Every finding on record at Norseland Nursing Home

Based on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect 34 of 34 residents. Surveyor observed food to have been removed from the original packaging and not dated with an expiration date, an open date, or a use by date. Surveyor observed undated and expired seasoning to be in circulation. Evidenced by: The Wisconsin Food Code 2020 states, in part, at 3-501.17 .(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: . (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat, time/temperature control for safety food that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the regulatory authority upon request .Disposition. (A) A food specified under 3-501.17 (A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17 (A) Except time that the product is frozen; (2) Is in a container or package that does not bear a date or day . Example - Undated food removed from original packaging On 6/16/25 at 10:28 AM, during initial tour of the kitchen, Surveyor and DM G (Dietary Manager) observed in the freezer an opened package of fish fillets out of the original cardboard box without a use by or expiration date. Surveyor and DM G also observed 3 unopened packages of pancakes out of the original cardboard box without dates on them. DM G verified the packages did not have dates and indicated the fish fillets and pancakes should have dates on them. On 6/18/25 at 2:20 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and VP H (Vice President of Health Services). Both indicated they would expect food to be labeled and discarded appropriately. Example - Undated and Expired Seasoning On 6/16/25 around 10:28 AM, during initial tour of the kitchen, Surveyor and DM G observed boxes of beef and chicken bouillon in the dry storage area to not have expiration dates on them. DM G indicated they should have dates on them. Surveyor and DM G also observed an opened container of onion powder in the main kitchen to have a use by date of 6/12/25 (initial tour of the kitchen occurred on 6/16/25). DM G indicated the onion powder was expired and should have been thrown away. On 6/18/25 at 2:20 PM, Surveyor interviewed NHA A and VP H (Vice President of Health Services). Both indicated they would expect food to be labeled and discarded appropriately.

Example 3 On 6/16/25 at 12:15 PM, Surveyor interviewed R8 who indicated that the ham they were having today, as well as beef and meats in general, are tough. R8 indicated the staff will assist with cutting but they can't help chew it. Based on observation, interview and record review, the facility did not ensure that each resident receives food and drink that is palatable and at a safe and appetizing temperature. This has the potential to affect 4 of 14 sampled residents (R27, R32, R11, and R8). R27 voiced concerns with her food being cold. R11 voiced concerns with food being cold. R32 voiced concerns with food being cold and tough to chew. R8 voiced concerns with meats being tough to chew. Surveyors conducted 2 test trays; both were not palatable. Evidenced by: Facility policy, entitled Infection Control - Preparing and Cooking Foods, last revised 7/20/2016, includes, in part: . Use hot holding equipment that can keep hot foods at 135 degrees Fahrenheit or higher . Cold foods must be maintained at 41 degrees Fahrenheit or below . Example 1 R27 admitted to the facility on [DATE]. R27's most recent Minimum Data Set (MDS), with a target date of 6/4/25, indicates a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R27 is cognitively intact. On 6/16/25 at 11:36 AM, R27 indicated during screening her food is often cold when she eats it. R27 chooses to eat meals in her room and stated her food isn't hot enough when it's delivered. Example 2 On 6/17/25 at 12:16 PM, Surveyor conducted a test tray from room trays on the 200 hallway. Surveyor observed a Certified Nursing Assistant (CNA) deliver the room trays to the hallway on a cart that was not enclosed, plates had cambro bottoms (not heated) and lids, drinks and bowls were covered. After the room trays were delivered, Surveyor took the temperature of the items on the test tray. The temperatures were as follows: Chicago Beef Sandwich (temped the beef on the sandwich) - 113 degrees Fahrenheit Sweet Potato Fries - 104 degrees Fahrenheit Creamy Cucumber Salad - 49 degrees Fahrenheit Fruited Gelatin - 48 degrees Fahrenheit Surveyor tasted the food and hot food was cold. The tray was not palatable and at a safe and appetizing temperature. On 6/18/25 at 12:24 PM, Surveyor interviewed DM G (Dietary Manager) about the food. DM G indicated she would expect the hot food to be hot and cold food to be cold. On 6/18/25 at 12:15 PM, Surveyor conducted a test tray in the facility's main dining room. Surveyor was cutting the country fried pork tenderloin with a fork and knife. Surveyor had to use a lot of pressure to cut the meat. Surveyor had a difficult time chewing the meat, particles got stuck in Surveyor's teeth. This test tray was not palatable. On 6/18/25 at 12:24 PM, Surveyor interviewed DM G about the toughness of the meat. Surveyor asked DM G to cut the meat and DM G indicated the pork was tough to cut. DM G stated they switched food companies recently and were trying different things on the menu. She also stated she would work on figuring out a way to make the meat more tender or take this off of the menu. Example 4 On 6/16/25 at 11:30 AM, R11 reported that food is lukewarm mostly all of the time. Example 5 On 6/16/25 at 3:45 PM, R32 reported that since getting the new food company the food has been rotten. She indicated they could improve the food 100%. She stated that the pork chop was tough as a brick and food is lukewarm. On 6/18/25 at 2:20 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and VP H (Vice President of Health Services). Both indicated policies should be followed, food should be hot enough and meat not hard to chew.

Based on interview and record review, the facility did not ensure a resident maintains acceptable parameters of nutritional status and weight. This affected 1 (R24) of 5 reviewed for nutrition and hydration. R24 did not receive cueing/reminders during meal times per her plan of care and R24 has had a significant weight loss over the last 6 months. Evidenced by: The facility policy, titled, Nutrition Support, dated 5/22/17, states, in part: I. Inadequate Oral Intake A. The Registered Dietician or Nursing staff will offer oral commercial nutrition supplements to residents with inadequate oral intake . III. Initiation of Nutrition Support A. The Physician's Order for nutrition support will be communicated to the Nutrition Services Department by Nursing . R24 was admitted to the facility on [DATE] with diagnoses that include Corticobasal degeneration (neurological degenerative disease that leads to progressive symptoms such as loss of movement, speech difficulties, and cognitive decline) and Parkinsonism (neurological disorder causing tremors, slowed movements, rigidity, and postural instability). R24's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) 4/9/25, shows R24 has a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating R24 is moderately cognitively impaired. R24's Diet Order states: DIET: General, Meats/all food cut up bite size. ADAPTIVE EQUIPMENT: Large Handled/Built Up utensils, lids on cups. R24's Comprehensive Care Plan states, in part: I have the potential to be at nutritional risk because I have a history of hypertension, chronic kidney disease, insomnia, anxiety, mild cognitive impairment, repeated falls, and constipation. My goal is to: maintain my weight 135 +/- 5 lbs. Goal date: 7/29/25 I need my nurses to: . ask my family to provide my favorite foods and drinks, try to figure out why I'm not eating, ask me about my preferences I need my aides to: . weigh me per nursing order, setup my meal so I can eat, let me take as much time to eat as I need, ask me if I like my meal, offer me something else if I don't like the meal, offer me a snack, I need cueing/reminders to keep eating at meals, cut up foods. I need dietary staff to: provide me with a general diet, foods cut up bite size, food I like to eat, offer me built up silverware. I prefer my hot cereal in a mug. (with extra milk to make it drinkable). (Of note: The intervention I prefer my hot cereal in a mug. (with extra milk to make it drinkable) was added 6/16/25. Prior to this, the intervention for providing built-up silverware was added 4/9/25. No other nutritional care plan changes were made after 01/2025.) R24's Annual Nutrition Assessment, dated 4/11/25 indicates, in part: . Usual Body Weight Range: Care plan weight goal: 135 +/- 5 lbs . Calorie needs: 1247 . Eating Ability: Supervision-Set-up . MNA (Mini Nutritional Assessment): 10, At risk for malnutrition . Monitoring/Evaluation: monitor weights, intakes, s/s (signs and symptoms) of dehydration, labs as available, and will follow up quarterly or sooner if needed . R24's Weight Documentation states, in part: 1/10/25: 137.2 lbs. 6/13/25: 122.6 lbs. (Of note: This indicates a weight loss of 10.64% in less than 6 months). R24's Meal Intake Documentation from 5/17/25 through lunch on 6/17/25 indicates R24 had 89 meal intakes recorded. Of these 89 meals, 42 of these meals indicated R24 ate 50% or less of her entire meal, indicating R24 is only eating 50% of her meal or less for around 47% of her meals. Surveyor was provided with an untitled document that facility staff report is a seating chart for the dining room. This chart indicates R24 usually needs cueing/supervision with meals. Surveyor requested two days of R24's meal cards during survey. Surveyor was provided with R24's meal cards for breakfast, lunch, and supper. These cards do not indicate a date, and do not include R24's recommended dietary supplement. On 6/13/25, a note from the Registered Dietician states, in part: . -11.0% (15.2 lb) in six months . With [Resident's Name]'s gradual weight loss and overall fair intake, will request order for 8 oz Ensure at supper for additional calories and protein. Will continue to monitor weights, intake, and acceptance to nutritional supplement. (Of note: There is no order for this supplement, and it does not appear on R24's meal card). On 6/17/25, Surveyor observed R24 eating breakfast. At 8:16 AM, R24 received her breakfast tray. At 8:19 AM, R24 attempted to take her first bite and dropped half of her spoonful. At 8:24 AM, R24 drops another entire spoonful onto her lap. At 8:30 AM, Surveyor notes R24's hands are shaking, and she is having difficulty bringing the spoon to her mouth. Surveyor also notes R24 has to adjust the spoon angle several times in order to take a bite. At 8:40 AM, R24 drops another spoonful of food onto her lap. At 8:53 AM, R24 attempted to eat a slice of toast, half of the slice was dropped onto her lap and R24 was having difficulty getting the bread into her mouth. At 9:00 AM, Surveyor ended observation and noted R24 was still trying to eat her breakfast. On 6/18/25, Surveyor observed R24 eating breakfast. At 7:56 AM, Surveyor started breakfast observation and R24 had already received her breakfast tray. At 8:06 AM, R24 brought the spoon up to her mouth, and attempted for an entire minute to get food into her mouth. R24 was unsuccessful and slowly put the spoon back down, still full of food. At 8:13 AM, R24 attempts to take another bite, and struggles, missing her mouth several times with the spoon before finally being able to take a bite. At 8:16 AM, R24 brought the spoon to her mouth to attempt to take a bite, missed her mouth several times, then put utensil back down with food still on it. At 8:19 AM, R24 attempts to take another bite, again missed her mouth several times before finally being able to take a bite. On 6/18/25 at 8:45 AM, Surveyor sat with R24 to ask her about breakfast. Surveyor noted R24 was struggling to reach her cup. On 6/18/25 at 8:25 AM, Surveyor interviewed DA C (Dietary Aide). Surveyor asked DA C if there were any CNAs (Certified Nursing Assistants) in the dining room with her. DA C indicates not at the start of breakfast, they usually won't come down until they get all the residents up. Surveyor asked DA C if she assists any residents with cueing or eating. DA C indicates, no, she is not allowed to. On 6/18/25 at 9:17 AM, Surveyor interviewed CNA D (Certified Nursing Assistant). Surveyor asked CNA D if there is usually a CNA assigned to the dining room. CNA D indicates, yes there always is a CNA assigned to assist with feeding. Surveyor asked CNA D how they know which residents need assistance. CNA D indicates the map with the seating chart on it. Surveyor asked CNA D how R24 eats. CNA D indicates she eats pretty good, she doesn't like her built up silverware, so we give her regular silverware, and she needs help with cutting up her food. CNA D also indicates she spills her food sometimes and can't use her left arm so it makes it more difficult for her to eat. On 6/18/25 at 10:15 AM, Surveyor interviewed CNA E. Surveyor asked CNA E if there is usually a CNA assigned to the dining room. CNA E indicates, yes, and that she was assigned but that she didn't get out to the dining room until later because she had to help get a resident up on another hall. Surveyor asked CNA E what time she thinks she was able to get out to the dining room. CNA E indicates around 9:15 AM. Surveyor asked CNA E if it is common that CNAs are late getting out to the dining room in the morning. CNA E indicates yes, because they are trying to get all of the residents up for the day. Surveyor asked CNA E how R24 eats. CNA E indicates she is a slow eater, frequently spills her food, staff always give R24 two sets of silverware, the regular and built-up because she often refuses the built-up silverware, and she has a hard time eating food because she can't use her left arm. CNA E also indicates she did have to cue R24 this morning and helped her by holding her bowl so she could eat. On 6/18/25 at 1:51 PM, Surveyor interviewed CNA F. Surveyor asked CNA F if there is usually a CNA assigned to the dining room. CNA F indicates, yes, and that there are 3 residents who require feeding assistance. Surveyor asked CNA F how R24 eats. CNA F indicates staff have been having to help her more lately and that it is hard for her to get a good grip on the silverware, and she frequently drops her food. On 6/18/25 at 2:01 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what the expectation is for staff when a resident requires cueing or supervision assistance. DON B indicates, to help cue and supervise that resident. Surveyor asked DON B what the expectation is for CNAs who are assigned to the dining room. DON B indicates, she expects the CNAs to be cueing, supervising, and assisting residents who need assistance. Surveyor asked DON B who monitors resident weights. DON B indicates, numerous people monitor weights, including herself, the two nurse managers, the registered dietician, and the dietary manager. DON B also indicates the electronic medical record creates weight alerts and these are discussed during morning meetings where they try to determine root cause. Surveyor asked DON B who monitors residents' food and fluid intakes. DON B indicates the dietary manager reviews the intakes then sends any changes in intake to the registered dietician. Surveyor asked DON B if registered dietician orders should be placed or sent to the physician for review. DON B indicates, she would have to double check as they are in the process of changing standing orders. Surveyor asked DON B if residents who have a recommendation for Ensure, should have that order placed. DON B indicates only if it is to be given during meal pass, otherwise dietary places the recommendation on the meal card. Surveyor asked DON B how R24 eats. DON B indicates she doesn't know her specifics. Surveyor relayed to DON B that according to the Registered Dietician, R24 has a caloric intake goal of 1247 calories a day, does DON B believe R24 is meeting that nutrition goal according to her meal intake documentation. DON B indicates, no. Surveyor asked DON B what interventions have been put in place to counteract R24 not meeting her intake goal. DON B indicates the facility has offered her assistance with meals and built-up utensils, however R24 often refuses both of those interventions. Surveyor asked DON B if those interventions have been effective at helping R24 meet her caloric intake goal. DON B indicates, no but she is also refusing those interventions. R24 did not receive cueing/reminders during meal times per her plan of care and R24 has had a significant weight loss over the last 6 months.

Based on observation, interview, and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 1 of 3 residents reviewed (R30) of a total sample of 15. R30 has a history of multiple falls. Facility staff did not implement and/or follow through on fall interventions. R30 had two falls with major injury: one unwitnessed fall that resulted in a 1.5 cm head laceration over left eyebrow with 2 stitches placed and another unwitnessed fall that resulted in a closed fracture of rib on left side. This is evidenced by: Facility Fall Prevention Policy and Procedure, dated 12/31/2009 with last revision date of 7/29/21 states in part: .A care plan will be developed and implemented to prevent falls and other accidents, based on their risk assessment .admitting nurse will do admission and fall risk assessments and adjust safety interventions as needed .care plan to be followed by staff .DON (director of nursing) will do a root cause analysis .and revise the plan of care as necessary to prevent further accidents . Facility Care Plan Policy and Procedure, dated 5/16/13 states in part: .The care plan will be continually reviewed and revised to represent the current status of the resident .the CNA (certified nursing assistant) assignment care can be posted in the resident's closet or it can be viewed from the kiosk .the care plan must be reviewed and revised quarterly, annually, and with any change in condition . Facility Resident Incident Report Policy, dated 7/12/21 and revised 4/1/24 states in part: When a resident injury or incident occurs the unit nurse will assess the situation, complete a resident incident report, and route to the Director of Nursing .Immediate interventions will be implemented by the Unit Nurse .The Director of Nursing or designee will copy the Resident Incident Report to Resident Services and as appropriate for PT (physical therapy)/OT (occupational therapy) for review .The Director of Nursing will make recommendations for improvement in care or other follow up . R30 was admitted to the facility on [DATE] with diagnoses that include corticobasal degeneration (a form of frontotemporal degeneration, a dementia that involves the loss of cognitive functions such as the ability to think, remember, or reason), chronic kidney disease, insomnia due to other mental disorder, anxiety disorder unspecified, Parkinsonism unspecified, other specified disorders of bone density and structure. R30's most recent Minimum Data Set (MDS) dated [DATE] states that R30 has a Brief Interview of Mental Status (BIMS) of 12/15 indicating that R30 has moderate cognitive impairment. Section GG of the MDS, functional abilities and goals, states that R30 requires one assist to transfer, one assist to walk in room, one assist to move about the unit, and one assist for toileting and all other ADLs (activities of daily living). R30's care plan dated 10/31/23 states in part, I fall down and hurt myself .because I have Parkinson's disease, take some medications that can make me dizzy, tired, confused, or weak .I need my nurse's to assess for unmet needs, remind me to ask for help .I need my aides to encourage me to use assistance, fall risk care plan, give me non-skid footwear so I don't slip, use the following assistive devices to be able to better help me. Goal .have no falls, avoid injury. R30's care plan dated 4/29/24 states in part, I fall down and hurt myself .because I have Parkinson's disease, take some medications that can make me dizzy, tired, confused, or weak .have fallen in the past .I need my nurse's to fall risk care plan, assess for unmet needs, remind me to ask for help, PT/OT to evaluate if walker is appropriate, may add arm holder if able to fit onto 4 wheeled walker, follow up with therapy recs .I need my aides to encourage me to use assistance, fall risk care plan, give me non-skid footwear so I don't slip, use the following assistive devices to be able to better help me, document my hand exercises in my binder, Call Don't Fall sign placed, 15 minute safety checks. Goal .continue to monitor and implement current fall interventions .may d/c (discontinue)15-minute safety checks to 30 minutes if resident remains fall free for 1 month. It is important to note that R30's care plan was updated during this recertification survey. R30's fall risk assessments are documented as follows: 10/31/23: Total Score: 11 - Resident at risk of falling. 1/29/24: Total score: 12 - Resident at risk of falling. 4/29/24 Total score: 12 - Resident at risk of falling. R30's fall reports list the following falls: 11/20/23 at 4:50 am - unwitnessed fall in resident room, no apparent injury - Resident lost balance while taking off her shoes and lowered herself to the floor. Facility fall interventions: Remind resident to use call light when going to the bathroom, offer to toilet on last rounds of NOC (nocturnal) shift. It is important to note that toileting on last rounds was not on the CNA's closet care card that they use for resident care, nor was it on resident's care plan. 12/30/23 at 3:33 am - unwitnessed fall in resident room - lost balance while attempting to open bathroom door. The facility Incident Report documents observed blood on the floor, walker and resident left side of head .Noted large 5 cm round hematoma around left above eye laceration .applied pressure to laceration .transferred to emergency room for evaluation/treatment. Facility fall interventions: Leave bathroom door ajar at night, night light added for visibility. Of note this is the second fall in less than 30 days where R30 was attempting to use the bathroom independently. The facility did not add toileting on last rounds to the care plan which the facility indicated was their new intervention after the 11/20/23 fall. R30 is care planned as a one assist with transfers and ambulation and should be assisted to the bathroom per R30's care plan to prevent further falls. R30 transferred to emergency roiagnom on [DATE] at 4:24 AM. ER encounter diagnosis: accidental fall, initial encounter - laceration of left eyebrow, initial encounter - left elbow pain. ER encounter notes state: .cleaned with Betadine, anesthetized with 1% lidocaine .wound closed with 2 sutures .laceration is 1.5 cm. 1/26/24 at 11:45 PM - unwitnessed fall in resident room - slid off bed due to soaker pad sliding while attempting to sit at edge of bed. The facility Incident Report documents c/o (complained of) pain left side/flank area .redden from shearing against bed frame. Facility fall interventions: Do not use soaker pad, add non-skid floor strips, resident refuses to wear gripper socks, instructed resident on using call light prior to transition/transferring safe transfer technique, use of call light. On 4/28/24 at 10:16 AM, Surveyor observed R30 in resident room in her recliner. The non-skid strips were not on the floor. R30 transferred to emergency roiagnom on [DATE] at 3:13 AM. ER encounter diagnosis: closed fracture of one rib of left side, initial encounter - ground level fall - new onset atrial fibrillation. ER encounter notes state: X-ray imaging of ribs, fracture along the posterior aspect of the left eight rib - CT (CAT Scan-medical imaging) of cervical spine without contrast, no cervical spine fracture seen - CT head without contrast, no intracranial hemorrhage. It is important to note this is the third fall for R30 in three months. Two falls have resulted in major injury. 3/3/24 at 7:15 PM - witnessed fall in resident room, no apparent injuries. The facility Incident Report documents: resident stood up to answer phone-resident turned and lost balance - falling to the floor - resident has hard time steering walker due to left arm weakness. Facility fall interventions: OT/PT to evaluate if walker is appropriate. Binder created to complete/check off R30's exercises. R30's Exercise Check List states in part: .These were implemented on January 24th. Her contractures are getting worse, and she is not the greatest at completing these on her own. Which is making her a bigger fall risk with her walker use. Please put a date and checkmark in the boxes. They are to be completed 3x/day. It is important to note that PT/OT evaluation for R30 was never completed, and the binder exercises indicated they are to be completed three times a day with staff assistance. The exercises were only completed 13 times from 3/18/23 to 4/15/23 with a total of 161 missed opportunities. 3/11/24 at 11:15 AM - unwitnessed fall in room, no apparent injuries. The facility Incident Report documents: resident was walked back to room from activities with assistance, resident got to doorway and walked to recliner by herself - resident attempted to turn around without the use of her walker. Facility fall interventions: educate staff to assist resident with ambulation to destination. Binder created to ensure R30 is completing her exercises from PT/OT. Call Don't Fall sign placed if she would need assistance. It is important to note R30 is a one assist with ambulation. R30 was assisted to her room from activities by a staff member. According to the fall incident report R30 was assisted to her doorway then walked to her recliner by herself instead of staff assisting to the recliner. R30 fell attempting to turn around this fall may have been prevented if R30's care plan was followed as written. On 4/28/24 10:16 AM, Surveyor observed R30 in resident room in her recliner. There was no Call Don't Fall signage in the room. 4/9/24 at 3:03 AM - witnessed fall in resident's room, no apparent injury. Facility Incident Report states: was walking back to her bed - did not use walker to turn around - staff lowered R30 to the floor. Facility fall interventions: PT consult to assess walker use and to see if an arm board will fit to make it more efficient and safe. It is important to note a PT consultation did not occur. 4/21/24 at 11:30 PM - unwitnessed fall in room, no apparent injury. Facility Incident Report states: slid out of bed while attempting to get out of bed to use the bathroom. Facility fall interventions: 15-minute checks ongoing, moved to other side of room to be closer to the bathroom, refuses gripper socks or different blanket/sheet. It is important this is the third fall related to attempting to use the bathroom. The facility did not identify this as a root cause of falls or implement toileting interventions to prevent further falls. Additionally, 15-minute checks were instituted for staff to chart on 4/22/24 to 4/27/24 but was not included on the care plan until 4/29/24. On 4/29/24 at 2:59 PM, Surveyor interviewed CNA Q (Certified Nursing Assistant). Surveyor asked CNA Q where you would find fall interventions. CNA Q stated in the care plan by the nurse's station. Surveyor asked CNA Q if he knew what the fall interventions were for R30. CNA Q reported that they do 30-minute checks and walk with her to dining room and encourage to use call light for bathroom. CNA Q indicated care plan notes are kept in resident's room inside the cupboard, called Closet Care Card. Surveyor asked CNA Q what was indicated for fall interventions on the Closet Care Card. CNA Q stated 15-minute checks. Surveyor asked CNA Q how often staff complete R30's exercises. CNA Q stated 3 to 4 times per week and that the exercise binder was kept at the nurse's station. On 4/29/24 at 4:17 PM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked if she would expect staff to assist R30 with her exercises every day. NHA A stated yes. Surveyor asked NHA A if she would expect staff to complete exercises with R30 three times per day as indicated in the binder. NHA A stated yes. On 4/30/24 at 10:39 AM, Surveyor interviewed DON B. Surveyor asked DON B how fall interventions get onto the resident's care plan. DON B stated that she updates the care plan within 24-72 hours. Surveyor asked DON B who is responsible for placing Call Don't Fall signage and non-skid floor strips in resident's rooms. DON B stated that she would put the Call Don't Fall signage up the same day of the fall, and that there were no non-skid fall strips per NHA A. DON B indicated that R30 has a Call Don't Fall sign that has been in the room since 3/11/24. Surveyor asked DON B what the process was for PT/OT to come and assess a resident post fall. DON B stated that the standing order would need to be activated. Surveyor asked DON B how she ensured the exercises that were ordered as a fall intervention were being completed with R30. DON B stated she created a binder for them to complete the exercises with R30. Surveyor asked DON B how often she expected the exercises to be completed. DON B stated once a day. Surveyor asked DON B how CNAs are made aware of changes to the care plan or new fall interventions. DON B stated the Closet Care Plan and verbal communication from shift to shift, as well as the CNA communication binder at the nurse's station. Surveyor asked DON B why if PT was added as intervention for R30's falls on 3/3/24, why was no order received from physician until 4/11/24. DON B replied, I don't know. Surveyor asked DON B if R30 had seen PT after the 4/11/24 order for consultation was received. DON B stated she had not. Surveyor asked DON B how quickly fall interventions should be implemented to keep residents safe. DON B stated immediately but at the most 2 weeks after a fall. Surveyor asked DON B at what point a new intervention should be implemented to keep R30 safe. DON B indicated within 2 weeks. Surveyor asked DON B if refusing to wear gripper socks was an appropriate fall intervention. DON B stated no and that a risk and benefit analysis should have been completed with R30. On 4/30/24 at 11:27 AM, Surveyor and DON B observed R30's room. There was no Call Don't Fall sign in the room. DON B placed Call Don't Fall signs at this time. The Closet Care Card had only 15-minute checks and ensure hand exercises are completed as fall interventions. DON B indicated that the Closet Care Card is the only thing the staff refers to for care of the resident. DON B indicated it is her expectation staff to check communication binder and Closet Care Card every shift. DON B reported they have been having communication concerns with staff and this is a work in progress. 4/30/24 at 11:25 AM, Surveyor interviewed NHA A. Surveyor asked NHA A why the non-skid strips were not installed in R30's room per the fall intervention after 1/26/24 fall. NHA A stated that the facility had gotten new flooring and the non-skid strips do not work well with new flooring, as they are similar color as the floor, and she worried they would create a greater fall risk. Surveyor asked if anything had been implemented as a fall intervention in place of the non-skid floor strips. NHA A indicated that other interventions would be found that were appropriate, but they would use the floor strips if they had to. The facility failed to create a robust fall care plan for a resident at risk for falls, update the care plan after with each fall with new and appropriate interventions, or ensure that the fall interventions were adequately communicated to the frontline care staff. R30 had multiple falls two which resulted in major injury.

Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, this has the potential to affect the total census of facility, 42 residents. The facility allowed staff to return to work too soon after reporting respiratory symptoms and were not requiring staff to be tested for COVID-19 per Centers for Disease Control and Prevention (CDC) guidance. The facility allowed staff to return to work too soon after gastrointestinal (GI) symptoms. This is evidenced by: The facility's policy titled Infection Control Measures for Acute Respiratory Illness Outbreak revised on 10/19/23 states in part .3. Surveillance 1. Monitor staff call- ins and have anyone with COVID like symptoms perform an Antigen test. If the test is negative and the staff member continues to present symptoms, they must wear a mask while working. 2. When an ARI (Acute Respiratory Illness) or COVID-19 outbreak is identified, the facility's Infection Preventionist will maintain and update a line list to organize case information .5. Documentation of testing 1. For symptomatic residents and staff, DON (Director of Nursing) or IP (Infection Preventionist) will document the date(s) and time(s) of the identification of signs or symptoms, when testing was conducted, when results were obtained, and the actions the facility took based on the results .6. Return to work for staff 1. If a staff member has tested positive for COVID-19, they will be required to follow quarantine guidelines as below .Per baseline [Facility Name] functions at a Contingency Staffing level .i. Conventional staffing: 1. At least 10 days since symptoms first appeared or 7 days with two negative tests (if asymptomatic) and 2. At least 72 hours have passed since last fever without the use of fever- reducing medications and 3. Symptoms have improved. ii. Contingency staffing: 1. 5 days with/ without negative test (if symptomatic or mild to moderate illness) and 2. Symptoms have improved . The facility's policy titled Employee Illness no date, states in part .Employees requesting to return to work after a communicable illness will consult with Infection Preventionist/ designee or their supervisor before returning to work .NOTE: these are examples only- See State and updates to Federal Guidance on restrictions for work: .Disease/ Problem: Diarrheal Diseases *Acute Stage (diarrhea with other symptoms) Work Restriction: Restrict from resident contact, contact with the resident's environment, or food handling Duration of Restriction: Until symptoms resolve, 48 hours since last episode (handwritten in). Disease/ Problem: *Norovirus (CDC) Work Restriction: Exclude from Duty Duration of Restriction: If you have symptoms consistent with norovirus infection (per the CDC symptoms include acute onset of vomiting, non-bloody diarrhea, abdominal cramps, nausea, and sometimes a low- grade fever), stay home for a minimum of 48 hours after symptom resolution. Disease/ Problem: Viral Respiratory Infections, Acute febrile Work Restrictions: Consider excluding from care of high-risk residents or contact with their environment during community outbreak of RSV or Influenza. Duration of Restriction: Until acute symptoms resolve, 24 hours fever free (handwritten in) . It is important to note that the facility's policy does not address Viral Respiratory Infections without a fever and does not indicate when an employee has symptoms that they should test for COVID-19. CDC guidance titled Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2 dated 9/23/22 states in part .Test-based strategy: HCP who are symptomatic could return to work after the following criteria are met: Resolution of fever without the use of fever-reducing medications, and Improvement in symptoms (e.g., cough, shortness of breath), and Results are negative from at least two consecutive respiratory specimens collected 48 hours apart (total of two negative specimens) tested using an antigen test or NAAT . https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assessment-hcp.html Surveyor reviewed the facility's Staff Illness Tracking for February 2024, March 2024, and April 2024. Per the documentation, the following staff returned to work too soon and did not perform COVID-19 testing per the guidance, nor did they test for Influenza during the facility's outbreak in February 2024. The documentation is as follows: Date: 2/7/24 Employee Name: CNA L (Certified Nursing Assistant) Unit last worked: 200. Date last worked: 2/6/24. Date of sx (symptoms): 2/6/24 Reason for call- in: Respiratory, Headache, Sinus/ Nasal Congestion Well date: 2/7/24. Return to work: 2/8/24. CNA L's Call-In/ [NAME] Report states that CNA L had migraine, sore throat, headache, and sinus. Date: 2/13/24 Employee Name: RN I (Registered Nurse) Unit last worked: 200. Date last worked: 2/13/24. Date of sx: 2/13/24 Reason for call- in: Diarrhea Well date: 2/14/24. Return to work: 2/16/24. RN I's Call-In/ [NAME] Report states that RN I left the faciity on [DATE] at 7:50 AM with diarrhea. RN I returned to work prior to 7:50 AM on 2/16/24. It is important to note that the facility entered an Influenza Outbreak on 2/17/24 that affected 4 residents. Date: 2/20/24 Employee Name: CNA F Unit last worked: 100. Date last worked: 2/15/24. Date of sx: 2/18/24 Reason for call- in: Nausea, Vomiting, Headache, Diarrhea, and Sinus Well date: 2/19/24. Return to work: 2/21/24. CNA F's Call-In/ [NAME] Report states that CNA F had Diarrhea and stomach cramps on 2/19/24. Date: 2/21/24 Employee Name: RN N Unit last worked: both (100 and 200) Date last worked: 2/21/24. Date of sx (symptoms): 2/21/24 Reason for call- in: Respiratory and Sinus Well date: 2/23/24. Return to work: 2/29/24. Surveyor did not receive RN N's Call-In/ [NAME] Report. Date: 2/20/24 and 2/21/24 Employee Name: RT O (Recreation Therapist) Unit last worked: rec therapy. Date last worked: 2/19/24. Date of sx (symptoms): 2/20/24 Reason for call- in: Respiratory and Sinus Well date: 2/21/24. Return to work: 2/22/24. RT O's Call-In/ [NAME] Report states that RT O reported symptoms of pressure in sinuses, exhaustion, sore throat, and congestion. RT O's COVID test was negative, no fever, and RT O was not tested for influenza as this was during the facilities influenza outbreak. Date: 2/27/24 Employee Name: RN I Unit last worked: 100. Date last worked: 2/26/24. Date of sx (symptoms): 2/26/24 Reason for call- in: Respiratory, Cough, Sinus Well date: 2/29/24. Return to work: 3/1/24. Surveyor did not receive RN I's Call-In/ [NAME] Report. Date: 3/5/24 Employee Name: CNA Q Unit last worked: 100. Date last worked: 3/4/24. Date of sx (symptoms): 3/5/24 Reason for call- in: Nausea, Vomiting, Diarrhea Well date: food related. Return to work: 3/6/24. CNA Q's Call-In/ [NAME] Report states that CNA Q had Diarrhea and Nausea/ Vomiting. Date: 3/12/24 Employee Name: DA P (Dietary Aide) Unit last worked: Kitchen. Date last worked: no date listed. Date of sx (symptoms): 3/12/24 Reason for call- in: Nausea Well date: 3/13/24. Return to work: 3/13/24. DA P's Call-In/ [NAME] Report states that DA P had Nausea/ Vomiting, not feeling well, feels like crap. On 4/30/24 at 3:36 PM, Surveyor interviewed RN M, who is also the Infection Preventionist. Surveyor asked RN M how she determines when staff can return to work after calling off with an illness, RN M stated staff have to be 48 hours without nausea and vomiting and have to be 24 hours fever free without a fever reducing agent. Surveyor asked RN M to review the Staff Illness Tracking form. Surveyor asked RN M what CNA L's respiratory symptoms were based off the line list, RN M reported that she believed CNA L had a cough. Surveyor asked if that should have been indicated on the line list, RN M stated yes. Surveyor asked RN M if CNA L called in sick on 2/7/24, how could her well date be 2/7/24 and then her return-to-work date be 2/8/24, RN M stated that she would have to do a better job at recording times. Surveyor asked RN M if RN I should have returned to work on 2/16/24, RN M stated that it depends on RN I's symptoms. Surveyor asked RN M if RN I had been symptom free for a full 48 hours before returning to work, RN M stated RN I should have returned to work on 2/17/24. Surveyor discussed CNA F's call- in with RN M. Surveyor asked RN M if CNA F were symptom free on 2/19/24, if she called in sick on 2/19/24, RN M stated that she would have to check. Surveyor asked RN M about RT O. Surveyor asked RN M if, considering that the facility was in an Influenza outbreak, did RT O get tested for influenza, RN M stated no. Surveyor asked RN M if RT O had 2 negative COVID tests before returning to work, RN M stated that the form does not indicate. Surveyor asked RN M if she would expect that RT O would have been tested for Influenza and have 2 negative COVID tests before returning to work, RN M stated yes. Surveyor asked RN M when CNA Q's well date was, RN M reported that CNA Q indicated that his illness was food related. Surveyor asked RN M, based on CNA Q's symptoms, when should he have returned to work, RN M stated 3/8/24. Surveyor asked RN M if DA P returned to work too soon, RN M stated that the Dietary Manager allowed DA P to return to work, but she should have been off longer. Surveyor asked RN M if the staff member with respiratory symptoms were tested for COVID, RN M stated no. Surveyor asked if she would expect them to have been COVID tested , RN M stated she would not expect COVID testing to be done if they weren't in a COVID outbreak. Surveyor asked RN M if during their Influenza outbreak, would she expect staff with symptoms to get tested for Influenza, RN M stated that a few staff members did get tested . RN M did not provide documentation of staff members that were tested for Influenza. The facility failed to ensure that staff members remained off work for the specified time based on current standards of practice for acute respiratory illnesses and GI symptoms, nor did they require staff to complete testing, when showing signs and symptoms of potential communicable diseases.

Based on record review and interview, the facility did not ensure that Physician Orders were signed and dated timely for 4 of 19 residents (R7, R5, R2, R16) and 1 supplemental resident reviewed for physician orders. R5's telephone orders are not signed by a physician. R7's telephone orders are not signed by a physician. R2's physician telephone orders were not signed and dated by a physician in a timely manner. R16's physician telephone orders were not signed and dated by a physician in a timely manner. Evidenced by: The facility policy, entitled Physician Services, dated 4/1/24, states, in part: . Policy: It is the responsibility of Norseland Nursing Home to ensure that physician services are available to the residents of this facility. Procedure: I. Physician Services 483.30 . 3. Physician Visits- The Physician must: a. Review the resident's total program of care, including medications and treatments . c. Sign and date all orders with the exception of influenza and pneumococcal polysaccharide vaccines . Example 1 R5 was admitted to the facility on [DATE], and has diagnoses that include Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), Type Two Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and hyperlipidemia (a condition in which there are high levels of fat particles in the blood). R5's telephone orders from 11/28/24 through 4/23/24 are not signed by a physician. Example 2 R7 was admitted to the facility on [DATE], and has diagnoses that include Interstitial pulmonary disease (a group of disorders that cause progressive scarring of the lung tissue), dementia (a general term for the loss of cognitive functioning that interferes with a person's daily life), and chronic kidney disease (longstanding disease of the kidneys leading to kidney failure). R7's telephone orders from 11/22/24 through 4/24/24 are not signed by a physician. On 4/30/24 at 9:05 AM, Surveyor interviewed RN J (Registered Nurse) and asked what the process is for obtaining a telephone order from a physician. RN J indicated one gets the order over the phone from the physician's nurse or physician and then it goes under physician tab in chart. The nurse who receives the order fills in the physician's name and medication. The order gets entered into the computer system. The carbon copy gets torn off and given to a second nurse to check the order against the order entered into the computer system. The second nurse co-signs physician's order under the co-sign tab. RN J indicated the pink carbon copy goes to the nurse desk until the end of the shift where we make sure it gets communicated to oncoming shift. The physician comes to facility typically once a week and the nurse working with the physician has the physician sign the copy. Surveyor asked RN J who would be responsible for obtaining the physician signature on the copies of the telephone orders and RN J indicated the nurse doing rounds with the physician. Surveyor asked RN J where the carbon copies of the telephone orders go after signature is obtained and RN J indicated not knowing. On 4/30/24 at 9:17 AM, Surveyor interviewed RN I and asked what the process is for obtaining a telephone order from a physician. RN I indicated the nurse taking the telephone order from the physician writes the orders on the slip with the date, resident, date of birth, physician's name and nurse receiving the order. The order then gets entered into the computer system into the MAR/TAR (medication administration record/treatment administration record). A second nurse checks the order and co-signs in computer system. The pink carbon copy goes in a folder at the nurse station for the physician to sign. Surveyor asked RN I where the pink carbon copies go after signed and RN I indicated she was not sure. Surveyor asked if a telephone order is required to be signed by a physician and RN I indicated yes within 7 days. RN I indicated the nurse manager rounding with the physician has the physician sign them weekly on Wednesdays. On 4/30/24 at 9:25 AM, Surveyor interviewed DON B (Director of Nursing) and RN M and asked what the process is for obtaining a telephone order from a physician. RN M indicated the nurse taking the order from the physician or the physician's nurse, puts the order on a Physician Order Sheet or on the Provider Communication Form. The order gets entered into the computer system by the nurse taking the order. A second nurse co-signs after checking the order entered into the computer system to the order on paper. DON B indicated the pink carbon copies go into the resident's thin file where we keep them for 5 years. DON B indicated the pink carbon copies are not signed by a physician; they are used for facility communication only. The carbon copies stay on the nurses 24-hour board for oncoming shifts to see. DON B and RN M indicated physicians never view telephone orders because the orders go into the computer system and physician orders get printed out for the physician to sign on rounds. Surveyor asked if a resident does not get seen one month what happens with telephone order and DON B indicated the order will get signed the next month. Surveyor asked DON B if a telephone order should be signed by a physician and DON B indicated not if it is a verbal order. DON B indicated RN M is responsible for printing physician orders off to be signed when a resident is seen by a physician. If a resident is not seen, they are signed on next visit. On 4/30/24 at 11:10 AM, NHA A (Nursing Home Administrator) indicated to Surveyor it is her expectation telephone orders are to be signed by a physician within 10 days. 49434 Example 3 On 4/29/24, Surveyor reviewed R2's physician's telephone orders from 1/2/24 through 4/24/24. Surveyor noted that these orders were signed by facility Registered Nurses (RNs), but no physician signatures were present. Example 4 On 4/29/24, Surveyor reviewed R16's physician's telephone orders from 12/1/23 through 4/22/24. Surveyor noted that these orders were signed by the facility RNs, but no physician signatures were present.

Based on interview and record review, the facility did not ensure a resident with limited range of motion receives appropriate treatment and services to increase their range of motion and/or to prevent a further decrease in range of motion for 3 of 16 total sampled Residents (R7, R8, R16) and 1 of 1 supplemental resident's (R31). R8 has therapy recommendations for restorative therapy including the [NAME] Med bike four times weekly for twelve minutes and passive range of motion exercises daily that are not being completed. R16 has orders to participate in a walking program twice a day-AM (morning) and PM (evening), CGA (contact guard assist) with four-wheeled walker, wheelchair to follow-distance as tolerated that is not being completed. R31 is on the restorative walking program and the facility does not have documentation to show R31 is being walked. R7 is on the restorative walking program and the facility does not have documentation to show R7 is being walked. Evidenced by: The facility policy titled, Restorative Policy last reviewed 4/1/2024, states in part, Purpose: to promote resident ability. To improve/maintain/regain self-performance or prevent decline in various ADLs (activities of daily living), so that they may adapt and adjust to living as independently and safely as possible. Resident participation is a requirement for all restorative programming except for PRM (passive range of motion) and splint/brace use to prevent contractures. Procedure: programs will be individualized by identifying goals, approaches, and safety areas for that resident. An accumulation of minutes will include explanations, set-up, verbal cuing, supervision, demonstration, clean-up, etc. Changes in ability and/or function will be reported to the unit nurse so that updates/revisions can be made. As a resident's needs and abilities change, the program will be updated. PT/OT/ST (Physical Therapy/Occupational Therapy/Speech Therapy) will communicate to nursing pertinent recommendations for the resident's restorative program and will be added by the nurse manager or the DON (Director of Nursing). A referral to PT/OT/ST will be forwarded as needed for the residents that are showing a decline in ADL function. Example 1 R8 was admitted to the facility on [DATE], with the latest readmission on 3/8/24. R8 has diagnoses that include in part . iliotibial band syndrome-right leg, contracture-unspecified hand, unspecified abnormalities of gait and mobility, low back pain, myoneural disorder-unspecified, pain in leg unspecified, osteoarthritis- right and left hand, weakness, vitamin D deficiency, syndrome of inappropriate antidiuretic hormone (SIADH). R8's Significant Change Minimum Data Set (MDS) dated [DATE] indicates R8 has a Brief Interview of Mental Status (BIMS) of 15 indicating that he is cognitively intact. No mood or behaviors noted. Resident has limited range of motion in upper and lower extremities. Resident is dependent on staff for bathing. R8 requires substantial/maximal assist for upper and lower body dressing, personal hygiene, bed mobility, and transfers. Urinary incontinence is not rated and R8 is always incontinent of bowel. On 8/23/23, facility document titled Therapy Communication to Nursing for R8 states in part, start the following therapy: PT. Goal: Restorative program. Recommendation: May use [NAME] med bike (a therapy device that enables patients with restricted mobility a motor driven, and motor assisted leg and/or arm training from a seated position) daily for maintaining leg strength and mobility. Four times weekly for 12 minutes. Will need assistance to set up. Questions, see therapy. On 3/22/24, facility document titled Therapy Communication to Nursing for R8 states in part . start the following therapy: PT. Goal: Range of motion program. Recommendation: See attached exercises. Complete one time a day to maintain mobility and flexibility in lower extremity. Attached exercises include, calf stretch PROM (passive range of motion), hip PROM-flexion-extension, hip PROM-abduction-adduction, and hip PROM-rotation. R8 is to receive [NAME] bike daily for maintaining leg strength and mobility 4 times weekly for 12 minutes. R8's restorative documentation indicates he has not received this treatment over the last 30 days. R8 is to receive PROM daily. Review of R8's restorative documentation indicates that from 3/22/24 to 4/30/24 R8 received restorative PROM 16 times out of a possible 39 times. Example 2 R16 was admitted to the facility on [DATE] with the diagnosis that include in part . Congestive Heart Failure (CHF), atrial fibrillation, cerebral infarction, pleural effusion, type 2 diabetes, and anemia. Review of R16's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/20/24, located in the EMR under the MDS tab, indicated R4 had a Brief Interview for Mental Status (BIMS) score of 13 of 15, which indicated R16 is cognitively intact. Toileting/hygiene, toilet transfers showering, personal hygiene, upper and lower body dressing are all partial/moderate assistance. R16 is independent with bed mobility. Frequently incontinent of urine and always continent of bowel. The MDS also indicates that R16 is on oxygen therapy. On 11/27/23, facility document titled Therapy Communication to Nursing for R16 states in part, Goal: Return to PLOF (prior level of function) and possibly wean from O2. Recommendation: Please resume walking program one to two times a day with four-wheeled walker, CGA (contact guard assist), with wheelchair to follow. Distance as tolerated. Also, can we try to wean O2. She was stable in the low to mid- 90's at rest and with activity on 1L with PT. Physical therapy discharge summary dated 2/29/24 at 4:37 PM states, in part, Restorative programs: Restorative program establish/trained=restorative ambulation program. Ambulation program establish/trained: Patient to ambulate with nursing daily distance as tolerated with four-wheeled walker and wheelchair to follow. The Certified Nursing Assistant (CNA) Care Card printed 4/30/24, states in part, Restorative: Walking program twice a day-AM and PMs. CGA with four-wheeled walker, wheelchair to follow-distance as tolerated. R8's comprehensive care plan does not address restorative services that were ordered by physical therapy. R8's restorative documentation from 3/1/24 to 4/30/24, shows R8 was walked on the following dates and times: 3/1/24 at 13:09 (1:09 PM) 3/1/24 at 21:03 (9:03 PM) 3/3/24 at 10:24 AM 3/4/24 at 10:44 AM 3/5/24 at 11:24 AM 3/6/24 at 13:15 (1:15 PM) 3/7/24 at 13:13 (1:13 PM) 3/9/25 at 13:50 (1:50 PM) 3/10/24 at 13:24 (1:24 PM) 3/12/24 at 13:14 (1:14 PM) 3/19/24 at 15:15 (3:15 PM) 3/21/24 at 13:16 (1:16 PM) 3/23/24 at 10:17 AM 3/24/24 at 13:50 (1:50 PM) 3/26/24 at 13:25 (1:25 PM) 3/30/24 at 13:40 (1:40 PM) 3/30/24 at 14:09 (2:09 PM) 4/15/24 at 13:28 (1:28 PM) 4/28/24 at 13:29 (1:29 PM) Of Note: From 3/1/24 through 4/30/24 R1 was walked a total of 19 times out of a possible 122 times. On 4/28/24 at 10:10 AM, Surveyor interviewed R8. Surveyor asked if R8 had any concerns regarding his care in the facility. R8 states, he is supposed to be receiving additional ROM assistance three time a week from staff; however, this is not being done. Surveyor asked R8 if he knew which staff members are supposed to be completing these exercises with him. R8 stated, physical therapy staff told him that nursing staff are supposed to assist him with his range of motion exercises, but no one had been helping him with his exercises. On 4/29/24 at 2:07 PM, Surveyor interviewed R8. Surveyor asked R8 how missing his restorative therapy sessions has affected him. R8 states, if they kept up on therapy, it would help my knees and legs .it's just never been done. Surveyor asked R8 if he ever refuses his restorative therapy exercises. R8 states, no, I always use it. Anything to help me get better, I'm going to do it. On 4/29/24 at 3:49 PM, Surveyor interviewed PTA R (Physical Therapy Assistant). Surveyor asked PTA R who is responsible for completing the restorative and walking programs. PTA R stated that the CNAs (Certified Nursing Assistants) are expected to complete both programs. Surveyor asked PTA R how restorative and walking program orders are communicated to the nursing staff. PTA R stated that she makes three copies of the orders. One copy goes to the Director of Nursing, one copy goes to the charge nurse, usually RN M (Registered Nurse), and the last copy goes to a floor nurse currently on shift. On 4/30/24 at 1:33 PM, Surveyor interviewed CNA C. Surveyor asked CNA C if the facility has a restorative or walking program. CNA C states we have a walking program and its done if we have time. We often can't get through the entire list. ROM is completed with dressing. Surveyor asked CNA C were the restorative program orders/recommendations come from. CNA C states that the restorative orders come from therapy. Surveyor asked CNA C how she knows who is on a restorative program. CNA C states she can ask others and she also keeps a personal cheat sheet as a reminder. Surveyor asked CNA C what she does when someone refuses restorative. CNA C states that she talks to the nurse or OT about anyone that declines. CNA C states that they have a binder that they document walking in, but since Surveyors have arrived in the building, management took away the binder. On 4/30/24 at 13:37 (1:37 PM) Surveyor interviewed RN I (Registered Nurse). Surveyor asked RN I what the procedure is for a resident who shows a decline in function or abilities. RN I states that if it is an acute change, the facility has standing orders for PT/OT/Speech evaluations and that RN I updates the provider to notify them that they are implementing the standing orders. A sheet is completed and given to management notifying them of the implementation of the standing orders. Surveyor asked RN I what staff do with therapy recommendations. RN I states that therapy will write out a communication sheet, 1 sheet goes to the nurse manager who updates the care plan. A copy is made and put into the communication book. Surveyor asked RN I what they do if the resident refuses restorative services. RN I states she talks to the resident about the refusals to attempt to determine a cause and updates the physician. Surveyor asked RN I what the expectation is for staff who can't complete the restorative program to-do list. RN I states that staff should report it to the nurse if they can't get it done and that the nurse should report it to management if they realize it isn't being done. RN I also stated, we really need a restorative aide. Every place I've worked has one and we really need one. On 4/30/24 at 13:45 (1:45 PM) Surveyor interviewed CNA F. Surveyor asked CNA F about the facility restorative program. CNA F states that we walk them and do ROM (range of motion). Surveyor asked CNA F where she finds the restorative program information. CNA F states that the information is on everybody's care plan. Surveyor asked CNA F how she is provided new orders or changes to someone's current restorative program. CNA F states, there may be a note on the desk or with staff report during shift change. Surveyor asked CNA F what she does if she notices someone has a decline in ROM. CNA F states that she notifies a nurse that the resident may need a therapy evaluation. Surveyor asked CNA F about R8's restorative program. CNA F states, R8 has ROM with left arm and leg. Surveyor asked if R8 ever refuses restorative therapy. CNA F states he never refuses ROM therapy. Surveyor asked CNA F what they do if someone refuses restorative therapy. CNA F states, they reapproach in the afternoon and chart any refusals. Surveyor asked CNA F how to perform and complete prescribed exercises. CNA F states, therapy gives us something to follow on what exercises we should do with print out pictures. Surveyor asked CNA F what they do if they are unable to complete restorative therapy with a resident. CNA F states, if it can't get done, I chart not completed because of environment which means i.e., staffing, it happens a lot. On 4/30/24 at 1:54 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what the process is for conducting the facility's restorative therapy program. DON B states, all the restorative therapy orders are put in through restorative nurse on the electronic charting system. The process was changed in January as we identified an issue with the electronic charting system not triggering staff to chart the restorative program. Communication comes from PT/OT and a copy is given to the floor nurse and all management personnel and added to the to-do list in the electronic charting system. The walking program binder was also added in January. Surveyor asked who is expected to conduct restorative program orders. DON B states, the CNA's are supposed to conduct restorative program orders, whatever the order is whether it be ROM or the walking program. Surveyor asked DON B what the expectations are for CNA's regarding the restorative program. DON B states, if they can't get it done it is to be passed off to the next shift unless the resident refuses. If the resident refuses it needs to be charted as a refusal. Documentation should be completed whether the resident refuses or the ordered activity is completed. Surveyor asked DON B if the expectation is for CNA's to chart in the walking binder, resident walks, and refusals. DON B states, yes. Surveyor asked DON B if she would expect the CNA to notify a nurse if a resident had a noticeable change in ability. DON B states, yes. Surveyor asked DON B if the expectation would be for a CNA to report frequent refusals of restorative orders. DON B states, yes. Surveyor asked DON B if R8 is at risk for a decline in function. DON B states if he continues to refuse and not participate in prescribed exercises with staff. It can be hit or miss with him. Surveyor asked DON B why R8 is at risk for a decline in ROM. DON B states, R8 has refusals, can make inappropriate comments towards staff, can be unpleasant and rude towards staff, and at times expects staff to do everything for him. DON B indicates also has a right-sided neuromuscular disorder. Surveyor asks DON B what interventions are in place to prevent a decline in R8's ROM. DON B states, R8 has a restorative plan but I do not know what that is off the top of my head. Surveyor asked DON B if R8 also has a ROM restorative plan. DON B states yes. Surveyor asked DON B if R16 is at a risk for a decline in function. DON B states yes, based on age and diagnosis. The facility did not ensure that restorative therapy exercises and activities were completed for each resident to maintain current abilities, prevent decline, or to restore baseline abilities. 41788 Example 3 R31 was admitted to the facility on [DATE], and has diagnoses that include Atherosclerosis of native arteries of left leg with ulceration of other part of lower leg (a disease that causes the arteries that supply the legs and feet to narrow and harden) and venous insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes). R31's Quarterly Minimum Data Set (MDS) Assessment, dated 3/20/24, shows R31 has a Brief Interview of Mental Status (BIMS) score of 15 indicating R31 is cognitively intact. R31's care plan dated 4/19/24, states, in part: . Need/Preference: I can't complete my cares on my own. I want to return to my previous living situation because I have hemiplegia- CVA (cerebrovascular accident)/left side affected. I show this by having a hard time moving getting tired quickly voicing frustration . Approach: I walk with 2 helpers providing more than half the effort follow my restorative walking plan ONCE DAILY 2A (assist) 2 WW (wheeled walker), gait belt, w/c (wheelchair) to follow. Currently tolerates 50-75 feet . R31's Therapy Communication to Nursing Form, dated 12/18/23, states, in part: . Resident is Changes to Plan of Care From the following therapy: PT (Physical Therapy) Goal: Walking Program Recommendations: Please walk 1x/day with 2 persons assist using 2 ww, gait belt, and w/c follow. Currently tolerates 50 -75 feet . Certified Nursing Assistant (CNA) documentation for daily ambulating for March 1, 2024, through May 1, 2024, shows R31 was not ambulated on following dates: 4/23, 4/22, 4/21, 4/19, 4/14, 4/13, 4/10, 4/9, 4/7, 4/6, 4/5, 3/31, 3/29, 3/28, 3/24, 3/21, 3/19, 3/18, 3/16, 3/15, 3/14, 3/13, 3/12, 3/10, 3/7, 3/6, 3/4, and 3/1. This shows R31 did not get ambulated 28 days out of 62 days. Of note: This is not following therapy recommendations for every day. R31's Walking Program Documentation sheets from 3/31/24- 4/29/24 shows R31 walked 2 days out of 30 days. Of note: This is not following therapy recommendations for every day. Example 4 R7 was admitted to the facility on [DATE] and has diagnoses that include Polyosteoarthritis (a joint disease that affects at least five joints simultaneously), Muscle weakness (generalized), and difficulty in walking. R7's Quarterly Minimum Data Set (MDS) Assessment, dated 3/20/24, shows that R7 has a BIMS score of 13 indicating R7 is cognitively intact. R7's Care Plan dated 3/1/24, states, in part: . Need/Preference: I need some assistance with my personal cares because I have poor balance, OA (osteoarthritis), get confused, chronic pain, some limitations. I show this by having a hard moving, being forgetful, trying things on my own . Approach: . I walk with the help of 1 person with gait belt and 4 ww . R7's CNA Kardex, with a print date of 4/30/24, states, in part: . Restorative: Walk with 1 assist FWW (Front wheeled walker), gait belt, with wheelchair to follow AM and PM daily . R7's therapy recommendations, dated 3/9/23, states, Walking: On the unit assist of 1 with 4 ww, gait belt, wheelchair to follow, and o2 (oxygen) on halfway down the hall and back to room two times a day every day. CNA documentation for daily ambulating for 3/1/24 through 4/28/24, shows a total of 61 days R7 should have been ambulated twice a day totally 122 times R7 should have been ambulated. R7 was ambulated only 30 times out of 122 times as per recommendations of therapy. Of note: This is not following therapy recommendations for every day. R7's Walking Program Documentation sheets from 3/31/24- 4/29/24 shows R7 walked 1 time/day x 1 day out of 30 days. Of note: This is not following therapy recommendations for every day. On 4/30/24 at 1:05 PM, Surveyor interviewed PTA R (Physical Therapy Assistant). PTA R indicated R31 is currently working with PT (physical therapy) and PT has recommended R31 to be on walking program for walking one time a day with a walker with 1 assist as tolerated. Surveyor asked PTA R if she would expect the recommendation to be followed and documented and PTA R indicated yes in the walking book at the nurses' station or in the computer. Surveyor asked who is responsible to walk the residents on the walking program and PTA R indicated the CNAs. PTA R indicated therapy would expect the CNAs to be following the walking program for residents on it and documenting. Surveyor asked PTA R if R7 was on the walking program and PTA R indicated yes. PTA R indicated therapy would expect the CNAs to be following the walking program for R7 and documenting as well.

Based on interview and record review, the facility failed to ensure that all residents were able to formulate an advance directive, specifically related to code status, for 1 of 19 sampled residents (R5) reviewed for advance directives. The facility does not have R5's advance directives in her medical record. Evidenced by: The facility policy, entitled POLST (Physician Orders for Life Sustaining Treatment)/Advance Directives, dated 2/1/22, states, in part: . Advance Directives: 1. Upon resident move in, the Social Worker will determine if the resident has any advance directives (i.e., Power of Attorney for Health Care, Power of Attorney for Finances). 2. If Advance Directives are not present, the Social Worker will meet with the resident within the first 14 days from arrival to advise them of their right to establish Advance Directives and to offer assistance should they wish to create them. 3. Advance Directives will be reviewed at the initial care conference and the quarterly care conferences. If changes are made to the Advance Directive, appropriate forms will be filled out and signed by the resident. 4. Copies of these documents will be filed in the resident's physical chart as well as updating the hospital records and informing agents of any changes made. R5 was admitted to the facility on [DATE], and has diagnoses that include Alzheimer's Disease, Type Two Diabetes Mellitus and Spinal Stenosis. R5's Quarterly Minimum Data Set Assessment, dated 7/27/22, shows R5 had a Brief Interview of Mental Status (BIMS) score of 3 indicating R5 has severe cognitive impairment. Advance Care Planning (ACP) note by (Physician Name) MD (medical doctor), dated December 3, 2020, states: I have personally examined the patient and have determined that she is unable to receive and evaluate information effectively, and communicate decisions necessary to manage her health care. I recommend that the provisions contained in her Power of Attorney for Health Care be activated. ACP note by (Physician Name) MD, dated December 5, 2020, states: I have personally examined the patient and have determined that she is unable to receive and evaluate information effectively, and communicate decisions necessary to manage her health care. I recommend that the provisions contained in her Power of Attorney for Health Care be activated. R5's Advanced Practice Nurse Prescriber (APNP) office visit note, dated 1/31/22, states, in part: . She has Alzheimer's. Her POA (Power of Attorney) is activated . On 4/29/24 at 3:10 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked if R5 has Advance Directives and NHA A indicated yes. Surveyor asked NHA A if she could show documentation of the Advanced Directives to Surveyor. NHA A was unable to locate them in R5's medical record but provided a social service note indicating R5's POA. NHA A also provided two doctor notes recommending POA be activated. Surveyor asked NHA A if R5 has advance directives should they be signed and in R5's medical record and NHA A indicated yes, and they are not. On 4/29/24 at 4:15 PM, NHA A supplied a copy of R5's Advance Directives to Surveyor. NHA A indicated she had just called over to the hospital and received the Advance Directives by fax. NHA A indicated she provided education to the social worker regarding Advanced Directives.

Based on interviews and record reviews, and facility policy review, the facility failed to develop and implement a baseline care plan within 48 hours of admission that included the minimum healthcare information necessary to properly care for R36's immediate needs related to his mental health diagnosis upon admission for one of three residents (Resident (R) 36) of 15 sampled residents. Findings include: Review of the facility's policy titled, Care Plan, updated 04/1/24, revealed each resident would have a specific plan of care, developed on information gathered from the Minimum Data Set (MDS)/Care Area Assessment (CAA)'s, other assessment tools, resident/family expectations, and physician/therapist orders. The policy stated that the plan of care would be developed through an interdisciplinary approach within 48 hours of resident's admission to the facility, and would contain goals, approaches, and interventions to address the risks, problems, and issues associated with the resident. Review of R36's Electronic Medical Record (EMR) under the Face Sheet tab, revealed R36 was admitted from an acute care hospital to the facility on [DATE], with diagnoses which included bipolar depression, post-traumatic stress disorder (PTSD), depression, and anxiousness associated with depression. Review of R36's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/4/24 revealed diagnoses which included bipolar mood disorder, anxiety disorder, and PTSD. The MDS indicated R36 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. Review of R36's EMR under the Physician Orders tab, dated 3/29/24, revealed R36 was administered Lamotrigine (anti-seizure medication) 100 mg (Milligram) tab twice daily for bipolar depression, Prazosin (alpha blocker medication) 1mg capsule once daily for PTSD, Trazodone (anti-depressant medication) 50 mg Tablet once nightly for insomnia associated with depression, Bupropion (anti-depressant medication) XL 300 mg daily for indications of anxiousness associated with depression, and Escitalopram (anti-depressant medication) 20 mg tablet daily for indications of anxiousness associated with depression. Review of the hospital discharge summary, dated 3/29/24 and located in the EMR under the Other tab, revealed the hospital physician indicated that R36 has word-finding difficulties at times and has a slower response time given his head injury in August 2023. The discharge summary indicated no tests were pending at discharge, a reference to Consult to Social Services, and restorative services of physical and occupational therapy. The summary included a list of discharge medications to include lamotrigine, prazosin, trazodone, bupropion, and escitalopram. Review of R36's EMR baseline care plan summary under the Care Plan tab with an ARD of 4/4/24 through 4/29/24, had no care planned problems or interventions associated with his psychosocial diagnosis or medications administered for his psychosocial diagnosis. During an interview on 4/29/24 at 11:34 AM, DON B (Director of Nursing), stated that her expectation for R36 upon his admission was that he should have had a care plan from nursing and social services to address his psychosocial needs. She stated that the care plan did not indicate nursing or social services had addressed his psychosocial needs related to his mental illness diagnosis and antipsychotic medications. During an interview on 4/30/24 at 3:00 PM, SW E (Social Worker) stated that she had not addressed R36's psychosocial needs in his care plan because it was not on the list of problems documented by the hospital discharging physician.

Based on interview, record review, and facility policy review, the facility failed to ensure physician's orders were followed according to professional standards for one resident (R) out of 19 sampled (R16). Specifically, the facility failed to follow physician daily weight orders and orders to check R16's O2 saturation on room air every shift to wean R16 off oxygen. This had the potential to cause R16 not to receive the necessary care for treatment of R16's congestive heart failure (CHF) and the use of unnecessary oxygen. Findings include: Review of the facility's policy titled Weights last reviewed on 4/1/24 states in part, Purpose: To identify and provide nutritional interventions to maintain control of weight loss or gain in residents. Weight will be monitored and assessed to prevent avoidable weight loss and/or weight gain. Procedure: If a resident is determined to be at nutritional risk, they will be weighed weekly, twice weekly, or daily depending upon the assessment of the IDT (interdisciplinary team) during weekly risk meeting. Weights triggering greater than 5lb loss or gain in 1 month/week MD (medical doctor) will be updated along with POA (power of attorney) or guardian. Of note: the facility policy does not address a physician's orders for daily weights for a resident with CHF. Review of the facility's policy titled Oxygen Use and Documentation last reviewed on 4/1/24 states in part, Purpose: To provide guidelines for oxygen use and documentation. Procedure: Oxygen use shall be checked every shift by a nurse. If oxygen is being used, indicate the flow in liters per minute (L/min) in the EMAR/ETAR (electronic medical record/electronic treatment administration record), If oxygen saturation (O2 Sat) checks are done according to the physician's order, note the results in the EMAR/ETAR. R16 was admitted to the facility on [DATE], with the diagnosis that include in part . CHF, atrial fibrillation, cerebral infarction, pleural effusion, type 2 diabetes, and anemia. Review of R16's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/20/24 indicates R16 has a Brief Interview for Mental Status (BIMS) score of 13 of 15, which indicates R16 is cognitively intact. Toileting/hygiene, toilet transfers showering, personal hygiene, upper and lower body dressing are all partial/moderate assistance. R16 is independent with bed mobility. Frequently incontinent of urine and always continent of bowel. MDS also indicates that R16 is on oxygen therapy. R16's care plan states, in part, I have the potential to have cardiovascular problems because I have high blood pressure. I show this by having to take BP (blood pressure) medication. I need my nurses to .monitor my vital signs as needed, observe for effectiveness or adverse side effects . assess heart/lung sounds . monitor my respiratory status and use of O2. I need my aides to notify the nurse if I have SOB (shortness of breath) . if I have an increase in edema to my lower legs or abdomen . check my weight as ordered. Of note: R16's care plan does not address her CHF diagnosis. Physician's orders dated 11/29/23, states in part, Check room air oxygen saturation to wean off oxygen every shift NOC (night) AM (morning) PM (evening). May apply oxygen 1-4 Liters via nasal cannula for respiratory distress or O2 (oxygen) sats below 88% every shift NOC AM PM. Physician's telephone order dated 4/2/24, states in part, 1. Increase Bumex to 2 mg BID (twice daily) for CHF. 2. Daily weights. 3. Monitor lung sounds, update Monday. In review of R16's EMAR, the facility was checking R16's oxygen saturation every shift but was not checking R16's oxygen saturation on room air as ordered. In review of R16's progress note dated 1/7/24 at 12:59 PM, resident was not feeling well this morning. Resident complained of dizziness, skin was pale, maybe almost nauseous. Vitals stable, blood sugar slightly higher than her usual in the morning. Sips of water taken in. I feel like my heart is fluttering around. Some work of breathing noted, oxygen saturations stable. Gave morning medications and instructed resident to take slow breaths and focus on her breathing. Sat resident by the cart with me to keep an eye on her. Resident ate breakfast and was doing ok. Resident also ate lunch and color looked better, also stated she felt a little better but felt off, just don't know why. Will continue to monitor resident. Doing well thus far in the shift. Progress notes dated 1/11/24 at 11:02 AM, 13:27 (1:27 PM), and 22:08 (10:08 PM) states, resident had complaints of SOB this morning. Oxygen saturation levels checked at that time was 92% on 2L of oxygen. Gave resident her morning medications, appeared to be doing ok. Resident was wheeling herself back to her room when she stopped RN (Registered Nurse) in the hallway and state, she felt shaky. Resident was taken down to her room, vitals were taken. Blood pressure on higher side though had morning medications. Pulse was still on higher side for resident though had taken her medications. Oxygen saturations were at 86-88% on 2L(liter) of oxygen. Increased to 4L of oxygen, stable at 93% at 4L, provider called and updated. UA (urinalysis) and labs obtained and sent out for review. Bladder scan done; 57 mL's (milliliters) noted in the bladder post void. Lungs diminished, heart irregular per baseline. Increased edema noted bilaterally to lower extremities and rechecked pulse oxygen. Resident was on 4L of oxygen at 96% saturation level, turned oxygen down to 3L and was stable at 92%. Labs reviewed which were unremarkable, faxed over to provider. Called provider and asked what she would like us to do more for resident. Order to give one time dose extra of 1 mg (milligram) Bumex (diuretic) this afternoon and then to call again later for an update. and Follow up on resident's status per physician request. Residents SOB (shortness of breath) has resolved. Oxygen saturation 94 percent of 4 liters. All other vital signs unremarkable. Slight congestion noted to the lower bases of both lungs. Edema 2+ (plus) pitting to the left lower leg and ankle. +1 edema noted to the right ankle. Resident states she is feeling better, but still feels ill. Progress note dated 1/12/24 at 13:29 (1:29 PM) states in part, . RLL (right lower lobe) continues to have course crackles noted, LLL (left lower lobe) clear and diminished. Edema noted to be 3+ bilaterally in the lower extremities yesterday. Today lower extremities are significantly improved (+1 edema). Work of breathing has improved as well. Skin color is more vibrant than yesterday . Progress note dated 1/16/24 at 10:35 AM states in part, . no complaints with exception of I'm a little short of breath . Progress notes dated 1/20/24 at 13:39 (1:39 PM) states, change in condition: resident not feeling well before lunch. Stated her head felt funny, maybe SOB, idk (I don't know). I just don't feel right. Noted that resident had +2 increased edema to LLE (left lower extremities), crackles noted to LLL. Oxygen saturations at 2L was 89-92%. Result: new orders received and noted. 1/20/24 give one-time extra dose of 1 mg Bumex for increased edema. Progress note dated 1/23/24 at 9:30 AM states in part, resident has +2 pitting edema noted to left ankle and +1 pitting edema to left leg. +1 edema to right leg and ankle. Progress note dated 1/24/24 at 13:33 (1:33 PM) states in part, . edema left sided, has 3+ pitting edema, increased edema noted to LLE in ankle and leg . Progress note dated 1/25/24 at 10:41 AM states in part, . lung sounds fine crackles heard in LLL, right lung is clear and diminished. O2 SAT: 97% (on oxygen) 3L. Progress note dated 1/26/24 at 13:54 (1:54 PM) states in part, . Edema has +2 pitting edema, to the left ankle +1 pitting edema to the right ankle. Lung sounds crackles heard, left lower lobes . Progress note dated 01/27/2024 at 20:58 (8:58 PM) states in part, .edema right sided, has 2+ pitting edema, left sided, has 1+ pitting edema . Progress note dated 3/14/24 at 9:58 AM states in part, . edema: bilateral, pedal edema present . Progress notes dated 3/16/24 at 14:52 (2:52 PM) and 14:53 (2:53 PM) state in part, . Edema: Has 2+ pitting edema, to the left foot/leg right sided, trace of edema noted to the right leg within normal limits . alert but sleepy at this time states that she don't [sic] feel good . physician notified and .new orders received and noted. 3/16/24 give another dose of Bumex 1 mg now and additional one 1 mg in the am and update her on resident condition. Progress notes dated 3/17/24 at 13:51 (1:51 PM) and 13:59 (1:59 PM) state in part, . spoke with on call provider regarding change in condition- resident vitals stable, continues to feel poorly, extra dose of Bumex administered this morning, poor output. Result provider stated that we could send resident out to urgent care, the ER (emergency room ), or we can't try another dose of Bumex . [Physician Name] given poor output and unknown kidney function did not feel comfortable to given [sic] another dose of Bumex. Given the last two extra doses of Bumex appeared to not work as well as it has in the past. Result: Ok to send out to ER . and Edema left sided, has 3+ pitting edema, right sided, has +1 pitting edema. Progress note dated 3/18/24 at 13:54 (1:54 PM) states, received verbal report from RN at [Hospital Name]. Weight in the hospital was 148.0, Some medication changes were done. She had a chest ex ray [sic] and a U/A while in the hospital. They report trace bilateral lower extremity edema. Resident has crackles in bilateral bases of her lungs. Progress note dated 3/19/24 at 13:17 (1:17 PM) states in part, resident doing well on this shift today . +1 trace of edema noted to BLE (bilateral lower extremities), +2 edema in left ankle which is more of residents baseline, left lower lobe of lung is diminished though clear, right lower lung has fine crackles present- encouraged to cough and deep breath, encouraged to ambulate as allows. Progress note dated 3/22/24 at 2:34 AM states in part, resident returned to facility from evaluation at [Hospital Name] ER (emergency room ). Dx (diagnosis) acute diverticulitis, constipation, pleural effusion, right . Progress note dated 3/29/24 at 13:54 (1:54 PM) states in part, Complaint/symptom: shortness of breath or trouble breathing when sitting at rest, Respirations: Rate: 22, regular, O2 Sat: 87% (on oxygen) 2L .Procedure done: oxygen administered at 4 LPM (liters per minute). Progress note dated 4/2/24 at 13:13 (1:13 PM) states in part, .Complaint: cough, nasal congestion . Respirations: Rate: 22 regular .Lung sounds: crackles heard, left lower lobes . O2 SAT: 93% (on oxygen) 4L . Other: uses accessory muscles . encouraged coughing and deep breathing, physician notified, and orders received. Obtained CBC and chest x-ray .chest x-ray impression [sic]: congestive changes with bibasal infiltrates (both lower lobes contain substances that fill the lung i.e., fluids) and effusions (unusual amount of fluid in the lung) .New orders received-daily weights, monitor lung sounds, start 2mg of Bumex BID for CHF, follow up Monday. Progress notes dated 4/8/24 at 9:58 AM, 10:06 AM, and 10:22 AM state in part, .complaint/symptom: cough: hacking .lung sounds: crackles heard, left lobes . O2 SAT: 94% (on oxygen) 3L . and cyanosis is present, in nailbeds bilaterally . fax sent to: attending physician regarding: faxed weights and medication list. Resident continues with crackles to base of left lung. Edema +1 to BLE. Continues to have cough, fatigue, and weakness. Oxygen saturations range from 90-94% on 3-4L of oxygen. Spoke to DON (Director of Nursing) about care conference given gradual decline . No new orders. Provider to evaluate Wednesday during rounds and Note: resident appears to be fatigued and continues to have weakness. Oxygen saturations are stable with supplemental oxygen via nasal cannula. Resident appears to have nonproductive hacking cough. Resident has been noted to have swallowing concerns during meals, speech therapist to evaluate and treat, as necessary. Noted that resident has increased supplemental oxygen needs, resident diuretics have been increased. Noted that resident heart is in poor condition and may continue to gradually decline. Care conference pending for goals of care. Progress note dated 4/8/24 at 13:37 (1:37 PM) states, Daily weight: lbs. (pounds)-did not obtain weight. Review of facility weight log indicates daily weights during these time frames: 1/25/24-1/29/24, 1/31/24, 3/17/24, 3/19/24-3/22/24, 3/24/24-3/25/24, 3/27/24, 3/29/24-4/8/24, otherwise weights were taken weekly. On 4/29/24, Surveyors reviewed electronic medical record (EMAR) for oxygen saturations to be done every shift on room air. EMAR shows oxygen saturations completed every shift on oxygen. Room air oxygen saturations were not completed as ordered. On 4/30/24 at 8:34 AM, Surveyor interviewed RN J (Registered Nurse). Surveyor asked RN J what the facility procedure was for weights. RN J stated, if they are a new resident, they obtain daily weights on same shift for 3 days then we go to weekly weights on bath day. RN J stated the CNA's get the weights. CNA's are told in the morning during report who needs weights done. Weights are brought to nurse and then the nurses chart the weight in the medical record. Changes in weights are communicated on the to do list in electronic charting system. RN J stated she would update the MD (medical doctor) if weight increase of 3#'s (pounds) overnight or 5#'s in a week. The weight increase would be communicated to the Physician, along with assessment (lung sounds, edema, etc.). On 4/30/24 at 8:40 AM, Surveyor interviewed CNA K (Certified Nursing Assistant). Surveyor asked CNA K what the facility procedure was for weights. CNA K stated, nurses inform us on shower day who we need to weigh, if new admit we weigh the first 3 days. If weight is off, we will have to get a reweight. Some people are daily weights. Surveyor asked CNA K if R16 is a daily weight. CNA K stated, R16 is not a daily weight. CNA K stated R16 received daily weights when she returned from hospital but that didn't last but just a couple of weeks. Surveyor asked CNA K how order changes are communicated with nursing staff and what is done with weights once obtained. CNA K stated weights are reported to the nurse and they report any weight changes to the physician and document the weights in the medical record. On 04/30/24 at 8:44 AM, Surveyor interviewed CNA L. Surveyor asked CNA L what the process is for obtaining weights. CNA L stated, weights are usually every week on bath day and given to the nurse to document, reweigh if not within 3 pounds. New admission weights are obtained every day for three days and reported to the nurse. Residents that are a daily weight are communicated during morning report. We get any changes in morning report from RN M. R16 used to be a daily weight but is not currently on daily weights. Surveyor asked CNA L if R16 is always on oxygen. CNA L stated that R16 is always on O2. On 4/30/24 at 8:49 AM, Surveyor interviewed RN I. Surveyor asked RN I what standard of practice the facility for CHF residents. RN I stated, we have standing orders with vital parameters, it's standard to do your assessments, vitals, update PCP (primary care provider), complete any new orders as prescribed and update family. Follow-ups are put into the to do list in the electronic charting system. Surveyor asked RN I, the process for obtaining weights. RN I stated, weights would be daily for three days on admission and are done right away in morning before breakfast. If a resident with CHF has acute changes or medication changes, they would be a daily weight. Surveyor asked RN I who decides the frequency of obtaining weights. RN I stated, the provider decides if someone is a daily weight and/or based on nursing discretion. Weekly weights are done on shower days. The CNA brings the nurse the weight and nurse puts it into the electronic charting system to do list. Surveyor asked RN I if R16 is currently a daily weight. RN I stated that R16 is not a daily weight and has had frequent issues with CHF and medication changes. Surveyor asked RN I who decides whether R16 is a daily or weekly weight. RN I stated, we do daily weights for a week when there is a change to her medication otherwise it is being done by the physician or our discretion. Surveyor asked RN I about R16's oxygen use. RN I stated that R16 is always on O2 and that O2 is being checked every shift. Surveyor asked RN I if staff are checking R16's oxygen saturation on room air or how often room air is being assessed. RN I stated, R16's room air O2 is checked monthly .I think, unless orders state otherwise. We have tried weaning R16 off oxygen and have been unsuccessful. On 4/30/24 at 8:57 AM, Surveyor interviewed RN M. Surveyor asked RN M about the facility process for obtaining weights. RN M stated, we get weights weekly on shower days and the nurses chart the weights in the electronic charting system. The Dietician looks at the weights when she comes in weekly and notifies management staff of any significant changes. We notify the provider of any changes, and we have weight notification sheets we send out to the PCP (primary care provider) if changes are noted. The CNAs obtain weights, and they give the weights to the nurse to chart in the electronic charting system. If a discrepancy exists, we will ask the CNA to get reweight. Surveyor asked RN M what the facility standard of practice is for a patient with a change of condition or CHF. RN M stated that the facility does not use a standard of practice. Surveyor asked RN M if R16 is always on oxygen. RN M stated that R16 is always on oxygen. We tried weening her a while ago she was in therapy but that did not work. She is uncomfortable without her O2. Surveyor asked RN M about R16's physician's orders for oxygen. RN M states I think this stem back to therapy's recommendation. She has had exacerbations. R16 for sure likes to wear her oxygen to sleep. Surveyor asked RN M, should staff be assessing R16's room air oxygen as ordered every shift. RN M stated, yes, we should be checking her O2 on room air, every shift, as the order indicates. We should also be trying to wean her off the O2 as the orders indicated. On 4/30/24 at 9:08 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what standard of practice the facility uses. DON B stated, Healthcare Academy, skills, 8-10 educational modules, and [NAME]. Surveyor asked DON B about the process for obtaining weights. DON B stated, the facility just implemented new procedures last week regarding weights as discrepancies had been noted. Surveyor asked DON B how staff are made aware of who to obtain weights on every day. DON B stated, the nurse would in morning report tell the CNA who needs weights and those show up on the nurses to do list. The CNA gets the weight, brings it to the nurse and the nurse charts it. Surveyor asked DON B where staff would find weight parameters. DON B stated the care plan under nutrition will indicate any weight parameters. The electronic charting system does trigger with any significant weight loss or gain. Surveyor asked DON B how frequently weights are obtained. DON B stated the standard is weekly weights. If they are daily weights, a physician orders them. We have had some issues with no stop dates for daily weights. During the interview with DON B, NHA A (Nursing Home Administrator) stated the goal for obtaining weights is weekly but at a minimum monthly, unless a physician order indicates specific parameters. Surveyor reviewed R16's weight order with NHA A and DON B. NHA A states R16's weights should be done daily unless there is an order to discontinue. Surveyor asked NHA A what the expectation of staff would be for following physician orders. NHA A stated that the expectation would be to follow the physician orders. The facility did not ensure physician's orders were followed for R16's daily weights and oxygen assessment and administration.

Based on staff interview and record review, the facility did not ensure that pain management was provided consistent with standards of practice for 1 of 2 residents reviewed (R7) reviewed for pain out of a total sample of 15. R7 has orders for scheduled Tylenol and Tramadol pain medication. R7 has pain in left knee and Polyosteoarthritis. Facility has not been assessing pain with scheduled pain medications to track effectiveness of medications. Evidenced by: The facility policy, entitled Pain Assessment and Monitoring, dated 4/1/24, states, in part: . Purpose: To provide care and services to attain or maintain optimal comfort and pain management from acute and/or chronic medical conditions. Procedure: 1. Evaluate the resident for signs/symptoms that may indicate the need for pain management . 3. Documentation will include, but not be limited to: origin/location, duration, intensity of pain, past relief measures, what precipitated the pain, what relieves the pain, etc. 5. Notify the MD (medical doctor) of any persistent or uncontrolled pain so scheduled pain medications or interventions may be implemented/ordered . 9. Residents receiving scheduled pain medications will be evaluated in the routine documentation. 10. The medical record will have parameters for administration of multiple pain medications . R7 was admitted to the facility on [DATE], and has diagnoses that include unspecified dementia, pain in left knee and Polyosteoarthritis. R7's Quarterly Minimum Data Set (MDS) Assessment, dated 2/7/24, shows R7 has a Brief Interview of Mental Status (BIMS) score of 13 indicating R7 is cognitively intact. Section J indicates R7 has pain frequently, pain intensity is severe, and pain interferes with day-to-day activities frequently. R7's Care Plan, dated 2/5/24, states, in part: . Need/Preference: I like to be comfortable because I sometimes hurt as I have arthritis. I show this by telling you that I have pain. Approach: I need my nurses to: -Ask me if I hurt, offer me pain medication, offer me a warm or cold pack, give me a massage . notify the provider of unrelieved pain. Evaluate need for routinely scheduled medications . Goal: My Goal is to maintain my pain at an acceptable level. Goal Time: thru 5/5/24 . R7's February, March, and April Medication Administration Record (MAR) states, in part: . Acetaminophen 500 mg (milligrams) Tablet Dose Ordered: (2 tablet/1000mg) by mouth twice a day AM PM First Date: 9/22/21 For: Pain . Tramadol HCI (hydrochloride) 50 mg Tablet Dose Ordered: (1 tablet/50mg) by mouth daily AM first date: 1/20/23 For: Pain . Of note: There are no pain ratings/assessments with administration of the acetaminophen and tramadol. R7's nurses' progress notes from May 1, 2024 - March 1, 2024, states, in part: . 4/9/24 @ 3:52:15 PM Pain/Hurting in Last 30 Days: Yes, Scheduled Pain Meds: Yes . 3/12/24 @ 6:34:51 PM Pain/Hurting in Last 30 Days: Yes, Scheduled Pain Meds: Yes . Of Note: No mention of any non-pharmacologic interventions used or pain ratings. R7's last pain assessment dated [DATE], states, in part: . Been on a scheduled pain medication regimen? Yes Received prn (as needed) pain medications? Yes Offered a prn pain med and declined? No Received non- medication? Yes Intervention for pain? (Left blank) Pain Interview: Have you had pain or hurting at any time in the last 5 days? Yes How much of the time have you been experiencing pain or hurting over the last 5 days? Frequently Location of pain: left ribs Description of pain: aching Over the past 5 days, has the pain made it hard for you to sleep at night? Frequently Over the past 5 days, how often have you limited your participation in rehabilitation therapy sessions due to pain? the past 5 days. Over the past 5 days, how often have you limited your day-to-day activities (excluding rehabilitation therapy sessions) because of pain? Frequently Please rate your worst pain over the last 5 days on a zero to ten scale (zero= no pain, 10 = worst pain you can imagine): 07 Please rate the intensity of your worst pain over the last 5 days: moderate On 5/1/24 at 9:49 AM, Surveyor interviewed RN I (Registered Nurse) and asked when one would do a pain assessment. RN I indicated with any acute pain and quarterly with Medicare. RN I indicated pain assessments get completed with administration of prn (as needed) meds. Surveyor asked how one would know if scheduled pain medications were effective and RN I indicated one would only know if residents spoke of pain or use nurse judgement. RN I indicated pain assessments only get completed on prn medications and pain levels are not being charted on scheduled meds. Surveyor asked RN I where a resident's comfort level would be found and RN I indicated it should be in the care plan, Surveyor asked RN I if a resident's comfort level could be found somewhere else other than care plan and RN I indicated not knowing. Surveyor asked RN I who is responsible for completing care plans and RN I indicated DON B (Director of Nursing) or nurse manager. On 5/1/24 at 10:03 AM, Surveyor interviewed DON B and asked if pain assessments/ratings are to be completed with administration of scheduled pain medications. DON B indicated with prn pain meds the computer system is set up to populate a pain assessment with administration. DON B looked on R7's MAR and indicated pain ratings/assessments are only pulling up for prn pain medications. Surveyor asked DON B if staff are completing pain ratings with R7's scheduled Tylenol and Tramadol DON B indicated no. DON B indicated she would expect a follow up on residents' pain levels to be documented within one hour of receiving a scheduled pain medication. Surveyor asked DON B how one would know if the pain medications administered were effective for the resident without pain ratings/assessments and DON B indicated one would not know. Surveyor asked for R7's pain assessments and DON B provided R7's pain assessments from 2/3/24 - 2/21/24. DON B indicated 2/21/24 pain assessment was the last pain assessment completed. DON B indicated pain ratings and follow up pain ratings are not being completed for scheduled pain medication and should be. Surveyor asked where a resident's pain goal would be found, and DON B indicated on the care plan. DON B pulled up R7's Care Plan. Surveyor asked if R7's pain goal was on her care plan and DON B indicated no and it should be. DON B indicated the expectation would be for a resident pain goal to be on the care plan. Surveyor asked DON B if R7's, care plan states to maintain R7's pain level at an acceptable level; what is R7's acceptable level? DON B indicated one would not know. Of note, Surveyor attempted to interview R7 and R7 elected not to speak to Surveyor.

Based on interviews and record reviews, and facility policy review, the facility failed to provide medically related social services for one of three residents (Resident (R) 36) related to his mental health diagnosis and physician recommendation upon admission of 15 sampled residents. Findings include: Review of the facility's policy titled, Care Plan, updated 04/01/24, revealed each resident would have a specific plan of care developed on information gathered from .physician/therapist orders. Review of R36's electronic medical record (EMR) under the Face Sheet tab, revealed R36 was admitted from an acute care hospital to the facility on [DATE], with diagnoses which included bipolar depression, post-traumatic stress disorder (PTSD), depression, and anxiousness associated with depression. Review of the hospital discharge summary, dated 3/29/24 and located in the EMR under the Other tab, revealed a reference Consult to Social Services . The summary included a list of discharge medications to include trazodone (anti-depressant medication), bupropion (anti-depressant medication), and escitalopram (anti-depressant medication). Review of R36's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/04/24 revealed diagnoses which included bipolar mood disorder, anxiety disorder, and PTSD. The MDS indicated R36 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. Review of R36's Electronic Medical Record (EMR) under the Care Plan tab with an Assessment Reference Date (ARD) of 4/4/24 through 4/29/24, had no care planned problems or interventions associated with his psychosocial diagnosis or medications administered for his psychosocial diagnosis. Review of R36's EMR under the Progress Notes tab, from admission through 4/29/24, social services did not have documentation to address his psychosocial diagnosis or medications administered for his psychosocial diagnosis and needs. During an interview on 4/29/24 at 11:34 AM, DON B (Director of Nursing), stated that her expectation for R36 upon his admission was that he should have had a care plan from nursing and social services to address his psychosocial needs. She stated that the care plan did not indicate nursing or social services had addressed his psychosocial needs related to his mental illness diagnosis and antipsychotic medications. During an interview on 4/30/24 at 3:00 PM, SW E (Social Worker) stated that she had not addressed R36's psychosocial needs in his care plan. She said her focus for R36 was based on the hospital discharge summary problem list located on page one, that did not include a mental illness diagnosis. The SW stated she did not see the physician's reference for social services consult on page three of the hospital discharge summary. The facility did not provide medically related social service consultation per physician orders or address his psychosocial needs as it relates to his diagnoses and medication therapy.

Based on interview and record review, the facility did not ensure that drug regimens are free of unnecessary psychotropic medications, and that a resident taking a psychotropic medication has a care plan that includes targeted behaviors and side effects for 2 of 5 residents (R32 and R36) reviewed for unnecessary medications. R32 was started on Clonazepam (sedative) for involuntary body movements and Citalopram (antidepressant) for Major Depressive Disorder. R32 does not have a diagnosis for Major Depressive Disorder and the care plan contained no mood or behavior monitoring to assess the effectiveness of these medications or any potential side effects. R36 did not have targeted behavior monitoring. Evidenced by: The facility policy titled, Psychotropic Medication Review and GDR (gradual dose reduction) Reduction, last reviewed 4/01/24, does not include any information on care planning targeted behaviors or monitoring for potential side effects of medications being taken. Example 1 R32 was admitted to the facility on [DATE] with diagnosis that includes in part, other specified anxiety disorders and unspecified involuntary movements. R32's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/20/24 states in part, R32 has a BIMS of 11, indicating moderate cognitive impairment. D0150. Resident mood interview: A. little interest or pleasure doing things, No. B. Feeling down, depressed, or hopeless, Yes-Never or 1 Day. E0100. Psychosis Z. None of the above. E0200. Behavioral Symptoms-Presence and Frequency. All indicate behavior not exhibited. R32 has upper and lower extremity impairment on both sides. Toileting, hygiene, and showering are partial/moderate assistance. Upper and lower body dressing and personal hygiene are supervision or touch assistance. Bed mobility is independent. Transfers are partial to moderate assistance. R32 is always continent of bowel and bladder. On 4/30/24, Surveyor reviewed R32's mood and behavior charting for the period of 1/1/24 through 5/1/24 with no documented behaviors noted. Surveyor reviewed Certified Nursing Assistant (CNA) closet card which includes a section for behavior which is blank. R32's comprehensive care plan states in part . Care plan dated 03/18/2024: I: can't complete my cares on my own. I WANT: to return to my previous living situation. BECAUSE I: Have acute illness, cardiac disease, involuntary movements after my strokes (take clonazepam). Of note, this is the only mention of Clonazepam and there is no mention of Citalopram within the care plan. R32's signed physician orders dated 4/18/24 state in part, Citalopram Hydrobromide 20 mg (milligram) tablet dose ordered: (1 tablet/20 mg) by mouth daily AM (morning). First date 09/27/2023 for Major Depressive Disorder (Major Depression). R32's signed physician orders dated 4/18/24 state in part, Clonazepam 0.5 mg tablet dose ordered: (1 tablet/0.5 mg) by mouth twice a day AM Supper. First date 10/23/23 for Involuntary Body Movements. Social services progress note dated 3/23/24 at 8:27 AM states, quarterly review: R2 is well adjusted to the facility and states that he is happy with his care, room, and roommate. R32 requires reminders of daily activities. His long-term memory is largely intact. There are no mood or behavior concerns. His family is supportive and visit often. R32 requires a level of assist that likely could not be met in a lower level of care setting. He gets along well with staff and other residents and participates in activities of his choosing. He denies any concerns or issues at this time. On 5/1/24 at 8:46 AM, Surveyor interviewed RN S (Registered Nurse). Surveyor asked RN S where staff would be able to find targeted behaviors and potential side effects of medication. RN S states, I would look in the care plan. RN S also states, I wish it indicated what behaviors we are to be looking for. On 5/1/24 at 8:48 AM, Surveyor interviewed RN I. Surveyor asked RN I where staff would be able to find targeted behaviors and potential side effects of medication. RN I states, I usually put them in the to-do list and specify what behavior you are looking for. I am not sure who puts the behaviors in the electronic charting system for the CNAs. Surveyor asked RN I how often they chart behaviors for residents taking psychotropic medications. RN I stated, every shift for someone on an antipsychotic. Surveyor asked RN I if mood, behavior, and side effects should be care planned. RN I stated, for sure. On 5/1/24 at 8:56 AM, Surveyor interviewed CNA L. Surveyor asked CNA L where she documents resident behaviors. CNA L states, there is behavior charting on the kiosk in the electronic charting system. Surveyor asked CNA L how she knows which behaviors to monitor. CNA L states that there are no targeted behaviors on the care plan. The care plan only includes wandering, fall risk, or no male cares. On 5/1/24 at 9:01 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if psychotropic medications should be care planned. DON B states, psychotropic medications should be care planned and added to the to do list in the electronic charting system. Surveyor asked DON B if targeted behaviors should be on the care plan. DON B states, targeted behaviors should be listed on the care plan. Surveyor asked DON B who creates the care plans. DON B states, the admission care plans are done by me and the nurse manager. Surveyor asked DON B how often care plans are reviewed and updated. DON B states, the care plans are reviewed and updated quarterly and as needed. The facility failed to ensure that each resident was free of unnecessary psychotropic medications and that the comprehensive care plan included targeted behaviors and potential side effects of the medications. 36917 Example 2 Review of R36's electronic medical record (EMR) under the Face Sheet tab revealed R36 was admitted from an acute care hospital to the facility on [DATE], with diagnoses which included bipolar depression, post-traumatic stress disorder (PTSD), depression, and anxiousness associated with depression. Review of R36's EMR under the Physician Orders tab, dated 3/29/24, revealed R36 was administered Lamotrigine (anti-seizure medication) 100 mg tab twice daily for bipolar depression, Prazosin (alpha blocker medication) 1 mg capsule once daily for PTSD, Trazodone (anti-depressant medication) 50 mg Tablet once nightly for insomnia associated with depression, Bupropion (anti-depressant medication) XL 300 mg daily for indications of anxiousness associated with depression, and Escitalopram (anti-depressant medication) 20 mg tablet daily for indications of anxiousness associated with depression. There were no specific orders for monitoring R36's medication side effects or behaviors. Review of R36's EMR under the Care Plan tab indicated his care plan with an Assessment Reference Date (ARD) of 4/4/24 through 4/29/24 had no problems or interventions associated with his psychosocial diagnosis or medications administered for his psychosocial diagnosis. Review of R36's EMR Medication Administration Record (MAR) from his admitted [DATE] through 4/29/24, indicated administration of R36's medications as ordered by the physician but did not indicate monitoring of side effects or behaviors associated with R36's diagnosis or medication administration. During an interview on 4/29/24 at 11:34 AM the Director of Nursing B (DON), stated that the care plan did not indicate nursing or social services had addressed his psychosocial needs related to his mental illness diagnosis and antipsychotic medications. She could not provide documentation from the EMR for R36 to indicate his psychotropic medications had been reviewed or monitored for side effects or behaviors associated with R36's mental health diagnosis or medications.

Based on record review and interview, the facility did not have evidence that residents or their responsible parties received timely Notice of Medicare Non-Coverage for 2 of 3 residents reviewed (R28 and R33). R28 and R33 did not sign the Notice of Medicare Non-Coverage. This is evidenced by: The facility policy titled, SNF Advanced Beneficiary Notice/Notice of Medicare Non-Coverage Policy, last reviewed 4/01/24, states in part . Purpose: To inform resident of their rights when being discharged from a Medicare Part A/Medicare Advantage covered stay, regardless of whether they remain in the facility or not. Medicare beneficiaries have specific rights and protections related to financial liability and the right to appeal a denial of Medicare services under the Medicare program. Procedure: 1. Any resident discharging from a Medicare Part A or Medicare Advantage covered stay will receive a notice of Medicare Non-Coverage at least 48 hours prior to their Last Covered Day. If necessary, notice will be provided to resident representative/POA. 2. A Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) and Notice of Medicare Non-Coverage will be completed when a resident has skilled benefit days remain and is being discharged from Part A services and will continue living in the facility. Example 1 R28 was receiving Medicare A benefits. R28's Medicare coverage ended on 1/30/24. R28 signed the Notice of Medicare Non-Coverage indicating she received the notice of non-coverage from the facility. R28 has a Activated Healthcare Power of Attorney (AHCPOA) and is not her own decision maker. The facility contacted R28's AHCPOA to inform them of the Notice of Medicare Non-Coverage but did not have the AHCPOA sign the form or provide a copy of the form to the AHCPOA. Example 2 R33 was receiving Medicare A benefits. R33's Medicare coverage ended on 1/17/24. R33 did not sign the Notice of Medicare Non-Coverage indicating she received the notice of non-coverage from the facility. On 4/29/24 at 1:58 PM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A who completes the Notices of Medicare Non-Coverage. NHA A indicates the social worker does or I do at times. Surveyor asked NHA A about R28 and R33's Medicare Notice of Non-Coverage. NHA A states, residents did not sign the notice of non-coverage, but it was discussed with them. NHA A states that R33 went onto hospice services, and they discussed the Notice of Non-Coverage but did not have her sign the form. R28 signed her own Notice of Non-Coverage and when the facility realized she was not her own person discussed the notice with R28's AHCPOA but did not provide her with a copy of the form or have her sign the form.

Based on interview and record review the facility must develop policies and procedures to ensure that residents and/or resident responsible party receives education regarding the benefits and potential side effects of the immunization prior to offering the immunization and documentation is noted in the medical record on whether the resident received or declined the immunization, this affected 4 of 5 residents (R28, R95, R31, R5) reviewed for influenza immunizations and 1 of 5 residents (R31) reviewed for pneumococcal immunizations of 12 sampled residents. R28 did not have the influenza immunization and no documentation. R95 did not have the influenza immunization and no documentation. R31 did not have the influenza and the pneumococcal immunization and no documentation. R5 did not have the influenza immunization and no documentation. The facility has not updated their pneumococcal policy regarding the CDC's (Centers for Disease Control) new guidelines on the pneumococcal immunizations. This is evidenced by: The facility policy, entitled Influenza and Pneumonia, dated 2/27/15, states, in part: . PURPOSE: Norseland Nursing Home wants to ensure that each resident and/or their legal representative, receives education on the benefits and potential side effects of the Influenza and Pneumonia Immunizations before they are offered. PROCEDURE: 1. Residents and/or their legal representative will receive education regarding the benefits and potential side effects of the immunizations before they are offered. 2. As appropriate, residents will be offered the opportunity to receive immunizations annually for Influenza and once for Pneumonia unless otherwise indicated by their medical provider. 3. Residents and/or their legal representative have the right to refuse the immunizations. 4. Documentation of the provision of education, and if the resident received or refused the immunization, is all included in the resident's medical record. Example 1 R28 was admitted to the facility 1/21/21. There is no documentation that R28 was provided education on the risk and benefits of the influenza immunization or that the immunization was offered, received, or declined. Example 2 R31 was admitted to the facility on [DATE]. There is no documentation that R31 was provided education on the risk and benefits of the pneumococcal immunization or the influenza immunization or that the immunizations were offered, received, or declined. Example 3 R5 was admitted to the facility on [DATE]. There is no documentation that R5 was provided education on the risk and benefits of the influenza immunization or that the immunization was offered, received, or declined. Example 4 R95 was admitted to the facility on [DATE]. There is no documentation that R95 was provided education on the risk and benefits of the influenza immunization or that the immunization was offered, received, or declined. On 2/8/23, at 2:24 PM, Surveyor interviewed DON B (Director of Nursing) and asked if R28, R95, R31 and R5 had received education, were offered, received, or declined the Influenza and Pneumococcal immunizations. DON B indicated DON B had recognized on 2/3/23 that was a break in the system with immunizations. DON B indicated the issue was taken to QAPI (Quality Assurance Performance Improvement), but nothing has been started. DON B indicated there should be documentation on education and declination of the immunizations in the residents' medical records and there was not. DON B provided education and declinations signed and dated 2/8/23 for R31, R95, and R28, after Surveyor had asked for the documentation. DON B indicated the facility did not have an updated policy on the pneumococcal immunization per CDC guidelines.

Based on interview and record review the facility failed to consult with the physician related to a significant change of condition for 2 of 3 residents (R4 and R19) reviewed for physician notification. The facility did not consult with R4's physician nor notify her APOAHC (Activated Power of Attorney for Health Care) when R4 experienced a 7.48% decrease in her weight on 1/2/23, 6.03% decrease on 1/16/23, 10.67% on 1/24/23 and 9.7% decrease on 1/30/23. R19's provider was not updated timely of his weight loss and gain. This is evidenced by: The facility policy titled, Weights, dated 7/23/13 states, in part, as follows: Purpose: To identify and provide nutritional interventions to maintain control of weight loss or gain in residents. Weight will be monitored and assessed to prevent avoidable weight loss and/or weight gain. Significant Change is defined as: 1 month - 5% weight loss/gain 3 months - 7% weight loss/gain 6 months - 10% weight loss/gain The facility policy titled, Change in Condition/Status Notification, undated, states the Purpose: To have a policy and procedure in place for notification of a resident's physician/practitioner, the Medical Director, and/or responsible party if there is a significant change in the resident's physical, mental, or emotional status Policy: Change in condition: A resident's MD/Practitioner, guardian or responsible party is to be notified of an accident, injury, or adverse change in condition. Procedure: The professional nurse on duty will notify the responsible party in the event of a significant change in condition or stats. Example 1 R4 was admitted to the facility on [DATE] with diagnoses including, but not limited to, Parkinson's disease, diabetes and atherosclerotic heart disease. R4's comprehensive care plan indicates, R4 needs some assistance to complete her ADLs (Activities of Daily Living) Because: I have poor balance and Parkinson's disease. I eat without help if you set out what I need I dine in the main dining room. R4's CNA Care Card documents the following diet order: Mechanical soft (NDD#2) with ground meal - may give pureed for a meal if needed, extra sauces and gravies on foods. R4's Annual MDS (Minimum Data Set), dated 1/18/23, Section K0100, indicates R4 has no swallowing issues and has not experienced a weight loss of 5% or more in the last month or loss of 10% more in the last 6 months. R4 is has an APOAHC (Activated Power of Attorney for Health Care). R4's weights are documented as follows: 11/28/22 144.3 12/19/22 141.9 (-1.66%) *1/2/23 133.5 (10.8 pounds, -7.48%) *1/16/23 135.6 (8.7 pounds, -6.03%) *1/24/23 128.9 (15.4 pounds, -10.67%) *1/30/23 130.3 (14 pounds, -9.7%) * Denotes a significant change On 1/25/23 DON B (Director of Nursing) documented the following WAR (weight at risk): Flagging for 9.2% loss in 1 month and 9.7% loss in 3 months Weight history: 1/24/23-128.9 lbs, 1/16/23-135.6, 1/2/23-133.5 lbs, 12/19/22-141.9 lbs, 10/12/22 - 142.7 lbs, 8/10/22- 140.2 lbs. Nutritional Care Plan: Resident has not been feeling well, she has been noted to be falling asleep at the table during meals, meal intakes have declined, per nursing at WAR meeting today resident is declining in overall status. Currently receiving 8 oz variety Ensure with all 3 meals. On 2/1/23 DON B (Director of Nursing) documented the following WAR (weight at risk): Flagging for 9.5% loss in 3 months. Weight history: 1/30/23 -130.3 lbs, 1/24/23-128.9 lbs, 1/16/23-135.6, 1/2/23-133.5 lbs, 12/19/22-141.9 lbs, 10/12/22 - 142.7 lbs, 8/10/22- 140.2 lbs Nutrition Care Plan: See RD sig change assessment from today's date. Resident has not been feeling well, she has been noted to be falling asleep at the table during meals, meal intakes have declined, per nursing at WAR meeting today resident is declining in overall status. Currently receiving 8 oz variety Ensure with all 3 meals. Speech will be screening resident this week. On 2/8/23 DON B (Director of Nursing) documented the following WAR (weight at risk): Flagging for 9.5% loss in 3 months (-7.1% in 6 months, not sig) Weight history: no new weight this week, 1/30/23 -130.3 lbs, 1/24/23-128.9 lbs, 1/16/23-135.6, 1/2/23-133.5 lbs, 12/19/22-141.9 lbs, 10/12/22 - 142.7 lbs, 8/10/22- 140.2 lbs Nutrition Care Plan: Sig change last week. Resident has not been feeling well, she has been noted to be falling asleep at the table during meals, meal intakes have declined. Currently receiving 8 oz variety Ensure with all 3 meals. Spoke with Speech today and she is working with resident to modify diet appropriately. Also adding 4 oz Ensure BID between meals to help resident meet nutrition needs on days she is sleeping through meals. Will continue to monitor. On 2/1/22 the Dietician documented the following note. R4 continues to receive a carbohydrate-controlled diet with advanced NDDL3 (Level 3 National Dysphagia Diet) textured foods, cut up into bite size pieces and extra sauces with meals. No current reported issues with chewing or swallowing. Speech will be evaluating resident this week due to significant change in status. Resident has own teeth with some missing. She receives small portions, an HS (bedtime) snack, and 8oz Ensure TID (three times a day) with all meals with poor-fair acceptance. Meal intakes have decreased with consistent refusals. Weight has continued to decline. Resident is flagging for 9.5% loss in 3 months. CBW is 130.3 lbs. Will continue to monitor and offer nutrition supplements. Resident is likely not meeting their nutritional needs. Fluid intakes continues to be poor at meals. No reported s/s (signs/symptoms) of dehydration. Resident is likely not meeting their fluid needs. Staff to continue to encourage and offer fluids between meals. Care plan reviewed; no changes made at this time. It is important to note, the facility did not notify R4's Physician or APOAHC (Activated Power of Attorney for Health Care) regarding her significant change in condition (weight loss). On 2/9/23 at 12:06 PM, DON B (Director of Nursing) documented the following progress note: Call placed to attending Physician at 9:00 AM regarding: Order change weight loss noted from WAR meeting, Ensure added between meals remains low intake and increased sleeping. Result: No return call received. On 2/9/23 at 12:50 PM, DON B (Director of Nursing), stated to Surveyor she implemented a new process today Resident Weight Change Communication for WAR (weight at risk) meetings. DON B stated she has not completed the Resident Weight Change Communication for R4. On 2/9/23 at 1:51 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B, what is the process for monitoring weights. DON B stated, she has started the WAR (weight at risk) binder and weekly meetings on Wednesdays. DON B stated, our Dietician is here weekly. The Dietician looks at the weights and they and makes her recommendations from that. DON B stated, we're trying to tighten up that system, so we are capturing the weights weekly. The recommendations from Nutrition are started right away. Surveyor asked DO B, when did you implement this WAR process. DON B stated the beginning of January. Surveyor asked DON B, who monitors for weight loss. We discuss this information with the Dietician weekly. Surveyor asked DON B, who monitors for significant weight loss. DON B stated, the Dietician looks at the weights weekly and as a team we look at them weekly. Surveyor asked DON B, when would you expect staff to notify the Physician and APOAHC (Activated Power of Attorney for Health Care) regarding a significant weight loss. DON B stated, that should be done when we are discussing that weekly (on Wednesdays). Surveyor asked DON B, did you or anybody at the facility notify the Physician and APOAHC when R4 started experiencing a significant weight loss. DON B stated, she discussed R4's weight loss with the Physician, however, this conversation is not documented. DON B stated the only documentation the facility has regarding Physician notification is on 1/24/23. Note, the Physician saw R4 on 1/25/23, however, there is no evidence that he was informed of R4's weight loss or reviewed the weight loss during his visit. DON B stated, it wasn't until today that she realized the Physician hasn't made a mention of R4's significant weight loss. DON B stated, we had no other documentation to document that the Physician nor APOAHC was notified when R4 experienced significant weight loss. DON B added, it wasn't until today that I realized he hasn't made a mention of it (significant weight loss) and that's our Medical Director, too. Surveyor asked DON B, should notification to the Physician be documented. DON B stated, yes. DON B stated, she thought the Physician would document this in his note. DON B added, that's why the form (Resident Weight Change Communication) came out because that's obviously not happening. Surveyor asked DON B, when was the APOAHC notified of the wt. loss? DON B stated, 1/25/23. DON B stated, she spoke with R4's APOAHC this morning. Surveyor asked DON B, when a resident has a significant weight loss when should the Physician and APOAHC be notified. DON B stated, the Physician and APOAHC should be notified on those Wednesdays that we meet. Surveyor asked DON B, should the facility document notification to the Physician and APOAHC. DON B stated, yes. Surveyor asked DON B, when should the Physician have initially been notified of R4's significant weight loss. DON B stated, 1/2/23. Note, the Physician was not notified and R4's weight continue to decline. On 2/9/23 at 2:14 PM, Surveyor left a message for MD E (Medical Director). MD E did not return Surveyor's phone call. 39849 Example 2 R19 was admitted to the facility on [DATE] with diagnoses that include, in part: Multiple fractures of ribs, left side .Paroxysmal atrial fibrillation; Epilepsy; Localized edema; Constipation. R19's facility recorded weights are as follows: 12/7/22: 167 lbs 12/16/22: 167.4 lbs 12/28/22: 164.4 lbs 1/3/23: 159.2 lbs 1/10/23: 152.8 lbs 1/17/23: 161.2 lbs 1/24/23: 154.2 lbs 1/31/23: 168 lbs 2/7/23: 169.2 lbs R19's Care Plan includes, in part: I: need some assistance .I eat without help if you set out what I need . I have the potential to: be at nutritional risk. Because I: have a history of constipation, edema, pain, and hypertension. I need my nurses to--- .ask my family to provide my favorite foods and drinks, let me eat uninterrupted, try to figure out why I'm not eating, ask me about my preferences. I need my aides to --- .weigh me per nursing orders .My goal is to maintain my weight +/- 5 lbs . R19's Nurses Notes, include, in part: 1/9/23 at 1:13PM: .Weight: Reviewed Weights Conclusion: 8lb increase in the last 90 days . 1/17/23 at 9:19PM: .Edema: Has no edema present . 1/23/23 at 4:13PM: .Edema: bilateral, has non pitting edema, lower extremities . 1/24/23 at 9:26PM: .Edema: has 1+ pitting edema . 1/26/23 at 10:39AM: .Edema: bilateral, has 2+ pitting edema, lower extremities . 1/30/23 at 1:56PM: .Edema: bilateral, lower extremity edema present . 1/31/23 at 9:37PM: .Edema: has non pitting edema . Of note, no evidence of physician notification regarding weight changes were noted. R19's Re-admission assessment dated [DATE], includes, in part: 12/7/22: .Current diet order: General Weight: 167 lbs Skin Conditions; 1+ pitting edema . Risk Level: 13; 12-14 Normal nutritional status . Summary: .His weight has been stable since admission in the upper 160s. Will need to monitor his weight as past weights have fluctuated between the 150s and 170s on recent admission . Of note, R19's MDS (Minimum Data Set) Indicates Discharge Assessment, return not anticipated on 11/12/22 and entry MDS on 11/23/22. Nutritional notes received from the facility, include, in part: 11/30/22: R19: Flagging for >5% loss in 1 month, >7.5% loss in 3 months, >10% loss in 6 months. Unsure of resident's UBW (Usual Body Weight) because weight has fluctuated between 150s-170s over the last 5 months. Weight on admission this time was between 161-165 lbs. Will continue to monitor weekly. 12/7/22: R19: Flagging for > 5% weight loss in 1 month, >7.5% loss in 3 months, > 10% loss in 6 months. Unsure of resident's UBW because weight has fluctuated between 150'-170's over the last 5 months. Resident working with therapy due to edema. Weight on admission this time was between 161-165lbs. Will continue to monitor weekly. 12-14-22: R19: Flagging for > 5% weight loss in 1 month, >7.5% loss in 3 months, > 10% loss in 6 months. Unsure of resident's UBW because weigh has fluctuated between 150's-170's over the last 5 months. Resident working with therapy due to edema. Weight on admission this time was between 161-165lbs. Per resident, UBW has fluctuated between 150-170. Will continue to monitor weekly. 12-21-22: R19: Flagging for 10.2% gain since October. Weight does appear to have stabilized in the 160's. Weight of 168.4lbs on 12/20. Weight has fluctuated between 150-170's over the last 5 months. Resident is working with therapy due to edema. Per resident, UBW has fluctuated between 150's - 170's. Will continue to monitor. 2-8-23: Flagging for 6.3% gain in 1 month and 10.7% in 4 months (readmitted October). Wt Hx: 2/7/23: 169.2 lbs, 1/31/23: 168 lbs; 1/24/23: 154.2lbs; 1/17/23: 161.2 lbs; 1/10/23: 152.8 lbs; 1/3/23: 159.2 lbs; 12/6/22: 167.4 lbs; 11/2: 173.6 lbs; 10/5/22: 152.8 lbs Nutrition Care Plan: Weights have been fluctuating widely between the 150's and 160's. Will continue to monitor, nursing aware. Of note, per R19's MDS, the most recent admitted is 11/23/22 after a discharge, return not anticipated date of 11/12/22. The Weights recorded prior to 11/23/22 are from a previous stay. Review of provider progress notes for 12/14/22 and 1/25/23 do include documentation regarding review of weights. Review of R19's Physician Orders and standing orders in the paper chart do not reference a weight gain or loss parameter for notification. On 2/9/23 at 1:37PM Surveyor interviewed CNA C (Certified Nursing Assistant) and asked what the process for obtaining Residents weights is. CNA C indicated; Residents get weighed on their shower days. Usually for admissions it's the first 3 days after admission. Surveyor asked CNA C, how she knows if anyone is supposed to be weighed more frequently than their shower day. CNA C indicated, it shows up on our care card and the nurses are good about reminding us of because it shows up on their care list. Surveyor asked CNA C how she knows how the resident should be weighed, for example, Hoyer, wheelchair, standing. CNA C indicated, from experience. Surveyor asked CNA C how she trains new employees to know this information. CNA C indicated, I'm not sure it's written anywhere, but if they use EZ-stand, get EZ-weight, Hoyer scale. I guess it goes by their transfer status. Surveyor asked CNA C after she gets the weight what she does with that information. CNA C indicated; I tell the nurse. Surveyor asked if this is written or verbal. CNA C indicated; I usually just tell them right away, so I don't forget. Surveyor asked CNA C, how she would know if a re-weight was needed. CNA C indicated, from the nurse. Surveyor asked CNA C, if she weighs someone in a w/c how she knows what to subtract for the wheelchair. CNA C indicated, we take the w/c down and weigh it after we take the resident out of the w/c. On 2/9/23 at 1:45 PM Surveyor interviewed RN D and asked what the overall process was for weights in the facility. RN D indicated, weights are obtained on shower days and new admission are done for 3 days in a row to get a good baseline. If there is someone that has CHF (Congestive Heart Failure) or something like that where the doctor wants it monitored, then it's on the to do list in [ECS} electronic health record. Surveyor asked RN D how she gets the resident weights. RN D indicated, verbally from the CNA. Surveyor asked RN D what she does with the weight once she receives it from the CNA. RN D indicated, it goes into [ECS] the electronic health record and the past weights show up when you put it in. Surveyor asked RN D, what would trigger you to ask for a re-weight. RN D indicated, a big weight gain or weight loss. Surveyor asked RN D what she would consider a big gain or loss. RN D indicated, if they are more than 3lbs up or down I would ask for a re-weight. I don't know if that is policy but that's what I would do. Surveyor asked RN D, how she knows when to contact the provider. RN D indicated, after the re-weigh I would be looking at that. Weight gain greater than 2-3 lbs. Weight loss, I've never called on a weight loss because people are here, and they are declining so it's individual. Is it edema, do they have a lot of swelling, are they symptomatic, shortness of breath, lung sounds. Surveyor asked RN D if there is a set parameter for calling with a weight loss. RN D indicated, probably 5 lbs. Surveyor asked if this is documented. RN D indicated; it should be in the nurses notes. On 2/9/23 at 2:17PM Surveyor interviewed DON B (Director of Nursing) and asked who is responsible for contacting the provider with a weight change. DON B indicated; the nurses contact the physician. Surveyor asked if this information should be documented in the nurses' notes. DON B indicated, yes. Surveyor reviewed weights with DON B and asked if she would have expected the provider to be called for the following weights: 1/31/23 - 168 lbs: An increase from 154.2 lbs on 1/24/23. A gain of 13.8 lbs. 1/24/23 - 154.2 lbs: A decrease from 161.2 lbs on 1/17/23. A loss of 7 lbs. DON B indicated, they should have done a re-weight, if it was a true weight loss, yes.

Based on interview, observation and record review, the facility did not ensure that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 5 residents (R15) reviewed for range of motion, of a total sample of 15 residents. R15 did not regularly receive her restorative therapies and the facility did not reassess resident to ensure the program was effective and the resident did not experience a decline in range of motion. Findings include R15 was admitted to the facility on [DATE]. Her most recent MDS (Minimum Data Set), dated 1/25/23, shows a BIMS score (Brief Interview for Mental Status) of 14, indicating R15 is cognitively intact. This MDS also shows R15's primary medical condition to be stroke. R15's care plan states, I can't complete cares on my own because I had a stroke, have poor balance and have hemiplegia .my goal is to: maintain my upper and lower extremity ROM (range of motion) with my current restorative program . Additionally, R15's Plan of Care Summary, dated 8/16/21 states, Passive ROM: RUE (Right upper extremity) use 3# dumbbell for elbow flexion and 2# dumbbell for chest press and overhead press. Follow directions posted in restorative binder. LUE (Left upper extremity) 5 repetitions, LLE (Left lower extremity) 5 repetitions two times a day every day, Goals: Prevent decline in ROM. The facility provided therapy recommendations for R15, which were signed and recommended by therapy staff, stated the following, Goal: To prevent decline and left upper extremity contracture .recommendation: restorative program of passive range of motion to be applied to LUE to prevent contracture .for RUE, use 1 lb dumbbell for bicep curls, wrist curls, and shoulder raises. 2x10. On 2/8/23 at 8:46 AM, Surveyor interviewed R15, who stated that she has not been getting any exercise or therapy in her room. R15 stated that she has trouble moving her left side and attempted to lift her arm up but could only slightly move it at the shoulder (a shrugging motion). While sitting in her bed, R15 looked straight ahead at her picture collage and stated that she would like to move her body more so that she could get stronger and spend more time with them as she pointed at her family pictures. R15 also stated that she has not seen a dumbbell and does not remember using one or where they are. On 2/9/23 at 1:21 PM, Surveyor interviewed CNA G (Certified Nursing Assistant) who stated that she regularly works with R15 and does do range of motion with her, however, stated that it sometimes does not get done due to other resident needs. Additionally, CNA G stated that she was unaware of the exercises R15 was to be doing. On 2/9/23 1:36 PM Surveyor interviewed CNA F, who frequently provides care for R15. CNA F stated that she does do exercises with R15 and a lot of those exercises revolve around doing cares and the resident does not know it, which may be why R15 believes she is not getting any therapy or restorative. CNA F then stated she did not do the dumbbell exercises and has never performed any exercises with R15's weak side (LUE). CNA F also stated that she believes the CNA's at the facility are good at regularly documenting when restorative therapies are being done. At around 2:15 PM, CNA F found Surveyor and stated she had found where the dumbbells were located and showed the Surveyor that they were right behind the nurse's station. The facility's documentation shows R15 did not receive restorative a total of 34 days from November 2022 through 2/7/23 (2/3, 2/1, 1/29, 1/25, 1/24, 1/23, 1/22, 1/19, 1/14, 1/13, 1/11, 1/8, 1/6, 1/5, 12/24, 12/25, 12/21, 12/19, 12/15, 12/10, 12/9, 11/30, 11/27, 11/26, 11/25, 11/23, 11/21, 11/19, 11/13, 11/12, 11/9, 11/7, 11/6, 11/5). On 2/9/23 at 3:38 PM, Surveyor interviewed DON B (Director of Nursing). DON B stated that the facility has some work to do on their restorative program, but that she believes it will be improving greatly in the very near future. Additionally, DON B stated that she was aware that restorative plans for residents were not being reevaluated and assessed to find if residents' range of motion was improving or declining and if plans needed to be updated. DON B stated that currently, a nurse is doing monthly general assessments on residents, which includes a statement that briefly mentions the resident's ADL (Activities of Daily Living) assist level, but does not address range of motion. The facility had therapy recommendations to provide daily upper and lower extremity restorative exercises for R15. Facility staff were not conducting the specified exercises, were not conducting them consistently, and were not assessing the resident's range of motion and if R15's range of motion had improved, declined or if her current restorative plan needed updating.

Based on interview and record review the facility must develop policies and procedures to ensure that residents or their responsible party receive risk and benefits of COVID immunizations, are offered the immunization and documented in the medical record whether the immunization was received or declined, this affected 3 of 5 residents (R28, R95, and R31) reviewed for immunizations of 12 sampled residents. R28 did not have the COVID immunizations offered and no documentation. R95 did not have the COVID immunizations offered and no documentation. R31 did not have the COVID immunizations offered and no documentation. This is evidenced by: The facility did not provide a policy and procedure that speaks of COVID immunizations for the residents. Example 1 R28 was admitted to the facility on [DATE]. There is no documentation that R28 was provided education on the risk and benefits of the COVID immunization or that the immunization was offered, received, or declined. Example 2 R95 was admitted to the facility on [DATE]. There is no documentation that R95 was provided education on the risk and benefits of the COVID immunization or that the immunization was offered, received, or declined. Example 3 R31 was admitted to the facility on [DATE]. There is no documentation that R31 was provided education on the risk and benefits of the COVID immunization or that the immunization was offered, received, or declined. On 2/8/23, at 2:24 PM, Surveyor interviewed DON B (Director of Nursing) and asked if R28, R95, and R31 had received education, were offered, received, or declined the COVID-19 immunizations. DON B indicated DON B had recognized on 2/3/23 that was a break in the system with immunizations. DON B indicated the issue was taken to QAPI (Quality Assurance Performance Improvement), but nothing has been started. DON B indicated there should be documentation on education and declination of the COVID-19 immunizations in the residents' medical records and there was not. DON B provided education and declinations signed and dated 2/8/23 for R28, R95, and R31, after Surveyor had asked for the documentation.

Based on observation, record review, and interviews, the facility did not prepare food in accordance with professional standards for food service safety. This has the potential to affect 38 of 38 residents residing in facility. The facility did not cool foods using the current process facility implemented. This has the potential to cause a foodborne illness outbreak in the facility. Findings include: The FDA Food Code requires that food be cooled from 135 degrees F to 70 degrees F within two hours and from 135 degrees F and 41 degrees F within a total of six hours. The FDA defines cooling as a critical point essential in preventing foodborne illness outbreaks. The Surveyor observed leftovers in the refrigerator dated 10/19/21. On 10/20/21, at 09:00 a.m., Surveyor interviewed Cook-D regarding how they monitor and track cooling of foods for leftovers. At the end of tray line, Cook-D will temp the food then recheck that two hours later. The temperatures get recorded on a clip board. Cook-D identified that leftovers are saved on a daily basis for a total of three days, they will use the leftovers for meal substitute upon resident request. Surveyor requested to review cooling logs. The cooling log read: Cool from 135F to 70F in 2 hours, then from 70F to 41F in 4 hours . No temperatures were recorded on the log. Cook-D stated that they had been lacking on documenting temperatures recently. Surveyor located no evidence the leftovers in the refrigerator had been cooled per the FDA food code. On 10/20/21, at 09:36 a.m., Surveyor interviewed NHA-A regarding lack of evidence on a system on cooling foods. NHA-A provided knowledge that staff was to obtain temperatures and document all leftovers using approved cooling procedures. On 10/20/21, at 11:05 a.m., NHA-A provided writer with prior months cooling log; the last time temperatures were documented was 09/26/21. NHA-A stated all leftovers were discarded from the facility since they could not ensure the foods had been cooled appropriately.

Based on interview and observations, the facility did not ensure Residents were treated with dignity for 1 of 12 (R10) Residents sampled. This is evidenced by: R10 was admitted to the facility on [DATE], and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R10's Brief Interview for Mental Status (BIMS) score is 07 (severely impaired cognition). R10's son is his Activated Durable Power of Attorney (ADPOA). On 10/18/21, at 12:20 PM, Surveyor observed R10 in the dining room for lunch. R10 is observed sliding down in his Broda chair. R10 states to CNA-C that he is sliding down. CNA-C approaches R10 and in an undignified manner states, I told you to stop squirming around in your chair. I told you to sit still or you're going to end up on the floor. CNA-C then walks away from R10 stating, He needs a Dycem. (Dycem: thin, non-slip pad to prevent sliding.) Surveyor also observed at this time that R10's Foley catheter drainage bag was hanging on the right side of his chair, under the arm rest completely exposed with no privacy bag covering it. On 10/18/21, at 2:54 PM, Surveyor interviewed R10's son, also his ADPOA regarding whether or not R10 would be bothered by other people seeing his catheter drainage bag exposed and hanging on the side of his chair. ADPOA stated, Yes, that would bother him. On 10/19/21, at 12:35 PM, Surveyor observed R10 in the dining room for lunch. R10 is sitting in his Broda chair properly positioned. R10 is wearing a pair of gray shorts. Urinary catheter can be seen with connection tubing draped over his thigh and hanging to the right side of his chair. Foley drainage bag is attached and hanging underneath his chair exposed and without a privacy bag.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent accidents from elopement for 1 of 3 sampled residents (R1) out of 18 total residents who have been identified to be a wander/elopement risk. The facility failed to provide adequate supervision to R1 who was assessed to be an elopement risk. R1 was found outside, on 1/24/19, during subzero weather. R1 was found on knees, on snowy frozen ground, and developed frostbite to bilateral knees and hands. Facility failure to supervise a resident who was assessed to be an elopement risk created a finding of Immediate Jeopardy (IJ) that began on 1/24/19. Surveyor notified NHA A (Nursing Home Administrator) and DON B (Director of Nursing) of the IJ on 1/31/19 at 3:25 PM. The IJ was removed on 1/31/19. However, the deficient practice continues at a scope/severity of a D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. This is evidenced by: The facility's elopement policy and procedure (P&P) entitled, Resident Wandering and Security, with effective date 11/2017, includes, in part, the following: .2. The care plan will identify any security needs and the Interdisciplinary Team (IDT) will develop appropriate intervention and team responsibilities. The IDT will review these approaches as necessary and at least quarterly. Assessments will be determined according to behavior displayed and behavior patterns . 4. All facility staff shall be advised of the potential for wandering for each resident in question and be able to assist as necessary. Facility's front door has a WanderGuard system, Accutech LS2400T. This system will alarm at the door when the door is opened if there is someone with the WanderGuard tag close by or going through that door. The system also sets off an alarm at the Nurse's Station, which can be silenced, but the alarm at the door will need to be cleared and reset after each time it goes off. The manufacturer's book for this system has an important notice on the front of Chapter 1 that states, in part: No security system can replace human vigilance. Creating a safe environment requires the combined efforts of personnel, physicians, security, and patients .No level of security can replace an informed and knowledgeable staff. Any electronic or physical security system should be considered as a supplemental deterrent, but by no means an end-all. On 1/31/19 at 10:32 AM, NHA A demonstrated how the WanderGuard system worked at the front door and also how it rang at the Nurse's Station. The WanderGuard panel has to be silenced at the door, even if the reset button has been pushed at the Nurse's Station. It only alarms when the door opens. A resident with a WanderGuard bracelet or tag can be sitting in the area, but it won't alarm unless the door opens. R1, who is 94, was admitted to facility on 8/22/18. R1's [DIAGNOSES REDACTED]. R1 has an activated Health Care Power of Attorney and is not own decision maker. R1's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/28/18 indicates R1 has a BIMS (Brief Interview of Mental Status) of 3/15 (3 out of 15), which indicates severe cognitive impairment. R1 is marked for wandering in 1-3 days during the assessment reference period. R1 had elopement assessments on 8/22/18 and 11/28/18 that indicates the resident is at risk for elopement. WanderGuard was placed on resident on 8/22/18. On 1/31/19 at 1:30 PM, Surveyor interviewed DON B about R1's care plan. On the initial care plan, dated 8/22/18, there was a need that says that R1 has the potential to feel anxious because I have a cognitive impairment when I feel this way, I may be disruptive, yell, shout, or scream or may try to leave the building. The interventions listed under this is for the nurses to: offer distractions, medication, try to figure out the cause of my mood or behavior, treat for pain and evaluate effectiveness, say nice weather as this is a long standing phrase that helps to calm me down. Interventions that the CNAs (Certified Nursing Assistant) need to do: ask me if I'm having pain, offer me snack or drinks, help me call my family, follow my toileting plan, talk with me about my past, give me something to do, say nice weather as this is a long standing phrase that helps to calm me down. The goal for this need is to interact appropriately with those around me. Unlike the initial care plan, the Comprehensive Care Plan is less complete. In the Comprehensive Care Plan, under the need that R1 can't complete care on own, is an intervention that states, I wear a WanderGuard on my ankle. This is the only reference to WanderGuard in care plan. No goal was found in Comprehensive Care Plan in regards to elopement and at risk for elopement and keeping resident safe from elopement. Surveyor asked DON B about these care plans. DON B indicated that the immediate Plan of Care should be carried forward to the Comprehensive Care Plan. DON B indicated that R1's risk for elopement wasn't carried forward to the Comprehensive Care Plan. Nurse's Notes include, in part: 1/24/19 at 22:40:47 (10:40:47 PM), time of incident: 2000 (10:00 PM); Incident type: Elopement, 0 windy; Location: outside; Mental state: confused; Activity at the time: wandering; .Narrative of what happened: Resident had been wandering up and down the hallways after supper. This Writer toileted (R1), gave a snack, and needed much redirection. Resident had red purse and was persistent about wanting to go home. Persistently going in and out of other resident's rooms .At 20:05 (10:05 PM) this Writer and CNA saw resident straight outside front door in parking lot. Dressing in pants, slipper, elbow length shirt, kneeling on the snow covered payment with arms and upper torso on WC (wheelchair). Resident was alert and orientated x (times) 2 (which is R1's baseline) appeared angry and upset stating, Leave me alone! I just want to die! I'm so cold! Get away from me! .Resident statement: What were you trying to do? I'm going home because you guys are all going to hell and I want to do that! .Injury: Hematoma/bruising RT (right) knee .Length of time outside approx. (approximately) 10-15 minutes Incident Report from 1/24/19 indicates, in part: . Narrative of what happened: repeats same notes as above Nurse's Notes. Vitals: B/P (blood pressure): unable to due to shaking; pulse: 74; respirations: 24; Temperature: 94.6 . The weather, on 1/24/19 around 8:00 PM, per Wunderground website, indicates that the temperature was around 0 degrees Fahrenheit with the winds blowing West North West at 13.8 MPH (miles per hour) with gusts up to 23 MPH. This would put the wind chill at -18 to -23 MPH at the time of elopement. Nurse's Notes include, in part: 1/26/19 at 06:03:43 (6:03:43 AM): Call placed to Dr. (name) regarding: change in condition - blisters on left and right hands (fingertips on left hand) .New orders received and noted. 1/26/19 Send to ER (emergency room ) this AM (morning) for evaluation of fingers/hands 10:30:51 (10:30:51 AM) Resident returned to (facility) around 0930 (9:30 AM) from ER with [DIAGNOSES REDACTED]. ER Report, from 1/26/19, includes, in part: Encounter Diagnosis: [REDACTED]. ED (Emergency Department) Course/Plan/Summary: A [AGE] year-old nursing home resident, cold exposure 2 days ago of unknown duration with superficial cold injury or frostbite to the palmar aspect of the hands, especially the distal digits with some blistering and anterior knees with blistering again, but the blisters have broken down on the knees. Patient appears somewhat uncomfortable .Superficial frostbite injury was treated with [MEDICATION NAME] ointment and sterile gauze wrapping. We recommend daily dressing change, limit use of involved extremities .History: .presents .with blisters on knees and palmar aspects of both hands, which occurred when (R1) had wandered outside on hands and knees with only socks, pants, and a T-shirt on several evenings ago. The patient has been uncomfortable, and several of the blisters, especially on the knees, have broken down. The patient has blisters on right hand index finger and left hand 3rd, 4th, and 5th distal ends of the fingers .Review of systems: .Skin: Multiple blisters palmar hands and anterior knees .Physical Exam: .Skin .Multiple blisters anterior knees with blister breakdown and healing epithelium; Palmar hands with [MEDICAL CONDITION] and [DIAGNOSES REDACTED] and blisters left hand 3rd and 4th distal fingers and right hand distal index finger; no drainage; blisters intact .Discharge instructions: Wounds care with antibiotic ointment and sterile gauze wrap daily dressing change. Avoid local trauma. Avoid further cold exposure. Follow up with MD (medical doctor) if worse or if new symptoms. On 1/29/18, primary MD evaluated R1 at facility and MD's Progress Note from that date, states, in part: Subjective: .Last Thursday in the evening, R1 was discovered to be outside the front door of the facility. R1 was seen on hands and knees trying to get back into w/c (wheelchair). It is not known how R1 eloped nor how long R1 was out . core temperature upon bringing R1 back in the facility was 94.0 .R1 saw the ER physician, 1/26/19, and was diagnosed with [REDACTED]. The knee blisters did subsequently collapse. On the left hand R1 had blisters on the 3rd 4th and 5th digit finger pads and on the hypothenar (palm of hand) aspect of the hands. On the right hand, had blister over the thenar (ball of the thumb) area. Some of these blisters are intact, some have collapsed .R1's only complaint is that hands sting as do knees .Objective: .Skin: R1 does have some tenderness of the skin of the hands when we examine them. R1 has blisters on the finger pads of the left hand 3rd, 4th and 5th digits .Impression/Plan: 1. Frostbite to multiple areas as described. Seems to be superficial. I do not see any darkened skin or eschar. Will add [MEDICATION NAME] for additional pain management . On 1/29/19 at 01:25:05 (1:25:05 AM), Nurse's Notes state, in part: [MEDICATION NAME] had moderate amount of light red/yellow drainage. [MEDICATION NAME] was changed. Resident unable to tolerate having new Kerlix applied. R1 stated, I'm going to hit you and moaning and groaning in pain. Scheduled Tylenol was given before dressing changes. Resident stated It hurts to the lightest touch. Resident unable to tolerate Band-Aid changes to fingers. On 1/29/19 at 13:51:18 (1:51:18 PM), Nurse's Notes indicate that R1 received [MEDICATION NAME] HCL 50 MG (milligram) for complaints of pain all over, resident states I hurt all of the time. R1 is unable to rate pain. On 1/30/19 at 01:20:06 (1:20:06 PM), Nurse's Notes indicate that R1 received [MEDICATION NAME] HCL 50 MG for pain/discomfort. R1 was unable to rate pain but verbalized oh it hurts, my legs hurt. On 1/31/19 at 10:00 AM, Surveyor observed dressing change procedure to R1. The dressing change was performed by RN K (Registered Nurse) with assist from RN E. RN K started the procedure by telling R1 to let me know if it gets too painful and we'll stop. RN E had pre-medicated R1 with scheduled Tylenol. R1 had received a shower prior to this procedure. RN K stated following direction from DON B, the gauze was left in place during the shower. Surveyor confirmed that R1 had no open areas or skin issues prior to the 1/24/19 incident. RN K started procedure by cutting off gauze from knees bilateral. Both knees had [MEDICATION NAME] gauze in place which was adhered to knees by drainage that was on them. Prior to RN K removing the adhered gauze, RN K sprayed it with a wound cleanser/saline spray. RN K started to remove the [MEDICATION NAME] from the right knee. R1 yelled out in pain, Ouch, Ouch, Ow, Ow, Ow! R1 stated that it was really painful, but I won't hit you. RN K applied more wound cleanser/saline spray to knees and tried again to remove [MEDICATION NAME]. R1 again called out in pain. RN K stated that they will have to give [MEDICATION NAME], will spray them and then come back. RN E left to go get [MEDICATION NAME] and returned at 10:05 AM and administered this. While RN E was out of room, RN K proceeded to spray the [MEDICATION NAME] dressings on both knees to try to saturate them. RN K was talking with R1 while spraying knees. R1 stated the pain is horrible. How would you like it if your skins pulled off? RN K told R1 that RN K would try to make it so R1 has less pain. R1 stated, I'll hold you to it with 2 black eyes if it's painful. R1 also made the comment, I'm pain tolerant. After RN E gave the [MEDICATION NAME] to R1, RN K continued to work on the dressings, spraying them, and trying to slowly remove them. No break was ever given to resident. R1 indicated it hurt several other times during this period. [MEDICATION NAME] dressings were completely removed around 10:07 AM. With the dressings removed, it opened the wounds up to be assessed by RN K. The open area on the left knee measured 7.1 x 6.7 cm (centimeter). RN K stated that there was 10-20% (percent) slough area to the distal (lower) portion on the wound. Granulation was noted throughout the rest. The peri-wound (area around the wound) was very red (more than on the right side). The open area on the right knee measured 7.1 x 3.2 cm with 10% slough to proximal (upper) end of wound. RN K stated that both dressings had small to moderate amount of purulent drainage noted to them upon removal. RN K stated that on Friday, 1/25/19, R1's knees had what looked like dry skin and some [MEDICAL CONDITION] was noted as well. RN K stated that when RN K reported to work on Saturday, 1/26/19, R1's knees bilateral presented as opened blisters and R1 was sent to ER for evaluation. R1 has daily dressing change to bilateral knees. RN K put on a Vaseline gauze contact layer and then [MEDICATION NAME] and wrapped with gauze when reapplied dressing. RN K was going to update MD with change in dressing procedure. Surveyor also observed R1's hands which were blistered. R1's right hand had discolored areas where blisters had been present, but have reabsorbed now. These areas were located on the area between the thumb and index finger and on the index finger as well. R1's left hand had dried blistered areas noted on the 3rd and 5th fingers and a large fluid blister on 4th (ring) finger which measured 3.7 x 2.2 cm. This area did not have a dressing on it when Surveyor arrived this AM. RN K put 2 Band-Aids on this area before the whole dressing change procedure was done. RN K indicated that R1 had a different dressing to fingers initially, but R1 would remove them, so they changed the dressing to Band-Aids, which R1 seems to leave on better. On 1/31/19 at 11:53 AM, Surveyor interviewed RN F about R1's elopement on 1/24/19. RN F was the nurse that was responsible for the 200 Hall where R1 resides. RN F stated that after supper, R1 was getting more agitated. Around 7:05 PM, RN F noted that R1 was on the carpeting in front of the main doors and that R1 was wheeling self closer to the door and attempted to open that door ,setting off alarm. RN F went over to R1 and backed resident up and silenced the alarm. RN F took R1 over to the kitchen area where there were lots of people in the dining room and R1 was mingling with others. RN F then went down the 200 Hall to administer medications to other residents. RN F noticed the group of people that RN F had placed R1 by, in the dining area, heading down the 100 Hall. R1 was following them, especially another resident and her daughter. R1 followed that daughter back up the 100 Hall, when she was getting ready to leave, and that daughter told RN F that R1 had indicated needing to use the bathroom. RN F then took R1 to the bathroom around 7:30 PM. RN F had left R1 in bedroom when finished with the bathroom. RN F continued passing medications to the 200 Hall residents. R1 proceeded to leave room and headed down the 200 Hall towards the exit door at the end. There is a yellow strip across the door to deter people from exiting through this door as it is for emergency use only. RN F stated that R1 was mad. R1 was determined to leave. RN F asked R1 what's the matter. R1 was pushing RN F away and wanted to leave to go home. R1 grabbed on the door handle and tore off the yellow strip that was velcroed on. RN F was able to turn R1 around. R1 proceeded to go past RN F's medication cart and head back up the 200 Hall towards the Nurse's Station and front doors. RN F stated that in a matter of minutes RN F heard the alarm go off at the main door and found R1 between the double doors at the main front entrance. R1 was very mad and agitated and wanting to leave to go home. RN F brought resident back but resident was trying to grab on to everything as they were bringing R1 in. RN F put R1 at the Nurse's Station so that R1 would be within eye sight and gave R1 some ice cream. RN F stated that R1 said, As soon as I'm done, I'm out of here. You sons of [***] es are going to hell and I'm not going with you. RN F stated that around 7:45-7:50 PM, RN F told CNA H, along with several other Aides sitting at the Nurse's Station, RN F had to go down the short hall off of the 200 Wing to give those residents their medications. RN F directed CNA H to watch R1 better, because R1 just got out the first door at the main entrance. RN F indicated when RN F went down the short hall off the 200 Wing, R1 was content and eating ice cream. RN F stated CNA C then came to RN F around 8:00 PM and stated that CNA C was looking for R1. RN F finished giving the medication RN F was working on (took around 2-3 minutes) and then proceeded to look for R1. RN F stated that the employee doors down the 3rd hall (this hall doesn't have resident rooms on it) were swung open and that they are typically shut. RN F looked down there first, since those doors were opened. RN F stated she looked in the rooms down that hall and spent around 3-5 minutes down that hall looking for R1. RN F came back to the Nurse's Station and RN G was there with the pharmacy delivery man. They had just come out of the medication room. The pharmacy delivery man stated that he would go out the back door and get in his car and look around outside. RN F was going to go look out the front door and proceeded there. RN F stated that everyone was looking for R1. RN G went down the 100 Hall to look for R1. RN F and CNA H went to the front door and looked out the door and saw R1 in the middle of the front/main parking lot. RN F stated that R1 couldn't be seen out the windows from the pillars in the dining room, but once they got close to the main door windows, they could see R1, then in the parking lot outside. RN F indicated that there was no alarm going off at the door or at the Nurse's Station. RN F thought RN F was looking 5-10 minutes. RN F stated that R1 was wearing long pants, TEDs (anti-embolism stockings), slippers, and a thin long sleeve shirt to elbows. R1 was off w/c with knees on the ground facing into w/c. R1 was telling RN F to get away. RN F and CNA H tried to get R1 to stand up. R1 brought ankles to knees when they tried to stand R1, so they set R1 back down. R1 was clinging to w/c so they were lifting R1 and the w/c. They tried to give R1 directions and tried 2 more times, but they were unable to get R1 to stand. RN F instructed CNA H to go inside and get more help. CNA H attempted to go in and found the doors locked and was working on getting back in when the pharmacy delivery man drove up. He helped RN F stand R1 up and got R1 sat back in w/c. RN F had to pop a wheelie in R1's w/c and pull R1 in backwards, because R1 was fighting them. RN F indicated that alarm rang when R1 was brought inside. RN F assessed R1 when they got back in. R1's exposed body was red in color. Initial temp was 94.6 degrees Fahrenheit. Unable to obtain B/P, because resident was shaking too much. R1 was toileted and when R1 grabbed the assist bar in the bathroom, R1 stated hands hurt. RN F assessed skin while sitting on toilet and didn't see any issues on arms, legs, or feet. RN F noted a bruise to right knee and that left knee was red in color. RN F stated that R1's hands were red as well. There was slight swelling in hands, but RN F indicated that swelling in hands is a norm for R1. Warm fluids and warm blankets were given to R1. RN F called on-call provider and was told to get temperature up to 97 degrees and continue to monitor. RN F stated that family was updated around 9 PM. Surveyor asked RN F if RN F would have done anything differently in regards to that evening. RN F stated that RN F would have called family earlier in the shift, when R1 was getting so upset, so they could have come in to help calm R1 down. Surveyor asked about making R1 a 1:1 (one-on-one) when resident was getting so upset and trying to get out the doors. RN F needed to review that policy and felt that RN F would need to contact DON B before making that decision to make her a 1:1. Surveyor asked if they thought about changing R1 to 1:1 after the incident and RN F indicated that DON B stated it was not necessary at this time, because she was in bed. On 1/31/19 at 10:09 AM, Surveyor interviewed CNA H about R1's elopement on 1/24/19. CNA H had worked the 200 Wing where R1 resides. CNA H stated that R1 was really angry and had tried to go outdoors a few times that night. CNA H indicated that R1 had made 3 attempts - 2 times at the front door and 1 time at the emergency door at the end of the 200 Hall. CNA H stated that RN F had brought R1 to the Nurse's Station for staff to watch, between putting residents to bed. CNA H last saw R1 between 7:30-7:45 PM and that R1 was found outside between 8:00-8:10 PM. CNA H stated that R1 was wearing long pants, [MEDICATION NAME] (care compression stockings similar to knee high socks), t-shirt, and slippers. CNA H stated that RN F and pharmacy delivery person found R1 outside. CNA H doesn't believe any education was provided. There is a binder at Nurse's Station for wanderers with policy in it, which she reviewed and signed a paper stating that CNA H had reviewed this. CNA H did an incident report. On 1/31/19 at 11:47 AM, Surveyor interviewed CNA C about R1's elopement on 1/24/19. CNA C was on the 200 Wing and responsible for R1. CNA C indicated that R1 was fine before supper, but was agitated after supper. R1 was propelling self in w/c up and down halls, which CNA C indicated was normal behavior. CNA C last observed R1 down the 200 Hall between 6:30-7:00 PM. CNA C wasn't aware of R1 being at the doors. CNA C stated that R1 was wearing short sleeve shirt, pants, [MEDICATION NAME], and slippers. CNA C was responsible for 3 showers and there were lots of call lights on and when CNA C got everyone situated, then went looking for R1 and couldn't find R1. CNA C indicated it was around 8 PM when CNA C began looking for R1. CNA C hadn't heard any alarms or reset any that evening after supper. CNA C stated RN F found R1 outside. CNA C did receive education the evening of the incident. CNA C stated that they were told that if an alarm goes off to go and check it out and not just silence the alarm at door. CNA C indicated that no one said they silenced the alarm. CNA C also stated that RN F indicated having to take R1 away from the doors 3 times that evening before the incident. CNA C looked through the WanderGuard book that is at the Nurse's Station and reviewed the procedure, which was in the book CNA C is unaware of any changes to the procedure. CNA C signed off that CNA C had reviewed this information. On 1/31/19 at 8:45 AM, Surveyor interviewed RN G about R1's elopement on 1/24/19. RN G was working that evening working as the 100 Wing (opposite wing that resident resides on) Floor Nurse. RN G had passed medication to the lower 2 rooms on the 200 Hall (wing that resident resides on) - the 1st room on either side of the Hall. RN G gave those residents their bedtime medications which was around 7:45-7:50 PM. (It is important to note that the last medication given to these 2 residents was documented at 7:36:49 PM.) RN G stated when done passing these medications to the 200 Wing residents, RN G moved cart to the 100 Wing. RN G moved cart past the Nurse's Station where RN G recalls that R1 was sitting eating ice cream. The next thing that RN G knew about the situation was around 8:00-8:05 PM, CNA came by and said that R1 was found outside. RN G stated that R1 was wearing slacks, [MEDICATION NAME], slippers, and a shirt where forearms were bare. RN G observed snow on R1's pants and slippers. R1 was assisted to put clean dry clothes on and was taken to the bathroom. Warm towels were used. They attempted to give R1 food and drink, but was too cold to worry about eating. RN G had seen RN F with R1 at one point at the front door with the alarm going off. RN G had given education to staff that evening of the elopement. Surveyor asked RN G if DON B had ever given RN G any additional education; DON B never gave RN G education. RN G stated that they have a 3 ring binder with the residents who are elopement risk individuals. RN G was unaware of any changes being made since this incident. On 1/31/19 at 9:22 AM, Surveyor interviewed CNA I about R1 and the elopement on 1/24/19. CNA I worked that evening. CNA I didn't have R1 that evening (wasn't assigned to care for). CNA I stated that after supper, R1 can get agitated and make attempts to go out front door, roughly at least 2 times/week. That evening, R1 was very hard to redirect. CNA I indicated that 1-2 weeks prior to this incident, R1 wouldn't redirect for the CNAs and that the DON had to come assist them. CNA I had last seen R1 at supper time between 5:30-6:30 PM. CNA I indicated that R1 was wearing short sleeve T-shirt, light colored pants, slippers, and thinks [MEDICATION NAME]. CNA I stated that RN F found R1 outside. CNA I had heard an alarm faintly around 7:30 PM and only heard it that one time. CNA I had signed a sheet about education that night and completed a statement for the incident. CNA I indicated that no changes have come in place because of incident, that there has just a review of what was already in place. On 1/31/19 at 9:33 AM, Surveyor interviewed CNA J about R1's elopement on 1/24/19. CNA J worked the 100 Hall that evening (this is the opposite hallway of where R1 resides). CNA J had seen R1 in the dining room per norm and also saw R1 propelling self in w/c, after supper, up and down the halls. CNA J indicated that R1 was wearing 3/4 length sleeve shirt, pants, and Velcro shoes. CNA J wasn't sure who found R1, but thinks it was RN F and CNA C. CNA J indicated that, on 1/24/19, after incident, CNA J was given a 3 ring binder that had residents who wander in it, to review the information in the binder. There was also a sheet to sign about not silencing the alarms, to ensure to check for residents prior to silencing the alarm. CNA J read through the policy that was in the 3 ring binder and was unaware of any changes to the policy. CNA J had never seen binder prior to this incident; CNA J had never received any education on it prior and didn't even know it existed. On 1/31/19 at 8:30 AM, Surveyor interviewed RN D about R1's elopement on 1/24/19. RN D was not working on that evening, but had heard that R1 was very agitated and was propelling self in w/c up and down halls. RN D would have made R1 a 1:1 or would have taken R1 down the hall with RN D to make sure to keep R1 in eyesight if RN D had been working. RN D heard that R1 was found outside after what facility believes was 5-10 minutes. RN D received an education, that it was a paper and signed after reviewing it. RN D stated that there was no change in the policy or nothing new done after this. On 1/31/19 at 8:54 AM, Surveyor was stopped by RN D who indicated that R1 should have been 1:1 the evening of the elopement. RN D stated it should have never happened. RN D also indicated that RN D felt the education in the facility could be better and feels like the bare minimum is done. On 1/31/19 at 8:32 AM, Surveyor interviewed RN E about R1 and R1's behavior. RN E stated that R1 is known to wander, has bad Sundowning, and is hard to redirect at times. RN E believes RN E received education on Monday 1/28/19 and stated that it was to ensure to go to alarm, to investigate why it was going off, and not just silence the alarm. RN E indicated that nothing new was put in place, just reviewed what should have already been done. On 1/31/19 at 9:25 AM, Surveyor interviewed DON B. He demonstrated the alarm system at each door. All doors are alarmed with the main entrance being the only one that requires a WanderGuard system. DON B indicated that door alarmed when R1 came back in from the outside, the evening of the incident. He indicated that nothing was found to be wrong with the WanderGuard system. On 1/31/19 at 11:10 AM, Surveyor interviewed DON B about the elopement and what changes have been done since then. DON B indicated that they haven't changed anything. R1's WanderGuard bracelet/tag is still on left ankle (no change in position) where it was on the evening of the incident. DON B indicated that the WanderGuard Company is coming out to check the system. On 1/31/19 at 1:40 PM, Surveyor interviewed DON B about the education staff received after the incident. DON B stated that everyone in the building, including therapy, was educated on the policy that he showed Surveyor. (It is important to note that Surveyors compared the sign off list, to employee list, and the facility still had around 30 out of approximately 80 employees that had not signed off that they received education.) DON B stated that nurses are capable of making decisions to make a resident a 1:1 if they feel they need to increase supervision. DON B stated that extra attention was causing more agitation for this resident. Surveyor asked if 1:1 could be given without being directly beside resident, could R1 be watched from a distance to ensure safety. DON B indicated that could have been done. According to the National Institute of Health, Older adults are especially vulnerable to hypothermia, which can be deadly if not treated quickly.Older people also are at risk for hypothermia because their body's response to cold can be diminished by certain illnesses such as diabetes (which this resident had) and some medicines, including over-the-counter cold remedies. In addition, older adults may be less active and generate less body heat. As a result, they can develop hypothermia even after exposure to relatively mild cold weather or a small drop in temperature. http://www.nih.gov/news/health/jan2009/nia-16.htm. According to http://www.livescience.com/6008-person-freeze-death.html, A drop in body temperature prevents critical organs from working properly - including the brain and heart, according to the Mayo Clinic. Improper functioning of the heart results in reduced blood flow to many organs, putting the body in a state of shock and increasing the risk of conditions, like liver failure and kidney failure . The very young and the very old are at greater risk for hypothermia because they generally have weaker heart muscles, he said. In addition, older people are more likely to take medications such as beta blockers that can slow heart rate, which further increases their risk of developing hypothermia in the cold .Symptoms of mild hypothermia, such as shivering, weakness and confusion, set in when core body temperature reaches about 95 F. After that, 'as you start dropping (in core body temperature), bad things happen .' The facility failed to provide adequate supervision to ensure resident was safe and prevent elopement out of building on an extremely cold night after R1 had made 3 attempts to go outdoors (2 at the front doors, eventually got out and 1 down the 200 Hallway). R1 was found outside on knees, subsequently developing frost bite areas to knees bilateral (that are now opened up) and blistered areas to hands bilateral. Although the front door is alarmed, manufacturer inst

Based on observation, interview and record review, the facility did not provide necessary care and services in order to attain or maintain the highest practicable physical, mental, and psychosocial well-being. This occurred for 1 of 12 residents (Residents #13) reviewed for pain; 3 of 9 (#2, #13, #9) who were reviewed for bowel incontinence. Resident #13 was experiencing pain with positioning after suffering a pelvic fracture in the facility on 05/31/16. The pain medication was not increased from 06/01/16 until 06/07/16 after six days of severe pain. Resident #13 continued to complain of pain until 06/14/16, when the dose was decreased for one day, and then increased on 06/15/16. Resident #13, #2 and #9 had a decrease in bowel continence, with no bowel assessment or bowel program implemented to maintain their continence. This is evidenced by: The facility policy, Pain Assessment and Monitoring .Procedure: 1. Evaluate the resident for signs/symptoms that may indicate the need for pain management. 2. Evaluate the resident at admission .Evaluations will be repeated .with changes in condition 5. Notify the MD of any persistent or uncontrolled pain so scheduled pain medications or interventions may be implemented/ordered . 1. Resident #13 fell in the facility on 05/31/16, and suffered extensive fractures of the right hemipelvis to include the iliac bone, iliac wing, pubic symphysis, superior and inferior pubic rami and a small fracture line was seen to extend into the anterior column of the acetabulum. Physician orders [REDACTED].>04/26/16 [MEDICATION NAME] 500 mg 1 tablet 500 mg three times a day for pain. 05/31/16 [MEDICATION NAME] 10/325 mg oral tab i(one) every 6 hours as needed for pain control. 06/01/16 Tordol 10 mg po tid (three times a day) x 5 days. [MEDICATION NAME] 5 mg po every 6 hours prn. [MEDICATION NAME]/APAP ([MEDICATION NAME]) can be given in a few days again when pain is less severe. 06/07/16 D/C (Discontinue) [MEDICATION NAME]/APAP .hold all oral medications. Comfort care .[MEDICATION NAME] SL (sublingual) 5 - 10 mg every 2 hours prn pain 06/14/16 .Change [MEDICATION NAME] to 2 mg or 4 mg SL every 2 hours as needed for severe pain. 06/15/16 [MEDICATION NAME] 4 - 6 mg SL every 2 hours as needed for severe pain. The nurses' notes in part: 05/31/16 .assisted to bed on return from ER (emergency room ) .she moaned with pain with movements . 06/01/16 11:59 Resident is having pain before she can have more pain medication .New orders received, [MEDICATION NAME] HCL 5 mg i tablet every 6 hours for pain. prn med given [MEDICATION NAME] HCL 5 mg, pain level before med: 8 location right groin. prn med result med effective. 19:25 prn med given [MEDICATION NAME] HCL 5 mg tablet pain level before med 8 Location :hips pelvic area . 06/02/16 1:31 a.m., prn pain med given [MEDICATION NAME] HCL 5 mg pain level :7 Location: right leg /hip .med effective . 06/02/16 15:29 Pain level 10 in pelvic area, prn med result: med effective. 06/02/16 19:42 [MEDICATION NAME] given for pain level before med: 10 in pelvic area prn med result: med ineffective- resident very restless, grimacing. Actions: continue to observe. 06/03/16 02:12 .resident moaning off and on and was grimacing several times with staff present. Resident fell asleep at 0000 and is presently sleeping . 05:49 a.m., .resident grimacing with repositioning and changing brief, more so when turned to her right side . 08:05 a.m., [MEDICATION NAME] 5 mg given for pain. Pain level before med: 8 Location: in pelvis. Prn med result: med effective resting . 16:45 (4:45 p.m.) [MEDICATION NAME] HCL 5 mg given for pain , pain level .8 in pelvis. prn med result. med effective . 06/04/16 01:21 a.m., [MEDICATION NAME] HCL 5 mg given for pain, pain level 8 in pelvis . 7:10 a.m., [MEDICATION NAME] HCL 5 mg given for pain. Unable to rate. Med effective . 14:53 (2:53 p.m.), [MEDICATION NAME] HCL 5 mg, .pain level 7, location in pelvis. Med effective. 23:10 (11:10 p.m.), [MEDICATION NAME] given pain level: NA location: Pelvis 06/05/16 Been on a scheduled pain medication? yes.How much of the time have you been experiencing pain or hurting over the last 5 days? frequently. Over the last 5 days has pain made it hard for you to sleep? Unable to answer. Over the last 5 days. Have you limited your day to day activities? unable to answer. Please rate your worst pain: 8 Manner of expressions: Verbal facial expression tightening. Onset/duration: movement. Pattern of pain: moving and repositioning of resident. Alleviating factors: [MEDICATION NAME]. Exacerbating factors: position changes. Transfers. We are administering the medication prior to transfers Should the staff assessment for pain be conducted? No 05:10 .[MEDICATION NAME] .pain level:8 Location: pelvis. prn med result: med effective. 18:45 (6:45 p.m.), [MEDICATION NAME] .given. Pain level: .facial grimacing and groaning upon movement. Location: Pelvic area .med effective. 06/06/16 7:25 a.m., [MEDICATION NAME] .given for pain with transfers and morning cares, unable to rate pain on the pain scale. Resident has grimacing with positioning .med effective . 16:16 (4:16 p.m.) [MEDICATION NAME] .given for pain, pain level: Resident states she has double pain, unable to rate using number scale, location: pelvic area. Prn med result: med effective, resting. 06/07/16 00:58 (12:58 a.m.), [MEDICATION NAME] given .pain level .unable to rate facial grimacing, moaning. Location: right leg/hip. Prn result: effective. Review of the Medication Administration Record [REDACTED]. Resident #13 was experiencing pain with moaning and grimacing, and not receiving the as needed pain medication as often as ordered. Resident #13 had Tylenol 500 mg tid (three times a day) for scheduled pain medication. Nurses' notes continue: 06/07/16 .attending physician .examined client .new orders. [MEDICATION NAME] 5 mg - 10 mg every 2 hours prn pain. (The scheduled Tylenol was discontinued on this date.) 12:36 .New orders received and noted for comfort measures of [MEDICATION NAME], .notify MD with any other comfort needs. 15:28 (3:38 p.m.), [MEDICATION NAME] (MS) 0.3 ml/6 mg, given for general discomfort .Location: all over. 18:48 (6:48 p.m.), MS 6 mg, given for general discomfort, .location:all over. 21:27 (9:27 p.m.), MS 6 mg given for general discomfort, .resident stating to family 'it hurts'. 06/08/16 .at 0001 (12:01 a.m.) staff checked on them again, resident still appears comfortable . 02:29 a.m., MS 6 mg given for pain/discomfort . location: all over. 05:12 a.m., Resident received [MEDICATION NAME] at 0210 due to family stating she was uncomfortable .resident did moan and grimace with turning. Family aware that [MEDICATION NAME] can be given every 2 hours. Family stated they will let us know when they need anything. 06:31 a.m., MS 6 mg give for comfort with repositioning. 08:36 a.m., 0700 family reports resident appears to have increased pain with repositioning,. Explained [MEDICATION NAME] will be increased to 8 mg when next dose is available . they verbalize wanting their mother as comfortable and pain free as possible. 08:33 MS 8 mg given, resident verbalized some pain . 19:59 (7:59 p.m.), MS 6 mg given for discomfort with cares . 21:07 (9:07 p.m.), .Has had no complaints of pain until about 1958 (7:58 p.m.)when she showed signs of discomfort. [MEDICATION NAME] as given which was effective 06/09/16 3:56 a.m., MS 8 mg given .resident moaned and had facial grimacing with toileting. When asked if she would like something to help with pain she stated, 'yes'. 06/09/16 6:39 a.m., MS 6 mg given for pain/discomfort .resident states, 'I hurt'. 14:18 (2:18 p.m.) MS 6 mg given for pain. Unable to provide pain level. It hurts when I move. Grimacing. Location: both legs . 06/10/16 11:40 a.m., MS 6 mg given for comfort is restless. Reports having some pain . 14:03 (2:03 p.m.), MS 6 mg given for pain/discomfort, facial grimacing/restless . 14:24 (2:24 p.m.), .she has facial grimacing with transfers and has been restless and confused . (Resident #13 was continuing to have pain with movement; the MS was given at 8 mg, when the family voiced concerns with pain on 06/08/16, the following 4 doses were given at 6 mg as the resident continued with facial grimacing and restlessness. Resident #13 is not on a scheduled pain medication since 06/07/16.) Nurses' notes continue: 16:48 (4:48 p.m.), MS 8 mg given for comfort measures . 06/11/16 05:51 a.m., MS 8 mg given for pain/discomfort .location: all over. 15:35 (3:35 p.m.), MS 8 mg given for pain, Location: all over . 23:52 (11:52 p.m.) MS 8 mg given for pain/discomfort, .facial grimacing noticed with repositioning. 06/12/16 00:38 (12:38 a.m.), .Have you had pain Yes. How much of the time have you been experiencing pain .: frequently. Has pain made it hard for you to sleep? Unable to answer.Have you limited your day to day activities? unable to answer. Rate your pain: unable to answer. Manner of expression: facial expression tightening. Location of pain: unknown. Onset/duration of pain: unknown. Description of pain: unknown. Alleviating factors: [MEDICATION NAME], position changes, rest. Exacerbating factors: unknown. 06/12/16 5:59 a.m., MS 8 mg given for pain/discomfort .facial grimacing noted . 06/12/16 22:51 (10:51 p.m.),MS 8 mg given for pain .location: unknown, facial grimacing and some moaning noted with turning and repositioning . 06/13/16 04:43 a.m., .resident did receive MS twice as a result of facial grimacing noted with reposition and cares. Once cares ceases, she did appear to be more comfortable . 10:51 MS 0.4 ml/8 mg, 4 mg given for pain with bedbath and repositioning .(Resident name), was grimacing and stating 'Oh I hurt so', she understood she was receiving pain medicine . 14:21 .she has had one dose of [MEDICATION NAME] this shift, having facial grimacing and verbalizing pain. Discussed with family the importance of administering pain medication before positioning and bathing. Family verbalized understanding . 15:14 (3:14 p.m.), MS 8 mg given for pain .location: 'I have pain.' .16:37(4:37 p.m.), med effective. 19:43 (7:43 p.m.), MS 8 mg given for pain. Location: 'I should have some pain medicine' prn effective. 23:43 (11:43 p.m.) MS 8 mg given for pain restless. med effective . 06/14/16 Doctor visit .change [MEDICATION NAME] orders to 2-4 mg every 2 hours as needed for pain. Dr. spoke with resident and asked about pain. Resident states, 'all over pain' .14:55 (2:55 p.m.), MS 4 mg given for pain. Resident showing facial grimacing. Med ineffective. 17:12 (5:12 p.m.) MS 4 mg given for pain, .resident restless and facial grimacing noted. prn med result: med ineffective. continues to complain of pain . 19:01 (7:01 p.m.) MS 4 mg given for pain, 20:03 (8:03) pain med ineffective. 21:01 p.m. (9:01 p.m.), MS 4 mg given for pain, 22:04 (10:04 p.m.), med ineffective. 22:09 (10:09 p.m.), .Has had [MEDICATION NAME] every 2 hours x 4. Gets restless and has pain by end of 2 hours . 06/15/16 03:26 a.m. MS 4 mg given for pain .family states medication effective for 'a little while' . 03:40 a.m. .has received [MEDICATION NAME] every two hours during the night. Daughter states this dosage is not maintaining comfort at prior dosing feels pain medication 'wears off' sooner and then becomes restless .comfort is main goal . 04:29 a.m., .Dr. called the nursing home to inquire about (resident name), .order to increase [MEDICATION NAME] to 4 to 6 mg SL every 2 hours . On 08/04/16 at 11:30 a.m., Surveyor interviewed the Director of Nursing (DON) about the pain concerns. The DON indicated they had done a lot for the resident and at times the family was questioning the pain medication. The following progress note was provided: 06/14/16 Subjective: .I had offered hospitalization and further evaluation .but the family decided against that. They wanted a comfort based approach .In my absence this past week she has had worsened pain from her recent pelvic fracture, thus the on call switched her to comfort care at the family request and increased her narcotic use .She still has considerable pain with transfers, however, at rest seems to be relatively comfortable at this time .Family is having some internal conflict about overall direction of care. Her daughter .is power of attorney for health care .They are in favor of comfort based approach .son in law is here today .he is concerned about (resident name) being too sleepy to take oral nutrition and hydration .1. She is getting sublingual [MEDICATION NAME] 5 - 10 mg every 2 hours as needed. She has a had a few doses per day. She does get fairly sleepy from this. Since she does look fairly comfortable at this time, I think it would be appropriate to back off on the dose at family request, .family understands that we can incrementally titrate this up as we need to for pain control . Telephone encounter document 06/15/16 .currently on [MEDICATION NAME] 2 mg or 4 mg sublingual every 2 hours as needed for severe pain since yesterday. Nurse has indicated that the dose is not sufficient to control her pain. Family has requested we increase the dose of [MEDICATION NAME] .thus we will increase the [MEDICATION NAME] to 4 mg to 6 mg sublingual every 2 hours as needed for severe pain. Surveyor interviewed the DON on 08/04/16 at 11:30 a.m., and shared concerns that the resident had an order for [REDACTED].#13 expressing facial grimacing and moaning. The dosage was then decreased to 6 mg, and then decreased to 4 mg on 06/14/16. On 08/09/16 at 2:30 p.m., Surveyor did a telephone interview with the DON and asked if the staff were supposed to do a different pain assessment when the resident was unable to answer the questions for the pain assessment. The DON replied, Yes they are to make observations and there is a specific list they are to follow. Surveyor asked for clarification on the scheduled pain medications. The DON stated that Resident #13 had [MEDICATION NAME] ordered on her readmission 05/31/16, but that it made her sick so it was changed to the [MEDICATION NAME] on 06/01/16. Surveyor asked if there were any other scheduled pain medications other than the Tylenol 500 mg tid that was discontinued on 06/07/16. The DON replied, No, she was comfort cares as of 06/07/16, so we gave her the [MEDICATION NAME] as needed. Surveyor asked if there were any parameters for the use of the [MEDICATION NAME] with a dose range of 5 - 10 mg. The DON stated there were no parameters for the use of the [MEDICATION NAME]. Bowel Incontinence 2. Resident #2's Annual Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 05/04/16, documents Resident #2 is continent of bowel and not on a bowel program. The Significant Change in Status MDS with assessment reference date, 06/22/16, documents that Resident #2 is now frequently incontinent of bowel, with no bowel program in place. The comprehensive nursing care plan was reviewed and does not address that Resident #2 is incontinent of bowel or have any individualized toileting program established for Resident #2. On 08/03/16, Surveyor requested the bowel tracking and assessments for Resident #2. The Certified Nursing Assistant documentation was reviewed and documents Resident #2 is currently frequently incontinent of bowel. On 08/03/16 at 9:25 a.m., Surveyor interviewed Certified Nursing Assistant (CNA) D to ask about Resident #2's incontinence. CNA D stated Resident #2 does not always know when she needs to go and no longer asks, so they try to use the bedpan every two hours. On 08/04/16 at 9:25 a.m., Surveyor interviewed the DON to ask for a comprehensive bowel assessment for Resident #2. The DON acknowledged a bowel assessment, bowel program or care plan had not been developed. 3. Resident #13's quarterly MDS with reference date, 04/27/16, documents that she is frequently continent of bowel with no bowel program. The Significant Change in Status (SCIS) MDS, with ARD of 06/08/16, documents Resident #13 is frequently incontinent of bowel with no bowel program. The comprehensive nursing care plan does not address that Resident #13 is incontinent of bowel or have any individualized toileting program established for Resident #13. On 08/03/16, Surveyor requested the bowel tracking and assessments for Resident #13. There was no bowel assessment provided. Resident #13's tracking documents that she was frequently incontinent of bowel for the SCIS MDS. On 08/04/16 at 9:10 a.m., Surveyor interviewed the DON about the above concerns. The DON acknowledged they had no bowel assessments, toilet programs or care plans to address the bowel incontinence. The DON went on to say they have started a process to address this for all of the residents. 4. Resident #9's MDS assessment, dated 04/20/16, identified Resident #9 was always continent of bowel function. Resident #9's 07/20/16 MDS identified Resident #9 as being frequently incontinent of bowel function. On 08/03/16, Surveyor requested a copy of a comprehensive bowel assessment for Resident #9 related to her decline from always continent of bowel to frequently incontinent. Surveyor was provided with the following weekly summary notes: 05/06/16 at 8:16 a.m. - BOWEL CONTINENCE: frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement) BOWEL PATTERNS: Constipation present? no BOWEL PROBLEMS: has unexpected bowel movements. 06/03/16 at 8:52 a.m. - BOWEL CONTINENCE: frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement) BOWEL PROBLEMS: has unexpected bowel movements. 07/01/16 at 2:10 p.m. - BOWEL CONTINENCE: frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement) BOWEL PROBLEMS: These notes identify Resident #9 has bowel incontinence. No comprehensive bowel function assessment was provided regarding the cause of Resident #9's bowel incontinence, contributing factors, or measures to promote continence.

Based on interview and record review the facilty did not ensure that each resident maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible for 1 resident out of 6 reviewed for weight loss (Resident 5). Resident 5 had a significant weight loss of a total of 24 pounds without interventions or revisions of the care plan and no physician update on how much weight loss had occurred. Findings as follows: Resident 5 was admitted to the facility on [DATE] after surgery on her right hip. Resident 5's "Admission Nursing Assessment" dated 6/24/11 indicates that Resident 5 is 5 feet 3 inches tall and weighs 147.8 pounds. Resident 5's care plan, dated 6/30/11, does not have an individual nutrition care plan. Resident 5 has self care deficit problem but no original weight goals. The weight intervention 6/30/11 states to provide diet as ordered, general. Added to the self care deficit approaches on 7/5/11 is an approach to add Recourse Juice 6 ounces at 10 am and 3 PM d/t weight loss which was probably rehydration on admit. On 7/7/11 a weight goal was added to Resident 5's self care deficit problem which states weight will stabilize with current interventions. Resident 5 has a physician's telephone order dated 7/5/11 for Resource Juice at 10 and 3 daily for healing. Resident 5's clinic note dated 7/5/11 states that Resident 5 is alert and oriented. Resident 5 does not have significant [MEDICAL CONDITION]. An initial Dietary assessment dated [DATE] indicates that Resident 5's current weight is 133 pounds and her usual body weight range is 148. The assessment indicates a 14 pound significant weight loss in less than 1 month. Resident 5's appetite is fair and consumes less than 1000 cc of fluid a day which places her at a high risk due to weight loss and decreased fluids. The nutritional approaches are: "None of above, giving extra protein in the form of Resource Juice." Resident 5's July 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. This is a 14.2 pounds, a 9.6% weight loss in 9 days. Resident 5's nursing notes reveal that she has loose stools which were positive for [MEDICAL CONDITION] and poor appetite. The notes are as follows: 7/1/11 was nauseated and felt it was medication 7/9/11 was nauseated and felt that she ate something that didn't agree with her. 7/10/11-had a loose stool, but felt better today. 7/11/11-c/o loose stool at 2:30 PM and appetite poor for 2 meals and good for supper. On 7/13/11-from 7/12/11 to the PM resident complained of several loose stools small to medium (6). Continue to complain of frequent stools and cramping. 2:00 PM CNA seen 3 stools medium with formed soft balls. 7/14/11-Resident positive for [MEDICAL CONDITION]. 7/16/11-1 stool today Appetite is poor. 7/17/11-appetite poor PM shift-Less stools so far today poor appetite. 7/18/11-appetite for solid foods is poor. 7/19/11-had small emesis after eating chicken broth and berry cheesecake, resident complained of stomach upset and feeling weak. Resident 5's "Supplement intake Monitoring" sheet reveals that Resident 5 had 28 times that she was to receive a supplement from 7/6/11 to 7/19/11. Nine times she received the supplement and took 50 to 100%. Resident 5 had 19 times that she refused or no intake recorded on the intake sheets. Resident 5's meal intake sheets from 7/6/11 to 7/12/11 indicate that out of 20 meals Resident 5 refused or ate poorly for 11 meals and she ate good for 9 meals. From 7/13/11 to 7/19/11 Resident 5 ate poorly for 16 meals out of 21 meals offered. The last 4 days Resident 5 ate poor for every meal. There is no evidence of Resident 5's physician or dietary being updated with Resident 5's continued poor intakes. On 7/20/11 at 1:00 PM Surveyor asked DON B for Resident 5's current weight as surveyor could not locate it. DON B stated that her weight was 130 #. Surveyor asked to find if and when a physician was called due to the weight loss. DON B stated that the nurse called on the 19th and told the physician that she wanted Florajen for her and reported her weight loss. DON B stated that she was going to have the nurse put in a late entry regarding her conversation. On 7/20/11 at 2:00 PM Surveyor interviewed Dietitian D regarding Resident 5's significant weight loss. Dietitian D stated that she had noted that there was a significant weight loss for Resident 5 and noted it on 7/5/11 in her note and put Resident 5 on Recourse Juice 2 times a day. Dietitian D states that if she has issues then she places a note in the nurses' mail box. If the resident has further concerns then she would see her again, but if the nurses do not inform Dietitian D of any further concerns she may not see her the next week for follow up. Dietitian D did not recall any further concerns with Resident 5, and was not on her list the following week for review. Dietitian D stated that when someone has a significant weight loss that the weights should be taken more frequently than once a month for monitoring; the nurses would get that order from the MD. Dietitian D did not recommend weekly or more often weights for close monitoring of the rapid weight loss, and no further follow up on her original 14 pound weight loss to slow weight loss or maintain that weight. On 7/20/11 an addendum to 7/19/11 nurses note is as follows: "(MD name) on call updated on residents poor appetite and wt loss. Wt 120 today. Resident had wt loss of 13 lbs since 7/3/11. (MD name) updated on residents stool today, and updated on small emesis after lunch." On 7/20/11 at 5:00 PM Surveyor interviewed RN C regarding Resident 5's weights and the documentation done earlier today as a late entry. RN C stated that she had done Resident 5's weight because she was told the MD was going to make rounds that day and see her. The weight was 120 pounds and she knew it was a loss. RN C stated that she waited for the MD to come; he didn't so she called the MD office and was told that the primary physician was gone. RN C stated that she talked to the nurse and wanted to get Florajen for Resident 5 as she threw up and was on [MEDICATION NAME] for [MEDICAL CONDITION] and that got missed. She was not able to keep things down. The nurse was going to pass it on to the on call MD. RN C mentioned that her appetite was poor and losing weight but does not remember if she said exactly how much weight loss was. Surveyor asked the facility if a re-weight could be done today and Surveyor observed Resident 5 get weighed. Resident 5's weight was 123.6. Resident 5 stated that her weight was a little higher than when they did it earlier today. DON B gave Surveyor a copy of her weights since admission. Resident 5's weights listed on the vitals signs and weight flow sheets are as follows: 6/24/11-147.8# 7/3/11-133.6# 7/19/11-120.6# 7/20/11 123.8#. This is a 24 pound weight loss from admission, which is a 16% weight loss in less than a month. Even though Resident 5 had a significant weight loss from admission to 7/3/11 there is no monitoring of her weights after to determine if Resident 5 is still losing weight until 7/19/11, when the MD was making rounds. During this time, Resident 5 had lost an additional 13 pounds. On 7/26/11 the facility faxed to Surveyor additional information stating they felt that Resident 5 had increased fluids during her hospitalization . The form is a hospital nursing flow sheet of vital signs. On 6/21/11 the form states that Resident 5 weighed 61.7 kg (135.7 lbs.), on 6/22/11 65.5 kg (144.1 lbs), 6/23/11 and 6/24/11- 72.7 (159.9 lbs). On 6/24/11 Resident 5 was admitted to the facility at a facility weight of 147.8 pounds, the same day the hospital weight was 159.9 pounds, this is a 12 pound difference indicating a loss. This information does not counter the fact that Resident 5 entered the facility on 6/24/10 and the facility documented her weight at 147.8 pounds and lost 14 pounds in 9 days. There is no evidence of monitoring or physician calls for weight loss in the 9 days, and additionally Resident 5 lost 10 more pounds with no interventions and monitoring with the facility aware of her poor intake and loose stools. In addition Resident 5's primary physician saw Resident 5 on 7/26/11 and documents as follows, "(nurse name) tells me today that since admission the patient did have a fairly significant weight loss and there was concern about that. She has been having some cramping and abdominal discomfort and had been diagnosed with [REDACTED]. She did have orthopedic surgery prior to admission to the nursing home and typically with the orthopedic surgery and its anesthesia patients will get quite a lot of IV fluid in the preoperative period and subsequently [MEDICATION NAME] contributing to her weight loss. She currently has had[DIAGNOSES REDACTED]icile infection and that may have contributed as well." The facility was asked for evidence of Resident 5's primary MD's colleagues being updated with her weight loss and interventions initiated. No further information was given to Surveyor as of 8/1/11.