Every finding on record at Edenbrook Omro

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 1 resident (R) (R1) of 4 sampled residents. R1 was on enhanced barrier precautions (EBP) due to a suprapubic catheter. On 4/1/26, staff did not wear gowns while providing personal care for R1. Findings include: The facility's Enhanced Barrier Precautions policy, dated 3/2024, indicates: It is the policy of this facility that EBP, in addition to standard and contact precautions, will be implemented during high-contact resident care activities when caring for residents who have an increased risk for acquiring a multidrug-resistant organism (MDRO) such as residents with chronic wounds requiring a dressing, indwelling medical devices .High-contact resident care activities include: Dressing, bathing/showering . On 4/1/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including history of urinary tract infection (UTI), suprapubic catheter, and pressure injury. R1's Minimum Data Set (MDS) assessment, dated 1/21/26, had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R1 had moderate cognitive impairment. R1 was responsible for R1's healthcare decisions. R1's medical record indicated R1 was hospitalized from [DATE] to 3/28/26 for a UTI, nose bleed, and suprapubic catheter dysfunction. R1 had a history of UTIs which resulted in the placement of a suprapubic catheter in November 2025. R1 had a diagnosis of paraplegia with lumbar and sacral spina bifida which placed R1 at high risk for pressure injuries. R1 was being treated for moisture-associated skin damage in the sacral/peri-area. R1 was on EBP related to the suprapubic catheter. On 4/1/26 at 10:00 AM, Surveyor observed Certified Nursing Assistant (CNA)-C and CNA-D bath and dress R1 without wearing gowns. On 4/1/26 at 10:20 AM, Surveyor interviewed CNA-C who indicated personal protective equipment (PPE) for EBP should be worn during high-contact resident cares. CNA-C verified CNA-C did not wear a gown while bathing and dressing R1. On 4/1/26 at 1:05 PM, Surveyor interviewed CNA-D who verified CNA-D did not wear a gown while bathing and dressing R1. On 4/1/26 at 12:26 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-E who indicated staff should wear a gown and gloves while bathing and grooming residents on EBP. On 4/1/26 at 1:09 PM, Surveyor interviewed Director of Nursing (DON)-B who verified staff should wear a gown and gloves while bathing and dressing residents on EBP.

Based on observation, staff interview, and record review, the facility did not ensure a fall intervention was in place and post-falls assessments were accurately completed for 3 residents (R) (R1, R2, and R3) of 3 sampled residents.R1 had multiple falls since admission. R1's care plan contained an intervention for 2 body pillows when in bed. The intervention was not consistently implemented. In addition, R1's post fall assessments were not completed per policy.R2 had a fall on 10/1/25. R2's post fall assessments were not completed per policy.R3 had a fall on 10/5/25. R3's post fall assessments were not completed per policy. Findings include: The facility's Fall Reduction Policy, revised 10/13/23, indicates: Risk Identification and Assessment: .4. Identified risk factors should be discussed in the Care Area Assessment (CAA) documentation via the Minimum Data Set (MDS) and addressed in the resident's care plan to assure individualized interventions to reduce the risk are implemented. The facility's Post Fall Policy, revised 10/13/23, indicates: After a fall, staff should document on the resident's condition at a minimum of every shift for 72 hours. Staff should document relevant post-fall clinical findings, such as vital signs, pain, swelling, bruising, and changes in function or cognitive status .report any changes in function, increased pain, and changes in cognition for further evaluation. 1.On 10/21/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including dementia with severe psychotic disturbance, Alzheimer's disease, and anxiety. R1 was admitted to the facility due to a fall that occurred at home with a sacral fracture. R1's Minimum Data Set (MDS) assessment, dated 8/29/25, had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R1 had severe cognitive impairment. R1 had a Guardian for healthcare decision making. A care plan, initiated 8/29/25, indicated R1 was at high risk for falls related to a closed fracture of the sacrum, severe dementia, and a history of falls and was unaware of R1's safety needs. The care plan contained an intervention, initiated 10/7/25 and revised10/8/25, for body pillow(s) in bed at night to use for comfort on each side of R1 when in bed. On 10/21/25 at 12:28 PM, Surveyor observed R1 in bed with one body pillow on the outside of R1's body. Surveyor noted a second body pillow was on a chair in the room. Surveyor interviewed Certified Nursing Assistant (CNA)-C who confirmed there was one body pillow in bed with R1. CNA-C stated CNA-C usually places a body pillow in between a resident's legs for comfort, but placed the pillow alongside R1 instead. When asked about the second body pillow on R1's chair, CNA-C indicated the pillow was used per staffs' discretion. When Surveyor showed CNA-C the care plan that indicated R1 should have 2 body pillows in bed, CNA-C stated CNA-C wasn't aware of the need for a second body pillow and didn't usually work on R1's wing. On 10/21/25, Surveyor reviewed post fall assessments for R1 and noted the following: ~ A post fall assessment, dated 9/20/25 at 12:55 AM, contained vital signs from 9/19/25 at 10:11 AM and a pain evaluation from 9/19/25 at 11:43 PM. ~ A post fall assessment, dated 9/20/25 at 11:53 AM, contained an oxygen saturation level from 9/19/25 at 10:11 AM. ~ A post fall assessment, dated 10/2/25 at 6:51 AM, contained vital signs from 9/29/25 at 1:28 PM. ~ A post fall assessment, dated 10/5/25 at 7:12 AM, contained vital signs from 10/5/25 at 12:10 PM. ~ A post fall assessment, dated 10/5/25 at 3:12 PM, contained vital signs from 10/5/25 at 12:10 PM and a pain assessment from 10/5/25 at 6:18 PM. ~ A post fall assessment, dated 10/6/25 at 1:02 AM, contained vital signs from 10/5/25 at 12:10 PM. ~ A post fall assessment, dated 10/6/25 at 5:58 AM, contained vital signs from 10/7/25 at 11:28 AM. ~ A post fall assessment, dated 10/6/25 at 9:18 AM, contained an oxygen saturation level from 10/5/25 at 12:10 PM. ~ A post fall assessment, dated 10/6/25 at 1:58 PM, contained vital signs from 10/7/25 at 11:28 AM. ~ A post fall assessment, dated 10/6/25 at 9:49 PM, contained a blood pressure and temperature from 10/6/25 at 3:32 PM, a pulse and oxygen saturation level from 10/6/25 at 5:40 PM, and a respiration rate from 10/6/25 at 9:19 AM. ~ A post fall assessment, dated 10/7/25 at 6:11 AM, contained vital signs from 10/7/25 at 11:28 AM. ~ A post fall assessment, dated 10/7/25 at 2:12 PM, contained vital signs from 10/7/25 at 11:28 AM ~ A post fall assessment, dated 10/7/25 at 5:34 PM, contained vital signs from 10/7/25 at 11:28 AM. ~ A post fall assessment, dated 10/8/25 at 2:43 AM, contained vital signs from 10/7/25 at 11:28 AM. On 10/21/25 at 12:42 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff had most likely missed some of the assessments and completed them in batches with one set of vital signs which is why some of the assessments had vital signs that were taken in the future. DON-B also verified old vital signs were used in some of the assessments. DON-B verified staff should take a set of vital signs for each post fall assessment completed. DON-B also confirmed care plan interventions should be in place for R1. 2. On 10/21/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including spinal stenosis, asthma, obesity, depression, and hypertension. R2's most recent MDS assessment, dated 7/25/25, had a BIMS score of 15 out of 15 which indicated R2 had intact cognition. R2 was responsible for R2's healthcare decisions. R2's most recent comprehensive care plan indicated R2 was at high risk for falls. On 10/21/25, Surveyor reviewed post fall assessments completed for R2 and noted the following: ~ A post fall assessment, dated 10/2/25 at 1:04 AM, contained vital signs from 9/27/25 at 12:26 PM and a pain evaluation from 10/1/25 at 10:51 PM. ~ A post fall assessment, dated 10/2/25 at 9:06 AM, contained a temperature, respiration rate, and oxygen saturation level from 9/27/25 at 12:26 PM. ~ A post fall assessment, dated 10/2/25 at 10:35 PM, contained a temperature and oxygen saturation level from 9/27/25 at 12:26 PM, a blood pressure and pulse from 10/2/25 at 10:37 AM, and a respiration rate from 10/3/25 at 6:51 AM. ~ A post fall assessment, dated 10/3/25 at 8:36 AM, contained a temperature and oxygen saturation level from 9/27/25 at 12:26 PM, a blood pressure and pulse from 10/2/25 at 10:37 AM, and a respiration rate from 10/3/25 at 6:51 AM. ~ A post fall assessment, dated 10/3/25 at 10:05 PM, contained a temperature and oxygen saturation level from 9/27/25 at 12:26 PM, a blood pressure and pulse from 10/2/25 at 10:37 AM, and a respiration rate from 10/3/25 at 6:51 AM. (See interview under example #3). 3. On 10/21/25, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including stroke, vascular dementia, type 2 diabetes, depression, anxiety, and dysphagia. R3's most recent MDS assessment, dated 7/28/25, had a BIMS score of 5 out of 15 which indicated R3 had severe cognitive impairment. R3 had a Guardian. R3's most recent comprehensive care plan indicated R3 was at high risk for falls. On 10/21/25, Surveyor reviewed post fall assessments completed for R3 and noted the following: ~ A post fall assessment, dated 10/6/25 at 1:17 AM, contained a blood pressure, pulse, temperature, respiration rate, and oxygen saturation level from 10/5/25 at 2:20 PM. ~ A post fall assessment, dated 10/6/25 at 6:23 PM, contained a blood pressure, pulse, temperature, respiration rate, and oxygen saturation level from 10/6/25 at 10:23 AM and a pain evaluation from 10/7/25 at 3:56 PM. ~ A post fall assessment, dated 10/7/25 at 2:23 AM, contained a blood pressure, pulse, temperature, respiration rate, and oxygen saturation level from 10/6/25 at 10:23 AM and a pain evaluation from 10/7/25 at 3:56 PM. ~ A post fall assessment, dated 10/8/25 at 2:40 PM, contained vital signs from 10/7/25 at 6:47 PM. ~ A post fall assessment, dated 10/8/25 at 12:57 PM, contained a blood pressure, pulse, temperature, respiration rate, and oxygen saturation level from 10/725 at 6:47 PM and a pain evaluation from 10/8/25 at 8:13 AM. On 10/21/25 at 12:45 PM, Surveyor interviewed DON-B who verified older vital signs were used in the post fall assessments and a new set of vital signs should be obtained during each assessment to ensure adequate trending and post-fall monitoring.

Based on observation, resident and staff interview, the facility did not ensure staffing was sufficient to meet care needs of residents. This had the potential to affect all 37 residents. Schedules were compared with daily census as well as the Facility Assessment and there were days staffing did not meet the needs of the daily census.Interviewed residents and family members indicated they waited a long time for call lights and call lights were observed to be turned off prior to the resident need being met. Interviews revealed weekends were more challenging because there was no office staff to assist as needed.Interviewed staff which revealed that the facility has many 2 person assist transfers and high acuity residents which affects care needs being met as well as meal times. Based on observation, staff and resident interview, and record review, the facility did not ensure there was sufficient staff to meet resident's needs. This practice had the potential to affect all 37 residents residing in the facility. On multiple dates, staffing levels were not in accordance with the facility's census or the Facility Assessment. Resident interviews indicated residents waited a long time for staff to answer call lights, especially on weekends when administrative staff were not there to provide assistance. In addition, call lights were turned off prior to residents' needs being met. Staff interviews indicated the facility had high acuity and a number of residents who required the assistance of 2 staff for transfers which affected staffs' ability to meet residents' needs and provide timely meals. Findings include: The Facility Assessment, updated [DATE], indicated on average, the facility's census was 32. The staffing plan indicated: Based on our resident population and their needs for care and support, below is our general approach to staffing to ensure we have sufficient staff to meet the needs of residents at any given time. The facility's evidence-based data tools are used on an ongoing basis to make adjustments to our staffing plan based on resident acuity and need. For Certified Nursing Assistants (CNAs): The Facility Assessment identified scheduling 8 CNAs per day (3 for the AM and PM shifts and 2 for the night (NOC) shift). On [DATE] at 10:58 AM, Surveyor interviewed Scheduler (SCH)-I who schedules nursing staff and helps on the floor. SCH-I indicated staffing is determined by the census and acuity. SCH-I indicated if the census is 36 or 37, the facility schedules 3 to 3.5 CNAs. SCH-I indicated the facility usually schedules 3 CNAs on the AM and PM shifts and 2 CNAs on the NOC shift when the census is under 36. SCH-I indicated SCH-I tries to schedule the same for weekdays and weekends and will beg and plead and offer incentives if needed. SCH-I indicated SCH-I meets with Director of Nursing (DON)-B, Assistant Director of Nursing (ADON)-L, Nursing Home Administrator (NHA)-A and Human Resources staff at least once daily related to staffing. SCH-I indicated if the facility doesn't have an extra CNA, ADON-L or SCH-I come in to help. SCH-I indicated the facility's acuity is higher than usual and the facility has Hospitality Aides (HAs) in the CNA training program who are scheduled Monday through Friday. SCH-I indicated HAs cannot provide direct care but can make beds that are unoccupied, answer simple call light requests, and pass water. SCH-I indicated it is more difficult to find help on the weekends. Surveyor reviewed facility's nursing schedules and noted the following: ~ On [DATE], the census was 37. There were 3 CNAs scheduled on the AM and PM shifts. ~ On [DATE] (Saturday), the census was 37. There were 3.5 CNAs and 1 HA scheduled on the AM shift and 3.5 CNAs scheduled on the PM shift. ~ On [DATE] (Sunday), the census was 36. There were 3.5 CNAs scheduled on the AM and PM shifts. ~ On [DATE], the census was 36. There were 3 CNAs scheduled on the AM shift and 3.5 CNAs scheduled on the PM shift. ~ On [DATE], the census was 37. There were 3 CNAs scheduled on the AM shift and 3.5 CNAs scheduled on the PM shift. ~ On [DATE] (Saturday), the census was 37. There were 3.25 CNAs scheduled on the AM shift and 3 CNAs scheduled on the PM shift. ~ On [DATE] (Sunday), the census was 37. There were 3.5 CNAs scheduled on the AM and PM shifts. ~ On [DATE], the census was 37. There were 4 CNAs and 1 HA scheduled on the AM shift and 3.5 CNAs scheduled on the PM shift. On [DATE], the facility provided Surveyor with a nursing schedule for the duration of the survey that indicated there were 3 CNAs and 1 HA scheduled on the [DATE] AM shift. On [DATE], Surveyor reviewed the actual AM shift schedule and noted there were 4 CNAs on the [DATE] AM shift. The facility's Payroll Based Journal (PBJ) report indicated a concern with low weekend staffing. Surveyor reviewed the facility's weekend staffing schedules for April, May, and June of 2025 and noted the following: ~ On [DATE] (Saturday), the census was 33. There were 3 CNAs scheduled on the AM shift (2 CNAs from 6:00 AM to 2:15 PM and 1 CNA from 6:00 AM to 2:30 PM). There were 4 CNAs scheduled on the PM shift (3 CNAs from 2:00 PM to 10:00 PM and 1 CNA from 1:45 PM to 5:30 PM). ~ On [DATE] (Saturday), the census was 36. There were 2 CNAs scheduled on the AM shift (1 CNA from 2:00 AM to 2:00 PM and 1 CNA from 5:45 AM to 6:00 PM). There were 4 CNAs scheduled on the PM shift (1 CNA from 2:00 PM to 10:15 PM, 1 CNA from 2:00 PM to 6:00 PM, 1 CNA from 6:00 PM to 10:30 PM, and 1 CNA from 1:45 PM to 10:30 PM). ~ On [DATE] (Sunday), the census was 36. There were 3 CNAs scheduled on the AM shift (1 CNA from 6:00 AM to 4:00 PM, 1 CNA from 6:00 AM to 2:30 PM, and 1 CNA from 12:00 PM to 2:00 PM). There were 3 CNAs scheduled on the PM shift. ~ On [DATE] (Saturday), the census was 34. There were 3 CNAs and 1 HA scheduled on the AM shift, 3 CNAs scheduled on the PM shift, and 1.5 CNAs scheduled on the NOC shift (1 CNA from 10:15 PM to 6:15 AM and 1 CNA from 12:00 AM to 6:00 AM). ~ On [DATE] (Sunday), the census was 34. There were 3 CNAs scheduled on the AM shift (1 CNA from 6:00 AM to 3:15 PM, 1 CNA from 8:00 AM to 2:15 PM, and 1 CNA from 6:00 AM to 11:45 AM). There were 3 CNAs scheduled on the PM shift (1 CNA from 2:00 PM to 9:00 PM, 1 CNA from 2:00 PM to 10:15 PM, and 1 CNA from 2:30 PM to 10:00 PM). On [DATE] at 11:54 AM, Surveyor interviewed DON-B who indicated the corporate office sets the levels for staffing which are based on the census and patients per day (PPD). DON-B indicated there are usually 3 to 3.5 CNAs on the floor and there are 4 when the census is 34 or higher. DON-B verified resident acuity should factor into scheduling and confirmed the facility has a higher acuity level. DON-B indicated the facility tries to ensure there are at least 3 CNAs in the building. If there is an unanticipated staffing shortage, DON-B indicated staff are asked to come in early or stay late and those who aren't scheduled are called. If there is a need to fill a CNA position, DON-B indicated the administrative team tries to ensure DON-B, ADON-L, SCH-I or SSD-C are on the floor. DON-B confirmed there have been staffing concerns, including the past 2 weekends. Resident. Staff, and Family Interviews: From [DATE] to [DATE], Surveyor reviewed R34's medical record. R34 was admitted to the facility on [DATE]. R34's Minimum Data Set (MDS) assessment, dated [DATE], had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R34 had intact cognition. On [DATE] at 9:30 AM, Surveyor interviewed R34 who indicated there are not enough staff and call light response times can take up to an hour, especially during the day and on weekends. R34 indicated R34 and a number of other residents require the assistance of 2 staff for transfers. R34 stated 4 CNAs have worked at times for part of a shift which R34 feels is helpful. R34 indicated the facility should have 4 staff on the AM and PM shifts. From [DATE] to [DATE], Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE]. R1's MDS assessment, dated [DATE], had a BIMS score of 15 out of 15 which indicated R1 had intact cognition. On [DATE] at 9:55 AM, Surveyor interviewed R1 who indicated R1 waited 2 and a half hours yesterday at shift change and was not washed up all weekend. R1 stated R1 also waits a long time for R1's call light to be answered. From [DATE] to [DATE], Surveyor reviewed R25's medical record. R25 was admitted to the facility on [DATE]. R25's MDS assessment, dated [DATE], had a BIMS score of 12 out of 15 which indicated R25 had moderately impaired cognition. On [DATE] at 10:40 AM, Surveyor interviewed R25 who indicated it can take staff up to an hour to respond to call lights on the AM and PM shifts. R25 indicated R25 spoke with NHA-A and DON-B who said their hands are tied. R25 indicated R25 has seen other staff help out recently. From [DATE] to [DATE], Surveyor reviewed R29's medical record. R29 was admitted to the facility on [DATE]. R29's MDS assessment, dated [DATE], had a BIMS score of 15 out of 15 which indicated R29 had intact cognition. On [DATE] at 11:45 AM, Surveyor interviewed R29 who indicated the facility does not have enough help and it can take staff a long time to answer call lights. R29 stated there is usually 1 staff scheduled per hall (which is 3 staff on the AM and PM shifts). R29 indicated a number of residents on R29's wing and the adjacent wing require 2 staff for transfers. R29 indicated R29 does not get washed up timely because some residents take a lot of staffs' time. R29 indicated R29 has recently seen more management staff provide assistance. R29 indicated the facility has good staff, however, there is turnover and staff can't assist residents in a timely manner. From [DATE] to [DATE], Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE]. R3's MDS assessment, dated [DATE], had a BIMS score of 15 out of 15 which indicated R3 had intact cognition. On [DATE] at 1:04 PM, Surveyor interviewed R3 who indicated R3 had a recent fall and needed to use an E-Z stand lift with the assistance of 2 staff for transfers. R3 indicated a number of residents on R3's wing need the lift and R3 has had to wait 30 minutes to an hour for assistance. On [DATE] at 11:34 AM, Surveyor interviewed Social Services Designee (SSD)-C who indicated one resident requires a lot of staffs' time which has affected other residents' care. SSD-C verified SSD-C's family member (R3) resides at the facility. SSD-C indicated another family member visited R3 over the weekend and notified SSD-C that R3's call light had been on for over an hour and R3 needed to use the bathroom. SSD-C called the unit and asked that someone assist R3 to the bathroom. On [DATE] at 12:33 PM, Surveyor interviewed CNA-H who indicated it can take a long time to answer call lights and stated 2 units have heavy cares. CNA-H indicated if the census is 35, the facility tries to schedule 4 CNAs on the AM and PM shifts. CNA-H indicated it can take 30 minutes to an hour to get some residents up and ready in the morning and stated things run smoother if there are 4 CNAs. CNA-H indicated R1's hall is difficult and it can be difficult to wash R1 in the morning. CNA-H indicated staff didn't get into the dining room to serve breakfast until between 9:00 AM and 9:30 AM on the weekend. CNA-H indicated earlier that morning, CNA-H radioed 3 times for assistance with a transfer but the other CNAs were busy and SCH-I provided assistance. CNA-H indicated weekends are horrible because ADON-L, SCH-I, NHA-A, and SSD-C are not there to help like they do during the week. On [DATE] at 4:51 PM, Surveyor interviewed CNA-J who usually works the AM shift. CNA-J indicated during the week the facility schedules 4 CNAs for the weekend, however depending on the census, staff don't always get the fourth CNA. CNA-J indicated the fourth CNA is helpful and stated it's draining to work with only 3 CNAs. CNA-J indicated the facility has a number of heavy care residents and residents don't always get the care they need, including R1. CNA-J indicated staff provide care as fast as they can because they know other residents are waiting. CNA-J indicated some residents take up to an hour to get ready which takes one staff off the floor. CNA-J indicated when there are only 2 CNAs left on the floor with a number of residents who require the assistance of 2 staff, it can take a long time to get to residents. On [DATE] at 11:37 AM, Surveyor interviewed Dietary Manager (DM)-K who indicated meals have been affected by CNA staff. DM-K indicated breakfast was an hour late on [DATE] (Saturday) and staff were still feeding residents at 10:30 AM on [DATE]. DM-K indicated the CNAs work hard, however, the facility has a lot of high-needs residents who require the assistance of 2 staff. DM-K stated a number of residents eat breakfast in the dining room and staff struggle to get everyone up and dressed in the morning. DM-K indicated if DM-K knows the CNAs are struggling, DM-K has dietary staff pass meal trays. DM-K stated DM-K is cardiopulmonary resuscitation (CPR) certified but can't assist with feeding. DM-K indicated if licensed staff aren't in the dining room on time, DM-K is in the dining room in case someone chokes. DM-K indicated there is a difference between weekday and weekend staff because the facility does not have extra management staff to help out. On [DATE], Surveyor requested a list of residents who require a Hoyer (full body) or sit-to-stand lift for transfers and noted on R1, R25, R29, and R3's wing, 9 of 14 residents require a mechanical lift and the assistance of 2 staff for transfers. On [DATE] at 11:54 AM, Surveyor interviewed DON-B who was aware of concerns from residents and CNAs about low weekend staffing. DON-B indicated residents feel there should always be 4 CNAs, however, it's not always possible to fill the fourth CNA position and the census may not warrant it. DON-B indicated the facility improved staffing by hiring new CNAs. Grievances: From [DATE] to [DATE], Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE]. R5's MDS assessment, dated [DATE], had a BIMS score of 15 out of 15 which indicated R5 had intact cognition. Surveyor reviewed the facility's grievance file and noted on [DATE], R5 complained of long call light wait times over the weekend. R5 felt R5 waited too long each time R5 activated R5's call light. R5 also stated nursing staff complained to R5 about the tasks they still needed to complete. The facility noted there were staffing challenges over the weekend that impacted R5's satisfaction, including a CNA who called in the night of [DATE] and another who walked off the job on [DATE] without notice. ADON-L was called to cover the floor but did not have experience working as a CNA which caused delays. A new CNA appeared to be overwhelmed and complained to R5. ADON-L received additional training as a CNA to be better equipped to cover the floor as a CNA in the future. Resident Council Meeting: From [DATE] to [DATE], Surveyor reviewed R7's medical record. R7's most recent admission to the facility was on [DATE]. R7's MDS assessment, dated [DATE], had a BIMS score of 15 out of 15 which indicated R7 had intact cognition. From [DATE] to [DATE], Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE]. R11's MDS assessment, dated [DATE], had a BIMS score of 13 out of 15 which indicated R11 had intact cognition. From [DATE] to [DATE], Surveyor reviewed R32's medical record. R32 was admitted to the facility on [DATE]. R32's MDS assessment, dated [DATE], had a BIMS score of 15 out of 15 which indicated R32 had intact cognition. On [DATE] at 9:59 AM, Surveyor participated in a Resident Council meeting that included R1, R32, R7, R3, and R11 and noted the following: ~ All residents in attendance indicated they felt staff response times were longer and meal times were later on the weekends. R7 indicated breakfast was recently over an hour late which pushed lunch back because staff struggled to get everyone up. ~ R1 and R7 indicated care is rushed. R1 stated 3 staff tried to quickly provide a bed bath for R1 before the end of the shift on R1's shower day and each staff washed a different area on R1. R1 indicated R1 was not washed thoroughly. R1 also indicated staff do not come around often. ~ R3 indicated staff turn R3's call light off and don't return. R3 stated R3 wishes staff wouldn't turn the call light off. All residents in attendance agreed that staff turn off call lights and don't return. ~ All residents indicated there are not enough staff in the evenings or on weekends because there are no extra management staff to help like there are on weekdays. ~ When asked if snacks are provided, R7 and R32 indicated it depends on who is working. R7 stated there should be 4 CNAs, especially on weekends, since a number of residents require mechanical lift transfers. R7 stated the facility tries to make adjustments in staffing and tries to have CNAs come in at different hours so there are 4 CNAs at times. Call Light Observations: Between [DATE] and [DATE], Surveyor observed call lights on the AM and PM shifts. On [DATE], there were 3 CNAs scheduled on the PM shift and a fourth CNA was scheduled to come in at 6:00 PM. Surveyor observed call lights between 3:00 PM and 5:00 PM and noted a number of call lights were activated simultaneously on 3 wings. Surveyor observed DON-B, ADON-L, and SSD-C assist with answering call lights during that time. On [DATE] at 4:05 PM, Surveyor noted R34's call light was activated. On [DATE] at 4:11 PM, Surveyor observed ADON-L and SSD-C enter R34's room and turn R34's call light off. On [DATE] at 4:15 PM, Surveyor observed CNA-G and SSD-C enter R34's room with an EZ-Stand lift. R34's call light was not on. On [DATE] at 4:18 PM, SSD-C and CNA-G exited R34's room. On [DATE] at 9:37 AM, Surveyor noted R29's call light was activated. On [DATE] at 9:40 AM, Surveyor observed SSD-C enter R29's room and speak with R29. SSD-C then exited the room and indicated R29 wanted to speak with Surveyor. On [DATE] at 9:41 AM, Surveyor noted R29's call light was off. Surveyor interviewed R29 who reported staffing concerns. When Surveyor asked why R29 activated the call light, R29 indicated R29 wanted to get washed up. R29 indicated SSD-C turned the call light off and stated staff were busy getting other residents ready for a meeting at 10:00 AM and would assist R29 after the meeting started. R29 indicated staff frequently turn call lights off and forget to come back. R29 indicated R29 sometimes dozes off while waiting and then staff turn off R29's call light without checking to see what R29 needs. R29 indicated R29 wishes staff would wake R29 up. On [DATE] at 10:50 AM, Surveyor interviewed R29 after the Resident Council meeting. R29 indicated staff had not come back to assist R29. R29 indicated R29 activated the call light again and SCH-I provided assistance. On [DATE] at 10:58 AM, Surveyor interviewed SCH-I who confirmed R29's call light was activated and SCH-I assisted with washing R29. On [DATE] at 11:54 AM, Surveyor interviewed DON-B who indicated the call light should be left on until staff return to complete the resident's request. DON-B indicated staff are expected to answer call lights within 9 minutes so residents are not left waiting.

Based on 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 2 residents (R) (R3 and R1) of 3 sampled residents.R3's plan of care indicated R3 should receive a weekly shower on the Thursday PM shift. R1's plan of care was not consistently followed. R1's plan of care indicated R1 should receive 2 full bed baths weekly. R1's plan of care was not consistently followed. Findings include:The facility's Activities of Daily Living (ADLs) policy, revised 2/25/25, indicates: .2. The facility will provide care and services for the following activities of daily living. Bathing and Hygiene: Assistance with bathing or showering and maintaining personal hygiene .9. If a resident refuses care, this shall be reported to the nurse and the resident reapproached. Documentation of refusal shall be completed in the electronic medical record.1.From 9/8/25 to 9/10/25, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including hemiplegia and hemiparesis and chronic pain syndrome. R3's Minimum Data Set (MDS) assessment, dated 7/18/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R3 had intact cognition. A care plan, dated 12/19/24, indicated R3 had an ADL self-care performance deficit related to hemiplegia and hemiparesis following cerebral vascular accident (CVA), chronic pain syndrome, edema, fatigue, muscle weakness, and obesity. The care plan contained an intervention, dated 12/19/24, for bathing/showering assist of one. A care plan, dated 8/12/25, indicated R3 had limited physical mobility and required a stand up lift with the assistance of two staff for transfers. Surveyor reviewed R3's shower documentation for June 2025 to the present and noted the following:~ In June 2025, Certified Nursing Assistant (CNA) documentation indicated R3 received 2 showers and 1 bed bath. An entry on 6/19/25 indicated not applicable (NA).~ In July 2025, CNA documentation indicated R3 received 3 showers and 1 bed bath. An entry on 7/17/25 indicated NA.~ In August 2025, CNA documentation indicated R3 received 1 shower, 2 bed baths (one on 8/28/25), and had 1 refusal. ~ On 9/4/25, CNA documentation indicated R3 refused a shower.On 9/8/25 at 1:04 PM, Surveyor interviewed R3 who indicated R3 did not get a shower the week before last and did not get a shower last Thursday (9/4/25) on the PM shift (R3's shower day). R3 indicated R3's family member (Social Services Designee (SSD)-C)) works at the facility and R3 mentioned it to SSD-C last week. R3 stated SSD-C indicated R3's shower was marked as a refusal. R3 indicated R3 did not recall being offered a shower last week and asked, How can I refuse something I was never offered? R3 stated staff on the 9/5/25 AM shift stayed after their shift to give R3 a shower. In a later interview at 1:46 PM, R3 stated R3 only gets one shower per week and likes to shower because R3's hair gets washed.On 9/9/25 at 11:34 AM, Surveyor interviewed SSD-C who indicated R3 is alert and oriented and told SSD-C that R3 was not offered a shower which made SSD-C sad.On 9/9/25 at 12:33 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-H who worked the AM shift on 9/5/25. CNA-H indicated when CNA-H got R3 ready that morning and asked about R3's shower the previous night, R3 stated R3 didn't get a shower. When CNA-H asked if a shower was offered, R3 stated a shower was not offered and R3 also did not get a shower the week prior. CNA-H indicated showers are missed, especially on R3's wing, because there are a number of residents who require the assistance of 2 staff for transfers as well as residents who frequently activate their call lights and require a lot of time to get ready in the morning or in bed in the evening. CNA-H was aware of another resident who didn't get a shower because there were 2 showers scheduled on the AM shift and not all nurses provide assistance. CNA-H indicated management has been assisting more lately. On 9/9/25 at 3:34 PM, Surveyor interviewed CNA-G who documented R3's shower refusal on 9/4/25. CNA-G indicated R3 likes to shower before 8:30 PM. CNA-G stated CNA-G got to R3 too late and R3 wanted to be transferred to bed. CNA-G asked the nurse what to do and then documented that R3 refused. CNA-G indicated if CNA-G had gotten to R3 earlier, R3 probably would have taken a shower.2. From 9/8/25 to 9/10/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including paranoid schizophrenia, generalized anxiety disorder, and chronic pain. R1's MDS assessment, dated 8/29/25, had a BIMS score of 15 out of 15 which indicated R1 had intact cognition. R1 was R1's own decision maker.A care plan, dated 4/19/25, indicated R1 had an ADL self-care performance deficit related to disease process mononeuropathy and chronic obstructive pulmonary disease (COPD). The care plan contained an intervention, dated 8/12/25, for bathing/showering assistance of 1 staff. Provide sponge bath when a full bath or shower cannot be tolerated. R3's Kardex (an abbreviated care plan used by nursing staff) indicated R3's baths were scheduled on the Tuesday and Friday PM shifts. On 9/8/25 at 10:57 AM, Surveyor interviewed R1 who indicated staff do not always wash R1 in the morning and do not always provide a second bed bath per week per R1's preference. R1 indicated R1 does not like to use the shower.Surveyor reviewed R1's bathing documentation for June 2025 to the present and noted the following:~ In June 2025, CNA documentation indicated R1 received 5 full bed baths. Four scheduled days indicated NA.~ In July 2025, CNA documentation indicated R1 received 2 full bed baths. Four scheduled days indicated NA and 2 days were blank.~ In August 2025, CNA documentation indicated R1 received 7 full bed baths. Two days indicated NA. ~ In September 2025, CNA documentation indicated R1 received 1 full bed bath. Two days indicated NA.On 9/10/25 at 11:54 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated DON-B attempted to educate staff in the past that NA should not be used for documentation. DON-B indicated if staff aren't able to shower a resident due to time constraints, they should let the resident know, ask the nurse to chart what occurred, and inform the resident the shower will be offered on the next shift or the next day. DON-B confirmed DON-B was aware that R3 didn't receive a shower and stated DON-B would look into it.

Based on staff interview and record review, the facility did not ensure a Power of Attorney for Healthcare (POAHC) document was accurate for 1 resident (R) (R1) of 14 sampled residents.R1's POAHC document was not in accordance with R1's wishes. The facility did not review the document with R1 to ensure accuracy.Findings include:From 9/8/25 to 9/10/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including paranoid schizophrenia, generalized anxiety disorder, congestive heart failure, and chronic pain. R1's Minimum Data Set (MDS) assessment, dated 8/29/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. R1 was R1's own decision maker.On 9/8/25, Surveyor reviewed a POAHC document signed by R1 on 6/8/12 that contained the names of POAHC-D, POAHC-E, and POAHC-F. Surveyor reviewed the contact list in R1's medical record and noted POAHC-D, POAHC-E, and POAHC-F were not on R1's contact list.On 9/9/25 at 10:48 AM, Surveyor interviewed R1 regarding the POAHC document. When Surveyor informed R1 of the individuals named in the document and asked if R1 still wanted those individuals to make decisions for R1, R1 indicated R1 was no longer friends with POAHC-D, and POAHC-E and was not sure about POAHC-F. R1 indicated R1 would like a different individual added who visits R1 regularly. R1 indicated the facility did not review the document with R1 to ensure accuracy.On 9/9/25 at 11:34 AM, Surveyor interviewed Social Services Designee (SSD)-C who was not aware that R1's POAHC document was inaccurate. SSD-C indicated SSD-C does not review POAHC documents with residents at any set intervals.On 9/10/25 at 2:14 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed residents' POAHC documents should be accurate.

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of disease and infection for 6 residents (R) (R6, R8, R9, R10, R11, and R4) of 12 sampled residents observed during medication administration. On 10/16/24, Licensed Practical Nurse (LPN)-D did not complete hand hygiene during medication administration for R6, R8, R9, and R10. On 10/16/24, Registered Nurse (RN)-E did not sanitize the blood pressure cuff between use for R11 and R4. Findings include: The facility's Hand Hygiene policy, dated 1/16/23, 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 .Using Alcohol-Based Hand Gel: .c. Before preparing or handling medications; d. Before applying gloves and after removing gloves or other PPE. The Centers for Disease Control and Prevention (CDC) website's Guideline for Disinfection and Sterilization in Healthcare Facilities, dated 2008, indicates: .Medical equipment surfaces (e.g., blood pressure cuffs, stethoscopes, hemodialysis machines, and X-ray machines) can become contaminated with infectious agents and contribute to the spread of health-care-associated infections. For this reason, non-critical medical equipment surfaces should be disinfected with an Environmental Protection Agency (EPA)-registered low or intermediate-level disinfectant. Use of a disinfectant will provide antimicrobial activity that is likely to be achieved with minimal additional cost or work .4. Selection and Use of Low-Level Disinfectants for Noncritical Patient-Care Devices: .Disinfect non-critical medical devices (e.g., blood pressure cuff) with an EPA-registered hospital disinfectant using the label's safety precautions and use directions. On 10/16/24 at 12:00 PM, Surveyor observed LPN-D prepare medication for R6. LPN-D did not complete hand hygiene prior to medication preparation. On 10/16/24 at 12:10 PM, Surveyor observed LPN-D prepare medication for R8. LPN-D donned and doffed gloves during medication preparation but did not complete hand hygiene prior to glove application or after glove removal. On 10/16/24 at 12:15 PM, Surveyor observed LPN-D prepare medication for R9. LPN-D donned and doffed gloves during medication preparation but did not complete hand hygiene prior to glove application or after glove removal. On 10/16/24 at 12:20 PM, Surveyor observed LPN-D prepare medication for R10. LPN-D donned and doffed gloves during medication preparation but did not complete hand hygiene prior to glove application or after glove removal. On 10/16/24 at 12:25 PM, Surveyor observed RN-E during medication administration. Surveyor noted RN-E took R11's blood pressure and did not sanitize the blood pressure cuff after use. RN-E then took R4's blood pressure with the same cuff and did not sanitize the cuff after use. Surveyor noted R4 was on evidence-based precautions (EBP) for infection and had an indwelling catheter. On 10/16/24 at 12:20 PM, Surveyor interviewed LPN-D who indicated LPN-D usually completed hand hygiene before and after glove application and before medication preparation. LPN-D indicated LPN-D was nervous and forgot to perform hand hygiene. On 10/16/24 at 1:32 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated DON-B expects nursing staff to complete hand hygiene before and after medication preparation and before and after donning and doffing gloves per the facility's policy. DON-B also verified DON-B expects staff to sanitize equipment between residents if EBP are in place.

Based on observation, staff interview, and record review, the facility did not ensure all drugs and biologicals were stored in accordance with the facility's policy when 1 of 2 medication carts was observed unlocked and unattended during medication pass. This practice had the potential to affect more than 4 of the 31 residents residing in the facility. On 10/16/24, the 100 wing medication cart was left unlocked and unattended during medication administration for 3 residents (R) (R6, R7, and R4). Findings include: The facility's Administering Medications policy, dated 1/2024, indicates: To ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations .Procedure: .18. Medications will remain secured in a locked cabinet/cart unless in direct view of the individual administering the medication. The facility's Medication Storage policy, dated 2/2024, indicates: To ensure medications and biological are stored in a safe, secure storage and safe handling .General Guidelines: .7. Compartments containing medications should be locked when not in use. Trays or carts used to transport such items should not be left unattended. On 10/16/24 at 12:00 PM, Surveyor observed Licensed Practical Nurse (LPN)-D leave a medication cart unlocked and unattended in the hallway with the drawers exposed during medication pass for 3 of 12 residents. On 10/16/24 at 12:20 PM, Surveyor interviewed LPN-D who verified the medication cart should not be left open when unattended. LPN-D stated LPN-D usually locked the cart but forgot that day. On 10/16/24 at 1:32 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed medication carts should be locked when unattended.

Based on staff interview and record review, the facility did not provide pharmaceutical services to ensure an allergy was conveyed prior to a medication order for 1 resident (R) (R1) of 12 sampled residents. R1 had an allergy to Zofran which was documented in R1's hospital discharge summary and the facility's admission orders. R1 was administered Zofran on 9/6/24 and 9/7/24. Findings include: The facility's Administering Medications policy, dated 1/2024, indicates: To ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations .Procedure: 4. Medications shall be administered per provider's written/verbal orders upon verification of the right medication, dose, route, time, and positive verification of the resident's identity when no contraindications are identified, and the medication is labeled according to accepted standards. On 10/16/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including cerebrovascular accident (stroke), neuropathic pain, and dysphagia. R1's Minimum Data Set (MDS) assessment, dated 6/11/24, stated R1's Brief Interview for Mental Status (BIMS) score was 0 out of 15 which indicated R1 had severe cognitive impairment. R1 had a guardian for healthcare decisions. R1's medical record and a hospital discharge summary, dated 6/7/24, indicated R1 was allergic to Zofran with side effects of headache and dizziness. On 9/6/24, a nurse notified Medical Doctor (MD)-F that R1 had nausea. MD-F ordered Zofran and was not informed by the nurse that R1 had an allergy to Zofran. R1 was provided a dose of Zofran on 9/6/24 and 9/7/24. On 10/16/24 at 11:15 AM, Surveyor interviewed Registered Nurse (RN)-E who indicated medication orders should be reviewed for allergies when staff are on the phone with the MD. RN-E indicated if an order was given and a concern was identified, RN-E would call the MD back to clarify the order. RN-E indicated allergies are listed in red at the top of the medication page and said RN-E hoped the pharmacy would catch the order prior to providing the medication. On 10/16/24 at 11:25 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-D who indicated nurses should provide the MD with a list of residents' allergies when they receive telephone orders. On 10/16/24 at 11:31 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated nurses should verify a resident is not allergic to a medication when they receive a medication order. DON-B verified the facility's medical record system should alert nurses to allergies when a medication order is entered. On 10/16/24 at 12:27 PM, Surveyor interviewed MD-F who did not recall the telephone conversation with the nurse who reported R1's nausea. MD-F indicated if MD-F was aware of the allergy, MD-F would have prescribed a different medication.

Based on observation, staff and resident interview, and record review, the facility did not ensure 1 resident (R) (R3) of 4 sampled residents had a call light within reach. On 10/16/24, R3 was observed in R3's room without a call light within reach. Findings include: On 10/16/24, Surveyor requested the facility's call light policy which was not provided. On 10/16/24, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] with diagnoses including spastic quadriplegic cerebral palsy, generalized anxiety disorder, unspecified behavioral and emotional disorders, unspecified intellectual disabilities, muscle wasting and atrophy, and cognitive communication deficit. R3's Minimum Data Set (MDS) assessment, dated 7/3/24, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R3 had intact cognition. R3's pain care plan, dated 6/30/24, contained interventions to assist R3 to meet needs, maintain safety, and keep R3's call light within reach. On 10/16/24 at 10:45 AM, Surveyor observed R3 in a wheelchair in the middle of R3's room. Surveyor noted R3's call light was on the bed. When Surveyor asked if R3 could reach the call light, R3 stated, No. When Surveyor asked how R3 would get help if needed, R3 responded, I just call out. On 10/16/24 at 10:48 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-C regarding R3's call light. CNA-C saw the call light on R3's bed and placed the call light in R3's lap. On 10/16/24 at 1:32 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated a call light should be on the resident's person or near them.

Based on observation, staff interview, and record review, the facility did not ensure 3 residents (R) (R6, R7, and R4) of 12 sampled residents were assessed as able to safely and accurately self-administer medication. On 10/16/24, Surveyor observed Licensed Practical Nurse (LPN)-D leave a cup with medication on R6's bedside table. R6 did not have a physician's order or an assessment that indicated R6 could self-administer medication. On 10/6/24, Surveyor observed Registered Nurse (RN)-E leave a cup with medication on R7's table for R7 to self-administer. R7 did not have a physician's order or an assessment that indicated R7 could self-administer medication. On 10/16/24, Surveyor observed RN-E leave cups with medication R4's table for R4 to self-administer. R4 did not have a physician's order or an assessment that indicated R4 could self-administer medication. Findings include: The facility's Administering Medications policy, dated 1/2024, indicates: To ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations .Procedure: .5. Medications may be self-administered by the resident or resident representative who have been assessed and determined to be safe and upon physician order. 1. On 10/16/24, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] with diagnoses including spinal cord dysfunction, paraplegia, diabetes, and malnutrition. R6's Minimum Data Set (MDS) assessment, dated 9/25/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R6 had intact cogitation. R6 was responsible for R6's healthcare decisions. On 10/16/24 at 12:00 PM, Surveyor observed LPN-D leave a medication cup with 10 milligrams (mg) of metoclopramide and 20 mg of baclofen on R6's bedside table. R6's medical record did not contain a self-administration of medication assessment or a physician's order to self-administer medication. 2. On 10/16/24, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] with diagnoses including diabetes, anemia, and renal failure. R7's MDS assessment, dated 9/8/24, had a BIMS score of 15 out of 15 which indicated R7 had intact cognition. R7 was responsible for R7's healthcare decisions. On 10/16/24 at 12:16 PM, Surveyor observed RN-E leave a medication cup with 25 mg of Hydralazine and 125 mg of vitamin D3 on R7's table for R7 to self-administer. R7's medical record did not contain a self-administration of medication assessment or a physician's order to self-administer medication. 3. On 10/16/24, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] with diagnoses including multiple fractures, coronary artery disease, heart failure, and cerebral vascular accident (stroke). R4's MDS assessment, dated 8/23/24, had a BIMS score of 15 out of 15 which indicated R4 had intact cognition. R4 was responsible for R4's healthcare decisions. On 10/16/24 at 12:18 PM, Surveyor observed RN-E leave medication cups with 325 mg of iron sulfate, 625 mg of Fiber-Lax, 1 mg of folic acid, and 10 milliliters (ml) of sucralfate on R4's table for R4 to self-administer. R4's medical record did not contain a self-administration of medication assessment or a physician's order to self-administer medication. On 10/16/24 at 1:32 PM, Surveyor interviewed Director of Nursing (DON)-B who verified R6, R7, and R4 were not assessed as able to safely and accurately self-administer medication and did not have a physician's order to do so.

Based on observation, staff interview, and record review, the facility did not ensure staff performed proper hand hygiene for 1 resident (R) (R2) of 3 residents observed during the provision of care. Registered Nurse (RN)-C did not perform appropriate hand hygiene during care for R2 on 7/22/24. Findings include: The facility's Hand Hygiene policy, with a revision date of 1/16/23, indicates: To provide guidelines to staff for proper and appropriate hand washing and hygiene techniques that will aide in the prevention of the transmission of infections .2. The use of gloves does not replace hand hygiene. 3. Hand hygiene is always the final step after removing and disposing of personal protective equipment (PPE). In addition, the policy indicates staff should perform hand hygiene under the following conditions: Before applying gloves and after removing gloves; After handling items potentially contaminated with blood, body fluids, or secretions; Before moving from a contaminated body site to a clean body site during resident care. On 7/22/24, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease. R2 had open areas on both buttocks from moisture-associated skin damage (MASD) which put R2 at high risk for infection and required enhanced barrier precautions (EBP) to prevent unintended transfer of infectious disease. On 7/22/24 at 1:21 PM, Surveyor observed RN-C provide wound care to the open areas on R2's buttocks. Surveyor observed RN-C remove the old dressing from R2's right buttock (there was not a dressing on the left buttock). Without changing gloves and cleansing hands, RN-C cleansed both buttocks with a wipe and removed RN-C's gloves. RN-C then applied new gloves, put zinc paste on the open areas on R2's left and right buttocks, and removed an absorbent pad soiled with blood. Without changing gloves and cleansing hands, RN-C applied clean dressings to R2's left and right buttocks, secured both dressings with tape, and gathered used supplies including R2's old dressing. RN-C then covered R2 with a blanket and put the used supplies in the garbage. RN-C repositioned R2 with the help of Director of Nursing (DON)-B and then removed RN-C's PPE and cleansed hands. On 7/22/24 at 1:42 PM, Surveyor interviewed RN-C who verified RN-C should have changed gloves and completed hand hygiene between glove changes when done with dirty before going to clean. RN-C verified RN-C missed hand hygiene opportunities in the above observation. On 7/24/24 at 10:36 AM, Surveyor interviewed DON-B who verified staff should change gloves between dirty and clean tasks and complete hand hygiene in between glove changes.

Based on staff and resident interview, and record review, the facility did not ensure 2 residents (R) (R9 and R434) of 4 sampled residents received the necessary care and services to prevent and/or monitor weight loss. R9 had an order to be weighed 3 times per week. R9's weights were not completed in accordance with the physician's order. In addition, R9 experienced a significant weight loss of 14.29% from 3/22/24 to 7/2/24. R434 was admitted to the facility on [DATE] and had an order for weights to be completed for the first 7 days after admission and one time a day every Monday, Wednesday, and Friday. R434's weights were not completed in accordance with the physician's order. Findings Include: The facility's Resident Height and Weight policy, with a revision date 7/7/23, indicates: A significant weight change is defined as a 5% weight change over 30 days, 7.5% weight change over 90 days, or a 10% weight change over 180 days .Upon admission and two days following, the nursing department staff will weigh the resident on the appropriate scale weekly for 4 weeks and then monthly unless otherwise ordered by the physician, recommended by the Dietitian, or the resident's medical condition requires .Weekly or monthly weights are recommended if any of the following are present .significant unplanned weight loss in 30, 90, or 180 days .gradual unplanned weight loss over multiple months .unstable congestive heart failure (CHF) or significant edema. 1. From 7/22/24 through 7/24/24, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] and had diagnoses including type 2 diabetes mellitus with diabetic polyneuropathy, abnormal weight loss, edema, unspecified dementia with psychotic disturbance, and unspecified protein-calorie malnutrition. R9's Minimum Data Set (MDS) assessment, dated 5/3/24, had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R9 had moderate cognitive impairment. R9's medical record indicated R9 weighed 199.5 pounds on 3/22/24 and 171 pounds on 7/2/24 which indicated R9 had a significant weight loss of 14.29% over a 14 week (102 day) period. R9 had a physician's order, dated 2/20/24, to be weighed on Monday and Friday which was revised on 6/6/24 to Tuesday, Thursday, and Saturday. R9's medical record contained the following weights: ~ Week of 7/21/24 - 7/24/24: No weights recorded ~ Week of 7/14/24 - 7/20/24: No weights recorded ~ Week of 7/7/24 - 7/13/24: No weights recorded ~ Week of 6/30/24 - 7/6/24: 7/2/24 - 171 pounds ~ Week of 6/23/24 - 6/29/24: 6/28/24 - 167 pounds ~ Week of 6/9/24 - 6/15/24: 6/15/24 - 164 pounds; 6/13/24 - 163 pounds ~ Week of 4/21/24 - 4/27/24: No weights recorded ~ Week of 4/7/24 - 4/13/24: 4/12/24 - 189 pounds ~ Week of 3/24/24 - 3/30/24: 3/29/24 - 189.5 pounds ~ Week of 3/17/24 - 3/23/24: 3/22/24 - 199.5 pounds; 3/22/24 - 199.5 pounds On 7/24/24, Surveyor reviewed R9's treatment administration record (TAR) which contained several entries for R9's weights coded 9 for See progress note. R9's progress notes did not contain documentation regarding R9's weights. On 7/24/24 at 11:34 AM, Surveyor interviewed Director of Nursing (DON)-B who stated staff should weigh newly admitted residents on the day of admission, 2 days after, weekly for 4 weeks, and then monthly. DON-B stated if a resident has certain medical issues, weights should be completed daily unless otherwise specified by the physician. DON-B stated R9 frequently refused weights which nurses should record in the TAR. DON-B stated code 9 in the TAR indicates the nurse should have entered a progress note with the rationale for why R9's weight was not obtained. DON-B acknowledged nursing staff did not consistently enter progress notes and put Per DON in progress notes. DON-B stated staff are supposed to give the weights to DON-B to enter so DON-B can ensure there are no discrepancies. DON-B stated if weights aren't turned in, DON-B is unaware they should have been completed. DON-B verified there were issues with the current process. 2. From 7/22/24 through 7/24/24, Surveyor reviewed R434's medical record. R434 was admitted to the facility on [DATE] with diagnoses including fracture of lower end of left femur, anemia, morbid obesity due to excessive calories, type 2 diabetes, and dyskinesia of esophagus. R434's MDS assessment, dated 7/22/24, had a BIMS score of 15 out of 15 which indicated R434 had intact cognition. A Nurse Practitioner (NP) note, dated 7/19/24, indicated R434 struggled with fluid overload and edema during and post hospitalization . The note also stated R434's home weight was approximately 211 pounds. R434 had a physician's order, dated 7/19/24, for weights one time a day for 7 days and one time a day Monday, Wednesday, and Friday for CHF. R434's initial admit weight on 7/18/24 was 230.5 pounds. No additional weights were recorded in R434's medical record. On 7/22/24 at 11:28 AM, Surveyor interviewed R434 who stated R434 did not have a bowel movement in over a week and had a history of edema. R434 denied having been weighed since the day R434 was admitted . On 7/24/24 at 11:34 AM, Surveyor interviewed DON-B who stated residents should be weighed on the day of admission, 2 days after, weekly for 4 weeks, and then monthly. DON-B stated if a resident has certain medical issues, such as CHF, weights should be completed daily unless otherwise specified by the physician. DON-B stated R434 should have been weighed daily per the physician's order. DON-B acknowledged R434 should have been weighed multiple times following R434's initial weight.

Based on observation, staff and resident interview, and record review, the facility did not ensure necessary care and services were provided to prevent pressure injuries from developing or worsening and/or promote healing for 2 Residents (R) (R10 and R30) of 4 sampled residents. R10 was admitted to the facility following a fall that resulted in a right hip fracture. R10 was assessed to be at risk for the development of pressure injuries. Interventions to elevate and protect R10's heels were not initiated until R10 developed suspected deep tissue injuries (DTIs) (areas of soft tissue damage due to pressure or shear which are anticipated to evolve into a deep PI, but have not yet done so. The affected skin is discolored purple or maroon, may be painful, firm, mushy, boggy, and warmer or cooler than adjacent skin. The wound may further evolve and become covered by eschar characterized by dark, crusty tissue at either the bottom or the top of a wound) to both heels approximately 3 weeks after admission. This example was cited at a level G (Actual Harm/Isolated). R30 developed a pressure injury to the coccyx after admission. Staff did not ensure interventions were followed to prevent the development of further pressure injuries. During multiple observations, R30's heels were not ofloaded with pillows or protective boots. Findings include: The facility's Pressure Injury Prevention and Wound Care Management policy, revised 2/24/23, contained the following information: Purpose: The purpose of the policy is to provide healthcare staff with the standards of care, and processes to be followed for all residents. *To identify factors that place residents at risk for the development of pressure injuries and to implement appropriate interventions to prevent the development of clinically avoidable wounds. *To promote a systemic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown. Procedure: Risk Identification and Assessment: 3. Risk factors identified by the Braden Scale, MDS (Minimum Data Set), or other assessment should be reviewed and addressed as determined appropriate through the RAI (Resident Assessment Instrument) process, including the resident's care plan. These risk factors include but are not limited to; b. Impaired or decreased mobility and functional ability d. Comorbid conditions J. Resident refusal of some aspects of care and treatment 1. During an initial tour of the facility on 6/12/23, Surveyor noted R10's door had a sign that indicated R10 was on contact precautions (implemented when residents have an infection that can be spread by contact with the skin including mucous membranes, feces, vomit, urine, wound drainage or other body fluids). Surveyor asked staff about the sign and was told R10 had infected sores on R10's heels. From 6/12/23 through 6/14/23, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] with diagnoses that included fracture of unspecified part of right femur (thigh bone), muscle weakness, other reduced mobility, and pain in right hip. R10's Admission MDS assessment, dated 3/14/23, contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R10 was not cognitively impaired. R10 required extensive assistance of staff for activities of daily living (ADLs), including bed mobility, transfers and personal hygiene, and had limited range of motion to the right lower extremity. R10 was at risk for the development of pressure injuries and was not on a turning/repositioning program. R10's admission skin assessment, dated 3/8/23, indicated R10 did not have any pressure injuries. R10's plan of care indicated R10 was at risk for alteration in skin integrity related to impaired mobility status post right hip fracture. A care plan, initiated on 3/9/23, contained the following intervention: ~Float my heels and use heel suspension boots while I am in bed (initiated on 3/29/23). A Mini-Nutritional Assessment (MNA)/Summary was completed on 3/9/23. R10 scored 8 out of 14 on the assessment which indicated R10 was at risk for malnutrition. A Registered Dietitian-Nutrition Assessment was also completed on 3/9/23. The summary indicated an ordered diet would be provided and R10 would be monitored for the need for dietary interventions. A nursing note, dated 3/12/23, indicated R10 was a one assist with transfers, made R10's needs known, stayed in bed all day and refused to get up. A nursing note, dated 3/19/23, indicated R10 liked to spend the majority of R10's time in bed, but got up in a wheelchair at times. A nursing note, dated 3/25/23, indicated R10 needed encouragement to get up and sit in chair. A nursing note, dated 3/27/23, indicated R10 required extensive assistance of staff with ADLs and didn't assist staff with washing up or turning. A nursing note, dated 3/28/23, indicated R10 liked to spend the majority of R10's time in bed, but got up in a wheelchair at times with much encouragement. A nursing note, dated 3/28/23, indicated R10 had weeping from the heel/foot area and heels that were mushy, and dark purple/black in color with scabbed areas on the outer edges. R10's feet were propped up on pillow at the time of the check and R10 stated, I don't like to have them up at all. Surveyor reviewed R10's medical record from 3/8/23 (the date of admission) until 3/28/23 when staff discovered R10's bilateral heel pressure injuries. Prior to 3/28/23, there were no documented pressure injury preventative interventions in place other than an alternating air mattress at the time of admission. In addition, R10's medical record did not contain documentation that additional offloading interventions were offered prior to R10 developing the bilateral heel pressure injuries. R10's TAR (Treatment Administration Record) contained an order, dated 4/4/23, to float heels off of bed every shift. On 6/13/23 at 2:03 PM, Surveyor observed R10's heels during wound care completed by two nurses, including Wound Care Certified Nurse (WCCN)-D. Following the observation, Surveyor interviewed WCCN-D who stated R10's pressure injuries were facility-acquired. When Surveyor asked what offloading interventions were put in place upon admission, WCCN-D stated R10 did not have protective boots until R10 developed the pressure injuries and R10's heels were not always floated off the mattress. WCCN-D stated R10's pressure injuries were found when a CNA (Certified Nursing Assistant) provided care and noticed blood on the sheet under R10's feet. WCCN-D stated R10 had an air mattress in place upon admission and indicated the development of pressure injuries to R10's heels didn't look good. Heel wound measurements on 6/12/23 were documented as follows: ~Left heel: 4.7 cm (centimeters) in length x 1.6 cm in width with depth documented as n/a ~Right heel: 4.2 cm in length x 2.8 c. in width with depth documented as n/a On 6/13/23 at 3:25 PM, Surveyor interviewed LPN (Licensed Practical Nurse)-J who completed R10's admission skin assessment on 3/8/23. LPN-J verified R10 did not have pressure injuries on R10's heels upon admission. LPN-J stated LPN-J made it a point to check residents' heels upon admission. LPN-J verified R10 was not issued protective heel boots upon admission. LPN-J verified a CNA notified LPN-J on 3/28/23 there was blood on R10's sheet near R10's feet. On 3/28/23, LPN-J took a picture of one heel, but was unable to get a picture of the other heel because R10 was in bed at the time. On 3/28/23, LPN-J put foam dressings on R10's heels, applied protective boots, and updated WCCN-D. On 6/13/23 at 3:32 PM, Surveyor interviewed CNA-K who verified CNA-K observed blood on R10's sheet near R10's feet. CNA-K could not recall the date of the observation, but stated CNA-K notified LPN-J. CNA-K did not recall R10 having protective heel boots prior to developing the pressure injuries. On 6/14/23 at 1:49 PM, Surveyor interviewed ROM (Regional Operations Manager)-C regarding offloading interventions staff used to protect R10's heels from breakdown from 3/8/23 until the pressure injuries were discovered on 3/28/23. ROM-C reviewed R10's medical record and stated R10 had an alternating air mattress on R10's bed. On 6/14/23 at 8:41 AM, Surveyor interviewed R10 who verified R10 did not have bilateral heel pressure injuries when R10 was admitted to the facility. R10 stated initially staff did not offer R10 protective heel boots and did not offload R10's heels with a pillow until after the pressure injuries were discovered. R10 stated R10 would have allowed R10's heels to be elevated off the mattress if staff offered. A fax to MD (Medical Doctor)-G, dated 3/29/23, indicated R10 had two intact DTIs on the right heel and one intact DTI on the left heel. The fax stated R10 had an air mattress and now wore heel boots in bed. Staff asked for orders to apply a daily dry dressing followed by Kerlix wrap and monitor for healing/opening. Despite the fact interventions (aside from an air mattress) weren't in place to protect R10's heels from 3/8/23 until 3/28/23, MD-G signed a statement on 3/29/23 that stated R10's pressure injuries were unavoidable due to non-compliance with turning/repositioning. A nursing note, dated 4/11/23, contained the following information: .New in house acquired DTIs to bilateral heels. New treatment order noted for dry dressing and wrap with Kerlix. Care plan updated for heel suspension boots and float heels .Care plan interventions: Skin care plan updated: LAL (low air loss) mattress, pressure relieving cushion for (wheelchair), ProHeal supplement for healing, heel boots and floating heels. Will initiate repositioning schedule. A nursing note, dated 4/12/23, contained the following information: Received orders from MD-G to discontinue treatment to heels. Betadine paint to bilateral eschar area daily and cover with dry dressing. A nursing note, dated 4/13/23, indicated R10's heels opened and orders were obtained from Advanced Practice Nurse Prescriber (APNP)-M for Xeroform (a fine mesh gauze occlusive dressing that maintains a moist wound environment) with bordered gauze to open areas of heels. Change daily and PRN (as needed). A fax to MD-G, dated 5/3/23, requested an order for R10 to be seen by the wound clinic. A consultation report from Wound Clinic Wound Nurse Practitioner (WNP)-L, dated 5/15/23, contained the following information: -Unstageable bilateral heel ulcers; Xeroform as a contact layer and ABD (abdominal) (a non-woven, thick, absorbent pad)/kling (absorbent gauze which clings to itself when wrapped); change daily and PRN; Continue offloading boots and offloading program; Consult placed to podiatry for debridement (surgical removal of necrotic, infected and non-healing tissue from the wound base); Follow up as needed. On 6/14/23 at 8:58 AM, Surveyor interviewed WNP-L who stated R10 had nasty heel ulcers and the eschar was too extensive for WNP-L to debride so R10 was referred to podiatry. WNP-L stated R10 was skin and bones, but offloading and good nutrition would have helped protect R10's heels. On 6/14/23 at 12:17 PM, Surveyor interviewed APNP-M who completed a compliance visit on 4/13/23 and noted R10 had dressings on both heels. APNP-M stated R10 declined to have the dressings removed so APNP-M could observe R10's heels. APNP-M stated R10's albumin (a protein) (abnormal levels of albumin can cause health problems and be signs of other issues such as kidney and liver disease) was low and could play a role in skin breakdown. APNP-M also stated not elevating R10's heels could play a significant role as well. A nursing note, dated 5/16/23, indicated R10's pressure injuries increased in size and contained more moisture. A podiatry consultation report, dated 5/22/23, stated R10 had stable eschar on both heels and was scheduled for surgical debridement on 6/1/23. The report contained orders for no bandages and to keep R10's heels offloaded/floated with a pillow. A podiatry consultation report, dated 6/1/23, indicated surgical debridement was performed on R10's heels and contained the following orders: -Leave dressings intact until follow up appointment with wound clinic. -Non-weight bearing to both feet. A wound clinic consultation report, dated 6/7/23, indicate a wound culture of R10's pressure injuries tested positive for pseudomonas (an MDRO (multidrug-resistant organism) and extensively drug-resistant bacteria that may be hard to treat because the bacteria may not respond to antibiotics) and contained the following orders: -Five minute acetic acid soaks; pat dry; apply adaptic, ABD and Kerlix; complete daily. -Doxycycline (an antibiotic) 100 mg (milligrams) BID (twice daily) for 2 weeks. -House protein supplement BID. -Follow up in 2 weeks. -Infectious Disease consult. A nursing note, dated 6/8/23, stated R10 was placed in contact isolation. A nursing note, dated 6/12/23, stated R10 was admitted to Hospice. On 6/14/23 at 2:12 PM, Surveyor interviewed DON (Director of Nursing)-B who verified R10's pressure injuries were facility-acquired and stated the best practice was prevention. DON-B verified DON-B expected staff to identify risk factors for skin breakdown and implement interventions for residents at risk for pressure injuries. On 6/14/23 at 3:00 PM, Surveyor interviewed ROM-C who stated staff should assess the current condition of a resident and implement interventions based on the assessment. ROM-C stated a plan of care should be developed for the resident and staff should follow the plan of care. 40343 2. R30 was admitted to the facility on [DATE] with diagnoses that included diverticulitis (inflammation in parts of the digestive system), clostridium difficile (infection of the large intestine), and moderate cognitive impairment. R30 required extensive assistance of staff with most ADLs. R30's Baseline care plan, dated 5/31/23, indicated R30 did not have any skin irregularities. R30's Braden Scale for Predicting Pressure Ulcer Risk, dated 5/31/23 and 6/7/23, indicated R30 was at mild risk for skin breakdown. A progress note, dated 6/10/23 at 9:18 PM, contained the following information: CNA called writer to R30's room. Writer noted a red area and a 0.5 cm (centimeter) by 0.5 cm open area on R30's coccyx. Chamosyn with Manuka Honey (nourishing skin barrier cream) was applied. A progress note, dated 6/10/23 at 9:42 PM, stated the on-call provider was notified of the open area and treatment. A Skin and Wound Evaluation, dated 6/10/23, stated R30 had an in-house-acquired abrasion to the coccyx. An air mattress and additional interventions were implemented, including heel suspension/protection device. During an initial tour of the facility on 6/12/23 at 10:04 AM, Surveyor interviewed R30 who was in bed on an air mattress. R30 stated R30 had a sore near the rectum. Surveyor noted R30's heels were in direct contact with the mattress. Surveyor observed heel protection boots in R30's room; one boot was on R30's wheelchair and the other was on the floor beneath the wheelchair. R30 stated the boots were not really used and staff sometimes forget to elevate R30's heels. R30 stated R30 would not refuse to elevate R30's heels. On 6/12/23 at 12:46 PM, Surveyor interviewed R30's daughter who stated the air mattress was put on R30's bed the day prior (6/11/23). R30's daughter stated the coccyx wound was discovered during cares when staff wiped the area and R30 said ow. On 6/12/23 at 3:22 PM, Surveyor observed R30 in bed with a pillow between R30's knees. R30's heels were in direct contact with the mattress. On 6/13/23 at 10:45 AM, Surveyor interviewed WCCN-D who initiated the interventions for an air mattress, Chamosyn with Manuka Honey, a wheelchair cushion, a recliner cushion, repositioning, and offloading heels with pillows or boots. WCCN-D stated R30's heels should be floated on pillows or with the boots and stated R30 brought boots to the facility from the hospital. On 6/13/23 at 10:57 AM, Surveyor interviewed CNA-I who stated pressure injury prevention interventions for R30 included being up for meals, positioning side to side, and offloading heels with boots or pillows. CNA-I verified R30's heels should be offloaded when R30 was in bed. On 6/14/23 at 2:12 PM, Surveyor interviewed DON-B who stated residents should be assessed for pressure injury risk and staff should implement interventions to prevent further pressure injury development. DON-B stated the standard was to prevent, provide education, and monitor daily.

Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program based on current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of communicable disease and infection. This practice had the potential to affect all 36 residents residing in the facility. The facility did not have a system for preventing the growth and spread of Legionella in the facility's water system. The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: - Include water management team members who were knowledgeable about Legionella - Identify acceptable ranges of control limits and corrective actions when control limits are not met Findings include: The 7/6/18 revised CMS (Centers for Medicare and Medicaid Services) Quality, Safety and Oversight Letter 17-30 titled, Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD) states: Facilities must have water management plans and documentation that, at a minimum, ensure each facility: - Specifies testing protocols and acceptable ranges for control measures and documents the results of testing and corrective actions taken when control limits are not maintained. The 6/24/21 CDC (Centers for Disease Control and Prevention) Toolkit titled Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings identifies the key elements of a water management program for healthcare facilities to include: 1. Establish a water management program team. 2. Describe the building water systems using text and flow diagrams. 3. Identify areas where Legionella could grow and spread. 4. Describe where control measures should be applied and how to monitor them. 5. Establish ways to intervene when control limits are not met. 6. Make sure the program is running as designed and is effective. 7. Document and communicate all the activities. The CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings located at https://www.cdc.gov/infectioncontrol/guidelines/core-practices/index.html#anchor_72633 states: This document concisely describes a core set of infection prevention and control practices that are required in all healthcare settings, regardless of the type of healthcare provided. The practices were selected from among existing CDC recommendations and are the subset that represent fundamental standards of care that are not expected to change based on emerging evidence or to be regularly altered by changes in technology or practices and are applicable across the continuum of healthcare settings . Core Practice Category 4. Performance Monitoring and Feedback notes: 3. Train performance monitoring personnel and use standardized tools and definitions CDC Legionella Control Measures for Potable Water systems recommendation .3. Water Systems in Health-Care Facilities .b. Water Temperature and Pressure .To minimize the growth and persistence of gram-negative waterborne bacteria hot water should be stored above 140 F (Fahrenheit) (60 C (Celsius)) and circulated with a minimum return temperature of 124 F. On 6/13/23, Surveyor reviewed the facility's Water Management Program which contained the following information: - The Water Management Program will be championed by the Maintenance Director. This role will know the water system, monitor, and document control locations and limits. -7. Document and communicate .maintain records of service. - Environmental Assessment of Water Systems (Appendix A) 2. How is the hot water system configured to deliver water to each building? Indicates boiler 1 and boiler 2 usual temperature settings are 120 degrees F. On 6/14/23 at 10:09 AM, Surveyor interviewed Maintenance Director (MD)-H who verified MD-H was not aware the hot water heater (boiler) temperature needed to be 140 degrees F with a return of 126 degrees F. On 6/14/23 at 10:12 AM, Surveyor noted the hot water heater in the south boiler room which accessed resident rooms in Chase Hall was set at 120 degrees F. MD-H stated the water heater was normally set at 140 degrees F, but had pressure valve issues. MD-H stated a plumber was consulted who recommended MD-H turn the temperature down. MD-H set the temperature dial at 120 degrees F. After the part was replaced, the temperature dial was not reset to 140 degrees F. MD-H stated the boilers had dials instead of temperature gauges. Surveyor noted the boiler did not contain a temperature gauge to measure the return temperature. After the mixing valve, Surveyor also noted a temperature grid that read 112 degrees F. MD-H stated if the temperature at the temperature grid after the mixing valve was 112 degrees F and if the temperature of resident room faucets was 105-115 degrees F, that was sufficient. Surveyor also inspected the north boiler room hot water storage tank. The temperature measured 123 degrees F via the temperature gauge. On 6/14/23 at 12:00 PM, Surveyor interviewed MD-H again and verified the following: - MD-H was involved in developing the facility's Water Management Plan. - There was no documentation of hot water heater temperature settings. - There was no way to measure the return temperature of the water. - The facility did not check the pH; the city checked the pH every 3 years. - MD-H was not fully educated on the CDC guidance for water management of Legionella. - MD-H stated MD-H was sent information on Legionella last year, but only knew the basics, including that you could get sick from it and can get it from stagnant water.

Based on staff interview and record review, the facility did not provide care and services to maintain acceptable parameters of nutritional status for 1 Resident (R) (R30) of 2 residents reviewed for nutrition. R30's weight decreased 7.5 pounds from 5/31/23 through 6/9/23. R30 lost 5.34 % of R30's body weight in a nine-day period. R30's nutrition plan was not revised to add supplements after R30 lost weight and developed a pressure injury. Findings include: The facility's undated Resident Heights and Weights policy contained the following information: A significant weight change is defined as a 5% weight change over 30 days, 7.5% weight change over 90 days or a 10% weight change over 180 days .If a re-weigh verifies a significant, unplanned weight change, this is communicated to the resident's Physician, POA, Dietitian and any others deemed necessary by the Interdisciplinary team. The policy also indicates if a resident's weights identify a significant weight change, the resident's care plan is updated with interventions, including but not limited to, adding a fortified or calorie dense food/snack and/or the provision of nutritional supplements. R30 was admitted to the facility on [DATE] with diagnoses that included diverticulitis (inflammation in parts of the digestive system), clostridium difficile (infection of the large intestine), and moderate cognitive impairment. R30 had an activated Power of Attorney for Healthcare (POAHC) and required extensive staff assistance with most activities of daily living (ADLs). R30's documented weights included: 6/9/23 at 11:59 AM - 133.0 pounds 6/8/23 at 9:14 AM - 130.5 pounds 6/3/23 at 1:03 PM - 135.0 pounds 6/2/23 at 7:48 AM - 138.0 pounds 6/1/23 at 7:25 PM - 138.0 pounds 5/31/23 at 9:24 PM - 140.5 pounds 5/31/23 at 8:57 PM - 140.5 pounds R30's Baseline Nutrition Data Collection document, dated 6/1/23, stated R30 weighed 140.5 pounds and R30's weight would be monitored. R30's Registered Dietitian Nutrition Assessment, dated 6/2/23 and signed on 6/5/23, contained a weight of 138 pounds. The assessment indicated R30 did not currently have edema, but had some edema upon admission. The assessment indicated R30 was at risk for malnutrition and stated Registered Dietitian (RD)-E would provide an ordered diet and monitor for the need for dietary interventions. R30's Mini-Nutrition Assessment, dated 6/5/23, indicated R30 was at risk for malnutrition and had a moderate decrease in food intake over the past three months. A progress note, dated 6/12/23 at 8:59 AM, contained the following information: Weight Warning: 133.0 lbs; Date: 6/9/23 at 11:59 AM; -5.0% change .RD review: Weight is down 2 pounds in 1 week and 7.5 pounds since admission .R30 is on a diuretic and had bilateral lower extremity edema present upon admission which has since resolved; R30's meal intakes vary from 26-100%; Will monitor at this time. A daily skilled nursing note, dated 6/12/23 at 2:55 PM, contained the following information: .R30 up at lunch time briefly, back to bed, offloading with pillow; Participated in therapies; Appetite is fair; Offered snacks left at bedside . On 6/13/23 at 2:45 PM, Surveyor interviewed RD-E who stated RD-E spoke with R30's POAHC who stated 133 pounds was R30's baseline weight. RD-E stated RD-E watched R30's weight every day, but verified R30 was not weighed daily. RD-E stated R30's last weight was obtained on 6/9/23. RD-E stated RD-E does not always start supplements for residents because then residents might not eat their meals. RD-E stated RD-E would not order a supplement unless R30 was below R30's baseline weight of 133 pounds. On 6/13/23 at 2:55 PM, Surveyor interviewed Medical Doctor (MD)-G who indicated some of R30's weight loss could be attributed to edema, but was probably a combination of edema and nutrition. MD-G stated MD-G would have ordered a protein supplement for R30 based on weight loss and the development of a pressure injury. Director of Nursing (DON)-B stated to Surveyor that DON-B looked for but could not find a nutrition services policy.

Based on staff interview and record review, the facility did not ensure a physician was notified of a change in weight for 1 Resident (R) (R30) of 2 residents reviewed for nutrition. R30's weight decreased 7.5 pounds from 5/31/23 through 6/9/23. R30 lost 5.34% of R30's body weight in a nine-day period. R30's physician was not notified of the weight loss. Findings include: The facility's undated Resident Heights and Weights policy contained the following information: A significant weight change is defined as a 5% weight change over 30 days, 7.5% weight change over 90 days or a 10% weight change over 180 days .If a re-weigh verifies a significant, unplanned weight change, this is communicated to the resident's Physician, POA (Power of Attorney), Dietitian and any others deemed necessary by the Interdisciplinary team. The facility's Change in Condition policy, revised 7/6/21, contained the following information: .2. Specific information that requires a prompt notification includes, 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 three months or 10% or more in past six months). R30 was admitted to the facility on [DATE] with diagnoses that included diverticulitis (inflammation in parts of the digestive system), clostridium difficile (infection of the large intestine), and moderate cognitive impairment. R30 had an activated Power of Attorney for Healthcare (POAHC) and required extensive staff assistance with most activities of daily living (ADLs). R30's documented weights included: 6/9/23 at 11:59 AM - 133.0 pounds 6/8/23 at 9:14 AM - 130.5 pounds 6/3/23 at 1:03 PM - 135.0 pounds 6/2/23 at 7:48 AM - 138.0 pounds 6/1/23 at 7:25 PM - 138.0 pounds 5/31/23 at 9:24 PM - 140.5 pounds 5/31/23 at 8:57 PM - 140.5 pounds R30's Baseline care plan, dated 5/31/23, documented R30's dietary goal was to maintain R30's current weight. R30's Baseline Nutrition Data Collection document, dated 6/1/23, stated R30 weighed 140.5 pounds and R30's weight would be monitored. On 6/13/23 at 2:45 PM, Surveyor interviewed RD-E who stated the physician was not updated regarding R30's recent weight loss. RD-E stated RD-E spoke with R30's POA and was told 133 pounds was R30's baseline weight. RD-E stated the last weight for R30 was on 6/9/23. RD-E stated RD-E does not always start supplements for residents because then residents might not eat their meals. RD-E stated RD-E would not order a supplement unless R30 was below R30's baseline weight of 133 pounds. On 6/13/23 at 2:55 PM, Surveyor interviewed Medical Doctor (MD)-G who stated some of R30's weight loss could be attributed to edema, but was probably a combination of edema and nutrition. MD-G stated if MD-G was notified of the weight loss, MD-G would have ordered a protein supplement for R30 based on the weight loss and the development of a pressure injury. On 6/14/23 at 9:45 AM, Surveyor interviewed Director of Nursing (DON)-B who stated R30's physician should have been notified of R30's weight loss according to the facility's policy and procedure.

Based on staff interview and record review, the facility did not ensure pharmacy recommendations were addressed by a physician for 2 Residents (R) (R3 and R6) of 5 residents reviewed. Two out of three pharmacy recommendations for R3 did not contain a response from R3's physician. Two out of six pharmacy recommendations for R6 did not contain a response from R6's physician. Findings include: The facility's Medication Regimen Review policy, dated of 3/6/19, contained the following information: .6. Any irregularities will be communicated to the physician utilizing a written recommendation and report for consideration. 1. R3 was admitted to the facility on [DATE] with diagnoses that included post traumatic stress disorder (PTSD), generalized anxiety disorder, paranoid schizophrenia, and major depressive disorder. On 10/26/22, the pharmacy reviewed R3's medications and recommended a dose reduction for the following psychotropic medications: ~temazepam (a benzodiazepine) 15 mg (milligrams) by mouth at bedtime for insomnia ~diazepam (a benzodiazepine) 2.5 mg by mouth three times daily for muscle spasticity ~quetiapine IR (an antipsychotic) 150 mg by mouth at bedtime for schizophrenia ~quetiapine ER 200 mg by mouth at bedtime for schizoaffective disorder ~duloxetine (an antidepressant) 120 mg by mouth once daily for depression On 12/28/22, the pharmacy recommended a dose reduction for the same psychotropic medications listed in the 10/26/22 pharmacy recommendation. On 6/14/22, the facility was unable to provide documentation that a physician responded to the pharmacy's recommendations. 2. R6 was admitted to the facility on [DATE] with diagnoses that included bipolar II disorder, borderline personality disorder, other low back pain, generalized edema, and other specified anxiety disorder. On 4/26/23, the pharmacy recommended a dose reduction for the following psychotropic medications: ~olanzapine (an antipsychotic) 10 mg by mouth at bedtime for bipolar disorder ~venlafaxine ER (an antidepressant) 225 mg by mouth once daily related to borderline personality disorder ~lamotrigine (an anticonvulsant) 0.5 mg by mouth twice daily for bipolar disorder. The recommendation also asked the physician to provide a rationale for extending the use of PRN (as needed) lorazepam (an anxiolytic) for anxiety beyond 14 days. On 5/24/23, the pharmacy again recommended the physician provide a rationale for extending the use of PRN lorazepam for more than 14 days. On 6/14/23, the facility was unable to provide documentation that a physician responded to the recommendations. On 6/14/23 at 11:31 AM, Surveyor interviewed Director of Nursing (DON)-B who worked at the facility for approximately three weeks. DON-B stated DON-B was unsure what previous staff did with the recommendations. DON-B stated there was confusion regarding who received pharmacy recommendations when they were sent to the facility. DON-B stated DON-B expected staff to provide timely follow up and indicated the facility will implement a new process to ensure pharmacy recommendations are addressed by a physician.

Based on staff interview and record review, the facility did not ensure rights were exercised by the appropriate decision-maker prior to and after findings of incapacity for 1 Resident (R1) of 3 sampled residents. The facility did not ensure R1, who did not have an activated Power of Attorney (POA) for healthcare, signed R1's own form designating who R1 wanted to have access to R1's medical information regarding changes in R1's care plan, medication, and physical status. Information was released to Family Member (FM)-D who was listed on the form. In addition, the facility disclosed R1's financial information to FM-D without POA for finance documentation that named FM-D or a financial information release. Findings include: 1. On 3/27/23, Surveyor reviewed R1's medical record which documented R1 did not have an activated POA for healthcare and was responsible for R1's own decision making at the time of admission on 11/11/22. R1's Notification of Change and Release of Information document indicated information regarding care plan changes, medications, and physical status could be released to R1's spouse (POA-E) and FM-D. The document also indicated financial information, room changes, and discharge planning could be discussed with POA-E. The form was signed by POA-E who was not authorized to act as POA at that time because R1 did not have a finding of incapacity to activate a POA at the time of admission. R1 was assessed as incapacitated on 12/7/22 and regained capacity on 3/2/23. On 3/27/23 at 1:45 PM, Nursing Home Administrator (NHA)-A verified R1 did not designate an alternate person to sign forms upon admission and R1 should have signed R1's own Notification of Change and Release of Information form. 2. On 3/27/23, Surveyor reviewed the facility's grievance file which contained a grievance submitted on 3/2/23 by FM-D who alleged Business Office Manager (BOM)-C kept R1's credit card. The facility investigated and found BOM-C opened R1's mail. (R1 was assessed as incapacitated on 12/7/22 and regained capacity on 3/2/23.) On 3/27/23 at 12:12 PM, Surveyor interviewed BOM-C regarding R1's mail. BOM-C could not recall the date BOM-C opened R1's mail. BOM-C stated R1's mail was accidentally opened along with facility mail. BOM-C contacted FM-D to ask what to do with the contents of R1's mail. FM-D directed BOM-C to pass the contents of the open letter to POA-E. BOM-C stated BOM-C batch opens facility mail and immediately discards envelopes so BOM-C did not replace the contents in the envelope. BOM-C stated FM-D seemed to understand financial information and indicated to BOM-C that FM-D was going to work on R1's Medicaid application. BOM-C stated BOM-C felt POA-E did not understand the financial information because POA-E asked BOM-C to assist with gathering materials Medicaid requested. BOM-C stated BOM-C believed FM-D was POA-E's POA. BOM-C confirmed the facility did not have documentation to show POA-E was incapacitated and confirmed R1 did not have a POA for finance on file.

Based on interview and record review, the facility failed to ensure there was a process for tracking testing status of unvaccinated staff who are routinely in the facility and ensure the implementation of testing requirements to mitigate the transmission and spread of Covid-19 (a mild to severe respiratory illness that is caused by a coronavirus), for 2 of 5 staff reviewed. This had the potential to affect the residents with whom they worked. Nurse Aide in Training (NAIT)-E, who was unvaccinated for Covid-19, was not consistently tested as required. Registered Nurse (RN)-F, who was unvaccinated for Covid-19, was not consistently tested as required. Findings include: Facility provided policy titled Covid-19 Testing Plan revised 3/14/22 stated, . 9. Up-to-Date - means a person has received all recommended Covid-19 vaccines, including any booster dose(s) when eligible . 4. Routine testing of staff: a. Testing frequency will be decided based on the community transmission level . b. The facility will test staff, who are not up-to-date, at the frequency prescribed in the Routine Testing table based on the level of community transmission reported in the past week . c. If the county positivity rate goes up causing a need to increase the testing frequency, facilities should begin at the higher frequency right away. d. If the county positivity rate goes down the facility should not decrease the frequency of testing right away. Continue to test at the higher frequency until the county positivity rate remains at the reduced activity level for at least two weeks . Table 2 of policy indicated High levels of county positivity required twice a week staff testing. Facility provided logs of positivity rates for Winnebago County, where facility was located, indicated High rates for the time periods of 6/6/22 through 7/31/22. Facility provided documentation indicated 86% of 35 residents were vaccinated. On 8/3/22, Surveyor reviewed facility provided testing logs, which included all staff tested chronologically by test date, for May, June and July 2022. Facility provided testing logs indicated NAIT-E tested on ly once the weeks of 5/1/22, 5/15/22, 5/22/22, 6/5/22, 6/26/22, 7/3/22 and 7/10/22. NAIT-E failed to test at any time during the weeks of 5/29/22, 6/12/22, 6/19/22, 7/17/22 and 7/24/22. The dates NAIT-E did test, the results were negative. Facility provided testing logs indicated RN-F tested on ly once the week of 5/15/22. RN-F tested positive on 6/27/22. On 8/3/22 at 9:48 AM, Surveyor interviewed Director of Nursing (DON)-B who, when questioned about the time gaps in NAIT-E's testing, stated, I don't know. I say all the time (about testing) and they agree to test but obviously [NAIT-E] has not. DON-B verified DON-B was unaware of NAIT-E not testing as required until brought to DON-B's attention by Surveyor. DON-B stated, I try to check but obviously I miss people. DON-B indicated NAIT-B consistently worked two to three days a week and should have been testing twice weekly. On 8/3/22 at 1:24 PM, Surveyor interviewed DON-B who indicated RN-F worked 5/15/22, 5/16/22 and 5/18/22 and should have tested twice the week of 5/15/22.

Based on record review and staff interview, the facility did not notify a physician of resident change of condition for 1 Resident (R) (R135) of 1 reviewed for physician notification. R135's weight changed by over three lbs (pounds) in April 2022. R135's physician was not notified of R135's weight changes as physician ordered. Findings include: On 8/1/22, Surveyor reviewed R135's medical record. R135 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R135 was discharged from the facility on 4/27/22. R135's medical record indicated R135 was weighed as follows: ~ 4/20/22 weight = 148.5 lbs ~ 4/21/22 weight = 148.5 lbs ~ 4/22/22 weight = 144 lbs (3.5 lbs loss within 24 hrs) ~ 4/23/22 weight = 142 lbs (5.5 lbs loss within 48 hrs) ~ 4/24/22 weight = 140 lbs - this weight was struck out by Registered Dietician (RD) on 4/26/22 with a note recommending re-weigh ~ 4/25/22 weight = 144.5 lbs (4 lbs loss compared to admission weight) ~ 4/26/22 weight = 144.5 lbs No weight was recorded for 4/27/22. R135's medical record contained the following physician order: ~ Call MD (physician) if weight increases or decreases by 3# (lbs) in one day or 3# in one week. (order dated 4/20/22) R135's care plan stated, .Weigh resident per facility policy or as ordered. Notify MD/NP (Nurse Practitioner) per order or with significant changes. R135's medical record did not contain evidence of physician notification of R135's weight changes. On 8/3/22 at 11:35 AM, Surveyor interviewed Director of Nursing (DON)-B who verified R135's medical record did not contain evidence of physician notification of R135's weight changes. DON-B verified R135's physician should have been updated with R135's weight changes as ordered by R135's physician.

Based on observation, record review and staff interview, the facility did not ensure that each resident received and the facility provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 (resident #1) of 7 sampled residents. Resident #1 was admitted with multiple risk factors that placed her at risk for dehydration that included multiple diagnoses, medications and poor meal intakes. The facility did not monitor resident #1's fluid intake to ensure she received the dietician's calculated 1620 cc (cubic centimeters) of fluid each 24 hours to maintain hydration status. In addition, the facility did not assess resident #1's oral mucosa and skin turgor daily per the facility's policy and procedures. Resident #1 was not added to the hydration cart daily documentation for 7 out of 21 days and had multiple shifts without any documentation, and according to staff interview the documentation did not indicate the percentage of fluids consumed. Findings include: According to the 2009 AMDA's Guidelines for Dehydration, "dehydration can have severe consequences. Dehydration may predispose frail older resident of LTC (Long Term Care) facilities to develop complications including falls, functional decline, increasing or new confusion and disorientation, and orthostasis." Resident #1 was admitted to the facility on [DATE], from the hospital emergency room . The medical record indicated that resident #1 is [AGE] years old and has [DIAGNOSES REDACTED]. According to resident #1's 1/10/14 Admission Data Collection she was identified probable inadequate nutrition related to rarely eating a complete meal and generally eats only about half of any food offered. According to the 2009 AMDA's Guideline for Dehydration medications including ACE inhibitors, Diuretics, Laxatives, Vitamin D/calcium formulations may increase one's risk for dehydration. Review of resident #1's medication on her MARS (Medication Administration Records) included multiple ACE inhibitors (Ramipril 10 mg daily since admission and [MEDICATION NAME]), multiple laxatives ([MEDICATION NAME] 17 grams daily and [MEDICATION NAME] Sodium 100 mg twice a day since admission), a diuretic ([MEDICATION NAME] 20 mg daily) and Vitamin D/calcium started on 1/27/14 twice a day. [MEDICATION NAME] 20 mg daily was initiated on 1/20/14. Resident #1's [MEDICATION NAME] was put on hold for one week, and staff were directed to take daily weights following change in condition which included a drop in blood pressure (86/52) and decrease in fluid intake on 1/29/14. Resident #1's Vital Signs & Weight Record did not include any weights for 1/29/14 or later, and the only day with a documented blood pressure was 1/31/14. A nurse's note dated 1/29/14 at 7:00 p.m. resident #1's blood pressure was 86/52. The physician was notified of the blood pressure and a weight loss of 4.16 pounds (this is within 19 days). The physician placed resident #1 on daily weights and blood pressures, and staff were stop administering the resident's [MEDICATION NAME] and to update him on 2/5/14 with the results. The physician indicated if resident #1 were to become [MEDICAL CONDITION] or have other changes to notify him ASAP (immediately). Nurse's notes following this did not include a daily weight, daily blood pressure, or monitoring related to resident #1's daily intake at meals and intake of fluids. Assessments for potential dehydration were not completed on the MAR indicated [REDACTED] The SBAR indicated resident #1 weighed 114.2. The weekly nursing progress note dated 1/29/14 indicated resident #1's appetite was fair, but that she needed encouragement. Resident #1's nurses notes and assessments did not include any hydration assessments; Therefore, on 1/31/14 at 1:44 p.m., surveyor # asked DON-A (Director of Nursing) for any hydration assessments completed on resident #1 since her admission, and according to RN-J (Registered Nurse) at 1:50 p.m., the admission assessment was the only one. When asked if staff monitored the residents' fluid intake, DON-A stated that the CNAs did not document fluid intake unless the resident was on I's & O's (intake and output), and that would not be done unless it was ordered by a physician. DON-A verified that when the CNAs documented the meal intakes it included fluids, but verified to surveyor # that the percentages did not differentiate between food and fluids. There is no way to know how many fluids resident #1 was drinking or if she was meeting her fluid requirements indicated in the Nutrition assessment. On 1/31/14 at 2:40 p.m., DON-A indicated to surveyor # that resident #1's MAR indicated [REDACTED]. DON-A explained indicated that all residents' MARs included the oral assessment, as a part of their plan of correction nursing was to also assess each resident's skin turgor as well. DON-A and RN-B both verified to surveyor # that nursing had not been assessing resident #1's mouth (oral mucosa) and skin turgor since her admission on 1/11/14 as required. On 1/31/14 surveyor # asked DON-A to assess resident #1's oral mucosa and skin turgor at 3:05 p.m. Resident #1 was lying in bed resting and allowed DON-A to look in her mouth and check her skin turgor on her sternum, both were fine at that time. When asked, resident #1 stated her mouth felt like she had some cotton in it. In addition, when asked about what she likes to drink, resident #1 shared that did not like water or milk and did not drink them, and maybe some juices. The resident added that she likes fruit. Resident #1 stated that she's not hungry or thirsty. Resident #1 agreed that she liked coffee when asked by surveyor # and when asked if she accepts coffee or juice from the girls when they go around with the hydration cart, resident #1 indicated that she "turns the girls down." The large cup used for resident #1's ice water was still full on her bedside table. DON-A had said the staff are expected to fill the cup up to 900 cc three times a day. There was 100 cc missing from the cup when surveyor # looked at the water cup more closely. A nurse's note dated 1/12/14 (9:00 p.m.) indicated resident #1 was alert and oriented to person and place, but confused at times. The note also indicated resident #1's appetite was poor. The Nutrition Assessment completed on 1/13/14 indicated resident #1 weighed 118.1 pounds and required 1512 calories a day with 54 grams of protein. In addition, resident #1 required 1620 cc of fluid within a 24 hours period to maintain adequate hydration status. On 1/23/14 Therapy sent a fax to resident #1's physician requesting to offer either a mighty shake or magic cup (supplements) at each meal related to poor intake. Resident #1's 1/24/14 CAAs (Care Area Assessments) indicated her meal intakes had been poor since admission, and resident #1 told staff that she had a very poor appetite. A plan of care for the potential for weight loss/dehydration was not added for resident #1 until 1/24/14, and was only added related to her use of a diuretic according to RN-B and DON-A to surveyor # on 1/31/14 at 2:40 p.m. Both staff verified that if resident #1 had poor intakes this would increase her risk for dehydration. A nurse's note dated 1/27/14, 2:00 p.m. resident noted to have a 2 cm (centimeter) by 2 cm read area to her sacrum/coccyx area with a blister noted in the center. The physician was updated and ordered skin protectant and an Island dressing. On 1/31/14 at 12:55 p.m. DON-A verified to surveyor # that resident #1 had developed a stage II pressure ulcer on 1/27/14, and that the blister still remained intact. A plan of care was added to address resident #1's altered nutrition on 1/27/14 indicating that she leaves 25% or more of her food uneaten. Approaches included offer Mighty shakes and weigh weekly. Throughout the period of 1/11/14 through 1/31/14 staff did not monitor resident #1's fluid intake, despite her poor appetite and poor intake. Surveyor # reviewed resident #1's meal intake record. The meal intake record indicated the following. Per staff interviews, documentation of intake reflected both fluid and food and did not differentiate between the two. From this documentation, one could not determine exactly the amount of fluids that were consumed: * 1/11/14-- breakfast: less than 25% lunch: less than 25 % dinner: between 25% - 50% * 1/12/14-- breakfast: less than 25% lunch: less than 25 % dinner: between 50% - 75% * 1/13/14-- breakfast: between 75% - 100% lunch: refused dinner: between 50% - 75% * 1/14/14-- breakfast: no documentation lunch: less than 25 % dinner: between 50% - 75% * 1/15/14-- breakfast: between 25% - 50% lunch: between 75% - 100% dinner: between 50% - 75% * 1/16/14-- breakfast: less than 25% lunch: less than 25% dinner: between 25% - 50% * 1/17/14-- breakfast: between 25% - 50% lunch: less than 25 % dinner: between 25% - 50% * 1/18/14-- breakfast: between 25% - 50% lunch: less than 25 % dinner: between 75% - 100% * 1/19/14-- breakfast: between 25% - 50% lunch: less than 25 % dinner: between 25% - 50% * 1/20/14-- breakfast: between 25% - 50% lunch: less than 25 % dinner: between 25% - 50% * 1/21/14-- breakfast: less than 25% lunch: refused dinner: between 25% - 50% * 1/22/14-- breakfast: less than 25% lunch: between 75% - 100% dinner: between 25% - 50% * 1/23/14-- breakfast: between 25% - 50% lunch: less than 25 % dinner: between 25% - 50% * 1/24/14-- breakfast: between 25% - 50% lunch: less than 25 % dinner: between 25% - 50% * 1/25/14-- breakfast: less than 25% lunch: between 25% - 50% dinner: between 25% - 50% * 1/26/14-- breakfast: less than 25% lunch: between 25% - 50% dinner: no documentation * 1/27/14-- breakfast: between 75% - 100% lunch: less than 25 % dinner: between 75% - 100% * 1/28/14-- breakfast: less than 25% lunch: less than 25% dinner: between 25% - 50% * 1/29/14-- breakfast: between 25% - 50% lunch: refused dinner: between 25% - 50% * 1/30/14-- breakfast: between 75% - 100% lunch: between 75% - 100% dinner: between 75% - 100% * 1/31/14-- breakfast: less than 25% lunch: less than 25% (The meal intake does not differentiate between food and fluid intake). On 1/31/14 at 1:06 p.m. surveyor # observed resident #1 in the main dining room. I was noted that resident #1 only ate a few bites of food, but did eat all of her mandarin oranges. Resident #1 drank about 75% of her coffee (approximately 7 ounces) and 75% of her three ounces of supplement. At 1:07 p.m. surveyor # interviewed CNA-D (Certified Nursing Assistant) regarding resident #1. CNA-D did not know if resident #1 drank anything when the hydration cart was passed and indicated that she started to watch how much resident #1 was drinking and is encouraging her to drink her fluids. On 1/31/14 surveyor # asked staff for resident #1's weight at approximately 2:00 p.m., and was told it was 109 pounds. This is a nine pound weight loss in 21 days, which is a significant weight loss. On 2/3/14 at 9:20 a.m. surveyor # observed resident #1 in the dining room for breakfast. Resident #1 drank her 4 ounce cup of orange juice, but barely touched her hot cereal, and only took a couple of small bites of her coffee cake. The scrambled eggs appeared untouched. At this time staff gave resident #1 three quarters of a cup coffee (6 - 7 ounces) per her request with nothing in it. Resident #1 went up to therapy as verified by surveyor # when observed in therapy at 10:14 a.m. On 2/3/14 at 12:45 p.m. surveyor # observed resident #1 in the dining room for lunch. She had chicken, a noodle dish, vegetables and a piece of buttered bread. She had a 4 ounce glass of juice, 8 ounce glass of milk, and an 8 ounce cup of coffee. At 1:10 p.m. resident #1 had only eaten a couple of bites of her food and drank about half of her coffee. This was verified by CNA-C to surveyor # at 1:12 p.m. The facility initiated passing drinks to all residents on a hydration cart that was passed at approximately 10:00 a.m., 2:00 p.m. and 7:00 p.m. In addition, staff were to document three times a day. Resident #1 was excluded from the daily documentation for the hydration cart for 7 out of 20 days (1/11/14 to 1/31/14), leaving 13 days or 39 opportunities for additional fluids. Resident #1 refused, had none or was not available for nine of those opportunities, and staff did not document for anyone on Pratt Place for 12 of the remaining 30 opportunities. The other times were documented with a 100%. This was verified to surveyor # by DON-A (Director of Nursing) on 2/3/14 at 9:55 a.m. DON-A indicated that all three shifts were expected to document, especially first and second shift. In addition, DON-A indicated that the hydration cart and documentation were initiated as result of their 12/10/13 citation at F309 to ensure residents received adequate hydration. When asked who monitored the documentation, DON-A indicated that she monitored it on a daily basis. According to the 12/10/13 provided by DON-A training notes staff were expected to document when they gave residents a snack or drink from the hydration cart. It was not clear if staff should document how much of snack and/or beverage the resident consumed. On 2/3/14 at 10:31 a.m. surveyor # observed resident #1's water cup in her room on the bedside table full to 900 cc. This meant that the resident had not drunk any water from her water cup on first shift yet. At 11:02 a.m. surveyor # interviewed CNA-C and when asked, said that she had never seen resident #1 drink out of her water cup in her room. CNA-C indicated that resident #1 only drinks coffee when she passed the hydration cart. CNA-C also added that when resident #1 was brought to the dining room table she would tell staff that "she's full." CNA-C indicated that she would encourage her to eat least one food item and drink one drink. Last, CNA-C verified that staff offer her a supplement. When asked, CNA-C also verified that resident #1 is usually taken to therapy after breakfast, around the time she passes the hydration cart. CNA-C indicated that she would give resident #1 a cup before she left for therapy. On 2/3/14 at 10:16 a.m. surveyor # interviewed TPM-E (Therapy Program Manager) about resident #1. TPM-E indicated that they usually brought her to therapy around 10:00 a.m. and that during that time they would offer her a cup of water (approximately 120 cc). TPM-E indicated they worked with the resident for about two hours each morning, or a hour in the morning and a hour in the afternoon. The resident would accept the water the majority of the time, but it would take her almost the entire hour to finish it with a lot of encouragement. TPM-E indicated that resident #1 would tell them she just wasn't hungry or thirsty. Resident #1 ate less than 25%, and the nurses and CNAs would tell her the resident didn't like to drink. When asked, TPM-E indicated that they treated resident #1 five days a week. TPM-E agreed with surveyor # that the building was dry this winter. At 11:43 a.m. surveyor # interviewed TPM-E, PTA-F (Physical Therapy Assistant) and OTR-G (Occupational Therapy) if resident #1 ever came to therapy with a cup of coffee, and they all said only once or twice. And the one time was because resident #1 was still eating when OTR-G came to get her and the resident asked of she could bring her cup of coffee with her. OTR-G also shared that the resident wouldn't drink any water unless they really encouraged her a lot to drink. On 2/3/14 at 1:51 p.m. surveyor # observed resident #1's water cup in her room with approximately 875 cc remaining. At 1:52 p.m. surveyor # noticed that the water cup was large and may be heavy for resident #1. At 1:56 p.m. surveyor # and CNA-C asked resident #1 to hold the water cup and take a drink. The resident indicated that the cup was heavy. Resident #1 took a drink from the cup with a some difficulty related to it's size and weight with a lot of encouragement. Resident #1 did take two or three small sips at that time. Resident #1 may need additional encouragement and physical assistance from staff to take frequent drinks from her water cup. On 2/4/14 at 8:20 a.m., surveyor # interviewed CNA-D via telephone regarding the hydration cart. CNA-D indicated that she does not pass drinks on the hydration cart that often, but when she had resident #1 refused any liquids. CNA-D indicated that CNA-C usually passed the hydration cart. When asked, CNA-D indicated that she documented each resident's percentage consumed. On 2/4/14 at approximately 9:00 a.m. surveyor # interviewed CNA-C via telephone regarding the hydration cart. CNA-C verified that she passes the hydration cart at least three times a week for the morning and afternoon pass. When asked how she documents, CNA-C indicated that she documents that the resident accepts 100% of the drink. A variety of drinks are available and she usually gives approximately 8 ounces, but give resident #1 about 7 ounces because she takes coffee, and she did want to fill the cup too full to prevent spilling. When asked if she knew how much each resident consumed, CNA-C indicated that she did not have time to go back and check. When asked about resident #1, CNA-C indicated that resident #1 would take between 1 to 3 sips before she left the room. A nurse's note dated 2/2/14, 1:00 p.m. indicated resident #1's weight was 112.6 pounds and that she ate approximately 50% at meals. Resident #1 did not have any [MEDICAL CONDITION] and indicated she was taking fluids well. The note also added that resident #1 eats in the tea room where encouragement can be given. On 2/3/14 at 1:17 p.m. DON-A and RDCS-H (Regional Director of Clinical Services) indicated to surveyor # that the facility reassessed all of the residents for any change of condition and hydration status related to missing resident #1 risk factors for dehydration. But this assessment did not include any monitoring of resident #1's fluid intake to determine of she was meeting her daily requirements of 1620 cc to maintain her hydration status. Surveyor # met with NHA-I, DON-A and RDCS-H at 2:45 p.m. to review the above concerns. DON-A indicated that they learned on 1/31/14 at the care conference from the daughter that resident #1 had already started declining with her appetite and fluid intake prior to her admission to the facility. NHA-I indicated that she understood the issues.

Based on record review and staff interview, the facility did not ensure that each resident received and the facility provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 (resident #1) of 3 sampled residents. Resident #1 was admitted with physician orders [REDACTED]. The dietician calculated that resident #1 required 1917 cc (cubic centimeters) to 2347 cc of fluid each 24 hours to maintain hydration status. When resident #1 presented at high risk for dehydration related to ongoing diarrhea, the facility did not develop a plan of care to include fluid monitoring. Although the facility monitored BM's (bowel movement), the facility did not identify the continuation of resident #1's diarrhea and the BM monitoring records did not document the consistency of BM's and per staff interview, the BM monitoring records were not accurate. Resident #1 developed diarrhea and the facility received an order from the APNP (Advanced Practice Nurse Practitioner) to administer [MEDICATION NAME] (an antidiarrheal) if the resident's diarrhea continued. Although resident #1 continued to have episodes of diarrhea, the facility did not administer [MEDICATION NAME] and continued to administer the [MEDICATION NAME] sodium twice a day. The facility did not monitor resident #1's fluid intake to ensure that the resident had received the required fluid intake. Subsequently, resident #1 was admitted to the hospital with [REDACTED]. The failure to more closely monitor this resident's diarrhea and fluid loss, the failure to treat with the anti-diarrheal medication that had been ordered, the failure to ensure that fluids were pushed as ordered and the failure to monitor fluid intake created a finding of immediate jeopardy, which began on 10/25/13. The Nursing Home Administrator was notified of the immediate jeopardy on 12/2/13. The facility removed the jeopardy on 12/06/13, however, the deficient practice continues at a scope/severity of D (potential for harm that is not immediate jeopardy/isolated) as the facility fully implements and monitors the effectiveness of its removal plan. Findings include: The facility's policy and procedure titled, "Hydration Policy," with a revision date of 01/01/2009, indicated the following: * Water will be served with all meals. The dietary department will provide a minimum of 420 cc's of fluid with each meal, including water, unless fluid restriction is ordered. Residents at high risk for dehydration will be given additional fluids with meals. The facility's policy and procedure titled, "Dehydration Prevention for Environmental or Medical Causes," revised on 09/01/2011. The policy indicated if medical conditions such as fluid loss and increased fluid needs (i.e. diarrhea....) the policy instructs staff to: * Unless fluids are restricted, they will be offered with each meal, with each medication administration and at least one other time on day and evening shifts while the resident is awake. * Unless restricted for safety or fluid consumption control, which must be included in the resident's care plan, water pitchers with fresh water will be maintained in the resident' room at a location convenient and accessible to the resident. CNA's will replace with fresh ice and water every shift. * Documentation of offering of fluids will be noted on the ADL (activities of daily living) record. * New dehydration risk factors demonstrated by the resident (i.e. diarrhea...) will be described in the prn (as needed) nursing notes, and the physician and responsible party will be notified in accordance with the facility notification of change policy. On 11/26/13 & 11/27/13, surveyor # reviewed resident #1's medical record. According to the face sheet, dated 11/04/13, resident #1 was admitted to the facility on [DATE]. Resident #1's "Cumulative [DIAGNOSES REDACTED].#1 was admitted to the facility status [REDACTED]. According to October and November 2013 MAR (medication administration record), resident #1 was receiving [MEDICATION NAME] sodium (a stool softener) 100 mg twice daily. According to the "Nutrition Data Collection Tool," without a date when completed, indicated resident #1 weighed 243 pounds and required 1917 cc to 2397 cc of fluid in 24 hours to maintain hydration status. Resident #1 developed diarrhea by the day after admission. The nurses' notes dated 10/25/13 indicated a call was placed to the APNP to update that resident #1 had two loose bowel movements and was still sitting on the toilet. (This was not documented on the bowel monitoring record). The APNP ordered Cholestryramine to be given twice daily and to obtain a stool test for [MEDICAL CONDITION] stat and to push fluids. If the [MEDICAL CONDITION] results are negative, may start [MEDICATION NAME]. (The medical record indicated that [MEDICATION NAME] was never administered). Subsequent monitoring of the resident's bowel movements was recorded on the facility's bowel record as follows. Note that the bowel documentation did not contain any information regarding the consistency of the stools. * 10/24/13-- one large BM (bowel movement) * 10/25/13-- one small BM * 10/26/13-- one medium and one large BM * 10/27/13-- no BM * 10/28/13-- one medium BM * 10/29/13-- no BM * 10/30/13-- no BM * 10/31/13-- one medium BM * 11/01/13-- one extra-large and one medium BM * 11/02/13-- two medium and one extra-large BM * 11/03/13-- one medium and one large BM * 11/04/13-- one medium BM * 11/05/13-- two medium BM Staff interviews below indicate that this record was inaccurate and that Resident #1 had diarrhea throughout her stay. a. On 11/26/13 at 12:55 PM, surveyor # interviewed CNA-A (Certified Nursing Assistant) regarding resident #1's diarrhea. CNA-A stated resident #1 had diarrhea throughout her stay at the facility. CNA-A indicated on occasion resident #1's stool was a little formed. CNA-A stated resident #1 had multiple episodes of diarrhea on the first few days from admission but thought the episodes had decreased. CNA-A indicated resident #1 consumed her meals in her room due to the diarrhea and later did go into the dining room and at some point had to be placed at the assisted meal intake table, but didn't know when. CNA-A stated resident #1 needed to have her fluids limited because she would drink the entire mug if staff gave her a full mug of water,. CNA-A stated she had given her approximately 200 cc's at a time at the beginning of her stay. CNA-A indicated resident #1 declined in status and at some point (didn't know when), resident #1 was unable to pick up a water mug independently and water she placed water in a small med cup, which she was able to drink herself. CNA-A stated the nurses always told staff to encourage fluids, in general, for all residents. CNA-A indicated fluid intake was not monitored unless a resident was on intake and output tracking. CNA-A verified resident #1 was not on intake/output monitoring. b. On 11/27/13 at 11:45 AM, surveyor # interviewed CNA-I regarding resident #1. CNA-I stated on admission to the facility, resident #1 had extreme bouts of diarrhea, and there had been one instance where resident #1 remained on the toilet for over an hour. CNA-I stated the episodes had decreased over her stay, but resident #1 continued with approximately 3 episodes of diarrhea every shift she had worked with resident #1. CNA-I indicated she could not distinguish the color of the urine as there had always been stool present. CNA-I stated in the beginning of resident #1's stay she would chug glasses of water but towards the ends she would only take sips of water when offered. CNA-I indicated her lips were dry. CNA-I stated the nurses were aware of resident #1's diarrhea because they would always tell us to encourage fluids. CNA-I stated the meal intake record is for the percentage of the food intake, and fluid intake was not documented. CNA-I indicated the bowel record was not accurate, as staff would try to document each episode of diarrhea but there wasn't always enough time. c. On 11/27/13, surveyor # interviewed CNA-E regarding resident #1. CNA-E stated resident #1 complained of being thirsty at first and she initially drank a lot of water. CNA-E indicated resident #1 had diarrhea throughout her stay, and had more episodes of diarrhea towards the end of her stay. CNA-E indicated resident #1 had 3 or 4 bouts of diarrhea on 11/05/13. Surveyor # and CNA-E stated the number of episodes frequently gets missed to get documented as staff do not always have enough time to go into the computer system and document after each episode of diarrhea. CNA-E indicated there was one episode, sometime at the end of her stay, where it took three CNA's to assist resident #1 as she had gross amount of diarrhea "all over the place." CNA-E verified the nurses were aware and always told staff to push fluids. CNA-E indicated if the bowel monitoring indicated resident #1 hadn't bowel movements on shift, she didn't believe that documentation because resident #1 always had diarrhea. CNA-E stated she had documented resident #1's meal intake at times, and hadn't observed what she had consumed. CNA-E indicated another CNA told her what to write. CNA-E stated the percentage of meal intake was a combination of food and fluid and there was no way to know how much fluid residents consume. CNA-E indicated she thought it was more important for food documentation. Despite the persistent nature of Resident #1's diarrhea, the facility did not develop and implement a plan of care for dehydration prevention when resident #1 presented with loose stools and became at high risk for developing dehydration. The nurses' notes dated 10/28/13 indicated the Clostridrium Difficile stool test was negative. Although the APNP had said to give [MEDICATION NAME] (an anti-diarrheal medication) if the test was negative, the MAR indicated [REDACTED] Resident #1 was seen by the APNP at the facility on 10/30/13. The APNP documentation indicated resident #1 was being seen for a surgical follow up as well as staff concerned regarding diarrhea. .....Post op complications included confusion/[MEDICAL CONDITION] and catatonia which resolved. She demonstrated with diarrhea over the weekend, with orders for [MEDICAL CONDITION] culture and Cholestryramine twice daily. Stools have since then solidified with bowels moving well twice daily. The resident feels this is still too often............Neuro assess: Alert, oriented to person, basic place and time. Struggles with accuracy of events over the last several days. Speech is clear, no one sided weakness or facial droop. No new twitching or tremors....Impression/Plan: Diarrhea, resolved. will discontinue [MEDICATION NAME] and continue on the [MEDICATION NAME] sodium twice daily. Will discontinue Cholestryramine twice daily. Will add [MEDICATION NAME] as needed once daily. [MEDICATION NAME] is available as needed for any further diarrhea. Staff will monitor and notify me of further issues while encouraging ambulation. On 11/04/13, the facility developed a "Nutritional Risk Plan of Care," related to complaints of excessive thirst....... An intervention written was to monitor for signs and symptoms of dehydration. (There was no documentation located in the medical record regarding signs and symptoms of dehydration). Surveyor # interviewed CNA-G on 11/27/13 at 10:20 AM regarding resident #1. CNA-G verified she had completed bowel documentation for resident #1 on 11/04/13 on the day shift. CNA-G verified there was no documentation of defecation from the night shift on 11/04/13. CNA-G stated she arrived to work at about 5:50 AM and was told to go assist in resident #1's room right away. CNA-G stated she entered resident #1's room and resident #1 had been incontinent of a large amount of diarrhea and she even was covered in diarrhea from her knees to her foot. CNA-G stated night shift should have documented, but verified there had been no documentation regarding the incident. CNA-G stated she also knew on 11/04/13, resident #1 had 3 or 4 large episodes of diarrhea on the day shift, and verified there hadn't been any documentation regarding these episodes. CNA-G stated she was in training on that day, and when she was entering the data at the end of the shift, the computer would only allow her to document one episode. CNA-G indicated she couldn't recall what color resident #1's urine was because of the diarrhea. Surveyor # interviewed CNA-E on 11/27/13 regarding resident #1. CNA-E verified she had worked the day shift of 11/05/13. CNA-E indicated resident #1 "wasn't with it" and could not hold a conversation and her cognition had declined further from admission. CNA-E stated resident #1 was "staring out into space." CNA-E indicated she had told the LPN and she had assessed her and brought her to the nurses' station. The nurses' notes on 11/05/13 at 12:00 PM indicated resident #1's assessment was completed per request of resident #1's caregiver. Resident #1's pupils were reactive to light, unequal pupils, the left pupil was approximately 1 mm (millimeter) and the right pupil was 3 mm Left eye appears to have a slight droop. Hand grasps are equal. The APNP was updated and labs were ordered stat. On 11/26/13 at 1:55 PM, surveyor # interviewed DON-C, who stated she had also updated the APNP and she had told the APNP the facility was pushing fluids and she responded "ok." DON-C verified she did not document the update to the APNP. The nurses' notes on 11/05/13 at 2:00 PM indicated the lab results of the [MEDICATION NAME] had returned and was elevated to 1.7 (normal value was 0.6 - 1.2). The psychiatrist was called and orders received to hold the [MEDICATION NAME] and restart on 11/06/13 with a lower dose, and to redraw cretonne and [MEDICATION NAME] on 11/11/13. On 11/26/13 at 1:55 PM, surveyor # interviewed DON-C (Director of Nursing) regarding resident #1. DON-C stated she had updated the psychiatrist on 11/05/13, regarding resident #1's cretonne, BUN and [MEDICATION NAME] lab results. DON-C stated the psychiatrist stated that resident #1 appeared slightly dehydrated and could be why her [MEDICATION NAME] level was elevated. The labs of 11/05/13 indicated resident #1's BUN (blood urea nitrogen) had increased to 48 (normal 10-20), cretonne was 1.47 (normal was 0.5 to 1.10) and chloride had increased to 109 (normal was 98 to 107). Surveyor # interviewed LPN-D (Licensed Practical Nurse) on 11/26/13 at 2:30 PM regarding resident #1. LPN-D verified she worked on 11/05/13 and sent resident #1 to the hospital. LPN-D indicated when her shift started resident #1 was significantly different than previously and was more lethargic. LPN-D indicated right before supper she had been administering medications and resident #1 started to vomit and vomited approximately four or five times and then presented with coffee ground emesis. LPN-D stated resident #1 stated she wished to go to the hospital. LPN-D indicated she had been told by the DON at the change of shift that resident #1 was becoming dehydrated and her [MEDICATION NAME] level was high and was told to push fluids. LPN-D verified she had not documented the number of times resident #1 was vomiting. The nurses' notes dated 11/05/13 at 5:00 PM indicated resident #1 had increased confusion and had a large coffee ground emesis with a very foul sour odor, resident #1 was having difficulty focusing and answering questions. Resident states she wants to go to the hospital. The physician was updated and resident #1 was sent to the emergency room . The hospital emergency room report, dated 11/05/13 indicates that resident #1 presented with persistent vomiting, postoperative recent cholecystectomy and possible small bowel obstruction. Lab values were Chloride is 110, BUN is 52 and her cretonne was 1.6. Her cretonne was 0.7 when she left the hospital previously. She would answer to verbal stimuli but her mucous membranes were very dry and she tended to stare into space. She is dehydrated. The plan is to admit and treat her with IV (intravenous) fluids, monitor labs test and to get a surgical consult. The hospital discharge summary, dictated on 11/13/13 indicated resident #1 was really unresponsive at the time of the emergency room evaluation. She had high [MEDICATION NAME] levels and had dehydration and vomiting. Over the course of her stay, we slowly hydrated her...We followed her laboratory work and corrected abnormal electrolytes....Discharge Diagnosis: [REDACTED]. Throughout the period of 10/24/13 through 11/5/13 staff did not monitor resident #1's fluid intake, despite the fluid loss from diarrhea. Surveyor # reviewed resident #1's meal intake record. The meal intake record indicated the following. Per staff interviews, documentation of intake reflected both fluid and food and did not differentiate between the two. From this documentation, one could not determine exactly the amount of fluids that were consumed: * 10/24/13-- breakfast: refused 10/24/13-- lunch-- less than 25% 10/24/13-- refused * 10/25/13-- breakfast: less than 25% 10/25/13-- lunch: less than 25 % 10/25/13-- supper: between 50% - 75% * 10/26/13-- breakfast: less than 25% 10/26/13-- lunch: between 75% - 100% 10/26/13-- supper: between 75% - 100% * 10/27/13-- no documentation * 10/28/13-- breakfast: between 75% - 100% lunch: no documentation supper: no documentation * 10/29/13-- breakfast: between 75% - 100% 10/29/13-- lunch: between 75% - 100% 10/29/13-- supper: no documentation * 10/30/13-- breakfast: between 75% - 100% lunch: between 75% - 100% supper: between 75% - 100% * 10/31/13-- breakfast: between 75% - 100% lunch: between 75% - 100% supper: between 75% - 100% * 11/01/13-- breakfast: less than 25% lunch: less than 25% supper: less than 25% * 11/02/13-- breakfast: between 75% - 100% lunch: no documentation supper: between 50% - 75% * 11/03/13-- breakfast: between 75% - 100% lunch: between 75% - 100% supper: between 75% - 100% * 11/04/13-- breakfast: between 50% - 75% lunch: between 75% - 100% supper: less than 25% * 11/05/13-- breakfast: between 75 - 100% lunch: between 50% - 75% supper: between 25% - 50% (The meal intake does not differentiate between food and fluid intake). On 11/26/13 at 1:25 PM, surveyor # interviewed RN-B (Registered Nurse-Unit Manager) regarding resident #1. RN-B stated resident #1 was always very quiet and cognitive status was difficult to "pinpoint" as sometimes she would answer and sometimes she wouldn't. RN-B indicated resident #1 did have diarrhea, but was not sure of how often or if the diarrhea continued throughout her stay at the facility. RN-B stated there had been possible concerns with [MEDICAL CONDITION] and hydration status. RN-B indicated staff had to be careful with giving fluids because if a pitcher of water was given, resident #1 would drink the entire pitcher right away and then would vomit it back up. RN-B stated staff were told to give resident #1 small glasses of water at a time. RN-B verified the APNP ordered to push fluids on 10/25/13. RN-B verified the facility did not implement a fluid monitoring system to ensure adequate fluid intake related to resident #1's diarrhea. RN-B stated the plan of care for nutrition indicated to monitor for signs and symptoms of dehydration and staff should have been monitoring in the nurses' notes. RN-B verified there wasn't any documentation regarding resident #1's hydration status. RN-B verified the dietician had calculated that resident #1 required 1917 cc's - 2397 cc's of fluid to maintain hydration status. RN-B verified there was no way to know if resident #1's fluid requirement was ever met. On 11/27/13 at 10:05 AM, surveyor # interviewed DM-F (Dietary Manager) regarding the facility's policy and procedure for "Hydration" dated 01/01/2009. DM-F stated not all residents would have a minimum of 420 cc of fluids on their tray and not all residents receive water on their meal tray. DM-F stated resident #1 would have received 240 cc of milk and 120 cc of orange juice and no water on her trays per resident #1's likes. DM-F stated she had never been told to increase resident #1 or any other residents' fluids on their meal trays. DON-C stated to surveyor # on 11/26/13 at 1:55 PM that the facility does monitor the oral mucosa every day on the MAR (medication administration record). A plus sign is written if the oral mucosa is moist and a negative sign is written if the mucosa is dry. If a negative sign was written, the facility would implement fluid intake/output monitoring. Surveyor # and DON-C reviewed resident #1's MAR for November 2013. There was a plus sign documentation from 11/01/13 - 11/05/13. Surveyor # questioned how oral mucosa could be a positive sign and later in the day resident #1 was diagnosed with [REDACTED]. DON-C indicated the nurses' review the bowel monitoring record. DON-C stated the software program for bowel monitoring had an area to indicate consistency. DON-C verified by reviewing the bowel monitoring record it would not have been known that resident #1 was having diarrhea. DON-C verified the facility did not implement a monitoring system of resident #1's fluid intake to ensure dehydration prevention, when the APNP ordered to push fluids on 10/25/13 and on 11/05/13. DON-C verified the facility documents meal intake to be a combination of food and fluids and there wasn't a way to determine resident #1's fluid intake with meals. DON-C verified there wasn't any way the facility could determine if resident #1 was meeting the fluid intake requirements per the dietician's recommendation. On 11/27/13 at 12:00 PM, surveyor # interviewed LPN-H regarding resident #1. LPN-H was the nurse responsible for resident #1's care on 11/05/13. LPN-H stated she assessed resident #1's oral membranes on 11/05/13 with the AM medication pass. LPN-H stated she recalled a [MEDICAL CONDITION] test was ordered, but not aware of any concerns with diarrhea. LPN-H indicated the CNA's would tell the nurses if resident #1 didn't consume all of her fluids. LPN-H indicated the CNA's monitor fluid intake. LPN-H stated if a resident had diarrhea, the resident would have been at risk for dehydration, but that wasn't a concern for resident #1 as she was "a good drinker." On 11/27/13 at 12:45 PM, surveyor # interviewed LPN-J. LPN-J stated the nurses always checked resident #1's oral membranes during the morning medication pass. LPN-J indicated if the mouth was dry, we would offer more fluid and place a negative sign on the MAR, and if the mouth was moist a positive sign was placed on the MAR. LPN-J stated if the CNA's notice a resident's intake wasn't good, then intake/output record would have been started. LPN-J stated she only worked with resident #1 one time and could not recall any specific information, but there was one occasion where she went to resident #1's unit to speak with the nurse and she recalled a CNA stating how resident #1 had diarrhea "all over the place". LPN-J stated the CNA staff monitor residents' hydration status and if there were concerns, the CNA's would notify the nurses. The failure to more closely monitor Resident #1's diarrhea and fluid loss, the failure to treat with the anti-diarrheal medication that had been ordered, the failure to ensure that fluids were being pushed and the failure to monitor fluid intake created a finding of immediate jeopardy. The jeopardy was removed on 12/06/13, when the facility implemented the following: ~ Resident #1 no longer resides at the facility. ~ Current residents were assessed for a change in condition to include but not be limited to vomiting, diarrhea, and/or dehydration along with vital signs and any lab results for the past 2 weeks to ensure that they were stable on December 5, 2013 by the Director of Clinical Services/Nurse Manager. ~ The Director of Clinical Services/Nurse Manager notified the physician immediately of any resident changes in condition for further orders on December 5, 2013. ~ Director of Clinical Services/Nurse Manager conducted education of Nursing Staff on change in condition (recognition of, communication of, and notification of) to include signs and symptoms of dehydration on December 5, 2013 using the Interact Program to include the Stop and Watch Early Warning Tool. ~ Director of Clinical Services/Nurse Manager conducted education of Licensed Nurses on December 5, 2013 regarding the Interact Situation Background Assessment and Request (SBAR) Form, Acute Change in Condition File Cards, & the Care Paths. Licensed Nurses were educated on reviewing medications upon recognition of a change in condition, and communicating any applicable medications that may be associated with the change in condition to the physician for further intervention. ~ Director of Clinical Services educated the licensed nurses on December 5, 2013 on use of the facility 24 hour report for shift to shift communication of a resident change in condition. ~ Any nursing staff members not educated by 11:59 p.m. on December 5, 2013 will not work until they are educated by the Director of Clinical Services/Nurse Manager prior to the start of their next scheduled shift. ~ The Director of Clinical Services/Nurse Manger will review the 24 report during morning meeting for changes in condition/potential changes in condition and to assure appropriate notification to the resident ' s physician and responsible party. New interventions will be reviewed to assure implementation as ordered by the physician. Residents ' plans of care will be updated accordingly. Quality Improvement monitoring for compliance with the use of the 24 hour report and morning meeting will be conducted 5 x weekly for 4 weeks, then 3 x weekly for 4 weeks, then 2 x weekly for 4 weeks, and then 1 x weekly for 3 months. ~ The Director of Clinical Services/Nurse Manager will report results of Quality Improvement monitoring to the Quality Assurance/Performance Improvement Committee monthly x 6 months for continued substantial compliance and/or revision.

Based on observation, staff interview and record review, the facility did not ensure that 3 (residents #1, #2 and #9) of 9 sampled residents received adequate supervision and assistance devices to prevent accidents. Resident #1 had experienced recent falls with head injuries. The facility implemented the use of a sensor alarm to alert staff to attempts of independent movement. When the intervention was observed by staff to be ineffective in preventing independent ambulation, the facility did not further evaluate resident #1's plan of care or supervision plan to prevent accidents/injuries. On 3/10/11 resident #1 sustained a fall resulting in further head injury. Resident #2 was assessed by the facility to be at risk for falls and had a history of [REDACTED]. The resident's plan of care intervention to prevent falling while seated at the toilet was not revised appropriately to ensure the resident had no further falls during toileting. Resident #2's plan of care directed staff to utilize a sensor alarm while the resident was in the wheel chair and bed. That intervention was not consistently implemented. Resident #9 was assessed by the hospital to be at risk for falls requiring a wheel chair alarm to alert staff to the resident's independent attempt to rise. That intervention was not implemented for the resident on admission. Resident #9 fell from her wheel chair approximately two and a half hours after admission to the facility. Findings include: The facility's "Fall Risk Prevention and Management" policy (3E-3), revised 8/10, documented, "Each resident/patient is evaluated upon admission, with change in clinical condition and quarterly to determine indicators of risk. Individualized interventions are implemented to decrease the risk of a fall...determine the reasons a resident/patient is at risk for falls...Review the Admission/Re-admission Data Collection & Initial Care Plan with the resident/patient and/or family/responsible party to determine individualized goals and interventions for inclusion in the care plan. Interventions to minimize or eliminate identified fall risk indicators...Identify resident/patient at higher risk of falling by placing a "star" symbol in an identified area near the resident/patient. Higher risk is defined as: Two (2) or more falls in the last six (6) months, As determined by the Interdisciplinary Team...Monitor and documented resident/patient response to fall risk reduction...Review, with the interdisciplinary team, the following when developing the comprehensive plan of care:..Resident/patient response to interventions, Changes in fall risk indicators...Evaluate effectiveness of interventions during Care Management meeting. Modify goals and interventions as indicated." 1. The face sheet, dated 3/8/11 and contained within the medical record, indicated resident #1 was admitted to the facility on [DATE]. The resident was not able to make her own medical decisions, and a guardianship was granted in January 2008. The hospital discharge summary, dated 3/8/11, documented [DIAGNOSES REDACTED]. The discharge summary further documented, "...history of Huntington's disease...was previously living in an assisted living and had been having multiple falls. She had been evaluated in the emergency room ...on 2/21/11 with chronic bilateral subdural hematomas. On day of admission, she was more confused. She had again fallen multiple times and had multiple ecchymotic (discolored area of the skin caused by seepage of blood beneath the epidermis, commonly called a bruise) areas. She was sent back to (hospital) where a repeat CT (computerized tomography) scan of her brain demonstrating increased size in her subdural hematomas with new acute components...She does have spastic and ataxic gait...She has been up walking in the halls with assist of one. She has never been allowed to ambulate without assistance...". The CT scan of resident #1's head, completed on 3/1/11, documented the right frontal subdural hematoma measured 7 mm (millimeters), and the left frontal subdural hematoma measured 6 mm. Both measurements were noted to be decreased from the prior CT scan completed on 2/25/11. The "Patient Care Summary", dated 3/8/11, documented resident #1 was restless and impulsive, gait very ataxic (loss of the ability to coordinate muscular movement) and required one assist with ambulation for safety reasons. The facility completed an "Admission/Re-Admission Data Collection & Initial Plan of Care" dated 3/8/11. The document indicated resident #1 was alert and oriented only to person (was not oriented to place or time), required assistance of one for transfers, ambulation and toileting. The document indicated resident #1 was "inconsistent in understanding his/her limitations" related to falls and had a history of [REDACTED]. The initial plan of care dated 3/8/11 documented, Goal: "Minimize risk of accidents/injuries." The interventions included: -Provide orientation, re-education and cueing as needed on facility routines, call light use, safety risks, and accident/injury prevention, -Monitor adherence to safety instructions, -Initiate additional fall prevention interventions--The plan directed staff to "describe" the additional fall prevention interventions. No additional interventions were listed on the plan of care, -Initiate starlight program (falling star). On 3/30/11 at 9:10 a.m. surveyor # interviewed DON (Director of Nursing)-B regarding resident #1. DON-B indicated resident #1 had been placed on the "Starlight" program, referred to as the "falling star" program. DON-B indicated that program placed a star on the resident's door frame, wheel chair or walker, and at the head of the bed to alert staff to the resident's fall risk. DON-B stated the star would inform staff the resident was at high risk for falls and needed to be monitored "more closely". The falling star program would also be documented within the care plan. The nurse aide's information sheet, not dated, documented resident #1 required one assist with ambulation and utilized a sensor alarm in the bed and wheel chair. The nurse aide information sheet did not include any information regarding the "falling star" program or describe any further safety concerns (i.e. impulsive behaviors) or assistive devices for resident #1 other than the use of the sensor alarm. The facility's "Fall Risk Reduction and Management" policy (3E-2), revised 8/10, also documented, "The interdisciplinary team works with the resident/patient and/or family/responsible party to identify and implement appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence...". During the interview with surveyor # on 3/30/11 at 9:10 a.m., DON-B verified she was not aware of a discussion with resident #1's guardian prior to or at the time of admission regarding the development of a plan of care to promote safety and to determine appropriate interventions based on fall risk and circumstances regarding the history of prior falls and injuries. DON-B indicated AC (Admissions Coordinator)-L may have discussed the plan with the guardian. On 3/30/11 at 11:00 a.m. surveyor # interviewed AC-L regarding resident #1. AC-L stated she had not discussed interventions or fall risk history information with resident #1's guardian prior to or at the time of admission. AC-L stated she completed an admission screening prior to admission while resident #1 was at the hospital. AC-L stated she was aware of resident #1's prior history of falls and the fact that resident #1 had an alarm on while in the hospital. AC-L stated the hospital had discontinued 1:1 monitoring of resident #1 on 2/28/11. Although resident #1 had experienced recent falls with head injuries requiring two hospital evaluations on 2/21/11 and 2/24/11 to 3/8/11 and had a [DIAGNOSES REDACTED].#1's safety. The facility did not evaluate resident #1's environment for safety, discuss the plan with resident #1's guardian regarding the history of falls and goal for safety (i.e. prevention of falls entirely vs. attempts to prevent significant injury), and did not evaluate other assistive devices that may reduce the potential for significant injury (i.e. low bed, supervision plan, helmet use, mat and/or mattress next to the bed, motion type sensor, etc...). The resident progress notes documented the following for resident #1: 3/8/11 at 9:40 p.m. "...Sensor pads in place for safety & hx (history) of falls...gait is ataxic..." 3/9/11 at 4:30 a.m. "...Movement is impulsive & quick. Sensor pads in place for safety, but resident is out of bed or chair when alarm rings..." 3/9/11 at 11:00 a.m. "...Earlier this AM, resident swung at staff members, was very restless et (and) had (increased) anxiety. Was up and down frequently..." 3/9/11 11:00 p.m. "Res. (resident) moved to room (number)...". On 3/29/11 at 2:30 p.m. surveyor # completed an interview with DON-B regarding resident #1. DON-B stated on the resident's admission, due to the known history of the subdural hematoma secondary to prior falls, the facility implemented the use of a sensor alarm in the bed and wheel chair. DON-B verified no further assessment of resident #1's fall and injury risk was completed, and no further interventions were initiated at the time of admission. DON-B stated resident #1 had been admitted to a room on the dementia unit. On 3/9/11 resident #1 was yelling out and was impulsive in her movements. DON-B stated resident #1 would "...get up and go", and had become aggressive with staff during an interaction. DON-B stated due to agitated behavior and the impulsiveness of movements, resident #1 was placed on 1:1 monitoring for a period of time (unknown length of time) on 3/9/11. DON-B stated on 3/9/11 resident #1 was moved to a different unit off of the dementia unit. DON-B stated she did not know what time the move occurred. Surveyor # reviewed the progress note with DON-B, which documented the room change at 11:00 p.m. DON-B stated she was certain the room change occurred prior to 11:00 p.m. DON-B stated after the room change was completed, the 1:1 monitoring was stopped. DON-B verified no changes were made to the plan of care for resident #1 with regard to safety/fall risk, despite the knowledge of her impulsive behavior. On 3/30/11 at 10:10 a.m. surveyor # interviewed CNA (Certified Nursing Assistant)-K regarding resident #1. CNA-K described resident #1's behavior as impulsive and quick with movement. CNA-K stated resident #1 would be laying in bed one minute then up and out of bed the next minute. CNA-K stated resident #1 always "jumped up" and would be already ambulating independently by the time the alarm began sounding or when staff responded. CNA-K stated he had informed the nurse of resident #1's impulsive and quick movements, and that resident #1 was ambulating independently before staff was able to respond. CNA-K stated he completed 1:1 monitoring for resident #1 on 3/9/11 prior to the room change to a different unit. CNA-K stated during the 1:1 monitoring, he had to stay close to resident #1, as her movements continued to be quick and unpredictable. During an interview completed on 3/29/11 at 2:25 p.m. with surveyor # , CNA-O stated resident #1 attempted to get out of bed independently during the night shift. CNA-O recalled responding to resident #1's sensor alarm. CNA-O stated resident #1 had already gotten out of bed independently and was ambulating in the hallway by the time he responded to the alarm. CNA-O stated resident #1 would not use her call light or wait for staff to respond. CNA-O stated resident #1 was quick and impulsive. CNA-O stated the nurse was aware of the fast and impulsive movements and had also responded to the alarm to find resident #1 ambulating independently in the hallway. CNA-O was aware of the use of the sensor alarm, but could not recall any other care planned interventions for safety. CNA-O stated he did check on resident #1 every fifteen minutes while she resided on the dementia unit (3/8/11) during the night shift, because CNA-O was concerned for resident #1's safety. On 3/29/11 at 1:40 p.m. surveyor # interviewed CNA-D regarding resident #1. CNA-D stated resident #1 did not remember to utilize the call light or wait for staff to assist. CNA-D stated prior to 3/10/11, resident #1 had been observed to be walking independently in the hallway. CNA-D stated she heard resident #1's alarm sounding, but by the time she responded, resident #1 was already walking down the hallway independently. CNA-D stated resident #1 was impulsive; and if she wanted to do something, she would just do it and not wait for staff assistance. The OT (Occupational Therapy) daily treatment note on 3/9/11 documented resident #1 was "impulsive with transfers", and her gait was ataxic. The OT daily treatment note on 3/10/11 documented resident #1 was "very impulsive". The note further documented resident #1 was in the wheel chair "...thrusting her pelvis forward to slide down on seat nearly with buttocks off w/c (wheel chair) X (times) 3, also pushing through feet pushing w/c backwards into therapist or other resident, as well as raising from (sic) (front) wheels off the floor. Both actions despite verbal cues regarding people behind her...and risk of falling from w/c. Pt. (patient) also flexed forward while in w/c nearly bumping her forehead on the railing at the nurses station...". On 3/29/11 at 2:05 p.m. surveyor # interviewed OT (Occupational Therapist)-N regarding resident #1. OT-N stated upon admission to the facility resident #1 was at high risk for falls due to the recent history of falls and ataxic gait. OT-N stated resident #1 was impulsive and required staff assistance for safety. During the interview with DON-B, completed on 3/30/11 at 9:10 a.m., surveyor # questioned what the care plan intervention of "Monitor adherence to safety instructions" required staff to do. DON-B indicated the staff would be educating the resident regarding the use of the call light, and that was a "resident focused" intervention. Surveyor # questioned if the care plan was revised when it was evident resident #1 was not "adhering to safety instructions". DON-B verified it had not been. Despite the knowledge of resident #1's impulsive behavior, and the "quick" movements which resulted in the resident being already out of the chair or bed before the alarm alerted staff to independent transfer/ambulation, no changes were made to the plan of care to promote safety. Progress notes on 3/10/11 documented the following for resident #1: 3/10/11 at 8:00 a.m. "Res. (resident) anxious, attempting to stand up (independently)...Given AM meds (medications) along (with) PRN (as needed) Lorazepam (an antianxiety medication) & Vicodin (pain medication) to promote decreased anxiety...". 3/10/11 at 10:00 p.m. "Res. transported by ambulance to (hospital name) @ (at) 9:20 p.m.. See change in condition eval (evaluation) form & neuro assessment flowsheet". A "late entry" for 3/10/11 (documented on 3/14/11 at 12:30 p.m.) documented, "Res. found face down on floor in room @ 8 p.m. Res. had blood coming from her mouth. Res. not responding to stimulus...family aware...MD (Medical Doctor) notified, ambulance notified...". The change in condition evaluation, dated 3/10/11 at 11:00 p.m., documented resident #1 was found on the floor, face down at 8:00 p.m. in her room. The resident was unresponsive to verbal/painful stimuli. A "goose-egg" was noted on the resident's forehead along with a cut to the inner bottom lip and a small cut under the resident's chin. The change in condition evaluation also indicated that at 5:00 p.m. that day the family had notified the writer that resident #1 had a small, soft, tender area, 1 cm (centimeter) x 1 cm on the back of her head. Per the documentation, the resident stated she fell but was unable to verbalize when or where it happened. Neuro checks were started and were found to be within normal limits. The neurological assessment flow sheet documented neurological checks were completed on 3/10/11 at 5:15 p.m., 5:30 p.m., 5:45 p.m., 6:00 p.m., 6:30 p.m., 7:00 p.m. and 7:30 p.m. and were WNL (Within Normal Limits). The Emergency Department note documented resident #1 was evaluated in the emergency room after a fall at the facility. A CT of the head was remarkable for acute on chronic subdural hematomas with diffuse mass effect. Resident #1 remained at the hospital until 3/21/11, when she was discharged back to the facility. The CT scan dated 3/10/11 documented the maximal thickness of the right-sided subdural hematoma was 11 mm and the left sided subdural hematoma measured 7 mm. The "impression" was documented as bilateral acute on chronic subdural hematomas with diffuse mass effect and compression of both lateral ventricles. As noted previously, the CT scan completed on 3/1/11, documented the right frontal subdural hematoma measured 7 mm and the left frontal subdural hematoma measured 6 mm. On 3/29/11 at 1:00 p.m. surveyor # completed a telephone interview with LPN (Licensed Practical Nurse)-J regarding the fall resident #1 sustained on 3/10/11. LPN-J stated she was passing medications on the hall where resident #1 resided on 3/10/11. LPN-J stated on 3/10/11 at approximately 8:00 p.m. she heard resident #1's alarm sound and responded to the room. When LPN-J entered the room, resident #1 was standing next to her bed, and indicated she needed to use the bathroom. LPN-J stated she asked resident #1 to sit back down on her bed and wait for her to find someone to assist her. LPN-J stated resident #1 responded by stating "yes" when she asked the resident if she would wait. LPN-J stated resident #1 sat down on the bed. LPN-J placed the call light on to obtain assistance with resident #1, as she was not familiar with resident #1's care needs (i.e. transfer ability). LPN-J stated she left resident #1 on the bed while she went to the doorway of the room to look for a staff member in the hallway. As LPN-J was looking into the hallway, she heard resident #1's sensor alarm sound again. LPN-J turned around to find resident #1 had fallen, face first onto the floor. LPN-J summoned RN (Registered Nurse)-M to the room, and an assessment was completed. LPN-J stated resident #1 was not responsive to verbal or painful stimuli. LPN-J stated that emergency services were contacted, and resident #1 was sent to the hospital. LPN-J stated she had not been aware of resident #1's impulsive behaviors or history of falls. LPN-J stated she was aware that resident #1 was at risk for falls, because she had a pressure sensitive alarm on. LPN-J stated she was not aware of any further prevention or safety measures that were in place for resident #1. On 3/29/11 at 3:42 p.m. surveyor # completed a telephone interview with RN-M regarding the fall resident #1 sustained on 3/10/11. RN-M stated on 3/10/11 at approximately 8:00 p.m. she was summoned to resident #1's room by LPN-J. RN-M stated upon entry to the room, resident #1 was found face down on the floor. Resident #1 was bleeding from her mouth and had a bump on her forehead. RN-M stated resident #1 was not responsive to verbal cues or a sternal rub. RN-M stated she assessed resident #1 and determined emergency services were required. RN-M indicated resident #1 was transported to the hospital for treatment. RN-M stated she had been assessing resident #1 prior to the fall on 3/10/11 at 8:00 p.m. due to the family report that resident #1 had a bump on the back of her head from a reported fall. RN-M had completed an assessment and initiated neurological checks at 5:00 p.m. RN-M stated resident #1 could not provide her any details of the reported fall (prior to 5:00 p.m.), and staff had no knowledge of a fall or accident involving resident #1. RN-M stated she assessed the environment and noted with resident #1's family that the toilet piping in resident #1's bathroom lined up with the bump to the back of the head. The toilet piping was padded to prevent further injury. RN-M stated when she responded to resident #1's room after the fall at 8:00 p.m., resident #1 had a significant change in her neurological status, including increased blood pressure. RN-M stated she had worked with resident #1 prior to the fall and was aware of resident #1's quick and impulsive behaviors. RN-M stated resident #1 was at high risk for falls and verified resident #1 would not wait for staff assistance. RN-M stated she was aware of the use of the sensor alarm but was not aware of any further interventions to promote safety for resident #1. On 3/30/11 at 9:10 a.m. surveyor # interviewed DON-B and NHA (Nursing Home Administrator)-E regarding resident #1. DON-B and NHA-E verified resident #1 was at high risk for falls and indicated the resident was on the "falling star" program prior to the 3/10/11 fall. DON-B and NHA-E verified LPN-J should have been aware of resident #1's risk for falls due to the alarm use and falling star. DON-B verified the care plan interventions to prevent falls/accidents entailed the use of the sensor alarm, but no other safety devices or direct supervision plan was in place. DON-B and NHA-E verified the fall risk assessment completed on admission was outlined on the "Admission/Re-Admission Data Collection & Initial Plan of Care", and no further detailed facility fall assessment was completed immediately upon admission. (The "Admission/Re-Admission Data Collection & Initial Plan of Care" asked the following questions: 1) Is resident inconsistent in understanding his/her limitations? 2) History of falls? Within last month: #of falls____ Within 2-6 mos.: # of falls____. History of a fracture or significant injury due to fall.) DON-B stated she felt the facility implemented the use of the sensor alarm for resident #1 on admission to provide the least restrictive device for safety. DON-B stated the 3/10/11 fall was the first fall resident #1 sustained at the facility, and the resident's plan of care was modified after the fall. DON-B verified no changes were made to the plan of care with regard to safety after documented incidents of impulsive behavior and staff observations of ambulating independently prior to staff assistance, despite the use of the alarm. 2. The face sheet, dated 6/5/07, revised on 3/23/10 and contained within the medical record, indicated resident #2 was protectively placed in the facility with [DIAGNOSES REDACTED]. The resident was readmitted to the facility on [DATE] after hospitalization for a traumatic hip fracture. The resident's MDS (Minimum Data Set), dated 2/4/11, indicated resident #2 was moderately cognitively impaired, did not ambulate, had behavior symptoms toward others and required extensive assistance to perform most activities of daily living including transfers. The associated falls CAA (Care Area Assessment) indicated the resident had a history of [REDACTED]. Sensor pads were indicated to be utilized both in wheel chair and bed to alert staff to independent transfer attempts. Resident #2's current fall plan of care included interventions dated 4/11/10 for use of a sensor alarm while the resident was in chair and bed; an intervention dated 4/17/10 of slip grip to wheel chair seat; an intervention dated 7/1/10 for use of a bariatric mattress on the floor; an intervention dated 7/22/10 not to place the resident in a recliner chair; an intervention dated 2/10/11 of two assistance with all transfers, to remind the resident to ask for assist for all transfers and to monitor for changes in condition that may warrant increased supervision/assistance; an intervention dated 2/14/11 not to leave the resident alone in the bathroom and an intervention dated 3/3/11 to lay the resident down after the evening meal. The resident's current self care deficit plan of care included an intervention dated 2/10/11 to include staff assist of one with activities of daily living and assistance of two staff when the resident was combative or striking out. Per the falls investigation reports, resident #2 experienced falls on 12/27/10, 2/2/11, 2/14/11 and on 3/2/11. The falls investigation report dated 12/27/10 indicated the resident had a witnessed fall in the hallway. The investigation indicated the resident's medications were reviewed and revised due to side effects of agitation. The falls investigation report dated 2/2/11 indicated the resident had attempted to self-transfer. The investigation indicated the resident was to be laid down when agitated and per the resident's request. The falls investigation report dated 2/14/11 indicated the resident sustained [REDACTED]. The investigation did not indicate if the resident was left unattended on the toilet or if her alarm had sounded. The investigation indicated the resident was not to be left alone in the bathroom due to fall risk. The falls investigation report dated 3/2/11 indicated the resident had an unwitnessed fall with a resultant bruise to her left knee when attempting self-transfer. The resident's plan of care was updated to indicate the resident needed to be laid down after the evening meal due to restlessness and complaints of a sore buttock. On 3/30/11 at 10:20 a.m. surveyor # interviewed CNA-D regarding resident #2. CNA-D verified she was unable to recall if she had witnessed resident #2's fall off the toilet on 2/14/11. CNA-D stated, "The resident was very quick to move, and she slides herself off the toilet." On 3/30/11 at 12:15 p.m. surveyor # interviewed CNA-A regarding resident #2. CNA-A stated, "If I did step out of the bathroom (on 2/14/11 while assisting resident #2), it was for a split second, but I was standing right there and lowered her to the floor. I didn't leave her unattended. I was waiting for another staff to help me and had the call light on. She is not be left unattended on the toilet. I know her, and she gets very anxious and agitated and moves quickly. I was waiting for another staff to assist me when the resident slid herself off the toilet." The facility did not complete a thorough investigation into the fall incident for resident #2, when the resident slid off the toilet. The resident had not been left alone on the toilet when the fall occurred on 2/14/11, and the intervention that had been implemented into the resident's plan of care to include not leaving her unattended in the bathroom was not appropriate to prevent further falls of that nature. On 3/30/11, from 10:30 a.m. until 10:50 a.m., surveyor # observed resident #2 lying on a mattress, which had been placed directly on the floor. The sensor alarm box was situated on the bedside table, and the cord from the sensor pad was not secured into the alarm box. The resident did not attempt to rise out of bed unattended during the observation. The surveyor summoned RN-I at 10:50 a.m. on 3/30/11. RN-I verified the bed sensor pad for resident #2 had not been activated and also verified resident #2's current plan of care included the use of a sensor pad while the resident was in bed. 3. The face sheet, dated 2/19/11 and contained within the medical record, indicated resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #9's Durable Power of Attorney for Health Care was not activated, and the resident was her own person. Admission papers from the hospital, dated 2/19/11, indicated resident #9 was at risk for falls and noted under additional pertinent information, "Needs a chair alarm on. Unsteady gait. Needs reminder to use walker at times. Bed alarm on at night. Doesn't use the call light." A nurses' note for resident #9 dated 2/19/11 showed the resident was admitted to the facility at 1:30 p.m. The next nurses' note dated 2/19/11 at 3:55 p.m. indicated resident #9 slid out of the wheel chair onto the floor and was not injured. A nurses' note for resident #9 dated 2/19/11 at 10:30 p.m. indicated a clip alarm was put on after resident (#9) slid out of her wheel chair. Review of the facility's initial care plan for resident #9 showed an approach for a clip alarm in the wheel chair on 2/19/11. During an interview with surveyor # on 3/30/11 at 11:00 a.m., DON (Director of Nursing)-B confirmed the wheel chair clip alarm was not added to the care plan or placed on resident #9's wheel chair until after the resident's fall on 2/19/11. DON-B indicated she would have expected her staff to have the care plan and alarm in place upon admission of resident #9 given the information on the hospital admission papers.

Based on staff interviews and record review, the facility did not ensure a resident having pressure ulcers received necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing for 1 (resident #3) of 4 sampled residents with pressure ulcers in a total sample of 9 residents. Resident #3 was admitted to the facility without pressure ulcers and was identified to be at risk for the development of pressure ulcers. A basic preventative plan was established. On 7/30/10 resident #3 presented with a stage I pressure ulcer on the left buttock. Although a treatment regimen was established for the area and basic wound assessment procedures were identified on the plan of care, no further measures were implemented to prevent development of further ulcers. On 8/25/10 resident #3 presented with a suspected DTI (Deep Tissue Injury) to the right buttock. Although a treatment was ordered for the area, no further changes were made to the plan of care. On 8/30/10 the ulcer on the right buttock was larger in size. The facility did not consult with the physician regarding the treatment plan, and did not evaluate the plan of care to promote healing of the area. The assessment dated [DATE] did not stage the ulcer and indicated slough (loose, stringy necrotic tissue) was present in the wound. On 9/9/10 the facility completed measurements of the right buttock ulcer, did not stage the ulcer and indicated the ulcer continued with slough in the wound. No changes were made to the overall plan of care to promote healing of the area or prevent further breakdown. Resident #3 was admitted to the hospital on [DATE]. The hospital records dated 9/17/10, documented the presence of a stage III pressure ulcer to the right buttock and a stage III pressure ulcer to the left buttock. Findings include: On 11/2/10 surveyor # reviewed the facility "Skin Care & Wound Management" policy and procedure dated 8/10. The policy documented the components of the skin care and wound management program to include, "...Application of treatment protocols based on clinical 'best-practice' standards for promotion of wound healing...Daily monitoring of existing wounds...Monitoring for consistent implementation of interventions and effectiveness of interventions, review and modification of treatment plans, as applicable...". The procedure directed staff to "...Develop a care plan...document individualized goals and interventions to manage risk factors...modify and document goals and interventions as indicated...communicate changes to the caregiving team...". The procedure further directed staff to complete a 'Skin Grid-Pressure' to document the status of an identified pressure area. The procedure directed staff to complete the skin grid at the following intervals: "...upon admission, if pressure area identified; upon identification of pressure area, at least weekly until area healed; more frequent documentation may be indicated based on changes in condition of wound...". The procedure further directed staff to measure the pressure area to include stage, length, width, depth and surface area. Indicate the wound bed status to include the type (i.e. [MEDICATION NAME], granulation tissue, slough, eschar, blister, etc.), color, describe wound edges and to indicate if any drainage was present. If drainage was present, the amount, type, odor and color should be documented. The procedure further directed that peri-wound should be assessed and documented as well. On 11/2/10 surveyor # completed a record review for resident #3. According to the facility face sheet, dated 7/8/10, resident #3 was admitted to the facility on [DATE]. The accumulative [DIAGNOSES REDACTED]. The facility completed a skin sweep sheet on admission. The initial skin sweep documentation recorded an area of light redness to the left sacral area. According to RN (Registered Nurse)-C, the area was blanchable and would not have been categorized as a pressure ulcer. RN-C verified resident #3 was at risk for skin breakdown related to his impaired mobility. The facility completed an admission MDS (Minimum Data Set) with a reference date of 7/15/10. The MDS documented resident #3 required extensive staff assistance with bed mobility and transfers and was not ambulatory. The MDS further documented resident #3 was occasionally incontinent of bladder. Resident #3 did not have any pressure ulcers or history of resolved ulcers in the past ninety days. The triggered RAP (Resident Assessment Protocol) for pressure ulcers dated 7/21/10 documented, "Resident is at risk for skin breakdown r/t (related to) decreased mobility, obesity, occasional bladder incontinence." Braden Scales for predicting pressure ulcer risks were completed on 7/8/10, 7/15/10, 7/22/10, 7/29/10, 8/6/10 and 9/5/10 and documented resident #3 was at risk for pressure ulcer development. The facility completed an initial care plan dated 7/13/10, which instructed staff to "...minimize the risk of skin impairment." On 7/22/10 the facility developed a plan of care for pressure ulcer prevention. The plan identified resident #3 to be at low risk and directed staff to provide the interventions, which included: -instruct resident to notify clinical staff of changes in skin condition -evaluate areas of skin where the resident may have impaired sensation (i.e. feet) -inspect skin daily for signs/symptoms of skin breakdown -monitor areas of a healed ulcer The plan of care did not identify any pressure reduction devices in place for the bed surface or wheel chair, and no specified repositioning program was established. The plan only directed staff to encourage and remind the resident to change position frequently. DOCUMENTATION REGARDING THE LEFT BUTTOCK ULCER: Progress notes dated 7/30/10 documented the following: - 10:00 a.m. "Stage I discoloration noted to left buttock this am during cares...barrier cream applied...fax sent to MD (Medical doctor)...". -12:00 p.m. "...Will measure area on left buttock when returns to bed this evening...". No measurements of the wound were completed, and no skin grid was completed (as directed by facility policy). Treatment orders were obtained from the physician on 7/30/10 to apply a [MEDICATION NAME] dressing to the area and change every three days and as needed. No changes were made to the plan of care. The progress notes from 7/30/10 to 8/4/10 did not contain any measurements of the pressure ulcer. On 8/4/10 a wound assessment was completed and documented on the skin grid. The assessment documented a stage I ulcer to the left buttock, which measured 3.4 cm (centimeters) by 0.8 cm with no depth and no drainage. On 8/4/10 the facility developed a "Plan of care: pressure ulcer". The plan directed the staff to implement the following interventions: treatment as ordered, documented wound measurements no less than weekly, assess for signs of infection, and teach resident about: pressure ulcer etiology, risk factors, treatment and prevention. There were no changes made to the plan of care with regard to the positioning schedule or support surfaces in both bed and wheel chair. On 8/11/10 the skin grid documented the ulcer to the left buttock continued to be a stage I and was decreased in size to 3 cm by 1 cm with no depth and no drainage. On 8/25/10 the skin grid documented the area of the left buttock as "healed", and a physician order [REDACTED]. On 8/30/10 the skin grid documented the area of the left buttock ulcer to be "scabbed" with a red wound bed and granulation tissue present. No measurements or further description of the "scabbed" area were documented. On 9/9/10 the skin grid documented the area of the left buttock ulcer continued to be "scabbed" with a red wound bed and granulation tissue present. No measurements or further description of the "scabbed" area were documented. No further assessments of the area were completed. Resident #3 was discharged to the hospital on [DATE]. DOCUMENTATION REGARDING THE RIGHT BUTTOCK ULCER: On 8/25/10 the facility identified a new pressure ulcer to the resident's right buttock area and documented the following on the skin grid: Stage I/DTI, which measured 3 cm by 0.5 cm with no depth and no drainage. The wound bed was documented as dark blue. On 8/25/10 the physician was contacted, and treatment orders were obtained for an Allevyn Thin dressing to be changed every three days. The NPUAP (National Pressure Ulcer Advisory Panel) has noted with a suspected DTI, evolution may be rapid, exposing additional layers of tissue even with optimal treatment. Despite this risk, the facility did not review/revise the plan of care to implement aggressive measures to prevent further breakdown and promote healing. On 8/30/10 the skin grid documented the area of the right buttock ulcer to be 7 cm by 0.5 cm with a depth of 0.1 cm. No stage of the wound was documented, and the assessment noted a small/medium amount of drainage. The type of drainage was not identified, and the wound bed was noted to have slough. The color of the slough was not identified, and the wound edges were documented to have redness. The progress notes on 8/30/10 at 10:00 p.m. documented, "Dressing change on buttock sore dry wound...(skin pilling (sic) off at the edge...) lt. (left) cheek midline (coccyx). No drainage noted...". Although the wound now had depth, drainage, and increased in size, the facility did not modify the treatment plan, consult with the physician or implement further measures to promote healing. The NPUAP, 2009 Pressure Ulcer Treatment guidelines recommended at least weekly assessments of the wound should be completed, including assessment of the stage of the ulcer, and further noted that "...signs of deterioration should be addressed immediately...". The guidelines further recommend to "...assess pressure ulcers carefully for signs of infection and delays in healing, which are more common in bariatric individuals...". On 9/9/10 the skin grid documented the ulcer of the right buttock ulcer to be 4 cm by 0.5 cm with a depth of 0.1 cm. Again, no stage was identified, and the assessment noted a small/medium amount of drainage. The type of drainage was not identified, and the wound bed was noted to have slough. The color of the slough was identified as yellow, and the wound edges were documented to have redness. No further treatment changes or modifications in the plan of care were completed. The facility did not document any further assessments of the ulcer. On 9/10/10 the progress note at 7:50 p.m., documented, "...Right dressing change on buttock due to "pain". The progress note did not provide any assessment or description of the wound. The progress notes dated 9/11/10 at 2:45 p.m. and 9/12/10 at 2:00 p.m. documented a dressing change had been completed to the buttocks and cream was applied. The progress notes did not provide an assessment or description of the wound. The progress note dated 9/14/10 at 2:10 p.m. documented, "...cream applied to buttocks...", but again did not document any assessment or description of the wound. The progress note dated 9/16/10 at 10:00 p.m. documented, "...had sore, vertical on buttock-right, measure ~ (approximately) 4 cm by 0.7 cm. Scant bloody & (not legible) drainage. Dressing applied." The documentation did not contain any assessment of the wound base, indicate if any depth was present to the wound and did not stage the ulcer. On 9/17/10 Resident #3 was admitted to the hospital. The hospital pressure ulcer assessment dated [DATE] documented a stage III pressure ulcer to the right buttocks, which measured 4 cm by 2 cm with a depth of 1 cm. The wound base had granulation tissue and slough present in the wound base with a scant amount of tan drainage. The record further documented a stage III pressure ulcer to the left buttocks, which measured 2 cm by 2 cm with no depth. The wound base was documented as having granulation tissue and slough present with a scant amount of tan drainage. On 11/2/10 at 1:37 p.m. surveyor # completed an interview with RN-A regarding resident #3's pressure ulcers. RN-A verified she was a certified wound nurse. RN-A verified resident #3's plan of care did not identify any support surface in place for the bed or the wheel chair. RN-A stated resident #3 had a bariatric bed but was uncertain of the pressure reducing/relieving properties of the surface. RN-A could not recall if resident #3 had a support surface in the wheel chair but stated if a support surface for the wheel chair was in place, it should have been documented on the plan of care. RN-A stated the care plan dated 7/22/10, which identified "frequent" repositioning, would indicate every two hours based on the facility practice. RN-A stated the documentation of 7/30/10 in the progress notes indicating a stage I pressure ulcer should have been documented on the skin grid, and should have included measurements of the wound. RN-A and surveyor # reviewed the clinical record, including the plan of care. RN-A verified, other than the implementation of the dressing to the area, no other changes were made to the plan of care following the development of the pressure ulcer on 7/30/10. RN-A verified the first documented wound measurements for the left buttock ulcer were completed on 8/4/10. RN-A verified the plan of care dated 8/4/10 was developed at that time. RN-A verified the plan directed staff to provide teaching, measurement/assessment of the wound weekly and provide the treatment as ordered by the physician. RN-A verified the plan was not modified to include a revision of the "frequent" repositioning, or evaluation of the support surfaces, or any other measures to prevent further breakdown. RN-A verified she completed the assessments of the left buttock ulcer on 8/25/10, 8/30/10 and 9/9/10. RN-A verified she documented the area as "healed" on 8/25/10 and then documented the area to be "scabbed" on 8/30/10 and 9/9/10. RN-A verified no measurements of the "scabbed" area were documented. RN-A stated by "scabbed" she meant the area had a "dry crust" over the healed area. RN-A verified no further assessment of the area was documented. RN-A stated the ulcer should have been assessed at least weekly due to the continued "scabbed" area being present. RN-A verified she completed the assessment of the right buttock ulcer on 8/25/10. RN-A indicated the ulcer was documented as a stage I/DTI. RN-A verified the area was intact, but was dark blue in color. RN-A verified no changes were made to the plan of care following the identification of the DTI. RN-A verified she completed the assessment of the ulcer to the right buttock on 8/30/10. RN-A verified the ulcer had increased in size, had depth, drainage, and slough was present in the wound base. RN-A verified no stage of the ulcer was documented. RN-A could not recall why the ulcer was not staged, but stated it may have been "unstageable" related to the slough. Surveyor # questioned if the wound was not stageable, would that documentation be present within the clinical record? RN-A and surveyor # reviewed the record; and RN-A stated if the wound was unstageable, she would have noted such. Therefore, since it was not documented as unstageable, it should have been staged. RN-A stated since she was able to determine depth, she should have been able to stage the wound. RN-A stated the wound should have been staged as a stage II pressure ulcer. When questioned if a stage II would have been an accurate stage based on the documented assessment of slough being present in the wound bed, RN-A indicated it would be. (Note: The NPUAP describes a stage II ulcer as a partial thickness loss of dermis presenting as a shallow open ulcer with a red pink-wound bed, without slough. Presents as a shiny or dry shallow ulcer without slough or bruising). RN-A verified no changes were made to the plan of care despite the progression of the wound, and no treatment changes were completed. RN-A verified the physician was not consulted regarding the deterioration of the wound and/or need to alter treatment interventions. RN-A verified she completed the wound assessment of the right buttock on 9/9/10. RN-A verified she did not document a stage of the wound, but verified the wound continued to have depth, drainage and slough present. Again, RN-A verified the wound would not have been unstageable, as she was able to determine depth; therefore, there she should have documented the wound as a stage II pressure ulcer. Surveyor # again questioned if a stage II would have been an accurate assessment based on the documentation of slough being present within the wound bed. RN-A stated it would have been accurate, as it was a shallow ulcer despite the slough. RN-A verified no changes were made to the plan of care following the 9/9/10 assessment. RN-A verified no further assessment was completed prior to resident #3's discharge to the hospital on [DATE]. RN-A stated resident #3's condition of back pain increased prior to his discharge to the hospital, which placed him at greater risk for skin breakdown due to his decreased willingness to reposition. RN-A stated resident #3's plan of care should have been revised given the increased risk. On 11/2/10 at 2:24 p.m. surveyor # interviewed RN-D. RN-D verified if pressure reduction devices were to be implemented, those devices would be noted on the plan of care. RN-D verified that would include pressure reducing wheel chair cushions. RN-D could not recall if resident #3 had a pressure reduction cushion in his wheel chair and stated she had not been involved in the resident's care. The medical record documented RN-D completed assessments of the resident's left buttock wound on 8/4/10 and 8/11/10, and RN-D initiated the plan of care dated 8/4/10. On 11/2/10 at 2:30 p.m. surveyor # interviewed CSC (Central Supply Coordinator)-F. CSC-F stated she was the person who ordered any supportive surfaces for residents. CSC-F stated resident #3 was provided a basic pressure reducing mattress and a basic foam cushion for his wheel chair at the time of admission. CSC-F verified she never was asked to order/provide any other supportive surfaces for resident #3, and she was not aware of any other devices that were provided to resident #3. CSC-F provided surveyor # manufacturer descriptions of the mattress and wheel chair cushion. The documentation noted the mattress was a foam mattress, which provided pressure redistribution; and the wheel chair cushion was a three inch reticulating foam cushion with a weight capacity of 250 pounds. The admission MDS documented resident #3's weight as 300 pounds. On 11/2/10 at 2:35 p.m. surveyor # interviewed CNA (Certified Nursing Assistant)-E. CNA-E stated she was not aware of any specific repositioning schedule or plan in place for resident #3 other than every two hours. CNA-E stated resident #3 had a foam cushion in his wheel chair, and at times the resident would spend quite a lot of time up in the wheel chair. CNA-E stated as resident #3's back pain increased, the resident was limited in the amount of time he could tolerate being up in the wheel chair. CNA-E stated that just prior to his hospitalization , resident #3 would not always want to be repositioned once he was comfortable in a position. CNA-E was not aware of any changes made to the plan of care with regard to skin care interventions. On 11/2/10 at 2:38 p.m. surveyor # interviewed CNA-G. CNA-G was not aware of any specific repositioning plan in place for resident #3. CNA-G indicated resident #3 utilized a blue foam cushion while up in his wheel chair. CNA-G stated resident #3 would call for assistance with repositioning, and CNA-G would check on him between those times and offer repositioning. On 11/2/10 at 9:55 a.m. surveyor # interviewed CNA-H. CNA-H stated resident #3 was on a standard repositioning schedule, which meant the resident required repositioning every two hours. CNA-H stated resident #3's back pain increased prior to his discharge to the hospital. CNA-H stated there were times when resident #3 would decline repositioning related to the back pain. On 11/2/10 at 2:55 p.m. surveyor # interviewed DON (Director of Nursing)-B. DON-B verified no measurements were completed of the stage I pressure ulcer to the resident's left buttock until 8/4/10. DON-B verified measurements should have been completed at the time of discovery, per the facility policy. DON-B verified she would have expected revision of the plan of care following the development of the DTI on the right buttock noted 8/25/10. DON-B verified she would have expected physician consultation and revision of the plan of care following the deterioration of the right buttock wound on 8/30/10. DON-B further stated the right buttock ulcer should have been staged with the 8/30/10 and 9/9/10 assessments, with at least weekly assessments thereafter. DON-B verified the last documented assessments of the right and left buttock ulcers were documented on 9/9/10. The facility developed an initial prevention plan of care due to the risk of pressure ulcer development. When ulcers developed, the facility did not implement further measures to prevent further ulcers from developing. The update to the comprehensive plan of care dated 8/4/10 only addressed teaching, evaluation of the wound, and treatment interventions to the wound, but did not comprehensively address risk. The facility did not evaluate items such as the positioning schedule and support surface. Furthermore, when resident #3 displayed increased back pain, which in effect decreased his mobility and willingness to reposition, the facility did not evaluate the increased risk and implement measures to prevent further deterioration of the wound.