Every finding on record at Golden Age Manor

Based on observations and interview, the facility did not store, prepare, distribute, serve food in accordance with professional standards for food service safety. This has the potential to affect all 62 residents. -Surveyor observed clean water pitchers not inverted on open shelf in kitchen. -Surveyor observed in the walk-in cooler an open bag of whipped topping, an open container of butter, and prepared cinnamon rolls in a baking pan without dates indicating when they were opened, prepared, or when they should be used by. -Surveyor observed in the walk-in freezer opened bags of potato wedges, vegetables, and berries all without dates of when they were opened. -Surveyor observed in the dry storage area opened packages of cookies, dried noodles, split peas, powdered pudding and gelatin mixes, all without dates indicating when they were opened or when they should be used by. Findings include: On 6/22/26 at 8:50 AM, during initial tour of the kitchen with Dietary Manager (DM) I, Surveyor observed clean pitchers on bottom shelf that were not inverted or covered. On a shelf below the serving area, a covered bowl of cereal was not labeled with contents or date. In the milk cooler, an open jug of milk did not have an opened on or use by date written on it. During tour of the walk-in cooler, Surveyor observed an open bag of whipped topping, an open container of butter, and prepared cinnamon rolls in a baking pan. All of these items did not have dates indicating when they were opened or prepared or when they should be used by. Surveyor and DM I then toured the walk-in freezer and observed opened bags of potato wedges, vegetables, and berries all without dates of when they were opened. Surveyor then toured dry storage area with DM I and found opened packages of cookies, dried noodles, split peas, powdered pudding and gelatin mixes, all without dates indicating when they were opened or when they should be used by. On 6/22/26 at 9:15 AM, Surveyor interviewed DM I, who stated the expectation would be that all clean dishes are to be inverted when stored to prevent contamination from debris and all opened food items should be labeled and dated with the opened-on date.

Based on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 62 residents residing in the facility. Improper hand hygiene was observed during personal cares for R4, R6, R13, R40. Staff did not disinfect mechanical lifts after use for R4, R13, and R40 observed transferring with a mechanical lift. Staff did not wear proper personal protective equipment (PPE) when caring for R30 who is on Enhanced Barrier Precautions (EBP).Example1 The facility policy, titled Handwashing/Hand Hygiene, dated 2000, states: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.1. Hand Hygiene is indicated:a. immediately before touching a resident;b. before performing an aseptic ask (for example.);c. after contact with blood, body fluids, or contaminated surfaces;d. after touching the resident's environment;e. before moving from work on a soiled body site to a clean body site on the same resident; andg. immediately after glove removal.5. The use of gloves does not replace hand washing/hand hygiene. On 6/23/26 at 4:11 PM, Surveyor observed Certified Nursing Assistant (CNA) N enter R13's room, complete hand hygiene, and put on gloves. CNA O pushed the sit to stand in R13's room. CNA O did not complete hand hygiene upon entering room before putting on gloves. The sit to stand sling was applied to R13, and they were raised with the sit to stand to a standing position by CNA O. CNA N pulled down R13's pants to check their brief. CNA M and CNA N then looked and touched the brief and resident's thighs to see if R13 needed to be changed. CNA O stated no, it's dry. CNA N pulled up R13's pants. R13 was lowered back into their wheelchair. CNA N took off gloves, completed hand hygiene, and pushed R13 out to the dining room. CNA O took off gloves, no hand hygiene, and pushed the sit to stand lift out of R13's room. On 6/23/26 at 4:20 PM, Surveyor observed CNA N and CNA M enter R40's room to provide cares. CNA N completed hand hygiene prior to donning gloves. CNA M did not perform hand hygiene prior to entering room and donning gloves. CNA M stated they had already emptied R40's ostomy, and they needed to place the sling under R40 and transfer them to their chair. CNA N and CNA M rolled R40 and placed a Hoyer sling under them. Once in place CNA N took off their gloves, completed hand hygiene, and left the room. CNA M remained with same gloves standing by R40's chair. At 4:26 PM, CNA O came into R40's room pushing the Hoyer lift. CNA O did not perform hand hygiene upon entering room or donning gloves. CNA O put R40's shoes on them. Then both CNAs attached the Hoyer sling to the Hoyer lift. CNA O operated the lift while CNA M assisted with sitting R40 correctly in their wheelchair. When R40 was in wheelchair, CNA O doffed gloves, completed hand hygiene, and pushed R40 out to the dining area. CNA M took off gloves, pushed Hoyer out of room, and parked it out in the community area. CNA M did not perform hand hygiene after taking off gloves, prior to leaving the room, or before they went over and touched R42's shoulder and attempted to chat with R42, asking if they were hungry. On 6/23/26 at 4:34 PM, Surveyor observed CNA N assist R6 to the bathroom. CNA N entered R6's room and guided R6 to the bathroom. CNA N put on gloves. Of note: CNA N did not complete hand hygiene upon entering the room or prior to putting on gloves. CNA N proceeded to assist R6 with pulling their pants down and sitting on the toilet. When R6 was ready, CNA N assisted R6 with peri cares and pulled up their pants. Afterwards, CNA N took off their gloves, followed R6 out of their room and toward the dining area. Once in the dining room, CNA N washed their hands at kitchen sink, touching faucets with hands after just completing peri-care. On 6/23/26 at 6:32 PM, Surveyor observed CNA O and CNA M provide personal cares to R4. CNA O pushed R4 in the wheelchair into their room. CNA O completed hand hygiene upon entering R4's room and donned gloves. CNA O positioned themselves behind R4's wheelchair. CNA M entered R4's room, did not complete hand hygiene and moved Hoyer lift into place. Of note: CNA O had brought Hoyer into room at 6:08 PM. This is the same Hoyer used at 4:11 PM and still not wiped down. CNA M donned gloves without completing hand hygiene. CNA M and CNA O attached the Hoyer sling to the Hoyer lift and R4 was transferred onto their bed. CNA O and CNA M undid the brief on their respective sides and CNA O completed peri-care. After completing peri-care and while wearing the same gloves, CNA O pulled R4's covers up to R4's chin and adjusted R4's pillow under their head. CNA O then took offer gloves, did not perform hand hygiene, and pushed the Hoyer out of the room. On 6/23/26 at 5:50 PM, Surveyor interviewed CNA M regarding infection control. Surveyor asked CNA M when hand hygiene is required. CNA M stated they wash their hands any time after a resident has a BM or catheter care. CNA M stated hand sanitizer is required before personal care. Surveyor asked CNA M if gloves replace the need for hand sanitizer. CNA M stated no, hand hygiene should be done before gloves and in between glove changes. CNA M stated hands should be washed before assisting residents with eating. Surveyor asked CNA M if they followed hand hygiene process today. CNA M stated no I probably did not, I was nervous and in a hurry. On 6/23/26 at 5:53 PM, Surveyor interviewed CNA O who stated hand hygiene is needed before and after cares, you can wash or use hand sanitizer. Surveyor asked if there is any other time hand hygiene needed. CNA O stated if you think they are dirty. Surveyor asked what if you are entering or leaving a resident's room. CNA O stated yes, you should use hand sanitizer before you enter a room and after you leave it. Surveyor asked CNA O if gloves replace the need for hand hygiene. CNA O stated no gloves do not replace it; you should complete hand hygiene when you put on and take off your gloves. Gloves should be changed if you do something dirty. On 6/23/26 at 6:22 PM, Surveyor interviewed CNA N who stated hand hygiene should be completed before you feed someone, before and after touching people, and especially after cares. Surveyor asked CNA N if gloves replace hand hygiene. CNA N stated that no gloves do not, you should always complete hand hygiene before gloves, between changes, and afterwards. On 6/24/26 at 6:28 PM, Surveyor interviewed Medication Aide (MA) L regarding when to complete hand hygiene. MA L stated hand hygiene should be completed every time you work with a resident or have body contact. MA L stated hand hygiene is required sometimes with medication. MA L stated in between residents you should at least use hand sanitizer, but MA L stated they wash their hands whenever they can. Surveyor asked when all staff should use hand hygiene. MA L started hand hygiene is supposed to be conducted before they enter and leave the room. MA L stated that hand hygiene is needed any time your hands are dirty. Surveyor asked if gloves replace the need for hand hygiene. MA L stated no gloves do not replace hand hygiene and should happen between glove changes. Example 2 The facility policy, titled Cleaning and Disinfecting Non-Critical Resident -Care Items, dated June 2011, states: d. Reusable items are cleaned and disinfected or sterilized between residents. On 6/23/26 at 3:55 PM, Surveyor observed CNA M assist R42 via a lift; no concerns with cares or hygiene. CNA M pushed the sit to stand lift out of R42's room, parked outside door and did not wipe it down. On 6/23/26 at 4:11 PM, Surveyor observed personal cares for R13 requiring use of the sit to stand lift. When cares were complete, CNA O pushed EZ Stand lift out of R13's room and parked it in the storage spot located in the community area. CNA O did not wipe down the sit to stand lift before use or after use. On 6/23/26 at 4:11 PM, Surveyor observed CNA O push the Hoyer lift into R40's room. CNA M and CNA O used the Hoyer lift with R40. When done with cares, CNA O pushed the Hoyer lift out of R40's room. CNA O parked the Hoyer lift in the spot located in large community area. CNA O did not wipe down the Hoyer lift. On 6/23/26 at 6:06 PM, Surveyor observed CNA M push the Hoyer lift, that has yet to be wiped down from the storage area, to R30's room, waited a few minutes and then pushed it over to R4's room. The dirty Hoyer lift was left in R4's room. On 6/23/26 at 6:32 PM, Surveyor observed CNA M and CNA O use the dirty Hoyer lift with R4. CNA M and CNA O transferred R4 from a wheelchair to R4's bed for evening cares. After cares were provided, CNA O pushed the Hoyer lift out of R4's room and parked it in the spot located in the community area. CNA O did not wipe down the Hoyer lift prior to or after use. On 6/23/26 at 5:50 PM, Surveyor interviewed CNA M who stated that lifts are cleaned at the end of the shift. Surveyor asked CNA M if they meant only once a shift or between residents. Surveyor informed CNA M that tonight none of the lifts have been observed being wiped down after use. CNA M stated it would be great to wipe it down in between, but we do not have the time. We only have to do it at the end of the shift. On 6/23/26 at 5:53 PM, Surveyor interviewed CNA O who stated lifts should be wiped down after use whenever possible and at the end of your shift. On 6/23/26 at 6:28 PM, Surveyor interviewed MA L who stated lifts should be wiped down every day and after every person. We used to keep the wipes with the lifts, but residents would take them, and one resident would eat them, and one resident would put them down their pants. So, they are kept up on the counter. Because the wipes are not with the lifts, I think the CNAs sometimes forget to wipe down the lifts between residents. The lifts get wiped down at the end of every shift for sure. On 6/24/26 at 12:38 PM, Surveyor interviewed Director of Nursing (DON) B who stated DON B's expectation is that lifts are cleaned with wipes after every use. There are wipes kept with the lifts. Surveyor shared with DON B the observation of no wipes with lift or visible on the unit. DON B said oh you're talking about the Cottage (special unit), that's true. DON B stated in the Cottage they planned to keep them somewhere else. DON B stated maybe on the counter. Surveyor asked DON B if not having the wipes with the lifts would change the expectation for wiping down the lifts. DON B stated, no they should be wiped after every use. Example 3 The facility policy titled, Enhanced Barrier Precautions, dated 5/1/2024, states: 3. Implementation of Enhanced Barrier Precautions:b. PPE for enhanced barrier precautions is only necessary when performing high contact care activities (described below) and may not need to be donned prior to entering the resident's room.4. High-contact resident care activities include:a. Dressingc. Transferringd. Providing hygienef. Changing briefs or assisting with toileting. On 6/23/26 at 7:11 AM, Surveyor observed CNA J getting R30 up off the toilet. Surveyor entered R30's unit and checked on R30, finding cares were in progress. CNA J had gloves on, but no gown. R30 was sitting on the toilet. CNA J used EZ stand to assist resident to stand and help off toilet. CNA J completed peri care, took off gloves, and completed hand hygiene. R30 was on Enhance Barrier Precautions (EBP). CNA J did not have a gown on during these cares. On 6/23/26 at 7:15 AM, Surveyor interviewed CNA J regarding Enhanced Barrier Precautions (EBP). Surveyor asked CNA J what the PPE on the door is for. CNA J said, For in here. CNA J opened the door and looked. CNA J stated, It must be new, definitely new to me, must be from yesterday. CNA stated, It has to do with their wound I'm guessing. I'll be honest we didn't have that before. I am back here every day, and it was not there. Surveyor asked if CNA J is supposed to use EBP. CNA J stated, Yes, I will have to and should have used it. On 6/23/26 at 10:02 AM, Surveyor interviewed Licensed Practical Nurse (LPN) K who stated EBP means a resident usually has a wound or catheter. The EBP sign means we should wear gloves and gowns any time we are toileting, providing cares, or dealing with the wound or catheter. LPN K stated R30 was placed on EBP yesterday morning. LPN K indicates they were aware of R30 being placed on EBP because they were on shift yesterday. LPN K stated staff are told about changes in report and in a message on messaging system regarding precautions. LPN K didn't recall if it was brought up to the CNAs in report but there was a message. On 6/23/26 at 10:30 AM, Surveyor interviewed DON B and asked what the expectation is for EBP. DON B stated the expectation is staff follow the EBP whenever they are providing personal care to residents. Surveyor informed DON B of their observations with CNA J not wearing a gown and only gloves. DON B stated CNA J should have known. DON B said we sent a Teams message about it. Surveyor asked how CNAs and nurses learn when residents have changes in their cares. DON B said it should have been passed on in report but there is a Teams message in case it is missed. CNA J should have known, there was a Teams message about R30.

Based on record review and interviews, the facility failed to ensure the Infection Preventionist (IP) is trained in the required specialized education for infection prevention and control. This has the potential to affect all 62 residents.-The facility failed to ensure Registered Nurse (RN) G, who is acting in the role of the facility's Infection Preventionist (IP), had completed specialized training in infection prevention and control.Findings include: On [DATE], Surveyor reviewed the documentation the facility had provided for proof of the IP's training and certification. Surveyor found a portion of the modules had certificates of completion from the Center for Disease Control (CDC) infection control program. The CDC training log stated expired for the certificate of IP final test indicating the test was not taken in the time allowed after completing the modules. The required IP course does not show the IP certification test was taken and passed. Surveyor requested missing documentation and proof of certification from RN G.On [DATE] at 1:24 PM, Surveyor interviewed RN G who reported they were not sure if they took a final test after completing the IP training modules. RN G stated they do not have a certificate which indicates passing the IP test. On [DATE] at 8:50 AM, Surveyor interviewed Nursing Home Administrator (NHA) A, who stated they had thought RN G had taken and completed the IP course and the expectation is the IP meets the qualifications as indicated by the federal regulations.

Based on interview and record review, the facility did not maintain documentation of screening, education, offering, and current Coronavirus 19 (COVID) vaccination status to staff. This has the potential to affect all 62 residents.Findings include: The facility policy titled, Employee Infection and Vaccination Status, with a revised date of January 2024 states: 2. Employees are offered or provided with vaccinations per state or local agency policies/regulations. 3. Employees are provided with educational materials to make informed decisions for non-mandated vaccinations. If declined, a declination form is completed and placed in the employee's health record. 5. Documentation of vaccinations includes the signature of the licensed healthcare provider and the employee when being administered. Vaccinations that are declined by the employee are documented on the applicable declination form and placed in the employee's health record.On 06/23/26 at 10:10 AM, Surveyor asked RN G if the facility maintains staff documentation on screening, education, offering, and current vaccination status. RN G stated only when staff are hired. RN G stated COVID vaccination information is provided at staff meetings and is offered yearly; a sign-up sheet is then put up. RN G reported very few staff get the COVID vaccine. RN G stated they do not maintain any documentation on the education which was provided or the staff who received the information. RN G reported they do keep record of the current vaccination status of the employees. On 06/23/26 at 12:39 PM, Surveyor interviewed Certified Nursing Assistant (CNA) P, who reported they were offered the COVID vaccine and Influenza this past year. CNA P stated the offer to immunize comes through a chat platform used by staff. CNA P does not get the vaccination. CNA P believes they signed a form declining COVID when starting employment a couple of years ago.Surveyor requested and reviewed CNA P's employee vaccination record noting it had their vaccinations received at the time of hire on 10/12/22 and a signed declination of the COVID vaccination on that date. On 06/24/26 at 8:52 AM, Surveyor met with Nursing Home Administrator (NHA) A and Director of Nursing (DON) B. NHA A and DON B verbalized understanding of the regulation to maintain documentation of screening, education, offering, and current Coronavirus 19 (COVID) vaccination status of the staff.DON B stated they were unaware this was not being done, as the facility used to maintain this information. DON B reported the expectation would be the Infection Preventionist maintains the required documentation of the employees screening, education, offering, and the current Coronavirus 19 (COVID) vaccination status of all staff.

Based on interview and record review, the facility did not ensure that the Advanced Directives information related to resuscitation status was clearly identified on residents' medical records to ensure their life-sustaining wishes would be honored. This occurred for 9 of 18 sampled residents (R) reviewed for Advanced Directives. (R31, R5, R9, R7, R2, R59, R4, R30, and R32) R31's physician order noted code status of Do Not Resuscitate (DNR)/Do Not Intubate (DNI). R31's advance directive did not include R31's wishes for resuscitation, no DNR/DNI form was signed by R31 or R31's representative, and no documentation in R31's medical record regarding conversation with R31 regarding code status. R5's physician order noted code status of Do Not Resuscitate (DNR)/Do Not Intubate (DNI). R5's advance directive did not include R5's wishes for resuscitation, no DNR/DNI form was signed by R5 or R5's representative, and R5's medical record did not document any conversation being held with R5 regarding code status. R9's physician order noted code status DNR/DNI. R9's medical record did not have documentation of the facility or provider discussing advanced directive with R9, an advance directive stated Full Code status, and social service assessment stated DNR/DNI. R7's physician order noted code status of Do Not Resuscitate (DNR)/Do Not Intubate (DNI). R7's medical record did not have a DNR/DNI signed by R7 or R7's representative, an inquiry report stated Full Code, and Resident Assessment stated Full Code. R2's physician order code status stated DNR/DNI. R2's advance directive did not include R2's wishes for resuscitation and no DNR/DNI form was signed by R2 or R2's representative. R59's physician order code status stated DNR/DNI. R59's medical record did not have documentation of the facility or provider discussing Advanced Directive with R59, an inquiry report noted Full Code status, and a Resident Assessment stated Full Code. R4's electronic medical record indicates that R4's code status is DNR, document titled Honoring Choices Wisconsin, checked the option I [R4] want CPR attempted unless my doctor determines: * I have a medical condition and no reasonable chance of survival of CPR, or* CPR would harm me more than help me, document titled Statement of Incapacity does not address code status, no evidence the facility provided education and discussed resuscitation changes from Full Code to DNR status, and no updated advance directive or DNR/DNI for signed by R4 or R4's representative. R30's physician orders stated DNR/DNI (do not intubate), R30's medical record does not address code status, R30's hospital transfer orders indicated Code Status: Full code. No evidence the facility provided education and discussed resuscitation changes from Full Code to DNR/DNI. No updated Advance Directive or DNR/DNI document was signed by R30 or R30's representative. R32's physician order states Code status: DNR/DNI, R32's medical record documents care conference with no change in code status, and no ave or DNR/DNI document signed by R32 or R32's representative. Findings include: Facility Policy titled, Advance Directives, states, in part: Definitions: b. Advance Directive-a written instruction, such as a living will or durable power of attorney (POA) for health care, recognizing by state law, relating to the provisions of health care when the individual is incapacitated. 1. Living Will. 2. A durable POA of healthcare, 3. Do Not Resuscitate (DNR)- indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used. 4. Do Not Hospitalize (DNH). Determining Existence of Advance Directive: 1. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. 3. Written information about the right to accept or refuse medical or surgical treatment, and the right to formulate an advanced directive is provided in a manner that is easily understood by the resident or representative. If the resident does not have an Advance Directive: 1. If the resident or representative has not established advance directives, the facility staff will offer assistance in establishing advance directives. A. The resident or representative is given the option to accept or decline assistance, and care will not be contingent on either decision. B. Nursing staff will document in the medical record the order to assist and the resident's decision to accept or decline assistance. 2. Information about whether or not the resident has executed an advance directive is displayed prominently in the medical record in a section of the record that is retrievable by any staff. 3. The attending physician provides information to the residents and legal representative regarding the residents' health status, treatment options and expected outcomes during the development of the initial comprehensive assessment and care plan. Example 1 R31 was admitted to the facility on [DATE]. R31's physician order, dated [DATE], noted code status of Do Not Resuscitate (DNR)/Do Not Intubate (DNI). Surveyor reviewed R31's Advanced Directive scanned on [DATE], dated [DATE], which did not include R31's wishes for resuscitation. No DNR/DNI form was signed by R31 or R31's representative. Surveyor reviewed R31's medical record and noted: -[DATE]: Social Service Assessment – under Finance/Legal section stated, 'DNR/DNI.' Of note: no documentation of provider documenting conversation of resuscitation wishes. On [DATE] at 9:08 AM, Surveyor interviewed R31's Family Member (FM) F and asked about R31's code status and if R31 was educated on risks and benefits of code status upon admission. FM F reported to Surveyor that FM F does not remember facility educating on advance directives and code status on admission. FM F reported facility should know R31's wishes. Surveyor reported to FM F upon review of advance directives it does not address code status. FM F reported to Surveyor FM F did not know code status was not on the advance directive, but the code status is in fact DNR/DNI. On [DATE] at 11:50 AM, Surveyor interviewed Registered Nurse (RN) D and asked if RN D processes new admissions. RN D reported to Surveyor they do assist with the admissions of new residents admitted to the facility. Surveyor asked RN D how they address code statuses with newly admitted residents. RN D reported they usually will review hospital discharge notes and use the order from the hospital for what the code status is while in hospital and then RN D places the order in the medical record. Surveyor asked RN D who discusses the risks and benefits of the residents' code status for being full code or DNR. RN D reported to Surveyor Social Services Aide C usually makes notes and educates on risks and benefits during the admission process. Surveyor asked RN D where this information is kept. RN D reported to Surveyor RN D is unsure but thinks it's in the medical record under advance directive tab in residents' scanned documents. Example 2 R5 was admitted to the facility on [DATE]. R5's physician order, dated [DATE], noted code status of Do Not Resuscitate (DNR)/Do Not Intubate (DNI). Surveyor reviewed R5's Advanced Directive scanned on [DATE], dated [DATE], which did not include R5's wishes for resuscitation. No DNR/DNI form was signed by R5 or R5's representative. Surveyor reviewed R5's medical record and noted: -[DATE]: Social Service Assessment – under Finance/Legal section stated, 'DNR/DNI.' Of note: no documentation of provider documenting conversation of resuscitation wishes. On [DATE] at 11:50 AM, Surveyor interviewed Registered Nurse (RN) D and asked RN D to review R5's medical record and to look at advance directive together to see if it matches up with R5's code status. RN D reported that RN D does not do anything with the advance directive and with R5's admission, RN D just reviewed hospital discharge notes and noted R5 was a DNR/DNI status, so another RN placed the information in the medical record. RN D stated, I'm assuming it was from the form from the hospital discharge note as that is how we address code status from hospital admissions. Example 3 R9 was admitted to the facility on [DATE]. R9's physician order, dated [DATE], noted code status DNR/DNI. Surveyor was unable to locate any documentation of the facility or provider discussing Advanced Directive with R9. Surveyor reviewed R9's Advanced Directive scanned on [DATE], dated [DATE], which included R9's wishes for Full Code resuscitation (CPR). Surveyor reviewed R9's medical record and noted: -[DATE]: Social Service Assessment – under Finance/Legal section stated, 'DNR/DNI.' Of note: no documentation of provider documenting conversation of resuscitation wishes. On [DATE] at 8:23 AM, Surveyor interviewed Social Services Aide C and asked to explain process for new admissions into facility and address advance directives/code status for residents. Social Services Aide C reported to Surveyor they do not have anything to do with the code status of residents as Social Services Aide C is the assistant of Social Services. Social Services Aide C reported code statuses are addressed by Nurse Practitioners (NP) or Providers on all new admissions. Surveyor asked Social Services Aide C what time frame residents are seen by providers on admission. Social Services Aide C reported the NP or provider has up to 14 days to assess all new admissions and then they will review code status with residents at that point. Social Services Aide C reported to Surveyor they do not do anything with the code statuses and Surveyor would need to talk with nursing staff and providers. On [DATE] at 8:37 AM, Surveyor interviewed Director of Nursing (DON) B and asked process for residents newly admitted and addressing code status. DON B reported providers usually address all residents' code status upon admission. Surveyor asked DON B for the time frame for when provider visits new admissions in the facility to address code status. DON B reported provider has up to 14 days to see new admissions for assessments. DON B reported to Surveyor then the provider will address code status and write an order of DNR/DNI status, nursing changes in the medical record, and it is placed in the medical record via scanned in document. Surveyor asked DON B what the document looks like when scanned in. DON B reported the form is the advance directives scanned into resident documents and/or the provider will dictate a note explaining if the provider has addressed code status with set resident. Surveyor asked DON B what are the elements that make an Advance Directive. DON B reported to Surveyor the Advance Directive includes care planning for health care needs, code status that being DNR/DNI or Full Code, and Power of Attorney information. Surveyor asked DON B to review the medical records of R31, R5, R9, R7, R2, R59, R4, R30, and R32 and find the code status POST sheet scanned into their medical record for their current code status and advance directives. DON B could not find a POST form but stated, Maybe the provider documented a visit note explaining the code status. Surveyor asked DON B who reviews the provider's dictation from the initial admission visit. DON B reported RN G and RN D review and change code status of provider orders and admission assessments. Surveyor asked DON B if it was best practice for newly admitted residents to wait up to 14 days before code status is addressed. DON B reported expectation would be within 24 hours of being admitted the code status should be addressed. Surveyor asked DON B who is addressing residents' code status then until provider assesses residents about code status. DON B stated, That is a good question. DON B reported NP will assess residents' code status and dictate it to a note if code status was addressed. Surveyor asked DON B how a new nurse coming on shift to work knows the resident was educated about code status and risks/benefits were explained. DON B reported NP does this for newly admitted residents and is unsure if that is in paper form or just dictation note. Surveyor requested code status policy to review. DON B reported to Surveyor that they would gather code status policy. Surveyor asked DON B if the code status paperwork is supposed to be scanned into the medical record. DON B's expectation is code status be scanned into the medical record. DON B reported that Surveyor will need to request follow up documentation from Medical Records. On [DATE] at 8:52 AM, Surveyor interviewed Director of Medical Record E and requested any pertinent information in the medical records of R31, R5, R9, R7, R2, R59, R4, R30, and R32 that would show Surveyor code status was addressed with residents and their representatives. Surveyor provided Director of Medical Record E with a list of 15 residents' names and requested POLST information for all residents so Surveyor could understand how code status is being addressed. On [DATE] at 8:36 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked for expectation of advance directives and what the elements are in an advance directive. NHA A reported to Surveyor the expectations would be what DON B noted to Surveyor yesterday [DATE] but that code status is addressed at care conferences. Surveyor reported to NHA A, DON B's expectation that was explained would be code status is addressed in advance directives upon admission within 24 hours of being in the facility. NHA A reported to Surveyor code statuses should be addressed within 24 hours for new admissions and then staff can address quarterly at care conferences. Surveyor explained that R31, R5, R9, R7, R2, R59, R4, R30, and R32 were either missing advance directives, had conflicting code status that did not match advance directives, and/or advance directives that did not address code status at all. Surveyor reported to NHA A Surveyors could not find documentation of conversations and education relayed to R31, R5, R9, R7, R2, R59, R4, R30, and R32 regarding the code status in the medical record. NHA A reported to Surveyor NHA A will fix the code status and advance directive expectation in facility going forward. Example 4 R7 was admitted to the facility on [DATE]. R7's physician order, dated [DATE], noted code status of Do Not Resuscitate (DNR)/Do Not Intubate (DNI). Surveyor reviewed R7's Advanced Directive did not include R7's wishes for resuscitation. No DNR/DNI form was signed by R7 or R7's representative. Surveyor reviewed R7's medical record and noted: -[DATE]: Inquiry Report – under special needs section stated, 'Full Code.' -[DATE]: Resident Assessment – under Physical Condition section stated, 'Full Code.' Of note: no documentation of provider documenting conversation of resuscitation wishes changed from Full Code to DNR/DNI were noted. On [DATE] at 7:34 AM, Surveyor interviewed Registered Nurse (RN) D regarding Advanced Directives. Surveyor asked RN D where staff look to find a resident's code status. RN D stated the electronic medical record will have a banner at the top displaying the code status, the physician orders, and a copy of the Advanced Directive will be uploaded into the chart. Surveyor asked RN D if there was any other place staff would look to find the Advanced Directive. RN D stated a copy should also be in the paper chart for the resident. Surveyor asked if nursing ensures the Advanced Directive is in place for each resident. RN D stated, no, the Nursing Home Administrator (NHA) reviews each resident's code status weekly and updates the 'Full Code' list at the nursing station. Example 5 R2 was admitted to the facility on [DATE]. R2's physician order, dated [DATE], noted code status DNR/DNI. Surveyor reviewed R2's Advanced Directive did not include R2's wishes for resuscitation. No DNR/DNI form was signed by R2 or R2's representative. Example 6 R59 was admitted to the facility on [DATE]. R59's physician order, dated [DATE], noted code status DNR/DNI. Surveyor was unable to locate any documentation of the facility or provider discussing Advanced Directive with R59. Surveyor reviewed 59's medical record and noted: -[DATE]: Inquiry Report – under special needs section stated, 'Full Code.' -Resident Assessment (with no date) – under Physical Condition section stated, 'Full Code.' Of note: no documentation of provider documenting conversation of resuscitation wishes changed from Full Code to DNR/DNI were noted. Example 7 R4 was admitted to the facility on [DATE]. Nurse Practitioner order dated [DATE] states, Change code status to DNR (do not resuscitate). Ok to hospitalize. Surveyor reviewed R4's electronic and paper medical record and noted: ~R4's electronic medical record indicates that R4's code status is DNR. ~Document titled Honoring Choices Wisconsin, dated and signed by R4 on [DATE] has checked the option I [R4] want CPR attempted unless my doctor determines: * I have a medical condition and no reasonable chance of survival of CPR, or * CPR would harm me more than help me. ~Document titled Statement of Incapacity, dated [DATE], does not address code status. Note: No evidence the facility provided education and discussed resuscitation changes from Full Code to DNR. No updated Advance Directive or DNR/DNI form was signed by R4 or R4's representative. Example 8 R30 was admitted to the facility on [DATE]. Physician orders dated [DATE] stated DNR/DNI (do not intubate), signed [DATE]. Surveyor reviewed R30's electronic and paper medical record and noted: ~Document titled Statement of Incapacity, dated [DATE], does not address Code status. ~R30's Hospital Transfer orders dated [DATE] indicated Code Status: Full code. Note: No evidence the facility provided education and discussed resuscitation changes from Full Code to DNR/DNI. No updated Advance Directive or DNR/DNI document was signed by R30 or R30's representative. Example 9 R32 was admitted to the facility on [DATE]. R32's physician order, dated [DATE] states Code status: DNR/DNI. Surveyor reviewed R32's electronic and paper medical record and noted: ~Progress note dated [DATE] 10:41, states: Care Conference: Initial care conference was held today w/ family.No changes to code status. ~R32's electronic medical record indicates that R32's code status is DNR. Note: No Advance Directive or DNR/DNI document signed by R32 or R32's representative. On [DATE] at 9:10 AM, Surveyor interviewed CNA J who stated they cannot do CPR; CNA J does not know resident's code status. CNA J stated if there is an issue she radios for the nurse immediately. CNA J stated I think their code status is listed in their plans, but we can't do anything, so I've never really looked, I'm not sure. On [DATE] at 9:19 AM, Surveyor interviewed Licensed Practical Nurse (LPN) K who stated it says right by resident's name what code status they are, and we have a red sheet on the bulletin board that highlights those that are Full Codes. If a resident is not listed on the sheet, then they are a DNR. LPN K took Surveyor to the nurse's station and showed Surveyor the red sheet on the bulletin board. It was turned over, so names were not visible but said Code Status, and there were two listed for the special unit. LPN K stated there is one of these sheets on every unit and list all full code residents, so all nurses have access. Surveyor asked what role nurses play in setting up the Advance Directive. LPN K stated they were not sure how that all works. This is a social service thing. It is all legal stuff, if they can't do it then the county ends up taking over. On [DATE] at 1:02 PM, Surveyor interviewed DON B who stated they already gave the information to the Team Coordinator for R4, R6, R30 and R32. DON B stated they thought this was part of the admission process and is already putting plans in place to correct that. Surveyor informed DON B that R4, R30, and R32 are missing evidence of education and discussion related to going from full code to DNR and a resident or representative signed document of code status. DON B stated they would make sure it wasn't missed. On [DATE] at 1:53 PM, DON B stated there wasn't more information regarding Advance Directives.

Based on observation, interview, and record review, the facility did not provide pharmaceutical services, including procedures that ensure that accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident, for 1 of 1 resident (R32) reviewed. R32 did not receive prescribed eye drops per physician order. Findings include: The facility policies, titled Administering Medications and Instillation of Eye Drops, both dated 2001, do not address reordering of medication or what to do when medication is not available. Per CFR S483.70 (f) the facility must provide routine and emergency drugs and biologicals to its residents or obtain them under an agreement as described. Per CFR S483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. R32 was admitted to the facility on [DATE] with a diagnosis of glaucoma. R32's Brief Interview of Mental Status (BIMS) of 04/15, dated 12/20/25, indicates that R32 is severely cognitively impaired. On 6/22/26 at 2:00 PM, Surveyor interviewed R32's Family Member (FM) R and asked if they were ever told why R32 is missing medications. FM R indicated they were told it was the pharmacy's fault but either way, sometimes R32 is without their medication over one week. R32's physician order states: Latanoprost drops; 0.005%; amt: 1 gtt both eyes; ophthalmic [Dx: Unspecified glaucoma] At bedtime; HS 1900-22:30. Start date: 12/12/2022- open ended. Per R32's electronic medication administration record (MAR),On 1/4/26, R32 did not receive eye drops. MAR documented Not Administered: Drug/Item Unavailable.On 2/12/26, R32 did not receive eye drops. MAR documented Not Administered: Drug/Item Unavailable.On 3/29/26, 3/30/26, and 3/31/26, R32 did not receive eye drops. MAR documented Not Administered: Drug/Item Unavailable.On 4/1/26, 4/2/26, 4/3/26, 4/4/26, 4/5/26, 4/6/26, and 4/7/26, R32 did not receive eye drops. MAR documented Not Administered: Drug/Item Unavailable.On 5/7/26, 5/9/26, 5/10/26, 5/11/26, 5/12/26, 5/15/26, 5/16/26, 5/17/26, 5/18/26, 5/19/26, 5/20/26, 5/21/26, 5/24/26, and 5/26/26, R32 did not receive eye drops. MAR documented Not Administered: Drug/Item Unavailable. On 6/23/26 at 5:18 PM, an email was sent from the facility's pharmacy to DON (Director of Nursing) B that states, in part Requested on 1/25/26. sent .1/25/25 for a 25-day supply.Requested on 2/5/26 but was refill to soon. 2/12/26 for a 25-day supply.We dispensed next 4/6/26. I do not see any refill request between 2/5 and 4/6. We sent a 25-day supply.Requested on 5/26/26 and we sent same day for a 25-day supply. Of note: This email from the facility pharmacy indicates there was no refill request from the facility between 2/5/26 and 4/6/26, indicating no order was present for the eye drops. On 6/23/26 at 4:35 PM, Surveyor interviewed Medical Assistant (MA) L regarding R32's eye drops having multiple missed administrations. MA L indicates staff had a hard time obtaining this medication. On 6/24/26 at 12:38 PM, Surveyor interviewed DON B regarding how the facility ensures medication is available to residents and refills are ordered. DON B indicated she believes Surveyor is asking about R32's eye drops. Surveyor noted to DON B there is a concern about R32's eye drops. DON B indicated she emailed the pharmacy yesterday. DON B indicated this has always been a concern for R32's family, even if it is only one day. Surveyor provided DON B with R32's MAR, the email of doses missed, when the medication was ordered, and the refill confirmations from the facility pharmacy. DON B indicated R32 has missed too many days of their medication. DON B also indicated Registered Nurse (RN) Q is very good about calling the pharmacy right away. Nurses are educated to keep calling to find out when the medication will be delivered. DON B indicated refills can be ordered by faxing, calling, or pushing a button in the electronic medical record. DON B indicated she will see if there is a report that can be run that shows evidence of the medication being ordered. On 6/24/26 at 1:53 PM, DON B brought medication related policies to Surveyor. DON B stated she was unable to print off a report that showed if staff ordered medications via the electronic system. DON B indicates she believe she knows what happened and that she found a bottle of eye drops in the refrigerator. DON B did not indicate any further information regarding the missing medication doses.

Based on interview and record review the facility did not complete a Minimum Data Set (MDS) assessment for significant change in a timely manner.-R1 was admitted to hospice. The MDS assessment for significant change was not completed within 14 days.Findings include:Facility Policy titled, Comprehensive Assessments, last revised [DATE], states: Comprehensive assessments are conducted in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) User Manual.The RAI User Manual states the Significant Change in Status Assessment (SCSA) must be completed by the end of the 14th calendar day following determination that a significant change has occurred.Surveyor reviewed R1's electronic health record. Last completed MDS assessment was completed on [DATE].R1 was admitted to hospice on [DATE]. A SCSA was started on [DATE] but was incomplete and never submitted. R1 expired on [DATE].On [DATE] at 2:50 PM, Surveyor interviewed Director of Nursing (DON) B. DON B stated the MDS assessments are completed upon admission, annually, quarterly, with a significant change, and as needed. DON B stated the facility follows the guidelines in the RAI. DON B stated a significant change would be a decline or improvement of 2 or more areas of care, or when a resident admits to or is removed from hospice. DON B stated the timeframe was 14 or 15 days after recognizing the change for completion of the assessment. DON B acknowledged R1's significant change MDS had not been completed and was past the 14 days.

Based on interview and record review, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents reviewed (R4).R4 had a fall during a 1-staff transfer with mechanical lift. Per care plan, R4 required 2-assist. Findings include:Facility policy titled, Falls and Fall Risk, Managing, last revised March 2018, reads in part: Unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force.The staff, with the input of the attending physician will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls.Facility policy titled, Care Plans, Comprehensive-Centered, last revised March 2022, reads in part: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.Each resident's comprehensive person-centered care plan is consistent with the resident's rights to.receive the services and/or items included in the plan of care.Example 1R4 was admitted to the facility on [DATE], with diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity.On 02/01/26, R4's MDS assessment showed a BIMS score of 13/15 indicating no cognitive impairment.R4's care plan includes problem of self-care deficits related to type 2 diabetes and obesity with an approach of all transfers are now sit-to-stand mechanical lift with assist of 2 (01/20/26).Progress notes on 01/24/26 states Certified Nursing Assistant (CNA) H called nurse to R4's room. R4 was lying on the floor with R4's feet on the sit-to-stand, R4's butt on the floor and R4's back against the bed, holding onto the trapeze on R4's bed. CNA H states CNA H was assisting resident to bed and trying to unhook the sling when R4 told CNA H to get R4's feet up on the bed. CNA H had 1 side unhooked and was attempting to unhook the other side, CNA H had a hard time reaching so CNA H unlocked the sit-to-stand lift and because R4 was pushing with R4's legs it started to move forward and R4 slowly slid to the floor. R4 was assisted back up to his bed using the Hoyer lift.On 01/26/26, RN M interviewed CNA H. CNA H stated CNA H knew to use 2 assist for R4's transfer and always does but this time chose not to. CNA H did not give reasoning for the choice not to get another staff member. CNA H was reminded to use the walkie talkie to get help if needed. CNA H was told this was unacceptable due to safety, and this would be documented as verbal counseling in CNA H's file and there is no tolerance for any further issues following this or any other safety policy. RN M stated education was completed with 3 staff on each shift, spot checked 3 mechanical lift transfers, verified for several days that staff had walkie talkies, and were communicating if help was needed.On 03/30/26 at 2:05 PM, Surveyor interviewed R4 about R4's recollection of R4's most recent fall. R4 stated R4 was partially on the bed with feet on the mechanical lift and R4 was hanging onto the trapeze on R4's bed. R4 stated the lift moved and R4 slid off the bed onto the floor. R4 stated there was only one CNA present and usually there are 2 because of R4's size. R4 stated R4 feels safe at the facility but knows to have the staff come in pairs from now on.On 03/30/26 at 2:26 PM, Surveyor interviewed RN E (Registered Nurse) in regard to what RN E would do if a resident had a fall. RN E stated RN E would make sure the resident is safe after a fall, complete assessments, use a lift or gait belt to assist the resident from the floor, and call an ambulance if there is a serious injury. RN E stated RN E would interview the resident if able, and/or the staff present if any to find out what happened and why. RN E stated RN E would speak with the supervisor. RN E stated all Hoyer lifts require 2 staff and the sit-to-stand require 1-2 assist depending on the resident's care plan.On 03/30/26 at 2:32 PM, Surveyor interviewed CNA C about how CNA knows what care each resident requires. CNA C stated the care plan/Kardex in the computer lets staff know what care residents need for transfers and other activities of daily living (ADLs). CNA C stated sit-to-stand lifts require 1-2 assist depending on the resident. CNA C stated CNA C has never had to use a lift alone when the care plan stated 2 staff were required. CNA C stated R4 uses a sit-to-stand lift and requires 2 staff for transfers.On 03/30/26 at 2:37 PM, Surveyor interviewed CNA D in regard to how CNA D knows how a resident transfers. CNA D stated the transfer status for each resident would be located in the computer in their care plan. CNA D stated all Hoyer lifts require 2 staff assist and sit-to-stand lifts can be 1 or 2 depending on what the care plan says. CNA D stated CNA D has never had to use a lift alone when it required 2 staff but has had to wait a while at times for someone to assist. CNA D stated R4 uses a sit-to-stand lift and requires 2 staff for transfers.On 03/30/26 at 2:41 PM, Surveyor interviewed RN F in relation to what RN F would do if a resident had a fall. RN F stated in the event of a fall, RN F would assess immediately, obtain vitals, and call 911 if needed. RN F stated RN F would start an event assessment and try to find out what happened. RN F stated if the fall is unwitnessed or if the resident hits their head, RN F would initiate neurological checks. RN F stated RN F would initially talk to the CNAs and give re-education.On 03/30/26 at 2:50 PM, Surveyor interviewed DON B about what DON B's expectations of the nurse would be in the event of a fall. DON B stated DON B's expectation in the event of a fall is for the nurse on duty to assess resident for injury. DON B stated the nurse should then start an event assessment and find out the cause of the fall. DON B stated interviews should be done with resident and staff as able. DON B stated the nurse should implement immediate intervention until the Interdisciplinary Team (IDT) can further investigate. DON B stated if a fall occurs as a result of staff not following a care plan re-education should be completed. If there is severe injury, DON B stated the staff member may get sent home or the workload would be adjusted if it would cause a staffing concern and would have the staff in question work with a partner. DON B acknowledged CNA H was working alone when R4's fall occurred, and CNA H was not following the care plan.

Based on interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who had completed the minimum qualification requirements for the position. This practice could potentially affect all 60 residents residing in the facility. This is evidenced by: On 4/7/25 at 9:10 AM, Surveyor conducted initial tour of the kitchen with Dietary Manager (DM) D. Surveyor interviewed DM D and requested verification of DM D's qualifications. DM D directed Surveyor to the two certifications on her office wall. On 4/8/25, Surveyor was provided copies of the certifications. In review of the DM certification, Surveyor noted it is for a Food Protection Manager which is accredited by the American National Standards Institute (ANSI)-Conference for Food Protection (CFP). Completed 2023-8-10 and valid through 2028-8-10 from the Always Food Safe Company. On 4/9/2025 at 8:50 AM, Surveyor interviewed Nursing Home Administrator (NHA) A, as DM D was unavailable. Surveyor asked if the facility has a full-time dietician in house. NHA A indicated they do not. The dietician is fully remote. Surveyor asked for any evidence the dietician was monitoring compliance in the kitchen. NHA A did not provide any information. NHA A reported the facility's understanding was the DM certification fell under the state qualifications listed in the SOM F801 483.60 (a) (2) (i) .(C) Has similar national certification for food service management and safety from a national certifying body. Surveyor investigated the certification further and informed NHA A the certificate provided does not meet requirements for Certified Dietary Manager.

Based on observation, interview and record review, the facility did not ensure the safety of food handling in accordance with professional standards for food service safety. The facility practices had the potential to affect all 60 residents. Foods stored in the walk-in-cooler were not labeled and dated and the Head [NAME] did not allow the thermometer probe to air dry after cleaning with isopropyl alcohol prior to inserting into foods items intended to be served to residents for lunch. This is evidenced by: The facility policies titled, Food Receiving and Storage revised December 2008, states in part, 7. All foods stored in the refrigerator or freezer will be covered, labeled and dates (use by date). The Food and Drug Administration (FDA) Food Code states in part, 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface SANITIZING solutions), before contact with food. On 4/07/25 at 9:10 AM, during initial tour of the kitchen with Dietary Manager (DM) D, Surveyor observed several opened foods in the walk-in-cooler had been opened but were not labeled with an opened date or use by date. These foods included sliced tomatoes, repackaged sour creams, opened bag of shredded cheese, a tray of individually portioned salads (coleslaw, potato salad, Jello salads) and pre-poured juice in cups. These foods were covered and on a tray; however, nothing on the tray was labeled or dated resulting in the potential for foodborne illness to spread. During this initial tour, Surveyor interviewed DM D, who reported the expectation would be that opened and/or prepared foods would be dated with an opened or prepared on date or a use by date. DM D did remove potentially hazardous foods and dispose of them. On 4/08/25 at 11:17 AM, Surveyor observed Head [NAME] G take temperature of foods to be served. During checking temperature of the foods, Head [NAME] G would stick probe into isopropyl alcohol probe wipe packet, rub probe end and immediately stick in next food item without waiting to let air dry as directed. This was done with 5 of the 9 foods that were checked during observation. On 4/08/25 at 11:44 AM, Surveyor interviewed Head [NAME] G, who reported she was trained on checking temperatures of foods a long time ago. Head [NAME] G reported she was unsure of when that would have been. Head [NAME] G reported she was not aware of the amount of time to allow cleaner to dry or that probe needs to dry and acknowledged she does not allow probe cleaning wipe to dry before checking temperature between foods. On 4/09/25, Surveyor informed Nursing Home Administrator A of the deficiencies in food preparation and storage that were observed.

Based on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. -The facility did not a have a clear water management process or plan in effect to prevent transmission of Legionella infection. This has potential to effect 60 of 60 residents reviewed. -The facility did not have a tracking program in place for the early detection of infected and exposed residents (R) and staff for COVID-19 and Norovirus during an outbreak. -R9 is on enhanced barrier precautions and staff did not perform proper hand hygiene practices during personal cares. -R1 has an indwelling catheter and was not on EBP -Staff did not perform proper hand hygiene during personal cares for R33. This is evidenced by the following: Example 1 Surveyor reviewed the facility policy titled, Water Management Program to Reduce Legionella Growth and Spread, dated last reviewed in September 2017. The policy did not have control measures for the building water system to prevent the spread of legionella described in the policy or on the flow diagram, addressing unoccupied rooms and the vacant North wing to decrease the spread of opportunistic waterborne pathogens. On 04/10/25 at 10:39 AM, Surveyor interviewed infection preventionist, Registered Nurse (RN) C, and asked who oversees the water management program. RN C indicated that RN C, Nursing Home Administrator A, and Maintenance work together to complete water management. Surveyor asked if RN C had control points and any corrective actions to address stagnation and decrease spread of Legionella for the unoccupied rooms and vacant north wing. RN C indicated that everyone completes flushes on Fridays for the vacant north wing but didn't know any other unoccupied rooms need to be flushed as well. Surveyor asked where that description of flushing on Fridays is occurring. RN C indicated that Flush Friday is just something that we know to do but it is not described in the facility water management policy. RN C indicated that RN C would update the water management policy to show control points and corrective actions needed when flushing vacant north wing and any unoccupied rooms in the facility. Example 2 Surveyor reviewed infection surveillance logs dated from February 2024-present. Surveyor found missing documentation on all line lists for surveillance to include complete: -Symptoms onset date. -Location/last worked. -Culture/test type and result. -Treatment parameters. -Isolation type/date start and end. -Resolution date and times for infections. Surveyor reviewed facility Influenza outbreak dated sometime in February. Surveyor could not find the exact start day of Influenza outbreak and what measures were placed to prevent the spread of infection. Surveyor could not find last worked dates for staff members that became infected and worked in the facility to decrease the spread of infection. Surveyor found missing documentation on all line lists for surveillance to include complete: -Culture/test type and result. -Treatment parameters. -Isolation type/date start and end. In Influenza outbreak summary, Surveyor could not find when isolation and proper PPE usage was underway, any audits of hand hygiene, proper PPE usage, or any education to staff to decrease the spread of Influenza. Surveyor reviewed facility COVID-19 outbreak dated sometime in September. Surveyor could not find the exact start day of COVID-19 outbreak and what measures were placed to prevent the spread of infection. Surveyor could not find last worked dates for staff members that became infected and worked in the facility to decrease the spread of infection. Surveyor found missing documentation on all line lists for surveillance to include complete: -Culture/test type and result. -Treatment parameters. -Isolation type/date start and end. -Return to work dates. In COVID-19 outbreak summary, Surveyor could not find when isolation and proper PPE usage was underway, any audits of hand hygiene, proper PPE usage, or any education to staff to decrease the spread of Influenza. On 04/10/25 at 10:39 AM, Surveyor interviewed RN C after reviewing facility's IC surveillance lists and asked RN C what is RN C's process for managing and decreasing the spread of infection. RN C indicated that she follows the CDC guidelines and keeps track of infections monthly. Surveyor asked RN C what the process is and expectations for sick employees. RN C indicated that the expectation is for staff to stay home and call staffing recruiter if symptomatic. Staff Specialist K will take sick calls and make referrals to staff on what staff should do as far as testing goes and when to return to work. Surveyor asked RN C if Staff Specialist K has training on consulting with staff about their sickness and actions to take going forward. RN C indicated that everyone is trained at the onboarding orientation on staying home when sick. RN C indicated that Staff Specialist K does not hold a CNA license or Nurse license and is not medically trained. Surveyor asked RN C to provide Surveyor with Staff Specialist K's training pertaining to how to consult with and make corrective actions for staff when sick. RN C indicated that RN C does not have any formal training that has been completed for Staff Specialist K. RN C indicated that before staff can return to work the staff member brings a form physically into the building and has charge nurse review the form to decide if sick employee is ok to return. RN C reviewed online spreadsheet with Surveyor in which Surveyor observed a staff member who had fever, migraine, and vomiting on 03/09/25 at 5:30 AM, and the staff member returned to work on 03/10/25 at 4:30 AM. RN C indicated that the staff member probably shouldn't have come back into work until over 24-hour fever free. Surveyor asked RN C to provide the spreadsheet to Surveyor to document the facility's process. In review of spreadsheet Surveyor asked RN C how RN C keeps track of what tests are performed to minimize the spread of infection. RN C indicated that Staff Specialist K has the COVID-19 test available to staff to test if symptomatic, but RN C does not have any other tests in place such as influenza or RSV. Surveyor asked RN C if RN C suggests staff members go get tested for anything else. RN C indicated that it is up to staff members if they want to see a doctor or not and get tested for other things. Surveyor asked RN C how RN C keeps track of testing on spreadsheet, resolution date, what precautions or isolation needed, and location of where employees had worked if staff were working sick while on shift. RN C indicated that RN C is not tracking location of employees worked unless an outbreak, resolution dates were not updated on spreadsheet accurately, and testing for infections is not being offered or suggested unless COVID-19. Surveyor asked RN C if RN C thought it was appropriate that staff needed to bring in their form and physically walk into building without properly making sure the staff member was still not currently sick. RN C indicated that RN C's line lists are not as thorough as they should be, and knows the process needs to be fixed as it is not decreasing the spread of infection. 31086 Example 3 Facility policy titled, Enhanced Barrier Precautions, dated 05/01/24, states in part: It is the policy of this facility to implement enhanced barrier precautions for the preventions of transmission of multidrug-resistant organisms . 2. Initiation of Enhanced Barrier Precautions: b. An order for enhanced barrier precautions will be initiated for residents with any of the following: 1. Wounds and/or indwelling medical devices (e.g., central lines, urinary catheters .) even if the resident is not known to be infected or colonized with a MDRO. The facility policy titled, Handwashing/Hand Hygiene revised October 2023 states in part, Indications for Hand Hygiene . c. after contact with blood, body fluids, or contaminated surfaces; d. after touching a resident; e. after touching a resident's environment; f. before moving from work on soiled body site to a clean body site on the same resident; and g. immediately after glove removal. R9 was admitted on [DATE]. R9's current diagnoses include multiple sclerosis, resistance to multiple antibiotics, dysphagia, acute right heart failure, pulmonary hypertension, neuralgia and neuritis, insomnia, vitamin D deficiency, myalgia, pain, hypertension, paraplegia, pressure ulcer of sacral region stage 4, colostomy, muscle weakness, and peripheral venous insufficiency. MDS dated [DATE], a quarterly assessment documented BIMS score of 11/15, meaning R9 has moderately impaired cognition. R9 has impairment to 1 side upper extremity and both sides of lower extremity. R9 requires maximum staff assistance for upper body dressing and personal hygiene. R9 is dependent on staff assistance for showering, lower body dressing, bed mobility and transfers. R9 has no behaviors of rejecting cares from staff. On 04/09/25 at 10:34 AM, Survey observed cares being provided by Certified Nursing Assistant (CNA) J. R9 has a sign on the outside of room door for enhanced barrier precautions. CNA J sanitized hands and applied gloves and gown. CNA J completed R9's upper body and peri care appropriately. After cleansing buttocks and applying barrier cream, CNA J removed gloves and did not complete hand hygiene. CNA J touched R9 to position in bed. CNA J did not complete hand hygiene and applied clean gloves. Then CNA J rolled resident, finished putting on brief, pulled pants up and applied the Hoyer sling. CNA J removed gloves, did not perform hand hygiene and applied clean gloves. CNA J applied heel protective boots to R9's feet. CNA J, with same gloved hands, touched the soiled plastic linen bags on the floor to move out of the way. With the contaminated gloves, CNA J placed a pillow between R9's legs. CNA J removed gloves, and without hand hygiene, gave R9 the call light and bed remote. CNA J removed gown and did not perform hand hygiene. CNA J moved R9's overbed tray table next to R9's bed. CNA J went to the bathroom, washed hands and with clean hands turned the faucet off. CNA J gathered garbage and the soiled linen bag and brought to the soiled utility room. On 04/09/25 at 10:56 AM, Surveyor interviewed CNA J about proper hand hygiene technique and glove use. CNA J indicated hand hygiene was not completed after removing soiled gloves. Surveyor asked what the proper technique for handwashing is when turning the faucet off. CNA J indicated she turned the faucet off with her clean hands but should have used a paper towel. On 04/09/25 at 2:31 PM, Surveyor interviewed RN C about hand hygiene and the observation with CNA J. RN C indicated staff have been trained and yesterday RN C reviewed with CNA J of proper hand hygiene practices. 49353 Example 4 R1 was admitted to the facility on [DATE] with pertinent diagnoses of chronic kidney disease stage, edema, and urinary tract infection. Review of R1's care plan identified no urinary catheter care plan in place to prevent the spread of infection. Review of R1's orders noted: 04/04/25 Foley Catheter for Urinary Retention. Of note: no order for enhanced barrier precautions (EBP) was noted. On 04/08/25 at 11:58 AM, Surveyor observed a transmission sign outside of R1's room stating, Contact Precautions. A personal protective equipment (PPE) cart was observed outside of room. No other precaution sign was noted. R1 was observed sitting in wheelchair in room. R1 had a urinary catheter hanging below wheelchair inside a dignity bag. Surveyor observed urinary catheter tubing exiting the bottom of R1's right pant leg with clear yellow urine. On 04/08/25 at 12:04 PM, Surveyor asked Registered Nurse (RN) I what the contact precaution sign outside of R1's room was for. RN I stated that it was for R1's roommate. On 04/10/25 at 10:24 AM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding observation. NHA A stated that R1 should have had EBP order initiated when the urinary catheter was placed. NHA A stated recognition that this had the potential to spread infection and put R1 and other residents at risk. 51095 Example 5 On 4/07/25 at 10:46 AM, Surveyor observed CNA F use sit to stand to transfer R33 from a wheelchair to the toilet. R33 remained on the toilet. On 4/07/25 at 10:56 AM, CNA F put on gloves and provided incontinence care for R33. CNA F wiped liquid stool from resident buttocks and perineal area. After getting bowel movement (BM) on gloves, CNA F used a disposable wipe to clean off her gloves. CNA F continued to provide incontinence cares for R33 without changing her gloves. After cleaning the BM, CNA F removed the gloves, did not practice any form of hand hygiene, and without donning new gloves put R33's clean incontinence pad on and pulled up her pants. CNA F then moved sit to stand lift, transferred R33 into her wheelchair, and removed R33's transfer belt for stand lift. CNA F continued without gloves to push R33 in the wheelchair to door before CNA F stopped and used hand sanitizer. On 4/07/25 at 11:01 AM, Surveyor interviewed CNA F who reported she had hand hygiene training last month. When Surveyor asked CNA F what should be done when there are visibly soiled gloves, CNA F reported she was not aware the gloves should be changed and not wiped cleaned. CNA F reported she is aware that she should use hand hygiene when leaving room. Surveyor pointed out that hand hygiene was not practiced immediately after removing soiled gloves. On 4/08/25 at 8:29 AM, Surveyor interviewed Licensed Practical Nurse (LPN) E who reported her expectations would be that if gloves are visibly soiled they be removed, and that hand hygiene should be performed immediately when gloves are removed. On 4/10/25 at 8:45 AM, Surveyor interviewed RN C, who reported the expectation would be soiled gloves be removed, not wiped clean, and hand hygiene be performed immediately after removing gloves, and after resident incontinence cares. RN C acknowledged further infection control/hand hygiene education is required and will be provided.

Based on interview and record review, the facility did not establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, the following elements: An Antibiotic Stewardship Program that includes antibiotic use protocols and a system to monitor antibiotic use. This has the potential to affect all 60 residents in the building who may utilize antibiotics. The facility did not ensure a standard of practice for antibiotic use or surveillance was being utilized in the facility's antibiotic stewardship program. This is evidenced by: The Facility policy titled Antibiotic Stewardship Program, dated 10/23, states in part: The Infection Preventionist is responsible for monitoring; investigating and setting forth a control plan to prevent unnecessary infections. The IP is responsible for monitoring and trending the facility infection incidence rates and this information is reviewed quarterly assurance committee with the interdisciplinary team and medical director each at least quarterly . Surveyor reviewed infection surveillance logs dated from February 2024-March 2025. Surveyor found missing documentation on all line lists for infection surveillance to include complete: -Symptoms onset date. -Culture/test type and result. -Treatment parameters. Such as Antibiotics of choice and when started and stopped. -Resolution date and times for infections. On 04/10/25 at 11:12 AM, Surveyor interviewed Infection Preventionist, Registered Nurse (RN) C, about antibiotic tracking and surveillance. RN C indicated that RN C receives a printout from Health Direct on who was on antibiotics for the month. Surveyor asked RN C when RN C receives this report. RN C indicated the report is sent roughly two weeks after residents are started on antibiotics for that month and that is when RN C is reviewing antibiotic use. Surveyor asked RN C how RN C is tracking infections, what kind of antibiotics residents are put on, and how RN C knows when residents are started on antibiotics and is it the correct antibiotic. RN C asked what Surveyor meant. RN C indicated that RN C leaves that up to the doctor to decide on antibiotic use. RN C stated, I am not a doctor. I don't know. Surveyor asked RN C what criteria is used to determine if an antibiotic is needed or that residents are on the correct antibiotic for their infections. RN C indicated to Surveyor that RN C is unsure what Surveyor is talking about. RN C indicated she does not have a process in place for monitoring correct antibiotic use for residents. Surveyor asked RN C what criteria RN C utilizes such as the McGeer's or Loeb's criteria. RN C indicated RN C was not using either the McGeer's or Loeb's criteria at all. Surveyor referred RN C to the CDC guidelines for monitoring antibiotic use and utilizing McGeer's or Loeb's. RN C indicated that she would start utilizing the McGeer's or Loeb's criteria.

Based on interview, observation and record review, the facility did not take action through documenting grievances, conducting a thorough investigation of the issues identified or provide resolution of the concerns brought to the attention of facility staff regarding missing laundry items. This affected R27, R42, R47, R44, and R4. This is evidenced by: Procedure for completing complaint reports: 1. All sections in complaint/grievance box must be completed entirely. 2. 2. After the complaint is recorded determine if a complaint is related to misappropriation. If the answer is Yes, the Administrator must be notified immediately. 3. In documentation of investigation box, the person in charge in the building will need to start the initial investigation. This may include interviews with staff or other residents, observations, memos posted to particular staff, etc. Use the back of form to contribute other details of investigation. 4. If a plan can be implemented right away, please implement and resolve the complaint. 5. If further investigation needs to occur, etc. The IDT will assist and resolve the complaint . Surveyor reviewed resident council meeting minutes for months December 2024-March 2025: -December 2024 resident council meeting minutes stated in part, [R27] said that his laundry has not been getting back to him as quickly as he would like, He is unsure if the clothing is getting lost before finding its way to him, but he would like to see them get back sooner. Surveyor reviewed Grievance logs: -On 01/07/25, grievance report filed by R42 who reported blue printed bathrobe was stolen. Documentation noted bathrobe was found in laundry on 01/08/25 and returned. Bathrobe was then marked with resident name in case it accidentally goes to laundry in the future. -On 01/08/25, grievance report filed by R47 who reported that he is missing a multicolored quilt that he received as a gift. Quilt was located in lower drawer of cabinet in room and now is gone. Documentation noted after staff searched, quilt was found in laundry services and returned to R47. On 04/09/25 10:30 AM, Surveyor met with resident council president R27, R44 and R4. R27 indicated that R27 had several missing clothing items over the last year. R27 reported the missing clothing items to staff members. R27 indicated the facility never could find R27's pants and shirts. R27 indicated that facility did not replace the missing items. R27 just let the missing items go and did not bring it up again until during resident council meetings. R27 indicated that activities aide usually helps find missing items. R44 spoke and indicated that R44 was missing several clothing items as well. R44 could not describe items. R4 indicated that R4 was admitted back August 2024 and had a beautiful grey, black, white fur coat that went missing. R4 indicated that R4 let a staff member know about the missing fur coat and R4 has never seen R4's fur coat again. R4 stated, I must keep a journal every day, and whenever an item goes to laundry, I write down the description of item and the date. When the item is returned to my room, then I cross it off so that I know I am getting my items of clothing back. On 04/09/25 at 11:01 AM, Surveyor toured laundry services with Laundry Director (LD) L. Surveyor asked LD L what the process for inventory is on residents' new clothes on admission and how unlabeled clothes are processed in the laundry department. LD L indicated that LD L's expectation would be that when residents are admitted , or any new clothing items come into the building that the Certified Nursing Assistants (CNA)s check inventory and bag the clothing items and mark on bag that clothes need labeling and send down to laundry to be labeled. LD L indicated what is happening is that CNAs are either labeling resident clothes with permanent marker and then it is not legible, or they are not labeling the clothing items at all. LD L then stated, Look at this clothing cart and how many items are unlabeled. Surveyor noted approximately 80 different pieces of clothing on unlabeled clothing cart. Surveyor asked LD how long the unlabeled clothing cart has been this way. LD L indicated that LD L has only been managing this site for a couple months and the facility has had the unlabeled clothing cart issue since LD L started. On 04/09/25 at 11:26 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked NHA A what the process is for labeling resident clothes. NHA A indicated there is not a clear process for labeling clothes. NHA A indicated that NHA A's expectation is that the CNAs will process new admission or new articles of clothing for a resident by placing clothes in a bag then labeling on front needs labeling and send the bag down to laundry so that LD L can process and label the clothing. NHA A indicated that if there is a missing item, staff will reach out to LD L. NHA A indicated that usually the item is found, and things are resolved. NHA A indicated that if residents complain of missing items or clothes, social services or the activities department will try to find the missing items and resolve the concern. NHA A stated, I hear about missing clothing items being resolved all the time and don't think about it much. Surveyor indicated to NHA A that there are about 80 articles of clothing not labeled on the unlabeled clothing cart in laundry in the basement. NHA A did not indicate any prompt efforts to resolve the missing clothing issue or have evidence of actively working toward a resolution for this resident concern. NHA A indicated the process for staff labeling unmarked clothes has been a part of the annual training for the last [AGE] years but could not provide documentation of training for staff to Surveyor. NHA A then stated, I did not realize there was such a problem with missing items grievances or complaints are to be filled out when items are missing that are of value, personal or financial. We replace things lost, especially when personal or financial value after talking to family. Surveyor asked NHA A if NHA A knew of any recent missing items. NHA A indicated that NHA A is not aware of anything recently but that NHA A's expectation is that staff members report the concern or grievance from residents who may not know how to formally file a grievance and then facility will look into missing items. On 4/9/25 at 2:55 PM, Surveyor was at nursing station in 100 wing when resident approached desk. R44 was attempting to communicate a need but was unable to verbalize. R44 was motioning to his clothing and attempting to verbalize needing something. RN I asked if R44 was referring to pads and R44 responded, Yes! Pants! On 4/9/25 at 3:05 PM, Surveyor observed R44 attempting to go through the locked doors that go to basement. Surveyor observed a staff member ask R44 what R44 needed. R44 indicated needed downstairs while R44 was pulling at R44's pants. Staff member indicated to R44 that staff member would let activities department know to search down in laundry room for R44's pants. On 4/10/25 at 12:00 PM, Surveyor interviewed Director of Nursing (DON) B and asked DON B what the process is for resolving grievances related to missing laundry. DON B indicated that DON B recognizes the potential for lost/missing items due to the incorrect labeling process for residents' clothing. DON B acknowledged that this concern of missing laundry items has not been resolved by the facility.

Based on observation, interview and record reviews, the facility staff failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, to develop comprehensive person-centered care plans to meet residents' goals for pain for or adequately assess and treat pain for 5 of 5 residents (R) reviewed (R49, R1, R24, R30 and R35). -Facility did not provide adequate pain relief, properly assess for pain, or develop a pain care plan for R49, R35 and R1. -R24 had no non-pharmacological interventions for pain. Care plan did not include resident's desired/tolerable pain level or follow-up pain assessment. -R30 received tramadol (an opioid medication) for pain. The facility did not implement pain assessments or interventions to determine the effectiveness of the medication. This is evidenced by the following: Facility policy titled, Pain Assessment and Management, dated last reviewed on October 2022, states in part, .General Guidelines: 1. The pain management program is based on a facility -wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management . 3. Pain management is a multidisciplinary care process that includes the following: a. Assessing the potential for pain; b. Recognizing the presence of pain; c. Identifying the characteristic of pain; d. Addressing the underlying causes of pain; e. Developing and implementing approaches to pain management; f. Identifying and using specific strategies for different levels and sources of pain; g. Monitoring for the effectiveness of interventions; and h. Modifying approaches as necessary. 5. Acute pain (or significant worsening of chronic pain) should be assessed every 30-60 minutes after the onset and reassessed as indicated until relief is obtained. Assessing Pain: 3. Assess the resident whenever there is a suspicion of new pain or worsening of existing pain. 4. Assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. 5. During the pain assessment gather the following information as indicated from the resident: c. Characteristics of pain: 1. Location of pain, 2. Intensity of pain (as measured on a standardized pain scale), 3. Characteristics of pain (e.g., aching, burning, crushing, numbness, burning, etc); 4. Pattern of pain (e.g., constant pain or intermittent); and 5. Frequency, timing, and duration of pain. Defining Goals and Appropriate Interventions: 1. The pain management interventions are consistent with the residents' goals for treatment which are defined and documented in the care plan. Pain management interventions reflect the sources, types, and severity of pain. 2. Pain management interventions shall address the underlying causes of resident's pain. Monitoring and Modifying Approaches: 1. Monitor the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. 2. Monitor the resident by performing a basic assessment with enough detail and, as needed, with standardized assessments tools (e.g., approved pain scales, etc) and relevant criteria for measuring pain management (e.g., target signs and symptoms). 5. Contact the prescriber immediately if the resident's pain or medication side effects are not adequately controlled. #6. If pain has not been adequately controlled, the multidisciplinary teal, including the physician, shall reconsider approaches and make adjustments as indicated . Example 1 R49 was admitted to the facility on [DATE] with diagnoses including encounter for palliative care, anxiety disorder, bipolar disorder, restlessness and agitation, alcoholic cirrhosis of liver without ascites, alcohol dependence, sleep disorder, personal history of suicidal behaviors, post-traumatic stress disorder, depression, and chronic pain. R49's Minimum Data Set (MDS) assessment, completed on 12/30/24, confirmed R49 scored 9/15 during Brief Interview for Mental Status (BIMS), indicating moderate cognition impairment. MDS indicated that R49 had chronic pain and was on an opioid for pain management. Surveyor reviewed pain assessments: -On 10/29/25, staff assessed R49's pain to be 9/10 pain. -On 11/04/25, staff assessed R49's pain of 9/10 pain. -On 12/29/24, staff assessed R49's pain of 10/10 frequent pain occurring more often. -On 02/05/25, staff assessed R49's pain of 10/10 frequent pain occurring more often. -On 03/31/25, staff assessed R49's pain to be 9/10 pain. Surveyor reviewed R49's care plan and did not find a pain care plan implemented to address R49's chronic and acute pain needs upon admission and during R49's care in the facility to present 04/10/25. R49's physician orders indicate: -General opioid monitoring for the following side effects will be monitored for while resident is on an opioid: -tolerance (more medication may be needed to achieve the same level of pain relief). -Medication is stopped, or a dose is held or missed. -Increased sensitivity to pain, constipation, nausea, vomiting, and dry mouth. Sleepiness, dizziness, and/or confusion. Depression, itching and sweating. Respiratory depression. Report to provider any noted side effects ordered on 10/29/2024. -Fentanyl 75mcg, give schedule II patch every 72 hours; 1 patch transdermal, check placement of patch every shift ordered on 11/21/24. -Lorazepam 1mg tab, give 2 tabs as needed every 4 hours for anxiety, nausea, and agitation ordered on 11/25/24. -Belbuca (buprenorphine hcl) - Schedule III film; 450 mcg; amt: 450 mcg; buccal every 12 Hours at 8:00 AM and 8:00 PM, ordered on 03/26/2025. -Oxycodone - Schedule II tablet; 5 mg; amt: 5 mg; oral special instructions: give for severe pain every 4 Hours as needed start date of 10/29/24. ordered on 03/28/2025. Surveyor reviewed R49's progress notes and assessments: -On 12/03/2024 at 6:32 AM (late entry), At 1:30 AM, Resident reports having terrible pain 10/10 in back. Requested and was given prn oxycodone which was effective, but didn't last long enough and pain came back rated 10/10 at 2:30 AM. Again, resident requested prn pain Rx, and it wasn't time yet. Repositioning and warm cloth offered but declined. Resident did not want to move at that time. This writer brought pain Rx at 4:20 AM. Resident was crying at that time. She says she is having terrible pain and needs her pain Rx ordered more often. Currently prn oxycodone 10 mg is q 3 hours. Resident reports her pain this AM was not controlled, and she is requesting to have it every 2 hours prn. Complaint of pain in right ribs and hip that travels down her leg. Message of the above left for Nurse Practitioner (NP). -On 12/04/2024 at 11:14, Serum labs obtained and taken to [town name] lab. In addition, NP written note to continue using as needed Lorazepam as an adjunct for pain. -On 12/08/2024 at 5:18 AM, Resident did awake approximately 2:15 AM and requested prn pain Rx for right hip, leg, and foot pain rated 10/10 which was given. Resident was weepy at that time. 1:1 given and effective. Offer given to reposition, and Res declined. Also offered warm pack but declined. Currently is resting quietly with HOB elevated 30 degrees, eyes closed, respiration 16, even, and non-labored. No facial grimace or other outward sx's of pain noted. -On 12/08/2024 at 7:15 AM, This writer noted Resident fentanyl patch had not been changed for > 3 days. (Order reads to change q 3 days). This writer and RN applied a new fentanyl patch. Also gave Resident prn pain Rx at 6:15 AM due to complain of pain in right hip, leg, and foot. Charge nurse updated of the above and will notify on-call MD, contact person, and hospice of med error. Resident cognition remains per baseline, and she is currently resting quietly in bed with eyes closed. Also, the above information printed and put in N.P. folder to update her. Surveyor found no other documentation addressing R49's pain during 11/30/24-12/10/24. The fentanyl patch was not placed on 12/3 or 12/6 as ordered. R49 did continue to utilize the prn oxycodone 3-5 times per day. Pain levels were not consistently documented on the MAR to determine R49's pain levels during this time. No new orders or interventions were put into place for R49's pain increase during the medication error of no Fentanyl patch being administered to R49 as physician orders stated. Surveyor did not find any assessments of pain for R49 after the increase in pain on 12/03/24, or after increase in pain on 12/04/24, and after increase in pain on 12/08/24. Medication error report review: -On 12/08/24, medication error was found that R49's Fentanyl patch 75 mcg was last applied on 11/30/24 and was noted it had not been changed since that date. Physician was notified with no new orders but to contact hospice. Clarified order in the Electronic Medication Administration Record (E-MAR). -On 12/08/2024 at 9:30, Doctor was updated about med error. No new orders. Hospice called and will update RN. Message left for POA to call facility for an update. -On 12/09/2024 at 6:50 AM, Resident complain of pain x1 during the night. This writer offered re-positioning, but Res declined. She was weepy at that time and was given prn oxy at 0110 for right hip and leg pain rated 10/10 which was effective. -On 12/09/2024 at 9:34 AM, NP noted fentanyl patch change incident. No new orders. Surveyor notes that pain medication is given with a pain level prior, but the post pain level is not entered in Medication Administration Record on a routine basis. Surveyor reviewed R49's Hospice progress notes: -On 12/04/24, Resident requesting her as needed pain medication more often. NP ordered to consult Hospice and use R49's as needed Lorazepam as an adjunct as well, which was not used. -On 12/09/2024 at 2:22 PM, Meeting held with Hospice, SS, NP, and nursing to discuss an update on the resident's plan of care. Hospice's official end date of service will be 12/24. At that time, care will be transferred to facility. NP is working with Palliative Services to see if they will work with the patient. Currently, there is no other option to take over. POA however wants to continue to move towards progressive care rather than a hospice approach. Currently, she is often sleeping or reporting that she is in pain. -All other Hospice progress notes indicate no pain assessment was completed as nurse states, could not complete pain assessment due to R49 in and out of sleep for all hospice visits. Surveyor reviewed NP visits and emergency room (ER) visits: -On 02/10/25- NP visit indicated, the plan after visit: A thorough discussion was had with the patient and her caregiver today. I explained that I had a thorough discussion with the doctor, who included there is nothing that we can offer to help the patient. We discussed that injections would not be helpful due to the patient already being on palliative care. We discussed that a total hip replacement would not be necessary. I discussed with the patient that we do not manage narcotic pain medications long term. I explained that a pain specialist would be a resource to help manage the patient's pain long term. All of the patient's questions were answered and she will follow up as needed. -On 03/13/2025 at 7:59 AM, Social Services Review: Resident complained of pain in knees and hips. NP will refer to pain clinic and palliative care regarding pain management. -On 03/23/2025 at 5:23 AM, Resident requested PRN pain medication. She stated that her pain is uncontrollable, and she stated that she needs to go to the ED for this as nothing is helping and if it does there is relief for a very short time. She stated that she wants to have her pain meds increased and she is not able to move the right leg much. She will not use the wheelchair to use the bathroom, so two staff have to assist her to the bathroom for safety. She stated that she needs to be sent over now. Call placed to her POA and she was okay with her being sent over. Updated that EMS would be called now. emergency room (ER) visits -On 03/23/25, ER visit note: Resident reports of bilateral hip pain and bilateral distal femur pain/knee pain. R49 does have a chronic underlying avascular necrosis involving bilateral hips. I suspect this is most likely etiology of her pain and likely progression of this disease. Unfortunately, resident has been evaluated by orthopedic surgery earlier on in her course of her nursing home stay and was determined not to be a candidate for injections or surgical management and was referred for pain management primarily as she was on hospice/palliative. -On 03/26/2025 at 3:39 PM, Resident requested pain medication for her right hip and knee. She stated that she wanted an extra dose of oxycodone. Writer let her know that we are not allowed to give an extra dose unless it is ordered by the doctor. She stated that she will call the doctor and get that changed. She then later stated that she felt like she might need to go to the ER again. Gave her different pain medication at that time and writer and CNA repositioned her in bed. Asked her what she was wanting from the ER. She stated that she wanted more pain meds. Repositioned her and she is now asleep at this time. -On 03/31/25, Addressing pain, Insurance issues for Orthopedic treatments for the pain in hips. Continues to decline. Observations: On 04/08/25 at 9:13 AM, Surveyor observed R49 in dining room to eat breakfast. R49 stated out loud in dining room with multiple staff members present, My back of knee hurts so bad right now. On 04/08/25 at 9:21 AM, Surveyor observed R49 request pain medication from Licensed Practical Nurse (LPN) H. Surveyor observed LPN H cut film and give to R49. At 9:25 AM, Surveyor interviewed LPN H and asked what LPN H's process is in assessing R49's pain and treating R49's pain appropriately. LPN H indicated that usually R49 will come to LPN H for pain medications, so LPN H waits for R49 to approach. Surveyor asked LPN H if LPN H usually asks R49 what pain level is and how does LPN H assess R49's pain as facility protocol entails. LPN H indicated that R49 whispered R49's pain was 8 out of 10, so LPN H gave pain medication as requested. LPN H stated, That is usually all I do. On 04/08/25 at 10:02 AM, Surveyor interviewed R49 and asked how R49 feels about how the facility manages R49's pain. R49 indicated the facility really has not completed much for R49 other than changing some medications around sometimes. Surveyor asked R49 if R49 can remember back in December if R49 had an increase in pain levels. R49 indicated that R49 remembers something went wrong with R49's Fentanyl patch and R49 stated, I remember being in an excruciating pain of 10/10. Facility had to give me more Oxycodone at the time. R49 indicated that R49 is supposed to see a specialist but facility has not set this up yet and R49's pain is still 10/10 at times during some days. On 04/09/25 at 12:52 PM, Surveyor interviewed Director of Nursing (DON) B and noted that in the Electronic Health Record (EHR) that R49 went several days without coverage of pain medication for R49's Fentanyl patch order and suffered increasing pain, which had to be supplemented with as needed medications. DON B indicated that a medication error form was filled out. DON B indicated that DON B did not place any new interventions into place for R49. Surveyor asked DON B if R49 had a pain care plan in place and what are some interventions put into place for R49 to manage R49's acute and chronic pain. DON B indicated that R49 does not have a pain care plan. Surveyor asked DON B what DON B's expectation is for R49's pain management. DON B indicated that all staff should be assessing pain adequately by using a numerical scale or FACES scale as appropriate for residents and ask how often pain is occurring, describe the pain, and rate the pain. Staff should be following back up with R49 after giving the pain medication to help assess if pain is being managed appropriately. DON B indicated that comprehensive pain assessments are to be conducted upon admission, quarterly, as needed, and with any increase in pain. Surveyor indicated to DON B that Surveyor could not find any comprehensive pain assessments during 11/30/24-12/10/24 when R49 had increased pain related to the missed doses of Fentanyl patch application. DON B indicated staff should have been assessing R49 closely for the increase in pain. Surveyor asked DON B if the facility has set up pain specialist services for R49. DON B indicated the facility has not set up services at this time as R49 has had some insurance issues, but they have been working on this. Surveyor asked DON B what steps the facility put into place to manage R49's pain management other than prescribing pain medications. DON B indicated they do offer nonpharmacological interventions, which R49 refuses. R49 does not have a care plan in place listing these interventions. 49353 Example 2 R1 was admitted to the facility on [DATE] with pertinent diagnoses of diabetes mellitus type 2 and polyneuropathy. R1's quarterly Minimum Data Set (MDS) assessment dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 11/15 indicating moderate cognitive impairment, makes self understood and able to understand others. R1 is noted to receive scheduled and as needed pain medications, pain presence is constantly, no non-medication interventions used, pain interferes with day-to-day activities occasionally, and numerically rates pain as 10/10. R1's care plan, dated 09/26/23, with a target date of 01/01/25, states: [R1] has chronic back pain that limits activity and sleep. Interventions include verbalize relief with PRN non-pharmacologic interventions, administer PRN medications as ordered, trial heat, ice, muscle rub, etc. as non-pharmacologic options. Of note: care plan did not include update of new pain areas noted on the medication administration record (MAR). Surveyor was unable to locate documentation of non-pharmacological interventions used, pain assessment to include resident's desired/tolerable pain level, or follow-up pain assessment. Review of R1's orders noted: 11/27/23 OPIOID MONITORING: The following side effects will be monitored for while resident is on an opioid: -tolerance (more medication may be needed to achieve the same level of pain relief). -Medication is stopped, or a dose is held or missed. -Increased sensitivity to pain. -Constipation. -Nausea, vomiting, and dry mouth. -Sleepiness, dizziness, and/or confusion. -Depression. -Itching and sweating. -Respiratory depression. Report to provider any noted side effects; Of note: no documentation was noted monitoring for the adverse reactions of constipation, sleepiness, respiratory depression, or pain tolerance associated with opioid use. 11/27/23 bisacodyl delayed release 5 mg once a day PRN for constipation; 11/27/23 Milk of Magnesia 400 mg/5 ml give 30 ml once a day PRN for constipation; 03/06/24 Miralax powder 17 g once a morning PRN for constipation; 03/25/24 Senna Plus 8.6-50 mg 2 tabs once a day for constipation; 01/27/25 hydrocodone-acetaminophen 5-325 mg (opioid medication) give 2 tabs four times daily for pain; 03/04/25 assess need for PRN oxycodone every 6 hours; 03/24/25 oxycodone 20 mg/dL (opioid medication) give 0.25 ml (5 mg) every 4 hours as needed for severe pain Of note: multiple entries did not include numerical pain scale to assess pain or location; MAR did not include numerical pain scale to evaluate efficacy. Review of R1's progress notes noted: 04/08/2025 17:26 Medication Error: It was reported to me that R1 received noon dose of Norco too early. No adverse effects noted. NP notified via phone and she is in agreement with plan to monitor vital signs Q shift for the remainder of the day (pms, nocts). NP to see R1 tomorrow to f/u on recent concerns and medication changes. R1 and son notified and neither had any concerns. R1 voiced her frustrations regarding the pain in her left foot and is requesting something for pain at this time. She declined offer of ice and elevation stating, nothing else helps. Updated pm nurse of resident's request. resident takes an Antidepressant Medication. Of note: this is the only mention of non-pharmacological interventions for pain noted in R1's medical record. R1 was assessed routinely after this incident for respirations, blood pressure, heart rate, and level of consciousness. No abnormal assessments noted. Review of R1's intake/output noted: On 04/03/25, R1 had 3 bowel movements. Between 04/04/25 - 04/09/25, documentation notes no bowel movement. Of note: No bowel assessment noted. R1 is noted to eat between 25-75% of all meals during this time period. No documentation of nausea or vomiting noted. Review of R1's medication administration record (MAR) noted: 04/08/25 at 9:38 AM administered PRN oxycodone 0.25 ml/5 mg; PRN reason: Pain; Comment: L foot -(no time noted) PRN result - Follow-up: Somewhat effective Of note: no pain scale used to assess pain prior to administration or follow-up for efficacy. No documentation of respiratory assessment completed. 04/08/25 at 9:40 AM (scheduled 8:00 AM) administered hydrocone-acetaminophen 5-325 mg 2 tabs; Late Reason: administered late; Comment: Care Prioritized Of note: no pain scale used to assess pain prior to administration or follow-up for efficacy. No documentation of respiratory assessment completed. 04/08/25 at 11:27 AM (scheduled 12:00 PM) administered hydrocone-acetaminophen 5-325 mg 2 tabs Of note: no pain scale used to assess pain prior to administration or follow-up for efficacy. No documentation of respiratory assessment completed. No administration documented for Milk of Magnesia for PRN constipation noted between 04/04/25-04/09/25. No administration documented for bisacodyl for PRN constipation noted between 04/04/25-04/09/25. No administration documented for Miralax for PRN constipation noted between 04/04/25-04/09/25. On 04/08/25 at 9:04 AM, Surveyor observed R1 struggling to wheel self in wheelchair in hallway and began to cry. Surveyor asked R1 why she was upset. R1 stated that she was angry and frustrated because of recent health changes and pain. Surveyor asked where R1 was having pain. R1 stated her foot and pointed to her left foot. On 04/08/25 at 11:45 AM, Surveyor observed R1 sitting in wheelchair in room sleeping. On 04/08/25 at 12:04 PM, Surveyor observed staff member wake R1 and state it was time for lunch. Staff wheeled R1 into dining room. Shortly after being seated at dining table in wheelchair, Surveyor observed R1 close eyes and appear to be sleeping. On 04/08/25 at 12:06 AM, Surveyor observed staff approach R1 and rub her shoulder. Staff asked R1 if she was sleepy today. R1 opened eyes, looked at staff, did not verbalize a response, and closed eyes again. On 04/08/25 at 12:23 PM, Surveyor observed Certified Nursing Assistant (CNA) N wake R1 and ask if she was going to eat today. R1 opened eyes and looked at CNA N, but did not verbalize a response. CNA N then began assisting R1 with meal. Surveyor observed R1 to consume approximately 15% of meal. On 04/08/25 at 12:54 PM, Surveyor observed CNA N assist R1 back to room. CNA N transferred R1 to recliner and positioned for comfort. Surveyor observed R1 close eyes and appear to be sleeping before CNA N left room. On 04/08/25 at 2:22 PM, Surveyor observed R1 sitting in wheelchair with eyes closed and appeared to be sleeping. On 04/08/25 at 2:23 PM, Surveyor interviewed Director of Nursing (DON) B regarding observation and record review. DON B stated the expectation is for nurses to give the scheduled pain medication first, wait 30-60 minutes, reassess pain, and then determine if additional PRN medication should be administered. DON B stated that it would not be acceptable practice for nurses to give both scheduled and PRN opioid pain medications at the same time and then to administer the next scheduled opioid 30 minutes early. DON B stated that R1 should be assessed after receiving the multiple doses of opioids. On 04/10/25 at 10:45 AM, Surveyor interviewed DON B regarding pain assessments and care plans. DON B stated the expectation is for nurses to complete a pain assessment with all administrations of pain medication. DON B stated the pain assessment should include, at a minimum, a pain score, location, and characteristic for both the initial and follow-up documentation. DON B stated that recent review of resident's MARs have been documented inconsistently in this area and the facility is working on fixing this. Surveyor asked DON B if residents receiving high-risk medications, like opioids, should have a care plan in place to monitor for adverse effects. DON B stated that residents receiving opioids should have a care plan in place to monitor for things like constipation, level of sedation, respirations, etc. DON B stated the charge nurse reviews all residents' bowel movements daily and are expected to administer a PRN medication if it has been at least 3 days since the last bowel movement. DON B was unable to state why R1 had not had an intervention during this timeframe. Example 3 R24 was admitted to the facility on [DATE] with pertinent diagnoses of chronic pain syndrome, malignant neoplasm of breast and lung, constipation, and dorsalgia (back pain). R24's annual MDS assessment dated [DATE] noted a BIMS score of 11 indicating moderately impaired cognition, makes self understood, and understands others. R24 received scheduled pain medications, as needed pain medications was offered, and did not receive non-medication interventions for pain. R24's care plan, dated 10/09/23, with a target date of 06/27/25, states: [R24] requires more assistance from staff .experiencing more anxiety and pain with end of life. Interventions include monitoring for signs and symptoms of tolerance, administering scheduled and as needed medications, and perform non-pharmacologic pain interventions such as heat, cold pack, repositioning, pillow support . Of note: no documentation found for non-pharmacological interventions being used. Care plan did not include resident's desired/tolerable pain level or follow-up pain assessment. Review of R24's orders noted: 03/27/25 morphine extended release 30 mg four times daily Special Instructions: cancer pain give in addition to the 60 mg 03/27/25 morphine extended release 60 mg four times daily Special Instructions: cancer pain give in addition to the 30 mg 03/24/25 morphine concentrate 100 mg/5 ml (20 mg/ml) give 15 mg four times daily 03/24/25 morphine concentrate 100 mg/5 ml give 0.5 ml-1.0 ml (10-20 mg) Special Instructions: pain/restlessness/dyspnea GIVE IRREGARDLESS OF SCHEDULED DOSES! Every one hour as needed Of note: documentation with administration did not include pain scale or location with initial or follow-up administration. 10/19/2023 OPIOID MONITORING: The following side effects will be monitored for while resident is on an opioid: -tolerance (more medication may be needed to achieve the same level of pain relief). -Medication is stopped, or a dose is held or missed. -Increased sensitivity to pain. -Constipation. -Nausea, vomiting, and dry mouth. -Sleepiness, dizziness, and/or confusion. -Depression. -Itching and sweating. -Respiratory depression. Report to provider any noted side effects Of note: no documentation was noted monitoring for the adverse reactions of constipation, sleepiness, respiratory depression, or pain tolerance associated with opioid use. On 04/10/25 at 10:45 AM, Surveyor interviewed DON B regarding pain assessments. DON B stated this should have been initiated on admission and revised at least quarterly to include resident's tolerable pain level, pain level before and after pain medication administration, location, duration, characteristics, and non-pharmacological pain interventions. DON B stated that all of this should have been documented and monitored to assess for efficacy and changes. Example 4 R30 was admitted to the facility on [DATE] with pertinent diagnoses of reduced mobility and diabetes mellitus type 2 with diabetic neuropathy. R30's admission Minimum Data Set (MDS) assessment dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 13 indicating cognition is intact. R30 receives scheduled and as needed pain medications. Review of R30's physician orders noted on 03/14/25 tramadol 50 mg three times a day; and tramadol 50 mg Special instructions: as needed for pain every 6 hours. Review of R30's care plan identified no pain care plan was developed to include specific and measurable goals and non-pharmacological interventions. Review of R30's medical record did not identify a pain assessment to include frequency, intensity, duration, outcomes, location, or precipitating factors to determine efficacy and monitor for change in pain characteristics. On 04/10/25 at 10:45 AM, Surveyor interviewed DON B regarding R30's use of a pain regimen. DON B stated recognition that R30 should have had a comprehensive pain assessment completed upon admission to identify cause and establish a baseline care plan to address pain concerns. DON B also stated that a detailed pain assessment should have been completed with each administration of a scheduled or as needed pain medication to include a pain score, location, and characteristic prior to administration and a follow-up assessment of, at minimum, a pain score to determine efficacy and have effective pain management. 51804 Example 5 R35 was admitted to the facility on [DATE] with the diagnoses that include bilateral primary osteoarthritis of knee, chronic pain syndrome, unspecified hip pain, anxiety, and vascular dementia with other behavioral disturbances. R35's MDS assessment, dated 1/7/25, indicates that R35 has moderate cognitive impairment, and is rated to be dependent to needing substantial assistance for personal cares and activities of daily living. R35 is dependent for mobility, staff use a mechanical lift to transfer from bed to chair and to shower/bathe chair. R35 has no impairment to the upper body but impairment to the lower body. R35's care plan, dated 1/13/25, does not include pain management. Surveyor found no pain management care plan or approaches for pain management embedded in other care planned areas either, including the general section titled health maintenance. R35 has an order in the eMAR for OPIOID MONITORING: The following side effects will be monitored for while resident is on an opioid: -tolerance (more medication may be needed to achieve the same level of pain relief). -Medication is stopped, or a dose is held or missed. -Increased sensitivity to pain. -Constipation. -Nausea, vomiting, and dry mouth. -Sleepiness, dizziness, and/or confusion. -Depression. -Itching and sweating. -Respiratory depression. Report to provider any noted side effects. 12/31/2024 - Open Ended On 4/8/25 at 8:09 AM, Surveyor interviewed R35 while sitting alone in dining room. R35 denied pain currently. R35 stated that movement hurts the most. R35 stated as long as R35 gets medication on time, R35 usually does not have a lot of pain. R35 stated R35 has other medications they can give R35 when that happens. On 4/8/25 at 1:20 PM, Surveyor interviewed LPN H regarding pain management. LPN H reported there are orders to monitor for opioid side effects but there is no formal tracker, checking off in the E-MAR, or required daily progress notes. Pain assessments are done quarterly for MDS. LPN H stated her process is to administer scheduled medication first; residents will let LPN H know if it doesn't help them. LPN H stated at that t [TRUNCATED]

Based on observation, interview and policy review, the facility did not maintain confidentiality of resident medical record information for 3 of 5 sampled and supplemental residents (R45, R19, R16) reviewed. This is evidenced by: Facility policy titled, Confidentiality, Security, and Access to Protected Health Information, with an effective date of 08/19/03, states in part: Protected health information .written, verbal, or stored in paper, photographic, video, or electronic format .will remain confidential. 2. Protected Health Information (PHI) - Health information (medical record) that is identifiable to a specific individual and that is maintained or transmitted by a covered entity in any form, whether in oral, paper, or electronic form. Confidentiality and Security of PHI: 2. Care needs to be taken .in an area and manner that ensures client privacy. Surveyor reviewed facility's training for new hire employees included in the employee handbook titled, Privacy/HIPAA, with no date, states in part: .employees are exposed to confidential information about residents .it is important that all such information be kept strictly confidential. On 04/09/25 at 7:32 AM, Surveyor observed medication administration performed by Licensed Practical Nurse (LPN) H. LPN H prepared R19's medications and entered R19's room leaving medication cart locked in hallway with the computer screen open with R19's medical record displayed unattended. On 04/09/25 at 7:35 AM, Surveyor observed LPN H exit R19's room and return to medication cart. LPN H retrieved a stethoscope from the medication cart and returned to R19's room. LPN H left R19's medical health record displayed on the computer screen unattended. Surveyor observed a staff member walk down the hallway past the open computer screen. On 04/09/25 at 7:40 AM, Surveyor observed LPN H prepare R45's medications and enter R45's room leaving medication cart locked in hallway with the computer screen open with R45's medical record displayed unattended. On 04/09/25 at 8:10 AM, Surveyor observed LPN H enter R16's room with medications leaving the medication cart outside of room in hallway with R16's medical record displayed unattended. Surveyor observed two certified nursing assistants walk past open computer screen looking for LPN H. On 04/09/25 at 8:32 AM, Surveyor was standing in the 100 unit and observed LPN H outside of rooms [ROOM NUMBERS] at the medication cart. Surveyor observed LPN H leave medication cart and enter a resident's room with the computer screen open and resident information displayed on the screen. Surveyor was unable to see which resident was displayed on the screen. Surveyor stopped Nursing Home Administrator (NHA) A in the hallway and asked if she could see the medication cart with the open computer screen unattended down the hallway. NHA A pointed to cart and stated, Ok. I see what you are seeing, and walked down to the medication cart as LPN H exited the resident's room. Surveyor heard NHA A ask LPN H why the computer screen was left open unattended. Surveyor heard LPN H respond that she forgot to close the screen. On 04/10/25 at 10:24 AM, Surveyor interviewed NHA A regarding observation. NHA A stated that employees are expected to safeguard PHI and close/lock the computer screen when left unattended to protect resident's privacy.

Based on observation, interview and record review, the facility did not develop and implement a comprehensive person-centered care plan addressing medical and nursing needs. This occurred for 2 of 15 residents (R), (R1, R3) reviewed. R1 did not have a care plan developed to monitor for adverse reactions when R1 was prescribed a diuretic medication. R3's care plans were not developed for hospice and end of life care. This is evidenced by: Facility policy titled, Care Plans, Comprehensive Person-Centered, with a revised date of 03/2022, states in part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .reflects currently recognized standards of practice for problem areas and conditions .interventions are chosen only after data gathering, proper consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. R1 was admitted to the facility on [DATE] with pertinent diagnoses of type 2 diabetes mellitus, chronic kidney disease stage 3b and edema. R1's quarterly Minimum Data Set (MDS) assessment dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 11/15 indicating moderate cognitive impairment, makes self understood and able to understand others. Medications being administered include diuretics. Surveyor reviewed R1's care plan after observation and record review and did not observe a plan of care in place for monitoring and assessing R1 while being administered diuretic medications. Review of R1's medication noted: Furosemide 20 mg once daily with a start date of 12/29/23; Furosemide 40 mg twice a day with a start date of 04/05/25. On 04/08/25 at 9:04 AM, Surveyor observed R1 wheeling self in wheelchair from dining. R1's left arm and both lower legs were significantly edematous. Surveyor observed a urinary catheter hanging below the wheelchair in a dignity bag. Surveyor observed R1 having difficulty wheeling self and having to stop numerous times. On 04/10/25 at 10:45 AM, Surveyor interviewed Director of Nursing (DON) B regarding R1's care plan. DON B stated recognition that R1 should have had a care plan in place to monitor for adverse events and efficacy with the use of diuretics. DON B stated that she is currently working with the pharmacist to identify high-risk medications requiring close monitoring, such as diuretics, to ensure resident safety. 31086 Example 2 R3 was admitted to the facility on [DATE]. R3's current diagnoses include Alzheimer's disease, dementia, constipation, hypertension, neuralgia, osteoarthritis of knee, muscle weakness, spinal stenosis, pain, transient ischemic attack, anxiety, dysphagia, hemiplegia and hemiparesis, dysphagia, atrial fibrillation, cognitive communication deficit. On 03/12/25, R3 was started with hospice services. R3's Minimum Data Set (MDS), dated [DATE], documented R3's Brief Interview for Mental Status (BIMS) score as having severely impaired cognition. R3 is dependent on staff for all activities of daily living (ADL) and receives hospice services. R3's care plans did not have a hospice or end of life plan of care developed. On 04/08/25 at 3:30 PM, Surveyor asked Nursing Home Administrator (NHA) A if a hospice care plan was developed for R3. NHA A indicated there is no hospice care plan.

Based on interview and record review, the facility did not ensure care plans were revised to reflect residents' current needs and to provide the needed direction to staff in providing necessary care and services. The facility practice affected 1 of 15 residents' care plans reviewed (R55). R55 had recent increase in behaviors resulting in resident-to-resident altercations on 3/03/2025 and again on 4/1/2025. R55's care plan was not updated to reflect changes identified and the care the resident received. Findings include: Surveyor reviewed the facility's policy titled Care Planning -Interdisciplinary Team revised March 2022. The policy reads in part: Policy Statement The interdisciplinary team is responsible for the development of the resident care plans. Policy Interpretation an Implementation . 11. Assessments of the residents are ongoing, and care plans revised as information about the residents and residents' conditions change. According to the Resident Assessment Instrument, The comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving. R55 was admitted to the facility on [DATE] with a diagnosis that includes Alzheimer's disease with late onset, dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, and anxiety disorder. R55's most recent quarterly Minimum Data Set (MDS) dated [DATE] stated a Brief Interview of Mental Status (BIMS) score of 3/15 indicating R55 is cognitively impaired. Surveyor requested and reviewed R55's care plan initiated on 12/30/2024 which states in part: Problem: Mood State Increased mood and behavior problems related to diagnosis of Alzheimer's disease with late onset and Anxiety Disorder. R55 is very angry, verbally, and physically abusive, resistive to cares and has delusional thoughts. Long Term goal Target Date: 04/02/2025 [R55] will not harm herself or others when she becomes anxious or confused. Approach- Approach start date 12/30/24 Give Trazadone as ordered. Monitor for effectiveness and report potential side effects. Monitor and record behaviors each shift: Physical aggression to others, Verbal aggression towards others, Delusional thoughts, threats of harm. Three Times a Day Surveyor reviewed R55's behaviors documentation: Documentation states in part, 03/30/2025 13:11[1:11 p.m.] -Res was reported to be walking out of her room when another res approached her and contact with her breast. Res screamed out, she hit me in the boob. No further contact, Res removed from one another's area. No injury noted to either breast. Call placed to POA and Administrator to update. Surveyor reviewed R55's charting notes: On 3/30/2025 at 1:18 p.m., Licensed Practical Nurse (LPN), E documented in part, It was reported by staff that resident approached another resident and made contact with her Breast area and the other res yelled out. Staff immediately intervened, removed res for one another's areas. No further incident noted. Message left for POA to call back for update regarding event, and call made to Administration for updated. Further documentation was noted on 3/31/25 and 4/1/25 of R55 behaviors including, Spitting, swearing, yelling, throwing things, mocking anyone that is speaking, following staff into resident rooms, slamming doors. CNA tried to give her something to drink and she knocked the glass over. She is getting upset when someone looks at her and upset if talked to or looked at and upset if not looked at or talked to. PRNs were given. Surveyor review Progress Note documented by LPN E on 4/01/2025 at 9:30 which states in part, Resident walked past another resident that was sitting in the common area watching television and punched at the back of her head. Resident [resident name] jumped up and started yelling at her. Writer immediately intervened and removed resident from situation. She was placed with a CNA while writer spoke and checked on [resident name]. [Resident name] stated she was alright. As long as no one cuts my hair I'll be alright. [Resident name] appears irritated but denies fear. Writer then brought resident into charting room and had her speak with her son/daughter-in-law. This calmed her down. Further documentation from LPN E on 4/1/25 at 14:26 is as follows Resident is screaming at people and throwing chairs and other objects she comes in contact with. Staff are following her at a safe distance to keep her from other residents. LPN E documented that NHA A was updated and NHA A is scheduling another 1:1 for her. R55's medications were adjusted. On 4/9/25, Surveyor requested from NHA A all documentation of interventions and updates that were done since R55's behaviors escalated. A recently constructed timeline was provided by NHA A indicating the facility is providing 1 on 1 care to R55, starting on 4/1/25 and when family was not available. Direction for 1 on 1 supervision of R55 was reportedly given but not documented until 4/8/25, after survey was initiated. On 4/09/25 at 8:55 AM, Surveyor interviewed NHA A. NHA acknowledges there should have been documentation of R55's interventions and R55's care plan should have been updated to indicate changes made.

Based on observation, interview and record review, the facility did not ensure a resident with limited mobility receives appropriate restorative services, and assistance to maintain or improve mobility with the maximum practicable independence for 2 out of 6 sampled residents (R3 and R9). R3 and R9's passive range of motion (PROM) exercise programs were not completed as ordered. The programs were not reviewed and assessed for appropriateness. This is evidenced by: Example 1 R3 was admitted to the facility on [DATE]. R3's current diagnoses include Alzheimer's disease, dementia, constipation, hypertension, neuralgia, osteoarthritis of knee, muscle weakness, spinal stenosis, pain, transient ischemic attack, anxiety, dysphagia, hemiplegia and hemiparesis, dysphagia, atrial fibrillation, cognitive communication deficit. R3's Minimum Data Set (MDS), dated [DATE], documented R3's Brief Interview for Mental Status (BIMS) score as having severely impaired cognition. R3 is dependent on staff for all activities of daily living (ADL). R3's care plan with the approach start date of 05/22/2020 read in part, Restorative: LLE (left lower extremity) gentle PROM (passive range of motion) in bed bending hip knee and ankle sliding leg out to the side. 2. Gentle BLE (bilateral lower extremities) ankle stretching in bed to prevent contractures. 3. Gentle UE (upper extremities) PROM all joints 5 reps each. Once a day on Mon, Tue, Wed, Thu, Fri, 06:45 - 14:45. Review of restorative nursing logs documenting the number of minutes PROM was completed. The month of January staff provided PROM for 1 minute one day, 2 minutes on three days, 5 minutes on nine days, 6 minutes on two days, 10 minutes on one day and 15 minutes on one day and did not complete PROM on 01/17/25. The month of February staff provided PROM for 2 minutes on one day, 3 minutes on three days, 4 minutes on two days, 5 minutes on five days, 6 minutes on three days, 7 minutes on two days, 10 minutes on two days, 15 minutes on one day, and did not complete PROM on 02/18/25. The month of March staff provided PROM for 2 minutes on two days, 3 minutes on two days, 5 minutes on eleven days, 6 minutes on two days, 15 minutes on one day and did not complete PROM on 03/14/25. On 04/08/25 at 1:15 PM, Surveyor interviewed Certified Nursing Assistant (CNA) J and asked when R3's PROM is completed. CNA J indicated ROM is completed with morning cares. Example 2 R9 was admitted on [DATE]. R9's current diagnoses include multiple sclerosis, dysphagia, acute right heart failure, pulmonary hypertension, neuralgia and neuritis, vitamin D deficiency, myalgia, pain, hypertension, paraplegia, pressure ulcer of sacral region stage 4, colostomy, muscle weakness, and peripheral venous insufficiency. MDS, dated [DATE], a quarterly assessment documented BIMS score of 11/15, meaning R9 has moderately impaired cognition. R9 has impairment to 1 side upper extremity and both sides of lower extremity. R9 requires maximum staff assistance for upper body dressing and personal hygiene. R9 is dependent on staff assistance for showering, lower body dressing, bed mobility and transfers. R9 has no behaviors of rejecting cares from staff. R9's care plan dated 04/11/24, Category: Restorative: R9 is at risk for contractions r/t (related to) MS. Long term goal target date: 06/26/25: R9 will be able to bend bilateral knees and elbows with assistance. Approach start date: 04/11/24: Restorative Program: Stretching program 10x each day QHS (every bedtime). See bulletin board for program specifics. At bedtime: HS 7:00 PM - 11:30 PM). Review of restorative nursing logs documenting the number of minutes PROM was completed. The logs started documentation on 03/25/25 with no previous data available. Staff provided PROM on 03/25/25 and 03/26/25 for 6 minutes, 03/27/25 and 03/28/25 for 12 minutes, 03/29/25 PROM was not completed, 03/30/25 for 10 minutes, 03/31/25 PROM not completed, 04/01/25 for 10 minutes during the AM shift and 5 minutes during the PM shift, 04/02/25 for 6 minutes, 04/03/25, 04/04/25, 04/05/25 and 04/06/25 PROM was not completed, 04/07/25 for 10 minutes, and 04/08/25 PROM was not completed. On 04/07/25 at 11:39 AM, Surveyor interviewed R9 asking if ROM is completed as ordered. R9 stated having contractures to her legs and the exercises are listed on the bulletin board. R9 likes to have ROM completed at bedtime and R9 needs to ask staff to complete ROM otherwise it does not get done. On 04/09/25 at 2:31 PM, Surveyor interviewed Registered Nurse (RN) C about ROM program assessments and monitoring. RN C indicated there is no review of the program and therapy would be consulted to evaluate if a decline was noted. Staff should be documenting when the resident refuses. Surveyor reviewed R3's number of minutes to complete PROM and R9's logs not being completed. RN C stated R9's ROM tracking was entered incorrectly prior and was not tracked. Surveyor asked if assessments of the program were completed would this issue have been identified. RN C indicated if the assessments of the program were completed it would have been caught.

Based on observations, interviews and record reviews, the facility failed to provide pharmaceutical services related to the accurate administration of inhaled medication for 1 of 2 residents (R), (R19) reviewed. This is evidenced by: Facility policy titled, Administering Medications, with a revised date of 04/2019, states in part: .22. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: c. the route of administration; d. the injection site (if applicable) R19 was admitted to the facility on [DATE] with a pertinent diagnosis of allergic rhinitis. R19's orders noted calcitonin spr 200/act instill one spray into 1 nostril once daily - alt nostril daily. On 04/09/25 at 7:24 AM, Surveyor observed medication administration performed by Licensed Practical Nurse (LPN) H. Surveyor observed LPN H administer the nasal spray into R19's right nostril. Surveyor observed LPN H document medication as administered. No documentation of which nostril was noted. On 04/09/25 at 7:38 AM, Surveyor interviewed LPN H regarding documentation of medication. LPN H stated that staff used to document which nostril the spray was administered, but it went it away a while ago. LPN H stated that she works everyday with R19 and knows which nostril to administer the medication. On 04/10/25 at 10:24 AM, Surveyor interviewed Director of Nursing (DON) B regarding observation. DON B stated that nursing staff are expected to document the location a medication is administered to ensure accurate medication adminnistration and was unaware this was not being completed.

Based on observation, interview and record review, the facility did not ensure that a resident's drug regimen was free from unnecessary medications for 3 of 5 residents (R) reviewed for unnecessary medications (R35, R8, R9). R3 is on medications for sleep, without adequate indication for use for the medications melatonin and trazadone. R8 receives an antibiotic daily for urinary tract infection (UTI) prevention. R8 receives a sleep aid of melatonin and hydroxyzine for sleep without adequate indication for use and no sleep care plan with non-pharmacological interventions to promote sleep. R9 receives melatonin for sleep without adequate indication for use and no sleep care plan with non-pharmacological interventions to promote sleep. Example 1 Findings include: The facility policy titled Behavioral Assessment, Intervention, and Monitoring, dated 2001, states: 1. Residents will have minimal complications associated with the management of altered or impaired behavior. 2. Behavioral symptoms are identified using facility-approved behavioral screening tools and the comprehensive assessment. Comprehensive Resident Assessment . 2. As part of the comprehensive assessment, staff evaluate (based on input from the resident, family and caregivers, review of the medical record and general observations): . d. the resident's previous patterns of coping with stress, anxiety, and depression. Cause Identification: 1. The IDT (interdisciplinary team) evaluates new or changing behavioral symptoms to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition, including: a. physical or medical changes (for example) . b. emotional, psychiatric, and/or psychological stressors (for example) . c. functional, social, environmental factors for example (3) sleep disturbances. Interventions and Management: 1. The care plan includes as a minimum: a. description of the behavioral symptoms, including: (1) frequency; (2) intensity; (3) duration; (4) outcome; . (7) precipitating factors or situations. b. targeted and individualized interventions for the behavioral and /or psychosocial symptoms; c. the rationale for the interventions and approaches; d. specific and measurable goals for targeted behaviors; and e. how the staff will monitor the effectiveness of the interventions. 4. Interventions are individualized and part of an overall care environment that supports physical, functional, and psychosocial needs, and [NAME] to understand, prevent, or relieve the resident's distress or loss of abilities. R35 was admitted to the facility on [DATE] and was admitted with the diagnoses that include bilateral primary osteoarthritis of knee, chronic pain syndrome, unspecified hip pain, anxiety, and vascular dementia with other behavioral disturbances. Surveyor reviewed R35's orders and noted the following: Melatonin tablet; 3 mg; Amount to Administer: 1 tab; oral At Bedtime trouble sleeping - started 12/31/2024 - Open Ended Trazodone tablet; 150 mg; Amount to Administer: 75 mg; oral At Bedtime Notify NP if behaviors worsen started- started 12/31/2024 - Open Ended R35's Minimal Data Set (MDS) assessment, dated 1/7/2025, indicates that R35 has moderate cognitive impairment, and is rated to be dependent to needing substantial assistance for personal cares, and movement. R35 has no impairment to the upper body but impairment to the lower body. R35's care plan, dated 1/13/25, does not include plan for sleep management. Surveyor reviewed in computer and the printed copy; no sleep management embedded in any of the problem areas in the care plan. Surveyor reviewed R35's medical records, no assessment or monitoring of sleep patterns or tracking of sleep quality completed. On 4/9/24, at 8:34 AM, Surveyor interviewed Director of Nursing (DON) B. DON B stated there is no sleep assessment or specific care plan for sleep issues to determine the effectiveness or need for the medication. DON B stated we do not monitor sleep. DON B stated there is no expectation of nightly or weekly nursing notes about a resident's sleep pattern. 31086 Example 2 R8 was admitted to the facility on [DATE]. R8's current diagnoses include Alzheimer's disease, muscle weakness, essential tremor, pulmonary hypertension, major depressive disorder, congestive heart failure, pain, dementia, depression, chronic kidney disease stage 3a, generalized anxiety disorder, insomnia, and type 2 diabetes mellitus. MDS dated [DATE] documented R8 having a BIMS score of 9/15 indicating R8 has moderately impaired cognition. The MDS documented R8 as having delirium, inattention and disorganized thinking. R8 has delusions, verbal behavioral directed toward others, and other behaviors not directed toward others. Review of physician order documented, 01/30/25 cephalexin capsule; 250 mg; amt: 1 capsule; oral Special Instructions: For UTI Prevention Once A Day; 08:00 01/13/25 melatonin tablet; 5 mg; amt: 10 mg; oral, Special Instructions: Give with Hydroxyzine 50 mg every HS PRN BETWEEN 2000-0200. At Bedtime - PRN HS dx: insomnia 01/13/25 melatonin tablet; 5 mg; amt: 5 mg; oral Special Instructions: GIVE BETWEEN 2000-0200 if needed At Bedtime - PRN HS. R8 was treated with antibiotic cephalexin for a UTI on 01/22/25 - 01/29/25 for lab results of >100,000 CFU/ML Escherichia coli (e coli). The previous UTI was treated on 09/23/24 - 09/30/24. No further documentation of previous UTIs was noted. Surveyor was not able to identify the physician's rationale for continued antibiotic prophylactic use. Surveyor requested information of the prophylactic antibiotic use, and no further information was provided. On 04/10/25 at 11:12 AM, Surveyor interviewed infection preventionist, Registered Nurse (RN) C, about antibiotic tracking and surveillance for R8 since R8 is on a prophylactic antibiotic. RN C asked Surveyor, What do you mean? Surveyor asked RN C what criteria RN C uses to indicate that R8 met the criteria for being on an antibiotic for E. coli and then after going forward as prophylactic. Surveyor asked if it was appropriate for antibiotic used to treat a culture of 100,000 CFU's for E.Coli. RN C indicated that RN C does not know and just does what the doctor ordered. RN C stated, I am not a doctor. I don't know. RN C stated, The NP (nurse practitioner) decides what residents should be on and is hard to change NP's mind. RN C indicated that NP just orders a urinalysis on everyone, especially R8, and if we don't do what that person wants, that person and family come after us. Surveyor asked if there is any rationale to show the antibiotic medication is needed for R8. RN C said, No. Example 3 R9 was admitted on [DATE]. R9's current diagnoses include multiple sclerosis, dysphagia, acute right heart failure, pulmonary hypertension, neuralgia and neuritis, insomnia, vitamin D deficiency, myalgia, pain, hypertension, paraplegia, pressure ulcer of sacral region stage 4, colostomy, muscle weakness, and peripheral venous insufficiency. MDS, dated [DATE], a quarterly assessment documented BIMS score of 11/15, meaning R9 has moderately impaired cognition. R9 has impairment to 1 side upper extremity and both sides of lower extremity. R9 requires maximum staff assistance for upper body dressing and personal hygiene. R9 is dependent on staff assistance for showering, lower body dressing, bed mobility and transfers. R9 has no behaviors of rejecting cares from staff. Review of physician order documented, 02/10/25 melatonin tablet; 5 mg; amt: 5 mg; oral Special Instructions: PRN between 0000-0300 for insomnia Once A Day - PRN R9 does not have a sleep care plan developed with non-pharmacological interventions to promote sleep. R9's medical record did not have sleep assessments and tracking of sleep to determine sleep patterns and effectiveness of the medication. On 04/09/25 at 1:58 PM, Surveyor interviewed Director of Nursing (DON) B about sleep behavior monitoring and physician rationale for continued medication use. DON B indicated sleep assessments are completed quarterly and the person completing the assessment would interview staff and ask what the resident's normal sleep pattern is. Surveyor asked if the staff interviewed are the same staff on day and night shift to identify the sleep patterns. Surveyor asked how are you accurately collecting data to support the need for the sleep medication. Surveyor asked if all staff are reporting and documenting when all residents are asleep or awake. DON B stated she understands the need to collect data to support the medication use. Surveyor asked if there was a sleep care plan with non-pharmacological intervention to promote sleep. DON B indicated there was not a complete assessment and there is not a care plan.

Based on observation, interview and record review, the facility did not ensure that 2 of 4 residents (R) reviewed for pressure injuries (PI) (R27 and R6) received care consistent with professional standards of practice to prevent the development of a new pressure injury and promote healing of existing PIs. R27 developed a stage II PI on 10/28/23. On 12/27/23, the PI reoccurred as a stage 3.The care plan for PI interventions was not updated since 12/4/2023. R27 was not repositioned as instructed on the PI care plan, nor had a support surface for a stage 3 PI. The PI reoccurred on 2/14/24, healed on 2/26/24 and reoccurred on 3/6/24 causing actual harm. R6 has a PI; repositioning was not done as indicated on the PI care plan to promote healing of R6's PI. This is evidenced by: Guidelines from the National Pressure Injury Advisory Panel (NPIAP) 2016, Pressure Injury Prevention Points, accessed 07, March 2024, Prevention Points | National Pressure Ulcer Advisory Panel (npiap.com), states in part: Turn and reposition all individuals at risk for pressure injury, turn the individual into a 30-degree side-lying position and use your hand to determine if the sacrum is off the bed, ensure that the heels are free from the bed, use heel offloading devices for high-risk pressure injuries. The facility policy entitled, Repositioning, dated 5/2013, states in part: - #4 For all residents with a Stage I or above pressure ulcer, and every two-hour repositioning schedule. -#5 Residents who are in a chair should be on every one-hour repositioning schedule. -#6 If ineffective, the turning and repositioning frequency will be increased -Documentation should be recorded in the resident's medical record with position placed, name/title who gave care, any changes in resident's condition, any problems, and if the resident refused. Example 1 R27 was admitted to the facility on [DATE], with diagnoses including vascular dementia unspecified with anxiety, muscle weakness, diabetes mellitus, dysphagia, abnormalities of gait and mobility, and unspecified cerebral infarction. R27's Minimum Data Set (MDS) assessment, completed on 11/30/23, confirmed R27 scored 99 during the Brief Interview for Mental Status (BIMS), indicating BIMS could not be conducted due to severe cognition impairment and not being able to answer questions. R27 is incontinent of urine and bowels. R27 is dependent on staff for toileting, transferring. R27 is at risk for pressure injuries. On 05/29/23, R27's Braden scale for predicting pressure sore risk was completed, confirming R27 scored 11, at high risk for skin breakdown. On 08/30/23, R27's Braden scale for predicting pressure sore risk was completed, confirming R27 scored 12, at high risk for skin breakdown. On 10/28/23, R27's pressure injury assessment was completed, confirming R27 developed stage II pressure injury to the coccyx measuring 1.25cm x 0.4cm x 0.2 deep. On 11/08/23, R27's pressure injury to the coccyx healed. On 11/29/2023, R27's quarterly Braden assessment was completed, confirming R27 scored 13 at moderate risk for skin breakdown. R27 is incontinent of bladder and R27 wears incontinent pads and needs changed every two hours and as needed. On 12/27/23, R27's pressure injury assessment was completed, confirming R27 developed a stage III to the coccyx measuring 0.7 x 0.2 x 0.1 cm with slough. On 01/03/24, R27's pressure injury to the coccyx healed. On 02/29/24, R27's quarterly Braden assessment was completed, confirming R27 scored 14 at moderate risk for skin breakdown. R27 is incontinent of bladder and R27 wears incontinent pads and needs changed every two hours and as needed. R27's care plan was initiated on 03/04/20, and included the following interventions: TOILET USE/BOWEL AND BLADDER care plan implemented on 06/07/23: -The resident requires the assistance of one to two staff for incontinent care every two hours and as needed. -Incontinent, does not use toilet. TRANSFER care plan implemented on 10/12/22: -The resident is dependent on two staff for transferring. -The resident requires a mechanical lift Hoyer lift with two staff assistants for transfers. URINARY INCONTINENCE care plan: -Report any signs of skin breakdown (sore, tender, red, or broken areas) implemented on 03/04/20. -Check and change on NOC shift rounds implemented on 04/18/22. PRESSURE ULCER/INJURY care plan: -Keep clean and dry as possible. Minimize skin exposure to moisture implemented on 03/04/20. -Keep linens clean, dry, and wrinkle-free implemented on 03/04/20. -Use pressure reduction when in bed and pressure reduction cushion in wheelchair implemented on 03/04/20. -Braden risk assessment quarterly implemented on 09/11/20. -Reposition every two hours implemented on 09/08/22. -Wound RN to assess Monday, Wednesday, and Friday implemented on 12/04/23. Surveyor reviewed no other interventions revised or updated since 12/04/23. R27's reviewed current physician orders: -On 10/28/23-open ended: pressure sore site to the coccyx, peri cares with house barrier cream every shift and as needed. While in bed reposition from side to side every shift. -On 02/29/24-open ended: pressure sore site to the coccyx if open- cleanse with normal saline or wound cleanser, apply sorbact and meplix border, and change Monday, Wednesday, and Friday once a day. Progress notes in part: On 02/07/24, R27's skin remains intact to the coccyx. On 02/14/24, R27's stage III pressure injury to the coccyx measured 0.4x 0.4 x 0.1 cm with granulation tissue 25%, and 75% slough. On 02/21/24, R27's stage II to the coccyx measuring 0.4x 0.2 x 0.1 cm with granulation tissue 5%, and 95% slough. (This is inaccurate as the PI was previously staged a stage 3 PI.) On 02/26/24, R27's stage II to the coccyx healed. (This is inaccurate as the PI was previously staged a stage 3 PI.) On 03/06/24, R27's stage II to the coccyx measuring 0.4x 0.2 x 0.1 cm. (This is inaccurate as the PI was previously staged a stage 3 PI.) Observations are continuous from 03/04/24 at 9:55 AM- 03/04/24 at 12:50 PM: On 03/04/24 at 9:55 AM, Surveyor observed R27 sitting upright in Broda chair at the nurse's station sleeping. R27 wears Podus boots and has a cushion in a Broda chair. On 03/04/24 at 11:43 AM, Surveyor observed R27 sitting upright in Broda chair in the assistant dining room (ADR). Surveyor did not observe the staff toilet or reposition R27 before entering ADR. On 03/04/24 at 12:32 PM, Surveyor observed Certified Nurse Assistant (CNA) J push R27 sitting upright in Broda chair to the nurse's station. On 03/04/24 at 12:43 PM, Surveyor observed CNA J wheel R27 from the nurses' station to R27's room and attached R27's call light to R27. On 03/04/24 at 12:50 PM, Surveyor observed CNA J and CNA L push Hoyer lift into R27's room to transfer to bed. Observations are continuous from 03/05/24 7:03 AM- 03/05/24 12:03 PM: On 03/05/24 at 7:03 AM, Surveyor observed R27 sitting at the nurse's station in Broda chair in an upright position. On 03/05/24 at 7:40 AM, Surveyor observed CNA K take R27 into the ADR to prep for breakfast. R27 was sitting in Broda chair in an upright position. Surveyor did not observe staff toilet or reposition R27 before breakfast. On 03/05/24 at 8:53 AM, Surveyor observed CNA K push R27 out of the ADR and into the activity room. R27 was observed to be sitting in Broda chair in an upright position. Surveyor did not observe the staff toilet or reposition R27 in wheelchair before or after breakfast. On 03/05/24 at 11:27 AM, Surveyor observed staff bring R27 out of the activities room and bring R27 to the nurse's station. Surveyor did not observe R27 repositioned or toileted. On 03/05/24 at 12:03 PM, Surveyor observed Registered Nurse (RN) M push R27 in R27's Broda chair into ADR. Surveyor did not observe any repositioning or toileting before bringing R27 to ADR. On 03/05/24 at 2:15 PM, Surveyor interviewed CNA I and CNA J about repositioning and checking the incontinence brief for R27. CNA I indicated that CNA K could have done a spot check at the nurse's station but usually, CNAs try and toilet R27 after every meal. CNA I and CNA J indicated that CNA I and CNA J had not toileted R27 after breakfast or lunch. CNA I indicated that R27 was not toileted for sure after breakfast and should have been but as far as lunchtime goes, CNA K could have completed it after lunch. CNA I and CNA J indicated that R27 is a two-person Hoyer lift to bed to check and change briefs and CNA I and CNA J have not performed this since R27 got up for the day before 7:00 AM. On 03/06/24 09:30 AM, Surveyor observed RN G and CNA P enter R27's room. CNA P indicated that RN G was performing a dressing change on R27's coccyx. Surveyor interviewed RN G and asked if R27 had an open wound on the coccyx as the medical record stated that R27's coccyx pressure injury was resolved. RN G indicated that R27 waxes and wanes. RN G indicated that RN G is assessing now to see if R27's coccyx has reopened. Surveyor observed wound tape measure, meplix, and gauze lying on the bedside table. RN G and CNA P rolled R27 towards the window to the left side and bowel movement (BM) was noted in R27's brief. RN G cleaned BM off R27's buttocks. Surveyor observed a reddened area around R27's coccyx with a slit opening. RN G indicated that R27's coccyx has reopened. RN G measured R27's coccyx wound at 0.4 x 0.2 x 0 cm depth. RN G cleansed area and applied Meplix dressing to R27's coccyx. On 03/06/24 at 9:45 AM, Surveyor observed RN G go back into R27's room and stated, I forgot that orders are to place sorbact dressing against skin then apply Meplix over wound if wound opens. RN entered R27's room and Surveyor followed. Surveyor observed RN G apply sorbact dressing and place Meplix back on R27's coccyx. On 03/06/24 at 12:35 PM, Surveyor interviewed RN G and asked about interventions placed after 02/14/24 for R27's pressure injury prevention. RN G indicated there were no interventions updated after 02/14/24. RN G indicated RN G felt the facility already had everything in place that they could do for R27 and thought R27 was being repositioned every two hours and provided incontinence care every two hours per the care plan and facility expectations. Surveyor asked RN G what stage is R27's wound noted on R27's coccyx. RN G indicated that RN G would stage R27's coccyx wound at stage II pressure injury. (This is inaccurate as the PI was previously staged a stage 3 PI.) Surveyor asked RN G if R27's wound was unavoidable. RN G indicated that staff should be repositioning and off-loading R27 every two hours as care planned and keeping R27 dry of incontinent urine. RN G indicated that if staff is not doing this then, [R27's] coccyx wound could have been avoidable. Surveyor asked RN G if any interventions were in place for nutrition for wound healing. RN G indicated that nothing new has been intervened for R27 at this time. RN G indicated, that low-sugar [NAME] milk was implemented on 05/31/22 but mostly for [R27] being diabetic and [R27] is on a pureed honey thick diet for dysphagia implemented on 11/09/23. Surveyor asked RN G what kind of mattress R27 has for pressure reduction. RN G indicated that all the mattresses in the facility are pressure-reducing mattresses. Surveyor asked RN G does R27's care plan indicates R27 is to have a pressure-reducing mattress. RN G indicated that R27 is to have a pressure-reduction mattress and pressure-reducing cushion insert in R27's wheelchair. On 03/06/24 at 12:55 PM, Surveyor interviewed Director of Nursing (DON) B and Nursing Home Administrator (NHA) A and asked about the facility's mattress usage for residents' mattresses for pressure injuries. NHA A indicated that all mattresses are pressure-reducing. Surveyor requested manufacturing information about mattresses. On 03/06/24 at 2:00 PM, Surveyor received manufacturing information that states, in part, This mattress is not intended for stage III or stage IV pressure ulcers. On 03/07/24 at 8:34 AM, Surveyor interviewed DON B and asked what the expectations are for staff for repositioning and incontinence care for dependent residents. DON B indicated that staff are to check and change incontinent residents every 2 hours or as care planned. DON B stated, [R27] should not have sat in a wheelchair for more than two hours without being repositioned and checked if incontinent, especially with [R27] at high risk for skin breakdown and history of pressure injuries to the coccyx. DON B indicated that DON B thought having a Broda chair was sufficient for repositioning but not for toileting or providing incontinence care. Surveyor asked DON B was DON B aware that R27 has a PI on the coccyx currently. DON B indicated that DON B was unaware until yesterday when RN G updated DON B. Surveyor asked DON B if any interventions were put into place after R27's last wound assessment in February. DON B indicated there were no other interventions revised. 40181 Example 2 Findings include: R6 was admitted to the facility on [DATE]. R6 had the following diagnoses, in part: vascular dementia; hemiplegia (paralysis on one side of body) and hemiparesis (weakness on one side of body) following cerebral infarction (stroke) affecting right dominant side; aphasia (difficulty speaking) following cerebral infarction; and adult failure to thrive. R6's annual MDS assessment, dated 12/21/23, identified R6 had a BIMS score of 06, which indicated R6 had severe cognitive impairment. The assessment also identified R6 was dependent or required substantial/maximal assistance for mobility and activities of daily living. The assessment identified R6 was at risk for developing Pressure Injuries (PIs), but R6 had no current unhealed PIs at the time of the assessment. Braden assessments for the risk of developing PIs were completed as follows: Braden Risk Assessment completed 03/21/23 score 12 = High risk Braden Risk Assessment completed 09/21/23 score 9.0 = Very high risk Braden Risk Assessment completed 12/20/23 score 11 = High risk. On 03/04/24, Surveyor received a resident matrix that indicated R6 had an unstageable pressure injury. Review of R6's medical record identified R6 had open areas noted on the bottom on 08/05/23. The wound was described as a PI to the coccyx on 08/16/23. On 09/06/23, the wound was documented as healed. On 10/11/23, the documentation identified R6's wound had re-opened. On 11/08/23, the documentation identified the PI to R6's bottom was healed with no open areas. On 01/24/24, the documentation identified R6 had an unstageable PI to the right side of sacrum measuring 1.5 by 1.4 centimeters (cm) and midline sacrum measuring 3 by 2 cm. The note on 01/24/24 also stated, in part, .Resident's air mattress overlay was in the off position so was not inflated. Res [resident] positioned to L [left] side lying and air mattress turned back on . On 03/04/24, Surveyor observed R6 seated in a broda chair with no repositioning or incontinence cares offered from 12:09 PM to 3:01 PM. On 03/05/24 at 9:06 AM, Surveyor observed R6 in bed on back with the head of bed slightly elevated. CNA F stated they did not usually get R6 up out of bed until after breakfast because R6 had a sore on the bottom covered with a bandage. CNA F stated they had provided cares and repositioning of R6 earlier in the shift. On 03/05/24 at 10:44 AM, Surveyor observed R6 still in the same position, flat on back in bed with no pillow behind back. On 03/05/24 at 11:02 AM, Surveyor observed CNA F and CNA C provide cares and transfer R6 to a broda chair using a mechanical lift. R6 was placed by the aviary area to wait for lunch. On 03/05/24 at 1:50 PM, Surveyor observed R6 still seated in broda chair by nurses station since getting up before lunch. Surveyor observed RN H come by and recline R6's broda chair back to get you off your bottom. At 1:55 PM, Surveyor observed CNA F bring a covered cup of iced tea to R6 and lifted back of broda chair up straighter for R6 to be able to sip on the tea. On 03/05/24 at 2:52 PM, Surveyor observed R6 still seated in broda chair by nursing station. Surveyor had a continuous observation of R6 seated in chair since 11:08 AM with no repositioning or incontinence care provided. At 2:53 PM, Surveyor interviewed CNA U and asked if they kept R6 up in chair for supper. CNA U stated they usually transferred R6 back in bed before dinner because the day shift usually kept R6 up in chair since before lunch. At 2:54 PM, Surveyor observed CNA U take R6 back to R6's room to lay down in bed. At 2:55 PM, Surveyor interviewed DON B and reported continuous observation of R6 in broda chair from 11:08 AM until 2:55 PM with no repositioning or incontinence cares offered. Surveyor asked DON B how often R6 should be repositioned due to having a pressure injury on the bottom. DON B stated she was not sure the exact plan for R6 without looking up R6's care plan, but their facility policy stated R6 should be repositioned at least every two hours. R6's care plan included the following problem and approaches, in part: .Problem Start Date: 12/18/2019 Category: Pressure Ulcer/Injury Impaired Skin Integrity R/T [related to] decreased mobility and incontinence, poor nutritional intake, low body weight. Has Hemiplegia of her right side .Approach Start Date: 07/07/2020 Reposition/offload/assist [R6] to shift her weight in w/c [wheel chair]. Q2HRS [every 2 hours] .Approach Start Date: 12/18/2019 Keep clean and dry as possible. Minimize skin exposure to moisture . On 03/06/24 at 7:59 AM, Surveyor observed wound care for R6's coccyx wound provided by RN G and RN H. No concerns were identified with infection control or wound care procedure during observation. When RN G removed the old dressing from R6's coccyx wound center of wound, Surveyor observed the center of the wound was covered with brown to black material. RN G measured the wound at 2.8 cm long by 3.1 cm wide. On 03/06/24 at 12:15 PM, Surveyor interviewed RN about the recurrence of R6's PI and asked what made this PI unavoidable. RN G stated they did not add any new interventions when the area re-opened up on R6's bottom because they already had everything in place that they could do such as an alternating pressure overlay on the mattress and a gel cushion in the chair. Staff was repositioning R6 every two hours and they had tried multiple nutritional interventions. R6's nutritional status was very poor and family did not want to do any aggressive nutritional interventions. RN G felt that R6's poor nutrition, low body mass, and constant stooling were contributing factors that made the PI unavoidable. Surveyor explained observations of R6 not being repositioned or provided incontinent cares for approximately 4 hours. RN G stated if staff was not following the care plan and turning or providing incontinent cares every two hours this could contribute to the recurrence of R6's PI.

Based on observation, interview, and record review, the facility did not develop an interdisciplinary, systematic program to assess residents for risk of elopement upon admission or when identified as an elopement risk. This occurred for 1 of 3 sampled residents, Resident (R) R1, who was protectively placed, had a diagnosis of dementia, and was assessed as being severely cognitively impaired. The facility did not complete an elopement risk assessment upon admission for R1 to identify the risk for elopement. The facility did not assess the resident for elopement risk after the speech therapist identified the resident as being an elopement risk on 12/30/20. On 03/02/21, when temperatures were in the mid-30s, R1 eloped from the facility wearing only a t-shirt, pants, and socks, and walked along a busy highway at dark with sidewalks available only though part of the route. The failure to assess for elopement risk and ensure adequate supervision for R1 created a finding of immediate jeopardy beginning on 03/02/2021. Nursing Home Administrator (NHA) A was notified of the immediate jeopardy on 03/08/2021 at 03:05 p.m. The immediate jeopardy was removed on 03/08/2021; however, the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. This is evidenced by: Surveyor reviewed a policy entitled Wandering and Elopements. The policy states, in part, If identified at risk for wandering, elopement or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety . When the resident returns to the facility .examine the resident for injuries, contact the attending physician and report findings and conditions of the resident, notify the resident's legal representative .complete and file an incident report and document relevant information in the resident's medical record . R1 was admitted to the facility on [DATE] for protective placement due to R1's unsafe behaviors and poor decision making. R1's diagnoses include: Major cognitive deficits from a self-inflicted gunshot wound to the head 11/19/20, traumatic [CONDITION(S)], [CONDITION(S)], suicidal ideation and dementia. R1's Brief Interview for Mental Status completed on 12/22/20 was 06, indicating severe cognitive impairment. Surveyor reviewed R1's clinical record. The Minimum Data Set (MDS), completed on 12/22/20, indicated R1 did not have any wandering attempts. There was no documentation in the clinical record the Interdisciplinary Team (IDT) discussed R1's risk of elopement. Surveyor reviewed a blank document entitled Elopement Risk Assessment. This document was not completed for R1 upon admission, or at any time. R1 met several criteria listed on the form including a diagnosis of dementia, confusion, a psychiatric diagnosis and being highly mobile. R1 also had a history of suicide attempt which put R1 at risk. No risk assessment was completed to identify whether or not a need for increased supervision to maintain R1's safety was needed. The elopement/risk assessment is not scoreable, and does not provide instructions to the staff preparing the document as to when to proceed with an elopement care plan. Surveyor reviewed R1's plan of care. Under the title Problem and Category the document read: Activities of Daily Living (ADL) Functional/Rehabilitation: Resident ability to care for self has deteriorated due to dementia and [CONDITION(S)] secondary to gunshot wound. The goal was for R1 to regain ability in personal hygiene tasks. Additional note added, .At times needs cues to where the bathroom is. Psychosocial Well-Being Category read, Health Maintenance: Dx (sic) dementia, BPH (sic). The next problem was entitled Category: Return to Community Referral Discharge Planning. The document read, Prior to admission, R1 was living in his own home. Recently his daughter and grandson had moved in and were physically and financially abusing R1. R1 attempted suicide and was hospitalized at (Name) Psych (Psychiatric Unit). He now has a guardian and will be protectively placed at [name of facility], long term care is planned. The care plan did not contain interventions to prevent elopement. R1 resided in the general population without a wander guard from admission on 12/11/21 until 03/02/21. On 12/30/20 Speech Therapy (ST) noted, Agitation and impulsivity. Loss of sense of risk. Moves about freely. May wander and seek exits. Despite the Speech Therapist's assessment that R1 was an elopement risk, there was no formal assessment by the facility to determine his risk for elopement. There was no documentation in the clinical record showing the Interdisciplinary Team had discussed R1's risk of elopement. On 01/04/21 ST noted, .Pt.(R1) noted to have impulsivity at times . On 01/23/21, Staff noted R1 walking up and down the hallways. On 01/30/21, staff noted R1 running in the hallways. NHA A provided surveyors with a document entitled Elopement: R1. The document stated, in part,R1 was last seen on 03/02/21 at 05:45 p.m., when he left the dining room to sit by the main entrance door, which is a usual practice for R1, who enjoys sitting by the entrance door .the door has remained locked since COVID-19 lockdown .it is believed R1 unlocked the entrance door after watching staff unlock at different times .The weather is mild for this time of year with a high of about 45 degrees .R1 was walking in jeans, a tee shirt and thick gripper socks .A passerby called the sheriff due to him walking without shoes R1 was confused due to dementia and was trying to walk back to his home town . R1 has been sitting by the front door for approximately 2 months or greater for a large portion of his day, watching people come and go and drop things off .The Interdisciplinary Team (IDT) met at different times to discuss R1's risk of eloping and team felt R1 was not a risk as he never mentioned leaving or tried to leave at any time, he seemed content sitting and watching. If wander guard was applied, he would not be able to sit in this spot due to location of sensors .facility is currently looking into a new front door .which will prevent this from being an issue in the future. On 03/08/21 at 10:35 a.m., Surveyor interviewed NHA A. NHA A stated R1 was initially placed on the covid unit, where 1:1 care was provided. Once R1 was off the covid unit, the facility decided to place R1 in general population, since R1 seemed to be adjusting well to the facility. NHA A stated R1 seemed content and We just never thought he would leave. During the interview, NHA A mentioned when R1 was returned to the facility, he said he left because his mom and dad said they would not visit him. Surveyor asked how the facility thinks R1 eloped. NHA A stated the assumption is R1 unlocked the front door by himself. R1 was last seen around 06:00 p.m On 03/08/21 at 11:30 a.m., Surveyor traced the route R1 would have taken after leaving the facility. 11 city blocks of the route would have been walking along a busy highway where there is no sidewalk. At the time it was dark outside. R1 was not wearing shoes, and had a T-shirt on. According to localconditions.com, the outside temperature in [NAME] during the time R1 was most likely missing from the facility ranged: 06:15 p.m.= 37.5 degrees 06:55 p.m.= 36.6 degrees 07:15 p.m.= 35.2 degrees Visual conditions were dark. On 03/08/21 at 11:45 a.m., Surveyor observed the facility entrance and exit doors. All doors were alarmed. The facility has a special care (locked) unit accessible by an employee code only. The main entrance door is not locked during business hours (08:00 a.m.-04:30 p.m.), and the Business Office Manager and office staff monitor the entrance door by observing through a glassed in area to the immediate right of the entrance door. On 03/08/21 at 11:50 a.m., Surveyor interviewed Business Office Manager (BOM) G. Surveyor asked BOM G How are the doors secured or monitored after you leave? BOM G told surveyor the door is locked by turning a silver lever on the door, located in the middle area of the door and easily reachable. The door can also be unlocked by turning the lever in the opposite direction. The automatic lock of the door is a button to the left upper portion of the door, only reachable by using a stick or hook to push the button in. This locks the automatic opening. BOM G told Surveyor she locks both the manual and automatic portions of the door when she leaves at night, which securely locks the door. No logs were kept to show the door had been locked at the time of the occurrence, although BOM G told Surveyor she locked the door on 03/02/21. Employees enter through an employee entrance, accessible only with the use of a key card. Surveyor reviewed a document entitled [NAME] Police Department--Incident. The document stated on 03/02/21, at 07:00 p.m., Police Officer (PO) C was contacted by a private citizen who reported an elderly male, later identified as R1, was wandering the streets and appeared to be confused. PO C's incident report stated R1 was .confused and suffering from some sort of mental disorder .R1 was wearing only a t-shirt and did not have any shoes on . PO C noted R1 did not know where he was, what day it was, or what time it was. R1 told PO C he came from a locked facility that he did not like being in. R1 told PO C he was on his way home (a town approximately 40 minutes by car from this location) .PO C contacted the facility and the facility staff told PO C R1 was supposed to be at the facility. R1 was returned to the facility. PO C met with Licensed Practical Nurse (LPN) D. LPN D told PO C R1 normally runs up and down the halls, and sits near the main entrance to the facility. LPN D told PO C LPN D did not have any further information as R1 was not her patient. PO C next spoke with Registered Nurse (RN) E. RN E told PO C R1 had last been seen at dinner, and it was unknown exactly when R1 left the facility. RN E told PO C some of the doors to the outside are locked and some are not. Some of the doors had alarms indicating when they were opened, but no alarms were tripped when R1 left. On 03/08/21, at 12:10 a.m.,Surveyor contacted the police department and attempted to interview PO C. Surveyor was told PO C was not available to interview at this time, and would not return to duty for a few days. Next, Surveyor attempted to contact LPN D, with no answer. On 03/08/21, Surveyor contacted RN E. RN E stated R1 was last seen on 03/02/21 at approximately 06:00 p.m. to 06:15 p.m. at dinner. RN E stated R1 likes to sit in a chair by the front door. RN E stated he did not know if the front door was locked or unlocked, and R1 was not wearing a wander guard (a bracelet or ankle alarm to alert staff when a resident attempts to leave the building). RN E stated the facility was not aware R1 was missing until the police returned R1 to the facility. RN E stated he performed an assessment on R1, which included examining him for injury. R1 did not display any signs of injury. RN E stated he checked R1's vital signs, and R1's temperature was within normal limits. RN E stated I know that he likes to sit in a chair by the front door. I usually don't watch the front door, but I try to keep an eye on him. RN E told surveyor R1 did not have any care plan interventions in place for risk of elopement until after R1 eloped, and then we put a wanderguard on him and placed him on 15 minute checks. Surveyor asked RN E, Does the facility provide staff training for residents who elope or are at risk for elopement? RN E stated Maybe .they might have .in the past. Surveyor asked what type of training was provided. RN E stated I don't know. On 03/08/21, at 09:30, Surveyor toured the facility and interviewed Certified Nursing Assistant (CNA) H and asked about residents that wander. CNA H indicated all doors are alarmed. The 200 unit CNA H is working on has a double door with an alarm. Surveyor asked if CNA H was familiar with R1. CNA H indicated R1 had escaped from the building. Surveyor asked if CNA H knew how that happened. CNA H stated R1 went out the front door, because somehow the door was left unlocked. Surveyor asked CNA H if R1 had behaviors. CNA H stated R1 always talked about going home and R1 always sat by the front door. He would say My daughter will be here soon. On 03/08/21, at 09:40 a.m., Surveyor toured the Special Care Unit (SCU), where R1 now resides. Surveyor asked LPN J about R1's elopement. LPN J stated, R1 resided on the East Hall at the time. R1 spent a lot of time sitting in front of the main front door. R1 must have figured out how to unlock the door or followed someone out the door. Surveyor asked if R1 had a wander guard in place at the time. LPN J stated No. LPN J told Surveyor, R1 is fast and can run. LPN J told Surveyor R1 has not attempted to leave the locked unit. At 10:00 a.m on 03/08/21., Surveyor interviewed LPN K and asked how a resident at risk for elopement is identified. LPN K told Surveyor there is a document in the Matrix computer system. LPN K pulled up the document entitled Risk Assessment for Elopement. LPN K said this should be completed for each resident. At 10:05 a.m on 03/08/21., Surveyor interviewed CNA I who works on the 100 hall also known as the East Hall. This is where R1 resided at the time of the elopement. Surveyor asked how staff know if a resident is at risk for wandering. CNA I stated a list of residents who wander is kept up at the desk. Surveyor asked about R1's elopement. CNA indicated R1 sat by the main front doors a lot of the time watching others go in and out of the building. Surveyor asked CNA I about R1's behaviors. CNA I stated R1 wandered up and down the halls. R1 would go from 100 hall all the way to the opposite side of the building down to the 200 hall and walk to the end of this hall to the sun room. Surveyor asked if R1 was on any checks for safety. CNA I stated, No. CNA I stated stated Resident would run in the hall .he would touch the exit door at the end, then pivot and run back. On 03/08/21 at 12:20 p.m., Surveyor interviewed DON B and Nurse Manger (NM) F. Surveyor asked how the facility identified residents who were at risk for wandering/elopement, such as an elopement risk assessment. DON B stated We don't do an elopement risk assessment on everybody. The front door is manned. We do the risk assessment if they (the residents) display wandering or tell the staff something like I am leaving .We don't want to just slap an alarm on them without knowing if they try to get out .I don't do a (elopement) risk assessment for all residents, just like I don't do a smoking assessment on everybody, you know, only people that smoke. Surveyor asked NM F How do you identify residents at risk for elopement when you perform admission assessments? NM F stated I ask them (the residents) how they feel about going to a nursing home and if they are okay with it. At 1:05 p.m. Surveyors asked DON B how the facility determines a resident at risk for elopement should have a care plan developed for elopement. DON B stated the facility .does nothing specific to determine if an elopement care plan should be developed. If a resident is admitted with a wander history they would go to the locked unit or a wander guard would be placed, or if a resident stated 'I want out of here' then we would do one (develop an elopement care plan). The failure to provide supervision for R1 to prevent elopement, and by not having an elopement risk assessment system in place created a finding of immediate jeopardy. The facility removed the immediate jeopardy on 03/08/21 when the facility implemented the following: Facility staff and medical director reviewed policy and procedure on wandering and risk assessment for elopement. A new assessment was put into place on 3/8/2021 to identify risk of elopement for all residents with a history of dementia or other risk factors for elopement. Professional nursing staff educated on assessment put in place to identify risk upon admission and quarterly with the MDS schedule beginning 3/8/2021. Facility staff educated on elopement/wandering policies, signs of elopement, what to do in the case of a missing resident beginning 3/8/2021. Additional Staff will be educated on their first shift working at Golden Age Manor on or after 3/8/2021. It should be noted that on 03/02/21, a wanderguard was placed secondary to the elopement attempt. On 03/03/21, at 03:15 p.m., the Social Worker interviewed R1, who told her he would probably leave the building again. After this discussion, R1 was transferred to the special care (locked) unit.

Based on observation, interview and record review, the facility did not ensure the residents' environment remains as free of accident hazards as possible, and each resident receives adequate supervision and assistive devices to prevent accidents. This occurred for 3 of 5 residents (R61, R423 and R64) who were reviewed for falls. R61 had multiple falls. A care planned approach to not leave unattended in her room was added. On 2/24/19, R61 was in her room unattended and was found on the floor. She complained of pain 10/10 to right rib area. She was hospitalized with a right clavicle fracture, right posterior 7th rib fracture and a trauma induced pneumothorax. R61 had five falls in (MONTH) 2019, three falls in (MONTH) 2019 and a fall in (MONTH) 2019. The facility did not provide adequate supervision for R61 to prevent falls from reoccurring, do a thorough investigation after each fall to determine the root cause, implement new measures to prevent further falls, or follow the current interventions. R423 had multiple falls. The facility did not complete a thorough investigation after each fall, determine the root cause for the falls, nor implement new measures after each fall to prevent further falls. The facility did not provide supervision to prevent falls for a resident with a history of falls, R64. This is evidenced by: On 01/15/20 at 10:45 a.m., Surveyor received and reviewed a facility policy entitled, Fall Risk Assessment, Fall Risk, Managing. The policy, which was revised on (MONTH) (YEAR), states the following, in part: Resident Centered Approaches . 5. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approaches remain relevant. 7. In conjunction with the attending physician, staff will identify and implement relevant interventions .to minimize serious consequences of falling. Monitoring Subsequent Falls . 3. If the resident continues to fall staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions . Example 1 R61 was admitted on [DATE], with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documents R61 has a history of 2 recent falls. R61 has a Brief Interview for Mental Status (BIMS) score of 2, meaning she has severe cognitive impairment. On 09/16/19, R61 had a significant change in condition MDS completed due to R61 suffering a [MEDICAL CONDITIONS] affecting activities of daily living (ADLs) . A Falls Risk assessment dated [DATE] has a score of 19; this tool identifies a score higher than 10 means the resident is at high risk for falls. On 08/18/19, the [NAME] Hopkins Falls Risk Assessment was completed. The risk score was 23; a score greater than 13 means a high risk of falling. The most recent risk score on 12/16/19 was 21. Falls care plan in part, 12/17/2019 Category: Falls, . has history of falling R/T prior to admit had fall that resulted in fracture of left pelvis. Long Term Goal Target Date: 03/16/2020 .will remain free from injury. Approaches include -12/17/2019 Assure She is wearing eyeglasses. Assure eyeglasses are clean and in good repair. -12/17/2019, Avoid leaving her in her room, in w/c, unattended. -12/17/2019, Bed sensor alarm when in bed and Chair sensor when up in wheelchair. -12/17/2019, Broda chair without foot pedals, may use foot pedals PRN keep chair in reclined position except for meals, Nursing Assistant: Enhanced 30 minute safety checks when in her bed; get her up if she is awake to prevent falls -12/17/2019, Give .verbal reminders not to ambulate/transfer without assistance. -12/17/2019 Keep personal items and frequently used items within reach. - (undated) a floor mat on door side of bed. Bed is to be in low position when .is in it. Provide . an environment free of clutter. Evaluation Notes: 11/24/2019, .Last fall was on 11/9/19 Resident will be using bed sensor alarm when in bed and will no longer be using tab alarm. Resident will have enhanced 30 minute checks when in bed, advised to get her up if she is awake. Last Reviewed/Revised: 12/22/2019. The care plan given to Surveyor contains the same date for most interventions. Surveyor asked for a care plan with the dates for each intervention from Registered Nurse (RN) D. RN D was unable to provide a care plan in that format for Surveyor. Surveyor was unable to locate the dates of the new interventions in the electronic health record. Documentation of R61's falls include: 01/10/2019 18:20 (6:20 p.m.) Heard alarm sounding. Responded ASAP but before we reached the room we heard her fall. She was found sitting on the floor legs out stretched. She denied hitting her head. Scalp was palpated and no lumps or bumps were found. Spine palpated no tenderness. Resident able to move all extremities without difficulty or discomfort. Gait belt applied and resident was easily assisted to stand per 2 assist. VSS and neuros intact. Will continue VS checks and neuros per protocol. IDT reviewed the fall and implemented the new intervention of Avoid leaving in room alone. IDT (interdisciplinary team) reviewed and continued the approach to avoid leaving resident alone in room. 02/24/2019 10:29 a.m., Resident found by housekeeping on floor of bathroom. Resident in sitting position with back to toilet, feet facing towards sink, pants down, grippers on and no alarms going off. Observed alarm in residents chair was folded in half to keep from beeping. Light was on and blinking- indicating alarm was in good working order. Resident did state she shut alarm off. Denies hitting head. No injuries initially noted. VS and neuros taken-all WNL. Resident assisted back to bed. Assessment noted sore spot to right rib area and resident began complaining of pain to right rib area. Resident was moaning during assessment and rated pain at a 10 on 0-10 scale. Resident has history of fractures d/t falls . Surveyor reviewed the hospital admission noted dated 02/24/19 that includes in part, .patient was found down this morning by her nursing facility staff in the bathroom (she has a history of turning off the bed alarm) CT of chest showing a moderate to large pneumothorax .had a cook catheter placed . 1. Moderate to large right pneumothorax with possible nondisplaced distal right clavicular and right posterior 7th rib fracture . Discharge Summary in part, dated 02/27/19, Discharge Diagnoses: [REDACTED].Hospital course: Orthopedic surgery was consulted for right clavicle fracture . On 01/15/20 at 1:15 p.m., Surveyor interviewed RN D and DON B asking if R61 was alone in the room at the time of the 02/24/19 fall. RN D indicated that R61 was. DON B indicated this was not willful; no one meant to have the resident alone in the room. DON B went on to say that R61 most likely took herself there after breakfast when staff was busy. Surveyor stated the previous intervention to prevent falls was to avoid R61 being alone so she would not have another fall when unsupervised. DON B acknowledged that is the intervention they had put in place prior to the 02/24/19 fall. R61's nurses' notes continued: 02/27/2019 12:29 p.m., Res has returned from Regions hospital where she was hospitalized following a fall here at GAM. She sustained a fx (fracture) to her R (right) clavicle and 7th rib, a R pneumothorax, .x 2 gauze pressure dressing CDI (clean, dry, intact) to R chest covering chest tube removal site. Also has bruising to this area. Resident states she is in Balsam Lake when asked. She has already been observed to ambulate by self in room on her way to the bathroom x1 today. Has bed and chair alarm in place and will initiate Q15 min safety checks d/t dementia and fall risk. These 15 minute checks were discontinued in (MONTH) 2019 per interview with Director of Nursing (DON) B on 01/15/20 at 3:00 p.m. On 08/26/19, R61 suffered a [MEDICAL CONDITIONS] affecting her ability to use her left side and increasing her need for assistance with transfers and mobility. R61 was unable to ambulate after the [MEDICAL CONDITION]. Documentation of R61's falls continued: *09/05/2019 19:18 (7:18) p.m. Chair alarm sounded and resident was found sitting on her buttocks, on the floor in the sun room. She denies injury. Scrape/abrasion noted on the right scapula. VSS, neuros intact. All extremities are movable without pain or restriction. Resident noted to have increased weakness of the left arm today. No fine motor skill of the left hand at this time. She is required to use her right hand to lift her left arm. This however was noted before the fall. Resident has very poor short term memory. She is able to move her head from side to side and up and down without restriction or pain. Gait belt used and resident lifted to her w/c. Brother/POA notified by phone. ER doctor, ( .) notified by fax and asked to respond when available that the fax was received. Will continue to monitor per protocol . IDT reviewed, resident was kept by staff for remainder of night. She did have another fall within 72 hours of this fall and was evaluated at the ED. Safety Event Report in part, Safety devices in use: Chair alarm, bed alarm, call light. Possible contributing factors: [MEDICAL CONDITION] left sided weakness, lost strength/weakness. Prevention plan: Resident within site of staff this evening. IDT review: Resident was kept by staff for remainder of night. She did have another fall within 72 hours and was evaluated at the ED (emergency department). *09/08/2019 08:14 a.m., Res had fall from w/c (wheelchair) at 0720 a.m. Certified Nursing Assistant (CNA) reports this morning when she arrived res was half crawling out of bed so she got her up in her w/c and brought res out to dining room. 10 minutes later CNA was in another room when she heard tab alarm sounding and a thud. CNA went to find (Resident name) R side lying on floor near bed. Assessment: T97.8, P105, R 28, BP 200/108, O2 95% R[NAME] She is cool and clammy. PERRL[NAME] No pain with ROM x4 extremities. Does have bump with swelling and tissue abrasion to L forehead measures 4.5 x 4 cm and a bruise to the R thumb. Res assisted off floor with hoyer lift and into w/c. Given a cold pack for forehead and 650 mg Tylenol. Res states I don't think Roy's got the car home Call placed to Dr. and assessment given. Res will be seen in ED for eval with GAM to transport. POA . called and in agreement. BP recheck after 15 min 172/80, R 24, P 93 15 min checks until 09/8/19, a new intervention was put in place of issuing a low broda chair. 09/08/2019 11:38 Call received from .ED. Reports res is ready to be picked up. CT of head and neck was clear . Safety Event Report in part, Safety devices in use: Chair alarm, call light. Possible contributing factors: loss of balance/strength. IDT reviewed, resident was issued a low broda chair that is to be reclined back except for meals. *09/11/2019 6:46 a.m., Resident was in dining room when last observed resident, (Resident name) was awake and was brought to the dining room. Housekeeper heard residents alarm sounding in residents room, resident found on floor as described in fall event. No new injuries noted, resident alert as she has been throughout the N[NAME], very chatty. No complaints of pain. Will go ahead with fall protocol. Safety Event Report in part, Safety Devices in use: chair alarm, anti tip bars. Possible contributing factors: Confusion. Prevention Plan: Continue current. IDT review: IDT reviewed, resident was issued a low broda chair that is to be reclined back except for meals. This is the same intervention as the 09/08/19 fall. *On 9/16/19, R61 had a fall out of bed; a low bed and floor mats were added on this date as new interventions. *09/26/2019 22:10 (10:10) p.m. Res found half out of bed. Alarm was sounding intermittently as res was on/off of it. She was on her knees on floor mat. VSS, no injury, mentation at baseline. Head examined and d/t positioning there is no reason to believe she bumped her head. Writer called on-call Dr . updated on fall and received order to do neuros 1x/shift d/t non-injury and comfort cares status. Safety Event Report in part, Safety devices in use: bed alarm, call light, low bed, mat on floor, contributing factors: decline in ADLs, loss of strength .Describe measures: Prn (as needed) [MEDICATION NAME], assisted into broda chair after being cleaned up after being incontinent. IDT reviewed, resident was given a low bed. Care plan documents low bed was added on 9/16/19. This date was verified with RN D as the date the low bed was initiated. The investigation does not include any information on incontinence, last toileting or need for a change in toileting plan. *10/09/2019 4:44 a.m., Slid out of bed at 04:30 a.m. Alarm was not sounding as she was found with upper half in bed and lower half on floor mat next to bed. It would not be possible for her to have hit her head, written update to NP (nurse practitioner) left in binder. Will do neuros q (every) shift per order r/t comfort care status. No injury ROM x4. Res does not state why she tried to get out of bed. She has noted decline since recent [MEDICAL CONDITION]. Will change pressure alarm to tab alarm with the unit placed on non-exit side of bed. IDT reviewed, tab alarm is in use while in bed and sensor alarm was taken off. Safety Event Report in part, Safety devices in use: bed pressure alarm. Contributing factors: recent [MEDICAL CONDITION], Prevention Plan: tab alarm. Describe measures:will use tab alarm as res will slide out of bed and not set off pressure alarm which was in correct location. *10/09/2019 23:40 (11:40 p.m.) Resident was found on the floor mat next to her bed at 2244 (10:44 p.m.). She was lying on her left side, parallel to the bed. She has no noted injuries. VSS. Neuros q shift restarted. ER MD was faxed with update. NP updated via communication board. IDT reviewed, has a low bed, floor mat and tab alarm while in bed, continue with these interventions. Safety Event Report in part, Safety devices in use: call light, matt on floor. Possible contributing factors: Recent [MEDICAL CONDITION], rolled out of bed. Prevention Plan: Care plan was recently updated to tab alarm when in bed. Tab alarm was not on. Make sure all staff are updated on changes to care card. Educate staff to make sure they are following care card. IDT review: Has a low bed, floor mat and tab alarm wile in bed, continue with these interventions. On 01/15/20 at 1:15 p.m., Surveyor interviewed RN D and asked who the staff member was that did not place the alarm on 10/09/19 and if any education had been done. RN D stated she does not know who the staff member was and can not locate any staff education. The root cause for this fall was not determined; there were no new interventions put in place to prevent future falls. *10/22/2019 06:44 a.m., Res found on floor by housekeeper . Alarm was not sounding and res was yelling help, help. Housekeeper immediately notified staff, and found res lying flat on back on floor mat alongside bed. No injury, VSS, neuros intact, denies pain, ROM x4. Res assisted to get up in Broda chair, CNA reminded to double check tab alarm is reattached after cares. Neuros q shift x 4 per existing order. IDT reviewed, added a lipped mattress to bed. On 01/15/20 at 1:15 p.m., Surveyor interviewed RN D asking what staff member had not put the alarm on. RN D provided education that was completed on 10/23/19 about the importance of following the care plan. *11/09/2019 04:11 a.m., Resident was found sitting on mat on floor next to bed, butt on mat arms resting on mattress. Tab alarm did not sound will educate staff and investigate as to why. Resident had been up sitting by nurses station and was helped to bed around 01:00 a.m. complaints of pain neuros are intact and VSS. Notified Dr . in ED who gave ok to do neuros Q shift x 4. Was assisted back to bed with assist of 3 and is resting comfortably at this time. Will continue to observe. Safety Event Report in part, Safety devices in use: tab alarm, call light, low bed. Possible contributing factors: Tab alarm did not sound. Prevention Plan: Staff education on tab alarm placement. IDT review: Resident will be using bed sensor alarm when in bed and will no longer be using tab alarm. Resident will have enhanced 30 minute checks when in bed, advised to get her up if she is awake. Surveyor was not provided with staff education for the incident of the tab alarm not being on for the 11/09/19 fall. Example 2 R423 was admitted on [DATE] with [DIAGNOSES REDACTED]. R423's admission MDS, dated [DATE], documents a BIMS score of 1, meaning R423 has severe cognitive impairment. The MDS documents R423 has a history of a fall and fracture and one fall since admission. Falls Risk Assessment, dated 12/18/19, titled, [NAME] Hopkins Falls Risk Assessment has a risk score of 21. A score greater than 13 means a high risk of falling. Falls care plan Category: Falls Risk for Falls R/T impulsive behavior, dementia, anxiety. Has had falls since her admit: 12/24/19 scooted self out of low bed. No injury; 12/30/19, unwitnessed fall in room. No injury. Long Term Goal Target Date: 04/06/2020 .will remain free from injury. Assure resident is wearing eyeglasses. Assure eyeglasses are clean and in good repair. Approach Start Date: 01/07/2020, Assure the floor is free of glare, liquids, foreign objects. Approach Start Date: 01/07/2020, Give .verbal reminders not to ambulate/transfer without assistance. Approach Start Date: 01/07/2020 Keep bed in lowest position when in bed. Approach Start Date: items and frequently used items within reach. Approach Start Date: 01/07/2020, Pressure sensor alarm to bed and chair at all times. Provide her an environment free of clutter. Self Care Deficit care plan in part, .had fall that resulted in [MEDICAL CONDITION] .has dementia with difficulty staying on task . 01/07/20 -Transfer with assist of 2 with walker otherwise ok to use w/c to and from bathroom or walk with hand hold assist of 2 . Nurses' notes in part, 12/19/2019 15:04 (3:04 p.m.), Pt. seen for skilled OT on this date with goal of increased safe positioning as pt. continuously standing up from w/c over and over again - sliding to edge of chair seat. Issued a new chair with anti roll back device, however pt. will slide to edge and push off which will not activate anti roll back properly. Trialed issue of Broda pedal chair lowered to lowest possible setting from floor and reclined in back to max. Dycem placed on seat. Pt. appears comfortable, however is able to rise to stand with ease from this position as well. Nursing addressing pt. agitation with on-call MD. Nursing will continue to use Broda chair. 12/24/2019 06:50 a.m., Heard bed alarm went to respond and (R423) had scooted self to lower half of bed then scooted self out of low bed to the floor before I could intervene. Left sitting up next to low bed in no obvious danger no distress noted and found CNA to assist. Less than 30 seconds passed and (R423) had scooted self to the middle of the room still sitting up in no distress. Assist of 2 to W/C and giving 1 on 1 or close supervision since scooting out of bed. VSS (Vital signs stable) neuros WNL (within normal limits) no distress noted after fall even tolerated lab draw well this AM. Continue to monitor. Safety Event Report in part, Safety devices in use .bed alarm, call light, low bed, 1/2 side rail .Possible contributing factors: purposefully scooted out of bed .Prevention Plan: continue with 1:1 or close supervision . IDT reviewed: continues with alarms at all times. 12/30/2019 13:07 (1:07 p.m.), Resident offered her recliner in her room to rest after lunch with chair alarm and call light in place. Alarm was sounding and resident was found scooting herself on the floor towards the doorway to the hallway. Resident is unable to make coherent sentences or answers when asked about the event and she was combative and uncooperative with assessments for injuries and/VSS. Daughter updated about fall. NP given notice of fall as well. Resident currently being 1:1 at this time. Safety Event Report in part, Safety devices in use and functioning: chair alarm, call light . Possible contributing factors: change in medications .Prevention Plan: 1:1 when anxious. IDT review: Continue with alarms an all times and 1:1 when needed. 01/08/2020 13:00 (1:00 p.m.) Alarm sounded when housekeeping was walking by and housekeeper seen her sitting up on the floor and alarm sounded again .(R423) was sitting up with left hip on footrest of recliner and recliner was tipped forward due to (R423's) wt on the footrest. No obvious injury noted was trying to scoot off the footrest no change in movement to bilateral lower extremities. Also moving upper extremities well and able to move head/neck freely. No obvious injury noted able to walk with assist no change noted. Message left for family to call GAM for update noted left for NP to update. Is not safe to be in recliner with footrest up but does not like recliner with the footrest down. Housekeeper was going by room when alarm sounded once and (R423) had already slid out of recliner with 2nd alarm sound. Safety Event Report in part, Safety devices in use: chair alarm, bed alarm, call light, low bed .Possible contributing factors: slipped out of recliner onto footrest .Prevention plan: recliner removed from room. IDT review: .when resident is up in her w/c she sit at the nurses station for close supervision. 01/11/2020 8:41 a.m. Res set off bed alarm this a.m. When answered she was already at the doorway of room. Assisted to toilet and sat down willingly. Large incontinent urine. Res washed and dressed- max to total assist. Sat quietly at desk until breakfast then sleepy. Unable to arouse fully at breakfast and for neuros. VSS. Pupils are reactive, had to lift eyelids Observations of inadequate supervision of R423 during survey: On 01/13/20 at 9:15 a.m., Surveyor noted R423 sitting by the nurse's station in a wheelchair. At 9:20, Surveyor heard an alarm going off; R423 was trying to get up and walk. R423 would begin to walk a few steps, staff then redirected R423 to sit down again. R423 repeated this approximately 6 times within the next hour, setting off the pressure alarm in her chair. Staff came after the alarm sounded each time to redirect R423 to sit in her chair. During the noon meal R423 got up from her wheelchair setting off the alarm multiple times, starting to walk away as staff came to redirect R423. On 01/14/20, Surveyor observed R423 getting up from the wheelchair by the nurse's station, displaying unsafe actions by getting up and walking before staff could respond. After the alarm sounded and R423 was up and taking a few steps staff did respond to assist R423. On 01/15/20 at 3:00 p.m., Surveyor interviewed RN D, who is the unit manager about the above falls and interventions for R423. Surveyor asked about the intervention on 12/24/19 of continuing with alarms. Surveyor asked what root cause was determined. RN D was not sure. Surveyor asked if any new interventions to prevent future falls had been implemented. RN D stated, No. Surveyor asked about the 1:1 and close supervision as an intervention. RN D indicated they do that most of the time. Surveyor asked if that was a new intervention on the above falls. Surveyor noted the nurses' notes document R423 has had 1:1 most of the time since 12/20/19. RN D acknowledged this was not a new intervention to prevent falls, the root cause has not been identified for R423's three falls. Example 3 R64's [DIAGNOSES REDACTED]. On 01/13/20 from 11:00 a.m. to 11:30 a.m., Surveyor observed R64. R64 was ambulating throughout the unit without staff assistance. R64's gait was slow and shuffling, with upper extremity fine tremors. R64 was wearing anti slip gripper socks. At 11:30 a.m., activity staff offered R64 an activity. She participated in the activity while seated at the counter. After the activity was completed, R64 ate lunch. On 01/14/20 from 9:30 a.m. to 10:30 a.m., Surveyor observed R64. R64 was ambulating throughout the unit without staff assistance. R64's gait was slow and shuffling, with upper extremity fine tremors. R64 was wearing anti slip gripper socks. On 01/16/20 from 9:30 a.m. to 10:45 a.m., Surveyor observed R64. R64 was ambulating throughout the unit without staff assistance. R64's gait was slow and shuffling, with upper extremity fine tremors. R64 was wearing anti slip gripper socks. Surveyor reviewed R64's clinical record. The MDS, dated [DATE], BIMS showed that R64 has severe cognitive impairment. The MDS also showed that R64 requires one person limited assistance with ambulation, and supervision with transfers. Surveyor reviewed R64's clinical progress notes. The progress notes/event report from 11/19/19, stated, in part . Staff reports that R64 was very agitated and walking about the dining room . Certified Nursing Assistant (CNA) states that she just started to shake and looked like she was going down to her knees. CNA lowered resident to the floor . No injuries noted . Plan to have stand by assist when walking . The intervention, dated 12/18/19, read: .Encourage R64 to ambulate with assistance of 1, 100 feet, twice a day On 01/16/20 at 8:01 a.m., Surveyor interview DON B. DON B stated that the interventions are added to the care plan when the interdisciplinary team meets to discuss the event.

Based on observation, interview and record review, the facility did not ensure a resident who entered the facility without a pressure injury did not develop a pressure injury, and a resident with a pressure injury receives the necessary treatment to promote healing and prevent infection. This occurred for four of five sampled residents with pressure injuries (Residents (R) 18, 9, 2 and 7). The first example rises to a G level. The additional three examples are at a D level. 1. R18 developed a stage 3 pressure injury to the coccyx, outside of the facility, which later became infected at the facility. The facility did not implement timely interventions to promote healing of the pressure injury, and prevent further skin breakdown from occurring. The resident later developed skin breakdown and deep tissue injuries to both heels. The facility did not follow current standards of practice for repositioning, offloading, preventing and treating R18's pressure injuries and to prevent infection. 2. R2 developed two stage 2 pressure injuries to the coccyx. The facility did not follow current standards of practice for repositioning, offloading, and preventing the resident's pressure injuries from occurring. The resident's care plan was not updated to identify the resident's current open areas. 3. R9 has a stage 4 pressure injury (PI), and is at risk for developing additional pressure injuries. The facility did not offload the pressure injury to promote healing, provide a mattress rated for a stage 4 pressure injury, or float R9's heels when in bed. 4. The facility did not perform wound care in a hygienic manner for R7. The facility did not identify, prevent or promote healing for a pressure injury for R7. The facility could not identify current standards of professional practice for wound care for R7. This is evidenced by: 1. On [DATE], Surveyor reviewed R18's medical record. The resident was orginally admitted to the facility in [DATE], and has type 2 diabetes, dementia with behavioral disturbance, and hypertension. The medical record identifies the resident did not have any skin issues or skin breakdown upon admission to the facility. R18 had a standard Panacea Original Foam mattress placed on the resident's bed at the time of admission. The resident's Brief Interview for Mental Status (BIMS) score, dated [DATE], was a 04 out of 15 possible points. According to the BIMS assessment, a score of 04 indicates the resident has severe cognitive function. The resident's BIMS score remained stable throughout the resident's stay at the facility. Surveyor reviewed the resident's nurses' notes, from [DATE] to [DATE]. On [DATE], the nurses' notes identify the resident was independent with bed mobility and walked independently in/out of the resident's room. R18 was able to walk outside of the room with the supervision of staff. The resident was continent of bowel and bladder function. On [DATE], the resident was admitted to an inpatient behavioral health unit for short term care. On [DATE], the resident was readmitted to the facility. R18's nurses' notes state, Resident arrived via w/c (wheelchair) .He was transferred to a chair with assist of two (staff). Resident is noted to be weak. He is a fall risk .Makes many attempts to self transfer, using wheelchair which allows resident to self propel .Added a tab unit (alarm) to bed and chairs due to desire to unsafely self transfer . A body assessment, dated [DATE], identifies R18 had an unstageable pressure injury to the left side of the coccyx (tailbone), with slough (yellow/white tissue which adheres to the wound bed in strings or clumps), which measures 1 centimeter (cm) by 0.6 cm. The care plan, dated [DATE], indicates R18 was at risk for pressure injury development. The problem was not updated to indicate R18 had an actual pressure injury. There are no approaches on the care plan, but refers caregivers to the Resident Care Card. R18's resident care card, dated [DATE], includes approaches of presssure-reducing mattress, a roho cushion in the chair, and respositioning every one and a half hours. R18's Braden Scale for Predicting Pressure Ulcer Risk assessment score, dated [DATE], was 16. According to the Braden assessment, a score of 16 indicates the resident is at risk for developing pressure injuries (ulcers). Nurses' notes, dated [DATE], identifies the resident needed assistance with positioning, getting in/out of bed, and was becoming incontinent of bladder function. The facility requested therapy services place a gel cushion in R18's wheelchair, and also requested Physical and Occupational therapy evaluations due to the resident's decline in function. On [DATE], the resident had poor balance which resulted in a fall with a head injury. The medical record identifies the resident now required assistance with toileting. On [DATE], the Pressure Injury Documentation note states the following, in part, .Stage 3 .1.3 (cm) x 0.9 (cm) x 0 cm .Character of Wound Bed: Slough .Exudate (fluid leaking from the wound): Scant .Exudate Color: Purulent (thick, bloody drainage) .no odor .Surrounding Tissue: Intact .Notes .Area cleansed with NS (Normal Saline) and [MEDICATION NAME] skin prep applied. New 3x3 [MEDICATION NAME] border (wound dressing) placed . On this day, the medical record indicates the resident was repositioned every one-and-a-half to two hours. According to the National Pressure Ulcer Advisory Panel (NPUAP), the current standard of practice is to reposition and offload a person's pressure injury every 60 minutes. On [DATE], the Dietician ordered R18 to be given four ounces of a nutritional supplement with all meals, along with Prosource protein supplement 30 cubic centimeters, three times a day, to promote skin integrity. On [DATE], the resident's Pressure Injury Documentation note indicates R18's coccyx wound was a stage 2, and measured 1 cm by 0.4 cm by 0.1 cm deep. According to the NPUAP, once a pressure injury has been staged (i.e. a stage 3), the wound should not be down staged (Position Statement on Staging-2017 Clarifications, 2017). On [DATE] at 10:16 a.m., the resident's nurses' notes state the following, in part, Resident has a blister on right heel measuring 6.5 cm x 4.5 cm. There is a red ring around the blister that .blanches (where skin takes on a whitish appearance when blood flow to the area is prevented) at this time. There are no open areas .Blister dose (sic) not seem to have fluid in it at this time .Implemented using heel protectors while in bed to protect the residents heels . R18's Resident Care Card includes a hand written, undated approach of Puffy boots on at all times. There were no other approaches related to off-loading R18's heels. On [DATE] at 9:55 a.m., Surveyor interviewed the facility's wound nurse, Registered Nurse (RN) M. Surveyor asked if the puffy boots used when the resident was in bed were a type of heel suspension boot. RN M showed Surveyor the boots. The boots did not float or suspend the resident's heel. The notes at 8:10 p.m., state the following, in part, Blister found to left heel that is 2cm by 2cm fluid filled skin intact. Denied pain and no redness or [MEDICAL CONDITION] noted to foot/lower leg. Appears to use heels to propel self around in W/C and slippers are loose on bare feet may have caused blisters. Applied socks to feet and slippers reapplied. Spoke with wife .stated, 'I can get him some new slippers those are too big .' Note left for (Name of Nurse Practitioner (NP) Q) continue to monitor blister . On [DATE], the nurses' notes state the following, Therapy gave new directives to wear puffy boots while in bed and the royal blue walking boots on while up. They are to be worn while walking and or transfers. Remain a 2 assist for ambulating . On [DATE], the Pressure Injury Documentation note for the sacral pressure injury states, Stage 2 .1.1cm by 1cm by 0.2 cm .Character of Wound Bed: Other-50% red granulation and 50% yellow slough .Exudate: Moderate. Exudate Color: Purulent .no odor. Surrounding Tissue: Intact .Describe Progress: [MEDICATION NAME] on buttocks was dated yesterday and had moderate amount of purulent drainage on old dressing. Measurements are larger than last weeks assessment no foul odor noted and no redness or warmth surrounding. Spoke with (NP Q) and note left to request that [MEDICATION NAME] silver be applied to wound bed due to increase in size and change in drainage. (NP Q) in agreement with change to dressing and message left for wife to update. Continue to monitor . On this date, the notes also state, in part, Right heel blister drained out large amount of serous (clear) fluid. Skin is intact to blister and skin is flatter in appearance Blister measures 6cm by 7.5cm and no S/S (signs or symptoms) of infection around blister. [MEDICATION NAME] border applied note left to update (NP Q) and requested that [MEDICATION NAME] be changed qod (every other day). Left heel blister is still intact no drainage noted. Continue to use heel free walking boots when up and heel protectors when in bed. On [DATE], an alternating air mattress overlay was placed on R18's bed, and this was added to the resident's Certified Nursing Assistant (CNA) care plan. The nurse's notes indicate the following, in part, .Turning side to side by staff makes no attempt to reposition self. Too weak to ambulate tonight and staff report he had to be fed . On [DATE], Occupational Therapy requested a low profile Roho cushion (has several air cells which help relieve pressure) be placed in R18's wheelchair, for maximum pressure relief. On this date, the resident fell out of the wheelchair and hit his head. On [DATE], the Pressure Injury Documentation note states the resident's coccyx injury was a stage 2 with slough, and had moderate purulent drainage. The wound was larger and now measured 1.1 cm by 1.1 cm by 0.2 cm. According to the NPUAP staging guidelines, a wound with slough should be considered a stage 3 pressure injury. There were no changes made to R18's care to promote the healing of the pressure injury. On this date, the medical record identifies the right heel was now an open blister, which measures 8.2 cm by 7 cm. The left heel is intact and measures 2 cm by 2.5 cm. On [DATE], R18's nurses' notes state the following, in part, .Coccyx wound is black in the center. Has a new reddened area that extends at an angle downward from the coccyx wound. It is 6.5 cm in length, and 2 cm wide. Charge (nurse) updated. This new reddened area may be indicative of an infection. On [DATE], the Pressure Injury Documentation note states the following, in part, .Stage 2 .2cm by 1.5cm by 0.2cm .Character of Wound Bed: Other-75% of wound is dull red dry granulation and 25% dusky nonblanchable skin to left wound edge .No exudate .No odor .Surrounding Tissue: Intact. Describe Progress: Wound to coccyx does not appear to be improving. Open wound is similar in size to last week wound bed is red granulation 1.2cm by 1cm that is dry no exudate noted. Had bloody drainage on old [MEDICATION NAME] border that was applied yesterday but no drainage on wound bed. On left edge of wound there is a dark dusky tissue non blanchable 2cm by 0.5cm. Spoke with wife concerning wound and recommended (wound clinic) referral wife in agreement. Spoke with (NP Q) and in agreement for (wound clinic) message to .arrange appointment . On [DATE], the facility wound nurse faxed NP Q an update regarding R18's pressure injury to the coccyx. The fax states the following, in part, Assessed wound to coccyx and when comparing to notes last 2 weeks wound is not improving. Requesting order to (change) dressing to just [MEDICATION NAME] border (change) q 3 days and PRN (as needed). Also after talking with POA (Power of Attorney) requesting (wound clinic) referral. Will continue to monitor . The NP agreed to the above fax. The facility did not update the resident's physician or the NP regarding the new reddened area by the resident's coccyx wound, which was first observed on [DATE]. The facility did not notify the physician or the NP the coccyx wound had increased in size from the previous week. On [DATE], the notes identify R18 continued to be repositioned every two hours. On [DATE], the notes identify the resident was very fatigued. The current repositioning program did not follow current Standards of Practice and was not effective in promoting healing of the pressure injury. No changes were made to R18's care card. On [DATE], the resident's nurses' notes state, in part, Lt (Left) heel blister appears like a light brown callus (sic) with no surrounding redness or fluid. Previous rt (right) heel blistered area was debrided of dried, harden skin with epithelizing tissue underneath. Small reddened-purplish bruise noted .cont. (continues) to wear special footwear . On [DATE], R18 had an appointment with the wound clinic. The wound clinic notes state the following, in part, .Note .Selective debridement performed today .Associated Diagnoses: [REDACTED]. The wound clinic also completed a culture of the wound to check for an infection. Nurses' notes on this date indicate the resident continued to be repositioned every two hours. The resident was placed on comfort care after the wound clinic appointment. R18's quarterly Braden Scale for Predicting Pressure Ulcer Risk assessment score, dated [DATE], was 14. According to the Braden assessment, a score of 14 indicates the resident is at moderate risk for developing pressure injuries. The resident was already at a high risk of developing further pressure injuries, after developing areas of breakdown to the coccyx and bilateral heels. R18's quarterly Minimum Data Set (MDS), dated [DATE], indicates the resident was frequently incontinent of bladder and bowel function, no longer walked in/out of the resident's room, and required staff assistance for dressing, bathing, toileting, bed mobility and eating. The Pressure Injury Documentation notes, dated [DATE], identifies the stage 3 coccyx wound had moderate amount of dark gray drainage, and measures 1.1 cm by 1.3 cm by 0.2 cm, and has no odor. The nurses' notes, on [DATE], state, in part, .Left lateral (outer) heel non-blanchable area measures 2x2x0cm. R (Right) medial (middle) heel proximal (closer) to malleolus (ankle) measures 1.5 x 1.5 x 0 cm. R medial heel proximal to dorsal aspect (top) measures 1.0 x 1.5 x (0) cm non-blanchable red area. Minimal amount of drainage to [MEDICATION NAME] removed .Continues with air mattress overlay, puffy boots, and repositioning, continue to monitor. On [DATE], the wound culture returned indicating Moderate Proteus mirabilis .Many Staphylococcus aureus . The resident had two types of a community-acquired infection in the coccyx wound. NP Q ordered a Bactrim (an antibiotic) 200 mg/40 mg oral suspension in 5 milliliters (mL) (give 10 mL by mouth), twice a day for ten days and [MEDICATION NAME] 500 milligrams (mg), three times a day for ten days. The nurses' notes, dated [DATE], identifies R18 had a calloused area on the left heel with loosening skin around the edges of the callous. The right heel had bruising, which was suggestive of a deep tissue injury, and had a small open area. The resident's lung sounds were noted to be very diminished at this time. On [DATE], the Pressure Injury Documentation notes identify the wound to the coccyx was unstageable and measured 2.2 cm by 1.5 cm by 0.3 cm deep. The documentation on this note states, in part, Wound is larger in size than last assessment and unable to stage wound due to wound bed being covered with yellow slough . On [DATE], NP Q assessed R18 at the facility, due to the resident's significant decline in function. The NP did not document any assessments regarding the coccyx or bilateral heel wounds. On [DATE], R18 died at the facility. On [DATE] at 3:30 p.m., a Surveyor interviewed RN E. RN E stated he is not sure if R18's repositioning schedule was changed after [DATE]. When asked for the facility's standard of practice for following pressure injury prevention and treatment, RN E replied the facility's wound care nurse has their own standards. On [DATE] at 3:33 p.m., Surveyor interviewed the Director of Nursing (DON). The DON indicated she did not know much about R18, or the resident's pressure injuries. The DON indicated she did not know the resident's coccyx wound was infected. The DON stated the facility uses the current NPUAP standards of practice for pressure ulcer prevention and treatment. On [DATE] at 9:55 a.m., Surveyor interviewed the facility's wound nurse, RN M. RN M indicated R18 did not refuse to be repositioned by staff after [DATE], and RN M believes the resident was repositioned about every two hours. Surveyor asked if the puffy boots used when the resident was in bed were a type of heel suspension boot. RN M showed Surveyor the type of boot R18 used while lying in bed, and the boots which were used did not float or suspend the resident's heel. RN M did not know if the walking boot R18 used was a heel suspension type boot. During the continued interview, RN M stated he assessed R18's coccyx wound on [DATE], and updated NP Q via fax in regards to the wound not healing. RN M stated when the wound was assessed on [DATE], the wound had no odor and did not appear to be infected. 2. On [DATE], Surveyor reviewed R2's medical record. The resident has [DIAGNOSES REDACTED]. The medical record identifies R2 is dependent on staff for bed mobility, dressing, toileting, bathing and eating. The resident transfers with a full-body mechanical lift. The record indicates the resident is always incontinent of bladder and bowel function. R2's Braden Scale for Predicting Pressure Ulcer Risk assessment score, dated [DATE], was 15. According to the Braden assessment, a score of 15 indicates the resident is at risk for developing pressure injuries. The resident's BIMS (Brief Interview for Mental Status) score, dated [DATE], was a zero out of 15 possible points. According to the BIMS assessment, a score of zero indicates the resident has severe cognitive function. Surveyor reviewed R2's Skin Integrity Event, dated [DATE]. The form states, .DESCRIPTION: 2 stage 2 pressure injuries proximal to coccyx .1cm round depth 0.1cm and right of open area/coccyx is 2cm by 1cm irregular shape depth 0.1cm .Stage II-Partial thickness/loss of skin layers that presents clinically as an abrasion blister, or shallow crater .Are any of the following factors present? Immobility, Pressure Injury History .INTERVENTIONS: reposition q 2 hours to care card .Will also request OT (Occupational Therapy) eval (evaluation) for cushion to broda chair .Outcome of Interventions: Interventions Somewhat Effective .may promote healing continue to monitor . R2's CNA care plan was updated on [DATE], instructing staff to reposition the resident every two hours. The resident's CNA and comprehensive care plans do not have the resident's two, stage 2 pressure injuries identified on either care plan. On [DATE] at 7:02 a.m., Surveyor observed R2 lying on his back in bed. At 8:11 a.m., staff transferred the resident from the bed to the wheelchair in the resident's room. At 9:47 a.m., R2 was sitting in the wheelchair, sleeping. At 10:30 a.m., Surveyor interviewed Licensed Practical Nurse (LPN) V, and CNAs L and O. Surveyor asked how often R2 was repositioned by staff prior to [DATE]. LPN V, CNAs L and O replied staff would toilet the resident every two hours, but the resident was not on a repositioning schedule prior to [DATE]. At 10:45 a.m., R2 was sitting in the wheelchair, and Surveyor's continuous observation ended at this time. According to Surveyor's calculations, the resident had been sitting in the wheelchair, on the coccyx area, for two hours and 34 minutes without any offloading. On [DATE] at 4:00 p.m., Surveyor interviewed RN E. RN E indicated R2 had a pressure injury to the right buttock in [DATE] which has since healed. Surveyor asked if the facility implemented a repositioning schedule at that time, or prior to [DATE], to prevent skin breakdown. RN E replied R2 did not have a repositioning schedule prior to [DATE]. Staff checked and changed the resident's incontinence products approximately every two hours, prior to [DATE], according to RN E. On [DATE] at 3:33 p.m., Surveyor interviewed the DON, and the above observations of R2 were discussed. The DON indicated the resident should have been repositioned during the continuous observation, the morning of [DATE]. 3. R9 was admitted to the facility from his home on [DATE] with a stage 4 pressure injury on his right ischial tuberosity [DATE], with a wound clinic visit scheduled for [DATE]. R9 is a paraplegic due to a motor vehicle accident many years ago. The most recent MDS documents R9 has a BIMS of 15, meaning he is alert and oriented and able to answer questions accurately. R9 is dependent on staff for all transfers and bed mobility. R9 had lived at home and taken care of himself independently prior to the nursing home admission. Braden score on admission and since is 16, meaning R9 is at risk to develop pressure injuries. The most recent Braden on [DATE] is 14, meaning R9 is at moderate risk to develop additional pressure injuries. The care plan, Impaired Skin Integrity as admitted with stage 4 pressure ulcer on his buttock. He has [MEDICAL CONDITION] and does not have any sensation in that area. He is also always incontinent of bowel for same reason which adds to risks for further complications with pressure injuries. Goal: .pressure injury will heal without any further complications XXX[DATE] Prosource 30 cc tid with med pass, .pressure relief air mattress and high profile roho cushion in chair, wound vac per directives, reposition every two hours around the clock. Is aware of need to be repositioned and will request this also . The wound documentation documents no odor to the drainage or increased drainage ,[DATE] - [DATE], R9's vital signs were within normal limits. The nurse practitioner examined the wound on [DATE] and had no new orders. R9 was seen at the wound clinic on [DATE] when a wound culture was taken. The results were E.coli [MEDICAL CONDITION]. R9 was treated with [MEDICATION NAME] and [MEDICATION NAME]. The measurements of the pressure injury in part: [DATE] 8 cm x 5 cm x 4 cm depth [DATE] 7.5 cm x 4 x 4 cm [DATE] 7.3 cm x 2.4 cm x 4 cm [DATE] 4 cm x 2.6 cm x 4 cm [DATE] 3.5 cm x 2.5 cm x 5 cm depth The wound clinic notes in part in bold writing: [DATE] . Offloading .stay off ischium as much as possible [DATE] . Offloading .stay off ischium as much as possible . [DATE] this wound has a depth of 4.5 cm, please be sure that foam touches the bottom of the wound and is in contact with all wound surfaces .stay off of ischium as much as possible . [DATE] .Offloading .stay off ischium as much as possible . [DATE] .Offloading .stay off ischium as much as possible . [DATE] .Offloading .stay off ischium as much as possible . On [DATE] at 1:09 p.m., Surveyor observed R9 with the head of bed elevated sitting on his back. Surveyor went into the room and interviewed R9. R9 indicated he was not happy about being in the nursing home. R9 stated he was independent at home and wants to go back home as soon as possible. Surveyor asked if R9 was being repositioned frequently. R9 stated that he does not get repositioned as scheduled, so he puts his call light on to get the staff to come in and reposition him. R9 stated he has to spend so much time in bed because of the wound. R9 stated all he wants is for the pressure injury to heal so he can go home and have his life back. On [DATE] at 1:30 p.m., Surveyor observed CNA A and CNA D reposition R9. Surveyor could observe reddened areas on R9's bottom as well as many indentations from the bedding. R9 was partially turned to the right side with a pillow under his back. The stage 4 pressure injury on the right ischium was not offloaded. R9's heels were not floated. R9 remained in this position until 3:20 p.m. At 3:20 p.m., R9 was positioned to the left side, with a pillow under his right back. R9 rolled back onto the pillow. The right ischium was not offloaded. R9's heels were not floated. On [DATE] at 7:20 a.m., R9 was on his back with the head of the bed elevated 45 degrees; this observation continued until 8:35 a.m. At 8:35 a.m., R9's head of bed was elevated to 80 degrees when breakfast was served. R9 remained with pressure on the right ischium until 9:40 a.m. when R9 put his call light on. At 9:45 a.m., Surveyor went in to interview R9 to ask if he was repositioned. R9 stated that a pillow was placed on his left side. R9's head of bed was at 45 degrees. Surveyor could observe R9 was in a sitting position; the right ischium was not offloaded. At 9:50 a.m., Surveyor interviewed CNA F about R9's repositioning schedule. CNA F indicated they go in every two hours and switch the pillow from side to side. Surveyor asked if R9 refuses repositioning. CNA F stated, No, he puts his light on to remind us to reposition him. Surveyor asked CNA F if the pressure injury was offloaded with this positioning CNA F was not sure what that meant, but indicated she would go in and make sure there was no pressure on the wound. On [DATE] at 1:45 p.m., Surveyor interviewed CNA C about R9's repositioning schedule. CNA C indicated they reposition R9 every two hours. Surveyor asked if the pressure injury is offloaded. CNA C indicated she did not know, just that they go in every two hours and place a pillow under his side. CNA C indicated R9 does not refuse repositioning. On [DATE] at 1:50 p.m., Surveyor interviewed RN M, who does weekly wound care for R9. RN M indicated that R9 tells staff how he wants to be positioned, if it is right or left. Surveyor asked if the pressure injury was offloaded, with R9's head of bed elevated. RN M acknowledged that the area was not offloaded. Surveyor asked what standards of practice the facility follows for pressure injury care. RN M did not know, but indicated it would depend on the wound and which nurse was caring for the wound. On [DATE] at 3:20 p.m., Surveyor interviewed the nurse manager, RN E. Surveyor asked about signs and symptoms of infection when R9 was admitted . RN E indicated there were no signs of infection noted, that the wound clinic did a routine culture on the first visit and found the infection. RN E stated he had called the wound clinic this afternoon about the repositioning if R9 sometimes does not want to. Surveyor stated that the care plan does not address refusals, or risks of not repositioning if that was occurring. Surveyor asked what alternatives were tried if R9 had refused. Surveyor then asked for the air overlay mattress specifications. RN E indicated he did not know but thought it was good for a stage 4. On [DATE] at 10:55 a.m., RN E came to Surveyor and stated that the current air mattress was not rated for a stage 4 pressure injury, and that the company was no longer in business. RN E had contacted a representative to request another appropriate mattress for R9. On [DATE] at 9:15 a.m., Surveyor interviewed the Director of Nursing (DON). The DON acknowledged the staff need more training on offloading. The facility currently has no mattresses rated for a stage 4 pressure injury. The DON indicated the Nursing Home Administrator had ordered one today. 4. R7's [DIAGNOSES REDACTED]. Surveyor reviewed R7's clinical record. On [DATE], a nurse's note stated: Stage 2 pressure injury to sacral. Will cover with [MEDICATION NAME] and monitor husband made aware of the open area. There are no indications that additional interventions were placed at this time for treatment, pressure relief or physician notification. The next note, dated [DATE], stated Wound is smaller in size than last assessment .current dressing appropriate .continue to monitor. On [DATE], R7 requested a donut (a round cushion) cushion because she stated her tailbone hurt. LPN W noted: Resident asking for donut cushion because her tailbone hurt. Dressing was removed and o/a (open area) is deeper and wider according to the CNA (Certified Nursing Assistant) who was assisting me. Resident was positioned off her back and was agreeable .Will ask charge nurse if it is ok to get an order for [REDACTED]. The next entry, dated [DATE], indicated the facility, at the resident's request, had provided the resident with a roho (a type of inflatable cushion). The facility noted that the wound was larger. The physician was updated, and an order was obtained for Occupational Therapy (OT) to assist with adaptive equipment for pressure relief. However; the documentation also showed that resident was encouraged not to sit in w/c (wheelchair) for longer than 2 hours .for position change .according to policy . On [DATE], an order was received for a wound clinic consult. R7 refused this consult at this time. On [DATE], R7 was seen by OT S. R7 declined several suggestions from OT related to repositioning and proper seated position despite education provided. R7 did, however, agree to try a high profile roho cushion instead of the low profile one she had in her chair. Surveyor reviewed R7's care plan. The current care plan, undated, read: .repositioning schedule every 2 hours .off loading 1 hour a.m., 1 hour p.m .low profile roho cushion .pressure reducing mattress . There were no additional pressure relief measures listed on the care plan. On [DATE], R7's wound showed signs of infection. R7 agreed to be seen in the wound clinic, and an update was left for the Nurse Practioner. The wound had a purulent drainage, and appeared larger. R7 was evaluated at the wound clinic, and placed on a course of antibiotics. On [DATE], a progress note indicated that R7's wound had increased depth. The wound is documented now as a stage 3. The documentation noted: Wound continues to have increased depth despite pressure reducing interventions. Has usually been spending more time in bed has alternating air mattress and repositioned side to side as tolerated. Air mattress checked to ensure it is functioning and is operating correctly. Continue current orders and interventions per wound clinic. R7 has appointment next week. On [DATE], the wound clinic physician ordered that resident be up only for meals. This was not added to the care plan. The progress notes state intermittently that R7 is compliant only at times with this order. There were no interventions noted to provide alternative measures for pressure relief, although risks were explained to R7. There were no documents besides the intermittent progress notes to determine when and how long the resident may have been up in the chair, contrary to physician orders, or if the resident was repositioned while in the chair. The NPUAP (National Pressure Ulcer Advisory Panel) guidelines, which the facility uses as a professional reference, recommends that if sitting in a chair is necessary for individuals with pressure ulcers on the sacrum, coccyx or isheum, limit sitting to three times a day in periods of 60 minutes or less .modify seating schedules and re-evaluate seating surfaces if ulcer worsens or fails to improve establish repositioning schedules that prescribe the frequency

Based on record review and interview, the facility did not ensure that the ability to stand did not diminish for 1 of 14 sampled residents (Resident #12) reviewed. Resident #12 was on a restorative/ROM program, the facility did not provide exercises per the current plan of care, and Resident #12 is no longer able to stand and requires a mechanical lift machine for all transfers. As evidenced by: Facility policy titled, Rehabilitative Nursing Care, dated April 2007, states the following: - Nursing personnel are trained in rehabilitative nursing care. Our facility has an active program of rehabilitative nursing which is developed and coordinated through the resident's care plan. - The facility's rehabilitative nursing care program is designed to assist each resident to achieve and maintain an optimal level of self-care and independence. - Rehabilitative nursing care is performed daily for those resident who require such service. Such program includes, but is not limited to: a. Maintaining good body alignment and proper positioning; c. making every effort to keep residents active and out of bed for reasonable periods of time, except when contraindicated by physicians' orders, and encouraging residents to achieve independence in activities of daily living by teaching self-care and ambulation activities; e. Assisting residents to carry out prescribed therapy exercises between visits of the therapists; f. assisting resident with their routine range of motion exercises. Facility policy titled, Goals and Objectives, Restorative Services, dated December 2007, states the following: - Rehabilitative goals and objectives are developed for each resident and are outlined in his/her plan of care relative to therapy services. - Goals may include, but are not limited to: assisting the resident in adjusting to his/her abilities; assisting the resident in developing and strengthening his/her physiological and psychological resources; encouraging the resident to maintain his/her independence and self-esteem; encouraging the resident to participate in the development and implementation of his/her plan of care. On 10/25/16 at 12:15 p.m., Surveyor reviewed Resident #12's medical record and noted the following: - Resident #12 has a [DIAGNOSES REDACTED]. - Minimum Data Set (MDS), dated [DATE], states Resident #12 has limited range of motion to both the upper and lower extremities and requires extensive assist from facility staff for all transfer needs. MDS states Resident #12 has a mild cognitive impairment. - Certified Nursing Assistant (CNA) care plan, received 10/25/16, states Resident #12 has a restorative plan in place, which is to be assisted into a standing position with hands on the handrail both during the morning and evening shift for one to two minutes and is to have this repeated five times throughout the day. Nursing is to be notified if the resident is unable to complete the restorative exercise. - Comprehensive nursing care plan, received 10/25/16, states, (Resident #12) will wash and dress his upper body after assist of set-up and continue maintenance program goals as follows: 1) stand with assist at handrail 2 times daily (AM & PM) 1-2 minutes x 5. 2) complete arm bike (minimum resistance) for 5 minutes in AM on Monday, Wednesday and PM's Friday. On 10/25/16 at 1:15 p.m., Surveyor interviewed CNA I, CNA A, CNA F and CNA E in regard to the restorative program for Resident #12. All four CNAs interviewed stated the facility has not been doing restorative for the residents in the facility due to not having the time. CNA A stated the facility had a restorative aide who is no longer employed at the facility for about a year and a half. CNA A stated when the restorative aide left, the facility put the CNAs in charge of making sure the ROM was provided to the residents who needed it. CNA A, along with the other three CNAs, stated they are unable to do the ROM for the residents because they do not have the time. CNA E stated, We try at times .just too busy. CNA A stated Resident #12 has had a decline and no longer can stand. CNA A stated Resident #12 is now transferred with a sit-to-stand mechanical lift because Resident #12 has lost the strength in his legs and is now a fall risk. On 10/26/16 at 9:05 a.m., Surveyor interviewed Resident #12 in regard to his restorative program exercises. Resident #12 stated the facility had not been standing him for over a year and he no longer can stand. Resident #12 states this upsets him because he now feels he is confined to a wheelchair and would like to start working again on standing and getting his legs stronger. Resident #12 stated he is disappointed the facility has stopped working with him and feels the facility has given up on him in regard to helping him ambulate. On 10/26/16 at 1:15 p.m., Surveyor interviewed Occupational Therapy Assistant (OTA) T and Physical Therapy Assistant (PTA) U in regard to the facility's restorative/ROM program. OTA T stated the facility had not had a restorative program in a very long while and the CNAs are to be providing these services to the residents currently on the program. PTA U stated therapy will recommend a restorative program and write the program up on a Functional Maintenance Program (FMP). Therapy will then provide a copy of the FMP to the nurses, CNAs and to medical records. Therapy will then check back a day or two later to ensure it has been written on the plan of care and then therapy no longer follows up. PTA U stated nursing is to communicate with therapy if there is a decline in function. PTA U and OTA T stated there seems to be a communication concern between therapy and the nursing department. On 10/25/16 at 2:20 p.m., Surveyor interviewed the Nursing Home Administrator (NHA) and the Director of Nursing (DON) in regard to the facility's ROM/restorative program. The NHA stated the facility has no documentation of restorative being done for the residents who are currently on the program. The NHA stated the ROM/Restorative program is not being done and not being monitored correctly. The NHA stated the ROM/Restorative program is a concern and she has been aware of the program not being utilized for a while. The DON stated she felt the nurses on the floor should have been monitoring the program and felt they had not monitored it correctly. The DON stated they have talked to staff in the past about ensuring the residents receive their ROM/Restorative exercises and feel it is just not getting done. Surveyor discussed concerns in regard to residents having a decline in ROM function and the facility not ensuring residents residing at the facility receive the appropriate ROM/Restorative care. The NHA agreed with Surveyor stating, It is a problem. The NHA and DON stated no summaries on the resident's restorative program had been completed. Surveyor discussed concerns with the NHA in regard to Resident #12 not being provided restorative exercises and no longer has the ability to stand without the assistance of a mechanical lift. Surveyor discussed concerns with the NHA in regard to Resident #12 stating he was disappointed he could no longer use his legs and feeling like the facility had just left him behind.

Based on observation, staff interview, record review and policy review, the facility did not establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. This had the potential to affect all 98 residents residing in the facility. The facility did not implement their infection prevention and control program and did not: -Follow their policy to promptly implement the outbreak control measures when more than one resident in the facility or area in the facility developed Acute Febrile Respiratory Illness (AFRI) during a one week period. -Look for new cases and if there were similar illnesses in the community. -Utilize the surveillance to identify that an outbreak had occurred on [DATE], when three residents on the 200 unit had displayed the symptoms of an ARI outbreak that met the definition. -Implement aggressive measures to prevent the spread of the infection. -Immediately suspend all resident gatherings for dining and activities when an outbreak was suspected and during the entire course of the outbreak to limit exposure and prevent further transmission of a potentially infectious agent -Educate staff, residents and visitors with an in-service about the existence of an outbreak, their individual responsibilities, and importance of compliance with isolation. Repeat information as appropriate for residents and visitors. Reinforce the importance of hand washing and proper PPE (personal protective equipment) use for all. -Update line list daily or as needed. -Investigate any suspected influenza like infection and initiate this procedure if the influenza-like criteria were present. McGeer's definitions of Infection: Temperature >100* F (usually sudden onset), nasal congestion, sore throat, muscle aches, cough, fatigue, headache. -Stop treatment of [REDACTED]. -Continue with individual isolation measures in the recuperative phase of illness. The facility's failure to implement an infection control program to prevent the spread of an acute respiratory illness created a finding of immediate jeopardy. The immediate jeopardy began when three residents on the 200 unit developed signs/symptoms of ARI on [DATE]. The facility did not identify this as an outbreak and did not put precautions into place in a timely manner to prevent the spread of infection. The immediate jeopardy began on [DATE]. The Nursing Home Administrator (NHA) was informed of the immediate jeopardy on [DATE] at 2:30 p.m. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope/severity of F (potential for harm that is not immediate jeopardy/widespread) as the facility continues to evaluate and complete training on infection control. This is evidenced by the following: Surveyor reviewed the facility's spread sheet of the respiratory outbreak and the facility's summary of the ARI outbreak: -[DATE] Resident #24 on the 200 unit was diagnosed by chest x-ray (CXR) with pneumonia. Resident went to the hospital on [DATE]. -[DATE] Resident #25 on the 100 unit had onset symptoms of cough, congestion, CXR positive pneumonia, and abnormal lung sounds resident went to the hospital on [DATE]. The Activity attendance record identified resident attended group activities on ,[DATE], 15, 17, 18, 19, 20, 21 ./15. Resident had a well date of [DATE], then was on the outbreak log again on [DATE]. -[DATE] Resident #26 on 200 unit had onset symptoms of fever, cough, abnormal lung sounds, and congestion and on [DATE] was diagnosed by CXR with pneumonia. Resident went to the hospital on [DATE] and [DATE]. -[DATE] Resident #3 on 200 unit had onset symptoms of sore throat, cough, abnormal lung sounds, and congestion. On [DATE], the facility had met the criteria of an outbreak with three residents having symptoms of an ARI on the same unit (200 unit) within 72 hours. The facility did not identify the outbreak and did not initiate precautions to prevent further spread of the illness to other residents in the building. The facility continued with group activities, group dining, did not limit admissions, and did not isolate and close the unit. -[DATE] Resident #27 on 300 unit had onset symptoms of fever, cough, abnormal lung sounds, and congestion. -[DATE] Resident #28 on 300 unit had onset symptoms of fever, cough, and abnormal lung sounds. This resident died on [DATE]. -[DATE] Resident #29 on 100 unit had onset symptoms of fever, cough and CXR positive for pneumonia on [DATE]. Resident went to the hospital on [DATE]. Resident had a well date of [DATE] and then was on the outbreak log again on [DATE]. -[DATE] Resident #30 on the Special Care Unit (SCU) had onset symptoms of sore throat, cough, abnormal lung sounds, and congestion. -[DATE] Resident #31 on 100 unit had onset symptoms of fever, cough, and congestion. On [DATE], a total of nine residents were having symptoms of ARI: three residents on 100 unit, three residents on 200 unit, two residents on 300 unit and one on the SCU. On [DATE], the resident census was 101. On [DATE], after a review of the infection logs, the facility identified that many residents were experiencing respiratory symptoms/illness on 3 of 4 wings but not meeting the outbreak criteria. Preventative action taken: a memo sent to all department heads and nursing station and Certified Nursing Assistant (CNA) communication books. The Assistant Director of Nursing (ADON) spoke with nurses working that day with instructions to enforce the preventative interventions listed on the memo. The NHA posted a sign at the front door asking visitors to reschedule their visit if they are ill and to practice hand hygiene by washing their hands before and after their visit. Activity Director cancelled some group activities and notified her volunteers of respiratory symptoms/illness. Extra face masks and hand sanitizer were ordered in anticipation of increased use with droplet precautions. An email was sent to the medical director alerting her of the symptoms/illness. The facility did not immediately suspend all resident gatherings for dining and activities when an outbreak was suspected and during the entire course of the outbreak to limit exposure and prevent further transmission of a potentially infectious agent -[DATE] Resident #32 on 100 unit had onset symptoms of sore throat, fever, cough, abnormal lung sounds, and congestion. This resident died on [DATE]. -[DATE] Resident #33 on 100 unit had onset symptoms of fever, cough, abnormal lung sounds, and congestion and on [DATE] a CXR positive for pneumonia. Resident went to the hospital on [DATE]. On [DATE], a total of 11 residents were having symptoms of ARI: 5 residents on 100 unit, 3 residents on 200 unit, 2 residents on 300 unit, and 1 on the SCU. On [DATE], the resident census was 98. On [DATE], the ADON received a call from the infection preventionist to notify of the outbreak criteria now met. They reviewed what steps had already been taken and what steps she was taking. -[DATE] Resident #34 on 200 unit had onset symptoms of fever, cough, and abnormal lung sounds. This resident died on [DATE]. On [DATE], the ADON called Public Health and reported an outbreak. The Health Department will contact the State and let the facility know if they had any recommendations. Administrator posted an updated sign at the front door. The Health Department requested nasopharyngeal swabs be collected from the three residents with the most recent symptoms to find out if pneumonia was viral or bacterial. On [DATE], the nasopharyngeal swabs were sent to the State laboratory. The facility continued with outbreak surveillance and precautions (contact for everyone/droplet for ill residents). -[DATE] Resident #19 on the 100 unit had onset symptoms of fever, cough, and abnormal lung sounds. Resident #19 was admitted to the hospital and later died on [DATE]. On [DATE], a total of 28 residents and 5 staff were having symptoms of ARI: 12 residents on 100 unit, 9 residents on 200 unit, 5 residents on 300 unit and 2 on the SCU. -[DATE] Resident #18 on the 300 unit had onset symptoms of fever, CXR positive for pneumonia. Resident went to hospital on [DATE] and later died on [DATE]. -[DATE] Resident #20 on the 200 unit had onset symptoms of fever, abnormal lung sounds, and congestion. Resident died on [DATE]. By [DATE], a total of 37 residents and 10 staff were having symptoms of ARI: 16 residents on 100 unit, 11 residents on 200 unit, 8 residents on 300 unit and 2 on the SCU On [DATE], the resident census was 106. On [DATE], Registered Nurse (RN) N informed the Director of Nursing (DON) and the Infection Preventionist of multiple new cases and initiation of quarantine proceedings. All group activities were cancelled, all meals were served in rooms, the fire doors were kept closed to keep residents on their own wings, and new admissions were informed of the outbreak, and if they still chose to come here, were not put with ill residents. On [DATE], quarantine was lifted and all usual activities resumed. By [DATE], a total of 44 residents and 20 staff were having symptoms of ARI: 18 residents on 100 unit, 13 residents on 200 unit, 10 residents on 300 unit and 3 on the SCU. A total of 12 residents went to the hospital and 6 residents expired. On [DATE], the resident census was 100. Surveyor reviewed activity calendar for ,[DATE] - ,[DATE], which identified group activities continued. Review activity attendance record documented ill and well residents were attending group activities during the outbreak. Review of resident admission log for [DATE] - [DATE] documented a total of six new admissions to the facility. Review of facility's 2015 influenza vaccination rate for resident is 88% and for staff is 52.5%. Review of facility staff education for the ARI outbreak of Influenza Prevention Protocols for Senior Care and AL Transmission - Based Precautions did not start until ,[DATE]. The daily surveillance logs documented residents were placed on the log days after the onset date. Surveyor asked ADON why the dates were different and if the daily surveillance logs were to be documented every day to be able to track and trend when there is a possibility of an outbreak. The ADON indicated the daily surveillance logs are to be documented every day when symptoms start and they are reviewed every day and could not explain why the log dates were after the onset date. Review of the outbreak log identified CNA P had onset symptoms of fever and cough on [DATE] with a well date of [DATE] and a return to work date of [DATE]. Licensed Practical Nurse (LPN) Q had onset symptoms of sore throat and cough on [DATE] with a well date of [DATE] and a return to work date of [DATE]. Surveyor was provided with a housekeeping list of products used during an outbreak. The list did not indicate when housekeeping started using the products or if increased or enhanced cleaning and disinfecting was started. On [DATE] at 1:15 p.m., Surveyor interviewed the ADON about the August outbreak. The ADON indicated the outbreak started on [DATE]. Notified and educated all staff of droplet precautions and to keep sick people in their room, and kept standard precautions for well residents. Staff doesn't float from wing to wing. No sick people went to activities and therapy, still held group activities for well residents. Signs were up by the door to reduce visitors and masks provided and reminders to use hand gel. The signs asked visitors to check at the nurses' station before visiting. Admissions were not restricted, the resident and family were notified that the facility had a respiratory illness and were asked if they still wanted to enter. After the quarantine, everyone ate in their rooms. In room activities were provided for the sick residents. On [DATE] at 8:05 a.m., Surveyor interviewed the ADON. The ADON indicated that some residents in the SCU came out for group activities with supervision. The education in August that was provided to staff was by the memo that was posted at all nurses' stations and in the communication books and there are no audits of staff during the outbreak. The E-learning education was started in September. No documentation was provided that the medical director was contacted after [DATE]. No further documentation was provided the Health Department was updated with the information of more residents and staff is getting sick. Specific residents: 1. On [DATE], Surveyor reviewed Resident #20's medical record. The resident has [DIAGNOSES REDACTED]. The resident's Brief Interview for Mental Status (BIMS) score, dated [DATE], is a 04 out of 15 possible points, indicating the resident has severe cognitive function. The resident resided on the 200 unit in the facility. Resident #20's comprehensive care plan indicates the resident has cognitive deficits, does not like to be alone, has difficulty staying on tasks and eats in the facility's assisted dining room. Surveyor reviewed the resident's vital sign documentation, from [DATE] to [DATE]. During this time, the resident's vital signs (i.e. blood pressure, pulse, respirations, temperature) were relatively stable. The resident's body temperature ranged from 95 degrees Fahrenheit to approximately 98 degrees Fahrenheit. Resident #20's nurses' notes, from [DATE] to [DATE], were reviewed. The notes state the following, in part: -[DATE]: Res (Resident's) T: (Temperature) at (midnight) was 99.5. Given (as needed Tylenol) and recheck at 0130 (1:30 a.m.)-T: 99.6. Res given cool cloth and blanket pulled down to waist. Recheck at 0300-T: 97.5 .Occasional non-productive episodes of cough . -[DATE]: Res up in w/c (wheelchair) to meals, propels self in w/c .Res with moist non-productive cough. Res T 99.9. PRN (As needed) Tylenol given. Skin warm and dry .Staff assist with all meals .Resident has moist loose cough. LS (Lung Sounds) coarse rhonchi (rattling respiratory sounds). Resident was accepting of PRN neb (nebulizer breathing treatment). Neb was slightly effective. LS slightly improved. Voice is hoarse .Continues to slowly propel self around west wing. Resident tolerates mask (Surveyor unable to determine if referring to nebulizer mask or surgical-type mask to contain secretions when in public area) .Continue to monitor . Assessed after supper due to fever cough and congestion. C/O (Complained Of) feeling good but tired. Had slept thru meal not eating with assist. Able to propel self slowly in w/c and able to answer simple questions .has occasional weak congested cough no sputum noted. Lung sounds had rhonchi and wheezing throughout bilateral (both) .Respirations decreased from 32 to 26 (per minute) after neb . -At 8:50 p.m.: Updated (physician's name) about general condition and slight improvement with PRN Neb and Tylenol. New orders .'ZPAK (antibiotic medication) 500 mg (milligrams) .once tonight and 250 mg daily for next 4 days. Q-[MEDICATION NAME] DM (cough syrup) 1 to 2 tsp (teaspoons) q (every) 6 hours PRN' . Resident started Z-pack. Is moaning and has moist sounding cough. Has some nasal drainage. Appears tired and ill .Last temp taken 99.7 after Tylenol given. -[DATE] at 5:50 a.m.: Res given (Tylenol) PRN for elevated T: 100.5 at 0400 (4:00 a.m.). Res also had increased RR (Respiratory Rate) and was given neb at 0400. Neb somewhat effective and T: at this time is 99.6. Cool cloth changed regularly through shift res slept 6 hours . -At 8:56 a.m.: Resident repositioned in bed. Cool cloth to head and PRN Tylenol provided for increased temp. LS very diminished bases bilaterally (normal lung sounds have decreased and harder to hear), coarse rhonchi in upper lobes. Resident has moist productive cough. No noted side effect from ABX (antibiotic medication) for URI (Upper Respiratory Infection) . -At 2:07 p.m.: Resident's LS are not improving. Continues with moist productive cough and increased temp. Resident has had max (maximum) PRN nebs and Tylenol this shift. Decreased intake of fluids and foods. Resident is not following direction for stand lift and was hoyered (a mechanical lift)into recliner. Appears weaker than norm. PRN O2 (oxygen) in place to maintain saturation (greater than) 90%. Spoke with granddaughter to update and inquire about POC (Plan of Care). Grand daughter is uncertain about sending resident to hospital for eval. She stated she would speak to her uncle and call back with decision . Spoke with grand daughter, she would like resident monitored for another 24 hours and would like to be called with an update tomorrow .this point she does not want resident sent to hospital . -At 6:00 p.m.: Assess after supper .sounds congested. Lung sounds had rhonchi bilateral and continues to have congested cough no sputum noted or possibly swallowing. O2 sats (saturation level) were 89% without O2 due to removing and 92% with 2 LPM (liters of oxygen flow per minute) . -At 8:49 p.m.: Resident continues with Rhonchi and wheezed thru out, has frequent congested coughing .Does not leave oxygen on. Skin is warm and flushed. Temps have been 99.0 and 100.5 and 100.1. Tylenol given for temp X2. Resident up in chair for supper and ate 100% . -[DATE], 12:37 a.m.: .T. 100.9 -At 11:31 p.m.: Res cont (continues) with rapid (shallow) respirations given PRN neb which was slightly helpful .rubs and wheezing heard in all lobes, res cont on antibiotic for URI will offer fluids frequently .Res up in recliner using Hoyer no verbalization but did open her eyes when feeding her .Updated granddaughter on res status .she and her uncle .are comfortable with treatment resident here at (facility) . -[DATE], 11:04 a.m.: Res cont with Rhonchi in all lobes (occasional) nonproductive cough PRN nebs given with little effect lips dusky .Res will open eyes and follow cammands (sic) but does not talk to staff up using Hoyer to recliner . -At 6:26 p.m.: Continues with rhonchi in all lobes and frequent cough which is productive and resident swallows phlegm. Respirations at ,[DATE] and note use of accessory muscles to breath. O2 SAT on room air at ,[DATE]% and with O2 at 2 LPM up to 91%-92%. Resident removing O2 frequently and c/o 'can't breathe' .fever of 100.1 .Primary MD faxed with information regarding resident continued decline in condition and family's request for comfort cares. -At 7:36 p.m.: .POA (Power of Attorney/granddaughter) called back and she was very adamant about not sending resident to ER (emergency room ) .POA .was in agreance (sic) with starting comfort cares . -[DATE] at 2:59 a.m.: .At this time res is crying with her exhalations. Repositioning ineffective MS ([MEDICATION NAME]) given for s/s (signs/symptoms) of discomfort .Loose cough noted. T: 98.5. -At 4:35 a.m.: Res received neb at 0200 for labored RR. Somewhat effective .at 0300 res began crying and grimacing and appeared in distress. MS 0.5 mL given PRN. Slightly effective, res still moaning but no longer grimacing. At 0415, res moaning is continuing .writer contacted On-call MD .who ordered MS 0.5mL-1mL q2 hours PRN . -At 7:32 a.m.: This AM resident continues to have elevated RR of 28 .Upon assessment resident warm to touch and upon checking temp it was 101.8. Given oral Tylenol which medication nurse stated it took resident a long time to swallow . -At 1:20 p.m.: Resident noted to be moaning with respiration in hallway. Upon checking resident had labored breathing .Resident has had a lot of secretions . Resident #20 died at the facility on [DATE]. The medical record and nurses' notes do not identify if Resident #20 was placed on droplet and or contact precautions from the time the respiratory infection symptoms began on [DATE], or thereafter. The documentation does not identify if the resident was kept and/or encouraged to be in isolation (i.e. confined to the resident's room or 200 unit), to prevent the spread of infection to other residents in the facility. The nurse's note, dated [DATE] at 1:20 p.m., identifies Resident #20 was having respiratory secretions in the hallway. The documentation does not identify the unit hallway the resident was presently located, or if the resident was wearing a protective mask to prevent the spread of infection. On [DATE] at 9:12 a.m., Surveyor interviewed ADON A. Surveyor asked when Resident #20 was placed on isolation and when droplet/contact precautions were implemented, after the resident showed symptoms of an acute respiratory infection. ADON A and Surveyor reviewed the facility's infection surveillance log. The section titled Precautions on the surveillance log for the resident was left blank. ADON A stated there is no other documentation other than in a nurse's note which would indicate if and when Resident #20 was placed in isolation or on precautions. ADON A stated she believes Resident #20 ate in the resident's room during meals, after [DATE]. ADON A did not have any documentation to show when the resident no longer ate in the assisted dining room with other residents. At 9:43 a.m., Surveyor interviewed Registered Nurse (RN) N. RN N indicated Resident #20 was not to be left alone in the resident's room, and spent the majority of the time sitting out by the nurses' station for supervision throughout the day. RN N further stated a mask was provided to the resident while out at the nurses' station; however, the resident removed the mask frequently. 2. Resident #3 had signs and symptoms on [DATE]. Per record review on [DATE] by Surveyor , on [DATE], Resident #3 had a complaint of a sore throat. The nurses' notes, dated [DATE] at 12:59 p.m., stated, LS (Lung Sounds) clear except to lower lobes, noted rub on LLL (Left lower lobe), and diminished in RLL (Right Lower Lobe). Res. with a dry harsh cough noted times one, res able to cough up thick light green mucus. On [DATE], per the activity attendance record, Resident #3 attended bible study and exercise class. 3. Resident #13 went to hosptial for pneumonia Per record review by Surveyor on [DATE], Resident #13 complained of generalized weakness and fatigue. The nurse's note, dated [DATE] at 11:38 a.m., stated, States she notices some increased SOB(Shortness of Breath) . Crackles in lungs throughout. Called RN (Registered Nurse) line in regards to finding. MD on call will address and call back. On [DATE] at 1:54 p.m., nurse's note stated, Received telephone call from (MD name) requesting res. to be seen at Urgent Care to be evaluated and treated. On [DATE] at 5:47 p.m., nurse's note stated, Call received from daughter that (Resident #13's name) was admitted to ARMC(Amery Regional Medical Center) due to fluid around heart and lungs. On [DATE] at 2:07 p.m., nurse's note stated, Res readmitted from Amery Hospital. 4. Per record review by Surveyor on [DATE], Resident #19 complained of a cough on [DATE]. The nurse's note, dated [DATE] at 11:43 a.m., stated, Resident up in w/c per usual. Skin pale and dry, said feels OK, did c/o of bothersome cough .Lungs have crackles and inspiratory wheeze RT (Right) upper lobe. Looser, chronic cough. Denies any sore throat or difficulties swallowing. On [DATE] at 2:23 p.m., nurse's note states, Resident had vague complaints of not feeling well this morning. Noted that she has a dry non productive cough. Lungs have rhonchi/rales at bases. Given Tylenol for temp of 99. Re check on temp was 98.4. Encourage increased fluids. On [DATE] at 3:30 p.m., nurse's note stated, Assessed due to frequent non productive cough. Noted wheezing to upper lobes bilateral and crackle to right lower lobe. Denied having SOB or difficulty breathing. C/O feeling tired and denied sore throat. Continue to monitor. On [DATE] at 12:55 a.m., nurse's note stated, VSS, clo cough and not feeling well. Wheezes noted, sats 99% on 2L/NC. On [DATE] at 9:43 a.m., Resident with chills and shaking, had visible, old looking blood in her stool, large amount of loose stool, pale and visible wheezy and SOB even when talks. Resident is requesting to be sent to hospital. Call placed to (physician's name), given order to send to ER to evaluate. Ambulance here and resident transferred now. On [DATE] at 1:13 p.m., nurse's note states, Call place to Amery Hospital, resident is admitted . On [DATE] at 12:13 p.m., nurse's note stated, Call received from grandson to inform us that (Resident #19's name) passed away. The facility transfer form, dated [DATE], documented the admitting [DIAGNOSES REDACTED]. 5. On [DATE] at 8:20 a.m., Surveyor reviewed the medical record for Resident #17 and noted Resident #17 to have been placed on the facility's infection control log in [DATE] for a respiratory outbreak. Resident #17 was placed on isolation precautions. Facility infection control log states Resident #17 was removed from isolation precautions on [DATE] when the facility declared the outbreak to be cleared within the facility. On [DATE] at 8:20 a.m., Surveyor reviewed the nurses' notes for Resident #17 from [DATE] - [DATE] and noted the following nursing entries: - [DATE]: Temperature of 100.1. Tylenol effective. - [DATE]: Complains of occasional cough with yellow sputum. - [DATE]: Continues to have low grade fever of 99.2. Faint crackles in the bases of lungs noted. - [DATE]: Resident finished antibiotics on [DATE] - feels tired and sleepy and reports rare, non productive cough. Lungs clear. - [DATE]: Temperature of 99.1 - Tylenol given. No loose stools. - [DATE]: Weak and tired and requested immodium for loose stools. Temperature 99.5. Will fax physician with temperatures. - [DATE]: Complains of rare cough and lungs sounds are moist with crackles. - [DATE]: 3:59 a.m.: Temperature of 100.1. Tylenol given for complaints of left rib pain. - [DATE]: 2:05 p.m.: Temperature of 99.2 - Tylenol given. Resident noted to have large emesis of undigested food after breakfast and complains of left rib cage pain which is constant and dull and is worse with deep breaths. [DATE]: 9:30 a.m.: Resident has temp of 101.1 and Tylenol given. Resident feels nauseated. Has ongoing left rib cage pain which is worse when laying in bed, lung sounds diminished on left side. Resident feels tired. Call placed to RN line and message left for physician. - [DATE]: Physician called and appointment scheduled today at 3:20 p.m. - [DATE]: Resident returned from physician appointment and was diagnosed by chest x-ray of left sided pneumonia. Resident complained of rib pain and not eating well. Resident was gagging tying to get medication down. Will continue to monitor. Resident to use incentive spirometer. - [DATE]: Continues on ATB and has occasional dry cough, feels tired and has diminished lung sounds with faint wheezing noted. - [DATE]: Resident continues on ATB for pneumonia and is able to ambulate in hallway with assist and continues to participate in therapy. Lungs have moist crackles at left bases. - [DATE]: Continues on ATB - has shortness of breath with exertion, lung sounds with scattered rhonchi, states she is very tired and wants to nap after lunch. Low grade temperature of 99.7. - [DATE]: Temperature of 100.2. Tylenol given. - [DATE]: Fax sent to physician in regard to low grade fever and fatigue. Physician ordered resident to continue on ATB for 4 more days and only check temperature if symptomatic. - [DATE]: Temperature of 99.5. - [DATE]: Temperature of 99.8. - [DATE]: Resident reports occasional productive cough which is yellow. Lung sounds clear. Temperature 100.9. - [DATE]: Resident finished ATB this evening. Temperature 99.4. - [DATE]: Resident has temperature of 101.1. Given Tylenol and requested blanket be removed and only sheet to cover her in bed. On [DATE] at 2:15 p.m., Surveyor observed Resident #17 in her room sleeping in bed. Surveyor noted no isolation bin or masks present and did not note any signs indicating Resident #17 was under isolation precautions. On [DATE] at 7:50 a.m., Surveyor observed Resident #17's room and noted Resident #17 to be absent. Surveyor noted no isolation bin or masks present and did not note any signs indicating Resident #17 was under isolation precautions. On [DATE] at 2:20 p.m., Surveyor interviewed RN R in regard to isolation precautions. RN R stated Resident #17 was isolated during the above noted outbreak but hasn't been isolated since the facility lifted the restrictions as noted above (on [DATE]). On [DATE] at 7:50 a.m., Surveyor interviewed LPN S in regard to Resident #17 being on isolation. LPN S stated Resident #17 is not on any isolation precautions and hasn't been since the outbreak noted above. On [DATE] at 1:00 p.m., Surveyor interviewed both Physical Therapist (PT) T and Occupational Therapist (OT) U in regard to Resident #17 needing isolation precautions. Both PT T and OT U stated Resident #17 comes to the therapy room for therapy and does not wear a mask and nursing staff have not notified them if isolation precautions should be implemented. On [DATE] at 7:35 a.m., Surveyor and interviewed the DON in regard to Resident #17 having signs and symptoms of respiratory illness after [DATE], which is the date the facility lifted all isolation restrictions on residents within the facility after the respiratory outbreak. Surveyor asked the DON why isolation precautions were not implemented due to resident still exhibiting signs and symptoms of respiratory illness after [DATE] and allowed to move freely throughout the facility. The DON stated she did not know and would have to get back to this surveyor. No further information was provided. 5. Resident #15's medical record states the following on [DATE]. Resident c/o (complained of) not feeling well at 1150 (11:50 a.m.) She reported that she felt a little lightheaded and dizzy, warm and sweaty, and can't see so sell. She is afebrile, grasps were equal. BP (blood pressure) was elevated to ,[DATE]; recheck BP ,[DATE]. BS (blood sugar) was 264. Respirations were 32 - 34 (normal rate is 12 - 20 breaths per minute). O2 (oxygen) was applied at that time. Writer encouraged her to eat her lunch. Writer reassessed resident after lunch. She reported that O2 was effective and felt a little better after eating. Productive loose cough was noted. Lung sounds assessed, rhonchi heard in upper lobes but cleared after coughing. Right upper lobe slightly diminished. PRN (as needed) neb treatment was given at 1300 (1:00 p.m.) Resident states feeling better after treatment. Resident is sleeping in her bed at this time, respirations 28 at rest. Will continue to observe .MD (medical doctor) faxed with update regarding elevated BS and request for any new orders. This fax did not inform the physician that Resident #15 was having respiratory symptoms. Note that the facility was currently having an outbreak of respiratory illness. On [DATE], the nurse's note states that Resident #15 had a temp of 99.1 and was given Tylenol. She does have an occasional cough and clear nasal drainage. A therapy note states that Resident #15 was brought to the therapy gym for exercises. This note does not address Resident #15's respiratory symptoms, nor that droplet precautions were followed. The nurse's note on [DATE] states init

Based on interview and record review, the facility did not ensure the physician was consulted regarding a significant change in condition for 1 of 7 residents (Resident #1) reviewed for physician notification. As evidenced by: On 05/06/15 at approximately 10:00 a.m., Surveyor reviewed the medical record for Resident #1 and noted the following: - Resident #1 was admitted to facility on 03/04/15, was his own person and was a full code. Resident #1 had a [DIAGNOSES REDACTED]. - Minimum Data Set (MDS), dated [DATE], indicated Resident #1 was alert and oriented and was able to make his own decisions, was very hard of hearing and required the use of bilateral hearing aids. MDS also indicated Resident #1's weight to be 161 pounds. - MDS, dated [DATE], indicated Resident #1's weight to be 140 pounds. - Comprehensive nursing care plan, received 05/06/15, titled, "Altered Nutrition r/t (related to) has been having a sore throat with difficulty with swallow and a poor appetite. Is a high risk for aspiration. Has chronic malnutrition. Risk for Dehydration r/t co morbidities and medications. Has resolving dehydration since admit (admission). GOAL: (Resident #1) will maintain his wt. (weight) at 165# (-) or (+) 5 lbs. (pounds) and not have any increased complications with aspiration. APPROACH: Approach start date: 03/16/15. DIET: Low Na (sodium), NDD2 (National dysphasia diet Level 2), Mechanically soft diet with ground meats, pureed fruits and vegetables and nectar thick liquids. S/T (Speech Therapy) per MD (Medical Doctor) order..Daily wts. Observe for s/s (signs and symptoms) of dehydration. I&O's (intakes and outputs) daily. (see Hydration Assessment) Discipline: Dietician, Nursing, Nursing Assistant, Speech Therapy." Surveyor was unable to identify any other interventions within Resident #1's care plans for hydration and nutritional needs. The care plan did not indicate Resident #1's weakness and dizziness and did not indicate any special communicational needs. - Certified Nursing Assistant (CNA) care plan, received 05/06/15, states Resident #1 was to have nectar thickened liquids, may have regular water at all times except at meals or when eating and when eating, the staff are to use thick liquids with foods. The care plan states Resident #1 can have soft food for snacks and was independent with meals. The CNA care plan did not state Resident #1 was on a dysphasia diet. Surveyor was unable to identify any other interventions on the CNA care plan that would assist in the nutritional and hydration needs of Resident #1. The CNA care plan did not indicate Resident #1 had weakness and dizziness and did not indicate any special communicational needs. On 05/06/15 at 9:20 a.m., Surveyor reviewed the nursing notes for Resident #1, dated 01/01/15 - 04/02/15, and noted the following nursing entries. - 03/04/15: Resident #1 was admitted to the facility. - 03/06/15: "Received fax from MD. Agrees with diet change and to discontinue the vitamin D and [MEDICATION NAME]." - 03/06/15: "Spoke with (primary physician) r/t intakes stated, "I've spoke with son and I want to change his fluids slightly to increase oral intakes. May have regular water at all times except during meals. Continue thickened fluids and foods at meals. Keep upright while drinking water. Start 1 cup of Kemp's BID (twice daily)." - 03/07/15: Dietary Nutritional Assessment: "Resident #1 was at high risk for aspiration and was receiving a low sodium, altered mechanical soft diet with ground meats, pureed fruits and vegetables and nectar thickened liquids. Resident #1 may have regular water between meals in upright position. Receiving 240 cc thickened Kemp's twice a day. Eats lunch and supper in the assisted dining room. Intakes have improved since admission to facility. Current nutritional approaches are appropriate, supplement is appropriate. Will continue to monitor. See nutritional Assessment." - 03/09/15: Speech Therapy note: "Phone call with son r/t benefits of thickened liquids and risks of aspiration." - 03/10/15: Speech Therapy note: Resident #1 stated he had a poor appetite - has had this prior to admission. - 03/11/15: Physical Therapy Note: Resident #1 reports having dizziness with transfers from wheelchair to bed. Occupational Therapy notified. - 03/11/15: Nursing stated Resident #1 had complained of dizziness with Physical Therapy. Encouraged Resident #1 to take it slow when changing positions. - 03/17/15: Physical Therapy Note: Resident #1 reports fatigue and continues to report dizziness at times. - 03/18/15: Physical Therapy Note: Resident #1 continues with lack of motivation and prefers to rest much of the day. Assist of 1 with all mobility with ongoing encouragement to participate at maximum potential. - 03/23/15: Dietary Nutritional Assessment: "Seen due to weight decline since admission to facility. Current weight 144 - was 169 on admission. Intakes are poor at meals, eating 25% or less of meals - needs assist with meals. Is being seen by ST (Speech Therapy). Is given 240 cc thickened Kemp's supplement BID. Supplement provides 960 Kcal per day and 40 grams protein. Will add 4 oz (ounces) thickened supplement with all meals, this will provide an additional 600 Kcal per day and 21 grams of protein. Will continue to monitor." - 03/23/15: Social Services Note: "Alert and oriented - able to make needs known." - 03/29/15: Weights faxed to primary physician to review. Continues with slow, steady weight loss. - 03/30/15: Aide reports that the resident experienced an episode of acute weakness and dizziness while ambulating to bathroom. Skin turgor is good and mucous membranes are moist. Will continue to monitor. - 03/30/15: Resident continues to experience increased weakness and dizziness. Refused breakfast. Contacted Amery hospital RN and noted drastic weight loss since admission and significant acute change in health status (weakness is affecting the resident's ability to ambulate and he has been in bed throughout shift). Son updated on condition. - 03/30/15: Resident is resting in bed. Complains of dizziness with position changes. Sluggish skin turgor to arms bilateral and chest. Pulse 98. Spoke with physician related to earlier fax sent earlier during day shift and condition. Physician stated he was attempting to call son to discuss comfort cares stating he will need to talk with the son and will attempt to contact him tonight. - 03/31/15: Resident's weight continues to be 142 pounds and continues with poor intakes. Faxed an update to primary physician related to resident's average intake for the past 7 days and possibly getting an order for [REDACTED]. - 03/31/15: Resident remains in bed on shift - appears weak and tired. Skin gray and poor skin turgor. Taking water but held Kemp's as he coughed up large amounts of phlegm. - 04/01/15: Resident continues to complain of feeling weak and lightheaded. Poor to no intakes for breakfast. Current medications and recent notes from therapy and nursing sent for primary physician review. - 04/01/15: Received a call from primary physician's office stating that Resident #1 had an appointment to be seen by the physician today. - 04/01/15: Spoke with primary physician and Resident #1 will be admitted to the hospital. - 04/02/15: Resident #1's son called and requested no bed hold and he would be coming to pick up the resident's belongings. Surveyor was unable to identify weekly summary notes for Resident #1 during this time frame. On 05/06/15 at approximately 12:15 p.m., Surveyor reviewed the weights for Resident #1 from 03/04/15 - 04/01/15 and noted the following entries: - 03/04/15: Admission weight: 169 - 03/09/15: Weight 164 - 03/11/15: Weight 161 - 03/13/15: Weight 157 (this weight was highlighted in RED.) - 03/15/15: Weight 153 (this weight was highlighted in RED.) - 03/18/15: Weight 147 (this weight was highlighted in RED.) - 03/20/15: Weight 144 (this weight was highlighted in RED.) - 03/21/15: Weight 139 (this weight was highlighted in RED.) - 03/26/15: Weight 141 - 04/01/15: Weight 140 On 05/06/15 at approximately 12:30 p.m., Surveyor reviewed the fluid intakes and meal intakes for Resident #1 and noted the following: FLUID INTAKES: - 03/05/15: Daily fluid intake: 1440 cc - 03/10/15: Daily fluid intake: 1500 cc - 03/14/15: Daily fluid intake: 1400 cc - 03/16/15: Daily fluid intake: 600 cc - 03/21/15: Daily fluid intake: 900 cc - 03/22/15: Daily fluid intake: 690 cc. - 03/24/15: Daily fluid intake: 540 cc. - 03/25/15: Daily fluid intake: 690 cc - 03/29/15: Daily fluid intake: 600 cc. - 04/01/15: Daily fluid intake: 420 cc MEAL INTAKES: - Surveyor observed out of 110 meals/snacks offered there were 19 times in which staff did not document meal intake. On 05/06/15 at 3:05 p.m., Surveyor requested all hydration assessments for Resident #1 from 03/04/15 - 04/01/15. Surveyor received the following hydration assessments from Medical Records (MR) G. MR G stated there was only one hydration assessment completed for Resident #1 during this time frame. - 03/04/15: Hydration assessment completed upon admission. Assessment stated Resident #1 exhibited and complained of diarrhea, weakness and required dependence on staff for eating and drinking. Assessment indicated Resident #1 was at risk for dehydration due to medications, decreased fluid intake and swallowing evaluation and indicated that nursing was consulting with the dietician. Comments included: "Potential risk due to above factors. Is receiving nectar thick liquids. Being seen by ST. Taking adequate fluids. Averaged 1505 cc in past 2 days. Has no physical s/s of dehydration. Was admitted to hospital with dx (diagnosis) of dehydration, now resolved, prior to being admitted to this facility...Fluid needs are 2250 cc per day...Average daily fluid intake with meals: 480 cc." On 05/06/15 10:30 a.m., Surveyor reviewed the physician progress notes [REDACTED]. - 03/04/15: Discharge Summary: diagnosed with [REDACTED]. Patient was stable to discharge to the nursing home for temporary strengthening and for nutrition. - 03/09/15: Resident #1 was seen post hospital follow up. Resident #1 is "very fussy with what he wants to eat and drink and was not taking much and requested free water not thickened. Did discuss with his son and have in the past with him aspiration risks, which I not sure they fully understand but did allow the water. He is much happier with that. He still has a sore throat which was quite significant in the hospital but is swallowing a little bit better. He does like the [MEDICATION NAME] in between though is better as well. He still coughs with drinking the water, not so much the others..He has been able to be up and walking. He states overall things are going quite well here and he is liking it pretty well....IMPRESSION/PLAN: 1. Severe dehydration. Had resolved with IV fluids. Will continue with the water, not thickened, though discussed again with him the risks of the same." - 04/01/15: "Patient (Resident #1) is an almost always [AGE] year old gentleman who was admitted from the nursing home. He initially was placed in the nursing home just under a month ago for failure to thrive and generalized weakness. Unfortunately, it had just come to my attention that his admission weight had been 169, and he had slowly been losing probably up until the last week and then more dramatically. Over the last couple of days his weight has been 142...the patient himself complains of nausea, dry heaves and has pain all over today. He does state he still is urinating some, still has some loose stools. He has been significantly dizzy the last couple of days per the nursing report, and some change in vision...IMPRESSION: Dehydration, more chronic but it was a little bit acute. The patient will be placed on observation for hydration, pending long-term care discussions. 2. Underlying dysphagia..5. Anorexia..will continue IV medication for the same. 6. General frailty." - 04/03/15: Resident #1 had a surgical procedure completed for the placement of a PEG tube to assist with tube feeding. Resident #1 was discharged to different local nursing home for skilled nursing needs. On 05/07/15 at 10:00 a.m., Surveyor requested all physician notifications for Resident #1 addressing severe weightloss, dizziness and signs and symptoms of dehydration. Surveyor was provided the following physician notifications: - 03/05/15: Facility fax sent to primary physician stating, "Resident is unable to swallow [MEDICATION NAME] and vitamin D. These can't be crushed. Can you D/C (discontinue) these?" Reply from physician stated, "Please D/C both for now." - 03/30/15: Facility fax sent to primary physician stating, "Please review daily wts. (weights). Do you want to continue + (and) check wt. daily?" Reply from physician states, "May change to weekly but I should probably been notified before 25# loss in 1 month...is he on any diuretic? Is he on dietary supplements?" No other MD notifications provided. On 05/06/15 at 1:10 p.m., Surveyor interviewed both CNA D and CNA E in regard to Resident #1. Both CNA D and CNA E stated they were very familiar with Resident #1 and assisted with cares for him while at the facility. CNA E stated Resident #1 sat alone at a table in the assisted dining room, which is a dining room in which residents who require assistance with meals are placed. CNA E stated Resident #1 sat alone because he had difficulties in eating and didn't want other residents to watch him. CNA E stated Resident #1 was a poor eater and was on thickened liquids during meals but could have thin water in his room. Both CNA D and CNA E stated Resident #1 had significant weight loss while at the facility and notified the nursing staff of the weight changes. CNA E stated the average fluid intake for Resident #1 during each shift was approximately anywhere from 120 cc - 180 cc. CNA E stated he enjoyed his mug of thin water in his room and always drank the mug completely within a 24 hour time frame. CNA E stated the mug in his room with thin water consisted of 660 cc. Resident #1 only had one mug per day. CNA E stated she would offer snacks to Resident #1 but he ate very little. CNA E stated, "Would eat a little bit of a banana from time to time." CNA E stated the Dietician reviewed all residents' weights on her own and the staff did not need to update her if there was a change in the weights. On 05/06/15 at 1:00 p.m., Surveyor interviewed Licensed Practical Nurse (LPN) C. LPN C stated she was not very familiar with Resident #1 and his cares while at the facility. LPN C stated CNAs would obtain the resident's weights and then either enter them into the computerized medical record or give the weights to the nurse to do so. LPN C stated if a weight flags in red the floor nurse is then suppose to update the Charge Registered Nurse so an assessment can be completed and the physician can be updated. LPN C stated it is the responsibility of the Charge RN to update the physician with a change in condition. On 05/06/15 at 1:40 p.m., Surveyor interviewed Charge Registered Nurse (CRN) F in regard to the above information for Resident #1. CRN F stated she was the nurse who had admitted the resident into the facility on [DATE]. CRN F stated Resident #4 was a daily weight. CRN F stated the CNAs would obtain the weight and either enter the weight into the computerized system or give the weights to the floor nurse so that he/she could enter them into the computerized system. CRN F stated the nurses review the weights for the resident at least weekly while completing their weekly summaries, which are then documented in the nursing notes. CRN F stated if a weight flags in red it indicates a loss or gain of five pounds or more. CRN F stated normally if the weights are flagged in red the physician would be notified but felt that in the case with Resident #1 she did not feel the physician needed to be notified due to weight loss not being a new sign and symptom for him. CRN F stated he had been gradually losing weight since his admission and weight loss was not considered a significant change in condition which warranted the physician to be updated. CRN F stated she did not feel the Dietician needed to be updated either. CRN F stated the nursing staff normally fax updates to the physician depending on how acute the patient is. CRN F stated all faxed updates and requests are then put into the hard chart. CRN F stated, "He was pale, skin dry and not well hydrated. He (Resident #1) was gradually declining..not eating well...didn't know until lightheadedness that he was dehydrated...we then updated the physician." CRN F stated the Dietician was responsible for reviewing the resident's weights on her own and nursing did not update her. On 05/06/15 at 1:20 p.m., Surveyor interviewed the Registered Dietician (RD) B in regard to the above noted information. RD B stated she was familiar with Resident #1 and that he had been admitted with malnutrition, dehydration which had been going on a while prior to his admission. Surveyor asked RD B how often a dietary assessment was completed on the residents within the facility and RD B stated, "Upon admission, quarterly and with significant changes in condition." RD B stated she reviews all residents' weights at the end of each month and felt if there were concerns with the residents' weights then the nursing staff should be updating her. RD B stated she did not know when Resident #1 had started declining. RD B stated, "The weights have to be in the computer in order for me to monitor them...sometimes people who are daily weights are not being entered daily." Surveyor reviewed Resident #1's care plan with RD B and asked her what interventions were put into place to prevent weight loss and dehydration. RD B stated, "I would have assessed (Resident #1) had I known he was losing weight...we can't force someone to eat...we tried everything...he came in with severe malnutrition, had nutritional interventions in place and Speech Therapy was also seeing him." Surveyor asked RD B when the physician was notified of his severe weight loss and signs and symptoms of dehydration and RD B stated, "The physician was first notified on 03/29/15...the physician should have been notified a lot sooner in regard to his weights." Surveyor asked RD B if IV fluids or tube feeding were recommended to assist with Resident #1's nutritional and hydration needs and RD B stated, "I do not know if IV fluids were recommended...I cannot recommend IV fluids because it is outside the scope of my practice to do so...I can't even fax or call the physician...can only recommend to the nurse to contact the physician...did not make any recommendations to the nursing department." Surveyor asked RD B if she had attempted a root cause and analysis to determine why the resident had a severe weight loss and was showing signs and symptoms of dehydration. RD B stated she did not do a root cause and analysis and "just went off the [DIAGNOSES REDACTED]." RD B stated, "We offered him everything...he didn't want any of it. It's not like we didn't get him to try to eat." RD B stated all interventions tried were not put on the resident's plan of care. On 05/07/15 at 1:45 p.m., Surveyor interviewed the NHA, Assistant Director of Nursing (ADON) A and RD B in regard to the above information. Surveyor addressed concerns in regard to Resident #1 having severe weight loss and signs and symptoms of dehydration and the physician not being notified. Surveyor also addressed concerns that the resident's care plan did not reflect interventions for dehydration and weight loss. ADON A stated if a weight is flagged red the staff are to report the red flag to the charge RN who then will investigate and consult with RD B. ADON A stated the facility follows AMDA (American Medical Directors Association) guidelines for physician notification and stated that if a resident has a weight loss of 5% or more within 30 days, 10% or more within 6 months or has a new onset of anorexia with or without weight loss, it was considered routine and the physician would then review the weights on the next physician visit or unless you fax the physician with the update. ADON A stated the physicians prefer faxes for routine information. ADON A stated if the situation was urgent then it was the expectation for the nurses to pick up the phone and verbally consult with the physician. RD B stated the nursing staff at times contacts her by leaving her a voicemail message when they do weekly summaries if there is a change in a resident's weight. RD B stated the nursing staff did not leave her a voicemail in regard to Resident #1's weight loss. RD B stated when the weights are flagged in red an alert is sent out to department heads to notify them of the alert. RD B stated, "We run a report every AM (morning) on all weights that are flagged red." Surveyor asked RD B who all received that report each morning and the NHA stated, "Myself, the Director of Nursing, the Dietician and possibly other department heads." RD B stated, "We are all aware of weights that have been red flagged." Surveyor asked if anyone had responded to the weights for Resident #1 which had flagged red and RD B stated, "If there isn't anything documented within the progress notes (nurses' notes) then it wasn't done." The NHA stated, "The daily report isn't a perfect system...we are not looking at the report very good." RD B agreed with the NHA in regard to the system not being good and stated, "We are going to be reviewing all weights daily from now on." ADON A stated, "It's hard...some of the information is computerized and some is on paper...it's hard to find some things and catch things...some things get missed." Surveyor asked if hydration assessments should have been completed on Resident #1 and RD B stated, "We don't have to do a hydration assessment...nurses should run a daily report on intakes for the day, give it to the nurse on the next shift to push fluids...nurses don't necessarily document in the computer...it all depends." 3. On 05/07/15 at 9:45 a.m., Surveyor reviewed the medical record for Resident #5 and noted the following: - MDS, dated [DATE], indicated Resident #5's admission weight was 173 pounds. - MDS, dated [DATE], indicated Resident #5's weight was 201 pounds. This is a 16.18% weight increase since admission. - Resident #5 had a [DIAGNOSES REDACTED]. - Comprehensive nursing care plan, dated 02/26/15, titled, "Altered nutrition," and, "Risk for Dehydration," states Resident #5 will maintain his weight at 177 pounds (-) or (+) 5 pounds. The care plan indicated targeted goal for Residents #5's weight had been changed to 200 pounds in April, 2015. No exact date in April was given. The care plan also states, "APPROACH: Diet: (Cardiac) Diet, mechanical soft her his request, observe for any increased problems with swallowing, ST (speech therapy) per MD order, weekly weights. Provide, offer and encourage extra fluids between meals. Observe for s/s of dehydration. I&O's daily. Surveyor was unable to identify any new interventions implemented between 02/26/15 - 04/28/15 which is where Resident #5 had significant weight gain on the care plan. On 05/07/15 at 9:50 a.m., Surveyor reviewed the weights for Resident #5 and noted the following: - 02/14/15: Weight 175 (admission weight) - 03/24/15: Weight 184 (this weight was highlighted in RED.) - 03/31/15: Weight 187 (this weight was highlighted in RED.) - 04/07/15: Weight 189 (this weight was highlighted in RED.) - 04/21/15: Weight 203 (this weight was highlighted in RED.) - 04/28/15: Weight 201 (this weight was highlighted in RED.) Resident #5 had a significant weight gain of 14.86% in just over two months. Resident #5's weights had been flagged indicating a significant gain and the interdisciplinary team did not monitor and implement new interventions to prevent the gain. The physician was not notified or consulted regarding the weight gain. 3. Resident #6 is a [AGE] year old, full code resident with [DIAGNOSES REDACTED]. Resident was admitted in September 2014 with a "normal weight" of 164 pounds. Surveyor reviewed the medical record for Resident #6. The notes are as follows: 12/18/14 Seen by M.D. ted hose PRN OK for resident to refuse when swelling is down. 12/19/14 Weight of 158 pounds (this weight is flagged in red) 12/20/15 Quarterly nutrition note: regular diet, no chewing or swallowing difficulties. Eats 25-100% of breakfast, 25-50% of lunch and 100% of supper. Weight stable 158 pounds. Current nutritional approaches appropriate. In January, there are nurses' notes that indicate the resident frequently has an emesis after eating or taking pills. This is believed to be due to eating too fast. 01/17/15 Nurses' notes state weight is 159 "within care plan goal" 01/21/15 Weight 168 pounds (this weight flagged in red, this is a 9 pound weight gain in 5 days) 01/22/15 Emesis after noon meal (question eating too fast) serve food in separate bowls, one at a time 01/23/15 Nutrition note - food items in separate bowls appears to eat too fast 01/27/15 Nutrition note - seen due to increase in last month current weight 168 pounds was 158 pounds one month ago, had been sick in December. Intakes good no nutritional concerns. There was no physician contact regarding weight gain and no indication that [MEDICAL CONDITION] was looked at as a factor for the weight gain. 02/04/15 Weight 170 pounds (this weight flagged red) 02/10/15 The physician saw the resident and noted 1+ [MEDICAL CONDITION], no changes were made 02/11/15 Weight 177 pounds (this is an additional seven pounds in one week and was flagged red) 02/14/15 Weekly nursing summary: weight range 170-177 pounds, plan to reweigh no signs of [MEDICAL CONDITION] plan of care appropriate (the reweigh was completed on 2/18/15, weight 177 pounds) 02/18/15 Nurse's note: middle chest hurts arms hurt near wrist bilaterally given lime soda - effective 02/26/15 Nutrition note - seen due to weight gain in last month current weight 176 pounds was 168 one month ago. Intakes improved. No nutritional concerns. *This is an 18 pound weight gain in five weeks; this is 10% weight gain. The first physician notification regarding the resident's weight gain was on 03/14/15. The weekly summary states, "Noted weight was significantly higher than goal weight. Intakes consistant and good last 3 months but gaining weight each month. Lung sounds clear. Bilateral [MEDICAL CONDITION] 2+ below the knee and feet bilateral. Fax sent to Dr. to update and faxed weights for last few months inquiring if want to adjust meds." The physician ordered knee high teds and low sodium diet. The "Nutritional Assessment" provided to surveyor is dated 03/26/15. The assessment documents: current diet order, where the resident eats, current weight and height, body mass index, calorie and fluid needs, food served in separate bowls and that the resident has no food complaints. The assessments do not identify [MEDICAL CONDITION] as a potential cause of the weight gain. The care plan start date 09/25/14 identifies a problem area "Risk for altered nutrition r/t her current goal is to continue to keep her weight stable which is and a strength for her versus a problem. Risk for dehydration r/t co morbidities and medications." The goal states, "Will maintain wt. at 164#'s." This is highlighted and changed to 158#'s. Approaches include "Diet regular, weekly wts., provide, offer and encourage extra fluids between meals, I&O daily and observe for dehydration." On 01/23/15, the approach of "Food in separate dishes to give 1 at a time to prevent eating too fast" was added. Surveyor and discussed Resident #6's weight gain with NHA, ADON A and RD B on 05/07/15 at 1:45 p.m. RD B stated that Resident #6 dropped weight in December due to illness then came back up in January. Resident #6 then started to gain weight in February. The only physician contact regarding weights was on 02/10/15 with rounds. The system for RD notification of weights was discussed (see notes below). Interview: On 05/07/15 at 1:45 p.m., Surveyor and Surveyor interviewed the NHA, ADON A and RD B in regard to alerting of weight loss. RD B stated when the weights are flagged in red an alert is sent out to department heads to notify them of the alert. RD B stated, "We run a report every AM (morning) on all weights that are flagged red." Surveyor asked RD B who all received that report each morning and the NHA stated, "Myself, the Director of Nursing, the Dietician and possibly other department heads." RD B stated, "We are all aware of weights that have been red flagged." Surveyor asked if anyone had responded to the weights for residents which had flagged red and RD B stated, "If there isn't anything documented within the progress notes (nurses' notes) then it wasn't done." The NHA stated, "The daily report isn't a perfect system...we are not looking at the report very good." RD B agreed with the NHA in regard to the system not being good and stated, "We are going to be reviewing all weights daily from now on." ADON A stated, "It's hard...some of the information is computerized and some is on paper...it's hard to find some things and catch things...some things get missed."

Based on record review and interview, the facility did not ensure nutritional care and services to residents who were identified with weight loss or gain for 5 of 7 residents reviewed (Resident #1, #4, #5, #6 and #7) for nutrition and weight loss and gain. 1. Resident #1 had a severe weight loss and the facility did not implement appropriate interventions to meet the resident's nutritional needs, did not update the resident's plan of care, and did not notify registered dietitian and the physician appropriately. Resident #1 lost 29 lbs (17% of his weight) in less than a month. This example is being cited at severity level 3, actual harm. The following examples do not reach the actual harm level. 2. Resident #4 had a significant weight loss and the facility did not implement appropriate interventions to meet the resident's nutritional needs and did not monitor weight loss. 3. Resident #5 had a significant weight gain and the facility did not implement appropriate interventions to meet the resident's nutritional needs and did not monitor weight gain. 4. Resident #7 lost a total of eight pounds (7% of her body weight) in six weeks. During this time there were no physician updates or dietary interventions to try to prevent the weight loss. 5. Resident #6 experienced a 10% weight gain in five weeks. During this time there was no physician notification of the rapid weight gain. [MEDICAL CONDITION] increased and interventions to prevent [MEDICAL CONDITION] and weight gain were not timely. As evidenced by: 1. On 05/06/15, Surveyor reviewed the medical record for Resident #1 and noted the following: - Resident #1 was admitted to facility on 03/04/15, was his own person and was a full code. Resident #1 had a [DIAGNOSES REDACTED]. - 03/04/15: Admission weight: 169 - 03/04/15: MD progress note - Hospital Discharge Summary: diagnosed with [REDACTED]. Patient was stable to discharge to the nursing home for temporary strengthening and for nutrition. -03/07/15: A dietary nutritional assessment on notes in part: Eats lunch and supper in the assisted dining room. Intakes have improved since admission to facility. Current nutritional approaches are appropriate, supplement is appropriate. Will continue to monitor. - 03/09/15: Weight 164 -03/10/15: A speech therapy note indicates that Resident #1 stated he had a poor appetite - has had this prior to admission. - 03/11/15: Weight 161 - 03/13/15: Weight 157 - 03/15/15: Weight 153 (this weight was highlighted in RED.) - 03/17/15: Physical Therapy Note: Resident #1 reports fatigue and continues to report dizziness at times. - 03/18/15: Weight 147 (this weight was highlighted in RED.) - 03/18/15: Physical Therapy Note: Resident #1 continues with lack of motivation and prefers to rest much of the day. Assist of 1 with all mobility with ongoing encouragement to participate at maximum potential. - 03/20/15: Weight 144 (this weight was highlighted in RED.) - 03/21/15: Weight 139 (this weight was highlighted in RED.) -03/23/15: A dietary nutritional assessment notes: Dietary Nutritional Assessment: "Seen due to weight decline since admission to facility. Current weight 144 - was 169 on admission. Intakes are poor at meals, eating 25% or less of meals - needs assist with meals. Is being seen by ST (Speech Therapy). Is given 240 cc thickened Kemp's supplement BID. Supplement provides 960 Kcal per day and 40 grams protein. Will add 4 oz (ounces) thickened supplement with all meals, this will provide an additional 600 Kcal per day and 21 grams of protein. Will continue to monitor." - 03/26/15: Weight 141 - 03/29/15: Weights faxed to primary physician to review. Continues with slow, steady weight loss. - 03/30/15: Aide reports that the resident experienced an episode of acute weakness and dizziness while ambulating to bathroom. Skin turgor is good and mucous membranes are moist. Will continue to monitor. - 03/30/15: Resident continues to experience increased weakness and dizziness. Refused breakfast. Contacted Amery hospital RN and noted drastic weight loss since admission and significant acute change in health status (weakness is affecting the residents ability to ambulate and he has been in bed throughout shift). Son updated on condition. - 03/30/15: Resident is resting in bed. Complains of dizziness with position changes. Sluggish skin turgor to arms bilateral and chest. Pulse 98. Spoke with physician related to earlier fax sent earlier during day shift and condition. Physician stated he was attempting to call son to discuss comfort cares stating he will need to talk with the son and will attempt to contact him tonight. - 03/30/15: Facility fax sent to primary physician stating, "Please review daily wts. (weights). Do you want to continue + (and) check wt. daily?" Reply from physician states, "May change to weekly but I should probably been notified before 25# loss in 1 month...is he on any diuretic? Is he on dietary supplements?" - 03/31/15: Resident's weight continues to be 142 pounds and continues with poor intakes. Faxed an update to primary physician related to residents average intake for the past 7 days and possibly getting an order for [REDACTED]. - 03/31/15: Resident remains in bed on shift - appears weak and tired. Skin gray and poor skin turgor. Taking water but held Kemp's as he coughed up large amounts of phlegm. - 04/01/15: Weight 140 - 04/01/15: Resident continues to complain of feeling weak and lightheaded. Poor to no intakes for breakfast. Current medications and recent notes from therapy and nursing sent for primary physician review. - 04/01/15: Received a call from primary physician's office stating that Resident #1 had an appointment to be seen by the physician today. - 04/01/15: Spoke with primary physician and Resident #1 will be admitted to the hospital. - 04/01/15 MD progress note: "Patient (Resident #1) is an almost always [AGE] year old gentleman who was admitted from the nursing home. He initially was placed in the nursing home just under a month ago for failure to thrive and generalized weakness. Unfortunately, it had just come to my attention that his admission weight had been 169, and he had slowly been losing probably up until the last week and then more dramatically. Over the last couple of days his weight has been 142...the patient himself complains of nausea, dry heaves and has pain all over today. He does state he still is urinating some, still has some loose stools. He has been significantly dizzy the last couple of days per the nursing report, and some change in vision...IMPRESSION: Dehydration, more chronic but it was a little bit acute. The patient will be placed on observation for hydration, pending long-term care discussions. 2. Underlying dysphagia..5. Anorexia..will continue IV medication for the same. 6. General frailty." - 04/03/15 MD progress note: Resident #1 had a surgical procedure completed for the placement of a PEG tube to assist with tube feeding. Resident #1 was discharged to different local nursing home for skilled nursing needs. - Surveyor observed out of 110 meals/snacks offered there were 19 times in which staff did not document meal intake. - Comprehensive nursing care plan titled, "Altered Nutrition r/t (related to) has been having a sore throat with difficulty with swallow and a poor appetite. Is a high risk for aspiration. Has chronic malnutrition. Risk for Dehydration r/t co morbidities and medications. Has resolving dehydration since admit (admission). GOAL: (Resident #1) will maintain his wt. (weight) at 165# (-) or (+) 5 lbs. (pounds) and not have any increased complications with aspiration. APPROACH: Approach start date: 03/16/15. DIET: Low Na (sodium), NDD2 (National dysphasia diet Level 2), Mechanically soft diet with ground meats, pureed fruits and vegetables and nectar thick liquids. S/T (Speech Therapy) per MD (Medical Doctor) order...Daily wts. Observe for s/s (signs and symptoms) of dehydration. I&O's (intakes and outputs) daily. (See Hydration Assessment) Discipline: Dietician, Nursing, Nursing Assistant, Speech Therapy." Surveyor was unable to identify any other interventions within Resident #1's care plans for hydration and nutritional needs. The care plan did not indicate Resident #1's weakness and dizziness and did not indicate any special communicational needs. - Certified Nursing Assistant (CNA) care plan, received 05/06/15, states Resident #1 was to have nectar thickened liquids, may have regular water at all times except at meals or when eating, and when eating the staff are to use thick liquids with foods. The care plan states Resident #1 can have soft food for snacks and was independent with meals. The CNA care plan did not state Resident #1 was on a dysphasia diet. Surveyor was unable to identify any other interventions on the CNA care plan that would assist in the nutritional and hydration needs of Resident #1. The CNA Care plan did not indicate Resident #1 had weakness and dizziness and did not indicate any special communicational needs. On 05/06/15 at 1:10 p.m., Surveyor interviewed both CNA D and CNA E in regard to Resident #1. Both CNA D and CNA E stated they were very familiar with Resident #1 and assisted with cares for him while at the facility. CNA E stated Resident #1 sat alone at a table in the assisted dining room, which is a dining room in which residents who require assistance with meals are placed. CNA E stated Resident #1 sat alone because he had difficulties in eating and didn't want other residents to watch him. CNA E stated Resident #1 was a poor eater and was on thickened liquids during meals but could have thin water in his room. Both CNA D and CNA E stated Resident #1 had significant weight loss while at the facility and notified the nursing staff of the weight changes. CNA E stated she would offer snacks to Resident #1 but he ate very little. CNA E stated, "Would eat a little bit of a banana from time to time." CNA E stated the Dietician reviewed all residents' weights on her own and the staff did not need to update her if there was a change in the weights. On 05/06/15 at 1:00 p.m., Surveyor interviewed Licensed Practical Nurse (LPN) C. LPN C stated she was not very familiar with Resident #1 and his cares while at the facility. LPN C stated CNAs would obtain the residents' weights and then either enter them into the computerized medical record or give the weights to the nurse to do so. LPN C stated if a weight flags in red the floor nurse is then supposed to update the Charge Registered Nurse so an assessment can be completed and the physician can be updated. LPN C stated it is the responsibility of the Charge RN to update the physician with a change in condition. On 05/06/15 at 1:40 p.m., Surveyor interviewed Charge Registered Nurse (CRN) F in regard to the above information for Resident #1. CRN F stated she was the nurse who had admitted the resident into the facility on [DATE]. CRN F stated Resident #4 was a daily weight. CRN F stated the CNAs would obtain the weight and either enter the weight into the computerized system or give the weights to the floor nurse so that he/she could enter them into the computerized system. CRN F stated the nurses review the weights for the resident at least weekly while completing their weekly summaries, which are then documented in the nursing notes. CRN F stated if a weight flags in red it indicates a loss or gain of five pounds or more. CRN F stated normally if the weights are flagged in red the physician would be notified but felt that in the case with Resident #1 she did not feel the physician needed to be notified due to weight loss not being a new sign and symptom for him. CRN F stated he had been gradually losing weight since his admission and weight loss was not considered a significant change in condition which warranted the physician to be updated. CRN F stated she did not feel the Dietician needed to be updated either. CRN F stated the nursing staff normally fax updates to the physician depending on how acute the patient is. CRN F stated all faxed updates and requests are then put into the hard chart. CRN F stated, "He was pale, skin dry and not well hydrated. He (Resident #1) was gradually declining...not eating well...didn't know until lightheadedness that he was dehydrated...we then updated the physician." CRN F stated the Dietician was responsible for reviewing the residents' weights on her own and nursing did not update her. On 05/06/15 at 1:20 p.m., Surveyor interviewed Registered Dietician (RD) B in regard to the above noted information. RD B stated she was familiar with Resident #1 and that he had been admitted with malnutrition, dehydration which had been going on a while prior to his admission. Surveyor asked RD B how often a dietary assessment was completed on the residents within the facility and RD B stated, "Upon admission, quarterly and with significant changes in condition." RD B stated she reviews all residents' weights at the end of each month and felt if there were concerns with the residents' weights then the nursing staff should be updating her. RD B stated she did not know when Resident #1 had started declining. RD B stated, "The weights have to be in the computer in order for me to monitor them...sometimes people who are daily weights are not being entered daily." Surveyor reviewed Resident #1's care plan with RD B and asked her what interventions were put into place to prevent weight loss and dehydration. RD B stated, "I would have assessed (Resident #1) had I known he was losing weight...we can't force someone to eat...we tried everything...he came in with severe malnutrition, had nutritional interventions in place and Speech Therapy was also seeing him." Surveyor asked RD B when the physician was notified of his severe weight loss and signs and symptoms of dehydration and RD B stated, "The physician was first notified on 03/29/15...the physician should have been notified a lot sooner in regard to his weights." Surveyor asked RD B if IV fluids or tube feeding were recommended to assist with Resident #1's nutritional and hydration needs and RD B stated, "I do not know if IV fluids were recommended...I cannot recommend IV fluids because it is outside the scope of my practice to do so...I can't even fax or call the physician...can only recommend to the nurse to contact the physician...did not make any recommendations to the nursing department." Surveyor asked RD B if she had attempted a root cause and analysis to determine why the resident had a severe weight loss and was showing signs and symptoms of dehydration. RD B stated she did not do a root cause and analysis and "just went off the [DIAGNOSES REDACTED]." RD B stated, "We offered him everything...he didn't want any of it. It's not like we didn't get him to try to eat." RD B stated all interventions tried were not put on the resident's plan of care. On 05/07/15 at 1:45 p.m., Surveyor interviewed the NHA, Assistant Director of Nursing (ADON) A and RD B in regard to the above information. Surveyor addressed concerns in regard to Resident #1 having severe weight loss and signs and symptoms of dehydration and the physician not being notified. Surveyor also addressed concerns that the resident's care plan did not reflect interventions for dehydration and weight loss. ADON A stated if a weight is flagged red the staff are to report the red flag to the charge RN who then will investigate and consult with RD B. ADON A stated that the facility follows AMDA (American Medical Directors Association) guidelines for physician notification and stated that if a resident has a weight loss of 5% or more within 30 days, 10% or more within 6 months or has a new onset of anorexia with or without weight loss, it was considered routine and the physician would then review the weights on the next physician visit or unless you fax the physician with the update. ADON A stated the physicians prefer faxes for routine information. ADON A stated if the situation was urgent then it was the expectation for the nurses to pick up the phone and verbally consult with the physician. RD B stated the nursing staff at times contacts her by leaving her a voicemail message when they do weekly summaries if there is a change in a resident's weight. RD B stated the nursing staff did not leave her a voicemail in regard to Resident #1's weight loss. 2. On 05/07/15 at approximately 9:00 a.m., Surveyor reviewed the medical record for Resident #4 and noted the following: - MDS, dated [DATE], indicated Resident #4 had a weight loss of 5% or more without a physician prescribed weight loss regimen. - MDS, dated [DATE], indicated Resident #4 had a weight loss of 5% or more without a physician prescribed weight loss regimen. - Resident #4 had a [DIAGNOSES REDACTED]. - Comprehensive nursing care plan, received 05/07/15, stated Resident #4 was at risk for altered nutrition and dehydration due to increased muscle movements and missing teeth and resistive dental hygiene. Resident is to have honey thickened liquids. Care plan indicated the resident was to maintain a goal weight of 100 pounds as of 03/24/14 but was changed to a goal weight of 88 pounds in December 2014. - Nutritional care plan, dated 03/24/14, stated, "APPROACH: Diet: Pureed with honey thick liquids. To be fed by staff. May have NON-pureed treats for pleasure. May have ensure or suppliments TID (three times a day) prn (as needed) --- observe for chocking per MD (medical doctor). Keep in upright position when fed. Supplements with meals. Monitor for mouth discomfort or difficulty swallowing." Surveyor was unable to identify any new interventions implemented between 03/24/14 - December 2014 which is where Resident #4 had significant weight loss on the care plan. On 05/07/15 at 9:30 a.m., Surveyor reviewed the weights for Resident #4 and noted the following: - 07/09/14: Weight: 96 (this weight was highlighted in RED.) - 10/08/14: Weight: 90 (this weight was highlighted in RED.) - 11/26/14: Weight: 88 (this weight was highlighted in RED.) Resident #4's weights had been flagged indicating a significant loss and the interdisciplinary team did not monitor and implement new interventions to prevent the loss. 3. On 05/07/15 at 9:45 a.m., Surveyor reviewed the medical record for Resident #5 and noted the following: - MDS, dated [DATE], indicated Resident #5's admission weight was 173 pounds. - MDS, dated [DATE], indicated Resident #5's weight was 201 pounds. This is a 16.18% weight increase since admission. - Resident #5 had a [DIAGNOSES REDACTED]. - Comprehensive nursing care plan, dated 02/26/15, titled, "Altered nutrition," and, "Risk for Dehydration," states Resident #5 will maintain his weight at 177 pounds (-) or (+) 5 pounds. The care plan indicated targeted goal for Residents #5's weight had been changed to 200 pounds in April 2015. No exact date in April was given. The care plan also states, "APPROACH: Diet: (Cardiac) Diet, mechanical soft her his request, observe for any increased problems with swallowing, ST (speech therapy) per MD order, weekly weights. Provide, offer and encourage extra fluids between meals. Observe for s/s of dehydration. I&O's daily." Surveyor was unable to identify any new interventions implemented between 02/26/15 - 04/28/15 which is where Resident #5 had significant weight gain on the care plan. On 05/07/15 at 9:50 a.m., Surveyor reviewed the weights for Resident #5 and noted the following: - 02/14/15: Weight 175 (admission weight) - 03/24/15: Weight 184 (this weight was highlighted in RED.) - 03/31/15: Weight 187 (this weight was highlighted in RED.) - 04/07/15: Weight 189 (this weight was highlighted in RED.) - 04/21/15: Weight 203 (this weight was highlighted in RED.) - 04/28/15: Weight 201 (this weight was highlighted in RED.) Resident #5 had a significant weight gain of 14.86% in just over two months. Resident #5's weights had been flagged indicating a significant gain and the interdisciplinary team did not monitor and implement new interventions to prevent the gain. They did not identify the cause of the weight gain (e.g., fluid retention). 4. Resident #7 has [DIAGNOSES REDACTED]. A review of Resident #7's medical record identifies that on 11/05/14, Resident #7 was on a regular diet, was able to feed herself, at 75-100% of breakfast, 50-100% of lunch and 75% of supper. Weight was stable at 113 pounds. On 11/23/14, the nurse's note identifies trouble swallowing. Resident #7 was chewing and then spitting out her food. She was given pureed food which she swallowed without difficulty. A fax was sent to the physician noting the trouble swallowing and requesting a speech therapy order. The speech therapy order was received on 11/26/14. Speech Therapy notes include: 11/27/14 recommend mechanical soft diet 12/01/14 requires cues to alternate bites with sips 12/02/14 needs cues to alternate bites and sips The notes continue to state that Resident #7 is able to follow cues to alternate bites and sips. No problems swallowing. Resident #7 was discharged from speech therapy on 12/11/14. 12/14/14 Resident #7 weight was 107 pounds (down six pounds in five weeks). 12/23/15 A nutritional note states, "Seen due to weight decline in last month. Current weight is 105#, was 111# 1 month ago. Seen by ST and diet downgraded to mechanical soft with ground meat. Intakes are fair. Does ambulate throughout hallways. Will continue to monitor for need of increased nutritional interventions. Current nutrition approaches appropriate." Quarterly "Nutritional Assessments" were completed on 11/05/14, 02/03/15 and 05/06/15. The assessments document: current diet order, where the resident eats, current weight and height, body mass index, calorie and fluid needs and that the resident has no food complaints. The assessments do not identify reasons for weight loss, interventions added to prevent weight loss or if the resident is meeting the calorie or fluid needs. The care plan first dated 08/11/14 identifies a problem of "risk for altered nutrition r/t needs encouragement at times to consume her meals and fluids." Added on 11/27/14 was "mechanically altered diet." The goal on 11/12/14 was "maintain weight stable at 113#'s." This goal was changed on 02/15/15 to read "103#." The approaches on the care plan are: "Diet: regular, weekly weights, provide, offer and encourage extra fluids between meals, I&O daily, observe for s/s of dehydration." Added on 11/27/14 was "per ST, mechanical soft diet with ground meats." No additional care plan interventions were added to maintain weight. Surveyors and discussed Resident #7's weight loss with NHA, ADON A and RD B on 05/07/15 at 1:45 p.m. RD B stated that the resident's ideal body weight is 90 #s. RD B stated the resident is more active than she was at home and walks approximately 20 laps a day at the facility. RD B stated the physician is updated on weights when he is at the facility on rounds. Physician's progress notes were received for 10/28/14, 12/26/14, 02/24/15 and 04/15/15. There is no mention of the resident's weight loss in the progress notes. The system for RD notification of weights was discussed (see notes below). 5. Resident #6 is a [AGE] year old, full code resident with [DIAGNOSES REDACTED]. Resident was admitted in September 2014 with a "normal weight" of 164 pounds. Surveyor reviewed the medical record for Resident #6. The notes are as follows: 12/18/14 Seen by M.D. ted hose PRN OK for resident to refuse when swelling is down. 12/19/14 Weight of 158 pounds (this weight is flagged in red) 12/20/15 Quarterly nutrition note: regular diet, no chewing or swallowing difficulties. Eats 25-100% of breakfast, 25-50% of lunch and 100% of supper. Weight stable 158 pounds. Current nutritional approaches appropriate. In January there are nurses' notes that indicate the resident frequently has an emesis after eating or taking pills. This is believed to be due to eating too fast. 01/17/15 Nurses' notes states weight is 159 "within care plan goal" 01/21/15 Weight 168 pounds (this weight flagged in red, this is a nine pound weight gain in five days) 01/22/15 Emesis after noon meal (question eating too fast) serve food in separate bowls, one at a time 01/23/15 Nutrition note - food items in separate bowls appears to eat too fast 01/27/15 Nutrition note - seen due to increase in last month current weight 168 pounds was 158 pounds one month ago, had been sick in December. Intakes good no nutritional concerns. There was no physician contact regarding weight gain and no indication that [MEDICAL CONDITION] was looked at as a factor for the weight gain. 02/04/15 Weight 170 pounds (this weight flagged red) 02/10/15 The physician saw the resident and noted 1+ [MEDICAL CONDITION], no changes were made 02/11/15 Weight 177 pounds (this is an additional seven pounds in one week and was flagged red) 02/14/15 Weekly nursing summary: weight range 170-177 pounds, plan to reweigh no signs of [MEDICAL CONDITION] plan of care appropriate (the reweigh was completed on 02/18/15, weight 177 pounds) 02/18/15 Nurse's note: middle chest hurts arms hurt near wrist bilaterally given lime soda - effective 02/26/15 Nutrition note - seen due to weight gain in last month current weight 176 pounds was 168 one month ago. Intakes improved. No nutritional concerns. *This is an 18 pound weight gain in five weeks; this is 10% weight gain. The first physician notification regarding the resident's weight gain was on 03/14/15. The weekly summary states, "Noted weight was significantly higher than goal weight. Intakes consistant and good last 3 months but gaining weight each month. Lung sounds clear. Bilateral [MEDICAL CONDITION] 2+ below the knee and feet bilateral. Fax sent to Dr. to update and faxed weights for last few months inquiring if want to adjust meds." The physician ordered knee high teds and low sodium diet. The "Nutritionanl Assessment" provided to surveyor is dated 03/26/15. The assessment documents: current diet order, where the resident eats, current weight and height, body mass index, calorie and fluid needs, food served in separate bowls and that the resident has no food complaints. The assessments do not identify [MEDICAL CONDITION] as a potential cause of the weight gain. The care plan start date 09/25/14 identifies a problem area "Risk for altered nutrition r/t her current goal is to continue to keep her weight stable which is and a strength for her versus a problem. Risk for dehydration r/t co morbidities and medications." The goal states, "Will maintain wt. at 164#'s." This is highlighted and changed to 158#'s. Approaches include "Diet regular, weekly wts., provide, offer and encourage extra fluids between meals, I&O daily and observe for dehydration." On 01/23/15, the approach of "food in separate dishes to give 1 at a time to prevent eating too fast" was added. Surveyor and discussed Resident #6's weight gain with NHA, ADON A and RD B on 5/7/15 at 1:45 p.m. RD B stated that Resident #6 dropped weight in December due to illness then came back up in January. Resident #6 then started to gain weight in February. The only physician contact regarding weights was on 02/10/15 with rounds. The system for RD notification of weights was discussed (see notes below). Interview: On 05/07/15 at 1:45 p.m., Surveyor and Surveyor interviewed the NHA, ADON A and RD B in regard to alerting of weight loss. RD B stated when the weights are flagged in red an alert is sent out to department heads to notify them of the alert. RD B stated, "We run a report every AM (morning) on all weights that are flagged red." Surveyor asked RD B who all received that report each morning and the NHA stated, "Myself, the Director of Nursing, the Dietician and possibly other department heads." RD B stated, "We are all aware of weights that have been red flagged." Surveyor asked if anyone had responded to the weights for residents which had flagged red and RD B stated, "If there isn't anything documented within the progress notes (nurses' notes) then it wasn't done." The NHA stated, "The daily report isn't a perfect system...we are not looking at the report very good." RD B agreed with the NHA in regard to the system not being good and stated, "We are going to be reviewing all weights daily from now on." ADON A stated, "It's hard...some of the information is computerized and some is on paper...it's hard to find some things and catch things...some things get missed."

Based on interviews and record review, the facility did not ensure that 1 of 7 residents (Resident #1) reviewed for hydration was provided with sufficient fluids to meet assessed needs. Resident #1 had signs and symptoms of dehydration, along with severe weight loss, and the facility did not implement interventions to provide appropriate fluid needs for the residents. As evidenced by: Facility policy titled, "Resident Hydration and Prevention of Dehydration," states, "6..Nursing will assess for signs and symptoms of dehydration during daily care...8. If potential inadequate intake and/or signs and symptoms of dehydration are observed, Physician will be notified...13. Nursing will monitor and document fluid intake and the Dietitian will be kept informed of status. Interdisciplinary Team will update care plan and document resident response to interventions until team agrees that fluid intake and relating factors are resolved." On 05/06/15 at approximately 10:00 a.m., Surveyor reviewed the medical record for Resident #1 and noted the following: - Resident #1 was admitted to facility on 03/04/15, was his own person and was a full code. Resident #1 had a [DIAGNOSES REDACTED]. - Minimum Data Set (MDS), dated [DATE], indicated Resident #1 was alert and oriented and was able to make his own decisions, was very hard of hearing and required the use of bilateral hearing aids. MDS also indicated Resident #1's weight to be 161 pounds. - MDS, dated [DATE], indicated Resident #1's weight to be 140 pounds. - Comprehensive nursing care plan, received 05/06/15, titled, "Altered Nutrition r/t (related to) has been having a sore throat with difficulty with swallow and a poor appetite. Is a high risk for aspiration. Has chronic malnutrition. Risk for Dehydration r/t co morbidities and medications. Has resolving dehydration since admit (admission). GOAL: (Resident #1) will maintain his wt. (weight) at 165# (-) or (+) 5 lbs. (pounds) and not have any increased complications with aspiration. APPROACH: Approach start date: 03/16/15. DIET: Low Na (sodium), NDD2 (National dysphasia diet Level 2), Mechanically soft diet with ground meats, pureed fruits and vegetables and nectar thick liquids. S/T (Speech Therapy) per MD (Medical Doctor) order..Daily wts. Observe for s/s (signs and symptoms) of dehydration. I&O's (intakes and outputs) daily. (see Hydration Assessment) Discipline: Dietician, Nursing, Nursing Assistant, Speech Therapy." Surveyor was unable to identify any other interventions within Resident #1's care plans for hydration and nutritional needs. The care plan did not indicate Resident #1's weakness and dizziness and did not indicate any special communicational needs. - Certified Nursing Assistant (CNA) care plan, received 05/06/15, states Resident #1 was to have nectar thickened liquids, may have regular water at all times except at meals or when eating and when eating the staff are to use thick liquids with foods. The care plan states Resident #1 can have soft food for snacks and was independent with meals. The CNA care plan did not state Resident #1 was on a dysphasia diet. Surveyor was unable to identify any other interventions on the CNA care plan that would assist in the nutritional and hydration needs of Resident #1. The CNA care plan did not indicate Resident #1 had weakness and dizziness and did not indicate any special communicational needs. On 05/06/15 at 9:20 a.m., Surveyor reviewed the nursing notes for Resident #1 dated 01/01/15 - 04/02/15 and noted the following nursing entries. - 03/04/15: Resident #1 was admitted to the facility. - 03/07/15: Dietary Nutritional Assessment: "Resident #1 was at high risk for aspiration and was receiving a low sodium, altered mechanical soft diet with ground meats, pureed fruits and vegetables and nectar thickened liquids. Resident #1 may have regular water between meals in upright position. Receiving 240 cc thickened Kemp's twice a day. Eats lunch and supper in the assisted dining room. Intakes have improved since admission to facility. Current nutritional approaches are appropriate, supplement is appropriate. Will continue to monitor. See nutritional Assessment." - 03/06/15: "Received fax from MD. Agrees with diet change and to discontinue the vitamin D and [MEDICATION NAME]." - 03/06/15: "Spoke with (primary physician) r/t intakes stated, "I've spoke with son and I want to change his fluids slightly to increase oral intakes. May have regular water at all times except during meals. Continue thickened fluids and foods at meals. Keep upright while drinking water. Start 1 cup of Kemp's BID (twice daily)." - 03/09/15: Speech Therapy note: "Phone call with son r/t benefits of thickened liquids and risks of aspiration." - 03/10/15: Speech Therapy note: Resident #1 stated he had a poor appetite - has had this prior to admission. - 03/11/15: Physical Therapy Note: Resident #1 reports having dizziness with transfers from wheelchair to bed. Occupational Therapy notified. - 03/11/15: Nursing stated Resident #1 had complained of dizziness with Physical Therapy. Encouraged Resident #1 to take it slow when changing positions. - 03/17/15: Physical Therapy Note: Resident #1 reports fatigue and continues to report dizziness at times. - 03/18/15: Physical Therapy Note: Resident #1 continues with lack of motivation and prefers to rest much of the day. Assist of 1 with all mobility with ongoing encouragement to participate at maximum potential. - 03/23/15: Dietary Nutritional Assessment: "Seen due to weight decline since admission to facility. Current weight 144 - was 169 on admission. Intakes are poor at meals, eating 25% or less of meals - needs assist with meals. Is being seen by ST (Speech Therapy). Is given 240 cc thickened Kemp's supplement BID. Supplement provides 960 Kcal per day and 40 grams protein. Will add 4 oz (ounces) thickened supplement with all meals, this will provide an additional 600 Kcal per day and 21 grams of protein. Will continue to monitor." - 03/23/15: Social Services Note: "Alert and oriented - able to make needs known." - 03/29/15: Weights faxed to primary physician to review. Continues with slow, steady weight loss. - 03/30/15: Aide reports that the resident experienced an episode of acute weakness and dizziness while ambulating to bathroom. Skin turgor is good and mucous membranes are moist. Will continue to monitor. - 03/30/15: Resident continues to experience increased weakness and dizziness. Refused breakfast. Contacted Amery hospital RN and noted drastic weight loss since admission and significant acute change in health status (weakness is affecting the residents ability to ambulate and he has been in bed throughout shift). Son updated on condition. - 03/30/15: Resident is resting in bed. Complains of dizziness with position changes. Sluggish skin turgor to arms bilateral and chest. Pulse 98. Spoke with physician related to earlier fax sent earlier during day shift and condition. Physician stated he was attempting to call son to discuss comfort cares stating he will need to talk with the son and will attempt to contact him tonight. - 03/31/15: Residents weight continues to be 142 pounds and continues with poor intakes. Faxed an update to primary physician related to resident's average intake for the past 7 days and possibly getting an order for [REDACTED]. - 03/31/15: Resident remains in bed on shift - appears weak and tired. Skin gray and poor skin turgor. Taking water but held Kemp's as he coughed up large amounts of phlegm. - 04/01/15: Resident continues to complain of feeling weak and lightheaded. Poor to no intakes for breakfast. Current medications and recent notes from therapy and nursing sent for primary physician review. - 04/01/15: Received a call from primary physician's office stating that Resident #1 had an appointment to be seen by the physician today. - 04/01/15: Spoke with primary physician and Resident #1 will be admitted to the hospital. - 04/02/15: Resident #1's son called and requested no bed hold and he would be coming to pick up the resident's belongings. Surveyor was unable to identify weekly summary notes for Resident #1 during this time frame. On 05/06/15 at approximately 12:30 p.m., Surveyor reviewed the fluid intakes and meal intakes for Resident #1 and noted the following: FLUID INTAKES: - 03/05/15: Daily fluid intake: 1440 cc - 03/10/15: Daily fluid intake: 1500 cc - 03/14/15: Daily fluid intake: 1400 cc - 03/16/15: Daily fluid intake: 600 cc - 03/21/15: Daily fluid intake: 900 cc - 03/22/15: Daily fluid intake: 690 cc. - 03/24/15: Daily fluid intake: 540 cc. - 03/25/15: Daily fluid intake: 690 cc - 03/29/15: Daily fluid intake: 600 cc. - 04/01/15: Daily fluid intake: 420 cc On 05/06/15 at 3:05 p.m., Surveyor requested all hydration assessments for Resident #1 from 03/04/15 - 04/01/15. Surveyor received the following hydration assessments from Medical Records (MR) G. MR G stated there was only one hydration assessment completed for Resident #1 during this time frame. - 03/04/15: Hydration assessment completed upon admission. Assessment stated Resident #1 exhibited and complained of diarrhea, weakness and required dependence on staff for eating and drinking. Assessment indicated Resident #1 was at risk for dehydration due to medications, decreased fluid intake and swallowing evaluation and indicated that nursing was consulting with the dietician. Comments included: "Potential risk due to above factors. Is receiving nectar thick liquids. Being seen by ST. Taking adequate fluids. Averaged 1505 cc in past 2 days. Has no physical s/s of dehydration. Was admitted to hospital with dx (diagnosis) of dehydration, now resolved, prior to being admitted to this facility...Fluid needs are 2250 cc per day...Average daily fluid intake with meals: 480 cc." On 05/06/15 at 10:30 a.m., Surveyor reviewed the physician progress notes [REDACTED]. - 03/04/15: Discharge Summary: diagnosed with [REDACTED]. Patient was stable to discharge to the nursing home for temporary strengthening and for nutrition. - 03/09/15: Resident #1 was seen post hospital follow up. Resident #1 is "very fussy with what he wants to eat and drink and was not taking much and requested free water not thickened. Did discuss with his son and have in the past with him aspiration risks, which I not sure they fully understand but did allow the water. He is much happier with that. He still has a sore throat which was quite significant in the hospital but is swallowing a little bit better. He does like the [MEDICATION NAME] in between though is better as well. He still coughs with drinking the water, not so much the others..He has been able to be up and walking. He states overall things are going quite well here and he is liking it pretty well....IMPRESSION/PLAN: 1. Severe dehydration. Had resolved with IV fluids. Will continue with the water, not thickened, though discussed again with him the risks of the same." - 04/01/15: "Patient (Resident #1) is an almost always [AGE] year old gentleman who was admitted from the nursing home. He initially was placed in the nursing home just under a month ago for failure to thrive and generalized weakness. Unfortunately, it had just come to my attention that his admission weight had been 169, and he had slowly been losing probably up until the last week and then more dramatically. Over the last couple of days his weight has been 142...the patient himself complains of nausea, dry heaves and has pain all over today. He does state he still is urinating some, still has some loose stools. He has been significantly dizzy the last couple of days per the nursing report, and some change in vision...IMPRESSION: Dehydration, more chronic but it was a little bit acute. The patient will be placed on observation for hydration, pending long-term care discussions. 2. Underlying dysphagia..5. Anorexia..will continue IV medication for the same. 6. General frailty." - 04/03/15: Resident #1 had a surgical procedure completed for the placement of a PEG tube to assist with tube feeding. Resident #1 was discharged to different local nursing home for skilled nursing needs. On 05/07/15 at 10:00 a.m., Surveyor requested all physician notifications for Resident #1 addressing severe weight loss, dizziness and signs and symptoms of dehydration. Surveyor was provided the following physician notifications: - 03/05/15: Facility fax sent to primary physician stating, "Resident is unable to swallow [MEDICATION NAME] and vitamin D. These can't be crushed. Can you D/C (discontinue) these?" Reply from physician stated, "Please D/C both for now." - 03/30/15: Facility fax sent to primary physician stating, "Please review daily wts. (weights). Do you want to continue + (and) check wt. daily?" Reply from physician states, "May change to weekly but I should probably been notified before 25# loss in 1 month...is he on any diuretic? Is he on dietary supplements?" No other MD notifications provided. On 05/06/15 at 1:10 p.m., Surveyor interviewed both CNA D and CNA E in regard to Resident #1. Both CNA D and CNA E stated they were very familiar with Resident #1 and assisted with cares for him while at the facility. CNA E stated Resident #1 sat alone at a table in the assisted dining room, which is a dining room in which residents who require assistance with meals are placed. CNA E stated Resident #1 sat alone because he had difficulties in eating and didn't want other residents to watch him. CNA E stated Resident #1 was a poor eater and was on thickened liquids during meals but could have thin water in his room. Both CNA D and CNA E stated Resident #1 had significant weight loss while at the facility and notified the nursing staff of the weight changes. CNA E stated the average fluid intake for Resident #1 during each shift was approximately anywhere from 120 cc - 180 cc. CNA E stated he enjoyed his mug of thin water in his room and always drank the mug completely within a 24 hour time frame. CNA E stated the mug in his room with thin water consisted of 660 cc. Resident #1 only had one mug per day. On 05/06/15 at 1:40 p.m., Surveyor interviewed Charge Registered Nurse (CRN) F in regard to the above information for Resident #1. CRN F stated he had been gradually losing weight since his admission and weight loss was not considered a significant change in condition which warranted the physician to be updated. CRN F stated she did not feel the Dietician needed to be updated either. CRN F stated the nursing staff normally fax updates to the physician depending on how acute the patient is. CRN F stated all faxed updates and requests are then put into the hard chart. CRN F stated, "He was pale, skin dry and not well hydrated. He (Resident #1) was gradually declining..not eating well...didn't know until lightheadedness that he was dehydrated...we then updated the physician." On 05/06/15 at 1:20 p.m., Surveyor interviewed the Registered Dietician (RD) B in regard to the above noted information. RD B stated she was familiar with Resident #1 and that he had been admitted with malnutrition, dehydration which had been going on a while prior to his admission. Surveyor asked RD B how often a dietary assessment was completed on the residents within the facility and RD B stated, "Upon admission, quarterly and with significant changes in condition." Surveyor asked RD B when the physician was notified of his severe weight loss and signs and symptoms of dehydration and RD B stated, "The physician was first notified on 03/29/15...the physician should have been notified a lot sooner in regard to his weights." Surveyor asked RD B if IV fluids or tube feeding were recommended to assist with Resident #1's nutritional and hydration needs and RD B stated, "I do not know if IV fluids were recommended...I cannot recommend IV fluids because it is outside the scope of my practice to do so...I can't even fax or call the physician...can only recommend to the nurse to contact the physician...did not make any recommendations to the nursing department." Surveyor asked RD B if she had attempted a root cause and analysis to determine why the resident had a severe weight loss and was showing signs and symptoms of dehydration. RD B stated she did not do a root cause and analysis and "just went off the [DIAGNOSES REDACTED]." RD B stated, "We offered him everything...he didn't want any of it. It's not like we didn't get him to try to eat." RD B stated all interventions tried were not put on the resident's plan of care. On 05/07/15 at 1:45 p.m., Surveyor interviewed the NHA, Assistant Director of Nursing (ADON) A and RD B in regard to the above information. Surveyor addressed concerns in regard to Resident #1 having severe weight loss and signs and symptoms of dehydration and the physician not being notified. Surveyor also addressed concerns that the resident's care plan did not reflect interventions for dehydration and weight loss. Surveyor asked if hydration assessments should have been completed on Resident #1 and RD B stated, "We don't have to do a hydration assessment...nurses should run a daily report on intakes for the day, give it to the nurse on the next shift to push fluids...nurses don't necessarily document in the computer...it all depends."

Based on resident, family and staff interviews, and medical record review, the facility did not ensure that residents are free of any significant medication errors for 1 of 8 sampled residents reviewed for medication errors. On 12/20/12, Resident #1 received her roommate's medications in error, which included [MEDICATION NAME], Atorvastatin, and Levetiracetam, which can cause multiple side effects, especially in people whose kidneys do not function well. The facility did not do a thorough investigation, did not document the medication error in Resident #1's medical record (cross reference F 514), did not retrain the LPN and other staff to prevent additional medication errors, and did not inform Resident #1's daughter of the medication error (cross reference F 157). Resident #1 had symptoms of lethargy, dizziness, weakness, vomiting, hallucinations, and confusion, which lasted through Christmas Eve. This is evidenced by: Resident #1's medical record states that she is alert and oriented, and is in chronic stage 5 kidney disease. Resident #1 was seen by her physician on 12/17/12, who stated, "She's not feeling badly. She denies any real change in energy, memory ability to focus on tasks is good...Impression: 1. [MEDICAL CONDITION] with a bit more acute worsening. Does not appear to be UTI (urinary tract infection)." Resident #1 was seen by her nephrologist on 12/18/13, who addressed "[MEDICAL CONDITION] stage V (5) with recent acute kidney failure...More recently kidney function has worsened and has not improved. This has prompt concern that she may need to progress to [MEDICAL TREATMENT] treatments." The progress note states that Resident #1's daughter, Family Member (FM) C, was present during the appointment. The physician stated, "The daughter feels that the patient is looking stable." Because of the condition of her kidneys, it takes longer for Resident #1's kidneys to excrete medications than for a person with normal kidney function. On 12/20/12, Resident #1 received her roommate's supper medications in error. Surveyor interviewed Licensed Practical Nurse (LPN) A on 02/11/13 at 2:20 p.m., who states that she was the nurse responsible for this medication error. LPN A stated that it was "chaotic that night" and that "I know my 5 rights" (the 5 rights of medication administration are the right drug, right patient, right dose, right route and right time). She stated, "It takes me twice as long to do my med pass now because I'm terrified I'll make another mistake like that. I had never had a medication error before." LPN A stated that she was off work for a couple of days after 12/20/12, unaware that the medication error had occurred, and that when she returned to work, another nurse asked her if it was possible if she may have given Resident #1 her roommate's medications. She stated that no one called her while she was off to ask about the medication error. LPN A stated that after she thought about it, that was the only logical conclusion, because Resident #6's medications were punched out twice, and Resident #1's medications had not been punched out, but were signed by LPN A as given. LPN A stated that she asked the nurse what she should do now, and the nurse told her that someone would handle the follow-up. LPN A stated that no one has told her what she should do/training, etc. since the discovery of the medication error. Surveyor interviewed RN F on 02/11/13 by telephone at 1:17 p.m. RN F was the nurse who discovered the medication error. She stated that when she came to give Resident #6 her supper medications on 12/21/12, they were already punched out, and when she looked at Resident #1's medications, they were signed out but still there. She stated that she discussed this concern with Registered Nurse (RN) B. RN F stated that Resident #1 was not feeling well on 12/21/12, but she remembered that she had a urinary tract infection [MEDICAL CONDITION] around that time and thought that was why she was ill. Surveyor interviewed RN B on 02/11/13 at 3:15 p.m., who is the unit's charge nurse for the p.m. shift. RN B confirmed that the medication error had been discovered the next day, when RN F noted that Resident #6's medications were already punched out, and that Resident #1's medications were not. RN B stated that Resident #1 became "confused and lethargic" and that "her speech was slurred". RN B stated that she had been the one to tell Resident #1 about the medication error, but could not remember which date, but it was after Resident #1 was feeling better, not when she was confused. RN B also stated that Resident #1's physician was not available, so she called the on-call physician, Medical Doctor (MD) D, to notify him of the medication error. She stated that MD D told her that Resident #1 should be "closely monitored" and that Resident #1's symptoms could be attributed to Resident #6's [MEDICATION NAME]. There were no nurse's notes written on 12/20/12. Nurse's notes on 12/21/12 state that Resident #1's daughter was with her at urgent care, but does not describe any of Resident #1's symptoms. A note written at 1:18 p.m. refers to Resident #1 being seen in the emergency room , but did not describe her symptoms. A note written at 9:58 p.m. written by RN B states, "Resident continued to be confused frequently through out shift. Very sleepy and responds when spoken to. C/O (complains of) being cold. Warm blanket applied. Resident having difficulty verbalizing thoughts. She states I just don't know what I am talking about. States that she hurts all over and c/o pain with urination. Urine is bright yellow/green. Incontinent X1 this shift. Unable to explain where her body hurts. Refused prn (as needed) pain meds. Received first dose [MEDICATION NAME] 1330 (1:30 p.m.) Updated on call MD regarding resident's condition. Per MD continue to monitor and update MD with significant changes. If resident has not improve (improved) by tomorrow update MD. Continue to monitor." Nurse's notes written on 12/22/12 at 4:49 a.m. state that Resident #1 had received as needed proclorperazine for nausea. "Res (resident) is slow to respond but answers appropriately. Res stated 'I don't know what is wrong with me.' Will continue to monitor." Nurse's notes state that Resident #1 was "back to her basic mentation" on 12/24/12. [MEDICATION NAME] is most often given for muscle spasms caused by [MEDICAL CONDITION] or spinal cord injuries. Side effects can include drowsiness, dizziness, weakness, tiredness, nausea, confusion and hallucinations. Resident #1 had all of these symptoms. The normal dose for [MEDICATION NAME] is 10 milligrams (mg). Resident #6 receives 20 mg 3 times per day, so Resident #1 received 20 mg of [MEDICATION NAME]. Resident #1 also received: Atorvastatin 40 mg (to reduce cholesterol: aka [MEDICATION NAME]) - which can have side effects of mild memory problems, confusion, muscle problems and liver problems. Levetiracetam 1,000 mg (for [MEDICAL CONDITION]: aka [MEDICATION NAME]) - which can have side effects of sleepiness, dizziness, unsteadiness, weakness, mild agitation, anxiety and depression. Surveyor asked the facility to provide a copy of the investigation of the above medication error. The facility provided a medication error sheet which stated that Resident #1 did not receive her normal 5:30 p.m. medications on 12/21/12, but there was no form filled out regarding the fact that she had received her roommate's medications. Surveyor asked if there was more to the investigation. A note to the Director of Nursing (DON) was found, written by RN B, which states that she spoke with Medical Doctor (MD) D, who told her that "[MEDICATION NAME] could cause (Resident #1)'s confusion & other sx (symptoms)." The DON was on vacation, and not available for interview. Surveyor interviewed Resident #1 on 02/11/13 at 1:30 p.m. Resident #1 stated that she remembered the incident, stating it was the weekend before Christmas. She stated she remembered her daughter meeting her at the physician's office on 12/21/12, and that a urine sample was taken, using a catheter. She stated that after returning to the facility, she does not remember much of Saturday. She remembered vomiting Friday night, and sleeping off and on until Sunday. She stated that one of the aides told her that she had gotten her roommate's medications. (RN B used to be a CNA.) Resident #1 stated that during the weekend, the nurse "told me I had a bladder infection, but I knew it had to be more than that. They did not let my daughter know about it and she was angry and sent a letter to the DON and the NHA and they never answered." Surveyor interviewed Resident #1's daughter, FM C, on 02/11/13 at 4:40 p.m. by telephone. Surveyor asked FM C how Resident #1, who is alert and oriented, would not realize that she was receiving the wrong medications. FM C stated that Resident #1 normally receives her supper pills in applesauce, because she has one big one at supper, which is difficult for her to swallow. FM C stated that Resident #1 had not had any symptoms when she attended her mother's appointment on 02/18/12 (which is verified in the above nephrologist's note). FM described her mother as "totally herself, and she felt good" (which is one reason the nephrologist did not insist on Resident #1 starting on [MEDICAL TREATMENT] immediately). FM C stated in the above interview that she had not yet been notified of the medication error which had occurred on 12/20/13. FM C stated that her mother was still shaky on 12/24/12, and that she needed to help feed her. FM C stated, "I thought she was dying." FM C stated that the physician was surprised that her mother was "that ill" from a UTI, and thought she had classic signs of her kidneys shutting down. The physician in urgent care asked FM C, "Is she usually like this?" -and I told him, "No." She stated, "Mom has had UTIs before, but she never looked like this - usually she has just a back ache and foul-smelling urine...generally they let me know if she is ill, if she has a UTI they would have called me. that's what concerns me - no one told me about the medication error, and no one has apologized. When I met my mother at the appointment, the transportation aide told me she had been sick." There is no mention of the above medication error, and no mention that the physician was consulted specifically regarding the medication error, in Resident #1's medical record. Staff, including LPN A, were not re-trained after the error occurred. The NHA stated to Surveyor that no one had told her about the medication error before the letter was received. Surveyor asked RN E, who is the facility's ADON (Assistant Director of Nursing) for the investigations for any other recent medication errors. Eight additional medication errors have been investigated since 01/22/13 for 7 other residents.

Based on record review, observation, and staff interviews the facility did not provide adequate supervision and assistance devices to prevent accidents for 7 of 16 sampled residents assessed to be at risk of falls. The facility's approach to resident safety did not include a systematic approach to evaluate and analyze hazards and risks, and the monitoring for effectiveness and modification of implemented interventions when necessary for 4 residents who experienced an accident/fall (Resident's #5, 15, 16, and 10). Facility staff did not follow interventions on the plan of care for 2 residents who experience an accident/fall (Resident's #19 and 3). The facility did not ensure the resident's environment remained as free from accident hazards as is possible for 1 resident (Resident #17). Resident #5 fell out of bed on [DATE]. There was no evidence that the facility evaluated the causal factors contributing to Resident #5 falling out of bed or revised Resident #5's plan of care to reduce the likelihood of another fall. On [DATE], Resident #5 fell out of bed and sustained a fractured femur. Resident #19's plan of care updated [DATE], revealed a problem of Self Care Deficit-Risk for falls related to increased confusion, disorientation and physical decline. An intervention to minimize Resident #19's risk for falls included bed sensor alarm while in bed, and patient alarm when up. Review of a facility self-report investigation regarding Resident #19 having a fall on [DATE], revealed facility nursing staff did not turn on Resident #19's bed sensor alarm or attach her patient alarm after assisting her to the bathroom. Resident #19 self-transferred from bed, fell and sustained a laceration to her head requiring 4 sutures to close. Resident #17 utilizes a bedside commode at night. On [DATE], the bucket on Resident #17's commode fell off causing urine to be spilled on the floor. Resident #17 stood up from the commode to get help, slipped in urine and fell . Following this incident facility staff inspected all commode buckets and found staff had been using improperly fitting buckets on residents' commodes including Resident #17's, which caused an accident hazard. Resident #16 experienced 13 falls without injury, from bed or chair from [DATE] through [DATE]. In [DATE], a ridged mattress was implemented. Resident #16 experienced 3 - 4 more falls from bed (without injury) after the ridged mattress was implemented. The Falls CAA review report dated [DATE], states to continue using alarming devices, low bed and floor mattress. There was no floor mattress in place, nor was that intervention listed on the care card or care plan. The facility completed a Post Fall Documentation form after each fall, but there was no evidence that the data had been analyzed to determine the appropriate plan of care for Resident #16. The facility re-evaluated Resident #16 on [DATE], and implemented a floor mattress. Resident #10 slid off the side of the bed while participating in morning cares on [DATE]. The Certified Nursing Assistant was present at the time of the fall. There was no injury. There was no evidence that Resident #10 was evaluated post fall, for potential changes to her plan of care. Resident #15, who utilizes a merry walker as the least restrictive device to keep her safe from falls, tripped and fell on [DATE], causing the bar on the Merry Walker to give way. CNA-Q, who was with her, used a gait belt to assist Resident #15 to the floor. There was no injury to Resident #15. The facility did not investigate the fall to determine if there were any changes to the merry walker or the resident's care plan to keep Resident #15 free of accidents. Resident #3 did not have foot pedals in place on [DATE] while her wheelchair was being pushed by staff as the care plan indicated. Resident #3 placed her feet on the floor and fell forward out of her wheelchair sustaining a black eye and carpet burns to the face. Resident #3 was also observed not to have the bed alarm attached to the bed on [DATE]. Findings include: On [DATE] and [DATE] Surveyor # requested to review the facility's policies and procedures for falls. The Policy and Procedure for Resident Falls was provided and indicates all falls will be addressed via assessment, intervention, and on-going monitoring of effectiveness of interventions and documented in the resident's record. The procedure directs staff to complete a Post-Fall Documentation Form, to send a copy to the DON and to place original in the chart. The procedure directs staff to make a notation in the nurse's notes that a fall occurred and refer to Post Fall Documentation Form. The procedure does not indicate how the facility evaluates and analyzes hazards and risk, and monitors for effectiveness and modifications of implemented interventions when necessary. [DATE], at 9:45 a.m., Surveyor # spoke with the Director of Nursing (DON) who indicated facility staff meet and discuss resident falls. The DON was not able to provide evidence that the facility has a process to systematically evaluate and analyze hazards and risks, implement interventions, and monitor for effectiveness and modifications of interventions when necessary. 1. On [DATE] Surveyor # reviewed Resident #5's medical record. The record indicates Resident #5 is [AGE] years old and was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), dated [DATE], indicates Resident #5 has a Brief Interview for Mental Status (BIMS) score of 5 (severe impairment), requires extensive assistance of staff for bed mobility, is dependent on staff for transfers and has a history of falls. The Nursing Notes, dated [DATE] indicates Resident #5 was found on the floor and to see the Post Fall Documentation. The Post Fall Documentation form, dated [DATE] at 9:30 a.m., indicates Resident #5 rolled out of bed, was found facing her bed laying on the left side and a patient monitor type safety device was in place and functioning. The nursing note and the Post Fall Documentation form do not indicate an evaluation and analysis of the hazards and risks related to the fall and\or implementation of interventions to reduce Resident #5's risk for future falls. The plan of care for Self Care Deficit, potential for falls, revised and reprinted on [DATE], was reviewed and indicates a bed sensor was installed on Resident #5's bed on [DATE]. The plan of care does not indicate the facility monitored for the effectiveness of the intervention and/or made modifications of interventions after the resident fell out of bed on [DATE]. The quarterly Minimum Data Set (MDS), dated [DATE], indicates Resident #5 has a Brief Interview for Mental Status (BIMS) score of 3 (severe impairment), requires extensive assistance of staff for bed mobility, is dependent on staff for transfers and has a history of falls. The Nursing Notes, dated [DATE], indicates Resident #5 was found on sitting on the floor next to her bed and a bed sensor was sounding. The note indicates Resident #5's right leg was inverted and in a precarious position, the physician was notified and Resident #5 was sent to the emergency room . The Radiology Report, dated [DATE], indicates the x-ray of Resident #5's right femur demonstrates generalized bony demineralization and no acute fracture. The report states if Resident #5 is having significant pain in the region of the knee, additional imaging in that region could be preformed to evaluate. The Nursing note, dated [DATE] at 7:15 a.m., indicates Resident #5's plan of care was updated to include a low bed. The plan of care for Self Care Deficit, potential for falls, dated [DATE], indicates a low bed was installed. The nursing notes dated [DATE] through [DATE] indicate Resident #5 was monitored and treated for [REDACTED].#5 had right knee imaging. The Radiologist report, dated [DATE], indicates Resident #5 has a fracture involving the distal femur. The Physicians Orders, dated [DATE], indicates Resident #5 has a fractured femur requiring an immobilizer and no weight bearing. The Physicians Order's, dated [DATE], indicate Resident #5 could be weaned off the immobilizer and bear weight as tolerated. On [DATE] though [DATE], Surveyor # observed Resident #5 on the living unit. Resident #5 was observed to be self propelling her wheelchair using her bilateral lower extremities. Resident #5 was not wearing the immobilizer and did not appear to have pain. On [DATE] at 9:15 a.m. and [DATE] at 9:45 a.m., Surveyor # spoke with the Director of Nursing regarding Resident #5's fall on [DATE]. The DON was not able to provide evidence that the fall on [DATE] was reviewed to determine what may have caused or contributed to the fall, to address the factors of the fall, and to revise Resident #5's plan of care after the fall to reduce the likelihood of another fall, which occurred on [DATE]. 2.) Surveyor # reviewed Resident #19's medical record on ,[DATE]-[DATE], as part of a facility self-report investigation. Resident #19 expired at the facility on the weekend of ,[DATE]-[DATE], after a decline in her physical condition beginning in ,[DATE]. Resident #19 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #19's plan of care updated [DATE], revealed a problem of Self Care Deficit-Risk for falls related to increased confusion, disorientation and physical decline. An intervention to minimize Resident #19's risk for falls included bed sensor alarm while in bed, and patient alarm when up. Review of Resident #19's Nurses' Note documentation revealed an entry dated [DATE], at 3:50p.m. The entry indicated Resident #19 was found sitting on the floor of her room with her back against the wall. Resident #19 reported bumping her head against the wall. Resident #19 sustained a 5.5c.m. X 3.25c.m. raised area on the middle back of her head. She also reported that she had become weak and had to sit on the floor. Following this fall the facility obtained an order for [REDACTED]. A nurses' note entry dated [DATE] at 4:00a.m., revealed Resident #19 was found sitting in another resident's scooter in the hallway. Resident #19 stated she was trying to take a walk and got very weak and dizzy. The entry also indicated Resident #19 continues to be weak and slightly confused. Following this incident facility staff applied a sensor alarm to Resident #19's bed and a patient alarm to her wheelchair for safety. On ,[DATE]-[DATE], Surveyor # reviewed a facility self-report investigation regarding a fall Resident #19 had on [DATE]. A summary of the facility investigation of Resident #19's fall revealed the following: "On [DATE] at 3:30a.m., Resident #19 was found on the floor of her room by Nurse Aide (NA)-L. Resident #19's care plan/care card instructs that a bed sensor and patient clip alarm be used at night. There was no alarm activated. The patient clip alarm was on the resident's bedside table. The bed sensor alarm was not on (We have determined the device was not malfunctioning.) NA-K had assisted the resident to the bathroom at 1:30a.m., she asked co-worker NA-L if the resident requires alarms and NA-L did instruct on the alarms ...Upon questioning NA-K by the DON (Director of Nursing), she stated "I can't say 100% that I put the alarm on." A statement obtained from NA-K during the course of the investigation dated [DATE], revealed, (Resident #19's) "alarm sounded approx 1:30a.m. I helped her to the bathroom and reset her alarms. This statement is true to the best of my knowledge. " A statement obtained from NA-L dated [DATE], indicated, "At approximately 3:30a.m., I was walking around the corner at the end of the West hall when I heard a faint call for help. I entered Resident #19's room and saw Resident #19 laying on the floor, on her back, with a lot of blood around her head. I immediately called the nurse. Neither the patient alarm or bed sensor were sounding ..." Review of a facility Post-Fall Documentation form dated [DATE] at 3:30a.m. revealed the following: Were safety devices in place: No. Were safety devices in use functioning: Patient monitor did not sound. Post Fall Assessment/Range of Motion: "Unable to assess due to pain." Injury Site: back of head laceration. Pain: "It hurts" Following this fall, Resident #19 was sent to the emergency room for treatment where she received 4 sutures to close the laceration. Surveyor # shared the concern that Resident #19's fall prevention devices were not applied and/or turned on resulting in a fall with injury, during the daily meeting with the facility on [DATE]. As of [DATE], no further information had been provided. 3.) Surveyor # reviewed Resident #17's medical record on ,[DATE]-[DATE], as part of the facility's annual survey. Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #17's Minimum Data Set assessment dated [DATE], indicated Resident #17 requires a limited assist of 1 staff member to complete transfers and is totally dependent on the assist of 1 staff member to ambulate. This assessment also indicates Resident #17 is cognitively intact. Review of Resident #17's nurses' note documentation on [DATE] at 11:00 p.m., indicated, resident on floor-see post fall documentation. Review of the Post-Fall Documentation form dated [DATE], regarding this fall indicated the resident stated "I was on the commode and the bucket came off, urine was going all over the floor and I slipped trying to get help..." The Post-Fall Documentation form under Cause of fall, indicated equipment malfunction-bucket below commode came off. Surveyor # spoke with the Director of Nursing (DON), on [DATE] at approximately 9:05a.m. The DON indicated that following this incident staff checked all the commode buckets and found that improper sized buckets were being used on some commodes, including Resident #17's. 4.) Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] Surveyor # reviewed the medical record of Resident #3 which indicated she was at a high risk for falls and had fallen in the past due to poor safety awareness. On [DATE] Surveyor # reviewed the nurse's note dated [DATE] at 10:15 a.m. The note read: at 8:30 a.m. Resident #3 had fallen out of the wheelchair. Resident #3 had been leaning per the Certified Nursing Assistant (CNA). CNA was wheeling Resident #3, Resident #3 leaned forward falling out of the wheelchair landing on her face. Had a nosebleed for 30 seconds. Hematoma noted to right forehead. Daughter and Medical Doctor notified. The facility completed an investigation following the fall and submitted it to the state agency. On [DATE] Surveyor # reviewed the investigation. CNA-J was sent home pending the outcome of the investigation. Surveyor # reviewed the statement of CNA-J taken by Social Worker-N on [DATE] which read: CNA-J stated that on [DATE] she was instructed to take Resident #3 and put her in her recliner chair because she was sleepy. As she was Moving Resident #3, Resident #3 put her feet down and fell out of the wheelchair. CNA-J stated she washed and dressed Resident #3 and read her care card. CNA-J stated "I guess I didn't see the foot pedals, I know I should have read it closer." On [DATE] Surveyor # reviewed the care card that was in place for Resident #3 at the time of the fall on [DATE] which read: padded foot rest on top of foot pedals to prevent feet from slipping off. On [DATE] Surveyor # reviewed the summary of the incident provided as part of the facilities investigation which read: nursing assistant did not follow care plan indicating that Resident #3 should have foot pedals on the wheelchair when moving chair. No pedals were present and Resident #3 put her feet down and she fell from the wheelchair. Resident #3 received rug burns to her face, cheek and nose. On [DATE] at 11:05 a.m. Surveyor # observed Resident #3 in the common area on the unit she resides. Resident #3 had a black eye and several red and bruised areas to her face. On [DATE] at 2:20 p.m. Surveyor # observed Resident #3 lying in bed, in her room; a magnetic alarm was attached to her but the base was loose on the bed frame and not attached to the bed. On [DATE] at 2:55 p.m. Surveyor # brought Licensed Practical Nurse (LPN) - E into Resident #3's room. Resident #3 was still lying in bed and the alarm was still not attached to the bed. LPN-E stated the alarm should be attached to the bed and she would fix it. On [DATE] Surveyor # reviewed the current care card of Resident #3 which read: patient alarm when in bed. On [DATE] at 9:05 a.m. Surveyor # interviewed DON-A who stated that the bed alarm for Resident #3 should be attached to the bed. 5.) Surveyor # reviewed Resident #16's record on ,[DATE] & [DATE]. Resident #16 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A nursing care plan for falls dated [DATE], (the date of the last quarterly care plan review) indicated Resident #16 was at risk for falls because she attempts to self transfer and is unable to do so safely. The plan approaches indicated she used a bed sensor when in bed and a chair alarm when up in her chair. She had a low bed and was to have gripper socks on at all times, as well as, having her call light always within reach. Both a Quarterly Minimum Data Set ((MDS) dated [DATE], and an annual MDS dated [DATE], indicated she had 2 or more falls without injury in the last assessment period. The Falls Care Area Assessment (CAA) dated [DATE], summarized that Resident #16 had a history of [REDACTED]. Falls are caused by Resident #16's impaired mobility yet desire and strong will to maintain independence and attempts to self transfer without assist. Resident #16 remains at risk for falls due to poor safety awareness. "We will continue to use alarming devices, and low bed with floor mattress." The following falls documentation was noted on the Post Fall Documentation form. On [DATE] at 4:45p.m., Resident #16 was found on the floor. Resident #16 indicated she slipped off the bed. Her knees were on the floor, but her buttocks were still on the bed. The alarm had not sounded since her weight was still on the bed. Resident #16 stated she was reaching for something and fell . On [DATE] at 3:15p.m., Resident #16 was found on the floor. The alarm did not sound as her elbow was still pressing on it. Resident #16 stated she was reaching for something and fell . On [DATE] at 2:00p.m., Resident #16 was found kneeling by the side of the bed. The bed alarm had not sounded because she was pressing against it. The sensor pad was readjusted. Resident #16 had told staff that she had been repositioning herself when she fell . The bed sensor alarm had not sounded with these three falls. There was no evidence that the effectiveness of the sensor alarm was evaluated post fall. On [DATE] at 7:10p.m., Resident #16 rolled out of bed, and was found sitting beside the bed with her upper body still on the bed. The alarm was sounding. The resident stated she had been repositioning herself. On [DATE] at 2:30p.m., Resident #16 was found sitting on the floor in front of her wheelchair. The chair alarm sounded. Resident #16 stated she had slipped while reaching for something. On [DATE] at 1:13p.m., Resident #16 was found kneeling on the floor by her nightstand. The bed alarm had sounded. Resident #16 stated she had been reaching for something when she fell . On [DATE] at 1:30p.m., Resident #16 was found on the floor by her bed. The bed alarm had sounded. Resident #16 stated she had been reaching for something. On [DATE] at 2:10p.m., Resident #16 was found on her knees facing her bed. She stated she got too close to the edge of the bed and fell out. The bed alarm had sounded. After this fall a ridged pressure relief mattress was added to her bed. On [DATE] at 6:30p.m., Resident #16 was found sitting on the floor with her back against the bed. Resident #16 stated she sat on the floor on purpose. The alarm had not sounded, and was still attached to her. On [DATE] at 6:40p.m., Resident #16 was found sitting on the floor in front of her wheelchair. Resident #16 stated she slid out of her chair. The chair alarm had sounded. On [DATE] at 3:00p.m., LPN-O heard Resident #16's alarm sounding, and went to her room. LPN-O witnessed Resident #16 lowering herself to the floor, landing on her knees. On [DATE] at 12:40p.m., Resident #16 was found sitting on the floor beside her bed. The alarm had sounded. On [DATE] at 5:00p.m., Resident #16 was found on the floor. Her bed alarm had sounded. Resident #16 stated she had slid out of bed to straighten her drawers. On [DATE] at 10:00a.m., Surveyor # observed Resident #16 up in her wheelchair. The alarm was attached. There was no mat noted in her room. There was no evidence that the effectiveness of fall interventions had been evaluated after [DATE]. On [DATE] at 11:20a.m., Surveyor # spoke with LPN-G regarding the use of floor mats as a fall intervention. LPN-G stated she did not think that Resident #16 had a mat in her room. LPN-G accompanied Surveyor # to Resident #16's room. There was no mat in the room. LPN-G then asked Resident #16 if she had ever had a mat, and Resident #16 stated she had not. The nurse who had written the CAA was on vacation and unavailable for interview. On [DATE] at 3:15p.m., Surveyor # asked the Director of Nursing (DON) about the numerous falls without evidence of evaluating the falls interventions. On [DATE] at 9:15a.m., the DON stated that the team had met after the surveyors had left on [DATE], and a mat beside the bed was being implemented. 6.) Surveyor # reviewed Resident #10's record on ,[DATE] - [DATE]. Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #10 was on a 1500 calorie diet for weight reduction. Her weight was 274 pounds. According to an annual Minimum Data Set (MDS), Resident #10 required extensive assistance with most activities of daily living (ADL's), with the exception of eating and the ability to move about once up in her wheelchair. According to the care plan dated [DATE], Resident #10 has a self care deficit with a goal to have a maximum level of independence in performing ADL's, specifically to be able to wash and assist with dressing her upper body after assist of set-up. A review of the Nursing Assistant care card revealed instructions to set up for upper body ADL's. According to documentation on a Post-Fall Documentation form, Resident #10 experienced a witnessed fall on [DATE]. Resident #10 was sitting on the edge of the bed to wash her face, when she leaned forward too far and slid out of the bed, landing on the floor with her legs bent underneath her. The Certified Nursing Assistant (CNA) was with her at the time of the fall. Resident #10 had just handed the CNA her washcloth, the CNA turned to put the washcloth back in the wash basin, and Resident #10 slid to the floor. According to documentation in the nurses' notes, Resident #10 had no obvious injuries and was assisted back to bed with a mechanical lift. There was no mention on the care card or plan of care regarding the fall from the side of the bed, or of any precautions needed to keep Resident #10 safe. On [DATE] at 10:00a.m., Surveyor # spoke with CNA-P who stated that Resident #10 still sometimes sits on the side of the bed, but most of the time she will wash up while in the bathroom. CNA-P stated Resident #10 needs assistance to get in a sitting position, but then does fine with sitting on the bed. On [DATE] at 1:30p.m., Surveyor # spoke with RN-C, who stated the fall off the side of the bed had been discussed in the interdisciplinary team meeting soon after the fall. RN-C stated there was no need to change the care plan since the incident was "considered a fluke." On [DATE] at 9:10a.m., Surveyor # spoke with the Director of Nursing, who stated she had no evidence the fall from bed was evaluated. The facility did not keep any record of the interdisciplinary team discussions regarding falls 7.) Surveyor # reviewed Resident #15's record on ,[DATE] - [DATE]. Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the nursing care plan, Resident #15 had a history of [REDACTED]. Resident #15 used the Merry Walker for independent ambulation about the facility. Resident #15 had been using the Merry Walker since March of 2010. According to documentation on a Post Fall Documentation form, Resident #15 was ambulating to the dining room in the Merry Walker, accompanied by CNA-Q. Resident #15 tripped over her feet and CNA-Q held the gait belt. As Resident #15 fell forward, the front bar of the Merry Walker gave way. CNA-Q lowered Resident #15 to the floor. A note on the back of the Post Fall documentation form stated, "Isolated incident. Continue with Merry Walker". On [DATE] at 9:15a.m., Surveyor # spoke with the Director of Nursing (DON) regarding the collapse of the Merry Walker. Surveyor # questioned how the bar functioned. The DON stated she wasn't sure, but thought the bar must have lifted as the resident fell . On [DATE] at 9:40a.m., Surveyor # had CNA-R demonstrate how to release the bar on the Merry Walker. There is a black release button on the bottom of the bar. When the button is slid forward, the bar is released to lift upwards. A safety belt is between the resident's legs. In order for the bar to lift the safety belt has to be removed. Falling forward on to the bar would not release the bar. On [DATE] at 9:55a.m., Surveyor # spoke with CNA-Q, who had been with Resident #15 when the bar collapsed. The DON was present during the interview. CNA-Q stated that she was walking with Resident #15 to the dining room. They had missed the first door to enter the dining room, and when Resident #15 turned towards the 2nd dining room entrance to the dining room she tripped over her own feet and fell to the side. CNA-Q stated she thought Resident #15 must have hit the release for the bar as she fell . The bar was pushed through the frame of the Merry Walker, it did not come upwards as when released by staff. CNA-Q stated it was difficult to get the bar back up through the frame of the Merry Walker. The DON stated the bar must have come up because of the way it hooks to the walker. CNA-Q stated, "No, it pushed through". There was no evidence that the facility had investigated how the incident occurred, or if changes were needed in the plan of care to ensure the safety of Resident #15.