Every finding on record at Pigeon Falls HCC

Based on observation, interview and record review, the facility failed to distribute food under sanitary conditions. This had the potential to affect all 35 residents. Observations revealed Food Service Worker (FSW) F serving and handling food on 2 of 3 days of survey with his facial hair cover under the level of his lips, allowing his moustache to remain uncovered.This is evidenced by: The facility policy titled Uniform Dress Code, dated last revised 01/24/25, states in part: Associates working with food .-Wear the approved hair restraint when on duty regardless of length or presence of hair.-Restrain all facial hair with a beard net/restraint.On 07/21/2025 at 12:15 PM, Surveyor observed FSW F in the main dining room kitchen area. FSW was plating food for multiple residents. As FSW F did this, he wore a facial hair cover under the level of his lips which allowed his moustache to remain uncovered. On 07/22/2025 at 9:00 AM, Surveyor observed FSW F go into the dining room kitchen area, retrieve food and take it to the main kitchen. As FSW F did this, he wore a facial hair covering under the level of his lips which allowed his moustache to remain uncovered. On 07/22/25 at 10:37 AM, Surveyor observed FSW F pushing food on a cart. As FSW F did this, he wore a facial hair covering under the level of his lips which allowed his moustache to remain uncovered. On 7/22/2025 at 1:20 PM, Surveyor's interview with FSW H revealed that dietary staff are to wear hair and beard nets while working with food.

Based on observation, interview and record review, the facility did not ensure 1 of 2 residents (R) reviewed for pressure injuries (PI) received care consistent with professional standards of practice to prevent the development of a new pressure injury and promote healing of existing PIs (R8).R8 developed one medical device related PI on 05/20/25. The facility did not have preventive measures to reduce friction related to medical device in place. The facility did not complete weekly comprehensive assessments with staging of the PI upon discovery and did not care plan new interventions timely to promote healing.This is evidenced by:Facility policy titled, Pressure Ulcers, Prevention & Treatment, with a reviewed date of 01/2025, states in part: General Guidelines of Prevention: 3. Pressure can also come from splints, casts, bandages, and wrinkles in the bed linen. If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident/client, and oftentimes become infected.Interventions and Preventative Measures: Residents with Risk Factors: 2. Risk Factor - Friction and Shear: h) monitor the placement of splints and casts to assure they are not placing friction on the resident/client's skin. k) Contractures need to be addressed and managed to prevent skin integrity disruption.Staging Protocols: Stage 1 Pressure Ulcer Interventions/Care Strategies. 1. Pressure: a. Determine cause of pressure and relieve. b. Redistribute pressure. c. Implement pressure-relieving device(s) in accordance with resident/client's assessed needs.Monitoring Pressure Ulcers: A. Daily monitoring. 1. Evaluate ulcer if no dressing is present. 3. Status of area surrounding ulcer that can be observed.B. Weekly or Dressing Change Monitoring: 1. Location and staging of ulcer. 2. Size, depth, and presence, location, and extent of undermining or tunneling. 3. Presence of exudate; if present, type (e.g., purulent, serous), color, odor, approximate amount. 4. Presence of pain. 5. Status of wound bed: color and type of tissue; evidence of healing; necrosis. 6. Description of wound edges and surround tissue (e.g., rolled edges, redness, hardness/induration, maceration). 7. Interventions and care plan approaches.R8 was admitted to the facility on [DATE] with pertinent diagnoses of cerebral infarction due to thrombosis of right middle cerebral artery, acute myocardial infarction, meiplegia and meiparesis following cerebral infarction affecting left non-dominant side, and diabetes mellitus type 2.R8's quarterly Minimum Data Set (MDS) assessment, dated 05/08/25, noted a Brief Interview for Mental Status (BIMS) score of 15/15 indicating cognition is intact. No PI is present and no other wounds present. Range of Motion (ROM) in upper and lower extremities have impairment on one side, dependent assist needed for oral hygiene, toileting hygiene, shower/bathe self, upper/lower dressing, footwear, personal hygiene, roll left to right, sit to lying, chair/bed transfer, and toilet transfer. Physical therapy service start date of 04/28/25 and restorative nursing program 7 days a week for active ROM and passive ROM.R8's care plan, dated 05/13/25, with a target date of 08/14/25, states: I want to keep my left foot free from contracture with intervention of apply contracture boot on left foot when in bed at night and remove when up in wheelchair in the am.R8's care plan, dated 07/31/19, with a target date of 08/14/25, states: Skin risk due to immobility with interventions to monitor skin and update medical provider with any concerns, assist with repositioning.R8's orders:03/02/24 Ensure tubi-grips from below knee to toes are present 24 hours per day (remove right tubi-grip at HS/replace at AM).04/23/25 PT to evaluate and treat. Special Instructions: For left foot brace.5/13/25 Apply contracture boot to left foot when in bed for the night and remove when up for the day.05/19/25 Consult to see Dermatology05/20/25 Apply sureprep to bilateral heels at AM and bedtime for further protection, also apply to blister on L lateral pinkie toe area. Twice A Day06/05/25 Mupirocin ointment: apply to blister left foot, 5th toe, per Dermatology twice a day.R8's most recent Braden assessment, dated 05/07/25, notes a score of 15 indicating R8 is at risk for PI.-Of note: No skin breakdown was documented at this time.R8's physical therapy notes:05/13/25 Mobility recommendations splinting/orthotics: Please put contracture boot on left foot when in bed and remove when up in wheelchair. Special instructions: check for reddened areas upon removal.-Of note: No daily skin assessment of left foot documented to assess for pressure injury related to contracture boot noted.05/15/25 PTA provided R8 with a pommel w/c cushion to trial over the next few days with hopes of increased positioning with sitting upright in w/c and decreased pressure through left foot on foot board/pedals. Please see therapy with any questions or concerns.05/20/25 PTA observed a blister on patient's left foot at 5th metatarsal/phalangeal joint. Patient has been complaining of pain in this foot recently and therapy has been focusing on w/c positioning and use of orthotics. PTA informed nursing of blister; recommended and located podus boot for patient to wear on left foot when up in w/c.05/23/25 Discharge from PT due to highest practical level achieved. Please complete PROM for B ankles for ankle DF/PF, IV/EV and circles for 2 x 15 reps each daily as tolerated to prevent risk of contractures and maintain ROM following discharge from physical therapy. Patient to continue with use of podus boot to L LE when up in w/c and contracture boot when in bed.Of note: No additional assessments or evaluations of contracture boot use completed by physical therapy after 05/23/25.Surveyor reviewed R8's treatment administration record (TAR) and noted between 05/13/25 - 07/23/25 contracture boot was applied at bedtime and removed in morning when out of bed.R8's progress notes:05/18/25 R8 had complaint of left foot pain again this am. No documentation of skin assessment completed.05/20/25 Left distal pink toe has 1 cm x 1 cm fluid filled blister. Posey boot given by therapy to left lower leg.-Of note: First assessment of blister noted. No documentation to assess cause of blister, description of skin surrounding, or notification to provider.No documentation for 6 days on newly discovered blister.05/26/25 Blister remains intact. Continues to utilize posey boot to left foot. Sure prep applied to blister and toes/heels per order.No documentation to measure size of wound, wound bed description, color, or peri wound assessment.Daily documentation of blister intact noted.05/30/25 Blister intact; area is dark in color and appears to be a blood blister. R8 stated that she thinks it was from not using the green cushion boot.No new interventions noted. No documentation to measure size of wound, wound bed description, color, or peri wound assessment. No documentation of notifying provider in change of wound appearance.Daily documentation of blister intact noted.06/04/25 R8 seen by Dermatology for blister. Dermatology notes: Friction blister left 5th toe under surface. Interventions: reduce pressure, mupirocin ointment twice daily.No new interventions implemented to reduce pressure. No assessment completed to determine cause of friction.06/08/25 Area continues to be intact. About the size of a dime. Dark purple in color. Continue mupirocin ointment. Left pinky toe blister measures 2 cm x 1.5 cm.Of note, wound size increasing from last documented measurement on 05/20/25. No new interventions implemented. No documentation of notifying provider of change in wound size.Daily documentation noted no change.06/14/25 Blister to left pinky toe appears to have reabsorbed. Area is intact, no longer appears to be fluid filled and measures 1.5 cm x 1.5 cm. Continues to utilize posey boot to left foot.06/16/25 Provider visit notes blister on left foot. Measures about 1.5 cm round. No new orders.Daily documentation noted no change.06/22/25 Improving: Blister monitoring measures 1.2 cm. No documentation of wound bed description, color, or peri wound assessment.Daily documentation noted no change.07/13/25 Scab to left lateral side of foot is present. Edges are beginning to loosen. Measures 1.4 cm x 1.4 cm. No documentation of notifying provider of wound size increasing since last measurement. No new interventions implemented.No additional wound size documentation noted after this date.On 07/23/25 at 9:36 AM, Surveyor observed R8 lying supine in bed with tubi grip in place on left lower extremity. Surveyor asked Certified Nursing Assistant (CNA) C to remove sock to observe wound. Surveyor observed a darkened, round, raised area on left distal side of foot. Wound bed could not be visualized due to presence of scab/callous present. No drainage present. No redness in peri wound area. No odor. Surveyor asked CNA C to show Surveyor the contracture boot being used at bedtime. CNA C said they stopped using it approximately a month ago and only use the podus boot. Surveyor asked CNA C if the care plan had been updated to reflect this change. CNA C said no, they still document applying the contracture boot since they are applying the podus boot. Surveyor asked R8 if she could recall when the contracture boot was discontinued. R8 stated she could not.On 07/23/25 at 12:45 PM, Surveyor interviewed Director of Nursing (DON) B regarding R8's wound. Surveyor asked DON B if the development of R8's blister was assessed to determine root cause. DON B stated unofficially it was thought to be caused by the use of the contracture boot, but it should have been more thoroughly investigated after the Dermatology visit noted the blister being due to friction. DON B stated verbally communicating with staff to discontinue use of the contracture boot, but unable to locate the documentation to confirm this. DON B was unable to recall when the contracture boot was discontinued. Surveyor asked DON B if she was aware that R8's TAR showed that the contracture boot was being applied daily from 05/13/25 - 07/23/25. DON B stated no, and the order should have been updated when the contracture boot was discontinued. Surveyor asked DON B what the expectation would be for documenting pressure injuries. DON B stated that a daily assessment should be completed with description of wound and weekly assessments completed to document size. DON B stated recognition that R8's PI was not properly assessed and documented.

Based on interview and record review, the facility did not ensure residents (R) with indwelling Foley catheters received care and treatment consistent with professional standards of practice to prevent complications or urinary tract infections from the catheter, for 1 of 1 resident (R7) reviewed with a Foley catheter. R7's Foley catheter was changed on a routine monthly basis without clinical indications and not following professional standards of practice. This is evidenced by:The Centers for Disease Control and Prevention (CDC), Healthcare Infection Control Practices Advisory Committee (HICPAC), Guideline for prevention of catheter-associated urinary tract infections 2009, read in part, E. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. Facility's policy titled, Catheter, Foley Insertion, with the reviewed/revised date of 01/2025, documented in part, The purpose of this procedure is to provide guidelines for the aseptic insertion of a urinary catheter. We do not routinely change catheters. We change them according to physician orders or as needed. R7 was admitted to the facility on [DATE] and current diagnoses included, in part, vascular dementia without behavioral disturbance, congestive heart failure, peripheral vascular disease, retention of urine, benign prostatic hyperplasia, rheumatoid arthritis, and cognitive communication deficit, Physician orders documented on 02/18/25, Change urinary catheter, 16 French,monthlyOnce A Day on Tue Every 4 Weeks. Record review did not identify physician rationale or clinical indications for the need to change the Foley catheter every 4 weeks. On 07/22/25 at 9:34 AM, Surveyor interviewed Director of Nursing (DON) B about the catheter changing policy. DON B stated the policy is to change as needed or as doctors order. Surveyor requested the physician's rationale for the need to change the Foley catheter monthly that follows clinical indications and professional standards of practice. DON B stated R7 has an appointment August 7th with urology, and this was the earliest appointment available. On 07/22/25 at 2:15 PM, DON B stated she does not have a physician rationale for changing R7's Foley catheter every four weeks.

Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 1 resident (R) (R5) observed.Facility did not place enhanced barrier precautions (EBP) for R5 who has an open wound. Facility staff did not wear appropriate Personal Protective Equipment (PPE) when providing wound care for R5. Activity Aide E was observed to perform ineffective hand hygiene. This is evidenced by: Example 1 Facility's policy titled Enhanced Barrier Precautions with reviewed date 01/08/25, documented 2.b. An order for enhanced barrier precautions (in accordance with physician-approved standing orders) will be initiated for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers)…even if the resident is not known to be infected or colonized with a MDRO… R5 was admitted to the facility on [DATE]. R5's current diagnoses include in part, non-pressure chronic ulcer of left lower leg and long term use of anticoagulants. Review of R5's medical record documented on 05/06/25 an open wound on the left lower leg had developed. On 07/21/25 at 10:50 AM, Surveyor observed Registered Nurse (RN) G provide R5 wound care. RN G entered R5's room, sanitized hands and set up supplies. RN G placed a barrier under R5's left leg. RN G sanitized hands, applied gloves and proceeded with wound care. RN G did not wear a gown as part of PPE when providing care to R5. Surveyor observed the front of R5's left lower leg wound to be open with granulation tissue in the wound bed. Surveyor observed the outside of R5's door to have no signage for EBP. On 07/23/25 at 2:00 PM, Surveyor interviewed Director of Nursing (DON) B about EBP for R5's wound care. DON B indicated R5 should be on EBP for his wound. Surveyor reviewed with DON B R5 having no signage stating precautions are in place and observation of RN G not wearing appropriate PPE when completing wound care. Example 2 The facility policy, titled “Policy and Procedure on Hand Hygiene,” dated last reviewed 01/09/24, states in part: i. Dry thoroughly with a disposable paper towel and discard the towel immediately. j. Turn water off with a clean paper towel and discard the towel immediately. On 07/21/2025 at 11:36 AM, Surveyor observed Activity Aide (AA) E in the main dining room. AA E turned on the faucet, washed his hands, and then shut off the water faucet with his bare hands and dried his hands on the sides of his white t shirt. AA E then picked up a covered tray and carried it to the kitchen. On 07/23/2025 at 11:30 AM, Surveyor interviewed Director of Nursing (DON) B, who stated hands should be dried with a paper towel and a clean paper towel should be used to turn off the faucet when washing hands. DON B stated AA E is a younger staff who is great with the residents but just needs education in that area.

Based on interview and record review the facility did not ensure that the resident received treatment and care in accordance with professional standards of practice of comprehensive weekly wound assessments for 1 of 1 resident (R) 5 reviewed. This is evidenced by:R5 was admitted to the facility on [DATE]. R5's current diagnoses include in part, non-pressure chronic ulcer of left lower leg and long term use of anticoagulants.Minimum Data Set (MDS) dated [DATE] a quarterly assessment documented a brief interview for mental status (BIMS) score of 15/15, meaning R5 is cognitively intact. R5 had no impairment to all extremities and is independent with activities of daily living. R5 is not at risk for pressure injuries. On 05/01/25, a Braden assessment for risk of pressure injury was completed with a score of 21. A score of 19 or higher the resident is not at risk for pressure injury. Physician orders document on 07/18/25 Change dressing to L lower leg area. Cleanse wound with cleanser, Apply collagen particles and Hydrogel gauze. Cover with Silicone bordered gauze. Wrap with gauze roll and secure with tape. Tubigrips size G applied to bilateral legs, then 2 ace wraps to be applied to R foot/ankle area then a 3rd up to knee. 2 to be applied on LLE. Special Instructions: .Once A Day, 07:00 - 12:00A comprehensive care plan was not developed to address the open wound. The progress notes documented: On 05/06/25 10:06 PM, Resident approached nurses tonight to provide a dressing to his L lower leg (anterior aspect), which is blistered and weeping from the edema. ABD pad and Kerlix dressing applied to area at this time. Encouraged resident to elevate legs and let staff know when dressing becomes saturated in order to keep area clean and dry. Surveyor noted no comprehensive assessment with size and description of the wound was completed at the time of development and weekly. The first assessment with measurement was completed on 06/06/25, [R5] had dressing changed this AM. LLE had scant drainage noted. Excoriated area measures like 5cm L x 2cm W. Another small area to the lateral side of bigger area. Applied dressings as ordered. Area is not red or warm to touch.On 06/12/25, [R5] was seen by [Name] Wound Specialist at this time. Dressing order changed per [name wound specialist] to super absorbent 4x4 verses ABD pad. Continue with collagen and cover with gauze wrap. Dressing to be changed daily. New dressing applied per order. On 06/13/25, [R5] approached this writer about 1600. Requested that the wraps be removed, dressing also removed. It was saturated at this time. Ace wrap wet. Explained that the moisture does aid in healing also. Excoriation measures 4cm x 3cm on medial side of leg, with smaller 2cm x 2cm area on lateral side of leg. On 06/21/25, Dressing change completed to LLE. Old dressing was sticking some to wound. Needed wound saline spray to help this detach. Area measured and wound assessed. Wound looks more superficial pink/red in color. Drainage had some scant bleeding noted. Medial wound is 5cm L x 3.5cm W at top widest area, at bottom 5cm L x 3cm W. Lateral wound measures 2.5 cm L x 2.3cm W, with 2 small areas to the inner side of medial wound measuring 0.5cm x 0.5cm.On 06/27/25, Measurements noted this AM of LLE wound. Middle one measures 5.6cm x 4.2cm. Smaller L medial area is 0.6cm x 0.8cm, with one to Lateral side measuring 2.8cm x 2.7cm.On 07/05/25, Skin check completed. Skin is intact. Areas to lower left shin measures 3.9 x 3.5 on inner open area and 3cm x 2cm to outer open area. Areas are deeper. Areas are red. No warmth noted. Edema 4+ to both lower extremities. Encouraged to elevate and reduce sodium intake. On 07/07/25, Dressing change completed. R5 complained of some increased pain in wound. Dressing was sticking to wound. Area sprayed with wound cleanser to release the dressing well. Cleansed well, applied new dressing as tolerated. PTA was there completing the massaging of legs. Placed ace wraps on as before. Questioned as the other day had switched to tubigrips. This was due to him going out, so she was going to check on this further. Measurements completed and was 5.5cm x 5.5cm with an area on the lateral side of leg measuring 2.5cm W x 4cm L. Redness is surrounding like 3cm, No real increased warmth noted. Referral sent to the Wound center at Mayo today per R5's request. Did update our wound certified resource person to see about him coming in to see it. Will update provider also. On 07/17/25 [R5] was seen today by [Name] WCC [Name] New orders received and carried:Change dressing to L lower leg area. Cleanse wound with cleanser, Apply collagen particles and Hydrogel gauze. Cover with Silicone bordered gauze. Wrap with gauze roll and secure with tape.Surveyor noted the facility did not have weekly wound assessment completed between 07/07/25 until 07/20/25. On 07/20/25, This RN concurs with skin observation completed. Measurements completed on LLE wound. Medial wound is 3cm x 1.5 at largest area toward bottom, rest is about 1cm wide. Lateral wound measures 3.8cm x 1.3cm. Granulation tissue is present. Less pain with dressing change noted. Edema is going down. No redness noted on leg. Dressing change completed per orders. Tolerated well. Tubigrips and Wraps applied as ordered. On 07/22/25 at 3:34 PM, Surveyor interviewed Director of Nursing (DON) B about weekly wound assessment documentation that comprehensively describes R5's wound. DON B stated R5 did not have weekly comprehensive skin assessments completed. DON B stated weekly comprehensive skin assessments should be completed and have now implemented an order for the nurses to complete weekly comprehensive skin assessments. The facility did not have a policy for wound assessments.

Based on interview and record review, a resident's medication order was not limited to 14 days, and prescribing practitioner did not document the rationale for the extended time use or a specific duration for use for 1 of 2 sampled residents, (R) R21, reviewed for PRN (as needed) psychotropic medications. R21 was prescribed PRN Hydroxyzine for anxiety on 06/06/2025; there was no rationale for extended use written and no specific duration for use.This is evidenced by: R21 was admitted to the facility in 2016 and has diagnoses that include anxiety disorder, vascular dementia, cerebral infarct, depressive disorder, dysphagia and aphasia. R21's physician order dated 06/06/25 states: Hydroxyzine 25mg as needed two times a day for anxiety. Review of R1's medication administration record (MAR) revealed R1 used Hydroxyzine 25mg for anxiety on 06/07/25, 06/09/25, 06/13/25, 06/16/25, 07/01/25, 07/02/25, 07/17/25, and 07/22/25. On 07/21/25-07/23/25, Surveyor reviewed R21's medical record and was unable to locate a rationale for the extended use for the as needed Hydroxyzine and did not locate a specific duration for its use. On 07/23/25 at 11:20 AM, Surveyor requested the facility policy and procedures on as needed psychotropic medication use and further information related to R21's PRN medication use. At 12:35 AM, Director of Nursing (DON) B stated she could not find any further information related to R21's medication use. DON B stated the facility does not have a specific policy and procedure related to this; they refer to the regulations.

Based on observations, interview and policy review, the facility did not prepare and distribute food under sanitary conditions. This has the potential to affect 35 of 35 residents. Staff were observed touching food with contaminated gloves. Scoop left in flour bin. Staff not properly washing hands. Dirty dishes crossing clean dishes. Dietary staff observed to touch food and clean items with contaminated gloves, observed to change gloves without washing hands and observed to place paper directly onto peoples food. This is evidenced by: On 05/08/23 at 12:10 PM, Surveyor was observing lunch being served on Hickory Heights Dining Room. Dietary Staff (DS) E has gloved hands, serving up plates, using same gloved hands to hold baked potato with one gloved hand and used a knife to cut in half then serving up another plate, with same gloved hands, touching resident meal slips with same gloved hands, pulled at mask with gloved hands, grabbed and held a baked potato with left gloved hand and cut with knife, touching resident meal slips with same gloved hands, pulled up mask over her nose with same gloved hands, grabbed another baked potato with tongs then used same gloved left hand to hold baked potato and cut up, same gloved hands, opening steam table lids, same gloved hands grabbed a piece of white bread from bread bag, DS E then removed gloves, and did proper hand washing. On 05/09/23 at about 11:39 AM, Surveyor met with DM D and toured the kitchen. Surveyor observed the flour bin and noted a plastic cup in the flour bin. DM D indicated that the flour was no longer to be used by staff and that they will be getting a new bag of flour. On 05/09/23 at 12:10 PM, Surveyor observed DS F washing their hands with soap and water. DS F turned off the faucet, then grabbed paper towels to dry their hands. On 05/09/23 at 2:56 PM, Surveyor interviewed Dietary Manager (DM) D and told him about the above observations and asked if this was the proper way for glove use and hand washing. DM D indicated I have never seen that, this is not the proper way. The food service policy, entitled Safety and Sanitation Glove Usage, revised on February 2018, reads in part single use gloves shall be used for only one task, then discarded. The food service policy, entitled Safety and Sanitation Hand Washing, revised on September 2013, reads in part use the towel to turn off faucets so you do not re-contaminate your hands. On 05/09/23 at about 2:50 PM, Surveyor went to the dish room with DM D. Surveyor asked DM D what way staff bring dirty dishes to the dish room. DM D indicated they come through the main kitchen. Surveyor asked the DM D if that means the dirty dishes then cross the clean dishes. DM D indicated yes. Surveyor asked why they do not use the door that enters the dish room from the dining room. DM D indicated they were going to start doing that effective immediately. 16692 Observations on 05/10/23 beginning at 8:23 AM revealed that Dietary Staff (DS) C preparing and serving breakfast to all of the facility's residents. DS C was observed to crack raw pasteurized eggs with gloved hands into the frying pan and then threw the shells into garbage, thereby contaminating the gloves. DS C then opened a bag of bread and took out a few slices of bread and set them on the counter, while using contaminated gloves. DS C then took toast out of the toaster with the same gloved hands, put jelly on it, sliced it in half and plated the food. Then DS C put dirty items into the dishwasher then removed his gloves and applied new gloves without washing his hands. DS C then put more dirty items into dishwasher, and started it, thereby contaminating his gloves. Then with the same dirty gloves on he began dating individual cartons of nutritional shakes and placing them into the refrigerator. DS C was observed to microwave an item for staff. DS C then removed the item from the microwave and handed it to staff. Then DS C took toast from the toaster with his contaminated gloved hand and buttered it, cut it and plated the toast. CNA staff were observed to pick up pieces of paper, and take them to the residents' tables and indicate what residents wanted for breakfast on them. Staff then placed the pieces of paper on the kitchen counter so that DS C could plate the residents' food. DS C was observed to plate food and then place the pieces of paper directly on top of the residents' food. These observations ended at 10 AM on 05/10/23. Interview with the NHA A at 1 PM on 05/10/23 revealed the following information. Surveyor relayed the above concerns to the NHA A. NHA A stated that they have done education with DS C previously in relation to when to wash hands and change gloves. NHA A stated that it hasn't seemed to fix the problems.

Based on interview, observation, and record review, the facility did not maintain an infection prevention and control program (IPCP) that included a system for identifying, investigating, and controlling infections and communicable diseases for all residents. Additionally, staff did not adhere to standard precautions to prevent spread of infections. This had the potential to affect all 37 residents. The facility did not implement a plan for identifying and monitoring, that included resident surveillance of fever, respiratory illness, or other signs/symptoms of COVID-19 at least daily and identify residents that required laboratory testing and/or the implementation of appropriate transmission-based precautions. This occurred for 3 of 3 newly admitted residents (R236, R237, and R35). Facility staff were not reporting respiratory symptoms as part of facility screening process and did not complete facility COVID testing when having symptoms. Facility staff continued to work with residents while having respiratory symptoms. Facility staff were wearing a surgical mask that was improperly positioned and would not prevent the spread of infection. Facility staff provided cares for Resident (R) 2 and did not perform hand hygiene with glove change after incontinence cares of stool and continued with wound care and improper hand washing technique. This is evidenced by: Covid 19 Surveillance: R236 was admitted to facility, from home, on 3/31/2022 and was up to date with COVID-19 and Influenza vaccinations. On 4/18/22 at 12:09 PM, Surveyor interviewed R236. R236 complained of having a cough, hoarse throat, feeling achy all over, no appetite, and fatigue. R236 thought the symptoms had been occurring for a few weeks and was wondering why no one had done anything more for R236. R236 stated they offer Tylenol, and that helps a little, but R236 is still not feeling well. Surveyor asked if R236 had been tested for COVID or Influenza; R236 stated, I don't think so. Review of Nurse's Notes in R236's medical record, indicated on 4/15/2022, R236 complained of allergy symptoms. At that time, the nurse contacted the provider, and an order was received for Loratadine (an over-the-counter allergy medication). The following day, on 4/16/2022, R236 requested PRN (as needed) Tylenol, stating, 'it is all in my head' from having a cold. Resident's voice is hoarse and stated that he is coughing and is productive with a small amount of clear sputum. On 4/19/22 at 2:35 PM, Surveyor interviewed Director of Nursing (DON) B. Surveyor asked what the process was when a resident displayed respiratory or cold/flu-like symptoms. DON-B stated the first step would be to perform a rapid (Binax) test to rule out COVID-19. Results would then be relayed to Physician and would follow through with any further orders, for example an influenza test. Surveyor asked specifically about R236. DON-B stated she would look into it further and get more information to share with Surveyor; DON-B stated she did remember the doctor recently ordered an allergy medication for R236. On 4/19/22 at 2:53 PM DON-B asked to speak to Surveyor. DON-B stated, I told you what we would normally do, but in this case, DON-B could not find that R236 had been tested for COVID-19 since arriving to facility or when R236 displayed respiratory symptoms. DON-B stated both R236 and his roommate (R237) were tested today, and both were negative. DON-B was not sure how this got missed or what happened but thought perhaps the Infection Preventionist (IP) would have more information related to the situation but would not be in until the next day. ON 4/20/22 at 9:50 AM, Surveyor interviewed Registered Nurse (RN) H. Surveyor asked about criteria for testing residents for COVID-19 and for implementing transmission-based precautions (TBP). RN H stated placing someone on TBP would be a collaborative decision between nurse, IP, and doctor, and would also depend on the current outbreak status. Resident COVID-19 testing is based on symptoms the resident is having and according to current CDC (Centers for Disease Control) guidance. Surveyor asked how residents were screened for signs and symptoms (s/sx) of COVID-19. RN-H stated all residents were screened twice daily for s/sx. RN-H stated Certified Nursing Assistants obtain vital signs, and there is a prompt on the electronic medical record for nurses to assess for additional s/sx twice a day. On 4/20/22 at 10:04 AM, Surveyor interviewed RN-G, who served as the facility's Infection Preventionist. Surveyor asked about criteria for testing residents for COVID-19 and for implementing TBP. RN-G stated when a resident displays cold or flu-like s/sx, a rapid test is performed to test for COVID-19 and results relayed to doctor right away and any additional testing or orders would be implemented. If there was a delay in test results, the resident would be placed on TBP. Education is provided to remind resident of proper hand hygiene and would need to wear mask when out of room. Surveyor discussed concerns regarding R236. RN-G stated, I missed that. RN-G stated she was the nurse R236 had reported his initial symptoms to, however, R236 kept talking about allergies, so that's why the doctor was updated, and ordered Loratadine. RN-G stated R236 should have received a COVID-19 test when he complained of cold-like symptoms, but it was missed. RN-G stated nursing staff assessed each resident twice a day for s/sx of COVID-19. Surveyor requested to see documentation of COVID-19 screening for R236. On 4/20/22 at 10:54 AM, RN-G brought Surveyor a copy of Nursing Order that read, Daily screen for COVID 19 symptoms. Reviewed and negative for the following: Cough, Shortness of breath or difficulty breathing, Decreased O2 sats, Fever, Chills, Muscle Pain, Sore throat, New loss of taste or smell, if any s/s present, assess and document in NN (nurse notes) .Frequency: Twice a Day. RN-G stated the order was placed in each resident's chart upon admission, however, unfortunately it had not been entered into R236's chart upon admission, so it had not been being done. On 4/20/2022 at 2:26 PM, Surveyor interviewed DON-B. Surveyor asked DON-B to explain process for testing for COVID-19 and ensuring monitoring was implemented for each resident. DON-B stated the facility had an admission checklist, it was discovered that the COVID-19 screening order was not on the checklist, therefore the facility had added it today (04/20/22). DON-B stated most residents admitted from another nursing facility or hospital and would come with information of their last test date. R236 admitted himself to facility directly from home, and DON-B figured that was how his testing upon admission was missed. Surveyor asked about two additional residents who were newly admitted , R237 and R35. DON-B stated, the COVID-19 screening order had not been implemented for R237 or R35, therefore, they had not been screened twice daily for s/sx of COVID-19 since their admitted s. R237 was admitted to facility from home, on 3/31/2022 and was up to date with COVID-19 vaccinations. Record review revealed no indication R237 had complained of s/sx of COVID-19 since admission. R35 was admitted to facility from home, on 3/24/2022 and was up to date with COVID-19 vaccinations. Record review revealed no indication R35 had complained of s/sx of COVID-19 since admission. Masks/Staff Covid Symptoms: On 04/19/22 at 10:12 AM, Surveyor observed Certified Nursing Assistant (CNA) E pushing a resident out of Hickory Heights dining room with CNA E's mask below the nose. On 04/19/22 1:15 p.m., Surveyor observed Certified Nursing Assistant (CNA) E and CNA F transferring R2 from the bed with a mechanical lift to the Broda chair. While in R2's room CNA E's surgical mask was positioned under the nose. When CNA E and CNA F were setting R2 in the mechanical lift sling CNA E was conversing with R2 and CNA E stated she has been fighting a respiratory cold. After CNA E and CNA F transferred R2 to the broda chair CNA E pulled the surgical mask over nose and then it was positioned on the very tip of CNA E's nose. On 04/20/22 at 11:00 a.m., Surveyor interviewed RN G about the observation of improper placing of a surgical mask with CNA E during cares. RN G indicated the staff are educated at the moment of observation of improper use and staff are educated when there is a resident on precautions and when there is new guidance. Surveyor reviewed with DON B the observation of CNA E's mask below the nose during cares with R2. DON B indicated education and audits are being conducted for wearing masks properly. Surveyors reviewed the facility's staff COVID screening and testing for CNA E. The documentation did not identify CNA E was tested or reports of respiratory cold symptoms. On 04/20/22 at 1:19 p.m., Surveyor interviewed DON B about CNA E indicating having been fighting a cold. DON B indicated she had called CNA E asking about symptoms and CNA E indicated that an at home COVID test was taken and was negative and CNA E did not tell anyone at the facility about symptoms. DON B indicated CNA E did not take a COVID test in the facility and DON B was not aware of CNA E illness and CNA E did not mark symptoms on the screening sheets. Wound Care - Hand hygiene: Review of the facility's policy titled, Hand Hygiene, with the revised date of 06/2004, read in part: .4. Employees must wash their hands for at least twenty (20) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: .b. When hands are visibly soiled (hand washing with soap and water); c. Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice); d. Before and after performing any invasive procedure .f. Before and after eating or handling food (hand washing with soap and water); g. Food service personnel must always wash their hands with soap and water when working in the kitchen area; h. Before and after assisting a resident /client with meals; i. Before and after assisting a resident/client with personal care (e.g., oral care, bathing); .o. Before and after assisting a resident with toileting (hand washing with soap and water); .w. After removing gloves .5. In most situations, the preferred method of hand hygiene is with an alcohol-based rub containing 60-95% [MEDICATION(S)] or isopropanol for all the following situations: a. Before and after direct contact with residents; .F. Before moving from a contaminated body site to a clean body site during resident care; .j. After removing gloves R2 has current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/19/22 at 11:05 a.m., Surveyor observed (Register Nurse) RN C and RN D provide wound care for R2. With gloves on, RN C and RN D positioned R2 on left side. RN C removed R2's pad and was soiled with stool. RN C wiped the stool and removed gloves and washed hands appropriately. RN C gathered wipes and a clean pad from the drawer. RN C applied gloves and with the wipes cleansed the additional stool. RN C removed gloves and without washing or sanitizing hands applied clean gloves and removed the old [MEDICATION(S)] dressing. RN C removed gloves and without washing or sanitizing hands applied clean gloves. RN C cleansed the wound with wound wash on a gauze pad and dried the area with a dry gauze. RN C removed gloves and without washing or sanitizing hands applied clean gloves and measured the wounds. RN C removed gloves and without washing or sanitizing hands applied clean gloves. RN C applied skin prep to peri wound and applied a [MEDICATION(S)] dressing to cover the wound. RN C removed gloves and without washing or sanitizing hands applied clean gloves and positioned R2 in bed on the right side with a wedge cushion. RN C removed gloves and without washing or sanitizing hands touched the bed controller and elevated the head of the bed and lowered the bed. RN C washed her hands and turned the faucet off with clean hands and then dried with a paper towel. After completion of assisting with positioning R2, RN D removed gloves and washed her hands and turned the faucet off with clean hands and then dried with a paper towel. Surveyor immediately interviewed RN D, asking about the process for hand hygiene. RN D explained the process appropriately. Surveyor asked RN D if she had just washed her hands appropriately. RN D stated she did not. At 11:20 a.m., Surveyor interviewed RN C asking about the process for hand hygiene. RN C explained the process appropriately. Surveyor asked RN C when changing gloves should hand hygiene be completed. RN C indicated she did not have hand sanitizer in the room and her gloves were not soiled to need to sanitize or wash her hands after removing gloves. Surveyor asked RN C should hand hygiene been completed after the cleansing of stool. RN C stated yes. Surveyor asked if the last handwashing was completed appropriately by turning the water off with clean hands. RN C indicated she thought she turned off the water with a towel and may not have. On 04/20/22 at 11:44 a.m., Surveyor interviewed Director of Nursing (DON) B asking about hand hygiene with glove use after peri care and wound care. DON B indicated RN D did come to her and explain the observation. DON B indicated hand hygiene audits are now put in to place and education to staff.

Based on observation and interview, the staff did not distribute food under sanitary conditions on 2 of 3 days of survey. Staff was observed to handle clean items and serve food with contaminated gloves. The same staff was observed to do dishes and go between clean and dirty items without changing gloves or performing hand antisepsis. Staff was observed to dish up a resident's food with no hair restraint on. Staff was observed to transport food thru the halls of the facility uncovered. Staff was observed to touch ready to eat foods with contaminated gloves on during meal service. This is evidenced by: The facility policy entitled, Safety & Sanitation, date revised September 2013, states in part: The number one cause of cross-contamination by team members is improper hand washing. The facility policy entitled, Hand Hygiene, dated December 2010, states in part: When to wash hands, Before putting on gloves, and then again when changing them, Between loading and emptying dishes from a dish machine. On 04/19/22 beginning at 12:06 PM, Surveyor observed Dietary Staff (DS) K preparing to serve lunch. DS K picked up a dirty/used napkin from the counter and put it in the dirty clothing bin, and then moved 2 dirty cups to a different location on the counter. Then DS K returned to the tray line, grabbed a clean plate with their thumb on the top of the plate surface and plated food. DS K did not change gloves or wash hands when going between touching dirty items and serving food. DS K continued plating food for numerous residents while wearing contaminated gloves. On 04/19/22 at 12:25 PM, Surveyor observed CNA E ask for another bowl of chicken hot dish from CNA L for R2. CNA L opened the cabinet doors took out a bowl and filled it with hot dish, retrieved a plate from the cabinet to place over the bowl to cover it, and handed it to CNA E. As CNA L did this she was not wearing a hair net and had not washed her hands prior to serving the food. On 04/19/22 at 01:12 PM, Surveyor observed DS K washing dishes in the dishwasher. DS K was observed to go back and forth between clean and dirty items without washing hands and changing gloves. One time DS K changed gloves but did not perform hand antisepsis prior to applying clean gloves. DS K was observed to continue to handle dirty items and then clean items multiple times. On 04/20/22 at 09:55 AM, Surveyor interviewed DS I. DS I stated, CNAs are not supposed to be serving food for residents from the tray line. DS I when asked, stated, when serving food staff should wear a hair restraint and should have washed their hands and or wear clean gloves while serving. When asked about the observation of DS K washing dishes, DS I stated DS K should change gloves and wash hands in between dirty and clean. On 04/18/22 at 11:40 am, Surveyor observed dietary supervisor (DS) I bring 18 pieces of chocolate cake from Willow Heights kitchenette to Hickory Heights kitchenette on a cart, all uncovered. On 04/15/22 at 11:45 am, Surveyor observed DS I handing out 10 cloth wrapped silverware holding them up against her shirt. On 04/18/22 at 12:01 PM, DS I was observed with her mask down to lips, she keeps saying, My asthma is really bothering me today. On 04/18/22 at 12:06 PM, DS I was observed by Surveyor washing her hands, putting on gloves, touching cupboard and resident chair, then removing gloves, and putting on a new pair of gloves. DS I kept pulling mask down by lips; with the same gloves on, grabbed toast from the toaster and buttered it, still same gloves on DS I proceeded to dish up other plates, opened the refrigerator with same gloved hands, touched her mask with same gloved hands, buttered bread with same gloved hands, pulled at mask again with gloved hands. At 12:15 PM, mask is now below her nose still while serving food; DS I touched mask with same gloves, then pulled off goggles with same gloves on and continued to dish up food for a resident. On 04/18/22 at 12:21 PM, DS I removed her gloves, no hand washing, put on another pair of gloves, and is serving up some more plates. On 04/18/22 at 12:24 PM, DS I removed her gloves, washed her hands with soap and water, turned off the faucet with her hands and then grabbed paper towels to dry hands. On 04/20/22 at 10:55 am, Surveyor interviewed Registered Nurse (RN) G who is also the facility's Infection Preventionist and asked who does training with the contracted kitchen staff. RN G indicated that she has them in her audits when she does them and she does training on hand washing and proper mask wearing. Surveyor read the above observations to the RN G and asked if there was a problem with the way DS I was using her gloves. RN G indicated, it's a problem - yes. Surveyor then told RN G about the observation of handwashing and asked if that is the way they are taught. RN G indicated that they were taught to turn off the faucet with a paper towel. Surveyor asked RN G when changing gloves what should be done. RN G indicated staff should have used hand sanitizer or washed hands in between uses of gloves. Surveyor then asked RN G if staff were trained to wear their mask below their nose. RN G indicated that staff were trained to wear a mask over their nose with it pinched tight. On 04/20/22 at about 1:20 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked if food should be transported from one kitchenette to the other uncovered. NHA A indicated no, it should be covered. Surveyor then asked NHA A if wrapped silverware should be carried against clothing. NHA A indicated she would expect staff to carry the wrapped silverware on a tray or something, not next to your body.

Based on interview and record review, the facility did not ensure that a care plan was developed that contained measurable objectives, non-pharmacological interventions, and time frames to meet the resident's concerns for for 1 of 12 (R27) sampled residents. The facility did not develop a care plan that describe the resident's mental and psychosocial needs and how the facility will assist in meeting these needs for R27. This is evidenced by: R27 was admitted to the facility on [DATE], and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor conducted a record review for R27. R27's last care conference was held on 03/23/22. There was no care plan in place to watch for side effects of the medications, no behavior care plan for non-pharmaceutical interventions, and nothing in the care plan for dementia care. On 4/19/22 at 2:10 PM, Surveyor interviewed Certified Nursing Assistant (CNA) J and asked how staff would know if a person has dementia or they need assistance with walking and she indicated she would look at the resident's care plan in the computer. On 04/20/22 at 12:45 PM, Surveyor interviewed DON B and asked when should a care plan be put in place for a resident with dementia or on [CONDITION(S)] medications. DON B indicated it should be put in right away. Surveyor told DON B that Surveyor could not find anything in R27's care plan for dementia care or non pharmacological interventions. DON B indicated she would look at it. On 04/20/22 at 1:15 PM DON B indicated it's not in the care plan.

Based on observation, record review and interview, the facility did not honor the resident's right to receive visitors of his or her choosing at the time of his or her choosing, and in a manner that does not impose on the rights of another resident. This practice had the potential to affect 33 of 35 residents. The facility did not expand their visitation guidelines to allow private and uninterrupted visits according to current standards of practice and visitation recommendations outlined in the CMS QSO 20-39NH memo Nursing Home Visitation - COVID 19 dated September 17, 2020. This is evidenced by: CMS QSO-20-39 NH states, .facilities may not restrict visitation without a reasonable clinical or safety cause, consistent with §483.10(f)(4)(v). For example, if a facility has had no COVID-19 cases in the last 14 days and its county positivity rate is low or medium . Residents who are on transmission-based precautions for COVID-19 should only receive visits that are virtual, through windows, or in-person for [MEDICATION NAME] care situations, with adherence to transmission-based precautions. However, this restriction should be lifted once transmission based precautions are no longer required per CDC guidelines . On 02/01/21 at 8:30 a.m., Surveyor conducted an entrance conference with Nursing Home Administrator (NHA) A. During the conference, Surveyor asked NHA A, How are you conducting resident visiting? NHA A stated, We do allow [MEDICATION NAME] visits for end of life we have window visits (temp 21 degrees, snow on ground) .and families can come to the inner vestibule and talk to the resident through the glass but a lot of them (the residents) cannot hear .we are going to start reviewing them (the door visits) to make sure that not just one family is doing it, since we have to be there to watch. Surveyor asked, How have you provided visitation areas for in-person visits? NHA A stated, We have not set up any other place in the building for visits .we are just allowing [MEDICATION NAME] visits and entryway visits. Surveyor asked, How have you changed your policy or practice in order to allow for in person visits, in accordance with current federal guidelines? NHA A stated, We haven't since Covid started, but we are planning on talking about it this week. Surveyor observed the facility entrance, which signage indicates is the only entrance into the facility. The outer door opens onto a small vestibule, which leads to another heavy glass door. The visitor is seated on the outside of the inner door, while the resident is placed on the inside of the heavy glass door. Visitor and resident must talk through the closed door. At 9:30 a.m., NHA A provided Surveyor with a policy, dated 03/20, entitled Isolation, visitation during Under the title of Restriction of Visitation, the document reads .guidance for visitation to prevent the spread of diseases in the community to the facility and from the facility to the community will be implemented .visitors must follow the instructions issued by the charge nurse on duty relative to facility infection control practices and visitation restrictions .the administrator has the right to implement visitor restriction policy. The policy did not include directions for allowing in person visitation, in person visitation screening, who may visit, and how and where the in person visits should be conducted. Another policy, dated 03/20, titled Visitation stated, in part, .pfhcc (Pigeon Falls Health Care Center) recognize the resident's need to maintain contact with the community . Therefore, the resident is permitted to have visitors as he/she permits. Residents' immediate family or other relatives may visit the resident at any time subject to the protection of the rights and safety of other residents and any restrictions imposed by the resident .The facility reserves the right to impose restrictions. On 02/03/21 at 12:00 p.m., Surveyor interviewed NHA A, Director of Nurses (DON) B and Registered Nurse (RN) D. NHA A and DON B stated they are familiar with QSO 20-39-NH. Surveyor asked, Explain how the facility follows the directions in the memo for current instructions? NHA A stated, We have not started the implementations yet. I just wanted to wait a while to be sure it was safe. We were going to start implementing them this week. Surveyor stated, To be safe .? NHA A stated, You know, just to make sure that it was safe to allow in person visitors. NHA A agreed the county positivity rate was 5.9%, indicating medium (yellow) risk. NHA agreed the last day of quarantine for a resident was 01/13/21 and that in person visits should have been initiated on that date. Surveyor reviewed the facility's county positivity dates. The data indicated that beginning on 12/16/20, the facility was at medium (yellow) risk, except for the week of 12/30/20, when the county positivity rate was low (green) risk. The facility was operating in outbreak status until 01/12/21. Visitation should have begun on 01/13/21. On 02/03/21 at 12:15 p.m., Surveyor interviewed Activity Director (AD) C. Surveyor asked, How have you started in person activities according to the current guidelines? AD C stated, We haven't started anything yet. I take my direction from NHA A and I haven't received any instructions to start that yet. We are doing activities and social distancing the residents during the activities .we have not had anyone from the outside come into the facility yet. 1. R3 was admitted on [DATE]. R3's [DIAGNOSES REDACTED]. R3's Brief Interview for Mental Status (BIMS) on 01/21/21, score is 99, indicating severe cognitive impairment. R3 has an activated POA-HC. R3 is non-interviewable. Surveyor reviewed R3's MDS (Minimum Data Set). R3's PHQ-9 score (a tool for measuring depressive symptoms), performed by the facility on 1/21/21 and 10/29/20. Both showed a score of 5-9, indicating mild depression. The resident did not show any behaviors. Surveyor reviewed R3's weights. R3 experienced an 11.3% weight loss over the last quarter. The physician noted on 11/20/20 that Suspect weight loss is due to progressive dementia. A [MEDICATION NAME] (narcotic) patch was added to encourage intake on 12/01/20. On 02/02/21 at 11:00 a.m., Surveyor interviewed Family Member (FM) E. Surveyor asked FM E, How are you able to visit with R3? FM E stated, Well, in the summer we did window visits, then when it got cold they were letting us in the front. Surveyor asked, Has the facility talked to you about in-person visits? FM E stated, Yes, it's the government's fault that we cannot have in-person visits. I think the facility tries but there is nothing that they can do to make the visits more accessible. Surveyor asked, Do you think R3 is able to hear you when you are visiting? FM E stated, I think so . On 02/02/21 at 2:00 p.m., Surveyor observed R3 and FM E during a visit. FM E sat behind the outer entryway door, while R3 sat behind the inner door. FM E had to repeat statements to FME several times to be heard. At one point, the visit was interrupted by another resident entering the facility. FM E had to rise from the chair and push the chair back to allow the resident to enter. Then, the facility staff had to move R3 back into place after the resident entered the inner door. Next FM E and R3 took their positions on either side of the door. R3 said to FM E, Oh! It's you! FM E stated, Yes, it's me. The resident's side of the entryway door was connected to the lobby/common area. The conversation was easily overheard by staff and other residents in the areas. Anyone entering the building had to interrupt the visit that was occurring between the two entry doors. 2. R32 was admitted to the facility on [DATE]. R32's [DIAGNOSES REDACTED]. BIMS score was 02, indicating severe cognitive impairment. On 02/02/21 at 9:35 a.m., Surveyor interviewed Family Member (FM) F. FM F stated, My mother experienced social isolation when she was first married and was depressed just like now. They don't allow us to come in. They only have window visits and how are we supposed to do that in the winter? We can go in the entryway one at a time and that's no good either . You can't hear or visit well .you have to yell .They really, really, really need to update their visitation guidelines, it is been the same since March 2020. Surveyor asked FM F, Has the facility notified you of any change in visitation since then? FM F stated, No, they have been keeping it the same. I have nothing positive to say about their visitation. My mom loves to sing, music, cards, church .you have to be there .It is not the same hearing the music or watching church on television, you know that You have to be there, that is part of it She dearly misses her family members, children, sister, sister-in-law, and her family loves her, and feel that we haven't really visited with her because of these restrictions. Surveyor asked, Do you think your mom is depressed now in relation to visits? FM F, It is hard to tell, but yes since she has it in her background. On 02/02/21 at 10:30 a.m., Surveyor reviewed R32's behavior monitoring. The behavior graph showed an increase in loss of interest and crying for the months of September October and November of 2020, with a steady trend after that. Surveyor reviewed R32's progress notes. On 09/10/20, the therapy staff reported that R32 made statements such as I can't and It won't matter anyway to the therapists during therapy. This was reported to Social Worker (SW) H who interviewed R32. SW H performed an assessment to determine R32's level of depression. R32's PHQ-9 score (A method used to measure depression) was 15 indicating moderate/severe depression. This was a 5 point increase since 07/23/20, when R32's PHQ-9 score was 10, indicating moderate depression. R32 told SW H that she did not know what was causing this, or what would make is better. R32 told SW H that she had been feeling down and depressed for quite a while. Progress notes showed that R32 would display intermittent episodes of crying. When staff would ask her what was wrong, R32 would state, I miss my kids. When this happened, facility staff would call one of R32's family members and they would talk on the phone. After the phone calls, the resident's mood would improve briefly. The facility began behavior monitoring and updated the physician. On 09/26/20, the physician ordered Sertaline (an antidepressant) 25 milligrams daily. On 10/06/20, the POA-HC called and wanted the Sertaline discontinued, and planned to do more window visits. The facility did not initiate [MEDICATION NAME] visits. On 02/03/21 at 12:00 p.m., Surveyor interviewed NHA A, DON B and RN D. NHA A told Surveyor the facility had not added [MEDICATION NAME] visits to R32's plan of care, and that visits remained entryway or window visits. No [MEDICATION NAME] care visits were added during the time period that R32 showed an increase in crying and loss of interest. The current care plan, although including interventions for depression, did not include a plan to increase R32's visitations according to the current guidelines. RN D, who is responsible for the development of R32's plan of care, told Surveyor, Resident care plans for visitation have not been initiated because things are changing .we were going to talk about that this week. 3. R26 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. R26's BIMS score on 01/07/21 was 05, indicating moderate cognitive impairment. On 02/01/21 at 12:33 p.m., Surveyor observed R26 during a meal. R26 was easily distracted, requiring staff to remind her to continue eating. Resident would refuse to eat if staff attempted to assist her with eating. On 02/01/21, Surveyor reviewed R26's weights. Documentation showed weight loss as follows: On 09/08/2020, the resident weighed 130 lbs. On 02/02/2021, the resident weighed 118 pounds which is a 9.23 % Loss. On 09/11/20, Dietary interventions included: Weekly weight monitoring, supply finger foods, cut up meat, 8 oz. (ounces) of ensure plus (a dietary supplement) was added with breakfast and lunch, while ensure clear was added at supper. 1/2 sandwich was offered as a 3:00 p.m. snack. On 09/11/20, a physician's visit note read, in part she has had a significant change over the past couple of months perhaps associated with the decreased interaction with her loved ones secondary to the current coronavirus pandemic .her eye contact is much poorer than it previously was .Her husband has also been struggling with increased depression secondary to not being able to see his wife .speech is somewhat stilted .rather than add another medication which may contribute to some of her dementia as well as imbalance of her [MEDICAL CONDITION], I would favor allowing her husband to come in as essential caregiver ([MEDICATION NAME] care) if she chooses to stay in the facility . On 02/03/21 at 11:35 a.m., Surveyor interviewed DON B, NHA A and RN D. DON B showed Surveyor a progress note dated 10/11/20. The document showed that R26 received 2-3 [MEDICATION NAME] care visits. R26 and spouse met in the adult day care room, where there is a separate entrance. The facility did not have an exact date or duration of the visits, and R26's subsequent reaction to the visits was not documented. No other [MEDICATION NAME] visits were allowed. Surveyor asked NHA A, How did you provide the [MEDICATION NAME] care visits for R26? NHA A stated, I have not (provided them). DON B stated that R26 had received a few [MEDICATION NAME] care visits on a trial basis. Surveyor asked, How is R26's visitation practices different from the current resident visitation practice? NHA A stated, There is no difference. He (spouse) does window or door visits. If he wants to visit more, he has to take her out. Her weights have stabilized. Surveyor reviewed R26's MDS. The MDS showed a PHQ-9 score of 02 on 10/08/20 and 01/07/21. This score indicated minimal depression. Surveyor reviewed R26's current plan of care. No care plan was developed outlining R26's need for [MEDICATION NAME] visits. Surveyor interviewed RN D, who is responsible for the development of resident care plans. Surveyor asked RN D, Was a plan of care developed for R26 regarding the need for [MEDICATION NAME] visits? RN D stated, No, since it changes from day to day. We talk about it (visitation) in stand up. We talked last week about how we were going to start it. During this annual survey, conducted from 02/01/21-02/03/21, Surveyors did not observe in person visits taking place as outlined in CMS memo QSO 20-39-NH.

Based on observation, interview and record review, the facility did not attempt the use of alternatives, or assess for the risk of entrapment prior to the use of bed rails for 1 of 1 sampled residents with bed rails which resulted in injury for the resident. The facility also did not complete assessments for 7 of 7 residents for the use of bed rails. Resident (R) 30 was not assessed for the risk of entrapment prior to installing bed rails. R30 fell on [DATE] and her left arm became entrapped resulting in a fracture. R37, R4, R8, R9, R39, R14 and R29 have bed rails in use. The facility did not try alternative measures first or assess for the risk of entrapment prior to using the bed rails. This is evidenced by: 1. R30 was admitted to the facility with [DIAGNOSES REDACTED]. R30's admission assessment states bed mobility - total dependence- staff performance every time during the 7 day period. Range of motion of upper extremity is described as limited. Observations of R30's room on 02/11/19 revealed that she has a bed rail attached to her bed. Review of R30's care plan stated on 11/01/18 extensive assist of one, bed rails facilitate bed mobility. R30 had two bed rails, one on each side of her bed. R30 had a change in her care plan on 11/12/18 following a fall and fracture; which reads bed mobility: extensive assist of 1, left assist rail only to facilitate bed mobility. The change to the care plan was a new intervention implemented by the facility as a result of R30's broken left arm due to entrapment in the bed rail on 11/11/18 during a fall. R30's progress note on 11/11/19 at 1525 (3:25PM) includes the following information: upon entering R30's bedroom she was noted to be lying face down off the side of her bed, with her left upper extremity caught in between her mattress and the bed railing. Her left arm was bent upward and appeared to possibly be out of socket. R30 was offering complaints of pain to her shoulder; Pain was rated 10/10. Writer updated physician and received orders to call for emergent transportation. Pillow placed beneath R30's head, but staff did not move her. 911 called and EMT's were asked to respond as well. Per LPN, R30 was heard to be yelling out just before she arrived to find that she had fallen out of bed. She reported she was getting up to pee despite being unable to ambulate or self-transfer. She had her call light within reach, but this had not been activated. Her bed was in the lowest position at the time of fall. EMT's arrived to facility at 1545(3:45PM) and assisted to remove R30's arm from railing. She pointed to her left mid arm, deltoid area, as the most painful. 1600 (4PM) - Ambulance crew arrived, and transported R30 to the emergency room . R30 returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. Progress note on 11/12/18 states R30's assist rails were assessed this date. R30 does utilize her left assist rail as she grabs this with her right arm and pulls herself over to the left side when repositioning in bed for cares. She does not utilize the right side rail to reposition though as she cannot use her left arm since stroke. R30 also no longer sits up on the side of her bed for exercises, so right side rail no longer remains appropriate. This was removed, physician updated, and plan of care updated. R30 does have a perimeter mattress in place to assist with prevention of falls though. A fall summary report dated 11/12/18 states, Moved bed up against the wall (left side of bed is up against the wall). This will help prevent future falls as R30's right side of bed was up against the wall by the window at the time of the fall/fracture. She did have the left bed rail on then due to using this to help with repositioning. (right-hand dominant/able) she would grab this to help with rolling and bed mobility repositioning. Due to her left side being out towards the door, she could not move it due to stroke and grabbed the rail with her right hand, rolled out over her left side and out of the bed, over her affected side. With the bed now moved up on the other wall, if she attempts to get out bed on her own, her right side she can move, but unfortunately due to the stroke, her left side will not follow. That should help her to not fall out of bed and she still uses the one bed rail to use for bed mobility and positioning. We anticipate that she will then see her reminder signs and puts on her call light for help, as at times she forgets her limitations. Continue current positioning of bed is important for her safety. Interview on 02/13/19 at 1:03 PM with the facility Director of Nursing (DON) and nursing home administrator (NHA) revealed lesser restrictive options have been tried for R30, including an assist rail and rearranging her room, prior to installing bed rails. Further information and documentation regarding these trials and their effectiveness was requested, but no further information was provided. 2. R37's [DIAGNOSES REDACTED]., and repeated falls Observations of R37's room on 02/11/19 revealed that he has a bed rail attached to his bed. R37's care plan dated 12/09/18 states in part bed mobility: independant; I may require assisstance at times; left sided bed rail in place to assist with mobility. Further review of R37's medical record did not reveal any alternatives tried prior to the use of the bed rail, or an assessment for entrapment prior to installing bed rails on R37's bed. Interview on 02/13/19 at 1:03 PM with the facility DON and NHA did not reveal that any lesser restrictive options had been tried for R37, prior to installing bed rails. Interview on 02/14/19 at 9:10 AM with the NHA revealed the facility did not have any assessments for entrapment for any of the facility's residents who use bed rails prior to 02/13/19. 3. R4's [DIAGNOSES REDACTED]. Observations of R4's room on 02/11/19 revealed she has a bed rail attached to her bed. R4's care plan states in part problem falls - I am at risk for falling d/t unsteady gait, poly-pharmacy, and previous history of falls approaches include bed mobility: extensive assist of 1-2, may use assist rails to aid in bed mobility. These approaches are dated 12/15/17. Further review of R4's medical record did not reveal any alternatives tried prior to the use of the bed rails, or an assessment for entrapment prior to installing bed rails on R4's bed. Interview on 02/13/19 at 01:03 PM with the facility DON and NHA did not reveal that any lesser restrictive options had been tried for R4, prior to installing bed rails. Interview on 02/14/19 at 9:10 AM with the NHA revealed the facility did not have any assessments for entrapment for any of the facility's residents who use bed rails prior to 02/13/19. The NHA stated that R4's bedrails had been removed from her bed on 02/13/19. The assessment completed for R4 on 12/13/19 indicates the resident is not consistently safe with the use of the bed rail. 4. R8 was admitted on [DATE] with [DIAGNOSES REDACTED]. R8 has a history of falls, and exit seeking due to her confusion. R8's care plan in part, .Assist Rails to aid in repositioning, 12/20/18 . R8 has confusion and has experienced falls in the facility, putting her at risk for entrapment in the assist rails. The physician orders [REDACTED]. Obtain written consent. Continuous A consent was signed but does not inform the resident about the risk for entrapment. Surveyor interviewed the NHA on 2/14/19 at 8:00 a.m., to ask if alternative measures had been tried prior to the use of the rails or a risk for entrapment had been completed. The NHA indicated, No. 5. R9 was admitted on [DATE] with a readmission on 6/17/18, with [DIAGNOSES REDACTED]. She is totally dependent on staff for transfers and positioning. Physician orders [REDACTED]. Nurses notes in part, 02/11/19 02:31 PM BILATERAL BED RAIL ASSESSMENT: R9 has been using and continues to benefit from her bilateral assist rails. Her bed rails are in place to assist R9 with bed mobility. On assessment, the assist rails do not limit or restrict R9 from movement. The PA-C order, POA-HC, and nursing team all feel that the assist rails remain appropriate and helpful for R9. P[NAME] reviewed and remains appropriate. The consent was reviewed it does not assess R9's risk for entrapment. The quarterly annual summary report dated 12/4/18 does not document other alternatives attempted prior to the use of the bedrail, or the risk for entrapment to the resident. On 02/14/19 at 9:13 AM, Surveyor interviewed the DON, who indicated the facility talks about consents and risks on admission. Surveyor reviewed the admission packet and noted no information about side rails or risks. 6. R39 was admitted on [DATE] with [MEDICAL CONDITION] and cognitive deficits. R39 has a history of falls out of his bed. Physician orders [REDACTED]. The care plan in part, BEDRAILS Reviewed/Revised: 12/19/2018 12:09 PROBLEM: I utilize bilateral assist rails to aid in my bed mobility, repositioning and transfer. Target date: 3/16/19. Goal: I will safely use these without injury. The quarterly annual summary report, dated 12/10/18, includes in part, Bedrail .Has the care plan been reviewed? Yes. The assessment does not contain information about other alternatives tried prior to the rails, or the risk of entrapment for the resident. On 02/13/19 at 1:04 PM, Surveyor interviewed the DON and NHA. Surveyor asked if they assess the risk for entrapment for each resident. The DON indicated they do it on admission paperwork. Surveyor asked where that is documented. The DON indicated it is not documented, just part of our nursing knowledge. Surveyor asked what alternatives to bed rails were tried first. The DON indicated they did not have that information. 7. On 02/12/19, Surveyor reviewed R14's medical record. The resident has [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set (MDS) assessment, dated 12/06/18, identifies the resident requires assistance with bed mobility and transfers. The resident's Brief Interview for Mental Status (BIMS) score, dated 12/06/18, was 12 out of a total of 15 points. According to the BIMS assessment, a score of 12 indicates R14 has moderately impaired cognition. On 08/20/18, R14 signed a consent for the use of bed rails. A physician's orders [REDACTED]. Surveyor reviewed R14's care plan. The care plan states the following, in part, Start Date: 08/30/2018 .Last Reviewed/Revised: 01/12/2019 .PROBLEM: I utilize an assist rail on my bed to help me with bed mobility, transfer out of bed . On 02/13/19 at 9:39 a.m., Surveyor observed a one-quarter bed rail on the left-side of the resident's bed. The right side of the bed was against a wall. On 02/13/19, Surveyor asked for the facility's risk of entrapment assessment for the use of R14's bed rail. On this date, Surveyor received and reviewed the resident's, Quarterly Annual Summary, with a completion date of 12/10/18. The Summary states the following, in part, .Mobility Devices .Bed cane/Bed rail .12/4/2018 Quarterly nursing note .Does utilize assist rails and these remain appropriate for use, for bed mobility and positioning . This does not identify the risk of entrapment for the resident's use of the bed rail. The resident's medical record does not identify alternative interventions which were attempted to assist R14 with bed mobility or positioning, prior to installing the bed rails. On 02/14/19 at approximately 9:23 a.m., the Nursing Home Administrator (NHA) and the Director of Nursing (DON) stated the facility did not assess R14's risk of entrapment for the bed rails, prior to 02/13/19. The NHA and DON further stated the facility did not measure the gap between the mattress and the bed rail, prior to 02/13/19. 8. On 02/11/19, Surveyor reviewed R29's medical record. The resident has [DIAGNOSES REDACTED]. The resident's most recent MDS assessment, dated 01/10/19, identifies the resident requires the assistance of two staff members with bed mobility and transfers. The resident's BIMS score, dated 01/10/19, was 15 out of a total of 15 points. According to the BIMS assessment, a score of 15 indicates R29 has intact cognition. On 08/04/18, R29 signed a consent for the use of bed rails. A physician's orders [REDACTED]. Surveyor reviewed the resident's care plan. The care plan states the following, in part, Start Date: 08/15/2018 .Last Reviewed/Revised: 01/24/2019 .PROBLEM: I utilize assist rails on both sides of bed .APPROACH: Encourage me to use assist rails to help with bed mobility and also transfers, sitting up in bed. ~ monitor effectiveness and make sure appropriate . On 02/11/19 at 11:25 a.m., Surveyor observed R29 lying in bed. One-quarter bed rails were located on each side of the resident's bed. On 02/13/19, Surveyor asked for the facility's risk of entrapment assessment for the use of R29's bed rails. On this date, Surveyor received and reviewed the resident's, Quarterly Annual Summary, with a completion date of 01/09/19. The Summary states the following, in part, .Mobility Devices .Bed cane/Bed rail . This does not identify the risk of entrapment for the resident's use of the bed rails. The resident's medical record does not identify alternative interventions which were attempted to assist R29 with bed mobility or positioning, prior to installing the bed rails. On 02/14/19 at approximately 9:23 a.m., the NHA and the DON stated the facility did not assess R29's risk of entrapment for the bed rails, prior to 02/13/19. The NHA and DON further stated the facility did not measure the gap between the mattress and the bed rail, prior to 02/13/19.

The facility did not ensure three occurrences of caregiver neglect were reported to the state agency for 1 of 12 (R39) sampled residents. R39 had three falls where the facility identified the care plan was not followed by the Certified Nursing Assistant (CNA). The facility did not self report these cases of neglect. This is evidenced by: The facility Abuse Prevention Program policy, last revised 11/2/16, in part, Policy Interpretation .8. Neglect is the failure to provide goods and services to a resident necessary to avoid physical harm, pain mental anguish or emotion distress .Investigation Protocol .1. Should an incident or suspected incident of resident .neglect occur .Upon administrator's determination of a reportable incident, she/he must immediately report all incidents of .neglect of residents .to be as soon as possible but not to exceed 24 hours after discovery of the incident . Surveyor reviewed falls investigations for R39 and noted the following. On 11/13/18, R39 had fallen in his room. The investigation identifies that the care plan was not followed as the call light was not clipped to his clothing as indicated it should be. The falls care plan had the following in part, dated 5/18/18, Attach call light to clothing. Surveyor could not determine which CNA did not follow the care plan. Surveyor interviewed the Nursing Home Administrator (NHA) on 02/14/19 who stated CNA B was the caregiver involved. On 12/19/18, R39 fell in his room, on the floor between the bathroom and the bed. The falls investigation documents R39 did not have his gripper socks on. This intervention had been on the care plan since 09/18/18. The care plan in part, Encourage me to wear gripper socks to bed at night. Surveyor interviewed the NHA to determine which CNA had not followed the care plan. The NHA indicated it was CNA A. On 12/23/18, R39 fell in his room, on the floor between his bed, wheelchair and recliner. The nurses notes in part, R39 was noticeably grimacing and he was having pain but unable to say where .He had no pain with taking steps and no grimacing noted. He was assisted to sit on his bed and had some discomfort with this, again asked where it hurt. He said, it hurts everywhere. My back, legs, head, stomach.' R39 was assisted to lay down .he was continuing to grimace.He pointed to his left side of his stomach near his rib cage .We will update son .see if he is interested in starting R39 on some [MEDICATION NAME] .In addition the call light was not clipped to his person at the time of the fall, so staff education was provided about this as this remains pertinent in the P[NAME] (Plan of Care). Surveyor could not distinguish which caregiver was involved from the report. Surveyor interviewed the NHA who indicated it was CNA C. Surveyor reviewed the staff education that had been provided for each of the above incidents. On 02/14/19 at 12:00 p.m., Surveyor interviewed the NHA to ask why they did not self report the above. The NHA indicated she was not sure, but thinks it is because R39 was a very difficult resident and may have taken the call light off or the gripper socks off himself. Surveyor stated that the falls investigations clearly state the care plan was not followed and education was provided because of that. The NHA agreed it meets the definition of neglect and should have been reported.

Based upon record review and interview, the facility did not follow standards of practice for four unwitnessed falls for 1 of 4 (R39) sampled residents. R39 experienced four unwitnessed falls. The facility did not do neurological assessments after the fall to determine if R39 had a head injury after the falls. This is evidenced by: R39 was admitted with [MEDICAL CONDITION] and dementia. The most recent MDS 12/06/18, documents R39 has a brief interview for mental status score of 1, meaning R39 would not be able to recall information or answer questions accurately relating to falls. Nurses notes in part, 10/29/18 1230 - writer summoned by housekeeping staff who observed to be on the floor in his bathroom. On assessment, R39 presents sitting on his buttocks in the bathroom. He was positioned perpendicular to the toilet, as if he just entered the bathroom. He states he slipped on the floor, enroute to the bathroom. He had on appropriate footwear and the floor was dry and clear of clutter. Skin assessed; no injury. Full ROM in bilateral upper and lower extremities. Equal strength also noted. No shortening, rotation or deformity of extremities noted. Vitals obtained; stable. R39 was assisted up via two staff with a gait belt. R39 denied pain/discomfort. He was assisted to use the bathroom and had results from his suppository. NHA; . PA-C; and son, updated re: fall. 11/05/2018 15:07 R39 was reviewed with, PA-C today with recent anger, mood fluctuations and striking out at staff. He has had [MEDICATION NAME] added for this in hopes to help him feel better. Updated who is in agreement and will sign the consent tomorrow. 11/13/2018 23:30 R39 found by staff sitting on the floor on the left side of his bed, with back resting against the bed. Wheelchair locked and in position at the bedside. Call light was secured to side rail and within reach. Gripper socks on. R39 was not incontinent. R39 states I just kind of slid down here. Denies any injury. No sign of injury, moving extremities per his normal. With assist of 2 staff R39 assisted back up on side of bed and further skin assessment done. Skin intact no redness or ecchymosis. Temp 98.7 HR94 RR20 BP 122/76 Sao2 on RA 93%. R39 reminded of importance of using call light if/when wanting to get up or go to BR. Resident then assisted to the BR where he voided, no stool, noting earlier had had loose BMs, again none at this time. R39 then assisted back to bed where he further declined any c/o discomfort. Settled for sleep with call light secured within reach . 12/19/18 R39 was found laying on his back at 0035 on 12/19/18. Resident was checked 5 minutes earlier and he was sleeping in his bed. R39 did not have his gripper socks on, wheelchair was locked by bedside. Floor was uncluttered and dry. R39 was found between the bathroom. bed and his table and he had spilled some of his water under the table. R39 had a lg brief on and it had slid down his buttocks and was by his knees. R39 had no deformation or rotation noted to extremities. Resident was able to squeeze hands equally and push down and pull up with feet without any pain. R39 mumbled when asked what happened and could not be understood but this writer then asked if he bumped his head and he replied yes. Neuro checks were started. Administrator, PAC and son .were all updated to fall. Immediate intervention: Please put me in pull-ups at all times. R39 was helped up from the floor with gait belt and 3 staff. He refused to go to the bathroom but did walk back to his bed. R39 does deny pain. Vital were BP 156/82, P 70, T 97.6, R 24. Surveyor did not see any further neuro checks after the initial check in the above note. Nurses' notes continued, 12/19/2018 14:34 R39 was seen by ., PAC today. He has been sleep and having difficulty brushing his teeth this morning, remains angry and irritable, wanting to leave, not following basic safety directives such as hold on to your walker. He is unbalanced and unsafe so has been 1:1 since about 1030 am. ordered increase in [MEDICATION NAME], .He denied pain to PA-C and other responses have been very difficult to understand if able at all. 12/19/2018 05:38 R39 was up at 0530 sitting on the edge of the bed . R39 still appears very tired and follows commands but needs repeating. R39 does have a small bump on the top of his head where the curve starts to go down. This is not red, no noted abrasion and no pain associated with the bump. This writer is not sure if this occurred related to fall or is just normal for his head. The area it is located would have been hard to hit when found laying on the floor and staff was immediately there because CNA heard the fall. 12/23/2018 03:07 CNA called this writer down to R39's room at 0235 this morning. R39 was found laying on the floor in his room between his bed, wheelchair, and recliner. His head was positioned near his recliner and actually leaning against that. His feet were toward the bottom of his bed and he was laying in a supine position. R39 was notably grimacing and said he was having pain, but unable to say where. He moved over to his left side and was resting on his left shoulder. R39 was unable to say what happened when he fell or what he was doing . Again, he was unable to say whether or not he fell . R39 was assisted to a seated position and assessed thoroughly for any redness, bruising, dislocation, etc . He had no pain with taking steps and no He said it hurts everywhere. My back, legs, head, stomach. R39's head was assessed and there was no sign of any head involvement from fall. He again was unable to say what happened and was mumbling things that were not intelligible to any of the staff in the room . Overall, it does seem R39 is deteriorating quite rapidly though and may be progression of disease . Given R39's recent unpredictability and instability, also placed on 15 minute checks for safety. Plan of care updated to this and staff notified of changes. Surveyor reviewed the medical record to review the neurological assessments that would have been completed after the above four unwitnessed falls. Surveyor could not locate them. The falls assessment did not include a plan to do neuros for any extended period of time. The nurses' notes do document changes in behavior, lethargy, and a change in ambulation ability after the falls that could indicate a possible head injury. On 02/13/19 at 3:00 p.m. Surveyor interviewed the Director of Nursing (DON) about neuros for unwitnessed falls. The DON indicated they ask the resident and if they say no they don't do neuros. Surveyor asked if that was true for dementia residents too. The DON said Yes. On 02/14/19 at 8:05 a.m., Surveyor interviewed the Nursing Home Administrator (NHA). Surveyor asked if staff had noted any neurological changes after the unwitnessed falls. The NHA gave surveyor the facility policy that stated any unwitnessed fall must have neurological assessments completed. The NHA acknowledged they had not done them. The facility policy Neurological Assessment, revised 12/18 includes in part, The purpose of this procedure is to provide guidelines for a neurological assessment: .2. when following an unwitnessed fall .Guidelines: 1. Neurological assessments are indicated: b. Following an unwitnessed fall c.Following a fall or other accident .involving head trauma .

Based on interview and record review, the facility did not develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and goals in order to meet a resident's medical, nursing, and psychosocial needs, which are identified in the comprehensive assessment. This occurred for one of twelve residents (Resident (R) 14) whose care plans were reviewed. The facility did not develop a care plan for R14's use of an anticoagulant (blood thinner). This is evidenced by: On 02/12/19, Surveyor reviewed R14's medical record. The resident has [DIAGNOSES REDACTED]. The resident was admitted to the facility in (MONTH) (YEAR). The resident is currently taking [MEDICATION NAME], an anticoagulant which is used to prevent and treat blood clots. Some of the potential risks involved when taking this medication are severe bleeding, reddish or brown urine, black or bloody bowel movements, severe headaches or stomach pain, joint pain/discomfort/swelling especially after an injury. R14's Quarterly Annual Summary, with a completion date of 12/10/18, identifies the following, in part: .Balance .Not steady, but able to stabilize without human assistance .Has the resident had any falls since admission/entry or reentry or the prior assessment .? Yes .12/4/2018 Quarterly nursing note .his knees give out. (Name of R14) has had 2 falls this past quarter with no injury . Surveyor reviewed R14's care plan. The resident does not have a care plan for the potential risks involved for taking the anticoagulant medication, and the care plan does not identify the resident is taking the anticoagulant. On 02/14/19 at 10:22 a.m., Surveyor interviewed the Nursing Home Administrator (NHA) and the Director of Nursing (DON). The NHA and DON reviewed R14's care plan and stated there is no care plan for the use of the resident's anticoagulant medication. The NHA stated the facility usually has care plans developed for the potential for bleeding with the use of the anticoagulant. The DON stated it is the facility's expectation to have a care plan developed for a resident who is taking a blood thinner.

Based upon interview and record review, the facility did not have adequate indications for increasing doses of [MEDICATION NAME] (antipsychotic medication) for 3 of 6 (R8, R39, R26) residents reviewed on [MEDICAL CONDITION] medications. R39 and R8 had their [MEDICATION NAME] doses doubled in dose, prior to trying non-pharmacological interventions first. R26's antipsychotic dose was doubled without adequate indications for the increase. This is evidenced by: 1. R8 was admitted on [DATE] with [DIAGNOSES REDACTED]. Care Plan Start Date: Last Reviewed/Revised: 01/07/2019, [MEDICAL CONDITION] Drug Use PROBLEM: [MEDICAL CONDITION] MEDS - I am on an antidepressant and an antipsychotic for my mood and visual hallucinations with my [DIAGNOSES REDACTED]. At times my moods have been unstable. Negative remarks towards other peers and family that are hurtful, paranoia - feeling that others are taking my things when I misplace them. Approach: Follow cognitive and medication protocols. Offer 1:1 when I appear unsettled. Surveyor does not see any individualized approaches, or addition of non-pharmacological interventions prior to the dose increase 1/16/19. Nurses notes in part, 01/14/2019 20:49 (8:49pm). This afternoon, DON reported that R8 wanted to leave with her and was very confused. She had torn her whole room apart, had clothes all over, and was convinced someone had done this to her room. Per AM staff, R8 had been cleaning her room all morning as well. No staff were in her room doing this. R8 was concerned someone was trying to steal her necklace as well. She was encouraged to lie down to rest for a while, then get up for supper in a little bit. R8 thought she had already eaten supper. DON reminded her she had lunch about 2 hours earlier, and that it was 3:45 in the afternoon, so she hadn't had supper yet. R8 did lay down to rest for a while and attended supper this evening. 01/16/2019 14:59 R8 was seen today by . PA-C for routine rounds. He reviewed current status including medications, recent labs, and vitals, etc . New orders received and carried to increase [MEDICATION NAME] to 25 mg BID for hallucinations/delusions related to dementia with behavioral disturbance . Physician note 1/16/19.IMPRESSION/ PLAN: The patient was seen today for routine nursing home follow up. 1. Mixed vascular and Alzheimer's type dementia: Once again her dementia is slowly progressive. Nursing staff does report that she does have some increasing behaviors and having some paranoia. She is on [MEDICATION NAME] 25mg daily. Will increase that to 50mg daily. Surveyor reviewed three behaviors that would be paranoid prior to the dose increase of [MEDICATION NAME]. The other documented behaviors are confusion to time and place and wanting to go home, which are normal dementia behaviors. There are no updates to the non-pharmacological interventions in the care plan prior to doubling the dose of [MEDICATION NAME]. On 02/14/18 at 12:05 p.m., Surveyor interviewed the Nursing Home Administer (NHA) to ask if the facility had tried other non-pharmacological interventions prior to doubling the dose of [MEDICATION NAME]. The NHA acknowledged there had been no changes to the care plan. 2. R39 was admitted [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. 12/19/18, [MEDICATION NAME] 50 mg twice a day Care plan in part, Start Date: 11/17/2018 Last Reviewed/Revised: 12/19/2018 12:09 PROBLEM: I am taking an antipsychotic medications for my paranoia/mood/aggression. Target Date:02/17/2019, GOAL:This medication will be effective on lowest dose possible with out any ill effects. Start date: 11/17/18, APPROACH: Monitor effectiveness and behaviors MD/pharmacist to review on regular basis. ~ AIMS assessments completed as scheduled. Follow behavior protocols. R39 had experienced a fall on 12/18/18 and 12/19/18. The nurses' notes in part, 12/18/18 14:51 (2:51p.m.) . his disorganized thinking and verbalization's seem to be worsened the past couple of days, he is less steady on his feet, has complaints of low back pain this afternoon and urine is very strong/dark in color. Pushing fluids has been ineffective. PA gave orders for Urinalysis and culture if needed to rule out UTI . 12/19/2018 14:34 R39 was seen by ., PAC today. He has been sleep and having difficulty brushing his teeth this morning, remains angry and irritable, wanting to leave, not following basic safety directives such as hold on to your walker. He is unbalanced and unsafe so has been 1:1 since about 1030 am . ordered increase in [MEDICATION NAME], decrease in [MEDICATION NAME] and keep [MEDICATION NAME] PRN for another 14 days, to wait for UA to return prior to any further changes . He denied pain to PA-C and other responses have been very difficult to understand if able at all. 12/19/18 14:34 (2:34 p.m.), .to wait for U/A (urinalysis) to return . 12/21/2018 12:45 p.m. Urine culture results returned and were reviewed with ., PA-C. Orders received to start Bactrim DS one tablet BID x7 days. Orders for this carried. Infection event started On 02/14/19 at 12:05 p.m., Surveyor interviewed the NHA about the increase in [MEDICATION NAME], when R39 was having a hard time walking and was experiencing falls. R39 was also having urinary tract symptoms that may have contributed to his behaviors. Surveyor asked if any non-pharmacological interventions had been tried or added to the care plan before doubling the dose of [MEDICATION NAME]. The NHA indicated they had not done that. The NHA stated she will be working with the Physician Assistant on this. 3. On 02/12/19, Surveyor reviewed R26's medical record. The resident has [DIAGNOSES REDACTED]. The resident is taking the following medications, in part: -[MEDICATION NAME] (an antidepressant) 20 milligrams (mg) daily, since 05/08/18 -[MEDICATION NAME] (an antipsychotic) 25 mg twice a day (BID), since 06/06/18. This medication is used for the resident's anxiety and agitation. This medication was increased on 09/27/18. -[MEDICATION NAME] (an antidepressant) 50 mg BID, since 10/16/18. This medication is used for the resident's anxiety. -[MEDICATION NAME] (an [MEDICATION NAME]) 25 mg daily and as needed (PRN), since 11/05/18. The medication is used for the resident's anxiety and itching. The resident's most recent Brief Interview for Mental Status (BIMS) score, dated 01/03/19, was 02 out of 15 possible points. According to the BIMS assessment, a score of 02 indicates R26 has severely impaired cognition. The resident's care plan was reviewed. R26's care plan states the following, in part: .Start Date: 05/18/2018 .Last Reviewed/Revised: 01/17/2019 .PROBLEM: Cognition and Behaviors: I have long and short term memory problems and am no longer able to take care of myself; but do not recognize that I need help either. At times I refuse cares, hit and yell/swear-as I do not understand what is happening .APPROACH: When upset, agree with me, tell me 'I'm sorry' and do not argue, remain quieter and let me vent. Help me to a quieter environment . .PROBLEM: At times I am anxious, appear to be hyperventilating, become unsettled. I am taking medication to help with my anxiety .APPROACH: Attempt toileting and offer me medication when alternatives are not helping .I sometimes am more comfortable when being reassured 'were are okay' and being distracted by things such as pictures of family or picture books, holding the baby doll .please engage me in something (magazine, newspaper, etc) when seated alone in the hallway or dining areas .Please use essential oils to help me cope, feel comfortable. Massage them on topically or place on a cotton ball near/on me . .PROBLEM: ANTI PSYCHOTIC USE-I am prescribed [MEDICATION NAME] for increased anxiety and agitation; I have been hitting out and at times difficult to redirect .APPROACH .When irritable, angry or aggressive, bring me to a quiet place, agree with me. Put some calming music on . Surveyor reviewed R26's nurses' notes, from 09/01/18 to 09/27/18. The nurses' notes state the following, in part: -09/02/18: (R26's name) was visibly anxious this afternoon, yelling at husband. Also noted to be vigorously scratching at buttocks. PRN [MEDICATION NAME] administered. PRN effective as (R26) was much calmer and no scratching noted at mealtime. -09/09/18: After (R26) had gotten up and came to the dining room she was breathing very heavy and yelling out. She was also grabbing at things. She was offered and received PRN [MEDICATION NAME] for anxiety. This was effective .(R26) has been doing ok since decrease in [MEDICATION NAME]. She has been more alert and awake during cares and when up for meals. She had an excellent day yesterday, no striking out, no calling out or swearing, participated in her cares, etc .Today again she got herself up and did very well, she wasn't anxious with cares, though got anxious a bit later on . -09/19/18: (R26) told CNA (Certified Nursing Assistant) this evening that she was 'going to kill you' and 'I wish you were dead' several times. She also hit CNA several times, though did not cause any injury. She did have PRN just after this. She would not redirect when making these statements. We will keep monitoring .(Name of spouse) got here around (3:00 p.m.) and stated that (R26) was feeling pretty anxious and breathing heavy. She was offered and accepted PRN [MEDICATION NAME]. This was effective. -09/23/18:(R26) was very pleasant most of day. She then after coffee time with her husband got very mad, breathing heavy, hitting out at staff. They assisted her as she had been incontinent of bowels and she did not want help. Reassured her they had to get her cleaned up, etc. She hit out at staff. She was brought out to hallway, 1:1 (one-to-one) given, attempted coffee, more quieter place to sit, etc .She was offered PRN as she was swearing, propelling WC (wheelchair), yelling out at staff, etc. She did knock her coffee into staff hand .(R26) was pushed due to request up and down hallway a few times so more quiet and then she did want to go eat. Brought down to dining room about 20-30 minutes later where she did start eating supper. NO complaints of pain when asked during this more anxious like episodes. Did also have warm blanket that was not effective, she threw this down off of her. -09/27/18: At this time staff came out of one room and found (R26) walking across the hall and was just going to enter room [ROOM NUMBER]. (R26) did re-direct back to her own room but once there and back in bed, (R26) told CNA, 'don't you ever talk to me again.' -09/27/18: Late Note: This writer walked into dining room Wednesday afternoon .(R26) was near the table with three other ladies. This writer heard (R26's) voice rise and she started arguing with two ladies at the table (R26) was breathing hard and was upset .this writer asked her if she wanted to lay down and .stated, yes. This writer assisted (R26) to her room and into bed. This writer reassured (R26) was safe and ok. She was able to calm herself somewhat and laid down with assistance. Later in the afternoon (R26) was sitting out in the hallway with her husband .when she started yelling loudly .(name of spouse) asked this writer to bring her closer to him in hopes she would calm. This did seem to help and with reassurance again, (R26) was able calm her breathing. -09/27/18: (Name of Physician's Assistant) was updated this date regarding (R26's) increase in negative expressions and behaviors, continued anxiety and paranoia, and striking out at staff .ultimately decided to try to increase the [MEDICATION NAME] first and see if this is effective in helping to better manage .negative expressions and help her to be more comfortable . On 09/27/18, R26's [MEDICATION NAME] was increased from 25 mg to 50 mg twice a day. According to the resident's medical record, there is no documented adequate indications why the antipsychotic was doubled. The nurses' notes identify the as needed dose of the [MEDICATION NAME] was effective in managing the resident's anxiety, along with non-pharmacological interventions identified in the care plan. Surveyor reviewed R26's Medication Change Review report, from (MONTH) (YEAR). The report states, in part, On 10/16 (2018), provider ordered increase in [MEDICATION NAME] as previous change (increase of [MEDICATION NAME]) was ineffective. After this change, behaviors are mostly unchanged . As of 02/14/19, R26 is taking the [MEDICATION NAME] 50 mg BID, since 09/27/18, even though this report identifies the increase in the antipsychotic was ineffective. On 02/14/19 at approximately 10:15 a.m., Surveyor discussed R26's [MEDICATION NAME] increase with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). The NHA and DON confirmed the antipsychotic was not reduced when the facility identified the medication was ineffective in (MONTH) (YEAR), and there was no documented adequate indications for the increase in the [MEDICATION NAME].

Based on interview and record review, the facility did not ensure each resident's care plan is reviewed and revised, based on the resident's needs and comprehensive assessment. This occurred for one of twelve residents (Resident (R) 14) whose care plans were reviewed. The facility did not update R14's care plan related to the resident's grieving, due to his spouse's hospice care. This is evidenced by: On [DATE], Surveyor reviewed R14's medical record. The resident has [DIAGNOSES REDACTED]. The resident is currently taking [MEDICATION NAME] (an antidepressant medication) 20 milligrams, daily, since [DATE]. Surveyor reviewed the resident's nurses' notes, from [DATE] to [DATE]. The notes state the following, in part: -[DATE]: R14's spouse was admitted to the facility on hospice care. -[DATE]: .(R14's name) is tearful this evening as his wife told him she thought the end was near and requested the pastor to come. (R14) has been by her side all evening . -[DATE] (R14) has been sitting in a recliner right next to his wife's bed, holding her hand. (R14) will dose (sic) for a short while but will continue to try and stay awake. (R14) is still in his clothes from yesterday refusing to get into night clothes. -[DATE] (R14) has been given lots of 1:1 (one-to-one) support as his wife is doing poorly. (R14) is tearful .(R14) ate dinner in room today as he didn't want to leave his wife and daughters side. -[DATE] .(R14) is being very supportive, but gets tearful. Given lots of 1:1 for support today again. He knows things are going down hill for his wife, and is thankful for everyone. -[DATE]: R14's spouse died at the facility. Surveyor reviewed R14's care plan. There is no care plan related to the resident's potential for grieving due to his spouse's hospice care, or individualized interventions to help the resident with the grieving process. On [DATE] at 11:04 a.m., Surveyor interviewed Social Worker (SW) D. The SW stated she normally would have a potential for grieving care plan for residents, but stated R14 does not currently have this type of care plan.

Based on observation, interview and policy review, the facility did not store controlled schedule II medications in a separately locked permanently affixed compartment in 1 of 1 medication rooms observed. This is evidenced by: The 12/2015 facility policy entitled Controlled Substances read in part: 5. Controlled substances must be stored in the medication room in a locked container, separate from containers for any non-controlled medications. This container must remain locked at all times, except when it is accessed to obtain medications for residents. On 12/01/16 at 8:30 a.m., Surveyor inspected the medication room with the Director of Nursing (DON). Surveyor asked the DON if they have a locked cabinet for back up narcotic medications. The DON showed Surveyor two plastic boxes that were sitting on the counter in the med room. A label on the red box identified it contained one vial of Morphine Concentrate 20 mg (milligrams)/ml (milliliter). A blue plastic box sitting on the counter contained numerous back up medications including five vials of Morphine Sulfate 10 mg/ml. Both boxes containing the morphine were not separately locked and stored in a permanently affixed cabinet or drawer. Surveyor observed both boxes were closed with a small plastic tag going through the top and bottom lock holes of the plastic boxes. On 12/01/16 at 10:33 a.m., Surveyor met with the DON and Nursing Home Administrator (NHA) to discuss the above concern. Surveyor asked if they consider the plastic tag a lock. The DON said yes, if the tag is open we know it has been opened or tampered with. Surveyor explained that system does not meet the regulation of the morphine being stored in a secure manner.

Based on interview and medical record review, the facility did not review and revise care plans to accurately reflect the current status and needs for 2 of 10 residents, from a sample of 10 residents whose care plans were reviewed. Resident (R) 7 and R8. R7 exhibited behaviors of hallucinations, delusional statements and hoarding. These were not clearly identified on R7's care plan, nor did R7's care plan include individualized approaches related to these behaviors. R8 exhibits verbal and physical behaviors toward staff. These behaviors were not included in R8's care plan and there were no individualized approaches to address these behaviors. R8 has wandering behaviors. There were no individualized approaches specific to R8 in R8's care plan related to wandering. This is evidenced by: 1. R7 has the [DIAGNOSES REDACTED]. R7 receives [MEDICATION NAME], an antidepressant medication for dysthymic disorder, [MEDICATION NAME], an antianxiety medication for anxiety and [MEDICATION NAME], an antipsychotic medication for auditory hallucinations. On [DATE], Surveyor began review of R7's care plan and noted a care plan problem that read: Problem Start Date: [DATE] Mood State MOOD: History of depression and anxiety with newer onset hallucinations. I receive antidepressants, anxiolytics, and antipsychotics for this. Goal is: Stable mood free of adverse side effects R/T (related to) my antianxiety and antidepressant usage. And Approach Start Date: [DATE] Follow medication administration and behavior management protocols. Approach Start Date: [DATE] If (R7) is down, direct conversation toward happy memories and positive topics (grandchildren, animals, etc.). Approach Start Date: [DATE] Supportive room visits. R7's care plan does not identify R7 has auditory hallucinations, types of hallucinations, delusional comments, taking things from other residents and hoarding. R7's care plan does not include approaches staff should implement if these behaviors occur. Surveyor reviewed behavior charting for R7 for the months of ,[DATE], ,[DATE] and ,[DATE]. Behaviors listed included: Seeking Reassurance. Documented as occurring: ,[DATE]-25 times. ,[DATE]-27 times. ,[DATE]-24 times. Hoarding. I have a history of taking items from fell ow residents and hoarding these in my room. Documented as occurring: ,[DATE]-8 times. ,[DATE]-11 times. ,[DATE]-3 times. Cries. Document depressive episodes with crying about deceased husband, losses in life, family situation, etc . Documented as occurring: ,[DATE]-4 times. ,[DATE]-1 time. ,[DATE]-3 times. Delusional Comments. Documented as occurring: ,[DATE]-2 times. ,[DATE]-3 times. ,[DATE]-3 times. Reports Auditory hallucinations. reporting hearing voices, noises, television, children, etc . Documented as occurring: ,[DATE]-1 time. ,[DATE]-2 times. ,[DATE]-3 times. On [DATE] at 4:33 p.m., Surveyor interviewed Certified Nursing Assistant (CNA) asking what behaviors R7 has. CNA B stated R7 seeks reassurance a lot. R7 used to hear and see things, music, hearing people talking about her. CNA B said to her knowledge R7 hasn't been hearing or seeing things any longer. Surveyor asked CNA B how she knew what approaches to use to help R7 if behaviors occur. CNA B said when R7 is tearful, CNA B talks to R7 about her husband or her grandkids. CNA B said she doesn't talk to R7 about her daughter because they do not have a good relationship and this upsets R7. Surveyor referred to R7's care plan problem for mood state that lists under approaches Follow . and behavior management protocols. CNA B was asked what that means for R7. CNA B stated she talks to R7 about other things. Surveyor was asked where she can find the protocols to use for R7. CNA B stated they are in the computer. Surveyor explained the concern of R7's care plan not including what approaches work and what ones don't work for R7. For example, CNA B knowing that talking about R7's daughter upsets R7, but that is not on R7's care plan. CNA B was asked how other staff would know that. CNA B said she passes it on to new staff. Surveyor stated that is good that CNA B does that but that would be important information to be in R7's care plan. On [DATE] at 3:27 p.m., Surveyor shared concerns about R7's care plan with the Director of Nursing (DON) and Social Service Worker (SSW) C. 2. R8 has [DIAGNOSES REDACTED]. R8 receives [MEDICATION NAME] for anxiety disorder and [MEDICATION NAME]. R8's physician order [REDACTED]. Surveyor reviewed R8's care plan and read Problem Start Date: [DATE] Category: [MEDICAL CONDITION] Drug Use BEHAVIORS/DEPRESSION - I have behavioral disturbances associated with my dementia, anxiety and depression. I take antidepressant and antipsychotic medications. The goal is I will experience no adverse effects related to medication usage. Approach Start Date: [DATE] Follow cognitive impairment and medication protocols. Another care plan problem with the start date of [DATE] read: WANDERING - I like to wander the halls and at times seek out the exits, looking to go home. Goal Target Date: [DATE]. Approach Start Date: [DATE] ~Place wander watch, following wandering protocols. Surveyor reviewed R8's behavior charting for the months of ,[DATE], ,[DATE] and ,[DATE]. Behaviors listed included: Wandering. Documented as occurring: ,[DATE]-2 times. ,[DATE]-3 times. ,[DATE]-2 times. Socially Inappropriate Behavior/Other. Documented as occurring: ,[DATE]-1 time. ,[DATE]-0 times. ,[DATE]-2 times. Verbally Abusive. Documented as occurring: ,[DATE]-0 times. ,[DATE]-0 times. ,[DATE]-1 time. Physically Abusive. Documented as occurring: ,[DATE]-0 times. ,[DATE]-1 time. R8 hit, kicked and scratched staff. ,[DATE]-1 time. This was not described. Surveyor noted R8's care plan did not identify R8 was verbally abusive or physically abusive. There were no individualized approaches specific to R8 being verbally or physically abusive contained in R8's care plan. On [DATE] at 4:16 p.m., Surveyor interviewed CNA A and asked CNA A about R8's behaviors. CNA A said R8 gets anxious; every day is different. R8 talks about going home. Sometimes R8 is easier to redirect than others, with time he can calm. CNA A was asked if R8 tries to leave the facility. CNA A said R8 does try to leave, sets off the door alarm. Surveyor asked if R8 has other behaviors such as yelling, swearing at staff. CNA A said yes, he does. CNA A was asked if she knows if R8 hits staff. CNA A stated R8 has not hit her but has heard he has hit other staff and tries to hit them. Surveyor asked CNA A how she knows what to do for R8 if behaviors occur. CNA A stated the first step is to remain calm yourself, redirect, take him to another place, try to change the subject if that's the case. Surveyor asked what she would do if R8 was yelling and swearing at her. CNA A said to leave him alone and come back later and then he will usually let you help him. CNA A was asked where she can find the protocols to use for R8. CNA A said they are in a filing cabinet at the nurses' station. The above concerns were shared with the DON and SSW on [DATE].

Based on observations, record reviews and interviews, the facility did not develop, review and revise the residents' care plans to reflect measurable objectives and timetables to meet the residents' medical, nursing and psychosocial needs that were identified in the residents' comprehensive assessment in 3 of 10 sampled residents. 1. Resident #2 did not have a care plan developed to address a [DIAGNOSES REDACTED]. 2. Resident #5 did not have a sleep assessment or care plan to address a sleep disorder. 3. Resident #1 did not have a care plan to address a [MEDICAL CONDITION]. This is evidenced by: 1. Resident #2's [DIAGNOSES REDACTED]. On 01/07/15, Surveyor reviewed Resident #2's clinical record. The Minimum Data Set (MDS) revealed that Resident #2's comprehensive assessment from 08/07/14 showed a score of 14 under the "Resident Mood Interview" (D0300) section, indicating moderate depression. The Physicians Order Sheet indicated that Resident #2 received [MEDICATION NAME] (an antipsychotic) 0.5 mg (milligrams) twice a day orally, [MEDICATION NAME] (an antidepressant) 20 mg daily orally, [MEDICATION NAME] (an antidepressant) 500 mg two tablets orally at bedtime and [MEDICATION NAME] (an antianxiety) 1.0 mg orally three times a day. Surveyor reviewed Resident #2's care plan. The care plan did not include a nursing [DIAGNOSES REDACTED]. Surveyor interviewed the Director of Nursing (DON). The DON acknowledged that the nursing care plan "should have included [DIAGNOSES REDACTED]. 2. Resident #5 was admitted to the facility on [DATE], secondary to a [MEDICAL CONDITION]. Resident #5 received ongoing therapy for rehabilitation following surgery. On 01/08/15, Surveyor reviewed Resident #5's current and previous Physician order [REDACTED]. The medication was given one time on 05/26/14 at night, when the resident stated, "I just can't shut my brain off." Upon clinical record review, no sleep assessment or care plan was developed by the facility to address Resident #5's [MEDICAL CONDITION]. Surveyor interviewed the DON. The DON stated that a sleep assessment and care plan should have been developed. 3. Resident #1 has a [DIAGNOSES REDACTED]. On 09/27/14, the physician ordered [MEDICATION NAME] 20 milligrams daily for depression. On 01/08/15 at 11:20 a.m., Surveyor reviewed Resident#1's current care plan with the DON, finding no care plan developed for depression. The DON stated the facility as a team develops the care plans. The DON stated, "We know the resident has a [DIAGNOSES REDACTED]."