Every finding on record at Oakbrook Health and Rehabilitation

Based on interview and record review the facility did not implement policies and procedures for ensuring the reporting of physical abuse in accordance with section 1150B of the Act when an allegation of physical abuse was not reported immediately, but no later than 2 hours to the local law enforcement in accordance with state law through established procedures for 1 of 3 residents (R) reviewed (R1).On 05/02/26, the facility was made aware of R1's allegation of abuse. The facility did not report this allegation to local law enforcement within 2 hours. This is evidenced by:Facility policy titled, Resident safety Abuse Policy, with reviewed date of 03/24, states in part: 8. Reporting Suspected Violations: .e. All facility staff members shall ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse.to the administrator and the administrator will ensure reporting to other officials (including to the State Survey Agency and adult protective services where state law provides jurisdiction in long-term care facilities). R1 was admitted to the facility on [DATE] with diagnoses of sepsis, urinary tract infection and weakness.On 03/27/26, Minimum Data Set (MDS) assessment documented R1 had moderately impaired cognitive skills for daily decision making, behaviors of inattention, disorganized thinking, and verbal behaviors directed towards others.The facility's investigation on 05/02/26 documented R1's allegation of abuse by stating, I want to go home, everyone is hurting me. Nursing staff reported to the Nursing Home Administrator (NHA) A. NHA A reported to the State Agency (SA) and completed a full investigation. NHA A did not report the allegation to local law enforcement.On 05/27/26 at 10:29 AM, Surveyor interviewed Certified Nursing Assistant (CNA) C asking about reporting allegation of abuse by a resident. CNA C stated if a resident said someone hurt or abused them CNA C would report to the nurse immediately and the nurse would report to Director of Nursing (DON) or NHA. Surveyor asked if R1 had reported any abuse. CNA C stated R1 was very nice and never had any complaints. CNA C knew at night R1 would have sundowning behaviors. Surveyor asked if CNA C received training about abuse and neglect. CNA C stated staff get training yearly and at staff meetings. On 05/27/26 at 4:02 PM, Surveyor interviewed CNA D asking about R1's reporting of abuse. CNA D stated CNA D was not here when R1 made the allegation. After R1 made the allegation, R1 required 2 staff assistance with all care. Surveyor asked if CNA D received training about abuse and neglect. CNA D stated CNA D gets training all the time, yearly and at every monthly staff meeting. On 05/27/26 at 2:00 PM, Surveyor interviewed NHA A regarding R1's allegation of abuse and reporting to local law enforcement. NHA A stated R1's allegation was reported to the charge nurse around 9:30 PM. The nurse called NHA A and came to the facility right away and interviewed R1. NHA A did not report to police since R1 did not name a person that could be reported to police. When R1 was interviewed R1 continued to say that it didn't happen and didn't recall saying any comments about abuse. On 05/29/26 at 1:05 PM, Surveyor interviewed CNA E regarding R1's allegation of abuse. CNA E stated that R1 was in the activity room and CNA E asked R1 if R1 was ready for bed and this was around 6:30 PM. R1 stated R1 wanted to go home, and everyone was hurting R1. CNA E kept asking R1 what happened and R1 would just say that R1 was wanting to go home. R1 had bad dementia and always would ask where my son is, where my family is, and wanting to go home. Surveyor asked if CNA E received training about abuse and neglect. CNA E stated CNA E received training upon hire and NHA A provided training to CNA E the next day before CNA E's shift.

Based on record review and interview, the facility did not implement policies and procedures for ensuring the reporting of physical abuse in accordance with section 1150B of the Act when an allegation of physical abuse was not reported immediately, but no later than 2 hours to the State Agency and local law enforcement in accordance with state law through established procedures for 1 of 3 residents (R) reviewed (R1).On 02/03/26, the facility was made aware of R1's allegation of abuse. The facility did not report this allegation to State Agency (SA) or to local law enforcement within 2 hours. This is evidenced by:Facility policy titled, Resident safety Abuse Policy, with reviewed date of 03/24, states in part: 8. Reporting Suspected Violations: .e. All facility staff members shall ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse.to the administrator and the administrator will ensure reporting to other officials (including to the State Survey Agency and adult protective services where state law provides jurisdiction in long-term care facilities).9. Procedure For Investigation:. g. An employee suspected of violation of the Resident Safety Abuse Policy or Social media Policy may be suspended pending investigation. Example 1R1 was admitted to the facility on [DATE] diagnoses of degeneration of nervous system due to alcohol, convulsions, hepatic failure, altered mental status, major depressive disorder, anxiety disorder, thiamine deficiency, and cerebrovascular disease.R1's progress notes documented on 02/03/26 at 9:38 PM stated, Grabbing staff/shouting threats at staff: pt (patient) put room light on, CNA (Certified Nursing Assistant) and this nurse responded. [R1] was sitting in [R1's] wheelchair with lower half of body/penis exposed. [R1] was asked to cover himself up. [R1] shouted, you sure you don't want some of this! This nurse put a folded blanket over exposed genitals. Pt stated things were missing out of [R1's] room but was not able to state what was missing. [R1] jumped up out of [R1's] wheelchair to standing, [R1] pushed this nurse and grabbed my left arm. I told [R1] to sit back down in [R1's] wheelchair before [R1] fell and to back up. [R1] then lunged at the CNA. [R1] was again told to back up and sit down. [R1] stood face to face to me. I told [R1] again to back up. Many dirty cups and dishes were then removed from [R1's] room. [R1] attempted to block the exit from his room and again lunged at this nurse and the CNA. [R1] was again told to back up and sit down. [R1] shouted the [R1] would get me and see that I was taken care of. Staff left [R1's] room and [R1] followed us out in to the hall. [R1] again, was face to face with me. [R1] was told to back up. [R1] shouted, call the cops! I know you already have before! 9:05 PM: [R1] came up to Nursing Station, jumped out of the wheelchair and shouted, she threatened me! she came at my throat! I want the cops called on her! She threatened me! She came at me! Multiple attempts by staff to find out what the missing items were. Shouting R1 wants cops called, (Name) Admin (Nursing Home Administrator (NHA A) was called and arrived. The facility did not contact the local law enforcement. The facility did not submit within 2 hours a Facility Reported Incident (FRI) concerning allegation of abuse to the State Agency. The FRI documented the Report submitted date of 2/4/2026 6:47:28 PMOn 3/10/26 at 1:26 PM, Surveyor interviewed NHA A regarding incident. NHA A stated R1's allegation was considered abuse, and the FRI was sent the next day. R1 was interviewed right away that night. When R1 was interviewed, R1 stated no one had hit R1. R1 likes it here, and R1 was upset about R1's shower. NHA A stated R1 will state what staff had done to R1 and in actuality this is what R1 had done to staff. NHA A stated felt this allegation did not occur and Licensed Practical Nurse (LPN) C continued to work, and local law enforcement was not called. The full investigation was completed the next day. Surveyor asked if NHA A had followed the facility's policy for reporting to SA and law enforcement within 2 hours. NHA A stated no, because the allegation did not occur. Surveyor asked how NHA A determined LPN C is not abusive to residents if the investigation was not completed until the next day on 02/04/26 when interviews with residents and staff were completed. NHA A stated the other interviews were completed on 02/04/26.

Based on observation, interview, and record review, the facility did not provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections which has the potential to affect all 39 residents.-R44 has open wounds with no Enhanced Barrier Precautions (EBP) in place.-RN I returned to work too soon after illness.-Inappropriate hand washing/gloving during cares (R2).Example 1 The facility protocol titled, Infection Prevention and Control Program, last revised 01/26, reads in part: During an infectious disease outbreak, facility staff along the with medical director will follow prevailing infectious disease protocol at the time-as directed by local or state health agencies or the Centers for Disease Control and Prevention (CDC).Enhanced Barrier Precautions (EBP) are applied for a group of CDC-targeted.for any long-term residents with wounds or indwelling medical devices.Antibiotic prescribing will include documentation of the dose, duration (start date, end date, and planned days of therapy) .for every course of antibiotics. Facility policy titled, Standard and Transmission-Based Precautions, last revised 02/24, reads in part: Change gloves, as necessary, during the care of a resident to prevent cross-contamination from one body site to another (when moving from a contaminated body site like the perineal area to a clean body site like the face).Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of resident organisms that employs targeted gown and glove use during high contact resident care activities. They are indicated for residents with.wounds or indwelling devices. R44 was admitted to the facility on [DATE]. R44's care plan includes in part: Problem of potential for impaired skin integrity with approach of perform weekly skin assessment on scheduled bath/shower day and as needed. Weekly wound measurements to be performed by wound care nurse (01/16/26). R44's care plan includes in part: Problem of impairment of skin integrity-ulcer present to left lateral calf with an approach of change bandages as ordered (01/28/26), which was added after Surveyors entered the facility for survey. On 01/27/26 at 2:13 PM, Surveyor interviewed R44. R44 stated when R44 admitted to the facility, R44's skin was intact but did have a history of pressure ulcers and other wounds. R44 stated now there was an open area to the left lower leg that was currently draining. Surveyor observed no EBP signage or PPE present for R44's room. On 01/28/26 at 2:33 PM, Surveyor interviewed Certified Nursing Assistant (CNA) G. CNA G stated CNAs know which residents require precautions because of the signs on/near the resident's door and the Personal Protective Equipment (PPE) hanging on the door. CNA G stated the nurses, nurse managers, or Director of Nursing (DON) are the staff responsible for hanging the PPE and signs. On 01/28/26 at 2:40 PM, Surveyor interviewed Registered Nurse (RN) H. RN H stated after assessing a resident for precautions, RN H would hang signs outside the door if warranted. RN H stated it would be appropriate for EBP if a resident had wounds, catheters, and infections such as upper COVID or Clostridium Difficile (C-Diff). RN H stated the Infection Control Nurse would let nurses know if they find it is warranted first and let nursing know. On 01/29/26 at 7:03 AM, Surveyor interviewed Director of Nursing (DON) B. DON B stated it would be appropriate to place a resident on EBP for lines that enter into a resident's body, tube feeding, Foley catheter, and open wounds. Surveyor spoke with DON B regarding R44's open wounds and no EBP in place. DON B acknowledged. Example 2 The CDC online article titled, Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, dated 03/18/2024, reads in part: Healthcare Personnel (HCP) with mild to moderate illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met: At least 7 days have passed since symptoms first appeared if a negative viral test* is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7), and at least 24 hours have passed since last fever without the use of fever-reducing medications, and Symptoms (e.g., cough, shortness of breath) have improved. Either a Nucleic acid amplification test (NAAT) (molecular) or antigen test may be used. If using an antigen test, HCP should have a negative test obtained on day 5 and again 48 hours later. Test-based strategy: HCP who are symptomatic could return to work after the following criteria are met: resolution of fever without the use of fever-reducing medications, and improvement in symptoms (e.g., cough, shortness of breath), and results are negative from at least two consecutive respiratory specimens collected 48 hours apart (total of two negative specimens) tested using an antigen test or NAAT. HCP who are not symptomatic could return to work after the following criteria are met: results are negative from at least two consecutive respiratory specimens collected 48 hours apart (total of two negative specimens) tested using an antigen test or NAAT. Surveyor reviewed the infection line list for residents and staff. RN I's name appears on the line list. The line list indicates RN I was positive for Influenza and had a date of illness onset of 01/01/26. Symptoms listed include runny nose and sneezing. The line list indicates a rapid COVID test was performed and was positive. The line list indicates symptoms starting on 01/01/26 and ending on 01/05/26. One negative COVID test was performed on 01/08/26. RN I returned to work on 01/09/26 without the second negative test 48 hours after the first. On 01/29/26 at 7:03 AM, Surveyor interviewed DON B with Chief Nursing Officer (CNO) F present. DON B stated the date of onset of symptoms is day 0. DON B stated if the staff member is negative for COVID, they can return 24 hours after symptom free for 24 hours with no medication. CNO F stated if a staff member is positive for COVID, test them in on day 5-7 and if negative, they can return on day 8. CNO F stated they do not always have the staff come in for 2 tests 48 hours apart as most of them live further away and it is not always easy getting them to come to the facility for 1 test. On 01/29/26 at 9:47 AM, Surveyor interviewed DON B. Surveyor viewed guidelines on CDC website with DON B, pointing out where 2 negative antigen tests were required before staff return to work after a positive COVID test. DON B stated DON B would update Surveyor if DON B found any other information to dispute this information. No further information was provided to Surveyor at this time. On 02/02/26, Nursing Home Administrator (NHA) A submitted additional information to Surveyor. A new line list was submitted with the date of illness onset changed to 01/01/26. A print timecard dialog indicated RN I worked from 5:58 AM to 10:05 AM and 10:33 AM to 3:31 PM on 01/01/26. The timecard indicates RN I worked from 5:57 AM to 6:18 AM on 01/02/26 which does not correlate with a positive test on 01/01/26. Example 3 Facility's policy titled Standard and Transmission-Based Precautions revised date of 02/24 read in part, Change gloves, as necessary, during the care of a resident to prevent cross-contamination from one body site to another (i.e. when moving from a contaminated body site like the perineal area to a clean body site like the face). f. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces. On 01/28/2026 at 9:10 AM, Surveyor observed Certified Nursing Assistant (CNA) C and CNA J provide R2 with personal care. R2 is on enhanced barrier precautions. CNA C applied a gown and gloves and entered R2's room. CNA C gathered R2's clothes. CNA C placed a clean washcloth in the bottom of the sink and ran water over the washcloth. CNA C did not use a basin in the sink for washing R2. CNA C took the washcloth from the bottom of the sink and applied bar soap to the washcloth. CNA C washed R2's peri area with the contaminated washcloth. CNA C and CNA J rolled R2 to the left, and CNA C used the same washcloth and washed buttocks and anal area. CNA C did not rinse the peri area and buttocks. CNA C dried the buttocks and applied a clean brief. CNA C did not remove gloves and continued to provide care to R2. CNA C placed a clean washcloth in the bottom of the sink and ran water over the washcloth. CNA C put bar soap on the washcloth and washed R2's right hand and applied hand brace. Surveyor observed R2's hand brace appeared to be soiled on the palm portion of the brace. CNA C and CNA J transferred R2 to wheelchair using the Hoyer lift. While transferring, R2's left hand held onto the Hoyer lift cross bar. Surveyor observed the protective cover of the Hoyer lift cross bar appeared to be soiled. CNA C, with the same contaminated gloved hands, wet a toothette and squeezed the toothette with contaminated gloved hands and gave the toothette to R2 to cleanse mouth. CNA C, with the same contaminated gloved hands, got another toothette and squeezed the toothette with the same contaminated gloved hands. CNA C placed a washcloth in bottom of the sink and let the water run over the washcloth. CNA C, with the same contaminated gloves, took the wet washcloth and washed R2's face. CNA J wiped the Hoyer lift with sanitizing wipes and did not cleanse the protective cover of the cross bar. Surveyor interviewed CNA C and CNA J asking when R2's hand brace is cleaned. CNA C and CNA J did not know when the brace was to be cleaned. Surveyor asked if the cover of the cross bar gets cleaned or laundered. CNA J stated it looks a little dirty and did not know if there is a replacement or when the protective cover gets cleaned. On 01/29/2026 at 11:20 AM, Surveyor interviewed Director of Nursing (DON) B about expectation during personal cares for R2. Surveyor reviewed with DON B of the observation with CNA C providing R2 personal cares. DON B stated this is not the expectation of care being provided. Education will be provided for staff. DON B stated a basin should have been used and the washcloths not put in the sink. After washing the peri area with bar soap, the area should have been rinsed. Gloves should be changed. Toothette should not have been touched with the contaminated gloved hands.

Based on record review and interview, the facility did not ensure to follow their antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 1 of 1 resident (R36) reviewed. This is evidenced by:Facility's policy titled Infection Prevention and Control Program revised date of 08/25 documented in part. 9. Antibiotic Stewardship. A. The facility follows the current CDC guidelines for Preventing Antimicrobial Resistance among Long-Term Care Facility Residents and has adopted facility-specific protocols (i.e. see Urinary Tract Infection Protocol) for certain high antibiotic-use infections. B. Additional antibiotic use protocols and systems to monitor antibiotic use: i. Antibiotic prescribing will include documentation of the dose (including route), duration (i.e. start date, end date and planned days of therapy, and indication, which includes both rationale (i.e. prophylaxis vs therapeutic) and treatment site (i.e. respiratory tract, urinary tract) for every course of antibiotics.R36 was admitted to the facility on [DATE]. R36's current diagnoses include enterocolitis due to clostridium difficile, pneumonitis due to inhalation of food and vomit, and immune thrombocytopenic purpura.R36's physician orders documented on 01/13/26 Doxycycline Hyclate 50 mg daily for bacterial infection and Valtrex (valacyclovir HCL) 1 GM tablet dose ordered: (1 tablet) by mouth daily AM FOR: Varicella Zoster Infection Therapeutic goal: decrease vital symptoms. Note, the orders did not document an end date of use for both medications and rationale for continued use. Review of R36's hospital discharge orders documented on 01/13/26 order for doxycycline 50 mg daily for meibomian gland dysfunction. With no end date.Review of the facility's antibiotic stewardship line lists did not document R36 being prescribed antibiotics of doxycycline and Valtrex.On 01/29/2026 at 8:53 AM, Surveyor interviewed Director of Nursing (DON) B asking if R36's use of doxycycline and reason for use should be listed on the facility's antibiotic stewardship infection control line list. DON B stated anyone on an antibiotic is to be on the line list. On 01/29/2026 at 9:50 AM, Surveyor interviewed DON B asking if R36 should be listed on the antibiotic stewardship infection control line list for Valtrex and reason for use. DON B stated this must have been missed. On 01/29/2026 at 11:50 AM, Surveyor interviewed DON B about Valtrex for a stop date. DON B stated had just found the diagnosis listed for Valtrex was incorrect. Surveyor asked if the information about the end date and reasons for both antibiotics should have been verified at the time of admission. DON B stated this information should have been found out at the time of admission.

Based on interview and record review, the facility did not ensure the accuracy of assessment related to Minimum Data Set (MDS) for 1 of 1 resident reviewed (R1).R1 had a Preadmission Screening and Resident Review (PASARR) 1 and 2 completed, which the MDS assessment did not reflect.R1 was admitted to the facility on [DATE].Surveyor reviewed R1's health record. PASARR 1 was completed upon admission dated 03/01/24. PASARR 2 was completed on 03/13/24.Surveyor reviewed R1's MDS assessments. The annual MDS on 03/01/24 indicated R1 did not have a PASARR 1 completed. A correction was made to reflect that R1 did in fact have both PASARR 1 and 2 completed.Upon further review, the MDS assessments completed after the correction had the previous information stating R1 did not have either PASARR completed.On 01/28/26 at 2:46 PM, Surveyor interviewed Social Worker (SW) D. SW D stated PASARR level 1's are completed upon admission and if the resident will be there 30 days or less, SW D would send the information to the county. SW D stated if the resident would be there longer than 30 days, the PASARR 2 will be submitted right away. SW D stated SW D updates the MDS all the time when changes occur. Surveyor showed SW D where the MDS assessments indicated no PASARRs were completed. SW D stated SW D would look into it.On 01/28/26 at 3:05 PM, Surveyor interviewed Clinical and Quality Consultant (CQC) E. CQC E stated there may be a glitch in the system that is pulling the old information from the MDS. CQC E stated there was a nurse working at the time that may have changed the information on the MDS back to the original information, but that nurse no longer worked there. CQC E stated CQC E stated it may not help at this time, but the facility would be working on fixing the issue so it would not continue to occur.

Based on interview, record review, and facility document and policy review, the facility failed to protect Resident #3's right to be free from repetitive verbal and mental abuse perpetrated by another resident (Resident #1). Specifically, Resident #1 yelled at their roommate, Resident #3, to shut up, shut their mouth, or stop talking on multiple occasions. This deficient practice affected 1 of 13 sampled residents.Findings included:A facility policy titled, Resident Safety Abuse Policy, revised 02/2022, specified, Residents have the right to be free from abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, visitors, friends, or other individuals. The policy also indicated, b. Verbal Abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability, and e. Mental Abuse includes but is not limited to humiliation, harassment, and threats of punishment or deprivation.A Face Sheet revealed the facility admitted Resident #1 on 06/25/2025 and readmitted the resident to the facility on [DATE]. According to the Face Sheet, the resident had a medical history that included diagnoses of unspecified dementia with other behavioral disturbance and generalized anxiety disorder. A Face Sheet for Resident #1's 07/24/2025 readmission revealed the resident was discharged from the facility on 09/03/2025. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/02/2025, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. The MDS revealed Resident #1 exhibited verbal behavioral symptoms directed toward others during one to three days of the seven-day assessment look-back period that significantly disrupted care or the living environment for others at the facility.A Face Sheet indicated the facility admitted Resident #3 on 10/12/2022. According to the Face Sheet, the resident had a medical history that included a diagnosis of other symptoms and signs involving cognitive functions and awareness.An annual MDS, with an ARD of 07/25/2025, revealed Resident #3 had a BIMS score of 6, which indicated the resident had severe cognitive impairment.Resident #3's Care Plan included a problem area, dated 09/24/2025, that indicated the resident had a potential for alteration in thought processes. Interventions instructed staff to approach the resident in a quiet calm manner, dated 07/31/2025. Review of Resident #1's and Resident #3's medical records revealed they were roommates during Resident #1's stay at the facility.Resident #1's progress notes revealed an entry dated 08/12/2025 at 11:12 PM that indicated Resident #1 began yelling that they wanted a roommate, because they were scared. The note indicated a certified nursing assistant (CNA) positioned Resident #1's roommate (Resident #3) in the doorway of their room so Resident #1 could see them, but Resident #1 began yelling at their roommate, Get out of here. The note indicated the CNA removed the roommate, and Resident #1 stated they did not want the roommate in their room because the roommate talked all night.Resident #1's progress notes revealed an entry dated 08/13/2025 at 5:52 AM that indicated Resident #1 yelled out several times at [his/her] roommate to 'shut up' and was reminded that it was not nice to yell at their roommate.The facility's 24-Hour Report Sheet, dated 08/13/2025, indicated Resident #1 was yelling at their roommate.Resident #1's progress notes revealed an entry dated 08/17/2025 at 11:13 PM that indicated Resident #1 became loud and disruptive at bedtime, yelling and screaming out to their roommate to Shut up and Shut your mouth.Resident #1's progress notes revealed an entry dated 08/22/2025 at 5:33 AM that indicated Resident #1 continued to yell Shut up at their roommate because the roommate was talking. The note indicated Resident #1 did not like their roommate talking and continued to yell out.Resident #1's progress notes revealed an entry dated 08/22/2025 at 9:39 PM that indicated Resident #1 was continuously using the call light and complained of their roommate talking in their sleep. According to the note, Resident #1's roommate was quietly talking in their sleep, and Resident #1 was angry that their roommate did not stop talking.The facility's 24-Hour Report Sheet, dated 08/22/2025, indicated Resident #1 was yelling at their roommate.Resident #1's progress notes revealed an entry dated 08/26/2025 at 6:38 AM that indicated Resident #1 yelled at their roommate throughout the shift, Shut up and Stop talking. The note indicated Resident #1 was educated that it was not appropriate to yell at people and that others were trying to sleep. The note indicated Resident #1 stated, I don't care, I can't sleep with [the roommate] talking. The note indicated that staff had not heard the roommate talking.The facility's 24-Hour Report Sheet, dated 08/26/2025, indicated Resident #1 was yelling at their roommate, who was not talking.Resident #1's progress notes revealed an entry dated 08/27/2025 at 2:08 AM that indicated Resident #1 yelled, Shut up at their roommate, who was not talking. The note indicated Resident #1 was reminded that others were trying to sleep, but Resident #1 continued to yell out. The note indicated Resident #1 was taken to the television (TV) room for a period of time, and once their roommate fell asleep, Resident #1 was assisted back into bed.The facility's 24-Hour Report Sheet, dated 08/27/2025, indicated Resident #1 was yelling shut up at their roommate, who was not talking. The Report Sheet indicated Resident #1 was taken to the TV room until the roommate was asleep, and then Resident #1 was put back to bed.Resident #1's progress notes revealed an entry dated 08/31/2025 at 2:04 AM that indicated Resident #1 was yelling at their roommate for talking and coughing. The note revealed Resident #1 was educated that their roommate could talk and cough and that Resident #1 should not yell at the roommate. The note indicated Resident #1 was reminded to please not yell at their roommate.Resident #1's progress notes revealed an entry dated 09/01/2025 at 6:45 AM that indicated Resident #1 yelled at their roommate several times throughout the shift to Shut up. The note indicated Resident #1 was reminded to not yell at their roommate as they were waking others up. The note indicated Resident #1 stated, I don't care, I can't sleep. Tell [him/her] to shut up. The note indicated the resident was reminded several times not to yell, and around 2:00 AM Resident #1 was taken to the TV room where they watched TV while their roommate fell asleep, and then Resident #1 was assisted back to bed around 2:45 AM.During an interview on 11/10/2025 at 7:18 AM, Licensed Practical Nurse (LPN) O stated Resident #1 was anxious and became scared when they did not know what was going on. LPN O stated that when Resident #1 was in bed at night, they yelled at Resident #3 to shut up. LPN O stated Resident #3 was hard of hearing and probably did not hear what was being said, but it was not good from a psychosocial standpoint for Resident #3 to be told to shut up multiple times a day.During an interview on 11/10/2025 at 9:26 AM, CNA P stated Resident #1 frequently told their roommate to shut up in the middle of the night. According to CNA P, Resident #1's roommate talked in their sleep, which would set Resident #1 off. CNA P stated that verbal and mental abuse included name-calling and using a raised voice. CNA P stated that telling a resident to shut up would be considered abuse.During an interview on 11/10/2025 at 9:40 AM, CNA F stated that if a resident told another resident to shut up, it was considered abusive. CNA F stated she had heard Resident #1 tell their roommate to shut up.During an interview on 11/10/2025 at 10:15 AM, the Director of Nursing (DON) stated verbal and emotional abuse included name calling, making derogatory remarks, and yelling at someone to get out of the way. The DON stated if a resident was being told to shut up, it could be considered harassment.During an interview on 11/10/2025 at 11:10 AM, the Administrator stated both residents were highly confused, and she did not know if they were really hearing what was being said.

Based on interview, record review, and facility document and policy review, the facility failed to ensure a care plan was developed to address ongoing verbal behavioral symptoms directed toward others for 1 (Resident #1) of 13 sampled residents.Findings included:A facility policy titled, Resident Assessment Instrument and Person-Centered Care Planning, revised 06/2024, indicated, iii. The comprehensive care plan will be developed to ensure the resident receives the desired care and services to attain or maintain their highest practicable physical, mental and psychosocial well-being. The policy also indicated, vi. The care plan will be revised as often as necessary to ensure that it provides an accurate depiction of the care of the resident, IDT [Interdisciplinary Team] members should evaluate the appropriateness of the care plan after each quarterly, annual and significant change assessment and modify the care plan on an ongoing basis as appropriate. The policy also indicated, The care plan is an evolving document that is updated continuously as care needs change and fluctuate.A Face Sheet revealed the facility admitted Resident #1 on 06/25/2025 and readmitted the resident to the facility on [DATE]. According to the Face Sheet, the resident had a medical history that included diagnoses of unspecified dementia with other behavioral disturbance and generalized anxiety disorder. A Face Sheet for Resident #1's 07/24/2025 readmission revealed the resident was discharged from the facility on 09/03/2025. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/02/2025, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. The MDS revealed Resident #1 exhibited verbal behavioral symptoms directed toward others during one to three days of the seven-day assessment look-back period that significantly disrupted care or the living environment for others at the facility. Section V Care Area Assessment (CAA) Summary of the MDS revealed the Care Area of Behavioral Symptoms was checked to indicate the Care Area triggered for care plan decision making.Resident #1's progress notes revealed an entry dated 07/01/2025 at 9:36 PM that indicated Resident #1 has been yelling out for staff to call their spouse because they were lonely, the power of attorney (POA) was called, and the resident said they wanted a roommate.Resident #1's progress notes revealed an entry dated 07/26/2025 at 9:17 PM that indicated Resident #1 yelled out quite a bit during the shift to call their spouse; a family member was called and came to the facility; the spouse came to the facility; and the resident repeatedly asked when a family member would come.Resident #1's progress notes revealed an entry dated 07/27/2025 at 6:26 PM that indicated Resident #1 yelled out for staff to call their spouse, and after speaking to their spouse on the phone, Resident #1 kept yelling and upset other residents in the television (TV) room.Resident #1's progress notes revealed an entry dated 08/06/2025 at 7:32 PM that indicated Resident #1 yelled out, repeated statements, and was not easily redirected.Resident #1's progress notes revealed an entry dated 08/10/2025 at 11:37 AM that indicated Resident #1 yelled out feed me very loudly over and over, was assured someone would assist them, but continued to yell until they were fed. Resident #1's progress notes revealed an entry dated 08/12/2025 at 11:12 PM that indicated Resident #1 began yelling that they wanted a roommate, because they were scared. The note indicated a certified nursing assistant (CNA) positioned Resident #1's roommate in the doorway of their room so Resident #1 could see them, but Resident #1 began yelling at their roommate, Get out of here. The note indicated the CNA removed the roommate, and Resident #1 stated they did not want the roommate in their room because the roommate talked all night.Resident #1's progress notes revealed an entry dated 08/13/2025 at 5:52 AM that indicated Resident #1 yelled out several times at [his/her] roommate to 'shut up' and was reminded that it was not nice to yell at their roommate.Resident #1's progress notes revealed an entry dated 08/17/2025 at 11:13 PM that indicated Resident #1 became loud and disruptive at bedtime, yelling and screaming out to their roommate to Shut up and Shut your mouth.Resident #1's progress notes revealed an entry dated 08/22/2025 at 5:33 AM that indicated Resident #1 continued to yell Shut up at their roommate because the roommate was talking. The note indicated Resident #1 did not like their roommate talking and continued to yell out.Resident #1's progress notes revealed an entry dated 08/24/2025 at 09:29 AM that indicated Resident #1 was yelling, being disruptive, and interfering with other residents' abilities to sleep. The progress note revealed Resident #1 stated they did not feel well, but refused to take their medications. The progress note revealed the facility called a family member to come to the facility to manage [Resident #1's] behaviors.Resident #1's progress notes revealed an entry dated 08/26/2025 at 6:38 AM that indicated Resident #1 yelled at their roommate throughout the shift, Shut up and Stop talking. The note indicated Resident #1 was educated that it was not appropriate to yell at people and that others were trying to sleep. The note indicated Resident #1 stated, I don't care, I can't sleep with [the roommate] talking. The note indicated that staff had not heard the roommate talking.Resident #1's progress notes revealed an entry dated 08/27/2025 at 2:08 AM that indicated Resident #1 yelled, Shut up at their roommate, who was not talking. The note indicated Resident #1 was reminded that others were trying to sleep, but Resident #1 continued to yell out. The note indicated Resident #1 was taken to the television (TV) room for a period of time, and once their roommate fell asleep, Resident #1 was assisted back into bed.Resident #1's progress notes revealed an entry dated 08/27/2025 at 9:07 AM that indicated Resident #1 screamed at others and made disruptive sounds daily. Resident #1's Care Plan, printed on 10/21/2025, revealed no documented evidence of goals or interventions related to the resident's ongoing verbal behavioral symptoms. During an interview on 10/22/2025 at 12:51 PM, Licensed Practical Nurse (LPN) L stated Resident #1 had behaviors, was disruptive, and yelled out. During an interview on 10/22/2025 at 1:19 PM, the Minimum Data Set (MDS) Coordinator stated that Resident #1 was not compliant with care and refused care. The MDS Coordinator acknowledged Resident #1's care plan should have been updated with interventions related to continuous behaviors of yelling. The Medical Director (MD) was interviewed on 10/23/2025 at 9:12 AM. The MD stated that at minimum interventions should have been care planned for all re-occurring behaviors and reassessed for effectiveness.During an interview on 10/23/2025 at 10:11 AM, the Director of Nursing acknowledged that Resident #1's care plan should have been updated with interventions related to the resident's behaviors. The Administrator was interviewed on 10/23/2025 at 10:37 AM. The Administrator acknowledged Resident #1's care plan should have been updated with interventions related to their behaviors. During an interview on 11/10/2025 at 1:49 PM, the Social Services Director stated they had determined there was a problem in their system with updating the CAAs that were checked on the MDS.

Based on interviews and record review, the facility failed to protect the resident's right to be free from verbal abuse by staff for 1 of 32 residents (R) reviewed for abuse (R2). Registered Nurse (RN) C verbally abused R2 by yelling and swearing at R2 while wheeling R2 down the hallway in the wheelchair. Facility did not ensure interventions were in place to ensure verbal abuse did not occur to nonverbal, vulnerable residents. This is evidenced by: Facility's policy titled Facility policy titled: Resident Safety Abuse policy, dated 2/22, states in part, under Section titled Protocol: states in part, 2. Application (a) the policy is regarding resident safety has application in the manner in which: .v. The staff members are supervised. R2 was admitted to the facility on [DATE] with diagnoses that include dementia and aphasia. R2's most recent [NAME] Data Set (MDS) assessment dated [DATE] indicated that R2 has both short and long-term memory problems and is severely impaired cognitively. Facility reported incident submitted to state agency on 05/29/25 stating: Staff reported that RN C yelled at R2 well god damn it pick your feet up. Staff reported that RN C has seemed to be impatient and anxious recently. Also reporting the RN seems to appear like is in a hurry. RN C stated, I was not as nice as I should have been. RN C also admitted that sleep schedule is off and has been very tired. RN C also stated needs to ask for assistance sometimes. On 06/13/25 at 10:15 AM, Surveyor requested information on how the facility plans to prevent further abuse from occurring. Surveyor received a sheet of paper that stated the following: On 05/24/25: RN C suspended. On 05/28/25: RN C completed education and was able to return to work. (Of note, Surveyor was given certificates of education provided to RN C to include stress management, abuse, and dementia care. RN C returned to 2nd shift duty on this date with no evidence of increased supervision provided during the shift.) On 05/29/25: Chatted with a few residents. No issues yesterday evening. (Of note, R2 is not interviewable and unable to report issues.) On 06/09/25: Watched RN C good interactions. (Of note: no details of what was observed or if potential residents at risk were observed.) On 06/12/25: Touched base with RN C, feels is doing good. There have been no other issues. Has been observed many times with positive interactions with residents. RN C completed additional education as directed. After reviewing the above mentioned audit notes regarding RN C, the facility did not do the following: -Audit notes did not state what residents were spoken to or what questions the residents were asked. -Audit notes did not state what was observed with RN C having good interactions. Facility did not state if potential residents at risk were observed. -Audit notes stated they touched base with RN C and feels is doing good. Facility did not show evidence that this comment would ensure residents will be free from verbal abuse. -Audit notes did not state specifics in detail as to how the facilty will ensure abuse will not reoccur for vulnerable residents who are unable to speak for themselves. No resident or staff have reported any negative interactions.(Of note: undated and no further interviews conducted.) Facility documentation shows three staff members who were interviewed at the time of the investigation stated, [RN C] is kind of short with the residents, Just stay out of [RN C's] way she is a tornado just on a mission, and [RN C] is not always patient. Three staff members stated [RN C] is in a hurry always, I would not say she is mean, but not nice either. On 06/13/25 at 11:58 AM, Surveyor interviewed DON B who was unable to provide any further information as to how they are monitoring the behaviors of nonverbal residents for abuse and what the facility has in place to prevent abuse from occurring for the nonverbal residents who can't speak for themselves.

Based on interview and record review, the facility did not ensure a thorough investigation was conducted of a staff to resident verbal abuse. The facility did not conduct a thorough investigation to ensure other residents have not been affected by abuse or have knowledge to prevent further potential abuse by Registered Nurse (RN) C for 1 of 32 residents (R2). Findings include: Facility policy titled: Resident Safety Abuse policy, dated 2/22, states in part, under Section 9. Procedure for Investigation: a. All alleged violations will be thoroughly investigated, and all investigations are conducted by or coordinated through facility administration.m. The facility must have evidence that all alleged violations are thoroughly investigated. R2 was admitted to the facility on [DATE] with diagnoses that include dementia and aphasia. R2's most recent [NAME] Data Set (MDS) assessment dated [DATE] indicated that R2 has both short and long-term memory problems and is severely impaired cognitively. The facility reported incident submitted to state agency on 05/29/25 stating: Staff reported Registered Nurse (RN) C yelled at R2 Well god damn it pick your feet up. Staff reported RN C has seemed to be impatient and anxious recently. Also reporting the RN C seems to appear like she is in a hurry. RN C stated, I was not as nice as I should have been. RN C also admitted her sleep schedule is off, and she has been very tired. RN C also stated she needs to ask for assistance sometimes. The facility started an investigation immediately suspending RN C. The facility interviewed the staff witness and 3 additional staff members. R2 was non-interviewable, and the facility completed 3 resident interviews from the building. The investigation had no evidence of interviews with other residents that reside in the facility or staff to ensure they were not subjected to verbal abuse by RN C. On 06/13/25 at 10:15 AM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding the lack of interviews with other residents and staff members, NHA A stated, That's all I had written down. On 06/13/25 at 11:58 AM, Surveyor interviewed Director of Nursing (DON) B regarding RN C's probability of having contact with all residents in the building. DON B stated RN C could have contact with all residents in the facility during a shift. Surveyor interviewed DON B regarding the statements made by the 3 staff members at time of investigation, stating [RN C] is kind of short with the residents, Just stay out of [RN C's] way she is a tornado just on a mission, and [RN C] is not always patient. Three staff members stated [RN C] is in a hurry always, I would not say she is mean, but not nice either. Surveyor asked if this would be an indication to investigate further. Director of Nursing (DON) B stated, I see what you mean,

Based on record review and interview, the facility did not accurately code the Minimum Data Set (MDS) assessments for 2 of 13 residents (R) reviewed. (R1 and R27) R1's MDS assessment is coded in error stating that a PASARR level 2 screen had not been completed when it was completed at the time of assessment. R27 receives hospice services; the MDS assessments were not coded for hospice service. This is evidenced by: Example 1 R1 was admitted to the facility on [DATE] with diagnoses including schizophrenia effective disorder, and anxiety. Review of R1's medical record found a PASARR level 2 screen was completed, dated 03/01/24. R1's admission MDS assessment, dated 03/07/24, indicated for question A1500 that no PASARR level 2 had been completed. On 10/16/24 at 9:46 AM, Surveyor interviewed Registered Nurse (RN) C, MDS coordinator, about the coding of R1's 03/07/24 MDS not having a PASARR level 2 completed. RN C indicated she did not start the MDS position until 07/15/24 and still has not been completing MDSs alone. Executive Assistant (EA) D indicated the previous MDS coordinator would have completed the MDS. EA D indicated a correction MDS will be completed. Example 2 R27 was admitted to the facility on [DATE] with diagnoses including dementia without behaviors, abnormal finding of lung and kidney and ureter, repeated falls, cancer of bronchus and lung, pain, restlessness and agitation, and anxiety disorder. On 12/29/23, R27 was enrolled with hospice services. R27's MDS quarterly assessments, dated 07/08/24 and 10/08/24, section O0110K1B was not coded receiving hospice services. On 10/16/24 at 9:48 AM, Surveyor interviewed RN C about R27's MDS dated [DATE] and 10/08/24 not coded receiving hospice services. RN C indicated R27 is on hospice. RN C indicated that she would have completed the MDS on 10/08/24 and may have just copied from the previous MDS. EA D indicated the previous MDS coordinator would have completed the 07/08/24 MDS and EA D will send in a correction for the MDSs

Based on observation and interview, the facility did not store food in accordance with professional standards for food service safety. This has the ability to affect 35 of the facility's 36 residents. In the refrigerator, raw hamburger was observed stored above fully cooked meats. In the freezer, multiple food items were stored directly on the freezer floor which does not allow for proper air circulation. This is evidenced by; Observations made during the initial kitchen tour on 09/17/19 at 8:41 AM In a refrigerator, two pans of raw hamburger that were made into meatloaf were observed on a shelf above sliced, fully cooked ham, and a frozen tube of hamburger was observed to be thawing above fully cooked diced chicken. Interview with Cook [NAME] as she is pulling and identifying the items in the refrigerator, and placing the items on different shelves. The Surveyor asked why she was placing items back onto different shelves. Cook [NAME] stated because raw foods belong lower than fully cooked items. The cook added that she didn't place all of the items in the refrigerator and added the meatloaf is the PM shift's. Surveyor noticed a sign on cooler door which indicated to store items in a proper hierarchy and asked the cook about this, to which she responded that, this isn't the first time things have been like that. Observations in the facility's walk in freezer revealed 13 boxes of frozen foods sitting directly on the freezer floor. Cook [NAME] assisted in identifying the items on the floor at 8:58 AM. They included boxes of cod, garlic toast, ice cream, doughnut holes, hash browns, a big box of Girl Scout cookies, two boxes of cookie dough, asparagus, crumbled sausage topping, pre cooked noodles and a box of carrots. On 09/17/19 at 10:58 AM, an interview with dietary manager (DM) D revealed that staff told her about the raw meat being stored over the top of cooked meat and about the things on the floor in the freezer. Surveyor requested policy and procedures related to food storage. The policy entitled Food Storage Standards reads in part: All foods are covered and raw meat items are stored below cooked items. and Freezer storage areas are designed and maintained to promote proper air circulation.

Based on interviews and personnel record review, the facility did not ensure that all persons administering medications are authorized according to state and federal requirements for 1 of 1 medication aide reviewed. This has the potential to affect all 36 residents. The facility did not have verification of annual four hours of pharmacy in-service for Certified Nursing Assistant (CNA) working as a Medication Aide throughout the facility. This is evidenced by: According to the Wisconsin Department of Health Services, Unlicensed personnel are required to meet specific requirements to be able to administer medications to Wisconsin nursing home residents . To maintain medication aide status a medication aide must complete 4 hours of pharmacy related in-service and 100 hours of work each calendar year. The medication aide must keep 3 full years of records showing they completed the 100 hours of work and 4 hours of in-service. If for some reason the hour requirements have not been met or the records maintained, please contact the DQA pharmacy consultant to determine the steps to become reinstated as a medication aide. Certified Nursing Assistant (CNA) G was hired by facility on 7/31/18. According to the Wisconsin Nurse Aide Registry, CNA G completed a medication aide program on 7/10/17. Thus far in calendar year 2019, CNA G has worked 87 hours as a Medication Aide at this facility. On 9/18/19, Surveyor requested documentation of CNA G's annual 4 hours of pharmacy-related in-service to ensure continued compliance. Facility supplied documentation of: Respiratory Therapy 101 (MONTH) Med Tech/Nurses Meeting-2 hrs, Med Tech Responsibilities & Wound Care-1 hr, and Medication Administration-1 hr; all completed in (YEAR). Surveyor then requested any training that would satisfy requirement for calendar year (YEAR). Facility supplied a Certificate of Completion for Medication Management Overview (1.5 HR), dated 5/15/2019, and Orientation/Skills Checklists completed by CNA G's second employer, dated (MONTH) 2019. No documentation was provided to verify pharmacy-related in-service during the year (YEAR). On 09/19/19 at 2:35 PM, Surveyor interviewed Nursing Home Administrator (NHA). Surveyor asked if the facility had any further documentation that would suggest CNA G completed four hours of pharmacy related in-service in (YEAR) to remain in compliance to work as a Medication Aide. NHA stated the facility has supplied all documentation they have. Surveyor asked how the facility determined CNA G was eligible to work as a Medication Aide. NHA stated she thinks CNA G must have had the training through her other employer; however, the facility does not have any documentation to support this claim.

Based on record review and interview, the facility did not maintain medical records on each resident that are complete in accordance with accepted standards and practices for 1 of 14 sampled residents, Resident (R) 31. R31's medical record was not documented completely. R31 was involved in resident to resident incidents; the details of the incidents and interventions related to incidents are not documented. This is evidenced by: Review of R31's medical record revealed the following information. R31's [DIAGNOSES REDACTED]. Review of resident to resident interactions involving R31 revealed on 07/09/19 at 2:29 p.m. R31 was witnessed kicking a peer's chair and leg when she was on the way to her table. Patient was later witnessed kicking another peer in the leg. Patient later witnessed elbowing another peer. The medical record does not document any indication as to who the other residents involved were, whether or not any injuries occurred, nor interventions that were put into place to keep residents safe or to prevent reoccurrences. Review of resident to resident interactions involving R31 revealed on 08/18/19 at 6:30 p.m. R31 was witnessed grabbing another resident. The residents separated on their own. The medical record does not document any indication of who the other resident is, or whether or not an injury occurred or if any interventions were put into place in order to prevent further occurrences. Review of resident to resident interactions on 08/21/19 revealed witnessed physical contact with peer. The medical record does not document what happened, whether or not any injury occurred or if any interventions were put into place. Surveyor requested further information related to the above incidents from the facility Nursing Home Administrator (NHA) on 09/18/19 at 1:30 p.m. Surveyor interviewed NHA on 09/19/19 at 12:15 p.m. When asked whom the other residents were who were involved in the 07/09/19 incident, NHA said perhaps it was, another resident's first name, but they weren't totally sure who all was involved. Surveyor again asked for more information. The NHA stated she was certain investigations were completed, and interventions were put into place but they do not have any further documentation in relation to these incidents.

Based on observation, interview and record review, the facility did not ensure a resident with a [DIAGNOSES REDACTED]. This occurred for one of twelve residents (Resident (R) R16) reviewed who have a [DIAGNOSES REDACTED]. R16 has dementia and exhibits wandering behaviors, sexual behaviors, smearing of bodily fluids in public places, and yelling out with disruptive comments which affects other residents in the facility. Staff did not complete a comprehensive assessment of physical, psychosocial and sexual needs to identify triggers, evaluate current interventions and implement new interventions to address the behaviors. This is evidenced by: R16 admitted on [DATE] with [DIAGNOSES REDACTED]. Significant Change in Status (SCIS) Minimum Data Set (MDS) 07/18/19 Brief Interview for Mental Status score (BIMS) of 7 which indicates severe cognitive impairment. Behaviors 4-6 days of threatening screaming at others, 4-6 days of hitting scratching or public sexual acts. Not disruptive to living environment or intrudes on activity of others. Transfer dependent assist of one, bed mobility and walking, frequently incontinent of bowel and bladder (b/b) is on a b/b program. On 09/17/19 at 9:35 AM, Surveyor heard falls alarm sounding from R16's room. Staff went to assist R16. Surveyor interviewed R16 who denies depression, observed R16 is sleepy with eyes partially shut during interview. Medical record review includes medications in part: [MEDICATION NAME]. [MEDICATION NAME] 25 mg bid (twice a day) for dementia with disruptive behaviors. On 07/02/19, [MEDICATION NAME] was increased from 25 mg daily to 25 mg twice a day for increased sexual behaviors. Care Plan in part, 02/22/18 .may make flirtatious comments to male residents/staff and may also attempt to touch them by rubbing their back or touching their wheelchair, redirect as needed .may be resistive to redirection and threaten to hit staff or become verbally aggressive. Be mindful of your proximity. may frequently cough and clear her throat this may disrupt other residents .offer kleenex, meet needs and re-direct. 04/30/19 Utilize newly developed 'conversation reminiscing book' blue folder to intimate, engage, and promote positive socialization. For undesirable behaviors related to phlegm/saliva management respond with 'do' versus do not. when I have phlegm in my throat I like to use a kleenex. Respond to emotion or need being displayed or communicated by behavior versus behavior itself. (This is the most recent update to the behavior of flinging and wiping phlegm throughout the facility other than the dining room intervention that was updated on 07/25/19.) 06/20/19 Expression of sexual behaviors in open areas of facility masturbating in public, sexual comments directed toward male resident .respectfully redirect to a private location if expression of sexuality is in open areas with other residents . 07/25/19 .Allow expression of sexuality but in a private location. 07/25/19 During dining times .may cough up phlegm remover her dentures, scratch her groin and wipe it on the table. If she is noted to be displaying any of these behaviors encourage her to eat in the small dining room to promote a positive dining experience for her .and her peers as her peers have a history of reprimanding her/telling her she is 'disgusting' which increases her agitation and she becomes argumentative. Disruptive Verbally: offer a snack or cup of coffee, ask if she needs to use the bathroom, assist to an activity or find a magazine .chart behavior, chart any sexual behaviors. 07/02/19 increase in [MEDICATION NAME]., manifested by .putting hands in pants, smearing feces, masturbation in public area, history of sexual comments to males, negative comments. verbal threats to staff .wandering in to other resident rooms at times. 08/06/19 When expressing her sexuality in public area of facility, redirect to the privacy of her room. If wander in to another resident's room, (may rummage) quietly redirect. (This intervention was initiated on the care plan on 06/20/19.) 09/04/19 .monitor resident interactions, may interrupt conversations. Redirect as needed .may frequently call out ouch, help me, 'oh god' 'you are hurting me' .contact son to come visit .remind her that son comes to visit every day and eats meals with her .when making disruptive sounds evaluate situation to determine if she has any unmet needs, needs to use bathroom, is feeling lonely, tired, hungry, thirsty or bored. Make attempts to meet needs. When she is agitated give her the rosary that is in the drawer in the TV room and this help her calm down. (MONTH) also give her ipod to listen to music, if appears agitated, offer some 1:1 time in a quiet location. (The intervention of the ipod and rosary were initiated on the care plan on 07/17/18, the son has routinely come to visit frequently so not a new intervention). Nurses note in part, 07/08/19 Targeted behavior: inappropriate sexual comments. Is this behavior persistent? Yes. continues to make sexual comments to staff and other residents. On 07/02/19 increased [MEDICATION NAME] from 25 mg - 50 mg. Outcome of last increase: no sexual comments noted since the medication increase. 07/11/19 .incontinent of stool, stuck hands in pants and smeared stool on the railing as well as the privacy curtain, when staff helping yelled at them to hurry up! 10:43 p.m.,resident go up to random resident and say things like 'you are stupid' went in other resident's rooms and said she was going to 'shoot him and kill him'. 07/15/19 clearing throat and tossing the tissues she was spitting into on the floor. Redirected. 07/18/19 Medical director review. No changes at the current time. Staff to continue to monitor behaviors. See care plan in regards to behavior triggers and also ways for staff to better aid in control of behaviors. Life story book, music, 1:1(one to one), 5 ways for staff to better aide in behaviors, 5 alive activities. 07/20/19 offered to go to bed with male resident, he said, over my dead body, spitting and wiping it on the hand rail, kicking med cart. 07/21/19 exit seeking back door, redirected. 07/24/19 was taking off her sports bra and shirt in the dining room when a few peers were present, assisted by staff . 07/28/19 .in front of room [ROOM NUMBER] and yelling at resident in room [ROOM NUMBER] and him talking loudly at her, staff has been attempting to redirect her each time. 08/04/19 In room [ROOM NUMBER] stripped clothes and put on another resident's clothes, Moving that resident's things .redirected. On 09/18/19 at 12:40 p.m., Surveyor interviewed the Nursing Home Administrator (NHA) and asked about several of the above notes. Surveyor asked whose clothes and things were being moved in the note for 08/04/19. NHA indicated R28 and R25's room; they were not in the room so it did not affect anyone. Nurses' notes continue, in part: 08/0719 wanting a male resident to kiss her. Spitting into hands and flinging it on floor, wiping it on walls, handrails, Argumentative with another resident . Surveyor interviewed NHA asking who the male resident is on 08/07/19. NHA states she does not know what male, but R16 was redirected to another room, was effective intervention. The resident was not bothered at that time or NHA would have included the name, so no effect on other resident. 08/13/19 loud yelling intrusive c/o pain in knee. given [MEDICATION NAME] gel, tylenol and [MEDICATION NAME]. She continues to yell and c/o pain. Was screaming in hall to go to bed and that she hurt all over. 08/18/19 has been loud, intrusive, spitting phlegm into her shirt or into hand then wiping it on handrails, walls, her bedside table.calling staff lazy and that she was going to hit staff. Got into verbal argument with another resident and told that res she was going to hit her. removed from area given memory book, looked a few minutes then obsessed with going to the bathroom wanting peri area washed, stopped a male resident and asked him to get a washcloth and 'wash my butt', wanted another male resident to love her. Surveyor asked the NHA on 09/18/19 who the male residents were in the note dated 08/18/19. NHA indicated R3 or R28 would have been the male residents. The NHA stated R16 was redirected it was effective. Staff had offered music and activity but resident has chosen not to do so. R16's nurses' notes continue in part: 08/21/19 email to Dr. regarding right shoulder discomfort that comes and goes with use since last observed on floor. 18:09 (6:09 p.m.)no c/o shoulder pain. 08/22/19 had some complaint of pain in right shoulder, patient able to use arm to help stand in bathroom, given tylenol. 08/23/19 c/o right shoulder pain with cares, when turned to side . 08/25/19 by nurses desk in front of peers room with her hand down her pants groaning out loud. Prior to this she was making sexual remarks to a male peer. She invited him back to her room and stated that 'older woman have experience too.' redirected to the bathroom. Surveyor interviewed NHA and asked what male resident was involved in the noted dated 08/25/19. The NHA stated it was R3 and that R16 was redirected, staff offered all interventions. R16's nurses' notes continue in part: 08/26/19 21:09 p.m. (9:09 p.m.) restless and shouting in hallways aggressive towards peers, offer use of headphones effective for 15 minutes, offered snacks, pain was assessed, provided 1:1, in west hall in hall with shirt off completely exposed in the hallway, assisted to put her shirt back on. 08/27/19 X-ray order of clavicle. Clavicle was found to have a healing fracture from fall on 08/10/19. 08/27/19 In room [ROOM NUMBER], pants down brief ripped off, had taken memory book belonging to one of the residents in that room and was starting to rip it apart. CNA intervened and assisted her to her room. changed brief and toileted her. X-ray result healing clavicular fracture, order for therapy for sling. wears sling intermittently, she takes it off and leave it where ever she can. Surveyor asked the NHA on 09/18/19 who resided in room [ROOM NUMBER]. NHA indicated it was R4, who has passed. R4 was not in the room when it happened so no effect on anyone. 8/30/10 9:39 a.m., witnessed slap, at 9:15 a.m., activity room sitting at table, resident slapped another resident . Surveyor interviewed with NHA and Social Services Director (SSD) F on 09/18/19 at 2:00 p.m. The NHA indicates R16 slapped R31 on the back, The residents were immediately separated. The NHA went through algorithm for reporting, not willful intention. Indicates neither remembered or affected afterwards. Did assess and update care plan for R31. NHA states R31 can agitate others. The behavior did not continue when monitored for next several days. Algorithm and documentation showed to Surveyor. R16's nurses' notes continue in part: 08/30/19 new orders for reddened labia/groin 08/31/19 c/o pain all over, given apap (Tylenol), [MEDICATION NAME] aches everywhere 09/02/19 .in the hall outside her bedroom door, having removed her shirt and bra . 09/11/19 OT consult, for dressing transfers with sling placement on right arm. denies pain in shoulder. 09/04/19 In #28's room, looking in his dresser drawers, staff redirected offered 1:1 conversation 09/12/19 .Activity Director gave R16 a cup of water, R16 then yelled 'I'm gonna toss this water on you, she repeated this several times which upset other residents who were in activity .was removed from activity and given her headphones. 09/14/19 resident found trying to push male resident's w/c into her room, staff intervened. resident stated, 'stay out of this I love him and he loves me' Male resident removed. Surveyor interviewed NHA to ask what resident was involved in the note dated, 09/14/19. The NHA indicated it was R28. R28 was monitored for depression signs and symptoms after this with no effects. NHA states R16 was redirected right away. R16 redirects with animals, story book, music and it was effective. Surveyor reviewed medical record for R28. R28 has severe cognitive impairment and would not be able to tell if the incidents affect him. Since increase in antipsychotic for behaviors, R16 has had multiple incidents where she has been sexually inappropriate, verbally abusive to other residents, smearing bodily fluids and one occurrence of physical abuse to another resident. Surveyor reviewed R16's behavior documentation for sexual behavior for three months. In June, three times verbally inappropriate sexual comments. In July, one occurrence. In August, eight occurrences. From (MONTH) 1-17, there have been six occurrences. Behavior documentation for coughing phlegm into hand and wipe it on objects or fling it: (MONTH) - 35 occurrences, (MONTH) 30 occurrences, (MONTH) 92 occurrences, (MONTH) 1 -17 it has occurred 15 times. The behavior monitoring does not include smearing of feces on objects. Observations On 09/18/19, during the breakfast meal observation, R16 ate no breakfast and threw her dentures on the floor. On 09/18/19 at 10:00 a.m., observed at nurses station in wheelchair with sling half off, right hand covering forehead, not engaged in any activities. On 09/18/19 at 10:30 a.m. in hallway, in wheelchair, wheeling up and down the hallway, very quiet, not yelling out. R16 is not supervised or engaged in any activity. On 09/18/19 at 12:20 p.m., observed R16 at lunch table. R16 took out her dentures, threw them on her lap, then they fell to the floor. On 09/19/19 at approximately 1:00 p.m., R16 was seated in the dining room at a table by herself, calling out, go get him, bring him here, I need him. Staff or other residents were not present in the area, interventions to engage R16 were not occurring. Group Interview Concerns during Group Meeting at 2:00 p.m. on 09/18/19. R11 states she overheard R16 say she was hot for him and she thought he was hot for her would you want to go home, to bed? R11 asked if Surveyor would like that. R16 is up all day and night in her night gown. R32 will not sit with R16, wipes her snot under the 1st table, when staff notice they clean extra. R11 and R26 state it is upsetting to them when someone goes into their room. R26 states R16 took candy from her table once, has come in to R26's room at 5:00 a.m. trying to use the bathroom. When these residents asked R16 to use her own bathroom R16 says it is too far down. R11 stated R16 knows what she is doing. Surveyor asked residents to rate from 1-10, 10 being the worst how bothersome R16's behaviors are: R11 rates a 20, bothers her that much R26 rates a 10 - R26 states R16 screams which R26 cannot take R25 rates about a 5 - It bothers others more than me. She doesn't proposition me at all or anything. R16 rates a 4- 5 R17 rates a 10, and objects to her smearing that snot all over On 09/18/19 at 12:40 p.m., Surveyor interviewed Social Services Director (SSD) F to ask for residents involved in above documentation and interventions. SSD F says R16 is redirectable with coffee and snacks. Has short term memory so doesn't recall. Likes rosary, talking on phone, I-pod music polka. Surveyor asked if staff are aware if R16's behaviors bother other residents. SSD F acknowledges R32 lived down that hall and moved to the other hall because R16 got into her room and ripped up some items. On 09/18/19 at 1:35 p.m., Housekeeper (HK) H states R16 spits on her hands and wipes on anything she can reach. HK H has seen R16 go into R25's room, R28's room, and R22's room. R16 forces her way into these rooms. R22 lies on his bed with his cane, R22 yells at R16 to get out of there. R16 says, Let me in I know you like girls. HK H states she tries to get R16 out of the room. I don't want R22 to hit her. There is not enough staff to catch her before it happens. Surveyor asked if there have been any new interventions with R16, which HK H states no changes. It is still happening. Last week I found her in R28's room going through his drawers and belongings R16's teeth were left in his room. HK H states frequently I hear her approach male residents and say can we cuddle or go back to my room? On 09/18/19 at 1:40 p.m., Surveyor interviewed Certified Nursing Assistant (CNA) I about R16's behaviors. CNA I indicated R16 has outbursts, yells at others and is sexually inappropriate to men. CNA I stated about one week ago, R16 asked R9 during mealtime if he was ready to go home and make love. This was done in the dining room in front of peers. Surveyor asked if CNA I had any specific dementia training. CNA I replied, No. On 09/18/19 at 2:00 p.m., Surveyor interviewed CNA C and asked about R16's behaviors. CNA C indicated R16 spits into her hand and wipes it everywhere. CNA C indicated sexual behaviors of taking her clothes off in front of others, masturbating in front off others. When we see it we take her to her room. CNA C indicated R16 follows men around and will follow them into their rooms and this upsets other residents. Surveyor asked if there are certain males R16 goes to. CNA C stated R25 and R6. They will tell her to leave them alone. Surveyor asked if there have been any changes made to the person centered interventions to prevent this. CNA C stated no changes, music and memory book but we've had those a few months. CNA C indicated R16 goes into others rooms and gets into their things. Surveyor asked how CNA C is to prevent this. CNA C indicated if I see her in the wrong room I go get her and redirect her. Surveyor asked if R16 is kept busy enough with activities to prevent things from happening. CNA C replied, Not exactly. Surveyor asked CNA C if she has had specific dementia training. CNA C replied, No. Surveyor asked if CNA C is aware of any triggers for the sexual behavior. CNA C indicated she does not know anything about triggers for R16's behaviors. On 09/19/19 at 6:15 a.m., Housekeeper (HK) J came to Surveyor with concerns about R16's behaviors affecting the cleanliness of the facility. HK J stated R16 frequently has incontinent bowel movements, puts her hands in her pants and puts feces everywhere. HK J indicated it has been put on the dining room tables, couch in the activity room, door frames of other resident's rooms. Surveyor asked if R16 has any triggers indicating when R16 will act out prior to this occurring. HK J stated no one catches it before, we have to clean it up after it happens. HK J shared concerns with R16 going after R22 trying to get into his room. R22 now has a cane so he can get her out of his room. HK J shares R16 goes into other rooms, goes through their belongings and puts on other resident's clothing. HK J has concerns this behavior is not acceptable to the other residents. Surveyor reviewed dementia training. CNA documentation was provided showing CNAs have had one hour of dementia training that was an online training. On 09/19/19 at 12:15 p.m., Surveyor interviewed SSD F asking what has been done about R16 smearing feces around. SSD F indicated R16 is checking herself for incontinence and then her hand gets dirty and she does not know what to do with it. Thinks this has only happened twice. Surveyor asked if toileting plan had been addressed. SSD indicated it was changed. Surveyor reviewed care plan and noted change in toileting plan dated 07/22/19. R16 has had this type of behaviors since this date with out identifying triggers or evaluating this intervention for effectiveness. Surveyor asked what goals or outcomes the facility and Health Care Power of Attorney (HCPOA) is desiring for R16. SSD F says to not have R16's behaviors affect others that live here. Surveyor asked if SSD F had done a sexual history assessment to determine R16's sexual and intimacy needs. SSD stated R16 has family that visits that gives her hugs. R16 has a stuffed cat in her room that she touches and kisses to meet her tactile needs. Surveyor asked if care plan was updated with potential for R16 to slap other residents after the 8/30/19 incident. SW said she does not think so but will update the care plan. The care plan was not updated with this behavior for R16. Surveyor asked what has been done for the behavior of phlegm being wiped everywhere. SSD F stated they offer kleenex as soon as resident needs it. R16 is given kleenex box, but due to dementia, loses the box and can not keep track of it. (The care plan has not been updated since 04/30/19 for general areas of the facility). It is noted the behavior monitoring document has increased to 92 occurrences in (MONTH) for this behavior. Surveyor asked SSD F if staffing levels have changed recently. SSD does not think so, they have adequate staff to care for residents but can't watch one resident all the time while you care for other residents. Surveyor asked for a comprehensive dementia assessment identifying what triggers have been identified for the above behaviors so that staff could intervene before the incident occurs (i.e. disrobing, masturbating, feces and phlegm smearing, yelling out, sexual comments to men.) Surveyor indicated the record review shows the interventions all occur after staff finds the incident occurring and wonder if some interventions could prevent the occurrences if the triggers were identified. SSD F indicates she completes section C (cognitive) Section D (mood) and Section [NAME] (behaviors) on the MDS. SSD F indicates there is no other assessment. Surveyor asked what R16's unmet needs are. SSD F stated R16 likes to be involved so talks loud during group or activities. SSD F indicated they did do a pharmacy med review for the phlegm, had considered [MEDICATION NAME] change but R16's daughter states she has had phlegm for years before the med so did not consider that. Facility looked into allergies [REDACTED]. (The nurses' notes dated 07/18/19 documents pharmacy and medical director review with no changes.) Surveyor asked for dates and documentation of these interventions. This information was not provided to the Surveyor. On 09/19/19 at 1:20 p.m., Surveyor interviewed HK J to ask for more details on the smearing of the feces. HK J indicated it has happened at least two times in the past month and ten times in the past three months. The table and couch in the activity room incident was approximately two months ago. The facility did not provide a comprehensive dementia assessment that identifies triggers for R16's behaviors. Interventions to address the behaviors have not been reevaluated for effectiveness for R16 as the behaviors have continued to affect R16's highest level of functioning and affected other residents. On 09/19/19 at 2:50 p.m., Surveyor interviewed the NHA about the above concerns. Dementia behaviors causing disruption for other residents. Surveyor indicated that R16 has sexual behaviors and could not locate a sexual assessment being done to determine R16's needs. The NHA stated it is done as needed if concern is identified. IDT (Interdisciplinary team) met and staff was trained on sexual intimacy policy. Surveyor asked for a policy for Dementia Care. The NHA stated they do not have a specific policy or procedure. The NHA indicated staff have had dementia training and in the past attending the dementia training at UW Oshkosh. Surveyor asked for a date; the NHA was not sure of the dates but it was not recent. Surveyor asked for an assessment with the full picture for physical, psychosocial and sexual needs to see if all areas were addressed. R16 had been experiencing pain due to clavicle fracture, and had a skin rash in her labia area during these behaviors. The NHA stated the facility has talked to Power of Attorney (POA) and taken a lot of steps to help her and other residents. Surveyor indicated needing information from the assessment that identify triggers that can be identified prior to behaviors occurring. Surveyor reviewed the significant disruptive behavior to other residents' environment as evidenced by the 92 documented behaviors in August, sexual comments towards several male residents, public disrobing, wandering into other's rooms. Surveyor shared that other residents have voiced concern with the behaviors and how it affects them. The NHA stated the facility has gone above and beyond to meet R16's needs and have to balance that this is R16's home too.

Based on observation, interview and record review, the facility did not provide care consistent with professional standards of practice to prevent the development of pressure injury for 1 of 4 residents, Resident (R) 18. R18 has an area of skin breakdown over the coccyx area; R18 was seated with direct pressure to area and not repositioned for more than 7 hours. This is evidenced by: R18 was admitted to facility on 4/19/19. Pertinent [DIAGNOSES REDACTED]. R18's Quarterly Minimum Data Set ((MDS) dated [DATE] indicates a Brief Interview for Mental Status score of 13, meaning R18 is cognitively intact. MDS also indicates R18 is totally dependent upon staff for bed mobility, transfers, locomotion and personal hygiene. MDS indicates R18 is at risk for developing pressure injuries, but does not indicate any current unhealed pressure injuries. Skin treatments indicated are: pressure-reducing device for chair, pressure-reducing device for bed, turning/repositioning program, and applications of ointments. R18's Care Plan PER ST. CROIX HOSPICE PROT[NAME]OL, states: Nurses: Assess skin condition daily and note any changes. Treat as ordered, Monitor med effect, Monitor use of skin protective devices. Develop and monitor turning schedule. Monitor vitals as needed, Keep clean and dry. Apply: Pressure relieving devices for chair, pressure relieving devices for bed, pressure relieving devices to extremities, flat heels in bed, Monitor turning/reposition program. A turning/repositioning program was not developed or implemented. R18's Nurse Aide Care Plan, dated 09/09/19, states: .offer to lie down/position change for relief of pressure/pain Q2-3 hours PRN (as needed). R18's most recent Braden Scale Assessment completed 7/22/19 showed a score of 15, which indicates a mild risk for skin breakdown. Previous Braden Scale Assessments dated 04/30/19 and 05/03/19 revealed scores of 14, indicating R18 was at moderate risk for skin breakdown. R18's Skin Care Flow Sheet revealed documentation of moisture associated skin damage small 0.5mm circular excoriated on left gluteal on 09/11/19. On 09/17/19, this area was documented as, Stage 2 2mm x 2mm inner circle .0.5cm x 0.25cm outside. On 09/17/19 at 9:39 AM, Surveyor interviewed R18. Surveyor asked if he has any wounds or sores anywhere; R18 replied, My bottom is raw like hamburger. It hurts. On 09/18/19 at 9:49 AM, Surveyor interviewed Registered Nurse (RN) [NAME] Surveyor asked if R18 has any pressure-related skin breakdown at this time. RN A stated she put a small [MEDICATION NAME] dressing on his buttocks yesterday because there was a small open area that was about 0.25cm. Surveyor asked if R18 has any interventions to prevent skin breakdown. RN A stated R18 has an alternating air mattress, and a soft thick cushion in his Broda chair that hospice provides. RN A stated R18 is repositioned from bed to chair all throughout the day, but sometimes likes to sit up while he watches TV and reads the paper. RN A stated R18 is not thrilled when asked to reposition side to side, but is agreeable. On 09/19/19 at 6:47 AM, Surveyor observed R18 sleeping in Broda chair with Hoyer sling under him. On 09/19/19 at 12:40 PM, Surveyor interviewed R18. R18 was seated in Broda chair in his room; Hoyer sling is noted to be under R18. Surveyor asked if R18 has laid down or changed positions at all today. R18 stated he has not laid down at all today. Surveyor asked if R18 wanted to lie down at all this morning. R18 stated, I suppose I could have. Surveyor asked if staff offered assistance to lay him down today. R18 stated, Nope. Surveyor asked if he is having any pain today and where the pain is located. R18 stated, yes, but it's better than yesterday. R18 stated the pain is on my seat. On 09/19/19 at 1:46 PM, Surveyor observed transfer of R18 from Broda chair to bed using Invacare Hoyer Lift. R18 was seated on Hoyer sling and had been observed to be sitting on Hoyer sling all morning. RN B and Certified Nursing Assistant (CNA) C performed the transfer. Once in bed, R18 was rolled to left side, revealing deep creases and indentations present on posterior upper thighs and buttocks. RN B removed [MEDICATION NAME] dressing from coccyx area revealing reddened skin with open area noted over coccyx; area noted would meet criteria for Stage 2 pressure injury according to the National Pressure Ulcer Advisory Panel. Surveyor asked what the open area was caused from. RN B stated, It looks like it's from pressure. Surveyor asked when the last time R18 was repositioned. CNA C stated he has not been repositioned since he got up at about 6:30 a.m. this morning. R18 had been sitting on his bottom for 7.25 hours without pressure relief for the current open area. On 09/19/19 at 12:53 PM, Surveyor interviewed Director of Nursing (DON). Surveyor asked if R18 currently has any pressure injuries. DON stated there is a slight open area about 0.5 x 0.25cm on his bottom. Surveyor expressed concerns with R18 being seated in same position in chair since 6:45 this morning, and asked if this was a common occurrence. DON did not offer any explanation for prolonged sitting that would have increased the risk of a pressure injury developing for R18.

Based on observation, record review and interview, the facility did not ensure that residents were treated with respect and dignity during meals. This occurred for 1 of 14 sampled residents observed during meals, Resident (R) 185. R185 was observed unable to eat in a dignified manner without spilling the food on self for four meal observations. This is evidenced by: R185 was admitted [DATE] from another facility, [DIAGNOSES REDACTED]. Surveyor interviewed R185 on the initial tour and noted R185 to be alert and oriented, answering questions accurately. The admission Minimum Data Set has not been completed as of 09/19/19. 09/17/19 12:16 PM During observations of the noon meal, R185 was seated approximately 12 inches from the table in a low broda type chair. R185's head was leaning to the right about touching her shoulder. R185 was having a hard time at first, then able to feed self ham, potatoes and peas. The peas spilled everywhere as R185 tried to get them to her mouth. R185 had apple juice in a covered mug with a straw. When R185 tried to bring cup to her and drink, the juice spilled. The back of the chair was not tilted up or forward during the meal to enable R185 to better reach the food. R185 had no adaptive equipment such as a lipped plate. On 09/18/19 at 8:20 a.m., during observation of breakfast, R185 was observed in broda chair which was leaning back. The back of the chair had not been brought forward to put the chair in a sitting position. R185 was 12-15 inches from table, reaching forward for her drink (orange juice) that was covered with a straw in it. R185's head was placed so that R185's nose was at the level of the table. R185's head was leaned far to the right. R185 had a straw tipped up to side of mouth to drink, spilling orange juice. At 8:23 AM, R185 was lifting orange juice again and spilling on self. At 8:25 a.m., R185 put straw in corner of mouth trying to drink. R185's head was extended far to the right almost resting on the right shoulder. Kitchen staff were giving cues to R185 at 8:27 a.m. and cutting up food. At 8:28 a.m., R185 was eating toast. R185 was able to get the toast to side of her mouth to take bites. No staff had offered to reposition or bring R185's chair forward so R185 could be in a better position to reach food. R185 was reaching up to get bite of egg to lift it up and towards her mouth. Meal served on a plate, not a lipped plate. Nurse came to help with large water bottle; the straw was very long. R185 spilled water on self. Nurse then took R185 from table. R185's cereal was towards center of table. R185 did not eat or have access to eat the cereal during the breakfast observation. On 09/18/19 at 12:20 p.m., Surveyor observed R185 at the dining table eating lunch of meatloaf, mashed potatoes and green beans. R185 was seated so height of table was at resident's mouth; head was extended far to the right onto her shoulder. R185 was reaching for food, getting a few bites of meatloaf. At 12:25 p.m., R185 was using the fork to try to get green beans and was unable to do so. R185 then used her fingers to get sliced cucumbers from a dish to the left of her. R185 was able to eat with her fingers. R185 did not have any adaptive equipment to make it easier to get to her meal. On 09/18/19 at 1:45 p.m., Surveyor interviewed R185 about the meal observation and her positioning. R185 said, I guess it just has to be that way. Surveyor asked if R185 had any concern with the way she is able to reach her food. R185 said, It bothers me. I ate but it is hard to do. I could not get the beans so I ate the cucumbers with my fingers. It is the only way I could reach them. I was battling to just eat the meal, then I spill and I don't like that. That is not my style. Surveyor asked about the pillow on the right side of R185. R185 indicated she has had that for a while but it does not make her sit up straight. Surveyor asked R185 if she is able to straighten her neck. R185 demonstrated she can have her head in a neutral position if she has support. On 09/18/19 at 1:50 p.m., Surveyor interviewed Registered Nurse (RN) A about the above dignity concerns. RN A indicates she did notice the inability to reach the food and spilling this morning. RN A indicated maybe staff didn't know to help her. RN A stated she will get occupational therapy (OT) involved for chair positioning and head and neck positioning. On 09/19/19 at 12:10 p.m., Surveyor observed R185 at the noon meal, eating cucumbers. Her broda type chair was 12 inches from the table, nose at table level. R185 was spilling cucumbers on to her lap as she was trying to eat her cucumbers. On 09/19/19 at 3:00 p.m., Surveyor interviewed the Nursing Home Administrtor (NHA) about the above observations. The NHA indicated she is aware of this as RN A brought it to her attention after Surveyor interviewed about it yesterday. NHA indicates an OT referral will be made, and they may offer an over the bed table to put her plate on. Surveyor shared the observation of the noon meal today. R185 had no over the bed table.

Based on observations and staff and resident interviews the facility did not ensure the facility was kept in a clean and comfortable homelike environment. This has the potential to affect all residents. Resident living areas had dirty and stained carpeting, scraped and splintered door edges, stained seat cushions, scraped and rusty heat registers, dust accumulation on furniture, light fixtures and wall hangings, etc. This is evidenced by: On 5/13/19 surveyors toured facility throughout and noted the following areas in which the facility was unkempt: 1. Jagged and splintered wood door edges were noted, rendering them hazardous to residents should they brush up against the door with bare legs Doors to the corridor: All resident rooms on the 100 Unit and resident rooms R3, R5, R6, R7, R9, R10, R12, R16, R17, and R40. Doors to bathrooms: Resident bathroom doors included R1, R2, R4, R5, R6, R7, R8, R9, R10, R18, R19, R20, R21, R22, R23, R34, R35, R37, R38, , and R40. Dented bathroom registers that were scraped of paint and rusty; Bathrooms located between two resident rooms: Resident bathrooms included R8, R9, R10, R11, R13, R14, R15, R16, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R36, R37, R38, and R39. Dented resident room heat registers that were scraped of paint and rusty included rooms R22, R23, R24, R25, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38 and R39. Holes in wall plaster rendering them unclean and unsanitary: ~R1 and R2's room had plaster scraped of its paint on the entrance wall to the left. This incorporated an area of approximately 1.5 feet x 3 inches ~R8's room had an area behind her bed headboard that measured approximately 2 feet x 6 inches in which the paint was chipped, exposing the plaster. ~R12's room had an unoccupied bed in which there was scraped paint exposing the plaster the entire length of the bed ~In soiled utility room of the 100 Unit, there was a hole in the wall near the flooring in which the plaster was coming out. Door frames scraped and rusty: All door frames to resident rooms were scraped and marred Doors badly marred and scraped on lower edges the widths of the doors: All doors of resident rooms to the corridor . Badly stained carpeting: ~The entrance and all corridor carpeting: The entrance carpeting harbored a strong old urine odor ~Resident rooms on the 100 Unit included R20, R21, R25, R39, R29, R30, R34, R35, and R36. ~Resident rooms on the 200 Unit included R1, R2, R5, R6, R9, R10, R14 and R15. ~The door labeled Therapy contained numerous spotty pink and gray stains. The surveyors were moved from this room during meal service as residents eat in this room. Accumulation of dust on resident wall lights. These lights were fixed to the walls above resident headboards and included: R22, R23, R29, R30, R33, R34 and R35. Main Dining Room: ~Spotty stains on main kitchen serving door with dried brown matter smeared on door; ~11 of 15 stationary dining chairs with stains on the seat cushions; ~One dining room chair had a splintered leg on the left front of the chair, easily scraped by a resident sitting in the chair; ~A wall hanging contained copious amounts of dust accumulation; ~The door to the patio contained scraped and rusty areas along the bottom width of the door; ~The set of double doors labeled Exit had a white and rusted coating along the entire width of the door; ~The door situated to the left of the basement door was scraped of its wood stain all along the lower width of the door; ~The heating register in the dining room was scraped of its paint; and ~One dining room chair contained dried food drippings. Miscellaneous: ~The nightstand in R5 and R6's room was scraped of stain and contained rough outer edges ~Toilets in resident bathrooms that were badly stained yellow and brown in R11, R13, R14 and R15's rooms. ~R36 had a stationary recliner in which a layer of dust was noted along the headrest ~Baseboard throughout the hall leading to the dining room was badly scraped on both sides of the hall; ~The walls of the hallway leading to the dining room were dirty on both sides; ~All handrails throughout facility were worn of its stain; ~There was a handrail corner piece, to the left of the water fountain in the hallway leading to the dining room which appeared to be previously repaired. This section was loose when pulled on; and ~The Shower Room on the 200 Unit contained black spotty stains on the floor tiling; and ~Several resident bathrooms flooring contained an accumulation of dirt and debris. On 5/13/19 at 9:40 AM, Surveyor interviewed R2, who stated she has lived in the facility over 1 year and has never had her carpets cleaned. At 10:00 AM, Surveyor interviewed R8 who stated that she had been living in the facility for about 1 year. R8 stated she has not had her carpeting cleaned since she has been living here. She stated that the housekeeper will come in daily and clean and only spot cleans the carpet when there is something on the floor. On 5/13/19 at 10:30 AM, the surveyor interviewed HSK-A (Housekeeper) regarding her cleaning schedule and deep cleaning of resident living areas. HSK-A stated carpets are deep cleaned upon resident discharge. She stated carpeting is otherwise spot-cleaned as needed or if they notice anything that needs attention, such as a spill. She stated main floor carpeting is cleaned once a month. At 10:45 AM, Surveyor interviewed the HSKS-B (Housekeeping Supervisor), who stated the resident carpets are cleaned only upon resident discharge. She stated she has been trying to create a regular cleaning schedule for the carpeting, but things always come up and they are unable to work on a schedule. She did state that spot cleaning is done as needed. At 11:30 AM, Surveyors spoke with the Maintenance staff, the Nursing Home Administrator (NHA) and the Regional Director (RD) regarding the condition of the facility and it's lack of cleanliness. The RD stated he was aware of carpet issues and they replace each square as needed. He stated they have plans to replace resident doors, but to date, no estimates or quotes have been explored.

Based on record review and interview the facility did ensure accurate MDS (Minimum Data Set) assessments for 2 out of 12 sampled residents (R8 and R28). R8 had errors in sections J and O of the significant change in status MDS assessment completed on 07/02/18. R8 also had errors in section A on the entry tracking assessment dated [DATE] as well as the MDS assessment completed on 05/29/18. R28 had a fall in (MONTH) (YEAR) that was not coded on a subsequent MDS. This is evidenced by: On 09/20/18 at 3:14 p.m., RN (Registered Nurse)-B stated she had been doing MDS assessments since November, (YEAR). RN-B stated she received on the job training to complete MDS assessments. RN-B stated learning a new computer software program was difficult. Example 1: R8 was admitted to the facility on [DATE] for long term care due to [MEDICAL CONDITION]. R8 was hospitalized from [DATE] through 10/06/17, 04/25/18 through 05/03/18, and again on 05/07/18 through 05/16/18 due to pneumonia. On 06/20/18, R8 enrolled into hospice due to [MEDICAL CONDITION] with less than 6 months life expectancy. The facility completed a significant change in status MDS assessment for R8 on 07/02/18. Section J question 1400 asks if the resident had a life expectancy of less than 6 months. This question was answered no. Section O question K asks if the resident was enrolled in a hospice program. This question was answered no. On 09/19/18 at 3:22 p.m., Surveyor interviewed RN-B regarding accurate MDS assessments. RN-B confirmed she had completed R8's significant change in status MDS assessment on 07/02/18. RN-B stated the significant change in status MDS was initiated because R8 had enrolled into a hospice program and was terminally ill due to end stage [MEDICAL CONDITION]. RN-B confirmed she did not code section J and section O correctly. RN-B stated she did a modification and corrected R8's MDS assessment on 09/19/18 to indicate R8's terminal condition in section J and hospice services in section O. On 05/07/18 R8 was hospitalized . The facility completed a discharge return anticipated MDS assessment for R8 on 05/10/18. On 05/16/18, R8 returned to the facility. The facility completed a entry tracking form for R8 on 05/16/18. Section A questions 1600 and 1700 indicated R8 was a new admission on 05/16/18 when in fact, R8 was a readmission on 05/16/18. On 05/29/18, the facility completed an admission MDS assessment for R8. According to the RAI (Resident Assessment Instrument) manual, R8 did not meet the definition of an admission MDS assessment. The facility selected the wrong reason for the MDS assessment. On 09/20/18 at 8:00 a.m., Surveyor interviewed RN-B regarding the admission assessment guidelines. RN-B confirmed the admission MDS assessment completed for R8 should not have been completed. RN-B stated an admission MDS assessment is only completed for a new admission or if the resident does not return from a hospital stay for greater than 30 days. RN-B confirmed R8 was discharged with return anticipated and was not gone for greater than 30 days. Example 2: On 7/27/18 R28 was lowered to the floor by staff. She did not have any injuries. Her next MDS dated [DATE] is not accurate as this fall was not recorded on the MDS.

Based on record review and interview the facility did not complete a significant change in status MDS (Minimum Data Set) assessment for 1 (R19) out of 12 sampled residents. R19 had a decline in cognition, an increase in behaviors and depressive symptoms, a decline in bladder control, decline in range of motion, and weight loss. The facility noted these changes on the quarterly MDS assessment completed in (MONTH) (YEAR) but did not complete a significant change in status assessment. This is evidenced by: R19 was admitted to the facility on [DATE] with the following, but not all inclusive, Diagnoses: [REDACTED]. The facility completed a quarterly MDS assessment for R19 on 05/16/18 with the following data noted: ~scored 4 out of 15 on the BIMS (Brief Interview for Mental Status) indicative of cognitive deficits. ~had inattentive behaviors that fluctuated. ~scored 2 out of 27 for depressive symptoms. ~had verbal behavioral symptoms that occurred 4 to 6 days and had delusions. ~had full range of motion of both upper extremities. ~was occasionally incontinent of urine. ~weighed 123#. The facility completed another quarterly MDS assessment for R19 on 08/17/18 with the following changes noted: ~was unable to complete the BIMS due to advanced cognitive deficits. ~continued to have fluctuating inattentive behaviors. ~scored 14 out of 27 for depressive symptoms indicative of an increase in depression. ~had physical, verbal, and other behaviors present 4 to 6 days which was an increase. ~had wandering behaviors. ~had limited range of motion on 1 side of the upper extremities. ~was frequently incontinent of urine. ~weighted 116#. On 09/20/18 at 3:03 p.m., Surveyor interviewed RN-B (Registered Nurse) regarding significant change in status MDS assessments. RN-B stated a significant change of status MDS assessment would require two or more areas of resident change. RN-B stated residents are discussed during the morning meetings and reviewed for changes by the interdisciplinary team. RN-B confirmed R19's changes identified on the August, (YEAR) quarterly MDS assessment. RN-B stated a significant change in status MDS assessment should have been completed in (MONTH) instead of the quarterly MDS that was completed.

Based on observation, record review and interview, the facility did not ensure that administration of medication was in compliance with manufacturer's specifications regarding the preparation of the medication for 2 of 7 residents (R15 and R17) who received a powdered laxative. This was evidenced by: R15's [DIAGNOSES REDACTED]. R17's [DIAGNOSES REDACTED]. On 07/10/17 at 11:40 a.m., Surveyor observed Registered Nurse (RN) C administer polyethylene [MEDICATION NAME] (a bulk-forming, powdered laxative) 1 capful (17 grams) to R15. RN C prepared the medication by measuring the amount of medication (1 capful) from a bottle stored in the medication cart. Next, RN C filled a 3.0-3.5 oz. (ounce) plastic cup of water and stirred the medication in order to dissolve the medication in the water. After mixing the medication, RN C gave the cup of medication to R15. R15 drank the medication. Additional fluid was not offered. On 07/11/17 at 8:30 a.m., Surveyor observed RN C administer polyethylene [MEDICATION NAME], 1 capful (17 grams) to R17. RN C prepared the medication by measuring the amount of medication (1 capful) from a bottle stored in the medication cart. Next, RN C filled a 3.0-3.5 oz. (ounce) plastic cup with water and stirred the medication in order to dissolve the medication in the water. After mixing the medication, RN C assisted R17 with drinking the cup of medication. No additional fluid was offered. RN C also added another medication, powdered potassium (an electrolyte replacement) 20 meq. (millequivilants) to the 3.0 oz. of polyethylene [MEDICATION NAME]. Surveyor interviewed Licensed Practical Nurse (LPN) D (a nurse who administers medications). LPN D stated, These cups are 3 oz. Yes, these are what we use to administer medications. Surveyor reviewed the manufacturer's directions on each bottle of polyethylene [MEDICATION NAME]. The manufacturer's directions stated .mix with 4-8 oz. of fluid . The manufacturer's directions on the potassium read: Dissolve in 4 oz. of water or other beverage. Additionally, mayoclinic.org recommends: To allow bulk-forming laxatives to work properly and to prevent intestinal blockage, it is necessary to drink plenty of fluids during their use. Each dose should be taken in or with a full glass (8 ounces) or more of cold water or fruit juice. This will provide enough liquid for the laxative to work properly. A second glass of water or juice by itself is often recommended with each dose for best effect and to avoid side effects (gas, bloating, abdominal cramping, intestinal blockage). (Laxative (Oral Route) published by mayoclinic.org 03/01/17 et al).

Based on observation, interview and record review, the facility did not ensure that the care and services were provided to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 of 10 residents (Resident #2) reviewed for dementia care. The facility did not apply fundamental principles of care for persons with dementia, focusing on the needs of Resident #2. The facility did not identify and determine if the resident's distress was due to pain and/or anxiety. Medications were not given as frequently as available to address behavioral expressions of distress, anxiety, moaning, whimpering, crying, and calling out that were observed and documented for Resident #2. This is evidenced by: Resident #2 was admitted on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set, (MDS) with assessment reference date (ARD) of 05/17/16 documents Resident #2's Brief Interview for Mental Status (BIMS) score is 2, meaning she has severe cognitive impairment. The mood score is 4, having 2-6 days of fidgeting, restlessness. The behavior does not significantly disrupt care or the living environment. Pain has not occurred in the last five days, Resident #2 is receiving scheduled pain medications, and no prn pain medications. The pain assessment 05/17/16, documents Resident #2 is using Tylenol 1000 mg twice a day, and it is effective. The significant change in status MDS, with ARD 8/09/16, documents a BIMS score of 01, severely cognitively impaired. The resident mood interview score is 11, documenting 7-11 days of feeling bad about yourself, and 12-14 days of being so fidgety or restless that you have been moving around a lot more than usual. The behaviors of other behavioral symptoms occurs 4-6 days, and is documented as significantly disrupting care or living environment. The MDS pain assessment is documented below in the nurses' notes on 08/09/16. Resident #2's physician orders [REDACTED]. The patient/resident is treated with dignity, respect .medication, positioning, .and other measures are used to relieve pain and suffering .If comfort measures fail, contact physician .12/03/15 The care plan, Alteration in thought and mood .manifested by: .repetitive comments/questions, long history of calling out for there children/parents, 12/03/15. Approaches in part: .Use task segmentation with cares, .if showing signs or symptoms of distress offer non-medicinal approaches such as folding clothes, or polka/old country music .may find comfort holding onto a stuffed animal or doll .may enjoy discussing navy as she is a veteran .may enjoy drawing or coloring .may enjoy office assistant tasks such as writing on paper .may call out for her children .may enjoy being outdoors when the weather -staff must be with .at all times if in broda chair . Comfort alteration, related to joint pain, abnormal posture, frequent falls, reports of headaches .approaches in part: Assess physical symptoms, notify MD as needed, minimize/relieve pain: apply heat or cold, not always able to verbalize pain when in distress due to her disease process of dementia. Monitor and treat verbal and non-verbal signs of pain .Nurse aide- encourage rest periods, position for comfort, offer diversion, provide quiet dark environment, use pillow for comfort, report pain to nurse . 08/09/16. The Certified Nursing Assistant (CNA) care plan in part: 08/19/16 Special care remarks: .to be in broda chair for meals in assist room. Do not leave unattended when in broda chair, when finished with meal help her back into her wheelchair, after lunch activity aide will monitor and provide activity time in broda chair. Use pillows in wheelchair as needed for positioning/comfort . All observations of Resident #2 were in her wheelchair, other than at meal time. Potential for sleep pattern disturbance, related to anxiety, due to dementia .the altered sleep pattern may be related to dementia or anxiety . Physician orders [REDACTED].>11/24/15 [MEDICATION NAME] 500 mg by mouth every 4 hours [MEDICATION NAME] 650 mg suppository rectal every 4 hours as needed for pain or fever 03/30/16 [MEDICATION NAME] .0.25 mg by mouth every 4 hour as needed for anxiety, therapeutic goal: control. 06/22/16 [MEDICATION NAME] .0.5 mg by mouth three times a day for anxiety. am, pm, and hs (hour of sleep). therapeutic goal: control. 07/27/16 [MEDICATION NAME] cream to apply bid for perirectal discomfort Increase [MEDICATION NAME] to 0.5 mg po TID (three times a day) 08/21/16 [MEDICATION NAME] changed to liquid form. [MEDICATION NAME] topical ointment 5% apply 5 grams tid prn (as needed) to neck and shoulders for pain/discomfort 08/17/16 [MEDICATION NAME] sulfate .solution .5 mg by mouth four times a day as needed . The medical record was reviewed and documents 16 falls occurring from 03/11/16 to 08/18/16 related to Resident #2's restlessness and attempts to self transfer and stand without assistance. The [MEDICATION NAME] was documented as refused two times August 1-22nd. The nurses' notes in part: 05/30/16 .complains of pain in right side of neck .Tylenol suppository 650 mg given . 06/01/16 1:15 a.m., [MEDICATION NAME] given for anxiety, [MEDICAL CONDITION] . 06/04/16 .[MEDICATION NAME] 500 mg for c/o headaches .prn Tylenol effective . 06/06/16 [MEDICATION NAME] 0.25 mg given for anxiety restless can not sit still .[MEDICATION NAME] . 650 mg suppository given for pain/discomfort . 06/08/16 Witnessed fall, .hallway pupils equal, round and react to light . 06/09/16 9:43 a.m., .when activity staff are providing 1:1 in the afternoon, she will be placed in her Broda chair to change position .therapy has contacted a vendor regarding alternative seating options, they are unable to see (resident name) for seating options until 07/01 . 06/12/16 [MEDICATION NAME] 500 mg noted to be holding her head, stated, 'yes', when asked if it hurt, face pain scale, 3/10 . 06/13/16 Resident up .standing up persistently said she was sore in her buttocks later said her head hurt was given Tylenol 650 mg suppository initially then later given [MEDICATION NAME] for restless behavior which were effective 06/15/16 [MEDICATION NAME] given for anxiety restless [MEDICAL CONDITION] can not lay down to sleep at night . 06/16/16 2:20 a.m., .witnessed fall out of wheelchair 06/16/16 2:34 a.m., [MEDICATION NAME] 650 mg suppository given for pain/discomfort Pain level .8 Location: in headache 06/17/16 [MEDICATION NAME] given for anxiety [MEDICAL CONDITION] and standing up out of w/c constantly . 06/18/16 .follow up incident: denied pain with ROM (range of motion). Does say her neck is 'sore' when trying to reposition her to sitting up straight. Would only lay down for 15 mins . 06/19/16 .[MEDICATION NAME] 500 mg for general discomfort, neck tension, repositioned in her dining chair . 06/20/16 [MEDICATION NAME] .0.25 mg given for anxiety restlessness in w/c standing up constantly . 06/22/16 Dr here .[MEDICATION NAME] increased 0.5 mg tid to help her sleep at night . 06/24/16 .slept most of the night .06/26/16 13:49 (1:49 p.m.), .Patient is in a good mood today. Patients chair alarms went off 20 + times . 23:35 (11:35 p.m.) [MEDICATION NAME] recently increased .continues to wander halls, cont. to stand frequently. Sleeps little and is up much of night as well as day. Does cont. to call out for son and cont. to have periods of tearfulness. 06/27/16 .lowered to floor .attempt C- collar for neck support . Incident report: .attempted to stand independently from her w/c .chiar vendor to ass .for improved chair arrangement this week . 06/28/16 .no anxiety noted today 06/29/16 .resident slept well since last evening . 06/30/16 .no crying . 07/01/16 .no crying . 07/02/16 .crying, calling out for son 07/05/16 .sat by nurses station whimpered and asked for (son's name) . 07/07/16 .awake and crying, given hs meds . 07/11/16 [MEDICATION NAME] given .been doing a lot of crying for her children, 'I have to make supper,, I have to take care of the dogs, 23:19 (11:19 p.m.) [MEDICATION NAME] 650 mg suppository given for pain/discomfort pain level: 7, location: all over . 07/12/16 .was up restless in bed Tylenol suppository given due to soreness of buttocks (has excoriation) . Nurses' notes 07/13 - 07/18/16 document resident was sleeping at night, and able to be redirected. 07/17/16 10:42 a.m., .she is redirectable for very short time. Morning medication was effective for short time .poor food intake for breakfast. She does drink fluids when offered from staff .staff offer multiple 1:1 visits to help sooth . 07/19/16 9:55 a.m. .crying, '(son's name) repetitively, denies pain but holding back of her head at times will not stay laying down 15:52 .[MEDICATION NAME] 650 mg suppository for pain, rubbing back of head . 07/20/16 Dr .here .Monitor behaviors and pain x 1 week . 07/21/16 [MEDICATION NAME] .given for anxiety calling out for son . 07/21/16 14:33 (2:33 p.m.), Patient has been very anxious and called out to her son many times . 07/22/16 8:11 a.m. .she was crying when writer entered facility. She reported she had a headaches sad was grabbing her head as she was crying. she would calm for short period of time and then continue to cry .writer attempted to dim lights as she stated the lights were bothering her eyes due to her headache, this did not seem to help continued to rock back and forth during visit . 19:06 (7:06 p.m.), Sad face much of shift and whimpering. Did c/o head hurting Was given her scheduled [MEDICATION NAME] this did help for short while. frequently has been standing up from w/c . 07/23/16 13:18 (1:18 p.m.), Denied pain, crying, can not relax. Took her Tylenol massaging neck muscles now and said it 'helps'. 13:42 [MEDICATION NAME] 0.25 mg for anxiety control .prn result: still anxious. reassurance given . 14:03 .layed down but does not stay .denies headache . 23:19 Perirectal area better . 07/24/16 5:51 a.m., Set off bed alarm .states she is sad and misses her kids and wants to go home . 07/24/16 Incident report: Observed floor .activity at time: had been propelling self in w/c up and down halls. Had stood up several times, each time staff had intervened and had her sit down again . 07/25/16 11:04 a.m. [MEDICATION NAME] given for anxiety med ineffective patient is still calling out for son and is crying . 1:05 p.m. Patient has been quite anxious today. Patient has been crying and calling out .[MEDICATION NAME] seems to be ineffective. she was holding her head .patient has set her chair alarm of 10+ times 20:13 (8:13 p.m.), [MEDICATION NAME] 650 mg suppository given for pain. 10 On faces scale; crying, grimacing, holding her head . 23:25 .She did c/o headache . 07/26/16 .follow up to fall will be offered her doll when calling out . 17:41 [MEDICATION NAME] 650 mg suppository .various modalities tried for restless behavior less restless . 07/27/16 [MEDICATION NAME] 650 mg suppository given for pain pain level 7, location: all over .Dr. here resident still restless, crying and not sleeping well [MEDICATION NAME] increased to 0.5 mg. TID . 07/28/16 9:53 a.m., [MEDICATION NAME] 5% ointment early a.m., for neck and shoulder achiness, sits with head forward in chair when propelling self .9:55 a.m , no signs of pain, fell asleep in w/c for awhile . 12:07 a.m. .[MEDICATION NAME] 5% ointment said yes when asked if her shoulders were sore . 15:09 (3:09 p.m.), [MEDICATION NAME] 5% ointment to keep neck and shoulders comfortable .med effective 07/30/16 00:17 (12:17 a.m.), [MEDICATION NAME] 0.25 mg given for anxiety, crying .1:38 a.m., med effective .[MEDICATION NAME] 650 mg suppository given for pain/discomfort pain level before med: 10 location: all over 1:39 a.m., med effective . 13:58 (1:48 p.m.), [MEDICATION NAME] given for anxiety crying out call for (son's name) . 07/30/16 15:56 (3:56 p.m.), .attempted to place C- collar support on neck this am to assist with enhanced neck and shoulder posture. She did not like this .and made her scared .writer removed collar .started to have increased behaviors after toileting after lunch. Prn [MEDICATION NAME] was given for crying and calling out .medication not effective. Is still crying , calms with 1:1 , but continues to cry after visit is over . 16:10 Doll not effective . 07/31/16 12:54 a.m., Peri rectal are slightly pink, no inflammation . 10:04 a.m., .did attempt to stand by self a few times but was redirectable .only ate bites of toast (cried when staff offered more food) . 08/01/16 [MEDICATION NAME] 650 mg suppository given for pain/discomfort Pain level: 10 location: all over .med effective after one hour . 08/02/16 03:07 a.m., Headache at this time . 20:25 (8:25 p.m.) Found in hallway lying on side .propels self up and down hallways even though she is fatigued .she is constantly standing up from w/c. staff will continue to attempt to keep her within public areas and staff eyesight, but she dos not stay in one area long . 08/03/16 Follow up to fall .placing a soft pillow on .lap to assist her with sitting up straight . 18:17 (6:17 p.m.), Patient has been trying to get up out of her wheelchair many times this afternoon. Patient has also been crying . 08/04/16 [MEDICATION NAME] 650 mg suppository given for pain/discomfort , pain level: 8 location: in foot . 1:13 a.m., [MEDICATION NAME]-HC 2.5 % cream given for pain/discomfort . 08/05/16 [MEDICATION NAME] 650 mg given for pain .pain level: 8 location: all over . 08/06/16 [MEDICATION NAME] 650 mg .given in place of scheduled oral Tylenol as she is laying down, med effective resting quietly . 16:30 .Witnessed fall .location: hallway .had been up and down halls, frequently standing up from w/c either holding w/c arms or handrails . 08/07/16 6:46 a.m., Was in bed til 0200, had set off bed alarm, was continent .assisted to bed at 0410, set off bed alarm at 0420, assist to wheelchair, had c/o headache, given prn Tylenol Suppos went back to bed at 0510, slept til 0600, Tylenol effective . 13:02 (1:02 p.m.) [MEDICATION NAME] 0.25 mg given po for calling out for (son's name), 'I got to go home and help them' reassured, will give prn Tylenol suppository when lays down . 22:43 (10:43 p.m.), .most of shift propelling self up and down halls .at times is just making whimpering sounds. had been given prn Tylenol .with little effect .wandering into rooms, frequent attempts to stand .she laid down for 15 minutes .but did not rest . 08/08/16 02:40 a.m., [MEDICATION NAME] 650 mg suppository pain/discomfort pain level 7, neck and buttocks . 3:23 a.m. Restless crying on and off can't sleep, repetitive speech, administered [MEDICATION NAME] prn at 0240 . 22:45 (10:45 p.m.), .has faint bruising to right forehead due to head being bumped with hoyer lift on day shift . 08/09/16 11:03 a.m., Scheduled pain medication regimen? Yes, Received prn pain medications? yes, Received non-medication interventions for pain? Yes, Have you had pain or hurting at any time in the last 5 days? No, .indicators of pain or possible pain: vocal complaints of pain (that hurts, ouch, stop, protective body movement or postures (bracing, guarding, rubbing or massaging a body part, clutching or holding a body part during movement), frequency of indicator of pain .: observed 3 to 4 days .negative vocalization: repeated troubled calling out, moaning, groaning, or crying .facial expression: sad, frightened, frowning, consolability: reassured or distracted by touch or voice .able to verbalize pain at times but at other times may be distressed and unable to verbalize pain . 14:55 (2:55 p.m.), [MEDICATION NAME] .for pain control, crying, does not know why .med ineffective . 08/11/16 07:04 When asked if having pain at 0615 a.m., she stated 'yes', no nonverbal s/s of pain, was unable to indicate where, . 22:38 (10:38 p.m.), .before supper standing up several times .given fluids, back rub .holding headache (sic) and said she had a headache. Given Tylenol suppository rather than scheduled liquid as she was laying down-was effective for headache . 08/12/16 13:30 (1:30 p.m.), [MEDICATION NAME] 650 mg suppository for pain control. Holding back of head, would not stay laying down. 08/12/16 22:34 (10:34 p.m.), [MEDICATION NAME] 650 mg suppository laying in bed crying, stated 'yes' when asked if she had a headache . 08/13/16 8:43 p.m., Resident crying in bed at beginning of shift, given prn Tylenol suppository, attempted to get out of bed at 2310 (11:10 p.m.), assisted to wheelchair, given snack, assisted to bed at 0130 a.m., attempted to get up at 0140 a.m., assisted to wheelchair, sat in hall by nurses desk .assisted to bed at 0230, back up at 0235 a.m., sat up til 0330 a.m., assisted to bed, slept til around 0530 a.m. 08/14/16 5:37 a.m., [MEDICATION NAME] 650 mg given for pain/discomfort, pain level before med: 5, location: all over . 08/15/16 03:50 a.m., [MEDICATION NAME] 650 mg suppository given for pain/discomfort, pain level: 5, location: all over . 08/16/16 00:41 (12:41 a.m.), [MEDICATION NAME] .crying in bed, stated 'yes', when asked if she had a headache . 03:28 a.m. [MEDICATION NAME] given for anxiety, laying in bed crying .04:36 a.m., med effective .13:57 (1:57 p.m.), [MEDICATION NAME] 0.25 mg .calling out, unable to settle with drinks, food . 18:36 (6:36 p.m.), Throughout shift resident speaks in whimpering indiscernible voice, Resident is not aggressive but continues to have a sad countenance with occasional crying . 23:45 (11:45 p.m.), [MEDICATION NAME] 650 .whimpering in bed, did state 'ya', when asked if she had a headache .med effective . 08/17/16 05:43 a.m., [MEDICATION NAME] 650 mg .for pain control, did state, 'ya', when asked if she has a headache . 11:10 a.m., [MEDICATION NAME] 650 mg .for pain control, whiny voice, restless, unable to tell if having discomfort. Not relaxing in her wheelchair . 08/18/16 15:00 (3:00 p.m.), [MEDICATION NAME] .given for pain, 5 on faces scale- she is whimpering, grimacing, states, 'I don't know', when asked if she is having pain, location: all over, 17:22 (5:22 p.m.), med effective not grimacing as much, still whimpering . 08/18/16 19:15 (7:15 p.m.), [MEDICATION NAME] (MS) 5 mg given for pain/discomfort. 6 on faces scale; whimpering, sad face, grimacing, med effective somewhat-she slept for 45 minutes, then started in with whimpering again but says no pain when asked . 23:44 (11:44 p.m.,), Observed on floor, time of incident: 19:05 (7:05 a.m.,), location dining room .had been wandering halls, propelling self in w/c .laying on her right side in front of w/c .Injury: .no change in facial expression; no increasing tone of whimpering, which she has been doing all shift .Physician notification: .response: Try giving the [MEDICATION NAME] more to see if she is less restless/whimpering, rather than Tylenol .w/c positioning continues to get worse .head is turned to side and it is becoming more difficult to straighten her . 08/19/16 00:56 (12:56 a.m.), MS given for pain/discomfort, pain level 7, location: all over .resident sleeping until 0100 a.m., then repetitive speech consistently .one dose of MS .will monitor . 08/19/16 10:27 a.m., MS 5 mg administered for pain relief, med effective patient is sleeping 08/20/16 [MEDICATION NAME] 650 mg, noted to be crying in bed . 05:22 a.m. [MEDICATION NAME] .for pain prevention, denies pain at this time . 08/20/16 10:08 a.m., MS 5 mg given for pain . 19:32 (7:32 p.m.), [MEDICATION NAME] .given for pain/discomfort, pain level before med: 10, location: all over . 08/21/16 04:07 a.m., [MEDICATION NAME] .for c/o headache .6:07 a.m., med effective .did lay down in bed for about a hour. 06:57 a.m., .set off bed alarm around 0130 a.m., was noted resident was getting tired around 0400, assisted to bed, then began whimpering, stated she had a headache, given prn Tylenol suppository, rested for about 1.25 hours in bed, then set off bed alarm again around 0515 a.m., . 15:19 (3:19 p.m.), [MEDICATION NAME] .given for pain/discomfort, pain level before med: 10 location: all over . 08/22/16 6:29 a.m., [MEDICATION NAME] 650 given for pain . 09:13 a.m., MS 5 mg given for pain/calling out . Medication review: The Medication Administration Records (MARs) were reviewed and it was noted that the MS had been given 08/18 one time, 08/19 two times, 08/20/16 one time, 08/21/16 not given, 08/22/16 given 9:13 a.m., 17:05 (5:05 p.m.), 21:07 (9:07 p.m.), on 08/23/16 the MS was given four times as ordered after Surveyor had been asking questions about Resident #2's pain medications. The MARs document the [MEDICATION NAME] ointment was used 07/28 two times, 07/29 two times, 07/30 one time, 08/01 one time, 08/02 one time, 08/23 one time. The MARS document the Tylenol 500 mg was given 08/22 two times, 08/23 on time. The MARS document the [MEDICATION NAME] 650 mg suppository had been given, one time on 8/1, 8/2, 8/4, 8/5, 8/6, 8/9, 8/10, 8/14, 8/18, and 8/22. It was given two times on 08/07, 08/08, 08/15, 08/17, 08/21. It was given three times on 8/3, 8/11/ 8/12, 8/16, and 8/20. The MARs document the prn [MEDICATION NAME] 0.25 mg had been given 08/02/16 one time, 08/07 one time, 08/08 one time, 08/16 two times, 08/23 one time. The [MEDICATION NAME] prn was not utilized 18 of 23 days that were reviewed by Surveyor from August 1 - 23rd. physician progress notes [REDACTED].>06/22/16 .depression risk: never feels sad, empty, or tearful; no loss of interest in activities .no agitation .staff notes patent not sleeping well or for more than 3 hours at any one time . Assessment/Plan: .family is not interested in hospice, but do want comfort cares .she will be kept comfortable at this time. [MEDICATION NAME] will be scheduled at night for difficulty staying asleep . 07/20/16 .depression risk: never feels sad, empty or tearful; no loss of interest in activities no agitation .sleep disturbances or [MEDICAL CONDITION], staff note resident not sleeping well .Complaining of hair pain and motions to her forehead. Patient reports headaches .Assessment/plan: .prn [MEDICATION NAME] not being used consistently. Staff encourage to use this and document benefit vs. no benefit . Observations On 08/22/16 at approximately 9:15 a.m., Surveyor observed Resident #2 in her wheelchair, with head and neck extended to the right, propelling herself whimpering, and crying. On 08/22/16 at 12:10 p.m., Surveyor observed Resident #2 in the east hallway, sitting in her wheelchair, whimpering and moaning. The observation continued until 1:40 p.m. when Resident #2 was served lunch. Resident #2 was not offered any interventions during this time. All staff were busy assisting with the noon meal. At 1:45 p.m., Surveyor observed Resident #2 in her broda chair in the assisted dining room. CNA H offered Resident #2 a drink of juice. Resident #2 continued to cry. CNA H said, Why are you crying? Resident #2 did not answer. CNA H continued to assist other residents with lunch, then went back to Resident #2 to assist her. Resident #2 did hold a cup of juice for a short time. Then Resident #2 refused all of her food, as she continued to cry out. CNA H touched the right side of Resident #2's head, to help straighten her neck to see if she could drink better. Resident #2 immediately yelled out. CNA H asked, Did I hurt you? Resident #2 replied in a high pitched loud voice, Yes. Resident #2 continued to call out, with crying and whimpering. The observation ended at 2:10 p.m. On 08/23/16 at 6:15 a.m., Surveyor observed Resident #2 in her wheelchair, propelling up and down the hall, crying out. -At 7:15 a.m., Resident #2 continued to cry out with whimpering noises. Surveyor was unable to make out any specific words. -At 7:30 a.m., Resident #2 continued to cry out and was propelling self in wheelchair. There were no staff interacting or offering interventions as they were all busy getting residents ready for breakfast. The observation continued until 8:10 a.m., when Resident #2 fell asleep in her wheelchair. Resident #2's neck was extended to the far right, in an awkward position as she was sleeping. At approximately 8:55 a.m., Resident #2 was put into bed. -At 9:05 a.m., the bed alarm was sounding, as she was restless and trying to get up. -At 9:20 a.m., Resident #2 fell asleep until approximately 10:45 a.m. At 10:45 a.m., Surveyor observed cares for Resident #2. CNA F used the hoyer lift to transfer Resident #2. As Resident #2 was raised in the lift, she yelled out, Eeeh! Eeeh! then continued with whimpering and crying out. CNA F did not ask Resident #2 if she had any pain. Surveyor asked CNA F what interventions calm Resident #2. CNA F replied, We can give her a magazine, offer her to color, or even brushing her hair back seems to help at times. Surveyor asked if CNA F thinks Resident #2 is expressing pain. CNA F replied, We believe it is frequent pain. She gets Tylenol suppositories regularly, because she gets really restless. CNA F transferred Resident #2 back into her wheelchair as Resident #2 cried out, Yeah! Yeah! Surveyor asked Resident #2 if she had pain. Resident #2 replied, Yes. Surveyor asked if her neck hurt. Resident #2 replied, Yes and my back. CNA F then stated, We forgot to get the nurse to give her a Tylenol suppository, it will have to be done later. Surveyor observed some different pillows and asked CNA F if they were used to help position Resident #2's neck. CNA F was not sure, so she went to the Physical Therapy Assistant (PTA) to ask. The PTA stated the pillow was for lumbar back support, and to be put behind the resident. At 1:45 p.m., Surveyor observed CNA F assisting Resident #2 in the dining room, Resident #2 was in the broda chair, was crying out, whimpering and moaning and not interested in eating. The observation ended at 1:50 p.m. At 2:00 p.m., Surveyor observed Resident #2 wheeling herself up and down the hallway saying, Help me, help me, and calling out for her son. Activity Assistant (AA) A offered Resident #2 a glass of water. Resident #2 continued to cry out, and wheel herself up and down the hallway. Resident #2 placed the glass on the railing, spilling the water on the floor and herself. Resident #2 then attempted to enter another resident's room. A gentleman pushed her out of the room. Resident #2 continued to cry and whimper. At approximately 2:25 p.m., two CNAs took Resident #2 into her room. On 08/23/16 at 2:40 p.m., Surveyor observed Resident #2 up in her wheelchair propelling in the east hall, whining, whimpering and calling out. -At 2:55 p.m., Resident #2 was at the end of the east hall, calling out, Eeeh! Eeeh! and leaning far to the right in her wheelchair, with her neck extended far to the right. At this time a CNA walked by and put a pillow on the resident's lap and walked away. -At 3:00 p.m., Surveyor observed Resident #2 propel herself into room [ROOM NUMBER] and continued to call out. -At 3:08 p.m., Licensed Practical Nurse (LPN) E assisted Resident #2 and gave her a drink of water. This was not effective in reducing the crying out. -At 3:09 p.m., Activity Director (AD) C offered to take Resident #2 to the garden. When AD C tried to raise up the legs of Resident #2 to propel the wheelchair, Resident #2 yelled out, Ooh! Ooh! -At 3:15 p.m., Resident #2 was wheeled back in the east end door, and then back into the garden. Surveyor observed Resident #2 in the garden area, as Resident #2 tried to wheel herself away from Activity Assistant (AA) A, who was now with Resident #2. AA A attempted to rub Resident #2's head and shoulders. Resident #2 was pulling away and flailing her arms, attempting to wheel away. -At 3:30 p.m., Surveyor observed Resident #2 in the garden, seated in her wheelchair as she continued to cry out, and whimper and was not calmed by any interventions that AA A tried. Resident #2 was slouched forward, with her neck and head leaning far to the right. The observation continued until 3:45 p.m., when Resident #2 was brought back inside. Resident #2 continued to propel the halls and cry out, with nonsensical words and whimpering. At 3:50 p.m., Surveyor interviewed AA A and asked if a position change may help Resident #2. AA A said she would have the CNAs lay her down and come and get the surveyor. -At 3:55 p.m., CNA D and CNA B were in Resident #2's room to assist her. Surveyor asked CNA D if Resident #2 has always called out like this. CNA D replied, When she first came she would call out at times for her son, calling out his name, but we could redirect her, but now it is all the time. Surveyor asked when the CNA noticed it getting worse. CNA D replied, The past one to two months. Surveyor asked if there was anything hurting Resident #2. CNA D replied, Usually headaches. CNA D asked Resident #2 if she had a headache. Resident #2 replied, Yes. Surveyor asked if Resident #2 always had her neck extended to the right since she was admitted . CNA D replied, This has evolved since she came here. CNA D touched Resident #2's head lightly when positioning the hoyer lift. Resident #2 cried out. CNA D asked Resident #2 if her neck hurt. Resident #2 replied, Yes. Surveyor asked CNA D and CNA B what they have tried in the wheelchair for positioning Resident #2's neck. CNA D replied, Nothing. Surveyor asked if they used a C-collar at one time. CNA D replied, Not that I am aware of. Surveyor then asked CNA B when she noticed increased crying out. CNA B replied, It is much worse the past month, she is crying out all the time. At 4:15 p.m., Surveyor observed Resident #2 near the nursing home entrance, calling out, whimpering with tears in her eye and on her check. Surveyor shared the observation with Surveyor . Surveyor went to observe Resident #2 and found tears in Resident #2's left eye, and could see the moisture on her cheek. Resident #2 was in an uncomfortable position, with her neck extended far to the right, and slouched over in her wheelchair. At 4:30 p.m., Surveyor again observed Resident #2 propelling herself in the hallway, with a distressed look on her face, calling out Eeeh! Eeeh! and whimpering. Surveyor went to LPN E to ask what time Resident #2 had received her pain medications. LPN E stated Resident #2 just had her MS now, and had it earlier today at 12:25 p.m. Surveyor asked how long the MS liquid was [MEDICATION NAME] and if it was effective. LPN E stated, I do not know that. I will have to get back to you. Surveyor asked when the last time Resident #2 had had her prn [MEDICATION NAME] for anxiety. LPN E reviewed the MAR and replied, 1:15 p.m., today. On 08/24/16 at 6:15 a.m., Surveyor entered the building and observed Resident #2 wheeling herself up and down the hallways moaning and crying. There was no staff in the area to assist or offer interventions to Resident #2. -At approximately 6:19 a.m., a nurse came from the report room to turn off the door alarm that had been set off by Surveyor when she entered the building. The nurse looked at Resident #2, lightly touched her shoulder and went back to her work. Resident #2 continued to moan and cry out. -At 6:20 a.m. Surveyor observed Resident #2 in the hallways in her wheelchair crying and whimpering; the observation continued until 6:40 a.m. The staff did not offer any interventions to Resident #2 to calm her. -At 8:50 a.m., Surveyor observed Resident #2 in the hallway in her wheelchair, leaning far to the right, with her neck extended far to the right, crying out and whimpering. Surveyor was in the hallway multiple times from 6:20 a.m. until 9:40 a.m., and each time could hear Resident #2, and locate her from