Every finding on record at Orchard Manor

Based on observation, interview, and record review, the facility did not ensure residents received care consistent with professional standards of practice to prevent or heal pressure injuries (PI) for 2 of 2 sampled residents (R9 & R3) reviewed for pressure injuries out of a total sample of 12. R9 was admitted with bilateral heel pressure injuries. The facility did not implement immediate offloading of the bilateral heels and the heels deteriorated. R9's wounds were not measured weekly, and her physician was not updated timely on changes to her wounds. R9 was observed not having her heels offloaded while seated in her recliner. R3 developed a facility acquired PI. The facility failed to measure and assess the PI weekly. R3's PI became infected multiple times requiring antibiotics. The facility states R3 has a Stage 3 PI - R3's medical record indicates PI, abscess, and diabetic wound. Evidenced by: Facility policy entitled Pressure Injury (ulcer) Treatment, revision date of 5/9/24, states in part: Purpose: The purpose of this procedure is to provide guidelines for the care of new and/or existing pressure injuries.2. When eschar is present, a pressure injury cannot be accurately staged until the eschar is removed .4. At the time a pressure injury is noted: assess the wound; Notify the physician for treatment orders; notify responsible party/family; initiate a wound/other treatment progress report 4; update care plan; update wound board & wound nurse. Definitions and Descriptions: Suspected deep tissue injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue.the wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. Stage I pressure injury: Intact skin with non-blancheable redness of a localized area usually over a bony prominence . Stage II pressure injury: Partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Further description: presents as a shiny or dry shallow ulcer without slough or bruising .bruising indicates suspected deep tissue injury. Stage III Pressure Injury: Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss . Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefor stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed . Facility policy entitled Pressure Injury (ulcer) Prevention, revision date of 5/9/24, states in part: Purpose: The purpose of this procedure is to provide information regarding pressure injury (formerly pressure ulcer) prevention. General Guidelines. 1. Pressure injuries are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue. 2. The most common site of a pressure injury is where the bone is near the surface of the body including the back of the head around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles, and toes.4. Pressure injuries are often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin (i.e., perspiration, feces, urine, wound, discharge, soap residue, etc.,) decline in nutrition and hydration status, acute illness and/or decline in the resident's physical and/or mental condition.Interventions and preventive measures: General .3. For a person in a w/c, geri chair, etc.: a. change position at least every hour; b. use foam, gel or air cushion as indicated to relieve pressure, unless the resident specifies otherwise. 4. When repositioning, reduce friction and shear by lifting (using appropriate lifting technique and equipment) rather than dragging. 5. Do not position directly on bony prominences . 2. Risk Factor - Friction and Shear.i. shoes need to be monitored for proper fit to avoid development of blisters, corns, and calloused areas . m. protect bony prominences as needed.5 .b. use pillows or wedges to keep bony prominences such as knees or ankles from touching each other. Do not massage bony prominences. C. when in bed, every attempt should be made to float heels (keep heels off of the bed) by placing a pillow from knee to ankle or with other devices as recommended by therapist and prescribed by the physician . Facility policy entitled Pressure Injury (ulcer) Risk Assessment, revision date of 5/9/24, states in part: Purpose. The purpose of this procedure is to provide guidelines for the assessment and identification of residents at risk of developing pressure injuries. General guidelines. 1. Pressure injuries are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area, which destroys the tissues.4. Pressure ulcers are often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin .5. Once a pressure injury develops, it can be extremely difficult to heal.9. Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of a developing pressure injury to the supervisor. Assessment .3. Because a resident at risk can develop a pressure injury within 2 to 6 hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure injuries. The admission evaluation and Braden scale helps define those initial care approaches. 4. In addition, the admission evaluation may identify pre-existing signs (such as a purple or very dark area that is surrounded by profound redness, edema, or induration) suggesting that deep tissue damage has already occurred, and additional deep tissue loss may occur. This deep tissue damage could lead to the appearance of an unavoidable stage III or IV pressure injury or progression of a stage I pressure injury to an injury with eschar or exudate within days after admission . Example 1: R9 was admitted on [DATE] with diagnoses to include Diabetes mellitus type 2, pressure ulcer of unspecified heel stage 1, and mild cognitive impairment of uncertain or unknown etiology. Baseline care plan dated 10/23/23 states in part: problems/strengths: Baseline care plan for new admission related to diagnoses: Type 2 diabetes mellitus with diabetic chronic kidney disease, major depressive disorder, non-pressure chronic ulcer of back limited to breakdown of skin, stage 1 pressure ulcer of heel . Goals: Nursing: skin goal - skin will regain integrity. Interventions: Nursing: Assess skin and treat/report for follow up as needed. Provide precautions for preventions of skin impairment. Has the following skin condition: chronic ulcer of back and a stage 1 pressure ulcer of heel. At risk for skin issues secondary to congestive heart failure . R9's admission assessment dated [DATE] indicates: Skin condition: body is marked with left heel and right heel both indicating 2x2 (2 centimeters by 2 centimeters). General skin condition intact, dry, cool, pink, pale and warm. Comments: scattered bruising, PI to bilateral heels, and PI to coccyx - WN (wound nurse) needs to verify staging of all PI. (Of note: No description of the wound is documented; it is not clear the stage of R9's PI upon admission.) R9's Care Plan dated 11/7/23 states in part: .potential for altered skin integrity related to decreased mobility/hx (history) of pressure injury.will regain skin integrity & remaining intact skin will continue to be free from skin impairments (skin tears, pressure injury, abrasions) . interventions: (12/07/23) Remind resident to lock both brakes on w/c (wheelchair) prior to transfer to prevent chair from moving and hitting resident. (11/7/23) inspect skin daily with cares for unusual findings, report concerns as indicated. (11/7/23) assess unusual findings, consult with MD/wound nurse for tx. (treatment) orders. (11/7/23) whirlpool bath or shower 2 days/wk. (per week) . (11/07/23) toilet on regular basis, incontinent products to wick away moisture from skin, prompt perineal cleansing after episodes of incontinence. (11/07/23) pressure redistribution mattress on bed and cushion in w/c and/or recliner. (11/7/23) encourage fluids at & b/t (between) meals to promote hydration. (11/7/23) lotion skin after bath or shower .& with cares daily to help keep skin moisturized per resident preference. (11/07/23) update MD on recommendations for findings/consult with wound care nurse PRN (as needed) for wound tx. (11/07/23) perform prescribed treatment regimen for deep tissue injury to bilateral heels, monitor response. R9's Minimum Data Set (MDS) dated [DATE] indicates R9 has a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating R9 is cognitively intact. R9 is indicated as needing partial/moderate assist with toileting hygiene and upper/lower body dressing. R9 is indicated as needing supervision with sit to stand, sit to lying, and chair/bed transfers and transferring to the bathroom. Section M indicates that R9 is at risk for pressure injuries and has unhealed pressure injuries that were present on admission. R9 is marked as having 2 (two) deep tissue injuries. R9's MDS date 8/2/24, indicates R9 is independent with transfers and toileting. Section M indicates R9 has two stage 2 pressure injuries present that were present on admit. R9's October 2023 Treatment Administration Record (TAR) has no pressure injury treatments indicated. R9's November 2023 TAR indicates the following: 11/2/23 Skin - prep wipes pad (barrier skin protectant) to bilateral heels topical two times daily for wound. (Stop date: 11/17/23.) 11/2/23 offloading boots to bilateral heels when in bed topical every shift for wound. 11/17/23 Skin - prep wipes pad (barrier skin protectant) to bilateral heels topical two times daily for wound. (Stop date 12/13/23) On 11/1/23, R9's PI documentation indicates: Right heel measures 2.5cm (centimeters) x 3.7cm x 0cm. (length x width x depth) stage is marked as a deep tissue injury. Wound bed is indicated as 100% dark purple. Left heel measures 2.5 cm x 2.4 cm x 0 cm, with deep tissue injury (DTI) marked. Wound bed is indicated as 100% dark purple. Physician updated. Notes: offloading boots and pt (patient) education provided. Of note: R9's PI went from a stage 1 upon admit to a DTI within 7 days of admission. R9 did not have PI interventions in place until 11/2/23 after R9's PI had deteriorated to a DTI. On 11/8/23, R9's Admission History & Physical Physician visit note, states in part: .physical exam: .skin: .comments: She has some shallow desquamation of the bilateral heels.Assessment and plan: .skin: Pressure sores ankles - daily prep and offloading boots . On 11/9/23, R9's PI documentation indicates: Right heel measures 3 cm x 3.3 cm x 0 cm. Wound bed is indicated as 100% black. R9 is marked as having pain. Left heel measures 2 cm x 2.4 cm x 0 cm, wound bed indicated as 100% black. R9 is marked as having increased pain. Physician updated for possible scheduled Tylenol. On 11/16/23, R9's PI documentation indicates: Right heel measures 2.6 cm x 3.6 cm x 0 cm. Deep tissue injury is marked as the stage. Wound bed is indicated as 100% black. Physician updated indicates on going. Left heel measures 2 cm x 2.4 cm x 0 cm. Wound bed is indicated as 100% black. Of note, both wounds are marked as a DTI and Physician update indicates ongoing, but does not indicate if the Physician/provider was updated on this date. On 11/23/23, R9's PI documentation indicates: Right heel measures 2.5 cm x 3 cm x 0 cm and wound bed is 100% black. Left heel measures 2.4 cm x 2.5 cm x 0 cm with a wound bed that is 100% black. On 11/30/23, R9's PI documentation indicates: Right heel measures 2.5 cm x 2.9 cm x 0 cm. Stage is marked deep tissue injury. Wound bed is marked close/resurfaced and indicated as 100% black. Left heel measures 2 cm x 2.2 cm x 0 cm. Stage is marked as a deep tissue injury. Wound bed is indicated as being 100% black. R9's December 2023 TAR indicates the following: 12/13/23 Betadine to bilateral heels 1 application topical one time daily for heel wounds (Stop date: 12/27/23) Betadine to bilateral heels 1 application topical on day shift for heel wounds. (Start date 12/27/23. Stop date 1/22/24) R9 should have a measurement on or around 12/7/23. There is no documentation of a wound assessment around this time. On 12/13/23, R9's Physician visit note, states in part: .we examined the heel wounds. A black scab is present overlying area. She has ankle pillows and does well in wearing them and offloading the heels. On 12/15/23, R9's PI documentation indicates left heel - wound bed is necrotic tissue. Percentage of tissue type: 100% dry black eschar and measures 2.5 cm x 2.5 cm x 0 cm. The wound is indicated to be a non-stageable. Update section indicates physician updated - name of doctor updated, and date notified: ongoing. Right heel wound is non-stageable and is 100% dry black eschar measuring 2.5 cm x 2.9 cm x 0 cm. On 12/29/23, R9's PI documentation indicates right heel measures 2.7 cm x 2.8 cm x 0 cm, wound bed is 100% dry black eschar. Left heel measures 2 cm x 2 cm x 0 cm, wound bed is 100% black eschar. R9's January 2024 TAR indicates the following: 1/22/24 betadine to right heel BID (Twice a day) 1 application topical two times daily for heel wounds. 1/22/24 tx (treatment) to left heel: cleanse with normal saline (NS), pat dry and cover with Opti foam every 3 days and as needed (PRN) if soiled or falling off on day shift for skin irritation. (Stop date: 3/7/24) 1/22/24 monitor left heel dressing daily, replace Opti foam if not intact on day shift. On 1/5/24, R9's PI documentation indicates left heel measures 2 cm x 1.9 cm x 0 cm with 100% eschar. Right heel measures 2.4 cm x 2.8 cm x 0 cm and 100% eschar. On 1/11/24, R9's Physician visit note states in part: .Being treated for pressure sores on posterior of her ankles. Daily wound care. She does not like the offloading boots. She prefers the bolster pillows so nursing wondering if order can be changed to that .Assessment/plan: .bolster pillow for ankle wounds. Continue betadine daily . R9's January 2024 TAR indicates the following: 1/11/24 Bolster pillow under legs when in bed to elevate bilateral heels every shift. (Stop date 2/4/24) On 1/12/24, R9's PI documentation indicates right heel is 100% light brown scab measuring 2.3 cm x 2.4 cm x 0 cm indicated as closed/resurfaced. Left heel 100% eschar measuring 2 cm x 1.9 cm x 0 cm. R9's January 2024 TAR indicates: Betadine to bilateral heels 1 application topical on day shift for heel wounds. (Stop date 1/22/24) this treatment is indicated as missed (M) on 1/14/24. R9's January 2024 TAR indicates the following: 1/11/24 Bolster pillow under legs when in bed to elevate bilateral heels every shift. Indicated as being missed on 1/13 on night shift and 1/14 on PM shift. On 1/19/24, R9's PI documentation indicates right heel is 100% black measuring 2 cm x 2 cm. Left heel indicated as 100% yellow slough measuring 1.5 cm x 2.2 cm x <0.1 cm with serosanguineous drainage and 2+ pitting edema. MD (medical doctor/physician) updated. R9's January 2024 TAR indicates the following: 1/22/24 betadine to right heel BID (Twice a day) 1 application topical two times daily for heel wounds. 1/22/24 tx (treatment) to left heel: cleanse with normal saline (NS), pat dry and cover with Opti foam every 3 days and as needed (PRN) if soiled or falling off on day shift for skin irritation. (Stop date: 3/7/24.) 1/22/24 monitor left heel dressing daily, replace Opti foam if not intact on day shift. Betadine to bilateral heels 1 application topical on day shift for heel wounds. (Stop date 1/22/24.) On 1/26/24, right heel measures 1.5 cm x 2.0 cm x <0.1 cm with light serous drainage, wound bed indicated as 100% epithelial. Left heel measures 1.5 cm x 2.0 cm x none indicated as 100% necrotic. On 1/31/24, R9's PI documentation indicates: right heel measures 2 cm x 2 cm x undetermined. Wound bed is indicated as 100% (dried) necrotic. Notes: needs encouragement to participate in whirlpool baths. (R9's right heel was 100% epithelial tissue on 1/26.) Left heel measures 1.5 cm x 2.0 cm x <0.3 cm with 100% slough, MD update as indicated. (Of note, the wound bed depth would be obscured by the slough, and would not be able to be determined) R9's February 2024 TAR indicates the following: 2/4/24 right heel cleanse right heel with NS, pat dry and cover with Opti foam. Check daily and change every 3 days as directed every AM for pressure ulcer of unspecified heel, stage 1. (Stop date 3/7/24) On 2/2/24 at 9:06 PM, Message to R9's Physician indicates (R9's) right heel is no longer dry, stable eschar, has opened with small amount of bleeding. Can we d/c (discontinue) iodine and start cleanse with NS, pat dry and cover with Opti foam Q (every) 3 days and PRN if soiled? Physician response on 2/4/24 at 1:10 PM indicates, agree with nursing wound care recommendations. On 2/6/24, R9's PI documentation indicates right heel measurement of 2.0 cm x 2.2 cm x scabbed over, unable to determine 100% necrotic - encourage to elevate heels and take w/p (whirlpool) baths resident is scheduled to take a w/p bath this PM and is in agreeance. New dressing applied. Left heel - measurement 1.7 cm x 1.2 cm x <0.1 cm and 100% slough. Notes: encourage to elevate heels and take w/p bath. Resident had a w/p bath last night (2/6) new dressing applied to heel. On 2/14/24, R9's PI documentation indicates left heel measures 1.5 cm x 1.1 cm x 0.1 cm. Stage is marked as stage III, with serosanguineous drainage, wound bed is 100% epithelial tissue. Signs and symptoms of infection edema. Surrounding tissue warm, pink, dry, intact, edematous. Pain is marked yes, intermittent, PRN (As Needed) Tylenol. Update: Physician ongoing. Right heel measures 2 cm x 2 cm x 0.1 cm, marked as a non-stageable (unstageable.) Wound bed is 60% black and 40% pink with light serosanguineous drainage. On 2/21/24, R9's PI documentation indicates: Left heel measurement is 1.5 cm x 1.1 cm x<0.1 cm with light serous drainage and wound bed is 100% granulation tissue. Right heel measurement is 2 cm x 2 cm x <0.1 cm with light serous drainage. Wound bed is 25% slough and 75% granulation tissue. Physician update: N/A R9 should have a measurement on or around 2/28/24. There is no documentation of a wound assessment around this time. R9's March 2024 TAR indicates the following: 3/7/24 Bilateral heel tx: check daily take whirlpool bath, pat area dry and apply piece of Aquacel AG to wound bed and cover with padded Tegaderm (or comparable dressing) two times a week and prn every am for wound. (Stop date 4/3/24) On 3/6/24, R9's PI documentation indicates: Right & Left heel wounds indicated both as having early granulation tissue present to both wound beds. Both wounds indicated as measuring 2 cm x 2 cm x 0.1 cm. Wounds are staged as a stage II. Physician updated: would recommend changing treatment to twice weekly/PRN with bath: remove dressing, take w/p. Pat areas on heels dry and apply piece of Aquacel AG to wound bed and cover with a Suresite + pad or comparable dressing. (Of note: R9's wounds have been downstaged at this time from an unstageable to a stage II pressure injury which does not follow the standard of practice for PIs. Wounds are not downstaged. There is no indication of what percentage of the wound bed is granulation tissue.) R9 should have a measurement on or around 3/13/24. There is no documentation of a wound assessment around this time. On 3/13/24, R9's Physician Visit note, states in part: .a shallow ulcer is present on bilateral heels. Skin surrounding ulcer is blancheable. She has her ankle over plenty of pillows and with legs elevated.Skin: pressure sores ankles. Daily prep and offloading boots . (R9's offloading boots were changed to a bolster pillow during the last MD visit) On 3/19/24, R9's PI documentation indicates: Right & Left heel (both are in the same wound review) documentation indicates the Right measures 1.5 cm x 1.9 cm x 0.1 cm and the left measures 0.5 cm x 1 cm x 0.1 cm. Stage is marked as stage II. The wound bed has slough and granulation tissue marked. Mixture of both 75% granular 25% yellow slough in RT (right). (There is no indication of what the Left heel wound bed percentage is.) Physician update: No changes. Notes: Both wounds are measuring smaller. Treatment remains appropriate. Will hold off on w/p this week until Friday since dressing just changed today. Recommend continuing current treatment. Offload heels as much as possible. Of note: Facility indicates Stage 2; wound should not be backstaged, and a Stage 2 wound would not present with slough. On 3/27/24, R9's PI documentation indicates: Left heel measures 0.8 cm x 0.5 cm x <0.1 cm, wound bed is 100% granulation tissue. Right heel measures 1.4 cm x 1 cm x <0.1 cm, wound bed is 100% granulation tissue. R9's April 2024 TAR indicates the following: 4/3/24 Aquacel AG to wound beds bilateral heels. Skin prep peri wound, cover with a composite dressing. Change 3 times a week and as needed for stage II pressure ulcer. (Stop date 5/2/24) On 4/3/24, R9's PI documentation indicates: Right measures 1.5 cm x 1.4 cm x 0.1 cm left measures 0.5 cm x 1.8 cm x 0.1 cm, stage II is marked. Wound bed Right is 75% granulation tissue 25% yellow slough. Left granulation tissue 100%. (R9's right heel went from 100% granulation to having 25% slough present.) Signs/symptoms of infection, edema is marked. Surrounding tissue: wound edges with maceration, skin prep applied. Aquacel AG to wound beds, covered with composite dressing. Update: Physician: current treatment remains appropriate, would recommend increasing dressing changes to 3 times a week, healing stalled out likely due to weeping edema/increase in edema. Notes: Bolster pillow remains in room under legs to float heels in bed. No active weeping noted from wound beds .Will continue with Aquacel AG to help with drainage control. Increase dressing changes to 3 times a week. On 4/10/24, R9's PI documentation indicates left heel measures 1.5 cm x 2 cm x 0.1 cm light serous drainage, no odor. Wound bed is 100% slough. Right heel measures 1.5cm x 2cm x 0.1 cm with light serous drainage. No odor. Wound bed is 100% slough. Update Physician is blank. Notes: continue plan of care. (Of note: R9's wounds worsened from 25% slough to 100% slough and no Physician notification was provided. R9's wounds would be unstageable.) On 4/17/24, R9's PI documentation indicates: Right heel measures 1.5 cm x 1.4 cm x 0.1 cm and the left measures 0.3 cm x 0.6 cm x 0.1 cm. Marked as stage II. Light serosanguineous drainage. Wound bed is marked slough and granulation tissue. Right heel is 90% granulation tissue, 10% yellow slough. Was able to mechanically debride some off of wound bed. Left is 100% early granulation tissue. Left heel wound with purple discoloration above and below wound bed. (R9) does not remember bumping or causing injury to area. Suspect DTI hopefully will resolve with applying skin prep peri wound as previously ordered. (There is no measurement of the area that is being indicated as a suspected DTI.) Surrounding tissue: slightly macerated dressing wet when removed. Enc (Encourage) staff to take dressing off, give W/P and have nurse reapply dressing. Skin prep peri wound and apply Aquacel AG to wound bed. Follow with a composite dressing. Change three times a week. Edema has improved to BLE (Bilateral Lower Extremities), helping the amount of moisture in wound beds. MD updated regarding left wound with purple tissue above and below wound. R9 should have a measurement on or around 4/24/24. There is no documentation of a wound assessment around this time. R9's May 2024 TAR indicates the following: 5/2/24 Aquacel AG to wound beds bilateral heels. Skin prep peri wound, cover with a composite dressing on day shift for stage II pressure ulcer. (Stopped on 7/3/24 then restarted on 7/3/24 then stopped on 7/31/24.) On 5/2/24, R9's PI documentation indicates: Wound document does not indicate which heel the documentation is on. Unable to say which is the left or which is the right heel. One heel measures 1.5 cm x 2 cm x 0.2 cm with foul odor, moderate amount of serosanguineous drainage and a wound bed with 10% slough and granulation tissue. Signs/symptoms of infection has redness and increased exudate marked. Physician update has N/A (Not Applicable) documented. Notes: dressing changes Aquacel AG applied followed by bourdered [sic] gauze. The other heel measures 1 cm x 1.5 cm x 0.5 cm with moderate amount of serosanguineous drainage. No odor. Wound bed is marked slough and granulation tissue with 10% slough. Signs/symptoms of infection has redness and increased exudate marked. Surrounding tissue is macerated. Physician updated N/A. On 5/2/24 at 10:37 AM, message sent to R9's Physician indicates: FYI resident heel dressings have increased serosanguineous drainage and area around wounds is macerated. No signs of infection will continue 3x week dressing change with Aquacel AG and bordered gauze. Physician response on 5/3/24 at 10:12 AM, agree with increase dressing changes. (Of note: R9's wound evaluation indicates redness and increased exudate (drainage) and a foul odor for one of the heels. The message to the MD says no signs/symptoms of infection.) On 5/8/24, R9's PI documentation indicates: Right heel measures 1.8 cm x 1.5 cm x 0.1 cm left heel measures 1.5 cm x 1.5 cm x 0.1 cm. Stage is marked as a stage II. Both are marked as 100% granulation tissue. Surrounding tissue macerated. Recommend changing to daily dressing change. Currently is experiencing weeping edema 2+ pitting edema BLE (bilateral lower extremities). Physician update: updated and new orders noted. Will change dressings daily d/t (due to) maceration concerns. On 5/8/24, R9's Physician Visit note states in part: .patient seen in her room .appears she has been struggling with increased leg swelling which have now caused some wounds in her heels. We examined heel wounds. A shallow ulcer is present on bilateral heels. Skin surrounding ulcer is blancheable. She has ankle over plenty of pillows and with legs elevated. Leg swelling 3+ with weeping noted . On 5/22/24, R9's PI documentation indicates: Right heel measures 1.3 cm x 1.1 cm x 0.1 cm and left heel measures 1.4 cm x 1 cm x 0.1 cm. Stage marked is stage II. Moderate serous drainage. Wound bed indicates 50%/50% slough/granulation tissue. (Both wounds are on the same document.) Surrounding tissue: maceration present d/t weeping edema present. Will recommend to staff to use more Aquacel AG over top wound [sic] to help pull fluid away from peri wound. Is already on a daily dressing change. 2-3+ pitting edema present BLE. Update: Physician updated: N/A (Not Applicable). (R9's wounds changed from 100% granulation to 50% slough and there is no indication the MD was updated. R9's heels would be unstageable at this time.) R9 should have a measurement on or around 5/29/24. There is no documentation of a wound assessment around this time. On 5/31/2024, R9's bed was removed from her room as she prefers to use her own recliner to sleep in. R9's June 2024 TAR indicates the following: Bolster pillow under legs when in bed to elevate bilateral heels every shift for wound remains on R9's TAR, when R9 no longer has a bed in her room as of 5/31/24 and sleeps in her recliner. On 6/5/24, R9's PI documentation indicates: Right heel measures 1 cm x 1 cm x 0.1 cm and left measures 1 cm x 1 cm x 0.1 cm. Stage is marked as stage II. Light serosanguineous drainage. Wound bed is 100% pale pink. Notes: wounds show improvement. Measure smaller. No active weeping edema noted. Peri wound with no maceration. Checked 2 ruptured blister areas on RLE (Right Lower Extremity.) Remains clean, no s/sx infection. Covered with a composite dressing. Treatments remain appropriate. Continues with 2+ pitting edema. Enc. to elevate legs. Tubigrips on. Instructed staff to monitor for rolling down. On 6/12/24, R9's PI documentation indicates: Left measures 1.5 cm x 1.5 cm x <0.1 cm and the Right measures 2 cm x 1.5 cm x <0.1 cm, light serous drainage, wound bed granulation tissue, 100% pale pink. Update: not initial assessment, PCP (primary care provider) has been updated previously. Notes: Continue current plan of care. On 6/13/24, R9's Provider visit note, states in part: .follow-up on her leg swelling and skin lesions. She has been experiencing significant swelling in her legs, which has been persistent and has not shown improvement. She has been diligent about keeping her legs elevated when resting. She uses Tubigrips but they are not on yet today .the bandages on her heel sores and shin sores were changed yesterday and are intact . R9 should have a measurement on or around 6/19/24 and 6/26/24. There is no documentation of a wound assessment around either time. R9's July 2024 TAR indicates the following: Apply Medihoney to bilateral wound beds covered by a composite dressing. Change dressing with bath days (Tues. and Fri.) or twice weekly and prn. For stage II pressure ulcer. (Start 7/31/24.) On 7/3/24, R9's PI documentation indicates: Right heel measures 1 cm x 0.7 cm x 0.2 cm and Left measures 0.5 cm x 0.6 cm x 0.1 cm, stage marked is stage II. Wound bed indicates right with 10% slough 90% granulation. (Of note the left wound bed percentage of tissue type is not documented.) Pain, yes episodic with cleansing. Physician update: N/A. On 7/10/24, R9's PI documentation indicates: Right and left heel measures 1 cm x 1 cm drainage is marked as light and purulent, no odor. Wound bed is marked as granulation tissue. Percentage 100% pale pink. Physician update: No, not initial assessment, PCP (Primary Care Provider) has been updated previously. On 7/16/24, R9's PI documentation indicates right heel measures 0.6 cm x 0.5 cm x 0.1 cm and left measures 1 cm x 1 cm x 0.1 cm. Stage is marked as stage II. Wound bed is marked slough and granulation tissue. Percentage 50% slough 50% granulation. (Of note, this does not differentiate if the left or the right percentage is different, the wounds would be unstageable due to 50% slough being present.) Surrounding tissue peri wound maceration, skin prep applied. Physician update: N/A. Notes: (right) ulcer is measuring smaller. (left) larger. (left) ulcer was drier when checked. Wounds cleansed with normal saline. Reapplied Aquacel AG to wound beds. No weeping edema noted from wounds like in the past. Does present with a 3+ pitting edema BLE . educated (R9) to continue to float heels. Did have them lying on bolster pillow. Current tx. remains appropriate at this time. On 7/24/24, R9's PI documentation indicates left measures 1 cm x 1 cm x 0.1 cm, wound bed marked as 100% granulation tissue. Notes: continue treatment Aquacel AG to wound beds. Skin prep peri wound, cover with a composite dressing. Right measures 1 cm x 1 [TRUNCATED]

Based on interview and record review, the facility did not ensure that residents that are diabetic received routine diabetic foot checks in accordance with professional standards of practice for 2 of 2 sampled residents (R3, R9), and 2 of 2 supplemental residents (R11, R27) reviewed for diabetic foot checks. R11 has no documentation of diabetic foot checks. R27 has documentation of once per month diabetic foot checks. R3's diabetic foot checks are not done daily. R9's diabetic foot checks are not done daily. This is evidenced by: The facility's Policy and Procedure entitled Foot Care Guideline dated 7/15/21 with last revision date of 5/9/24 states in part: .The nursing staff will provide residents' foot care with licensed nurses performing nail care for the diabetic individual .Objectives: To prevent infection of the feet .To assess skin integrity . Of note: The facility policy did not address the issue of diabetic foot checks or ongoing monitoring. Per American Diabetes Association (ADA), dated 2017, foot checks/screens should be conducted daily with a comprehensive exam conducted annually. Per American Medical Director Association (AMDA), dated 12/9/14, these foot checks/screens are vitally important for treatment of foot problems in patients with diabetes. Common foot problems in diabetic patients are broken down into three categories: at risk foot, current mild foot/ankle or heel infection or ulcer, and limb-threatening foot/ankle/heel ulcer. Example 1 R11 was admitted on [DATE]. R11 has a diagnosis of type 2 diabetes mellitus. R11's medical record was reviewed for documentation of diabetic foot checks for June, July and August 2024. R11's medical record does not include any documentation of the facility completing diabetic foot checks. Example 2 R27 was admitted on [DATE]. R27 has a diagnosis of type 2 diabetes mellitus. R27's medical record was reviewed for documentation of diabetic foot checks for June, July and August 2024. R27's medical record only includes documentation of diabetic foot checks on 6/24/24 and 7/24/24. 36192 Example 3: R3 was admitted on [DATE] with a diagnosis of diabetes mellitus type 2. R3's Treatment Administration Record (TAR) for March through August 2024 indicate: (R3) is diabetic check feet monthly for skin impairments. one time daily, start date 3/6/24. This order is signed out once a month. Example 4: R9 was admitted on [DATE] with a diagnosis of Diabetes mellitus type 2. R9's Treatment Administration Record (TAR) for October 2023 through December 2023, and January 2024 through August 2024, indicate: 10/24/23 Diabetic foot check; this order is signed out once a month. On 8/14/24 at 3:24 PM, Surveyor interviewed DON B (Director of Nursing) regarding diabetic foot checks. Surveyor asked how often diabetic foot checks are done, DON B indicated foot checks should be done monthly. Surveyor asked what standard of practice the facility follows, DON B indicated she needed to check. No further diabetic foot check information was provided.

Based on interview and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment, all alleged violations were thoroughly investigated for 1 of 2 sampled residents (R13) and 1 of 1 (R34) supplemental residents reviewed for abuse. On 5/5/24, the facility became aware of an alleged violation of abuse between R13 and R34 and did not conduct an investigation. Evidenced by: The facility policy, Abuse Investigation Protocol, with a reviewed date of 3/20/24, indicates, in part: Policy Statement: All reports of alleged resident abuse in any form .resident-to-resident abuse .are promptly and thoroughly investigated by facility management .Policy Interpretation and Implementation: 1. Should an incident or suspected incident of resident abuse .be reported, the administrator, or her designee, will appoint an individual to investigate the incident .11. The administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency . R13's 5/5/24 Certified Nursing Assistant (CNA) Behavior/Cognitive .Summary note, authored by CNA H, includes, in part: 5/5/24 - Day - Verbally Abusive (Yes), Verbally Abusive Comment: telling her roommate [sic] her boyfriend doesn't love her and is with another woman and making resident cry. told [sic] her romate [sic] to shut up and stop crying. being [sic] rude and cussing at staff for trying to help her and the other resident . On 8/14/24 at 11:35 AM, Surveyor interviewed CNA H, reviewed the behavior note she wrote on 5/5/24 regarding R13 and R34, and asked what she recalled of the incident. CNA H indicated that the call light had gone off and it was R34 and she was upset and mad that R13 was in the bathroom too long and she was crying and I tried to calm her down. R13 told R34 to stop crying and she was calling her names. CNA H indicated R13 was using a loud voice, not yelling, but raising her voice and that R13 was being very rude and demeaning to R34. CNA H indicated that on this same day, R34 was worked up because her boyfriend couldn't come. R34 was crying and CNA H indicated she had gone in her room because you could hear her crying from the top of the hall by the nurse's station. CNA H indicated when she went in the room R34 told her she was sad her boyfriend couldn't come. CNA H indicated she was trying to console her and was trying to distract her. CNA H indicated after she tried calming R34 down, R13 told R34 that she (CNA H) was lying to her and that the real reason her boyfriend wasn't coming was because he doesn't love her and was cheating on her. CNA H indicated this got R34 all sorts of worked up and she started crying more. CNA H indicated she heard R13 tell R34 to shut up and quit crying. On 8/14/24 at 1:52 PM, Surveyor interviewed NHA A regarding the incident from 5/5/24 between R13 and R34. During the interview NHA A indicated the incident should have been investigated through their abuse process. The incident between R13 and R34 was not investigated.

Based on observation, interview, and record review, the facility did not ensure provision of an environment free from accidents and hazards for 1 of 1 sampled residents (R3) with a power wheelchair out of a total sampled of 12 residents. R3s electric wheelchair was being charged in R3's room. This is evidenced by: Facility policy entitled Motorized scooter/wheelchair, revision date 5/9/24, does not address where electric chairs are to be charged. R3 was admitted on [DATE]. R3's Minimum Data Set (MDS) dated [DATE], indicates R3 has a Brief Interview of Mental Status (BIMS) of 15 out of 15, which indicates R3 is cognitively intact. On 8/13/24 at 9:45 AM, Surveyor observed R3 to be in her recliner sleeping and the electric wheelchair appeared to be plugged in to a cord behind the nightstand. On 8/13/24 at 10:01 AM, Surveyor observed R3 to have an electric wheelchair in her room. The chair was not plugged at this time but R3 had the charger in her room on the floor behind her nightstand near the window. Surveyor asked R3 where her wheelchair gets charged, R3 and her husband replied, In here, while pointing towards the cord. On 8/15/24 at 8:24 AM, Surveyor and CNA D (Certified Nursing Assistant) went into R3's room. Surveyor asked CNA D to look at R3's cord in her room. CNA D looked at the cord plugged into the outlet, and CNA D indicated, This is the wheelchair cord. CNA D indicated we did charge it in the lounge, they may have moved it since I was off the last 2 weeks. On 8/15/24 at 10:11 AM, CNA D indicated she moved the cord where it's supposed to be, in the day room. On 8/15/24 at 10:06 AM, Surveyor interviewed LPN G (Licensed Practical Nurse) regarding electric wheelchairs. Surveyor asked where electric wheelchairs get charged? LPN G indicated in the middle day rooms. LPN G indicated the wheelchair is not to be charged in R3's room. On 8/15/24 at 1:30 PM, Surveyor spoke with NHA A (Nursing Home Administrator), NHA A asked if Surveyor asked R3's husband if he moved the cord. Surveyor had not asked R3's husband if he moved the charging cord into their room. NHA A indicated the chair should not be charged in R3's room.

Based on interviews and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act. the facility failed to ensure that all alleged abuse violations are reported to the administrator and other officials in accordance with State law through established procedures for 1 of 2 sampled residents (R13) and 1 of 1 (R34) supplemental residents reviewed for abuse. On 5/5/24, the facility became aware of an alleged violation of abuse between R13 and R34. This allegation of abuse was not reported to the administrator or state agency. Evidenced by: The facility policy, Reporting Abuse to the Facility Management, with a revision date of 4/20/23, indicates, in part: Policy Statement: It is the responsibility of our employees, facility consultants, attending physicians, family members, visitors, volunteers, etc., to immediately report any incident or suspected incident of .resident abuse .to the administrator . Policy Interpretation and Implementation: .3. Employees, facility consultants, volunteers and/or attending physicians must report any suspected abuse or incidents of abuse or alleged abuse to the Administrator or their immediate supervisor, who will in turn report to the Administrator, promptly. If such incidents occur or are discovered after normal business office hours, the Administrator must be called and informed of such incidents, as soon as possible .4. When an alleged or suspected case of .abuse is reported, the facility Administrator or his/her designee will promptly notify the following persons or agencies of such incident (as appropriate): .c. The DQA (Division of Quality Assurance) through the online Misconduct Incident Reporting (MIR) system .7. To assist one in recognizing incidents of abuse, the following definitions of abuse are provided: .b. Verbal abuse is defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability . R13's 5/5/24 Certified Nursing Assistant (CNA) Behavior/Cognitive .Summary note, authored by CNA H, includes, in part: 5/5/24 - Day - Verbally Abusive (Yes), Verbally Abusive Comment: telling her roommate [sic] her boyfriend doesn't love her and is with another woman and making resident cry. told [sic] her romate [sic] to shut up and stop crying. being [sic] rude and cussing at staff for trying to help her and the other resident . Of note: R13's roommate is R34. On 8/14/24 at 11:35 AM, Surveyor interviewed CNA H, reviewed the behavior note she wrote on 5/5/24 regarding R13 and R34, and asked what she recalled of the incident. CNA H indicated that the call light had gone off and it was R34 and she was upset and mad that R13 was in the bathroom too long and she was crying and I tried to calm her down. R13 told R34 to stop crying and she was calling her names. CNA H indicated R13 was using a loud voice, not yelling, but raising her voice and that R13 was being very rude and demeaning to R34. CNA H indicated that on this same day, R34 was worked up because her boyfriend couldn't come. R34 was crying and CNA H indicated she had gone in her room because you could hear her crying from the top of the hall by the nurse's station. CNA H indicated when she went in the room R34 told her she was sad her boyfriend couldn't come. CNA H indicated she was trying to console her and was trying to distract her and was trying to find her something to watch on TV. CNA H indicated after she tried calming R34 down, R13 told R34 that she (CNA H) was lying to her and that the real reason her boyfriend wasn't coming was because he doesn't love her and was cheating on her. CNA H indicated this got R34 all sorts of worked up and she started crying more. CNA H indicated she heard R13 tell R34 to shut up and quit crying. Surveyor asked CNA H if she felt this should have been reported as a potential abuse. CNA H indicated, yes, it was not OK, I witnessed something that I thought should be reported for potential abuse. CNA H indicated she reported this to the nurse but could not recall the nurse's name. CNA H indicated she is to report abuse to the nurse and if they don't say they are going to inform SSM I (Social Services Manager), then we tell her. CNA H indicated she sent SSM I an e-assignment (internal electronic messaging) and pulled this up in the computer to show surveyor. CNA H indicated she sent a summed up version of the incident and that usually SSM I comes to talk to them after but she could not recall if she did or not for this incident. On 8/14/24 at 1:14 PM, Surveyor interviewed SSM I. During the interview SSM I indicated staff should report abuse to herself as the grievance officer, the charge nurse, DON (Director of Nursing) or the NHA (Nursing Home Administrator). SSM I indicated she did not recall an incident between R13 and R34 from 5/5/24. Surveyor asked SSM I if she recalled receiving an e-assignment regarding an incident on 5/5/24 from CNA H. SSM I reviewed the e-assignments with surveyor present and surveyor asked if she recalled what she did with the information. SSM I indicated she was trying to remember if she even saw it and that she did not recall getting a phone call about it or if the CNA H even told her nurse. Surveyor asked SSM I how often she is supposed to check her e-assignments. SSM I indicated she would have to ask what the expectation is and that it would depend on if she was in the office. SSM I indicated she tries to check it daily depending on what other things are happening. SSM I indicated that she does not believe she followed up on the e-assignment on 5/5/24 from CNA H regarding the incident with R13 and R34. SSM I indicated if CNA H reported this to her nurse then the DON or NHA should have been called as it was a Sunday and she was not in the office. SSM I indicated that if a resident told another resident to shut up and quit crying it should be reported as a potential allegation of abuse. Surveyor asked SSM I if she is involved in the abuse training and if so who are staff trained to report abuse to. SSM I indicated she is and staff should report immediately to their immediate supervisor. On 8/14/24 at 1:52 PM, Surveyor interviewed NHA A regarding reporting of abuse and the incident from 5/5/24 between R13 and R34. During the interview NHA A indicated staff should first stop the abuse, ensure safety, and then report suspected or allegations of abuse immediately to the charge nurse who should then reference the policy and contact the administrator. NHA A indicated they can then work together on figuring out what needs to happen. NHA A indicated that the incident should have been reported to her, there was a break down in reporting, an e-assignment message would not be considered immediate, and that she would report this to the state agency as an allegation of verbal abuse. This incident was not reported to the NHA or to the state agency within the required timeframes.

Based on interview and record review, the facility did not ensure that the residents' physician was consulted when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 17 residents (R48). R48 had a change in weight status and the facility did not consult R48's physician per physician orders, resulting in R48 having to go to the emergency room with CHF (Congestive Heart Failure) exacerbation requiring medical intervention and a hospital stay. This is evidenced by: Facility policy entitled, Physician Notification, reviewed 4/6/22, includes, in part: The professional nursing staff will notify the resident's physician when a change in the resident's condition has occurred. Sometimes the telephone contact to the physician is one of urgency while at other times it may be less urgent but still necessary to obtain a new order. During his or her office hours contact the primary physician when an update or an order is indicated. The on-call physician is to be contacted for resident needs when the primary physician is unavailable. when the primary and on call physician are unavailable then notify the medical director for orders until the primary physician is available. when a change in resident's condition occurs or a resident expresses a concern that requires physician notification on your shift it is your responsibility to notify the physician. you are safer to over report than to neglect a situation that could jeopardize the resident's health and comfort. refer to AMDA manual standards of practice for physician notification. R48's Hospital Discharge Summary, dated 4/6/23, included the following: History of present illness: History of Atrial fibrillation (heart arrthymia), prior pulmonary embolism (blood clot in lung), hypertension, major depressant disorder who presented with STEMI (a heart attack with a completely blocked coronary artery) post status PCI (percutaneous coronary intervention) with DESx1 (drug-eluting stents). On 4/4/23 R48 presented at the ER (emergency room ) for chest pain. An ECG (electrocardiography-check cardiac rhythm) was obtained showing anterolateral ST elevations (heart muscle is dying). R48 was med flighted to another hospital for cardiac catheterization. En route R48 had an episode of VF (ventricular fibrillation-nonviable heart rhythm) arrest requiring cardioversion x1 (procedure to restore normal heart rhythm) . Call Heart Failure Nurse Practitioner if weight increases by 2 to 3 lbs. in one day or 5 pounds in one week. Discontinue after one week if stable and then start weekly weight. R48 admitted to the Skilled Nursing Facility on 4/6/23 with diagnoses, including atrial fibrillation, congestive heart failure, stress-induced cardiomyopathy (enlarged heart), ST elevation myocardial infarction, cardiac asystole (without heart rhythm/pulseless), prior pulmonary embolism (blood clot in lung), and status post permanent pacemaker. R48's Physician Order, start date 4/7/23, Daily weight- call Heart Failure Nurse Practitioner if weight increases by 2 to 3 lbs. in one day or 5 pounds in one week. Discontinue after one week if stable and then start weekly weights. R48's medical record contained the following: 4/6/23 admission weight: 156.0 lbs. (pounds) 4/9/23 weight 155.0 lbs. 4/10/23 weight 157.2 lbs. (It is important to note R48's weight increased by 2.2 lbs. increase and there is no evidence if facility notified R48's Heart Failure Nurse Practioner or her Medical Doctor of this change.) 4/12/23 159.0 lbs. (It is important to note R48's weight increase of 4lbs between 4/9 and 4/12 and there is no evidence if facility notified R48's Heart Failure Nurse Practitioner her Medical Doctor of this change.) 4/13 161.3 (It is important to note R48's weight gain of 5.3 lbs. since admission weight and a gain of 2.3lbs from 4/12 to 4/13 and there is no evidence of facility updating and consulting R48's MD or Heart Failure Nurse Practitioner per physician orders.) R48's Nurse Note, dated 4/13/23, includes, in part: . shortness of breath, gained 6.3lbs in one-week, low BP noted at times, asking granddaughter to take her to ER . granddaughter took her to ER, and she was admitted for CHF exacerbation. A fax, dated 4/19/23, was sent to R48's MD with all recorded weights. R48's MD hand wrote the following and returned the fax on 4/19/23: yes continue daily weight indefinitely recent admission due to Congestive Heart Failure. R48's Hospital Discharge Summary, dated 4/17/23, includes, in part: .admitted on [DATE] and discharged [DATE] . a heart healthy diet . has been residing at (facility), due to weakness and prolonged hospitalization as well as pacemaker implantation. She notes she has gained 10 lbs. from her dry weight, has been feeling increasingly short of breath, and having dark brown stool, not black . Suspect shortness of breath secondary to heart failure with bilateral pleural effusions . appears to be in acute on chronic heart failure . BNP of 1250 to 1080 . strict intake and outputs . increase Lasix 40mg twice daily .continue diuresis plan . continue Plavix . decrease valsartan to 10mg daily . increase paroxetine to 20mg . R48's Nurse Note, dated 4/17/23, includes, in part: . returned from hospital on 1 Liter of oxygen . On 5/17/23 at 7:39 AM during an interview RN F (Registered Nurse) and RN E indicated either the CNAs (Certified Nursing Assistants) or the nurse will weigh residents before breakfast. RN E and RN F indicated staff should have consulted with R48's Medical Doctor about her weight gain of 2.2 lbs. on 4/10/23 and again on 4/12/23 with her weight gain. RN F and RN E indicated the order was put in the computer wrong, so a box did not pop up asking for the daily weights. On 5/17/23 at 9:57 AM NHA A (Nursing Home Administrator) and Dietary Manager G indicated R48 should have been weighed every day and the nurse on the unit should have consulted with R48's MD/Heart Failure Nurse Practitioner per R48's physician orders. On 5/17/23 at 3:12 PM NHA A and RN D indicated R48's weight order was not put in the computer correctly, so a box did not pop up asking for R48's daily weight. RN D indicated once weight gain was within 2-3 lbs. gain the nurse should have consulted with R48's MD. RN D indicated the standard of practice they use is AMDA (American Medical Directors Association). R48 had orders for daily weight and to contact the Heart Failure Nurse Practitioner (NP) if weight increases by 2 to 3 lbs. in one day or 5 pounds in one week. The facility failed to update the NP with weight gain which prevented the NP from altering treatment. R48 was re-hospitalized with CHF exacerbation.

Based on observation, interview, and record review the facility did not ensure the preparation of food in a clean and sanitary environment with potential to affect all 47 residents residing in the facility. Surveyor observed the facility's downstairs freezer to have liquid dripping from the ceiling into boxes of food that was no longer sealed by the manufacturer. Surveyor observed Cook K wet stacking clean cups. Cook K indicated she was talked to the previous year by Surveyors for not allowing the dishes to air dry completely and knows she should allow them to dry completely before stacking them. This is evidenced by: Facility policy, entitled Dish Machine, reviewed 5/17/23, includes, in part: Dishes/glasses should be air dried in racks on shelf until completely dry. Recommendations for use of the [NAME] High temperature Dishwasher, includes, in part: . Allow dishes to drain and air-dry before removing the ware from the rack . On 5/17/23 at 9:04 AM Surveyor observed Cook K placing wet cups upside down on trays and then placing trays in a storage area near the food line. Cook K indicated she was talked with last year on survey about stacking wet dishes. Surveyor indicated that is what she was observing for and asked Cook K to lift a plastic cup from one of the serving trays. Cook K did this. Surveyor asked if these cups were able to dry when they were turned upside down onto the plastic tray. Cook K lifted a couple more cups up. Surveyor and Cook K observed the cups to have moisture inside of them. Cook K indicated these cups were not completely air dried before placing them upside down on the plastic tray and they should have been, because they are not able to air dry completely when stored in this manner. On 5/17/23 at 9:38 AM during an interview DM G (Dietary Manager) and NHA A (Nursing Home Administrator) indicated staff should allow all dishware to dry before stacking to store in. On 5/15/23 at 10:29 AM Surveyor, Cook L and DM G observed frozen drips on the ceiling and piping inside of the facility's walk-in freezer. Surveyor, Cook L, and DM G also observed boxes with ice buildup and ice pieces under the drips from the ceiling and piping. Some of these boxes, containing breaded chicken pieces, chunks, and breasts, were opened, and resealed by facility staff. When Cook L opened the flaps of the box ice chips were visible inside of the box. Cook L and DM G indicated there is potential for contamination of the food inside of the boxes that are no longer sealed by the manufacturer. On 5/17/23 at 9:38 AM during an interview DM G and NHA A indicated they threw the opened boxes of chicken away and they placed a barrier between the ceiling and the boxes stored underneath so this would protect the food.

Based on interview and record review the facility staff failed to adequately assess and treat pain and provide necessary care and services to attain or maintain the highest practicable physical well-being for 1 (R15) of 2 residents reviewed for pain out of a total sample of 17. R15 reported to Surveyor to be in 8 out of 10 pain and was observed crying. R15 reported to CNA I (Certified Nursing Assistant) and CNA J that she had pain in her shoulder that started during an EZ stand transfer. CNA I voiced she was aware of R15 crying and in pain after EZ stand transfer and did not report this pain to RN H. RN H indicated CNA J reported R15 was experiencing 5 out of 10 pain. RN H (Registered Nurse) did not immediately perform a thorough RN assessment into this pain, including a visual assessment, a descriptive assessment, or a root cause analysis. RN H did not talk with R15 about options to reduce pain. Evidenced by: Facility policy, entitled Pain Assessment and Management, reviewed 4/26/22, includes in part: The pain management program is based on a facility-wide commitment to resident comfort. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Pain management is a multidisciplinary care process that includes the following: Assessing the potential for pain . Effectively recognizing the presence of pain . Identifying the characteristics of pain . Addressing the underlying causes of pain . Developing and implementing approaches to pain management . Identifying and using specific strategies for different levels and sources of pain . monitoring the effectiveness of interventions . Modifying approaches as needed . observe resident for . signs of pain: verbal expressions . crying . irritability . guarding, rubbing, favoring a particular part of body . Assessing pain: . gather the following information as indicated from the resident: history of pain and treatment . characteristics of pain . intensity of pain . description of pain . pattern of pain . location and radiation of pain . frequency, timing, and duration of pain . impact of pain on quality of life . factors that precipitate or exacerbate pain . factors and strategies that reduce pain . Identifying the Cause of Pain: . identify conditions or situations that may predispose the resident to pain . R15 admitted to the facility on [DATE]. Her diagnoses include pain in right hip and weakness. R15's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 4/19/23 indicates R15's cognition is intact with a BIMS (Brief Interview for Mental Status) score of 13 out of 15. R15's MDS indicates during the 5-day lookback period R15 had pain, has taken as needed medications for pain reduction, has used nonpharmaceutical interventions for pain reduction, pain is present, pain is frequent, pain has limited R15's day to day activity, and her pain intensity is a 9. R15's MDS also indicates she requires the extensive physical assistance of one or two staff members to meet her needs in the following care areas: bed mobility, transfer, toileting, locomotion, dressing, and personal hygiene. R15's Comprehensive Care Plan, with original date of 1/5/22, includes, in part: 1/9/23 Potential for alteration in comfort related to right hip pain, weakness, and congestive heart failure . Effective date- 1/25/21 R15 will report to staff when having pain and will experience relief . with staff interventions with each occurrence . Effective date- 4/23/23 sit to stand transfer (EZ stand transfer) Effective date- 1/25/21 encourage independence Effective date- 1/5/21 discourage and avoid abrupt position changes Effective date- 1/25/21 alternate pain relief interventions such as massage, heat/cold application, distraction, etc. Monitor effectiveness . Effective date- Monitor for any non-verbal indicators of pain such as facial grimacing, restlessness, irritability, moaning, sweating, increased pulse/respirations 1/9/23 Deficit related to weakness and history of pain . Effective date 1/25/21 encourage R15 to report any complaints of pain/discomfort, plan activities to provide distraction, such as reading, crafts, television, or visits . Effective date 1/25/21 Consult with Medical Doctor as needed if current pain relief interventions not effective Effective date 1/25/21 Provide minimal assist for dressing/grooming needs daily. Encourage and allow R15 to perform as much for self as able and allow ample time for completion of tasks. Praise efforts. On 5/15/23 at 12:05 PM Surveyor observed R15 crying in the easy chair in her room. R15 indicated she was in pain rated 8 out of 10 and staff are not helping her with this pain. R15 indicated she always has some pain in her shoulder, but after breakfast two staff were assisting her with an EZ stand transfer and her shoulder was pulled on causing pain. R15 indicated she told the two CNAs she was in pain and began to cry while they were still in the room. R15 indicated she has been crying and in pain since this incident that occurred around breakfast time. On 5/15/23 at 12:10 PM CNA I indicated she was contracted agency staff and did not know the residents as good as a direct staff would. CNA I stated, R15 said her arm hurts. I think it is chronic. When CNA J and I were standing her in EZ stand, she said it hurt. CNA I indicated she did not report R15's complaint of pain to the nurse, because everyone just knows about it already. CNA I indicated this is a common concern of R15 and her care plan has no special instructions for R15's pain in her shoulder but it should. On 5/15/23 at 12:16 PM RN H indicated R15 was tearful and crying earlier at breakfast. RN H indicated CNA J reported R15 was in 5 out of 10 pain in her shoulder at breakfast time. Surveyor asked what R15's pain goal was. RN H was not sure. RN H indicated she did not perform an RN assessment of R15's pain, including a visual assessment, a descriptive assessment, or a root cause analysis when she was made aware R15 was crying and had pain 5 out of 10, because R15 has chronic pain in her shoulder. RN H indicated she was not made aware that R15's pain became worse after a transfer in the EZ stand. RN H indicated she expects CNAs to report new pain or worsened pain to her. On 5/17/23 at 9:38 AM NHA A (Nursing Home Administrator) indicated it is her expectation that CNAs report verbal complaints of pain, a resident crying, and/or an incident that could have injured a resident to their nurse. NHA A indicated it is her expectation that a nurse completes a thorough assessment on a resident when being made aware of a resident crying and/or a verbal complaint is made of pain, including a visual assessment, a descriptive assessment, and a root cause analysis. NHA A indicated it is her expectation that staff will try nonpharmaceutical interventions when a resident reports pain.

Based on interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 sampled residents (R3). Staff did not complete appropriate hand hygiene during wound care for R3. This is evidenced by: The facility policy titled, Infection Prevention and Control Manual, Standard Precautions, Hand Hygiene, with a revised and/or reviewed date of 4/12/23, states, in part: Policy: It is the policy of this facility that hand hygiene (HH) (e.g., hand washing and/or Alcohol-based hand rub (ABHR) .is to be performed consistent with accepted standards of practice in order to reduce the potential of the spread of pathogens . Procedure: There are 2 methods for hand hygiene: 1. Alcohol-based hand sanitizers (ABHS) .is the preferred method of use in most clinical situations .ABHR should be used: i. Immediately prior to touching a resident. ii. Before performance of an aseptic technique .iii. When caring for a resident, when moving from a soiled body site to a clean body site of the same resident. iv. After touching a resident or the resident's immediate environment. v. After any contact with blood, body fluids or contaminated surfaces. vi. Immediately upon removal of gloves and PPE (Personal Protective Equipment). 2. Hand Hygiene with soap and water should be performed: i. When hands are visibly soiled . On 5/16/23 at 1:27PM Surveyor observed RN C (Registered Nurse) perform wound care for R3. RN C entered the room, completed hand hygiene with soap and water, and put on a new pair of gloves. RN C then touched the bed control at the foot of the bed to adjust the bed for cares. RN C then assisted with turning R3 and moving a yellow absorbent pad away from R3's buttock. RN C then removed her gloves and began to place new gloves while indicating to Surveyor, if I had hand sanitizer, I would sanitize my hands and then put new gloves on. No hand hygiene was performed between this glove change. RN C then washed the wound with wound cleanser. RN C removed her right glove but not the left. RN C then used the right, ungloved hand, to take a new gauze and dab the wound. RN C then changed her gloves, did not complete hand hygiene between the glove change, and applied the ordered topical cream to the wound. RN C then removed gloves, did not perform hand hygiene, and assisted with repositioning of the resident, used the bed controls at the foot of the bed to adjust the bed, retrieved R3's blanket from the top of a dresser and covered resident. RN C then performed hand hygiene utilizing the resident's bathroom sink. Surveyor interviewed RN C after completion of wound care. Surveyor asked RN C when hand hygiene should be performed. RN C indicated, before starting anything, anytime you change gloves, and when you are done. Surveyor asked RN C when gloves should be changed. RN C indicated, when you take the dirty treatment off, when you clean it and when you're done. Surveyor asked RN C if gloves should be changed after touching things in the resident's environment. RN C indicated, yes. Surveyor asked RN C if she should have changed gloves and performed hand hygiene after touching the bed control, assisting to turn resident, and moving the pad. RN C indicated, yes. Surveyor asked RN C when you stated if you had hand sanitizer you would use it, should you have stopped and got what you needed to perform hand hygiene. RN C indicated, yes. Surveyor asked RN C if she should have done a complete glove change with hand hygiene when she used the clean gauze to dry the wound. RN C indicated, yes. On 5/17/23 at 10:13AM Surveyor interviewed Nurse Manager D. Surveyor asked Nurse Manager D when staff should change gloves and perform hand hygiene during wound care. Nurse Manager D indicated, when they start, they should wash hands and put on gloves, do the treatment, take gloves off and wash their hands. Surveyor reviewed the above observation with Nurse Manager D and asked if she would expect a glove change and hand hygiene after using the bed control and repositioning the resident prior to starting treatment. Nurse Manager D indicated, yes. Surveyor asked Nurse Manager D if she would expect hand hygiene to be performed with every glove change. Nurse Manager D indicated she would. Surveyor asked Nurse Manager D what staff should do if hand sanitizer is not available between glove changes. Nurse Manager D indicated she would expect them to use the sink to wash hands in between. Surveyor asked Nurse Manager D if RN C should have done a full glove change and performed hand hygiene prior to getting the clean gauze to dry the wound. Nurse Manager D indicated she should have.

Based on observation, interview and record review, the facility did not ensure it maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections such as COVID-19. This had the potential to affect all 46 residents (R) in the facility. -The facility did not have a system in place to keep up to date on COVID-19 guidance. -The facility did not place residents (R22, R36, and R41) that were unvaccinated in TBP (Transmission Based Precautions) during a COVID-19 outbreak. -Staff were hanging gowns used in a COVID-19 positive room on the outside of the room door. -Receptacles used for removal of PPE (Personal Protective Equipment) for COVID-19 positive residents were in the hallway. -The facility did not have a process in place to accurately monitor staff and visitors temperatures during screenings. This is evidenced by: The CDC's (Center for Disease Control) updated guidance, titled Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes dated 2/2/22, states in part: .Residents and HCP (Health Care Providers) who are not up to date with all recommended COVID-19 vaccination doses: .should generally be restricted to their rooms, even if testing negative, and cared for by HCP using an N95 or higher- level respirator, eye protection, gloves, and gown. They should not participate in group activities. The facility's policy titled COVID-19: Infection Control, revision date 4/7/21 states in part: .ii. Will use protective equipment (PPE) appropriately. Donning PPE upon room entry and properly discarding before exiting the resident room is done to contain pathogens .Removing and discarding the gown in a dedicated container for waste or linen before leaving the resident room or care area. The facility does not have a policy for employee screening. They have a Daily Staff Screening that instructs the employee to take his/ her temperature, and review signs and symptoms of COVID-19. Additionally, the facility was unable to provide Surveyor with the manufacturer's recommendations for their facial scanner kiosk that scans the employee for their temperature. Example 1: The facility is currently in a COVID-19 outbreak, there are 2 COVID-19 positive residents on the 400 wing. R22 resides on the 400 wing. R22 has received 2 COVID-19 vaccinations, but has declined the 3rd dose; therefore, she is not considered up to date with the vaccine. R36 resides on the 400 wing. R36 has received 2 COVID-19 vaccinations, but is not yet due for the 3rd dose; therefore, he is not considered up to date with the vaccine. R41 resides on the 400 wing. R41 has declined all doses of the COVID-19 vaccine, therefore she is not considered up to date with the vaccine. The facility has not placed R22, R36, or R41 on TBP, nor have they required their staff to wear full PPE (gown, N95 respirator, or gloves) when caring for these residents. On 2/21/22 at 10:21 AM, Surveyor was on the 400 wing. Surveyor observed reusable isolation gowns hanging on the outside of a COVID Positive room. The gowns were on the outside of the room door and the dirty linen bin in the hallway. Staff working the 400 wing were observed wearing eye protection and surgical masks. On 2/23/22 at 8:00 AM, Surveyor observed reusable isolation gowns hanging on the outside of the door of room COVID positive room on the 400 wing. On 2/23/22 at 9:15 AM, Surveyor observed reusable isolation gowns hanging on the outside of the door of the COVID positive room on the 400 wing. On 2/24/22 at 12:25 PM, Surveyor interviewed IP I (Infection Preventionist) Surveyor asked IP I to help this Surveyor understand why there were used isolation gowns hanging outside of a COVID positive room, IP I stated that during the facility's big COVID-19 outbreak, they had to reuse gowns and that staff is just used to reusing equipment. Surveyor asked IP I if the gowns should be doffed inside the room or outside, IP I stated staff should exit the room and then take their PPE off in the hallway. Surveyor asked IP I why the soiled linen bin is in the hallway, IP I stated that is for when staff remove their PPE. Surveyor asked IP I if doffing in the hallway and hanging used gowns on the outside of resident's doors is considered appropriate infection control practices to prevent infection, IP I stated no. Surveyor asked IP I if she had reviewed the updated guidance from the CDC regarding TBP and residents that are not up to date on their COVID-19 vaccinations, IP I stated that she had thought that she had read the most recent guidance. Surveyor reviewed the updated guidance with IP I, which states that residents that are not up to date should be isolated to their room and that staff should be wearing full PPE; IP I stated that she had not read the updated guidance. On 2/24/22 at 1:08 PM, Surveyor interviewed CNA J (Certified Nursing Assistant). Surveyor asked CNA J if she had received education regarding donning and doffing PPE, CNA J stated yes and explained to Surveyor the donning and doffing process. Surveyor asked CNA J where she received the guidance to hang the used isolation gowns on the outside of the resident's room, CNA J stated that they started doing it at the beginning of COVID. Surveyor asked CNA J if the dirty linen bins had ever been inside the resident rooms, CNA J stated that they have always been in the hallway. On 2/24/22 at 1:34 PM Surveyor interviewed CNA K. Surveyor asked CNA K if she had received education regarding donning and doffing PPE, CNA K stated yes and explained to Surveyor the donning and doffing process. Surveyor asked CNA K where she received the guidance to hang the used isolation gowns on the outside of the resident's room, CNA K stated that she had heard it from multiple people through shift to shift report. On 2/24/22 Surveyor interviewed CNA L. Surveyor asked CNA L if she had received education regarding donning and doffing PPE, CNA L stated yes and explained to Surveyor the donning and doffing process. Surveyor asked CNA L where she received the guidance to hang the used isolation gowns on the outside of the resident's room, CNA L stated that was from when they were using cloth gowns and that the ones they are using now should be disposed with. Example 2: Surveyor reviewed staff screenings for the last 4 weeks. Surveyor noted that many staff had a temperature reading of 96.01 degrees F (Fahrenheit). The following list is the temperature data: 1/23/22: 23 out of 44 staff screened with a temperature of 96.01 degrees F. 1/24/22: 41 out of 52 staff screened with a temperature of 96.01 degrees F. 1/25/22: 49 out of 60 staff screened with a temperature of 96.01 degrees F. 1/26/22: 62 out of 65 staff screened with a temperature of 96.01 degrees F. 1/27/22: 46 out of 59 staff screened with a temperature of 96.01 degrees F. 1/28/22: 47 out of 59 staff screened with a temperature of 96.01 degrees F. 1/29/22: 21 out of 30 staff screened with a temperature of 96.01 degrees F. 1/30/22: 18 out of 32 staff screened with a temperature of 96.01 degrees F. 1/31/22: 43 out of 52 staff screened with a temperature of 96.01 degrees F. 2/1/22: 44 out of 65 staff screened with a temperature of 96.01 degrees F. 2/2/22: 57 out of 63 staff screened with a temperature of 96.01 degrees F. 2/3/22: 45 out of 52 staff screened with a temperature of 96.01 degrees F. 2/4/22: 40 out of 48 staff screened with a temperature of 96.01 degrees F. 2/5/22: 30 out of 37 staff screened with a temperature of 96.01 degrees F. 2/6/22: 29 out of 39 staff screened with a temperature of 96.01 degrees F. 2/7/22: 47 out of 56 staff screened with a temperature of 96.01 degrees F. 2/8/22: 37 out of 56 staff screened with a temperature of 96.01 degrees F. 2/9/22: 52 out of 66 staff screened with a temperature of 96.01 degrees F. 2/10/22: 42 out of 62 staff screened with a temperature of 96.01 degrees F. 2/11/22: 41 out of 60 staff screened with a temperature of 96.01 degrees F. 2/12/22: 18 out of 32 staff screened with a temperature of 96.01 degrees F. 2/13/22: 23 out of 33 staff screened with a temperature of 96.01 degrees F. 2/14/22: 45 out of 55 staff screened with a temperature of 96.01 degrees F. 2/15/22: 38 out of 60 staff screened with a temperature of 96.01 degrees F. 2/16/22: 43 out of 64 staff screened with a temperature of 96.01 degrees F. 2/17/22: 45 out of 54 staff screened with a temperature of 96.01 degrees F. 2/18/22: 40 out of 51 staff screened with a temperature of 96.01 degrees F. 2/19/22: 39 out of 45 staff screened with a temperature of 96.01 degrees F. 2/20/22: 27 out of 39 staff screened with a temperature of 96.01 degrees F. 2/21/22: 41 out of 59 staff screened with a temperature of 96.01 degrees F. 2/22/22: 34 out of 50 staff screened with a temperature of 96.01 degrees F. 2/23/22: 7 out of 7 staff screened with a temperature of 96.01 degrees F. It is important to note that the screening log indicates that on 2/23/22, no staff screened in after 4:04 AM. Additionally, the 3 Surveyors screened in at 96.01 degrees F on all 4 days of the survey. On 2/23/22 at 12:46 PM, Surveyor interviewed BOM N (Business Office Manager). Surveyor asked BOM N how often she reviews the employee and visitor screenings, BOM N stated that she reviews them at least once a week. Surveyor asked BOM N if she noticed the frequent readings of 96.01 degrees F on the screening log, BOM N stated that it was because everyone is coming in from the cold and that is the lowest temperature that the machine reads. Surveyor asked if that would be considered an accurate temperature, BOM N stated that even when they had the hand- help thermometer, it would read low and would have to wait for staff to warm up and then re-check it. Surveyor asked BOM N how often the machine gets calibrated, BOM N stated that she does not know. On 2/24/22 at 10:16 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what her expectation was for staff screenings, DON B stated that she expects all staff to screen before going to the floor. Surveyor asked DON B how often the screenings should be reviewed, DON B stated they should be reviewed as needed and that if staff have a temperature it is reported to the nurse and they are asked to leave the building. DON B stated that she doesn't really have anything to do with it. Surveyor asked DON B how she can be assured that the scanner is giving an accurate reading if instead of reading low, it gives a reading of 96.01 degrees F, DON B stated that we can't be assured of an accurate reading with any thermometer. On 2/24/22 at 10:33 AM, Surveyor interviewed MS O (Maintenance Supervisor). MS O reported to Surveyor that the temperature scanner updates itself with ambient temperature automatically, so he has never calibrated the machine. MS O stated that it will not give an accurate temperature if you walk in from the cold and that staff needs to wait 30-40 seconds before scanning. MS O stated that it is set to read 96.01 degrees F as the lowest temperature and flags staff if reading is 99.0 degrees F or above. Surveyor asked MS O if he has shared this information with the DON or the NHA (Nursing Home Administrator), MS O stated that he just received this information. Surveyor asked MS O if he had the manufacturer's recommendations for the scanner, MS O reported that they are supposed to be sending him something.

Based on interview and record review the facility failed to ensure each resident was treated with respect and dignity and cared for in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, this affected 3 sampled residents (R10, R40, and R23) and 4 supplemental residents (R12, R24, R34 and R29). R10, R40, R23, R12, R24, R34 and R29 stated that LPN T (Licensed Practical Nurse) spoke roughly and rudely to them over the course of several months. Residents stated they had reported LPN T's rude and rough communication to staff members. Staff interviewed said they had informed DON B (Director of Nursing) of residents' reports. LPN T's personnel file contains multiple counselings from 2021 and continuing to 2022. The subjects of the counselings are respecting residents rights, being courteous to residents and not to disrespect resident's belongings. Surveyor reviewed resident grievances on the grievance log as part of survey process. R40 submitted a grievance on September 29, 2021 about LPN T. R40 stated in her grievance that LPN T removed her commemorative cap from R40's head, and removed the commemorative stickers. The commemorative stickers indicated the cap was a collectable item. R40 asked LPN T why she removed her cap from her head and removed the stickers. LPN T said the stickers did not need to be on the cap. R40 reported this to SW S (Social Worker). R40 told SW S about what LPN T did with her cap. SW S told DON B and both went to retrieve R40's cap stickers from the trash container where LPN T threw them. SW S and DON B were able to replace the stickers on R40's cap. On 2/22/22 at 1:15 PM., Surveyor spoke with R40. Surveyor asked R40 about the incident with LPN T and her cap. R40 said I was so upset, I cried, and I don't cry easily. That cap cost me $33 dollars. It made me feel violated when she took the stickers off my hat. On 2/23/22 at 12:30 PM, Surveyor spoke with CNA Q (Certified Nurse Assistant). CNA Q said she has heard LPN T be rude to residents a lot. I was working the evening that R40 had an incident with LPN T and her cap. R40 was crying and really upset. I did not see the incident, but I saw R40 crying and being very upset over her cap and the stickers being removed. I have told DON B about LPN T and how she talks to residents. On 2/24/22 at 2:32 PM, Surveyor spoke with SW S. SW S said when a grievance or incident happens, we investigate it right away. I focus on the resident the grievance or incident that occurred and the staff involved. I receive guidance from the NHA (Nursing Home Administrator) and DON on when to report it. I will speak to the resident and staff involved. When R40's incident happened, we were still here and were able to get the stickers out of the trash. I have heard things about LPN T but I did not follow up on it. On 2/23/22, Surveyor spoke to residents about LPN T: -R10 said when she talks rude to me I feel dismayed; -R12 said LPN T talks rough to me a week or so ago, when she put me in my chair, I thought she was a little rough; -R23 said LPN T is rude, she makes me feel like I want to be left alone; -R24 said LPN T talks rude at times. I feel disgusted when she does that; -R29 said about three weeks ago I had a visitor come in. LPN T didn't say anything but she had an attitude that made us feel like we were doing something wrong. I was in tears and felt humiliated and condescended to; -R34 said about two weeks ago I asked her to help me move in bed a little, that I wasn't comfortable. LPN T said to me that she wasn't going to break her back so I can be more comfortable. That made me feel angry and apprehensive. I felt like if there was an emergency, she would protect herself before she would protect me. On 2/23/22 at 12:45 PM, Surveyor spoke with CNA K. CNA K said I have worked with LPN T and she is rude to residents. On 2/24/22 at 4:00 PM, Surveyor spoke with DON B. DON B said she did not consider the incidents she received from coworkers as reportable or abuse. The resident or family has to use the word abuse for me to consider it to be abuse. The facility failed to ensure each resident is treated with dignity and respect.

Based on interview and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 4 of 6 residents (R2, R9, R17, and R32) reviewed for fall concerns out of a total sample of 14 residents. R9 had a fall resulting in a fracture on 11/21/21 and the facility did not ensure that they identified the root cause of the fall to ensure proper intervention were put into place to prevent further falls. R17 had 5 falls between 9/11/21 and 1/31/22, 3 of which the facility did not ensure that they identified the root cause of and ensure proper interventions were put into place to prevent further falls. R2 and R32 have multiple falls with no identified root cause thoroughly investigated and interventions ineffective. This is evidenced by: The facility's Fall Risk Assessment policy and procedure, dated 7/01/21, states, in part: . Purpose: The nursing staff will seek to identify resident risk factors for falls. This will be documented on a Fall Risk Assessment. The assessment will be completed upon admission, along with the MDS (minimum data set) schedule and after every fall. Implementation: 1. The nursing staff will review a resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time. The nursing staff will ask the resident and/or his/her family about any history of the resident falling. 6. The staff will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, continence, and cognition. The attending Physician will be consulted as needed. Therapy screens to be completed if indicated. The facility's Fall Huddles policy and procedure, dated 7/01/21, states in part: .Purpose: Fall Huddle forms will be completed by nursing staff following any resident fall. All facility staff in the vicinity should actively participate. Objectives: 1. To determine the root cause of the fall, 2. To identify any potential safety concerns in the physical environment, 3. To allow for prospective and ideas by a variety of staff members, 4. To help decrease risk for additional falls. Procedure: 6. All staff members participating in the fall huddle will sign and date at the bottom of the form. The facility's Falls: Assessment and Root Cause Analysis policy and procedure, dated 7/01/21, states in part: . Purpose: The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff identifying causes of the fall. General Guidelines: 1. Falls are a leading cause of morbidity and mortality among the elderly in nursing homes. 2. Approximately 50 percent of residents fall annually and 10 percent of these falls result in serious injury. 3. Fear of falling may limit an individual's participation in activities. 4. Falling may be related to underlying clinical conditions and functional decline, medication side effects, and/or environment risk factors, 5. Resident must be assessed in a timely manner for potential causes of falls, 6. Relevant environmental issues should be addressed promptly. Steps in the Procedure: f. All staff caring for the resident and those in the vicinity of the fall should meet to discuss the fall and events leading to the fall to begin investigation into the root cause of the fall. 2. Defining Details of Falls: a. After an observed or probable fall, that staff will clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred. Obtain statements as indicated. 3. Identifying Causes of a fall or Fall Risk: a. The licensed nursing staff will begin to try to identify possible or likely causes of the incident. They will refer to resident-specific evidence including medical history, known functional impairments, etc. b. Staff will evaluate chains of events or circumstances preceding a recent fall. c. The staff will continue to collect and evaluate information until they either identify the cause of falling or determine that the cause cannot be found. f. If cause of fall is identified, interventions will be put in to place to assist in preventing future falls of the same nature. Care plan will be updated to reflect these interventions. Example 1 R9 was admitted to the facility on [DATE] with diagnoses including: Unspecified dementia without behavioral disturbance, weakness, and [CONDITION(S)]. R9's quarterly MDS on 11/24/21 noted a BIMS (Brief interview for Mental Status) score of 9, indicating moderate cognitive impairment. R9's Comprehensive Care Plan, date initiated 3/08/21 and last revised on 12/03/21, includes, in part: Problem: Impaired Mobility/Potential for Falls r/t (related to) hx (history) of falls, weakness. Interventions: Anticipate needs and remind/encourage resident to use call light for assistance, initiated 11/21/21. Ambulates independently with FWW (front wheeled walker), initiated 12/02/21. R9 had a fall resulting in a fracture of the coccyx on 11/12/21. The fall on 11/12/21 was a result of R9 trying to take her food tray out to staff, using her bedside table as a walker. The facility evaluated R9 and completed the Fall Assessment. The facility failed complete root cause analysis, implement interventions related to R9's fall to prevent further falls. R9's fall was documented on the Fall Assessment, as follows .11/12/21 at 13:16 (1:16 PM), Summary of Call: Resident was pushing her side table to her door and lost balance and fell and hit her head. Unwitnessed. Contributing Factors, Mark all that apply . Arthritis, dementia, and incontinence. Plan: Educated resident to use walker and not table when ambulating. On 2/23/22 at 8:11 AM, Surveyor reviewed fall investigation with DON B and RN C. Surveyor asked RN C what the root cause of R9's fall was. RN C stated, She always tries to take her food tray out to staff and in doing so used her tray table as a walker and fell . Surveyor asked RN C and DON B what the root cause of R9's fall was based on that information. RN C stated, Using her tray table as a walker. Surveyor asked what RN C what R9 was attempting to do when she fell . RN C stated, Take her lunch tray out to staff. Surveyor asked RN C if this would be considered the root cause. RN C stated, Yes. Surveyor asked based on that information was the intervention of educating R9 to use her walker was an appropriate intervention. RN C stated, No. Surveyor asked when it is no longer appropriate to use education for a resident with dementia. RN C stated, I think you wouldn't educate anyone with a BIMS of less than 13. Surveyor asked RN C if the fall assessment was complete. RN C stated, No, staff did not fill in some of informations, such as, was the resident incontinent at the time of the fall. Surveyor asked RN C if she would expect forms to be complete thoroughly to help staff identify a root cause. RN C stated, Yes. Example 2 R17 was admitted to the facility on [DATE], with diagnoses that include, Unspecified dementia without behavioral disturbance, Other symptoms and signs involving cognitive functions an awareness, alcohol dependence, anxiety disorder, unspecified mood [affective] disorder, and delusional disorder. R17's annual MDS on 12/03/21 noted a BIMS (Brief interview for Mental Status) score of 99, indicating severe cognitive impairment. R17 has an AHCPOA (Activated Healthcare Power of Attorney) and is not her own decision maker. R17 had 5 falls between 9/11/21 and 1/31/22, for 3 of those falls the facility failed to identify the root cause of the falls and put interventions in place that would prevent further falls. R17's fall was documented on the Fall Assessment, as follows, .9/11/21 at 10:05 AM, Summary of fall: Resident was lowered to the floor by the CNA. Residents legs gave out while she was getting dressed. Witnessed. Contributing Factors, Mark all that apply . Dementia, Alzheimer's, decline in cognitive skills, incontinence, and impaired vision and speech. Plan: Continue current interventions, wears padded hip protectors to protect from injury if she does fall. Arthritis, dementia, Alzheimer's, anxiety, depression, incontinence, and impaired speech. Plan: POA in agreement to continue current interventions. Note: The facility did not identify the root cause of the fall or care plan an appropriate intervention to prevent further falls. R17's fall was documented on the Fall Assessment, as follows, .12/30/21 at 11:25 AM, Summary of fall: Resident attempted to sit on arm of love seat et (and) slid to floor landing on buttocks, did not hit head. Witnessed. Contributing Factors, Mark all that apply . Dementia, Alzheimer's, decline in cognitive skills, and incontinence. Plan: Put towels on arms of love seat. Staff educated. R17's fall was documented on the Fall Assessment, as follows, .1/31/22 at 8:33 AM, Summary of fall: Called back to Memory Care, CNA reported She just fell back to her butt, I seen her do it, she didn't hit her head, R17 sitting on her butt in dining area. Witnessed. Contributing Factors, Mark all that apply . Arthritis, dementia, Alzheimer's, anxiety, depression, incontinence, and impaired speech. Plan: Continue current interventions, wears padded hip protectors to protect from injury if she does fall. Note: The facility did not identify the root cause of the fall or care plan an appropriate intervention to prevent further falls. On 2/23/22 at 8:11 AM, Surveyor interviewed DON B and RN C. Surveyor asked DON B and RN C what the facility process is for falls. DON B states, We review falls in morning huddle. RN C knows more about the falls investigations that I do. RN C states, If I am the nurse on and a fall happens it is my responsibility to assess the resident and do the fall investigation. If a resident has a BIMS of less that 13, we would assume they hit there head. Interventions would need to be put into place, and eAssignment sent to staff so they are aware of the new intervention, and the care plan needs to be updated. The nurse on the floor or the first to respond should complete this. Surveyor asked DON B and RN C what the facility determined to be the root cause of the fall on 9/11/21 for R17. RN C stated, R17's legs gave out while getting dressed. Surveyor asked RN C if she could tell from the fall assessment where this incident occurred. RN C reviewed falls assessment and stated, In the shower room. Surveyor asked if it was possible that R17 slipped on the wet floor in the shower room. RN C stated, I would have to believe that the reason she was being dressed in the shower room was because she just got done with her shower. If that is the case that would be the root cause of the fall. I guess we need to do some education with staff. Surveyor asked DON B and RN what the intervention was that was put into place for this fall. RN C states, There wasn't any. Surveyor asked RN C if there should have been an intervention. RN C stated, Yes, for every fall. Surveyor asked DON B and RN C what the root cause for the fall on 12/30/21 was for R17. RN C stated, R17 was trying to sit on the arm of the love seat. Surveyor asked RN C what intervention was put into place for that fall. RN C stated, To put towels on the arm of the love seat. We did this so there was a color variance from the seat. Surveyor asked RN C if she thought that adding these towels would cause a slippery surface that could contribute to a fall. RN C stated, I guess we didn't think of that. We were just trying to find a way for her to be able to see the seat of the love seat. Surveyor asked DON B and RN C to look at R17's fall from 1/31/21. Surveyor asked DON B and RN C what the root cause of this fall was. RN C stated, It doesn't identify the root cause only that she sat down. Surveyor asked RN C what intervention was put into place for this fall. RN C stated, It says to continue current interventions. Surveyor asked RN C if an intervention should have been put into place for this fall. RN C stated, Yes. The facility failed to identify the root cause of falls and put interventions in place to prevent residents from having further falls. Example 3 R2 was admitted to the facility on [DATE] with diagnoses that include stroke, Alzheimer's Disease and anxiety disorder. His most recent MDS (Minimum Data Set) measures R2's cognitive ability at 3, which is severely cognitively impaired. The MDS measures R2's transferring and toileting ability as limited assistance required from staff. Limited assistance indicates assistance of one staff member. R2's fall care plan includes wear gripper socks or shoes with grip, clear path of clutter. R2's most recent falls and interventions include: -1/14/22 9: 50 AM-Noted to be sitting on buttocks in hallway against wall. Was previously wandering, redirected back to bed or chair several times. No injury noted. Intervention-Continue current care plan interventions. There is no root cause analysis for this fall. -2/14/22 6: 22 AM-Noted to be on buttocks in front of wife's recliner, had walker. Gripper socks did not have quality grip. Intervention-ensure gripper socks have quality grip. There is no root cause analysis for this fall. -2/14/22 1: 15 PM- Resident on back next to bed-skin tear right wrist-Intervention-Continue plan of care and fall prevention interventions. Encourage activity attendance during day due to sleeps a lot during the day. There is no root cause analysis for this fall. -2/22/22 9:49 AM-Found resident sitting on floor next to his recliner. He said I slid off the recliner. Intervention-place non slip pad under soaker pad in recliner. There is no root cause analysis for this fall. Example 4 R32 was admitted to the facility on [DATE] with diagnoses that include kyphosis, unspecified lack of normal physiological development, artificial right eye and cognitive communication deficit. R32's MDS measures he requires supervision with transfers and his cognitive ability measures at 13, which is mildly cognitively impaired. R32 has multiple fall interventions dating from 2017. Interventions include gripper socks at all times, (repeated three times in care plan), sign placed in room for resident to ask for assistance (R32 is kyphotic and unable to raise his head), keep floor free of clutter (repeated twice in care plan), remind to use call light, keep walker close to him (repeated twice in care plan). R32's care plan documents he is independent with transfers. R32's activity of choice is to polish pop tops in the lounge area. The call light in the lounge area is across the room from where R32 sits at a table doing his activity. R32's most recent falls and interventions include: -1/11/22 9:12 AM-in lounge counting pop tops and dropped some to floor-while trying to pick them up, lost balance and fell -Intervention-educated resident to ask for help to get things off floor-remind him to use call bell on table. During four day recertification survey, Surveyor observed R32 in lounge all days. No call bell observed on table. -2/7/22 8:00 PM-Returning from bathroom with his walker, turned to get in bed and lost balance. Intervention-resident to wear nonskid footwear at all times. There is no root cause analysis for this fall. -2/11/22 1:00 PM-At table in dining room, reached for walker and lost balance, fell to floor. Intervention-keep walker close to him at table. There is no root cause analysis for this fall.

Based on observation, interview and record review the facility did not provide an ongoing program of activities designed to meet the interests and the physical, mental and psychosocial well-being of each resident. This has the potential to affect 2 of 2 supplemental residents (R6, R38) and 2 of 2 sampled residents (R17 and R21) residents in the Memory Care Unit. R6, R17, R21, and R38 are on the facility's Memory Care Unit and were observed on several occasions to be seated in the common area without an activities or a diversional activity provided. This is evidenced by the following: Example 1 The facility's Memory Care Unit is located on the back end of one hallway in the facility with alarming doors separating it from the rest of the facility. At the end of the hall on the left is a lounge with 1 square table, 4 recliners, a love seat, a television and small radio. On the right is the dining room with approximately 6 tables. The lounge and dining room are used for all activities on the unit including meals, structured activities and unstructured activities. On 2/23/22, at 12:57 PM Surveyor completed a direct observation from 12:57 PM until 3:52 PM. Surveyor observed residents sitting in the lounge in the Memory Care Unit. Music was playing lightly in the background, the television was shut off and residents R21 and R17 were just sitting in the day room in recliners. R6 and R38 were sitting in the dining room at tables with nothing in front of them. Surveyor completed direct observation for approximately 6.5 hours over a 2 day period. Throughout the almost 4 hour direct observation on 2/23/22, Surveyor observed R17 and R21 get up out of recliners and ambulate about the unit. R21 was also observed going in and out of resident rooms. Both R17 and R21 were continuously redirected back to the recliners in the day room on the unit. These residents would sit for a few minutes, then get back up and again start pacing and wandering the unit. Surveyor observed staff sit residents back in chairs in day room on approximately 30 different occasions. Surveyor did observe CNA E (Certified Nursing Assistant) attempt to give R17 a doll while she was in the recliner but R17 was not interested, no other activities or diversions were attempted for these residents. R6 and R38 were in their rooms until approximately 2:30 PM, at which time they were brought out to the dining room and placed at the tables with nothing in front of them. During Surveyors direct observation on 2/24/22, it was again noted that residents were not participating in any activities. R17 and R21 were sitting in recliners in the day room and R6 and R38 were either in their rooms or sitting at tables in the dining room with nothing in front of them. Throughout the 4 day survey there were no activities observed by Surveyor on the Memory Care Unit. Surveyor reviewed the activity participation logs for the Memory Care Unit and noted the activity choices are: Music therapy, craft, nails, hair, storytelling, reading, courtyard time, 1:1. The following activities were documented: 2/21/22-Sensory and 1:1 for R6, R17, R21, and R38. 2/22/22-1:1 and reading out loud for R17 and 1:1, reading, and ball toss for R6, R21, and R38. 2/23/22-1:1 and sing along for R6, R17, R21 and R38 Note: Staff working on the unit report activities are not or rarely occurring on the Memory Care Unit. Example 2 Resident 17 was admitted to the facility on [DATE] and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R17 has a BIMS (Brief Interview of Mental Status) of 99, indicating severe cognitive impairment, and has an AHCPOA (Activated Health Care Power of Attorney). Resident 17's Comprehensive Minimum Data Set (MDS) assessment dated [DATE] states in section F0800 for Staff Assessment of daily Activity Preferences for Resident 17 are listed as I. Family or significant other involvement of care discussion. M. Listening to music. Activities Director H provided Surveyor with a hand written form titled, Initial/Annual Activity Assessment, dated December 2021, which states in part . Loves sports and pet visits. Items listed as very important, are as follows . Have snacks available between meals, have your family or a close friend involved in discussion about your care, and being around animals such as pets. R17's comprehensive care plan dated 3/25/19, states in part . Problem/Strengths: Activity Deficit. Husband reports that R17 enjoyed traveling - Hawaii was her favorite. She likes all animals, football (Badgers/Packers). Interventions: R17 will participate in the Music Therapy program on the Memory Care Unit to promote socialization and general well-being. Provide weekly calendar of events. Provide with 1:1 room visits weekly. R17 comprehensive care plan dated 3/10/21, states in part . Problem/Strengths: Potential Activity Deficit related to psychosocial diagnosis/behaviors, characteristics. She reports she enjoys music, enjoys pet visits, does not enjoy keeping up with the news, enjoys activities with groups of people, enjoys going outdoors when the weather is good, and does not enjoy participating in religious services and practices. Hobbies and interests include: She is not able to tell me what she really enjoys. Interventions: Invite to activities of interest daily; especially memory care activities, provide with leisure material for room as requested/needed; i.e. fancy hats, encourage to reminisce over past roles as needed, provide with 1:1 room visits 3 times a week, and encourage to participate in no religious services. On 2/23/22, Surveyor did continuous observations on the memory care unit from 12:45 PM to 3:50 PM. At 12:57 AM, R17 was pacing/wandering in the day room, dining room and hallway of the memory care unit. Staff would approach R17 and would repeatedly redirect her to sit back in the recliner in the day room. Other residents were sitting at the tables in the dining room, the dining room table was empty. The television was off and music was playing very softly in the background. Residents were not engaged in any activities during this time frame. R17 was up pacing/wandering the memory care unit and redirected to sit in a recliner on approximately 15 different occasions. At 1:19 PM CNA E did attempt to give R17 a doll to hold but R17 had no interest in the doll. That was the only occasion in which a staff member offered any type of activity or diversion to any resident on the unit. On 2/24/22, Surveyor did continuous observations on the memory care unit from 8:55 AM to 11:13 AM. At 8:55 AM, R17 was sitting in day room in recliner. At 10:42 AM, CNA G was noted to be cutting R17's nails. R17 remained in recliner sleeping on and off with no activities provided to her throughout the observation time. Note: On 2/24/22, staff report to Surveyor that R17 had 2 falls on 2/23/22, one in the morning and one in the afternoon. Example 3 R21 was admitted to the facility on [DATE] and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R21's BIMS of 99, indicating severe cognitive impairment. R21 also has an AHCPOA. Resident 21's Annual Minimum Data Set (MDS) assessment dated [DATE], states in section F0800 for Staff Assessment of Daily Activity Preferences that it is Resident Prefers to D. Receiving shower, G. Snacks between meals, I. Family or significant other involvement in care discussions. M. Listening to music, P. Doing things with groups of people, Q. Participating in favorite activities, S. Spending time outdoors, T. Participating in religious activities or practices. Activities Director H provided Surveyor with a hand written form titled, Initial/Annual Activity Assessment, dated December 2021, which states in part . Baby dolls, dancing, and loves music. Items listed as very important, are as follows . Have your family or a close friend involved in discussion about your care, and listening to music you like. R21's comprehensive care plan dated 12/31/19, states in part . Problem/Strengths: Communication deficit. R21 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She has no hearing difficulty. R21 sometimes usually understands verbal content/understands message when spoken to, may miss part/intent of message. Her speech is clear but she is minimally verbal and she is sometimes understood, only able to make concrete requests by giving simple answers. Her responses are not always appropriate to content of conversation. R21 can make very few basic needs known secondary to her cognitive impairments, most needs are anticipated. Interventions: Encourage/assist resident to participate in memory care activity schedule. R21 comprehensive care plan dated 12/20/21, states in part . Problem/Strengths: Potential Activity Deficit related to cognitive impairment, psychosocial diagnosis/behaviors/characteristics. R21 reports she enjoys music, enjoys pet visits, enjoys keeping up with the news, enjoys activities with groups of people, enjoys going outdoors when the weather is good, and does not enjoy participating in religious services and practices. Hobbies and interests include: music and dancing. Interventions: Provide weekly calendar of events, provide with 1:1 room visits 3-5 times a week, and consult with Music Therapy as needed to promote music interests and preferences. On 2/23/22, Surveyor did continuous observations on the memory care unit from 12:45 PM to 3:50 PM. At 12:57 PM, R21 was pacing/wandering in the day room, dining room and hallway of the memory care unit. Staff would approach R21 and would repeatedly redirect her to sit back in the recliner in the day room. Other residents were sitting at the tables in the dining room, the dining room table was empty. The television was off and music was playing very softly in the background. Residents were not engaged in any activities during this time frame. R21 was up pacing/wandering the memory care unit and redirected to sit in a recliner on approximately 24 different occasions. At no time did any staff member offer R21 any type of activity or diversion. On 2/24/22, Surveyor did continuous observations on the memory care unit from 8:55 AM to 11:13 AM. At 8:55 AM, R21 was lying in bed awake. At 9:11 AM, CNA G brought R21 out to the day room and sat her in a recliner. At 9:30 AM, R21 was observed wandering the around on the unit. CNA G approached R21 and offered to paint her nails. R21 was in agreement but the CNA got busy and never returned to paint R21's nails. R21 observed to wander the unit and be redirected by staff to sit back in recliner on approximately 12 different occasions. No activity or diversion was offered to R21. On 2/24/22 at 11:05 AM, Surveyor interviewed CNA E. Surveyor asked CNA E what type of behaviors R21 has. CNA E stated, Only behaviors is wandering. Surveyor asked CNA E if R21's behaviors were harmful to herself or others. CNA E stated, They are not harmful to self or others. On occasional she does touch people but she is not mean, she just likes to touch. She has a short attention span but if you sit and play with or do her hair she will sit for like 2 hours. It makes me nervous on PM's when they are more active. Most are two assist too we go into a room and they are down here alone. Like yesterday R19 had two falls, one in the morning and one in the afternoon. Example 4 Resident 38 was admitted to the facility on [DATE] and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R38 has a BIMS of 99, indicating severe cognitive impairment. R38 has an AHCPOA. Resident 38's Initial Minimum Data Set (MDS) assessment dated [DATE], states in section F0800 for Staff Assessment of Daily Activity Preferences that it is Resident Prefers to C. Receiving a tub bath, D. Receiving shower, G. Snacks between meals, I. Family or significant other involvement in care discussions. M. Listening to music, Q. Participating in favorite activities, S. Spending time outdoors, T. Participating in religious activities or practices. Activities Director H provided Surveyor with a hand written form titled, Initial/Annual Activity Assessment, dated January 2022, which states in part . Enjoys sports, blocks, and music. Items listed as very important, are as follows . Have your family or a close friend involved in discussion about your care, listening to music you like, go outside to get fresh air when the weather is good, and participate in religious services or practices. R38's comprehensive care plan dated 11/15/12, last updated 4/19/18, states in part . Problem/Strengths: Psychosocial Well-Being/Activities: Due to decline in overall status and unable to make his needs known and he requires assist for all of his needs. Interventions: Encourage participation in Namaste Program and Namaste Day Music Programs, Involve in activities not dependent on R38's ability to communicate; resident choir and church services, Provide with 1:1 attention during Namaste, and R38 will participate in the Music Therapy program on the Memory Care Unit to promote quality of life and general well-being. R38 comprehensive care plan dated 1/12/16, last updated 8/01/17, states in part . Problem/Strengths: Severe cognitive impairment related to dementia - poor short and long-term memory and poor decision-making. R38 is non-verbal and unable to make his needs known. R38 has a guardian to assist in decision making, his sister. She is his resident representative. R38 resides on the Memory Care Unit and is able to benefit from the smaller/quieter environment. R38 is a long term resident at this facility with no plans to discharge. Interventions: Take to activities as resident allows. On 2/23/22, Surveyor did continuous observations on the memory care unit from 12:45 PM to 3:50 PM. At 2:27 PM, R38 was brought out to the dining room by staff and placed at a table alone with nothing in front of him. At no time did any staff member offer R38 any type of activity or diversion. On 2/24/22, Surveyor did continuous observations on the memory care unit from 8:55 AM to 11:13 AM. At 10:05 AM, R38 was brought out to the dining room by staff and placed at a table alone with nothing in front of him. At no time did any staff member offer R38 any type of activity or diversion. Example 5 R6 was admitted to the facility on [DATE] and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6 has a BIMS of 99, indicating severe cognitive impairment. R6 has an AHCPOA. Resident 6's Annual Minimum Data Set (MDS) assessment dated [DATE], states in section F0800 for Staff Assessment of Daily Activity Preferences that it is Resident Prefers to D. Receiving shower, G. Snacks between meals, I. Family or significant other involvement in care discussions. M. Listening to music, P. Doing things with groups of people, Q. Participating in favorite activities, S. Spending time outdoors, T. Participating in religious activities or practices. Activities Director H provided Surveyor with a hand written form titled, Initial/Annual Activity Assessment, dated February 2022, which states in part . Loves music. Items listed as very important, are as follows . Have your family or a close friend involved in discussion about your care, listening to music you like, go outside to get fresh air when the weather is good, and participate in religious services or practices. R6's comprehensive care plan dated 11/15/12, last updated 4/19/18, states in part . Problem/Strengths: Potential Activities Deficit related to cognitive impairments, Physiological impairments, psychosocial diagnosis/behaviors/characteristics. R6's wife reports that he responds positively music (specifically hymns and classic country), enjoys pet visits, seems to enjoy activities with groups of people such as mass and music, enjoys going outdoors when the weather is good, and enjoys participating in religious services and practices. Hobbies and interests include: music and mass. Interventions: Provide with weekly calendar of events, invite to activities of interest daily; especially group activities, memory care activities, music activities/groups, outdoor activities, respect resident's right to refuse and document, consult with Music Therapy as needed to promote music interests and preferences. Encourage to participate in Catholic religious services, R6 will participate in the Music Therapy program on the Memory Care Unit to promote socialization and general well-being. On 2/23/22, Surveyor did continuous observations on the memory care unit from 12:45 PM to 3:50 PM. At 12:49 PM, upon entering the memory care unit, Surveyor observed R6 sitting at the dining room table alone with nothing in front of him. At no time did any staff member offer R6 any type of activity or diversion. On 2/24/22, Surveyor did continuous observations on the memory care unit from 8:55 AM to 11:13 AM. At 10:00 AM, R6 was brought out to the day room by staff with nothing in front of him. At no time did any staff member offer R6 any type of activity or diversion. On 2/23/22 at 10:37 AM, Surveyor interviewed AD H. Surveyor asked AD H, to tell her about the facilities activity program on the memory care unit. AD H stated, For the Activity Program we strive to meet all the areas for state regulations. We do 1:1, beauty shop/manicure, hit as many criteria as we can. Surveyor asked if there was an activities aide that goes to the Memory Care Unit. AD H stated, We do and don't, they want us to have a CNA back there. We have people that go back and help during breaks in the afternoons. I go back and do 1:1 as much as I can. We strive to see everyone 3-5 times a week. At least three times a week, whether weekend or during the week. Surveyor asked if there is activity calendar on the Memory Care Unit. AD H stated, We have the weekly one. There is not one back there (calendar). If the aide is back there they communicate it with the staff back there and we communicate with the residents what is going and what things can be done. On 2/23/22 at 2:32 PM, Surveyor asked CNA G about the activities log. CNA G states, They haven't had a lot of activities back here due to staffing. She also states she normally works approximately 40 hours a week but mostly days and rarely does anyone come back to do activities, maybe 1 time a week, if that. Surveyor asked CNA G if activities occurred on the unit today. CNA G stated, not today. On 2/24/22 at 1:50 PM, Surveyor interviewed Activity Aide M. Surveyor asked Activity Aide M if she was expected to do activities on the Memory Care Unit. Activity Aide M stated, We don't usually have a specific staff that does the activities down there. Surveyor asked Activity Aide M if any staff go down and do activities on the Memory Care Unit. Activity Aide M stated, I think our director might go down there. Surveyor asked Activity Aide M if a log of attendance was for activities on the Memory Care Unit. Activity Aide M stated, I don't think so. Surveyor asked Activity Aide M how long it has been since the Memory Care Unit had an activity person down there. Activity Aide M stated, Maybe at least a month. Surveyor asked Activity Aide M if there was a separate calendar for the Memory Care Unit. Activity Aide M stated, No. Surveyor asked Activity Aide M if activities occurred on the unit today. Activity Aide M stated, to my knowledge, not today. On 2/24/22 at 2:03 PM, Surveyor interviewed AD (Activities Director) H. Surveyor asked AD H about activities log and activities on the Memory Care Unit. AD H stated, If it is on the log as being done, it was done. Surveyor asked how I could see the time in which the activity was completed. AD H stated, We don't document the time it was done, just that it was done. AD H also states, Staff are expected to go back on the Memory Care Unit and complete activities with them daily. If the staff don't have time I will do it. Per Surveyor direct observations and staff interviews individualized activity program is not consistently being provided on the Memory Care Unit.

Based on interview and record review the facility did not develop a comprehensive person-centered care plan for 2 of 14 sampled (R14 and R2) and 4 of 15 supplemental residents (R22, R41, R36, R19) reviewed for person centered care plans. R22 does not have a care plan for COVID-19. R41 does not have a care plan for COVID-19. R36 does not have a care plan for COVID-19. R14 does not have a care plan for COVID-19. R2 does not have a care plan for COVID-19. R19 does not have a care plan for COVID-19. The facility failed to develop and implement individualized, patient specific care plans that addressed precautions, psychosocial concerns, or active disease related to COVID-19. This is evidenced by: The facility's policy titled, Care Plans- Comprehensive last reviewed March of 2021, states in part: .3. Each resident's care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; g. Aid in preventing or reducing declines in the resident's functional status and/ or functional levels; i. Reflect currently recognized standards of practice for problem areas and conditions. Example 1: R22 resides on a hall that has 2 COVID-19 positive residents. R22 is not up to date on her COVID-19 vaccinations. The facility failed to implement a COVID-19 care plan to address TBP (Transmission Based Precautions), psychosocial concerns related to isolation, or monitoring for disease. Example 2: R41 resides on a hall that has 2 COVID-19 positive residents. R41 is not up to date on her COVID-19 vaccinations. The facility failed to implement a COVID-19 care plan to address TBP, psychosocial concerns related to isolation, or monitoring for disease. Example 3: R36 resides on a hall that has 2 COVID-19 positive residents. R36 is not up to date on her COVID-19 vaccinations. The facility failed to implement a COVID-19 care plan to address TBP, psychosocial concerns related to isolation, or monitoring for disease. Example 4 R2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 was infected with COVID 19 virus while residing in the facility. The facility failed to implement a COVID-19 care plan to address TBP, psychosocial concerns related to isolation, or monitoring for disease. Example 5 R14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R14 was infected with COVID 19 while residing in the facility. R14 did not have a care plan The facility failed to implement a COVID-19 care plan to address TBP, psychosocial concerns related to isolation, or monitoring for disease. Example 6 R19 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R19 was infected with COVID 19 virus while residing in the facility. The facility failed to implement a COVID-19 care plan to address TBP, psychosocial concerns related to isolation, or monitoring for disease. On 2/23/22 at 12:50 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B the process for completing care plans for residents. DON B stated, Care plans should be created.

Based on observation, interview, and record review the facility did not ensure that each resident and his/her family member received a written summary of the baseline care plan for 3 of 3 (R9, R20 and R45) sampled and 2 of 15 supplemental residents (R29 and R34) reviewed. The facility had no evidence that they provided a written summary of the resident baseline or comprehensive care plan for R9, R20, R29, R34, and R45. Evidenced by: Facility policy titled Care Plan-Comprehensive, last revised 3/2021, states in part: .Policy: A base-line, comprehensive care plan will be completed and signed by all contributors, resident, and representative within 48 hours of admission. Example 1 R9 was admitted to the facility on [DATE]. There is no evidence that the facility shared or reviewed R9's care plan with R9 or her POA (Power of Attorney). Example 2 R20 was admitted to the facility on [DATE]. There is no evidence that the facility shared or reviewed R20's care plan with him. Example 3 R29 was admitted to the facility on [DATE]. There is no evidence that the facility shared or reviewed R29's care plan with her. On 2/23/22 at 12:39 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B the process for completing the baseline care plans for residents. DON B stated, Those are completed by the Nurse that is doing the admission. Surveyor asked DON B if the facility documents that the care plan was reviewed and provided to the resident or resident representative. DON B stated, We do not chart or document that they review the baseline care plans with the resident or resident representative. Surveyor asked DON B if that should be completed. DON B stated, I would have to look. Example 4 R45 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R45 MDS (Minimum Data Set) indicates her cognitive ability is severely impaired. R45 had a baseline care plan, but the baseline was not documented as reviewed with the activated POA, or signed that the activated POA reviewed the care plan with the facility staff. Example 5 R34 was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R34 had a baseline care plan but the baseline care plan was not documented as reviewed with R34 or signed by R34 that she reviewed and agreed with the plan of care.

Based on record review and interview, the facility did not ensure drug regimens are free from unnecessary [CONDITION(S)] medications for 1 of 5 sampled residents (R21) reviewed for unnecessary medications out of a total sample of 14. R21 has a diagnosis of Alzheimer's disease and unspecified dementia with behavioral disturbance and is taking [MEDICATION(S)]. This is evidence by: Facility policy entitled [CONDITION(S)] Medication Use, undated, states, in part . Purpose: Facility Name Professional Nursing Staff will administer all [CONDITION(S)] medication (as ordered. Nursing staff will work to ensure those medications being used to treat challenging behaviors will be used only after all non-pharmalogical care-planned interventions have failed and other medical causes (infections, pain, etc.) or environmental factors have been eliminated. Procedure: 6. A mood/behavior care plan will be initiated if not already in place. 9. The Interdisciplinary team will review [CONDITION(S)] medications at least quarterly to ensure the appropriate medication is administered (at least 3 other interventions should be attempted before medication use). R21 was admitted to the facility on [DATE]. R21's diagnoses include in part . Alzheimer's disease, unspecified dementia with behavioral disturbance, anxiety, and restlessness and agitation. R21's Physician Orders state, in part: [MEDICATION(S)], [MEDICATION(S)], tablet 25 mg, Give 2 tablet (50 mg) by mouth two times daily for Alzheimer's disease. R21's care plan states in part . Problems/Strengths: Exhibits mood and behavior symptoms related to diagnosis of dementia as well as anxiety. She often exhibits a flat affect. She can be resistive to cares. She does wander and will wander into other resident's rooms. R21 will often 'shadow' others and attempts to be helpful (pushing others in wheelchairs, guiding other residents, soothing, etc.) R21 does occasionally have peer incidents - pushing. She is quick and incidents appear to be unprovoked and come with little/no warning. R21 has thrown items. She has a history of flushing personal items. R21 has a history of paying close attention to males. R21 will also bang on the doors/windows. When she had her beauty shop she would often bang on the window to wave at passerby's [sic]. Interventions: Medication(s) as ordered, see current Physician Orders for specific meds/doses/times. Consent for medication(s) obtained from resident representative with listed use and potential side effects explained. If exhibiting mood or behavior symptoms, i.e., intrusive wandering, combative, resistive, anxious, restless, etc., provide redirection. If persists, and assisting with cares, leave (if safe to do), and return later. Loves to dance - provide redirection/distraction with music. Redirect by offering to take for a guided walk/stroll, as R21 allows. R21 does better with physical redirection vs. verbal redirection. Make sure you are very mindful of R21 when other residents have items in their hands, dolls or stuffed animals, as she may attempt to take items out of others hands. Keep in line of sight when able. Utilize relaxing aromatherapy lotion as indicated when R21 appears agitated, stressed, or irritable. Note: Care plan does not have specific care plan for which targeted behaviors to monitor for. Surveyor reviewed R21's behaviors charting from 12/2021 to 2/2022 which shows documented behaviors as follows . 2/16 - yelling, wandering/pacing, and going into other peoples rooms 2/03 - yelling, going into other peoples rooms, and resisting cares 12/24 - yelling/screaming, going into other peoples rooms, and wandering 12/23 - wandering and yelling 12/22 - yelling and banging hands on walls, 12/07 - yelling, wandering, banging on windows 12/02 - yelling/screaming, banging on windows, wandering, and going into other peoples rooms R21's MDS (Minimum Data Set) dated 12/21/21 indicates the following . BIMS (Brief Interview of Mental Status): 99 indicating R21 has severe cognitive impairment; bed mobility extensive assistance of two staff; transfers limited assistance of one staff; eating extensive assistance of one staff member; toileting dependent assistance of two staff; hygiene dependent assistance of one staff member. On 2/24/22 at 11:05 AM, Surveyor interviewed CNA E (Certified Nursing Assistant). Surveyor asked CNA E what type of behaviors R21 has. CNA E stated, Only behaviors is wandering. Surveyor asked CNA E if R21's behaviors were persistent and harmful to herself or others. CNA E stated, They are not harmful to self or others. On occasional she does touch people but she is not mean, she just likes to touch. She has a short attention span but if you sit and play with or do her hair she will sit for like 2 hours. On 2/24/22 at 1:54 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if Alzheimer's Dementia was an appropriate diagnosis for the use of [MEDICATION(S)]. DON B stated, I have seen it used before for more the behaviors. R21 has behaviors of yelling, rattling doors, banging on windows. Surveyor asked DON B if these behaviors would be persistent, harmful to herself or others. DON B stated, I think so, if she would hit a window and it would break she could be injured. Surveyor asked DON B how often these types of behaviors occur. DON B stated, It used to happen more often but not so much anymore. Surveyor asked DON B to review R21's behaviors documented by staff. Surveyor asked DON B if what was documented would be appropriate for the use of [MEDICATION(S)]. DON B stated, I would have to look.

Based on interview and record review, the facility did not ensure residents who are incontinent of bladder and bowel receive the services and assistance to maintain continence, unless his or her clinical condition is or becomes such that continence is not possible to maintain for 1 of 1 residents reviewed (R32) for incontinence. While R32 had an episode of acute illness, staff documented his bladder and bowel incontinence changed from occasionally incontinent to frequently incontinent. The facility failed to complete a bowel and bladder assessment to assess R32's incontinence or implement interventions to improve R32's incontinence. The facility staff did not do a bladder or bowel diary or bladder or bowel assessment since admission. R32 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R32's MDS (Minimum Data Set) indicates his cognitive ability is mildly impaired. R32's MDS dated [DATE] indicated he was frequently incontinent of urine and occasionally incontinent of bowel. The MDS documents he requires supervision for toileting. R32's MDS dated [DATE] indicated he was frequently incontinent of urine and frequently incontinent of bowel. The MDS documents he requires limited assistance from staff for toileting. During December 2021, R32 experienced an acute illness of [CONDITION(S)] [MEDICATION(S)]. This illness caused a very sore throat, so that R32 was unable to eat, drink or talk for a few days. On 2/22/22 at 11:00 AM, Surveyor spoke to R32. Surveyor asked R32 if he needed assistance from staff with toileting. R32 signaled an OK sign to the Surveyor. On 2/22/22 at 1:00 PM, Surveyor spoke to CNA K (Certified Nurse Assistant). CNA K said that during the time R32 was ill, he was weak and had more incontinence. Surveyor asked how CNA K knew R32 was more incontinent, if CNA K checked his brief or asked R32 if he was soiled. CNA K said no, we never check R32 he uses the bathroom independently, we just check the trash can. If he has more soiled briefs in the trash can, we empty it. On 2/22/22 at 1:30 PM, Surveyor spoke to CNA R. CNA R said when R32 was sick in December, he got weak and soiled himself more. Surveyor asked CNA R how she knew he soiled himself more. CNA R said R32 always changes his briefs himself, so the staff check the trash can to see if R32 was incontinent. The facility failed to complete a bowel and bladder diary to assess R32's bowel and bladder incontinence and failed to implement interventions to improve R32's continence. On 2/23/22 at 2:00 PM, Surveyor spoke with DON B (Director of Nursing). DON B said a bladder diary is completed at admission for the residents. DON B said a bowel or bladder assessment or diary is done once for each resident and not repeated if their incontinence increases.

Based on record review and staff interview, the facility did not post the actual hours for licensed and unlicensed staff scheduled on the daily nurse staffing postings during the month of February 2022. This has the potential to affect all 46 residents in the facility. The facility's Nursing Staff sheet postings were not updated and do not reflect actual hours worked. Evidenced by: Division of Quality Assurance (DQA) memo 12-020 titled Clarification Concerning Posting Requirements for Nurse Staffing documents: Required Staffing Information .Nursing homes must post information about the number of staff directly responsible for resident care on each shift. This information must be posted in a prominent place, readily accessible to residents and visitors at the start of each shift . The information that is posted must include the following . 1. Facility name. 2. The current date. 3. The total number of staff directly responsible for resident care per shift for each of the following categories: licensed (RNs (Registered Nurse), LPNs (Licensed Practical Nurse)), and unlicensed (CNAs (Certified Nursing Assistant)). (For example, 1 RN, 2 LPNs, and 4.5 CNAs.) The number of RNs must be separate from the number of LPNs. 4. The actual hours worked per shift for each of the following categories: licensed (RNs, LPNs), and unlicensed (CNAs). 5. Resident census. Timing: Information is to be posted daily and must be present at the start of each shift. Nursing homes can choose to post staffing information for the entire day or for the current shift. Nursing homes are required to update the posted staffing if any changes arise, for example, if a nursing assistant calls in sick or goes home sick and is not replaced. The facility posts individual forms of the daily Nursing Staff sheet. Surveyor reviewed the facility's Nursing Staff and the facility's Staff Schedules for February 6th thru February 24th, 2022 noting the following discrepancies: Staff posting do not include the actual hour staff worked and are not updated when staffing changes occur. On 2/23/22 at 8:55 AM, Surveyor interviewed CNA/Scheduler P. Surveyor asked CNA/Scheduler P to explain her process for completing the daily census postings for staff. CNA/Scheduler P stated, I post them daily and then I try to get them updated on who actually worked within a few days. Surveyor asked if the Nurse Staff postings should be updated to reflect any changes related to staff call-in's and total the actual hours worked as they occur, CNA/Scheduler P stated this is how I was taught to complete them and I don't do that as it occurs, as I am not always here. Surveyor asked CNA/Scheduler P if she is the one that updates the staffing sheets. CNA/Scheduler P stated, Yes. Surveyor asked CNA/Scheduler P about posting actual hours staff worked on staffing census sheets. CNA/Scheduler P stated, This is how I was taught to do it. If it is not right I want to know so I am doing it right. The facility's Nursing Staff posting do not reflect actual staffing hours and are not updated with changes and should be.

Based on observation, interview, and record review, the facility did not ensure safe and secure storage, including limited access and mechanisms, to minimize loss or diversion for scheduled medications in 1 of 1 medication rooms. -R5's multi-dose bottle of liquid [MEDICATION NAME] (Schedule IV) was stored in an unlocked refrigerator in the medication storage room. -R58's multi-dose bottle of liquid [MEDICATION NAME] (Schedule IV) was stored in an unlocked refrigerator in the medication storage room. This is evidenced by: Facility policy, dated 5/2014, states, in part: . Storage of medications: [REDACTED] Statements: 2. Schedule II (C-II narcotics) controlled substance medication will be stored under double lock. 4. Medication requiring refrigeration will be stored in a secured container in an area of the refrigerator that is separated from food and drinks. -We recommend this refrigerator be located or located in a locked medication room and not contain food or drink. On 1/28/20 at 9:06 AM, Surveyor and LPN C (Licensed Practical Nurse) conducted an observation of the medication storage room. Surveyor observed two multi-dose bottles of liquid [MEDICATION NAME] concentrate in an unlocked refrigerator. The refrigerator observed was inside of the medication room, within the Nurses Station. R5's order indicates [MEDICATION NAME] 2mg (milligram) per mL (milliliter), 30mL bottle. Take 1mg (0.50mL) PO (by mouth) in fluid, coffee, juice oral every AM (morning) for agitation. R58's order indicates [MEDICATION NAME] 2mg per mL, 30mL bottle. Take 1mg (0.50mL) by mouth every hour as needed. On 1/28/20 at 9:06 AM, Surveyor interviewed LPN C. Surveyor asked LPN C if [MEDICATION NAME] concentrate should be double locked in the refrigerator. LPN C stated, Yes, but I have never seen this refrigerator locked before. On 1/28/20 at 9:21 AM, Surveyor interviewed DON B (Director of Nursing) regarding [MEDICATION NAME] not being double locked. Surveyor asked DON B if [MEDICATION NAME] should be double locked. DON B stated, Yes, it should be double locked. We are working with the pharmacy currently to ensure that those medications that are required to be double locked are. Currently we have not been locking the refrigerator but will provided education to staff and ensure from now on it is. The facility did not ensure scheduled medications are stored with a double lock.

Based on record review and interview, the facility did not immediately consult with the resident's physician when 2 of 19 sampled residents (R41 and R56) experienced a significant change or required a change in treatment. R41's physician was not consulted when there was a delay in obtaining an x-ray. R56 experienced a significant weight loss and the facility did not contact a physician. This is evidenced by the following: Example 1 The facility policy and procedure Physician Notification, undated, states, in part: 2. The on-call physician at local hospital is to be contacted for resident needs, when the primary physician is unavailable. The on-call physician list is posted at the nurse's station. The Medical Director should be contacted for all other needs. 7. When a change in a resident's condition occurs or a resident expresses a concern that requires physician notification on your shift it is your responsibility to notify the physician. 8. Rule of Thumb: You are safer to over-report than to neglect a situation that could jeopardize the resident's health and comfort. 9. Refer to AMDA (American Medical Directors Association) manual Standards of Practice for Physician Notification. R41 was admitted to the facility, on 12/19/19, after hospitalization related to a farm accident. R41's [DIAGNOSES REDACTED]. R41's MDS (Minimum Data Set), completed on 11/18/19, shows a BIMS (Brief Interview of Mental Status) of 14, indicating that R41 is cognitively intact. On 10/4/19 at 9:25 PM, upon returning from outing with wife, it was reported to the facility that R41 had fallen on the right side. A fall assessment was completed at that time and indicates the following: Resident was out with wife getting pictures done. Wife stated that resident was just standing there, and then fell on right side, knees didn't even buckle. Resident reports getting off balance and falling. Wife witnessed fall, reports resident did not hit his head and resident denies hitting head. Fall occurred at 6:45 PM, reported to staff upon arriving back to facility at 9:45 PM. Hand grasps: right side weakness per baseline, left side strong. Movement of extremities: Pain with passive movement of right shoulder and palpation. Right side weakness per baseline. Nurse charting following reported fall states, in part, as follows: On 10/4/19 at 10:51 PM, Updated Hospital ER (emergency room ) on fall, c/o (complaints of) right shoulder discomfort with palpation and movement, requesting portable right shoulder x-ray and wife also requesting PRN (as needed) [MEDICATION NAME] for discomfort. On 10/5/19 at 1:45 AM, Call placed to Hospital ER to address fax, state they did not receive, was refaxed. On 10/5/19 at 3:52 AM, Orders received .2 view x-ray of right shoulder d/t (due to) pain after a fall .call placed to (Imaging Company). On 10/5/19 at 12:35 PM, (Imaging Company) contacted x2 (twice) this AM (9:45 and 11:00) with no response on wait time for x-ray to right shoulder. Called back at 12:30 and reported that they would not be able to do the imaging until 'later that evening'. Resident and wife updated. The physician was not consulted at this time with the delay in x-ray and continued pain. On 10/5/19 at 6:24 PM, (Imaging Company) here to do right shoulder x-ray. Tolerated procedure with some stated pain. On 10/5/19 at 9:07 PM, X-ray results sent to Hospital ER Physician for review. Returned, signed by physician, right shoulder with lucency of the proximal humeral head neck junction is suspicious for non-displaced fracture. No evidence is seen for acromioclavicular separation. Per physician, if insurance allows, he can see orthopedic physician. There is very little treatment usually needed for these fractures. R41 and wife updated on findings and recommendations. They plan to discuss with doctors when they are at an appointment on 10/7/19. On 1/30/20 at 8:30 AM, Surveyor interviewed R41. Surveyor asked R41 if the facility asked him if he wanted to be seen in the ER. R41 stated, No one ever asked me. On 1/30/20 at 8:49 AM, Surveyor interviewed R41's wife. R41's wife stated, It took a really long time for the x-ray, I feel it was way too long and could have been sooner and we could have been sent to the ER for the x-ray . On 1/30/20 at 9:09 AM, Surveyor interviewed RN D (Registered Nurse). Surveyor asked RN D the protocol for using (Imaging Company). RN D stated, (Imaging Company) x-ray is our first go to, unless emergency. Surveyor asked RN D if a fracture was an emergency. RN D stated, Yes, but we didn't know, it was R41's affected side. Surveyor asked RN D what was a reasonable time frame for (Imaging Company) to complete that x-ray. RN D stated, I think a couple of hours. Surveyor asked RN D if waiting up to 12 hours is acceptable and if not, what she would expect staff to do. RN D indicated everyone is different, but probably should not have waited that long, should have been sent to the ER for evaluation. On 1/30/20 at 11:16 AM, Surveyor interviewed MD F (Medical Doctor). Surveyor asked MD F if she would have expected staff to update her on a delay in obtaining an x-ray. MD F stated, There are a lot of variables, but should have been contacted about the delay . On 1/30/20 at 2:13 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B about what she would expect from staff regarding R41's pain and the delay in x-ray. Surveyor asked DON B if staff should they have called and updated the physician on the x-ray delay. DON B stated, Yes they should have. Example 2 The facility uses AMDA (The Society for Post-Acute and Long-Term Care) guidelines for physician notification. AMDA guidelines state a physician should be contacted with a weight loss of 5% or more within 30 days. R56 was admitted to the facility on [DATE]. Her most recent MDS, dated [DATE], shows a BIMS score of 11, which indicates R56 is moderately cognitively impaired. On 1/27/20 at 12:42 PM, Surveyor observed R56 during the lunch meal service. R56 took only a few bites of her food and ate approximately 10 percent of her meal. At 3:02 PM, Surveyor interviewed R56 who stated she just doesn't eat that much. Facility documentation shows R56 weighed 150.1 lbs (pounds) on admission. The facility dietician noted, on 12/9/19, that R56's weight was down 4%, with a weight of 143 lbs, and her PO (per oral) intake was poor at 38% for meals. On 12/25/19, R56's recorded weight was 141.6 lbs, a 5.6% weight loss from admission. No other notes from the dietician, a physician or other facility staff were found or provided addressing R56's weight and diet, nor does her care plan reflect dietary changes. On 1/30/20 at 10:20 AM, Surveyor interviewed DON B. DON B stated she would expect the doctor to be notified once a 5% weight loss occurred. In addition, DON B stated she would expect a resident to be monitored, with documented continual weight loss occurring, to better ensure all possible interventions are being implemented to address a resident's dietary needs. DON B was unable to find that the doctor was notified of R56's weight loss.

Based on interview and record review, the facility did not provide the appropriate treatment and services for a resident who is fed by enteral means to prevent complications resulting from enteral feeding for 1 of 2 residents (R1) reviewed with [DEVICE]s (gastrostomy tubes). The facility failed to ensure the staff was properly trained to provide appropriate treatment and services for R1's newly placed [DEVICE]. (A [DEVICE] is a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications. The most common type is a percutaneous endoscopic gastrostomy (PEG) tube, which is what R1 had placed on 2/26/19.) When R1's [DEVICE] fell out, R1's nurse did not report this to the Charge nurse nor R1's physician. Staff re-inserted two new [DEVICE]s even though the facility did not have a physician order [REDACTED]. These failures created a finding of Immediate Jeopardy (IJ) that began on 3/23/19 when R1's [DEVICE] fell out. Surveyor notified NHA A (Nursing Home Administrator) of the need for IJ call on 4/23/19 at 4:20 PM. The NHA was notified of the IJ at 3:15 PM on 4/24/19. The IJ was removed on 4/23/19, however, the deficient practice continues at a scope/severity of D as the facility continues to implement its action plan. This is evidenced by: The article ASPEN Safe Practices for Enteral Nutrition Therapy notes: This document provides recommendations based on the available evidence and expert consensus for safe practices, across each step of the process, for all those involved in caring for patients receiving EN .The patency and placement of an EAD should be confirmed before using it for feeding or medication administration. Proper radiographic imaging is recommended to confirm the position of any blindly placed enteral feeding tube. Healthcare professionals cannot rely on auscultatory methods to differentiate between gastric and [MEDICATION NAME] tube placement because auscultatory methods cannot distinguish tubes improperly placed in the lung or coiled in the esophagus from properly positioned tubes. The Academy of Medical-Surgical Nurses notes: Unintended enteral tube dislodgment is more of an issue for the immature tract (one that has been established for less than 4 weeks), as it can begin to close within a matter of hours of tube dislodgment. These patients should be taken to the endoscopy suite to have their tube replaced as soon as possible .The mature tract will allow for introduction of a new tube without difficulty, and this procedure can often be performed at the bedside. Follow facility policies to determine which health care providers can replace gastrostomy or PEG tubes with a mature track. https://www.amsn.org/practice-resources/care-term-reference/ginutrition/question-practice-has-been-if-pe[DEVICE]-pulled-out The facility's Policy and Procedure entitled Gastrostomy Tube or Nasogastric Tube- Confirming placement, not dated, states, in part: .6. Check placement by aspirating stomach contents with syringe by gently pulling back on the plunger to visualize stomach contents and the re-instill .7. If the above suggests improper tube positioning, do not administer feeding or medications. Notify the Charge nurse or Physician . The facility's Policy and Procedure entitled Gastrostomy Tube- Changing of, not dated, states, in part: .13. Stop the procedure if resistance is met and try again. Never force against restiveness. 14. Cease procedure and update MD (Medical Doctor) if continue to meet restiveness .17. Check for placement. Refer to policy Gastrostomy Tube- Confirming Placement . It is important to note that this Policy and Procedure does not reference how to care for a gastrostomy tube that is new and does not speak about pain. R1 was admitted to the hospital 2/11/19 following a stroke that was complicated by [MEDICAL CONDITION]. R1 had [DEVICE] placed 2/26/19. R1 admitted to this facility 3/2/19 for rehabilitation with plan to return home. Upon admission R1 was a hoyer lift (full body lift) to transfer and was NPO (nothing by mouth). As R1 participated in PT/OT/ST (physical therapy/occupational therapy/speech therapy), R1 was advanced to use the stand lift (partial body lift) and diet was advanced to pureed diet on 3/21/19. The facility Social Worker assessed R1's BIMS (Brief Interview of Mental Status) on 3/12/19 documenting a score of 14/15 in R1's medical record. This indicates that R1 is cognitively intact. R1's Physician order [REDACTED]. R1's baseline care plan dated 3/2/19 documents NURSING: Provide treatment for [REDACTED]. R1's comprehensive care plan dated 3/6/19 documents, in part: Potential for Altered Nutrition/Hydration Status due to pharyngeal dysphagia and need for gastrostomy tube . R1's care plan does not provide instruction on size of [DEVICE], when or if to re-insert [DEVICE], or emergency protocol for dislodgement. R1's Nurses Notes for 3/22/19 when R1 had abdominal pain, documents, in part: 3/22/19 at 5:16 PM: Resident c/o (complained of) left upper quadrant abdominal pain. Tylenol given. Vital signs as follows BP128/72 76HR (heart rate) 98%on room air (oxygen saturation level) 98.1 resp 18 (respirations). Bowel sounds activex4. Had BM (bowel movement) this afternoon. Denies nausea/vomiting. Residual checked with 60cc in return. Tube feeding held at this time d/t (due to) pain/discomfort. Resident did eat 75% breakfast and 50%lunch. Updated ER (emergency room ) MD and agrees to hold tube feeding for an hour and recheck. Fiancé at bedside. (SIC) 3/22/19 at 7:00 PM: Reassessed resident at this time, stating LUQ (left upper quadrant) pain has not gotten better rating at a 10 out of 10, best pain gets is a 7. Reporting sharp pain. Tube feeding still on hold, residual checked and 0cc. Flushed with 60cc warm water, flushed with ease. BS (bowel sounds) active x4. Reports prn (as needed) Tylenol utilized was not effective. Spoke with Fiancé and POA (power of attorney) and would like R1 sent to ER for further evaluation. Updated ER and resident. Called squad to transfer. 3/22/19 at 7:39 PM: BP: 112/78, O2 99% ORA (on room air), P79 (pulse), Temp. 98.1 (temperature), RR 16 (respiratory rate) even and non-labored. Transferred to ER at this time. (SIC) 3/23/19 at 12:24 AM: returned from ER with dx (diagnosis) of abdominal pain and a new order for Tylenol #3, 1 tab PO (by mouth) (clarified to administer per [DEVICE]) Q (every) 6 hours PRN for pain, Hold [MEDICATION NAME] x2 days and draw serum creatinine prior to restarting (lab slip completed and placed on LAB clipboard). Contact PCP (primary care physician) Monday. Had the following labs drawn from Rt (right) ac (antecubital) while there: CBC with diff (complete blood count with differential), CMP (complete metabolic panel), D-dimer (help diagnose blood clot), lactic acid (help [MEDICAL CONDITION]), and lipase serum (check pancreas). imaging tests include: CT (computed tomography) abd (abdomen) and pelvis w (with) IV (intravenous) contrast, CT angia chest and ORD EKG (electrocardiogram). Medications given include: Omnipaque at 10:22 PM, [MEDICATION NAME] injection (PF) at 8:50 PM and 10:08 PM. denies pain at this time. TF (tube feeding) flushed and restarted without difficulty, resting in bed, call light within each. Report send to MD. ED (Emergency Department) Provider Notes for R1 from 3/22/19-3/23/19, states, in part: .Patient has a [DEVICE] present without any surrounding [DIAGNOSES REDACTED]. Minimal left upper quadrant tenderness without any guarding, rigidity .CT abdomen/pelvis with contrast .no acute process in the abdomen or pelvis identified .X-ray Esophagram Video .swallow mechanism is within normal limits .CT Angio Chest .1. Negative for [MEDICAL CONDITION] embolism or acute aortic pathology. 2. Bibasilar atelectasis/fibrosis. 3. Mild compression of T3 and T10, age undetermined . It is important to note that these tests were all inconclusive and there is no evidence that R1's [DEVICE] was out of place during this ER visit 3/22/19-3/23/19. Summary of 3/22/19 events: R1 had pain, RN assessed, tube feeding was stopped, residual was checked by aspirating stomach contents, RN updated MD, MD gave orders, RN followed orders, R1's pain was not relieved with interventions attempted, RN updated MD and R1 was sent to ER for evaluation. R1's Nurses Note for 3/23/19 at 1:08 PM: Called down to resident's room as residents [DEVICE] had come out with balloon deflated. New 14F (french) [DEVICE] place but tube feeding connection not compatible. Second tube placed with success but resident having a significant amount of discomfort. Placement confirmed but 2 nurses and tube feeding running smoothly. PRN Tylenol #3 given .rated pain 12/10. After some time R1's Fiancé reported that R1 was having a lot of pain at site and in abdomen and requested to have PRN [MEDICATION NAME]. Call placed to ER .Order received for PRN [MEDICATION NAME] 2mg (milligrams) q 6 hours PRN for pain x 2 days then consult with primary physician. A dose of [MEDICATION NAME] was given and at that time noticed formula leaking around [DEVICE] site. Tube advanced and 3 ml (milliliters) sterile water placed in balloon. Tube was flushed and feeding continued. R1's Fiancé very tearful and upset at this time because is having hard time seeing R1 in pain. R1 repositioned to be more comfortable and R1's Fiancé appreciative of nursing care. LPN D's statement given to DON B 3/25/19 documents, in part: Approximately 12:30 PM, LPN C asked for assistance as LPN C had not replaced a [DEVICE] in some time. LPN D agreed to replace [DEVICE] and instructed LPN C to let R1's family know and cover the site with a wet 4x4. LPN D went to find [DEVICE] 14Fr (French). Once located, LPN D asked LPN E to assist as they both had multiple experience with [DEVICE] replacement, especially on IID (Individuals with Intellectual Disabilities) side. LPN D and LPN E went down to the room, told R1 and Fiancé they were putting a new tube in at this time. LPN D states that R1 was still having abdominal discomfort. LPN D tested the balloon which was good. Did meet slight resistance with the first inch or so where the tube is a bit thicker due to the delated balloon but then went right in to the 4 marker. LPN D then placed the lip/disc down. Then LPN D and LPN E both checked and verified placement of the tube. When LPN D went to hook up the spike set from the TF bag to the [DEVICE] it was noted to be incompatible. LPN E went to look for an adapter but none could be located. They did however find a syringe that could hook onto the tub so they could administer Tylenol #3 for pain. LPN D informed family that they would need to replace the tube. LPN D found another [DEVICE] and checked to ensure connections world work and balloon functional. LPN D removed fluid from the balloon of the tube in order to remove, [DEVICE] was easily removed an balloon was intact. LPN D then inserted the new tube and once past that deflated balloon area the tube went to 4, LPN D filled the balloon and moved the disc into place. LPN D then checked and verified placement flushed and restarted the feeding. Around 1/1:30 PM R1's pain continued and no real relief from the T#3 (Tylenol #3). The family was requesting [MEDICATION NAME] as that worked well in the ER the previous night. LPN D then called ER and received an order for [REDACTED]. The MD at the ER was notified and stated LPN D could just replace the tube or could advance the tube and add some additional fluid in the balloon. LPN D advanced the tube and added an additional 3cc into the balloon. The tube was running ok at that time. Approximately 2:30 PM LPN D and the oncoming nurse supervisor, RN F (Registered Nurse) went down to the room to check on R1. RN F had LPN D check the placement again and had her draw up fluid into the syringe then push back in with a flush (approximately 40cc). All appeared to be functioning . LPN E's statement given to DON B on 3/25/19 documents, in part: Approximately 12:30 PM was called by LPN D to come over to the other unit. When LPN E got to station LPN D was already standing there and had a [DEVICE] in her hand and asked if LPN E would assist with a [DEVICE] placement. LPN E saw the other tube that had come out and stated it looked like the balloon had burst open. LPN E observed and was available to assist LPN D who did the actual insertion. LPN E states LPN D measured the tube and puts it in and then moves the disc down flush to the skin. LPN E observed that there was some resistance when LPN D attempted to do this but when attempted to move disc down second time it went without problem. Once the balloon was inflated both nurses checked placement and determined tube in place .LPN E stated she was aware that resident was having increased pain and that a call was placed to MD with new orders for [MEDICATION NAME]. Also aware that the tube had some slight leakage and that LPN D was to advance the tube . On 4/23/19 at 2:23 PM, Surveyor interviewed LPN E. Surveyor asked LPN E to walk through events of 3/23/19 with R1. LPN E explained, approximately 12:30-1:00 PM LPN D requested assistance. LPN D has put [DEVICE]s in before but wanted reassurance. LPN D measured from old tube 4 cm (centimeters), LPN D re-inserted, quite a bit of resistance at first, got in and checked placement. Surveyor asked LPN E how placement was checked, LPN E explained that LPN D instilled air and listened for whoosh sound, LPN D was listening low on left abdomen and heard faint sound. I listened higher on left abdomen and heard a distinct sound. Then we realized the [DEVICE] didn't connect to feeding, so we looked for an adapter but couldn't find one. We did find another [DEVICE]. LPN D deflated balloon and removed tube, this tube inserted much easier. Surveyor asked LPN E if R1 had any pain medication, LPN E wasn't sure. Surveyor asked LPN E how placement was checked after the second tube was inserted, LPN E wasn't sure, was washing hands. Surveyor asked LPN E if R1 was uncomfortable with procedure, LPN E stated worse with the first insertion than with the second. RN F's statement given to DON B, undated, documents, in part: RN F stated when she arrived on duty at 2:00 PM RN G and LPN D were discussing the dose of [MEDICATION NAME] to be given. They also stated they were having some difficulty with the tube that it had come out and had to be replaced. And that it was leaking some formula and LPN D stated she had advanced the tube and had added more water to balloon per the ER MD instruction. After full report at approximately 2:30 PM RN F and LPN D went down to R1's room to check on R1. RN F asked LPN D to verify placement, by pulling back for gastric contents, they did get a small amount of cloud fluid, the tube was then flushed. RN F did ask about pain on scale of 1-10 and R1 stated 12. RN F reminded R1 [MEDICATION NAME] was just taken and it should be working soon, RN F then positioned R1 for comfort . On 4/23/19 at 2:35 PM, Surveyor interviewed RN F. Surveyor asked RN F to walk through events of 3/23/19 with R1. RN F explained, right at change of shift LPN D was on phone with MD obtaining order for [MEDICATION NAME], I was told placement was checked. LPN D and I went to R1's room, I had LPN D aspirate back stomach contents and then flush with 120cc water. Surveyor asked RN F if R1 was having pain at this time, RN F said R1 rated his pain 12/10. RN F said R1 was repositioned with pillows and given call light. Then later R1's Fiancé said they wanted R1 out. R1's Nurses Note for 3/23/19 at 3:35 PM: R1's Fiancé approached this nurse stating they request to have R1 go to the ER for an evaluation as he is still in in pain with no relief. They would like R1 to go to Platteville Hospital, call placed to sheriff's department to see if they could bypass local ER and awaiting a call back. LPN D's statement given to DON B 3/25/19 documents, in part: .At approximately 3:00 PM R1's Fiancé approached LPN D and stated they have talked it over and they want to go to the hospital as the pain meds are not working. The would prefer to go to Platteville Hospital. LPN D then contacts the sheriff to see if they can bypass local ER to go to Platteville Hospital. Sheriff states he will call back .I left the facility at approximately 3:50 PM and as I was leaving the medic pulled up to the building . RN F's statement given to DON B, undated, documents, in part: .R1 and family requesting to go to hospital as pain still not relieved. RN F assessed R1 and noted bowel sounds not present and there was no distention .Later in eve called Platteville Hospital for update and notified R1 was air-flighted to University of Wisconsin Hospital due to formula noted in abdominal cavity . R1's Nurses Note for 3/23/19 at 3:42 PM: [MEDICATION NAME] 1 tab oral Q 6 hours PRN, reason: Nauseated R1's Nurses Note for 3/23/19 at 4:45 PM: 4:30 PM Left via rescue squad. Family following. Being transported to Hospital per family request for evaluation. DON updated on transfer. R1's Nurses Note for3/23/19 at 9:04 PM: Per Platteville Hospital, resident will be transferred to University of Wisconsin Hospital for further treatment. R1's Nurses Note for 3/24/19 at 1:00 AM: admitted to University of Wisconsin. St. [NAME]'s Hospital currently in surgery to cleanse abdominal cavity and plans to be placed in ICU (intensive care unit) for at least a day then plans to have a least a 3 day hospital stay on med surg unit (medical surgical). MAR (medication administration record) faxed to pharmacist per request. ED Provider Noted for R1 from 3/23/19-3/24/19, states in part: .Abdomen somewhat rigid area surrounding [DEVICE] shows no [DIAGNOSES REDACTED] or swelling X-ray abdomen obstruction series completed 3/23/19 at 6:01 PM .[MEDICATION NAME] contrast present predominantly within the colon. This film was taken immediately following the injection of [MEDICATION NAME] contrast, this would be malpositioning of the [DEVICE] .Given these findings, CT is recommended to confirm appropriate placement of [DEVICE] .CT of the abdomen and pelvis was performed without oral or intravenous contrast 3/23/19 at 7:05 PM .Impression: Malpositioned [DEVICE]. [DEVICE] tip superficial to the [MEDICATION NAME] colon .Patient initially stable, [DEVICE] found to be patent flushed easily with contrast used to determine its location flat/upright for evaluation of this as well as for sbo/perforated hollow viscus. Flat and upright indeterminate for tube location CT scan revealed tube was located intraperitoneally. [MEDICATION NAME] (antibiotic) begun as well as fluid bolus. Receiving Hospital contacted (Hospital Name). Hospital was unable to accept R1 as their general surgeon was in surgery. Hospital then contacted another Hospital. (Hospital Name) was able to accept R1. R1 then required air transport for surgical intervention as well as intensive care visit for management of peritonitis/sepsis (severe infection in peritoneal cavity). On 4/23/19 at 10:30 AM, Surveyor interviewed RN F. Surveyor asked RN F what would you do if you had a [DEVICE] fall out, RN F replied contact the MD, follow protocol, depends on if new tube or not some can re-insert. Surveyor asked RN F, if it is a new tube, what then; RN F stated call MD and attempt to put in if given order to do so. Surveyor asked RN F what training has been done in regard to re-inserting [DEVICE]s, RN F said I've had training prior to working here, did get training here when hired except during orientation was shown [DEVICE] procedure. Surveyor asked RN F what if a resident has new pain and has [DEVICE], RN F stated to assess bowel sounds, check placement via gastric contents and update MD. On 4/23/19 at 10:46 AM, Surveyor interviewed RN K. Surveyor asked RN K what you would do if you had a [DEVICE] fall out, RN K said check on resident, check orders, call MD, try to get in right away. Surveyor asked RN K what training has been done in regard to re-inserting [DEVICE]s, RN K said I've had training other places, only training here was recently because of this issue. Surveyor asked RN K what training was done and when, RN K stated on 4/4/19 we were educated on [DEVICE] Policy revision and had to do a competency check with another nurse. On 4/23/19 at 3:55 PM, Surveyor interviewed LPN [MI] Surveyor asked LPN L what you would do if a residents' [DEVICE] came out, LPN L said go check on resident, go tell the charge nurse, check the orders to reinsert. Surveyor asked LPN L who could reinsert. LPN L said LPN or RN. Surveyor asked LPN L what training has been had on [DEVICE]s, LPN L said we recently had a meeting about policy changes. Surveyor asked LPN L if there was a competency about [DEVICE]s done, LPN L said haven't had one here but I have done [DEVICE]s before. On 4/23/19 at 4:15 PM, Surveyor interviewed LPN N. Surveyor asked LPN N what you would do if a resident's [DEVICE] came out, LPN N said check on resident, inform charge nurse, check chart for orders and contact MD for further interventions. Surveyor asked LPN N how to check placement, LPN N said aspirate for placement. Surveyor asked LPN N what training has been had on [DEVICE]s, LPN N stated I was watched with R2, checking placement and water administration. On 4/23/19 at 3:15 PM, Surveyor interviewed DON B. DON B gave surveyor time sheet with LPN D's hours, DON B explained that LPN D had not worked since they decided to do competency check after reviewing with Medical Director. Surveyor asked DON B for competencies for LPN D and LPN E prior to 3/23/19, DON B stated would look for them and said the next time they do this on an actual person, a RN must be present to observe them. On 4/23/19 at 3:30 PM, Surveyor interviewed DON B. DON B stated they do not have competencies for LPN D or LPN E prior to 3/23/19. DON B went on to explain they discussed this event with Medical Director on 3/28/19 and updated policies. They then took revised policies to QA (Quality Assurance) and then put out new education that included competency. Surveyor asked DON B who was conducting competency, DON B stated the Nurse Managers. Surveyor asked DON B how the competency was being performed, DON B said either with R2 or residents on the IID Unit. It is important to note that competency was set up on 4/4/19, LPN D worked on 4/7/19 and did not have competency completed. On 4/23/19 at 4:00 PM, Surveyor interviewed RN, MDSC M (Minimum Data Set Coordinator). Surveyor asked RN, MDSC M what would you do if a resident's [DEVICE] came out, RN, MDSC M said if they are a new person, call the MD and send them out, if [DEVICE] is old and established, put new one in after checking orders. RN, MDSC M said new being less than 90 days old. Surveyor asked RN, MDSC M how to check placement, RN, MDSC M said aspirate fluid every time. Surveyor asked RN, MDSC M what training has been had on [DEVICE]s, RN, MDSC M said competencies are being done. The Facility assessment dated (MONTH) (YEAR) states, in part: . 1.5 Describe your residents' acuity levels that help you to understand potential implications regarding the intensity of care and services needed .Special Treatment-Feeding Tube, Number/Average or Range of Residents- 2 . 2.1 List the types of care that your resident population requires and that you provide for your resident population .The intent is to identify and reflect on resources needed to provide these types of care .General Care- Nutrition, Specific Care or Practices- .tube feeding . It is important to note that the Facility Assessment does not speak to training staff or skills required to care for [DEVICE]s either new or established. Summary of 3/23/19 events: R1's [DEVICE] fell out. LPN C requested assistance from LPN D to replace. LPN D gathered supplies and asked LPN E to assist. LPN D noted resistance with re-insertion, did not stop, and inserted tube. LPN D and LPN E checked placement via auscultation (listening). Feeding supplies and [DEVICE] were not compatible and no adaptor could be located. Tylenol #3 was administered for a pain rating of 12/10. LPN D removed this [DEVICE] and re-inserted a second [DEVICE] with proper connections, checked and verified placement, flushed and restarted feeding. R1's pain continued with no relief from Tylenol #3. Fiancé requested [MEDICATION NAME] as that seemed to work the previous night in the ER. LPN D notified MD and obtained order, then administered [MEDICATION NAME]. LPN D noted formula leaking from around [DEVICE] site. LPN D notified MD, new order to either replace tube or advance tube and add water to balloon. LPN D advanced tube and added water to balloon. At change of shift RN F and LPN D went to R1's room. RN F had LPN D check placement again by drawing up cloudy fluid into syringe and reinsert. R1 stated pain rating was still 12/10. RN F said the [MEDICATION NAME] should work soon and R1 was repositioned. R1 and family requested transfer to Platteville Hospital as pain was not resolving. R1 was taken to Platteville Hospital and it was determined that the [DEVICE] was not properly placed in stomach but in peritoneal cavity. Platteville Hospital contacted St. [NAME]'s Hospital. St. [NAME]'s Hospital was unable to accept R1 as their general surgeon was in surgery. St. [NAME]'s Hospital then contacted University of Wisconsin Hospital. University of Wisconsin Hospital was able to accept R1. R1 then required air transport for surgical intervention and management of severe infection. It is important to note that auscultation is not the current standard of practice for checking placement of [DEVICE]s, aspirating stomach contents is and for new [DEVICE]s, less than 90 days old an abdominal x-ray must be obtained to verify placement prior to administering anything through the tube. Facility provided Surveyor with additional information on 4/29/19. This additional information documents that on 3/7/19, a little over 2 weeks before the events with R1 took place there was an in-service put out on how to check placement of the [DEVICE]. LPN D did not receive this in-service. LPN E signed this in-service on 3/11/19, therefore had already been educated prior to R1's events on 3/23/19. The failure to ensure that nurses had the appropriate skill set to care for a new [DEVICE] and the failure to follow professional standards of practice after R1's [DEVICE] came out on 3/23/19 created a finding of Immediate Jeopardy. The facility removed the IJ on 4/23/19, after the facility completed the plan to include: 1. All nursing staff to be educated on ensuring Physician order [REDACTED]. Initiated 4/23/19. To be completed by next working shift. 2. Nurses will complete a competency for [DEVICE] placement and checking residual per current standards of practice. Initiated 4/4/19. To be completed by next working shift. Any nurses who do not complete the competency will not be scheduled until completed. 3. All nursing staff to be educated on the facility's Policy and Procedure on [DEVICE] including: checking placement (initiated 3/25) and change of [DEVICE] (initiated 4/4/19). To be completed by next working shift. 4. All nursing staff to be educated on the need for RN assessment for any dislodged tube or [DEVICE] needing replacement. Initiated 4/23/19. To be completed by next working shift. 5. All nursing staff to be educated on need for RN to assess any change in pain. Initiated 4/23/19. To be completed by next working shift. 6. All nursing staff to be educated on the need to notify the MD immediately for any [DEVICE] that dislodges, if they meet resistance during the procedure, and/or if the resident complaints of pain. Initiated 4/23/19. To be completed by next working shift. 7. All nursing staff to be educated to check Physician order [REDACTED]. Initiated 4/4/19. To be completed by next working shift. 8. All nursing staff to be educated on resident care plans that includes thorough approaches for [DEVICE] care. Nursing staff will be educated on care plan development for [DEVICE]s. Initiated 4/23/19. To be completed by next working shift. 9. Nursing managers and DON will conduct audits daily x 2 weeks, weekly x 8 weeks, and monthly x3 months of residents with [DEVICE]s to ensure all required components are in place. Results of the audits will be reviewed at the QA meeting for further recommendations. Competencies and education will be conducted by nursing management and/or a nurse who has passed the competency education and has been designated to give an education. (SIC)

Based on record review, interviews, and observation, the facility did not establish an infection control and prevention program that included a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers and visitors during a gastrointestinal outbreak in January 2017; this outbreak affected 34 residents and 49 staff and had the potential to affect all 85 Residents residing within the facility. Facility failure to prevent the spread of an infection by allowing staff to float between units, by lifting the quarantine on units too early, thus allowing residents to mingle with other residents, by failing to reinstate quarantine when numbers again showed an outbreak on the unit, by failing to get stool samples timely to the physician, and by not proactively closing all units when residents and staff had become ill on more than one unit, created a finding of immediate jeopardy that began on 01/06/2017. Nursing Home administrator (NHA) A and Director of Nursing (DON) B were notified of the immediate jeopardy on 08/10/2017 at 3:07PM. The immediate jeopardy was removed on 08/10/2017, however the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as evidenced below. Handwashing and glove changes were not done per guidelines for 1 of 9 Residents (R2) observed for cares out of a total sample of 17 Residents. This is evidenced by: The facility policy entitled Gastroenteritis (Viral), indicates the facility uses the Division of Quality Assurance Memo 10-033, which references Recommendations for the Prevention and Control of Viral Gastroenteritis Outbreaks in WI LTC Facilities (Long-term care facilities), this document states in part: .Viruses (norovirus specifically) cause most of these outbreaks, and they are almost always transmitted from person-to-person (including residents, staff, visitors and volunteers). Norovirus can persist in the environment and is resistant to most disinfectants, as a result contamination of the environment plays a key role in transmission .Norovirus outbreaks can be detected early by recognizing the typical symptoms of illness, and can be controlled by promptly implementing aggressive infection control measures to prevent the virus from being transmitted from person to person. When appropriate prevention and control measures are not implemented immediately, outbreaks can continue for weeks causing many illnesses, some hospitalization s and the occasional death from dehydration and other complications of vomiting and diarrhea .main symptoms of viral gastroenteritis are sudden onset of vomiting and diarrhea. Vomiting is usually prominent but may be infrequent or absent. Diarrhea tends to be watery, short lived and less severe .the affected person may also have headache, fever (usually low-grade), chills and abdominal cramps(stomach ache) .Illness begins between one to two days following exposure of the virus .excretion of virus in the stool beings a few hours before the onset of symptoms and reaches a maximum 24-72 hours after exposure and the duration of shedding may last up to 4 weeks. The virus can continue to be present in the stool of infected persons for a week or more after symptoms have subsided .can survive on inanimate surfaces for up to a week or more .stool samples should be obtained from 4 to 6 ill persons within 48-72 hours after the onset of symptoms .An outbreak of viral gastroenteritis should be suspected when two or more residents and/or staff develop new onset of vomiting and/or diarrhea within one to two days .B. Management of Residents and Staff. 1. Immediate isolation of the resident and restricting access to affected areas is essential. 2. Confine symptomatic residents to their rooms until 48 hours after symptoms cease .7. Consider discontinuing use of common dining areas and instituting in-room dining .B. Management of Residents .2. Cancel or postpone group activities for at least 48 hours after the last identified case .C. Management of Staff 1. Staff assignments .b. limit staff from moving between affected and unaffected units . Example 1 Review of the facility's gastrointestinal outbreak line list for January 2017 notes the following Resident/staff with at least one symptom of GI illness (Nausea, Vomiting, and/or diarrhea). 12/31/2016 - 1 Resident from 300 wing became ill with symptoms suggestive of the Norovirus (Vomiting x 4) 1/1/2017 - 1 Certified Nursing Assistant (CNA) who had floated between the 300/400 wing became ill. 1/2/17 - three staff became ill (1 CNA on 300 wing, 1 Registered Nurse (RN) floating between 300 & 400 wing, and 1 CNA on the 700 wing). 300 wing placed on quarantine. 1/3/17 - one 300 wing Resident became ill. Facility contacted Public Health and 300 wing remains on quarantine. 1/4/17 - one 300 wing Resident, one 300 wing CNA, and one CNA floating between 300 & 400 wing became ill. Public Health recommended obtaining two stool samples. On 01/04/2017 internal message sent to all staff states: Due to the recent outbreak on 300 wing, Please Please Please make sure that you are washing hands well and using hand sanitizer when appropriate. If you need hand sanitizer, please let a nurse know and we will supply it for you. Staff will need to be on 300 wing, we will try to staff the wing as consistent as possible. All other staff please try to stay off wing if possible. (Please note: no observations or audits of hand washing or of isolation precautions/personal protective equipment use were completed at the beginning of the outbreak.) 1/5/17 - CNA called in reporting illness, who last worked the 300 wing on 1/3/17. 1/6/17 - one 600 wing Resident and one 300 wing CNA (last worked 1/4/17) became ill. Facility Outbreak timeline states in part: .Quarantine lifted on 300 wing due to 48 hours since last GI symptom from Resident or staff. The facility removed the quarantine off 300 wing on 1/6/17, despite having knowledge a staff member, who previously worked on the 300 wing, had become ill that day. Residents on the 300 unit could now attend communal dining and activities. 1/7/17 - three 400 wing Residents and one 400 wing CNA became ill. Facility placed the 400 wing on quarantine at 7:30pm and Public Health updated. 1/8/17 - one 600 wing CNA became ill (last worked 1/7/17) 1/9/17 - one 300 wing Resident, one CNA floating between 300 & 400 wing (last worked 1/6/17), two 400 wing CNAs (worked last 1/8/17 & , and one 600 wing CNA (last worked 1/9/17) became ill. Facility contacted public health, stool sample requested. Please note the 600 wing currently has 1 Resident and 2 CNAs ill meeting the definition of an outbreak on the 600 wing as of 1/9/17; this wing has not been placed on quarantine. 1/10/17 - CNA floating between 700 & 800 wings became ill. The facility lifted the quarantine on the 400 wing despite having two ill staff on 1/9/17. 1/11/17 - one 300 wing CNA becomes ill (last worked 1/8/17) Please note this is another case on the 300 wing, resulting in 3 cases since 1/9/17, and at this time the 300 wing has not been re-quarantined and 300 wing Residents continue to be able to attend communal dining and activities. 1/12/17 - one 800 wing Resident became ill 1/13/17- Public Health Updated 1/14/17 - one 800 wing Resident became ill. 1/15/17 - one 800 wing Resident and one 700 wing Resident became ill 1/16/17 - two CNAs on the 800 wing, one on the 700 wing, two CNAs floating between the 700 & 800 wing, and two Licensed Practical Nurses (LPNs) floating between the 700 & 800 wing became ill. Quarantine implemented on 700 wing and 800 wing. Public Health updated, try and obtain stool specimens from 2 different Residents. 1/17/17 - one 800 wing Resident, one 700 wing Resident and one 600 wing Resident, along with one 600 wing CNA became ill. One ill 800-wing Residents stool sample collected 1/17/17, came back on 1/20/17 as Norovirus Geno group II RNA detected. On 01/17/2017 internal message sent to all staff states: 700 and 800 wings are both under quarantine at this time. The DD Residents from 700 and 800 are on modified quarantine, meaning do your best with co-habitating and keeping in there (SIC) rooms. At this time we have multiple staff with diarrhea and emesis that have worked 700/800, 3 Residents that are on the tail end of this illness, and one Resident on 800 that just started with emesis 1/17/17 @ 10:00. Please wash hands frequently use PPE as appropriate. Remember PPE supplies can not be kept in the hallway, this is a dignity issue, place the supplies in there (SIC) rooms . 1/18/17 - one 800 wing Resident and one 600 wing Resident became ill. Two 700 wing CNAs, and one LPN floating between the 700 & 800 wing became ill. Stool sample from one ill 700-wing resident collected 1/18/17, which came back on 1/20/17 as Norovirus Geno group II RNA detected. On 1/18/2017 internal message sent to all staff states in part: .1. If any Resident expressed or displays (signs or symptoms) of not feeling well, be proactive and keep them in their room, try not to wait for an emesis or diarrhea to occur. 2. Any staff that does not have to be on the quarantined wings, please do not enter. 3. Be diligent with continued cleaning throughout the day, no just when housekeeping is here. Clean any and all surfaces that an ill Resident may have touched .4 .dietary staff should stay off of the quarantined units; they can bring carts to the top of the hallway, if any item is needed staff working on the unit should meet them at the top of the hallway. 5. Make sure that PPE is in any room of an ill Resident, at this time I do not have enough infection control carts for all of the ill Residents. So have a package of gowns, and masks in each room of any ill Resident. Booties are only necessary if accidents occur on the floor. And as always, be diligent with handwashing . On 1/18/2017, random audits of handwashing done throughout facility on 11 staff members by a Registered Nurse. This is the first time handwashing audits were conducted despite continuation of outbreak within the facility. 1/19/17 - two 600 wing Residents, two CNAs who floated between 700 & 800 wings, one 600 wing CNA, one Housekeeper who floated between 500 & 600 wing, and one 800 wing CNA became ill. The 600 wing has met the definition of an outbreak by having three Residents ill , one CNA and one housekeeper, and the 600 wing has not been placed on quarantine. 1/20/17 - two 700 wing Residents, one 500 wing CNA, two 800 wing CNAs, and one 700 wing CNA became ill. 1/21/17 - two 600 wing Resident, one 400 wing Resident and one 800 wing Resident became ill, One 300 wing CNA, and one 600 wing CNA became ill. 1/22/17 - one 700 wing Resident, one 800 wing Resident, one 600 wing CNA and one 700 wing CNA became ill. Please note the 600 wing has two Residents and two CNAs ill between 1/21-1/22/17, which meets the definition of an outbreak. The 600 wing has not been quarantined thus far even though it has met the definition at least twice. 1/23/17 - one 800 wing Resident and one 600 wing CNA became ill. 1/24/17 - one 800 wing Resident, one 600 wing Resident, one Activity person assigned to 300/400/500/600 wing became ill. The 600 wing has an additional two Staff members and one Resident ill as of 1/24/17, equaling 7 total ill on the 600 wing between 1/21/17 & 1/24/17 and has not been placed on Quarantine. On 1/24/2017 random PM shift staff monitored washing their hands for compliance with facility policy, by the same RN who conducted random audits on 1/18/17. 1/25/17 - one 700 wing Resident and one 600 Wing Resident became ill. 1/26/17 - one CNA floating between 700 & 800 wing became ill. 1/27/17 - Public Health updated 1/28/17 - Quarantine lifted off 800 wing. On 1/28/2017 random PM shift staff monitored washing their hands for compliance with facility policy, by the same RN who conducted random audits on 1/18/17 and 1/24/17. 1/29/17 - one 800 wing Resident became ill; quarantine lifted off 700 wing 1/30/17 - one Activities person for 700/800 wing became ill. 1/31/17 - one CNA floating 300/500 wing, and two Activities personnel assigned 700/800 wing became ill. Quarantine initiated for the 700 wing. The 800 wing meets the definition of an outbreak by having one Resident and 3 Activities personnel becoming ill between 1/29/17 & 1/31/17, and quarantine was reinitiated for the 800 wing unit. 2/2/17 - two Activities Personnel assigned 700 wing became ill. 2/4/17 - quarantine lifted on 700 wing 2/7/17 - updated Public Health. Based on review of the outbreak line listing for January 2017, by the time the outbreak concluded on 2/7/17, it had resulted in a total of 34 of 85 Residents (of current census) (40%)-developing GI symptoms, as well as 49 staff. During this time period, the facility wanted to limit staff to one unit and not to float staff. However, due to the number of staff who had become ill, the facility was not able to do this. On 08/10/2017 at 9:40 AM Surveyor interviewed Housekeeping (HSK) K. HSK K indicated there is only one housekeeping cart for two hallways. On 08/10/2017 at 9:55am, Surveyor interviewed Activity (ACT) aide J. ACT aide J indicated that during the January outbreak, those on quarantine were encouraged to stay in their rooms and would go see Residents using mask, gloves and gown depending on outbreak and what the nurse recommended. ACT aide J indicated they would keep healthy Residents in groups and sick Residents weren't able to join to keep from spreading. ACT aide J indicated activities continued on as they normally would and that activities does not change their routine due to an outbreak. ACT aide J indicated they would not stop activities because they would wipe down the chairs and tables with bleach water provided by housekeeping. On 08/10/2017 at 10:10am, Surveyor conducted infection control review interview with Licensed Practical Nurse (LPN) C. LPN C indicated their January outbreak was identified on 1/2/17, due to one CNA not being in the building for 48 hours prior to onset of symptoms. LPN C indicated 300 wing was removed from quarantine on 1/6/17 because they go by the last work date for employees. LPN C stated Yes, ones that are titled float indicating staff were floating between halls during outbreak. LPN C indicated they tried to do consistent staffing but too much illness happened. LPN C indicated Activities were restricted on quarantined wings, and the rest of activities went on. LPN C indicated the 700/800 wing activities were stopped and Activities helped with additional cleaning. LPN C indicated Residents who were not quarantined continued activities. LPN C indicated meals were in rooms down quarantined hallways, but ones off quarantine ate in the main dining room. Facility tried to keep developmentally delayed individuals in rooms. LPN C indicated one person was hospitalized related to outbreak. LPN C indicated the outbreak was talked about with pharmacy, and Medical Director in the quarterly meeting and other meetings. LPN C indicated the QA committee talked about the outbreak and is unaware of any actions taken related to the outbreak and that she did not receive any feedback from the QA committee. LPN C also indicated there was not enough activity staff to provide one on ones through outbreak and that the 600 wing has their own activity program. LPN C indicated the 600 wing Residents ate in their rooms if they were sick and if actively sick stayed in their rooms; otherwise, they ate in the dining room on the 600 wing during the outbreak due to not enough staff to assist with meals. In addition, LPN C indicated she had no office time during this outbreak to complete the timeline while the outbreak was occurring, and that the timeline was completed while working the floor and that all the paperwork for the outbreak was completed a few weeks after the outbreak. On 08/10/2017 at 11:50am, Surveyor interviewed DON B regarding outbreak. DON B indicated their January outbreak was talked about in an infection prevention meeting and with public health. DON B indicated they talked about it in Quality Assurance committee meeting and provided education to nursing related to doing timeline and who's responsible for doing it. DON B indicated they tried not to float CNAs but with CNA shortage, if there wasn't enough for rotating have to work other units, but they try to keep them there. DON B indicated with healthy residents tried to do small group activities on wings and that Activities would go down on quarantine wings to do activities with healthy Residents, typically in their rooms. DON B indicated if Residents were not on quarantine they could continue going to the main dining room for meals and attend normal activities. On 08/10/2017 at 1:45PM, DON B stated to Surveyor We have a systems failure referring to January 2017 outbreak. On 08/10/2017 at 3:50pm, Surveyor interviewed DON B regarding when precautions are implemented. DON B indicated as soon as a person has symptoms they go on precautions, and don't wait for an outbreak. DON B indicated the facility found out Norovirus was rampant in the community upon first contact with Public Health. The Facility failure to prevent the spread of an infection by allowing staff to float between units, by lifting the quarantine on units too early, thus allowing residents to mingle with other residents, by failing to reinstate quarantine when numbers again showed an outbreak on the unit, by failing to get stool samples timely to the physician, and by not proactively closing all units when residents and staff had become ill on more than one unit, created a finding of Immediate jeopardy. The facility removed the jeopardy on 08/10/2017, when it had completed the following: 1. All nurses educated prior to next shift on responsibility to update line list in real time does not wait for Infection Preventionist. (QA to follow, in addition to ongoing education). We will audit daily during each outbreak. 2. All nurses educated prior to next shift on Gastroenteritis policy, including when an outbreak should not be lifted. Isolation precautions - quarantine should not be lifted until 0 staff or Residents are ill for 48-72 hours. Audits will be completed daily during the outbreak. 3. Gastroenteritis policy revised to state 2 ill Residents, and or staff, in a common area constitutes an outbreak. 4. All staff will be educated on GI policy and procedure to include: - Discontinue the floating staff from the affected unit to non-affected units. - Discontinue use of common dining areas and instituting in-room dining. - Postpone group activities for at least 48 hours after the last identified case. 5. Temperature ranges of dishwasher cycles posted on the dish machine, policy developed to include instruction on procedure for temperatures out of range (high or low) 6. Digital thermometer ordered for dishwasher to minimize risk of human error. 7. Educate dietary staff on dishwasher policy and procedure regarding temperatures. 8. Stool samples will be obtained within 48-72 hours after onset of symptoms or requested by public health. Staff will be educated on importance of obtaining stool specimens. Audits will be performed during outbreak to assure stool samples are obtained. 9. The facility will immediately institute aggressive infection control measures when an outbreak is suspected. Audits will be completed daily during the outbreak to insure all policies are being followed. 10. Once an outbreak is identified PPE use, handwashing, cleaning/housekeeping audits will be completed daily for the durations of the outbreak. Example 2 Certified Nursing Assistant (CNA) D did not change soiled gloves or perfume hand hygiene when gloves were visible soiled. On 08/09/2017 at 8:50am, Surveyor conducted an observation of cares for Resident 2 (R2). Surveyor observed Certified Nursing Assistant (CNA) D provide incontinence care to R2. CNA D had visible stool on her gloves while cleaning up R2. CNA D with stool on her gloves went to R2's drawer, opened and closed the drawer after obtaining clean towels with her stool contaminated glove. CNA D then placed the towels into a basin of water, then proceeded to reach into the water with her stool contaminated gloves. CNA D grabbed the bottle of body wash, placed body wash on wet towel then proceeded to clean R2's bottom with her same gloves. CNA D with her same gloves grabbed a clean towel to dry R2's bottom off and then went to R2's drawer again to grab a new incontinent product and linen pad (soaker pad), while wearing the gloves that had, had visible stool on them. CNA D placed clean pad and incontinent pad under R2, still wearing the same pair of gloves, and rolled R2 towards her touching R2's Left thigh/hip area with her gloves. CNA D continues to wear gloves that had visible stool on them, and hands drinking cup to R2, placed transfer belt on bathroom door, and repositioned R2's Left arm, all while wearing the same pair of gloves that previously had stool on them. CNA D removed her gloves at this time and performed hand hygiene for the first time since beginning starting incontinence care on R2. On 08/09/2017 at 9:10am, Surveyor interviewed CNA D regarding above observation. CNA D indicated hand hygiene should be done every time you remove your gloves, with physical contact, when you leave the room. CNA D indicated to change gloves when visibly soiled and after cleaning stool. CNA D stated yes indicating she should have removed her soiled gloves and washed her hands prior to touching R2's dresser, water cup, clean linen, clean incontinent product, and transfer belt. On 08/10/2017 at 5:15pm, Surveyor interviewed DON B regarding above observation. DON B indicated gloves are to be changed when visibly soiled, after dirty portion /contamination of cares are performed. DON B indicated Hand hygiene is to be done immediately after glove removal. DON B stated absolutely indicated CNA D should have changed her stool contaminated gloves while providing cares.

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for 11 of 23 residents reviewed for accidents hazards (Resident 20, 19, 17, 14, 12, 8, 10, 9, 15, 2, and 1). Resident 20 is at moderate to severe risk for aspiration. The facility failed to provide Resident 20 adequate supervision to prevent choking/aspiration during meal service. Facility staff had knowledge that Resident 20 would take food, not within her diet consistency, off of other resident's plates. However the facility failed to ensure staff was present in the dining room to supervise Resident 20 and failed to implement a plan of care directing staff to supervise Resident 20 during meal service. Resident 20 was observed taking and drinking another resident's unthickened fluids on 7/11/16, after which she began coughing, and was observed taking and eating/drinking another resident's potato chips and another resident's unthickened milk on 7/12/16. Resident 20 began coughing after drinking the milk. Lack of supervision in the dining room placed Resident 20 at risk for choking and created a finding of Immediate Jeopardy, which began on 7/11/16. The Nursing Home Administrator was notified of this finding on 7/13/16 at 4:09pm and the Immediate Jeopardy was removed on 7/13/16. The deficient practice continues at a scope /severity of G (actual harm/isolated, as evidence by the fractured hip sustained by Resident 14 in the following examples of continued noncompliance. Resident 19 was not supervised during meal time. Resident 19 was served a whole sausage and is supposed to have cut up meat during the unsupervised time. Contrary to her dinner meal tray card Resident 17 received a peanut butter sandwich with crust, broccoli that was not cut up fine and chicken that was not cut up enough. Resident 14 experienced a fall resulting in a hip fracture on 11/14/15. This was the third fall since 5/19/15 Facility response to the two falls prior to 11/14/15 was to encourage resident to use the call light, even though she has short term memory loss and severe cognitive impairment. Resident 14 was not wearing gripper socks on 11/14/15 even though these were indicated in the fall prevention care plan. The facility failed to identify the root cause for the falls, monitor the effectiveness of the interventions and modify the interventions as necessary. On 3/28/16 Resident 12 experienced her third fall since 3/17/16. The facility failed to identify the root cause for the fall, monitor the effectiveness of the interventions and modify the interventions as necessary. Resident 8 sustained a fall and the root cause was not thoroughly investigated. Resident 10 was left unattended in the bathroom and is at risk for falls. Resident 9 did not have proper footwear on during a transfer. Resident 15's sensor pad alarm was not placed correctly for proper functioning. Resident 2 was observed with a package of cigarettes and a lighter lying in her bed and an electronic cigarette lying on her over the bed table. Resident 2's smoking care plan was not developed to indicate whether or not she could keep her own smoking products during unsupervised times. Resident 1's Interdisciplinary Progress Notes indicate Resident 1 was observed putting nickels from bingo into his mouth. Resident 1's care plan was not updated to indicate what staff should do to prevent this from happening. This is evidenced by: Example 1 According to http://www.emedicinehealth.com/choking/article_em.htm, Choking is a blockage of the upper airway by food or other objects, which prevents a person from breathing effectively. Choking can cause a simple coughing fit, but complete blockage of the airway may lead to death. Choking is a true medical emergency that requires fast, appropriate action by anyone available. Emergency medical teams may not arrive in time to save a choking person's life. .When someone is choking with a completely blocked airway, no oxygen can enter the lungs. The brain is extremely sensitive to this lack of oxygen and begins to die within four to six minutes. It is during this time that first aid must take place. Irreversible brain death occurs in as little as 10 minutes. Resident 20 is [AGE] years old and was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident 20 had a Minimum Data Set (MDS) completed on 6/29/16, Resident 20's BIMS (Brief Interview for Mental Status) was unable to be completed, and the staff assessment of mental status reveals Resident 20 has short and long-term memory problems, is rarely or never understood and has severely impaired decision-making abilities. On 9/15/15 Speech therapy received a referral related to Resident 20 has demonstrated new functional deficits or changes in mental/behavioral status and patient/family/nursing reports difficulty with current diet. The recommendations identified were: Resident 20 exhibits a moderate-severe oral-pharyngeal dysphagia characterized by poor labial closure, reduced bolus control and awareness. She has anterior oral spillage and likely premature spillage into the pharynx. She had less symptoms of aspiration with honey thick liquids. Diet change to honey thick liquids and remain on pureed solids. Allow extra time to initiate swallow, slow rate, small boluses, and avoid talking or asking her questions when she has bolus in oral cavity. Resident 20's comprehensive care plan has identified the problem area of Potential for Altered Nutritional Status Interventions include: Eats meals in assisted dining module on 500-wing to receive cues and assistance as needed (Dated 8/27/14). Swallowing strategies for care givers: 1. Allow only 2-3 sips of liquid. If she takes more she typically coughs (sign of aspiration). 2. Liquid wash after 1-2 bites of pureed food. 3. Verbally encourage her to swallow when food sitting in mouth. 4. If assisting with feeding, try placing food in right side of mouth. 5. Allow slow rate. 6. Oral cares after every meal (Dated 8/27/13). Resident 20's current diet order is written as Pureed solids, regular portions, honey thick liquids, oral cares following all meals and snacks. On 6/27/16 the dietitian noted that Resident 20's has a swallowing problem and needed cuing and assistance with close supervision. On 7/11/16 at 1:08pm during the noon meal Surveyor observed Certified Nursing Assistant (CNA) M assisting six residents in the 500 wing dining room. CNA M served a meal to a resident seated next to Resident 20 and left the dining room leaving no staff present in the dining room. As soon as CNA M left the dining room Resident 20 reached across the table and picked up a cup of white creamy fluid from the other resident and started drinking it. Immediately after drinking her peers' fluids Resident 20 started coughing. Upon return to the dining room Surveyor informed CNA M that Resident 20 took the drink from her peer next to her. CNA M replenished the other resident's drink which she identified as Ensure. At 1:52pm CNA M identified that Resident 20 should be drinking honey thick liquids and that the resident sitting next to her drinks regular consistency liquids. During the meal Resident 20 was continually coughing as CNA M assisted her to eat. CNA M stated to Surveyor that Resident 20 is having a difficult time during lunch today due to coughing. It should be noted that after Resident 20 drank her peer's fluids, which were not within her diet consistency, Resident 20 was noted to be continually coughing during the meal and was only able to tolerate 25 % of her meal. Surveyor informed CNA M that Resident 20 had been coughing since she drank her peer's Ensure that was the incorrect consistency. CNA M immediately left the dining room and notified the nurse. On 7/11/16 at 2:27pm Licensed Practical Nurse (LPN) Q documented in Resident 20's nursing notes at lunch today Resident 20 reached over and drank another resident's drink that was the wrong consistency. She did do a fair amount of coughing at the time. Lungs are clear but diminished. Resident 20 is in bed with the head of the bed up. Resident 20 is noted to do some coughing with meals and honey consistency liquids daily. Medical Doctor (MD) was updated and Resident 20's son/power of attorney was notified. The plan is to monitor lungs and temperature for 24 hours. On 7/12/16 at 5:04pm Surveyor observed CNA N set up a resident's supper tray who was seated next to Resident 20 and then she exited the dining room leaving no supervision in the dining room. Resident 20 reached over the table and took a bag of potato chips from the other resident and began eating them. At 5:05pm CNA N returned to the dining room and was notified by Surveyor that Resident 20 took the other residents potato chip bag and is eating them. CNA N told Resident 20 that you cannot eat those and removed the bag of potato chips placing them across the table. CNA N stated that Resident 20 is our Snatcher. At 5:07 pm CNA N left the dining room again leaving the residents with no supervision. As soon as CNA N left the dining room, Resident 20 reached across the table picking up a glass of regular milk from the resident next to her and started drinking from it which caused her to immediately cough. At 5:08pm CNA O entered the dining room and Surveyor informed her that Resident 20 had picked up a cup of milk from the resident next to her and was drinking it. When CNA N returned to the dining room, CNA O informed her that Resident 20 had reached over and taken the milk from the resident next to her. CNA N again stated that Resident 20 is our snatcher in the dining room. Neither CNA N nor CNA O notified the nurse after Resident 20 ate and drank the wrong consistency food. Resident 20's physician was not updated. On 7/13/16 at 10:40am Surveyor asked LPN Q if she was aware that Resident 20 takes food and drink off of other resident's trays. LPN Q stated she was not aware Resident 20 has taken food or drinks from others. Surveyor asked LPN Q how staff should proceed if a resident consumes the wrong diet and is an aspiration risk. LPN Q stated if a resident received the wrong diet the MD should be notified and the resident's vital signs monitored. On 7/13/16 at 1100 Surveyor spoke to RN T regarding Resident 20's swallowing. RN T noted that Resident 20 is not listed in the MDS as having a swallowing concern because according to the Resident Assessment Instrument (RAI) it requires a 7 day look back period and there are no nursing notes identifying Resident 20 having a swallowing problem. On 7/13/16 at 10:50am Surveyor spoke to LPN P and asked LPN P if she was aware that Resident 20 takes food and drinks from other resident's at her table and that some staff call her the Snatcher because she frequently removes food from other resident's trays. LPN P replied that she was not aware Resident 20 took food items from other resident's. LPN P stated Resident 20 coughs a lot through meals. LPN P was aware of the incident on 7/11/16 at lunch time but was not aware Resident 20 had removed potato chips and milk off of a resident's tray and eaten them today. LPN P stated she would update Resident 20's care plan right now and ensure staff do not leave her alone in the dining room. Surveyor observed Resident 20's updated Care Plan Potential for Altered Nutritional Status dated 7/13/16. The new interventions state: Take Resident 20 to the table last during meal times. Staff must be within arm's reach of Resident 20 while there is any food or fluids at the dining room table. Notify the nurse if Resident 20 consumes nutrition that is not in her diet. On 7/13/16 at 4:35pm Surveyor spoke to RN R regarding how many residents eat in the 500 and 600 unit dining rooms. RN R stated the 500 unit serves 7 residents in the dining room and the 600 unit serves 16 residents in the dining room. RN R identified the 500 unit dining room has 3 residents who need supervision when eating, 2 residents who need assistance when eating and 3 residents who have altered diets. The 600 unit dining room has 6 residents who need supervision, 7 residents who need assistance, and 6 residents who have altered diets. Surveyor asked if a staff member should be present when residents start eating in the dining rooms. RN R replied, Yes they should be in there especially if they are a choking risk or if they have an altered diet. Surveyor asked if anyone is assigned to stay in the dining room and how they are supervised. RN R replied that in the units the float staff goes to the main dining room to assist residents; on 1st shift 3 staff stay and work on the unit and on 2nd shift 2 staff stay on the unit to assist the residents in the small unit dining rooms. On 7/13/16 at 4:55pm Surveyor spoke to CNA S on how they determine who works in the dining room on the unit. CNA S replied that on 2nd shift there are 3 staff. The float goes to the main dining room and the other two both help set up the 500 unit dining room. One will stay in the dining room and the other will watch the hallway and assist with the call lights. No one is assigned to work in the specific dining room or hallway they just work together on it. Resident 20 is at moderate to severe risk for aspiration. The facility failed to provide Resident 20 adequate supervision to prevent choking/aspiration during meal service despite facility staff having knowledge that Resident 20 would take food, not within her diet consistency, off of other resident's plates. The facility failed to have a system to ensure staff was present in the dining room to supervise Resident 20 and failed to implement a plan of care directing staff to supervise Resident 20 during meal service. The failure to provide adequate supervision created a situation of immediate jeopardy. The facility removed the immediate jeopardy on 7/13/16 when: 1. All direct care and dietary staff present at this time have been educated on the need to provide direct supervision for all residents receiving modified diets once food/fluids are served. 2. All direct care and dietary staff will be educated prior to the start of their next shift on the need to provide direct supervision for all residents receiving modified diets once food/fluids are served. 3. Prior to each meal, a nurse will assign a CNA to supervise dining rooms on each wing. 4. Dining service and supervision policy has been reviewed and revised to ensure necessary dining supervision is provided to maintain resident safety. 5. All dietary staff educated to check each menu and compare with food to be served to ensure correct items and textures are sent and served to residents. 6. 2 of 3 meals daily for one week will be observed by Director of Nursing (DON) or designated nurse to ensure supervision is present during meal times. 1 of 3 meals will be observed by DON or designated nurse for one week to ensure supervision is present during meal times. 1 meal 5 days for one week will be observed by DON or designee to ensure supervision is present during meal times as long as compliance is observed. The frequency of checks will increase if compliance is not observed. 7. Dietary Manager or designee will perform a secondary check on 2 meals daily for one week, and beyond as needed, to compare the menu and ordered diet with contents to be served to ensure compliance. The deficient practice continues at a scope/severity of G (actual harm/isolated) as evidenced by the following: Example 2 Resident 19's physician orders [REDACTED]. Resident 19's care plan includes giving verbal cues to clear her mouth and swallow foods, updated 6/6/13. On 10/9/12 Resident 19's care plan was updated to include needs cues and supervision at meals. On 7/12/16, at 7:44 AM, Surveyor observed Certified Nursing Assistant (CNA) X serving meals in the dining room on the Dementia Care Unit. At 7:47 AM CNA X left the dining room. There was no staff in the dining room once CNA X left. Surveyor noted Resident 19 had her meal and was eating independently. Surveyor noted Resident 19 was eating a whole sausage link with an English Muffin wrapped around it. Surveyor noted the meal ticket indicates and is highlighted to have cut up meat with gravy. The sausage was not cut up and there was not gravy or sauce on the meat. At 7:53 AM, Registered Nurse (RN) G entered the dining room and continued to serve resident's their meals. Resident 19 consumed the entire whole sausage during this time. Resident 19 was unsupervised eating the wrong diet for 6 minutes. On 7/13/16, at 8:17 AM, Surveyor interviewed Cook Y who stated dietary is responsible for serving the meats cut up if it is indicated on the resident's diet ticket. Cook Y stated it should be cut up before it is on the cart to go to the unit. On 7/13/16, at 8:27 AM, Surveyor interviewed RN R regarding the meal service. RN R stated that there needs to be supervision at all times in the dining room by a CNA or nurse when the residents are eating. RN R stated if a resident needs their foods cut up it is typically done by the kitchen but the CNAs can also do it when they serve the meal if it is not done. RN R stated Resident 19 needs to have her meats cut up. The facility has discussed down grading her diet more because Resident 19 coughs even with the cut up meats but the family does not want her diet altered further. RN R stated they have discussed with family the risks as Resident 19 is at high risk for aspiration even with the cut up meats and gravy. Surveyor informed RN R of the observations in the dining room on 7/12/16. RN R stated staff should have cut it up for her and Resident 19 should not be eating without supervision. Example 3 Resident 17 was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. Resident 17's Minimum Data Set (MDS) assessment, dated 6/14/16, indicated that Resident 17 has a BIMS (Brief Interview of Mental Status) of 13. Resident 17's care plan, dated 10/28/13, states in part: Potential for altered Nutritional/Hydration status . Provide diet as ordered: see MD (Medical Doctor) order or tray card. Physician order [REDACTED]. May have sandwiches without crust and peanut butter sandwiches Resident 17's Diner meal Tray Card on 7/12/16 states in part: Special notes . cooked vegetables cut up fine, crust less PB (peanut butter) sandwich Lunch & supper . On 7/12/2016 at 4:45PM, Surveyor observed Resident 17's evening meal. CNA D was assisting Resident 17 with her meal. Resident 17 received whole broccoli florets, peanut butter sandwich with the crust on, and a chicken salad croissant. CNA D gave Resident 17 a bite of chicken salad, Resident 17 spit chicken out into a napkin and stated, Not cut up enough. CNA D did not offer to get Resident 17 a different entrée selection. Resident 17 asked CNA D if there was anything else she could eat. CNA D replied cottage cheese and pears. CNA D placed Peanut Butter sandwich on Resident 17's bedside table. Resident 17 then grabbed the sandwich and asked CNA D to put honey on her sandwich. CNA D proceeded to put honey on Resident 17's sandwich, cut the sandwich in half, placed back into bag with crust still on. On 07/12/2016 at 4:50PM, Surveyor interviewed CNA D regarding Resident 17's meal items. CNA D shook head in yes motion indicating Resident 17's Peanut butter sandwiches normally have crust on them. CNA D also indicated that kitchen cuts up meal items. On 7/12/2016 at 5:27PM, Surveyor interviewed DON (Director of Nursing) B and DM (Dietary Manager) C regarding Resident 17's evening meal. DM C indicated that Resident 17 is to have peanut butter sandwiches without crust and that Resident 17's broccoli should be cut up by the kitchen staff otherwise the CNAs should do it if the kitchen did not. DON B and DM C both indicated that CNA D should have asked for different chicken for Resident 17. DM C indicated that Resident 17 should be on a pureed diet. DON B and DM C both indicated that CNAs are to check tray card then check tray card against the resident's tray. DON B indicated that Resident 17 should be a pureed diet, but her daughter says no. DM C indicated that one-person plates and places on trays and that there is a second person who checks the trays and Should have caught it. On 07/13/16 at 7:55am, Surveyor observed a peanut butter sandwich with crust on it on Resident 17's bedside table. On 07/13/16 at 8:45am, Surveyor interviewed Resident 17 who indicated her sandwiches usually have crusts on them. Example 4 Resident 14 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident 14's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/21/15 indicates Resident 14's mental status is Severely Impaired. Resident 14 is not of her own person and has an activated health care power of attorney as of 1/16/12. Resident 14's comprehensive care plan states in part; Communication Deficit: usually understands but may miss part of the message spoken (Dated 4/27/10). Potential for Falls: (Dated 4/27/10), Staff will check resident every two hours and offer toileting assistance (Dated 11/14/15), Non-slip footwear with all transfers (Dated 11/24/15), and to Remind resident not to transfer self. Remind to use call light and wait for staff to assist before getting up from bed or chair (Dated 4/27/10). Potential for Impaired Vision: Adapt environment as able to assist with visual deficits and promote independence (Dated 4/27/10).Impaired short term memory, impaired decision making and judgment related to dementia. On 5/19/15 at 7:45am Resident 14 was in her bedroom when staff heard a noise from the room and they responded finding Resident 14 on the floor on her left side in a lying position between the bed and the recliner. The bedside table was pushed up to the head of the bed. Resident 14 reports to losing her balance while attempting to ambulate to the bathroom when she fell to the floor hitting the back of her head on the floor. Her walker was tipped over and a few blankets were on the floor. The planned intervention was to encourage Resident 14 to ask for assistance during times of illness or antibiotic use as she currently is receiving Bactrim for cellulitis. No injury was noted after this fall. Of note, the facility failed to identify the root cause for Resident 14's fall. The facility implemented an intervention of encouraging Resident 14 to ask for assistance during times of illness despite the fact that Resident 14 has short term memory loss and severe cognitive impairment that impede her safety awareness and ability to recall safety interventions. On 6/13/15 at 9:30pm Resident 14 was in her bedroom walking over from her recliner to her bed when she slipped and fell on to her knees. Resident 14 was wearing gripper socks, but not using her walker. The planned intervention was identified to encourage Resident 14 to use her call light for assistance and use the walker when ambulating or transferring. The fall will be reviewed with the fall committee. The fall committee had no further recommendations. Resident 14 directs her own care and often refuses to follow staff recommendations despite education of risks. She had mobility monitors on past but wants them removed and will shut them off. Of note, the facility failed to identify the root cause for Resident 14's fall and implemented an intervention of encouraging Resident 14 to use a call light for assistance and to use the walker when ambulating and transferring. Resident 14 has short term memory loss and severe cognitive impairment that impede her safety awareness and ability to recall safety interventions. On 11/14/15 at 1:30am, Resident 14 was in her bedroom when staff heard a very faint yell. Resident 14 had fallen at the foot of the bed. She was found lying on her right hip and her right arm was grasping the footboard. She had an incontinent pad and a pair of underwear but her lower body was unclothed. A puddle of urine was found on the floor near Resident 14's buttock. Resident 14's pajama pants were draped over the walker located by her chair. When asked to move her right leg, she refused and was tearful. Any touching of the right hip caused duress. A Post Fall Huddle was completed by RN W on 11/14/15 noting that Resident 14 fell in her room at 1:30am and that she had no gripper socks on and that the path to the bathroom was unobstructed. The huddle report noted that Resident 14 was on her way to the bathroom, but it was unknown the last time she had used the toilet as she toilets independently. Certified Nursing Assistant (CNA) V completed a Fall Statement Form on 11/14/15 at 2:45am noting that Resident 14 was sleeping prior to the fall and that Resident 14 said she got up to go to the bathroom and get a new pad and underwear. CNA V notes that Resident 14 does not use the call light or walker which may have contributed to the fall. The fall statement asks what factors of the resident's environment, equipment, clothing or supplies if any that may have contributed to the fall? CNA V notes the room was dark and that Resident 14 did not have gripper socks on. When the report asks if the fall is related to a transfer and what kind of a transfer is it? CNA V wrote that Resident 14 walks independently. On 11/14/15 RN W sent a Facsimile Transmittal Sheet to the Medical Doctor (MD) which states in part; Resident 14 fell and is complaining of right hip pain. She requested to be transported to the hospital to have the right hip looked at. On 1/25/16 RN T completed a Late Entry Interdisciplinary Progress Note under Fall Committee Review for 11/16/15 at 10:00am. RN T notes Resident 14-Review of fall: check Resident 14 every two hours at night for toileting assistance. It was noted that on 11/14/15 Resident 14 was treated for [REDACTED]. Of note, the facility identified Resident 14 was not wearing her gripper socks however the facility did not determine the root cause for the gripper socks not being on. On 2/02/16 at 9:43pm Resident 14 was found sitting on her bottom leaning up against her bed. Resident 14 was attempting to sit on the edge of the bed when her feet slid out from under her. Resident 14 claims to have hit her head on the temple area on the bed frame when she fell . The Planned intervention was to remind Resident 14 not to get up on her own. On 2/11/16 at 8:50pm Resident 14 was in her bedroom seated in the recliner and turned on her call light for assistance. Staff was assisting other residents at the time so Resident 14 attempted to get up to get her bed clothes and she slid off the chair onto her buttock. No injury was noted from this fall. The planned intervention is to continue with the current plan of care; Resident 14 agrees to wait for assistance. Of note, the facility failed to identify the root cause for Resident 14's falls and implemented an intervention of reminding Resident 14 not to get up on her own. Resident 14 has short term memory loss and severe cognitive impairment which impedes her safety awareness and ability to recall safety interventions. Example 5 Resident 12 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident 12's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 5/27/16 indicates Resident 12 is rarely or never understood and his cognition skills for daily decision making are severely impaired. Resident 12 has an activated health care power of attorney. Resident 12 has a Care Plan with the following problems identified: Potential for Falls with the following interventions: Non-slip footwear with all transfers and ambulation (Dated 11/05/12), Discourage and avoid abrupt position changes (Dated 11/05/12), Sensor pad alarms to bed and chair to alert staff of attempts to transfer self, Dycem on recliner in Resident 12's room and do not extend recliner's foot in his room when resident is sitting on it (Dated 3/13/15), Resident to sit in non-reclining stationary chairs only (Dated 3/17/16), Resident up in dayroom when agitated/restless for his safety (3/27/16),When agitated or restless attempt to have Resident 12 in dayroom areas (Dated 3/28/16) and Keep walker within reach when in recliner (Dated 3/28/16). On 3/13/15 at 11:15am Resident 12 was found in his bedroom seated on his bottom with half of his body on the footrest of the recliner and half onto the floor. Resident 12 stated he wanted to use the toilet. The planned intervention was to place Dycem in the recliner do not extend the foot rest of the recliner and to continue with the bed/chair alarm. Of note, the facility failed to identify the root cause for Resident 12's fall. Resident 12 stated her wanted to use the restroom however the facility implemented dycem as an intervention without addressing Resident 12's toileting needs. On 3/17/16 at 6:25am Staff found Resident 12 had slid down and was sitting on the recliner foot rest with his sensor pad underneath him. No injury was noted at that time. The planned intervention is to remove the current recliner from his room and replace it with a stationary non-reclining chair. Of note, the facility failed to identify the root cause for Resident 12's fall and monitor the effectiveness of the fall interventions. On 3/27/16 at 9:45pm Resident 12 was found lying on his right side in the doorway of his room. The planned intervention is to have Resident 12 up in the dayroom when he is agitated and/or restless. Of note, the facility failed to identify the root cause for Resident 12's fall and monitor the effectiveness of the fall interventions. On 3/28/16 at 2:15pm Resident 12 was found on the bathroom floor on his right side. He stated he hit his head. Originally the assessment revealed that Resident 12 had a minor injury when he fell on his way to the bathroom and the intervention recommended was to keep his walker within reach. The Incident and Analysis report written on 3/28/16 at 2:15 noted that Resident 12 received Seroquel on 3/27/16 at 7:10pm. Resident 12's behavior at the time of the fall was noted at Agitated and Restless. Resident 12 was not using any assistive devices, but his pressure pad alarm was being used and was sounding at the time of the fall. Of note, the facility failed to identify the root cause for Resident 12's fall and monitor the effectiveness of the fall interventions. Example 6 Resident 8 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident 8's Brief Interview for Mental Status, completed on 5/24/16, was scored 15 indicating no cognitive impairment. Resident 8 was receiving Physical Therapy and Occupational Therapy for strength training. On 6/2/16 Resident 8 sustained a fall. The facility incident report indicates Resident 8 was found in the bathroom and Resident 8 stated she lost her balance when getting up. Plan to prevent falls was to encourage to use the call light and wait for assistance. On 6/20/16 at 5:0

Based on observation, interview and record review the facility did not ensure that the resident environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistant devices to prevent accident for 2 of 14 residents (Residents 5 and 13), and also for 1 unit affecting 8 residents. Resident 5 sustained a fall without injury on 3/29/15 when CNA (Certified Nursing Assistant) T did not ensure that Resident 5's bed alarm was placed and functioning properly. Resident 5 sustained a fall on 4/26/15 resulting in a femur fracture when CNA (Certified Nursing Assistant) T did not use a gait belt when ambulating Resident 5 at the time of this fall, per the facility's policy. Resident 13 had several falls when the facility had not implemented the interventions documented on the care plan, fell and fractured her left hip. The following examples were noted at level 2. The facility was observed charging a lift battery during waking hours on the lower 600 unit. Eight residents reside on this lower unit. This is evidenced by: The facility's Mobility Monitors policy, updated on 10/15/14, states .ensure proper functioning whenever resident is moved and monitor engaged. The facility's Gait Belt policy, updated on 8/13/14, states that the facility's nursing staff and rehab team will utilize a gait belt for resident mobility when resident requires one or more staff to assist him/her during transfer and/or ambulation. Example 1 Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 5 has an activated Power of Attorney for Health Care. The facility completed an initial Minimum Data Set (MDS) assessment on 2/12/15. This assessment notes that Resident 5 scored seven points on the Brief Interview for Mental Status (BIMS), indicating cognitive impairment. Section V Care Area Assessment (CAA) Summary notes that the CAA for falls triggered and a care plan was developed. The facility's initial Fall Risk Assessment for Resident 5 on 2/6/15 score is 26, indicating Resident 5 is at high risk for falls. This assessment tool includes a scale of 0-11 indicates low risk; a score of 12 and above indicates a high risk for falls. Resident 5's care plan dated 2/6/15 includes in part for Impaired Mobility/Potential for Falls . need for assist/assistive devices for transfers/ambulation/mobility secondary to weakness deconditioning related to recent [DIAGNOSES REDACTED] other [DIAGNOSES REDACTED]. Goal: Will continue to remain free from falls and associated injuries. Approaches: .Sensor pad in bed and wheelchair, transfer with assist of 1 and walker, leave out of bed and in supervised area when restless or anxious, uses wheelchair for distances with dycem. Record review indicates the following fall events: On 3/29/15 at 11:15AM Resident 5 was propelling self in her wheelchair on to carpeted area and slid out her wheelchair. Resident 5's care plan was updated to include the intervention of placing Dycem in Resident 5's wheelchair. On 3/29/15 at 9:30 PM Resident 5 was found on the floor in the doorway of her room. Resident 5 had ambulated by herself from her bed to the doorway of her room, the bed sensor alarm was not sounding. CNA (Certified Nursing Assistant) T had not ensured that the bed alarm was placed and functioning, CNA T was provided with education. On 4/17/15 at 8:15 PM Resident 5 was found sitting on the floor in her room, Resident 5's family had just lef. Care plan was updated to ask family to leave Resident 5 in a public area and not alone in her room when they are done visiting. On 4/19/15 at 3:30 PM Resident 5 was found lying on right side on carpet area at end of 100 wing. Care Plan was updated for staff to be aware of Resident 5's location, monitor when active/agitated. On 4/26/15 at 8:10 PM Resident 5 was ambulating with CNA (Certified Nursing Assistant) T when Resident 5 began to tip back and fell to the floor, complaining of left hip and pelvic pain. CNA T had not put a gait belt on Resident 5 so CNA T was not able to stabilize Resident 5 and she sustained a fall. Resident 5 was discharged to the hospital on 4/2715 with [DIAGNOSES REDACTED]. On 5/19/15 at 10:45 AM Survey interviewed DON (Director of Nursing) B to discuss the investigation and corrective actions regarding Resident 5's falls. DON B stated that on 3/29/15, CNA (Certified Nursing Assistant) T was provided with education about the need to ensure that resident's mobility monitors are in place and functioning properly. DON B stated that CNA T was not monitored for effectiveness of this education, nor did other facility staff receive re-education on the proper use of mobility monitors at this time. DON B stated that on 4/27/15 CNA T received education and disciplinary action for failing to use a gait belt when ambulating a resident however, CNA T was not monitored for effectiveness of this education, nor did other facility staff receive re-education on the need to use a gait belt when physically assisting a resident with transfers or ambulation. DON B agreed that these corrective actions should have occurred. Example 2 Resident 13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 13's Quarterly Minimum Data Set ((MDS) dated [DATE], Brief Interview for Mental Status (BIMS) scored a 15, which indicates that Resident 13 is cognitively intact. The facility's admission Fall Risk Assessment dated 12/18/14 scored a 23, which states, A score of 12 or more equals high risk. Proceed to care plan approaches. Resident 13's Comprehensive Care Plan Impaired Mobility/Potential for Falls dated 12/18/14 states in part, .Non-Slip footwear with all transfers and ambulation . Physicians Progress notes, dated 12/18/14, state in part, . (Resident 13) has mental status changes that have been stabilized. She has [DIAGNOSES REDACTED]s present and still leans to the side when she turns left . Resident 13's Fall Assessment dated 1/7/15 at 4:25 PM, (Resident 13) was in her room, turned and tripped on own feet and fell on to her left hip. Resident requested to go to the emergency room to be evaluated. Injury - Possible hip injury. Went to GRHC (Grant Regional Health Center) for X-ray. On 1/7/15 at 4:51 PM, Resident 13 complained of pain to her left hip a (7) out of a 1-10 scale and was given 2 Acetaminophen prior to ambulance transport. The facility's Fall Statement Form dated 1/7/15 at 4:25 PM, completed by Registered Nurse (RN) N, indicates #5, what kind of characteristics does the resident have that may have contributed to the fall? Slippery slippers was the documented answer. Item #7 Do you have knowledge of anything different in the past forty eight (48) hours that may have contributed to the fall? Slippers was documented as the answer. The facility's Fall Assessment dated 1/7/15 at 4:55 PM, indicated the new intervention Give resident gripper socks, her slippers contributed to the fall. Resident 13's care plan, dated 12/18/14, already indicated non-slip footwear was to be worn with all transfers and ambulation so these interventions should have been implemented prior to this fall. Resident 13's Left Hip X-Ray report dated 1/7/15, states in part, .Impression: Appearance of the proximal left femur at the neck raises concern for a fracture. Further evaluation with a CT or MRI may be helpful . The facility's Fall Assessment dated 1/19/15 at 8:25 PM states, (Resident 13) fell while stepping over her bedside stand leg and lost her balance and fell and hit her eye as she went down, husband was present. Injury- Swollen area above right eye with bruising, states her hand she's able to move it and denies pain in it. Right pupil is odd shape states she has an implant. Physicians Progress notes dated 1/15/15, state in part, . (Resident 13) possibly has a fracture of her left hip, rather subtle. Clinically it would fit because of her fall and because of the minor discomfort she has on that side . The facility's Fall Assessment dated 1/19/15 at 8:25 PM indicated a new intervention of Resident will be 1 assist. Resident 13's Fall Assessment dated 2/3/15 at 10:00 PM states, (Resident 13) was found on the floor in her room. Laying on her left side c/o (Complain of) left hip pain. Denies head injury. Hoyer (Mechanical lift) lifted back to bed. Resident assessed my RN. Hip looks to be WNL (With in normal limits). Resident requesting to be evaluated in emergency room . Injury- None. This fall assessment indicates a new intervention Resident to use call light for assistance. Resident one assist now. There is no documentation regarding footwear and no indication as to why they are reinstituting the resident be a one assist, as this intervention was previously added based on the 1/19/15 assessment. Resident 13's Left Hip X-Ray report, dated 2/3/15, states in part, .Impression: Sub capital left femoral neck fracture, which is slightly more impacted than on prior exam . Physicians Progress notes dated 2/12/15 state in part, .(Resident 13) had a recent fall. Probably not surprising in view of her deconditioning, her central nervous system tumors and so forth. Neurologically she is quite stable though. She does have a fractured leg . Physicians Progress notes dated 3/12/15 state in part, .(Resident 13) has had a fractured hip, Balance problems- there are concerns about falls in the past . The facility's Fall Assessment dated 3/16/15 at 2:30 PM stated, (Resident 13) was walking in her room she thinks her shoe caught on the floor and she lost her balance, she stated that her walker broke her fall, she landed on her right shoulder, was wearing her hip protectors. Injury - None. The facility's Fall Assessment dated 3/16//15 at 2:30PM, indicated the new intervention Educated to slow down. There is no documentation regarding footwear or that the resident did not ask for assistance as she is to be an assist of one, or what the facility is going to do as the Resident does not seem to ask for assistance prior to attempting to move about her room. The facility's Fall Assessment dated 4/7/15 at 11:00 AM states, (Resident 13) was putting stuff in her drawer and lost her balance falling sideways. States she does not know why she lost her balance. She hit her back and arm on the drawer pull. Injury- Skin tear to her left under forearm and an abrasion/ bruise to her left lower back. The facility's Fall Assessment dated 4/7//15 at 11:00 AM indicated the new intervention Educate (Resident 13) to ask for assistance when putting items away that require a change in position. Physicians Progress notes dated 4/9/15 state in part, . (Resident 13) continues to have some falls . On 5/14/15 at 2:30 PM, Surveyor interviewed Registered Nurse (RN) L who stated, RN N reported that Resident 13 was wearing slippery slippers at the time of the fall on 1/7/15. RN N removed the slippers and put gripper socks on Resident 13. RN N put the slippers in Resident 13's drawer and the family took them home. On 5/14/15 at 10:50 AM, Surveyor interviewed Director of Nursing (DON) B regarding Resident 13's fall on 1/7/15. DON B indicated Resident 13 should have had non- skid footwear on. DON B stated, The risks and benefits should have been discussed and documented if the resident refuses to wear the non-skid footwear. On 5/14/15 at 9:00 AM, Surveyor interviewed Resident 13 regarding her footwear at the time of her first fall. Resident 13 was resting in bed with shoes on at the time. Resident 13 stated, I had on slippers like these. Resident 13 pointed to her feet and Surveyor felt the bottom of her shoes and noted they were made of a hard plastic material. Resident 13 stated, The slippers are at home now that I was wearing when I had fallen. On 5/18/15 at 1:15 PM, Surveyor was given a copy of the 24 hour report record dated 2015 Wednesday January 7 next to Resident 13's name it states in part, .offer gripper socks offered . Example 3 On 5/19/15 at 1:16 pm Surveyors and observed a mechanical lift battery being charged in the restroom on the lower 600 unit. The doors to this unit are kept closed. There are 8 residents on this until. On 5/19/15 at 1:27 pm Surveyor asked CNA (Certified Nursing Assistant) G about the charging of batteries in this restroom. CNA G stated the door to the restroom is usually locked and the batteries are charged behind the closed door. Surveyor asked if the room is ever used while batteries are charging. CNA G stated the unit is small enough that if a residents needs to use the toilet, they are assisted to their room, but stated the room is used if needed in a hurry. Surveyor asked CNA G if, when the room needs to be used while a battery is being charged, what is done. CNA G stated: Well, it's a wall mount, but we could just pull it (the battery) out (of the charger). As CNA G said this she pulled the battery out of the wall mounted charge. Surveyor asked CNA G if that is what is done (removing the battery from the charger while a resident uses the restroom.) CNA G stated no, that is not usually what is done (removing the battery from the charger). On 5/19/15 at 1:40 pm Surveyor spoke with DON (Director of Nursing) B regarding the charging of batteries in the lower 600 unit during daytime hours. DON B stated she would look into this and provide education.

Based on record review and interview the facility did not ensure all alleged violations involving mistreatment, neglect, or abuse including injuries of unknown source and resident to resident incidents are reported immediately to the administrator of the facility and to other officials in accordance with state law and the facility did not have evidence that all alleged violation were thoroughly investigated to prevent further potential abuse while the investigation was in progress. The results of all investigations must be reported to the administrator immediately and to other officials within 5 working days of the incident. This was not done for 2 of 2 (Residents 1 and 2) resident investigations reviewed. Resident 1 was found being inappropriately touched by an unfamiliar facility visitor. Resident 1 was alone with the unknown visitor in her room, behind a closed curtain at the time of the incident. This incident met the definition of a sexual abuse. The facility did not immediately stop the incident, report the incident to facility administration, local law enforcement, and the state agency or thoroughly investigate the incident to prevent further potential abuse. Resident 3 was noted to have his hands under Resident 2's dress. The facility did not complete a thorough investigation. The facility did not interview other residents in attempt to identify the scope of the problem. This is evidenced by the following: Example 1 Resident 1 has been a resident at the facility since 1/22/10. Resident 1's [DIAGNOSES REDACTED]. Resident 1 has an Activated HealthCare Power of attorney. Resident 1's Annual MDS (Minimum Data Set) with completion date of 11/13/13, Section B: Hearing, Speech, Vision indicates that Resident 1's, has no hearing impairments, speech is clear, is able to understand others and make self understood. Resident 1 sees adequately with glasses. Section C: Cognitive Pattern indicates that Resident 1's BIMS (Brief Interview for Mental Status) scored a 3, meaning that Resident 1 has severe cognitive impairment. Section E, Behavior indicates that Resident 1 has no [MEDICAL CONDITION] or overall presence of behavioral symptoms. Review of Resident 1's CAA (Care Area Assessment Summary) Results, with a completion date of 11/13/13, indicates that Resident 1 triggered the care area of Cognitive Loss/Dementia. The CAA summary states, "Cognition triggered due to short and long term memory impairment related to dx.(Diagnosis) of Alzheimer's Dementia. Resident 1 scored 03 of 15 on her annual cognitive assessment. Resident 1 is oriented to person. She continues to make most of needs known by initiation and or especially when questioned by staff. Resident 1 is a very pleasant lady who enjoys socializing with peers and attending activities of interest; staff provides reminders/cues as needed of location of activities. Resident 1 ambulates with her walker; she needs reminders/cues to use her walker. Resident 1 has an activated POAHC, her husband. Cognition addressed on care plan." Resident 1's Quarterly MDS with completion date of 5/12/14, Section B: Hearing, Speech, Vision indicates that Resident 1's, has no hearing impairments, speech is clear, is usually able to understand others and usually able to make self understood. Resident 1 sees adequately with glasses. Section C: Cognitive Pattern indicates that Resident 1's BIMS (Brief Interview for Mental Status) scored a 3, meaning that Resident 1 has severe cognitive impairment. Section C1300 indicates that Resident 1 behavior of inattention and disorganized thinking now fluctuates. Section E, Behavior indicates that Resident 1has no [MEDICAL CONDITION], and behavior of rejection of cares is present 1-3 days. The following information is from documents related to an allegation of abuse regarding Resident 1. An Accident/Incident Report-Resident Form dated 6/8/14 at 15:15 states, Describe Incident: Visitor L asked staff member (CNA K) to take Resident 1 to Resident 1's room. When staff (CNA F) went to check on Resident 1, CNA F noted Visitor L placing Resident 1's hand in Visitor L's groin. Staff (CNA F) summoned nurse (RN J) who upon entering Resident 1's room, noted Visitor L adjusting zipper on his trousers. Resident 1 was immediately removed from area, staff stayed with Visitor L until Visitor L was no longer in building. Indicate location of injury on diagram- the box other is checked and "Inappropriate Sexual Contact" is written in the report. Under list intervention to prevent further incident it states, "Only Immediate family to visit with resident in her room." RN J also documented on the back of the report the following, Spoke with Resident 1 following incident, no signs of being upset, no recall of incident or even having a visitor in the afternoon. A written statement from CNA F dated 6/8/14, no time, states the following, "I walked into (Resident 1's) room, there sat a guy (Visitor L) on her chair next to (Resident 1's) chair. The guy (Visitor L) was taking (Resident 1's) hand and putting it in his pants. I told the nurse right away." A written statement from CNA K dated 6/8/14, no time, states the following, "I was taking a resident into the 3/4 day room and an older guy (Visitor L) approached me and said that that lady needed help to the bathroom and pointed to (Resident 1). I walked over to (Resident 1) and had her stand up and I walked (Resident 1) to her room. While we were walking to (Resident 1's) room the guy (Visitor L) followed us. I sat (Resident 1) in her recliner and walked out, but the guy (Visitor L) sat in a chair next to (Resident 1). (CNA F) went to pull the curtain back so we could see what was going on. (CNA F) stated that (CNA F) saw the guy (Visitor L) put (Resident 1's) hand between (Visitor L's) legs. After that (RN J) walked in and told the guy (Visitor L) he needed to leave. The guy (Visitor L) left the room but continued to go into other residents rooms. He (Visitor L) was watched closely until he (Visitor L) left." Review of timeline prepared by RN J attached to Accident/Incident Report dated 6/8/14 for Resident 1 states the following: 2:15 Received report, 3:12 Spoke with CNA's on 400 wing, Reported Visitor L in Resident 1's room, 3:14 CNA F in Resident 1's room to pull back curtain, observed incident, 3:15 RN F went into Resident 1's room observed gentleman pulling up zipper (Visitor L) told him to leave Resident 1, RN J followed visitor, 3:16 Resident 1 to 300/400 day room, CNA escorted to day room sat Resident 1 on sofa, 3:17 Visitor L in RN J's direct line of site, 3:20 Visitor L in RN J's direct line of site, 3:30 Visitor L sitting in day room, no residents present, 3:40 spoke with 300 staff instructed to continue to observe Visitor L staff to update RN J if Visitor L leaves day room, 3:45 Spoke with Resident 1- no recall of incident did not appear upset- stayed with Resident 1, 4:05 Visitor L to dayroom, got glass of water, 4:06 Visitor L left building- needed assistance with door codes- observed by RN J. Talked with SW (Social Worker) I in house management, staff updated on incident, 4:30 Resident 1 supper- usual behavior, 6:10 CNA statements to prepare incident report, 6:50 Spoke with SW I clarified need to complete incident report. 6:55-8:30 other Residents assessments, spoke with SW I may need to contact law enforcement, 7:45 called DON B, 7:47 Called NHA A, 7:55 Called Sheriff, 9:10 Submitted Report, 10:00 Spoke with Deputy. On 6/17/14 at 12:18 PM, Surveyor spoke with LPN (Licensed Practical Nurse) E regarding the incident between Visitor L and Resident 1 that happened on 6/8/14. Surveyor asked LPN E if LPN E was familiar with Visitor L, LPN E stated that LPN E is new to the area. LPN E stated that no report was given to LPN E regarding Visitor L. LPN E stated that around 3:30 PM on 6/8/14 RN J stated that RN J was going to have to hang out and watch a creepy man. LPN E stated that Resident 1 seemed to be in usual behavior/smiling. On 6/17/14 at 12:40 PM, Surveyor spoke with CNA F regarding the incident between Visitor L and Resident 1 on 6/8/14. CNA F stated, When we got walk through report from day CNA G, CNA G told us that this guy was wanting Resident 1 to go to her room with him and CNA G would not do that. CNA K who was working on another wing and did not receive the report about the guy, came through the day room and the guy told CNA K that Resident 1 wanted to get to her room, so CNA K took Resident 1 to her room. CNA F and RN J were standing by Resident 1's room when CNA K came out into the hall. CNA F could see the guy (Visitor L) scooting his chair closer and closer to Resident 1's chair. CNA F stated that RN J did not seem worried about what was going on and that CNA F had to tell RN J 3 times before RN J told CNA F to go into Resident 1's room and pull the curtain open. CNA F stated upon entering Resident 1's room CNA F observed that Visitor L had Resident 1's hand down Visitor L's pants. CNA F stated that CNA F exited the room. Surveyor asked CNA F if CNA F told Visitor L to stop, CNA F stated, "No, (RN J) was right there, I went and got her." CNA J then stated that RN J went into Resident 1's room, and saw Visitor L zipping up his pants and RN J politely asked Visitor L to leave. CNA F went on to say, "I thought it was funny no one asked (Visitor L) to leave the building, just to leave the room." Surveyor then asked CNA F if CNA F should have asked Visitor L to stop upon initial observation of the incident, CNA F stated, "Yes I probably should have, but the nurse was right outside the door. If it wouldn't have been for me, (RN J) probably would not have done anything about it. In my training we are to tell the DON and NHA right away." On 6/17/14 at 12:55 pm, Surveyor interviewed CNA G regarding the 6/8/14 incident between Visitor L and Resident 1. CNA G stated, "At approximately 12:45 PM on 6/8/14 after lunch I saw (Resident 1) walking down the hall with an unknown male visitor (Visitor L), I approached (Resident 1) and took to her room to use the restroom. One of my co-workers said there was something odd about (Visitor L); I had never seen (Visitor L) before. When we were done in (Resident 1's) room, it was decided to have (Resident 1) sit in the 300/400 hall day room where (Resident 1) could be better observed by the nurses. (Resident 1) was ambulated to the day room and (Visitor L) followed (Resident 1) into the day room." CNA G then stated, "I thought this was odd, (Visitor L) asked me 3 times to take (Resident 1) back to (Resident 1's) room so they could visit." CNA G then stated that LPN H stated to CNA G, "Oh my god, he has touched her leg 2 times." CNA G then stated to LPN H, "You seen it, you go talk to him." CNA G stated that CNA G approached Visitor L and asked Visitor L how he knew Resident 1. CNA G stated that Visitor L was vague in his reply, stating that Visitor L had known Resident 1 for a long time, and that Visitor L asked CNA G for a fourth time to take Resident 1 back to Resident 1's room. CNA G stated that Visitor L said, "If you take (Resident 1) back to her room I will watch her, it is quiet in there and we can talk." CNA G then stated that CNA G reported to RN (Registered Nurse) M that Visitor L had made a fourth request for CNA G to take Resident 1 back to Resident 1's room. CNA G stated that "information was passed onto oncoming CNA's in walk through shift change report." Surveyor asked CNA G if CNA G felt that this incident could have been avoided, CNA G stated, "Yes, I felt it could have been prevented. I told the nurses, and do not feel that the nurses listened when I gave them the information." Surveyor then asked CNA G if anyone from the facility had requested a statement from CNA G regarding the incident, CNA G stated, "No." On 6/17/14 at 1:15 PM, Surveyor interviewed LPN H regarding the incident between Visitor L and Resident 1 that occurred on 6/8/14. LPN H stated, "The 400 wing CNA's mentioned an unfamiliar gentleman (Visitor L) asking to go to (Resident 1's) room several times. We thought it was suspicious. I did not know who the gentleman (Visitor L) was, never had seen him before." Surveyor then asked LPN H if LPN H witnessed Visitor L touch Resident 1's leg, LPN H stated, "I thought I saw (Visitor L) touch (Resident 1's) leg, it was nothing alarming, just a pat on the leg. If I thought it was a problem I would have intervened. We chose to have (Resident 1) and (Visitor L) stay within our view." Surveyor then asked LPN H if LPN H had asked Visitor L what his name is, LPN H stated, "No, the CNA's had already talked with him." On 6/17/14 at 10:30 AM, Surveyor interviewed DON B regarding the allegation of sexual abuse regarding Visitor L and Resident 1. DON B stated, "I was informed of the allegation on 6/8/14 at 7:45 PM, and I called (NHA A) at 7:47 PM. (RN J) stated that (RN J) watched (Visitor L) from the time that (RN J) asked (Visitor L) to leave (Resident 1's) room. I would have expected for (RN J) to have reported this to me sooner and the police too. I did not interview any other residents, or staff. Only interviewed the staff involved with the incident. I cannot tell you why the staff did not ask (Visitor L) to leave, I would have expected that staff would have escorted (Visitor L) immediately from the building, the police also conducted an investigation and (Visitor L) will not be allowed back in the facility until I make contact with the Ombudsman, awaiting the ombudsmans return call. Our policy does not say what staff should do with visitor/resident or family to resident allegations I plan to update that in our abuse policy to include how situations like this should be handled." On 6/9/14 DON B sent out 2 email's to all staff with the following information: 1."If there is any type of suspected abuse to a resident by staff, another resident, family, or anyone else, the NHA and DON need to be notified ASAP (as soon As Possible)! We will give you directions as to how to proceed." 2. "If you come across any situation where a resident may be experiencing any form of abuse you should protect the resident first and then notify the nurse." On 6/12/14, the facility held a face to face inservice with the CNA's. The inservice content was as follows: Reviewed the types of abuse, reviewed what to do in the event of potential abuse, and reviewed the case scenario on visitor to resident contact. The NHA was not immediately notified, and the person accused of abuse was not immediately removed from resident areas to protect other residents and Resident 1 from further abuse. Day staff was concerned that a visitor wanted Resident 1 placed in her room and the staff did not forward this information to the oncoming shift to prevent this situation from occurring. Cross reference F223 and F226 Example 2 The following example is cited at a "D" level. According to "Client [DIAGNOSES REDACTED]. Resident 3's Plan of Care dated 4/5/13 states, "Transfers & ambulates independently with FWW (front wheeled walker)." According to "Client [DIAGNOSES REDACTED]. The facility completed "Misconduct Incident Report" dated 5/16/14. This document states, " ...Briefly describe the incident: Inappropriate resident-to-resident contact. Describe the effect: (Resident 2) had dementia and has no recollection of the incident occurring following the incident. Explain what steps the entity took upon learning of the incident to protect the affected person(s) and others from further potential misconduct: Residents were immediately separated, fifteen-minute checks for (Resident 3) were initiated, and Velcro strap with stop sign attached was placed across (Resident 2's) door to (SIC) (Resident 2) from entering. Both residents counseled after the incident." The facility included additional documentation in their investigation as follows: "Summary; It was reported on May 16, 2014 that there was inappropriate resident-to-resident contact between (Resident 3) and (Resident 2), geriatric resident both of which have a [DIAGNOSES REDACTED]. I went to see whose it was and when I went into the room, I saw (Resident 3) with his hand up her dress. When I told him he couldn't be in there, he said he wasn't bothering anyone he was just talking to her. I told him it was inappropriate and he walked out mumbling something. (Certified Nursing Assistant (CNA) D). The facility did not ask additional residents who reside near Resident 3 to determine the scope of the problem. On 6/17/14 at 1:20 PM, Surveyor spoke with Administrative Assistant (AA) C, who is responsible for the facility's abuse investigations. Surveyor asked AA C if she interviewed any other residents regarding the incident. AA C stated that she did not and that she probably should have. Surveyor asked AA C if she had completed other investigations regarding inappropriate sexual contact by (Resident 3). AA C stated that she had not. The facility did not conduct a thorough investigation and did not ensure that other residents did not experience sexual contact by Resident 3.

Based on interview and record review the facility did not ensure that 1 of 8 residents reviewed (Resident 1) was free from sexual abuse. On 6/8/14 Resident 1 experienced inappropriate physical contact with an unknown male visitor. CNA (Certified Nursing Assistant) G expressed concerns to nursing staff and the information was not passed onto all nursing staff of the oncoming shift. CNA F observed the inappropriate contact between Visitor L and Resident 1 and did not immediately tell Visitor L to stop. RN G did not immediately report the incident to the DON (Director of Nursing), NHA (Nursing Home Administrator), or local Law Enforcement, therefore placing every other resident in the facility and Resident 1 at risk for further abuse. Findings as follows: The following information is from documents related to an allegation of abuse regarding Resident 1. An Accident/Incident Report-Resident Form dated 6/8/14 at 15:15 states, Describe Incident: Visitor L asked staff member (CNA K) to take Resident 1 to Resident 1's room. When staff (CNA F) went to check on Resident 1, CNA F noted Visitor L placing Resident 1's hand in Visitor L's groin. Staff (CNA F) summoned nurse (RN J) who upon entering Resident 1's room, noted Visitor L adjusting zipper on his trousers. Resident 1 was immediately removed from area, staff stayed with Visitor L until Visitor L was no longer in building. Indicate location of injury on diagram- the box other is checked and "Inappropriate Sexual Contact" is written in the report. Under list intervention to prevent further incident it states, "Only Immediate family to visit with resident in her room." RN J also documented on the back of the report the following, Spoke with Resident 1 following incident, no signs of being upset, no recall of incident or even having a visitor in the afternoon. A written statement from CNA F dated 6/8/14, no time, states the following, "I walked into (Resident 1's) room, there sat a guy (Visitor L) on her chair next to (Resident 1's) chair. The guy (Visitor L) was taking (Resident 1's) hand and putting it in his pants. I told the nurse right away." A written statement from CNA K dated 6/8/14, no time, states the following, "I was taking a resident into the 3/4 day room and an older guy (Visitor L) approached me and said that that lady needed help to the bathroom and pointed to (Resident 1). I walked over to (Resident 1) and had her stand up and I walked (Resident 1) to her room. While we were walking to (Resident 1's) room the guy (Visitor L) followed us. I sat (Resident 1) in her recliner and walked out, but the guy (Visitor L) sat in a chair next to (Resident 1). (CNA F) went to pull the curtain back so we could see what was going on. (CNA F) stated that (CNA F) saw the guy (Visitor L) put (Resident 1's) hand between (Visitor L's) legs. After that (RN J) walked in and told the guy (Visitor L) he needed to leave. The guy (Visitor L) left the room but continued to go into other residents rooms. He (Visitor L) was watched closely until he (Visitor L) left." Review of timeline prepared by RN J attached to Accident/Incident Report dated 6/8/14 for Resident 1 states the following: 2:15 Received report, 3:12 Spoke with CNA's on 400 wing, Reported Visitor L in Resident 1's room, 3:14 CNA F in Resident 1's room to pull back curtain, observed incident, 3:15 RN F went into Resident 1's room observed gentleman pulling up zipper (Visitor L) told him to leave Resident 1, RN J followed visitor, 3:16 Resident 1 to 300/400 day room, CNA escorted to day room sat Resident 1 on sofa, 3:17 Visitor L in RN J's direct line of site, 3:20 Visitor L in RN J's direct line of site, 3:30 Visitor L sitting in day room, no residents present, 3:40 spoke with 300 staff instructed to continue to observe Visitor L staff to update RN J if Visitor L leaves day room, 3:45 Spoke with Resident 1- no recall of incident did not appear upset- stayed with Resident 1, 4:05 Visitor L to dayroom, got glass of water, 4:06 Visitor L left building- needed assistance with door codes- observed by RN J. Talked with SW (Social Worker) I in house management, staff updated on incident, 4:30 Resident 1 supper- usual behavior, 6:10 CNA statements to prepare incident report, 6:50 Spoke with SW I clarified need to complete incident report. 6:55-8:30 other Residents assessments, spoke with SW I may need to contact law enforcement, 7:45 called DON B, 7:47 Called NHA A, 7:55 Called Sheriff, 9:10 Submitted Report, 10:00 Spoke with Deputy. On 6/17/14 at 12:18 PM, Surveyor spoke with LPN (Licensed Practical Nurse) E regarding the incident between Visitor L and Resident 1 that happened on 6/8/14. Surveyor asked LPN E if LPN E was familiar with Visitor L, LPN E stated that LPN E is new to the area. LPN E stated that no report was given to LPN E regarding Visitor L. LPN E stated that around 3:30 PM on 6/8/14 RN J stated that RN J was going to have to hang out and watch a "creepy man." LPN E stated that Resident 1 seemed to be in usual behavior/smiling. On 6/17/14 at 12:40 PM, Surveyor spoke with CNA F regarding the incident between Visitor L and Resident 1 on 6/8/14. CNA F stated, When we got walk through report from day CNA G, CNA G told us that this guy was wanting Resident 1 to go to her room with him and CNA G would not do that. CNA K who was working on another wing and did not receive the report about the guy, came through the day room and the guy told CNA K that Resident 1 wanted to get to her room, so CNA K took Resident 1 to her room. CNA F and RN J were standing by Resident 1's room when CNA K came out into the hall. CNA F could see the guy (Visitor L) scooting his chair closer and closer to Resident 1's chair. CNA F stated that RN J did not seem worried about what was going on and that CNA F had to tell RN J 3 times before RN J told CNA F to go into Resident 1's room and pull the curtain open. CNA F stated upon entering Resident 1's room CNA F observed that Visitor L had Resident 1's hand down Visitor L's pants. CNA F stated that CNA F exited the room. Surveyor asked CNA F if CNA F told Visitor L to stop, CNA F stated, "No, (RN J) was right there, I went and got her." CNA J then stated that RN J went into Resident 1's room, and saw Visitor L zipping up his pants and RN J politely asked Visitor L to leave. CNA F went on to say, "I thought it was funny no one asked (Visitor L) to leave the building, just to leave the room." Surveyor then asked CNA F if CNA F should have asked Visitor L to stop upon initial observation of the incident, CNA F stated, "Yes I probably should have, but the nurse was right outside the door. If it wouldn't have been for me, (RN J) probably would not have done anything about it. In my training we are to tell the DON and NHA right away." On 6/17/14 at 12:55 pm, Surveyor interviewed CNA G regarding the 6/8/14 incident between Visitor L and Resident 1. CNA G stated, "At approximately 12:45 PM on 6/8/14 after lunch I saw (Resident 1) walking down the hall with an unknown male visitor (Visitor L), I approached (Resident 1) and took to her room to use the restroom. One of my co-workers said there was something odd about (Visitor L); I had never seen (Visitor L) before. When we were done in (Resident 1's) room, it was decided to have (Resident 1) sit in the 300/400 hall day room where (Resident 1) could be better observed by the nurses. (Resident 1) was ambulated to the day room and (Visitor L) followed (Resident 1) into the day room." CNA G then stated, "I thought this was odd, (Visitor L) asked me 3 times to take (Resident 1) back to (Resident 1's) room so they could visit." CNA G then stated that LPN H stated to CNA G, "Oh my god, he has touched her leg 2 times." CNA G then stated to LPN H, "You seen it, you go talk to him." CNA G stated that CNA G approached Visitor L and asked Visitor L how he knew Resident 1. CNA G stated that Visitor L was vague in his reply, stating that Visitor L had known Resident 1 for a long time, and that Visitor L asked CNA G for a fourth time to take Resident 1 back to Resident 1's room. CNA G stated that Visitor L said, "If you take (Resident 1) back to her room I will watch her, it is quiet in there and we can talk." CNA G then stated that CNA G reported to RN (Registered Nurse) M that Visitor L had made a fourth request for CNA G to take Resident 1 back to Resident 1's room. CNA G stated that "information was passed onto oncoming CNA's in walk through shift change report." Surveyor asked CNA G if CNA G felt that this incident could have been avoided, CNA G stated, "Yes, I felt it could have been prevented. I told the nurses, and do not feel that the nurses listened when I gave them the information." Surveyor then asked CNA G if anyone from the facility had requested a statement from CNA G regarding the incident, CNA G stated, "No." On 6/17/14 at 1:15 PM, Surveyor interviewed LPN H regarding the incident between Visitor L and Resident 1 that occurred on 6/8/14. LPN H stated, "The 400 wing CNA's mentioned an unfamiliar gentleman (Visitor L) asking to go to (Resident 1's) room several times. We thought it was suspicious. I did not know who the gentleman (Visitor L) was, never had seen him before." Surveyor then asked LPN H if LPN H witnessed Visitor L touch Resident 1's leg, LPN H stated, "I thought I saw (Visitor L) touch (Resident 1's) leg, it was nothing alarming, just a pat on the leg. If I thought it was a problem I would have intervened. We chose to have (Resident 1) and (Visitor L) stay within our view." Surveyor then asked LPN H if LPN H had asked Visitor L what his name is, LPN H stated, "No, the CNA's had already talked with him." On 6/17/14 at 10:30 AM, Surveyor interviewed DON B regarding the allegation of sexual abuse regarding Visitor L and Resident 1. DON B stated, "I was informed of the allegation on 6/8/14 at 7:45 PM, and I called (NHA A) at 7:47 PM. (RN J) stated that (RN J) watched (Visitor L) from the time that (RN J) asked (Visitor L) to leave (Resident 1's) room. I would have expected for (RN J) to have reported this to me sooner and the police too. I did not interview any other residents, or staff. Only interviewed the staff involved with the incident. I cannot tell you why the staff did not ask (Visitor L) to leave, I would have expected that staff would have escorted (Visitor L) immediately from the building, the police also conducted an investigation and (Visitor L) will not be allowed back in the facility until I make contact with the Ombudsman, awaiting the ombudsmans return call. Our policy does not say what staff should do with visitor/resident or family to resident allegations I plan to update that in our abuse policy to include how situations like this should be handled." On 6/9/14 DON B sent out 2 email's to all staff with the following information: 1."If there is any type of suspected abuse to a resident by staff, another resident, family, or anyone else, the NHA and DON need to be notified ASAP (as soon As Possible)! We will give you directions as to how to proceed." 2. "If you come across any situation where a resident may be experiencing any form of abuse you should protect the resident first and then notify the nurse." On 6/12/14, the facility held a face to face inservice with the CNA's. The inservice content was as follows: Reviewed the types of abuse, reviewed what to do in the event of potential abuse, and reviewed the case scenario on visitor to resident contact. The NHA was not immediately notified, and the person accused of abuse was not immediately removed from resident areas to protect other residents and Resident 1 from further abuse. As Resident 1 is cognitively confused and unable to express concern the reasonable person standard is instituted here, a woman who requires total care would be harmed if taken to a room and placed behind a curtain with a "creepy man" and he placed her hand down his pants would feel harmed. Cross reference F225 and F226

Based on resident and staff interview, and record review the facility did not implement it's written policy and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property for 1 resident out of 8 reviewed (Resident 1). Resident 1 was found being inappropriately touched by an unfamiliar facility visitor. Resident 1 was alone with the unknown visitor in her room, behind a closed curtain at the time of the incident. This incident met the definition of sexual abuse. The facility did not immediately stop the incident, report the incident to facility administration, local law enforcement, and the state agency or thoroughly investigate the incident to prevent further potential abuse. This is evidenced by the following: The facility's Policy Titled, "Investigating Allegations of Sexual Abuse" policy dated 5/12/14 states the following, "All reported incidents of sexual abuse are promptly and thoroughly investigated. 1. Sexual abuse means acts of sexual nature committed for the gratification of the abuser and in the presence of the resident without the person's informed consent. Sexual abuse includes, but is not limited to; fondling, exposure of the residents sexual organs, rape, engagement in sexual acts without the resident's informed consent, sexual harassment, etc. 2. When conducting an investigation of sexual abuse implement the following protocol: A. If the allegation of sexual abuse does not involve rape, conduct the investigation in accordance with the established policy.(See policies entitled, "Abuse Investigation Protocol" and "Guidelines for Investigating Allegations of Abuse") The facility Policy Titled, "Guidelines for Investigating Allegations of Abuse dated 5/12/14 states the following,"1. First Response *Protect the Resident* 2. Gather all the available facts. 3. Determine what immediate action is necessary to preserve the safety of the client. 4. A Nurse must check the client for possible injuries. 5. Immediately notify the administrator that an allegation of abuse has occurred and an investigation is being conducted. 6. If serious injury or a criminal act is believed to have occurred to a client, the administrator or designee shall notify law enforcement officials. 10. As soon as possible, but not to exceed 24 hours after discovery, all incidents or allegations of Abuse, Neglect, Mistreatment, Misappropriation of Resident Property, or Injury of Unknown Source must be reported to the Division of Quality Assurance via the online reporting system. 11. Interview the individual making the allegations. 12. Determine who also needs to be interviewed and the questions that need to be asked. *Take into account the clients, the staff, visitors, family members, anyone having knowledge of the incident. 13. Interview each witness. The facility's Reporting Abuse to State Agencies and Other Entities/Individuals policy dated 5/12/10 states the following. "All alleged/suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies and other entities or individuals as may be required by law. 1. When an alleged or suspected case of mistreatment, neglect, injuries of unknown source, or abuse is reported, the facility administrator or his/her designee will promptly notify the following persons or agencies of such incident (as appropriate): ...c. The Division of Quality Assurance (DQA) through the Online 24 Reporting and Incident form ...3. The administrator, or his/her designee, will provide the appropriate agencies/individuals, per State law, with a written report of the findings of the investigation within 5 working days of the occurrence of the incident. 4. Should the findings reveal abuse did occur, the written report will include the corrective actions taken by the facility to prevent abuse from recurring..." The following information is from documents related to an allegation of abuse regarding Resident 1. An Accident/Incident Report-Resident Form dated 6/8/14 at 15:15 states, Describe Incident: Visitor L asked staff member (CNA K) to take Resident 1 to Resident 1's room. When staff (CNA F) went to check on Resident 1, CNA F noted Visitor L placing Resident 1's hand in Visitor L's groin. Staff (CNA F) summoned nurse (RN J) who upon entering Resident 1's room, noted Visitor L adjusting zipper on his trousers. Resident 1 was immediately removed from area, staff stayed with Visitor L until Visitor L was no longer in building. Indicate location of injury on diagram- the box other is checked and "Inappropriate Sexual Contact" is written in the report. Under list intervention to prevent further incident it states, "Only Immediate family to visit with resident in her room." RN J also documented on the back of the report the following, Spoke with Resident 1 following incident, no signs of being upset, no recall of incident or even having a visitor in the afternoon. A written statement from CNA F dated 6/8/14, no time, states the following, "I walked into (Resident 1's) room, there sat a guy (Visitor L) on her chair next to (Resident 1's) chair. The guy (Visitor L) was taking (Resident 1's) hand and putting it in his pants. I told the nurse right away." A written statement from CNA K dated 6/8/14, no time, states the following, "I was taking a resident into the 3/4 day room and an older guy (Visitor L) approached me and said that that lady needed help to the bathroom and pointed to (Resident 1). I walked over to (Resident 1) and had her stand up and I walked (Resident 1) to her room. While we were walking to (Resident 1's) room the guy (Visitor L) followed us. I sat (Resident 1) in her recliner and walked out, but the guy (Visitor L) sat in a chair next to (Resident 1). (CNA F) went to pull the curtain back so we could see what was going on. (CNA F) stated that (CNA F) saw the guy (Visitor L) put (Resident 1's) hand between (Visitor L's) legs. After that (RN J) walked in and told the guy (Visitor L) he needed to leave. The guy (Visitor L) left the room but continued to go into other residents rooms. He (Visitor L) was watched closely until he (Visitor L) left." Review of timeline prepared by RN J attached to Accident/Incident Report dated 6/8/14 for Resident 1 states the following: 2:15 Received report, 3:12 Spoke with CNA's on 400 wing, Reported Visitor L in Resident 1's room, 3:14 CNA F in Resident 1's room to pull back curtain, observed incident, 3:15 RN F went into Resident 1's room observed gentleman pulling up zipper (Visitor L) told him to leave Resident 1, RN J followed visitor, 3:16 Resident 1 to 300/400 day room, CNA escorted to day room sat Resident 1 on sofa, 3:17 Visitor L in RN J's direct line of site, 3:20 Visitor L in RN J's direct line of site, 3:30 Visitor L sitting in day room, no residents present, 3:40 spoke with 300 staff instructed to continue to observe Visitor L staff to update RN J if Visitor L leaves day room, 3:45 Spoke with Resident 1- no recall of incident did not appear upset- stayed with Resident 1, 4:05 Visitor L to dayroom, got glass of water, 4:06 Visitor L left building- needed assistance with door codes- observed by RN J. Talked with SW (Social Worker) I in house management, staff updated on incident, 4:30 Resident 1 supper- usual behavior, 6:10 CNA statements to prepare incident report, 6:50 Spoke with SW I clarified need to complete incident report. 6:55-8:30 other Residents assessments, spoke with SW I may need to contact law enforcement, 7:45 called DON B, 7:47 Called NHA A, 7:55 Called Sheriff, 9:10 Submitted Report, 10:00 Spoke with Deputy. On 6/17/14 at 12:18 PM, Surveyor spoke with LPN (Licensed Practical Nurse) E regarding the incident between Visitor L and Resident 1 that happened on 6/8/14. Surveyor asked LPN E if LPN E was familiar with Visitor L, LPN E stated that LPN E is new to the area. LPN E stated that no report was given to LPN E regarding Visitor L. LPN E stated that around 3:30 PM on 6/8/14 RN J stated that RN J was going to have to hang out and watch a creepy man. LPN E stated that Resident 1 seemed to be in usual behavior/smiling. On 6/17/14 at 12:40 PM, Surveyor spoke with CNA F regarding the incident between Visitor L and Resident 1 on 6/8/14. CNA F stated, When we got walk through report from day CNA G, CNA G told us that this guy was wanting Resident 1 to go to her room with him and CNA G would not do that. CNA K who was working on another wing and did not receive the report about the guy, came through the day room and the guy told CNA K that Resident 1 wanted to get to her room, so CNA K took Resident 1 to her room. CNA F and RN J were standing by Resident 1's room when CNA K came out into the hall. CNA F could see the guy (Visitor L) scooting his chair closer and closer to Resident 1's chair. CNA F stated that RN J did not seem worried about what was going on and that CNA F had to tell RN J 3 times before RN J told CNA F to go into Resident 1's room and pull the curtain open. CNA F stated upon entering Resident 1's room CNA F observed that Visitor L had Resident 1's hand down Visitor L's pants. CNA F stated that CNA F exited the room. Surveyor asked CNA F if CNA F told Visitor L to stop, CNA F stated, "No, (RN J) was right there, I went and got her." CNA J then stated that RN J went into Resident 1's room, and saw Visitor L zipping up his pants and RN J politely asked Visitor L to leave. CNA F went on to say, "I thought it was funny no one asked (Visitor L) to leave the building, just to leave the room." Surveyor then asked CNA F if CNA F should have asked Visitor L to stop upon initial observation of the incident, CNA F stated, "Yes I probably should have, but the nurse was right outside the door. If it wouldn't have been for me, (RN J) probably would not have done anything about it. In my training we are to tell the DON and NHA right away." On 6/17/14 at 12:55 pm, Surveyor interviewed CNA G regarding the 6/8/14 incident between Visitor L and Resident 1. CNA G stated, "At approximately 12:45 PM on 6/8/14 after lunch I saw (Resident 1) walking down the hall with an unknown male visitor (Visitor L), I approached (Resident 1) and took to her room to use the restroom. One of my co-workers said there was something odd about (Visitor L); I had never seen (Visitor L) before. When we were done in (Resident 1's) room, it was decided to have (Resident 1) sit in the 300/400 hall day room where (Resident 1) could be better observed by the nurses. (Resident 1) was ambulated to the day room and (Visitor L) followed (Resident 1) into the day room." CNA G then stated, "I thought this was odd, (Visitor L) asked me 3 times to take (Resident 1) back to (Resident 1's) room so they could visit." CNA G then stated that LPN H stated to CNA G, "Oh my god, he has touched her leg 2 times." CNA G then stated to LPN H, "You seen it, you go talk to him." CNA G stated that CNA G approached Visitor L and asked Visitor L how he knew Resident 1. CNA G stated that Visitor L was vague in his reply, stating that Visitor L had known Resident 1 for a long time, and that Visitor L asked CNA G for a fourth time to take Resident 1 back to Resident 1's room. CNA G stated that Visitor L said, "If you take (Resident 1) back to her room I will watch her, it is quiet in there and we can talk." CNA G then stated that CNA G reported to RN (Registered Nurse) M that Visitor L had made a fourth request for CNA G to take Resident 1 back to Resident 1's room. CNA G stated that "information was passed onto oncoming CNA's in walk through shift change report." Surveyor asked CNA G if CNA G felt that this incident could have been avoided, CNA G stated, "Yes, I felt it could have been prevented. I told the nurses, and do not feel that the nurses listened when I gave them the information." Surveyor then asked CNA G if anyone from the facility had requested a statement from CNA G regarding the incident, CNA G stated, "No." On 6/17/14 at 1:15 PM, Surveyor interviewed LPN H regarding the incident between Visitor L and Resident 1 that occurred on 6/8/14. LPN H stated, "The 400 wing CNA's mentioned an unfamiliar gentleman (Visitor L) asking to go to (Resident 1's) room several times. We thought it was suspicious. I did not know who the gentleman (Visitor L) was, never had seen him before." Surveyor then asked LPN H if LPN H witnessed Visitor L touch Resident 1's leg, LPN H stated, "I thought I saw (Visitor L) touch (Resident 1's) leg, it was nothing alarming, just a pat on the leg. If I thought it was a problem I would have intervened. We chose to have (Resident 1) and (Visitor L) stay within our view." Surveyor then asked LPN H if LPN H had asked Visitor L what his name is, LPN H stated, "No, the CNA's had already talked with him." On 6/17/14 at 10:30 AM, Surveyor interviewed DON B regarding the allegation of sexual abuse regarding Visitor L and Resident 1. DON B stated, "I was informed of the allegation on 6/8/14 at 7:45 PM, and I called (NHA A) at 7:47 PM. (RN J) stated that (RN J) watched (Visitor L) from the time that (RN J) asked (Visitor L) to leave (Resident 1's) room. I would have expected for (RN J) to have reported this to me sooner and the police too. I did not interview any other residents, or staff. Only interviewed the staff involved with the incident. I cannot tell you why the staff did not ask (Visitor L) to leave, I would have expected that staff would have escorted (Visitor L) immediately from the building, the police also conducted an investigation and (Visitor L) will not be allowed back in the facility until I make contact with the Ombudsman, awaiting the ombudsmans return call. Our policy does not say what staff should do with visitor/resident or family to resident allegations I plan to update that in our abuse policy to include how situations like this should be handled." On 6/9/14 DON B sent out 2 email's to all staff with the following information: 1."If there is any type of suspected abuse to a resident by staff, another resident, family, or anyone else, the NHA and DON need to be notified ASAP (as soon As Possible)! We will give you directions as to how to proceed." 2. "If you come across any situation where a resident may be experiencing any form of abuse you should protect the resident first and then notify the nurse." On 6/12/14, the facility held a face to face inservice with the CNA's. The inservice content was as follows: Reviewed the types of abuse, reviewed what to do in the event of potential abuse, and reviewed the case scenario on visitor to resident contact. The facility did not follow its policy and procedures when an allegation of abuse made. The NHA was not immediately notified, and the person accused of abuse was not immediately removed from resident areas to protect other residents and Resident 1 from further abuse. Day staff was concerned that a visitor wanted Resident 1 placed in her room and the staff did not forward this information to the oncoming shift to prevent this situation from occurring. Cross reference F223 and F225