Every finding on record at Markesan Resident Home

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect more than 4 of the 38 residents residing in the facility. Staff did not monitor and document food cooling temperatures. Staff did not follow safe reheating protocols for food meant for resident consumption. Findings include: On 2/10/25 at 8:50 AM, Surveyor began an initial kitchen tour with Dietary Manager (DM)-F who indicated the facility follows the Food and Drug Administration (FDA) Food Code. The 2022 FDA Food Code documents at 3-402.12 Records, Creation and Retention: Records must be maintained to verify that the critical limits required for food safety are being met. Records provide a check for both the operator and the regulator in determining that monitoring and corrective actions have taken place. Cooling Temperatures: The 2022 FDA Food Code documents at 3-501.14 Cooling: (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 135 Fahrenheit (F) to 70 F; and (2) Within a total of 6 hours from 135 F to 41 F or less. (B) Time/temperature control for safety food shall be cooled within 4 hours to 41 degrees F or less if prepared from ingredients at ambient temperature, such as reconstituted foods and canned tuna. The 2022 FDA Food Code documents at 3-501.15 Cooling Methods: (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3-501.14 by using one or more of the following methods based on the type of food being cooled: (1) Placing the food in shallow pans; (2) Separating the food into smaller or thinner portions; (3) Using rapid cooling equipment; (4) Stirring the food in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. The facility's Food Temperatures and Thermometer Protocol, dated August 2017, indicates: It is the policy of the facility to have thermometers available to take the internal temperature of food .Thermometers are available in the kitchen for checking food temperatures to maintain food safety .Stem thermometers will be used for foods that are cooked and cooled for later service. Temperatures will be monitored and recorded promptly. During an initial tour of the kitchen that began at 8:50 AM on 2/10/25 at 8:50 AM, Surveyor and DM-F observed pre-cooked eggs, beef patties, and French toast in the cooler and two tubs with plastic bags of previously cooked meat in the freezer. DM-F confirmed the items were for resident consumption and were previously prepared and cooked in the kitchen. DM-F indicated the facility does not use cooling logs. Microwave Reheating/Food Safety Temperatures: The 2022 FDA Food Code documents at 3-403.11 Reheating for Hot Holding: (A) Except as specified under (B) and (C) and (E) of this section, time/temperature control for safety food that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the food reach a temperature of at least 74 degrees Celsius (C) (165 degrees Fahrenheit (F)) for 15 seconds. (B) Except as specified under (C) of this section, time/temperature control for safety food reheated in a microwave oven for hot holding shall be reheated so that all parts of the food reach a temperature of at least 74 degrees C (165 degrees F) and the food is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating. The facility's Food Temperatures and Thermometer Protocol, dated August 2017, indicates: It is the policy of the facility to have thermometers available to take the internal temperature of food .Thermometers are available in the kitchen for checking food temperatures to maintain food safety .Foods that are heated in the microwave are only heated for immediate service and will be heated to palatable temperatures. During an observation of lunch on 2/10/25 at 11:48 AM, Surveyor observed [NAME] (CK)-H pour beef broth in a bowl, cover the bowl, and heat the broth in the microwave for 50 seconds. CK-H then temped the broth with a thermometer that read 131 degrees F. CK-H then heated the broth for an additional 30 seconds and temped the broth with a thermometer that read 164 degrees F. On 2/10/25 at 11:48 AM, Surveyor interviewed CK-H who stated reheated food should reach a minimum temperature of 135 degrees F. CK-H acknowledged CK-H was not aware the temperature for reheated food should be 165 degrees. On 2/11/25 at 12:58 PM, Surveyor interviewed DM-F who acknowledged the reheating protocol concern and stated it was a misunderstanding on the facility's part as they were not aware the internal temperature needs to reach 165 degrees F.

Based on staff interview and record review, the facility did not ensure a written transfer notice was provided for 4 residents (R) (R188, R20, R25, and R2) of 4 residents reviewed for hospitalization . In addition, the facility did not ensure the Ombudsman was notified of hospital transfers for 3 (R20, R25, R2) of 4 residents. R188 was transferred to the hospital on 2/10/25. The facility did not provide R188 or R188's representative with a written transfer notice. R20 was transferred to the hospital on 1/10/25. The facility did not provide R20 or R20's representative with a written transfer notice and did not notify the Ombudsman of R20's transfer. R25 was transferred to the hospital on 11/9/24. The facility did not provide R25 or R25's representative with a written transfer notice and did not notify the Ombudsman of R25's transfer. R2 was transferred to the hospital on 10/28/24. The facility did not provide R2 or R2's representative with a written transfer notice and did not notify the Ombudsman of R2's transfer. Findings include: The facility did not provide a discharge/transfer notice policy. 1. From 2/10/25 to 2/12/25, Surveyor reviewed R188's medical record which indicated R188 was transferred to the hospital on 2/10/25 and admitted for pneumonia. R188's medical record did not indicate R188 or R188's representative received a written transfer notice. 2. From 2/10/25 to 2/12/25, Surveyor reviewed R20's medical record which indicated R20 was transferred to the hospital on 1/12/25 and admitted for a bowel obstruction. R20's medical record did not indicate R20 or R20's representative received a written transfer notice. 3. From 2/10/25 to 2/12/25, Surveyor reviewed R25's medical record which indicated R25 was transferred to the hospital on 11/9/24 for an unresponsive episode and low blood pressure. R25's medical record did not indicate R25 or R25's representative received a written transfer notice. R25's medical record indicated R25 had an activated Power of Attorney (POA). 4. From 2/10/25 to 2/12/25, Surveyor reviewed R2's medical record which indicated R2 was transferred and admitted to the hospital on 10/28/24 for gastrointestinal symptoms and intravenous (IV) antibiotics. R2's medical record did not indicate R2 or R2's representative received a written transfer notice. R2's medical record indicated R2 had an activated POA. On 2/12/25 at 9:00 AM and 11:11 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding discharge/transfer and Ombudsman notification. NHA-A indicated the facility made adjustments last year and the bed hold and transfer form the facility completes at the time of transfer meets the requirements. NHA-A indicated the facility does not notify the Ombudsman of hospital transfers. On 2/12/25 at 11:26 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated a transfer form is sent in the folder with Emergency Medical Services (EMS) to the hospital if the form has been completed when the resident leaves the facility. If the form has not been completed when the resident leaves the facility, staff fax a copy of the form to the hospital. DON-B stated the facility does not give a copy of the form to the resident or their representative.

Based on staff interview and record review, the facility did not implement policies and procedures that prohibit and prevent abuse for 3 of 8 facility and contracted staff reviewed for caregiver background checks. The facility did not ensure thorough and timely caregiver background checks were completed for Physical Therapist (PT)-C, Certified Nursing Assistant (CNA)-D, and CNA-E. Findings include: The facility's Abuse, Neglect and Exploitation policy, revised 12/2019 indicates: The objective of the abuse policy is to comply with the seven-step approach to abuse and neglect detection and prevention .screening, training, prevention, identification, investigation, protection, reporting, and response .A. Screening: .It is the policy of this facility to screen employees and volunteers prior to working with residents. Screening components include verification of references, certification and verification of licenses, and a criminal background check .The facility will not employ or otherwise engage individuals who have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law .As the license holder/legal representative, the facility will do the following: Have the employee or contractor complete a Background Information Disclosure (BID) form. The completed BID will be kept on file .A complete caregiver background check will consist of the following documents: A completed BID form .a response from the Department of Justice (DOJ) .a Response to Caregiver Background Check letter These three items are retained with the employee's records and are made available when requested by Department of Quality Assurance (DQA) staff for survey purposes. Other documentation must be obtained by the facility when information is needed to complete the background check, such as other state's conviction records .The facility will conduct repeat background checks at a minimum of four-year intervals or as needed per Wisconsin Chapter 13 requirements. On 2/11/25, Surveyor reviewed background check information for 8 facility and contracted staff, including PT-C, CNA-D, and CNA-E. PT-C was hired on 7/8/21. The facility provided an undated BID form for PT-C and did not provide proof that PT-C's BID form was completed prior to or on the date of PT-C's hire. CNA-D was hired on 10/8/00. The facility provided an undated BID form for CNA-D and did not provide proof that CNA-D's BID form was completed prior to or on the date of CNA-D's hire. CNA-E was hired on 11/30/20. CNA-E's BID form indicated CNA-E resided outside of Wisconsin from July 2022 to September 2022, however, the BID form did not indicate in which state CNA-E previously lived. The facility did not provide an out-of-state background check for CNA-E. On 2/11/25 at 12:59 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed PT-C and CNA-D's BID forms were not dated and CNA-E's BID form indicated CNA-E lived outside of Wisconsin within the last three years. NHA-A indicated Human Resources (HR) staff should have reviewed PT-C and CNA-D's BID forms and obtained an out-of-state background check for CNA-E. On 2/12/25 at 10:55 AM, Surveyor interviewed NHA-A who stated PT-C and CNA-D's BID forms should have been dated the same day their background checks were completed. NHA-A indicated BID forms should be dated when signed by staff to ensure the BID form was checked within the last 4 years and coincides with the employee's current DOJ and Integrated Background Information System (IBIS) letters.

Based on observation, staff interview, and record review, the facility did not ensure 1 resident (R) (R140) of 1 sampled resident received the appropriate care and services to prevent urinary tract infections (UTIs). On 2/11/25, R140's uncovered catheter drainage bag was observed on the floor next to R140's recliner. Findings include: The facility's Catheter Care and Drainage Bag Covers policy, revised 3/12/21, indicates: .1. Minimize the risk of catheter-associated urinary tract infections and related problems .It is the policy of the facility to cover catheter drainage bags at all times to provide privacy and dignity to the resident . From 2/10/25 to 2/12/25, Surveyor reviewed R140's medical record. R140 was admitted to the facility on [DATE] and had diagnoses including ischemic colitis, heart failure, and diabetes. R140's Minimum Data Set (MDS) assessment, dated 1/17/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R140 had intact cognition. On 2/11/25 at 1:43 PM, Surveyor observed R140's uncovered catheter bag on the floor of R140's room while R140 was sitting in a recliner. On 2/11/25 at 1:49 PM, Surveyor interviewed Registered Nurse (RN)-G who confirmed R140's uncovered catheter bag was on the floor. RN-G indicated the catheter bag should not be on the floor and should be covered with a privacy bag. On 2/11/25 at 1:51 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated catheter bags should be covered with a privacy bag and not on the floor.

Based on observation and staff interview the facility did not ensure food was stored and prepared in a safe and sanitary manner, which had the potential to affect all 33 residents (R) at the facility. Staff did not complete proper hand hygiene when moving from working with dirty dishes to clean dishes. Staff did not properly heat food in the microwave that was served to residents. 9 items in dry storage were either past the use by date or past the manufacturer best by date. Findings include: On [DATE] at 8:57 AM, Surveyor began the initial kitchen tour with Dietary Manager (DM-C). At this time, DM-C indicated the facility utilized the State of Wisconsin Food Code. Hand Hygiene The Wisconsin Food Code at ,d+[DATE].14 Personal Cleanliness, When to Wash states Food employees shall clean their hands and exposed portions of their arms .(E) After handling soiled equipment or utensils; (I) After engaging in other activities that contaminate the hands. On [DATE] at 1:12 PM, Surveyor observed the dish washing process. Surveyor observed Cook-D walk into the dish area and go to assist staff on the dirty side by putting dirty dishes in a dish rack. Cook-D took trays and covers that had been used for lunch, stacked them into a dish rack, then pick up the dish rack and place it in a position to slide it into the dishwasher. Cook-D then pushed the rack into the dishwasher. Cook-D then moved to the clean side of the dishwashing operation and grabbed clean cups out of a rack that had just come out of the dishwasher and stack them on a rolling cart. Cook-D then went back to the dirty side to stack more used lunch trays and covers into another dish rack, lift that dish rack over to the dishwasher and push the rack into the dishwasher. Cook-D then went over to the clean side of dishwashing operation and pushed a cart that had clean dishes on out of the dish area. Surveyor observed Cook-D push the cart around the front of the kitchen and stop (in front of the entire dish area), Cook-D then pushed dirty plates towards the staff rinsing dishes, turned around and adjusted stacked clean plastic containers on the shelf. Cook-D then washed Cook-D's hands. At this time Surveyor interviewed Cook-D who indicated Cook-D does not generally work in the dish area and was helping out because of being short on staff. Cook-D indicated Cook-D was not aware Cook-D should have washed hands going from the dirty side to the clean side of the dishwashing operation. On [DATE] at 1:25 PM, Surveyor spoke with DM-C who confirmed the expectation that staff should be washing hands when going from the dirty side of the dishes to the clean side. DM-C indicated that staff were reminded of hand hygiene during dishes today before Surveyor entered the kitchen, but Cook-D was not part of that reminder group, but should have known about hand washing between crossing from dirty to clean. Reheating Food Wisconsin state food code at ,d+[DATE].12 Microwave Cooking indicates: Raw animal foods cooked in a microwave oven shall be: (A) Rotated or stirred throughout or midway during cooking to compensate for uneven distribution of heat; (B) Covered to retain surface moisture; (C) Heated to a temperature of at least 74 C (165 F) in all parts of the FOOD; and (D) Allowed to stand covered for 2 minutes after cooking to obtain temperature equilibrium. On [DATE] at 10:34 AM, Surveyor observed Certified Nursing Assistant (CNA-E) heating up R33's breakfast in the microwave. CNA-E turned the microwave on then left to go assist another resident. On [DATE] at 10:45 AM, CNA-E came back to the kitchen area and pushed a button to turn the microwave on for approximately 15 seconds. CNA-E then took the plate out of the microwave and placed it in front of R33. Surveyor observed the breakfast to be scrambled eggs and a brown substance in a bowl. Surveyor did not observe CNA-E complete a temperature on the food and wait 2 minutes before serving. On [DATE] at 10:46 AM, CNA-E then took R23's breakfast plate out of the refrigerator and place it in the microwave. CNA-E then turned the microwave on for approximately 1 minute. CNA-E took the plate out of the microwave and immediately served it to R23. Surveyor observed the breakfast to be pancakes and what looked like ground sausage. Surveyor did not observe CNA-E complete a temperature on R23's food or wait 2 minutes prior to serving. On [DATE] at 10:51 AM, Surveyor interviewed CNA-E who confirmed CNA-E did not complete a temperature on the food or wait 2 minutes prior to serving. CNA-E indicated CNA-E knew CNA-E should have completed a temperature and wait a bit before serving, though CNA-E was unsure what the temperature was supposed to be and how long to wait. CNA-E opened the drawer to look for a thermometer to use to complete a temperature, but CNA-E could not locate one and did not know where the thermometer was. CNA-E indicated that R33 and R23 do often eat a later breakfast in the morning. On [DATE] at 1:25 PM, Surveyor interviewed DM-C who confirmed staff should have completed the temperature of the food and wait for 2 minutes when reheating resident food. DM-C indicated there was a thermometer there but then also confirmed that if regular staff did not know where to locate it, it wasn't being used. Out of date items The Wisconsin State Food Code at ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking indicates: .Commercially processed food open and hold cold refrigerated, ready to eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked at the time the original container is opened in a food establishment and, if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in paragraph (A) of this section and; (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. On [DATE] during the initial kitchen tour, Surveyor noted the following items were past the best by or manufacturer's expiration date: ~1 - ,d+[DATE] full non -original container of granola that was marked with a use by date of [DATE]. ~5 - 1 quart 14 ounce containers of [NAME] Ready Care Thickened Cranberry Cocktail with a Manufacturer's Expiration Date of January of 2022. These containers were also marked with a received date of ,d+[DATE] and DM-C indicated these containers were just delivered last week. ~3 - 1 quart 14 ounce containers of [NAME] Ready Care Thickened Cranberry Cocktail with a Manufacturer's Expiration Date of September of 2022. These 3 containers were hand marked with a received date of ,d+[DATE]. On [DATE] during the initial kitchen interview DM-C indicated the expectation that staff should be looking at dates when putting items away. DM-C also indicated the expectation that items should not be expired.

Based on observation, interview and policy review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored and distributed. This has the potential to affect all 41 residents who reside in the facility. Surveyor observed expired thickened ice tea and an undated Mighty Shake for when it was taken from the freezer in the Nurse's Station refrigerator; opened, undated gallon of milk in the refrigerator on Anna's House Unit; and a dirty ice machine. Evidenced by: The facility policy & procedure, Ice Machine, states: Ice machines will be used and maintained to assure a safe and sanitary supply of ice. The facility policy & procedure, Food Safety, states: #5. Bottled juices, such as prune juice, thickened liquid bottles and cartons, need to be labeled with a date opened and are good for 7 days. On [DATE] at 8:09 AM, Surveyor did the initial tour of the kitchen; then viewed the different kitchen areas on Units and Nurse's Station. Surveyor interviewed DS H (Dietary Supervisor) who stated the Mighty Shakes were dated with the day they were taken from the freezer and were only good for 14 days. In the Nurse's Station refrigerator, Surveyor observed a Mighty Shake that was not dated, when it was taken from the freezer, and thicken iced tea that was opened and dated ,[DATE]. The iced tea stated on the label that it was good for 10 days after it was opened. In the Anna's House Unit refrigerator Surveyor observed a gallon of 2% milk open and not dated. On [DATE] at 9:26 AM, Surveyor viewed the facility's ice machine in a Supply Room that had pink and dark spots in corners of the plastic spout that ice comes out of. DM I (Dietary Manager) contacted MS G (Maintenance Staff), who is responsible for scheduling the ice machine to be cleaned. MS G used a glove and was able to move the pink substance around on the plastic spout and some of the darker colored substance. MS G later gave Surveyor the cleaning schedule and the next scheduled cleaning date would have been [DATE]. On [DATE] at 8:10 AM, Surveyor interviewed DM I who agreed the items on the Units should have been dated if opened or discarded if expired.

Based on interview and record review, the facility did not develop and implement an effective Discharge Plan that focused on the resident's discharge goals for 1 of 1 resident (R40) reviewed for Discharge Planning. The facility did not include regular re-evaluation of R40 to identify changes that require modification of the Discharge Plan and updating it to reflect changes or have evidence that the resident was involved with updating the Discharge Care Plan with changes. Evidenced by: R40 was admitted to the facility, on 6/11/18, with [DIAGNOSES REDACTED]. R40 was responsible for making own decisions. R40's care plan, created on 6/11/18, for desire to return home / need to evaluate potential for discharge to less restrictive environment states R40's discharge destination was uncertain. The only other item on the Discharge Care Plan stated that (Managed Care Organization) case manager would assist. The Home Care Plan review was signed by R40 on 6/18/18 R40's Social Service Note, dated 8/1/18, states, in part: .Resident upset that primary choice of assisted living placement will not accept (resident) so (resident) called (Managed Care Organization) Case Manager to discuss. (Case manager) told (R40) they were uncertain of D/C (discharge) plans at this time, but to continue paying the rent on (R40's) apartment. (R40's) other Case Manager is on vacation until 8/7/18 so we have to wait until then to discuss D/C plans. (R40) wishes to remain in (the facility). ADON C (Assistant Director of Nursing) and Executive Director (Nursing Home Administrator (NHA A) notified. Proceed. (Note that R40's care plan was not updated with R40's choice to go to an assisted living.) R40's Social Service Note, dated 8/22/18, states, in part: .Active D/C planning has begun and (Managed Care Organization) is working with (R40) on D/Cing to CBRF (Community Based Residential Facility) in (city resident wants to reside in) . Note that this was not updated on R40's care plan. R40's Physician Note, dated 9/11/18, states, in part: .Pt. (R40) reports not depressed but frustrated that not getting information about discharge plans. (R40) understands that not physically capable of going back to apartment but does feel that (R40) is ready to go to assisted living / CBRF even though (R40's) transfers are not quite perfect . Ideally (R40) sees self in (two cities where R40 would like to reside) . Again these preferences were not documented on Discharge Care Plan and there is no documentation of how the facility was working with R40 for discharge placement. R40's Physician Note, dated 11/13/18, states, in part: . (R40) states that more depressed as not accepted to (Facility) Assisted Living and will be going to (city resident doesn't want to reside in). (R40) states multiple s'x (times) that always been a (facility) resident and feels uncomfortable going somewhere (R40) does not know anyone. (R40) states would like a reason why (R40) has to go to (city resident doesn't want to reside in). (R40) feels that no one is listening and that no one cares about what is best for (R40) . Makes poor eye contact. Mood is more depressed. Affect is depressed and guarded . Denies SI (suicide ideation) but hopeless about situation . R40's Home Care Plan review was signed by facility staff on 7/17/18 and 9/6/18, but did not include R40's signature. On the care plan review, date of 11/19/18, R40 did sign the Care Plan Review Sheet. R40 was discharged to an assisted facility in (city resident did not want to live in) on 11/20/18. On 2/4/19 at 10:10 AM, Surveyor interviewed ADON C and SW D (Social Worker). ADON C stated that she was responsible for ensuring R40's Discharge Care Plan was updated as SW D was on leave. ADON C agreed it should have been updated with R40's preferences and changes in potential placement. Surveyor asked how often SW D would update the Discharge Care Plan. ADON C stated, Whenever we had a plan developed. ADON C stated that she did update R40 and on 11/19/18, when she reviewed R40's Discharge Care Plan with R40, resident was excited to discharge to the assisted living in (city resident did not want to reside in). They did not know if anyone had followed up with R40 after 11/13/18, when the Physician's Note was written, 11/19/18.

The facility did not ensure the resident environment remained as free of accident hazards as is possible for 2 of 6 residents (R6 and R27) reviewed for falls and the facility did not ensure each resident receives adequate supervision to prevent accidents for 1 of 1 resident (R10) reviewed for wandering. R6 did not have fall investigations or interventions for 3 falls. R27 did not have a fall intervention in place. R10's WanderGuard was not being checked for function. This is evidenced by: Example 1 The facility's policy and procedure entitled Falls Standards, dated 6/20/18, states, in part: .A root cause analysis will be performed. A preventative measure will be care planned, to help prevent further falls . Per R6's Nurses Notes: R6 had two falls on 12/11/18 and one fall on 12/25/18. The Nurses Notes document the falls, in part, as follows: 12/11/2018 01:45 PM - Writer was called to resident's room by CNA (Certified Nursing Assistant) at 1:45 PM. Resident was found on knees with elbows on bed. Resident denies hitting head and also denies pain. It appears as (R6) was self-transferring from wheelchair to bed. Resident is a red dot, (falls risk) but very frequently wheels self into room. Frequent safety checks are in place. VSS (vital signs stable). Neuro checks WNL (within normal limits). Will continue to monitor. (Spouse) updated. 12/11/2018 05:33 PM - Writer was called down to resident's room by dietary at 5:15 PM. Resident appeared to be self-transferring from bed to w/c (wheelchair). No injuries. Denies hitting head and pain. VSS. Neuro checks WNL. Will continue to monitor. (Spouse) updated. 12/25/2018 10:15 AM - Resident found sitting on the floor mat next to low bed. Resident stated was trying to get out of bed. Resident reminded to ask for assistance with transfers. Resident denies pain. Denies any injuries. VSS. No injuries noted. Resident assisted to the w/c. Will cont (continue) to monitor. The facility had no evidence that fall investigations were completed for the two falls on 12/11/18 or the fall on 12/25/18. The facility had no evidence that fall interventions were put into place for the two falls on 12/11/18 or the falls on 12/25/18. On 2/5/19 at 3:53 PM, Surveyor interviewed ADON C (Assistant Director of Nursing). Surveyor asked ADON C for the fall investigations for R6 for 12/11/18 and 12/25/18. ADON C went to retrieve and returned stating that the facility could not locate the fall investigations for those dates. On 2/6/19 at 8:54 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if there were fall investigations for R6 for 12/11/18 and 12/25/18. DON B stated, I don't have them, I've never not had them, but I'm unsure of where they are; they are missing right now. Surveyor asked DON B if the fall investigations are to be done for all falls, DON B said, Absolutely they are to be done. Surveyor asked DON B if the fall investigation included the interventions put into place for the fall. DON B stated, Yes, the interventions and root cause are completed in the investigation. Example 2 The facility did not have a dycem in R27's recliner per care plan. R27 was admitted to the facility, on 5/16/14, with [DIAGNOSES REDACTED]. R27's Quarterly MDS (Minimum Data Set), dated 12/17/18, indicates the following: R27's Brief Interview for Mental Status (BIMS) is 10, indicating moderate cognitive impairment. R27 requires limited assistance of 1 person to transfer, and supervision when walking in room. R27's care plan, dated 2/24/16, indicates: Problem: Altered mobility/potential for falls r/t (related to) hx (history) of falls with fx (fracture), impaired balance, intermittent confusion, dementia, DM II (Diabetes Mellitus Type 2) with insulin use. Long Term Goal Target Date: 4/3/19. See facility's standard protocol goals for altered mobility/falls. Approach: .Dycem in recliner. On 2/5/19 at 10:50 AM, Surveyor noted there was not a Dycem in R27's recliner. On 2/5/19 at 10:55 AM, Surveyor spoke with CNA J (Certified Nursing Assistant). Surveyor asked CNA J if there should be a Dycem in R27's recliner. CNA J stated, Yes. CNA J looked around the room, including in R27's wheelchair, and there was no Dycem. CNA J exited the room, returned with a Dycem and placed it in R27's recliner. On 2/5/19 at 1:50 PM, Surveyor spoke with DON B. Surveyor asked DON B if she expects staff to follow resident care plans. DON B stated, Yes. DON B agreed that R27's Dycem should have been in recliner per care plan. Example 3 R10 has dementia and documented wandering and exit seeking. The facility did not have evidence that R10's WanderGuard was checked daily to ensure it was working to keep resident safe. R10 has a [DIAGNOSES REDACTED]. R10's care plan with problem of Wandering, started 2/13/18, includes on the same date that R10 has a WanderGuard attached to walker. It also states to follow the facility protocol for wandering. The facility Wandering protocol includes to check the WanderGuard units daily to ensure optimal status and was revised in 5/2013. Surveyor viewed the WanderGuard in place on R10's walker during survey dates of 1/31/19, 2/4/19, and 2/5/19. The facility Progress Notes includes, in part, the following for R10: 12/3/2018 4:27 PM - Resident intermittently looking to leave, wanting to go look for car because (R10) had to get home. Easy to redirect with diversional conversation. 12/5/2018 9:46 AM - STCP (Short Term Care Plan): Resident continues with exit behavior stating, I need to get home and take care of the kids. Provided education and tried to redirect. Unsuccessful. Resident then sat in recliner and started raising voice with staff stating, You are all lying to me, I just want to take care of my kids. I did turn music on in common area which appeared to help. 12/10/2018 2:16 PM - Resident exit seeking intermittently throughout morning, stating needed to get home to the boys . knows sons are grown men but still needed to get home. Unable to state where home is, states used to live in (city) but not anymore. Able to be distracted by activities. 12/11/2018 6:06 PM - Resident exit seeking this shift. Wondering if resident's car is here. Wondering how to get home. (R10) states . small children at home to take care of. Was able to redirect and inform (R10) family knows that resident is here and family is taken care of. 1/3/2019 1:24 AM - (Recorded as Late Entry on 1/10/2019 1:25 AM) Weekly Summary: Psych Resident does cont (continues) to have exit-seeking behaviors usually in the evenings. Resident's memory is very short and has to be redirected often. 1/4/2019 6:54 AM - Resident has been awake since around 1:00 AM and has been exit seeking until the end of this N[NAME] (evening) shift. 1/25/2019 3:05 PM - Behavioral Team met . with decrease in exit seeking behaviors, seems easier to redirect. On 2/5/19 at 8:40 AM, Surveyor interviewed CNA SS F (CNA Support Staff). CNA SS F stated that R10 checks the WanderGuard daily when leaving the Unit. CNA SS F stated did not know where it was documented and did not document the WanderGuard checks. RN E (Registered Nurse) stated that nursing checks R10's WanderGuard to ensure it's working weekly and thought it would be documented on R10's Medication Administration Record. On 2/5/19 at 12:26 PM, Surveyor interviewed ADON C who viewed the Wandering protocol that included checking the WanderGuard daily. ADON C would look to find documentation. Surveyor was not provided any evidence of R10's WanderGuard being checked daily.

The facility did not provide medically-related social services to attain or maintain the highest practicable mental and psychosocial well-being of each resident for 1 of 15 sampled residents (R40). The facility had documented that R40 was frustrated about discharge, on 9/11/18, and hopeless about the situation, on 11/13/18, and did not ensure R40 received medically-related social services. As evidenced by: R40 was admitted to the facility, on 6/11/18, with [DIAGNOSES REDACTED]. R40's care plan, created on 6/11/18, for desire to return home / need to evaluate potential for discharge to less restrictive environment, states R40's discharge destination was uncertain. The only other item on the Discharge Care Plan stated that (Managed Care Organization) Case Manager would assist. R40's Social Service Note, dated 8/1/18, states, in part: .Resident upset that primary choice of assisted living placement will not accept (resident) so (resident) called (Managed Care Organization) Case Manager to discuss. (Case manager) told (R40) they were uncertain of D/C (discharge) plans at this time, but to continue paying the rent on (R40's) apartment. (R40's) other Case Manager is on vacation until 8/7/18 so we have to wait until then to discuss D/C plans. (R40) wishes to remain in (the facility). ADON C (Assistant Director of Nursing) and Executive Director (Nursing Home Administrator (NHA A)) notified. Proceed. R40's Social Service Note, dated 8/22/18, states, in part: .Active D/C planning has begun and (Managed Care Organization) is working with resident (R40) on D/Cing to CBRF (Community Based Residential Facility) in (city resident wants to reside in) . R40's Physician Note dated, 9/11/18, states, in part: . (R40) reports not depressed but frustrated that not getting information about discharge plans. (R40) understands not physically capable of going back to apartment but does feel .ready to go to assisted living / CBRF even though (R40's) transfers are not quite perfect . Ideally sees self in (two cities resident would like to live in) . There is no documentation of how the facility was working with R40 for discharge placement or if they addressed R40's frustration. R40's Physician Note, dated 11/13/18, states, in part: . (R40) states more depressed as not accepted to (Facility) Assisted Living and will be going to (city resident doesn't want to live in). R40 stated multiple s'x (times) that always been a (facility) resident and feels uncomfortable going somewhere where R40 does not know anyone. R40 states would like a reason why R40 has to go to (city where resident doesn't want to reside). R40 feels that no one is listening and no one cares about what is best for R40 . Makes poor eye contact. Mood is more depressed. Affect is depressed and guarded . Denies SI (suicide ideation) but hopeless about situation . On the care plan review, date of 11/19/18, R40 signed the Care Plan Review Sheet. R40 was discharged to an assisted facility in (city where resident doesn't want to reside) on 11/20/18. On 2/4/19 at 10:10 AM, Surveyor interviewed ADON C (Assisted Director of Nursing) and SW D (Social Worker). ADON C stated that she did update R40 and, on 11/19/18, when she reviewed R40's Discharge Care Plan with R40. She said R40 had no concerns at that time and was excited to discharge to the assisted living in (city where resident doesn't want to reside). They did not know if anyone had followed up with R40 after 11/13/18, when the Physician's Note was written, 11/19/18, when ADON C spoke with R40. On 2/5/19 at 12:42 PM, Surveyor interviewed DON B (Director of Nursing) who stated she would expect that the note from R40's physician, written on 11/13/18, be read by nursing staff or the ADON C and followed up on within 24 hours of the note being written. DON B agreed someone should have spoken with resident about statements included in the 11/13/18 Physician's Note.

Based on record review and interview, the facility did not ensure drug regimens are free from unnecessary [MEDICAL CONDITION] medications for 1 of 5 residents (R16) reviewed for unnecessary medications. R16 has a [DIAGNOSES REDACTED]. The facility did not ensure that R16 had a specific condition as diagnosed and documented in the Clinical Record and received a gradual dose reduction (GDR) unless clinically contraindicated. The facility did not have specific target behaviors monitored that were harmful or distressing for R16. Evidenced by: R16's Care Area Assessments, completed on 12/3/18, are, in part, as follows: Mood review . increased in mood score indicating moderate depression, discussed a recent fall and pain as likely reason for the increase. Remains on [MEDICAL CONDITION]; no changes noted. [MEDICAL CONDITION] Medication Use review it listed decline in health, dementia, [MEDICAL CONDITION], hallucinations, mood affective disorder, anxiety, severely cognitively impaired, and states takes [MEDICATION NAME] for [MEDICAL CONDITION] and [MEDICATION NAME] for anxiety. GDR indicated as clinically inappropriate. Staff to monitor mood and behavior. Behavioral Symptoms review it stated R16 has episodes of wandering, socially inappropriate behavior (not specifically described), and rejection of cares during look back period and discussed the non-pharmacological interventions in place. R16's care plan, started 11/18/16, includes, in part, the following: [DIAGNOSES REDACTED]. restlessness, inattention, disorganized thinking, forgetfulness, severe signs of cognitive impairment, wanders to seek something to do. Rejects care at times, calling out/yelling help me, wanders into peer's rooms, hallucinations, rummaging through things/rooms. R16's problem of altered socialization also includes little interest or pleasure in doing things. Has altered sleep pattern, anxiety, worried people are going to leave (R16), and has [MEDICAL CONDITION] medications. Care plan does not include specific hallucinations or chronic patterns of behavior that are harmful to self or others. R16's Physician order [REDACTED]. Started 3/14/17 [MEDICATION NAME] 75 mg at bedtime Started 7/11/17 [MEDICATION NAME] 30 mg at bedtime The facility had a separate system that included some behavior monitoring which stated: R16 is diagnosed with [REDACTED]. R16 has potential for hallucinations, delusions, restlessness, wandering, rejection of cares, inattention, disorganized thinking, calling/screaming out, and has severe signs and symptoms of cognitive impairments. If symptoms are present, offer purse to rummage through or hold, as gives comfort, offer coffee or ice cream, offer 1:1 (one-on-one) and hold hand. Enjoys holding hands and walking around the Memory Care Unit. Offer sleepy time tea. On 3/13/18, R16's Psychiatrist Order has circled [MEDICATION NAME] use when symptoms are significant enough that the resident is experiencing inconsolable/persistent distress, a significant decline in function, or substantial difficulty receiving care. It states no change in medication at that time and written as, Pt. (R16) with some impairment in sleep and less distress times. There is no documentation of specific times when R16 was distressed. An additional note, the same date by the Psychiatrist, includes, Will not decrease [MEDICATION NAME] as sleep is impaired. On 9/11/18, R16's Psychiatrist Order includes: [MEDICATION NAME] for paranoia and PRN (as needed) [MEDICATION NAME] for when not redirectable and used rarely (not in last 14 days). Changes would likely result in increased behavior and distress for patient. R16's documentation does not show any specific paranoid behaviors or what caused the distress for R16. R16's Weekly Progress Note, dated 1/30/19, states: R16 continues taking a combination of [MEDICAL CONDITION] medications. Including [MEDICATION NAME] qHS (every day at bedtime), [MEDICATION NAME] BID (twice daily), [MEDICATION NAME] qHS and [MEDICATION NAME] PRN. Shows no side effects of medications. Effectiveness varies as resident occasionally refuses medications. When medications are being taken regularly they do appear to be beneficial to resident's overall mood and behavior. Despite medication regimen, resident still wanders, becomes agitated, has delusions, illusions and hallucinations. Usually easily redirected by distraction or 1:1. PRN [MEDICATION NAME] used on bath days as needed for intervention. Surveyor requested any documentation for R16 which described specific incidences of delusions, hallucinations, or other distressing occurrences and none were provided during the survey. On 2/5/19 at 12:28 PM, Surveyor interviewed ADON C (Assistant Director of Nursing) who agreed that the facility's documentation of the behaviors for R16 did not show persistent behaviors that were harmful to self or others. She did agree that for a resident to warrant being on an antipsychotic, the resident would have persistent behavior that was harmful/distressing to themselves or others.

Based on interview and record review, the facility did not provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs for 3 of 41 residents (R21, R10, and R30) out of 2 of 2 medication carts observed. The facility has been administering eye drops that are expired and undated. Evidenced by: The facility policy, Eye Drop Instillation, revised ,[DATE], indicates the following: Expiration of eye drops is determined by the manufacturer's guideline. On [DATE] at 9:00 AM, while completing the Medication Storage and Labeling task, Surveyor observed the medication room and two medication carts with RN E (Registered Nurse). Surveyor observed the following expired eye drops: R21's Bausch & Lomb Muro eye drops with an opened date of [DATE]. R21's Sunmark Lubricant Eye Drop with an opened date of [DATE]. R10's 2 bottles of Refresh Tears (both opened) with no opened date. Both bottles were sent from the pharmacy [DATE]. R30's Rugby Artificial Tears Solution Lubricant Eye Drop with no opened date. The eye drop was sent from the pharmacy on [DATE]. Example 1 R21's Bausch & Lomb Muro 128 Sodium Chloride Hypertonicity Opthalmic Solution, 2% - Instill 1 drop into both eyes twice daily - Opened [DATE] - Expiration ,[DATE] On [DATE] at 9:02 AM, Surveyor asked RN E if R21 still receives these eye drops. RN E stated, Yes. Surveyor asked RN E what is the opened date on the Bausch & Lomb Muro eye drops. RN E stated, [DATE]. RN E stated the eye drop was sent from the pharmacy on [DATE]. Surveyor asked RN E if the eye drop was expired. RN E would check. R21 has physician's orders [REDACTED]. Example 2 R21's Sunmark Lubricant Eye Drop - Instill 1 drop into both eyes twice daily - Opened [DATE] - Filled [DATE] - Expiration ,[DATE]. On [DATE] at 9:03 AM, Surveyor asked RN E if R21 still receives these eye drops. RN E stated, Yes. Surveyor asked RN E what is the opened date on the Sunmark Lubricant Eye Drop. RN E stated, [DATE]. RN E stated the eye drop was sent from the pharmacy on [DATE]. Surveyor asked RN E if the eye drop was expired. RN E would check. R21 has physician's orders [REDACTED]. Example 3 R10's Refresh Tears 0.5% Lubricant Eye Drop (2 bottles) - Take as directed into eye(s) ,[DATE] times daily - No open date on either bottle - Filled [DATE] - Expiration ,[DATE] & ,[DATE]. The manufacturer guidelines for Refresh Tears indicate Discard 90 days after opening. On [DATE] at 9:04 AM, Surveyor asked RN E if there was an open date on either of these bottles. RN E stated, There is no open date on either bottle, so we would go with [DATE], the date they were sent from the pharmacy. Surveyor asked RN E if the eye drop was expired. RN E would check. R10 has physician's orders [REDACTED]. 5:00 AM - 10:00 AM, 10:00 AM - 1:00 PM, 2:15 PM - 6:00 PM, 6:00 PM - 10:00 PM Example 4 R30's Rugby NDC Artificial Tears Solution Lubricant Eye Drop - Instill 1 drop into both eyes as needed - No open date - Filled [DATE] - Expiration ,[DATE]. On [DATE] at 9:04 AM, Surveyor asked RN E if there was an opened date on the bottle. RN E stated, No, I would go with [DATE] since nobody dated it. Surveyor asked RN E if the eye drop was expired. RN E would check. R30 has physician's orders [REDACTED]. (It is important to note that the only manufacturer guideline that indicates a discard date after opening is Refresh Tears, as indicated above. The Muro, Sunmark and Rugby eye drops should have been discarded 28 days after opening. Facility staff should indicate when eye drops are opened in order to determine the expiration date.) The facility pharmacy provided the following information regarding the eye drops: Refresh Tears ([MEDICATION NAME] sodium solution) - Expiration Information per Package Insert: Medication expires after date indicated on product by the manufacturer if unopened. Once opened, product has an expiration date of 90 days and should be discarded 90 days from the date opened. Muro 128 (Sodium Chloride Solution) - Bausch & Lomb - Expiration Information per Package Insert: Medication expires after date indicated on product by the manufacturer. Sunmark Lubricating Tears (polyethylene [MEDICATION NAME] 400, [MEDICATION NAME] liquid) - Expiration Information per Package Insert: Medications expires after date indicated on product by the manufacturer. Rugby Artificial Tears ([MEDICATION NAME] alcohol solution) - Expiration Information per Package Insert: Medications expire after date indicated on product by manufacturer. On [DATE] at approximately 9:35 AM, RN E stated to Surveyor that the facility determines the expiration date by the manufacturer expiration date on the bottle. RN E stated that eye drops should be dated when opened. On [DATE] at 1:50 PM, Surveyor spoke with DON B (Director of Nursing). DON B stated it is the facility policy to follow manufacturer expiration dates. DON B stated the expiration date for eye drops is right on the bottle. After speaking with the Pharmacist, DON B stated the facility follows the manufacturer expiration on the bottle and the only exception is Refresh eye drops that are good for 90 days after date opened. Surveyor shared information with DON B regarding eye drops expiring 28 days after open date unless manufacturer guidelines state differently. DON B stated she was unaware of this information.

Based on interview and record review, the facility did not ensure residents are free from verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion in 1 of 4 total residents (R4). Facility staff member witnessed R1 reach over the top and into R4's shirt. This is evidenced by the following: R1's [DIAGNOSES REDACTED]. R1's most current MDS (Minimum Data Set), with an observation end date of 9/28/18, documents that R1 has a BIMS (Brief Interview for Mental Status) score of 1; however, R1 would not answer the questions for the BIMS test. Documentation shows R1 is alert to self and place. R1 is deaf and reads lips or uses a white board to communicate. On 10/2/18 at approximately 7:09 PM, R1 and R4 were sitting in the common area side by side near the Nurse's Station. R1 was witnessed by staff reaching over the top and into R4's shirt. R1 is alert and oriented to self and place and R4 has late stage dementia and is oriented to self. Upon witnessing the situation, staff immediately separated both residents from one another. Immediate 1:1 was initiated with R1. NHA (Nursing Home Administrator) and DON (Director of Nursing) were contacted. R4 provided no immediate ill effect from the event. Skin and pain assessments were completed with negative findings. R1 admitted to reaching into R4's shirt and touching R4's breast. Police was contacted due to the nature of the situation. Following questioning, R1 was escorted from the facility by the local police department. Facility's Medical Director was in the building during the time of the incident and was made aware. Both families were updated on the situation. The Officer Report, dated 10/4/18, documented that he interviewed R4 and R4 did not understand any questions he was asking her. The Officer Report, dated 10/4/18, documented the following: I interviewed R1 along with two resident workers. I asked questions and the worker wrote the questions on the white board. R1 is deaf. I asked if R1 knew why I was there. R1 shook head yes. I asked if R1 was grabbing the breast area of R4. R1 pointed to YES on the board. I asked R1 if R4 told him it was okay. He pointed to NO on the board. R1 understood what he did was wrong. He did not seem to be phased (sic) by it or show any regard. On 10/18/18 at 2:00 PM, Surveyor spoke with Social Worker C (SW). SW C stated the eerie part of the situation was when the Officer interviewed R1, He was aware what he did. SW C stated R1 would not answer questions related to his intention. The situation was viewed as abusive and the Officer did not give the facility a choice as to how they would proceed. The Officer only gave R1 two choices (go with his Sister, or go to jail) to prevent further abuse and to ensure safety of residents. SW C stated R1, who is his own person, wanted to go home. On 10/18/18 at 2:25 PM, Surveyor spoke with NHA A (Nursing Home Administrator). NHA A stated the Officer presented two options (above) to R1. NHA A stated this action was appropriate for the safety of our staff and other residents here. NHA A feels the resident being sent home with his Sister was appropriate, as this was an emergent situation of taking him out of the building. On 10/18/18 at approximately 3:10 PM, Surveyor spoke with DON B (Director of Nursing). DON B stated to Surveyor that R4's Activated Power of Attorney for Healthcare (APOAHC) would not let R4 remain a resident in the facility if R1 was a resident in the facility. The facility did not ensure that R4 was kept free from abuse by another resident. A reasonable person would not want a stranger to put their hand down their shirt.

Based on interview and record review, the facility did not consult with the resident's physician when there was a change in the resident's physical condition or a need to alter treatment for 2 of 10 residents (R) reviewed (R3 and R6). On 9/3/17 at 4:00 AM, R3 fell during an assisted transfer. R3 was holding her right knee, right knee had swelling and R3 was grimacing. Ice was applied to her right knee and [MEDICATION NAME] was given for pain. R3's physician, MD H (Medical Doctor) was sent a fax on 9/3/17. There was no direct physician contact made regarding R3's fall, knee swelling and increase in pain. On 9/4/17 at 11:05 PM, a physician was notified of R3's severe pain with passive range of motion (PROM). An order was given to send R3 to the ER (emergency room ) for evaluation. R3 was found to have a fractured right hip. Example 1 (R3) is being cited at a severity level 3. R6 developed a stage 2 pressure injury (PI) to right buttocks and an intact blister to medial right shin, after admission to the facility. There is no evidence that the facility immediately consulted with R6's physician. Evidenced by: The facility's Notification of Changes policy, dated 3/9/17, includes, in part, the following: It is the policy of (facility) that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident representative, according to their authority and reported to the attending physician or delegate. Procedure for Notification of Changes for Resident: 1. The nurse will immediately notify the resident, resident's physician and the resident's representative(s) for the following (list is not all inclusive): An accident involving the resident, which results in injury and has the potential for requiring physician intervention. A need to alter treatment significantly (a need to discontinue or change an existing form of treatment due to adverse consequences or to commence a new form of treatment). Example 1 R3's [DIAGNOSES REDACTED]. R3 is not her own decision maker. R3's most current MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 9/15/17 indicates R3 has severe cognitive impairment; needs extensive assistance of two persons for transfer. R3's Quarterly Fall Risk Assessment, dated 7/26/17, indicates R3 is at high risk for falls. R3's Incident/Accident Report, dated 9/3/17, included, in part, the following: 1. Date of Incident: 9/3/17. 2. Time of Incident: 0400 (4:00 AM). 3. Location of Incident: Res (Resident) room. 4. Description of what happened and position of Resident: Ambulating Res to day room from her room and lost her balance and was lowered to floor landing on R (Right) side. 7. Resident oriented? X (times) 1, No. 10. Pain Assessment/Results: Holds R knee, grimaces, non-verbal. Intervention including non-medicinal: Icepack to R knee. 21. Any decline in mobility: Yes, was unsteady. R3's Medical Record included the following Fax: Date: 9/3/17. To: (MD H). Resident: (R3). FYI Only: (R3) lost balance while ambulating (with) CNA (Certified Nursing Assistant) and fell /was lowered to floor. She has a bruised R elbow and R knee (with) some swelling present. Ice applied. Response: MD aware. Signed by: ADON J (Assistant Director of Nursing). Dated 9/5/17. R3's medical record included, in part, the following notes: 9/3/17 - 4:52 AM, CNA was ambulating resident out of room/bathroom to go out in the common area when (R3) lost her balance and was lowered to the floor in her room. She was lowered/falling onto right side. She has bruising to the right elbow and her right knee shows some bruising/swelling. Ice was applied to her knee and Tylenol was given. Fax was prepared for the MD and family will be notified in waking hours. Will continue to monitor. 9/3/17 - 10:23 PM, resident has stayed in bed this whole shift. Complains of pain in her right knee. Has some swelling in the knee area. PRN (as need) and scheduled [MEDICATION NAME] (pain pill) given. 9/4/17 - 4:53 AM, Resident continues to c/o (complain of) pain to right knee. Right knee noted to be swollen and tender to touch. Resident moaned when writer tried to do PROM. Writer had staff check and change her while in bed to help minimize pain. Will continue to monitor. (Of note, R3 presents with swelling, pain to include moaning with PROM and tenderness with touch to the right knee after a fall yet MD was not notified of these changes status [REDACTED]. 9/4/17 - 11:16 PM, Resident continues to c/o right knee pain with ROM (range of motion). Scheduled and PRN pain medications given with little effectiveness noted. In comparison to the left knee the right knee appears to be much more swollen. Ice pack was applied. Will continue to monitor. (Of note, R3 presents with increased swelling to the right knee - much more than compared to the left and pain after a fall yet MD was not notified of these changes status [REDACTED]. 9/5/17 - 3:30 AM, Resident noted to have increase pain to right knee beginning of shift. Resident had severe pain when writer tried to do PROM. PRN [MEDICATION NAME] given and ice applied to swollen knee. Writer updated on-call (physician's name) and he gave order to have resident evaluated at ER at 11:05 PM. Writer called and left message for 1st contact then called and talked with 2nd contact and they were in agreement for resident to be seen at ER for evaluation. Writer called non-emergency ambulance for resident to be transferred to (hospital name) ER. EMT's (Emergency Medical Technician) here at apprx (approximately) 11:25 PM and left with resident at 11:35 PM. At 1:45 AM (hospital name) ER nurse called and said resident has a fractured right hip and will be admitted to hospital for possible surgery. Right knee x-ray was negative. Family is with resident at hospital. Writer left message for DON (Director of Nursing). 9/6/17 - 9:07 AM, Out of sequence charting for 9/3/17. Res continues to have swollen knee and small bruises to right elbow. Daughter (daughter's name) called 9/3/17 AM, to update regarding res change in status. Explained to daughter that res was ambulating with CNA earlier this AM when Res started losing her balance and was eased to the ground. Per report from previous day shift nurse, res right knee had become swollen and was iced. This writer monitored res throughout day and when asking res if her knee hurt, while palpating, res stated, No. However, per CNA, when transferring res did c/o pain. PRN [MEDICATION NAME] given with effectiveness. Will cont (continue) to monitor. 9/6/17 - 9:14 AM, Out of sequence charting for 9/4/17. Res resting peacefully, however, when transferred by CNA res c/o pain. When this nurse assessed res, with CNA, res was rubbing her right knee. Right knee was swollen compared to left knee. No bruising noted. Right elbow examined again and continues with 2 small bruises. PRN [MEDICATION NAME] given with effectiveness, res resting in chair. R3 History and Physical, dated 9/5/17, included, in part, the following: (R3) is admitted for right intertrochanteric [MEDICAL CONDITION]. She resides at the memory care unit at (facility). Two days ago she was walking in her room and an aid helped her to the floor, as apparently she was falling. The following day she was having difficulty ambulating, so was brought to the (hospital name) Emergency Department for evaluation. The [MEDICAL CONDITION] was identified and she was admitted for surgical repair today. On 11/1/17 at 8:50 AM, Surveyor interviewed CNA I. CNA I stated she worked 9/4/17. CNA I stated R3 stayed in bed during the shift she worked, due to complaining of pain. CNA I stated R3 was very sleepy, not eating much, and not ambulating. On 11/1/17 at 9:05 AM, Surveyor interviewed RN C (Registered Nurse). RN C stated she was working when R3 fell . RN C stated she was called to R3's room to assess R3; she did not have any rotation of her legs or irregularities. RN C stated R3's knee did have some swelling. RN C stated she, along with other staff, stood R3 up and ambulated her to the day room. R3 did grimace with leg movement and R3's right knee was iced. RN C stated the knee swelling was a change for R3 and she told the oncoming nurse to monitor the knee and update the family regarding the fall. RN C stated she should have called the MD on-call to update about R3's knee. RN C stated she did fax MD H about the fall on 9/3/17. On 11/1/17 at 9:30 AM, Surveyor interviewed MD H via telephone. MD H stated he was not on call 9/3/17 or 9/4/17. MD H stated when a fax comes to him it sits in queue in the clinic computer system until someone retrieves it. MD H stated the fax the facility sent was received 9/6/17, due to holiday weekend, and was not responded to, because it was informational only. MD H stated he would have expected the facility to contact the physician on-call after R3's fall, especially since there was knee pain and swelling, as this was a change in condition for R3. On 11/1/17 at 10:45 AM, Surveyor interviewed DON B. DON B stated she did an investigation into R3's fall. DON B stated she realized that R3's physician or physician on-call should have been notified of her change in condition after falling, as her knee swelling and pain was not usual for R3. On 9/3/17 at 4:00 AM, R3 had a fall. R3's right knee had swelling and pain. R3 continued to complain of right knee pain and had right knee swelling. R3 received pain medications to treat the pain; the medications were not always effective. R3's physician, MD H, was faxed, regarding R3's fall. The facility did not call a physician until 31 hours after R3's fall. R3 was sent to the ER and found to have a right [MEDICAL CONDITION] which needed surgical intervention. Example 2 R6 is a long term resident at the facility. Her MDS, completed 10/11/17, states that she scored modified independence for the staff assessment for mental status. R6's [DIAGNOSES REDACTED]. R6 transfers and ambulates with 1 assist and walker. Per Pressure, Vascular and Diabetic Injury Treatment Policy and Procedure, dated 8/2017, . a. Upon discovering a resident with a pressure, vascular or diabetic wound, the nurse shall perform the following . f. Notify provider of wound Per Nurse's Note, dated 10/26/17, it states, in part, .She also has 2 new sores on the buttocks . (There is no evidence that R6's physician was consulted.) Per R6's Physician order [REDACTED]. (It is important to note that during wound observation, on 10/31/17, RN C removed a dressing from the right buttocks.) Per Nurse's Note, dated 10/30/17, it states, in part, .she has a new fluid filled blister on her right anterior shin . (There is no evidence that R6's physician was consulted.) Per R6's Physician order [REDACTED]. (It is important to note: during wound observation, on 10/31/17, RN C removed a dressing from right shin; the right shin was noted to have a popped blister.) On 11/1/17 at 3:25 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B when she would expect the physician to be updated about a pressure injury or wound of any type; DON B stated physician should be updated upon seeing wound.

Based on observation and interview, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 36 residents who reside in the facility. DA E (Dietary Aide) was observed washing her hands in the pot sink and drying her hands with a rag, prior to working with clean dishes in the dish room. The meat slicer was observed with dry food particles on the working surface. The large Hobart mixer was observed with dry food particles on the undercarriage. The juices, in the juice machines in the main dining room and cottage area, did not have an open date or use by date. Evidenced by: The facility's Hand Washing policy, dated 7/2011, includes, in part, the following: 6. Dry hands on paper toweling. 7. Turn off faucets with paper toweling - do not touch faucet handles with your hands. The facility's Sanitation and Sanitizer policy, dated 7/2016, includes, in part, the following: 3. All utensils, counters, shelves, and equipment will be kept clean, maintained in good repair, and will be free from breaks, corrosions, open seams, cracks and chipped areas. The facility's Food Safety policy, dated 8/2016, includes, in part, the following: 5. Bottled juices, such as prune juice, thickened liquid bottles and cartons, need to be labeled with a date when opened and are good for 7 days. Label and write a use by date. Dispose of on the 7th day. Example 1 On 10/30/17 at 9:17 AM, Surveyor observed DA E wash her hands in the dish room pot sink using Dawn dish soap, touching the sprayer faucet with her bare hands when rinsing her hands, and drying her hands on a rag. DA E did this twice, using the same rag to dry her hands. DA E then worked with the clean dishes and moved a rack of clean dishes to a cart, after each time she washed her hands. On 10/30/17 at 9:17 AM, Surveyor interviewed DA E regarding her hand washing. DA E stated she always washes her hands in the pot sink, with Dawn dish soap, when she works in the dish room. However, she should have grabbed a new rag when drying her hands. On 10/30/17 at 9:40 AM, Surveyor interviewed DC F (Dietary Coordinator). DC F stated she would expect DA E to go to the hand sink to wash her hands and use disposable paper towels to dry them. Example 2 On 10/30/17 at 9:30 AM, Surveyor observed the meat slicer and the large Hobart mixer in the kitchen. Both pieces of equipment were covered and staff indicated this meant they were clean. The meat slicer had dried food particles on the working surface and the large Hobart mixer had dry food particles on the undercarriage. On 10/30/17 at 9:30 AM, Surveyor interviewed DC F. DC F stated all equipment should be cleaned after each use and prior to covering. DC F asked staff to clean the equipment. Example 3 On 10/30/17 at 9:45 AM, Surveyor observed the juice machine in the main dining room. The apple juice, cranberry cocktail juice, grape cocktail juice, and orange juice containers did not have an open date or a use by date on them. On 10/30/17 at 10:45, Surveyor interviewed DC F. DC F stated she would expect all juice containers to be dated when they were open and to be disposed of in 7 days if not used by then. On 10/30/17 at 1:05 PM, Surveyor observed the juice machine in the cottage area. The apple juice, strawberry kiwi flavored water, tropical mango flavored water, and lemon lime citrus flavored water containers did not have an open date or a use by date on them.

Based on observation, interview, and record review, the facility did not ensure that it was free of medication rates of five percent or greater. Two errors, out of twenty seven opportunities, resulted in an error rate of 7.40%. R12 has an order for [REDACTED]. This resulted in a medication error. R11 has an order for [REDACTED]. This resulted in a medication error. This is evidence by: Example 1 R12's Physician Orders, signed on 10/26/17, state the following: [MEDICATION NAME] (insulin [MEDICATION NAME]) solution 100 unit/ml (milliliter); amt (amount): 8 units; subcutaneous Dx (diagnosis) Type 2 diabetes mellitus with unspecified diabetic retinopathy without [MEDICATION NAME]. Once a day: Noon On 10/31/17 at 11:50 AM, Surveyor observed RN C administered 7 units of scheduled [MEDICATION NAME]. RN C administered 1 unit less [MEDICATION NAME] than was ordered. This resulted in a dosing error. Example 2 R11's Telephone Order, dated 10/31/17, states, as follows: Start [MEDICATION NAME] 40 mg PO (by mouth) QD (once a day). On 11/1/17 at 9:00 AM, Surveyor observed LPN K administer 20 mg of NAME]. The order was for 40 mg of Pantoprazole. This resulted in a dosing error. On 11/1/17 at 3:45 PM, Surveyor spoke with DON B. Surveyor asked DON B if she expects staff to follow Physician Orders. DON B stated, Yes. Surveyor informed DON B of the medication error rate of 7.40 %. DON B agreed that the medications for R12 and R11 should have been administered as ordered.

Based on observation, interview and record review, the facility did not ensure a resident receives care, consistent with professional standards of practice, to prevent pressure injuries and does not develop pressure injuries, unless the individual's clinical condition demonstrates that they were unavoidable. The facility did not have evidence, that upon development, the pressure injury was assessed and measured or that an order for [REDACTED]. R6 developed a stage 2 PI (Pressure Injury) to R buttocks after admission to the facility. A Nurse's Note, dated 10/26/17, documents the development of the PI. There is no evidence that the PI was assessed and measured upon discovery or that an order was obtained for treatment for [REDACTED]. Evidenced by: R6 is a long term resident at the facility. Her MDS, completed 10/11/17, states, in part, that she scored modified independence for the staff assessment and for mental status. R6's [DIAGNOSES REDACTED]. R6 transfers and ambulates with 1 assist and walker. Per R6's Pressure Ulcers Care Area Assessment (CAA), completed 10/11/17, documents, in part, .Current Braden score of 17 indicates at risk for pressure ulcers. No pressure ulcers currently present .History (Hx) of healed pressure ulcers . Per Pressure, Vascular and Diabetic Injury Treatment Policy and Procedure, dated 8/2017, .II. TREAMENT OF PRESSURE ULCERS . a. Upon discovering a resident with a pressure, vascular or diabetic wound, the nurse shall perform the following: i. Documents on the Initial Wound Evaluation form describing the following characteristics: .f. Notify provider of wound . Per Braden Skin Assessment on 10/6/17, R6 scored a 17 indicating that she is at risk for PI's. R6's Braden scores have all been 17 on the following dates: 9/18/17, 9/11/17, 9/4/17, and 8/28/17. R6's care plan, that the CNA's utilize, state, in part; Potential for Alteration in Skin Integrity, initiated 8/28/17 and last reviewed/revised on 10/24/17, does not document PI to R buttocks; Approach, dated 8/28/17, barrier cream to buttock; Special Skin Care, other barrier cream buttocks. Per R6's Physician Orders, for 10/1/17-10/31/17, do not contain any orders for wound care to R buttocks. Per Nurse's Note, dated 10/26/17, states, in part, .She also has 2 new sores on the buttocks . Wound Evaluation Flow Sheet, the first measurement documentation for PI to R buttocks, is 11/1/17. Per R6's physician's orders [REDACTED]. On 10/31/17 at 9:15 AM, Surveyor observed CNA D ambulate R6 from w/c (wheelchair) in room to bathroom. RN C donned gloves, assisted with pulling down pants and a dressing was removed from R6's R buttocks. RN C washed hands and stepped out of bathroom. Upon return, RN C had a new dressing in hand. RN C donned gloves, applied NS to gauze, cleansed wound to R buttocks and then covered with [MEDICATION NAME] dressing. On 10/31/17 at 11:50 AM, Surveyor interviewed RN C. Surveyor asked RN C when wound would be measured. RN C stated she would do wound rounds tomorrow, seen as she was on the floor today and a new sheet would be started then. On 11/1/17 at 8:50 AM, Surveyor interviewed RN C. Surveyor asked RN C if she had the wound documentation for R6. RN C explained that she had not measured wound yet, because R6's physician was coming in on rounds and she wanted him to observe. On 11/1/17 at 2:25 PM, Surveyor interviewed RN C. Surveyor asked RN C if R6's physician had been in yet and if wound documentation could be viewed. RN C handed Surveyor Wound Evaluation Flow Sheet. (It is important to note that the Wound Evaluation Flow Sheet, given to Surveyor at this time, did not include an evaluation for R6's right buttocks.) Surveyor asked RN C where the sheet was for the right buttocks. RN C stated she had it in the office. On 11/1/17 at 3:10 PM, Surveyor interviewed RN C. Surveyor asked RN C the stage of the wound on R6's R buttocks; RN C stated stage 2. Surveyor asked RN C if she is wound care certified. RN C explained that she is not, but would like to be, and that she recently took over the wound care in the facility. Surveyor asked RN C to locate documentation on the development of stage 2 PI to the R buttocks; RN C said she would look. On 11/1/17 at 3:25 PM, Surveyor interviewed DON B. Surveyor asked DON B when she would expect the physician to be updated about a PI. DON B stated physician should be updated upon seeing the wound. On 11/1/17 at 4:30 PM, Surveyor interviewed RN C. Surveyor asked RN C if she had found when the PI to R6's R buttocks developed. RN C stated, I can't find it, I'm just not sure. R6 developed an in-house stage 2 PI. The facility did not have evidence, that upon development, the PI was assessed and measured or that an order for [REDACTED].>

Based on observation, staff interview and record review, the facility did not store, prepare, distribute and serve food under sanitary conditions. The quat (quaternary) sanitizer was below the required 200 ppm (parts per million) from the automated dispenser that staff use to fill the red buckets and use to sanitize food preparation areas, food contact and non food contact surfaces, resident tables and clean equipment. DC (dietary cook)-B did not follow the manufacturer's directions for the use of the quat test strips, to ensure an accurate test result for staff to know if the quat sanitizer solution was at the proper concentration for sanitization. Findings include: The 2013 Federal Food Code's preface I indicates most foodborne illnesses occur in persons who are not part of recognized outbreaks. For many victims foodborne illness results only in discomfort or lost time from the job. For ....older adults in health care facilities, and those with impaired immune systems, foodborne illness is more serious and may be life threatening. In addition, the 2013 Federal Food Code's preface 1 indicates epidemiological outbreak data repeatedly identify five major risk factors related to employee behaviors and preparation practices in retail and food service establishments including contaminated equipment. On 8/11/14 at 3:45 p.m., DA (Dietary Aide)-A verified to surveyor # that the facility uses the 2013 Federal Food Code as their standard of practice. DA-A was filling in for the Dietary Manager who was unavailable during survey. The "QAC QR Test Strips (FMP Franklin Machine Products)" direct staff to dip the test strip in the quat sanitizer solution for 1 to 2 seconds and compare the strip to the color chart within 10 seconds. On 8/19/14 at 9:11 a.m., DA-E filled a red bucket from the automatic quat dispenser in the mop room to be tested for concentration of the quat solution. On 8/19/14 at 9:35 a.m., surveyor # interviewed DC (Dietary Cook)-B regarding routinely testing the quat sanitizer solution in the red buckets. DC-B stated that she routinely tested the solution. At that time, surveyor # asked DC-B to test the concentration of the quat sanitizer solution in the red bucket that had been filled by DA-E at 9:11 a.m. DC-B swished the test strip back and forth in the quat sanitizer solution for 5 to 6 seconds. Surveyor # could see the pad on the test strip turning dark in color and DC-E removed the test strip and compared it to the color chart immediately. The test strip indicated the quat was at 200 ppm. On 8/19/14 at 9:37 a.m., surveyor # reviewed the instructions on the QAC QR Test Strips with DC-B. Surveyor # checked the temperature of the quat sanitizer solution and it was 80.7 degrees F. Afterwards, surveyor # in the presence of DC-B and DA-A tested the quat sanitizer solution and it was 100 ppm. Surveyor # tested the quat sanitizer solution a second time and again it was 100 ppm, this was verified by DA-A. At 9:38 p.m., DA-A verified that the quat solution should be at 200 ppm. When asked, DA-A verified staff used the quat sanitizer solution to sanitizer the food preparation areas, food and nonfood contact areas, clean equipment and the resident tables. On 8/19/14 at 9:43 a.m., surveyor # observed MD (Maintenance Director)-C by the automatic quat dispenser and he indicated the orfice may need changing. When asked, MD-C indicated the orfice controls the amount of quat chemical mixed into the water by the dispenser. On 8/19/14 at 8:45 a.m., DA-A informed surveyor # that she tested the quat sanitizer solution yesterday at approximately 2:30 p.m., and it was at 200 ppm. DA-A also verified to surveyor # that she was knowledgeable regarding the directions and followed them when she tested the quat sanitizer solution. On 8/19/14 at 10:58 a.m., NHA (Nursing Home Administrator)-D informed surveyor # that MD-C found "...a speck in the orfice" that caused the concentration of the quat sanitizer solution to be too low. MD-C tested the quat sanitizer from the automatic dispenser and it was again 200 ppm for proper sanitization.

Based on observation, interview and record review, the facility did not ensure that 1 (resident #7) of 2 sampled residents reviewed for peri care, received the necessary care and services to prevent UTI's (Urinary Tract Infection). Resident #7 had an episode of urinary incontinence. During an observation of care, CNA (Certified Nursing Assistant)-I cleansed the resident's urethral area with a back and forth motion, which could put the resident at risk for a UTI. Findings include: According to the facility's procedure "Providing Perineal Care for Incontinent Residents," dated 4/2011, staff are to wash the entire perineal area with a soapy washcloth, moving from front to back, while using a clean area of the washcloth or clean washcloth with each stroke. On 8/20/14, at 9:25 a.m., surveyor # observed CNA-I provide perineal care for resident #7, after an episode of urinary incontinence. CNA-I removed resident #7's incontinent brief, then washed hands and applied gloves. CNA-I reached from behind resident, and with a soapy cloth, cleansed the urethral area with a back-and-forth scrubbing motion. On 8/20/14 at 9:45 a.m., surveyor # interviewed CNA-I regarding the observation. CNA-I stated "I know I should use a front-to-back motion. I had to use my left (non-dominant) hand because of how the resident was standing, and I didn't want to ask her to move."

Based on record review, observations, staff and resident interviews, the facility did not ensure 1 (resident #7) of 6 sampled residents reviewed for pressure ulcers, received the necessary treatment and services to prevent pressure ulcers, and to promote healing and prevent infections in existing pressure ulcers. Resident #7 was assessed to be at risk for pressure ulcers and was being treated for [REDACTED]. May also present as an intact or open/ruptured blister). Although resident #7 sat on a pressure redistribution cushion while in a wheelchair at the facility, the [MEDICAL TREATMENT] center was not made aware of the need for using the cushion. LPN-H did not appropriately complete hand hygiene during a wound dressing change, putting resident #7 at further risk for infection in the wound. Findings include: The Quick Reference Guide entitled "Pressure Ulcer Prevention", published in 2009 by the National Pressure Advisory Panel indicated to limit the time an individual spends seated in a chair without pressure relief. Use a pressure redistributing seat cushion for individuals sitting in a chair whose mobility is reduced and who are thus at risk of pressure ulcer development. When an individual is seated in a chair, the weight of the body causes the greatest exposure to pressure to occur over the ischial tuberosities. As the loaded area in such cases is relatively small, the pressure will be high; therefore, without pressure relief, a pressure ulcer will occur very quickly. The use of repositioning should be considered in all at risk individuals. Repositioning should be undertaken to reduce the duration and magnitude of pressure over vulnerable areas of the body. High pressures over bony prominence's, for a short period of time, and low pressures over bony prominence's, for a long period of time, are equally damaging. On 8/18/14, surveyor # reviewed resident #7's medical record. According to resident #7's Braden assessment dated [DATE], the score of 18 indicated that the resident was at risk for developing pressure ulcers. The resident's care plan entitled" Potential for Alteration in Skin Integrity", dated 7/17/14, also contained within the medical record, indicated resident #7 had risk factors of decreased mobility, incontinence and [MEDICAL CONDITION] (End Stage [MEDICAL CONDITION]) and listed the facility's 1/2013 "Standard Skin Care Protocol". One of the interventions listed included: "Obtain pressure-reducing cushion...for residents that consistently use a wheelchair." Resident #7's latest wound evaluation sheet, dated 8/12/14, documented that resident #7 had a healed, stage II right buttock wound, and a stage II wound, measuring 2.1 cm (centimeters) in length and 0.5 cm in width, with a depth of less than 0.1 cm. Interventions documented on this wound sheet included the use of an air mattress and wheelchair (pressure redistribution) cushion. On 8/19/14 at 12:10, surveyor # interviewed ADON (Assistant Director of Nursing)-F regarding resident #7. ADON-F indicated resident #7 had one stage II pressure ulcer to the buttock area and a healed pressure ulcer. In regard to the time resident #7 spent sitting in a chair, ADON-F indicated resident #7 received [MEDICAL TREATMENT] treatments 3 times per week and verified the 3 hour-minimum [MEDICAL TREATMENT] treatment, and transportation, provided "long periods" of time sitting for the resident. ADON-F confirmed that issues regarding resident #7's pressure ulcer had not been communicated to the [MEDICAL TREATMENT] center and communication only happens "if something unusual occurs." On 8/20/14 at 9:30 a.m., surveyor # observed LPN (Licensed Practical Nurse)-H provide wound care/dressing change to resident #7's right buttock area. While wearing gloves, LPN-H removed the resident's soiled dressing. While wearing the same soiled gloves, LPN-H cleansed the wounds with gauze and saline and then applied a clean dressing, touching the outer edge of the clean dressing before applying it to resident #7's wounds. On 8/20/14 at 9:40 a.m., surveyor # interviewed LPN-H regarding the observation. LPN-H stated "I should have changed gloves and washed my hands. I usually do." On 8/21/14 at 8:20 a.m., surveyor # interviewed resident #7 regarding [MEDICAL TREATMENT] appointments. The resident stated "It's too much sitting...It's hard on my bottom." Resident #7 confirmed using a (pressure redistribution) cushion while at [MEDICAL TREATMENT] only the past two appointments, on 8/18/14 and 8/20/14.

Based on record review and staff interviews, the facility did not provide the necessary care and services for 1 (resident #7) of 3 residents reviewed for [MEDICAL TREATMENT] treatments, to attain or maintain the highest practicable well being in accordance with their care plan. Resident #7 routinely left the facility to obtain [MEDICAL TREATMENT] services. The facility did not secure an agreement/arrangement with the [MEDICAL TREATMENT] center to address all aspects of how the resident's care was to be managed, to include: the interchange of information useful/necessary for the care of the resident and the development and implementation of the resident's care plan. Finding's include: On 8/18/14, surveyor # reviewed resident #7's Plan of Care which indicated the resident received [MEDICAL TREATMENT] Monday, Wednesday and Friday of each week. On 8/19/14, at 12:10 p.m., surveyor # interviewed ADON (Assistant Director of Nursing)-F regarding resident #7. ADON-F indicated that communication between the facility and the [MEDICAL TREATMENT] center did not take place, "unless something unusual occurs." On 8/21/14 at 8:05 a.m., surveyor # interviewed DON (Director of Nursing)-G regarding resident #7. DON-G stated the facility used a notebook for each resident, to communicate with [MEDICAL TREATMENT] centers. DON-G indicated that the facility did not utilize a notebook for resident #7 to communicate with the [MEDICAL TREATMENT] center. When asked about how the facility and [MEDICAL TREATMENT] communicated, DON-G replied "nothing formal, nothing in writing." On 8/21/14 at 8:45 a.m., surveyor # interviewed NHA(Nursing Home Administrator)-D regarding communication with the [MEDICAL TREATMENT] center for resident #7. NHA-D stated "No we don't have any arrangement. We haven't seen a need for it. If problems arise we can discuss it...there are notebooks used."