Every finding on record at Meadowbrook at Bloomer

Based on observation, interview and record review the facility did not store, prepare, or serve food in a sanitary manner. This has the potential to affect all 30 residents. ~Staff did not consistently perform hand washing during food service.~Staff did not consistently take temperatures prior to food service.~Staff did not store cold and frozen foods in a timely manner after receiving food delivery.~Surveyor observed refrigerator/freezer logs incomplete on 3 separate units.~Surveyor observed ice scoop cleaning logs not complete.~Surveyor noted dishwasher temperature logs not complete.~Surveyor observed an open gallon of milk without a date on it.~Surveyor observed tray line service audit (food temps) incomplete.~Surveyor observed [NAME] F not wearing a beard restraint. ~Surveyor observed [NAME] F touching ready to eat foods with contaminated gloves. Findings include: Example 1 The facility policy, titled Hand Washing, dated January 2021, states: Proper hand washing promotes safe food handling practices and infection control . 1. The following list includes, but is not limited to, when hands are washed: ~ When entering the kitchen ~ When hands are visibility soiled ~ Before applying gloves ~ After handling soiled utensil or dishes ~ During food preparation as often as necessary to remove soil and prevent cross contamination ~ When changing tasks ~ After removing gloves or aprons. 3. Hands are washed using the following steps: ~check that soap and paper towels are available. ~ apply soap and lather using a rotating motion and friction to adequately clean surfaces including the backs of hands and fingernails for at least 15 seconds; do not put hands back under water during friction rub. At 11:25 AM, Surveyor entered the kitchen and observed [NAME] I's hands on the door and preparing to leave the kitchen. [NAME] I went over to the food prep area, did not wash hands prior to putting on gloves and took the spatula and started to plate cake and adjust some slices of cake on serving plates. At 11:27 AM, Surveyor observed [NAME] I touching the stove and moving items around on the stove. [NAME] P told [NAME] I that a resident wanted a hamburger. [NAME] I put gloves on without performing hand hygiene. Surveyor observed [NAME] I grab a hamburger from the freezer. [NAME] I removed gloves and did not wash hands. At 11:58 AM, Surveyor observed [NAME] L return to the kitchen. [NAME] L did not perform hand hygiene. [NAME] L put gloves on without completing hand hygiene, opened a can of tuna, added mayo, took out two slices of bread and made a tuna sandwich. At 11:59 AM, Surveyor observed Dietary Manager (DM) J enter the kitchen. DM J stood next to the food service line. DM J did not wash DM J's hands upon entering the kitchen. At 12:02 PM, Surveyor observed DM J go to the sink to wash hands. Surveyor observed DM J wash DM J's hands for about 8 seconds. At 12:05 PM, Surveyor observed [NAME] I return to the kitchen. [NAME] I did not wash [NAME] I's hands upon entering the kitchen. [NAME] I started dishing up food. [NAME] I did not complete hand hygiene prior to starting food service line. At 12:06 PM, Surveyor observed [NAME] I step away from the service area and leave the kitchen. [NAME] I entered the kitchen and did not complete hand hygiene. [NAME] I started to blend chicken and made a chicken salad for a resident. At 12:08 PM, Surveyor observed DM J take the dirty blender cup to the dishwashing area. Surveyor observed DM J go to the hand-washing sink and wash DM J's hands for about 10 seconds. DM J continued working with trays for the smaller cart, then left the kitchen with the smaller cart of food. At 12:28 PM, Surveyor observed DM J return to the kitchen and wash DM J's hands for about 10 seconds. On 4/28/26 at 12:45 PM, Surveyor interviewed [NAME] I who stated you should wash your hands when you enter the kitchen, touch a doorknob, between different foods, or when you change gloves. Surveyor asked what about when you put on gloves. [NAME] I stated before you put on gloves. [NAME] I stated you should wash your hands for 20 seconds. On 4/28/26 at 12:54 PM, Surveyor interviewed DM J who stated in the kitchen you wash your hands all the time. DM J stated staff should wash their hands when they enter, touch doorknobs, between tasks, touch their face, touch garbage. You should wash hands for 30 seconds. Example 2 The facility policy titled, Storage, Prepare, Distribute and Serve Food, dated February 2026, states: PROCEDURE 1. Temperatures b. Food Temperature Record (FS-21/A) must be completed prior to the service of each meal . to ensure cold and hot foods are served at the proper temperatures. The facility policy titled, Food Temperature Record, dated February 2020, states: 7. Holding temperatures must be recorded on Food Temperature Records (FS-21/A) immediately prior to serving time and checked periodically as needed to maintain acceptable temperatures. 10. Temperatures must be checked and recorded separately for each steam table or serving area. On 4/28/26 at 11:18 AM, Surveyor observed [NAME] I remove food prepared for lunch meal out of the oven. Each pan of food was put in a like size pan with water on top of the stove top. Stove was turned on low. Surveyor did not observe [NAME] I take temperatures of food when it came out of the oven. On 4/28/26 at 11:34 AM, Surveyor observed [NAME] I dish the first meal of the day. [NAME] I did not take food temperatures prior to food service. On 4/28/26 at 12:14 PM, Surveyor observed [NAME] I take the empty pan of chicken and water off the stove and put it to the side. [NAME] I then took the new pan of chicken out of the oven and placed it directly on the stove and checked the temperature of the chicken. Chicken thermometer was fluctuating between 205-214 degrees. [NAME] I did not write the temperature down. On 4/28/26 at 12:16 PM, Surveyor observed [NAME] I take a pan of green beans out of the oven. [NAME] I took a strainer and dumped the green beans into it, draining all the hot liquid then [NAME] I took the temperature of the green beans. The temperature was 161 degrees. After taking the temperature of the green beans, [NAME] I put the pan over the top of the strainer like a loose cover. [NAME] I wrote the results down on a note pad stationed by the serving window. Surveyor observed the location where [NAME] I wrote the temperature in the note pad. On 4/28/26 at 12:24 PM, Surveyor observed [NAME] I take green beans from the strainer to blend for a resident's meal. [NAME] I did not get the temperature of the green beans that were sitting drained of liquid in a steamer pan prior to blending the food or serving. Surveyor asked [NAME] I how many trays she needed to prepare for minced and moist and pureed diet. [NAME] I stated she would have to count but she does them as needed every day. On 4/28/26 at 12:41 PM, Surveyor interviewed [NAME] I who stated DM J told [NAME] I to take the temperature log over to [NAME] I's work area and write directly in the log [NAME] I stated it is easier to write it on my note pad. Surveyor asked what [NAME] I does with the temperatures on the note pad. [NAME] I stated [NAME] I writes them on the form (temperature log) and proceeded to walk over to the temperature log. [NAME] I looked at [NAME] I's note pad for a few minutes, flipping the pages. [NAME] I stated I took temps, I know I did. [NAME] I stated this while looking at the note pad. [NAME] I stopped flipping pages and stated I think this 161 degrees Fahrenheit is the mashed potatoes. Surveyor asked if she took the temperature of the other foods prior to food service. [NAME] I stated I know I did. [NAME] I did not have temperatures recorded to transfer from the note pad to the temperature log. Surveyor stated to [NAME] I that Surveyor did not observe [NAME] I take any temperatures of the initial food, only the second pan of chicken and second pan of green beans. [NAME] I groaned, I should have taken the form over there and filled it out right away. Surveyor asked [NAME] I how do you ensure the food remains in a safe temperature range during food service. [NAME] I stated that [NAME] I takes the temperature when it comes out of the oven and prior to serving it. Surveyor asked how do you ensure it stays at temperature. [NAME] I stated I turn on the burners under the pan, like I had them on today. On 4/28/26 at 12:45 PM, Surveyor interviewed DM J regarding completing food temperature. DM J stated DM J expects everything is temped and written on the form (temperature log) right away. On 4/28/26 at 12:54 PM, Surveyor interviewed DM J on how the facility ensures safe temperatures of food during food service. DM J stated that food should be kept in pans on the lit stove top. DM J stated food should be temped at the right times. Surveyor asked what the right times are. DM J stated when it is done cooking and before serving it. DM J stated we do not take temperatures throughout food service, but DM J stated DM J does a test tray once a week. DM J says she used the last tray of the day for the test tray. On 4/28/26 at 1:00 PM, Surveyor requested the temperature logs from the past month. These were not received. Surveyor did receive a copy of the current week's temperature log and observed temperatures to be incomplete. Example 3 The facility policy titled Food Safety Requirements, dated February 2026, states: It is the Policy of this company that all facilities provide safe and sanitary storage, handling. of all foods. It is the policy of this facility to procure foods from sources approved or considered satisfactory by federal, state or local authorities. It is also the policy of this facility to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, including safe food handling by all dietary personnel and any other staff handling food, from the point of receiving through the preparation and service of the meal. The State Operations Manual section titled, Appendix PP, dated 7-23-25, states: ~ Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage. ~ Refrigerated Storage - PHF/TCS foods must be maintained at or below 41 degrees F (Fahrenheit), unless otherwise specified by law. ~ Frozen foods must be maintained at a temperature to keep the food frozen solid. ~ Danger Zone means temperatures above 41 degrees Fahrenheit (F) and below 135 degrees F that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness. Potentially Hazardous Foods (PHF) or Time/Temperature Control for Safety (TCS) Foods held in the danger zone for more than 4 hours (if being prepared from ingredients at ambient temperature) or 6 hours (if cooked and cooled) may cause a foodborne illness outbreak if consumed. On 4/29/26 at 11:04 AM, Surveyor entered the kitchen and observed boxes stacked up in front of the freezer and the walk-in cooler. [NAME] L opened the freezer door when Surveyor walked in the kitchen and started putting the boxes into the freezer. Surveyor asked [NAME] P when the delivery arrived. [NAME] P stated this morning. Surveyor asked [NAME] L to open the top box to see if items were still frozen. Surveyor observed the box to contain frozen bread. DM K touched the bread and stated it is not frozen and should be frozen. Surveyor observed the following items for the cooler were still outside on the floor, closest to the stove. DM K took the temperatures of the following items: ~ Chocolate Milk was 43.5 degrees Fahrenheit ~ [NAME] milk we 46.6 degrees Fahrenheit ~ Liquid eggs were 48.4 degrees Fahrenheit On 4/29/26 at 11:23 PM, Surveyor interviewed kitchen staff regarding the time the delivery came in. [NAME] P said it comes around 7:30AM. [NAME] I stated well I don't know. [NAME] I stated I think it came after breakfast was finished being served and we were going on break. [NAME] P said maybe after breakfast. Surveyor asked what time that was. [NAME] I said about 8:30 AM. DM K came back with the invoice; Surveyor observed there was no time of delivery on the invoice. DM K thinks the delivery was around 8:30 AM. [NAME] L said [NAME] L came in at 9:00 AM and hadn't had a chance to put anything away until now. On 4/29/26 at 11:15 AM, Surveyor asked DM K what the expectations are for storage of cold and frozen foods. DM K stated that milk should be 40 degrees, and frozen food should remain frozen, and it wasn't. DM K said DM K is going to call [NAME] Brothers for direction on food. DM K stated staff should put deliveries away right away. On 4/29/26 at 11:46 AM, Surveyor interviewed Nursing Home Administrator (NHA) A who stated the expectation is to put food away right away and maintain food safety. Facility policy titled, Refrigerator/Freezer Temperature Log revised last on February 2020, stated in part:Procedure1. Refrigerator/Freezer temperatures shall be recorded by the A.M. [NAME] or designee at the beginning of the morning shift.2. All refrigerators and freezers shall be identified by Refrigerator/Freezer key.3. All temperatures must be initialed by A.M. [NAME] or designee on the Refrigerator/Freezer Temperature Log.4. The following guidelines shall be used:a. Refrigerator: At or below 41 degrees Fahrenheit (F)b. Freezer at or below 0 degrees F5. Any readings in excess of the above guidelines must be reported immediately to Dietary Manager (DM) and /or Maintenance Supervisor.6. If temperatures are above guidelines for greater than 4 hours, all potentially hazardous foods must be placed in an alternative refrigerator or freezer until such time that temperatures are again within guidelines.7. The Refrigerator/Freezer Temperature Log shall be monitored for compliance by the DM or designee on a daily basis. Facility policy titled, Dishwashing Temperature Log revised last on February 2020 stated in part:Procedure1. Wash and rinse temperatures shall be documented for each meal on the Dish Machine Temperature Log form. In addition to temperature, for low temperature (chemical sanitizing) machines, concentration of sanitizer must also be recorded on form.2. All temperatures shall be initialed by the facility designee on the form The 2022 FDS Food Code documents at 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food: Disposition .A date marking system may be used which places information on the food, such as on an overwrap or on the food container, which identifies the first day of preparation, or alternatively, may identify the last day that the food may be sold or consumed on the premises. A date marking system may use calendar dates, days of the week, color coded marks, or other effective means, provided the system is disclosed to the Regulatory Authority upon request, during inspections. Example 4 Refrigerator/Freezer Logs On 04/27/2026 at 8:36 AM, Surveyor observed in the kitchen there were missing temperature recordings on the Refrigerator/Freezer Temperature Log when inspecting cold storage areas. The log was missing temperatures for April 23rd for AM and PM, 24th for AM, 25th for AM, 26th for AM. Example 5 Ice Scoop Cleaning LogOn 04/27/26 at 8:36 AM, Surveyor observed a log which was incomplete titled, Ice Scoop Cleaning Log. This log was missing initials for Breakfast and Lunch for the following dates April 23, 24, 25 and 26. Example 6 Dishwasher Temperature LogOn 04/27/2026 at 8:36 AM, Surveyor walked into the dishwashing area and noted the Dish Washer Temperature Log was missing temperatures and parts per million (PPM). The log was missing Wash/Rinse/PPM and initials for breakfast and lunch on April 24th, breakfast, lunch and supper for April 25th, breakfast and lunch for April 26th. Example 7 Temperature Logs On 04/27/2026 at 8:36 AM, Surveyor observed on the tray line service in the kitchen, a gallon of milk and no temp audit completed. Surveyor then opened the refrigerator which held the liquids for serving that were opened and noticed a gallon of milk with no opened date written on the outside of the jug. Surveyor asked [NAME] F, When you see an open gallon of milk with no date on it, do you serve it to the residents here? [NAME] F replied, No, I take it and throw it away. [NAME] F took the opened gallon of milk from the Surveyor's hands to dispose of it. At this time, [NAME] F pointed out the tray line service audit (food temps) log which was performed for breakfast for taking temperature of food items. Surveyor observed temperatures missing for breakfast: regular meat and dinner, milk/juice coffee temperatures from 4/26/26. On 04/27/2026 at 9:47 AM, Surveyor asked Dietary Manager (DM) J for the previous month's logs of the items found missing in the kitchen during initial tour. DM J indicated it may take some time as they are in the office or in a box somewhere. On 04/27/2026 at 10:00 AM, Surveyor followed DM J to the office where DM J found the other logs to provide Surveyor with a copy. On 04/27/2026 at 10:20 AM, Surveyor reviewed the logs provided by DM J as follows:Refrigerator/Freezer log for February was missing temperature on [DATE]st.Ice Scoop Cleaning log missing March 7th, 27th and 28th.Dishwashing Temperature Log missing March 1, 24, 25, 26, 27, 29, 30, 31.Food Temperature Record for the week of 4/5/26 through 4/12/26, showed a food temp item missing every day that week. For 4/5/26, 4/6/26, and 4/7/26 temperatures missing for regular meat at breakfast and 4/5/26, 4/6/26, 4/7/26, 5/8/26, and 4/9/26, missing Milk/Juice/Coffee temperatures for dinner. Regular meat temperature is missing for 4/10/26 and the dessert temperature is missing for 4/11/26. Example 8 On 04/27/2026 at 11:35 AM, Surveyor observed [NAME] F distribute food to the residents both on the carts to their rooms and trays brought out to the dining room while not wearing a beard restraint. Surveyor observed [NAME] F's facial hair was greater than 1/4 inch long and dark brown in color. Surveyor observed [NAME] F wearing single use gloves touching tray service line counter, serving utensils, opening a bag of bread, and touching plates. Surveyor observed [NAME] F cut a toasted cheese sandwich into small pieces with a knife then pick up the toasted cheese sandwich with the same contaminated gloves and plate for a resident. On 04/27/2026 at 11:48 AM, Surveyor informed DM J of the observations with no beard restraint and touching ready to eat foods with potentially contaminated gloves. DM J informed Surveyor this was not acceptable and left Surveyor and went directly to [NAME] F to inform [NAME] F to put on a beard restraint and to use tongs when touching ready to eat foods. On 04/27/2026 at 12:06 PM, Surveyor informed Director of Clinical Services (DCS) C of observations made in the kitchen. DCS C informed Surveyor DCS C had already heard of these issues and stated this was unacceptable in the kitchen.

Based on observation and interview, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure staff wore appropriate personal protective equipment (PPE) while handling soiled linens and laundry. This has the potential to affect 30 out of 30 residents.Findings include: Per facility policy titled Handling Linens and Laundry, dated January 2026, states: Purpose: To provide a process for safe and aseptic handling, washing, and storage of linen.7. Employees sorting or washing linens shall wear a gown/apron, gloves and if aerosolization occurs, a mask.16. Remove barrier attire when leaving the soiled linen area. On 4/29/26 at 8:43 AM, Surveyor reviewed laundry services. Laundry Aide (LA) M started tour by walking Surveyor through the process. LA M stated that she uses gloves only, unless clothes come in a yellow bag, that is usually COVID stuff. LA M stated that if clothes come in a yellow bag LA M has access to gown and would wear then. LA M stated LA M does not wear the gown when sorting clothes or doing laundry normally. On 4/29/26 at 8:50 AM, Surveyor observed LA M fold towels and a mechanical lift sling. Surveyor observed LA M hold the mechanical lift sling to her chest while folding and patting it smooth. LA M did not have a barrier between her clothes while folding clean linen. On 4/29/26 at 8:54 AM, Surveyor observed LA M take whites out of the washing machine and put them into the clean cart to take to the dryer. LA M did not have a barrier on between her clothes and the clean clothes. On 4/29/26 at 8:57 AM, Surveyor observed LA M take the cart with dirty towels, soaker pads and linen and pull it over to the wash machine. LA M put on gloves and picked through the laundry to find like soiled items and place in wash machine. LA M set the machine to the appropriate wash cycle, took off her gloves and did hand hygiene. LA M did not have a barrier between her clothing and the soiled linen. On 4/28/26 at 9:02 AM, Surveyor interviewed Maintenance Director (MD) N who stated that MD N is supervisor of laundry services. MD N stated that MD N's expectation is that staff wear appropriate PPE when dealing with soiled linen. Surveyor asked what appropriate PPE should be worn. MD N stated when you are sorting dirty linens LA M should have been gowned up with gloves and should wear a shield if it might splash. MD N stated after sorting, take off the PPE and wash your hands. Then you they (laundry aide) can move over to the other side. Surveyor asked if that is just when sorting clothing. MD N stated no, it is for anytime your work with dirty linen. MD N stated the expectation with folding clean linen is they (laundry aide) should wash hands before folding laundry and it should be folded away from you and should not touch the floor.

Based on interview and record review, the facility did not ensure 5 of 5 residents (R5, R7, R11, R13, & R35) or the residents' legal representatives were notified of the resident's reason for transfer/discharge in writing to the resident and their representative, notify the ombudsman of the transfer and 3 of 5 residents (R5, R7 and R11) did not receive a bed hold. R5 was transferred from the facility, and no notice of transfer was given. R5 did not have a bed hold given.R7 was transferred from the facility, no notice of transfer or bed hold was given on 1/16/26 and no reason for transfer was listed on the notice of transfer on 1/12/26. R13's notice of transfer documentation was missing the date, location R13 was transferring to and reason for the transfer.R11's notice of transfer was missing the date, R11's name, location of transfer and reason for transfer. There was no notice of transfer with the 3/14/26 transfer. The notice for transfer dated 3/28/26 was missing location and the reason for transfer. R11 did not have a bed hold given.R35 was not issued a notice of transfer, and the State Ombudsman was not notified of R35's transfer.Findings: Facility policy titled, Transfer and Discharge revised on December 2025 stated in part: .Once admitted , the resident has the right to remain at the facility unless their transfer or discharge meets one of the following specified exemptions: a. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility . 3. The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: a. The specific reason and basis for transfer or discharge. b. The effective date of transfer or discharge. c. The specific location .to which the resident is to be transferred or discharged 5. The facility will maintain evidence that the notice was sent to the ombudsman. Example 1 R13 was admitted to the facility on [DATE] with a Brief Interview of Mental Status (BIMS) score of 13 which indicated R13 was cognitively intact. R13 had Minimum Data Set (MDS) which shows, Discharge Return Anticipated dates of 2/25/26 and 4/15/26. On 4/28/2026 at 8:19 AM, Surveyor reviewed R13's transfer notice dated 2/25/26. R13's transfer notice was missing the date, location R13 was transferring to and the reason for the transfer. Surveyor then reviewed R13's transfer dated 4/15/26 and noticed the transfer did not have R13's name, the location to which R13 was being transferred to, or the appropriate reason for transfer. Example 2 R11 was admitted to the facility on [DATE] with a BIMS score of 15 which indicated R11 was cognitively intact. R11 had three MDS's which show, Discharge Return Anticipated dates of 1/4/26, 3/14/26, and 3/28/26. On 4/28/2026 at 8:28 AM, Surveyor reviewed the transfer notice for R11 provided by the facility. The transfer notice was missing the date, R11's name, location of transfer and reason for transfer. R11 was provided with a bed hold for this transfer dated 1/4/26. There was no notice of transfer notice for the 3/14/26 transfer. The notice for transfer dated 3/28/26 was missing location, and reason for transfer. Example 3 R35 was admitted to the facility on [DATE] with a BIMS score of 13 indicating R35 is cognitively intact. R35 had a MDS dated [DATE] which stated, Discharge Return Anticipated. On 4/29/26 at 11:20 AM, Surveyor was unable to locate the notice of transfer or find R35's name on the Ombudsman list. Surveyor asked the Interim Nursing Home Administrator (INHA) A for this notice and showed INHA A the ombudsman's list. INHA A informed Surveyor there was no notice of transfer for R35's transfer and the Ombudsman was not notified of R35's transfer. Example 4 R5 was admitted to the facility on [DATE] and has diagnoses that include end stage renal disease, [NAME] Danlos syndrome (heritable connective tissue disorders caused by genetic changes that affect collagen production, leading to joint hypermobility, skin hyperextensibility, and tissue fragility), asthma, infection and inflammatory reaction due to peritoneal dialysis catheter, acute respiratory failure, kidney transplant rejection, hypertensive heart and chronic kidney disease with heart failure, fibromyalgia, dependence of dialysis, anxiety, depression and anemia. R5's admission Minimum Data Set (MDS) dated [DATE] indicated that R5's BIMS score is 15 indicating R5 is cognitively intact. Review of R5's medical record indicates R5 was transferred to the hospital on [DATE] and on 01/25/26. Further record review did not locate any transfer notice forms or bed hold agreements for R5. On 04/29/26 at 2 PM, Surveyor requested the bed hold agreements and notice of transfer forms from INHA A. On 04/29/2026 at 2:18 PM Surveyor interviewed INHA A. When asked if any bed hold notice or notice of transfers had been located for R5. INHA A stated no notices of transfer were found for R5. Example 5 R7 was admitted to the facility on [DATE], and has diagnosis that include hemiplegia following cerebral infarction, aphasia, weakness, end stage renal disease, chronic kidney disease, diabetes mellitus, encephalopathy, depression, weakness, dysphagia, anorexia, pulmonary embolism, and anemia. Review of R7's medical record indicates R7 was transferred to the hospital on [DATE] and on 01/16/26. R7's transfer form from 01/12/26 did not list a reason for transfer; further record review did not locate any transfer forms or bed hold agreements for R7's 01/16/26 hospital transfer. On 04/29/2026 at 2:18 PM, Surveyor interviewed INHA A. When asked if any further information related to R7's bed hold notice or notice of transfers had been located, NHA A stated, No.

Based on record review and interview, the facility did not ensure that trauma informed care was provided in accordance with professional standards of practice and account for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization for 1 of 2 residents (R11) reviewed for Post Traumatic Stress disorder (PTSD).R11's care plan did not provide individualized interventions based on the triggers noted in R11's trauma informed assessment.Findings:Facility policy titled, Trauma Informed Care Revised on January 2026, stated in part:.6. The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident and will be added to the residents care plan .R11 was admitted to the facility on [DATE] with a Brief Interview of Mental Status (BIMS) score of 15 which indicated R11 was cognitively intact. R11 had diagnoses of depression, PTSD, adult failure to thrive (a syndrome in older adults characterized by a rapid decline in physical, functional, and cognitive abilities, often marked by unexplained weight loss, malnutrition, decreased appetite, and social withdrawal), personal history of suicidal behavior, and obsessive-compulsive disorder (a chronic mental health condition characterized by uncontrollable, recurring thoughts (obsessions) and repetitive behaviors (compulsions performed to reduce anxiety).A trauma informed care assessment was completed at the facility on 12/26/25. This assessment indicated that R11 was held underwater by his friends until he nearly drowned and because of this he is afraid of taking a shower.On 4/27/26 at 1:45 PM, Surveyor reviewed the care plan titled, Resident has a behavior problem which stated in part: related to opioid abuse, alcohol dependence, major depressive disorder and PTSD related to water and is utilizing and antipsychotic. Goal- the resident will have no evidence of behavior problems by review date. TARGET BEHAVIOR: agitation, restlessness. Intervention: R11 enjoys walking around facility utilizing walker to alleviate stress.On 4/27/26 at 1:48 PM, Surveyor was unable to find triggers based on the trauma assessment. Surveyor asked Director of Clinical Services (DCS) C if there was a care plan that showed what R11's triggers were based on R11's diagnosis of PTSD.On 4/27/26 at 1:59 PM, DCS C informed Surveyor that R11's care plan did not include the triggers and has been updated, and the facility is looking at all of the PTSD care plans to ensure that the triggers are individualized.

Based on observation and interview, the facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles. This occurred for 1 of 1 medication storage rooms observed. Surveyor observed control medication Lorazepam not double locked in a permanently affixed compartment.Findings include:The facility policy, titled Controlled Substance Management, dated January 2026, states in part: It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure.1. General Protocols:a. Controlled substances are stored in a separate compartment of an automated dispensing system or other locked storage unit with access limited to approved personnel. The facility policy, titled Storage of Medication, revised 4/2007, states in part:Compartments (including but not limited to, drawers, cabinets, rooms.boxes) containing drugs.shall be locked when not in use. On 04/28/2026 at 3:07 PM, Surveyor observed the medication room with Registered Nurse (RN) H. Upon entering the medication storage room, Surveyor observed the refrigerator was unlocked. RN H stated that it should be locked. Surveyor observed inside the refrigerator plastic boxes and zip locks with residents extra unopened labeled medications. There was a rectangular box that had a zip tie holding it closed. RN H pulled the rectangular box out and stated that it was the stock supply of liquid ativan. On 4/29/26 at 10:03 AM, Surveyor interviewed Director of Clinical Services (DCS) C and Assistant Director of Nursing (ADON) E while in medication room regarding unlocked Ativan. DCS C stated the expectation is that ativan be double locked in the medication cart and in the medication room, the medication room door counts as one lock. Upon entering the medication room, fridge was locked on 4/29/26 at 10:03 AM. Surveyor informed DCS C of observation with RN H of the refrigerator being unlocked. ADON E unlocked the refrigerator and opened it up for observation. Surveyor asked ADON E what was in the smaller rectangular box. ADON E pulled the box out of the refrigerator and said it was ativan. Surveyor asked DCS C if a zip tie would act as a second lock. DCS C replied no.

Based on interview and record review, the facility did not follow through with the appropriate steps of the Preadmission Screening and Resident Review (PASARR) process for 1 of 2 residents (R1) reviewed for PASARR screening.R1 did not have a PASARR level II (2) completed. Findings include:R1 was admitted to the facility on [DATE] with a Brief Interview of Mental Status (BIMS) score of 14 which indicated R1 was cognitively intact. R1 has diagnoses that include . schizophrenia (a serious mental health condition that affects how people think, feel and behave) and bipolar (a common, severe, and persistent mental illness characterized by recurrent episodes of mania and depression).R1 had a 5-day Minimum Data Set (MDS) dated [DATE]. Section A, subsection 1500 of the MDS was marked No.PASARR Level I completed 3/13/26:Does the person have a major mental disorder? Yes.Has the person displayed any symptoms that may suggest the presence of a major mental illness? Yes.Has the person received a psychotropic medication to treat symptoms or behaviors of a major mental disorder? Yes.Is there a diagnosis or history of intellectual disabilities? Yes.Hospital discharge Exemption- 30 day maximum? Yes. (No PASARR Level II required).On 4/29/26 at 11:57 AM, Surveyor interviewed MDS Nurse E regarding this resident having Section A, subsection 1500 marked No. Surveyor asked MDS E, Should this resident have had a level II PASARR completed? MDS E replied, No, his level I would have triggered it if he did. Let me check.On 4/29/26 at 12:03 PM, MDS Nurse E returned with her computer and informed Surveyor that she goes by what Social Services (SS) G puts in the level I. This level I indicates a hospital discharge exemption 30-day maximum- Yes. MDS Nurse E replied, You'll have to talk to SS G.On 4/29/26 at 12:48 PM, SS G explained to the Surveyor, This resident was supposed to go back to the group home that he lived in for 15 years before coming here. But that facility closed while he was here. Surveyor asked SS G, Is this resident past the 30 days since admission? SS G replied, Yes. Moving forward every Monday I will be checking the dates for a level II screen based on the 30- day exemptions.

Based on observation, record review and interview, the facility did not prepare, store or distribute foods in a sanitary manner. The facility practices had the potential to affect all 25 residents. Dietary Aide (DA) G did not allow the thermometer probe to air dry of alcohol prior to inserting into glasses of milk and juice intended to be served to residents for breakfast. Resident foods that were brought in were not labeled with resident names/dates and disposed of in a manner to prevent illness. DA G was observed with her shirt, which had been sprayed with water and food debris, putting away clean dishes in a manner that contaminated the clean dishes. DA G put the clean dishes away when still saturated with water. This is evidenced by: Example 1: Surveyor reviewed the facility policy titled, Thermometer, dated February 2020. The policy, in part, read: Procedure: ~Sanitize thermometer before and between testing of different foods. ~The thermometer may be stored in or dipped into sanitized solution to sanitize. The policy does not direct if using an alcohol preparation pad to sanitize the thermometer probe it should be allowed to air dry before inserting into foods/beverages. On 3/12/25 at 7:13 AM, Surveyor observed preparation for breakfast in the kitchen. Surveyor observed DA G taking temperatures of beverages that had been poured in glasses and removed from refrigeration. DA G wiped the thermometer probe with an alcohol prep pad and immediately inserted the thermometer into a glass of milk. DA G wiped the thermometer probe with another alcohol pad and immediately inserted into a glass of juice. Surveyor asked DA G if she has ever been instructed to wait and allow the thermometer probe to air dry of alcohol before inserting into foods or beverages. DA G indicated she has always wiped the thermometer probe and inserted right away to check temperatures and was never told to wait. Surveyor asked Dietary Manager (DM) H about the observation and expectations regarding air drying the thermometer probe prior to inserting into foods/beverages. DM H expressed he would expect staff to allow the thermometer probe to air dry of alcohol before inserting into foods or beverages to not contaminate the items with alcohol. Example 2: Surveyor reviewed the facility policy titled, Food from Outside Sources, dated April 13, 2020. The policy, in part, read: Policy: All residents have the right to accept food brought into the facility by family or other visitors, however, the food must be handled in a way to ensure safety to the resident. Procedure: All food items that are already prepared by the family or visitor brought in must: a. Be labeled with content, date (the date the item was brought into the facility) and the residents name. b.will be dated when accepted for storage and discarded after five days. On 3/12/25 at 7:33 AM, Surveyor and DM H observed the refrigerator where foods are brought in for residents. The refrigerator contained resident items that were dated with one set of dates or not dated. The refrigerator contained the following items: ~Muscle milk, chocolate milk and whole milk with no dates labeled with R19's name. ~Snack size jello and apple sauce which were not dated, limes dated 2/12/25, and pineapple juice which was not dated. Items were marked with R22's name. ~Protein drink tabled with initials D.S. and no date. ~Yogurt with no name or date ~Pickled eggs with no name or date ~Peanut butter and jelly sandwich with no dates. ~Grape juice dated 3/05/25. Surveyor noted refrigerator with sign that read: Can be kept up to 3 days. If food is not dated it will be thrown away, no exceptions. After the observation, Surveyor spoke with DM H about the expectation of labeling resident food/beverages brought in by visitors. DM H indicated the items should be labeled with resident names and date brought in. Items should be disposed of within 3 days to prevent residents from getting sick. Example 3: Surveyor reviewed the facility policy titled, Dishwashing Procedure, dated February 2020. The policy read, in part, Purpose: To ensure that dishes are properly washed and sanitized to prevent the spread of food borne illness. Procedure: ~All items must be air-dried after wash and rinse cycles are completed. ~Before any dish machine operator moves from soiled dishes to clean dishes, on of the following must occur: a. Hands shall be washed using proper hand washing procedures. b. If using gloves, soiled gloves shall be removed, hands shall be washed using hand washing procedures and clean, unused gloves shall be put on. The procedure did not address the need to don and doff an apron to ensure the clean dishes do not come into contact with any contaminated surfaces such as staff's clothing. On 3/12/25 at 9:35 AM, Surveyor observed DA G at dish machine spraying and scrubbing dirty dishes. DA G was not wearing an apron or gloves. DA G's shirt was sprayed with the spray from the dirty dishes. DA G's shirt was visibly wet and dirty of food particles. DA G loaded the dishes to the dishwasher rack and unloaded the dish rack from the machine. Surveyor observed DA G lean over the dish counter to obtain clean dishes to put away. DA G's shirt was in direct contact with the clean dishes that she immediately put away. Surveyor observed the plate covers taken from the dish rack across the kitchen to be put away. The plate covers were saturated with water, dripping to the kitchen floor. The plate covers were placed on a stack of clean covers. The plate covers were visibly wet. Following the observation, Surveyor asked DA G about the observation of her wet/dirty shirt coming into contact with clean dishes and if dishes should be put away wet. DA G responded she was never informed she should wear apron or gloves when washing dirty dishes and no aprons are available to be used when washing dirty dishes. DA G stated she understood how her dirty shirt coming into contact with the clean dishes could cause contamination. Surveyor asked about the wet dishes being put away and risk for bacterial growth. DA stated she understood the risk. DM H, who was present during the observation, indicated he would obtain aprons for dishwashing due to the potential for contamination of clean dishes as observed. DM H pulled the plate covers from the stack to be re-washed and informed DA G she needed to allow more time for dishes to air dry as he has told her in the past. DM H indicated he understood how putting away wet dishes poses a risk of contamination. DM H also indicated he understood how DA G's shirt contaminated the clean dishes.

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. This has the potential to affect all 25 residents (R). -Residents with infection symptoms not placed on proper precautions. -Observations of Certified Nursing Assistants (CNA) not donning Personal Protective Equipment (PPE) and providing proper hand hygiene prior to entering/exiting rooms for residents on precautions. Certified Nursing Assistant (CNA) C did not wear her surgical mask in a manner (above her nose) to prevent the spread of infection during a facility outbreak of respiratory illness, covid 19 and gastrointestinal illness (GI). CNA C did not perform hand hygiene before donning gown and gloves and entering R23's room who was on precautions for gastrointestinal illness (GI). CNA D did not don gown and gloves before entering R23's room who was on precautions for GI. CNA E did not handle dirty linens in a manner to prevent the potential spread of infection. Findings include: Surveyor requested and reviewed the facility policy titled, Personal Protective Equipment, dated January 2023. The policy, in part, read: Purpose: To provide guidance for the use and selection of appropriate personal protective equipment (PPE) based on risk of exposure to blood or body fluids in accordance with state and federal regulations. Procedure: 1. All staff who have contact with residents and/or their environments must wear personal protective equipment as appropriate during resident care activities and other times in which exposure to blood and body fluids, or potentially infectious materials is likely. Face Protection: Wear a mask to protect the face from contamination Gloves Perform hand hygiene before donning gloves and after removal. Gloves are not a substitute for hand hygiene. Example 1 On 03/11/25 at 10:05 AM, Surveyor observed R20 sitting in a chair with a basin next to her. R20 complained of feeling sick and throwing up all night, and said, I wouldn't even come in here if I was you. Roommate confirmed, Yeah, all night long. Outside the room was a sign for Enhanced Barrier Precautions (EBP) but not the required contact precautions. At 4:00 PM, contact precautions were still not initiated. On 03/12/25 at 7:10 AM, contact precaution sign was posted outside R20's room. Example 2 On 3/11/25 at 10:24 AM, Surveyor observed R130 lying in bed with a basin. R130 stated, I came in here a few weeks ago for 'breathing' and now I am sick with vomiting and diarrhea. The required contact precaution sign was not in place. At 4:00 PM, contact precautions were still not initiated. On 03/12/25 at 7:10 AM, contact precaution sign was posted outside R130's room. Nursing progress notes dated 03/11/25 at 4:36 PM stated, Note Text: Resident had large emesis early this AM and several times into this shift. Afebrile at 97.8 Resident attempted to eat breakfast but could not finish and refused lunch. Example 3 On 3/11/25 at 10:14 AM, Surveyor reviewed infection control surveillance and noted that R22's medical record indicated R22 developed symptoms of nausea, vomiting, and diarrhea on 03/08/25 and was removed from contact precautions on 03/11/25. Surveyor observed no signage outside R22's room alerting staff and visitors of contact precautions. At approximately 4:00 PM, required contact precaution sign still was not posted. The following day, 03/12/25 at 7:18 AM, Surveyor observed that contact precautions signage was posted. Example 4 On 03/12/25 at 7:32 AM, Surveyor observed CNA O set up R19 for morning cares. Contact precaution sign was posted outside R19's room stating, Everyone must: clean their hands, including before entering and when leaving the room. Providers and staff must also: put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. CNA O appropriately followed the signage until CNA O realized she forgot to retrieve washcloths and towels. At 7:38 AM, CNA O entered R19's room without proper PPE to give R19 washcloths and towels. Example 5 On 03/12/25 at 7:40 AM, CNA O entered R12's room to assist with toileting. Signage on door was posted for contact precautions and EBP. CNA O entered and exited R12's room without sanitizing hands or donning/doffing PPE. CNA O left room to gather supplies and entered room again without appropriate PPE except for wearing only surgical mask. CNA O assisted R12 in bathroom and after finishing, at 7:48 AM, brought bagged soiled items outside the room, down hallway, and behind the nurses station to the soiled utility room. Surveyor then asked CNA O what the process is for residents on contact precautions. CNA O said, [R12's] roommate is the resident that is ill. I don't know why there are no bins in there. I did not gown the second time in [R12's] room because it is the roommate that was ill. Surveyor reviewed the surveillance line list, nursing progress notes, and checked for signage outside the rooms and noted the following: 1. R20 had nausea, vomiting and diarrhea on the night shift between 03/10/25 and 03/11/25. Was not placed on precautions until 03/12/25. 2. R130 had nausea, vomiting and diarrhea on 03/11/25 and was not placed on precautions until 03/12/25. 3. R22 had nausea, vomiting and diarrhea on 03/08/25 and was not placed on precautions until 03/12/25. 4. R8 had nausea, vomiting and diarrhea on 03/10/25 and was not placed on precautions at all and had no resolve date on line list or documentation in nursing progress notes regarding precautions at all. On 03/12/25 at 11:44 AM, Surveyor interviewed Director of Nursing (DON) B and the Infection Control Preventionist (ICP) F and asked what the staff expectation is for hand hygiene and PPE for residents on precautions. DON B stated they would expect the staff to follow the signage on the door and that correct precautions are implemented timely. 30570 Example 6 On 3/11/25 at 10:04 AM, Surveyor observed CNA C in the hallway with surgical mask worn below her nose. On 03/11/25 at 10:09 AM, CNA C entered room [ROOM NUMBER] with her mask below nose. room [ROOM NUMBER] had posting indicating mask, gown, and gloves should be worn when entering room. On 03/11/25 at 12:05 PM, CNA C was observed passing resident lunch trays in their rooms with her mask below nose. On 3/12/25 at 4:05 PM, Surveyor interviewed CNA C about the observation of her surgical mask worn below her nose. CNA C indicated it is expected for staff to wear surgical masks in common areas during outbreaks. Staff should not wear masks below the nose. It is important to wear masks above the nose to keep yourself safe and prevent the spread of infection. Surveyor reviewed the facility line list of resident infections, and R23, who resides in room [ROOM NUMBER], presented with incontinence, liquid stool, and nausea on 3/09/25. On 3/13/25 at 10:21 AM, Surveyor spoke with DON B and ICP F. ICP F has been on staff 2 weeks and is the facility's Infection Control Preventionist. Surveyor asked about the facility outbreak status. ICP F explained the facility was in respiratory, covid and GI outbreak when the survey team entered the building on 3/11/25. The last day of respiratory outbreak was 3/11/25. The facility remains in covid outbreak status. The covid outbreak started in November 2024. Per the facility policy, which is based on Centers for Disease Control, the facility remains in outbreak status 28 days post last positive test. The facility is also in a GI outbreak status with resident first symptoms noted 3/07/25 and 2 residents positive for norovirus on 3/08/25. Surveyor asked about expected staff PPE in common areas during the outbreaks and shared the observation. DON B expressed a standard surgical mask is expected to be worn in common areas. Wearing a mask below the nose is an ineffective use of a surgical mask during an outbreak. DON B explained it is important to wear the mask over the nose to prevent symptoms and the potential spread of the infection. Example 7 On 3/11/25 at 10:09 AM, Surveyor observed CNA C enter R23's room after donning a gown and gloves. CNA C did not perform hand hygiene prior to donning the gloves. R23's room has posting indicating mask, gown and gloves should be worn when entering room. On 3/12/25 at 4:05 PM, Surveyor spoke with CNA C about the observation of not performing hand hygiene prior to donning gloves to enter R23's room. CNA C indicated it is expected that staff perform hand hygiene prior to putting on gloves to help prevent the spread of infection. Surveyor reviewed the facility line list of resident infections, and R23 presented with incontinence, liquid stool and nausea on 3/09/25. On 3/13/25 at 10:21 AM, Surveyor spoke with DON B and ICP F about the observation. DON B and ICP F explained R23 presented on 3/09/25 with symptoms of incontinence of liquid stool and nausea and is on precautions. Staff should follow the posted sign on R23's door and don gown and gloves before entering the room. Hand hygiene is expected prior to donning PPE to help prevent the spread of infection. Example 8 On 03/11/25 at 10:09 AM, Surveyor observed CNA D enter R23's room with no gown or gloves donned. CNA D was wearing a surgical mask. Surveyor observed a cart with PPE outside R23's room and a posting on the room door for precautions of gown, gloves and mask to be worn. CNA D walked to R23 who was in bed and exited the room. Surveyor asked CNA D about the lack of PPE of gown and gloves when she entered room [ROOM NUMBER]. CNA D responded she should have worn a gown and gloves when entering R23's room to not spread infection. Surveyor reviewed the facility line list of resident infections, and R23 presented with incontinence, liquid stool and nausea on 3/09/25. On 3/13/25 at 10:21 AM, Surveyor spoke with DON B and ICP F about the observation. DON B and ICP F explained R23 presented on 3/09/25 with symptoms of incontinence of liquid stool and nausea and is on precautions. Staff should follow the posted sign on R23's door and don gown and gloves before entering the room to help prevent the spread of infection. Example 9 Surveyor requested and received the facility policy titled Handling Linens and Laundry dated March 2020. The policy in part read: Purpose: To provide a process for the safe and aseptic handling .of linen. Procedure: Consider all soiled linen to be potentially infectious. ~In resident rooms: a. Do not allow linen, clean or soiled, to touch clothing or uniform. b. Handle all soiled linen as though it is potentially infectious. On 3/11/25 at 12:27 PM, Surveyor observed CNA E exit R24's room with dirty bed linens that had been removed from R24's bed. The linens were not bagged and were carried out of the room up the hallway against CNA E's upper body. CNA E was observed not wearing gloves. Surveyor asked CNA E if the linens were dirty and if it is normal to carry dirty linens from resident rooms without bagging them. CNA E indicated the linens were dirty and had been removed from R24's bed. CNA E further indicated it is normal to carry dirty linens out of rooms without bagging them. Surveyor asked CNA E if standard precautions would direct her to bag the dirty linens prior to exiting resident room and carrying them up the hallway. CNA E responded she has never been told the expectation of bagging dirty linens. On 3/13/25 at 10:21 AM, Surveyor spoke with DON B and ICP F about the observation. DON B and ICP F expressed staff are expected to have gloved hands when handling dirty linens. The dirty linens should be bagged before exiting resident rooms. All dirty linen is treated as potentially hazardous, and staff are expected to be handling the linens with gloves and bagging before leaving resident rooms to prevent the potential spread of infection.

Based on interview and record review, the facility did not report 1 of 3 residents' (R), R131, allegations of exploitation to the State Survey Agency via the State's Misconduct Incident Reporting (MIR) system immediately upon learning of the incident. Findings include: Facility policy titled Abuse Prevention Program, stated in part, -#1. Initial Reporting of Allegations. When an allegation of abuse, exploitation, neglect, mistreatment, or misappropriation of resident property has been made, the administrator, or designee, shall complete and submit a DQA form F-62617, notifying DQA that an occurrence of potential abuse, neglect, exploitation, mistreatment or misappropriation of a resident property has been reported to the administrator and is being investigated. This report shall be made immediately. On 03/13/25, Surveyor reviewed an anonymous complaint, dated 10/30/24, alleging that Certified Nursing Assistant (CNA) E took a picture of R131's private area from her personal cell phone to show another staff member, on AM shift, that they used the wrong cream on R131's bottom at the hospital. R131 cannot agree to this as she is not mentally capable of understanding what is going on. R131 was not in the facility at the time of the investigation. On 3/13/25, Surveyor reviewed R131's medical record. R131 was admitted on [DATE] with cerebral palsy and epilepsy. R131's care plan, dated 09/30/22, indicates R131 is dependent on staff for meeting emotional, intellectual, physical, and social needs due to inability to communicate and physical mobility. Care plan dated 08/10/22 states R131 has impaired cognitive function or impaired thought processes. On 03/13/25, Surveyor attempted to contact CNA E and CNA K via phone. Messages were left and there were no return calls. On 3/13/25 at 11:37 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and Director of Nursing (DON) B and asked if they were aware of an event on 10/28/24 - 10/29/24 that involved staff taking a picture of a resident's private part. Both agreed that they recalled the incident. NHA A stated the event was investigated. A night CNA took a picture to show the oncoming shift that the wrong cream was applied. Day shift staff immediately reported the incident to DON B. DON B stated that she observed the CNA delete the picture and completed a disciplinary action and completed all staff education regarding cell phone usage. DON B reported that CNA E admitted the error and was apologetic. Surveyor asked why a facility reported incident was not completed. NHA A stated they did not report because there was no ill intent, and she misinterpreted the regulation. On 03/13/25, Surveyor reviewed the investigation file for R131. Records indicated the incident as described above. NHA also provided the Disciplinary Action Report for CNA E. Surveyor could not find any facility documentation of this incident being reported to the State Agency.

Based on record review and interview, the facility did not accurately code the Minimum Data Set (MDS) for 1 of 12 sampled residents (R) reviewed. (R18) -The MDS assessments are coded in error stating that a Preadmission Screening and Resident Review (PASARR) level 2 screen had not been completed when it was completed at the time of assessment for R18. Findings include: R18 was admitted to the facility on [DATE] with diagnoses including depression, anxiety, and PTSD. Record review identified R18 had a PASARR level 2 screen completed on 12/06/24 indicating R18 has a major mental disorder. R18's comprehensive MDS assessment, dated 12/08/24, indicated for question A 1500 that No PASARR level 2 had been completed. Section I of the MDS notes R18 has PTSD. On 03/12/25 at 2:02 PM, Surveyor interviewed Director of Nursing (DON) B who agrees that the discrepancy had occurred and question A 1500 should have been coded Yes.

Based on interview and record review, the facility failed to provide interventions in the comprehensive care plan to mitigate re-traumatization for 1 of 1 resident (R18) reviewed for Post Traumatic Stress Disorder (PTSD). -Staff were not aware there was a resident with PTSD. R18's PTSD care plan did not indicate triggers and specific interventions related to loud noises. Findings include: R18 was admitted to the facility on [DATE] with diagnoses including anxiety, depression, and PTSD. R18's most recent quarterly Minimum Data Set (MDS), dated [DATE], stated a Brief Interview of Mental Status (BIMS) score of 15 indicating R18 is cognitively intact. R18 was independent with bed mobility, eating, transferring, and toileting. On 03/12/25 at 12:18 PM, Surveyor reviewed R18's medical record that indicated a Trauma Informed Care assessment, dated 12/02/24, noted loud noises trigger R18. Care plan dated 12/05/24 includes a plan for PTSD, however, does not include loud noise triggers R18, or interventions to loud noises that can result in potential for re-traumatization. On 03/12/25 at 12:22 PM, Surveyor interviewed R18 who clarified not wanting or needing any special therapy services related to PTSD, and that R18 will be discharged soon. On 03/12/25 at 12:57 PM, Surveyor interviewed Certified Nursing Assistant (CNA) L and asked if any residents in the facility have PTSD. CNA L stated, Nobody has PTSD. I have been employed here for almost a year. On 03/12/25 at 1:02 PM, Surveyor interviewed Licensed Practical Nurse (LPN) M and asked if there are any residents that have PTSD. LPN M stated she works the floor and would have to check with the Director of Nursing (DON). On 03/12/25 at 1:05 PM, Surveyor interviewed LPN N and asked if any residents have PTSD. LPN N stated, I am the floor nurse to care for all residents today and when I work. I am not aware of anyone that has PTSD. On 03/12/25 at 2:02 PM, Surveyor interviewed DON B and asked about R18's trauma informed care assessment that identified loud noises trigger PTSD. DON B stated that R18's PTSD care plan should be more clear and would expect the staff to know about it and how to approach the issue.

Based on interview and record review, the facility did not ensure each resident receives adequate supervision to prevent accidents for 5 of 5 residents (R1, R2, R4, R5, and R6). R1 experienced a fall after staff did not appropriately place sling for mechanical lift transfer. The facility did not ensure all direct care staff were educated on proper sling placement to ensure all other residents requiring a mechanical lift transfer, did not sustain a fall or injury during a transfer. Findings: R1 was admitted to the facility in 07/19/24 for rehabilitation services, after a right below the knee amputation (BKA) on 07/12/24. Facility assessment of R1's transfer status indicated on 07/19/24, R1 was assessed for needing assistance of two with mechanical (Hoyer) lift transfers. On 08/03/24, R1 was in his wheelchair and the sling needed to be placed in order to transfer him into bed per his request. Two Certified Nursing Assistants (CNAs) were present and placed the sling but did not get the sling far enough underneath R1 in order to safely lift him. R1 began to slip out from the sling and one CNA reported helping R1's butt to the bed and then slid R1 to the floor. R1 denied pain, vital signs were taken, and these were within normal limits. R1 stated he was not upset and not hurt. This was a witnessed fall and R1 did not hit his head per the CNAs and R1. R1 was assisted with the Hoyer back to the bed. Root Cause: Staff did not properly place the sling all the way beneath his buttock and legs prior to lifting. Immediate Intervention: The involved staff were given immediate training on the lift and proper placement of sling. They then had to demonstrate back to the educator they can properly place sling on resident, which they completed and signed the 1:1 training/education. Primary care provider updated. On 08/26/24 at 1:32 p.m., Surveyor interviewed Nursing Home Administrator (NHA) A who indicated the facility scheduled a training for all direct care staff on 08/27/24, to provide education and repeat demonstration of proper sling placement and safe mechanical lift transfers. This training was scheduled 25 days after R1's fall from mechanical lift, placing R1, R2, R4, R5 and R6 at risk for accidents or injuries during transfers.

Based on observation, interview and record review, the facility failed to store prepare and distribute food under sanitary conditions this has the ability to affect 21 of the facility's 22 residents. Low temperature chemical sanitization dish machine is used but the facility has no monitoring system in place to monitor the machine to ensure proper chemical sanitization occurs. Beard restraints were not always worn during food preparation. Oscillating fan on kitchen wall is dirty and blows towards food preparation areas. This is evidenced by: The facility policy, entitled Dishwashing Temperature Log, dated February 2020, states in part: For low temperature (chemical sanitizing) machines, concentration of sanitizer must be recorded on form. The facility policy, entitled Personal Cleanliness and Hygienic Practices, dated February 2020, states in part: All dietary staff, including the dietary manager, and any person entering the kitchen, must wear an approved hair restraint* to keep hair and particles in the hair from falling into food. Hair restraints must entirely cover all hair. Food handlers with facial hair should also wear beard restraints. On 03/04/24 at 9:03 AM, Surveyor observed Maintenance Director (MD) C doing dishes following the breakfast meal. Surveyor asked what the facility does to ensure the dish machine is working appropriately. MD C stated that MD C checks the temperature and writes it on the log on the wall. MD C indicated the temperature should be between 120-150 degrees. MD C indicated this is a low temperature, chemical sanitization machine. Surveyor asked what is done to ensure the chemical sanitization occurs. MD C indicated MD C looks to ensure there are chemicals in the bottles on the wall that feed into the machine. MD C stated the company services the machine monthly and checks the machine for functioning. Surveyor asked about a procedure taped on the wall, which talks about test strips. MD C stated MD C is not sure how or when it is done, but Dietary Manager (DM) I surely knows. Observation of the dishwasher temperature log revealed no documentation of sanitizer monitoring. On 03/04/24 at 9:03 AM, Surveyor observed an oscillating fan mounted on the wall near the microwave and juice machine running and blowing toward food preparation areas. The cage around the fan was dirty with blackish gray debris on the bars encasing the fan blades. On 03/04/24 at 9:35 AM, Surveyor observed DM I in the kitchen near food preparation areas. On 03/05/24 at 9:18 AM, Surveyor observed DM I in the kitchen preparing food. On 03/06/24 at 8:45 AM, Surveyor observed DM I in the kitchen preparing food. DM I was noted to have a beard and was observed multiple times on all three days of survey to be in the kitchen without a beard net on. On 03/06/24 at 9:05 AM, Surveyor interviewed DM I related to the above concerns. Surveyor asked what monitoring system was in place to ensure the dishwasher is adequately sanitizing the dishes. DM I replied that they record temps for wash and rinse cycles with each meal. Surveyor asked if anything else is done. DM I stated that staff have stickers for plate surfaces, they monitor chemical levels, and they use test strips. Surveyor asked how often any of these things are done. DM I stated, It has not been done as often as it should be. Surveyor asked DM I to clarify. DM I stated, It has been done a few times in the past month, but it is not documented anywhere. Surveyor requested the facility policy and procedure related to this. After reviewing the policy, DM I stated that the policy states to Check sanitizing solution throughout the day. Surveyor requested the facility policy and procedure on hair restraints. Surveyor asked DM I about the facility's beard net policy. DM I stated the policy states, Beard nets should be worn. Surveyor asked if DM I has been wearing a beard net for the past 3 days. DM I stated DM I has not been wearing a beard restraint and has been working with food without one. Surveyor asked about the dirty oscillating fan. DM I stated that it is on a cleaning schedule, but maybe it needs to be cleaned more often.

Based on interviews and record review, the facility failed to submit complete and accurate data to the Centers for Medicare and Medicaid Services (CMS) mandatory Payroll Based Journal (PBJ) data for quarter four of 2023 (July 1 - September 30). This has the potential to affect all 22 residents. This is evidenced by: Surveyor noted during survey preparation that the facility triggered for failing to have licensed nursing coverage 24 hours each day for the dates of: 07/08/23 (Saturday), 07/09/23 (Sunday), 07/22/2023 (Saturday), 08/05/2023 (Saturday), 08/06/2023 (Sunday), 09/02/23 (Saturday), 09/03/23 (Sunday), 09/04/23 (Monday), 09/16/23 (Saturday), 09/30/23 (Saturday). On 03/05/24 at 11:18 AM, Surveyor spoke with Nursing Home Administrator (NHA) A and Corporate Human Resources Director (CHRD) H regarding the nursing coverage for the months of July, August, and September of the [AGE] year. Neither NHA A nor CHRD H could think of a time when they did not have full nursing coverage. Surveyor then reviewed the staff schedules for the period of July 1 - September 30, 2023, specifically the dates in question and compared the data with the time punches provided. There were no concerns uncovered related to licensed staff coverage or certified nursing assistant coverage. However, it was noted that the dates in question did have only two registered nurses working a 12-hour shift each of those days. On 03/05/24 at 12:15 PM, Surveyor interviewed NHA A and CHRD H after they reviewed their PBJ submissions regarding the months with missing nursing coverage. NHA A and CHRD H had discovered that one registered nurse's hours were not being pulled into the PBJ report. Those hours were not being submitted in the PBJ report. Currently the facility has no issues with the PBJ accuracy. The facility had failed to submit accurate PBJ data for the fourth quarter (July 1 - September 30) of the [AGE] year. Surveyor reviewed the PBJ submission for Fiscal Year 2024 Quarter 1 (October 1 - December 31). The facility was noted to have submitted the 1st quarter's data on 02/13/24, accurately. The facility is in compliance as of 12/31/23. The facility did not have any errors in the PBJ report for the first quarter of the [AGE] year and the issue was corrected. This was cited as past noncompliance.

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 with control measures to prevent transmission of Legionella infection. This has potential to effect 22 of 22 residents (R). Findings include: Example 1 The facility policy entitled, Water Management Program, dated 08/02/23, states in part: The organization will follow guidance of ASHRAE and CDC guidelines in creating this Water Management Program. The purpose of this program is to ensure the facility is inhibiting microbial growth in the buildings water system that reduce risk of growth and spread of legionella and other opportunistic pathogen by properly maintaining water systems. The facility will create a flowsheet of the path the water takes and any points with potential for growth. Decide where control measures should be applied and how to monitor them. Water Management Program Log Sheet states in part Flush for 5 minutes. The Center for Disease Control and Prevention (CDC) toolkit, entitled Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings, dated June 24, 2021, states in part: Once you have developed your process flow diagram, identify where potentially hazardous conditions could occur in your building water systems. The Center for Disease Control and Prevention (CDC) guidelines, entitled Controlling Legionella in potable water systems, last reviewed February 3, 2021, states in part: Flush low-flow piping runs and dead legs at least weekly and flush infrequently used fixtures (e.g., eye wash stations, emergency showers) regularly as-needed to maintain water quality parameters within control limits. On 03/06/24 at 7:51 AM, Surveyor reviewed the facility's water flow diagram, which was generic and does not specify the path the water takes from the facility's water source to assure any distinguished locations or areas where Legionella could grow or spread. On 03/06/24 at 7:45 AM, Surveyor interviewed Director of Nursing (DON) B who is responsible for the facility infection control. DON B indicated unawareness of having a flow water chart to map the facility water flow. On 03/06/24 at 8:14 AM, Surveyor interviewed Maintenance Director (MD) C, asking if the facility has a water flow diagram from the source of water and how it flows through the facility. Surveyor asked if areas where Legionella could grow were identified. MD C stated this is not clear in the facility water management policy. On 03/06/24 at 7:51 AM, Surveyor observed 2 separate operatable water fountains accessible to all residents. On 03/06/24 at 7:35 AM, Surveyor interviewed MD C regarding the 2 water fountains being managed for Legionella. MD C stated that housekeeping flushes them every morning when cleaning and confirmed they were not addressed on the Water Management Program Log sheet. On 03/06/24 at 7:38 AM, Surveyor interviewed Housekeeper (HSK) F, regarding expectations of maintaining the 2 water fountains. HSK F stated they are wiped down every morning and flushed for about 5 seconds. HSK F indicated this procedure is not logged. HSK F stated nobody uses them and was not sure why facility still had them. On 03/06/24 at 7:45 AM, Surveyor interviewed DON B and made DON B aware of concern regarding 2 water fountains and facility practice of flushing them. DON B stated that staff utilize the water fountains and doesn't feel they are a source of risk for Legionella. On 03/06/24 at 7:55 AM, Surveyor interviewed Registered Nurse (RN) E regarding usage of the 2 water fountains. RN E indicated that no one uses them. On 03/16/24 at 7:56 AM, Surveyor interviewed Licensed Practical Nurse (LPN) D and Certified Nursing Assistant (CNA) G regarding the 2 water fountains; both indicated nobody uses them. Both LPN D and CNA G stated the facility has a [NAME] water system behind the nurses station and all staff and residents prefer water from there, including when filling the daily water pass because it tastes better. The water fountains are unused, with a high potential for stagnate water, where Legionella can grow. The facility does not have documentation of flushes for 5 minutes to ensure the control measures are being followed.

Based on observation, interview and record review, the facility did not prepare, distribute or store foods in a sanitary manner. This has the potential to affect 25 of 27 residents who eat foods orally. Dietary staff observed in the kitchen did not have their hair fully restrained. The Dietary Manager (DM) F repeatedly removed her reading glasses from the top of her head to place on her face. The glasses were presumably dirty. DM proceeded to touch clean items in the kitchen without washing her hands. The dry storage rooms floors were visibly dirty with a staff break area in the middle of the upstairs dry storage room and staff coats hanging on hooks in the storage area. The refrigerator and freezer that is used for foods brought into the facility for residents does not have a thermometer or system to monitor safe temperatures for storing foods. This is evidenced by: Example 1 On 1/10/23 at 9:35 AM, Surveyor conducted and initial tour of the kitchen. Dietary Manager (DM) F accompanied Surveyor on the tour. Surveyor observed DM F with her hair bangs and hair curls on both sides of her face not restrained with the hair net she was wearing. DM F continued the tour throughout the storage areas and kitchen with her hair not properly restrained. Surveyor also observed Dietary Aide (DA) G and (DA) H working in the kitchen and the kitchen's dish room. Both DA G and DA H had visible hair that was not restrained with the hair nets they were wearing. Following the tour Surveyor spoke with DM F about her expectation regarding staff hair restraint in the kitchen. DM F responded she would expect all hair be restrained in the kitchen. Surveyor requested the facility policy regarding expected dress code in the kitchen. Surveyor was provided a policy titled Uniform Information, which is not dated. Surveyor reviewed the policy which does not address hair restraint in the kitchen. Example 2 On 1/10/23 at 9:35 AM, Surveyor conducted an initial tour of the kitchen and the kitchen storage areas. Surveyor observed DM F repeatedly removing her glasses from the top of her head to place on her face to read various food labels and logs. DM F placed the glasses back to the top of her head after reading the food labels and logs for the refrigerator/freezer temperature logs and dish machine log. DM F continued the tour, touching various items in the kitchen without performing hand hygiene. After the observation, Surveyor spoke with DM F about the observation. DM F expressed it is normal for her to place her reading glasses on her head and place them on when she needs to read small print. DM F further expressed she had not realized she was touching her glasses as it is a habit and how her glasses are worn. DM F indicated she now realizes her glasses are dirty and hand washing should occur before touching clean items in the kitchen. Surveyor requested the facility policy regarding hand washing when going from dirty to clean items in the kitchen. Surveyor was provided a policy titled Handwashing section: Safe Food Handling with a revised date of January 2021. The policy in part reads ~Purpose: Proper hand washing promotes safe food handling practices and infection control. Guidelines: The following list includes, but is not limited to, when hands are washed .after engaging in any other activities that contaminate the hands. Example 3 On 1/10/23 at 9:35 AM, during the initial tour of the kitchen and the storage areas Surveyor noted the dry storage area in the basement with visibly dirty floors and debris on floor. The dry storage area upstairs near the kitchen had a dirt pathway down center of the room. DM F indicated the floor was dirty as the area has high staff traffic due to the area being a staff break area. Surveyor observed coats on hooks on the wall and a table and chairs in the middle of the storage area. Surveyor asked DM F about kitchen cleaning schedules. DM F responded the kitchen cleaning schedules are outdated and not currently being used. Surveyor asked DM F about the staff break area in the area where dry goods are stored. DM F responded the break area in the storage area creates a potential for contamination of foods and should not be there. Dietary staff coats from outside are not clean and staff eat and drink in the area. DM F further expressed the break area was placed there a few months ago; it should not be there and will be removed. Surveyor requested the kitchen sanitation policy. The policy titled Sanitation and Cleaning Schedule with section noted as: Food Services is dated as revised on April 2020. The policy in part reads: Purpose: ~The purpose of the policy is to maintain regulatory compliance under F812 which states that a facility must store, prepare, distribute and serve foods under sanitary conditions . ~The dietary department shall be responsible for maintaining sanitary conditions in the kitchen, all storage and dining areas, including all equipment located in/or utilized in these areas. ~All dry storage areas must be clean and free of clutter, including personal items, so dry goods, canned goods, packaged goods and disposables are free from contamination. Example 4 On 01/11/23 at 2:05 PM, Surveyor and DM F observed the refrigerator and freezer in the activity room. The refrigerator and freezer is used for food and drink brought into the facility for residents. Surveyor observed no thermometer in the refrigerator or freezer. Surveyor noted no log in place for monitoring the temperatures of the refrigerator or freezer. Surveyor noted tomato juice with resident name dated 1/11. Resident foods brought in from family discussed with DM F. DM F indicated foods brought in for residents are not stored in the kitchen and are stored in activity room refrigerator. DM F expressed she is not sure if the 1/11 date on the tomato juice is an open by or use by date. DM F further expressed there is no system in place to monitor temperatures of the refrigerator or freezer to ensure foods are stored at safe temperatures. Surveyor requested and received the facility policy titled Foods from Outside Sources section: Food Services dated as revised on April 13, 2020. The policy in part reads: ~Family members or other visitors may bring the resident food of their choosing. ~All refrigeration units will have internal thermometers to monitor temperatures. All units must be maintained at internal temperatures that are deemed safe for food storage according to state and federal standards.

Based on interview and record review, the facility did not develop and implement a comprehensive person centered care plan for colostomy care for 1 of 12 total residents (R) reviewed (R4). This is evidenced by: Facility policy titled Bowel and Bladder Management Policy with revision date of July 2020 stated in part: .A resident who requires colostomy, urostomy or ileostomy services, receives care in accordance with his or her care plan . On 1/11/23, Surveyor reviewed R4's diagnoses that include but are not limited to: Colostomy status, GERD. R4's admitted at the facility was 12/19/22. On 1/11/23, Surveyor reviewed R4's most current MDS (minimum data set) dated 12/19/22 and 12/26/22 states R4 with ostomy status. BIMS (brief interview for mental status) for R4 is 9. (8-12 moderately impaired). On 1/12/23, Surveyor reviewed R4's Orders include (related to current issue) but are not limited to the following: Change system every 3-7 days or PRN. Use ConvaTec sure fit barrier #404594 seal/ring 2 Pouch ConvaTec Closed end 2-1/4 Flange #416421 every evening shift every 3 day(s) for Colostomy care AND as needed. Start date 1/12/23 On 1/11/23, Surveyor reviewed R4's Care Plan. There was no care plan noted concerning colostomy. On 1/11/23, Surveyor reviewed R4's Kardex. There was nothing noted concerning colostomy. On 1/12/23, Surveyor reviewed R4's Baseline Care Plan/ Evaluation dated 12/19/22 note that R4 has an ostomy in the bowel and bladder section under bowel and bladder appliances Nothing noted based on cares of colostomy. R4 head to toe evaluation dated 12/19/22 under section G. Digestive does include devices LLQ (left lower quadrant) ostomy, bowel sounds active in all quadrants, resident reports passing gas. Stool in ostomy appears brown and watery. Abdomen soft, nontender, rounded, denies nausea or any other discomfort. R4's bowel and bladder evaluation dated 12/23/22 does not discuss anything concerning colostomy. On 01/10/23 at 3:56 p.m., Surveyor interviewed R4 about colostomy. R4 stated she has a sore colostomy since coming here. Staff empties the colostomy bag but doesn't clean it good like R4 did at home. R4 wishes staff to care for the colostomy. There is no care plan in place for colostomy care. On 01/11/23 at 12:56 p.m., Surveyor interviewed RN C about R4's colostomy asking how does she know who cares for the colostomy or the wishes of the resident concerning the care of the colostomy. RN C stated she usually will help R4 to change the colostomy device. R4 is mostly independent in changing it. RN C stated R4 has not had any issues with stoma infection, soreness, or pain that she is aware of. RN C states the colostomy device last changed 1/3/23 and 1/10/23. This is changed every 3-7 days on the evening shift. On 01/12/23 at 9:00 a.m., Surveyor interviewed RN C asking how she would know if R4 has a colostomy. RN C states she knows this from R4's hospital information and that the information on R4's TAR (Treatment Administration Record) would be there to notify of need to change colostomy device.

Based on observation, interview and record review, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice based on the comprehensive assessment, comprehensive person-centered care plan, and policy and procedure of the facility for 1 of 12 total residents (R) reviewed (R14). The facility did not do a thorough comprehensive assessment for R14. R14's care plan does not address the risk of gastrointestinal issues or assessment of the gastrointestinal system. The facility did not routinely assess R14's gastrointestinal system to assess for bowel obstruction, when R14 had a history of ileus. This is evidenced by: Facility policy titled Bowel and Bladder Management Policy with Revision date of July 2020 only includes information on incontinence care and treatment. Nothing is noted concerning assessment of gastrointestinal system or bowel assessments. Bowel Protocol: Milk of Magnesia Suspension 400mg/5ml give 30ml (milliliters) by mouth as needed for constipation in evening of 3rd day of no BM (bowel movement). Bisacodyl Suppository, insert 1 suppository rectally as needed for constipation in afternoon of 4th day of no BM. Enema Sodium Phosphates, insert 1 dose rectally as needed for constipation in afternoon of 4th day of no BM. If no results from bowel protocol, notify primary physician or NP (nurse practitioner). On 01/10/23, Surveyor reviewed R14's diagnoses that include, but are not limited to: Cerebral Palsy, Lennox-Gastaut syndrome, intractable, with status epilepticus, localization related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, without status epilepticus, symptoms and signs involving cognitive functions and awareness, adrenomedullary hyperfunction, gastrostomy status, GERD (Gastroesophageal reflux disease), dysphagia, ileus, abnormal posture, dependence on wheelchair. R14's admitted to the facility was on 4/20/21. On 01/10/23, Surveyor reviewed R14's most current MDS (minimum data set) dated 10/25/22 documents that R14 is unable to make needs known and is fully dependent on staff and is always incontinent of bowel and bladder. Tube feeding initiation of 4/21/21: Focus: R14 requires tube feeding Jevity with fiber r/t (related to) Chewing problem, Swallowing problem. Date Initiated: 04/21/2021 Revision on: 07/27/2021 Goal: R14 will remain free of side effects or complications related to tube feeding through review date. R14 will maintain adequate nutritional and hydration status and weight stable, no s/sx (signs/symptoms) of malnutrition or dehydration through review date. R14 will be free of aspiration through the review date. Bowel obstruction initiation of 1/11/23: Focus: R14 has actual bowel obstruction Date Initiated: 01/11/2023 Revision on: 01/11/2023 Goals: R14 will remain free from discomfort, complications or s/sx related to gastrointestinal alterations through review date. Date Initiated: 01/11/2023 Target Date: 12/20/2022 Interventions: o Give medications as ordered. Monitor/document side effects and effectiveness. Date Initiated: 01/11/2023 o Monitor bowel sounds q shift (every shift) update MD/ NP with any concerns Date Initiated: 01/11/2023 o Monitor vital signs (specify frequency). Notify MD of significant abnormalities. Notify MD of significant abnormalities (rapid pulse, shallow, rapid, or labored respirations, low blood pressure) Date Initiated: 01/11/2023 Revision on: 01/11/2023 o Obtain and monitor lab/ diagnostic work as ordered. Report results to MD and follow up as indicated. Date Initiated: 01/11/2023 Nothing noted in R14's Care plan concerning risk of gastrointestinal issues or assessment of gastrointestinal system such as bowel sounds, palpation of abdomen, prior to 01/11/23. Survey team onsite starting 01/10/23. On 01/12/23, Surveyor reviewed R14's Orders include (related to current issue) but are not limited to the following: 1/12/23: Hold TF (tube feeding) and medication except Dilantin until NP (nurse practitioner) can review XR (x-ray) per on call provider. 1/11/23: Monitor bowel sounds q-shift (every shift) update MD/ NP (medical doctor/nurse practitioner) with any abnormal changes three times a day 1/11/23: MiraLax Powder 17 GM/SCOOP (Polyethylene Glycol 3350) Give 1 scoop via G-Tube (gastro tube) in the morning for constipation until 01/20/2023 1/4/23: On call provider states send to ER (emergency room ) for tube replacement and vomiting 4/20/21: Bowel protocol per facility policy On 01/12/23, Surveyor reviewed R14's MAR (Medication Administration Record) and TAR (Treatment Administration Record): Per review, staff are charting care of R14's G tube, residual checks, flushes, holding feeding for Dilantin. Noted no documentation of bowel sounds or abdominal assessment. Surveyor reviewed R14's bowel records from 12/30/22 through 01/12/23. R14 averaged 2 to 3 bowel movements (BMs) per day with loose to normal consistency. No BMs recorded for 01/07/23 or 01/08/23. 5 BMs recorded on 01/09/23: 3 loose and 2 normal. 3 loose BMs recorded on 1/10/23, 1 normal BM recorded on 1/11/23, and 2 loose BMs recorded on 1/12/23. Surveyor reviewed R14's record for assessment of gastrointestinal system and identified a bowel and bladder evaluation completed on 10/21/22. The only other documentation of gastrointestinal status was the following Nursing Summary dated 01/06/23, which included the following: 1 emesis 1/4/23. Tube has been becoming dislodged. Active bowel. No other bowel assessment items noted. On 1/12/23, Surveyor reviewed R14's recent radiology reports with results as follows: 1) XR (x-ray) ABD (abdominal) KUB (kidneys, ureter, bladder) completed 1/5/23 by ER MD at Sacred Heart Hospital that states for finding: The patient's indwelling gastrostomy tube was injected with approximately 50 milliliters of Gastrografin. The injected contrast is contained within the gastric fundus. There is bowel distension which is largely colonic but with some loops of small bowel suggestive. This raises concern for ileus. Impression: 1. Appropriate G-tube positioning. 2) X-ray Chest 2 View ordered by facility provider was completed 1/11/23. This report was received 1/11/23 at 4:51 p.m. Results: . Diffuse abdominal bowel obstruction with elevation of the hemidiaphragms . Diffuse abdominal bowel obstruction with elevation of the hemidiaphragms. 3) Abdominal x-ray completed 1/12/23 at [hospital] for indication of abdominal distention and ileus. Findings: Post operative changes at the proximal left femur. G tube injecting over the central left lateral abdomen. IVC filter in good position. No substantial change in few mild to moderately dilated loops of large bowel along with multiple upper limits normal size gas filled loops of small bowel .1. Persistent mild to moderately diluted loops of large bowel consistent with mild more likely chronic ileus. On 01/11/23 at 11:32 a.m., Surveyor observed RN C administer medications to R14 through PEG tube. Procedure was performed correctly. RN C did not check for bowel sounds or assess R14's gastrointestinal status. On 1/12/23, Surveyor reviewed R14's Progress note dated 1/10/23 at 0900 written by nurse practitioner that stated the following: Services are being provided at [name of facility] History of present illness: Resident is seen today at staff request. They tell me that she is simply not looking right and is tachycardic. review of systems: blood pressure 149 / 93, pulse 117, respiratory rate 16, temperature 97.2 degrees Fahrenheit, SPO2 (oxygenation saturation) 93%. Physical exam: General: Resident looks at me when I greet her but does not verbalize which is her baseline. Respiratory effort is increased respiratory rate 24 per minute. mouth is open. Pharynx somewhat dry. Heart rhythm is regular. Posteriorly there are rhonchi on the left scattered rhonchi anteriorly as well. Normal bowel tones. G tube site is intact. Extremities are warm. Impression/Plan: 1) Recurrent aspiration pneumonia. She has a history of aspiration pneumonia and has had a change in her vital signs so I'm going to start empiric treatment. Augmentin 875 milligrams / 125 milligrams tablet via enteral tube twice daily for 10 days. Chest X-ray. CBC / CRP / BMP. nasal swab for COVID 19/ RSV / Influenza. 2) Epilepsy with complex partial seizure, seizures not intractable, without status epilepticus. She has a history of seizure disorder and has had multiple breakthrough seizures. I ordered a Dilantin level to be checked today. She is also on Keppra. I will have staff arranged for her to be seen by her neurology team for follow up and medication management. 3) PEG status. Patient has had multiple issues with her g-tube in the past couple of weeks. At this time, it is functioning well. 4) intellectual functioning disability. She has two guardians in place for health care decision making. On 1/12/23, Surveyor reviewed R14's Progress note dated 1/12/23 at 0950 written by Emergency department doctor at the hospital. History of presenting illness: Patient who is nonverbal with cerebral palsy and indwelling peg tube that presents today for bowel obstruction. patient is unable to provide history. Per nursing she reportedly has been having bowel movements, but it is unclear when her last one is. radiology report made available to us via paper handoff states in part, . Diffuse abdominal bowel obstruction with elevation of the hemidiaphragm. The osseous structures are unremarkable .ED course/medical decision making: Patient was brought to the hospital with suspicion of bowel obstruction as noted on imaging obtained from outside facility. We are unable to see the imaging only the report which states diffuse abdominal bowel obstruction with elevation of the hemidiaphragm. Patient reportedly still having flatulence and bowel movements last one unknown. CBC CMP lactic acid all ordered. General surgery consulted for further recommendations and on chart review he noted she has episodes of ileus which he suspects this is. No additional recommendations at this time consulted hospitalist services for admission obtained additional KUB imaging for evaluation. KUB pending. Admit to hospital service admit diagnosis bowel obstruction and ileus. On 1/16/23 an email sent to Surveyor from the CNO (Chief Nursing Officer) L at the facility concerning R14 stated, On 1/13/23 the resident returned to the facility for continuation of care and follow up KUB. CNO L states, .has the diagnosis of ileus with the summary states the following: Physical examination states the following: resting on cot no acute distress. GI: Rounded and soft. Active bowel sounds in all four quadrants. High pitched tiny sounds in left and right upper quadrants. No apparent guarding. PEG tube present to left abdomen, dressing clean dry and intact. Assessment: Ileus. Abdominal KUB on 1/5/23 shows bowel distention which is largely colonic but with some loops of small bowel which is suggestive of ileus. Repeat KUB on 1/12/23 shows continued moderately dilated large bowel. Plan: hold tube feeding overnight with repeat KUB and labs in the morning. Plan for nursing to give fleet enema times two tonight along with 120 milligrams simethicone for gas relief. General surgeon has been consulted. Patient seen and examined labs and chart reviewed I agree with the above note. At this point the patient appears to have decent bowel sounds, just received an enema, and has some liquid stool. Will await surgery recommendations . should be able to start some tube feeds on her tomorrow. I did change her fluids to supply with some dextrose since she is NPO. It is noted on the MAR (medication administration record) R14 received IVF (intravenous fluids) during this hospital stay. Sodium chloride 9.0% infusion rate 75ml/hr continuous. Start 1/12/23 1400 end 1/12/23 1706. Dextrose 5% and 0.9% NaCl (sodium chloride) with KCL (potassium chloride) 20 mEq (milliequivalents) infusion rate 75ml/hr continuous. Start 1/12/23 1730. Surveyor reviewed R14's progress notes from 12/31/22 through 1/12/23 to find no documentation of bowel sounds / gastrointestinal assessment except for the following: 1/12/2023 02:43 Nursing Progress Note: Note Text: R14 CXR (chest x-ray) returned noting diffuse abdominal bowel obstruction. Call placed to on call provider to update. Advises to hold TF (tube feeding) and medications, except Dilantin, until provider can review and advise. TF stopped immediately. TO (telephone order) faxed to on call provider for signature. R14 continues to have normoactive bowel sounds, multiple BMs (bowel movements) throughout yesterday, 1/11. Abdomen is soft, flat and nontender. PEG (percutaneous endoscopic gastrostomy) tube is patent, and Dilantin can be administered. R14 is afebrile, no vomiting. Will continue to monitor and await orders from PCP (primary care provider). There were no bowel assessments from 1/5/23 - 1/12/23, when ileus had been identified on the hospital report 1/5/23. 1/12/2023 08:39 Nursing Progress Note: Note Text: On call provider called this morning requesting that R14 be sent out to the ER for evaluation. Message left for POA (power of attorney) with no return call. 911 called and R14 left the facility at this time. Nurse report called to [hospital]. 1/12/2023 12:38 Nursing Progress Note: Note Text: This nurse called [hospital] and spoke with the ER (emergency room ) nurse. ER Nurse states that R14 was not admitted with aspiration pneumonia but admitted with the X-ray report bowel obstruction that was sent with R14. ER Nurse also states that R14's increased gas may have caused an ileus causing this current problem. On 01/12/23 at 8:40 a.m., Surveyor was informed R14 was being sent to the hospital via ambulance to rule out bowel obstruction per Med Tech D. On 1/12/23 at 12:45 p.m., Surveyor interviewed RN C about R14's status and RN C stated R14 has been having consistent formed bowel movements with last ones yesterday that were formed. R14 had bowel sounds last night. RN C spoke with hospital RN just before this interview, who stated R14 is being admitted with x-ray indicated bowel obstruction. No new x-ray has been performed yet at the hospital, they are going off the x-ray report sent with R14. Hospital RN told RN C that it is possible increased gas could have caused an ileus causing this current problem. On 1/12/23 at 1:15 p.m., Surveyor interviewed DON B asking what the bowel protocol means as this was an order for R14. DON B stated this is a standing order that would start day three with no bowel movement. DON B provided the bowel protocol orders. Surveyor asked DON B what the expectations for bowel assessments were. DON B stated bowels would not really be assessed unless there is a concern. Nurses chart by exception. DON B told this Surveyor that she has started a PIP (Performance Improvement Project) for alert charting. On 1/12/23 at 1:30 p.m., Surveyor interviewed RN C about when bowel assessments would be done by nurses. RN C stated we chart by exception. If there is an issue, we assess the resident, chart, and notify the provider, DON, and POA if applicable. Follow up on orders if ordered and continue monitoring the resident. We have a 24-hour report log to report to the oncoming shift. Asked if this surveyor could see the report log and RN C stated, she was unsure where it is at that time. Based on standards of practice found on the Wisconsin Technical College System website nursing skills of assessment related to enteral tubes states, When caring for patients with enteral tubes, it is important for the nurse to routinely assess and document the patient's condition. Objective assessments for patients with enteral tubes include Bowel sounds should be present in all four quadrants, and the abdomen should be soft and nondistended .https://wtcs.pressbooks.pub/nursingskills/chapter/17-3-assessments-related-to-enteral-tubes/ American Nurse Official Journal of the American Nursing Association. Enteral Feeding: Indications, complications, and nursing care states the following: To identify complications of enteral feeding, thoroughly assess the patient before tube feeding begins and monitor closely during feedings. When beginning enteral feedings, Assess the abdomen by auscultating for bowel sounds and palpating for rigidity, distention, and tenderness. Know that patients who complain of fullness or nausea after a feeding starts may have higher a GRV (gastric residual volume). https://www.myamericannurse.com/enteral-feeding-indications-complications-and-nursing-care/

Based on observation, interview and record review, the facility did not ensure that residents who require colostomy services receive care consistent with the resident centered comprehensive care plan and address the goals and preferences of the resident for 1 of 12 total residents (R) reviewed (R4). The facility did not do a thorough comprehensive assessment for R4's colostomy status. The facility did not address the desires of R4 to have the colostomy cared for as she did at home. This is evidenced by: Facility policy titled Colostomy/Ileostomy Care Policy with revision date of March 2020 stated in part: .19. Observe stoma / peristomal area and measure stoma with guide. The normal stoma is bright red. Poor circulation suggested of if pale, black or purple report to physician . Suggested documentation: Condition of stoma and peristomal area. Amount and character of fecal drainage. Tolerance of procedure, self-care performed, and any education provided. Unusual observations and or complaints and subsequent interventions including communication with physician. Facility policy titled Bowel and Bladder Management Policy with revision date of July 2020 stated a resident who requires colostomy, urostomy or ileostomy services, receives care in accordance with his or her care plan. Surveyor reviewed R4's diagnoses that include but are not limited to: Colostomy status, GERD. Surveyor reviewed R4's most current MDS (minimum data set) dated 12/19/22 and 12/26/22 states R4 with ostomy status. BIMS (brief interview for mental status) for R4 is 9. (8-12 moderately impaired). R4's admitted at the facility was 12/19/22. On 01/10/23 at 3:56 p.m., Surveyor interviewed R4 about colostomy. R4 stated she has a sore colostomy since coming here. Staff empties the colostomy bag but doesn't clean it good like R4 did at home. On 1/12/23, Surveyor reviewed R4's Orders include (related to current issue) but are not limited to the following: Change system every 3-7 days or PRN. Use ConvaTec sure fit barrier #404594 seal/ring 2 Pouch ConvaTec Closed end 2-1/4 Flange #416421 every evening shift every 3 day(s) for Colostomy care AND as needed. Start date 1/12/23 On 1/11/23, Surveyor reviewed R4's Care Plan and Kardex; there is nothing noted concerning resident's preference of care for colostomy, nor assessment of stoma. On 1/12/23, Surveyor reviewed R4's Baseline Care Plan/ Evaluation dated 12/19/22 does have the box checked next to ostomy in the bowel and bladder section under bowel and bladder appliances. R4's head to toe evaluation dated 12/19/22 under section G. Digestive does include devices LLQ (left lower quadrant) ostomy, bowel sounds active in all quadrants, resident reports passing gas. Stool in ostomy appears brown and watery. Abdomen soft, nontender, rounded, denies nausea or any other discomfort. R4's bowel and bladder evaluation dated 12/23/22 does not discuss anything concerning colostomy. Reviewed the progress notes related to colostomy, no documentation noted on stoma assessment, nothing concerning pain to stoma and no documentation on R4's preference concerning care of colostomy. On 01/11/23 at 12:40 p.m., Surveyor observed CNA (Certified Nursing Assistant) K empty R4's colostomy. Hand hygiene completed with use of gloves. Privacy and explanation of what is being done. Bag was not very full of stool. During the observation R4 stated the stoma was hurting. Surveyor asked R4 if she had told staff of this before and R4 stated she has. Bag and site care not done at this time. The dressing and bag look good, no signs or symptoms of infection noted on outside, unable to really see the stoma due to stool residue left in bag. R4 stated she used to care for the colostomy at home. R4 stated the staff are not doing this how she took care of changing the bag daily. R4 states she would wash out the bag every time. On 01/11/23 at 12:56 p.m., Surveyor interviewed RN C about R4's colostomy asking how does she know who cares for the colostomy or the wishes of the resident concerning the care of the colostomy. RN C stated she usually will help R4 to change the colostomy device. R4 is mostly independent in changing it. RN C stated R4 has not had any issues with stoma infection, soreness, or pain that she is aware of. RN C states the colostomy device last changed 1/3/23 and 1/10/23. This is changed every 3-7 days on the evening shift. On 01/12/23 at 9:00 a.m., Surveyor interviewed RN C asking how she would know if R4 has a colostomy. RN C states she knows this from R4's hospital information and that the information on R4's TAR (Treatment Administration Record) would be there to notify of need to change colostomy device. R4 had a colostomy on admission, reported it has been sore since admission and staff was not caring for it as R4 desired. No initial, or routine comprehensive assessments documented on stoma condition. No determination on R4's preference of care were initiated. No comprehensive care plan directing staff of care for R4's colostomy.

Based on record review and interview, the facility did not develop a care plan with behavioral non-pharmacological approaches or have a system in place for monitoring the effectiveness of psychotropic medications prescribed. This has the potential to affect 2 of 5 residents reviewed for unnecessary medications (R19 and R4). R19 is prescribed Duloxetine an Antidepressant for depression, Trazodone an Antidepressant at bedtime for sleep and Escitalopram for depression. R19 has no care planned approaches for her depressive symptoms or to promote sleep. R19 has no system in place to monitor the effectiveness of the medications. R4 is prescribed Citalopram an antidepressant for depression. R4 has no care planned approaches for mood and behavior with no system in place to monitor the effectiveness of this medication This is evidenced by: Example 1 Surveyor reviewed R19's record and noted the following: R19's diagnosis included adjustment disorder with depressed mood. R19's most recent Admission Minimum Data Set (MDS) dated [DATE] notes R19 took antidepressant medication 7/7 days evaluated, she had no behavioral concerns and had depressive symptoms of feeling down, depressed or hopeless, trouble falling or staying asleep or sleeping too much, feeling tired or having little energy. R19's Physician orders included: 11/06/22: Duloxetine (Antidepressant) 60 mg bid (twice daily) for depression 11/03/22: Trazadone (Antidepressant) 25 mg by mouth daily at bedtime for sleep 11/04/22: Escitalopram (Antidepressant) 20 mg QD (every day) for depression R19's care plan was reviewed by Surveyor. Surveyor noted no care planned goal or individual care planned approaches to address R19's indicators of depression or sleep disturbance. R19's record was reviewed by Surveyor. Surveyor noted system in place to monitor R19's depressive symptoms or sleep. There was no system in place to evaluate the effectiveness of R19's psychotropic medications. On 01/12/23 at 1:20 PM, Surveyor spoke with Director of Nursing (DON) B regarding R19's psychotropic medications, care plan and system to monitor the effectiveness of the medications. DON B indicated she has been on staff since 11/22. DON B expressed she would expect a care plan be developed after a comprehensive sleep study. The care plan should contain a focus of insomnia and depressive symptoms with a specific goal and individualized approaches. DON B explained the facility is aware there are concerns with the facility's behavior program. The facility has held one meeting to discuss the facility processes but due to other priorities in the building the system has not yet been developed and R19 has not yet been reviewed by team. Should have some type of charting to show how she is doing. DON B indicated she would check R19's record and get back to the surveyor. On 01/12/23 at 3:32 PM, DON B informed Surveyor R19 had no behavior monitoring or charting in place for her depressive symptoms or sleep. The facility just began looking at their processes and R19 has not yet been reviewed. 47284 Example 2 On 1/11/23, Surveyor reviewed R4's diagnoses that include but are not limited to: Anxiety and major depressive disorder. R4 was admitted to the facility on [DATE]. On 1/12/23, Surveyor reviewed R4's Orders to include (related to current issue) but are not limited to the following: Citalopram Hydrobromide Tablet 20 MG Give 1 tablet by mouth one time a day for depression Nursing order: Antidepressant medication - monitor for sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash, photosensitivity (skin) excess weight gain Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and progress note findings two times a day On 1/12/23, Surveyor reviewed R4's care plan which states nothing related to mood or behavior, targeted behaviors, non-pharmacological interventions. On 1/12/23, Surveyor reviewed R4's record and did not identify any behavior assessments, nor behavior monitoring to assess for levels of depression. On 1/12/23, Surveyor reviewed R4's Kardex that states under behavior/mood: behaviors - verbally aggressive. On 1/12/23, Surveyor reviewed R4's Progress Notes since admission to find three nursing progress notes that discuss R4's behaviors. Two notes stated R4 was confused and became agitated, cursing at staff, difficult to redirect. One note stated R4 has been pleasant and appropriate this shift. Resident reviewed in behavioral meeting by IDT (interdisciplinary team) and pharmacist. Resident is on Citalopram due to depression, no changes recommended at this time. Will continue to monitor.

Based on interview and record review, the facility failed to provide basic life support, including Cardiopulmonary Resuscitation (CPR), to a resident requiring emergency care and failed to notify emergency medical personnel for 1 of 3 sampled residents (R) R1. R1 was found pulseless and not breathing on [DATE]. R1's Physician order [REDACTED]. Facility failure to begin cardiopulmonary resuscitation and for failing to call 911 created a finding of immediate jeopardy that began on [DATE]. The Nursing Home Administrator (NHA) was notified of the immediate jeopardy on [DATE] at 3:30pm. The immediate jeopardy was removed on [DATE]. However, the deficient practice continues at a scope/severity of E (potential for more than minimal harm/pattern) as the facility continues to implement its action plan. This is evidenced by: On [DATE] at 9:00 a.m., Surveyor performed a tour of the facility. An undated sign posted at the nurse's desk read Full code list. The list contained the names of 9 residents. Surveyor interviewed Licensed Practical Nurse (LPN) E, who was the charge nurse for the facility. LPN E told Surveyor that the Full code list is reviewed daily and updated with new admissions. LPN E stated that the Full code list is populated from the computer. LPN E showed Surveyor the listed residents' Medication Administration Records which contained code status listed at the bottom of the document. Surveyor reviewed physician orders [REDACTED]. The Full code list reflected accurate information, as noted in the physician orders [REDACTED]. LPN E told Surveyor that residents' code information is also kept in a binder at the nurse's station for easy access, in case the facility needs to transport a resident to the hospital. The binder was titled Resident Info. Binder. Surveyor reviewed the Resident info. Binder. LPN E told Surveyor that this information is also listed in the computer. Surveyor reviewed and compared residents' physician orders [REDACTED]. Binder. The life sustaining information that was available in the Resident Info. Binder coordinated with residents' POLST information and physician orders. However, not all residents in the facility were included in the binder. Surveyor interviewed LPN J regarding facility teaching/training for CPR. LPN J told Surveyor that she completed Relias (a computer program) training a year or more previous, that was through the last company ownership. The training included: When to initiate CPR, use of the crash cart and emergency notifications. LPN J stated, I am certified in Basic Life Support. At 10:15 a.m., Surveyor reviewed R1's clinical record. R1 was admitted to the facility on [DATE]. R1's [DIAGNOSES REDACTED]. R1's Minimum Data Set (MDS) listed only entrance and exit data. However, R1's cognitive status on admission, [DATE], is documented as alert and oriented, with periods of confusion. The physician order [REDACTED].Resuscitate. Treatment options when the patient/resident has a pulse and or is breathing .Aggressive Treatment: Includes the above and/or endo tracheal intubation .advanced airway and cardiac defibrillation Under the title of Antibiotics the POLST states Aggressive treatment. Progress Notes stated, in part: [DATE], 04:31 p.m.: Resident condition remains stable. VSS (Vital signs stable) at this time. Resident is alert and oriented, cognitive status at baseline. Resident does continue to have episodes of nausea with emesis .Resident condition will continue to be monitored. [DATE], 03:02 p.m.: Resident has been pleasant this shift. No nausea or vomiting today, complainants of pain managed well with prn (as needed) pain medication. Resident PO (oral) intake improving with decreased n/v (nausea and vomiting) .Resident spoke with family on the phone today Resident will continue to be monitored for changes. [DATE], 09:17 p.m.: Resident noted to be increasingly sob (short of breath) and complains of increased pain this evening. Prn [MEDICATION NAME] administered for sob/pain. Call placed to MCHS (Mayo Clinic Health System) Home Health and Hospice. Awaiting reply. This note was written by LPN D. [DATE], 12:35 a.m.: Writer (RN (Registered Nurse) F) alerted by prior shift that resident passed away at 09:55 p.m. on [DATE], prior nurse had contacted family and hospice to update and request processing of the death. RN F is no longer an employee at the facility, and therefore unavailable for interview. At 11:45 a.m., Surveyor interviewed LPN D. LPN D stated that R1 became agitated around the time of bedtime or medication pass. LPN D stated that R1 offered no specific complaints, and was restless, changing positions in bed often. LPN D stated that she assisted R1 with calling his sister by giving him the facility's portable phone. After R1 talked to his sister and prayed, he calmed down. LPN D stated she did not know what time this was, but it was after medication pass. LPN D stated the next time she checked on R1, at an unknown time, but after medication pass, R1 was dead. LPN D confirmed R1 was dead by auscultating his lungs and checking his pulse and blood pressure, which was not registering. LPN D stated R1 was not breathing. LPN D stated CNA G accompanied her into R1's room. Surveyor asked LPN D if CPR was attempted. LPN D stated, No, CPR was not attempted since he was a hospice patient. Surveyor asked LPN D to describe R1's code status. LPN D stated, We knew he was a full code. LPN D stated she had not checked physicians' orders at the time of the incident. Surveyor asked LPN D why she did not document the circumstances surrounding R1's death in the progress notes. LPN D stated, Because I passed that onto the next shift. Asked to describe how CPR information is communicated to staff, LPN D stated, Our DON comes out of her office and gives us updates. I'm not sure if it was on [DATE], but I told her during shift report, while discussing R1's code status This is bizarre. R1 is a hospice patient .What are we supposed to do? LPN D stated DON B told her We are in the process of changing R1's code status to do not resuscitate. LPN D told Surveyor the Full Code List was not posted. LPN D told Surveyor she has had no training through the facility regarding CPR initiation or emergency management when a resident is found pulseless and is not breathing. At 11:48 a.m., Surveyor interviewed DON B. DON B stated no staff had asked her about R1's code status, or interventions for R1 if R1 became breathless or pulseless. At 12:40 p.m., Surveyor interviewed Medical Doctor (MD) G, who is the Medical Director at the facility. MD G stated, If a resident is a full code, I would expect the staff to do CPR. At 1:00 p.m., Surveyor interviewed Social Services Director (SSD) I, who is responsible for coordination of advance directive information for the facility. SSD I stated, I talked to his Power of Attorney for Health Care (R1's sister). R1's sister stated she was aware R1 wanted to be a full code, and she wanted R1's wishes followed. No, I did not document this conversation. It occurred sometime after the resident was admitted . At 1:50 p.m., Surveyor interviewed Certified Nursing Assistant (CNA) H, who was responsible for R1 on [DATE] p.m. shift. CNA H told Surveyor that sometime after medication pass, LPN D assisted R1 in using the portable phone to call his sister. CNA H stated LPN D returned the phone to the charging station, then re-entered R1's room After entering R1's room, CNA H stated LPN D came out of the room and stated, Oh my God, I think he is dead. CNA H stated she was shocked since R1 had just been talking and laughing with the staff after talking to his sister. CNA H told Surveyor LPN D did not begin CPR or issue instructions to CNA H regarding EMS activation. CNA H stated, No, she did not give us any instructions. I didn't see LPN D check R1's pulse or blood pressure or nothing when I went into the room. At 3:45 p.m., Surveyor interviewed Corporate Nurse (CN) C. CN C stated that all nurses are required to be CPR certified. On [DATE], Surveyor received a policy entitled CPR. The facility policy instructs the facility to call a Code Blue for pulseless patients without respirations. The policy states, in part, the resident identified as resuscitate will have CPR begun by a qualified and trained person .each shift is to perform a code blue drill one time per month. The DON will review the results of the drill and inservice as needed. Surveyor interviewed DON B. DON B stated that she could not locate staff training on CPR since she is new and there is new ownership in the facility. DON B stated that the facility is not performing code blue drills, but will do so now. The failure to follow the resident's wishes and provide CPR created a finding of immediate jeopardy. The facility removed the immediate jeopardy on [DATE] when it began implementing the following: *All staff on-site had immediate education clarifying that regardless to a resident being on palliative care or hospice their code status will be followed. *All staff to be educated on where the code status forms are as well as random audits to ensure compliance. *All staff to be educated on code status, to verify code status in the chart and to initiate CPR for full code status residents.

Based on observation, interview and record review, the facility failed to prepare, store and distribute food in a sanitary manner, in accordance with professional standards of practice to prevent the outbreak of foodborne illness for 1 (R10) of 1 sampled resident who was observed eating non-pasteurized (over-easy) eggs with runny yolks that were not set and completely firm. The facility's practice of cooking and serving non-pasteurized eggs that were not fully cooked and set created a finding of Immediate Jeopardy beginning on 01/27/20. Administrator A was informed of the immediate Jeopardy on 02/12/20 at 1:30 p.m. The immediate jeopardy was removed on 01/27/2020; however, the deficient practice continues at a scope and severity of F (potential for more than minimal harm/widespread) as evidenced by: Out of date coleslaw and tortilla shells were stored in the cooler and available for use. Items in the freezer were stored in a manner that would not prevent contamination. A bag with raw hamburger patties was observed touching a bag with thaw and eat shredded cheddar cheese. A raw ground pork roll stored above ready-made muffins and dinner rolls. Ready-made muffins were sitting on a bag of raw bacon. Staff were observed to change their gloves and did not perform appropriate hand hygiene. This deficient practice has the potential to affect 21 of the facility's 22 residents, who reside at the facility and receive their meals from the main kitchen. This is evidenced by: According to the (YEAR) FDA Food Code: 3-302.13 Pasteurized Eggs, Substitute for Raw Shell Eggs for Certain Recipes. Raw or undercooked eggs that are used in certain dressings or sauces are particularly hazardous because the virulent organism Salmonella Enteritidis may be present in raw shell eggs. Pasteurized eggs provide an egg product that is free of pathogens and is a ready-to-eat food. The pasteurized product should be substituted in a recipe that requires raw or undercooked eggs. Highly susceptible population means PERSONS who are more likely than other people in the general population to experience foodborne disease because they are: (1) Immunocompromised; preschool age children, or older adults; and (2) Obtaining FOOD at a facility that provides services such as custodial care, health care, or assisted living, such as a child or adult day care center, kidney [MEDICAL TREATMENT] center, hospital or nursing home, or nutritional or socialization services such as a senior center. 3-801.11 Pasteurized Foods, Prohibited Re-Service, and Prohibited Food. In a FOOD ESTABLISHMENT that serves a HIGHLY SUSCEPTIBLE POPULATION: (B) Pasteurized EGGS or EGG PRODUCTS shall be substituted for raw EGGS in the preparation of . (2) A partially cooked animal FOOD such as lightly cooked FISH, rare MEAT, soft-cooked EGGS that are made from EGGS, and meringue; Observations on 01/27/20 beginning at 8:55 a.m. In the dining room R10 was observed eating breakfast. R10 had fried eggs, the yolks were runny on R10's plate. R10 dipped his toast into the runny yolk and ate. In the kitchen there was a partially full regular carton of eggs. Surveyor did not observe a P mark on the eggs, which would indicate the eggs were pasteurized. Three empty cartons of the same type of eggs were observed on a cabinet behind the stove. Surveyor asked Cook C about the eggs on 1/27/20 at about 8:55 a.m. Cook C verified the eggs were used for breakfast this morning. Cook C also stated residents could order their eggs cooked however they wanted, including over easy, over medium, sunny side up etc. In the cooler another partial carton with 7 eggs, and a partial case of eggs were observed. No marks were observed on the eggs, the cartons or the case box to indicate pasteurization. 01/27/20 2 p.m. Surveyor interviewed Dietary Aid (DA) D. When asked if many of the residents like to eat eggs, DA D stated almost everyone likes the fried eggs to order. There were only 2 residents she could think of who didn't like them, nor eat them regularly. Surveyor interviewed Nursing Home Administrator (NHA) A on 01/27/20 at 4:30 p.m. NHA A stated the dietary manager is on leave currently, so she would relay any questions and get back to Surveyor. When asked if the facility uses pasteurized eggs for made to order eggs, NHA A reported yes they do. When Surveyor shared observations of breakfast and concerns, NHA A indicated she would look into the matter further. On 01/29/20 at 11:15 a.m., NHA A reported the eggs they were using were not pasteurized. The serving of unpasteurized eggs not fully cooked created the potential residents could contact Salmonella. This created a finding of Immediate Jeopardy. The Immediate Jeopardy was removed on 01/27/2020 at 4:30p.m. when the facility began implementing the following: Eggs were physically removed from the center on the evening of 1/27/2020; Staff were immediately re-educated identifying pasteurized and unpasteurized eggs and protocols for the serving and preparing of eggs; Facility order guide with supplier was changed to allow only ordering of pasteurized eggs. The scope and severity of the deficient practice continues at a scope and severity of an F (potential for harm/widespread) related to the following examples. Surveyor made the following observations on 01/27/20 beginning at 8:55 a.m. during initial tour. A frozen, raw 5 lb. roll of pork sausage was stored on a shelf above a box of precooked dinner rolls and box of thaw and serve muffins in the freezer. The muffins were sitting on top of a partially used package of raw bacon. Shredded cheddar cheese was on shelf with a bag of raw hamburger patties touching it. The walk in cooler contained a box of coleslaw with a use by date of 01/24/20. Tortilla shells were found in the walk in cooler with a made on date of 08/2019. Both items were still available for use. On 01/28/20 at 7:31 a.m., Surveyor observed Cook K leave the kitchen with gloved hands, and present R11 with his plate for breakfast. Cook K assisted in getting R11's oxygen tubing unstuck, from being caught on the wheelchair tire. Cook K then assisted R11 by putting on his clothing protector. Cook K walked back into kitchen, and picked up the whisk and stirred the hot cereal. Cook K then stepped back and took off the gloves and retrieved and put on a new pair of gloves and grabbed the whisk again. Cook K did not perform any hand hygiene in between glove change. Surveyor conducted interview with NHA A on 01/28/20 at 4:30 p.m. When Surveyor asked about food storage and hand hygiene, NHA A responded, Hand hygiene should be performed every time gloves are removed and replaced.

Based on observation, interview and medical record review, the facility did not provide care related to pain management and cardiac monitoring to 2 of 8 sampled residents (R4 and R1). R4 has multiple open wounds on her feet. R4 was was experiencing significant pain in her feet that was not adequately controlled by her current pain medication regimen. The lack of pain control caused R4 to refuse wound treatment to her foot. In addition, staff were not accurately documenting the effectiveness of the pain medication. R1 had weight changes which were not reported to the physician as the physician had ordered. This is evidenced by: 1. The facility's 08/01/15, policy entitled Pain Assessment and Management read in part: 1.1 Facility will, through assessment and management, strive to alleviate, to the extent possible, the pain that may be experienced by the patient/resident due to acute or chronic medical conditions. 3.3 Pain is defined as an individual's unpleasant sensory or emotional experience. Acute pain is pain of abrupt onset or escalation. Chronic pain is pain that is persistent or recurrent. Pain is a highly subjective, personal experience for which there are no consistent objective biological markers. Basically, pain is whatever the person experiencing the pain says it is. 4.1 The comfort and well-being of the patient/resident should always be paramount. This principle is the foundation of effective pain management. 4.3 Members of the interdisciplinary team have a responsibility to advocate for patient/resident comfort and to find clinically appropriate, cost-effective ways of achieving it . R4 was admitted with [DIAGNOSES REDACTED]. R4 was admitted on scheduled [MEDICATION NAME] (Tylenol) 1000 mg (milligrams) three times per day for pain. R4 also had an order for [REDACTED]. R4's initial pain care plan dated 03/23/17, read in part: The resident has pain. Goal: The resident will voice a level of comfort through the review date. The resident will not have an interruption in normal activities due to pain through the review date. Will state pain is less than goal of 3 via numeric scale. From interviews with R4 and review of her MAR and pain scale ratings, R4's pain was not at her goal of a 3. R4's pain was not well controlled with the scheduled Tylenol as written in the above progress note by LPN C. R4's Skin Observation Tool signed by an RN on 03/23/17 identified the following wounds: Right ankle (outer) old wound on admin. (sic) irregular half moon; red/black wound bed; 2.1cm (centimeter) x 1.5cm; apprx (approximately) 0.3cm deep. Left ankle (outer) vascular wound on admission; 7cm x 4 1/2 cm kidney shaped irregular; apprx. 0.2cm deep wound bed yellow slough large amount. Left toe(s) vascular wound on admission; left outer toe; 4 1/4cm x 3 cm kidney shaped; 0.1 cm deep apprx. irregular; blood and yellow slough; top left toe slit 2cm; with 1cm circumference open area. Other (specify) top of right foot; old wound 2.25cm x 1.2cm blood and yellow slough; small scab top on third toe; scab top of large toe right foot. A Pain Evaluation signed by LPN C on 03/24/17, identified: 1. R4 has no cognitive impairment, sensory impairment or communication difficulties that would impede R4's ability to report pain. 2. R4's most recent pain level at a 0 for 03/23/17 at 11:50 p.m. 3. Residents acceptable level of pain was blank. 4. Does the resident report pain .? a. yes. 5. Is pain reported to be better, worse or the same since last evaluation? c. Same/unchanged. 6. Describe location, characteristics and duration of pain, in residents words if able . Pain in feet or general all over. 7. What makes the pain better? [MEDICATION NAME]. 9. If new or increased pain, please notify physician: R4's physician name and phone number were listed. C. Interventions/Medications 1. Received scheduled pain medication regimen? Yes 2. Received PRN (as needed) pain medications or was offered and declined: No. (R4 received the PRN [MEDICATION NAME] on 03/23/17). On 03/28/17 at 2:20 p.m., Surveyor observed Registered Nurse (RN) A ask R4 what her pain rating is now. R4 said a 7. RN A said it was a 10 before. On 03/28/17 at 3:22 p.m., RN A asked R4 how her pain was. R4 Said same as last time, a 7. On 03/29/17 at 7:55 a.m., Surveyor asked R4 how her pain was this morning. R4 stated it is a 9 or 10. Surveyor asked R4 if she had a pain pill lately. R4 said No, I haven't. Surveyor asked R4 is she thinks her pain is controlled well enough. R4 said it could be a little better. R4 was asked what level she would want her pain to be at and be comfortable. R4 said I wish I wouldn't ache so much. R4 did not give Surveyor a number for a comfortable pain level. At 8:07 a.m. on 03/29/17, Surveyor told Licensed Practical Nurse (LPN) B about R4 telling Surveyor her pain level was a 9 or a 10. On 03/29/17 at 9:48 a.m., Surveyor asked LPN B what she had given R4 for pain that morning. LPN B said her scheduled Tylenol and a prn [MEDICATION NAME]. R4's Medication Administration Record (MAR) showed R4 had an [MEDICATION NAME] 5 mg at 8:16 a.m. on 03/29/17 for a pain rating of 9. The MAR for the [MEDICATION NAME] had an E charted meaning effective. On 03/29/17 at 9:30 a.m., the Director of Nursing (DON) asked R4 how her pain was today. R4 said it is a little better after taking 2 pain pills, but it is still there. The documentation in the MAR indicating the medication was effective is not consistent with R4's report of pain. The DON said to R4, you may need something stronger. R4 was agreeable with this. The DON said she sent a fax to the doctor last evening but haven't gotten a response back. R4 stated I could do a lot better with therapy if I wasn't having all this pain. On 03/29/17 at 10:25 a.m., the DON asked R4 what her pain rating is now. R4 stated it is at an 8 and the pain is mainly in her left foot and R4 pointed to her left outer ankle. R4's pain only improved by 1 point after receiving the [MEDICATION NAME]. On 03/29/17 at 11:25 a.m., Surveyor asked LPN B if she was going to do R4's treatments to R4's feet. LPN B said R4 was having too much pain and wanted to wait until after her appointment. Review of R4's MAR from 03/22/17-03/29/17 at 3:42 p.m., showed the prn [MEDICATION NAME] was administered 16 times. R4 reported pain at levels of 5-10. The prn [MEDICATION NAME] was charted as E for effective. No follow up pain scale number was documented on R4's MAR or in nursing progress notes except for a nursing note of 03/26/17 at 8:46 a.m. read PRN Administration was: Effective Follow-up Pain Scale was 8. A numerical rating for the effectiveness of the medication is essential in determining the overall effectiveness of the pain regimen. A nursing progress note written on 03/26/17 at 6:05 p.m., by LPN C read in part: Resident is being monitored for pain, Pain well controlled with scheduled medication . This entry is not consistent with R4's self-reported pain scale rating. On 03/28/17 at 3:54 p.m., Surveyor spoke with the DON and shared the concern of R4 having sufficient pain control. Surveyor shared that R4 had reported to RN A on two occasions on 03/28/17 that her pain was at a 7 after receiving her pain medications and documentation of R4's being at a 10 at times. The DON said R4's pain goal is to be at a 3. Surveyor asked if R4's physician had been consulted regarding her pain ratings since her admission on 03/22/17. The DON said R4's physician had not been notified of R4's pain levels that she was aware of. After Surveyor discussed the concern about R4's pain management a fax was sent to R4's physician. On the afternoon of 03/29/17, Surveyor reviewed the fax that was sent to R4's doctor on the late afternoon of 03/28/17. The time on the fax was 5:46 p.m. During an interview with the DON on 03/29/17 at 4:35 p.m., the DON told Surveyor the 5:46 p.m. was the time the fax was received at the physician's office. Surveyor asked the DON if it was likely that R4's physician would have been at the office at the time of day. The DON said she was not sure. The fax read: Concerns: Resident currently has an order for [REDACTED]. Her pain level is steady at 7. Is there something we could do to better manager her pain? Recommendations? [MEDICATION NAME] perhaps? The DON told Surveyor the fax was returned to the facility on [DATE] at 9:55 a.m., the doctor had signed the fax but had not written any orders. During an interview with the DON on 03/29/17 at 2:15 p.m., Surveyor asked if they had heard back from R4's physician yet regarding her pain management. The DON said she needed to check on it. Survey asked for verification of the facility's pain scale used. The DON stated they use a 0-10 scale. (A 0-10 pain scale indicates; 0 as no pain, 1-3 mild pain, 4-6 moderate pain and 7-10 severe pain). During an interview with the DON on 03/29/17 at 4:35 p.m., the DON told Surveyor phone calls were placed to R4's physician on 03/29/17 at 2:00 p.m. and again at 4:00 p.m. regarding R4's pain control. The DON said R4's doctor called the facility at 4:20 p.m. on 03/29/17 and R4's physician gave the order for R4 to have [MEDICATION NAME] (a long acting pain medication) 10 mg po two times per day and the prn [MEDICATION NAME] was decreased to two times per day prn. 2. On 03/28/17 at 1:15 p.m., Surveyor reviewed R1's medical record. R1 has [DIAGNOSES REDACTED]. R1 is dependent on supplemental oxygen at 2- 4 liters per minute per nasal cannula. R1 currently receives the following medications for heart failure: [MEDICATION NAME] (a diuretic medication) 40 milligrams (mgs) twice a day and [MEDICATION NAME] 100 mg daily. R1 is weighed daily. The current interdisciplinary care plan and the Certified Nursing Assistant care plans state,Weigh at the same time of day and record: daily, per physician notify if up or down 5 lbs in one week. On 02/27/17, the physician wrote the following order,Call if 5# wt (weight) gain up or down per week. R1 had the following weights recorded: 03/06/17 - 226# 03/07/17 - 231.5#. (5.5# weight gain in one day. No documentation found in the medical record that the physician had been notified.) 03/09/17 - 227# 03/10/17 - 235# (8# weight gain in one day. No documentation found in the medical record that the physician had been notified.) On 03/29/17 at 7:30 a.m., Surveyor reviewed R1's weight gain with the Director of Nursing (DON) and the physician order [REDACTED]. Surveyor questioned the DON if the physician had been notified of the weight gain on 03/07/17 and 03/10/17. The DON stated she did not know and would look for the documentation. No further information was provided to the surveyor.

Based on interview and record review, the facility did not consult a physician when a need to alter treatment should have been identified resulting in an immediate jeopardy situation for 1 of 6 sampled residents (Resident #1). 1. Resident #1 was admitted to the nursing home with a recent [MEDICAL CONDITIONS] with dysphagia and nutritional deficiency. The resident lost 12.5 lbs (7.3%) in 18 days from 01/04/15 to 01/22/15. The Registered Dietician (RD) assessed Resident #1's fluid needs and initiated fluid intake monitoring. Resident #1 consistently took less than her assessed fluid needs of 2220 milliliters per day. Beginning 01/23/15, Resident #1 had a significant decline in fluid intakes, with intake ranging from 91 to 100% less than what the resident required. Staff could not rouse the resident or get her to drink. The facility did not consult with a physician when the resident became more lethargic and was not able to drink. On 01/26/15, Resident #1 was transferred to the hospital (per daughter's request) with admitting [DIAGNOSES REDACTED]. The facility's failure to consult with a physician when Resident #1 had a significant decline in fluid intake, which subsequently led to increased confusion and the need for hospitalization s, created a finding of immediate jeopardy. Immediate jeopardy began on 01/23/15, the date that Resident #1 was noted to have a decline in oral intake. The Nursing Home Administrator (NHA) was notified on 02/12/15 at 10:35 a.m., that immediate jeopardy existed. The immediate jeopardy was removed on 02/12/15. The deficient practice continues at a scope/severity level of D (potential for harm that is not immediate jeopardy/isolated) as all portions of the corrective actions have not been fully implemented and as evidenced below. 2. Resident #1 had blood in the urine intermittently from 01/09/15 - 01/14/15. The facility faxed the physician on 01/14/15, but the physician did not respond. The resident continued to have blood in the urine. The facility did not follow up with the fax sent and did not consult with the physician until 01/18/15, when the physician ordered lab tests. This is evidenced by: The facility's "Acute Change in Condition (Identification & Reporting)" policy dated 03/19/12, states, "Policy: It is the policy of this facility to ensure that each resident receives necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care and professional standards; within the limits of his/her right to refuse treatment and within the limits of recognized pathology and the normal aging process and to ensure the resident's abilities in activities of daily living do not diminish unless circumstances of the individual clinical condition demonstrates that diminution was unavoidable. A resident who is unable to carry out activities of daily living will receive necessary services to maintain good nutrition, grooming, and personal hygiene. Purpose: To identify, record and report any acute change of condition (ACOC) to the attending physician, resident and responsible party. Guideline: An acute change of condition is a sudden, clinically important difference from a resident's baseline in physical, cognitive, behavioral, or functional status. "Clinically important", means a deviation that, without intervention, may result in complications or death. Monitoring signs and symptoms may help define an acute change in condition following injuries or changes in physical condition or mental functioning... Weight/ Eating Patterns- A change in intake patterns (e.g. consuming < 75% of all meals in 24 hours or < 25% of any one meal) should trigger additional evaluation. In documentation of intake, identify both solid and liquid intake in as much detail as possible. Evaluate signs and symptoms that may suggest fluid imbalance (e.g. [MEDICAL CONDITION] or change in [MEDICAL CONDITION]) such as...Acute, rapid weight loss over several days should trigger concern about a hydration emergency... Change in Elimination Patterns- The following may indicate a change in condition and should be assessed further: Appearance of frank blood in stool, urine, or vomit... Staff Roles and Responsibilities in Monitoring Patients with Change in Condition- Staff/Charge Nurse - Recognize condition change early. Assess the resident's symptoms and physical function and document detailed description of observations and symptoms...Report resident's status to the physician." 1. DEHYDRATION Resident #1 was admitted to the facility on [DATE] with a recent [DIAGNOSES REDACTED]. The resident also has dementia and a past history of a nephrectomy due [MEDICAL CONDITION]. Resident #1's Power of Attorney for Health Care was activated prior to admission to the facility. From 01/03/15 to 01/14/15, Resident #1 took in 240 to 780 ml of fluid each day, as calculated on the resident's Oral Intake/Appetite Record for January 2015, which is completed by dietary staff at mealtime. A Nutritional Assessment, dated 01/14/15 at 8:22 a.m., notes: "Initial Assessment - Fluid Requirements - 2220 cc. Hydration Status-fair. Goal is for nutritional status to remain stable as evidenced by no further weight loss and no skin breakdown. Plan - Continue present diet order and supplement offer. Monitor and assess as needed." Fluid intakes continued to be documented on the Oral Intake/Appetite Record as: 01/15/15 - Breakfast 4 ounces, Lunch 8 ounces, Supper 22 ounces = 1020 ml 01/16/15 - Breakfast 4 ounces, Lunch 8 ounces, Supper 10 ounces = 660 ml 01/17/15 - Breakfast 12 ounces, Lunch 8 ounces, Supper 10 ounces = 900 ml 01/18/15 - Breakfast 12 ounces, Lunch 5 ounces, Supper 16 ounces = 990 ml 01/19/15 - Breakfast 8 ounces, Lunch 8 ounces, Supper 20 ounces = 1080 ml 01/20/15 - Breakfast out of building for test, Lunch 8 ounces, Supper 12 ounces = 600 ml 01/21/15 - Breakfast 6 ounces, Lunch 6 ounces, Supper 2 ounces = 420 ml 01/22/15 - Breakfast 6 ounces, Lunch 6 ounces, Supper 5 ounces = 510 ml Fluid intake from 01/15/15 to 01/22/15 ranged from 51 to 81% less than the resident's assessed fluid need. 01/23/15 - Breakfast out of building for test, Lunch 0 ounces, Supper 0 ounces = 0 ml 01/24/15 - Breakfast 0 ounces, Lunch 6 ounces, Supper 0 ounces = 180 ml 01/25/15 - Breakfast 0 ounces, Lunch 0 ounces, Supper 2 ounces = 30 ml 01/26/15 - Breakfast 0 ounces, transferred to the hospital. Fluid intake from 01/23/15 to 01/26/15 ranged from 92 to 100% less than the resident's assessed fluid needs. Per dietary note, dated 01/23/15 at 3:14 p.m., "Resident has had a significant 12# or 7% weight loss since admission. Current weight is 158#. She continues on supplements TID with snacks offered TID in between meals. Resident is usually very lethargic and hard to keep alert enough to eat..." The facility did not consult with the physician regarding this significant change in weight or the decline in fluid intakes. On 02/12/15 at 8:20 a.m., Surveyor interviewed Certified Nursing Assistant (CNA) F who worked on 01/24/15, 01/25/15 and 01/26/15. CNA F stated the resident had a poor appetite and wouldn't wake up. CNA F stated, "Anytime we offered drinks it just ran out. We couldn't get her to eat or drink. The nurses were aware of this." On 02/12/15 at 8:15 a.m., Surveyor interviewed Registered Nurse (RN) E who worked on 01/25/15. RN E stated Resident #1 was sleepy and hard to rouse. Surveyor and RN E reviewed the intake records. RN E stated she was not aware of the resident's low intake. RN E stated she did not know where CNAs document intake and didn't know where the intake was recorded on the cheat sheets. RN E further stated she does not review the intake records. RN E stated if she would have know what the intake records documented on Resident #1 she would have called the daughter to come and see if she could get the resident to drink, would have checked the resident's skin turgor and vital signs and if not good would have called the doctor. RN E further stated no one totals the fluid intakes. The Speech Therapy note, dated 01/26/15, stated, "Pt demonstrating a decline. Pt was seen in room as she was in bed. Max verbal and tactile cues were provided. However pt did not wake up. Staff state she was sleepy like this all weekend with little intake. ST provided pt with oral cares using a moistened toothette. Pt still did not wake. Mouth moisturizer was applied to lips and in mouth." Nursing notes from 01/23/15 to 01/26/15 document: "*01/23/15 at 2:03 p.m ...Resident had had no s/s of increased pain noted today but has been very lethargic since coming back from CT scan. *01/25/15 at 2:48 p.m., Resident continues to be lethargic hs medications held. *01/26/15 at 2:26 p.m. Resident was extremely lethargic this am though vitals were within normal limits...Resident has had small sips of her health shake supplement but when staff was trying to get resident to eat this am resident was pocketing food and not swallowed so they stopped...Resident's daughter felt her mother was very lethargic and since there was no results from the bladder CT she wanted her mother sent to the ER for evaluation and treatment...Resident left the facility at 1120 via ambulance." The medical record does not contain documentation of a hydration assessment of Resident #1 from 01/23/15 - 01/26/15 when food/fluid intake declined, no documentation of referral to the Registered Dietician and no consult with a physician regarding the resident's decreased fluid intake and her extreme lethargy. The Hospital History and Physical, dated 01/26/15, stated, "Lab Studies: Sodium 161, BUN 131, Creatinine 4.66... Assessment and Plan: 1. Acute [MEDICAL CONDITION].. Etiology likely severe dehydration from poor oral intake. Will start the patient on IV fluids...2. Altered mental status. Combination of metabolic [MEDICAL CONDITION] secondary to uremia, [MEDICAL CONDITION] and hypercalemia. 3. [MEDICAL CONDITION], likely severe dehydration." The Hospital Discharge Summary report, dated 02/04/15, stated, "Pertinent Admission Physical Examination Findings: HEENT: Dry oral mucosa... Hospital Course: Throughout the rehydration regiment, the patients kidney function continued to increase... The patient slowly improved her mental status... Of note: On January 30th, ... it was decided to change therapy to comfort care measures..." On 02/12/15 at 9:00 a.m., Surveyor questioned the NHA if they found information related to documentation that the physician had been notified of the resident's decline in intake. The NHA had none. The NHA stated the facility should have called the doctor when the resident had a decline in intake. The facility's failure to consult a physician when the resident had a significant decline in fluid intake and when there was a need to alter treatment created an immediate jeopardy situation that began on 01/23/15. The facility removed the immediate jeopardy on 02/12/15 when the facility began a new process to track and assure physician notification and began training with the facility nursing staff. CROSS REFERENCE F327. HEMATURIA 2. Resident #1 has a history of bladder and [MEDICAL CONDITION]. The resident also has dementia and a past history of a nephrectomy. On 02/11/15, Surveyor reviewed Resident #1's medical record which included the following notes: *01/09/15 at 5:17 a.m., Intake 120 cc output times 1 of blood tinged urine. Denies pain or discomfort. Is afebrile. *01/14/15 7:07 a.m., Resident continues to have vaginal bleeding noted...Resident Afebrile. At 2:11 p.m., Resident continues to have blood tinged urine and noted lethargy throughout the day. Fax sent to MD (Medical Doctor) to updated in resident's change in condition and requesting if UA/UC could be obtained and sent out. At 2:17 p.m., Still waiting for MD to fax back response for UA/UC. *01/15/15 at 1:18 p.m., Resident still has had blood tinged urine and lethargy at times throughout the day. (No documentation that the physician was consulted.) * 01/16/15 at 5:11 a.m., Intake 120 cc output times 1 slightly pink tinged urine. At 2:53 p.m., Resident has had blood tinged urine and lethargy at times throughout the day. (No documentation that the physician was consulted.) *01/17/15 at 1:35 p.m., Resident continues to have blood tinged urine and lethargy at times throughout the day. (No documentation that the physician was consulted.) *01/18/15 at 11:30 a.m., (MD G's name) notified that resident continues to have blood tinged urine (for approximately one week and lethargy at times throughout the day...Provider states he has not received fax communications previously sent. Orders received : UA/UC. Consult with urology. Obtain ultrasound of kidneys and bladder. At 1:57 p.m., Resident continues to have blood tinged urine with some clots; some orange crusted drainage on diaper pad; lethargy at times throughout the day. .. UA/UC sent today. *01/19/15 at 3:06 a.m., Received UA fax back from Bloomer Lab with positive results for a possible infection. Spoke with (MD G's name) and received new orders [MEDICATION NAME] mg BID (twice a day) for 7 days and to fax him the culture results when received. The urine culture report, dated 01/19/15, stated no growth. The ultrasound report, dated 01/20/15, stated, "There are three possible 2 mm diameter stones within the very decompressed urinary bladder." The CT scan of the abdomen and pelvis report, dated 01/23/15, stated the bladder wall had some thickening which could be a chronic [MEDICAL CONDITION] process. Direct visualization would be necessary. The left kidney had a peripelvic cyst. On 02/12/15 at 8:25 a.m., Surveyor interviewed RN E who had charted on Resident #1 on 01/15/15 and 01/17/15 related to hematuria. RN E stated she did not call or fax the physician on either of those dates. RN E stated she called the physician on 01/18/15 as he had not called or followed up on the fax. RN E stated she thinks the resident had passed clots of blood prior to her phone call on that day. RN E stated MD G said he had not received a fax and/or a phone call from the facility. RN E stated the nurses monitor the fax bin of faxes sent and no response received yet. When you report off duty you communicate lack of response. RN E states she thinks the Director of Nursing (DON) also checks as she has said she wished the doctors would get back to us. RN E stated there are guidelines at the nurses' station when to fax vs call the physician. RN E stated she called the physician because of resident having blood on periarea and family expressing concern. On 02/11/15 at 1:45 p.m., Surveyor reviewed the nurses' notes with the NHA and the DON. Surveyor questioned the NHA if the facility had consulted by fax or phone with a physician on 01/09/15 - 01/14/15 and 01/15/15 - 01/18/15. The NHA stated, "No, nurses would have charted it if they did." Surveyor questioned if the resident had vaginal bleeding. The NHA stated the agency nurse's notes, dated 01/14/15, was based on her perspective of what she saw on the incontinent pad. The DON stated the nurses check the fax bin and if a fax is not received the facility receives a failure note. The DON stated they did not receive such a note. The DON stated MD G does not respond to our faxes or phone calls. The NHA stated she would expect the nurses to call the physician if the physician has not responded to a fax. On 02/11/15 at 3:10 p.m., Surveyor interviewed Licensed Practical Nurse (LPN) C who stated she had not faxed or called the doctor before 01/14/15. LPN C stated the facility is having problems with faxing to the clinics with faxes spit out and not going through. LPN C stated the facility has been having problems getting a hold of MD G. LPN C stated the nurse would have documented a response if doctor responded. LPN C stated RN E called the doctor on 01/18/15 because the doctor did not respond. LPN C stated, "When a doctor doesn't respond to a fax. I call the doctor." LPN C stated she called MD G on 01/19/15 for antibiotic orders and was put on hold for 1 1/2 hours. On 02/11/15 at 3:30 p.m., the NHA told Surveyor that she had no further information related to consultation with a physician from 01/14/15 - 01/18/15.

Based on interviews and record review, the facility did not ensure that 1 of 5 residents (Resident #1) reviewed for hydration was provided with sufficient fluids to meet assessed needs. Resident #1 was admitted to the nursing home with a recent [MEDICAL CONDITIONS] with dysphagia and nutritional deficiency. The resident lost 12.5 lbs (7.3 %) in 18 days from 01/04/15 to 01/22/15. The Registered Dietician (RD) assessed Resident #1's fluid needs and initiated fluid intake monitoring. Resident #1 consistently took less than her assessed fluid needs of 2220 milliliters per day. Beginning 01/23/15, Resident #1 had a significant decline in fluid intakes. There is no evidence that staff analyzed the daily fluid intakes, alerted the RD to the low intakes, completed a dehydration assessment and notified the physician. On 01/26/15, Resident #1 was transferred to the hospital with admitting [DIAGNOSES REDACTED]. This is evidenced by: On 02/12/15 at 10:00 a.m., Surveyor requested the hydration policy. The facility provided the surveyor with the following policies: "Nutrition Hydration Monitoring Protocol" dated 2011, states, "Guideline: Residents at risk for dehydration will be identified using the Dehydration Risk Assessment, Care Assessment Areas (CAAs) for dehydration/fluid maintenance, Nutritional Screening Assessment, or quality indicators. Following hydration protocol is the responsibility of the Dining Services Manager, Registered Dietician and nursing staff. Procedure: 1. Resident fluid needs shall be determined according to Registered Dietician recommendations. 2. Fluids consumed at meals will be documented in addition to meal intake for at risk residents on the meal tray consumption record form resource. This is not an all inclusive fluid consumption for the entire day and does not measure amount of fluids offered at meals or throughout the day. 3. Dietary notes shall reflect factors that put the resident at risk for dehydration, and what is being done to reduce the risk factors and ensure adequate fluid intake. If adequate fluid intake is difficult to maintain, alternative treatment approaches developed to increase fluid intake shall be mentioned. Resident progress and lab values when available shall also be included. 4. The Director of Nursing, designee, Dining Services Manager, and/ or Registered Dietician will meet to determine whether each resident is still at risk. If the resident is determined to be free of risk, then the PAR (Persons at Risk) committee and Registered Dietician will decide if the current plan is the best course of action. If it is not, other options will be developed to resolve the issue. 5. All residents determined to be at risk for dehydration must be care planned." "Intake and Output- Recording" policy undated, states, "Purpose: To provide an accurate record of the resident's intake and output. Policy- An intake and output record is maintained by the nursing staff when needed to monitor residents for adequate fluid balance. Procedure for Measuring Intake- 2. Check for amount of liquid consumed. 3. Use the liquid measure chart to determine the amount of each fluid consumed. 4. Check to determine if the resident has consumed any additional fluids or nourishment. 5. If the resident has consumed any other fluid, determine the approximate amount, and the time consumed, 6. Licensed nursing staff will add fluids from I.V., Gastrostomy fluids or consumed with medications. 7. At the end of each shift, record on the medical record the total intake and output for the 24 hour period. Note: At the end of each 24 hour cycle, record on the medical record the total intake and output for the 24 hour period. Intake and /or output may be initiated for, but not limited to: Residents with a change in hydration status..." Resident #1 was admitted [DATE] to the facility with a recent [DIAGNOSES REDACTED]. The resident has dementia and a past history of a nephrectomy due [MEDICAL CONDITION]. Resident #1's Power of Attorney for Health Care was activated prior to admission to the facility. Per dietary note, dated 01/08/15 at 1:15 p.m., "Resident admitted to SNF [MEDICAL CONDITIONS] and dysphagia. OT, PT and ST are working with resident. ST upgraded diet to regular texture and regular liquids. While admitted to hospital resident had little or no intake. Family declined feeding tube per resident wishes. She was then placed on a full honey liquid diet. H&P notes very poor intakes. Resident continues with poor intakes. Staff assist her at all meals, but she is often hard to keep alert and awake. She also will refuse to eat, and refuse assistance. ST has attempted feeding resident at lunch the last two days. Nosey cups are being trialed due to her leaning far forward and to the left. Nutritional supplements were offered when meals was refused, but not accepted by resident. Current weight is 166.5#. Admit weight was 170.5# on 1/4/15. Resident is nutritional risk and risk for weight loss due to poor intakes and recent dysphagia. Will continue to monitor." Per the admission Minimum Data Set (MDS), dated [DATE], Resident #1 required extensive assistance with eating from staff and was always incontinent of urine and bowels. The Care Area Assessment (CAA) Nutritional Assessment, dated 01/09/15, stated, "Needs eating assistance. Leans to her left due to [MEDICAL CONDITION]. Head tilted down. Uses nosey cups. Family declined to have a feeding tube for little to no PO (oral) intake. Wish for diet to be regular. Aware of aspiration risk with dysphagia. Resident is a nutritional risk due to poor intakes post [MEDICAL CONDITION], dysphagia. Supplements implemented TID (three times per day). Staff seeing signs of food pocketing. Resident diet was advanced to regular at family request." The CAA Dehydration, dated 01/09/15, stated, "Symptoms of dehydration- Confusion or change in mental status. Lethargy. Blood urea nitrogen test -indicated high on hospital labs 12/28/14. Oral intake- Recent change in oral intake. Newly prescribed diet. Decreased perception of thirst. Analysis of Findings- Resident has had a recent decline in intake post [MEDICAL CONDITION], Dementia and cognitive status are affecting intakes. Resident was previously able to feed herself, and is now reliant on staff for food and fluid intakes." Per dietary note, dated 01/12/15 at 1:33 p.m., "Resident continues with poor PO intake. She is more actively participating in feeding herself, but still requires extensive assistance, and feeding when necessary. Continues to be fatigued and hard to keep alert at some meals. Unable to communicate needs to staff. Current weight is 166#. Fax sent to MD requesting a house supplement TID due to poor intakes." Per Nutritional Assessment, dated 01/14/15 at 8:22 a.m., "Initial Assessment - Fluid Requirements - 2220 cc. Hydration Status-fair. Goal is for nutritional status to remain stable as evidenced by no further weight loss and no skin breakdown. Plan - Continue present diet order and supplement offer. Monitor and assess as needed." The MDS, dated [DATE], documented the resident was totally dependent on staff for assistance with eating, was holding food in her mouth/cheeks after meals, and had a weight loss of 5% or more in the last month. The resident continued be incontinent of urine and bowel. Resident #1's current care plan titled, "Nutritional Status" states, "Problem: Potential for nutritional risk, weight loss, and dehydration risk. Related to [MEDICAL CONDITION] in [MEDICAL CONDITION] and dysphagia, recent and history of poor PO intake, family deferred feeding tube at hospital. Need for assistance with meals, fatigue and dementia interfere with intakes. Need for ST (Speech Therapy) due to dysphagia. 1/12/15 house supplement started TID for poor intakes and weight loss. Goal - Resident will maintain weight without significant change. Resident will increase PO intakes. Resident will not show any s/s dehydration. Interventions- Monitor weight and intakes. Encourage food and fluid intakes. Observe for s/s of dysphagia. Assist with food and fluids. Monitor vitals, labs, and cognitive status for changes...Document all assessments in nurses notes. Update MD and POA as indicated...Monitor weights and intakes. Refer to RD as needed for consult...Try to keep aroused and alert for PO intake. Offer snacks including pudding and ice cream. Assist with set-up, ADL's and positioning as needed. Report any changes to the nurse in charge." A review of Resident #1's weight summary revealed: 01/04/15, weight 170.5 lbs 01/22/15, weight 158 lbs The resident lost 12.5 lbs (7.3 %) in 18 days from 01/04/15 to 01/22/15. Per dietary note, dated 01/23/15 at 3:14 p.m., "Resident has had a significant 12# or 7% weight loss since admission. Current weight is 158#. She continues on supplements TID with snacks offered TID in between meals. Resident is usually very lethargic and hard to keep alert enough to eat. She was recently diagnosed with [REDACTED]. Resident is also noted to be pocketing/holding food in her cheeks after meals. ST recommends alternating liquids and solids, and rubbing cheeks to help push out pocketed foods. Ice cream is also offered often as it is a favorite food. Will continue to monitor." On 02/11/15, Surveyor received a copy of Resident #1's Oral Intake/Appetite Record for January 2015. The documentation did not have the daily total calculated (survyeor added the totals). The records document fluids in ounces. This document is completed by dietary staff at meal time. 01/03/15 - Breakfast 4 ounces, Lunch 2 ounces, Supper 2 ounces = 240 ml 01/04/15 - Breakfast 6 ounces, Lunch 8 ounces, Supper 2 ounces = 480 ml 01/05/15 - Breakfast 2 ounces, Lunch 8 ounces, Supper 8 ounces = 540 ml 01/06/15 - Breakfast 2 ounces, Lunch 4 ounces, Supper 10 ounces = 480 ml 01/07/15 - Breakfast 12 ounces, Lunch 4 ounces, Supper 4 ounces = 600 ml 01/08/15 - Breakfast 12 ounces, Lunch 4 ounces, Supper 10 ounces = 780 ml 01/09/15 - Breakfast 4 ounces, Lunch 12 ounces, Supper 10 ounces = 780 ml 01/10/15 - Breakfast 2 ounces, Lunch 4 ounces, Supper 6 ounces = 360 ml 01/11/15 - Breakfast 4 ounces, Lunch 4 ounces, Supper 12 ounces = 600 ml 01/12/15 - Breakfast 4 ounces, Lunch 8 ounces, Supper 16 ounces = 840 ml 01/13/15 - Breakfast 6 ounces, Lunch 4 ounces, Supper 4 ounces = 420 ml 01/14/15 - Breakfast 6 ounces, Lunch 8 ounces, Supper 16 ounces = 900 ml. (Note: goal established on this date was for 2220 ml fluid daily) 01/15/15 - Breakfast 4 ounces, Lunch 8 ounces, Supper 22 ounces = 1020 ml 01/16/15 - Breakfast 4 ounces, Lunch 8 ounces, Supper 10 ounces = 660 ml 01/17/15 - Breakfast 12 ounces, Lunch 8 ounces, Supper 10 ounces = 900 ml 01/18/15 - Breakfast 12 ounces, Lunch 5 ounces, Supper 16 ounces = 990 ml 01/19/15 - Breakfast 8 ounces, Lunch 8 ounces, Supper 20 ounces = 1080 ml 01/20/15 - Breakfast out of building for test, Lunch 8 ounces, Supper 12 ounces = 600 ml 01/21/15 - Breakfast 6 ounces, Lunch 6 ounces, Supper 2 ounces = 420 ml 01/22/15 - Breakfast 6 ounces, Lunch 6 ounces, Supper 5 ounces = 510 ml Intake from 01/15/15 to 01/22/15 ranged from 51-81% less than the resident's established fluid need. 01/23/15 - Breakfast out of building for test, Lunch 0 ounces, Supper 0 ounces = 0 ml 01/24/15 - Breakfast 0 ounces, Lunch 6 ounces, Supper 0 ounces = 180 ml 01/25/15 - Breakfast 0 ounces, Lunch 0 ounces, Supper 2 ounces = 30 ml 01/26/15 - Breakfast 0 ounces, transferred to the hospital. Intake from 01/23/15 to 01/26/15 ranged from 92-100% less than the resident's established fluid need. The Nursing Assistant Flow Sheet for January 2015 also documented fluid intake that is entered by Certified Nursing Assistants (CNAs) using the Oral Intake/Appetite Record. The information documented does not match the information on the Oral Intake/Appetite Record on the following dates 01/13/15 - Breakfast 4 ounces, Lunch 4 ounces, Supper 4 ounces = 360 ml 01/14/15 - Breakfast 2 ounces, Lunch 8 ounces, Supper 16 ounces = 780 ml 01/18/15 - Breakfast 12 ounces, Lunch 5 ounces, Supper 12 ounces = 870 ml 01/25/15 - Breakfast 0 ounces, Lunch 0 ounces, Supper 0 ounces = 0 ml The "Daily Tasks" sheet, dated 01/25/15, documented the resident took in 30 cc's of fluids and was incontinent of urine seven times. The Speech Therapy note, dated 01/23/15, stated, "Pt was seen for lunch following appt this morning. Pt lethargic. Staff state pt is pocketing more and losing liquids from L side. St notes that feeding attempts giving meds when pt is not alert. Staff unsure of what they should do as pt is always lethargic. ST to provide staff with guidelines for PO intake. Also order written trial of dysphagia III secondary to inability to chew adequately." Speech guidelines, "Feeding Program," dated 01/23/15, stated, "Trial of Dysphagia III (mech soft) textures and continue with thin liquids. Trial to begin 1/23/15 and end 1/26/15. Nursing and Restorative: 1. Feed pt when she is alert and awake. May have to offer more frequent meals/snacks throughout the day if to lethargic for safe PO intake. Use max verbal and tactile cues to wake pt. 2. May use ice cream or sherbet as cold may help wake pt. 3. Alternate liquids and solids to help remove any residuals or pocketed foods. Also rub outside of cheek to help push out any food that may be pocketed. 4. Give small bites, 1/2 tsp amts. 5. Ensure pt has completed swallow before giving another bite of solids. 6. If after 15-20 min pt is still not alert enough, try again at a later time. Pt is at an increased risk of aspiration if not awake and alert. 7. Keep pt upright for 20-30 mins after all meals/snacks." The Speech Therapy note, dated 01/26/15, stated, "Pt demonstrating a decline. Pt was seen in room as she was in bed. Max verbal and tactile cues were provided. However pt did not wake up. Staff state she was sleepy like this all weekend with little intake. ST provided pt with oral cares using a moistened toothette. Pt still did not wake. Mouth moisturizer was applied to lips and in mouth." A review of the nurses' notes regarding appetite and fluid intake from 01/02/15 admisison day to 01/26/15 when the resident was transferred to the hospital show a decline in appetite, fluid intake and mental status. Excerpts of these notes include: *01/02/15 at 2:28 p.m., patient has poor appetite...At 11:45 p.m., Resident ate about 10 % of supper and intake was poor tonight. *01/03/15 at 1:19 p.m., patient has poor appetite..Awake for meals but eating little. *01/08/15 at 3:32 p.m., Resident is now easily aroused for meals. *01/12/15 at 11:05 a.m., Resident is verbal cueing and assist for meals. Resident is on a regular diet and thin liquids for meals. At 2:38 p.m., New order for house supplement's three times per day. *01/15/15 at 1:10 p.m., Resident drooling liquids at meal time onto clothing. *01/23/15 at 2:03 p.m., Medicare charting: Resident went out for appointment today at 0930 at the Marshfield Clinics in Eau Claire for a bladder CT. Resident returned to the facility at 1200 p.m., via van for transportation...New instructions from appointment drink 8 ounces of water every hour for 8 hours after CT. Resident also received a new order from ST to request dysphagia 3 (mech soft) texture trial 1/23/15 - 1/26/15 due to decreased ability to masticate. ..Resident had had no s/s of increased pain noted today but has been very lethargic since coming back from CT scan. *01/25/15 at 2:48 p.m., Resident continues to be lethargic hs medications held. *01/26/15 at 2:26 p.m. Resident was extremely lethargic this am though vitals were within normal limits...Resident has had small sips of her health shake supplement but when staff was trying to get resident to eat this am resident was pocketing food and not swallowed so they stopped...Resident's daughter felt her mother was very lethargic and since there was no results from the bladder CT she wanted her mother sent to the ER for evaluation and treatment...Resident left the facility at 1120 via ambulance." *02/04/15 at 4:02 p.m., Resident returned from Sacred Heart Hospital... Resident has comfort care orders. *02/05/15 at 12:39 p.m. Resident is on Hospice program. The medical record does not contain documentation of a hydration assessment of Resident #1 from 01/23/15 - 01/26/15 when food/fluid intake declined, no documentation of referral to the Registered Dietician and no consult with a physician. The Hospital History and Physical, dated 01/26/15, stated, "Lab Studies: Sodium 161, BUN 131, Creatinine 4.66... Assessment and Plan: 1. Acute [MEDICAL CONDITION].. Etiology likely severe dehydration from poor oral intake. Will start the patient on IV fluids...2. Altered mental status. Combination of metabolic [MEDICAL CONDITION] secondary to uremia, [MEDICAL CONDITION] and hypercalemia. 3. [MEDICAL CONDITION], likely severe dehydration." The Hospital Discharge Summary report, dated 02/04/15, stated, "Pertinent Admission Physical Examination Findings: HEENT: Dry oral mucosa... Hospital Course: Throughout the rehydration regiment, the patients kidney function continued to increase... The patient slowly improved her mental status... Of note: On January 30th, ... it was decided to change therapy to comfort care measures..." On 02/11/15 at 1:15 p.m., Surveyor interviewed Dietary Manager (DM) A related to documentation of fluid intake. DM A stated the cooks document the fluid intake of meals on an Oral Intake/Appetite Record in a Cook's binder. The CNAs then copy this information to the Nursing Assistant Flow Sheet. The numbers documented on the forms represent ounces. DM A stated these forms only document meal intake. DM A stated she did not know where the facility documents water consumed at bedside and snacks. The surveyor and DM A reviewed the dietary assessment dated [DATE] that documented the resident required 2220 cc daily of fluids. DM A stated she was aware of the resident not meeting the fluid requirements. DM A stated Resident #1 is not able to get her own fluids and requires assistance with eating and drinking. DM A stated, "I was not aware of no intake by the resident until Monday when she went to the hospital. I was here on Friday when she came back from the CT scan. The nurse was unable to wake resident up to take fluids right after CT scan." On 02/11/15 at 1:35 p.m., Surveyor interviewed CNA B who stated the only place intake is documented is on the CNA flow sheets and in the nurses' notes. On 02/11/15 at 1:45 p.m., Surveyor interviewed the Director of Nursing (DON) and the Nursing Home Administrator (NHA). The DON stated dietary documents fluid intake from meals only. The CNAs copy this information on to their flow sheets. The CNAs document water and other fluids consumed in the resident's room on cheat sheets. The cheat sheets are then given to the nurses who chart the intake in the nurses' notes. The cheat sheets are thrown and not kept. The DON stated nurses are to total every shift the residents' fluid intake. The DON stated they do not have a written policy for this. The surveyor and the DON reviewed the intake records for January 2015 and the nurses' notes from 01/23/15 - 01/26/15. No documentation of a dehydration assessment was found and no documentation of consultation with the physician was found. The NHA stated the family had signed the POLST agreement on admission stating they did not want a feeding tube or IVs, but they could change their mind. The NHA stated nurses are not monitoring fluid intake and are not totaling daily fluid intake. The NHA further stated we need to improve on this. On 02/11/15 at 3:10 p.m., Surveyor interviewed Licensed Practical Nurse (LPN) C who stated she worked on 01/23/15. LPN C stated she was aware the resident was to be offered 8 ounces of water every hours for 8 hours after the CT scan. LPN C stated the staff attempted. LPN C stated she did not work 01/24/15 and 01/25/15. LPN C returned to work on 01/26/15. LPN C stated, "I would have done a dehydration assessment but (Family Member name) never gave me a chance, she wanted resident to be transferred to the emergency room ." On 02/11/15 at 4:10 p.m., Surveyor interviewed CNA D who worked days and pms on 01/24/15 and 01/25/15 related to Resident #1's fluid intake. CNA D stated, "We tried our hardest and she would cough and nothing worked. She would spit it out or it would run out of her mouth. We tried fluids in between and she wouldn't swallow anything both days. I told the nurse on ams and pms about this." On 02/11/15 at 4:15 p.m., LPN C told Surveyor she remembered writing the order to offer 8 ounces of fluids every hour for 8 hours on the Treatment Administration Record (TAR). LPN C was unable to find the January TAR. No further information was provided. On 02/12/15 at 1:00 p.m., Surveyor interviewed the NHA who stated she would expect the RD to be notified when a resident has a decrease in food and fluid intake. The NHA stated the RD has access to her laptop and can access notes. On 02/12/15 at 8:15 a.m., Surveyor interviewed Registered Nurse (RN) E who worked on 01/25/15. RN E stated Resident #1 was sleepy and hard to rouse. Surveyor and RN E reviewed the intake records. RN E stated she was not aware of the resident's low intake. RN E stated she did not know where CNAs document intake and didn't know where the intake was recorded on the cheat sheets. RN E further stated she does not review the intake records. RN E stated if she would have known what the intake records documented on Resident #1 she would have called the daughter to come and see if she could get the resident to drink, would have checked the resident's skin turgor and vital signs and if not good would have called the doctor. RN E further stated no one totals the fluid intakes. On 02/12/15 at 8:20 a.m., Surveyor interviewed CNA F who worked on 01/24/15, 01/25/15 and 01/26/15. CNA F stated the resident had a poor appetite and wouldn't wake up. CNA F stated, "Anytime we offered drinks it just ran out. We couldn't get her to eat or drink. The nurses were aware of this." On 02/12/15 at 9:00 a.m., Surveyor questioned the NHA if they found information related to hydration assessment completed on Resident #1 and documentation that the physician had been notified of the resident's decline in intake. The NHA had none. The NHA stated the facility should have called the doctor when the resident had a decline in intake and should have assessed the resident for dehydration.

Based on interview and record review, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents for 2 (Residents #1 and #5) of 6 sampled residents reviewed for falls. A Certified Nursing Assisant (CNA) transferred Resident #1 with an EZ stand without the assistance of a second person (as directed) and without using the leg strap. Due to weakness related to influenza, Resident #1 could not hold onto the handles of the EZ-Stand, her knees buckled and her arms raised upward allowing her to slide out of the EZ-Stand transfer belt while still attached. Resident #1 sustained a compression fracture of her T 12 Vertebrae. Resident #5 was transferred by a CNA who did not use a gait belt per the resident's care plan. The resident's legs slipped and the CNA lowered the resident to the floor. This is evidenced by: Resident #1's [DIAGNOSES REDACTED]. Resident #1's care plan on 12/06/14 included, "Mobility-CGA (Care Giver Assist) of 1/gait belt/wc (wheelchair)/walker. Encourage walker." Resident #1's medical record identified at times staff elected to use the sit-to-stand list for transfers. The EZ Way stand Operator's Instructions contained "Safety Notes," which included: "The EZ way stand was designed to transfer weight bearing patients to and from a chair, wheelchair, toilet, or bed and safely ambulating patients. Please make sure the accessories used with each stand are appropriate for both the patient and transferring situation. The EZ Way stand was designed to be operated by one caregiver. However, depending on the situation, facility policy, and the patient's condition, two caregivers may be necessary." Harness selection: As patients do vary in size, shape, and weight these conditions must be taken into consideration when deciding which EZ Way harness and accessories are suitable for each patient's needs. Transferring the patient: -Use of Shin Pad Strap: If a caregiver deems it necessary to keep a patient's shins or feet on the foot plate, secure the shin strap around the patients's legs. -Attach harness to EZ Way stand: Use the shortest loops possible. -Raise the patient: 1) Position patient's arms on the outside of the harness and have them place their hands on the padded handles. 2) At the patient is being raised, simultaneously tighten the safety strap buckled around their torso. On 12/06/14, Resident #1 had been ill with influenza, had increased weakness with transfers. Staff had been instructed to use an EZ stand lift with two staff if they could not do a safe transfer with one to two staff assistance. On 12/07/14 at 7:44 a.m., Resident #1's nurses' notes contained the following entry written by Licensed Practical Nurse (LPN) A. "This writer was called into resident's room due to resident falling onto the bathroom floor and hitting the toilet with her back and right hip on the way down. Staff was in the room and tried to catch her when she started to slip but was unable to. Resident's right hand/wrist is bruise and elbow. Resident also complained of extreme pain to her right upper back and hip and could not move her hip/leg. Called Medical Doctor (MD) G on call and received an order to send resident to Bloomer emergency room (ER) for evaluation and treatment." "Resident returned via ambulance at 3:30 a.m. with no new orders. Bloomer ER called and stated they did X-rays and a CT of her back/neck and hip and nothing was broken she just has old fx (fracture) and osteoarthritis." The Incident and Investigation Report completed by LPN A, dated 12/07/14 at 12:05 a.m., stated: "Describe how the resident was found: Sitting/laying with her back against the toilet and her legs/feet laying out the doorway. Resident was cry/yelling in pain and for CNA to get out of her room." "Describe circumstances surrounding incident: Resident had not been feeling well throughout the day and became more weak with transfers. Explained to staff if they felt they couldn't safely do a 1-2 assist transfer with resident to use the EZ-Stand but had to have 2 people but only as a last resort." Was incident witnessed: Yes. By whom: (CNA C's first name) " "Plan of care: Note the interventions applied: 2 person transfer w (with)/EZ Stand or hoyer lift." CNA C's statement, written on 12/07/14 at 5:50 a.m., identified the fall took place on 12/06/14 at 11:45 p.m and that CNA C was taking Resident #1 into the bathroom with the EZ-Stand when Resident #1 stated she was slipping. Resident #1's knees buckled and slipped out of the harness. Resident #1 fell by the toilet and the door. CNA C documented Resident #1 was weak from illness and that the care plan was being followed. On 12/07/14 at 7:40 a.m,. Resident #1's nurses' notes documented, "Resident's bruises to her right hand/wrist are extremely dark purple/blue in color and tender to the touch and also measures 24 cm (centimeters) x (by) 17.3 cm. The small bruise on her left wrist measure 4 cm x 4 cm and the larger bruise measures 6 cm x 4 cm and are also dark purplish/blue in color. Resident also has some bruising to her right elbow measuring 1 cm x 2 cm and 5 cm x 2 cm noted to be dark purple/blue in color." Resident #1's nurses' notes on 12/07/14 identified extreme amounts of pain, was unable to assist with aspects of daily living (ADLs) or transfers and was a two person assist with transfers using the EZ-Stand lift. The Post Fall Assessment/IDT (Interdisciplinary Team) Review, dated 12/07/14, identified Resident #1 was agitated and alert/oriented to person, place and time at the time of the fall. The fall occurred at 12:05 a.m. when Resident #1 was being taken to the bathroom in an EZ-Stand. The EZ-Stand was being used according to manufacturer's instructions as it could be used as a one to two person assist. Resident #1's care plan was updated: "2 person transfer w (with)/EZ Stand or Hoyer." The post fall assessment did not include the specific details related to what occurred at the time of the fall. Resident #1's nurses' notes on 12/08/14 at 3:13 a.m. stated, "Received a call from the Bloomer ER in regards Radiologist reread to resident's CT scans and resident has a compression fracture of her T 12 vertebrae and a herniation to her stomach." The undated post fall assessment summary written by the Director of Nurses (DON) stated, "(Resident #1's first name) tends to take a long time to feel comfortable with newer staff member, so at times she is more fearful of transfers and lifts than at others." "In the early hours of 12/07/14, (Resident #1's first name) was transferring in the bathroom with a mechanical lift and one staff member when something happened to destabilize her and she fell from the lift, striking her back and right hip on the toilet rim, landing on the floor. She was transferred into ambulance by crew and x-ray and CT images were taken. In the absence of radiologist's findings, (Resident #1's first name) was transferred back to the SNF (Skilled Nursing Facility) with no new orders. However, the following day her images were reviewed and it was determined (Resident #1's first name) had sustained a compression fracture at T 12. She was sent to her primary MD in the AM for further evaluation." The summary written by the Nursing Home Administrator (NHA) on 12/09/14 included, "Due to increased weakness from GI (Gastrointestinal) illness, had fallen out of the sit to stand mechanical lift while being transferred onto the toilet." "The floor was noted to be clean, dry, and free of obstacles and the lift was found to be in proper working order." "Care plan was updated for resident to remain a two assist for transfer until she is strong enough for therapy to assess her." On 12/17/14 at 9:00 a.m., Surveyor interviewed the NHA, who stated CNA C was the only person involved with the fall. Prior to the fall, Resident #1 had transferred with one staff person. Resident #1 was transferred with an EZ-Stand lift on 12/07/14 due to increased weakness related to influenza. The NHA stated the facility's policy is one CNA can transfer residents alone when using the EZ-Stand if the resident is safe to transfer with one. On 12/17/14 at 3:15 p.m., Surveyor interviewed LPN A about Resident #1's fall on 12/07/14. LPN A stated when the night staff (LPN A, CNA B and CNA C) came on duty on 12/07/14, the PM nurse had informed them Resident #1 was sick with the flu and was really weak. The PM nurse informed the night staff she wanted Resident #1 to be transferred using an EZ-Stand with assistance of two staff due to the weakness. CNA C informed CNA B and LPN A Resident #1 needed to use the bathroom. CNA B and LPN were assisting other residents at the time and CNA C was instructed to wait for another staff person. LPN A stated CNA B and herself heard Resident #1 hollering. CNA B responded first and was in the bathroom with Resident #1 and CNA C when LPN A arrived. LPN A stated when she arrived, CNA C was pulling the EZ-Stand out of the bathroom with Resident #1's feet caught on the base platform of the EZ stand. LPN A stated the transfer harness was not in Resident #1's bathroom when she arrived. LPN A stated CNA C informed her she had not used the leg straps during the transfer. LPN A stated the facility policy is the leg straps are to be used during transfers with the EZ-Stand. LPN A stated CNA C informed her she thought Resident #1 would be able to transfer with assistance of one using the EZ-Stand because Resident #1 couldn't wait for another staff person to arrive to assist her to the bathroom. CNA C stated during the transfer into the bathroom, Resident #1's knees buckled and she started to slide out of the lift. CNA C stated Resident #1 slid out the the transfer belt while it was secured around Resident #1's upper torso. CNA C stated the transfer belt had not come undone. LPN A stated she had provided this information to the DON after the fall. On 12/17/14 at 3:34 p.m., Surveyor interviewed the NHA and DON related to the incident. The DON stated she was unsure if the shin strap had been utilized at the time of the fall. The NHA stated Resident #1 had "slipped" right out of the transfer belt during the transfer. The DON stated the transfer belt could have loosened during the transfer and this allowed Resident #1 to slide out of the belt. The DON and NHA stated they did not recall if they interviewed CNAs B or C or LPN A for additional details related to how Resident #1 slid out of the transfer belt following the fall. On 12/17/14 at 4:00 p.m., Surveyor interviewed the NHA, who stated she had not interviewed LPN A after she read the incident report and written statements. The NHA stated she was not sure if the DON had interviewed the staff involved. The NHA stated if interviews had been conducted, they should have been documented and included in the investigation report. No interviews with LPN A, CNA B or CNA C were in the investigation report. 2. Resident #5 has [DIAGNOSES REDACTED]. The annual Minimum Data Set, dated dated [DATE], documented the resident had cognitive impairment and a history of falls. The resident's current care plan, dated 10/14/13, stated, "Approach 10/14/13 Mobility: CGA (Contact Guard Assist) of 1, gait belt, quad cane with w/c to follow." The Incident and Investigation Report, dated 10/04/14 at 12:45, stated, "Describe how resident was found: Patient was assisted to ground by CNA in bathroom. Describe circumstances surrounding incident: Patient needed to use restroom...Plan of Care: Grip strip in bathroom." No injuries were documented in the report. Incident statement, dated 10/04/14 at 12:45, by CNA D stated, "Did you observe the incident? Yes. If so, describe what happened: was assisting resident to restroom his feet slid from under him and I lowered him to the floor... What equipment /furniture was in use at the time of the incident? (Circle all that apply)." Gait belt was circled but then crossed off and wrong written on the statement. Incident Statement, dated 10/04/14 at 12:45, by CNA H stated, "Did you find resident after the incident occurred? Yes. If so, where was the resident found? Resident was sitting on the floor in the bathroom...Was the care plan followed? No. If no, why not? Resident did not have a gait belt on." On 12/17/14 at 3:15 p.m., Surveyor interviewed the NHA related to the incident on 10/04/14. The NHA stated Resident #5 had refused to wear the gait belt and usually does not refuse to wear it. Surveyor questioned the NHA as to what education had been provided to staff as what to do when the resident refuses to wear a gait belt. The NHA stated no education had been provided to the nursing staff. On 12/17/14 at 4:30 p.m., the NHA stated the facility does not have a written policy for following the care plan but stated she would expect staff to follow residents' care plans.

Based on interview and record review, the facility did not ensure that appropriate fall interventions were utilized to prevent further falls and injury and did not ensure therapy recommendations were followed for 1 of 8 residents (Resident #10) reviewed for falls. This resulted in an additional fall and distal right clavical fracture. This is evidenced by: On 04/15/14 at 11:05 a.m., Surveyor # reviewed the medical records for Resident #10 and noted the following: - Resident #10 was [AGE] years old who had a [DIAGNOSES REDACTED]. - Comprehensive Care Plan, dated 02/09/14, stated Resident #10 was at risk for falls and targeted goal was for Resident #10 not to experience serious injury from a fall. Care plan also stated Resident #10 had trouble seeing and to anticipate any increased ADL needs. - 02/11/14: Minimum Data Set (MDS) stated Resident #10 had not had any previous falls since admission to facility.. - 04/01/14: MDS for Resident #10 stated Resident #10 had sustained fall(s) since admission to facility which resulted in major injury. - Comprehensive care plan, dated 03/05/14, states Resident #10 is at risk for falls due to potential for injury/trauma from a fall related to: dementia, severe visual impairment, wandering, anxiety and anti-anxiety medication. - 03/26/14: Resident #10 started receiving hospice care. - 04/02/14: Resident passed away at facility. On 04/15/14, Surveyor # reviewed nursing notes for Resident #10 and noted the following information: - 02/27/14: Fax sent to physician from facility stating, "Resident has been receiving APAP (Acetaminophen) 650 mg (milligrams) PRN (as needed) at noon for the past week for increased agitation and confusion which was possibly linked to non verbal pain or discomfort. The days the resident was showing obvious signs of restlessness and agitation the APAP did not appear to be effective. PRN Alprazolam 0.25 mg PO (oral) has also been implemented several times in the past few weeks and has been effective in calming the resident. Would you consider scheduling Alprazolam 0.25 mg PO at noon due to increase agitation in the afternoon? Please contact us with any questions, concerns, or new orders. Thank you." - 02/28/14: Above mentioned fax sent to physician returned to facility stating the following medication order: "Change Alprazolam to 0.25 mg PO at noontime due to increased agitation in afternoon...Continue Alprazolam 0.25 mg PO every 8 hours as needed for restlessness." On 04/15/14, Surveyor # was unable to locate a fall risk assessment for Resident #10 due to change in Antianxiety medication which was ordered on [DATE] and was unable to determine any new fall interventions for the change in medications on 02/28/14. According to http://www.drugs.com/sfx/alprazolam-side-effects, Alprazolam has the following common side effects: Clumsiness or unsteadiness, difficulty with coordination, drowsiness, shakiness and unsteady walk, unsteadiness, trembling, or other problems with muscle control or coordination and unusual tiredness or weakness. On 04/15/14, Surveyor # , while reviewing Resident #10's nursing notes, noted Resident #10 had a fall at the facility on 03/03/14. This surveyor reviewed the fall investigation and noted the following from the investigation report: - 03/03/14: "Resident was found on the floor of her room on 03/03/14 at 1655 (4:55 p.m.). She was sitting on her buttocks facing her rocking chair. Resident was last seen by staff in the hallway heading to her room as she stated she needed to find the bathroom. This was about 15 minutes prior to her fall. Resident was assessed by charge nurse. It was immediately noted an intact 4 cm (centimeter) hematoma to the forehead, bridge of nose has a 1 cm abrasion glasses were noted to be bent out of shape, and pain was expressed by resident in the right upper extremity with no bruising or deformities noted. Resident was maintained in comfort position." Charge nurse then contacted on call physician to obtain further instruction. Order was obtained to have resident sent out via ambulance to Mayo Bloomer Hospital for further evaluation. - Fall was unwitnessed. - "Has the resident had an exacerbation of a medical condition or an acute illness? YES (due to) increase confusion in pm (evening) hours due to dementia." - "Contributing factors: memory/orientation compliance, behaviors and vision/perception." - "Medication History: Other meds that affect balance, judgement, or perception: Alprazolam and Zantac." - Staff incident statement from Certified Nursing Assistant (CNA) B, who found Resident #10 sitting on the floor in front of her rocker (glider chair) which was next to her bed, states, "I believe she (Resident #10) came from the bathroom." - Statement from Resident #10 states, "Humiliated she fell and "I was just trying to sit down" also stated her arm hurt right arm." - 03/03/14: Order received to send Resident #10 to emergency room for further evaluation. - 03/03/14: Nursing Note: "Resident returned at 2035 (7:35 p.m.) per ambulance...ER (emergency room ) report stated resident had a closed head injury without LOC (loss of consciousness)." - No Fall assessment noted in investigation report, nursing notes or within Resident #10's medical record upon return fromER on [DATE]. - Nursing Evaluation notes in fall investigation states, "Resident has had no changes in vision, ROM (range of motion) or in functional status since her recent fall incident of 3/4/14. Resident continues to ambulate self on and off the unit using FWW (front wheel walker), is able to continue with daily activities per norm (normal), and vitals remained stable. Therapy screen was requested." On 04/16/14, Surveyor # reviewed the medical chart for Resident #10 along with the therapy screening notes, dated 03/05/14, in regard to fall which occurred on 03/03/14. The following was noted: "Pt (patient) had fall Sunday evening transferring out of rocker glider, found on the floor in front of the chair. Not observed. Becomes very agitated with redirection. Pt. is a poor candidate for therapy. Does not respond to verbal cueing. Recommend removing rocker/glider. Replace with a reg (regular) cushioned chair. Staff to supv (supervise) pt. as needed." On 04/16/14, Surveyor # reviewed the comprehensive nursing care plan for Resident #10 and noted the following: - Comprehensive care plan, dated 03/05/14, states Resident #10 is at risk for falls due to potential for injury/trauma from a fall related to: dementia, severe visual impairment, wandering, anxiety and anti-anxiety medication. On 03/04/14, it is noted on care plan for staff to anticipate her (Resident #10's) needs and therapy screen was requested. - Supplemental Care Plan for Resident #10, dated 03/04/14, states, "Neurological assessment daily d/t (due to) head injury, apply ice to hematoma on forehead as needed, monitor for any changes in vision, n/v (nausea/vomiting), dizziness, unsteady gait, administer pain medication as needed and ordered, update MD and family as needed, Resident has f/u (follow-up) appointment in 1-2 weeks for post fall." This surveyor did not find any fall interventions on the care plan to prevent Resident #10 from falling again post fall on 03/03/14. On 04/16/14, Surveyor # reviewed the nursing notes and noted the following: - 03/05/14: Therapy was considering screening resident due to recent fall with injury. - 03/07/14: Resident #10 unable to continue with FMP (restorative program) due to being unable to follow cues and direction. - 03/08/14: Family notified facility staff indicating Resident #10 was weak and needed to use a wheelchair for ambulation. - 03/10/14: Resident continues to be somewhat unsteady and weaker than previously...appears to have a hard time seeing where she is going and requires cues and assistance from staff while ambulating. - 03/13/14: Resident ambulated with staff and had unsteady gait and weakness in the knees. Wheelchair provided. - 03/20/14: Fax sent to pharmacy consultant requesting a review of medications which may have contributed to fall on 03/03/14. Pharmacy consultant replied to fax stating, "Following medications could contribute to falls: 1. Lorazepam, 2. Alprazolam at noon - Recently started? May reduce to 1/2 tab (tablet) or separate from lorazepam by at least six hours., 3. Metoprolol 12.5 BID (twice a day) - how is blood pressure?" This surveyor was unable to locate any response from physician in regard to pharmacy consultant's review. - 03/23/14: FALL: "Resident (#10) was found in her room between her recliner and her bed. She was sitting on her right leg with left leg out in front of her. (Resident #10) complained of R (right) arm with movement, however no redness or abnormalities were noted. All other extremities move appropriately with no c/o (complain) of pain or discomfort...Resident was hoyered to her bed....POA contacted and states that (Resident #10) had c/o discomfort in her arm in the past and would prefer we (facility) monitor her in facility if possible...on-call physician updated on fall and agreed to monitor in facility x 24 hours, update MD with any changes in condition." On 04/16/14, Surveyor # reviewed the fall investigation for Resident #10, dated 04/02/14, and completed by Licensed Practical Nurse (LPN) D, and noted the following: - Resident #10 had fallen in her room at 11:20 a.m. Post fall assessment/IDT Review note, dated 03/23/14, stated, "Resident (#10) was sleeping 5 minutes prior to fall." - "Activity at time of fall or what was resident attempting to do: appears to have been self-transferring." - "Incontinent (at time of fall): No." - "Psychiatric/cognitive: Anxiety Disorder." - "Orthopedic: Osteoporosis." - "Intervention(s) added: Scoop mattress was added to resident's bed." - Staff statement from LPN D stated Resident #10 was last seen sitting in her chair by staff at 11:15 a.m. and it appears Resident #10 attempted to self transfer from her recliner (glider chair) to her bed and fell during the transfer. Resident #10 was offered a snack." - Fall Event form, dated 03/23/14, filled out by LPN D, stated immediate interventions taken were "rest" and "Other - offered food/drink." - 03/24/14: Resident calling out verbalized pain to right shoulder. - 03/25/14: Order received from physician to x-ray right shoulder. - 03/25/14: X-ray results showed Resident #10 had a fractured clavicle. Surveyor # reviewed the x-ray report, dated 03/15/14, and the results stated, "Subacute fracture involving the distal right clavicle." - Falls Interdisciplinary Care Plan for Resident #10, dated 03/23/14, did not provide any new interventions from recent fall on 03/23/14. - Incident statement from CNA C, who found resident on floor, stated resident was last seen at 11:15 a.m. sitting her glider chair sleeping which was five minutes prior to the fall. Resident #10 was found sitting on the floor between the bed and the rocking chair. On 04/16/14 at 9:00 a.m., Surveyor # interviewed CNA C. This surveyor asked CNA C to provide details in regard to the fall Resident #10 had on 03/23/14. CNA C stated she had looked into Resident #10's room at 11:15 a.m. and noted the resident to be sleeping in her glider chair. CNA C stated she went across the hallway to check on another resident and when she returned to the hallway at 11:20, she heard a faint crying out of "Help, help" coming from Resident #10's room. CNA C stated she immediately went into Resident #10's room and noticed Resident #10 was sitting on the floor between the bed and the chair. CNA C stated Resident #10 did not have a history of self-transferring and believed Resident #10 was attempting to stand up from the glider chair and fell attempting to transfer due to the time frame in which she had just recently seen her, which was about five minutes. CNA C stated no staff had attempted to transfer Resident #10 to her bed within the five minutes last seen prior to the fall. On 04/16/14 at 9:15 a.m., Surveyor # interviewed LPN D. This surveyor asked LPN D to provide details in regard to the fall Resident #10 had on 03/23/14. LPN D stated the resident was found on the floor between the glider chair and the bed by CNA C. LPN D stated, from her investigation of the fall, it was reasonable to conclude Resident #10 had fallen when trying to stand up from the glider chair and self-transfer to the bed. This surveyor asked what interventions were put into place at the time of the fall to prevent further falls. LPN D stated a scoop mattress was provided to the bed. This surveyor asked LPN D if she felt the resident had fallen while attempting to self transfer from the chair to the bed if a scoop mattress was an appropriate intervention. LPN D stated the scoop mattress was not an appropriate intervention and she should have placed an intervention which would have prevented her from falling out of her chair. On 04/16/14 at 9:30 a.m., Surveyor # interviewed the Director of Nursing (DON). The DON stated Resident #10 was not assessed for falls when she (Resident #10) had received a change in antianxiety medication on 02/28/14 and confirmed no fall interventions were put into place to prevent falls with the change in antianxiety medication. The DON stated Resident #10, at the time of the medication change, was able to ambulate on her own with the use of a walker. The DON stated when Resident #10 had fallen on 03/03/14, she was found sitting in front of her glider chair and was unsure as to how she fell but felt it had to do with her poor vision because Resident #10 had Glaucoma. The DON stated Resident #10 usually feels with her hand when she attempts to sit down, due to not being able to see well, and felt when she was finished using the bathroom she attempted to sit down and misjudged the distance which resulted in her falling to the floor or she could have stumbled and then fell . The DON stated no safety assessment for the glider chair had been done for Resident #10 and no assessment for safety in sitting had been done. The DON stated a PT screen was requested after the fall occurred. This surveyor asked if a fall assessment had been completed on Resident #10 due to head injury from fall and the DON stated no charted assessment was done; however, she (the DON) was monitoring the resident herself for safety when she had the chance. The DON stated she did not chart any observations or monitoring of Resident #10 for safety and confirmed she (the DON) was not in line of site of the resident at all times during ambulation. The DON stated they did not assess Resident #10's vision at the time of the first fall or the second fall and only checked pupil sizes for neuro-checks. The DON stated her expectation was for the nursing staff to chart on ambulation status with each fall and felt her nursing staff did not do this correctly. This surveyor discussed interventions for the fall on 03/03/14 and the DON confirmed no interventions were put into place to prevent further falls from occurring and also confirmed Resident #10 remained able to self-ambulate with use of walker after the first fall on 03/03/14. The DON stated the facility should have placed Resident #10 on either 15 minute checks or have completed a three day bowel and bladder monitoring. This surveyor asked what interventions were put into place on the second fall on 03/23/14. The DON stated a scoop mattress was put into place at the time but felt now the scoop mattress was not an appropriate intervention. On 04/16/14 at 12:20 p.m., Surveyor # interviewed the DON. This surveyor asked the DON if she was aware of the therapy request to remove the glider rocker chair. The DON reviewed the therapy request, dated 03/05/14, and stated she had never seen the request before. The DON stated therapy was to give all recommendations to both the nursing staff and herself to follow through. The DON stated neither the nursing department nor the nursing staff received the therapy recommendations to remove the glider chair. The DON stated they would have immediately replaced the glider chair according to therapy recommendations and would have then monitored the resident for safety and appropriateness. The DON reviewed the nursing notes with this surveyor for documentation of the therapy recommendations but no documentation was noted within the nursing notes for Resident #10. The DON stated therapy, at times, will just place their therapy recommendations sheet directly in the residents' charts which then is overlooked because nursing staff do not know they are there. The DON confirmed Resident #10 had a glider chair which moved back and forth and all documentation which might be found in Resident #10's medical record referring to a rocking chair or lounger chair was actually referring to the glider chair. On 04/16/14 at approximately 1:30 p.m., Surveyor # interviewed the Nursing Home Administrator (NHA). This surveyor expressed concern in regard to falls, interventions and therapy recommendations not being following for Resident #10. The NHA stated the facility had had communication problems in the past with their contracted therapy department and felt the therapist should have communicated both with the nursing staff and the DON on their recommendations to remove the glider chair. No further information was provided.