident #8's medical record included documented skin problems as follows: ~11/17/11 physician progress notes [REDACTED]. ~11/28/11 physician assistant progress note read no improvement to the moisture [MEDICAL CONDITION] on buttock, change treatment to [MEDICATION NAME]; ~12/01/11 nurse's notes read open area to right buttock treated with barrier cream; ~12/04/11 physician order [REDACTED]. ~12/29/11 readmission nursing assessment noted no open areas on right buttock; ~12/29/11 nurse's notes read [MEDICATION NAME] to left buttock; ~01/07/12 nurse's notes read order to discontinue [MEDICATION NAME] and start barrier cream; ~01/09/12 nurse's notes indicated buttock area was intact; ~01/10/12 physician orders [REDACTED]. ~01/12/12 nurse's notes read to continue to treat excoriated buttock with [MEDICATION NAME]; ~01/26/12 weekly wound rounds noted 2 excoriated buttock areas that measured 3.5 cm by 1cm and 1.5 cm by 0.5 cm, continue with [MEDICATION NAME]; ~01/31/12 weekly wound rounds noted 1 excoriated buttock area that measured 1cm by 0.8 cm by 0.2 cm and to continue with [MEDICATION NAME]; and, ~02/01/12 physician assistant progress note read buttock lesion with no improvement, will change treatment to calcium alginate dressing and cover with [MEDICATION NAME]. On 02/08/12 at 7:40 a.m., Surveyor # observed CNA-P and CNA-V assist Resident #8 with morning hygiene and dressing. CNA-P stated at approximately 6:30 a.m. a

Based on observations, policy review, record reviews and interviews, the facility did not ensure that 2 out of 8 sampled residents reviewed for incontinence received care and services designed to restore as much bladder function as possible. Resident #8 returned from a hospital stay without his indwelling Foley catheter and was totally incontinent of urine. Resident #14 had a decline in bladder function. The facility did not assess the causes of the decline in bladder function, did not comprehensively assess the resident's usual voiding patterns, did not identify the types of incontinence, and did not explore reversible causes of incontinence in order to assist the resident with restoring or maintaining as much bladder function as possible for both Resident #8 and #14. This is evidenced by: According to WOCN (Wound Ostomy and Continence Nurses Society), reversible causes of incontinence include: [MEDICAL CONDITION], infection, medications, bladder irritants, vaginitis, pharmaceuticals, polyuria, retention, constipation, environmental barriers, and physical limitations. Assessment of these factors is needed to determine a plan of care that could include bladder retraining, prompted voiding, and individualized scheduled toileting. This individualized schedule should be used rather than the facility's incontinence management toileting schedule currently being used for all cognitively impaired and incontinent residents who are unable to communicate with staff that they have to go to the bathroom. The outcome of incontinence services can be determined by recognition of the problem, nursing assessment, and referral for diagnostic evaluation and treatment. All residents with incontinence should be evaluated for causative factors, as treatment is dependent on these factors. However, before successful treatments can be initiated, the problem needs to be identified. The identifying of the type of incontinence is essential in a multidisciplinary collaboration for both the assessment of the individual and the treatment of [REDACTED]. The goal should be to restore as much normal bladder function as possible for each resident by decreasing or eliminating the incontinent episodes. This promotes dignity, reduces risk factors for skin breakdown, and reduces the incidents of urinary tract infections. This is evidenced by: On 02/09/12 Surveyor # requested and reviewed the facility policy titled "Urinary Continence and Incontinence - Assessment & Management." Noted in the policy under the policy statement was: ~Item #1. "The staff and practitioner will appropriately screen for, and manage, individuals with urinary incontinence." ~Item #3. "The physician and staff will provide appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible." In addition, the policy under policy interpretation and implementation was: ~Item #3. "Periodically, ...staff will define each individual's level of continence, referring to the criteria in the MDS..." ~Item #4. "As part of its assessment, nursing staff will seek and document details related to continence. Relevant details include: a. Voiding patterns (frequency, volume, nighttime or daytime, quality of stream, etc); b. Associated pain or discomfort; and c. Whether incontinence occurs in relation to coughing or sneezing..." ~Item #7. "The staff and physician will summarize an individual's continence status. For residents deemed incontinent, this includes categorizing incontinence as urge, stress, overflow, mixed, or functional; and relevant causes, risk factors, and complications." ~Item #8. "The staff and physician will identify individuals with complications of existing incontinence, or who are at risk for such complications..." ~Item #9. "The physician will consider a more detailed assessment if new incontinence is identified or risk factors and reversible causes have not yet been sought or identified. The review should focus especially on possibly treatable causes such as medication side effects, severe constipation, or urinary tract infections..." ~Item #15. "The physician and staff will address treatable causes or contributing factors related to urinary incontinence..." ~Item #17. "As indicated, and if the individual remains incontinent despite treating transient causes of incontinence, the staff will initiate a toileting plan...Toileting programs will start with a 3 to 5 day toileting assistance trial..." ~Item #21. "The staff and physician will evaluate the effectiveness of interventions and implement additional pertinent interventions as indicated." Example #1: Resident #8 was admitted to the facility on [DATE] and readmitted multiple times with the most recent being on 12/29/11. Resident #8 had the following, but not all inclusive, Diagnoses: [REDACTED]. The MDS assessment dated [DATE], indicated Resident #8: ~Was able to understand and make self understood; ~Had short and long term memory deficits; ~Was moderately impaired with daily decision making; ~Required total assist of 2 or more staff for bed mobility, walk in room, and toilet use; and, ~Had a catheter. The MDS assessment dated [DATE], following a hospital stay indicated Resident #8: ~Was able to understand and make self understood; ~Had short and long term memory deficits; ~Was moderately impaired with daily decision making; ~Required total assist of 2 or more staff for bed mobility, transfers, dressing, and toilet use; ~Was always incontinent of bladder and on no toilet program; and, ~Had a UTI in the last 30 days. The facility completed the CAA for urinary incontinence for Resident #8 on 01/09/12 and noted bladder incontinence and lacks the perception to urinate. There is no toilet program identified. Upon Resident #8's return from the hospital on [DATE], the facility completed a bladder incontinence evaluation which noted Resident #8 had multiple daily episodes of incontinence and to be without a Foley catheter. The evaluation did not identify the type of incontinence or any voiding patterns noted for Resident #8. The evaluation had an entry dated 01/12/12 by RN-E (Registered Nurse) that read, "Resident currently has a Foley catheter." Resident #8 did not have a Foley catheter and the assessment was not accurate, comprehensive, or identified a program to restore bladder function for Resident #8. Review of the CNA (Certified Nursing Assistant) Care Guide noted Resident #8 had an indwelling catheter. This information was not accurate. Review of the care plan titled "Altered Urinary Elimination R/T (related to) [MEDICAL CONDITION] and History of UTIs (Urinary Tract Infections)," dated 3/10/10 and last updated 2/2012, noted a Foley catheter was placed 12/2011 and discontinued with no date identified. During the initial tour conducted on 02/06/12 by Surveyor # with CNA-U, it was reported that Resident #8 was totally incontinent of urine. On 02/08/12 at 7:40 a.m., Surveyor # observed CNA-P and CNA-V assist Resident #8 with morning hygiene and dressing. Resident #8 had been incontinent of urine and was wearing a brief. CNA-P provided perineal hygiene for Resident #8. CNA-V stated Resident #8 was always incontinent of bladder and bowel and no longer used the urinal or bed pan. CNA-V stated Resident #8 had a Foley catheter but it was recently discontinued because of frequent infections. On 02/09/12 at 11:00 a.m., Surveyor # met with RN-BB (Registered Nurse), RN-E, and the SDC (Staff Development Coordinator) to discuss Resident #8's bladder control. RN-E stated Resident #8 had a Foley catheter reinserted on 12/04/11 as an intervention to heal a pressure ulcer on the coccyx. RN-E stated the Foley catheter was removed during a hospital stay that occurred 12/25/11 through 12/29/11 due to reoccurring infections. RN-E stated upon Resident #8's return, a 3-day bladder diary was completed followed by a bladder incontinence evaluation. RN-E stated the bladder evaluation was completed by herself and was inaccurate as it reflected a Foley catheter. The SDC stated the facility's process for bladder assessment was to have the front page of the evaluation completed on the day of admission and to start a 3-day bladder diary at midnight. The SDC stated that following the completion of the 3-day diary, the UM (Unit Manager) was responsible for completing the second page of the evaluation, reviewing the data collected, and to determine what type of bladder program would serve the resident. The SDC further stated the UM was responsible to update the care plan and the CNA Care Guide. Example #2: Resident #14 was admitted to the facility on [DATE] and readmitted on [DATE] with the following, but not all inclusive, Diagnoses: [REDACTED]. The MDS assessment dated [DATE], indicated Resident #14: ~Required extensive assist of 2 or more staff for toilet use; ~Was occasionally (less than 7 episodes of incontinence) incontinent of bladder; and, ~Was not on a toileting plan. The MDS assessments dated 08/29/11 and 11/25/11, indicated Resident #14: ~Required extensive assist of 2 or more staff for toilet use; ~Was frequently (7 or more episodes of urinary incontinence, but at least one episode of continent voiding) incontinent of urine; and, ~Was not on a toileting plan. During the initial tour conducted on 02/06/12 by Surveyor # with CNA-U, Resident #14 was reported to be incontinent of bladder and needing the EZ stand mechanical lift for transfers and toilet use. On 02/07/12 at 8:07 a.m., Surveyor # observed CNA-D provide morning hygiene and dressing for Resident #14. Resident #14 was incontinent of urine and required extensive assistance for perineal hygiene. Resident #14 was not offered or assisted to the toilet/commode. On 02/09/12 at 8:25 a.m., Surveyor # interviewed CNA-V regarding Resident #14's care needs. CNA-V stated she has cared for Resident #14 since her admission and was familiar with her needs. CNA-V stated Resident #14 needed extensive staff assistance with toilet use and would sometimes request to be placed on the commode. CNA-V stated Resident #14 was often incontinent in the early morning hours, but usually continent during the day so long as she was toileted regularly. On 02/09/12 at 8:28 a.m., Surveyor # interviewed CNA-W regarding care needs for Resident #14. CNA-W stated she usually worked the night shift and stated she had cared for Resident #14 recently. CNA-W stated Resident #14 was both continent and incontinent of urine. Review of the care plan titled "Functional incontinence related to alzheimer/dementia, need for assistance with all toileting..." that was developed 06/06/11, noted Resident #14 should be toileted 2-3 times per shift and as needed. This intervention was dated 9/16/11. Review of the CNA Care Guide noted Resident #14 was incontinent of bladder and wore briefs and Resident #14 should be toileted 2-3 times per shift and as needed. Surveyor # requested from RN-E all bladder assessments completed for Resident #14. The facility completed an admission bladder incontinence evaluation for Resident #14. The assessment was dated for 5/27/11 and was incomplete. The assessment did not identify the type of incontinence for Resident #14. The facility documented that no voiding patterns were identified for Resident #14; however the assessment was completed on the day of admission, prior to the 3-day bladder diary that was required according to the facility policy. The facility did not evaluate Resident #14 for bladder programing potential or identify any bladder program that would assist Resident #14 to maintain or improve her bladder function. The facility provided Surveyor # with another bladder incontinence evaluation that was again not dated and not complete. Again, the facility did not identify the type of bladder incontinence for Resident #14 and there was no second page of the evaluation provided.

Based on observations, staff interviews and record reviews, the facility did not consistently implement restorative maintenance programs, range of motion programs and adaptive devices to prevent contractures for 10 of 15 sampled and supplemental sampled residents. Resident #14 had a decline in upper extremity range of motion and function that was noted on 2 quarterly MDS (Minimum Data Set) assessments completed on 08/29/11 and 11/25/11. An upper body exercise program was developed, however no frequency of partipation was developed. Resident #14's participation in the upper body program declined and resulted in a referral back to Physical Therapy. Resident #12 was not given a hand splint or washcloth for her right hand. The device is being used to prevent further contraction and prevent fungal infections in her severely contracted hand. Residents #22, #32, #33, #35, #37, #38, #39, and #40 did not have their restorative maintenance programs for upper and lower extremity exercises and range of motion consistently implemented as specified in their restorative programs. This is evidenced by: Example #1: Resident #14 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set) assessment dated [DATE], indicated Resident #14: ~Was sometimes able to make self understood and understand others; ~Required extensive assist of 1 staff for bed mobility, locomotion on and off unit, dressing, hygiene, and bathing; ~Required extensive assist of 2 or more staff for transfers and toilet use; ~Had no upper extremity impairments; ~Had lower extremity impairments on both sides that limited daily function or placed at risk for injury; and, ~Did not participate in any range of motion programs. The quarterly MDS assessment dated [DATE], indicated Resident #14: ~Was sometimes able to make self understood and understand others; ~Required extensive assist of 1 staff for bed mobility; ~Required extensive assist of 2 or more staff for transfers, dressing, and toilet use (decline from 06/07/11 assessment); ~Required total assist for hygiene, walk in corridor, and locomotion on and off unit (decline from 06/07/11 assessment); ~Had upper extremity impairment on one side that limited daily function or placed at risk for injury (decline from 06/07/11 assessment); ~Had lower extremity impairment on both sides that limited daily function or placed at risk for injury; and, ~Did not participate in any range of motion programs. On 02/07/12, Surveyor # requested and reviewed Resident #14's comprehensive care plan. There was no restorative care plan provided and there was no intervention related to restorative programs on the comprehensive care plan. Review of the CNA (Certified Nursing Assistant) care guide for Resident #14 did not indicate any restorative nursing programs or any reference to range of motion programs. On 02/07/12 at 8:07 a.m., Surveyor # observed CNA-D provide morning hygiene and dressing for Resident #14. CNA-D did not complete any range of motion exercises while assisting Resident #14 with morning cares. On 02/09/12 at 8:25 a.m., Surveyor # interviewed CNA-V regarding care needs of Resident #14. CNA-V stated she has cared for Resident #14 since her admission and was familiar with her needs. CNA-V stated Resident #14 needed an EZ stand mechanical lift for all transfers. On 02/09/12 at 11:00 a.m., Surveyor # interviewed the SDC (Staff Development Coordinator) who identified herself as the licensed nurse who oversees the restorative nursing program. The SDC stated restorative nursing hours were recently reduced. The SDC stated she attempts to write a monthly progress note on all residents under a restorative program and the progress note was located on the back of the monthly flowsheets. The SDC also stated the restorative programs will indicate the frequency for each program. Review of Resident #14's monthly restorative flowsheets was completed with the following information noted: ~July 2011- a Saturday and Sunday standing program was started on 7/23/11. Resident #14 participated on 7/27/11 (Wednesday). There was no documentation for 7/23/11, 7/24/11, 7/30/11, and 7/31/11. ~August 2011 - the same standing program was noted but no frequency identified and no reference to Saturdays and Sundays. Resident #14 participated in the program on 08/08/11, 08/14/11, 08/15/11, 08/19/11, 08/20/11, 08/21/11, 08/26/11, and 08/29/11. The monthly progress note was not dated and referrals were made to therapy relating to standing status. ~September 2011 - Resident #14 continued with the standing program as in August without any frequency indicated and no reference to Saturdays or Sundays. Resident #14 participated in this program on 09/03/11, 09/05/11, 09/07/11, 09/09/11, 09/19/11, 09/21/11, 09/23/11, 09/26/11, 09/28/11, and 09/30/11. The monthly progress note that was not dated read to discontinue the standing program as staff were using the EZ stand mechanical lift and referred back to therapy. Resident #14 continued to participate in the program for 6 more days after it was discontinued. Also on 09/05/11, Resident #14 was started on an upper body exercise program that did not list the frequency of the program. Resident #14 participated in this program on 09/03/11 (2 days before it was started) as well as on 09/05/11, 09/07/11, 09/09/11, 09/12/11, 09/14/11, 09/16/11, 09/19/11, 09/21/11, 09/23/11, 09/26/11, 09/28/11, and 09/30/11. ~October 2011 - Resident #14 continued on the standing program that had been discontinued on 09/12/11. Participation dates were 10/03/11, 10/05/11, 10/07/11, 10/09/11, 10/10/11, 10/12/11, 10/14/11, 10/17/11, 10/19/11, 10/21/11, 10/26/11, 10/28/11, and 10/31/11. Resident #14 also continued with the upper body exercise program that did not include frequency on 10/03/11, 10/05/11, 10/07/11, 10/09/11, 10/10/11, 10/12/11, 10/14/11, 10/19/11, 10/21/11, 10/26/11, 10/28/11, and 10/31/11. The monthly progress note was again not dated and read continue use of the EZ stand mechanical lift...will educate staff on how to complete. ~November 2011 - Resident #14 continued on the standing program until 11/23/11 when it was discontinued for the second time. Participation dates were 11/04/11, 11/09/11, 11/11/11, 11/16/11, 11/18/11, and 11/21/11. Resident #14 participated in the upper body exercise program that did not include frequency on 11/04/11, 11/09/11, 11/11/11, 11/16/11, 11/18/11, 11/21/11, and 11/25/11. The monthly progress note was not dated and read to discontinue standing program due to use of EZ stand mechanical lift. The facility completed a quarterly MDS assessment for Resident #14 on 11/25/11 and noted the following: ~Sometimes able to make self understood and understand others; ~Required extensive assist of 1 for bed mobility; ~Required total assist of 2 or more staff for transfers, dressing, and toilet use (decline from 8/29/11 assessment); ~Required total assist of 1 staff for hygiene; ~Had upper extremity impairment on one side that limited daily function or placed at risk for injury; ~Had lower extremity impairment on both sides that limited daily function or placed at risk for injury; and, ~Did not participate in any range of motion programs. Restorative flow sheets continued: ~December 2011 - Resident #14 continued with the upper body exercise program that did not include frequency on 12/05/11, 12/07/11, 12/09/11, and 12/12/11. The monthly progress note dated 12/14/11 read the program was discontinued as resident was referred back to therapy. Another upper body exercise program was started on 12/26/11, and again no frequency was noted; however Resident #14 did not participate in this program until January 2012. ~January 2012 - Resident #14 participated in the upper body exercise program that did not include frequency on 01/02/12, 01/03/12, 01/04/12, 01/05/12, 01/09/12, 01/10/12, 01/11/12, 01/13/12, 01/14/12, 01/16/12, 01/17/12, 01/18/12, 01/19/12, 01/20/12, 01/23/12, 01/24/12, 01/25/12, 01/26/12, 01/28/12, 01/30/12, and 01/31/12. The back page of the monthly flowsheet was not provided, thus there was no review of the monthly progress note. ~February 2012 - Resident #14 participated in the upper body exercise program that did not include frequency on 02/01/12, 02/02/12,02/03/12, 02/06/12, 02/07/12, and 02/08/12. The back page of the monthly flowsheet was not provided, thus there was no review of the monthly progress note. Surveyor # was provided with 2 therapy program referrals. The first one was from physical therapy, dated 07/22/11, regarding the standing program Resident #14 participated in. The second was a photocopy of theraband exercises that was dated 12/23/11 from occupational therapy. Neither therapy referral program included frequency of the program. On 02/09/12 at 3:15 p.m., RN-E (Registered Nurse) approached Surveyor # and stated the quarterly MDS completed in November was miscoded. RN-E stated she made a mistake and should have coded a 0 for upper body function and she coded a 1 instead. RN-E stated she had no documentation to provide to the Surveyor that would support her coding. Example #2: Resident #12 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. According to her MDS (Minimum Data Set) assessment dated January of 2012, Resident #12 is completely dependent on staff for all of her mobility, dressing, and eating. Surveyor # reviewed the resident's physician orders [REDACTED]. On 1/10/11, her physician ordered mouthwash to be swabbed into her contracted hand three times a day to prevent yeast infections. On 11/8/11, the splint was changed to a green foam carrot-shaped device. Directions were given on how to put it in her hand, how often it was to be washed, and that it could be removed for cares and meals. On 2/8/12 at 8:14 a.m. Surveyor # observed CNA-J and CNA-R assist Resident #12 with her personal hygiene and dressing. Resident #12 had a washcloth rolled up in her right hand. The nurse aides removed the cloth and discussed not being able to find the resident's "green carrot." The nurse aides did not find the splint in her room and did not place a clean cloth in her hand. At this time Surveyor # began a continuous observation of the care of Resident #12. Resident #12 was taken to the breakfast meal by CNA-J. At 9:21 a.m., the DM (Dietary Manager) took Resident #12 back to her room, reclined her wheelchair a bit, and turned on her TV. At 9:56 a.m. to 10:05 a.m., Surveyor # observed a housekeeping staff member clean her room. No other staff entered her room. Surveyor # observed no staff entering the resident's room from 11:07 a.m. to 11:11 a.m. At 12:07 p.m., Surveyor # observed the AD (Activity Director) enter Resident #12's room. At 12:11 p.m. CNA-Q and CNA-R came to the room and told Resident #12, "going lay you down and get you changed." The CNAs did not splint her hand. Resident #12 had gone all morning without her hand being splinted. Example #3: Surveyor # 's review of Resident #38's medical record reveals the following right and left lower extremity exercise program developed on 12/14/11: Total Left Hip Sitting Chair Flexion with 4# (pounds) weight on ankle, bring knee to chest 15-20 times 1 time per day. Total Knee Long Arc Quads using 4# weights on ankle, straighten operated leg and try to hold it repeat 15-20 times 1 time per day. Hip adduction, left leg out to side and back in wheelchair, repeat 15-20 times 1 time per day. Ankle/Foot Bends keeping both heels on floor. Press toes to floor, raising heels, repeat 20 times 1 time per day. Review of the December 2011 flow sheets recording this program, reveals that between 12/15/11 through 12/31/11, this program was implemented on 12/28/11, 12/29/11 and 12/30/11. 11 days had lines drawn through and three days had Rs (refusals). This program was not implemented 11 days in December. Review of January 2012 flow sheets recording this program, reveals this program was implemented 18 of the 31 days. 13 days had lines drawn through them. Review of February 2012 flow sheets recording this program, reveals that between 2/1/12 through 2/18/12 the program was implemented 5 of the 8 days. 3 days had lines drawn through them. Example #4: Surveyor # 's review of Resident #37's medical record reveals the following lower extremity exercise program developed on 01/17/12: Total Hip sitting chair flexion, bring knee up toward chest repeat with other leg. Repeat 15 times 1 time a day. Total knee Long Arc Quads, straighten operated leg and try to hold it, repeat 15 times 1 time a day. Hip adduction, squeeze knees together, spread them apart and bring them back together. Work within the controllable range, even if only a few inches. Repeat 15 times 1 time per day. Review of January 2012 flow sheets recording this program, reveals that between 1/20/12 and 1/31/12 this program was implemented 8 of the 12 days. 4 days had lines drawn through them. Review of February 2012 flow sheets recording this program, reveals that between 2/1/12 through 2/8/12 this program was implemented 5 of the 8 days. 3 days had lines drawn through them. Example #5: Surveyor # 's review of Resident #35's medical record reveals the following lower extremity exercise program developed on 08/02/10: Total Knee Long Arc Quads, straighten operated leg and try to hold it 5 seconds, use 3# on ankle repeat 15 times x 2- 1 time a day. Total knee chair flexion, Bend each knee using red theraband behind ankle for resistance, repeat 15 times x2-1 time per day. Total hip sitting chair flexion bring knee up toward chest. Use 3# on ankle. Repeat with other leg. Repeat 15 times x2-1 time per day. Review of October 2011 flow sheets recording this program, reveals this program was implemented 9 of the 31 days. 22 days had lines drawn through them. Review of December 2011 flow sheets recording this program reveals the program was implemented 10 of the 31 days. 21 days had lines drawn through them. Review of January 2012 flow sheets recording this program, reveals the program was implemented 16 of 31 days. 15 days had lines drawn through them. Review of February 2012 flow sheets recording this program, reveals that between 2/1/12 through 2/8/12 this program was implemented 4 of the 8 days. 3 days had lines drawn through them and February 1 had zeros written in. Example #6: Surveyor # review of Resident #22's medical record reveals the following lower extremity exercise program developed on 11/30/11: Total Hip Sitting Chair Flexion, bring knee up toward chest use 1-3 pounds on ankle repeat with other leg, repeat 15 times 1 time a day. Total Knee Long Arc Quads, straighten operated leg and try to hold it 1-2 seconds, use 1-3 pounds on ankle, repeat 15 times 1 time per day. Hip Adduction using green theraband and ball squeezes, squeeze knees together, spread them apart and bring them back together. Work within the controllable range, even if only a few inches, repeat 15 times 1 time per day. Ankle Foot Ankle Bends Hamstring and heel stretches, sitting point toes up, keeping both heels on floor. Then press toes to floor, raising heels. Repeat 15 times, 1 time per day. Review of December 2011 flow sheets recording this program, reveals the program was implemented 12 of the 31 days in December. 19 days had lines drawn through them. Review of January 2012 flow sheets recording this program, reveals the program was implemented 21 of the 31 days. 10 days had lines drawn through them. Review of February 2012 flow sheets recording this program, reveals between 2/1/12 and 2/8/12, this program was implemented 5 of the 8 days. 3 days had lines drawn through them. Example #7: Surveyor # 's review of Resident #39's medical record reveals the following lower extremity exercise program implemented October 2011: Legs-Hip Flexion, with your feet flat on floor, lift your knee and raise your foot off the floor. Hold this position for 5 seconds, put your foot down. Repeat the exercise with your other leg. Do 1 sets of 10 repetitions. Do these exercises 1-2 times a day at home, move slowly with each and do not hold your breath. Lower extremity Quadriceps, Strengthening Exercise Long Arc Quad, sit on a sturdy surface, grip the sides of the surface for support. Straighten your knee completely, lower your leg and relax, repeat 10 times. Lower extremity Ankle Musculature, strengthening exercise, hold for five seconds, relax, repeat 10 times tap toes and heels on floor. Hip legs apart using green theraband ball squeezes sitting straight, move legs widely apart, then together again, repeat 10 times 1 time per day. Review of the October 2011 flow sheets recording this program, reveals the program was implemented 7 of the 31 days. 22 days had lines drawn through them and 2 days were left blank. Review of the November 2011 flow sheets recording this program, reveals the program was implemented 7 of the 31 days. 24 days had lines drawn through them. Review of the December 2011 flow sheets recording this program, reveals the program was implemented 13 of the 31 days. 18 of the days had lines drawn through them. Review of the January 2012 flow sheets recording this program, reveals the program was implemented 17 of the 31 days. 12 days had lines drawn through them, 1 day had an R (refusal), and 1 day ill. Review of February 2012 flow sheets recording this program, reveals that between 2/1/12 and 2/8/12, this program was implemented 6 of the 8 days. 2 days had lines drawn through them. Example #8: Surveyor # 's review of the Resident #40's medical record reveals the following upper extremity restorative exercise program developed on 09/19/2011: Tabletop sander 4# weight in sander seated shoulder check x 10/3 repetitions, shoulder abduction x10/3 reps (side to side). Upper extremity restorator-standing-patient to complete 3 min/3 reps with rest periods between each rep. This was to be done 3 times a week. Review of October 2011 flow sheets recording this program, reveals that from 10/15/11 through 10/22/11 this program was not implemented, lines were drawn through those days. Between 10/25/11 and 10/31/11 this program was implemented on 1 day. Review of the November 2011 flow sheets recording this program, reveals that from 11/8/11 through 11/14/11 this program was implemented 1 day, lines were drawn through the other days. From 11/15/11 through 11/21/11, this program was implemented 2 days, lines were drawn through the other days. From 11/22/11 through 11/31/11 this program was implemented 2 days, lines were drawn through the other days. Review of December 2011 flow sheets recording this program, reveals that from 12/1/11 through 12/7/11, this program was implemented 1 day, lines were drawn through the other days. Example #9: Surveyor # 's review of Resident #33's medical record reveals the following lower extremity restorative exercise program developed on 06/9/11: Bilateral seat hip flexion in sitting with 2# ankle weights 3 x 10 reps, may increase weight as tolerated. Bilateral seated knee ext. in sitting with 2# ankle weight 3x 10 reps, may increase weight as tolerated. This was to be done 3 times a week. Review of October 2011 flow sheets recording this program, reveals that from 10/1/11 through 10/7/11 this program was implemented 2 days, lines were drawn through the other days. From 10/15/11 through 10/21/11, this program was implemented 2 days, lines were drawn through the other days. Review of November 2011 flow sheets recording this program, reveals that from 11/1/11 through 11/7/11 this program was implemented 1 day, lines were drawn through the other days. From 11/8/11 through 11/14/11 this program was implemented 1 day, lines were drawn through the other days. From 11/22/11 through 11/31/11 this program was implemented 2 days, lines were drawn through the other days. Example #10: Surveyor # 's review of Resident #21's medical record reveals the following upper extremity exercise program developed on 08/30/11: Upper extremity restorator seated in wheelchair-2 minutes 3 reps. Pt. (patient) to rest after each rep. Sit to Stand transfers-walker placed in front of her. Have pt. sit to stand x10/2 repts. Use gait belt for safety. This was to be done 3 times a week. Review of December 2011 flow sheets recording this program, reveals that from 12/1/11 through 12/7/11 this program was implemented 1 day, lines were drawn through the other days. From 12/8/11 through 12/14/11, this program was implemented 2 days, lines were drawn through the other days. From 12/15/11 through 12/21/11, this program was implemented 2 days, lines were drawn through the other days. On 02/09/12 at 8:00 a.m., Surveyor # spoke with RA-AA (RestorativeAssistant). RA-AA indicated she and RA-Z are often pulled to work the floor as Certified Nursing Assistants. RA-AA indicated she and RA-Z were pulled that morning to work on the 500 wing as CNAs. RA-AA said the restorative programs don't get implemented on those days. Surveyor # observed both RA-AA and RA-Z working as Certified Nursing Aides on the 500 wing. On 02/09/12 at 8:20 a.m., Surveyor # spoke with RA-Z. RA-Z said she had been called the evening before to work the floor as an aide on the day shift of 02/09/12. RA-Z said that when the restorative aides get pulled, the restorative program does not get implemented. RA-Z said on the individual flow sheets they draw a line through the day that the program doesn't get implemented. RA-Z said if the resident refuses, they write an R in the box for the day. RA-Z said they have had problems with implementation of the restorative programs for months. RA-Z said the problems are related to the restorative aides being pulled to work the floor as aides. On 02/09/12 at 8:45 a.m., Surveyor # spoke with COTA-EE (Certified Occupational Therapy Assistant). COTA-EE said if the restorative programs do not spell out the number of days a week that the program is to be implemented, that 3 times a week is sufficient. On 02/09/12 at 8:55 a.m., Surveyor # spoke with the Staff Development Coordinator (SDC). The SDC indicated to Surveyor # that she oversees the restorative program. SDC said Occupational or Physical Therapy sets up the restorative programs and they turn it over to the unit. SDC said they staff with one restorative aide a day, and they work weekends, alternating weekends working as a CNA. SDC said RA-AA, RA-Z and CNA-C work with the residents in the restorative program. SDC said at times, the restorative aides get pulled to work the floor as certified nursing assistants, then the program does not get done. SDC said October, November and December 2011 were difficult months to get the restorative program implemented. On 2/9/12 at 9:05 a.m., Surveyor # questioned the facility Staff Development/Restorative Program Coordinator/Quality Assurance Coordinator/Infection Control Preventionist regarding the Restorative Program. This nurse stated the restorative staff available are based on the facility's budget per day availability. She stated there is not enough hours according to the budget, to carry the restorative program seven days a week. Because of this, she stated the facility has been providing restorative programs every other day. She further stated that if the facility could increase restorative programming to two restorative staff per day, all residents in need could be seen for two programs every day, which is then reimbursed on the Minimum Data Set for the services. She then stated that restorative hours were again cut when the facility census dropped, so in turn, the caseloads were dropped to those residents who must have it. The nurse was then asked what the responsibilities are of the restorative staff besides the restorative programs themselves. The nurse replied the restorative staff are required to feed at meal times (approximately 30 minutes each meal with two meals being served during their shift), and when she includes the 1/2 hour meal time for their personal break, and the two 15-minute breaks each day (one in the morning and one in the afternoon), that leaves the restorative staff completing restorative tasks only 5.5 hours per day.