Every finding on record at Norwood Health Ctr-Central

Based on record review and interview, the facility did not ensure residents were free of misappropriation and/or exploitation. The facility's failures of not investigating and not reporting to the State of Wisconsin or local authorities when alleged misappropriation was first reported by R1 on 3/20/23 allowed a facility Social Worker to continue to misappropriate resident funds and exploit resident information for personal gain. This affected 16 of 31 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, and R16) and caused R1 psychosocial harm of prolonged crying, increased anxiety and agitation, removal from activities, distress, disturbed sleep, and hospitalization due to suicidal ideation. R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, and R16 had misappropriation of funds with personal checks cashed, funds diverted, forged checks, and missing identification cards, and/or exploitation of personal information, which was obtained to create email accounts, g-mail accounts, apply for loans/credit cards, ATM withdrawals, cash application transfer of funds and homestead act claims for funds by the facility Social Worker (SW) C. The facility's failure to respond to a resident's report of misappropriation created a finding of immediate jeopardy that began on 3/20/23. Surveyor notified Nursing Home Administrator (NHA) A and Director of Nursing (DON) B of the immediate jeopardy on 6/21/23 at 3:42 pm. On 06/01/23, the facility discovered the misappropriation and exploitation being done by the Social Worker and took steps to correct the deficient practice and ensure compliance at the time of the survey. Based on this determination, the IJ was removed and corrected on 06/06/23. This is being cited as past noncompliance. Findings Include: Surveyor reviewed the Facility Reported Incident (FRI) submitted to the Wisconsin Department of Health Services. The facility identified residents had misappropriation of funds with personal checks cashed, funds diverted, forged checks, and missing identification cards; as well as exploitation of personal resident information to obtain email accounts, loans, credit cards, ATM withdrawals, cash app transfer of funds, and homestead act claims for funds. The facility identified the concern on 6/01/23 when R5's representative payee was contacted about a check that was requested weeks earlier. The facility investigation identified 16 of 31 residents were affected. The facility determined Social Worker (SW) C was the staff member misappropriating the funds. The facility policy titled Abuse, Neglect, Exploitation of residents, Misappropriation, Injuries of Unknown Origin and Reporting of Crimes dated 10/20/22 in part states: Policy Statement: .The Administrator is responsible for oversight of abuse prohibition standard. Purpose: To prohibit and prevent abuse, neglect, exploitation of residents or misappropriation of property and injuries of unknown origin. Definitions: Exploitation is defined as unfair treatment or use of a resident or the taking advantage of a resident for personal gain . Misappropriation of resident property, including identifying information, means deliberate or intentional taking, carrying away, using, transferring, concealing or retaining possession, misplacement, exploitation, or wrongful, temporary or permanent use of resident's belongings, movable property or money or of a negotiable security without the residents consent .Additionally, Wisconsin State Regs, DHS 13 further defines misappropriation as obtaining property of a resident by intentionally deceiving the resident with false representation which is known to be false, made with intent to defraud, and which does defraud the person to whom it is made. False Representation includes a promise made with the intent not to perform it if promise is part of a false of fraudulent scheme. Protection: All residents will be protected from harm . Example 1: R1's record shows she was committed to facility due to mental illness and probable harm to self or others with recent overact or patterns of recent acts on 1/04/23. R1 had previous stays at the facility that were voluntary admissions. R1 was admitted to the secured wing from the hospital admissions wing. R1's most recent quarterly Minimum Data Set (MDS) completed 4/12/23 notes she understands, is understood, and has a BIMS (Brief Interview of Mental Status) of 15 indicating she is cognitively intact. R1 experiences hallucinations and delusions and has depressive mood indicators. R1's diagnosis includes schizo-affective disorder, bi-polar (primary type.) R1's record shows she is her own decision maker and guardian of estate. R1 receives $714.00 each month for SSDI. R1 did not have an account for petty cash at the facility. Surveyor reviewed R1's Psych Consult information and noted the following: Behaviors monitored: 1. Physical: anxiety, sweating, pacing, bouncy knee 2. Verbal: Paranoid/delusional 3. Other: Internal Stimuli/hearing voices Documentation shows R1 had 39 behaviors in April. This is a significant increase from March, after R1 reported the missing money and items, and highest since R1's admission. Surveyor review of R1's [NAME] County Human Services counseling notes: 3/07/23: feeling more comfortable on pathways . 3/21/23: reports crying almost daily, voices have not been bothering her as much, believes she is addicted to on-line shopping app, buying things from app. Almost daily .tearful and requested to end session . 4/04/23: believes father may be stealing things from her, hopeless, tearful, guarded, expressed a lot of anger . 4/18/23: identified anxiety, unsure if she can pay for her brace on her own .anxiety about not knowing how much money in bank account, she does not know how to check her money but concerned the app is stealing money from her for browsing . 5/23/23: discussed increased depression, more sick last 2 weeks, wants to go to different hospital as no one likes her here, does not feel safe, conspiring against her. Increased paranoia and agitation. Difficulty finishing thoughts. This is the first session she swore in front of writer. Getting CT next week for signs of dementia. 6/09/23: Reports relief of news of SW taking money. It means she is not crazy as she and everyone thought. Identified anger. Discussed hospitalization . Decreased meds, but not sure why, Feels less emotional. Wished she could start ECT now to see if she would benefit from it . 6/13/23: Had ECT and believes it is helping, Feels resentful towards staff regarding SW situation. Discussed how staff did not believe her and she was hospitalized , and she was correct. Surveyor reviewed R1's nurses note and noted the following: 1/29/23: Note from SW C .the one thing on her mind appears to be when her monthly money will go down to $45.00 per month . 3/01/23: Note from SW C, resident request writer to hold on to her debit card. Writer assured resident the best idea would be to have it placed in the business office. Writer filled out envelope with her signature on it . 3/20/23: CNA note, Resident approaches staff and stated I was told to talk to you about a card I lost, it is a government funded card. I looked everywhere and can't find it Writer asked if she had it with her when she went shopping but resident could not remember. Asked if she wanted her to help look for it. Resident responded sure. Writer was unable to find the direct express card identified as green in color. Resident stated she will call and cancel card. Although resident identified a missing debit card no investigation was initiated or conducted or that police or state agency were notified to prevent misappropriation and exploitation from occurring to residents. 3/21/23: Note from SW C, writer reminded resident her card is kept safe in business office. Resident did not remember this but was relieved. 4/02/23: Note from SW C, continues to experience overall instability in mental health. Her mental health has improved since her admission but can be unpredictable sometimes on an hourly basis. Mental health symptoms continue to include delusional thoughts, paranoia and responding to internal stimuli. Resident out to eat at culvers ., given her debit card before she left. When she returned, she returned her card to be locked safely, reviewed notes, and see resident concerns about how much money was left on her card balance. This writer theorizes resident feels she should have money because benefits come on the first, the first fell on weekend day and it is possible she did not receive the funds . 4/02/23: Note from RN, Resident made comments last evening regarding her debit card .reassured card is locked in office, and no one has access. Resident comment she was just panicking and accepted reassurance from staff Again, there is no evidence of investigation regarding R1's debit card or verification R1's debit card was located in the business office to ensure that misappropriation or exploitation was not occurring. 4/04/23: Note from SW C, resident continues to experience overall instability with her mental health, continues to experience depression, anger, voices that do interfere with daily routine and cause her distress. Writer has met with resident one on one past two days. Resident angry and made accusations directed at care staff Writer reminded resident she can trust writer .Resident did make a statement about possibly having a rep-payee to help her with her finances . 4/07/23: Note from SW E, to tobacco outlet to withdraw $100.00, resident request cards to be locked in business office. SW and nurse signed envelope confirming debit card placement . 4/07/23: Note from RN, Debit card in Narc drawer for resident better access. 4/12/23: 1:45 Note from RN, Resident came to med room yelling It's not funny, I only have $70.00 left in my account since last week Someone is stealing my money, walked away crying, refusing to listen to staff, repeating someone is stealing my money .SW to unit to speak with her. 4/12/23: 2:57 Note from SW C, continues to experience overall instability with mental health. Resident continues to experience depression and anger; voices interfere with daily routine causing distress .Had a very difficult with increased mental health symptoms today. Received a call from nursing staff very upset about money. I thought I was doing good with my money; I should have more. Crying during first part of meeting. Writer asked investigative questions about, and resident appears to be having some delusional thoughts . Resident believes dad using money and taking packages she orders . Reminded card is locked, and she is the only one with the pin. Resident states she is never going to get better. Asked if she wants to contact police and said No. I am just not thinking very clearly. There is no evidence the facility conducted an investigation into R1's allegation of someone stealing her money or notified State of Wisconsin or police to ensure misappropriation was not occurring for R1 or other residents. 4/19/23: Note from CNA, Resident tearful about a phone call she made. SW made aware. 4/20/23: Note from CNA, left at this time for Walmart with SW. 4/20/23: Note from RN, Made accusations regarding her credit card. While talking with writer resident had a flat affect, aggressive tone, jumped from topic to topic, walking very slowly throughout shift, displayed paranoid thoughts. Talked with HN (Head Nurse/RN) and NHA (Nursing Home Administrator) about it. Although the facility shared an exchange of email regarding the situation there is no evidence a thorough investigation was conducted or the State of Wisconsin/police were notified when R1 made accusations regarding her credit card. The inaction allowed misappropriation to continue for the residents. The email states: 4/20/23: RN F: R1 came out of her room .had a small flat bag and asked where she could put it where it would be safe and no one could get to, the most safest untouchable spot where no average just anybody could get to it .R1 stated over the last two months a lot of her items have gone missing and her card was missing and it had over 2,000 missing from it and that was from the business department and still does not know how it happened .R1 stated she just got a new card and there is already money missing and she does not know how she is going to prove it . 4/20/23: NHA A: R1 is basically saying someone is using her debit card. With that said, can you please investigate in the morning? It should be easy to rule out by helping her check her balance .R1 seems extremely unwell . 4/21/23 SW C: We will investigate this. Unfortunately, R1 still is unwell. 4/21/23: SW E: We gave R1 a lock box this morning. She said SSDI told her they can see specific people that use her card. I asked her if she meant the store that the stolen purchases were coming from and she said no, they can see people on each transaction. She mentioned an [name] has used her card, but denied it was a resident Resident also mentioned she had misplaced her cream-colored small wallet that held her ID and insurance cards .Found wallet in the bottom of her purse . Nurses Notes continued: 4/21/23: Note from CNA, was heard this morning talking to a peer about how things are missing in her room. SW and CSA [Client Service Assistant] are notified about her concerns. There is no evidence of an investigation into what items R1 alleges are missing. 4/21/23: Note from SW C: This writer and CSA staff staffed resident case and recent accusations this morning. A cumulative review of all fact-based information confirms resident accusations of someone using her debit card are unfounded. Resident mental health remains extremely unpredictable, and she continues to experience delusions, paranoid, voices, and frequent mood swings. Received a new debit card today in a sealed envelope. Delivered personally with CSA witness. Reminded to put in lock box. No one has access to the debit card pin. Resident receiving numerous packages from online ordering. Also sent money in the mail to her family. Resident stated, I shop online impulsively when I am anxious. Resident interviewed and social services did not argue with her delusions .Made referral to MD to access the need for rep payee regarding continued concerns spending/financial accusations .IDT will look into evaluation for dementia . 4/21/23: Email from SW E to Physician: Resident is in need of a rep-payee. She is accusing people of stealing her money, but she is spending it. She is forgetting and we are worried she may have some memory impairments . 5/03/23: Note from SW E: resident expressed just put me in the hospital, I don't want to be here anymore, they think I am going to hurt people, denied having these thoughts. 5/04/23: Note from CNA, Appears to be in sad mood today .Declined playing cards . 5/05/23: (RN D, R1, SW C, MD) tearful/depressed, crying often, agitation decreased. Resident concerns with complaints of depression/anxiety. Medication changes. 5/08/23: Note from SW E, resident would like to cash a large check from her brother. Declined cashing at Walmart and voiced she would like to open a bank account. Resident does not have a bank. Resident returned NHC lock box stating she does not need it. 5/10/23: tearful, declined outing, too much pain 5/11/23: Due for assistance renewal, sought CSA help. 5/11/23: Note from CNA, Very frustrated and sensitive upon waking .even coming to the point of bawling when she couldn't get her leg brace on . 5/12/23: Note from Charge Nurse, Resident came to writer stating she needed to go to the bank today urgently as her card has been compromised .Writer stated she needed to talk with SW and CSA about it. Writer spoke with SW/CSA, and they informed resident to call her bank to see if she can put a hold/freeze on it. Writer spoke with resident who changed story of card compromised to she needed to put money in the bank .so she does not become compromised .Resident upset . 5/14/23: resident reports having nightmare 5/16/23: Note from SW E, Appeared in CSA office and was visibly crying and upset, expressed she would rather be in jail then stay at [NAME], felt staff are trying to entrap her. Adamant about not staying at [NAME] as she does not feel safe here .Paranoia and behaviors increasing .Nursing made aware of resident comments and agitated mood . 5/21/23: resident reports not sleeping, wants to talk with psychiatrist about it . 5/22/23: Note from SW E, Appeared more emotional and tearful today. Reported depression worse .believes apartment ended lease due to non-payment . 5/23/23: Note from SW E, resident experienced an acute change in mental status today that prompted a call to [NAME] County Crisis and subsequent move to more restrictive environment on the [NAME] admissions unit (hospital.) Resident demanded to speak to SS (Social Services.) Resident appeared upset and crying .Thought process was difficult to follow, became very angry and verbally aggressive .Demanded to leave .Yelled while continuously crying .repeated anger over medications that were discontinued .unable to process and evaluate information .Concerns of self-harm .Crisis team contacted .Today was the most unstable that this writer has witnessed resident mental health while working with her as a SW. Hospital notes per outpatient treating psychiatrist, evaluated need for returning to inpatient setting from skilled nursing facility. Mental health is decompensating, endorsing suicidal ideations and need for more intensive acute care then outpatient setting for further treatment and stabilization . 6/06/23: readmitted . 6/07/23: Noted distress related to ongoing financial investigation. 6/07/23: Note from SW E, Resident received mail from Citibank and kept personal copy. Shortly after receiving mail came to writer's office distressed. Nursing staff was notified of resident's distress and a prn had already been given 10-15 minutes prior to receiving the mail. 6/08/23: Resident request daughter become rep-payee .Resident stated I am committed here; I will not do shock therapy .Resident mood was a mix of anger and frustration . 6/10/23 Note from CNA, heard resident talking in room and it was getting louder .Resident heard saying Why can't I go to a different hospital; I don't want to be in this hospital. You can let me go to a different one, you are punishing me based on what others are saying about me. I don't want ECT, they will have to take me kicking and screaming and why can't I go to stores. Resident crying harder and becoming louder. Nurse notified to see if resident can have a prn. 6/10/23: Adjusting to unit, gotten very little sleep, increased anxiety related to ECT appointment and financial investigation . 6/11/23-6/13/23 No emotional distress 6/12/23: Note from SW E, writer and resident called Direct Express per detective request .Resident was able to cancel her card and obtain information for detective .Resident was upset but remained calm . 6/12/23: Quiet with return from ECT 6/16/23: Charge Nurse: Resident opened 2 letters from SSDI with writer, allowed writer to scan letters. Originals given to resident .Letter stated she will receive a check now sent to her in person so she can take it to the bank and cash it .No concerns over letter. 6/18/23: In room most of the day, resident keeping to self. Appears anxious, but stated she is feeling ok .Ate well and made needs known. On 6/19/23 at 9:45 am, Surveyor spoke with R1. R1 reported she noticed in late winter her monies were going fast. R1 believed it was due to payments made to the facility. The facility thought she was delusional and making up the missing monies. R1 further expressed she never received a May deposit from Social Security Disability Income (SSDI.) R1 called Direct Express card account where her SSDI was directly deposited, cancelled her card, and requested a new card. R1 called social services office and spoke with Social Worker (SW) C as she did not have much money and it was not making sense to her. R1 indicated this is why she went to the hospital in May. R1 expressed she was in the hospital for 2 weeks. In the hospital they wouldn't talk to her about it and wouldn't let her check her accounts. R1 expressed she experienced constant sadness/hurting, would cry constantly and was anxious and depressed about it. R1 was told her medications were not effective. The facility changed her medications and discussed ECT (electroconvulsive therapy) with her. R1 expressed tomorrow will be her 3rd treatment of ECT. R1 reported she is feeling better, mostly because people are listening to me. R1 expressed the incident caused her to cry a lot. R1 further expressed she wants her money returned to account, and she wants to be able to manage her money like she always has. R1 indicated there is still money not accounted for and they say insurance will cover it. R1 expressed she was not good at all, at one point about this, couple weeks ago, when went to admissions (hospital.) She was very angry, and this did not help. Further expressing she was yelling at staff that she never yelled at before. Surveyor noted R1 with visibly shaking hands and tone of voice when talking with Surveyor about incident in the presence of head nurse/Registered Nurse (RN) D. Following the interview with R1, Surveyor spoke with RN D about R1's behavior. RN D expressed she had worked with R1 during her several stays at the facility. During the incident R1 was yelling at her. R1 had never done that before. Surveyor reviewed the facility's investigation. The investigation showed R1 had an email account created in her name, debit/bank cards missing, homestead credit applied for, mail diverted, cash apps opened in her name, credit cards opened in her name, and her government funded Direct Express affected. Example 2: R2 was admitted to the facility 9/19/22 and discharged from the facility on 6/12/23. R2's most recent quarterly MDS completed 3/28/23 notes she understands, is understood, and is cognitively intact. R2 has no depressive mood indicators. She experiences hallucinations and delusions. Her diagnoses include Parkinson's disease and psychotic disorder. R2 nurse's notes show upon discharge: 6/12/23: R2 updated on TracFone and new phone number. Did not appear to have any emotional distress regarding the financial investigation. Facility's investigation shows R2 was impacted by SW C's misappropriation/exploitation by an email account being created in her name, credit card and loan applications, and a Venmo account created in her name. Example 3: R3 was admitted to the facility 7/07/23. R3's most recent quarterly MDS completed 5/02/23 notes he understands, is understood, and is cognitively intact. R3 has no depressive mood indicators. He experiences hallucinations and delusions. His diagnosis includes schizophrenia. On 6/19/23 at 9:30 am, Surveyor spoke with R3 regarding his impact from SW C's misappropriation. R3 indicated he had a check cashed by SW C and he did not receive the money. R3 expressed he is doing okay and has been offered meetings/counseling regarding the situation, which he has declined. Facility's investigation shows R3 was impacted by SW C's misappropriation/exploitation by an email account being created in his name and a forged check in the amount of $500.00. Example 4: R4 was admitted to the facility 12/14/22. R4's most recent quarterly MDS completed 4/29/23 notes she understands, is understood, and is cognitively intact. R4 has no depressive mood indicators. She experiences delusions. Her diagnosis includes seizure disorder and schizophrenia. R4's nurses notes from 6/01/23 to present show distress from financial investigation. On 6/19/23 at 9:35 am, Surveyor spoke with R4 regarding her impact from SW C's misappropriation. R4 indicated she had $200.00 in cash taken and $200.00 from her savings. R4 expressed the situation is a bummer but she is fine. She was offered counseling/meetings to express her feelings/share information. R4 further expressed she believes the facility is doing what they can. Facility's investigation shows R4 was impacted by SW C's misappropriation/exploitation by an ATM/debit card missing, personal mail diverted, cash, and a family members Social Security. Example 5: R5 was admitted to the facility 3/24/23 and discharged on [DATE]. R5's most recent admission MDS completed 3/30/23 notes she understands, is understood, and is cognitively intact. R5 has depressive mood indicators. She experiences no delusions or hallucinations. Her diagnoses include anxiety, manic depression, and psychotic disorder. R5's nurses notes from 6/01/23 to discharge show distress from financial investigation. 6/13/23 note shows R5 was given $200.00 cash from the facility liability insurance due to missing check. Facility's investigation shows R5 was impacted by SW C's misappropriation/exploitation by a forged check, email created in her name, homestead credit applied for in her name, a loan applied for in her name, and a cash app created in her name. Example 6: Facility's investigation shows R6 was impacted by SW C's misappropriation/exploitation by the following: $300 of her cash kept in lock box in SW C's office, had cash App account opened, received credit card statement in mail on Monday, June 5 from Capital One. R6 and guardian state she does not have a credit card. SW C's computer activity appears to show he applied for the card in her name, created Gmail account in her name, applied for Homestead credit on IRS, missing ID and wallet, [NAME] Fargo Personal Loan-owes around $3k and life insurance policy cashed out. Example 7: Per the facility's investigation, R7 was impacted by SW C's misappropriation/exploitation by the following: personal mail was diverted and R7's social security information was found in SW C's office. Example 8: Per the facility's investigation, R8 was impacted by SW C's misappropriation/exploitation by the following: $700.00 in cash found in lock box hidden in office and g-mail account created in his name. Example 9: Per the facility's investigation, R9 was impacted by SW C's misappropriation/exploitation by the following: Check signed over to SW C which he cashed at bank. Check in the amount of $300.00. Example 10: Per the facility's investigation, R10 was impacted by SW C's misappropriation/exploitation by the following: G-mail account created in resident name and loan application in R10's name. Example 11: Per the facility's investigation, R11 was impacted by SW C's misappropriation/exploitation by the following: G-mail account opened in his name. Example 12: Per the facility's investigation, R12 was impacted by SW C's misappropriation/exploitation by the following: G-mail account created in resident name. Example 13: Per the facility's investigation, R13 was impacted by SW C's misappropriation/exploitation by the following: G-mail account created in resident name and chime card (a secured card designed for people who are trying to build credit.) Example 14: Per the facility's investigation, R14 was impacted by SW C's misappropriation/exploitation by the following: E-mail account created in resident name. Example 15: Per the facility's investigation, R15 was impacted by SW C's misappropriation/exploitation by the following: E-mail account created in resident name and filed homestead tax credit in her name. Example 16: Per the facility's investigation, R16 was impacted by SW C's misappropriation/exploitation by the following: E-mail account created in resident name. On 6/19/23 at 8:30 AM, Surveyor spoke with Head Nurse/RN D and DON B about the facility investigation into SW's misappropriation and exploitation of the impacted residents. DON B expressed there has been no arrest of SW C at this point and there is an ongoing criminal investigation. At this time the total amount of monies involved for each resident is not completely known due to the criminal investigation. The facility discovered the misappropriation on 6/01/23 when R5's representative payee was contacted about a check. The check was traced to the bank where it was cashed. The signature on the check did not match R5's signature. The facility then identified R15, R6, R1, R5, and R3 had loans and credit cards applied for and social security funds affected. All 5 residents had no guardian of estate. The facility then discovered residents were paying other residents via cash apps through email or g-mail accounts that were created by SW C. In addition, monies were being taken out at ATMs and credit unions. SW C started getting resident mail which was not in turn being delivered to residents. The police were called immediately, and State of Wisconsin was informed on 6/01/23 when the misappropriation was discovered. SW C was noted to be acting uncommon, running to his office and ransacking it. SW C was suspended at that point and his office was checked. A bank statement and $700.00 cash were found in his office. Further investigation found R3 and R9 had signed over checks to SW C. Information Technology (IT) did an initial computer search of SW C's computer and tracked from January to present SW C had created 8 resident fake g-mail accounts and applied for credit cards in numerous resident names. SW C had downloaded an application which showed when mail is being delivered to the facility, so he knew what mail was coming in to divert it. The facility updated several of their policies including their mail process. Facility staff were educated on the policy changes as well as the abuse policy (6/06/23.) Residents' care plans were developed, and nursing assessed each resident for distress related to the situation daily. Residents were also offered counseling and meetings to discuss their feelings about the situation. Adult Protective Services was contacted and is working with guardians to do credit checks. On 6/19/23 at 10:10 am, Surveyor spoke to NHA A and Director of Nursing (DON) B about the FRI and R1's report of misappropriation. NHA A explained R1's reports of misappropriation were reported to the Social Services office. There was informal communication between facility staff via email but nothing formal prior to the FRI reported to the State of Wisconsin on 6/01/23. There was no formal investigation based on what SW C reported to Administration. The facility did not investigate further or contact the police. The facility should have investigated further, reported to the State of Wisconsin, and notified the police. The failure to do so allowed misappropriation to continue for 16 residents. On 6/20/23 at 3:40 pm, Surveyor again spoke with NHA A about R1's safekeeping of her debit card and the facility obligation to investigate R1's allegations. NHA A expressed R1 is her own person and guardian of estate. R1's debit card was placed in the business office per resident request on 3/21/23; it had previously been in resident possession. At one point the Activity Director went to the business office to obtain card for an outing, and it was not there. SW C had it in his desk. NHA A indicated the nurse updated SW C with R1's reports. Further expressing it was his job to report it to NHA A so an investigation could be started, and police could be informed; and he did not. Should have been investigated and reported and it was not. There was facility exchange of email about the situation on 4/21/23 but no formal investigation was initiated based on SW C's notes/report. These failures created a situation of immediate jeopardy that began on 03/20/23. On 06/01/23, the facility identified the misappropriation and exploitation being done by Social Worker C and took steps to correct the deficient practice and ensure compliance at the time o [TRUNCATED]

Based on record review and interview, the facility did not thoroughly investigate a resident's report of misappropriation and/or exploitation. The facility's failure to thoroughly investigate the report of misappropriation allowed a facility Social Worker to continue to misappropriate and exploit other residents. The facility's failure to thoroughly investigate affected 1 of 1 residents (R1.) R1's repeated allegations of missing items and monies from her Direct Express debit card were not thoroughly investigated by the facility. Lack of facility investigation allowed a facility Social Worker (SW C) to continue to misappropriate resident funds. The misappropriation caused R1 distress and psychosocial harm of prolonged crying, increased anxiety and agitation, removal from activities, distress, disturbed sleep, and hospitalization due to suicidal ideation. The facility's failure to thoroughly investigate a resident report of misappropriation created a finding of immediate jeopardy that began on 3/20/23. Surveyor notified Nursing Home Administrator (NHA) A and Director of Nursing (DON) B of the immediate jeopardy on 6/21/23 at 3:42 pm. On 06/01/23, the facility discovered the misappropriation and exploitation being done by the Social Worker and took steps to correct the deficient practice and ensure compliance at the time of the survey. Based on this determination, the IJ was removed and corrected on 06/06/23. This is being cited as past noncompliance Findings Include: Surveyor reviewed the facility policy titled Exploitation of residents, Misappropriation Suspicion of Crimes dated 10/20/22 which states in part: ~Policy Statement: The facility staff will conduct an investigation of any alleged or suspected . exploitation of residents or misappropriation of property . The Administrator is responsible for oversight of abuse prohibition standard. Surveyor reviewed the Facility Reported Incident (FRI) submitted to the state of Wisconsin Department of Health Services on 06/01/23. This was the first reporting of SW C's misappropriation of resident funds. The facility identified 16 residents, including R1, who were victims of misappropriation and/or exploitation by SW C. Surveyor requested and reviewed the facility policy titled Abuse, Neglect, Exploitation of residents, Misappropriation, Injuries of Unknown Origin and Reporting of Crimes dated 10/20/22 which states in part: Identification: Staff will immediately report any suspicious event that may constitute .exploitation, misappropriation, occurrence of a crime. Investigation: ~The facility will conduct an internal investigation and report the results of the investigation to enforcement agency in accordance with state law including the states survey and certification agency within five working days of the incident occurring or according to state law. ~The facility will immediately begin a thorough investigation of any reported incident, collect information that corroborates or disproves the incident and document the findings for the incident. The investigation is the process used to try to determine what happened. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed. The facility will document the investigation and the reasons for conclusion. The information gathered will be given to the administration and grievance officer. ~Investigations will be prompt, comprehensive and responsive to the situations and contain founded conclusions. Investigations will include, but is not limited to the following: Notification of physician and family, Identification and removal of the alleged person or persons, type of alleged abuse, when and where the incident occurred, interview and or written statements from individuals with first-hand knowledge of the incident, follow up resolution, measures to prevent repeated incidents, all materials and documentation of the pertinent data to the authorities will be legally required . ~Actions taken during the investigation will based on outcomes of the investigation On 6/19/23 at 10:10 am, Surveyor spoke with NHA A and Director of Nursing (DON) B about the FRI and R1's report of misappropriation. NHA A explained R1's reports of misappropriation were reported to the Social Services office. There was informal communication between facility staff via email but nothing formal prior to the FRI reported to the State of Wisconsin on 6/01/23. At this time the facility had determined Social Worker (SW) C was misappropriating money from residents. This was the first reporting of the incident. The police were first contacted with the discovery on 6/01/23. There was no reporting based on what SW C reported to Administration. The facility did not contact the police. The facility should have reported to the State of Wisconsin and notified the police. R1's record shows she was committed to facility due to mental illness and probable harm to self or others with recent overact or patterns of recent acts on 1/04/23. R1 had previous stays at the facility that were voluntary admissions. R1 was admitted to the secured wing from the hospital admissions wing. R1's most recent quarterly Minimum Data Set (MDS) completed 4/12/23 notes she understands, is understood, and has a BIMS (Brief Interview for Mental Status) score of 15 indicating she is cognitively intact. R1 experiences hallucinations and delusions and has depressive mood indicators. R1's diagnosis includes schizo-affective disorder, bi-polar (primary type). R1's record shows she is her own decision maker and guardian of estate. R1 receives $714.00 each month for SSDI. R1 did not have an account for petty cash at the facility. Surveyor reviewed R1's Psych Consult information and noted the following: Behaviors monitored: 1. Physical: anxiety, sweating, pacing, bouncy knee 2. Verbal: Paranoid/delusional 3. Other: Internal Stimuli/hearing voices Documentation shows R1 had 39 behaviors in April. This is a significant increase from March, after R1 reported the missing money and items, and the highest monthly count since R1's admission. Surveyor review of R1's [NAME] County Human Services counseling notes: 3/21/23: reports crying almost daily, voices have not been bothering her as much, believes she is addicted to on-line shopping app, buying things from app. Almost daily .tearful and requested to end session . 4/04/23: believes father may be stealing things from her, hopeless, tearful, guarded, expressed a lot of anger . 4/18/23: identified anxiety, unsure if she can pay for her brace on her own .anxiety about not knowing how much money in bank account, she does not know how to check her money but concerned the app is stealing money from her for browsing . 5/23/23: discussed increased depression, more sick last 2 weeks, wants to go to different hospital as no one likes her here, does not feel safe, conspiring against her. Increased paranoia and agitation. Difficulty finishing thoughts. This is the first session she swore in front of writer. Getting CT next week for signs of dementia. 6/09/23: Reports relief of news of SW taking money. It means she is not crazy as she and everyone thought. Identified anger. Discussed hospitalization . Decreased meds, but not sure why, Feels less emotional. Wished she could start ECT now to see if she would benefit from it . 6/13/23: Had ECT and believes it is helping, Feels resentful towards staff regarding SW situation. Discussed how staff did not believe her and she was hospitalized , and she was correct. Surveyor reviewed R1's nurses note and noted the following: 1/29/23: Note from SW C, .the one thing on her mind appears to be when her monthly money will go down to $45.00 per month . 3/01/23: Note from SW C, resident request writer to hold on to her debit card. Writer assured resident the best idea would be to have it placed in the business office. Writer filled out envelope with her signature on it . 3/20/23: Note from CNA, Resident approaches staff and stated I was told to talk to you about a card I lost, it is a government funded card. I looked everywhere and can't find it Writer asked if she had it with her when she went shopping but resident could not remember. Asked if she wanted her to help look for it. Resident responded sure. Writer was unable to find the direct express card identified as green in color. Resident stated she will call and cancel card. Although resident reported a missing debit card there is no investigation for this allegation. 3/21/23: Note from SW C, writer reminded resident her card is kept safe in business office. Resident did not remember this but was relieved. 4/02/23: Note from SW C, continues to experience overall instability in mental health. Her mental health has improved since her admission but can be unpredictable sometimes on an hourly basis. Mental health symptoms continue to include delusional thoughts, paranoia and responding to internal stimuli. Resident out to eat at culvers ., given her debit card before she left. When she returned, she returned her card to be locked safely, reviewed notes and see resident concerns about how much money was left on her card balance. This writer theorizes resident feels she should have money because benefits come on the first, the first fell on weekend day and it is possible she did not receive the funds . 4/02/23: Note from RN, Resident made comments last evening regarding her debit card .reassured card is locked in office, and no one has access. Resident comment she was just panicking and accepted reassurance from staff 4/04/23: Note from SW C, resident continues to experience overall instability with her mental health, continues to experience depression, anger, voices that do interfere with daily routine and cause her distress. Writer has met with resident one on one past two days. Resident angry and made accusations directed at care staff Writer reminded resident she can trust writer .Resident did make a statement about possibly having a rep-payee to help her with her finances . 4/07/23: Note from SW E, to tobacco outlet to withdraw $100.00, resident request cards to be locked in business office. SW and nurse signed envelope confirming debit card placement 4/07/23: Debit card in Narc drawer for resident better access. (RN note). 4/12/23: 1:45 Note from RN, Resident came to med room yelling It's not funny, I only have $70.00 left in my account since last week Someone is stealing my money, walked away crying, refusing to listen to staff, repeating someone is stealing my money .SW to unit to speak with her. 4/12/23: 2:57, Note from SW C, continues to experience overall instability with mental health. Resident continues to experience depression and anger; voices interfere with daily routine causing distress .Had a very difficult with increased mental health symptoms today. Received a call from nursing staff very upset about money. I thought I was doing good with my money; I should have more. Crying during first part of meeting. Writer asked investigative questions about, and resident appears to be having some delusional thoughts . Resident believes dad using money and taking packages she orders . Reminded card is locked, and she is the only one with the pin. Resident states she is never going to get better. Asked if she wants to contact police and said No. I am just not thinking very clearly. There is no evidence the facility did an investigation when R1 stated someone was stealing her money on 4/12/23. 4/19/23: Note from CNA, Resident tearful about a phone call she made. SW made aware. 4/20/23: Note from CNA, left at this time for Walmart with Social Worker 4/20/23: Note from RN, Made accusations regarding her credit card. While talking with writer resident had a flat affect, aggressive tone, jumped from topic to topic, walking very slowly throughout shift, displayed paranoid thoughts. Talked with HN (Head Nurse/RN) and NHA (Nursing Home Administrator) about it. Although the facility shared an exchange of email regarding the situation there is no evidence a thorough investigation was done to rule out misappropriation. The emails state: 4/20/23: RN F: R1 came out of her room .had a small flat bag and asked where she could put it where it would be safe and no one could get to, the most safest untouchable spot where no average just anybody could get to it .R1 stated over the last two months a lot of her items have gone missing and her card was missing and it had over 2,000 missing from it and that was from the business department and still does not know how it happened .R1 stated she just got a new card and there is already money missing and she does not know how she is going to prove it . 4/20/23: NHA A: R1 is basically saying someone is using her debit card. With that said, can you please investigate in the morning? It should be easy to rule out by helping her check her balance .R1 seems extremely unwell . 4/21/23 SW C: We will investigate this. Unfortunately, R1 still is unwell. 4/21/23: SW E: We gave R1 a lock box this morning. She said SSDI told her they can see specific people that use her card. I asked her if she meant the store that the stolen purchases were coming from and she said no, they can see people on each transaction. She mentioned an [name] has used her card, but denied it was a resident Resident also mentioned she had misplaced her cream-colored small wallet that held her ID and insurance cards .Found wallet in the bottom of her purse . Nurses Notes continued: 4/21/23: Note from CNA, was heard this morning talking to a peer about how things are missing in her room. SW and CSA [Client Service Assistant] are notified about her concerns. There is no evidence of an investigation after R1 made the allegation of missing items on 4/21/23. 4/21/23: Note from SW C, This writer and CSA staff staffed resident case and recent accusations this morning. A cumulative review of all fact-based information confirms resident accusations of someone using her debit card ore unfounded. Resident mental health remains extremely unpredictable, and she continues to experience delusions, paranoid, voices and frequent mood swings. Received a new debit card today in a sealed envelope. Delivered personally with CSA witness. Reminded to put in lock box. No one has access to the debit card pin. Resident receiving numerous packages from online ordering. Also sent money in the mail to her family. Resident stated, I shop online impulsively when I am anxious. Resident interviewed and social services did not argue with her delusions .Made referral to MD to access the need for rep payee regarding continued concerns spending/financial accusations .IDT will look into evaluation for dementia . 4/21/23: Email from SW E to Physician: Resident is in need of a rep-payee. She is accusing people of stealing her money, but she is spending it. She is forgetting and we are worried she may have some memory impairments . 5/03/23: Note from SW E, resident expressed just put me in the hospital, I don't want to be here anymore, they think I am going to hurt people, denied having these thoughts. 5/04/23: Note from CNA, Appears to be in sad mood today .Declined playing cards . 5/05/23: (RN D, R1, SW C, MD) tearful/depressed, crying often, agitation decreased. Resident concerns with complaints of depression/anxiety. Medication changes. 5/08/23: Note from SW E, resident would like to cash a large check from her brother. Declined cashing at Walmart and voiced she would like to open a bank account. Resident does not have a bank. Resident returned NHC lock box stating she does not need it. 5/10/23: tearful, declined outing, too much pain 5/11/23: Due for assistance renewal, sought CSA help. 5/11/23: Note from CNA, Very frustrated and sensitive upon waking .even coming to the point of bawling when she couldn't get her leg brace on. 5/12/23: (Charge Nurse) Resident came to write stating she needed to go to the bank today urgently as her card has been compromised .Writer stated she needed to talk with SW and CSA about it. Writer spoke with SW/CSA and they informed resident to call her bank to see if she can put a hold/freeze on it. Writer spoke with resident who changed story of card compromised to she needed to money in the bank .so she does not become compromised .Resident upset . 5/14/23: resident reports having nightmare 5/16/23: Note from SW E, Appeared in CSA office and was visibly crying and upset, expressed she would rather be in jail then stay at [NAME], felt staff are trying to entrap her. Adamant about not staying at [NAME] as she does not feel safe here .Paranoia and behaviors increasing .Nursing made aware of resident comments and agitated mood . 5/21/23: resident reports not sleeping, wants to talk with psychiatrist about it . 5/22/23: Note from SW E, Appeared more emotional and tearful today. Reported depression worse .believes apartment ended lease due to non-payment . 5/23/23: Note from SW E, resident experienced an acute change in mental status today that prompted a call to [NAME] County Crisis and subsequent move to more restrictive environment on the [NAME] admissions unit (hospital). Resident demanded to speak to SS (Social Services). Resident appeared upset and crying .Thought process was difficult to follow, became very angry and verbally aggressive .Demanded to leave .Yelled while continuously crying .repeated anger over medications that were discontinued .unable to process and evaluate information .Concerns of self-harm .Crisis team contacted .Today was the most unstable that this writer has witnessed resident mental health while working with her as a SW. Hospital notes per outpatient treating psychiatrist, evaluated need for returning to inpatient setting from skilled nursing facility. Mental health is decompensating, endorsing suicidal ideations and need for more intensive acute care then outpatient setting for further treatment and stabilization . 6/06/23: readmitted . 6/07/23: Noted distress related to ongoing financial investigation. 6/07/23: Note from SW E, Resident received mail from Citibank and kept personal copy. Shortly after receiving mail came to writers' office distressed. Nursing staff was notified of resident's distress and a prn had already been given 10-15 minutes prior to receiving the mail. 6/08/23: Resident request daughter become rep-payee .Resident stated I am committed here; I will not do shock therapy .Resident mood was a mix of anger and frustration . 6/10/23: Note from CNA, heard resident talking in room and it was getting louder .Resident heard saying Why can't I go to a different hospital; I don't want to be in this hospital. You can let me go to a different one, you are punishing me based on what others are saying about me. I don't want ECT, they will have to take me kicking and screaming and why can't I go to stores. Resident crying harder and becoming louder. Nurse notified to see if resident can have a prn. 6/10/23: Adjusting to unit, gotten very little sleep, increased anxiety related to ECT appointment and financial investigation . 6/11/23-6/13/23 No emotional distress 6/12/23: Note from SW E, writer and resident called Direct Express per detective request .Resident was able to cancel her card and obtain information for detective .Resident was upset but remained calm . 6/12/23: Quiet with return from ECT 6/16/23: Charge Nurse: Resident opened 2 letters from SSDI with writer, allowed writer to scan letters. Originals given to resident .Letter stated she will receive a check now sent to her in person so she can take it to the bank and cash it .No concerns over letter. 6/18/23: In room most of the day, resident keeping to self. Appears anxious, but stated she is feeling ok .Ate well and made needs known. On 06/19/23 at 9:45 am, Surveyor spoke with R1. R1 reported she noticed in late winter her monies were going fast. R1 believed it was due to payments made to the facility. The facility thought she was delusional and making up the missing monies. R1 further expressed she never received a May deposit from Social Security Disability Income (SSDI.) R1 called Direct Express the card account where her SSDI was directly deposited, cancelled her card, and requested a new card. R1 called the social services office and spoke with Social Worker (SW) C as she did not have much money and it was not making sense to her. R1 indicated this why she went to the hospital in May. R1 expressed she was in the hospital for 2 weeks. In the hospital they wouldn't talk to her about her monies and wouldn't let her check her accounts. R1 expressed she experienced constant sadness/hurting, would cry constantly, and was anxious and depressed about it. R1 was told her medications were not effective. The facility changed her medications and discussed ECT (electroconvulsive therapy) with her. R1 expressed tomorrow will be 3rd treatment of ECT. R1 reported she is feeling better, mostly because people are listening to me. R1 expressed the incident caused her to cry a lot. R1 further expressed she wants her money returned to account, and she wants to be able to manage her money like she always has. R1 indicated there is still money not accounted for and they say insurance will cover it. R1 expressed at one point she was not good at all about this, couple weeks ago, when went to admissions (hospital.) She was very angry, and this did not help. Further expressing she was yelling at staff that she never yelled at before. Surveyor noted R1 with visibly shaking hands and tone of voice when talking with Surveyor about incident of stolen money by SW C, in the presence of head nurse/Registered Nurse (RN) D. Following the interview with R1, Surveyor spoke with RN D about R1's behavior. RN D expressed she had worked with R1 during her several stays at the facility. During the incident R1 was yelling at her. R1 had never done that before. On 6/19/23 at 10:10 am, Surveyor spoke with NHA A and Director of Nursing (DON) B about the FRI and R1's report of misappropriation. NHA A explained R1's reports of misappropriation were reported to the Social Services office. There was informal communication between facility staff via email but nothing formal for an investigation was completed prior to the FRI on 6/1/23. This was not investigated based on what SW C reported to Administration. The facility did not investigate further. The facility should have investigated this allegation of misappropriation. On 6/20/23 at 3:40 pm, Surveyor again spoke with NHA A. NHA A expressed it was SW C's job to report the incident to NHA A so an investigation could be started, and police could be informed. He did not. It should have been investigated and reported and it was not. These failures created a situation of immediate jeopardy that began on 03/20/23. On 06/01/23, the facility identified the misappropriation and exploitation being done by Social Worker C and took steps to correct the deficient practice and ensure compliance at the time of the survey. Based on this determination, the IJ was removed on 06/06/23 and corrected on 06/06/23 when the facility implemented the following: 06/01/23: NHA A removed Social Worker C from the premises and had him turn in all work-related items. Marshfield Police Department notified. Department of Quality Assurance facility reported incident filed. 06/02/23: Collected staff witness statements. Adult Protective Services referral was made and referral made to the WI Department of Safety and Professional Services Letter/email sent to representative payees requesting to send resident's statements of checks sent to facility from January to current to compare resident records. Letter/email sent to representatives of new procedure to send resident funds. Replaced mailbox at front to a locked mail slot. 06/05/23: Mail policy updated. 06/06/23 Email to staff of education of Misappropriation of Funds Email education to staff of new mail procedure. Guardians and representative payees called and updated on events. Impacted residents care planned for trauma informed care. Offered counseling to impacted residents. Monitored impacted residents for psychosocial distress. On 6/06/23, when the facility provided all staff education on the policy titled Exploitation of residents, Misappropriation, Suspicion of Crimes dated 10/20/22. The policy includes procedures for reporting to the State of Wisconsin and local authorities. 06/07/23: SW C was terminated from facility in writing. 06/08/23: Policies updated of Check Cashing, Incoming Checks Updated residents on financial investigation at resident council. The 5-day investigation and report submitted to DQA. Mail log audits will be conducted monthly at the QAPI meeting and reviewed at the next quarterly in QA meeting. Financial audits will be conducted with a separate financial personal possession log for each resident. Will review monthly with each resident for three months, and then quarterly at care conferences thereafter if there are no issues identified, it will be filed in the resident chart, as well as a copy in the business office. Will review this process at the next three monthly QAPI meetings and again at our quarterly meeting.

Based on record review and interview, the facility did not report a resident's allegations of misappropriation and/or exploitation to the State of Wisconsin or local authorities immediately upon the resident reporting the alleged misappropriation. The facility's failure to report the allegations affected 1 of 1 residents (R1) who reported incidents of missing items and funds from her accounts. R1 reported missing items from her room and funds from her Direct Express government funded debit card on numerous occasions that the facility did not report to the State of Wisconsin or local authorities. The facility's failure to respond caused R1 distress and psychosocial harm of prolonged crying, increased anxiety and agitation, removal from activities, distress, disturbed sleep, and hospitalization due to suicidal ideation The facility's failure to report the resident misappropriation created a finding of immediate jeopardy that began on 03/20/23. Surveyor notified Nursing Home Administrator (NHA) A and Director of Nursing (DON) B of the immediate jeopardy on 06/21/23 at 3:42 pm. On 06/01/23, the facility discovered the misappropriation and exploitation of 16 residents including R1 was being done by a facility Social Worker, reported the resident misappropriation, and took steps to correct the deficient practice and ensure compliance at the time of the survey. Based on this determination, the IJ was removed and corrected on 06/06/23. This is being cited as past noncompliance. Findings Include: Surveyor reviewed the Facility Reported Incident (FRI) submitted to the state of Wisconsin Department of Health Services. On 06/01/23, the facility identified 16 residents, including R1, who had been the victims of misappropriation of funds by a facility Social Worker (SW C.) Surveyor requested and reviewed the facility policy Abuse, Neglect, Exploitation of residents, Misappropriation, Injuries of Unknown Origin and Reporting of Crimes dated 10/20/22 which states in part: Identification: Staff will immediately report any suspicious event that may constitute .exploitation, misappropriation, occurrence of a crime. The facility will report the allegation to the state agency and law enforcement in accordance with state and federal law. Reporting and Response: Allegations will be reported to the Administrator immediately. The facility shall report all alleged violations and substantiated incidents to the state agency and all other agencies as required and will take all necessary corrective actions depending on the results of the investigation. The facility and/or staff shall report suspicion of a crime to local authorities and/or agencies as required. Reporting to law enforcement of reasonable suspicion of crimes: Reporting Requirements: In general: Each covered individual shall report to the state agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual receiving care from the facility. Examples of situations that would likely be considered crimes include but are not limited to .Theft/robbery .Identity theft fraud or forgery . On 6/19/23 at 10:10 am, Surveyor spoke with NHA A and Director of Nursing (DON) B about the FRI and R1's report of misappropriation. NHA A explained R1's reports of misappropriation were reported to the Social Services office. There was informal communication between facility staff via email but nothing formal prior to the FRI reported to the State of Wisconsin on 6/01/23. At this time the facility had determined Social Worker (SW) C was misappropriating money from residents. This was the first reporting of the incident. The police were first contacted with the discovery on 6/01/23. There was no reporting based on what SW C reported to Administration. The facility did not contact the police. The facility should have reported to the State of Wisconsin and notified the police. R1's record shows she was committed to facility due to mental illness and probable harm to self or others with recent overact or patterns of recent acts on 1/04/23. R1 had previous stays at the facility that were voluntary admissions. R1 was admitted to the secured wing from the hospital admissions wing. R1's most recent quarterly Minimum Data Set (MDS) completed 4/12/23 notes she understands, is understood, and has a BIMS of 15 indicating she is cognitively intact. R1 experiences hallucinations and delusions and has depressive mood indicators. R1's diagnosis includes schizo-affective disorder, bi-polar (primary type.) R1's record shows she is her own decision maker and guardian of estate. R1 receives $714.00 each month for SSDI. R1 did not have an account for petty cash at the facility. Surveyor reviewed R1's Psych Consult information and noted the following: Behaviors monitored: 1. Physical: anxiety, sweating, pacing, bouncy knee 2. Verbal: Paranoid/delusional 3. Other: Internal Stimuli/hearing voices Documentation shows R1 had 39 behaviors in April. This is a significant increase from March, after R1 reported the missing money and items, and the highest monthly count since R1's admission. Surveyor review of R1's [NAME] County Human Services counseling notes: 3/21/23: reports crying almost daily, voices have not been bothering her as much, believes she is addicted to on-line shopping app, buying things from app. Almost daily .tearful and requested to end session . 4/04/23: believes father may be stealing things from her, hopeless, tearful, guarded, expressed a lot of anger . 4/18/23: identified anxiety, unsure if she can pay for her brace on her own .anxiety about not knowing how much money in bank account, she does not know how to check her money but concerned the app is stealing money from her for browsing . 5/23/23: discussed increased depression, more sick last 2 weeks, wants to go to different hospital as no one likes her here, does not feel safe, conspiring against her. Increased paranoia and agitation. Difficulty finishing thoughts. This is the first session she swore in front of writer. Getting CT next week for signs of dementia. 6/09/23: Reports relief of news of SW taking money. It means she is not crazy as she and everyone thought. Identified anger. Discussed hospitalization . Decreased meds, but not sure why, Feels less emotional. Wished she could start ECT now to see if she would benefit from it . 6/13/23: Had ECT and believes it is helping, Feels resentful towards staff regarding SW situation. Discussed how staff did not believe her and she was hospitalized , and she was correct. Surveyor reviewed R1's nurses note and noted the following: 1/29/23: Note from SW C, .the one thing on her mind appears to be when her monthly money will go down to $45.00 per month . 3/01/23: Note from SW C, resident request writer to hold on to her debit card. Writer assured resident the best idea would be to have it placed in the business office. Writer filled out envelope with her signature on it . 3/20/23: Note from CNA, Resident approached staff and stated I was told to talk to you about a card I lost, it is a government funded card. I looked everywhere and can't find it Writer asked if she had it with her when she went shopping but resident could not remember. Asked if she wanted her to help look for it. Resident responded sure. Writer was unable to find the direct express card identified as green in color. Resident stated she will call and cancel card. Although resident reported a missing debit card to staff there is no evidence the police or state agency were notified. 3/21/23: Note from SW C, writer reminded resident her card is kept safe in business office. Resident did not remember this but was relieved. 4/02/23: Note from SW C, continues to experience overall instability in mental health. Her mental health has improved since her admission but can be unpredictable sometimes on an hourly basis. Mental health symptoms continue to include delusional thoughts, paranoia and responding to internal stimuli. Resident out to eat at culvers ., given her debit card before she left. When she returned, she returned her card to be locked safely, reviewed notes and see resident concerns about how much money was left on her card balance. This writer theorizes resident feels she should have money because benefits come on the first, the first fell on weekend day and it is possible she did not receive the funds . 4/02/23: Note from RN, Resident made comments last evening regarding her debit card .reassured card is locked in office, and no one has access. Resident comment she was just panicking and accepted reassurance from staff 4/04/23: Note from SW C, resident continues to experience overall instability with her mental health, continues to experience depression, anger, voices that do interfere with daily routine and cause her distress. Writer has met with resident one on one past two days. Resident angry and made accusations directed at care staff Writer reminded resident she can trust writer .Resident did make a statement about possibly having a rep-payee to help her with her finances . 4/07/23: Note from SW E, to tobacco outlet to withdraw $100.00, resident request cards to be locked in business office. SW and nurse signed envelope confirming debit card placement 4/07/23: Debit card in Narc drawer for resident better access. (RN note). 4/12/23: 1:45 Note from RN, Resident came to med room yelling It's not funny, I only have $70.00 left in my account since last week Someone is stealing my money, walked away crying, refusing to listen to staff, repeating someone is stealing my money .SW to unit to speak with her. 4/12/23: 2:57, Note from SW C, continues to experience overall instability with mental health. Resident continues to experience depression and anger; voices interfere with daily routine causing distress .Had a very difficult with increased mental health symptoms today. Received a call from nursing staff very upset about money. I thought I was doing good with my money; I should have more. Crying during first part of meeting. Writer asked investigative questions about, and resident appears to be having some delusional thoughts . Resident believes dad using money and taking packages she orders . Reminded card is locked, and she is the only one with the pin. Resident states she is never going to get better. Asked if she wants to contact police and said No. I am just not thinking very clearly. There is no evidence the facility notified the State of Wisconsin or police when R1 reported someone was stealing her money on 4/12/23. 4/19/23: Note from CNA, Resident tearful about a phone call she made. SW made aware. 4/20/23: Note from CNA, left at this time for Walmart with Social Worker 4/20/23: Note from RN, Made accusations regarding her credit card. While talking with writer resident had a flat affect, aggressive tone, jumped from topic to topic, walking very slowly throughout shift, displayed paranoid thoughts. Talked with HN (Head Nurse/RN) and NHA (Nursing Home Administrator) about it. Although the facility shared an exchange of email regarding the situation there is no evidence the State of Wisconsin or police were notified. The emails state: 4/20/23: RN F: R1 came out of her room .had a small flat bag and asked where she could put it where it would be safe and no one could get to, the most safest untouchable spot where no average just anybody could get to it .R1 stated over the last two months a lot of her items have gone missing and her card was missing and it had over 2,000 missing from it and that was from the business department and still does not know how it happened .R1 stated she just got a new card and there is already money missing and she does not know how she is going to prove it . 4/20/23: NHA A: R1 is basically saying someone is using her debit card. With that said, can you please investigate in the morning? It should be easy to rule out by helping her check her balance .R1 seems extremely unwell . 4/21/23 SW C: We will investigate this. Unfortunately, R1 still is unwell. 4/21/23: SW E: We gave R1 a lock box this morning. She said SSDI told her they can see specific people that use her card. I asked her if she meant the store that the stolen purchases were coming from and she said no, they can see people on each transaction. She mentioned an [name] has used her card, but denied it was a resident Resident also mentioned she had misplaced her cream-colored small wallet that held her ID and insurance cards .Found wallet in the bottom of her purse . Nurses Notes continued: 4/21/23: Note from CNA, was heard this morning talking to a peer about how things are missing in her room. SW and CSA [Client Service Assistant] are notified about her concerns. There is no evidence the State of Wisconsin or local authorities were notified of R1's report of items missing in her room. 4/21/23: Note from SW C, This writer and CSA staff staffed resident case and recent accusations this morning. A cumulative review of all fact-based information confirms resident accusations of someone using her debit card are unfounded. Resident mental health remains extremely unpredictable, and she continues to experience delusions, paranoid, voices and frequent mood swings. Received a new debit card today in a sealed envelope. Delivered personally with CSA witness. Reminded to put in lock box. No one has access to the debit card pin. Resident receiving numerous packages from online ordering. Also sent money in the mail to her family. Resident stated, I shop online impulsively when I am anxious. Resident interviewed and social services did not argue with her delusions .Made referral to MD to access the need for rep payee regarding continued concerns spending/financial accusations .IDT will look into evaluation for dementia . 4/21/23: Email from SW E to Physician: Resident is in need of a rep-payee. She is accusing people of stealing her money, but she is spending it. She is forgetting and we are worried she may have some memory impairments . 5/03/23: Note from SW E, resident expressed just put me in the hospital, I don't want to be here anymore, they think I am going to hurt people, denied having these thoughts. 5/04/23: Note from CNA, Appears to be in sad mood today .Declined playing cards . 5/05/23: (RN D, R1, SW C, MD) tearful/depressed, crying often, agitation decreased. Resident concerns with complaints of depression/anxiety. Medication changes. 5/08/23: Note from SW E, resident would like to cash a large check from her brother. Declined cashing at Walmart and voiced she would like to open a bank account. Resident does not have a bank. Resident returned NHC lock box stating she does not need it. 5/10/23: tearful, declined outing, too much pain 5/11/23: Due for assistance renewal, sought CSA help. 5/11/23: Note from CNA, Very frustrated and sensitive upon waking .even coming to the point of bawling when she couldn't get her leg brace on. 5/12/23: (Charge Nurse) Resident came to write stating she needed to go to the bank today urgently as her card has been compromised .Writer stated she needed to talk with SW and CSA about it. Writer spoke with SW/CSA and they informed resident to call her bank to see if she can put a hold/freeze on it. Writer spoke with resident who changed story of card compromised to she needed to money in the bank .so she does not become compromised .Resident upset . 5/14/23: resident reports having nightmare 5/16/23: Note from SW E, Appeared in CSA office and was visibly crying and upset, expressed she would rather be in jail then stay at [NAME], felt staff are trying to entrap her. Adamant about not staying at [NAME] as she does not feel safe here .Paranoia and behaviors increasing .Nursing made aware of resident comments and agitated mood . 5/21/23: resident reports not sleeping, wants to talk with psychiatrist about it . 5/22/23: Note from SW E, Appeared more emotional and tearful today. Reported depression worse .believes apartment ended lease due to non-payment . 5/23/23: Note from SW E, resident experienced an acute change in mental status today that prompted a call to [NAME] County Crisis and subsequent move to more restrictive environment on the [NAME] admissions unit (hospital). Resident demanded to speak to SS (Social Services). Resident appeared upset and crying .Thought process was difficult to follow, became very angry and verbally aggressive .Demanded to leave .Yelled while continuously crying .repeated anger over medications that were discontinued .unable to process and evaluate information .Concerns of self-harm .Crisis team contacted .Today was the most unstable that this writer has witnessed resident mental health while working with her as a SW. Hospital notes per outpatient treating psychiatrist, evaluated need for returning to inpatient setting from skilled nursing facility. Mental health is decompensating, endorsing suicidal ideations and need for more intensive acute care then outpatient setting for further treatment and stabilization . 6/06/23: readmitted . 6/07/23: Noted distress related to ongoing financial investigation. 6/07/23: Note from SW E, Resident received mail from Citibank and kept personal copy. Shortly after receiving mail came to writer's office distressed. Nursing staff was notified of resident's distress and a prn had already been given 10-15 minutes prior to receiving the mail. 6/08/23: Resident request daughter become rep-payee .Resident stated I am committed here; I will not do shock therapy .Resident mood was a mix of anger and frustration . 6/10/23: Note from CNA, heard resident talking in room and it was getting louder .Resident heard saying Why can't I go to a different hospital; I don't want to be in this hospital. You can let me go to a different one, you are punishing me based on what pothers are saying about me. I don't want ECT, they will have to take me kicking and screaming and why can't I go to stores. Resident crying harder and becoming louder. Nurse notified to see if resident can have a prn. 6/10/23: Adjusting to unit, gotten very little sleep, increased anxiety related to ECT appointment and financial investigation . 6/11/23-6/13/23 No emotional distress 6/12/23: Note from SW E, writer and resident called Direct Express per detective request .Resident was able to cancel her card and obtain information for detective .Resident was upset but remained calm . 6/12/23: Quiet with return from ECT 6/16/23: Charge Nurse: Resident opened 2 letters from SSDI with writer, allowed writer to scan letters. Originals given to resident .Letter stated she will receive a check now sent to her in person so she can take it to the bank and cash it .No concerns over letter. 6/18/23: In room most of the day, resident keeping to self. Appears anxious, but stated she is feeling ok .Ate well and made needs known. On 06/19/23 at 9:45 am, Surveyor spoke with R1. R1 reported she noticed in late winter her monies were going fast. R1 believed it was due to payments made to the facility. The facility thought she was delusional and making up the missing monies. R1 further expressed she never received a May deposit from Social Security Disability Income (SSDI.) R1 called Direct Express, the card account where her SSDI is directly deposited, cancelled her card, and requested a new card. R1 called the social services office and spoke with Social Worker (SW) C as she did not have much money and it was not making sense to her. R1 indicated this is why she went to the hospital in May. R1 expressed she was in the hospital for 2 weeks. In the hospital they wouldn't talk to her about her monies and wouldn't let her check her accounts. R1 expressed she experienced constant sadness/hurting, would cry constantly, and was anxious and depressed about it. R1 was told her medications were not effective. The facility changed her medications and discussed ECT (electroconvulsive therapy) with her. R1 expressed tomorrow will be 3rd treatment of ECT. R1 reported she is feeling better, mostly because people are listening to me. R1 expressed the incident caused her to cry a lot. R1 further expressed she wants her money returned to account, and she wants to be able to manage her money like she always has. R1 indicated there is still money not accounted for and they say insurance will cover it. R1 expressed at one point she was not good at all about this, couple weeks ago, when went to admissions (hospital.) She was very angry, and this did not help. Further expressing she was yelling at staff that she never yelled at before. Surveyor noted R1 with visibly shaking hands and tone of voice when talking with Surveyor about incident of stolen money by SW C in the presence of head nurse/Registered Nurse (RN) D. Following the interview with R1, Surveyor spoke with RN D about R1's behavior. RN D expressed she had worked with R1 during her several stays at the facility. During the incident R1 was yelling at her; R1 had never done that before. On 6/19/23 at 10:10 am, Surveyor spoke NHA A and Director of Nursing (DON) B about the FRI and R1's report of misappropriation. NHA A explained R1's reports of misappropriation were reported to the Social Services office. There was informal communication between facility staff via email but nothing formal prior to the FRI reported to the State of Wisconsin on 6/01/23. This was the first reporting of the incident. The police were first contacted with the discovery on 6/01/23. This was not reported based on what SW C reported to Administration. The facility did not investigate further or contact the police. The facility should have reported to the State of Wisconsin and notified the police. On 6/20/23 at 3:40 pm, Surveyor again spoke with NHA A. NHA A expressed it was SW C's job to report the incident to NHA A so an investigation could be started, and police could be informed. He did not. It should have been investigated and reported and it was not. These failures created a situation of immediate jeopardy that began on 03/20/23. On 06/01/23, the facility identified the misappropriation and exploitation being done by Social Worker C and took steps to correct the deficient practice and ensure compliance at the time of the survey. Based on this determination, the IJ was removed on 06/06/23 and corrected on 06/06/23 when the facility implemented the following: 06/01/23: NHA A removed Social Worker from premises and turning in all work-related items. Marshfield Police Department notified. Department of Quality Assurance facility reported incident filed. 06/02/23: Collected staff witness statements. Adult Protective Services referral was made and Department of Safety and Professional Services Letter/email sent to representative payees requesting to send statements of checks sent to facility from January to current to compare resident's records. Letter/email sent to representatives of new procedure to send resident funds. Replaced mailbox at front to a locked mail slot. 06/05/23: Mail policy updated. 06/06/23 Email to staff of education of Misappropriation of Funds Email education to staff of new mail procedure. Guardians and representative payees called and updated on events. Impacted residents care planned for trauma informed care. Offered counseling to impacted residents. Monitored impacted residents for psychosocial distress. On 6/06/23, when the facility provided all staff education on the policy titled Exploitation of residents, Misappropriation, Suspicion of Crimes dated 10/20/22. The policy includes procedures for reporting to the State of Wisconsin and local authorities. 06/07/23: SW C was terminated from facility in writing. 06/08/23: Policies updated of Check Cashing, Incoming Checks Updated residents on financial investigation at resident council. The 5-day investigation and report submitted to DQA. Mail log audits will be conducted monthly at the QAPI meeting and reviewed at the next quarterly in QA meeting. Financial audits will be conducted with a separate financial personal possession log for each resident. Will review monthly with each resident for three months, and then quarterly at care conferences thereafter if there are no issues identified, it will be filed in the resident chart, as well as a copy in the business office. Will review this process at the next three monthly QAPI meetings and again at our quarterly meeting.

Based on observations and staff interviews the facility did not serve food under sanitary conditions by ensuring that that the dishwashing machine washed the resident dishes at the proper temperatures and by dating open foods and foods taken out of original containers in the freezer for 16 of 16 facility residents. This is evidenced by: Example 1 On 05/16/17 at 10:00 a.m., the surveyor observed an open bag of wheat bread, rye bread and 2 bags of dinner rolls in the facility freezer in the kitchen with no dates of when they were opened. In addition, 4 bags of diced chicken taken out of the original container were observed on a tray in the same freezer with no use by dates and or dates that indicate when it was put on the tray. On 05/16/17 at 10:05 a.m., C-B (Cook) told the surveyor that these items should have been dated. On 05/17/17 at 2:30 p.m., the Dietary Manager told the surveyor that food items taken out of their original containers or opened in the freezer or refrigerator should be dated with the use by date or by the date when opened. Example 2 On 05/17/17 beginning at 8:10 a.m., the surveyor observed Cook-B and DA-C (Dietary Aide) putting racks of resident dishes through the kitchen dish machine. 4 racks of resident dishes were run through the dish machine and the wash temperatures noted on the gauge of the machine were as follows: 140 degrees, 140 degrees, 142 degrees, and 145 degrees. C-B and DA-C continued to run dishes through the machine. The surveyor asked DA-C what the wash temperature should be. DA-C indicated that the wash temperature should be 150 degrees. On 05/17/17 at 11:45 a.m., the surveyor spoke with the Dietary Manager. The Dietary Manager was informed of the low wash temperature's on the dish machine. The Dietary Manager said he had spoken to the Maintenance staff and they had increased the temperature on the booster heater on the dish machine. The Dietary Manager indicated the wash temperature should be at least 150 degree's Fahrenheit.

Based on observation, record review, and interview the facility did not achieve a 5% or less medication error rate. The Survey team observed 2 (R12 and R10) errors out of 30 opportunities. The medication error rate calculated to 6.66% RN-B (Registered Nurse) did not administer a medication to be dissolved on the tongue in accordance with the physician orders [REDACTED]. RN-B administered [MEDICATION NAME] (an inhaled steroid medication) and did not instruct R10 to rinse the mouth and spit out the water in accordance with the manufacturers recommendation. This is evidenced by: Example 1: R12 was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. Review of the signed physician orders [REDACTED]. On 05/18/17 at 7:05 a.m., the Surveyor observed RN-D place 4 pills, including the [MEDICATION NAME] 25 mgs, into a souffle cup. RN-D gave the souffle cup to R12 who immediately poured the 4 pills into his mouth and swallowed them with a glass of water. The [MEDICATION NAME] 25 mgs was not placed on the tongue and dissolved according to physician orders. On 05/18/17 at 8:25 a.m., the Surveyor interviewed RN-D regarding the above observation. RN-D stated she was unaware the [MEDICATION NAME] 25 mgs was to be dissolved on R12's tongue. RN-D stated she has never administered the [MEDICATION NAME] to R12 by dissolving on the tongue. RN-D confirmed R12 swallowed all 4 medications. Example 2: According to the manufacturer's recommendations, the resident should immediately rinse the mouth with water and spit out the water following administration of [MEDICATION NAME]. [MEDICATION NAME] contains a steroid and puts residents at risk of getting thrush (a yeast infection of the mouth) if the resident does not rinse and spit immediately after administration of [MEDICATION NAME]. R10 was admitted to the facility on [DATE] with the following, but not all inclusive, Diagnoses: [REDACTED]. Review of the signed physician orders [REDACTED]. On 05/18/17 at 8:12 a.m., the Surveyor observed RN-D hand the [MEDICATION NAME] 500/50 disc container to R10. R10 placed the [MEDICATION NAME] disc mouthpiece to her mouth and inhaled once. R10 gave the [MEDICATION NAME] disc back to RN-D. RN-D did not provide R10 with a glass of water and RN-D did not instruct R10 to rinse her mouth out and spit out the water. On 05/18/17 at 8:25 a.m., the Surveyor interviewed RN-D regarding the above observations. RN-D stated [MEDICATION NAME] may cause thrush if the resident does not rinse the mouth thoroughly after inhaling the medication. RN-D confirmed she did not instruct R10 to rinse her mouth and spit out the water after the [MEDICATION NAME] was administered.

Based on observation, interview and facility documentation review, the facility did not store, prepare and distribute food under sanitary conditions. This had the potential to affect 14 of 14 residents who reside on the Central/Crossroads unit. During observations of the dietary services department, surveyors observed the following concerns: Several loaves of bread were beyond their use by dates. A small fan was dusty and dirty was blowing toward the tray line service area. A box fan was dusty and dirty and was blowing on clean dishes. The floors of the kitchen, tray line area, dish machine room and hall by walk in coolers was soiled with build up at edges, corners, thresholds and in grout lines. Staff were observed to wash hands in a manner that contaminated their hands. Staff used contaminated gloves to handle food. During temperature taking at tray line, staff did not sanitize the thermometer between each food item. This is evidenced by: On 05/23/16 beginning at 9:15 a.m., Surveyor began tour of the dietary services department accompanied by Food Service Supervisor (FSS) A. Surveyor observed the following: In a metal cabinet near the food tray line, Surveyor noted two loaves of light wheat bread with use by dates of 05/14/16, a partial loaf of Italian bread with a use by date of 05/07/16, a partial loaf of English toasting bread with a use by date of 05/19/16 and a partial loaf of honey wheat bread with a use by date of 05/21/16. Surveyor pointed out to FSS A that the loaves of bread were past their use by dates. FSS A said the breads had been frozen. Surveyor noted there were no dates on the loaves of bread to identify when each had been removed from the freezer and put in use. FSS A asked Cook H when the breads had been taken out of the freezer. Cook H said yesterday. This was not asked specifically of each loaf of bread. Surveyor requested the facility policy regarding bread storage and use. A Lasko fan was sitting on top of the metal cabinet the bread was stored in. This fan was dirty and dusty and was blowing directly toward the tray line area where food is held and plated. The floor behind and to the sides of the tray service line was unclean and had build up of dirt and debris at the edges, corners and by the thresholds going into the kitchen. The main kitchen floor and the dish machine room floors also had a build up of dirt and debris at the edges, corners, seams and in the grout lines. The floor in the hall by the walk in freezers and coolers was also soiled. A box fan in the dish machine room was dusty and dirty and was blowing directly at the clean end of the dish machine. There were two racks of clean dishes sitting on the counter in line of this soiled fan. On 05/24/16 at 1:50 p.m., the Nursing Home Administrator (NHA) spoke with Surveyor and explained when the bread is delivered it goes right to the freezer, then when needed it is pulled out for use. The NHA said the bread can be in the freezer for up to three months; once it is taken out of the freezer they have ten days to use it but it should be labeled with the date it came out of the freezer and with the date it should be used by. On 05/25/16, Surveyor was emailed a Policy and Procedure titled Food And Supplies (Storage Of) dated 02/16/15. This policy did not address the storage, freezing, use and dating of bread. On 05/24/16 at 2:18 p.m., the above concerns were discussed with FSS A. Surveyor asked FSS A about the dietary department's floor cleaning schedule. FSS A said they sweep and mop them daily. Surveyor asked how often a more thorough cleaning of the floors is done. FSS A stated when he first got there a couple of years ago they did some of the floor by his office, but they do not have a contract with the current housekeeping for that, to do deep cleaning of the floors. On 05/24/16, Surveyor reviewed the daily Production Sheet for 05/01/16-05/22/16. These sheets included tasks that were to be completed by dietary employees. Floors were listed as a daily task. On 05/24/16, Surveyor reviewed the 04/2016, cleaning scheduled that included FANS (SMALL ONES). The fans were set up on a monthly cleaning schedule and were initialed as last being cleaned on 04/24/16. The fans had not yet been cleaned in 05/2016. During the interview with FSS A, he stated he would be changing the fan cleaning schedule to weekly. The following observations were made by Surveyor of staff preparing food on 05/25/16; they began at 11:15 a.m. and ended at 11:30 a.m. Cook F was observed preparing scalloped potatoes and ham for lunch. Cook F had gloves on her hands when the observation began. Cook F pushed a metal cart over by the oven, touching the handle with her gloved hands. Cook F then opened the oven door, and then grabbed hot pads and used them to remove two pans of scalloped potatoes, contaminating her gloves in the process. Cook F placed the pans of potatoes on the counter. Cook F then opened a large container of shredded cheese and grabbed handfuls of the shredded cheese (with her contaminated gloves) and placed it onto the scalloped potatoes. Cook F then stirred the cheese into the potatoes, covered the potatoes with tin foil, and took them to the tray line for service. Cook F was observed to remove her gloves and wash her hands at the sink. Cook F washed her hands and left the water running as she grabbed a paper towel. Cook F then dried her hands and disposed of the paper towel. Cook F then shut off the water with her hands, thereby contaminating her hands. Dietary Assistant (DA) G was observed to remove her gloves and wash her hands at the sink. DA G washed her hands and left the water running as she grabbed a paper towel. DA G then dried her hands and disposed of the paper towel. DA G then shut off the water with her hands, thereby contaminating her hands. Cook F was observed taking temperatures of food at tray line prior to service. Cook F took the temperature of the carrots, then removed the thermometer and placed it directly into the gravy. Cook F did not clean or sanitize the thermometer when going from one food item to the next. Interview with FSS A at 11:35 a.m. on 05/25/16, revealed that only clean gloves should be used when handling food items. FSS A also stated that when washing hands, staff should be turning off the water with the paper towel instead of their bare hands. FSS A also stated the thermometer is supposed to be sanitized between each food item.

Based on record review and interviews, the facility did not maintain an Infection Control Program to help prevent the development and transmission of diseases and infections. The deficient practices have the potential to affect all residents. ~According to the facility policy, staff should stay home from work for 48 hours after gastrointestinal symptoms resolve and 24 hours after fever resolves in an effort to prevent the spread of any illness to other staff or residents. The infection control line list for staff surveillance was incomplete. There were no well dates noted and often there were no areas worked noted from June 2014 through March 2015. Given the lack of data, staff may have returned to work too soon exposing residents and other staff to their illnesses. ~The facility does not have an Antimicrobial Stewardship Program which ensures antibiotics are used appropriately and only when medically indicated. Residents #9 was prescribed antibiotics to treat a urinary tract infection without an identified organism in May 2014, July 2014, September 2014, November 2014, March 2015 and twice in April 2015. Imprudent use of antibiotics is associated with an increase in multi-drug resistant organisms. ~Residents were not offered hand hygiene prior to eating in the cafeteria and Pod 1 dining room. This is not consistent with current infection control standards. ~Resident #3 was observed conducting his blood sugar test on a table in Pod 1. No barrier was placed on the table. The table was not sanitized and later used to serve beverages to other residents. This is evidenced by: Example #1: This facility shared nursing, dietary, housekeeping, laundry, therapy, activity, administrative and social services staff between this 16 bed facility and an 8 bed facility. The scheduler is responsible for entering staff call-in data onto a spread sheet which is then reviewed by the DON (Director of Nurses). The resident infection data is reviewed by the ICP (Infection Control Preventionist) who is the head nurse over both nursing units. On 04/14/15, Surveyor # requested both resident and staff surveillance data from May 2014 through present. On 04/15/15, Surveyor # was provided with staff surveillance forms beginning in June 2014 through March 2015. The form was a spread sheet that listed the call-in date, staff name, age, sex, department, onset date, well date, 8 different symptoms, return to work date, hospitalized , lab data, area worked previous 24 hrs. and an "other" column. Upon review of the staff surveillance data, Surveyor # noted the following: ~2 staff called in ill for June 2014 and no well dates for either staff along with no area worked noted for 1 staff. ~1 staff called in ill for July 2014 and there was no well date or area worked noted. ~6 staff called in ill for August 2014 with no well dates noted for all 6. ~2 staff called in ill for September 2014 with no well dates and no area worked noted for both. One staff member had chills and fever on 9/22 and returned to work on 9/23/14. ~10 staff called in for October 2014. One staff had an onset date of 10/07/14, a well date of 10/09/14 and a return to work date of 10/09/14. This staff had a fever and a respiratory virus. The other 9 staff had no well dates listed. Four out of the 10 had no area worked noted. ~7 staff called in for November 2014 and there were no well dates for all 7. ~7 staff called in for December 2014 and there were no well dates for all 7. In addition, 2 out of the 7 had no area worked noted. One staff had an onset date of 12/27/14 and was diagnosed with [REDACTED]. ~10 staff called in for January 2015 and there were no well dates for all 10 staff. One staff had an onset date of 01/08/15 and was diagnosed with [REDACTED]. ~1 staff called in for February 2015 and there was no well date. ~4 staff called in for March 2015 and there was no well date noted for all 4. In addition, 1 out of the 4 had no area worked listed. On 04/14/15 at 4:08 p.m., Surveyor # interviewed the DON regarding the facility infection control practices. The ICP was also present for the interview. The DON confirmed it was the facility's expectation that staff do not return to work until 24 hours after fever resolved and 48 hours after last gastrointestinal symptom. The DON confirmed the staff line list was incomplete and did not have any well date data. The DON stated it was her responsibility to keep accurate and complete data for staff infection surveillance. Example #2: The Loeb Criteria, first published by SHEA (Society for Healthcare Epidemiology in America) in 2001 is the gold standard for initiation of antibiotics. This criteria outlines the minimum criteria for initiating an antibiotic for those resident that do not have a catheter. This standard is outlined in the "Interact Care Paths" 2010. The minimum clinical criteria for initiating an antibiotic for a UTI (Urinary Tract Infection) are: 1). Dysuria alone (pain with urination), 2). Fever, (2.4 degrees Fahrenheit over base line) and at least one other symptom of abdominal tenderness, blood in the urine, or new or worsening urinary urgency, frequency, or incontinence. 3.) Consider antibiotic treatment after check of the results of urinalysis and culture. The CDC (Centers for Disease Control) in conjunction with the NHSN (National Healthcare Safety Network) has set up surveillance guidelines to differentiate a Symptomatic UTI (both with and with out a catheter) and Asymptomatic Bacteremia. The criteria is similar to the clinical signs and symptoms: Fever 2 degrees over baseline, new low blood pressure, shaking, new onset of confusion, acute pain, drainage, blood in the urine, and new or increased urgency, frequency, and incontinence. Resident #9 was admitted to the facility in 2007 for long term care related to schizoaffective disorder, chronic mental illness, Parkinson's disease, and diabetes. Review of the resident infection control data noted Resident #9 was treated for [REDACTED]. ~05/28/14 Resident #9 was treated with Bactrim DS twice daily for 7 days. The only symptom noted was changes in behaviors. ~05/30/14 Resident #9 was treated with [MEDICATION NAME] 100 mgs twice daily for 7 days as the previous antibiotic was not sensitive to the organism identified. ~07/03/14 Resident #9 was treated with [MEDICATION NAME] 500 mgs three times per day for 7 days. The only symptom noted was a strong urine odor. There were no nonmedicinal approaches attempted such as increasing fluids for 48 hours and increasing perineum hygiene. ~09/25/14 Resident #9 was treated with [MEDICATION NAME] 250 mgs twice daily for 7 days. The only symptom noted was a change in behavioral symptoms. ~11/06/14 Resident #9 was treated with [MEDICATION NAME] 100 mgs twice daily for 10 days and there were no symptoms identified. ~03/30/15 Resident #9 was treated with Bactrim DS twice daily for 7 days. The only symptom noted was a change in behavioral symptoms. There was no urine specimen obtained and no evidence of an infection. ~04/07/15 Resident #9 was treated with Bactrim DS twice daily for 7 days and there were no symptoms identified. ~04/13/15 Resident #9 was treated with [MEDICATION NAME] 100 mgs twice daily for 7 days and there were no symptoms identified. Review of the nurse's note, dated 05/24/14 and 05/27/14, noted Resident #9 to be "crabby" and refusing cares. The intervention was to obtain a urine specimen for "testing." There was no identified organism from the urine specimen yet on 05/28/14 the physician ordered to start Bactrim DS twice daily for 7 days. The nurse's notes did not support any acute illness, evidence of an infection, no changes in urinary function, and no changes in behavioral symptoms. Review of the lab reports, dated 05/30/14, noted Resident #9's urine specimen cultured greater than 100,000 organisms of Escherichia coli along with mixed bacterial flora. The sensitivity panel identified the organism was resistant to Bactrim DS but sensitive to [MEDICATION NAME]. According to the physician orders, the facility treated Resident #9 with Bactrim DS twice daily from 05/28/14 until 05/30/14 at which time the antibiotic was changed to [MEDICATION NAME] 100 mgs twice daily for 7 days. Review of the nurse's notes, dated 07/03/14, noted Resident #9 had a strong urine odor and the physician ordered to obtain a urine specimen, then begin [MEDICATION NAME] 500 mgs three times per day for 7 days. There was no identified organism from the urine specimen. There was no nonmedicinal approach to Resident #9's strong urine odor such as increasing fluids for 48 hours and providing good perineum hygiene. Review of the nurse's notes, dated 07/03/14 through 07/09/14, noted no acute illness, no evidence of an infection, no evidence in changes in urinary function, and no changes in behavioral symptoms for Resident #9. Review of the lab reports, dated 07/03/14, noted the final report was not faxed to the facility until 10/06/14 at 9:05 a.m. This was 3 months after Resident #9 was treated. The urine specimen did identify Escherichia coli and was susceptible to [MEDICATION NAME]. Review of the nurse's notes, dated 09/23/14, noted Resident #9 slapped a staff person on the arm. The physician was contacted and a urine specimen was obtained. On 09/26/14 notes, indicated an abnormal urinalysis and the physician started [MEDICATION NAME] 250 mgs twice daily for 7 days. There was no identified organism at this time. The nurse's notes did not support an acute infection, changes in urinary function, or evidence of a urinary tract infection. Review of the lab report, dated 09/28/14, noted Resident #9's urine culture identified greater than 100,000 organisms of Escherichia coli which were sensitive to [MEDICATION NAME]. Review of the nurse's notes, dated 11/02/14 through 11/09/14, revealed no evidence of an acute illness, no evidence of an active infection, no evidence of changes in urinary function, and no abnormal behaviors. On 11/04/14, the facility obtained an order to straight catheterize Resident #9 for a urine specimen. The physician ordered [MEDICATION NAME] 100 mgs twice daily for 10 days on 11/06/14. Review of the lab report, dated 11/06/14, noted Resident #9's urine culture identified greater than 100,000 organisms of Escherichia coli which were sensitive to [MEDICATION NAME]. Review of the nurse's notes, dated 03/28/15 through 04/03/15, revealed no abnormal behaviors, no urinary tract symptoms or evidence of an active infection. On 03/29/15, the physician ordered Bactrim DS twice daily for 7 days. There was no urine specimen obtained and there was no evidence of an infection or identified organism. On 04/07/14, the physician ordered to obtain a urine specimen and also ordered Bactrim DS twice daily for 5 days. Review of the lab report, dated 04/09/15, noted Resident #9's urine culture identified greater than 100,000 organisms of Escherichia coli which were sensitive to Bactrim. On 04/14/15 at 4:08 p.m., Surveyor # interviewed the ICP and the DON regarding antibiotic stewardship. The ICP stated Resident #9 has a long history of frequent UTIs and staff often request antibiotics when Resident #9 has changes in behaviors. The ICP stated the physician or staff do not wait for an identified organism before beginning antibiotics. The ICP stated staff do not increase fluids, increase perineum hygiene, or monitor residents prior to contacting the physician to request antibiotics. The DON stated the physicians are quick to order antibiotics and do not like to wait for lab results. Example #3: On 4/14/15 at 11:40 a.m., Surveyor # observed lunch service to residents that ate in the main dining area. The residents were not offered hand washing or hand sanitation prior to eating. Of note is that approximately 50% of the residents ate BBQ on a bun with their hands. On 4/14/15 at 11:45 a.m., Surveyor # observed lunch being served to residents in the Pod 1 dining room on the unit. At no time before or during the meal were residents offered hand hygiene. On 4/15/15 at 7:25 a.m., Surveyor # observed CNA-A serving breakfast in the downstairs cafeteria. At no time before or during the meal were residents offered hand hygiene. On 4/15/15 at 10:15 a.m., Surveyor # spoke with CNA-A about resident hand hygiene before meals. CNA-A indicated residents are not offered hand hygiene before meals in the cafeteria as no supplies are available to do so. CNA-A further expressed residents are not allowed in the cafeteria serving area where hand sanitizer is available. CNA-A expressed residents' hands should be washed at the sink in Pod 1 prior to eating. On 4/15/15 at 11:48 a.m., Surveyor # observed lunch service to residents who ate in the common area on the unit. The residents were not offered hand washing or hand sanitation prior to eating. Of note is that approximately 50% of the residents ate a brat patty on a bun with their hands. On 4/15/15 at 11:00 a.m., Surveyor # spoke with RN-G on the unit regarding resident hand hygiene before meals. RN-G indicated the kitchen was supposed to purchase individual handi-wipe packets as a result of the last survey. The packets were to go on residents' meals trays to be used for hand hygiene before eating. RN-G further expressed the handi-wipe packets were not purchased and supplies are not available in the cafeteria for resident hand hygiene. Example #4: On 4/14/15 at 4:30 p.m., Surveyor # observed CNA-C bring a tray to Resident #3. Resident #3 was sitting at a small table in Pod 1. Resident #3 removed a glucometer and supplies to conduct a finger stick and placed them directly on the table surface. Resident #3 completed his finger stick and tested his blood sugar with the glucometer that was on the table. When finished, Resident #3 placed the glucometer back on the tray and discarded his gauze and lancet in a cup on the table. CNA-C removed the tray and cup and exited Pod 1. CNA-C returned to Pod 1 with a pitcher of juice and paper cups. CNA-C placed the pitcher and cups on the table where Resident #3 conducted his blood sugar test. Neither Resident #3 nor staff placed a barrier on the table when conducting the blood sugar test. CNA-C did not sanitize the table after completion of the blood sugar test. CNA-C proceeded to serve residents in Pod 1 juice that was poured in the paper cups. On 4/15/15 at 10:15 a.m., Surveyor # spoke with CNA-A regarding Resident #3 and his blood sugar test procedures. CNA-A indicated she was familiar with Resident #3 and had worked at the facility for many years. CNA-A indicated Resident #3 prefers to conduct his blood sugar test at the small table in Pod 1. CNA-A further expressed staff are supposed to sanitize the table after Resident #3 is done. On 4/15/15 at 11:00 a.m., Surveyor # spoke with RN-G regarding the observation with Resident #3. RN-G expressed staff are expected to clean the table before and after Resident #3's blood sugar test for infection control purposes.

Based on record review and interview, the facility did not ensure the development of a comprehensive plan of care for 4 of 8 sampled residents with measurable goals and timetables to meet each resident's needs in terms of behaviors affecting others and themselves, and constipation. Resident #3 has no care plan developed for the need for [MEDICAL CONDITION] medications. Resident #7 has no care plan developed for her constipation, her recurrent vaginal infections, and self-isolating behavior. Resident #4 displays self injurious behaviors and verbal behaviors. The facility did not develop a care plan that included a measurable goal for the behaviors. Resident #1 has ongoing concerns about the amount of Vitamin C she receives, about staff needing to throw out her expired food items and the noise and activity of peers on her living area. Staff have not assisted Resident #1 in developing non-pharmacological approaches, approaches for self monitoring her food items and proactive coping strategies in dealing with these concerns. This is evidenced by: Example #1: Resident #3 has been a resident of the facility since [DATE]. His [DIAGNOSES REDACTED]. He receives [MEDICATION NAME] (an antipsychotic) and duloxatine (an antidepressant) on a daily basis. The [MEDICATION NAME] was last increased in [DATE] and the duloxatine was decreased in [DATE]. In addition, he receives 3 fiber laxatives twice daily and Clearlax daily for constipation. There is no plan of care developed for his constipation. There is no individual goal for regularity and no exploration of non-pharmacological interventions to relieve his constipation. The only treatment goal for his [MEDICAL CONDITION] drug use is that he will not have any adverse side effects from the drugs. A review of his current plan of care outlines one unmeasurable goal for treatment that has been unchanged since [DATE]: ~"Resident #3 will recognize when he is demonstrating inappropriate symptoms relating to his diagnosis." At no point are those "inappropriate symptoms" described in terms of what they are, how often they happen, and how these affect his quality of life and that of his peers. There are no individualized non-pharmacological approaches that address his needs and behaviors outlined in the plan of care. Example #2: Resident #7 has been a resident of the facility since 2003. Her [DIAGNOSES REDACTED]. She receives [MEDICATION NAME] (an antipsychotic) and [MEDICATION NAME] (an antidepressant) on a daily basis. The [MEDICATION NAME] was last increased in [DATE] and the [MEDICATION NAME] was increased on [DATE]. She also receives daily Clearlax and other as needed laxatives. She receives vaginal gel for recurrent vaginal infections. There is no plan of care developed for the need for laxatives and her apparent "... history of abusing laxatives." (progress note of [DATE]). There is no individual goal for regularity and no exploration of non-pharmacological interventions to relieve her constipation. There is no plan of care developed for her recurrent vaginal infections and treatment. She is currently using [MEDICATION NAME] gel on a daily basis. There are no non-pharmacological interventions outlined. The only goal for her [MEDICAL CONDITION] drug use is that she will not have any adverse side effects from the drugs. A review of her current plan of care found some goals for treatment related to her behavior that have been unchanged since [DATE]: ~"Resident #7 will come out of her room for 1 hour each afternoon." ~"Resident #7 will continue to attend counseling appointments regarding eating disorder." ~"Resident #7 will become involved in self care." ~"For social, interaction and motivational purposes, Resident #7 will answer questions during 1:1 visits." There are no individualized non-pharmacological approaches to her needs and behaviors outlined in the plan of care. Example #3: Resident #4 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #4's care plan, dated [DATE], included Behavior Symptom: "Specialized Services: Self Injurious Behavior..." Long Term Goal: "[DATE]: Will not have injury related to self harm." The care plan also included Behavior Symptoms: "Specialized Services: Has verbal behavior symptoms directed towards others..." Goal: "Resident #4 will be redirected by verbal prompts from staff when inappropriate." On [DATE] at 11:00 a.m., Surveyor # spoke with RN-G (Registered Nurse/Head Nurse) and the SW (Social Worker) of the unit regarding Resident #4's care plan for her behaviors. Surveyor # asked if Resident #4's behavioral goals are stated in a measurable manner to make decisions related to her medical and behavioral management. RN-G and the SW indicated the care plans do not state goals in a measurable manner, such as duration, frequency or severity, and the care plan does not have a quantifiable means of making decisions on the management of Resident #4's behaviors. Example #4: On [DATE] at 11:10 a.m., Surveyor # spoke with Resident #1. Resident #1 expressed that she wanted to receive more Vitamin C than she currently receives. Resident #1 said she receives 1000 milligrams and when she asks for more the staff show her information indicating that she is receiving an adequate amount. Resident #1 also expressed that another resident on her living area is sometimes verbally loud and snorts, and another resident swears and slaps her head. Surveyor # 's review of Resident #1's progress notes reveal staff entries of Resident #1 going to nursing and dietary staff about wanting more Vitamin C and then putting her fingers in her ears and throwing the written information given about the Vitamin C back at staff. In addition, the progress notes show entries of Resident #1 arguing with staff about throwing out her outdated food items from the refrigerator. On [DATE] at 8:50 a.m., Surveyor # observed Resident #1 arguing with staff about them throwing out her food from the refrigerator. Staff were observed to tell Resident #1 it was outdated and not safe to eat because of this. Surveyor # spoke with PT-D (Psychiatric Technician) on [DATE] at 9:00 a.m. PT-D indicated Resident #1 can become argumentative and yell and throw papers at staff when she is demanding something that they can't give her or doesn't like the answer they give her. PT-D also indicated Resident #1 will go to multiple staff to get the answer she wants. PT-D also indicated they had to throw out Resident #1's food from the refrigerator because it was not safe to eat as it was outdated. Surveyor # 's review of Resident #1's care plan received from facility staff on [DATE], does not reveal goals and approaches to address the repeated requests for more Vitamin C, individual coping strategies related to the noise that her peers make on her living area, and goals and approaches related to self monitoring of food items and use of the items before they become outdated.

Based on observations, interviews and record reviews, the facility did not ensure that 3 of 8 sampled residents' medication regimens were free from unnecessary medications due to inadequate monitoring of the effectiveness of the medications. Resident #4 received [MEDICATION NAME] (antipsychotic medication) 10 mg at bedtime and 37.5 mg injection on Mondays and [MEDICATION NAME] (antipsychotic medication) 4 mg a day for Paranoid [MEDICAL CONDITION]. Resident #4 received [MEDICATION NAME] (antianxiety medication) 1 mg three times a day and [MEDICATION NAME] 1 mg as needed 4 times a day for anxiety and agitation. Staff are to monitor Resident #4's self injurious behaviors (hitting self, slapping ears, pulling her hair and hitting pushing up on her jaw) and verbal behaviors directed towards others (threatening others, screaming at others and cursing others). Resident #4's behavior monitoring is not collected in a quantifiable manner in order to make decisions on the effectiveness of her medications. Residents #7 and #3 where given [MEDICAL CONDITION] drugs without adequate indications for use in terms of relieving the symptoms of individualized targeted behaviors. In addition, there is no monitoring of the effectiveness of the medication in terms of how often and how severe these symptoms are. This is evidenced by: Resident #4 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #4's physician orders [REDACTED]. ~[MEDICATION NAME]/[MEDICATION NAME] (antipsychotic medication) 10 mg at bedtime and 37.5 mg injection on Mondays. ~ [MEDICATION NAME] (antipsychotic medication) 4 mg a day for Paranoid [MEDICAL CONDITION]. ~[MEDICATION NAME] (antianxiety medication) 1 mg three times a day and [MEDICATION NAME] 1 mg as needed 4 times a day for anxiety and agitation. Resident #4's admission MDS (Minimum Data Set) assessment, dated 8/5/14, indicated: ~Physical behavioral symptoms directed towards others (hitting, kicking, pushing, scratching, grabbing, abusing others sexually)=0 (behavior not exhibited); ~Verbal behavioral symptoms directed towards others (threatening others, screaming at others, cursing at others)=0 (behavior not exhibited); and ~Other behavioral symptoms not directed towards others (physical symptoms such as hitting or scratching self, pacing, rummaging public sexual acts, disrobing in public, throwing or smearing food or bodily waste or verbal/vocal symptoms like screaming, disruptive sounds)=3 (behavior of this type occurred daily). Resident #4's MDS, dated [DATE], indicated: ~Physical behavioral symptoms directed towards others=0; ~Verbal behavioral symptoms directed towards others=1 (behavior occurred 1-3 days); and ~Other Behavioral symptoms not directed towards others=3. Resident #4's MDS dated [DATE] indicated: ~Physical behavioral symptoms directed towards others=0; ~Verbal behavioral symptoms directed towards others=1; and ~Other behavioral symptoms not directed towards others=1. Surveyor # reviewed Resident #4's care plan and noted the following: Behavior Symptom: Specialized Services: Self Injurious Behavior (hitting self, slapping her ears, pulls hair, hitting/pushing up on her jaw. Approaches: Redirect to a calm, quiet environment. Staff to reorient and redirect, offer alternate activities to keep hands occupied (lotion hands, offer to hold hands for comfort), staff to set limits and give positive feedback and praise. Behavior Symptoms: Specialized Services: Has verbal behavior symptoms directed towards others (threatening others, screaming at others, cursing at others). Approaches: convey an attitude of acceptance towards resident, explore with resident previous effective and ineffective coping mechanisms, maintain a calm environment and approach, offer time in room to cool down, encourage diversion activities which resident likes to do. Praise resident when behavior is appropriate, refocus conversation when resident becomes verbally abusive. Resident #4's nursing notes state the following data collection of behaviors: 07/2014: Other Behavior noted: 1 occasion. Verbal Behavior noted: 0 occasions. Physical Behavior noted: 0 occasions. 08/2014: Other Behavior noted: 9 occasions. Verbal Behavior noted: 0 occasions. Physical Behavior noted: 0 occasions. 09/2014: Other Behavior noted: 1 occasion. Verbal Behavior noted: 0 occasions. Physical Behavior noted: 0 occasions. 10/2014: Other Behavior noted: 11 occasions. Verbal Behavior noted: 1 occasion. Physical Behavior noted: 0 occasions. 11/2014: Other Behavior noted: 7 occasions. Verbal Behavior noted: 0 occasions. Physical Behavior noted: 0 occasions. 12/2014: No documentation. 01/2015: Other Behavior noted: 3 occasions. Verbal Behavior noted: 0 occasions. Physical Behavior noted: 0 occasions. 02/2015: Other Behavior noted: 3 occasions. Verbal Behavior noted: 4 occasions. Physical Behavior noted: 1 occasion. 03/2015: Other Behavior noted: 1 occasion. Verbal Behavior noted: 0 occasions. Physical Behavior noted: 0 occasions. 04/2015: Other Behavior noted: 1 occasion. Verbal Behavior noted: 0 occasions. Physical Behavior noted: 0 occasions. Surveyor # reviewed Resident #4's progress notes as it relates to behavior monitoring and noted vague narrative summaries of Resident #4's behavior. The entries do not indicate the severity of the behavior, the duration or non-pharmacological interventions tried and the outcome of each. The above data with no progress documentation does not provide a picture for a practitioner to make an informed decision on the effectiveness of medications. On 4/14/15 at 2:15 p.m., Surveyor # asked CNA-B about Resident #4's behavior. CNA-B indicated it is usual for Resident #4 to display self injurious behaviors. CNA-B further expressed the self injurious behavior has increased in the past few days. On 4/14/15 at 3:50 p.m., Surveyor # spoke with RN-G in regards to data collection of resident behaviors. RN-G indicated staff record all resident behaviors in progress notes. RN-G and the SW review the progress notes and present them to the psychologist for consultation visits. Surveyor # asked RN-G if the data is collected in a quantifiable manner such as frequency, duration of severity. RN-G responded, "No, it is not in black and white." Surveyor # asked RN-G what is reviewed when making decisions regarding medication effectiveness. RN-G explained the one-on-ones and PRN (as needed) medication use is looked at, not specific behaviors. On 4/15/15 at 11:00 a.m., Surveyor # again spoke with RN-G along with the unit's SW regarding Resident #4's approaches in her care plan to manage her behaviors and observations made by Surveyor # . RN-G and the SW indicated Resident #4's care plan does not contain measurable goals. RN-G and the SW further indicated the care plan directs staff to redirect Resident #4 when she is displaying these behaviors. Staff are to offer alternate activity, provide distraction and try different approaches. RN-G further expressed she has had to remind staff to intervene, indicating some staff are better at following these approaches than others. RN-G indicated staff who previously worked in the area serving individuals with intellectual disabilities were told in the past to ignore these behaviors. Surveyor # asked what information is used to make decisions regarding medication effectiveness. RN-G reiterated staff record behavior narratives in progress notes per behavior definitions in the MDS. RN-G indicated this data, along with staff reports of behavior and observations made on the unit, are used to make decisions about medications. RN-G further indicated some staff are better than others at recording the behaviors, noting she has had to address the lack of documentation at meetings with staff. On 04/16/15 at 10:00 a.m., Surveyor # spoke with Resident #4's guardian regarding behaviors and staff approach to the behaviors. The guardian indicated Resident #4's self injury and verbal behaviors have been long standing in various settings. The guardian further expressed that staff will sometimes offer a snack, talk to Resident #4 and attempt to redirect her when she is displaying these behaviors. The guardian indicated she had not seen staff redirect Resident #4 to a quiet setting or offer an activity when displaying these behaviors. The guardian further expressed Resident #4's behavior seems to get worse when a particular male resident gets loud. Example #2: Resident #3 has been a resident of the facility since December 2011. His [DIAGNOSES REDACTED]. He receives [MEDICATION NAME] (an antipsychotic) and duloxatine (an antidepressant) on a daily basis. The [MEDICATION NAME] was last increased in July 2013 and the duloxatine was decreased in December 2011. Review of his psychology consults dated 4/23/14, 6/18/14, 8/20/14, 1/14/15 and 3/25/15, indicate that his mood is stable, he has no hallucinations, no delusions, and his speech/communication is normal and at normal volume. The only treatment goal for his [MEDICAL CONDITION] drug use is that he will not have any adverse side effects from the drugs. A review of his current plan of care finds one unmeasurable goal for treatment that has been unchanged since July 2013: ~"Resident #3 will recognize when he is demonstrating inappropriate symptoms relating to his diagnosis." At no point are those "inappropriate symptoms" described in terms of what they are, how often they happen, and how these affect his quality of life and that of his peers. Review of the nursing progress notes documentation found little to no indications that staff are monitoring how often and to what severity these behaviors were. There was no ongoing documentation of these behaviors in order to determine if the medications he is receiving are effective. Documentation is sporadic for any behaviors but rejection of care. There has been no monitoring since 3/29/15 and blank for July, August, October, November, January and February. Review of the progress notes found some weekly notes that Resident #3 is social with staff and peers, enjoys sports, and participates in activities of choice. Example #3: Resident #7 has been a resident of the facility since 2003. Her [DIAGNOSES REDACTED]. She receives [MEDICATION NAME] (an antipsychotic) and [MEDICATION NAME] (an antidepressant) on a daily basis. The [MEDICATION NAME] was last increased in January 2014 and the [MEDICATION NAME] was increased in September 2013. Review of her psychology consults dated 5/21/14, 7/9/14, 9/17/14, 11/19/14 and 2/25/15, indicate Resident #7 is quiet/withdrawn, isolates herself in her room almost all day, refuses routine blood draws and cares, will not take phone calls from her family and repeats, "I don't want to talk about it," when asked for reasons and details of her feelings and actions. A review of her current plan of care found some goals for treatment that have been unchanged since May 2013: ~"Resident #7 will come out of her room for 1 hour each afternoon." ~"Resident #7 will continue to attend counseling appointments regarding eating disorder." ~"Resident #7 will become involved in self care." ~"For social interaction and motivational purposes, Resident #7 will answer questions during 1:1 visits." The only treatment goal for her [MEDICAL CONDITION] drug use is that she will not have any adverse side effects from the drugs. Review of the nursing progress notes documentation found little to no indications that staff is monitoring how often and to what severity these behaviors were. There was no ongoing documentation of these behaviors in order to determine if the medications she is receiving are effective. Documentation is sporadic for "rejecting care." There has been no monitoring since 2/20/15 and is blank for June, July, September, October (but 2 shifts), December and January (but 1 shift). There is no documentation for the goal of coming out of her room. Review of the progress notes found monthly notes indicating she "occasionally," or "often," will walk in the halls and continues to keep to herself but this is not quantitative.

Based on observations, record review and interviews, the facility did not ensure that 1 of 8 sampled residents received care and services per their written plan of care. Resident #4 has care planned behavioral approaches that direct staff to redirect to a calm environment and to offer alternate activities to keep her hands occupied when displaying self injurious behaviors. Resident #4 also has care planned approaches to maintain a calm environment, offer time in her room to cool down and encourage diversion activities when displaying verbal behavioral symptoms. Observations were made in which staff did not redirect to Resident #4 to a calm environment or offer diversional activities when Resident #4 was displaying these behaviors. This is evidenced by: Resident #4's care plan related to self-injurious behavior include approaches of, "Redirect to a calm, quiet environment, Staff to reorient and redirect, offer alternate activities to keep hands occupied (lotion hands, offer to hold hands for comfort), staff to set limits and give positive feedback and praise." The care plan for verbal behaviors include approaches of, "Convey an attitude of acceptance towards resident, explore with resident previous effective and ineffective coping mechanisms, maintain a calm environment and approach, offer time in room to cool down, encourage diversion activities which resident likes to do. Praise resident when behavior is appropriate, refocus conversation when resident becomes verbally abusive." On 4/14/15 from 11:40 a.m. until 12:40 p.m., Surveyor # observed the Pod 1 dining and living area. Resident #4 was sitting on a couch in the living area. At 11:57 a.m., Resident #4 was observed talking to herself and slapping herself on the side of the head. Resident #4 continued with loud self talk, rubbing her head vigorously and slapping her ear periodically. This behavior continued until 12:40 p.m. when Surveyor # exited the unit. CNA-B (Certified Nursing Assistant) was present in Pod 1 during the observation. No staff approached Resident #4 to attempt and assist with redirection of the behaviors. On 4/14/15 at 2:15 p.m., Surveyor # asked CNA-B about Resident #4's behavior. CNA-B indicated Resident #4's self injurious behaviors have increased in the past few days. On 4/14/15 at 3:30 p.m., Surveyor # again observed Resident #4 in the Pod 1 living area. Resident #4 was watching television with other peers. At 3:50 p.m., Surveyor # noted the unit noise level getting louder with another resident yelling in the living room. Resident #4 was then heard stating loudly, "You never shut up," and was observed slapping herself on the head. CNA-C approached the other resident who is sitting across the living room from Resident #4. Resident #4 states, "[***] ," and begins talking to herself. Resident #4 states, "You f***g s**t" and slapped herself on the head several times as CNA-C continued speaking to the other resident. Resident #4 continues talking to herself, slapping her head and vigorously rubbing her head and chin until 4:40 p.m. when CNA-B approached her and offered her a glass of juice. On 4/15/15 at 10:15 a.m., Surveyor # spoke with CNA-A regarding Resident #4's behaviors and approaches in management of the behaviors. CNA-A indicated she is familiar with Resident #4 and has worked at the facility for several years. CNA-A indicated it is important to redirect Resident #4 when she is displaying self injurious behaviors as they can become very severe. CNA-A expressed Resident #4 has caused facial bruising and broken her glasses by hitting herself in the head. CNA-A expressed Resident #4 often gets set off by another resident as she thinks he is making fun of her. CNA-A further indicated staff should redirect Resident #4, offer alternate activity, talk with her and hold her hand when she is displaying these behaviors. On 4/15/15 at 11:00 a.m. Surveyor # spoke with RN-G and the SW of the unit regarding Resident #4's care plan for her behaviors and the observations noted. RN-G and the SW indicated staff are to redirect Resident #4 when she is displaying these behaviors. Staff are to offer alternate activity, provide distraction and try different approaches in management of Resident #4's behaviors.

Based on observation and interview, the facility did not have the required resident information postings to include names, addresses, and telephone numbers of the State survey and certification agency, the Medicaid fraud control unit, a statement that the resident may file a complaint with the State survey and certification agency, information on how to apply for Medicaid benefits, the protection and advocacy network, and non-compliance with the advance directives requirements. This had the potential to affect all residents. This is evidenced by: On 04/15/15, Surveyor # toured the nursing unit and noted a 4' by 4' bulletin board in the hallway near the day room. The bulletin board contained a posting on Resident Rights, two posters for the Ombudsman Program, a posting regarding disability rights, and the most recent survey results. The bulletin board did not contain any information on the State survey and recertification agency, the Medicaid fraud control unit, a statement that the resident may file a complaint with the State survey and certification agency, information on how to apply for Medicaid benefits, the protection and advocacy network, and non-compliance with the advance directives requirements. On 04/15/15 at 1:20 p.m., Surveyor # interviewed the NHA (Nursing Home Administrator) regarding the above missing resident information. The NHA stated it was the responsibility of the Social Worker and the Administrative Assistant to ensure all postings were in place. The Surveyor asked if there was another location where these postings could be found and the NHA stated no.

Based on observation and interview, the facility had no postings regarding The Elder Justice Act for reporting suspicion of a crime. In addition, staff had no knowledge of this requirement. This has the potential to affect all residents. This is evidenced by: According to the Survey and Certification Memo 11-30-NH issued 06/17/11 and revised 01/20/12, the nursing facility is required to notify/educate employees of the reporting obligations when an employee suspects a crime was committed against a resident, post a notice for all employees regarding the reporting obligations and inform the employee the facility may not retaliate against the employee who reports a crime. On 04/15/15, Surveyor # toured the nursing unit and was unable to locate any posting regarding the Elder Justice Act or reporting suspicion of a crime. On 04/15/15 at 1:20 p.m., Surveyor # interviewed the NHA (Nursing Home Administrator) regarding the Elder Justice Act posting. The NHA stated the Social Worker or the Administrative Assistant was responsible for keeping the postings up-to-date. The Surveyor asked if there was another location where the postings would be. The NHA stated she would check with the Administrative Assistant and get back to the Surveyor. There was no additional information provided by the end of survey on 04/15/15. On 04/14/15 at 12:25 p.m., Surveyor # interviewed RN-F (Registered Nurse) who stated she had worked for Norwood for five years. RN-F stated she was unaware of any postings regarding the Elder Justice Act or reporting suspicions of a crime. RN-F stated she was unaware of her reporting obligations for reporting suspicion of a crime.

Based on interviews, the facility did not provide adequate bath linens to meet the needs of each resident. This has the potential to affect all residents. This is evidenced by: On 04/15/15 at 8:30 a.m., the survey team discussed staff complaints of short linen supplies on Sundays and Mondays. On 04/15/15 at 11:25 a.m., Surveyor # interviewed the Laundry Supervisor who stated she had worked at Norwood for four years. The Laundry Supervisor stated laundry staff work Monday through Friday and stock extra linen every Friday. The Laundry Supervisor stated during that four-year time frame, nursing staff had complained about not having enough wash cloths and towels on Sundays and Mondays. The Laundry Supervisor stated attempts had been made to fix the problem but not to the satisfaction of the nursing staff. The Laundry Supervisor stated she had allotted four towels and four wash cloths per resident per day. The Laundry Supervisor stated according to the budget "it was not feasible to provide more towels and wash cloths per resident per day." On 04/15/15 at 1:40 p.m., Surveyor # interviewed CNA-A (Certified Nursing Assistant) regarding linen supplies. CNA-A stated she works every other weekend and has been employed by Norwood for [AGE] years. CNA-A stated she had reported linen shortages numerous times over the past several years and there have been no changes. CNA-A stated on Sundays and Mondays staff are short wash cloths and towels. CNA-A stated staff are forced to wash residents using rags or disposable cloths or borrow from other units. CNA-A stated staff have been accused of stealing linens and supplies. On 04/15/15 at 1:45 p.m., Surveyor # interviewed CNA-D regarding linen availability. CNA-D stated she works every other weekend and linen shortages have been a problem every Sunday and Monday. CNA-D stated staff do not have enough wash cloths or towels for residents and residents have to wait on Mondays to get their shower when the supplies arrive. CNA-D stated staff had to use rags to wash residents or would have to borrow from other units.

Based on interviews and record review, the facility did not provide written notification of the facility's bed-hold policy to each resident and legal decision maker at the time of transfer to a hospital. This was found for 1 sampled resident. Resident #1 was transferred to the hospital on [DATE] for a respiratory illness. No written notification was given to Resident #1 or Resident #1's guardian/family member at the time of admission, or at the time of the transfer, to inform them of the facility's bed-hold policy. This is evidenced by: The facility's bed-hold and readmission policies in place at the time Resident #1's discharge (4/25/14) outlined that if hospitalization exceeded the 15 days of Medicaid payment "the resident may be admitted to Norwood long-term care units upon the availability of a semi-private room as long as the resident continues to need the care/services that Norwood Health Care Center is licensed to provide." This policy is dated 2/23/06. On 5/29/14, Surveyor # was given a revised policy dated 4/28/14 (3 days after Resident #1's discharge). At 1:20 p.m., the DON told Surveyor # that omitted on the copy given was the addition of "Norwood Health Center is licensed to provide and requires the services on a locked unit." Resident #1 has [DIAGNOSES REDACTED]. He was admitted to the facility on [DATE]. Resident #1 was protectively placed at the facility with the last Watts review of July 2013 indicating that he still needed placement there. (Watts review is when a guardianship and protective placement is ordered, the case does not disappear from the radar of the court. It must be reviewed every year to make sure that the placement is the least restrictive given the circumstances of the person. Every person under a guardianship and protective placement is entitled to an annual Watts review.) Surveyor # reviewed Resident #1's progress notes and found that on the evening of 4/9/14, he was assessed by RN-E (Registered Nurse) with symptoms of a respiratory infection, crackles in his lungs and an escalating temperature. The on-call physician was called and he was transferred, via a non-emergent ambulance, to the emergency room for monitoring and stabilization at 8:34 p.m. At 1:10 a.m. on 4/10/14, the hospital informed RN-E that Resident #1 was being admitted to the hospital. There is no evidence that the bed-hold paperwork was sent on with the resident. On 5/29/14 at 9:15 a.m., Surveyor # interviewed SW-B (Social Worker) about Resident #1's discharge. SW-B stated she was not working at the time Resident #1 was transferred on 4/9/14 and then subsequently discharged on [DATE]. SW-B stated there had only been 3 discharges from the unit in the past year and Resident #1 had been the only one to go to the hospital and stay that long. When asked if anyone had informed the guardian at the time or within 24 hours of Resident #1's transfer to the hospital, SW-B stated, "I don't believe so." She stated, "We should have, I know that now." On 5/29/14 at 2:48 p.m., Surveyor # interviewed G-A (Guardian) about his knowledge of the bed-hold policy at the facility. G-A stated Resident #1 had been a resident of the facility for [AGE] years and he was never made aware of any 15-day bed-hold policy. G-A stated he found out about Resident #1's discharge from the facility and the facility's decision to not take Resident #1 back, by the county social worker. It wasn't until he talked to SW-B 3 days after the discharge, that he was informed they would not be taking Resident #1 back because they said Resident #1 was now a "medical patient not a psych patient." G-A stated he had only one conversation with RN-F, the day after Resident #1 was taken to the hospital, to inform him of the transfer. G-A stated he received no phone calls or correspondences from the facility over the course of Resident #1's hospitalization until 4/25/14 when he was left a message to call back. G-A stated he assumed the call was to update him on Resident #1's condition at the hospital. G-A stated, "I felt that Norwood wanted to get rid of (Resident #1). He wasn't an easy one to take care of and they wanted to get rid of him. They found a door open and took it and didn't bother telling me. I told SW-B that I didn't care for the way Norwood handled it."

Based on interview and record review, the facility did not follow written policy to readmit a resident into an available room when his hospitalization exceeded the 15-day bed-hold policy under the state plan. This was found for 1 sampled resident. Resident #1 was not permitted to be return to his place of residence for the last [AGE] years as the facility had made plans to admit another resident (#3) in his place. This is evidenced by: Resident #1 has [DIAGNOSES REDACTED]. He was admitted to the facility on [DATE]. Resident #1 resided on a locked unit called Crossroads. Resident #1 was protectively placed there with the last Watts review of July 2013 indicating that he still needed placement there. (Watts review is when a guardianship and protective placement is ordered, the case does not disappear from the radar of the court. It must be reviewed every year to make sure that the placement is the least restrictive given the circumstances of the person. Every person under a guardianship and protective placement is entitled to an annual Watts review.) The facility's bed-hold and readmission policies in place at the time Resident #1's discharge (4/25/14) outlined that if hospitalization exceeded the 15 days of Medicaid payment "the resident may be admitted to Norwood long-term care units upon the availability of a semi-private room as long as the resident continues to need the care/services that Norwood Health Care Center is licensed to provide." This policy is dated 2/23/06. On 5/29/14, Surveyor # was given a revised policy dated 4/28/14 (3 days after Resident #1's discharge). At 1:20 p.m., the DON told Surveyor # that omitted on the copy given was the addition of "Norwood Health Center is licensed to provide and requires the services on a locked unit." Surveyor # reviewed Resident #1's progress notes and found that on the evening of 4/9/14, he was assessed by RN-E (Registered Nurse) with symptoms of a respiratory infection, crackles in his lungs and an escalating temperature. The on-call physician was called and Resident #1 was transferred, via a non-emergent ambulance, to the emergency room for monitoring and stabilization at 8:34 p.m. At 1:10 a.m. on 4/10/14, the hospital informed RN-E that Resident #1 was being admitted to the hospital. There is no evidence that the bed-hold paperwork was sent with the resident. On 4/10/14, nursing notes indicated RN-F and G-A (Guardian) spoke about Resident #1's hospitalization and trust account, however there is no evidence the 15-day bed-hold policy was discussed. Of note is that according to SW-B (Social Worker), the resident had $1,652.44 in his account at that time and the facility purchased for him a Roho brand wheelchair cushion and $300 of new clothes totaling $600. Resident #1 had $1,000 of personal assets. When surveyor asked SW-B about this money and whether it could have been used to continued the bed hold, SW-B stated she never thought of using these monies to pay for the extended bed-hold days. On Tuesday, 4/22/14, RN-F received a call from a case manager at the hospital asking if the facility would readmit Resident #1 as he was to get a PEG (Percutaneous Endoscopic Gastrostomy) tube. The hospital staff told RN-F the anticipated discharge date was in the next 2 to 3 days and information would be forthcoming on the supplies needed. Of note is that there is another resident on the unit with a PEG tube. On Thursday, 4/24/14 at 12:01 p.m., the DON wrote a note as a late entry notation recorded on 4/28/14 and edited by the DON on 4/29/14: The final version being re-timed and re-dated to read: "4/25/14 5:01 p.m. Notified by head nurse RN-G and SW-B that the hospital has informed us that Resident #1 has a sleep study and they are looking at placing him on a [MEDICAL CONDITION] or [MEDICAL CONDITION] related to these results and they are not sure which but he will for sure be in the hospital a least through the weekend. Originally Resident #1 was transferred for respiratory distress and had since received a peg tube and now needs to be on a bypap. Concerns in regards to him being on the bypap and the safety of this related to his constant coughing, especially when he cannot remove the mask were discussed. The hospital still do not have a definite discharge date . I notified RN-F that per medicaid his 15 day bed hold would be up today or yesterday and that we needed to remind the hospital and guardian of our need to discharge him due to that provision. Given the fact that Resident #1 appears to have more medical needs and that his bedhold will be expiring I suggested that they (hospital staff) look for alternative placement that better suites his needs. With his decline in medical condition and the lack of needing a locked unit he does not require our services and are not the least restrictive environment. Resident #1 is wheelchair bound, a 1-2 person transfer and does not have any behaviors needing a locked CMI SNF. RN-F will contact the hospital and guardian and inform them of our concerns. A call was placed to Monroe County social services where Resident#1's protective placement is managed and they were also informed of his change in needs and the elapse of his bed hold. Resident #1 will be discharged as of his last bed hold day and his continued medical needs in the hospital." The next entry is dated 4/25/14 when RN-G called CM-H to say that the resident's 15-day bed-hold had lapsed and that he had been discharged from the facility. RN-G stated his medical needs were more than they had been prior to his hospitalization . On 5/29/14/at 9:15 a.m., Surveyor # interviewed SW-B (Social Worker) about Resident #1's discharge. SW-B stated she was not working at the time Resident #1 was transferred on 4/9/14 and then subsequently discharged on [DATE]. SW-B stated there had only been 3 discharges from the unit in the past year and Resident #1 had been the only one to go to the hospital and stay that long. When asked if anyone had informed the guardian at the time or within 24 hours of his transfer to the hospital, SW-B stated, "I don't believe so." She stated, "We should have, I know that now." SW-B stated her understanding was that in addition to the bed-hold expiring, she was told by the DON, "His medical needs were exceeding his psych needs so he didn't need a locked unit." On 5/29/14 at 9:37 a.m., Surveyor # interviewed RN-G. RN-G stated she was not really involved in the decision making. She stated the DON had explained to her that with the PEG tube and [MEDICAL CONDITION], he was "not a good fit for the unit" and "better suited for a nursing home" and the unit was "not the least restrictive environment for him." RN-G stated, "We did the count and it was 15 (days) and his bed hold was up. I called the hospital to tell them the bed hold was up. I called and left a message for (G-A)." RN-G stated as far as making sure the bed hold information was given to the guardian, the facility had added it to the discharge information at the time of transfer to the hospital. Surveyor # interviewed CM-C (Case Manager) and SW-D at 10:50 a.m. CM-C stated that according to the hospital records, Resident #1's guardian wanted him to return to the facility. CM-C stated that on Tuesday a call was placed to the facility to RN-F to ascertain if the facility would accept him back with the PEG tube and was told yes. CM-D stated that once Resident #1 was medically cleared by his doctor, he would be discharged . CM-C stated that on 4/24/14 a call was placed that Resident #1 was nearing discharge to who was thought to be the same nurse that Resident #1 would be accepted for readmission on 4/26/14, Saturday. Of note is that both primary RN's in the unit have the same first name. In the mean time a sleep study was done and the Bi-pap was ordered. On 4/25/14 the hospital CM-H received a call at 3:10 p.m. that the 15 day bed hold was up and that Resident #1 had been discharged from the facility and would be better suited in a conventional nursing home. On 5/29/14 at approximately 1:20 p.m., Surveyor # interviewed the DON about the discussion to discharge Resident #1 and not take him back. The DON reiterated her concerns about the safety of Resident #1 returning with the [MEDICAL CONDITION] machine and it had been her experience that if a patient is not able to remove the machine by himself, he would require a one-to-one sitter and the unit was not equipped for that. Of note is that the facility had worked with a resident in the past who needed a C-Pap. The DON also stated there are residents on the unit who wander which could be a safety concern. The DON told Surveyor # the decision to "not take him back" was: 1. The bed hold was up. 2. Resident #1 didn't require the services of this unit. 3. There was someone else they needed to admit. When asked who needed to be admitted , the surveyor was told there were 2 patients in the facility's admission unit that needed to be admitted to the long term care unit. The DON stated Resident #3 was in the admission unit of the facility and needed to be admitted to the long-term care unit. Of note is that Resident #3 was not admitted to the unit until 5/2/14, 7 days after Resident #1 was discharged and after the time the hospital had anticipated discharging the resident. The DON stated the discussion to admit Resident #3 was going on at the same time the hospital was delaying the discharge of Resident #1 and there was no set time for the discharge. The DON expressed frustration about how long should the facility wait to readmit Resident #1 when Resident #3 needed their services and would benefit. On 5/29/14 at 2:48 p.m., Surveyor # interviewed G-A (Guardian) about his knowledge of the bed-hold policy at the facility. G-A stated Resident #1 had been a resident of the facility for [AGE] years and he was never made aware of any 15-day bed-hold policy. G-A stated he found out about Resident #1's discharge from the facility and the facility's decision to not take Resident #1 back by the county social worker. It wasn't until he talked to SW-B (Social Worker) 3 days after the discharge, that he was informed they would not be taking Resident #1 back because he was now a medical patient not a psych patient. G-A stated he had only one conversation with RN-F the day after Resident #1 was taken to the hospital to inform him of the transfer. G-A stated he received no phone calls or correspondences from the facility over the course of Resident #1's hospitalization until 4/25/14, when he was left a message to call back. G-A stated he assumed the call was to update him on Resident #1's condition at the hospital. G-A stated, "I felt that Norwood wanted to get rid of (Resident #1). He wasn't an easy one to take care of and they wanted to get rid of him. They found a door open and took it and didn't bother telling me. I told SW-B that I didn't care for the way Norwood handled it."

Based on observations, staff interviews, and record review, the facility did not prepare and store food under sanitary conditions for all 16 of the Norwood Crossroads residents. The facility kitchen was observed to 1) have peeling paint on the ceiling in the dish room, dust on the fan in the dish room and on a large wall fan in the food service area, and dust on the ceiling in the dish room, and 2) C-C (Cook) did not initiate hand hygiene at appropriate intervals and did not ensure his beard was in an appropriate hair restraint. This is evidenced by: Surveyor # observed, on 05/05/14 starting at 11:40 a.m., C-C (Cook) behind the food service counter without a beard restraint during the lunch meal in the main dining room in the facility. 7 Cross Roads residents were observed to come into the main dining room to get their lunch meal and eat it in the main dining room. On 05/06/14 from 6:50 a.m. through 9:00 a.m., Surveyor # observed C-C in the facility kitchen preparing food for the lunch meal and serving the breakfast meal for all of the Cross Roads residents without a beard restraint. On 05/06/14 at 6:53 a.m., Surveyor # observed C-C answer the phone in the kitchen with his bare hands. C-C then hung up the phone and came around to the food preparation area and put disposable clear gloves on his hands without first washing his hands. C-C then pushed a small black cart into the food service area and returned to the sink area where cans of tuna fish were on the counter. A metal strainer was in the area in a pan. C-C, with the same gloved hands, proceeded to take the lids of the cans and scoop the tuna into the strainer with his gloved hands. C-C indicated the tuna was for a tuna pasta salad that was the lunch alternate for the residents. After scooping the tuna fish out of the cans into the strainer, C-C took the sprayer and sprayed out the tuna cans. This was done in close proximity to the tuna fish that was in the strainer. After completing this task, C-C then removed his gloves and went over to the handwashing sink and washed his hands. C-C did not have a beard restraint on. On 05/06/14 from 7:12 a.m. through 7:22 a.m., Surveyor # observed C-C and DA-D (Dietary Aide) serve the breakfast trays for all of the Crossroads residents on the unit and the residents that came to the main dining room. During this time, C-C did not have a beard restraint on. On 05/06/14 at 8:55 a.m., Surveyor # spoke with C-C. C-C said he washes his hands when he comes into the kitchen, before putting on gloves and after taking off gloves, and when moving between the clean and dirty sides in the kitchen. C-C was asked about the beard restraint. C-C said no one has ever said anything to him about a beard restraint. On 05/06/14 between 6:50 a.m. and 9:00 a.m., Surveyor # observed a large wall fan in the food service area with dust on it. Dust was also observed hanging down from the ceiling tiles on the clean dish side in the dish room. Peeling paint was observed on the drop ceiling brackets in the dish washing room and one drop ceiling tile on the clean dish area of this room had peeling paint. Surveyor # also observed a fan in the dish room on the clean dish area with dust on it. At 9:00 a.m., Surveyor # spoke with DA-D. DA-D said the maintenance department cleans the ceiling fans and the dietary department is responsible for cleaning the smaller portable fans. DA-D said they have a schedule for cleaning in the kitchen. DA-D showed Surveyor # the cleaning schedule. DA-D received a copy of the Monthly Cleaning Schedule for April 2014 from DA-D. The area for the small fans was blank. On 05/06/14 at 12:15 p.m., Surveyor # spoke with DS-A (Dietary Supervisor). DS-A said staff are to wash their hands before putting on gloves and after taking them off, when coming into the kitchen, after going to the bathroom, when moving between dirty and clean areas in the kitchen and moving between dirty and clean tasks. DS-A was asked about hair and beard restraints. DS-A said staff are required to wear hair restraints (nets) but they have never had C-C wear a beard restraint. DS-A was asked about the cleaning schedule for the fans. DS-A said maintenance does the large ones and the dietary staff are responsible for the smaller ones.

Based on observation, interview, and record review, the facility did not ensure that each resident was given help to restore as much bladder function as possible. This was found for 1 of 1 resident reviewed with urinary incontinence. The facility did not complete a comprehensive assessment of Resident #2's bladder habits and did not develop an individualized toileting plan. This is evidenced by: According to WOCN (Wound Ostomy and Continence Nurses Society), reversible causes of incontinence include: [MEDICAL CONDITION], infection, medications, bladder irritants, vaginitis, pharmaceuticals, polyuria, retention, constipation, environmental barriers, and physical limitations. Assessment of these factors is needed to determine a plan of care that could include bladder retraining, prompted voiding, and individualized scheduled toileting. This individualized schedule should be used rather than the facility's incontinence management toileting schedule currently being used for all cognitively impaired and incontinent residents who are unable to communicate with staff that they have to go to the bathroom. The outcome of incontinence services can be determined by recognition of the problem, nursing assessment, and referral for diagnostic evaluation and treatment. All residents with incontinence should be evaluated for causative factors, as treatment is dependent on these factors. However, before successful treatments can be initiated, the problem needs to be identified. The identifying of the type of incontinence is essential in a multidisciplinary collaboration for both the assessment of the individual and the treatment of [REDACTED]. The goal should be to restore as much normal bladder function as possible for each resident by decreasing or eliminating the incontinent episodes. This promotes dignity, reduces risk factors for skin breakdown, and reduces the incidents of urinary tract infections. Resident #2 has been a long time resident of the facility. His [DIAGNOSES REDACTED]. Resident #2 was recently hospitalized in April 2014 for pneumonia and [DIAGNOSES REDACTED]. When he returned, a 3-day bladder diary was used to assess his urinary incontinence. The assessment indicated Resident #2 was incontinent but no changes would be made to the plan of care. Review of his MDS (Minimum Data Set) assessments of 8/16/13 and 2/16/14, indicated he is occasionally incontinent of urine and is currently on a toileting program. Review of Resident #2's plan of care found no toileting plan. The care plan dated 12/4/13 and updated on 3/4/14 states: ~"Resident #2 has occasional urinary incontinence related to decreased mobility, cognitive impairment, and [DIAGNOSES REDACTED]. The approaches are: ~"Assist Resident #2 to restroom when he requests. ~"Monitor skin for any areas of redness and update nurse." ~"When Resident #2 has incontinent episode, assist, provide him with incontinence cares and a fresh change of clothing." There is no individualized toileting plan outlined for the staff even though the MDS states he is on a toileting program. Under the plan of care for "Behavior Symptoms" due to "urinating in public places," the goal is to reduce these incidents to once a week. The approach is for staff to divert this behavior by intervening when they notice he is about to do so and assist him to the restroom and stress the appropriate places to urinate. On 5/5/14 at 10:06 a.m., during initial tour of the facility with RN-B (Registered Nurse), Resident #2 was observed by Surveyor # standing outside the shared resident bathroom, in front of the cabinets. He was holding onto his walker and had observed that another resident currently occupied the bathroom. He began to pound on the counter top below the cabinets and then grabbed a hold of his walker and urinated on the floor through his shorts. RN-B observed the behavior and called the housekeeper to the area from down the hall. On 5/5/14, Surveyor # observed Resident #2 ambulate about the unit with his wheeled walker from 11:20 a.m. to 12:35 p.m. At 12:12 p.m., Resident #2 went to the restroom and slammed the door. The surveyor overhead several flushes almost immediately upon entering the room and Resident #2 came out shortly thereafter. There was no staff intervention. On 5/7/14 at 9:00 a.m., Surveyor # interviewed CNA-E (Certified Nursing Assistant) about Resident #2's toileting plan. CNA-E reviewed the plan of care in the binder on the unit and it had the same information as above. CNA-E stated staff "did a 3-day" (data collection), but there had been no changes to the care plan. CNA-E stated staff remind Resident #2 to use the bathroom every 2 hours. CNA-E stated since Resident #2 came back from the hospital "he is always incontinent and he wears a (disposable) brief now." On 5/7/14 at 10:30 a.m., Surveyor # interviewed RN-B about toileting plans in general and the plan for Resident #2. RN-B stated the facility is reviewing the facility's current Continence Management policies and procedures in order to individualize the programs for each resident.

Based on observation, staff interview, and record review, the facility did not develop care plans for 1 of 8 sampled residents. Resident #4 was admitted on [DATE], with a [DIAGNOSES REDACTED]. Review of Resident #4's physician orders [REDACTED]. Resident #4 does not have an individualized care plan for this. This is evidenced by: Surveyor # 's review of Resident #4's medical record revealed an admission order dated 10/02/13, which indicated a 2000 cc fluid restriction due to Polydipsia. Review of Resident #4's current physician order [REDACTED]." Review of Resident #4's current 9 page care plan with a last care conference date of /14, does not include a care plan for Polydipsia. Review of Resident #4's fluid intake records revealed that on 01/15/14, 01/18/14, 02/16/14, 03/04/14, 03/25/14, 04/16/14, 04/18/14, 04/22/14 and 04/30/14, Resident #4 exceeded his 2000 cc fluid restriction. Review of Resident #4's psychiatric progress note on 01/08/14, indicated under mood and behavior that Resident #4 is drinking constantly. The 03/12/14 psychiatric progress note under mood and behavior indicate Resident #4 is still drinking. During the days of the survey (05/05/14, 05/06/14, and 05/07/14), Surveyor # observed Resident #4 independently ambulating throughout his living environment and in his room. Water sinks were observed in the living area and in Resident #4's room. On 05/06/14 at 2:50 p.m., Surveyor # spoke with RN-B (Registered Nurse/Head Nurse). RN-B was asked why Resident #4 was on a 2000 cc fluid restriction. RN-B indicated she thought it was because of SIADH (Syndrome of Anti Diuretic) but she would have to check further on this. RN-B was asked if Resident #4 had an individualized care plan for this. RN-B reviewed Resident #4's care plan and said Resident #4 did not have a care plan for this. At 3:00 p.m., RN-B indicated to Surveyor # that Resident #4 was on the fluid restriction due to Polydipsia.

Based on observation, record review, and interview, the facility did not ensure that each resident's fall was comprehensively reviewed in order to determine the cause of the fall, determine effectiveness of current approaches to reduce falls, and explore options and approaches to prevent a future fall. This was discovered for 1 of 2 sampled residents reviewed with falls. Resident #1 has had 7 falls over the last 8 months, (4 of those falls occurring in the month of April 2014) without any changes to the plan of care until 4/21/14. On 4/21/14, Resident #1 fell and hit her head and was sent to the ER (emergency room ). Blood work and CT (Commuted Tomography) scan on 4/21/14 found nothing significant and she returned. The nursing notes state a new floor alarm was instituted and an alarm was moved on 4/21/14. However, the plan of care was not updated after this fall event. This is evidenced by: Resident #1 was admitted to the facility in January 2013. Her [DIAGNOSES REDACTED]. Surveyor # reviewed the MDS (Minimum Data Set) assessments dated 4/26/14 and 1/24/14. The MDSs indicate Resident #1 has had an increase in her falls over the last quarter. Resident #1's plan of care for fall prevention is dated 9/26/13, and states she is at risk for falls but does not identify possible reasons why. The goal is that she is "free from falls daily." The approaches are: ~11/3/13 - Escort to and from bathroom at night. ~9/26/13 - Assess medications per policy. ~9/26/13 - Educate Resident #1 regarding seizures. ~9/23/13 - Educate on safety and awareness. Educate on need to use call light to ask for assistance. ~9/23/13 - Reorient Resident #1 on surrounding environment. Resident #1 has a night light in her room. Resident #1 is on 5-minute checks at night. Make sure bed and floor alarms are on and in good working order. ~4/24/13 - Patient is to be stand by assist while ambulating and be reassessed in one month. Surveyor # reviewed the following incident reports: ~9/30/13. The report indicated Resident #1 had tuned off her alarm at 4:00 a.m. and fell in the bathroom. There were no changes to the care plan interventions. The resident was educated not to turn it off. ~10/10/13. The report indicated the alarm sounded at 12:30 a.m. as Resident #1 stood up out of bed and fell . The approaches continued and she was reminded to use the call light. ~3/16/14. The report indicated Resident #1's roommate alerted staff at 2:00 a.m. that Resident #1 had fallen. Resident #1 was found in her room in the middle of the floor. The report states she can turn off her alarm. There was no change to the plan of care. ~4/8/14. The report indicated Resident #1's roommate again alert staff at 9:51 p.m. that Resident #1 had fallen and hit her head on her night stand. The night stand was moved and again Resident #1 was educated not to turn off her alarm. ~4/13/14. The report indicated Resident #1 fell in the day room at 9:00 p.m. The current care plan was "deemed appropriate." ~4/21/14. The report stated staff in the day room heard Resident #1 up at 2:45 a.m. Resident #1 had again turned off her alarm and fell and hit her head on the floor. Ice was applied to her head and pressure applied for a nose bleed. She was sent to the ER to rule out a stroke. Tests at the hospital found nothing significant. The alarm box was moved and a floor alarm was placed. ~4/24/14. The report stated Resident #1 fell in the bathroom at 2:25 p.m. It was at that time when the plan of care was changed to include stand by assist. The was changed on 4/25/14 to be only if Resident #1 allowed it. Observations throughout the survey of 5/5/14 to 5/7/14, found Resident #1 to ambulate independently at all times. Her gait was slow with exaggerated purpose. On 5/7/14 at 10:30 a.m., Surveyor # interviewed RN-B (Registered Nurse)and the SW (Social Worker) about the facility's fall prevention program and procedures. RN-B and the SW stated they had a conversation with Surveyor # the previous day and recognized "room for improvement" in their current processes. The staff members stated the nurse on the unit was responsible to assess for injuries and implement interventions such as routine checks or the addition of alarms to try to prevent a subsequent fall. They also stated the SW would then review each fall to see if staff error could have been the cause of the fall. The SW and RN-B stated medications are reviewed with the resident's psychiatrist in relation to falls every other month. RN-B and the SW stated missing in their previous follow-ups after a fall was a root cause analysis in order to identify an intervention. RN-B stated her and the SW were just reviewing one in which they had identified that in their investigation that a resident fell due to not being able to reach the garbage can while on the recliner. They stated the root cause of the fall led to staff simply ensuring that a garbage can was next to the recliner.

Based on observation, interviews, and record review, the facility did not maintain an effective infection control program. Percentages of different types of facility-acquired infection rates were not being calculated on a timely basis to monitor the trend of those infection rates within the facility. Residents were not afforded an opportunity to wash/sanitize their hands prior to meals. The practice had the potential to affect all residents residing in the facility. This is evidenced by: Example #1: On 5/23/13 at 7:45 a.m., Surveyor # reviewed the facility line lists for resident infections for the past 3 months. Noted on the bottom of each monthly line list were the number of each type of infection (ex. eye, respiratory, urinary tract, etc.) for that month. Identified was an Influenza outbreak on 1/2013. There was no indication that the individual types of infections had percentage rates calculated on a monthly basis. On 5/23/13 at 8:00 a.m., Surveyor # interviewed the ICP-C (Infection Control Preventionist) who works mainly in the hospital unit. ICP-C stated LPN-D has been working under her for the past year for Crossroads and Pathways (2 different entities in the building). ICP-C stated surveillance rates should be done quarterly and she does those in the hospital. ICP-C stated LPN-D will be doing Crossroads and Pathways when she learns how. On 5/23/13 at 8:15 a.m., Surveyor # interviewed LPN-D who stated her training consisted mostly from the ICP and one training session on Infection Control at Wisconsin Dells last fall. LPN-D stated she was not trained or told how to calculate the percentage rates on a monthly basis. Example #2: On 5/22/13 at 7:30 a.m., Surveyor # observed meal service for breakfast on the Crossroads Unit. Staff transported residents to the dining room, prepared resident meal trays and assisted residents with dining. At no time during the observation were staff observed to offer handwashing to residents. On 5/22/13 at 11:50 a.m., Surveyor # observed meal service in the cafeteria for 8 residents from the Crossroads Unit. Staff served residents from a dining cart, prepared resident meal trays and assisted residents with lunch. Residents were not provided hand hygiene in the cafeteria prior to eating. On 5/23/13 at 7:30 a.m., Surveyor # observed breakfast on the Crossroads Unit. Residents were served a breakfast tray from a cart by Psych. Techs CNA-E and CNA-A (Certified Nursing Assistants). Residents were not provided hand hygiene prior to eating. On 5/23/13 at 8:20 a.m., Surveyor # interviewed CNA-E. Surveyor # asked CNA-E if residents are offered handwashing prior to eating. CNA-E responded, "Not usually, unless they ask for something." On 5/23/13 at 9:30 a.m., Surveyor # met with RN-I and the DON regarding the expectation of resident handwashing prior to eating. The DON responded residents should have the opportunity to wash hands prior to eating. On 5/23/13 at 11:15 a.m., Surveyor # interviewed CNA-A. Surveyor # asked CNA-A if residents are offered handwashing prior to eating. CNA-A responded, "Not usually before meals. Handwashing is done with cares when they get up." Surveyor # asked CNA-A if any hand sanitizer, wipes or handwashing is offered prior to eating. CNA-A responded, "No." On 5/23/13, Surveyor # requested the facility policy for resident handwashing from the DON. The DON provided a policy on handwashing in which resident handwashing was not addressed.

Based on observations, record reviews and interviews, the facility did not ensure that 3 out of 4 sampled residents reviewed for incontinence received care and services designed to maintain or restore as much bladder function as possible. Resident #1, #2, and #7 had declines in bladder function. The facility did not comprehensively assess the cause of the declines in bladder function, did not monitor the residents' usual voiding patterns, did not identify the types of incontinence, did not implement an individualized toileting plan, did not develop care plans to improve bladder function, and did not explore reversible causes of incontinence in order to assist each resident with restoring or maintaining as much bladder function as possible. The facility does not have a procedure for bladder function and assessments and does not have a data collection tool for determining voiding patterns and identifying incontinence types. This could affect all residents at the facility. This is evidenced by: According to WOCN (Wound Ostomy and Continence Nurses Society), reversible causes of incontinence include: [MEDICAL CONDITION], infection, medications, bladder irritants, vaginitis, pharmaceuticals, polyuria, retention, constipation, environmental barriers, and physical limitations. Assessment of these factors is needed to determine a plan of care that could include bladder retraining, prompted voiding, and individualized scheduled toileting. This individualized schedule should be used rather than the facility's incontinence management toileting schedule currently being used for all cognitively impaired and incontinent residents who are unable to communicate with staff that they have to go to the bathroom. The outcome of incontinence services can be determined by recognition of the problem, nursing assessment, and referral for diagnostic evaluation and treatment. All residents with incontinence should be evaluated for causative factors, as treatment is dependent on these factors. However, before successful treatments can be initiated, the problem needs to be identified. The identifying of the type of incontinence is essential in a multidisciplinary collaboration for both the assessment of the individual and the treatment of [REDACTED]. The goal should be to restore as much normal bladder function as possible for each resident by decreasing or eliminating the incontinent episodes. This promotes dignity, reduces risk factors for skin breakdown, and reduces the incidents of urinary tract infections. The Long-Term Care Nursing Desk Reference states, " ... Incontinence is not a normal consequence of aging and can frequently be cured or improved. Many treatable problems contribute to incontinence. Some residents have several coexisting problems, and to successfully manage the incontinence, all must be identified and treated... Remember that the sensation of needing to use the toilet is one of the last to be lost in cognitively impaired residents. Their problem is often one of communication. They are unable to communicate the need to use the bathroom...Most believe that toileting residents every two hours is the best means of keeping them dry, when in fact this is a dated and ineffective method..." On [DATE] at 4:35 p.m., Surveyor # interviewed the DON (Director of Nurses) regarding the facility's procedure for bladder function and assessments. The DON stated the facility did not have a policy for bladder assessments. The Surveyor asked how the facility gathers data on voiding patterns. The DON stated the facility does not have a data collection tool for voiding patterns. The Surveyor asked how the facility determines what type of incontinence a resident may have. The DON stated she was unfamiliar with incontinence types. The Surveyor stated the types of incontinence discussed in the State Operations Manual and the DON continued to be unfamiliar with these terms. The DON stated residents who are incontinent are on either an every 1 hour or 2 hour toilet schedule. On [DATE] at 9:30 a.m., Surveyor # interviewed the DON (Director of Nursing) about the facility's incontinence program in order to restore as much continence as possible. The DON stated there is "no formal policy." She stated that in the past year, the facility has incorporated an incontinence screen for all residents. She stated information is "sketchy" as they rely on information from the residents, the family, or hospital. The information centers around if the resident is incontinent or not. The DON stated RN-H (Registered Nurse) will see if the resident is incontinent and communicates the toileting schedule to the "techs (Certified Nursing Assistants)." Example #1: Resident #1 was admitted to the facility on [DATE] with the most current readmission on [DATE]. Resident #1 has the following, but not all inclusive, Diagnoses: [REDACTED]. The facility completed an annual MDS (Minimum Data Set) assessment for Resident #1 on [DATE], with the following data noted: ~able to make self understood and understand others; ~required limited assistance with toilet use; and, ~continent of bladder and not on a toilet program. The facility completed another annual MDS assessment for Resident #1 on [DATE], with the following declines noted: ~usually able to make self understood and usually able to understand others; ~occasionally incontinent of bladder (7 or more episodes of urinary incontinence) and not on a toilet program. Review of the medical record noted an incontinence assessment dated [DATE], which indicated Resident #1 was incontinent of bladder. Reason for incontinence was known; however, the explanation was left blank, no pattern was identified, it noted dribbling and confusion, and to use a prompted voiding program. Review of the care plan for Resident #1 with a start date of [DATE], and titled "ADL (activities of daily living) Care," had a goal that read, "To enhance and promote optimal level of additional function during goal dated periods." The goal date was [DATE]. Neither the problem statement nor the goal referenced any bladder function for Resident #1. The approach for this problem read that when Resident #1 needs to use the restroom she requires a 1 person assist transfer. Surveyor # completed a comprehensive record review and noted no identification by the facility of the decline in bladder function for Resident #1, as well as no facility intervention or plan to determine the cause of the decline in bladder function. On [DATE] at 4:40 p.m., Surveyor # observed CNA-D (Certified Nursing Assistant) assist Resident #1 into bed and remove the incontinent brief. CNA-D stated Resident #1 was both continent and incontinent and wore an incontinent brief. On [DATE] at 9:18 a.m., Surveyor # interviewed CNA-A regarding Resident #1's bladder function. CNA-A stated Resident #1 will ask for help to use the toilet. CNA-A stated Resident #1 was usually continent, but did have some episodes of incontinence. On [DATE] at 4:15 p.m., Surveyor # interviewed CNA-B regarding Resident #1's bladder function. CNA-B stated Resident #1 was on an every 2 hour toilet schedule and also Resident #1 would ask for help to use the toilet. CNA-B stated Resident #1 was usually continent of bladder, but did have some incontinence episodes as well. Example #2: Resident #2 was admitted to the facility on [DATE] with the most recent readmission on [DATE]. Resident #2 had the following, but not all inclusive, Diagnoses: [REDACTED]. The facility completed an annual MDS for Resident #2 on [DATE] and noted the following: ~sometimes able to make self understood and understand others; ~impaired short and long term memory; ~severely impaired daily decision making skills; ~signs of [MEDICAL CONDITION] (inattention, disorganized thinking, altered level of consciousness, and psychomotor [MEDICAL CONDITION]) that were continuously present; ~required total staff assistance for bed mobility, transfers, locomotion on/off unit, eating, toilet use, hygiene , dressing, and bathing; ~did not ambulate; ~had impairments on both sides for upper extremity range of motion; ~had impairments on one side for lower extremity range of motion; ~was frequently incontinent (7 or more episodes or incontinence, but at least one episode of continent voiding) of bladder and was on no toilet program. Review of the urinary incontinence CAA (Care Area Assessment) summary, which was triggered for Resident #2 due to bladder incontinence and needing total staff assistance for toilet use, was not completed. The facility completed a quarterly MDS assessment for Resident #2 on [DATE] and noted the following changes: ~was always incontinent of bladder and was on a toilet program. The facility completed an "Incontinence Assessment" for Resident #2 dated [DATE]. The assessment noted Resident #2 was incontinent at times. The reason for the incontinence was "confusion, old age, delusional" and the resident does not feel the urge to void. The assessment did not identify a pattern. The assessment also noted a toileting schedule and the use of absorbent products. The assessment does not identify the type of incontinence or the individualized toileting schedule to be implemented. Review of the comprehensive care plan for Resident #2 titled "Medical Management General Health" which was developed on [DATE] with an expired goal date of [DATE], had a goal of "Optimal physical functions as demonstrated by monitoring and diagnostic values during goal dated periods." There was no mention of bladder incontinence, type of incontinence, toileting program, or assistance needed for toilet use. Review of an additional comprehensive care plan titled "Medical Management Rashes and Potential for Alteraction (sic) in Skin Integrity" which was developed on [DATE] with an expired goal date of [DATE], noted an approach to assist Resident #2 with toilet use every 2 hours and as needed. There was no mention of the type of incontinence Resident #2 had or the individualized care approaches. Review of the CNA care guide for Resident #2 noted incontinent of bladder and bowel, assist to bathroom. There was no toileting program or toileting schedule. On [DATE] at 1:35 p.m., Surveyor # observed CNA-A and CNA-B assist Resident #2 onto the commode. Resident #2 was incontinent of bladder and received incontinence care from CNA-B. On [DATE] at 4:15 p.m., Surveyor # interviewed CNA-B regarding Resident #2's toilet program. CNA-B stated Resident #2 was toileted every 2 hours and was "always" incontinent. Example #3: Resident #7 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. Resident #7's Minimum Data Set ((MDS) dated [DATE] indicated Resident #7: ~Had a moderate cognitive impairment; ~Required limited assistance of 1 staff person for bathing, dressing, grooming, and toileting; and, ~Was occasionally incontinent of bladder. Surveyor # completed a review of Resident #7's MDS dated [DATE]. This indicated that Resident #7 was always continent. This indicates a decline in bladder function. There was no bladder assessment completed to determine the cause of the decline in attempts to restore continence. On [DATE] at 1:20 p.m., Surveyor # spoke with the Director of Nursing (DON). The DON indicated they were unable to find a bladder assessment completed around the noted decline in Resident #7's bladder function.

Based on interviews and record review, the facility did not ensure that 1 of 8 sampled residents was free from abuse including involuntary seclusion. The facility houses 3 separate entities: a nursing home, a [MEDICAL CONDITION] unit, and an acute in-patient psych (phychiatric) unit. Many staff float between all 3 units. It is facility practice for the staff in the in-patient psych unit to utilize 4-point restraints and a seclusion room. It is the facility practice for staff in the nursing home to utilize a "time out" of sorts when a resident's behaviors escalate. Residents are requested to go to their room. There is supposed to be no physical contact involved. Resident #7 resides in the nursing home. On multiple occasions, Resident #7 had been escorted to her room by force and against her will by 2 or more staff. This constitutes physical and mental abuse as well as involuntary seclusion in the forcible act of bringing Resident #7 to her room. Staff in the facility were aware and had witnessed Resident #7 being taken to her room by force, however, did not consider it abuse. This is evidenced by: Surveyor # completed a review of Resident #7's clinical record and noted the following. Resident #7 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. Resident #7's Minimum Data Set ((MDS) dated [DATE], indicated Resident #7: ~Had a moderate cognitive impairment; ~Inattention that fluctuated; ~No mood indicators; ~Verbal behavioral symptoms directed toward staff which did not occur daily; ~Required supervision and setup help for transfers, walking, and eating; ~Required limited assistance of 1 staff person for bathing, dressing, and grooming; and, ~Had no falls. Resident #7's psycho-social/mood and behavior care plan dated 3/4/09 had the following approaches: ~ 3/8/12, "...Provide gentle verbal guidance to change the topic or redirect..." ~ 3/8/12, "...Engage resident in social conversation..." ~ 3/8/12, "...If...becomes agitated attempt distraction with another task...or provide quiet time in her room and re-approach later..." ~ 3/8/12, "...Encourage...participation in daily activities..." ~ 3/8/12, "...Assess if the behavioral symptoms present a danger to Resident #7 and/or others. Intervene as needed..." The facility utilized a form titled "Mood Observation Flow Sheet." Surveyor # completed a review of the form from 3/11/12 through 4/7/12. Resident #7 was noted to have mood symptoms present on 6 of the 28 days. Surveyor # completed a review of Resident #7's nursing notes and noted the following: ~ 3/28/12, "...upset because...didn't receive her $5 that she usually gets....became very upset and was yelling and threatening staff...tried to calm...redirect...without success...became upset to the point that...was asked to go to her room. She refused and required a 2 person escort to her room...She then became physically aggressive...was kicking, grabbing, scratching, and trying to spank staff...required 3 physical escorts to her room and a prn (as needed) was given by the nurse..." This charting indicated that when Resident #7 did not want to go to her room, Resident #7 was then bodily taken there by 3 staff members against her will. This constitutes both physical and mental abuse in both the act of force in getting Resident #7 into her room, as well as secluding Resident #7 to her room against her will. Nursing notes continue: ~6/7/11, "...has...become aggressive on a couple of occasions when staff offered her H2O (water) in between snack Xs (times) instead of giving her a soda or juice. On these occasions...had to be escorted to her room by 2 staff..." ~7/21/11, "...After...given...1400 (2:00 p.m) soda...demanded she be given more...Staff once again explained her fluid monitoring...and needed to be followed...was informed she could not have any more soda until the next snack time...offered her a med cup of H2O...ran up to the nurse and spanked her twice on the butt...was escorted by 3 staff to her room to calm down..." ~7/31/11, "...Staff had just given Resident #7 her 1400 soda when a half hour later she asked for more.. Staff had already explained to her numerous times that the next time she could have soda would be 1900 (7:00 p.m.)...Resident #7 grabbed staff's wrists, digging her nails into the skin...Three staff escorted her to her room..." ~9/24/11, "...yelling loudly insisting on having more soda, staff redirected...could not have more because of her fluid restriction...began to yell and point @ (at) staff, staff two escorted...to her room..." On 5/2/12 at 9:20 a.m., Surveyor # spoke with Certified Nursing Assistant (CNA)-F. CNA-F indicated she had worked in the facility for the past [AGE] years. CNA-F also indicated that she floats to all the different units within the facility. Surveyor # asked CNA-F about Resident #7's behaviors and the practice of staff escorting Resident #7 to her room. CNA-F indicated when Resident #7's behaviors escalate, it takes more than 1 staff person to get her to her room. CNA-F indicated staff take Resident #7's wrist in one hand and place their other hand under Resident #7's arm pit. On 5/2/12 at 11:45 a.m., Surveyor # spoke with CNA-D. CNA-D indicated that she works full time and usually works in the nursing home. CNA-D stated she does however, float to all units in the facility. Surveyor # asked CNA-D about the practice of escorting residents to their rooms for a "time out." CNA-D indicated that in the nursing home no staff were to place their hands on any residents unless it was an emergency. CNA-D indicated at that point, a STAT or emergency call would be paged for staff assistance. CNA-D indicated that in the acute in-patient psych unit, they utilize restraints on wrists, legs, arms, as well as a seclusion room. Surveyor # asked CNA-D about Resident #7. CNA-D indicated Resident #7 could get agitated and was difficult to talk down. CNA-D also indicated Resident #7 would refuse to go to her room at which point staff would physically take her there. CNA-D also stated she had witnessed 3 staff physically take Resident #7 to her room in the past. CNA-D stated Resident #7's aggression was always directed towards staff. CNA-D also stated Resident #7 did not like to be touched and felt that some of the aggression towards staff was related to this. Surveyor # asked if Resident #7 had ever been injured during an escort. CNA-D indicated she wasn't sure but stated there was a potential for injury. CNA-D stated staff did block her swings as well as held onto her wrists, at which time Resident #7 would fight and try to pull away. Surveyor # asked CNA-D if she had ever considered the manner in which staff escorted Resident #7 abuse. After some hesitation CNA-D indicated she did not. On 5/2/12 at 8:55 a.m., Surveyor # spoke with Social Worker (SW)-Q. Surveyor # asked SW-Q about the incident with Resident #7 that had occurred on 3/28/12. SW-Q indicated she had been unaware of the incident until today. Surveyor # asked SW-Q if this practice was part of Resident #7's plan of care. SW-Q stated is was "absolutely not a part" of Resident #7's plan of care. SW-Q also stated Resident #7 is not accepting of physical touch. SW-Q stated there should never be hands-on physical escorts unless it was an emergency. SW-Q stated at this point a STAT call would be paged for staff to immediately assist. SW-Q also stated the Director of Nursing (DON) should have been notified. On 5/2/12 at 8:15 a.m., Surveyor # spoke with the DON. Surveyor # asked the DON about the incident regarding Resident #7 on 3/28/12. The DON indicated she had been unaware of the incident until it had been pointed out by Surveyor # . The DON stated residents should never be physically escorted and there should never be hands-on or holds of any type on any resident in the nursing home unless it was an emergency.

Based on interviews and record reviews, the facility did not ensure that 1 of 8 sampled residents received necessary care and services to maintain their highest practicable level. Resident #7 had been hospitalized with dehydration, fever, and [MEDICAL CONDITION] associated with Diabetes Insipidus. Prior to Resident #7's hospital admission, Resident #7 demonstrated a significant decline in her overall functioning. During this decline, Resident #7 exhibited classic signs and symptoms of dehydration. Despite this, there were no nursing assessments, no hydration assessments and no changes made to Resident #7's plan of care. Additionally, on [DATE], the day Resident #7 was admitted to the hospital, there were no RN assessments completed. This is evidenced by: Resident #7 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. The facility utilizes a form titled "Activities Of Daily Living Flow Record." This form is completed by the CNAs on a daily basis. Surveyor # completed a review of Resident #7's flow record and noted that from [DATE] through [DATE], Resident #7 was independent in bed mobility, transfers, walking, toileting, required supervision for eating, and required limited assistance for bathing. On [DATE], Resident #7's ability to walk declined and Resident #7 was requiring supervision or 1 person assistance for walking. On [DATE], Resident #7 further declined and was requiring limited to extensive assistance of 1 staff person for bed mobility, transfers, and toileting as well as assistance with walking. On [DATE], Resident #7 further declined and was now requiring up to 2 staff to walk. On [DATE], Resident #7 further declined and was requiring extensive assistance of ,[DATE] staff persons for transfers, and toileting. By [DATE], Resident #7 consistently required 2 staff to transfer, walk, toileting, and was now requiring assistance to eat. This shows a dramatic and significant decline in Resident #7's overall functioning. Surveyor # noted the following weights. All weights are noted in pounds: ~ [DATE], 160 ~ [DATE], 156 ~ [DATE], 153 ~ [DATE], 150 ~ [DATE], 147 This is a 13 pound weight loss in approximately 1 month's time. Surveyor # completed a review of Resident #7's nursing notes (documented by both licensed nurses and CNAs) and noted the following: ~[DATE], "...seemed to be confused...walking was very slow and little steps...spent much of shift lying in bed..." These entries were documented by a CNA. There was no RN assessment completed. ~[DATE], "...appeared to have more difficult time walking this shift. Her gait was more of a shuffle. She needed assistance in walking...required 1 and 2 staff assistance...when ambulating" These entries were documented by a CNA. ~[DATE], an RN documented that Resident #7 had changes to her gait pattern. There was however, no assessment completed. ~[DATE], "...very unsteady on her feet, ambulation is very slow and deliberate, and she seems lethargic and confused...1:1 staff assist for all ambulating...did not eat breakfast and only ate ,[DATE] of lunch...appears to need staff assistance of one with ambulating, transfers, adls (activities of daily living)...gait is shuffled and unsteady...much difficulty eating..." These entries were documented by a CNA. ~[DATE], "...shuffling gait, P (pulse) 127, ,[DATE] (blood pressure) 98.4 (temperature)...arms very stiff, denies feeling ill..." This entry was documented by an RN. According to the nursing notes, Resident #7's physician was contacted. ~[DATE], "...very unsteady on her feet. Appears to need one staff assistance with ambulating transfers...Staff had to help her hold her water glass...shuffles her feet. Very confusing (sic)...required two staff with most transferring...She was unable to sit up on her bed with out leaning over and then laying down...ambulating...with two...legs gave out and were shaking terribly, staff then used a w/c (wheelchair)..." These entries were documented by a CNA. Despite a rapid decline in physical functioning, there was no RN assessment completed until [DATE]. ~[DATE], "...seemed to need more help to turn and sit on toilet...shaky when walking...had difficulty holding cup of water to her mouth..." These entries were documented by a CNA. ~[DATE], "...has been in w/c all day...Intermittent X's (times) of being shaky and not able to hold cup in hand...appears to be weak..XXX,[DATE], 99.3, 100 (pulse), 16 (respirations)..." These entries were completed by an RN but does not constitute a thorough assessment. ~[DATE], "...appeared to start to tip on toilet needing to be steadied . Also needed to be assisted holding on to her cup of water...unable to sit or stand without extensive assist...has been sleeping a lot...little interest in her meals and has an extremely difficult time keeping her hand steady in order to feed self. Staff had to even assist her in eating. There have been 2 staff needed to assist her with transfers...stuttering her speech more..." These entries were completed by a CNA. ~[DATE], "...is weak assist of 1 to sit her up in bed. T (temperature) 99.1...Resident been sleeping most of shift...is weak...assist 2 to transfer to w/c..." These entries were documented by an RN, however, is not considered a thorough assessment. ~[DATE], "...appeared to have no strength to assist staff with transferring (sic) herself...was 2 assist all shift...even had difficulty eating...appeared to think she had a spoon in her hand even though she didn't..even stuck her hands in her mashed potatoes making a big mess. Finally staff had to feed her...would stick her spoon on a place on her tray where there was no food. She had difficulty getting any food on her spoon...it took ,[DATE] staff to move Resident #7...when she was sitting in the chair, she leaned over to the side, appears to be unable to sit up on own..." These entries were documented by a CNA. On [DATE] there was no RN assessment of Resident #7's condition. Resident #7 was admitted to the hospital on [DATE]. Surveyor # completed a review of hospital Discharge Summary dated [DATE]. The discharge [DIAGNOSES REDACTED]. This results in increased thirst, excessive urination, and an increased risk of dehydration and electrolyte imbalances. The dehydration and electrolyte imbalances can be life threatening if not treated. Careful fluid management is critical to prevent dehydration.) associated with Dehydration and [MEDICAL CONDITION]. On [DATE] at 9:40 a.m., Surveyor # spoke with RN-G about the facility's process for charting. RN-G indicated CNAs do chart in the nursing notes. RN-G indicated the CNAs' entries were to be strictly observations. RN-G indicated that any resident with a change in condition should have an assessment completed by a nurse. Surveyor # also asked RN-G about physician orders [REDACTED]."

Based on record review and interviews, the facility did not ensure that 1 out of 4 residents reviewed for range of motion concerns were receiving services to prevent further decrease in range of motion. Resident #2 had range of motion limitations in one lower extremity. There was no evidence that range of motion exercises or a restorative plan was put into place to maintain Resident #2's current functioning. During the next assessment, Resident #2 demonstrated limited range of motion in both lower extremities. This is evidenced by: Resident #2 was admitted to the facility on [DATE] with the most recent readmission on [DATE]. Resident #2 had the following, but not all inclusive, Diagnoses: [REDACTED]. The facility completed an annual MDS for Resident #2 on [DATE], and noted the following: ~sometimes able to make self understood and understand others; ~impaired short and long term memory; ~severely impaired daily decision making skills; ~signs of [MEDICAL CONDITION] (inattention, disorganized thinking, altered level of consciousness, and psychomotor [MEDICAL CONDITION]) that were continuously present; ~required total staff assistance for bed mobility, transfers, locomotion on/off unit, eating, toilet use, hygiene , dressing, and bathing; ~did not ambulate; ~had impairments on both sides for upper extremity range of motion; ~had impairments on one side for lower extremity range of motion; ~did not receive any restorative range of motion. Review of the Falls CAA (Care Area Assessment) summary did not include range of motion limits as a fall risk factor. The fall CAA was incomplete. The facility completed a quarterly MDS assessment for Resident #2 on [DATE] and noted the following changes: ~had impairments on both sides for lower extremity range of motion (decline). Review of the comprehensive care plan for Resident #2 titled "Medical Management General Health," which was developed on [DATE] with an expired goal date of [DATE], had a long term goal of "optimal physical functions as demonstrated by monitoring and diagnostic values during goal dated periods." There were no approaches which included range of motion exercises to maintain or prevent decline in range of motion. Surveyor # reviewed Resident #2's "Activities of Daily Living Flow Record" from January through [DATE]. Noted under the section titled "Range of Motion," Resident #2 either had "NA" (non-applicable) entered or the column was blank, for all 4 months reviewed. Review of the CNA care guide for Resident #2, under the section titled "Exercises/Range of Motion" were choices of Passive ROM, Independent ROM, and Walks. All three areas were left blank. On [DATE] at 4:35 p.m., Surveyor # interviewed the DON (Director of Nurses) regarding range of motion services. The Surveyor requested the facility policy on the range of motion procedure. The DON stated the facility currently did not have any restorative nursing programs in place and there were no range of motion policies to provide. The DON stated the facility has considered developing a restorative nursing program that would encompass range of motion. The DON stated CNA (Certified Nursing Assistant) staff have not been trained in range of motion. The DON stated some residents do receive range of motion programs that have been recommended by therapy. The DON stated she was unaware of any range of motion programs for Resident #2. On [DATE] at 3:30 p.m., Surveyor # interviewed RN-G (Registered Nurse) regarding the coding of Section G range of motion on the MDS. RN-G stated she interviews the CNA staff when assessing for any range of motion limitations. RN-G stated she does not have a clear understanding of the range of motion coding. On [DATE] at 8:45 a.m., Surveyor # interviewed CNA-F regarding range of motion exercises for Resident #2. CNA-F stated Resident #2 had no range of motion exercises. CNA-F stated range of motion was not provided unless it was ordered by the doctor or therapy. On [DATE] at 9:18 a.m., Surveyor # interviewed CNA-A regarding Resident #2's range of motion. CNA-A stated Resident #2 did not have any range of motion program for either upper or lower body extremities. CNA-A stated Resident #2 wheels self from room to dining room which provided him with upper body exercise. CNA-A stated he has never provided any range of motion exercises for any residents including Resident #2. On [DATE] at 4:15 p.m., Surveyor # interviewed CNA-B regarding Resident #2's range of motion. CNA-B stated she does not perform any range of motion exercises for Resident #2 beyond assisting him with dressing. On [DATE], Surveyor # had arranged to observe morning ADL cares for Resident #2; however, when Surveyor arrived onto the floor, Resident #2 was seated in the wheelchair with morning ADL cares completed.

Based on observations, interviews, and record reviews, the facility did not ensure that 3 out of 8 sampled residents received services to maintain adequate hydration. Resident #7 had been hospitalized with dehydration, fever, and [MEDICAL CONDITION] associated with Diabetes Insipidus. Prior to Resident #7's hospital admission, Resident #7 demonstrated a significant decline in her overall functioning. During this decline, Resident #7 exhibited classic signs and symptoms of dehydration. Despite this, there were no hydration assessments completed and no changes made to Resident #7's plan of care. Additionally, on [DATE], the day Resident #7 was admitted to the hospital, there were no RN assessments completed. When Resident #7 returned from the hospital, the physician ordered that Resident #7's intake and output (I&O) be closely monitored. While the facility completed intake, there was no measurement of Resident #7's output. Resident #1 was at risk for dehydration due to diuretic (water pills) therapy and restricted fluid intakes. Resident #1 was on an 1800 ml (milliliter) fluid restriction to treat [MEDICAL CONDITION]. During [DATE] through [DATE] (121 days), Resident #1 never received 1800 mls of fluid per day as per physician order. During the same time frame, Resident #1 only received her minimum daily fluid needs based on weight for 17 out of 121 days. In addition, the facility does not have a system in place to periodically evaluate Resident #1's fluid consumption based on fluid needs. The lack of assessment puts Resident #1 at risk for dehydration. Resident #2 was at high risk for dehydration due to diuretic (water pills) use, impaired cognition, impaired communication, unmet thirst needs, unrecognized thirst needs, psychoactive medication, totally dependent on staff for all fluids, history of UTIs (urinary tract infections) due to a dysfunctional ureter, [MEDICAL CONDITION], and altered fluid consistency. Resident #2 had physician orders [REDACTED]. Resident #2 did not receive 12 ounces of juice at all three meals. Resident #2 received only 8 ounces of juice at two meals per day and 8 ounces of milk at one meal per day. In addition, the facility identified a dehydration risk for Resident #2; however, did not develope a care plan to monitor hydration status. Based on observation, record review, and interviews Resident #2 had fluid needs ranging from ,[DATE] mls per day and only received fluids of 1080 mls per day. This is evidenced by: On [DATE], Surveyor # requested the facility policy on hydration assessments. The Surveyor was provided with an educational handout titled "Dehydration" and not a facility policy and procedure for maintaining hydration. According to the clinical practice guideline "Dehydration And Fluid Maintenance In the Long-Term Setting," "...Dehydration is defined as a loss of body water that causes significant signs and symptoms, including physiological and/or functional decline from the individual's baseline..." The signs and symptoms included: ~ Recent rapid weight loss; ~ Dry eyes and/or mouth; ~ Change in mental status; ~ Postural [MEDICAL CONDITION]; ~ Fever; ~ Pulse greater than 100 beats per minute; ~ Dizziness; ~ Lethargy and weakness; ~ Falling; ~ Change in ability to carry out activities of daily living; ~ Increased combativeness and confusion. The practice guideline also indicated, "...The presence of multiple signs and symptoms may provide a more urgent or specific indication that the patient has a fluid or electrolyte imbalance..." Example #1: Resident #7 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. Surveyor # requested Resident #7's hydration assessments. On [DATE] at 1:20 p.m., the Director of Nursing (DON) indicated that they were unable to find any hydration assessments for Resident #7. The facility utilizes a form titled "Activities Of Daily Living Flow Record." This form is completed by the CNAs on a daily basis. Surveyor # completed a review of Resident #7's flow record and noted that from [DATE] through [DATE], Resident #7 was independent in bed mobility, transfers, walking, toileting, required supervision for eating, and required limited assistance for bathing. On [DATE], Resident #7's ability to walk declined and Resident #7 was requiring supervision or 1 person assistance for walking. On [DATE], Resident #7 further declined and was requiring limited to extensive assistance of 1 staff person for bed mobility, transfers, and toileting, as well as assistance with walking. On [DATE], Resident #7 further declined and was now requiring up to 2 staff to walk. On [DATE], Resident #7 further declined and was requiring extensive assistance of ,[DATE] staff persons for transfers, and toileting. By [DATE], Resident #7 consistently required 2 staff to transfer, walk, toileting, and was now requiring assistance to eat. This shows a dramatic and significant decline in Resident #7's overall functioning. Resident #7 had been on I&O (Intake and Output) dating back to [DATE]. The I&O records only included intake. No output was documented. Surveyor # completed a review of Resident #7's weight record. This indicated that Resident #7's weight had been stable, averaging between 160 pounds to 165 pounds. Surveyor # noted the following weights. All weights are noted in pounds: ~ [DATE], 160 ~ [DATE], 156 ~ [DATE], 153 ~ [DATE], 150 ~ [DATE], 147 This is a 13 pound weight loss in approximately 1 months time. Surveyor # completed a review of Resident #7's I&O beginning [DATE] and noted the following: ~From [DATE] through [DATE], 3 of the 18 days were not tallied for the 24 hours. Surveyor # calculated the average intake over the 18 days and noted it to be 1700 cc's (cubic centimeters) in 24 hours. ~On [DATE], Resident #7's 24-hour intake was 1200 cc's. ~On [DATE], a 24-hour total had not been tallied. Surveyor # tallied the total intake and noted it to be 1260 cc's. This is 500 cc's less per day than what Resident #7 had averaged previously. Surveyor # completed a review of Resident #7's nursing notes (documented by both licensed nurses and CNAs) and noted the following: ~[DATE], "...seemed to be confused...walking was very slow and little steps...spent much of shift lying in bed..." These entities were documented by a CNA. There was no RN assessment completed. ~[DATE], "...appeared to have more difficult time walking this shift. Her gait was more of a shuffle. She needed assistance in walking...required 1 and 2 staff assistance...when ambulating." These entries were documented by a CNA. ~[DATE], an RN documented that Resident #7 had changes to her gait pattern. There was no assessment completed. ~[DATE], "...very unsteady on her feet, ambulation is very slow and deliberate, and she seems lethargic and confused...1:1 staff assist for all ambulating...did not eat breakfast and only ate ,[DATE] of lunch...appears to need staff assistance of one with ambulating, transfers, adls (activities of daily living)...gait is shuffled and unsteady...much difficulty eating..." These entries were documented by a CNA. ~[DATE], "...shuffling gait, P (pulse) 127, ,[DATE] (blood pressure) 98.4 (temperature)...arms very stiff, denies feeling ill..." This entry was documented by an RN. According to the nursing notes, Resident #7's physician was contacted. ~[DATE], "...very unsteady on her feet. Appears to need one staff assistance with ambulating transfers...Staff had to help her hold her water glass...shuffles her feet. Very confusing (sic)...required two staff with most transferring...She was unable to sit up on her bed without leaning over and then laying down...ambulating...with two...legs gave out and were shaking terribly, staff then used a w/c (wheel chair)..." These entries were documented by a CNA. Resident #7 had significant changes to her overall functioning, including her ability to eat and drink. On [DATE], an RN completed an assessment, however it did not include a hydration assessment. On [DATE], a physician saw Resident #7 and initially ordered that Resident #7 be sent to the emergency room . This was later rescinded by the physician in lieu of sending Resident #7 to a neurologist related to Resident #7's unsteady gait. Nursing notes continue: ~[DATE], "...seemed to need more help to turn and sit on toilet...shaky when walking...had difficulty holding cup of water to her mouth..." These entries were documented by a CNA. ~[DATE], "...has been in w/c all day...Intermittent X's (times) of being shaky and not able to hold cup in hand...appears to be weak..XXX,[DATE], 99.3, 100 (pulse), 16 (respirations)..." These entries were completed by an RN. ~[DATE], "...appeared to start to tip on toilet needing to be steadied . Also needed to be assisted holding on to her cup of water...unable to sit or stand without extensive assist...has been sleeping a lot...little interest in her meals and has an extremely difficult time keeping her hand steady in order to feed self. Staff had to even assist her in eating. There have been 2 staff needed to assist her with transfers...stuttering her speech more..." These entries were completed by a CNA. ~[DATE], "...is weak assist of 1 to sit her up in bed. T (temperature) 99.1...Resident been sleeping most of shift...is weak...assist 2 to transfer to w/c..." These entries were documented by an RN. ~[DATE], "...appeared to have no strength to assist staff with transfering (sic) herself...was 2 assist all shift...even had difficulty eating...appeared to think she had a spoon in her hand even though she didn't...even stuck her hands in her mashed potatoes making a big mess. Finally staff had to feed her...would stick her spoon on a place on her tray where there was no food. She had difficulty getting any food on her spoon...it took ,[DATE] staff to move Resident #7...when she was sitting in the chair, she leaned over to the side, appears to be unable to sit up on own..." These entries were documented by a CNA. On [DATE], there was no RN assessment of Resident #7's condition. There was no hydration assessment completed at any time during Resident #7's decline. Resident #7 was admitted to the hospital on [DATE]. Surveyor # completed a review of Resident #7's hospital admission lab work and noted the following. The values noted in parenthesis indicate normal values: ~Glucose, 172 mg/dL (milligrams per deciliter), (70 - 99); ~Sodium, 158 mmol/L (millimoles per liter), (,[DATE]); ~Urea N, 46 mg/dL (,[DATE]); ~Creatinine, 1.5 mg/dL (0.4 -1.0). All values were noted as "H" or high on the lab report. Surveyor # completed a review of hospital Discharge Summary dated [DATE]. The discharge [DIAGNOSES REDACTED]. This results in increased thirst, excessive urination, and an increased risk of dehydration and electrolyte imbalances. The dehydration and electrolyte imbalances can be life threatening if not treated. Careful fluid management is critical to prevent dehydration.) associated with Dehydration and [MEDICAL CONDITION]. Resident #7 was readmitted to the facility on [DATE]. On [DATE], a physician ordered that Resident #7's I&O be monitored closely for 48 hours. Surveyor # completed a review of the I&O and noted that the facility completed I&O from [DATE] to [DATE]. During this time, intake was completed, however output was not recorded. Resident #7's current care plan dated [DATE] did not contain a problem identifying Resident #7's history of dehydration or Diabetes Insipidus. Resident #7's care plan under the problem titled, "General Health Maintenance" indicated, "...PM (evening) staff should monitor fluid intake. If excess fluid intake is suspected, notify nursing to consider writing an order to document I/O..." The discipline responsible to implement this approach is a Certified Nursing Assistant (CNA). This approach indicates that a CNA was to assess whether or not Resident #7's fluid intake was in excess. This is beyond the scope of practice for a CNA. There were no other approaches on Resident #7's care plan directing staff on how to manage Resident #7's fluid status. On [DATE] at 9:40 a.m., Surveyor # spoke with RN-G about the facility's process for charting. RN-G indicated that CNAs do chart in the nursing notes. RN-G indicated the CNAs' entries were to be strictly observations. RN-G indicated that any resident with a change in condition should have an assessment completed by a nurse. Surveyor # also asked RN-G about physician orders [REDACTED]." On [DATE] at 10:42 a.m., Surveyor # spoke with RN-W about hydration assessments. RN-W indicated that these would be done when an MDS was completed. RN-W also stated that one should be done anytime a resident was not eating or drinking well. Example #2: Resident #1 was admitted to the facility on [DATE] with the most recent readmission on [DATE]. Resident #1 had the following, but not all inclusive, Diagnoses: [REDACTED]. The facility completed an annual MDS (Minimum Data Set) assessment for Resident #1 on [DATE] with the following data: ~usually able to make self understood and understand others; ~short and long term memory problems; ~severely impaired for daily decision making; ~had disorganized thinking, inattention, and psychomotor [MEDICAL CONDITION] symptoms present that fluctuate; ~required supervision for eating; ~frequently incontinent of urine (7 or more episodes); ~on a mechanically altered diet as well as a therapeutic diet; ~current weight of 124#. Resident #1 was admitted to the hospital on [DATE] and discharged on [DATE]. The hospital admission history and physical noted dry oral membranes. The discharge summary noted "Oral membranes quite dry." "She was thought to be a little dehydrated on admission and gentle hydration was accomplished with normal saline." Lab data was a normal sodium 137 level, an elevated BUN of 26, and a normal creatinine of 1.0. Review of Resident #1's discharge summary noted physician orders [REDACTED]. Resident #1 also had orders for [MEDICATION NAME] 20 mgs (milligrams) every morning and [MEDICATION NAME] 40 mgs once daily. Review of the current physician orders [REDACTED].#1 returned on [DATE]. Review of the MAR (Medication Administration Record) noted Resident #1 received both doses of [MEDICATION NAME] at 8:00 a.m. daily. Surveyor # requested all dietary assessments. The Surveyor was provided with a comprehensive assessment that was dated for ",[DATE]" and signed by RD-I (Registered Dietician). The assessment noted Resident #1 required 1581 mls fluids per day based on a weight of 112# (pounds). The facility completed a "Nutritional Screen Follow-up" dated [DATE], and noted Resident #1 to have a usual body weight of ,[DATE]#. RD-I documented quarterly for Resident #1, but the documentation did not include any fluid needs based on current weight, any clinical summary of fluid intakes, any laboratory data reviewed for hydration, or any hydration status. RD-I documentation as follows: ~[DATE] "O- (objective) Checked diet order. Diet order unchanged. Wt. (weight) 128#." ~[DATE] "O-Checked diet order. Continues to receive a heart healthy diet...1800 cc (cubic centimeters) FR (fluid restriction) as ordered. Wt. 125#." ~[DATE] "O-Checked diet order. Continue to receive a heart healthy diet...c (with) 1800 cc FR as ordered. Wt. 130.2#." ~[DATE] "O-Checked diet order. Diet order unchanged. Wt. 126.2#." Based on Resident #1's weight range of ,[DATE]# or 56XXX,[DATE].0 kilograms, fluid needs for a person with cardiac conditions are calculated at 25 mls per kilogram. Resident #1's fluid needs range from ,[DATE] mls/day. Surveyor # reviewed Resident #1's intake and output records from [DATE] through [DATE]. During the months of January through April, Resident #1 had zero days where she received 1800 mls of fluids per day as per physician order. January data: # of days Resident #1 received 1400 mls to 1700 mls fluid per day was 4; # of days Resident #1 received less than 1400 mls fluid per day 22; # of days incomplete data recorded was 5. February data: # of days Resident #1 received 1400 to 1700 mls of fluid per day was 5; # of days Resident #1 received less than 1400 mls fluid per day was 22; # of days incomplete data recorded was 2. March data: # of days Resident #1 received 1400 to 1700 mls of fluid per day was 5: # of days Resident #1 received less than 1400 mls fluid per day was 20; # of days incomplete data recorded was 6. April data: # of days Resident #1 received 1400 to 1700 mls of fluid per day was 3; # of days Resident #1 received less than 1400 mls fluid per day was 24; # of days incomplete data recorded was 3. During the month of March, Resident #1 was also treated for [REDACTED]. Infections increase the body's fluid needs and increase the risk for dehydration. The facility completed an annual nursing assessment for Resident #1 on [DATE] with the following information noted: ~had memory problems, was confused, mental function varies; ~had no behavior problems, was cooperative; ~was independent in eating; ~dehydration risk was 5 with concern areas to include incontinence, medical diagnoses, and medication use. A score of 10 or above represents high risk for dehydration. Review of Resident #1's comprehensive care plan did not include the cardiac [DIAGNOSES REDACTED]. The care plan titled "Medical Management" with a start date of [DATE] and a goal date of [DATE], noted a 1200 calorie diabetic and cardiac diet. The care plan approach was inaccurate as Resident #1 was on a heart healthy, salt restricted (< 2 grams daily) diet with an 1800 mls/day fluid restriction. Review of the CNA (Certified Nursing Assistant) care guide noted Resident #1 was on an 1800 ml fluid restriction, salt restricted, cardiac diet. The CNA care guide also noted intake and output for Resident #1. Review of the activities of daily living flow records from [DATE] through [DATE], noted Resident #1 required limited assistance for all meals. Resident #1 usually consumed ,[DATE]% of all meals. Also on the flow record were snacks that were provided. Resident #1 received 3 snacks per day. The flow record noted Resident #1 consumed usually 100% of snacks. Surveyor # observed Resident #1 at meals on the following dates and times: ~[DATE] at 5:00 p.m., CNA-D served Resident #1 the meal tray which contained ground meat, noodles, vegetables, glass of milk, cup of coffee, and applesauce. Resident #1 drank only the coffee (approximately 240 mls), 100% of the meat, and 75% of the noodles. CNA-D did provide one verbal cue for Resident #1 to finish eating at the end of the meal prior to taking the meal tray away. ~[DATE] at 7:30 a.m., RN-J (Registered Nurse) served breakfast tray which contained toast, cold cereal, glass of milk, cup of coffee, and orange juice. Resident #1 drank the coffee and milk, and ate her cereal. Resident #1 was not provided with verbal cues or assistance during the breakfast meal. ~[DATE] at 12:07 p.m., Resident #1 was served soup, egg salad in a bowl, potatoes, peaches, glass of milk, and cup of coffee. Resident #1 ate all of the soup, egg salad, and potatoes, and drank only a cup of coffee. CNA-F removed Resident #1's meal tray and Resident #1 stated to CNA-F that she preferred to have her egg salad in a sandwich. Resident #1 was not provided with any verbal cues or assistance during the meal and Resident #1 was not provided with any alternatives. ~[DATE] at 7:40 a.m., Resident #1 was served french toast, prune juice, glass of milk, cup of coffee, and fruit. Resident #1 ate nothing and drank only the cup of coffee. Resident #1 was not provided with any verbal cues or assistance during the meal. CNA-F removed the meal tray, but did offer something else for breakfast. Resident #1 declined alternatives offered. On [DATE] at the conclusion of the interview with RD-I and DM-H that began at 3:35 p.m., Surveyor # requested any additional information including progress notes, assessments, or care plans related to Resident #1's hydration status. At the time of exit, no additional information had been provided to Surveyor # . Example #3: Resident #2 was admitted to the facility on [DATE] with the most recent readmission on [DATE]. Resident #2 had the following, but not all inclusive, Diagnoses: [REDACTED]. The facility completed an annual MDS for Resident #2 on [DATE] and noted the following: ~sometimes able to make self understood and understand others; ~impaired short and long term memory; ~severely impaired daily decision making skills; ~signs of [MEDICAL CONDITION] (inattention, disorganized thinking, altered level of consciousness, and psychomotor [MEDICAL CONDITION]) that were continuously present; ~required total staff assistance for bed mobility, transfers, locomotion on/off unit, eating, toilet use, hygiene , dressing, and bathing; ~did not ambulate; ~frequently incontinent of urine and was not on a toilet program; ~occasionally incontinent of bowel and was on a toilet program; ~was at risk for pressure ulcer development; ~had no pressure ulcers and had no history of healed pressure ulcers; ~was on a mechanically altered diet; ~was on a therapeutic diet; ~weight was 178#. The nutrition CAA (Care Area Assessment) summary was triggered for Resident #2 because of the therapeutic and mechanically altered diet as well as an elevated BMI (body mass index). The CAA indicated to proceed to care plan; however, Surveyor # was unable to locate any nutritional care plan. The nutrition CAA was not completed. Please reference F272. The facility completed a quarterly MDS assessment for Resident #2 on [DATE] and noted the following changes: ~always incontinent of bladder (a decline) and was now on a toilet program; ~always continent of bowel (an improvement) but no longer on a toilet program ~weight was 169# and no weight loss noted. Review of the comprehensive care plan titled "Medical Management General Health" that was developed on [DATE] and with an expired goal date of [DATE], noted a goal of "Optimal physical functions as demonstrated by monitoring and diagnostic values during goal dated periods." The approaches read, "Reference current diet order. Liquids to be of nectar consistency and give one spoonful at a time. No gulp drinking. Make sure mouth is empty and he has swallowed previous spoonful before giving another of food or liquid. No straws." An additional problem titled "Constipation" had the same development and goal date with an approach that read, "Encourage adequate hydration with fluids at each meal and prn (as needed)." Another problem titled "Right Ureteropelvic Junction Obstruction" had the same development and goal date with an approach that read, "Monitor...for signs and symptoms of urinary tract infection...Monitor...for signs and symptoms of decreased hydration and provide fluids to enhance elimination. Hydrate per nutrition/swallowing guidelines." Surveyor # reviewed the entire medical record and was unable to locate any nutritional care plan. Review of the CNA care guide for Resident #2 noted an 1800 calorie puree diet with thickened liquids. The CNA care guide noted Resident #2 required total assistance with eating. The CNA care guide did not include any special feeding techniques noted by speech therapy. Surveyor # reviewed the medical record of Resident #2 and noted the following: ~dehydration risk assessment completed on [DATE] with a score of 11 indicative of high risk. The risk factors identified were mobility, swallowing problems, incontinence, history of dehydration, history of UTIs (Urinary Tract Infections), history of kidney failure, history of psychiatric disorders, and medication use. ~physician order [REDACTED]." ~physician progress notes [REDACTED]. Probably 2 (secondary) to under - hydration...Recommend: Adequate hydration - at least 1500 mls daily..." The physician note described an enlarged parotid gland (gland that was located along side of each jaw/neckline). ~physician progress notes [REDACTED]." ~speech therapy instructions dated [DATE] that included, "No gulp drinking. No straw drinking. Liquids should be given via tsp. (teaspoon) amts. (amounts). (No restrictions on amount given during day). Puree should be given in tsp amts at a time. Staff to feed at all times. Make sure...swallows before giving more food." ~physician orders [REDACTED]. Review of the most recent nutritional assessment for Resident #2 did not include any fluid needs based on current or usual weight. The date of the assessment was [DATE]. The following was data from RD-I's progress notes for Resident #1: ~[DATE] "O-Checked diet order. Diet order unchanged. Wt. 173#. A (Assessment)-...Diet appropriate & provides the RDI (Recommended Daily Intake)...P (Plan)- Continue same POC (plan of care)." ~[DATE] "O-Checked diet order. Diet order unchanged. Wt. 176#. A-...Diet appropriate. P-Continue same POC." ~[DATE] "O-Checked diet order. Diet order unchanged. Wt. 170#. A-...Diet appropriate. P-Continue same POC." [DATE] "O-Checked diet order. Diet order unchanged. Wt. 179#. A-...Diet appropriate. P-Continue same POC." The nutritional progress notes did not identify fluid needs for Resident #2 or evaluate fluid consumption. Based on an average weight range of ,[DATE]#, Resident #2 required ,[DATE] mls fluids per day. During the 3-day survey, Resident #2 was observed to be totally dependent on staff for eating and drinking. Resident #2 was observed at 4 meals eager to receive spoonfuls of food or fluid. Resident #2 often had mouth open waiting the approach of the spoon. Surveyor # observed Resident #2 at the following meal times: ~[DATE] at 5:12 p.m., fed by CNA-C. Resident #2 consumed 100% of meal which included 8 ounces of cranberry juice (240mls). ~[DATE] at 7:38 a.m., fed by CNA-F. Resident #2 consumed 100% of meal which included 4 ounces of prune juice and 8 ounces of cranberry juice (360mls). ~[DATE] at 12:07 p.m., fed by CNA-F. Resident #2 consumed 100% of meal which included 8 ounces of milk (240mls). ~[DATE] at 7:47 a.m., fed by CNA-F. Resident #2 consumed 100% of meal which included 8 ounces of cranberry juice and 4 ounces of prune juice. On [DATE] at 5:17 p.m., Surveyor # interviewed CNA-C regarding Resident #2's meal intakes. CNA-C stated Resident #2 eats 100% almost all of the time. CNA-C stated Resident #2 does receive a jello snack prior to bedtime. On [DATE] at 3:35 p.m., Surveyor # interviewed DM-H and RD-I together regarding Resident #2's meal plan. DM-H stated Resident #2 received 8 ounces of cranberry juice and 4 ounces of prune juice for breakfast; 8 ounces of milk for lunch; 8 ounces of cranberry juice for supper; and was provided with a jello snack twice daily. The total daily fluid provided by dietary for Resident #2 was 1080 mls. On [DATE] at the conclusion of the interview with RD-I and DM-H that began at 3:35 p.m., Surveyor # requested any additional information including progress notes, assessments, or care plans related to Resident #2's hydration status. At the time of exit, no additional information had been provided to Surveyor # . On [DATE] at the conclusion of the interview with the DON that began at 4:35 p.m., Surveyor # requested any additional information including progress notes, assessments or care plans related to Resident #2's hydration status. The DON provided me with a handwritten note on a blue post-it note that read, "...is not on I/O (Intake/Output)." On [DATE] at 3:35 p.m., Surveyor # interviewed DM-H (Dietary Manager) as well as RD-I (Registered Dietician) regarding hydration assessments. Both RD-I and DM-H stated nursing staff was responsible for collecting the intake data as well as to evaluate the data. RD-I stated an assessment was not completed annually or with a significant change in status; however she completed a quarterly assessment. RD-I stated she does not calculate fluid needs or hydration status quarterly or even following a hospital stay, only upon admission. RD-I stated she did not calculate weight loss on usual body weight, but rather actual weight fluctuations. The Surveyor shared the weight loss formula that was in the State Operations Manual with RD-I and she stated she was unfamiliar with that formula. RN-I stated she may have reviewed Resident #1's intakes; however did not document her assessment or identify any concerns. RN-I stated she had not identified a hydration risk for Resident #2 during the past year's assessments completed. On [DATE] at 4:35 p.m., Surveyor # interviewed the DON (Director of Nurses) regarding hydration assessments. The DON stated intakes record would reflect all fluids consumed during that shift for residents on intakes. The DON stated the nurse should be reviewing the intake and output data to ensure adequate hydration. The DON stated the nurse should assess why residents are not consuming the required fluids, review the documentation for accuracy, review weights, followup with a hydration assessment, update the doctor, and inform dietary of the findings.