Every finding on record at Neighbors - West Neighborhood (The)

Based on observation, interview, and record review, the facility did not establish an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 4 residents (R5, R1, and R31) observed for proper hand hygiene during cares. Findings: Facility policy titled, Hand Washing, Hand Hygiene reviewed 9/19/2025 stated in part: .Examples of hand hygiene moments: Before touching a resident, before clean/aseptic procedures, after body fluid exposure risk, after touching a resident, after touching a resident's surroundings, before and after utilizing gloves .Example 1 R5 was admitted to the facility on [DATE] with a Brief Interview of Mental Status (BIMS) score of 15/15, which indicated R5 was cognitively intact. R5 had a diagnosis of acute cystitis with sepsis (a medical emergency where a bladder infection spreads into the bloodstream, causing a severe systemic response). On 03/18/26 at 8:16 AM, Surveyor observed Certified Nursing Assistant (CNA) D perform morning cares with R5. CNA D performed proper hand hygiene when entering R5's room and put on proper Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP). CNA D took out clothes from R5's closet, touching cabinet doors with gloved hands, and filled water basin in sink in R5's bathroom. CNA D then removed R5's gripper socks, then put clean compression socks and blue gripper socks over R5's compression socks. CNA D provided R5 with a wet washcloth to wash R5's face. CNA D then went into R5's top drawer for R5's bra. CNA D cleaned R5's back, front torso, under R5's armpits, under breasts and abdominal folds. CNA D applied lotion to R5's back and arms. CNA D removed soiled gloves and put on clean gloves without performing any hand hygiene. CNA D applied a medicated powder under R5's breasts bilaterally. CNA D then removed soiled gloves and again performed no hand hygiene before putting on clean gloves. CNA D then continued cares with no concern with the rest of the observation. On 03/19/26 at 9:45 AM, Surveyor informed Director of Nursing (DON) B of observation made during cares. DON B replied, She really should've performed hand hygiene in between glove changes. Example 2 R1 was admitted to the facility on [DATE] with a BIMS of 15/15 which indicated R1 was cognitively intact. R1 had a diagnosis of urine retention. On 03/19/26 at 8:44 AM, Surveyor observed CNA E perform urinary catheter care to R1. CNA put on PPE for EBP and gathered supplies to clean R1. CNA E cleaned R1's upper body. CNA E handed R1 the deodorant. CNA E assisted R1 to roll onto R1's left side, and CNA E then washed R1's back. CNA E assisted R1 to roll onto her back and helped R1 put on a purple sweatshirt. CNA E removed R1's pressure relieving boots to both feet. CNA E then removed soiled gloves and put on new gloves with no hand hygiene performed between the glove changes. CNA E placed a disposable attend on the floor next to R1's bed and placed a graduate on the attends. Surveyor observed CNA E emptying R1's catheter. There were no concerns with the rest of the observation. On 03/19/26 at 9:45 AM, Surveyor informed DON B of the observation made during cares. DON B replied, She should've performed hand hygiene in between glove changes. Example 3 R31 was admitted to the facility on [DATE] and current diagnoses include dementia and rheumatoid arthritis. R31 is dependent on staff for personal hygiene. On 03/19/2026 at 8:55 AM, Surveyor observed CNA G provide R31 morning cares. CNA G sanitized hands, entered R31's room, and gathered R31's clothes, washcloth and basin of water. CNA G applied gloves and applied socks and pants on R31. CNA G washed and dried R31's eyes. CNA G did not wash R31's hands. CNA G removed R31's brief and washed peri area appropriately and rolled R31 to side and washed buttocks and anal area appropriately. CNA G did not remove gloves and applied clean brief on R31. CNA G removed gloves and did not complete hand hygiene. CNA G assisted R31 to sit at edge of bed. With contaminated hands CNA G moved the [NAME] steady lift in front of R31 and put gait belt on R31. CNA G assisted R31 to stand and pulled up pants and transferred to wheelchair. CNA G with contaminated hands applied slippers on R31's feet. CNA G with contaminated hands brushed R31's hair. Then CNA G sanitized her hands and brought R31 to the dining room. When in the dining room CNA G did not offer hand hygiene to R31 before breakfast was provided. On 03/19/2026 at 1:05 PM, Surveyor interviewed CNA G asking about hand hygiene with R31's cares. CNA G stated they did not complete hand hygiene when gloves were removed and should have sanitized R31's hands before eating. On 03/19/2026 at 1:32 PM, Surveyor interviewed DON B about hand hygiene with cares. Surveyor reviewed with DON B of the observation with CNA G. DON B stated the staff had just done training on hand hygiene.

Based on interview and record review, a resident's medication order was not limited to 14 days, and prescribing practitioner did not document the rationale for the extended time use or a specific duration for use for 1 of 3 sampled residents, (R) R15, reviewed for PRN (as needed) psychotropic medications. R15 was prescribed PRN lorazepam for anxiety on 02/27/2026; there was no rationale for extended use written and no specific duration for use. This is evidenced by: R15 was admitted to the facility on [DATE] and has diagnoses that include vascular dementia with agitation and anxiety. R15's physician order dated 02/27/26 states: lorazepam - Schedule IVtablet; 0.5 mg; amt: 0.25mg; oral, Special Instructions: anxiety AEB (as evidenced by) frightened facial expr;verbal statements; Monitor response and consider alternative if ineffective. Every 4 Hours - PRN, PRN 1, PRN 2, PRN 3, PRN 4, PRN 5, PRN 6 - Open ended date. Review of R15's medication administration record (MAR) revealed R15 used lorazepam 0.25mg for anxiety on 02/27/26, 02/28/26, 03/01/26, 03/02/26, 03/04/26, 03/06/26, 03/07/26, and 03/09/26. Surveyor reviewed R15's medical record and was unable to locate a rationale for the extended use for the PRN lorazepam and did not locate a specific duration for its use. On 03/19/26 at 1:55 PM, Surveyor interviewed Director of Nursing (DON) B about R15's PRN lorazepam order greater than 14 days with no end date or rationale for continued use. DON B stated the facility works with hospice and tries not to have PRN psychotropic medications. This order was missed getting the continued order.

Based on interview and record review, the facility did not adequately assess and provide necessary care and services to attain or maintain the highest practicable physical wellbeing for 1 of 1 resident (R)(R37) reviewed for pain management. R37 did not have an individualized pain assessment completed to monitor, assess, and evaluate for efficacy for pain management and non-pharmacological interventions were not implemented.This is evidenced by:Facility policy titled, Pain Management, with a reviewed date of 04/13/25, states in part: POLICY: Control of resident's pain is integral to the mission statement of the facility; Nursing will set a high priority on pain management and pain control. Pain will be assessed, treated, and evaluated for effectiveness whenever a resident experiences pain, whether chronic, breakthrough or acute. Upon admission, all residents will be assessed for the presence of pain. The appropriate pain scale will be used to rate the pain. The health care team will collaborate with resident and family to set realistic goals and limitations for pain management. Pharmacological as well as non-pharmacological measures will be implemented to ensure that the resident's pain is appropriately managed. Specific measures that have been determined to be effective for individual residents will be incorporated into the care plan if appropriate. PROCEDURE: 1. The nurse will complete a Pain Management-Pain Observation on admission, quarterly, and if new pain diagnosis presents. 2. If pain is present, pain will be re-assessed using pain scale and recorded on the MAR Pain Flow Sheet, and Nurses notes, if appropriate: A. whenever a resident has a new risk factor for pain; B. whenever a resident complains of pain or exhibits nonverbal signs of pain; C. whenever a resident is administered a PRN pain medication; D. at least daily for residents on regularly scheduled pain meds; weekly for residents stable in a pain management program.4. Pain is quantified using the appropriate pain scale: a. Verbal score of 0-10; b. Wong-Baker face scale; c. PAINAD scale.R37 was admitted to the facility on [DATE] with pertinent dx of Parkinsonism, panic disorder, disorientation, generalized anxiety disorder, polyneuropathy, intervertebral disc degeneration lumbar region with discogenic back pain, presence of brain stimulator implant.R37's admission Minimum Data Set (MDS) assessment, dated 02/13/26, noted a Brief Interview for Mental Status (BIMS) score of 13/15, indicating cognition intact. R37 received scheduled pain medication. R35's pain assessment interview noted pain is present and frequently effects sleep. R37 noted a pain score of 4/10 as the worst pain.R37's care plan, dated 02/24/26, with a target date of 05/24/26, states: [R37] has potential for pain/discomfort related to right shoulder with a goal of [R37] will verbalize or score relief of pain/discomfort of <6. Interventions include: Administer pain relief measures as identified on the MAR. Evaluate and document effectiveness on MAR pain flow sheet and summarize in nursing notes as appropriate. Review the continued need for any routine administration of medication and adjust or discontinue as appropriate. Use appropriate pain scales: A. 0-10 scale. B. Wong-Baker scale. C. PAINAD scale as identified on pain assessment/pain flow sheet for the following situations: pain assessments with vital signs, daily for residents on regularly scheduled pain medications, weekly per policy/procedure and as needed. Provide non-therapeutic interventions as needed.R37's provider orders:02/06/26 Weekly pain assessment.02/06/26 acetaminophen 650 mg for pain/back ache every 6 hours as needed.02/06/26 meloxicam 15 mg for right shoulder pain once daily.02/06/26 Muscle Rub (methyl salicylate-menthol) cream topical as needed.02/06/26 tramadol (narcotic pain med) 25 mg for pain three times a day as needed.02/06/26 Voltaren Arthritis Pain (diclofenac sodium) gel topical for right shoulder pain three times a day.02/06/26 Apply ice/cold compress to right shoulder for pain/swelling fluid build up three times a day as needed.02/23/26 Muscle Rub (methyl salicylate-menthol) cream topical for right shoulder four times a day.-Of note: as needed (PRN) medications did not include clear parameters or indication of when to use each one.Surveyor reviewed R37's MAR and noted the following PRN administrations:02/07/26 - Acetaminophen 5:44 AM Reason: pain; Tramadol 5:44 AM Reason: right shoulder pain-Severity and characteristics of pain not documented.02/09/26 - Tramadol 4:36 AM Reason: right shoulder pain-Severity and characteristics of pain not documented.02/13/26 - Tramadol 9:32 AM Reason: right shoulder-Severity and characteristics of pain not documented.02/14/26 - Acetaminophen 7:59 PM Reason: right side hip pain-Severity and characteristics of pain not documented. First time documenting this area for pain; no documentation of notifying provider of new pain.02/15/26 - Acetaminophen 5:42 AM Reason: right lower rib pain-Severity and characteristics of pain not documented. First time documenting this area for pain; no documentation of notifying provider of new pain.02/16/26 - Acetaminophen 6:00 AM Reason: right lower quadrant pain-Severity and characteristics of pain not documented. First time documenting this area for pain; no documentation of notifying provider of new pain.02/17/26 - Acetaminophen 7:55 PM Reason: pain-No location, severity, or characteristic of pain documented.02/18/26 - Tramadol 1:41 AM Reason: back pain-No location, severity, or characteristic of pain documented.02/21/26 - Acetaminophen 8:56 PM Reason: pain-No location, severity, or characteristic of pain documented.02/22/26 - Acetaminophen 7:37 AM/11:17 PM Reason: right shoulder pain-Severity and characteristics of pain not documented.02/25/26 - Acetaminophen 8:06 PM Reason: back pain-No location, severity, or characteristic of pain documented.02/26/26 - Acetaminophen 11:17 AM/11:43 PM Reason: back pain; Tramadol 11:17 AM Reason: right shoulder-Severity and characteristics of pain not documented.02/27/26 - Acetaminophen 6:17 AM Reason: pain; Tramadol 4:01 PM Reason: pain-No location, severity, or characteristic of pain documented.02/28/26 - Tramadol 12:47 PM Reason: pain-No location, severity, or characteristic of pain documented.03/02/26 - Acetaminophen 10:21 PM Reason: pain-No location, severity, or characteristic of pain documented.03/03/26 - Acetaminophen 8:35 PM Reason: pain-No location, severity, or characteristic of pain documented.03/05/26 - Acetaminophen 7:46 AM Reason: bilateral arm pain- Severity and characteristics of pain not documented.03/06/26 - Acetaminophen 8:43 PM Reason: pain-No location, severity, or characteristic of pain documented.03/07/26 - Acetaminophen 4:22 AM/3:57 PM Reason: backache-No location, severity, or characteristic of pain documented.03/11/26 - Acetaminophen 9:18 PM Reason: pain-No location, severity, or characteristic of pain documented.03/16/26 - Acetaminophen 12:35 AM Reason: shoulder pain-No specific location, severity, or characteristic of pain documented.03/17/26 - Acetaminophen 12:54 AM/8:08 PM Reason: pain-No location, severity, or characteristic of pain documented.Of note: follow-up PRN pain assessments did not include intensity, severity or characteristics of pain. R37's non-pharmacological intervention of ice/cold compress was not administered at any time between 02/06/26 - 03/19/26.Review of R37's MAR of scheduled pain meds noted Voltaren pain gel was documented as refused on: 02/07/26, 02/10/26, 02/13/26 - 02/16/26, 02/18/26 - 02/25/26, 02/27/26 - 03/05/26, 03/08/26, 03/10/26 - 03/14/26, 03/18/26, and 03/19/26. No documentation of notifying provider of medication refusal was noted. No pain assessment or alternative interventions were noted with refusals.On 03/19/26 at 9:00 AM, Surveyor interviewed Registered Nurse (RN) C regarding pain assessments. RN C stated that typically a pain score would be documented in the MAR if there is an order to do so. Otherwise, a comment box will pop-up and this would be where the nurse enters a pain score. Surveyor asked RN C if location and characteristic of pain is assessed and documented. RN C stated no, not typically, but it depends on the nurse. Surveyor asked RN C how a resident's pain would be monitored for changes or worsening if this wasn't assessed. RN C stated being unsure and that it would be a good idea to do that. Surveyor asked RN C how a nurse decides which PRN medication to give if there are multiple options. RN C stated that it would either be the up to the nurse or whatever the resident states they prefer to take. RN C stated not being aware of any particular standard to follow on which PRN to give when or if there was a specific hierarchy for opioid or non-opioid. Surveyor asked RN C why R37's non-pharmacological pain interventions had not been administered. RN C stated that he wasn't aware there was a non-pharmacological intervention ordered.On 03/19/26 at 11:25 AM, Surveyor interviewed Medical Doctor (MD) F regarding as needed medications. MD F stated that the expectation would be for nursing staff to administer narcotic medications for breakthrough pain when scheduled pain meds are also ordered. MD F stated the expectation would be for the nurse to administer non-opioid meds first, evaluate efficacy, and then determine if opioid med should be used.On 03/19/26 at 12:03 PM, Surveyor interviewed Director of Nursing (DON) B regarding pain assessments. DON B stated that pain assessments should usually include a pain score or use of a pain face scale, depending on cognition. If staff don't have an option to choose a score, a note should be entered with administration of a PRN med indicating location and severity of pain. Surveyor asked DON B how nurses determine which PRN med to give if the order does not include parameters. DON B stated that it would be expected to do non-pharmacological interventions first, then try non-opioid, and if these options are ineffective will try opioid. Surveyor asked DON B if the provider should be notified when a resident refuses scheduled pain meds. DON B stated yes so that it can also be assessed to see if that med should be discontinued as it would likely be unnecessary. Surveyor showed DON B R37's MAR and the refusals documented of the scheduled Voltaren. DON B stated she was unaware of this and that the nurses should have informed her.

Based on observation, interview and record review, the facility did not ensure the resident environment remains free of accident hazards as possible and each resident receives adequate supervision and assistive devices to prevent accidents for 2 of 3 residents (R)(R11 and R35) reviewed.R11 and R35 had fallen; the facility did not initiate immediate intervention to prevent future falls, investigate the root cause of the fall and review and revise care plan fall interventions.This is evidenced by:Facility policy titled, Fall Risk Program, with a reviewed date of 03/04/25, states in part: POLICY: This program emphasizes assessment, identification, and intervention of resident falls, utilizing the least restrictive method to keep the resident safe. The program identifies the factors that place residents at risk for falls, promotes proactive healthcare practices for resident care planning, and identifies the main components of an effective fall prevention program. These components are fall risk assessment, interventions, documentation, and regular reassessment and evaluation. PROCEDURE: A. Prevention 2. All residents identified to be at risk for fall will have care plans and master assignment sheets that reflect risk status. a. Residents who score 10 or above are considered High Risk for falls and it will be documented on the MAS as DO NOT leave on toilet alone. 4. Falls will be discussed at the morning meeting to ensure all departments are aware of safety needs and interventions are put into place to prevent further falls if appropriate. 5. Residents who experience multiple falls will be assessed for trends and reviewed by DON, MD/provider and pharmacy consultant as needed.Example 1R11 was admitted to the facility on [DATE] with pertinent diagnoses of Parkinsonism, anxiety disorder, and age-related osteoporosis.R11's quarterly Minimum Data Set (MDS) assessment, dated 03/02/26, noted a Brief Interview of Mental Status (BIMS) score of 11, indicating moderately impaired cognition. R11 has impaired range of motion (ROM) on both upper extremities and impaired ROM on one side of lower extremities. R11 requires substantial/maximal assistance with all Activities of Daily Living (ADL). R11 had one fall with major injury.R11's care plan, dated 09/04/25, with a target date of 06/10/26, states: [R11] has potential for injury/falls related to Parkinsonism and history of falls with a goal to have no serious injuries through target date. Interventions include: Fall risk assessment and physical device assessments on admission, quarterly, with significant changes in condition and after a fall. Follow facility policy/procedure for falls and incidents. Investigate cause of fall/incident and review risk factors as appropriate.R11's fall risk assessments:05/27/25 Score: 10: > or = to 10 But can make own decisions, [NAME] on MAS May leave on toilet alone, and rationale is: independent for toileting.08/26/25 Score 12 (high risk): > or = to 10 But can make own decisions, [NAME] on MAS May leave on toilet alone, and rationale is: calls for staff when finished.02/25/26 Score 19 (high risk): > or = to 10 But can make own decisions, [NAME] on MAS May leave on toilet alone, and rationale is: responsible for self.Surveyor reviewed R11's fall investigations:On 01/28/26 at 3:05 PM, R11 had an unwitnessed fall in room. Staff found R11 lying on floor in room. No injuries were assessed at that time. On 01/29/26 at approximately 2:00 AM, R11 reported 8/10 pain in right wrist. Nurse observed R11's right wrist to be swollen and bruised. Provider was notified and R11 was transferred to local hospital for evaluation. R11 returned to facility on the same day with a diagnosis of right radius fracture. Facility investigated R11's fall and noted root cause to be R11 self-transferring without assist. No new safety interventions were implemented to prevent falls and care plan was not updated.On 03/19/26 at 12:19 PM, Surveyor interviewed Director of Nursing (DON) B regarding R11's fall. DON B stated after reviewing the fall, appropriate safety interventions were in place and no changes to the care plan were needed.Example 2R35 was admitted to the facility on [DATE] with pertinent diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, unspecified dementia with agitation anxiety and mood disorder, major depressive disorder, insomnia, polyneuropathy, overactive bladder.R35's quarterly MDS, dated [DATE], noted a BIMS score of 10, indicating moderately impaired cognition. R35 requires substantial/maximal assist with lying to sitting and transfers; partial/moderate assist with rolling left to right, sitting to lying and sit to stand. R35 had two or falls with no injury.R35's care plan, dated 12/09/25, with a target date of 06/10/25, states: [R35] has a potential for injury/falls related to fall risk assessment score of 19, periods of confusion, and limited/decreased mobility with a goal of no serious injuries. Interventions include: Fall risk assessment and physical device assessments on admission, quarterly, with significant changes in condition and after a fall. Follow facility policy/procedure for falls and incidents. Investigate cause of fall/incident and review risk factors as appropriate. Remind of need for assist and safety interventions as needed. Do not leave alone on toilet. Low bed. Mat on floor. Hourly safety checks when in bed. Encourage to sleep in bed, discourage recliner. 30 minute safety checks at night.R35's fall risk assessments:11/28/25 : Score 13 (high risk) > or = to 10 But can make own decisions, [NAME] on MAS May leave on toilet alone, and rationale is - Aware of limitations.12/01/25 19 (high risk): > or = to 10 But can make own decisions, [NAME] on MAS May leave on toilet alone, and rationale is - Responsible for self.02/28/26 15 (high risk): > or = to 10: [NAME] on MAS as Do Not Leave on toilet alone. Resident not safe. Needs assistance with task, fall history, [NAME] steady used for transfers.Surveyor reviewed R35's fall investigations:On 12/02/25 at 8:45 PM, R35 had unwitnessed fall in room. R35 found seated on floor mattress at bedside. No injuries. Provider notified. Root cause: presumed R35 was reaching for something and slid off side of bed. New safety interventions: place personal items and call cord within reach. Care plan updated.On 12/13/25 at 4:35 AM, R35 had unwitnessed fall in room. CNA answered R35's call light and found R35 sitting on floor mat. R35 stated she crawled out of bed to look under it for her catheter bag and just 'slid out of bed.' No injuries. Provider notified. Root cause: slid out of bed. New safety interventions: hourly safety checks when in bed. Care plan updated.On 01/01/26 at 2:35 AM, R35 had unwitnessed fall in room. CNA answered R35's call light and found R35 sitting on floor in front of recliner on floor mat. Recliner legs noted to be partially lowered. R35 did not provide answer for how fall occurred. No injuries noted. Provider notified. Root cause: cognitive decline and dementia, poor decision making, and failed to self-transfer. New safety interventions: R35 not to sleep in recliner. Care plan updated.-Of note: no documentation of recliner/equipment assessed for safety and/or functioning.On 01/04/26 at 6:00 AM, R35 had unwitnessed fall in room. CNA entered room and found R35 seated upright on floor mattress. R35 stated she thought she slipped off side of bed and woke up sitting there on floor. No injuries noted. Provider notified. R35 re-educated on calling for assistance. Root cause: R35 slid off bed.-Of note: no new safety interventions implemented. No documentation of bed/equipment assessed for safety and/or functioning.On 03/09/26 at 1:30 AM, R35 had unwitnessed fall in room. CNA entered R35's room after hearing R35 calling out for help. R35 found sitting on fall mat next to bed. R35 stated she couldn't sleep and thought she might be able to in the recliner. R35 stated she slid out of bed. No injuries. R35 re-educated of fall safety. Provider notified. Root cause: slid out of bed.-Of note: no new safety interventions implemented. No documentation of bed/equipment assessed for safety and/or functioning.On 03/09/26 at 9:45 PM, R35 had unwitnessed fall in room. Staff found R35 sitting on floor mat next to bed. R35 stated she thought she dropped a piece of paper. No injuries. Provider notified. R35 re-educated on fall safety. Root cause: leaning too far over edge and slipped off disposable chuck pad on bed. New safety intervention: do not use disposable chucks on bed. Care plan updated.On 03/15/26 at 3:00 AM, R35 had unwitnessed fall in room. CNA heard R35 call out for help and found R35 sitting on floor mat next to bed. R35 stated she slid off bed. No injuries. Provider notified. Root cause: slid off bed.-Of note: no new safety interventions implemented. No documentation of bed/equipment assessed for safety and/or functioning.On 03/19/26 at 12:13 PM, Surveyor interviewed DON B regarding R35's falls. DON B stated that all of R35's falls were investigated and appropriate safety interventions were already in place and effective. DON B stated that no new safety interventions were necessary for R35 because the facility is not responsible for preventing falls, but to prevent injuries and R35 had not sustained any injuries from any falls.

Based on interview and record review, the facility did not complete comprehensive weekly wound assessments for 1 of 2 residents (R)30 to ensure that residents receive treatment and care in accordance with professional standards of practice. R30 did not receive weekly measuring and comprehensive assessment of a skin injury. This is evidenced by: Review of the facility's policy titled: Wound management with the revised date of 12/03/21, read in part: .PURPOSE: To track, prevent, heal pressure ulcers/wounds according to standards of practice . PROCEDURE: .II. Assistant Clinical Mentors or licensed designee are responsible for weekly wound documentation. Review of the facility's Treatment Order form, read in part: 9. Weekly measurement and documentation (in Matrix under wound management tab) on Wed. AM's until healed (pressure sores, venous stasis, arterial, diabetic ulcers, open surgical wound) R30 was admitted to the facility on [DATE] and has current diagnoses of open wound left lower leg, osteoporosis with current pathological fracture right femur, Alzheimer's disease, and dementia. The event report, dated 11/02/24 at 4:32 AM, documented R30 developed a skin tear to the left posterior lower calf measuring 5.5 cm by 3 cm. R30 stated had a itch on her leg and scratched to hard. Wound edges were irregular. R30's progress notes documented on 11/02/24 at 8:03 AM, Writer (Registered Nurse) went to change pt bandage that was placed on overnights on the back of pt's left calf due to blood dripping on to the Broda. Pt had c/o burning sensation from wound. Writer unwrapped and planned to place ABD and coban wrap on. Writer did see fatty tissue and protruding from the wound and with the bleeding, made the call to send pt to ER via non emergent ambulance. Progress notes documented on 11/02/24 at 10:15 AM, Pt returned from ER at 0845. Transported back by son [name] in personal vehicle. Transfer out of vehicle with staff was appropriate. Stitches that were placed, they are to be removed in two weeks (11/16). Review of the Treatment Administration Record (TAR) documented 11/02/24 - 11/17/24 dressing changes were completed every other day and as needed and monitored daily of drainage, wound edges, odor, pain, type of drainage, and wound progression. Progress notes documented on 11/13/24 at 2:42 PM, .Night CNA mentioned that bandage was being picked at. CNA staff changed bedding and writer and CCM changed bandage in the bathroom. Moderate to heavy drainage noted in the bandage. VSS . Progress notes documented on 11/14/24 at 1:02 PM, Md alerted to res digging at her left post calf wound repeatedly (sic) and will try coban 2 for further padding and protection . The TAR documented on 11/17/24, small amount of serosanguinous drainage, no odor, and wound is stable. Progress notes documented on 11/18/24 at 2:47 PM, Writer (RN) received call from POA [Name] that res is at ortho appt and hip is fine however res left LE post calf wound with green drainage at appt; res in a lot of pain r/t wound so they want to admit resident and send her back in am . [R30] was admitted to the hospital for debridement of the wound. Hospital wound care notes dated 11/25/24 documented wound length 5.8 cm, wound width 4.2 cm, wound depth 1 cm, wound bed is red, granulation, yellow, no odor, small amount exudate of serosanguineous fluid. On 11/27/24, R30 was readmitted to the facility with orders for a wound vac to the left calf wound. Dressing to be changed every Monday, Wednesday, and Friday. Progress notes documented on 11/27/24 at 1:02 PM, .res also sustained a new skin tear next to the wound vac wound as she frequently will pull it off; there is a foam drsg on the new skin tear; res is on 2 po abx for current wound ; res does have equagel cushion in [NAME] and w/c; not restless and cooperative at present; staff instructed to keep close eye on wound vac as may need to be plugged in. Surveyor noted the facility did not complete a comprehensive wound assessment on 11/27/24 when the wound vac was first changed in the facility. On 12/04/24 at 12:43 PM, a wound management detail report in part: The wound length is 4.3 cm and width 3.8 cm, incision with open area, skin surrounding incision is normal color and warm. Incision drainage: serous (clear, amber, thin and watery). Wound healing status: Improving Comments: wound vac at 75mmhg cont; depth is 1cm. This assessment did not assess and describe the wound bed. Note this is the first documented report of a comprehensive assessment of the wound, one week after admission. No further wound comprehensive assessments were completed for the month of December. The next assessment of the wound size was documented in the progress notes on 01/02/25, four weeks later, .inpsected (sic) res left IE with wound vac in place and no redness noted as well as size is significantly smaller compared to what it was; ~3x4cm and filling in per TL (team lead) . This assessment did not measure the depth of the wound, describe the wound bed, and if any drainage. On 01/08/24 at 8:46 AM, Surveyor interviewed Director of Nursing (DON) B about R30's comprehensive wound assessments. DON B indicated the facility does not complete measurements of surgical wounds. R30 wound was sutured, and it was closed. The wound did not open and when DON B assessed the area there was no odor or signs of infection. DON B was not surprised of an infection developing since R30 would scratch at the area and remove the dressing. Surveyor asked when R30 returned from the hospital with wound vac orders post debridement, would the facility expect a complete comprehensive wound assessment to be done. Surveyor asked about the missing weekly assessments that would include measurements, description of the wound depth, appearance of the wound bed to determine wound healing. DON B indicated this is a surgical wound and they don't do weekly measurement for surgical incisions. We do assessments on pressure sores, venous stasis, arterial, and diabetic ulcers. We can tell if the area is healing with granulation tissue and the wound edges pulling together when changing the wound vac.

Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Staff did not initiate enhanced barrier precautions (EBP) for 1 of 3 residents observed (R21) with a wound. Facility staff did not wear personal protective equipment (PPE) for R30 who is on EBP or perform proper hand hygiene with cares. Facility staff used contaminated scissors to cut a wound dressing treatment and placed the cut dressing in R30's skin wound. Staff did not disinfect body sling after use for R11 and R21. Staff wore mask below nose when assisting one resident. This was evidenced by: Centers for Disease Control and Prevention (CDC) Enhanced Barrier Precautions recommendations, dated 06/28/24, state in part: Enhanced Barrier Precautions are recommended for residents with any of the following: 1) infection or colonization with a MDRO or 2) a wound or indwelling medical device, even if the resident is not known to be infected or colonized with a MDRO. Facility policy titled, Enhanced Barrier Precautions, with a revised date of 10/18/24, states in part: POLICY: Facility will implement Enhanced Barrier Precautions for the prevention of transmission of certain multidrug-resistant organisms. DEFINITIONS: Enhanced Barrier Precautions (EBP): refer to an infection control intervention to reduce transmission of multidrug-resistant organisms that employ targeted gown and gloves use during high contact resident activities. 2. Initiation of Enhanced Barrier Precautions b. An order for EBP will be initiated for residents with any of the following: ii. Wounds (e.g. chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) 3. Implementation of Enhanced Barrier Precautions b. PPE for EBP is only necessary when performing high-contact care activities and may not be donned prior to entering the resident's room. 4. High-Contact Resident Care Activities Include a. Dressing b. Bathing c. Transferring d. Providing hygiene e. Changing linen f. Changing of incontinence products or assisting with toileting g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy h. Wound care of chronic skin opening requiring a dressing Example 1 R21 was admitted to the facility on [DATE] with pertinent diagnoses of diabetes mellitus type 2, congestive heart failure, and chronic kidney disease. R21's Minimum Data Set (MDS) assessment, dated 11/10/24, indicated that R21 had 1 current unhealed, unstageable diabetic foot ulcer with treatment of application of dressing to feet. R21's care plan, dated 05/15/24, with a target date of 02/05/25, states: Impaired skin integrity and potential for impaired skin integrity. No interventions listed for implementation and use of EBP. R21's orders included: Wound--DTI left heel--daily documentation until healed x7 days then DC. Daily documentation should include: amount drainage, type of drainage, dressing intact, odor after cleansing, pain, progress of wound, wound edges, healed. Special Instructions: Notify MD of symptoms of infection - change of appearance Once A Day START: 4/16/24 No orders found to initiate EBP. On 01/08/25 at 2:30 PM, Surveyor interviewed Director of Nursing (DON) B regarding initiation of EBP. Surveyor asked DON B when EBP should be initiated. DON B stated EBP would be initiated for residents who have any indwelling device - such as a foley catheter or feeding tube, multidrug-resistant organism (MDRO), pressure injury, or chronic wound/ulcer. Surveyor asked DON B if this included chronic diabetic ulcers. DON B stated yes. Surveyor asked why EBP was not ordered or initiated for R21 who has a documented diabetic ulcer. DON B stated that even though R21 was receiving daily dressing changes for this wound, the presence of eschar provided a natural barrier and did not feel this required EBP. Surveyor asked DON B where this indication came from. DON B stated it was based on her experience and wound care training. Surveyor asked DON B if this was in agreement with facility policy and current practice recommendations. DON B shrugged and stated she did not know but felt R21 did not need EBP for her diabetic ulcer. 31086 Example 2 R30 was admitted to the facility on [DATE] and has current diagnoses of open wound left lower leg, osteoporosis with current pathological fracture right femur, Alzheimer's disease, and dementia. R30 returned from the hospital on 11/27/24 with a diagnosis of a wound infection with bacteria of staphylococcus aureus, staphylococcus epidermidis, which are both resistive to oxacillin antibiotic, and escherichia coli. R30 was placed on EBP. Surveyor observed the door frame at the entrance of R30's room has a sign attached stating EBP. On 01/07/25 at 7:36 AM, Surveyor observed Certified Nursing Assistant (CNA) D transfer R30 in the Broda chair to R30's room. CNA D did not apply gown and gloves. Gown and gloves are required PPE for a resident on EBP. CNA D used a gait belt and transferred R30 from the Broda chair to the toilet. CNA D applied gloves and pulled R30's pants and brief down. CNA D removed the urine soaked brief, removed gloves, and without hand hygiene, applied clean gloves then applied a clean brief. CNA D assisted R30 to stand and cleaned frontal peri area with wipes and with clean wipes cleansed perineum and buttocks. With the same gloves, CNA D applied barrier cream to R30's buttocks. CNA D removed gloves and pivot transferred R30 to the Broda chair. CNA D washed hands for approximately 5 seconds, turned faucet off with clean hands, dried hands, and applied clean gloves to brush R30's hair. During the entire observation CNA D did not apply a gown. On 01/08/25 at 9:09 AM, Surveyor observed CNA E without wearing a gown assist R30 in bed and pull R30's pants down. Surveyor asked CNA E if CNA E had transferred R30 into bed. CNA E indicated yes she just transferred R30 to bed and pulled R30's pants down. Registered Nurse (RN) F stated to CNA E you should be wearing a gown when doing cares with R30. CNA E stated she just transferred R30 to bed. RN F washed hands, and without wearing a gown or gloves, RN F went to R30's bed side and removed R30's left leg from the pant leg. Then RN F applied gown and gloves. Example 3 On 01/08/25 at approximately 9:10 a.m., Surveyor observed RN F complete wound care for R30. RN F placed a barrier under R30's leg. RN F removed R30's sock, tubi grip, and ace bandage. RN F gathered supplies and placed on barrier on the overbed tray table. RN F used scissors to cut off kerlix bandage from R30's leg. RN F removed gloves, washed hands and applied clean gloves. RN F washed the wound with saline wound wash and dried area. RN F applied skin prep to the surrounding skin of the wound. RN F did not clean the scissors that were used to cut the old dressing. RN F used the contaminated scissors, cut the zeroform dressing and placed the cut dressing into R30's wound bed. RN F applied gauze sponge over the wound, applied kerlix dressing around the leg, and applied ace wrap around. RN F removed gloves, gathered garbage and washed hands. Surveyor interviewed RN F about using the scissors to cut old dressing then used the same scissors to cut the new zeroform dressing without prior cleaning of the scissors. RN F indicated she should have cleaned the scissors before cutting the new dressing. Surveyor asked if a gown should be worn before providing cares and when CNA transferred R30 to bed. RN F indicated yes a gown should be worn when providing cares and transferring because R30 is on precautions. On 01/09/25 at 3:48 p.m., Surveyor interviewed DON B about the use of PPE for R30's cares. Surveyor reviewed the observations with DON B, and DON B indicated PPE of a gown and gloves to be worn when providing cares and education will be provided. Example 4 On 01/06/25 at 12:38 PM, Surveyor observed CNA G and CNA E complete a transfer with R11 using sit-to-stand lift. After transfer was complete, CNA G was observed disinfecting sit-to-stand and placing sling on top of the lift. Sling was not disinfected after use with R11. On 01/06/25 at 12:48 AM, Surveyor interviewed CNA G. Surveyor asked CNA G if the slings used for transfer with the sit-to-stand were used for multiple residents. CNA G stated they were. Surveyor asked CNA G if the slings were disinfected after use with a resident. CNA G stated no because there are only a few residents who use them. On 01/08/25 at 7:08 AM, Surveyor observed CNA H complete a transfer with R21 using sit-to-stand lift. After transfer was complete, CNA H disinfected sit-to-stand, placed sling on lift, and disinfected the sling straps. The body of the sling was not disinfected after use with R21. On 01/08/25 at 2:30 PM, Surveyor interviewed DON B regarding disinfecting slings. Surveyor asked if there was a policy on disinfecting slings after resident use. DON B was unable to provide a policy but stated the expectation is for staff to disinfect slings after every use with either a wipe or a spray disinfectant. Surveyor informed DON B of observation of staff not disinfecting slings after use. DON B stated disappointment with staff not practicing infection prevention practices and stated staff would be re-educated on this. DON B stated recognition of the potential of spreading infection from resident to resident if slings were not disinfected between uses. 16692 Example 5 The facility policy titled Pandemic Plan dated reviewed 05/22/23, states in part. Pandemic viruses can be introduced through facility personnel and visitors; once a pandemic virus enters such facilities, controlling it's spread is problematic .diseases and outbreaks . Outbreak measures will be used to reduce the chances of transmitting pandemic viruses to others within the facility Wear masks when caring for residents. On 01/07/25 at 4:35 PM, Surveyor observed CNA C in the day room pushing a resident in her broda chair out to the dayroom for supper. As CNA C did this she wore her face mask below the level of her chin. The mask worn this way exposed both her nose and mouth. There were 5 residents in the day room at the time. On 01/08/25 at 11:30 AM, Surveyor interviewed DON B who is also the facility's infection preventionist. Surveyor relayed the above observation to DON B. DON B stated that CNA C is aware of how to wear a mask appropriately. DON B stated that all staff should have been masking at the time. Signs and masks are available at the entrances to the unit. Staff are currently masking as a preventative measure in place as the facility had an outbreak a while ago, and they implement masking for 14 days following this.

Based on record review and interviews, the facility did not implement interventions to protect other residents from abuse by a resident (R) (R97) with a history of aggressive behaviors which resulted in a fall with fracture for 1 of 1 resident (R28) reviewed for falls. Findings include: The facility policy entitled Reporting & Investigating Resident Rights Violations, approved on: March 9, 2007, reads in part It is the intent and desire of [Then [sic] Neighbors of Dunn County] to provide resident care in a safe and professional manner and to avoid allegations of resident abuse or other misconduct. R97 was admitted [DATE] and has diagnoses that include Alzheimer's, depression, and anxiety disorder. Surveyor reviewed R97's Minimum Data Set (MDS) quarterly assessment dated [DATE]. The MDS documented R97 as having severely impaired cognitive skills for daily decision making and continuous behavior of inattention and disorganized thinking. R97 has delusions, physical and verbal behavioral symptoms directed toward others occurring one to three days and wandering occurring daily. Surveyor reviewed R97's Certified Nursing Assistant (CNA) care plan. Written on the bottom of the care plan is, Close supervision when angry to avoid res to res. dated 08/07/23. Surveyor reviewed R97's comprehensive care plan with the start date of 12/21/22 for anti-depressant medication. On 10/21/23, there was an update to the care plan for an increase in aggressive behaviors towards others. The comprehensive care plan did not document approaches or interventions to prevent R97 from abusing or having aggressive behaviors towards residents. Surveyor reviewed R97's chart for any history of abuse. On 05/15/23, R97 slapped and poked a female peer on left arm and left side. On 07/22/23, another resident accused R97 of hitting her across her face. R28 was admitted to the facility on [DATE] and has diagnoses that include neurocognitive disorder with Lewy bodies, neuroleptic induced parkinsonism, dementia, generalized anxiety disorder, and is unsteady on their feet. R28's Minimum Data Set (MDS) assessment indicated that R28 has a Brief Interview for Mental Status (BIMS) score of 00 which indicates that R28 has severe impairment. Surveyor reviewed an incident report involving R97 and R28 for a fall that happened on 08/04/23. Creator of the report is Registered Nurse (RN) G. The chronological description of the event reads: [Homemaker H] was in the kitchenette, she reports seeing [R28] and [R97] next to each other and when [R28] walked past [R97], [R97] reached out and grabbed [R28's] right arm with both hands and pulled down on [R28's] arm forcefully. [R28] staggered, losing their balance and fell backwards onto their right side/back. Further review of the incident report documented: Why did this occur stated, fell ow resident having behaviors. How did this occur, fell ow resident pulled on R28's arm. Outcome of the incident/accident/event, Fall resulted in injury to R28's right arm. Swelling and bruising noted. Other resident redirected and calmed. Surveyor reviewed R28's progress notes. On 08/04/23, a mobile x-ray was done, and it showed a possible fracture. R28 was sent to the ER for right shoulder pain and swelling and was diagnosed with a closed right humerus fracture. On 12/13/23 at 1:33 PM, Surveyor interviewed Nursing Home Administrator (NHA) A about investigation notes for the 08/04/23 incident and asked if they investigated this incident as abuse. NHA A indicated they do not have a formal investigation due to not believing it was an abuse situation. Surveyor asked NHA A what they did to protect the other residents on the household from R97 after these incidents. NHA A indicated for the 05/15/23 incident the residents were separated. Surveyor noted no interventions were put into place to protect all residents from R97. For the 07/22/23 incident, a cloth barrier was placed on the resident's door to deter R97 from entering the room. Surveyor noted that no interventions were put into place to protect all residents from R97. On 12/13/23 at 2:36 PM, Surveyor interviewed Director of Nursing (DON) B and asked what interventions were put into place to protect all residents from R97. DON B indicated that they redirected R97 and that R97 was already on 15-minute checks due to safety reasons, not due to aggression.

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; hand hygiene before meals was not offered for 10 of 43 residents (R) (R24, R14, R40, R12, R8, R36, R23, R197, R6, and R21) Findings include: A facility policy specific to resident hand hygiene was requested. Surveyor received the facility policy titled, Hand Washing, Hand Hygiene, not dated; it stated in part, The facility will utilize hand hygiene practices that assist in the decrease of infectious disease transmittal. On 12/12/23 at 11:38 AM, Surveyor observed coffee, water, and milk being served to residents seated in the dining room for lunch. No hand hygiene was given to residents R24, R14, R40, R12, R8, R36, R6, and R21. On 12/12/23 at 11:51 AM, Surveyor observed that no hand hygiene had been offered to residents R24, R14, R40, R12, R8, R36, R6, and R21 yet. On 12/12/23 at 11:53 AM, Surveyor observed utensils wrapped in a cloth napkin being handed out to R24, R14, R40, R12, R8, R36, R6, and R21. Residents were putting cloth napkins on their laps and rearranging utensils; no hand hygiene was observed being offered to residents. On 12/12/23 at 11:57 AM, Surveyor observed food being served, and no hand hygiene was given to residents R24, R14, R40, R12, R8, R36, R6, and R21; residents started eating. On 12/12/23 at 12:06 PM, Surveyor observed R197 and R23 entering the dining area for lunch. R23 was assisted in a wheelchair, and R197 used a walker and staff assistance to enter the dining area. Both residents were seated at the table; no hand hygiene was offered to either resident before receiving food and eating. On 12/12/23 at 1:02 PM, Surveyor interviewed Certified Nursing Assistant (CNA) D and CNA E about hand hygiene before lunch that day. CNA D said hand hygiene was in the back of their mind, but it did not get done. CNA E said that they do as residents wash hands in their rooms before coming to meals. Surveyor asked CNA E about the possibility of a resident who uses a wheelchair touching something dirty like their wheels or a resident touching a handrail. CNA E mentioned that most residents would prefer soap and water and that hand washing would be better than the hand wipes they have. On 12/13/23 at 11:07 AM, Surveyor interviewed Director of Nursing (DON) B regarding expectations of resident hand washing before meals. DON B said they would expect hand hygiene to be performed before every meal. DON B mentioned that they would not necessarily expect hand hygiene to be done only in the dining room, but they do have alcohol and hand wipes to be used in the dining room for the residents.

Based on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when a resident to resident abuse was not reported immediately but not later than 2 hours after the allegation is made, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law for 1 of 1 incidents with (R) R97 and R28 reviewed. Findings include: The facility policy entitled, Reporting & Investigating Resident Rights Violations Policy and Procedure, approved on March 9, 2007, reads in part Residents may be the intended or unintended recipients of abuse or the cause of abuse resident-to-resident abuse must also be reported immediately. R97 was admitted [DATE] and has diagnoses that include Alzheimer's, depression, anxiety disorder, and hypertensive heart disease. R97's Minimum Data Set (MDS) assessment indicated that R97 has a Brief Interview for Mental Status (BIMS) score of 00 which indicates that R97 has severe impairment. R28 was admitted to the facility on [DATE] and has diagnoses that include neurocognitive disorder with Lewy bodies, neuroleptic induced Parkinson's, dementia, generalized anxiety disorder, and is unsteady on their feet. R28's Minimum Data Set (MDS) assessment indicated that R28 has a Brief Interview for Mental Status (BIMS) score of 00 which indicates that R28 has severe impairment. On 12/13/23, Surveyor reviewed an incident report for a fall that happened on 08/04/23. Creator of the report is Registered Nurse (RN) G. The chronological description of the event reads, [Homemaker H] was in the kitchenette, she reports seeing [R28] and [R97] next to each other and when [R28] walked past [R97], [R97] reached out and grabbed [R28's] right arm with both hands and pulled down on [R28's] arm forcefully. [R28] staggered, losing their balance and fell backwards onto their right side/back. Further review of the incident report under why did this occur the report says, fell ow resident having behaviors. How did this occur, fell ow resident pulled on [R28's] arm. Outcome of the incident/accident/event, Fall resulted in injury to [R28's] right arm. Swelling and bruising noted. Other resident redirected and calmed. Surveyor reviewed R28's progress notes. On 08/04/23, a mobile x-ray was done, and it showed a possible fracture. R28 was sent to the ER for right shoulder pain and swelling and was diagnosed with a closed right humerus fracture. On 12/13/23 at 1:33 PM, Surveyor interviewed Nursing Home Administrator (NHA) A about investigation notes for the 08/04/23 incident and asked if they reported the incident to the police and state agency. NHA A indicated they did not report it as it wasn't aggressive action towards R28. Surveyor asked NHA A what they follow to determine if an incident needs to be reported. NHA A indicated they use the resident to resident altercation flowchart put out by the Department of Health Services/Division of Quality Assurance. Surveyor reviewed the incident report with NHA A that states R97 forcefully grabbed R28's arm pulling downwards and R28 staggered, losing balance, falling, and causing injury of a humerus fracture. Following the flowchart this would be a reportable incident.

Based on interviews and record review, the facility did not thoroughly investigate an incident of potential resident to resident abuse for 1 of 1 incident reviewed. Findings include: R97 was admitted [DATE] and has diagnosis that include Alzheimer's, depression, anxiety disorder and hypertensive heart disease. R97's Minimum Data Set (MDS) assessment, indicated that R97 has a Brief Interview for Mental Status (BIMS) score of 00 which indicates that R97 has severe impairment. R28 was admitted to the facility on [DATE] and has diagnoses that include neurocognitive disorder with Lewy bodies, neuroleptic induced Parkinson, dementia, generalized anxiety disorder, and is unsteady on their feet. R28's Minimum Data Set (MDS) assessment indicated that R28 has a Brief Interview for Mental Status (BIMS) score of 00 which indicates that R28 has severe impairment. On 12/13/23, Surveyor reviewed an incident report for a fall that happened on 08/04/23. Creator of the report is Registered Nurse (RN) G. The chronological description of the event reads, [Homemaker H] was in the kitchenette, she reports seeing [R28] and [R97] next to each other and when [R28] walked past [R97], [R97] reached out and grabbed [R28's] right arm with both hands and pulled down on [R28's] arm forcefully. [R28] staggered, losing their balance and fell backwards onto their right side/back. Further review of the incident report under why did this occur the report says, fell ow resident having behaviors. How did this occur, fell ow resident pulled on [R28's] arm. Outcome of the incident/accident/event, Fall resulted in injury to [R28's] right arm. Swelling and bruising noted. Other resident redirected and calmed. No further resident to resident abuse investigation information was documented. Surveyor reviewed R28's progress notes. On 08/04/23, a mobile x-ray was done, and it showed a possible fracture. R28 was sent to the ER for right shoulder pain and swelling and was diagnosed with a closed right humerus fracture. On 12/13/23 at 1:33 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked if the facility did a resident to resident abuse investigation on the incident. NHA A indicated there was no investigation, just an incident report as it wasn't aggressive action towards R28.

Based on observation, interview and record review, the facility did not develop a comprehensive person-centered care plan that reflected resident care and needs related to urinary catheters for 1 of 3 residents (R) with catheters. (R22) Findings include: R22 was admitted to the facility on [DATE] with the following diagnoses, in part: paraplegia, chronic kidney disease stage 2, neuromuscular dysfunction of bladder, and retention of urine. On 12/11/23 at 11:53 AM, Surveyor observed R22 in a chair in her room with a urinary drainage bag hanging from the side of the chair. R22 said they had a suprapubic catheter, but it fell out and could not be re-inserted. R22 stated they put a regular Foley catheter in until they can get in to the urologist to have the suprapubic catheter replaced. Surveyor reviewed R22's medical record and identified R22 had a suprapubic catheter placed in June of 2023. Surveyor reviewed R22's comprehensive care plan and identified a bowel and bladder care plan that was initiated on 09/28/22. The care plan stated the following, in part: Bladder: -Both continent and incontinent of bladder Resident is at increased risk for incontinence r/t [related to]: -limited mobility, non-ambulatory-requires hoyer lift for transfers .-paraplegia-receives diuretic and antidepressant medication .-dx [diagnosis] mixed urinary incontinence-hx [history] urinary retention . The bowel and bladder care plan problem had the following interventions, in part: .Assess for type of absorbent disposable product and measure for correct size. Assist to the bathroom as needed. Assist with perineal care and disposable absorbent product as needed .Provide well lit, clear path to bathroom or commode and easy access to devices such as urinal or bed pan . The bowel and bladder care plan made no reference to R22 having a suprapubic catheter placed in June and also no reference to the temporary placement of an indwelling Foley catheter after the suprapubic catheter was dislodged. There was no other problem on R22's comprehensive care plan related to a suprapubic or Foley catheter. On 12/12/23 at 1:03 PM, Surveyor interviewed Director of Nursing (DON) B and asked if R22 had a care plan related to the suprapubic catheter or the temporary placement of the indwelling Foley catheter. DON B provided Surveyor with a copy of the bowel and bladder care plan which had a hand written note, dated 06/02/23, that said suprapubic, and another hand-written note below that, dated 06/13/23, that said suprapubic. The words from the original problem under Bladder and incontinent of bladder were crossed off. There were no updates or additions to the care plan interventions related to suprapubic or indwelling Foley catheter. Surveyor asked DON B if this was an individualized care plan that reflected R22's status of having a suprapubic catheter and then a temporary indwelling Foley catheter. DON B stated somehow the notes about the suprapubic catheter got dropped from the bowel and bladder care plan in the electronic medical record. Surveyor asked DON B if the approaches on R22's bowel and bladder care plan were generic and not individualized to reflect that R22 had a urinary catheter. DON B agreed this was a standardized care plan and not individualized to reflect R22's current status. DON B stated the comprehensive care plan would be updated to include a problem related to R22's urinary catheter.

Based on interview and record review, the facility did not ensure a resident with a dementia diagnosis had a Gradual Dose Reduction (GDR) of psychotropic medications in the past year. This occurred for 1 of 5 residents (R) reviewed for unnecessary medications. (R26) Findings include: According to the American Psychiatric Association patients with dementia who show adequate response of behavioral/psychological symptoms to treatment with an antipsychotic drug, an attempt to taper and withdraw the drug should be made within 4 months of initiation, unless the patient experienced a recurrence of symptoms with prior attempts at tapering of antipsychotic medication. (The American Journal of Psychiatry, May 2016) R26 was admitted to the facility on [DATE] with the following diagnoses, in part: unspecified dementia with mood disturbance and anxiety, unspecified mood disorder, major depressive disorder single episode, anxiety disorder, dementia with psychotic disturbance, visual hallucinations. Record review identified R26 had the following psychotropic medication orders: Clonazepam (antianxiety medication) 0.5 mg (milligrams) twice per day for anxiety. Escitalopram (antidepressant) 10 mg daily for negative statements, sad facial expression, and crying. Olanzapine (anti-psychotic medication) 7.5 mg daily at bed time for hallucinations. R26's most recent Minimum Data Set (MDS) assessment, dated 10/07/23, identified R26 had a Brief Mental Status Score (BIMS) of 10 which means R26 had moderate cognitive impairment. The PHQ-9 score (depression indicator) was 00. The MDS assessment also identified R26 had no hallucinations or delusions and exhibited no behaviors during the assessment period. Surveyor reviewed the MDS assessments for the past year and all of the assessments identified R26 had no hallucinations or delusions and exhibited no behaviors. Surveyor reviewed the behavior monitoring documentation on R26's medical record from 10/01/23 to 12/13/23. The behavior monitoring documentation showed R26 had no behaviors. Surveyor reviewed the nursing progress notes on R26's medical record for the past year and did not identify any documentation describing any hallucinations or behaviors. The documentation did identify R26 had some intermittent anxiety. On 12/12/23 at 10:35 AM, Surveyor interviewed Registered Nurse (RN) I and asked if R26 had any behaviors or hallucinations or delusions. RN I stated they had never observed any hallucinations or delusions and was not aware of R26 ever having any hallucinations or behaviors. RN I stated R26 occasionally had trouble with anxiety. Surveyor identified a Note To Attending Physician/Prescriber dated 12/21/22 from the consultant pharmacist that said, [R26] is taking the following medication, Zyprexa [olanzapine] and Clonazepam. Routine assessment of this medication to ensure positive outcomes and avoid the use of unnecessary medications is recommended. PLEASE CONSIDER THE FOLLOWING: Review the above psychotropic medication for appropriateness. Consider a gradual dose reduction if clinically indicated. If therapy is to continue, it is recommended that the prescriber document an assessment of risk versus benefit, indicating that is continues to be a valid therapeutic intervention for this individual. The prescriber checked the box Disagree and wrote a note stating See Dictation. The physician dictation note dated 12/21/22 stated, in part, .We received a note from pharmacy regarding her Zyprexa and clonazepam. She takes Zyprexa 7.5 mg at bedtime. This has helped reduce nighttime hallucinations. Her clonazepam is 0.5 mg twice daily, which is helpful for her anxiety. She would like that clonazepam dose increased, which I do not this is appropriate. However, I do not think a dosage decrease should be attempted at this time, as her hallucinations, anxiety, and restless legs all seem to be under reasonable control at this time. On 12/13/23 at 11:15 AM, Surveyor interviewed Director of Nursing (DON) B and asked since the documentation showed R26 was not having any behaviors, delusions, or hallucinations in the past year, did they attempt a GDR of R26's psychotropic medications since the prescriber declined a GDR of those medications a year ago. DON B stated the providers had reviewed R26's psychotropic medications several times over the past year and decided it was not a good idea to try a GDR of any of the psychotropic medications. DON B stated they would look for rationale from the provider why a GDR was clinically contraindicated. On 12/13/23 at 12:43 PM, DON B provided a few progress notes that mentioned R26 had anxiety and one note that mentioned phantom music. None of the documentation described any disturbing hallucinations that would make a GDR of antipsychotic medication clinically contraindicated. Surveyor asked DON B since the documentation over the past year did not show any behaviors or hallucinations that would make a GDR of psychotropic medications clinically contraindicated, was there a rationale for not attempting a GDR. DON B stated they would address this with the provider.

Based on observations, record review and interviews, the facility did not prevent untrained staff from feeding residents (R27 and R31) for 2 of 2 observations. This is evidenced by: Surveyor reviewed R31's medical record. Current diagnoses include dementia and Parkinson's disease. Review of Minimum Data Set (MDS) quarterly assessment with the review date of 10/06/23, documented R31 as being dependent on staff to assist with meals. Surveyor reviewed R27's medical record. Current diagnoses include non-traumatic brain dysfunction and dementia. Review of MDS quarterly assessment with the review date of 11/11/23, documented R27 needing partial to moderate assistance from staff with meals. On 12/13/23 at 8:12 AM, Surveyor observed Homemaker C give R31 a bite of their eggs. On 12/13/23 at 8:14 AM, Surveyor observed Homemaker C sitting next to resident R31 giving them bites of their breakfast again. On 12/13/23 at 8:27 AM, Surveyor observed Homemaker C give R27 a bite of their breakfast. On 12/13/23 at 11:38 AM, Surveyor interviewed Director of Nursing (DON) B and asked if they employed paid feeding assistants. DON B indicated they do not. Surveyor then asked DON B if homemakers are allowed to assist with feeding residents. DON B indicated no. Surveyor asked if there was any policy on who is allowed to assist residents with eating. DON B indicated they did not know but will check. DON B came back to the conference room and indicated there was no policy that they could find.

Based on observation, interview and record review, the facility did not ensure a resident received adequate supervision and assistance to prevent accidents. No smoking safety assessment was completed and no smoking safety care plan developed for 1 of 1 residents (R) reviewed for smoking. (R6) Findings include: Facility Policy and Procedure entitled, Resident and Visitor Smoking Policy, last revised 10/16/13, stated in part, .The interdisciplinary team of The Neighbors which directs the individual resident's plan of care will make the determination if individual residents are able to smoke independently or not .: R6 was admitted to the facility on [DATE] with a diagnosis of multiple sclerosis. R6's most recent Minimum Data Set assessment, dated 09/03/22, identified R6's short and long term memories were okay. The assessment also indicated R6 was independent with decision-making and made consistent and reasonable decisions regarding tasks of daily living. The assessment identified R6 required set up only for locomotion off the unit and did not demonstrate any wandering behaviors. On 11/01/22 at 9:36 AM, Surveyor interviewed R6 who reported they smoke occasionally. R6 stated when they wanted to smoke, staff assisted them to get into power wheelchair, gave R6 a cigarette, assisted R6 to exit the building, lit the cigarette, and R6 was then required to leave the facility grounds to smoke. R6 rang the doorbell when done smoking, and staff assisted them back into the building. Surveyor asked if any staff had assessed R6 for safety with smoking independently. R6 did not remember anyone doing a safety assessment. Surveyor reviewed R6's medical record and did not identify a smoking safety assessment or a smoking safety care plan. On 11/02/22 at 7:45 AM, Surveyor interviewed Assistant Clinical Mentor (ACM) C about their smoking policy. ACM C stated they are technically a non-smoking facility, but if a resident wanted to smoke they were required to smoke off the campus grounds. Surveyor asked if they did a smoking safety assessment for R6 to determine they were safe to smoke independently off campus grounds. ACM C stated they used to do smoking safety assessments, but was not sure if an assessment was done recently for R6. ACM C stated they would look in R6's medical record for a smoking safety assessment. On 11/02/22 at 1:22 PM, ACM C informed Surveyor they could not find a smoking safety assessment on R6's medical record. ACM C stated they did one today and determined R6 was safe to smoke independently. Surveyor asked ACM C if they had a safe smoking plan on R6's comprehensive plan of care. ACM C stated they did not have a safe smoking care plan in place for R6, but they should probably add one.

Based on observation, staff interview and record review, the facility did not store and distribute food in accordance with professional standards for food service safety. This has the potential to affect 29 (13 residents in the Red Cedar Lodge Unit and 16 residents in the Even Tide Unit) of the 43 residents residing in the facility. Red Cedar Lodge household kitchenette had expired ready to eat food items that were available to be consumed by 13 residents that resided in the household. Even Tide household kitchenette had five expired food items stored in the cupboard that were available to be prepared and consumed by the 16 residents that resided in the household. This is evidenced by: On [DATE] at 3:30 PM, Surveyor opened the Red Cedar Lodge kitchenette refrigerator and viewed Ziploc packages of sliced cheese, ham and turkey in the lower drawer that had dates written on them from [DATE] - [DATE]. This included: One package of ham dated ,[DATE], one package of ham dated ,[DATE] and one package of turkey dated ,[DATE]. It is a standard of practice for food service safety to discard repackaged, ready to eat food items within 5 days of the date written on the package. There is a potential for this to affect 13 of the 13 residents residing in the Red Cedar Lodge unit. There were no staff present at time of discovery. This observation ended on [DATE] at 3:40 PM. On [DATE] at 4:00 PM, Surveyor entered the Red Cedar Lodge kitchenette. Certified Nursing Assistant (CNA) C was present. Surveyor asked CNA C how long sandwich meat and cheese can be refrigerated in Ziploc bags before being discarded. CNA C said three days and then said some foods are good for six days. CNA C said if food had a date more than three days, it would get thrown out. Surveyor encouraged her to check the dates on the food items in the refrigerator. CNA C removed one package of cheese dated ,[DATE], one package of cheese dated ,[DATE] and one package of ham marked ,[DATE]. On [DATE] at 4:05 PM, the Assistant Director of Nursing (ADON) A came to the Red Cedar Lodge kitchenette. CNA C and Surveyor were present. Surveyor told ADON A there were foods in the refrigerator that had dates of ,[DATE], ,[DATE] and ,[DATE]. The DON said that outdated food has to be thrown out when it reaches the out date. This observation ended on [DATE] at 4:10 PM. On [DATE] at 7:15 AM, Surveyor interviewed Dietary Manger (DM) B. DM B said they are working on a process to prevent having outdated foods in neighborhood refrigerators. DM B said they rely on the CNAs and homemakers and are going to have to come up with a better plan for rotating the food and checking dates to prevent this from happening again. DM B said all the refrigerators in the neighborhoods were checked for outdated foods yesterday afternoon and any outdated foods were removed. This interview was completed on [DATE] at 7:20 AM. On [DATE] at 7:30 AM, Surveyor checked the refrigerator in the Red Cedar Lodge kitchenette. There were no expired food products in the refrigerator. On [DATE] at 1:14 PM, Surveyor interviewed DM B and Dietician D. Surveyor requested a list of all residents residing in the Red Cedar Lodge who could have potentially eaten the outdated cheese, ham and turkey found in the Red Cedar Lodge kitchenette on [DATE]. Surveyor requested a copy of the facility policy for storage of foods. DM B and Dietician D agreed to locate this information for the surveyor. On [DATE] at 2:40 PM, DM D provided a list of residents in the Red Cedar Lodge with the potential to be affected if they had eaten the out of date food in the Red Cedar Lodge refrigerator. The list included 13 of 13 residents who reside in the unit. On [DATE] at 2:40 PM, DM D provided the(NAME)County Healthcare Center Policy and Procedure for Food Storage (in file). The policy included: Old stock is always used first (first in - first out method .food .should be used within ,[DATE] days, or as labeled, or discarded. Dates to be checked before food handling and serving. On [DATE] at 11:01 a.m., Surveyor reviewed Even Tide household kitchenette and observed in the cupboard expired foods that were available to be prepared and consumed by the 16 residents. ~ Two boxes of gluten free yellow cake mix with the expiration date of [DATE] and [DATE]. ~ Two boxes of Moist Classic Angel Food fat free cake mix with the expiration date of [DATE] and [DATE]. ~ One box of gluten free pancake mix with the expiration date of [DATE]. On [DATE] at 1:14 p.m., Surveyor and the training Surveyor reviewed with Dietary Manager (DM) B and Registered Dietician (RD) D the observations of expired food. DM B indicated a new training of dating food items will be provided to staff.

Based on interview, medical record review and facility policy review, the facility did not ensure 5 of 11 residents were appropriately assessed for and care planned for hydration needs. Resident #3, #8, #10, #4 and #1. 1. Residents #3, #8, #10, #4 and #1 had risk factors for dehydration. The residents did not have care plans to address the risk or identify interventions to prevent dehydration. This is evidenced by: 1. On 08/22/16 beginning at 8:30 a.m., Assistant Clinical Mentor (ACM) A provided Surveyor with information about the residents, including Resident #3. ACM A told Surveyor that Resident #3 has had declines in her status. On 08/22/16, Surveyor began review of Resident #3's medical record and identified Resident #3 has [DIAGNOSES REDACTED]. Resident #3 also has had weight loss and currently has a pressure injury to her coccyx and upper buttocks. These [DIAGNOSES REDACTED]. Surveyor read a Dehydration Risk Observation assessment, dated 04/29/16. This assessment scored Resident #3 at 0-2, No/Low Risk for dehydration. On 08/23/16, Surveyor reviewed Resident #3's care plan and noted a problem with the start date of 02/15/16, that read Resident is at risk for dehydration R/T (related to) recent UTI (urinary tract infection) and moderate risk per facility assessment. With the Long Term Goal Target Date: 05/15/16. And Resident will not exhibit signs of dehydration. A handwritten date of 08/17/16 was below this goal. All approaches were dated 02/15/16. Surveyor requested a more recent Dehydration Risk Observation assessment. On 08/24/16, Surveyor was informed one had not been done since the 04/29/16 date. Surveyor reviewed Resident #3's vitals report that contained documentation of Resident #3's urine output and some entries for fluid intake. These are not recorded consistently. Surveyor noted Resident #3 was placed on a 1000 ml (milliliter) per day fluid restriction on 06/25/16 and this was discontinued on 07/07/16. Surveyor reviewed Resident #3's fluid intake and output documentation for those dates and noted intake documented ranged from 480 ml, 600 ml per day to 1000 ml per day. Surveyor was unable to find documentation of Resident #3's fluid intakes being totaled for each day while Resident #3 was on the fluid restriction. On 08/23/16 at 7:58 a.m., Surveyor asked Dietician D if staff track Resident #3's fluid intake and output due to her dehydration risk, decrease in kidney function and having the catheter. Dietician D said, it depends. At 1:03 p.m., Dietician D followed up with Surveyor and said intake and outputs are done if a resident is at high risk for dehydration. They should have done intake and output tracking during the time Resident #3 was on the fluid restriction, that is our practice. On 08/24/16 at 8:42 a.m., Surveyor shared the above concerns with ACM A and Dietician B. Surveyor asked who was responsible to total intake and outputs and to review these to ensure Resident #3 was receiving the correct amount of fluids. Surveyor was informed by ACM A, no one totals the intake and output on a daily basis or reviews daily intakes routinely. The nurses would be monitoring her for symptoms of dehydration. 2. On 08/23/16, Surveyor began review of Resident #8's medical record and identified Resident #8 was admitted [DATE]. Resident #8 has [DIAGNOSES REDACTED]. The facility policy directs new admissions are to have their intake and output tracked and documented every shift for seven days. Review of Resident #8's intake and output records contained in the vitals report starting 06/29/16, had no fluid intake recorded for 06/29/16. 06/30/16: 9:46 a.m.-Supplements 120 ml (milliliter) Amount (consumed) 76-100% 12:36 p.m.-Supplements 120 ml Amount 76-100% 1:08 p.m.-Fluids 240 ml 5:47 p.m.-Supplements 120 ml Amount 76-100% The facility does not calculate a total amount of fluid intake per day. Based on the fluid intakes recorded, Surveyor totaled the following documented intakes. Surveyor identified Resident #8 consumed 600 ml of fluid on 06/30/16. 07/01/16: 5:50 a.m.-Fluids 60 ml 8:45 a.m.-Fluids 120 ml 12:15 p.m.-Fluids 60 ml 1:41 p.m.-360 ml A total of 600 ml documented. 07/02/16: 9:15 a.m.-Fluids 120 ml 10:35 a.m.-Fluids 240 ml A total of 360 ml documented. 07/03/16: 9:20 a.m.-Fluids 120 ml 2:13 a.m.-Fluids 600 ml A total of 720 ml documented. 07/04/16: 7:46 a.m.-Supplements 100 ml 12:47 p.m.-Supplements 60 ml A total of 160 ml documented. 07/05/16: No fluid intake was documented. 07/06/16: 8:45 a.m.-Fluids 120 ml 1:09 p.m.-Fluids 360 ml A total of 480 ml was documented. Resident #8's Nutritional Assessment Worksheet dated 07/11/16, signed by Dietician B, listed Resident #8's estimated fluid intake needs at 1050 ml. On 08/24/16 at 9:35 a.m., during an interview with ACM A, Surveyor 6 asked about Resident #8's intake documentation. ACM A said the CNAs document intakes for one week. Surveyor showed ACM A Resident #8's first week of admission intake and output records and pointed out, it looked like intakes were not being documented consistently or Resident #8 was consuming little fluids. ACM A said the nurses don't always document what they give. Surveyor asked ACM A if fluid intakes would be documented anywhere else. ACM A said the nurses would sign on the med sheet that they gave a supplement with med pass but they may not think of documenting it for fluid intake. Surveyor asked if anyone does a daily total of intakes and outputs. ACM A said no. Surveyor asked how they get an accurate picture of what the resident is taking in. ACM A stated the nurses assess for signs and symptoms of dehydration and notice at the meal table. On 08/23/16 at approximately 3:20 p.m., the Director of Nursing (DON) was asked if intakes and outputs are documented separately by nurses and Certified Nursing Assistants (CNAs). The DON said, No, it's combined. The above fluid intake documentation entries were made by nurses and CNAs. A Dehydration Risk Observation document completed 06/29/16, for Resident #8, assessed Resident #8 as being 3-7 = Moderate Risk - Proceed to Care Plan with potential or actual risk for dehydration. On the morning of 08/24/16, Surveyor read Resident #8's care plan and found no dehydration risk care plan, or dehydration risk addressed in Resident #8's care plan other than under Resident #8's Impaired Skin Integrity care plan problem listed risk factors for skin integrity of .mixed incontinence, decreased mobility, decreased appetite and decreased fluid intake . Approaches under this problem included NUTRITION: See Nutritional Care Plan. Resident #8's Imbalanced nutrition care plan contained the following approaches: Document and report refusal of meals/liquids. And Encourage oral intake of food and fluids. Resident #8's care plan did not contain specific individualized approaches for Resident #8 on how to promote adequate fluid intake. Surveyor reviewed Resident #8's Master Assignment Sheet, also referred to as Resident #8's CNA care plan, and noted this did not identify Resident #8 was at risk for dehydration or interventions/approaches CNAs should utilize to prevent dehydration for Resident #8. On 08/24/16 at 8:35 a.m., Surveyor shared the above concerns with Dietician B and asked her to look for a dehydration risk care plan for Resident #8. Dietician D looked at Resident #8's care plan and stated I don't find one either. On 08/24/16 at 9:25 a.m., Surveyor spoke with ACM A and showed her the Dehydration Risk assessment and where it read proceed to care plan and that Surveyor could not find a care plan with individualized approaches for Resident #8 related to her moderate dehydration risk. ACM A also looked at Resident #8's care plan and did not locate this information. 3. On 08/23/16, Surveyor reviewed Resident #10's medical record. Resident #10 has [DIAGNOSES REDACTED]. Resident #10's most recent Brief Interview for Mental Status (BIMS) score, dated 07/15/16, is a 03 out of 15 possible points, indicating severe cognitive impairment. Surveyor reviewed Resident #10's most recent Dehydration Risk Assessment, dated 07/10/16. The assessment indicates the resident is at moderate risk for dehydration. The assessment states in part, .Moderate Risk-Proceed to Care Plan with potential or actual risk for dehydration . Resident #10's comprehensive care plan states the following, in part: Problem Start Date: 04/25/2016 Resident has need for adequate fluid intake .assessed at moderate risk for dehydration per facility assessment . Goal Target Date: 10/26/16 Resident will not exhibit signs of dehydration . Approach Start Date: 04/25/2016 Assess for dehydration (dizziness on sitting/standing, change in mental status, decreased urine output, concentrated urine, poor skin turgor, dry, cracked lips, dry mucus membranes, sunken eyes, constipation, fever, infection, electrolyte imbalance) .Assess risk factors for dehydration .Avoid/limit fluids with a diuretic effect ( .coffee, tea, caffeinated pop/soda) .Encourage fluids daily. Offer a variety of fluids, juices, gelatins, soups .Report abnormal labs indicative of dehydration .Weigh resident. The care plan does not identify Resident #10's individual risk factors for dehydration, including [DIAGNOSES REDACTED]. 4. On 08/22/16, Surveyor reviewed Resident #4's medical record. Resident #4 has [DIAGNOSES REDACTED]. Resident #4's most recent BIMS score, dated 07/08/16, is a 10 out of 15 possible points. According to the BIMS assessment, indicating moderately impaired cognitive function. Surveyor reviewed Resident #4's most recent Dehydration Risk Assessment, dated 07/06/16. The assessment indicates the resident is at moderate risk for dehydration. The assessment states in part, .Moderate Risk-Proceed to Care Plan with potential or actual risk for dehydration . Resident #4's comprehensive care plan states the following, in part: Problem Start Date: 01/18/2016 Category: Dehydration/Fluid Maintenance. Resident needs adequate fluids to help with constipation Goal Target Date: 10/19/16 Resident will not exhibit signs of dehydration . Approach Start Date: 01/18/2016 Assess for dehydration (dizziness on sitting/standing, change in mental status, decreased urine output, concentrated urine, poor skin turgor, dry, cracked lips, dry mucus membranes, sunken eyes, constipation, fever, infection, electrolyte imbalance) .Assess risk factors for dehydration .Assist with fluids as needed .Avoid/limit fluids with a diuretic effect ( .coffee, tea, caffeinated pop/soda) .Encourage fluids. Offer a variety of fluids, juices, gelatins, soups, popsicles .Keep fluids accessible .Report abnormal labs indicative of dehydration .Weigh resident. The care plan does not identify Resident #4's individual risk factors for dehydration, including [DIAGNOSES REDACTED]. 5. On 08/22/16, Surveyor reviewed Resident #1's medical record. Resident #1 has [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS), dated [DATE], identifies Resident #1 requires assistance from staff for eating and drinking, and has range of motion limitations on both sides of the upper body. The MDS identifies Resident #1 has short and long term memory problems, and has severely impaired decision making abilities. Surveyor reviewed Resident #1's most recent Dehydration Risk Assessment, dated 05/30/16. The assessment indicates the resident is at moderate risk for dehydration. The assessment states in part, .Moderate Risk-Proceed to Care Plan with potential or actual risk for dehydration . Resident #1's comprehensive care plan states the following, in part: Problem Start Date: 05/30/16 Resident is at risk for dehydration R/T (Related To) increased risk per facility assessment . Goal Target Date: 09/14/16 Resident will not exhibit signs of dehydration . Approach Start Date:12/14/2015 Assess for dehydration (dizziness on sitting/standing, change in mental status, decreased urine output, concentrated urine, poor skin turgor, dry, cracked lips, dry mucus membranes, sunken eyes, constipation, fever, infection, electrolyte imbalance) .Assess risk factors for dehydration .Assist with fluids as needed. 6/14/16 .Avoid/limit fluids with a diuretic effect ( .coffee, tea, caffeinated pop/soda) .Encourage fluids daily. Offer a variety of fluids, juices, gelatins, soups .Report abnormal labs indicative of dehydration .Weigh resident. The care plan does not identify Resident #1's individual risk factors for dehydration, including diagnoses, physical limitations, and cognitive impairments. The care plan does not identify individual interventions used to prevent dehydration. On 08/23/16 at 12:45 p.m., Surveyor interviewed Dietician B. Dietician B stated she assessed each resident's daily fluid needs on an annual basis. Dietician B stated a resident's daily fluid intakes are documented if a resident is not drinking much or has signs and symptoms of dehydration. Dietician B stated she completes the dehydration section of each resident's care plans. On 08/24/16 at 10:31 a.m., Surveyor interviewed ACM A. Surveyor and ACM A discussed the absence of individualized interventions to prevent dehydration, on the resident's care plans. ACM A indicated she will have to review the resident's care plans.

Based on observation and interview, the facility did not promote care for residents in a manner which maintains or enhances each resident's dignity and respect, in full recognition of his or her individuality. This occurred for one of four supplemental residents (Resident #14). 1. A staff member mimicked Resident #14's behavior and engaged in personal conversation during a meal in front of other residents. 2. A staff member referred to residents who require assistance with dining as feeders. This is evidenced by: 1. On 08/24/16 at 8:08 a.m., Surveyor observed the breakfast meal on the dementia unit. At 8:21 a.m., Residents #12, 13, and 14 were seated at a table in the dining room. Certified Nursing Assistants (CNAs) C and D were seated at the same table to assist the residents. CNA D was seated between Residents #13 and #14. At 8:26 a.m., Surveyor heard CNA D telling CNA C about a resident who was previously attempting to drink from the bottom of a cup, and the resident was spilling the drink on her (Resident #14). At this time, CNA D held up Resident #14's cup, and pointed to the bottom of it, indicating the location from which resident was attempting to drink. CNA D then set the cup back on the table, looked at Resident #14 and stated this was why the CNA had to sit next to the resident during meals. Resident #13 was observed to be laughing at this time. There was one other CNA and nine other residents present in the dining room at this time. At 8:45 a.m., Surveyor heard CNAs C and D discussing CNA D's mortgage and interest rates. The CNAs were not engaging in conversation with the residents. On 08/24/16 at 10:31 a.m., Surveyor interviewed the Assistant Clinical Mentor (ACM) A, and the above observations were discussed. ACM A stated CNA D's comments regarding Resident #14, and discussing a personal mortgage in front of the residents, were not appropriate. On 08/23/16 at 8:00 a.m., Surveyor was waiting to observe Resident #1's morning cares. CNA D said to Surveyor , We will get her up after breakfast. We got our feeders all set up and we will feed them; then after breakfast we will get her up. CNA D referred to residents that need assistance with dining as feeders.

Based on interview, medical record review and policy review, the facility did not ensure measures were followed to monitor residents for acceptable parameters of nutritional status, including comprehensive assessments of weight loss and comprehensive individualized care plans related to weight loss for 2 of 6 residents (Resident #3 and #4) reviewed for weight loss. 1. Resident #3 experienced weight loss. Resident #3's weights were not being done consistently per facility policy and a comprehensive individualized care plan addressing weight loss was not in place. 2. Resident #4 has a physician's orders [REDACTED]. Resident #4 was not consistently weighed per the physician's orders [REDACTED]. This is evidenced by: The 09/09/15 facility policy titled Referral for Nutritional Assessment contained an attachment that read in part: Weights and Heights should be obtained on admission Weights should than (sic) be continued for three days to determine accuracy/baseline. If stable, weights should be obtained weekly thereafter. In some cases, monthly is acceptable. If a weekly or monthly weight is refused by the resident, then this should be charted and it should be attempted the next day and day after that until obtained. A refused weight does not mean you wait until the next weekly weight. If a weight shows an alert when charted, report this to the nurse. The weight should also be rechecked the next day to ensure accuracy. The nurse should send a nutrition referral for and weight alert and it will be investigated by the RD (Registered Dietician) and followed up. 1. On 08/22/16, beginning at 8:30 a.m., Assistant Clinical Mentor (ACM) A made Surveyor aware that Resident #3 has had declines in status, has had weight loss and has an open area (pressure injury) on her coccyx. On 08/22/16, Surveyor began review of Resident #3's medical record and identified Resident #3's weight on the 11/05/16 quarterly Minimum Data Set (MDS) assessment was listed as 157 pounds. No weight loss was identified on this MDS. -The annual MDS, dated [DATE], listed Resident #3's weight as 145 pounds. Weight loss was identified on this MDS. -The quarterly MDS, dated [DATE], listed Resident #3's weight at 150 pounds. No weight loss identified. Resident #3 had a gain from the previous annual MDS. -The quarterly MDS, dated [DATE], listed Resident #3's weight at 138 pounds. This MDS identified no weight loss because the 12 pound loss did not meet the MDS criteria for weight loss of 5% or more in the last month or 10% or more in the last six months. Surveyor reviewed Resident #3's care plan for the weight loss and noted the care plan problem for impaired skin integrity and potential for impaired skin integrity, dated 02/10/16, read in part, Recent weight loss, decreased appetites. An approach dated 02/10/16 read, NUTRITION: See Nutritional Care Plan. Surveyor was unable to locate a Nutrirional Care Plan for Resident #3. On 08/24/16 at 8:42 a.m., during an interview with ACM A, Surveyor explained she could not locate a nutrition care plan in Resident #3 medical record. ACM A said it's addressed under the Resident #3's Fluctuations in blood glucose care plan. Surveyor read this care plan problem and noted this care plan read: Fluctuations in bld (blood) glucose levels secondary to DM (diabetes mellitus) R/T: -changes in nutritional intake/appetite/activity. -acute/chronic illness -drug interactions or medication side effects -change in activity/exercise level -wound healing -recent significant weight loss. The Long Term Goal Target Date was 05/15/16. The goal read Blood sugar levels will remain within parameters (desired range: 79-125 before meals, 70-200 1.5-2 hrs (hours) postprandially). There was a hand written date of 08/17/16 under this goal. There were no goals related to Resident #3's weight. Approaches were all dated 02/15/16 and primarily pertained to Resident #3's diabetes. One approach section read Consult with dietitian regarding resident's personal likes/dislikes and nutritional/metabolic needs. Offer high calorie supplements to stabilize weight. Provide HS (hour of sleep) snack as ordered/needed to maintain nighttime blood glucose. Resident #3's care plan problem start date of 02/15/16, and redated 05/01/16, Resident is at risk for dehydration R/T recent UTI (urinary tract infection) and moderate risk per facility assessment care plan included an approach dated 02/15/16, that read Weigh resident. It does not identify the frequency weights are to be done. Resident #3's Master Assignment Sheet read in part Wt (weight): Wed (Wednesday) AM weekly. This approach was not dated. Surveyor reviewed Resident #3's weights from 01/06/16 to 08/17/16 and noted the following weights were documented: (In pounds) 01/06/16 - 152.6 02/03/16 - 144.8 04/01/16 - 147.6 04/06/16 - 149.8 06/14/16 - 142.6 06/20/16 - 136 06/29/16 - 141.6 07/06/16 - 139.8 07/13/16 - 139.0 07/20/16 - 134.2 07/27/16 - 138.2 08/03/16 - 138 08/17/16 - 137.4 No weights were recorded for the month of March or May 2016. Resident #3 was not consistently weighed weekly. When weight loss occurred from month to month or week to week, no re-weights were completed the following day. There was no documentation of Resident #3 refusing to be weighed. Surveyor had asked ACM A and Dietician B to see if they were able to locate weights for the two months that were missing. During the interview with ACM A and Dietician B on 08/24/16 at 8:32 a.m., Surveyor was told no further weights were found for Resident #3. Dietician B said her weights were being done monthly before 06/27/16. After that they were being done weekly. 2. On 08/22/16, Surveyor reviewed Resident #4's medical record. Resident #4's physician order, dated 01/06/16, states, WEIGHT WEEKLY R/T (Related To) RECENT WEIGHT LOSS. Surveyor reviewed the documented weights in Resident #4's medical record and found the following: -01/20/16 to 02/10/16: Twenty-one days without a documented weight -03/29/16 to 04/14/16: Sixteen days without a documented weight -04/26/16 to 05/10/16: Fourteen days without a documented weight -05/10/16 to 05/20/16: Ten days without a documented weight -05/24/16 to 06/02/16: Nine days without a documented weight -06/02/16 to 06/14/16: Twelve days without a documented weight -06/21/16 to 07/03/16: Twelve days without a documented weight -07/19/16 to 08/02/16: Fourteen days without a documented weight -08/02/16 to 08/16/16: Fourteen days without a documented weight The facility is not consistently weighing the resident weekly, per the physician's orders [REDACTED].>Resident #4's weight loss from January 2016 to present is documented by the following, in part: -01/19/16: 135.8 pounds (lbs) -04/14/16: 132.6 lbs -06/21/16: 129.2 lbs -08/16/16: 128.1 lbs On 08/23/16 at 12:45 p.m., Surveyor interviewed Dietician B. Dietician B stated additional weights for Resident #4 may be documented in the resident's Medication Administration Record (MAR), or in the resident's nurses' notes. Dietician B stated she will review Resident #4's MAR and nurses' notes, and provide the surveyor with any additional weights. No additional information was provided to the surveyor. Surveyor reviewed Resident #4's nurses' notes and the MAR, from 01/06/16 to 08/22/16. No other weights were documented in these records. On 08/24/16 at 10:31 a.m., Surveyor interviewed ACM A, who stated Resident #4's physician's orders [REDACTED].

Based on interview and record review, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, for one of eleven sampled residents (Resident #10). Resident #10 has a physician's orders [REDACTED]. The facility was not consistently weighing the resident weekly. This is evidenced by: Resident #10's physician order, dated 02/01/16, states, WEIGHT WEEKLY R/T (Related To) [MEDICAL CONDITION] w/ (with) [MEDICAL CONDITION] ASSESSMENT. Surveyor reviewed the documented weights, in Resident #10's medical record. Resident #10's dates in which the weights were obtained and documented are as follows: -02/01/16 to 02/23/16: Twenty-two days without a documented weight -02/29/16 to 03/10/16: Ten days without a documented weight -04/01/16 to 04/21/16: Twenty days without a documented weight -04/30/16 to 05/12/16: Twelve days without a documented weight -06/02/16 to 06/16/16: Fourteen days without a documented weight -07/16/16 to 07/29/16: Thirteen days without a documented weight -08/03/16 to 08/12/16: Nine days without a documented weight The facility is not consistently weighing the resident weekly, per the physician's orders [REDACTED].>On 08/23/16 at 12:45 p.m., Surveyor interviewed Dietician B. Dietician B stated other weights may be documented in a resident's Medication Administration Record [REDACTED]. Surveyor reviewed Resident #10's nurses' notes and the MAR, from 02/01/16 to 08/22/16. No other weights were documented in these records. On 08/24/16 at 10:31 a.m., Surveyor interviewed Assistant Clinical Manager (ACM) A. ACM A stated Resident #10's physician's orders [REDACTED].

Based on observations, interviews and review of facility and resident records, the facility did not establish and maintain an Infection Control Program designed to provide a safe and sanitary environment to help prevent the spread and transmission of disease and infections. The facility did not recognize an outbreak of an Acute Respiratory Illness at the facility when one resident was confirmed positive for influenza and three other residents had symptoms of an acute respiratory illness. This had the potential to affect all 14 residents within the facility dementia household. Staff did not perform appropriate resident bathing and proper hand washing technique during 1 of 5 care observations. - The facility did not have a system to monitor and track when signs and symptoms of an acute respiratory infection are present in residents and staff to recognize when an outbreak has occurred. - The facility did not offer [MEDICATION NAME] to all residents on the unit as a [MEDICATION NAME] measure when a confirmed case of influenza was identified in the household. - The facility did not report to public health of the positive influenza and the outbreak of Acute Respiratory Illness (ARI). - Staff floated between households during the outbreak. - Resident #5 continued to eat in the common dining room. - Resident #4 received daily cares and facility staff did not perform appropriate bathing technique and hand washing technique. This is evidenced by: Surveyor reviewed the facility policy Policy for Outbreak Investigation, which read in part: It is the policy of this facility that outbreak measures will be instituted whenever there is an incidence of infections above what would normally be expected, considering seasonal variation. The infection preventionist will conduct the outbreak investigation. In the absence of the infection preventionist, the director of nursing or the assistant director of nursing will conduct the investigation. Appropriate notifications will be issued to the medical director, administrator, all departments, attending physicians, and family members at a minimum and to appropriate state and local agencies. Outbreak monitoring and reporting will continue until resolution. At that time, narrative reports will be completed and forwarded to appropriate state and local agencies. The infection preventionist will have the authority to implement control measures as appropriate, in coordination with facility administration and medical staff as well as state and local agencies. For example, these control measures may include simple resident or unit isolation or quarantine measures for the entire facility. An interdisciplinary evaluation of the outbreak will be completed, and recommendations for preventive measures will be presented at the quarterly quality improvement and infection prevention and control committee meetings. On 07/23/15, Surveyor reviewed the infection control program with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). During the review, the DON indicated the facility did not have outbreak of infections. The DON indicated if the facility had two or more confirmed cases of influenza within a 48 hour time frame it would be considered an outbreak and would be reported to public health. The ADON indicated the facility tracks the infection for each household. The facility monitors infections on a daily basis during morning report. The ADON indicated in the central building staff keep track of the master schedule, when staff is sick and when they can return to work. The DON provided the outbreak line list and indicated that Resident #16 was tested for influenza and was confirmed to be positive. This was not reported to public health as only one confirmed case and others were presumed positive due to signs and symptoms and were kept in room. Residents #16, #5, #17, #18 were treated with [MEDICATION NAME]. The DON indicated only residents with symptoms were treated with [MEDICATION NAME]. The Medical Director was notified of the positive influenza and directed the facility to treat only the residents with symptoms. Review of the outbreak line list read in the following order: Resident #16 with the date of onset 02/11/15 with fever and lethargy. Resident #5 with the date of onset 02/10/15 with fever, cough, and decreased appetite. Resident #17 with the date of onset 02/12/15 with fever and increased cough. Resident #18 with the date of onset 02/11/15 with fever and moist cough. Surveyor asked the ADON if the outbreak line list was prepared after the confirmed positive influenza. The ADON indicated the line list was prepared after the positive influenza. Surveyor asked how residents are tracked when having symptoms of infection but are not tested to be positive for an infection at the time. The ADON indicated each household has a daily report book that is reviewed in morning meeting and if a resident becomes positive for an infection, then they are put onto the line list for the monthly report of infections. Surveyor requested to see the daily report book for a line list of signs and symptoms of infections for each household from 02/09/15 to 02/15/15. The ADON indicated each household did not have residents with respiratory illness during that time period. Surveyor asked how the facility tracks and monitors for trends of signs and symptoms of illness to put precautions in place before positive infections are identified and have spread to other residents, and other households and staff. The ADON indicated she reviews the daily report book. Surveyor was not provided with a documented system to track and trend signs and symptoms of illness. Surveyor asked the ADON if staff is tracked for infections. The ADON indicated the staff is tracked on the master schedule in the Central office. Surveyor asked the ADON if the staff line lists are reviewed and compared with the resident line lists for a possible trend and outbreak and to define the root cause of the infection. The ADON indicated the staff line lists are kept with the master schedule in the Central office. Surveyor reviewed the cleaning schedule with the ADON. The ADON indicated the cleaning schedule is a standard schedule staff use and there is no documented cleaning schedule of what was completed during the time of the influenza. The ADON indicated homemakers are to increase cleaning of railings and door knobs and are to clean with bleach. Review of Resident #5's nurses' notes identify isolation was not maintained during the outbreak of the acute respiratory illness. The nurses' notes read in part: -02/10/15 6:49 p.m., Res ambulating with staff with slight unsteady gait. Res sounds congested. Tympanic tem 99.0 Res resting in bed at this time. Will monitor. Care plans and CNA (Certified Nursing Assistant) master assignment sheet information are appropriate for this res at this time. -02/11/15 7:20 a.m., Res up x 2 overnight to void, not as active and wandering around the unit as usual for res, T-99.2 with an occasional cough. -02/11/15 11:13 a.m., Awake and assisted with AM cares this morning. CNA reported (resident name) was still unsteady with occasional congested cough. Assisted to lie back down on bed and has been resting. Temp 99.0 -02/11/15 6:01 p.m., Temp 99.5 given scheduled Tylenol. Resident tired, came to supper in wheel chair. Some head congestion present, no cough noted, lungs clear, no edema. Appetite poor, fluids encouraged. -02/12/15 3:01 p.m., Continues with cold symptoms. Voice more hoarse today. Walking with better balance today. Temp 99.0. (Family member) here to visit and updated on cold symptoms. Personal Care Observation On 07/22/15 at 9:25 a.m., Surveyor observed CNA D and CNA E provide cares for Resident #4. CNA D washed hands for approximately ten seconds, applied gloves, turned on bathroom faucet water, filled basin and added body wash. CNA D gathered linens and clothes. While taking clothes out of the closet, a white t-shirt fell to the floor. CNA D picked up the t-shirt and placed it on the bed. CNA D removed gloves, applied clean gloves, wet a washcloth from the bathroom sink and then washed Resident #4's face. CNA D then proceed to wash Resident #4's underarms and under breast with the wet washcloth that had no soap. CNA D applied Resident #4's socks, pant and shoes, then removed gloves, washed hands for approximately ten seconds and applied gloves. CNA D took the washcloth out of the wash basin, washed Resident #4's peri area and did not spread the labia to properly wash. CNA D then used the same washcloth that was used to wash Resident #4's face, underarms and under breasts to rinse the peri area. CNA D set the rinse washcloth to the side. CNA D assisted Resident #4 to sit on edge of bed, and then took the same rinse washcloth that was used to wash face, underarms, under breast, and to rinse the peri area, to wash Resident #4's back. CNA D dressed Resident #4 with the t-shirt that fell on the floor. CNA D and E transferred Resident #4 to the bathroom using the sit to stand. Surveyor asked CNA D if the washcloth used to wash Resident #4's back was the same washcloth that was used to rinse Resident #4's peri area. CNA D indicated he did use the same washcloth and should have gotten another washcloth. CNA D removed gloves, took clean gloves from the box and CNA E told CNA D to wash his hands. CNA D placed the clean gloves on the wet edge of the sink. After CNA D washed his hands, CNA D took the wet gloves and started to apply. Surveyor stopped CNA D and asked what the next task he was going to complete was. CNA D indicated he was going to brush Resident #4's teeth. Surveyor requested CNA D remove the soiled gloves that he just applied before he starts brushing Resident #4's teeth. CNA D indicated the gloves were just taken out of the box and set on the sink and he washed his hands before applying the gloves. Surveyor explained the sink is a contaminated surface and was wet and the gloves were now wet and contaminated and that has the potential to transfer the contaminents to Resident #4's mouth as CNA D was going to assist with brushing her teeth. On 07/27/15 at 9:50 a.m., Surveyor reviewed the above finding with the ADON. The ADON indicated the staff had reviewed with her about Resident #4's care that was given. The ADON indicated staff was educated.

Based on observation, interview, record review and policy review, the facility did not ensure nutritional care and services were provided to each resident, and each resident with weight loss was identified, evaluated and each resident's nutritional needs were assessed and met. This occurred for 3 of 11 residents (Resident #9, 2, and 8) reviewed for nutrition and weight loss. 1. Resident #9 had a 24% weight loss from 10/01/13 to 03/06/14. The facility did not conduct a comprehensive nutritional assessment to identify the resident's nutritional likes/dislikes, as well as identifying the contributing factors to the resident's weight loss. 2. Resident #2 had a 13.70% weight loss from 10/01/13 to 01/08/14. The facility did not conduct a comprehensive nutritional assessment, to identify the resident's nutritional likes/dislikes, as well as identifying the contributing factors to the resident's weight loss. 3. Resident #8 was admitted to the facility on [DATE] on a regular diet. Resident #8's medical record (hard copy and computerized) contained no dietary assessments or notes since admission. No care plan updates had been made to the Imbalanced Nutrition care plan since 01/02/14. This is evidenced by: On 03/20/14 at 2:00 p.m., Surveyor received and reviewed an undated facility policy, entitled "Resident Care Plan." The policy states the following, in part: "POLICY: A nutritional care plan will be on file in each resident's medical record prepared by the Dietician or the Culinary Mentor. PURPOSE: To serve as a means of communicating the individualized nutritional care provided for the resident's dietary needs or problems. PROCEDURE: 1. Care plans will be developed within 21 days of admission and revised quarterly, or as needs, approaches and goals change. 2. Evaluation will be done at a conference with all disciplines participating. 3. The Dietician or Culinary Mentor will document resident's needs, problems or assets. 4. The individualized approach will include all procedures utilized by the dietary department to fulfill needs, eliminate or avoid problems..." On 03/20/14 at 2:00 p.m., Surveyor received and reviewed a second undated facility policy, entitled, "Referral for Nutritional Assessment." The policy states the following, in part: "POLICY: Criteria will be established to identify individuals who are at nutritional risk. PURPOSE: To develop a method of nutritional intervention. PROCEDURE: 1. The following criteria will be used as a screening aide in identifying a nutritional problem: a. Resident won't or cannot eat. b. Weight 20% above ideal body weight or 10% below ideal body weight (taking into account any [MEDICAL CONDITION]). c. Significant weight loss of 5 pounds or more in one month (not attributed to fluid loss), or 10 pounds or more in six months of any resident not on a reduction diet or who has not been grossly overweight. d. Conditions causing increased needs or decreased intake of nutrients (cancer, diarrhea, decubiti, etc.)... f. Chronic use of any drugs that affect nutritional status. g. Routine refusal of a major food group containing vital nutrients. 2. Checklists containing the criteria will be available in the Physician's office, at the Nurse's station, and in the Dietary Department. 3. After checking the particular problems, the Physician, Charge Nurse, or Culinary Mentor will refer to the Dietician. 4. Chart Review, meal observation, and a two or three day Food Acceptance Study may be done on the individual by the Dietary Department, based on the professional clinical judgment of the Registered Dietician... 5. From this study, the daily intake of calories, protein, carbohydrates, fats, or other essential nutrients will be calculated. 6. A Nutritional Assessment will be done from the completed information and placed in the resident's medical record..." EXAMPLES 1. On 03/24/14 at 8:00 a.m., Surveyor reviewed Resident #9's medical record. A review of the physician's orders, signed by the physician on 03/03/14, identifies the resident is currently prescribed scheduled [MEDICATION NAME] (used for [MEDICAL CONDITION]) 0.5 milligrams (mg) everyday, [MEDICATION NAME]-[MEDICATION NAME] (narcotic pain medication) 5-325 mg four times a day, [MEDICATION NAME] Sprinkles (sometimes used for depression or delusions) 250 mg twice a day, [MEDICATION NAME] (antianxiety medication) 1 mg, four times a day, and [MEDICATION NAME] (antipsychotic medication) 0.5 mg, three tablets (1.5 mg total) twice a day. Resident #9 also receives as needed [MEDICATION NAME] 2 mg/ml (milliliters), one-half ml every four hours, [MEDICATION NAME] 1 mg every four hours, and [MEDICATION NAME] 5 mg every 15 minutes. The resident also was receiving [MEDICATION NAME] (antidepressant medication) 20 mg twice a day, from 02/03/14 until 03/03/14. The physician's orders also indicates Resident #2 is supposed to be weighed weekly due to a [DIAGNOSES REDACTED]." This order was first received on 02/05/14. Surveyor reviewed Resident #9's weights, which are documented in the medical record. The following are the resident's documented weights and the date the weight was obtained: -10/01/13: #191 (Admission weight) -10/10/13: #189 -11/07/13: #184 -12/04/13: #172 -12/06/13: #170.8 -01/03/14: #172.8 -01/31/14: #155.6 -03/06/14: #148.6 Resident #9 had a 42 pound weight loss from October 2013 to March 2014. Based on Surveyor 's calculation of the percentage of weight lost, Resident #9 had a 24% weight loss in five months, which would be considered a severe weight loss. No other weights for Resident #9 were found in the medical record, and these weights indicate the resident was being weighed once a month instead of every week, as indicated by the physician's orders. The facility was not frequently monitoring Resident #9's declining weight. On 03/24/14, Surveyor reviewed Resident #9's comprehensive care plan. The resident's care plan states, in part: "Problem Start Date: 02/24/2014. Resident has experienced weight loss R/T (related to) decreased intake. Current BMI (Body Mass Index) is elevated... Approach Start Date: 02/24/2014. Assess resident's food preferences. Avoid foods that resident complains about taste. Diet: General. Encourage oral intake of food and fluids. Monitor and record intake of food. Monitor need for changing diet consistency to increase ease of eating. Monitor/record weight weekly. Offer available substitutes if resident has problems with the food being served. Provide (setup help, cueing, physical help, etc.) assistance for meals. Tell res (resident) location of food/drink items on plate/table due to loss of vision." Surveyor also reviewed Resident #9's Certified Nursing Assistant (CNA) care plan. The CNA care plan indicates the resident receives a general diet and to "adjust placement of food items as needed." The CNA care plan also indicates Resident #9 should be weighed weekly. The CNA care plan does not indicate if Resident #9 receives any nutritional supplements or has had recent weight loss. Surveyor reviewed Resident #9's documented meal intakes, from 10/01/13 to 03/23/14. The resident's average intake from 10/01/13 to mid January 2014 varied between 1-50% and 76-100% of the meal. Resident #9's average intake from mid January 2014 to 03/23/14 is approximately 1-25% of the meal. Resident #9's nurses' notes indicate the resident receives a nutritional supplement. The notes do not consistently indicate the frequency or the type of supplement the resident receives. No documentation was found in the medical record evaluating Resident #9's intake for the nutritional supplements. The physician progress 01/01/14 states, "The POA is not happy with her sedative medication, but unfortunately we might have to do this." The next progress note dated 01/16/14 states, "She does appear more drugged...". does not identify any weight loss in the physician's progress notes. On 02/12/14 the physician progress notes [REDACTED]. We should discontinue some of the unnecessary medications and we should consider comfort care." This is the first physician's note addressing intakes (resident had already lost 35.4 pounds in four months). The Nutritional Assessment Worksheet was reviewed by Surveyor . The Worksheet has the Minimum Data Set (MDS) date of 12/10/13, with an Assessment Reference Date (ARD) of 12/09/13. The Assessment Worksheet does not have a signature as to who completed the assessment, nor does it have a date in which the assessment was completed. The Nutritional Assessment Worksheet form, states the following, in part: "...Preferences/Dislikes: Meals are going good. Ht: 66 Wt: 12/4/13, 172 Previous Wt/1 mo (month): 11/7 (2013), 184. 3 mo: (left blank), 6 mo: (left blank). UBW (Usual Body Weight): left blank IBW (Ideal Body Weight): 130... BMI (Body Mass Index): 28... Needs Kcal: 1309-1701 Pro (Protein): 62.5 g (grams) Fluid: 2345 cc (cubic centimeters) Appetite: left blank... Fluid Intake: left blank) Dehy (Dehydration) Risk Factor: left blank Meds: Vit (Vitamin) D3, [MEDICATION NAME], Tylenol, [MEDICATION NAME], MOM (Milk of Magnesia), Mirlax, Senna, [MEDICATION NAME] (eye drops to control [MEDICAL CONDITION]). Dx (Diagnosis): Aphagia, CVD ([MEDICAL CONDITION] Disease), apaxia (inability to execute learned, purposeful movements),[MEDICAL CONDITION](Hypertension), gout, constipation. Feeding Ability: left blank Mobility & Alertness: left blank... Skin Condition: left blank Current Care Plan: left blank New Care Plan: Nutrition weight loss, BMI (arrow up) 27.76, Dehydration-constipation..." This nutritional assessment is not a comprehensive assessment that identifies Resident #9's nutritional status. The assessment does not identify Resident #9's dietary likes and dislikes, and it does not identify the amount of food and fluids the resident generally consumes for meals. It does not identify the contributing factors and possible causes for Resident #9's severe weight loss, including how the psychoactive medications may affect the resident's appetite. The assessment does not identify the percentage of weight the resident has lost since being admitted to the facility on [DATE]. The assessment does not identify any interventions that have been attempted to increase the resident's weight, nor does it identify the effectiveness of those interventions. The assessment does not identify that Resident #9 is supposed to receive nutritional supplements, nor does it evaluate the effectiveness of the use of supplements. The assessment does not identify how Resident #9's weight will continue to be monitored. A second Nutritional Assessment Worksheet was reviewed by Surveyor . The Worksheet has the MDS ARD of 02/07/14. The Assessment Worksheet does not have a signature as to who completed the assessment, nor does it have a date in which the assessment was completed. The Nutritional Assessment Worksheet form, states the following, in part: "...Preferences/Dislikes: left blank. Ht (Height): 66 (inches)... Wt (Weight): 2/2 (2014), 156 Previous Wt/1 mo: 1/3 (2014), 173. 3 mo: 11/7 (2013), 184. 6 mo: left blank. UBW: left blank IBW: left blank... BMI: left blank... Needs Kcal: left blank Pro: left blank Goal Wt: left blank BMI: left blank Appetite: left blank... Fluid Intake: left blank Dehy (Dehydration) Risk Factor: left blank Meds: [MEDICATION NAME] (used to treat nausea), [MEDICATION NAME], Biscadyl, MOM, [MEDICATION NAME]. Dx: left blank Feeding Ability: left blank Mobility & Alertness: left blank... Skin Condition: good Current Care Plan: left blank New Care Plan: left blank... Vision poor. Nut (Nutritious) Juice Drink on unit." This nutritional assessment is not a comprehensive assessment that identifies Resident #9's nutritional status. The assessment does not identify Resident #9's dietary likes and dislikes, and it does not identify the amount of food and fluids the resident generally consumes for meals. It does not identify the contributing factors and possible causes for Resident #9's severe weight loss, including how the psychoactive medications may affect the resident's appetite. The assessment does not identify the percentage of weight the resident has lost since being admitted to the facility on [DATE]. The assessment does not indicate the resident's usual or ideal body weight, along with a calculation of a BMI. The assessment does not identify any interventions that have been attempted to increase the resident's weight, nor does it identify the effectiveness of those interventions. The assessment states a nutritious juice is on the unit, but the assessment does not identify if Resident #9 is offered and consumes the juice. The assessment also does not evaluate the effectiveness of the use of the nutritious juice. The assessment does not identify how Resident #9's weight will continue to be monitored. Upon completing Resident #9's medical record review, there was no information under the "Dietary" tab in the resident's chart, which is located at the Red Cedar nurses' station. No other dietary information or paperwork was located in the hard chart by Surveyor . Upon a medical record review of the resident's electronic chart, no dietary assessments were found. No dietary notes from the Culinary Mentor or Registered Dietician were found since Resident #9's admission to the facility on [DATE]. On 03/24/14 at 8:34 a.m., Surveyor interviewed the Red Cedar Homemaker G. Homemaker G indicated the staff try to assist Resident #9 with eating, and the resident has recently lost a lot of weight. Surveyor asked if Resident #9 receives a nutritional supplement, which Homemaker G replied she was not sure and referred Surveyor to speak with the nurse. At 8:35 a.m., Surveyor interviewed the Agency Staff Registered Nurse (RN) M. Surveyor asked if Resident #9 receives a nutritional supplement, which RN M stated she was not sure. RN M then reviewed the resident's Medication Administration Record [REDACTED]. Surveyor then observed RN M approach Resident #9, who was sitting at the dining room table in the Red Cedar household. RN M requested the resident's supplement from the Homemaker, to which Homemaker G replied, "Ensure or Resource (supplement)?" RN M told Homemaker G the physician's order "just said supplement," and did not specify what type of supplement Resident #9 should receive. On 03/24/14 at approximately 9:00 a.m., Surveyor interviewed the Registered Dietician (RD) B. Surveyor asked when Resident #9's nutritional supplements were started, to which RD B replied she did not know as there is no documentation as to when the resident started receiving the supplements. Surveyor also discussed the physician's order for Resident #9 to be weighed weekly. Surveyor asked if RD B has observed any of Resident #9's meals, as indicated in the facility nutrition policy; to which RD B replied she has observed some of the resident's meals, but the observations have not been documented. RD B could not indicate when these meal observations occurred since 10/01/13. During the continued interview with RD B, Surveyor asked if the facility has assessed Resident #9's nutritional likes and dislikes, as indicated on the resident's care plan. RD B stated Resident #9 is unable to inform the facility of the nutritional likes/dislikes, due to the resident's cognition. However, RD B indicated she usually asks facility staff of the resident's likes/dislikes, and usually does not consult with the resident's family. Surveyor and RD B also discussed the amount of psychoactive medications Resident #9 receives, and how it relates to the resident's appetite and weight loss. RD B stated she "doesn't touch the meds," since these medications were ordered by Amery Behavioral Health. RD B stated she reviews the resident's medication every quarter, and writes them on the nutritional assessment. Surveyor discussed the physician's order to have Resident #9 weighed weekly. RD B stated she was not aware Resident #9 needed to be weighed weekly, since the resident was placed on comfort cares as of 02/12/14. Surveyor informed RD B the most recent documented weight for the resident is from 03/06/14. RD B stated she would look for a recent weight, since some of the agency nurses write the resident's weight on a sheet of paper, and do not document the weight in the computer. On 03/24/14 at 9:31 a.m., Surveyor observed Resident #9 was standing up, and holding onto a wooden pillar, next to the kitchenette. Surveyor observed two CNAs, one of which was wheeling a chair-scale, approach Resident #9 to weigh her. The CNAs assisted Resident #9 to sit in the chair, which measured the Resident #9's weight at 144.8 pounds. Resident #9 lost four more pounds since 03/06/14. At 9:45 a.m., RD B notified Surveyor of Resident #9's current weight. RD B further stated there are no other weights which were documented for the resident since 03/06/14. Surveyor asked RD B if Resident #9's physician was ever updated regarding the weight loss, to which RD B was not sure. On 03/24/14 at 11:30 a.m., Surveyor interviewed the Assistant Clinical Care Mentor (ACCM) A. Surveyor informed ACCM A there is no documentation in Resident #9's medical record that the physician was notified of the resident's continued weight loss. There is no documentation in Resident #9's physician notes which identifies the resident has had any weight loss. ACCM A reviewed the physician visit notes on the computer at this time. ACCM A stated Resident #9's physician was updated regarding the resident's continued weight loss, but that this was not documented by the facility or the physician. See below for additional interviews with RD B. 2. On 03/19/14 at 7:40 a.m., Surveyor observed the breakfast meal in the Eventide household dining room. At 8:21 a.m., Resident #2 was brought to the dining room table, by staff. At this time, Resident #2 received a cup of coffee, and an 8-ounce glass of a white liquid, which appeared to be milk. Resident #2 also received a plate containing two pancakes, and scrambled eggs. CNA D cut up the resident's pancakes into smaller pieces. CNA E was sitting to the left of Resident #2, but was assisting another resident with the meal. During the continued observation, Resident #2 ate the pancakes very slowly with a fork, and took several sips of coffee between bites of food. Surveyor did not observe CNA E encourage or assist Resident #2 with the breakfast meal. CNA E was not observed to encourage the resident to drink the white liquid. The above observation was completed approximately 8:50 a.m. Surveyor did not observe Resident #2 to drink any of the white liquid. On 03/19/14 at 9:00 a.m., Surveyor reviewed Resident #2's medical record. The resident's physician's orders, dated 10/01/13, indicate Resident #2 is supposed to be weighed weekly due to a [DIAGNOSES REDACTED]." A physician's note, dated 12/19/13, states the following, in part, "...She is losing weight I think primarily due to her dementia..." Surveyor reviewed Resident #2's weights, which are documented in the medical record. The following are the resident's documented weights and the date the weight was obtained: -10/01/13: #111 (Admission weight) -10/23/13: #107.8 -11/16/13: #106 -12/11/13: #98.2 -01/08/14: #95.8 -02/05/14: #99.6 -03/12/14: #103 Based on Surveyor 's calculation of the percentage of weight Resident #2 lost, the resident had a 13.70% weight loss from 10/01/13 to 01/08/14. This indicates the resident had a severe weight loss in three months. No other weights for Resident #2 was found in the medical record, and these weights indicate the resident was being weighed once a month instead of every week, as indicated by the physician's orders. The facility was not frequently monitoring Resident #2's declining weight. On 03/19/14, Surveyor reviewed Resident #2's comprehensive care plan. The resident's care plan states, in part: "Problem Start Date: 10/18/2013. Imbalance nutrition: less than body requirements R/T (related to) recent significant weight loss due to decreased intake due at least in part to advanced dementia. Goal:...Resident will maintain current body weight of 105-115#... Approach Start Date: 10/18/2013...Encourage oral intake of food and fluids. Monitor for signs of malnutrition. Monitor need for changing diet consistency to increase ease of eating. Monitor/record weight. Notify physician, RD and family of significant weight change. Offer available substitutes if resident has problems with the food being served. Provide set up and physical assist as res (resident) allows for meals. Provide supplements tid (three times a day). [MEDICATION NAME] (antidepressant medication which may be used to stimulate appetite) tried in the past but stopped due to family request as felt res was more sleepy with the med (medication)...." Surveyor also reviewed Resident #2's CNA care plan. The CNA care plan indicates the resident receives a general/mechanical soft diet, and may receive regular bacon. The CNA care plan also indicates Resident #2 should be assisted with "feeding." The CNA care plan does not indicate if Resident #2 receives any nutritional supplements or has had a recent weight loss. Surveyor reviewed Resident #2's documented meal intakes, from 10/01/13 to 03/23/14. The resident's average intake from 10/01/13 to mid January 2014 was approximately 1-50% of the meal. Resident #2's average intake from mid January 2014 to 03/23/14 is approximately 50-100% of the meal. The increase in Resident #2's oral intake coincides with her slight weight increase in February and March 2014. No documentation was found in the medical record regarding Resident #2's intake for the nutritional supplements. Upon completing Resident #2's medical record review, there was no information under the "Dietary" tab in the resident's chart, which is located at the Eventide nurses' station. No other dietary information or paperwork was located in the hard chart by Surveyor . Upon a medical record review of the resident's electronic chart, no dietary assessments were found. No dietary notes from the Culinary Mentor or Registered Dietician were found since Resident #2's admission to the facility on [DATE]. On 03/19/14 at 12:01 p.m., Surveyor observed the noon meal in the Eventide household dining room. At 12:16 p.m., Resident #2 was brought to the dining room table by staff, and she received a bowl of soup, and a cup of coffee. Surveyor observed Resident #2 take small spoonfuls of soup, eating very slowly. Resident #2 drank all of her coffee during the observation. Surveyor did not observe any staff member encourage or assist Resident #2 with eating or drinking. No other fluids were given to the resident during the noon meal observation. On 03/20/14 at 8:40 a.m., Surveyor interviewed the Eventide Homemaker H. Surveyor asked if Resident #2 receives any nutritional supplements, which Homemaker H stated she was not sure if the resident receives supplements. Homemaker H indicated the CNA staff have access to the supplements, which are located in the pantry fridge, behind the household kitchenettes. Homemaker H indicated the CNA staff would get the resident's supplements. At 10:10 a.m., Surveyor received and reviewed the Eventide Homemaker's "Meal Service Report," for Resident #2, along with the resident's Nutritional Assessment Worksheets. The Homemaker meal report, dated 01/16/14, indicates the resident is to receive a regular, mechanical soft diet. No nutritional supplements are identified on Resident #2's Homemaker meal report. The Nutritional Assessment Worksheet was reviewed. The Worksheet has the MDS date of 12/10/13, with an ARD of 12/05/13. The Assessment Worksheet does not have a signature as to who completed the assessment, nor does it have a date in which the assessment was completed. The Nutritional Assessment Worksheet form, states the following, in part: "...Preferences/Dislikes: wt (arrow pointing down). Ht: 63 inches Wt: 12/4/13, 99.2 Previous Wt/1 mo month: 11/6/13, 106. 3 mo: (left blank), 6 mo: (left blank). *UBW: left blank IBW: 115... BMI: 18 (a BMI below 18.5 indicates the person is underweight. It is recommended an elderly person have a BMI between 25-27). Needs Kcal: [PHONE NUMBER], Pro: 36.1 g (grams), Fluid: 1352 cc (cubic centimeters) Appetite: left blank Fluid Intake: left blank, Dehy Risk Factor: left blank Meds: [MEDICATION NAME], Tylenol, [MEDICATION NAME], MOM (Milk of Magnesia), [MEDICATION NAME], Aspirin, [MEDICATION NAME] Cl ER (Extended Release), Senna Plus, Vita C (Vitamin C). Dx: [MEDICAL CONDITIONS], constipation, [MEDICAL CONDITION]. Feeding Ability: (eft blank Mobility & Alertness: left blank Labs: none Skin Condition: left blank Current Care Plan: At risk for dehydration. Imbalance nutrition, weight loss New Care Plan: left blank This nutritional assessment is not a comprehensive assessment that identifies Resident #2's nutritional status. The assessment does not identify Resident #2's dietary likes and dislikes, and it does not identify the amount of food and fluids the resident generally consumes for meals. It does not identify the contributing factors and possible causes for Resident #2's severe weight loss, nor does it identify the percentage of weight the resident has lost. The assessment does not identify any interventions that have been attempted to increase the resident's weight, nor does it identify the effectiveness of those interventions. The assessment does not even identify that Resident #2 is supposed to receive nutritional supplements, nor does it evaluate the effectiveness of the use of supplements. The assessment does not identify how Resident #2's weight will continue to be monitored. A second Nutritional Assessment Worksheet was reviewed. The Worksheet has the MDS ARD of 02/13/14. The Assessment Worksheet does not have a signature as to who completed the assessment, nor does it have a date in which the assessment was completed. The Nutritional Assessment Worksheet form, states the following, in part: "...Preferences/Dislikes: left blank. Ht: 63 inches... Wt: 2/5/14, 100 Previous Wt/1 mo: 1/8/14, 96. 3 mo: left blank, 6 mo: left blank. UBW: left blank IBW: left blank... BMI: left blank... Loss of Liq/Solid (Liquid): (coughing is circled). Needs Kcal: ...1200..., Pro: 40-50 g, Fluid; 1500 cc Appetite: left blank Fluid Intake: left blank Dehy Risk Factor: left blank Meds: [MEDICATION NAME], Tylenol, [MEDICATION NAME], MOM prn (as needed). Dx: left blank Feeding Ability: left blank Mobility & Alertness: left blank Skin Condition: good Current Care Plan: left blank New Care Plan: left blank..." This nutritional assessment is not a comprehensive assessment that identifies Resident #2's nutritional status. The assessment does not identify Resident #2's dietary likes and dislikes, and it does not identify the amount of food and fluids the resident generally consumes for meals. It does not identify the contributing factors and possible causes for Resident #2's severe weight loss, nor does it identify the percentage of weight the resident has lost. The assessment does not indicate the resident's usual or ideal body weight, along with a calculation of a BMI. The assessment does not identify any interventions that have been attempted to increase the resident's weight, nor does it identify the effectiveness of those interventions. The assessment does not even identify Resident #2 is supposed to receive nutritional supplements, nor does it evaluate the effectiveness of the use of supplements. The assessment does not identify how Resident #2's weight will continue to be monitored. On 03/20/14 at approximately 10:50 a.m., Surveyor interviewed Registered Dietician (RD) B regarding Residents #2 and #9's Nutritional Assessments. Surveyor asked if any of the information from the assessments are put into the resident's medical record; which RD B stated not all of the information is put into the medical record. RD B further stated the above assessments are more "information gathering," which is why the information is not usually put into the medical record. RD B explained both of the resident's assessments from December 2013 were completed by the Dietary Intern, and RD B did not review it or supervise the intern's assessments. RD B explained she completed the nutritional assessments from February 2014. During the above interview, Surveyor discussed the fact there are no dietary notes in Residents #2 or #9's medical record. RD B apologized and stated the above Nutritional Assessment Worksheets are the only documentation RD B, and the dietary department, would have for the two residents. RD B also stated, "I probably should've documented more..." At 12:20 p.m., Surveyor again observed the noon meal in the Eventide household dining room. Resident #2 was eating a bowl of soup, and drinking a cup of coffee. Surveyor again observed Resident #2 take small spoonfuls of soup, and eat very slowly. The resident drank almost 100% of her coffee. Surveyor did not observe any staff member encourage or assist Resident #2 with eating or drinking. No other fluids were given to the resident during the noon meal observation. At this time, Surveyor again interviewed Homemaker H. Surveyor asked if Resident #2 ever receives milk with meals; to which Homemaker H replied the resident does not like to drink milk and never receives it. Homemaker H indicated the only fluids Resident #2 received today during the noon meal was coffee. Surveyor also interviewed an Agency Staff Registered Nurse (RN) M, during the noon meal on 03/20/14. Surveyor asked if Resident #2 receives a nutritional supplement; to which RN M stated the resident receives a supplement for breakfast and supper. RN M was not sure if Resident #2 ever receives a supplement for the noon meal. RN M stated there is no physician's order for Resident #2's nutritional supplement, and the nurses do not document the supplemental intakes. RN M indicated the color of Resident #2's supplement differs, depending on the flavor. RN M stated the white liquid the resident received for breakfast on 03/19/14 may have been a vanilla-flavored supplement. During the above meal observation, Surveyor also interviewed CNA N. CNA N stated she is not sure if Resident #2 receives any nutritional supplements, and indicated the resident did not receive a supplement with the noon meal on 03/20/14. On 03/20/14 at 2:00 p.m., Surveyor interviewed Culinary Mentor (CM) C, and RD B. Dietetic Intern O, and Surveyor were also present during the interview. Surveyor asked what kind and how often Resident #2 receives the nutritional supplement. RD B stated Resident #2 is supposed to receive a Resource supplement, three times a day, with meals. Surveyor asked when Resident #2's nutritional supplements were started, which RD B thought the supplements were started in either November or December 2013. CM C stated he would look into when the resident's supplements were started. During the above interview, Surveyor discussed the above meal observations, along with Surveyor 's staff interviews. RD B stated she spoke with Homemaker H this morning, and Homemaker H told RD B that Resident #2 does receive a supplement with meals. RD B stated she requested a physician's order, on 03/20/14, for Resident #2's supplement. RD B is hoping with an order, the need for the supplements will be communicated to the charge nurse, and the consumption will also documented. Surveyor asked about the facility's procedure regarding weight loss. RD B explained the facility nursing staff weighs the resident, and the weight is usually documented in the electronic medical record. The nursing staff is then responsible for filling out and giving RD B a "Refer